On Dementia

There has been a flurry of research into dementia. This is most welcome and not before time. Because medical advances are enabling us to live longer, most of us will reach the point when our brains become our weakest link and succumb to dementia. I have witnessed how dementia can destroy quality of life, so anything that can understand it, defer it, ameliorate it or simply cope with it has immense value.

Just this last week I have seen references to two reports about factors appearing to make dementia more likely. One was about sports, and especially sports involving knocks to the head and possible concussions. The indication is that soccer players who head the ball a lot are three to five times more prone to dementia than most of us. I can only imagine what this would imply for NFL players or boxers. It calls to mind those sad last years of Muhammad Ali. It seems to make sense that bashing the brain repeatedly is not the healthiest thing for us to be doing. Within a generation, these sports will be outlawed or have been radically changed. Perhaps in soccer there is already enough relief through using less dense balls with softer impact.

The second report had more subtle conclusions. We have long thought that exercising the brain helps to keep it in shape, hence the craze for mind puzzles like word search or even Candy Crush. That can only be good for the mobile phone generation – so long as those benefits are not more than offset by any damage to the brain from electrical pulses and the like. This report confirmed the benefits of mild brain exercise, but concluded that too much brain exercise may be a bad thing. People with stressful brain occupations seemingly are more prone to dementia.

My guess is that this may be about sleep. Sleep is emerging as critical for health in so many ways. It feels intuitively correct that, since sleep is the sort of cleaning reset function for the brain, good sleep patterns will help to fight off dementia. Perhaps those rocket scientists are thinking so hard and so often that they take their problems to bed with them, and that disrupts sleep and its positive effects.

While it is good to understand the causes of dementia, for now the more urgent priority is what we can do about it. For a life with dementia can be a horrible one.

The clearest symptom of dementia is the loss of short-term memory. We all start to suffer from a bit of that from our fifties or earlier, and initially it can seem rather harmless and even quite funny. At the home where we volunteer, the majority of residents have some issues with short-term memory. Many times we will be asked for a bowl of soup by a resident who had already eaten one just five minutes before and forgotten all about it. At this stage the resident can share the joke: we point out that their soupspoon has vanished to the kitchen and they can accept that they must have already eaten their soup.

But as the short-term memory weakens the impact quickly ceases to be funny at all, and our experience is that the onset can happen within a few short weeks. First the resident can become frequently lost, and anxious about it. Then, they see themselves in a different scenario to the one they are really in, often regressing to moments from their youth.

I liken this to being awake in a dream. We often dream about situations from our past. The resident responds to that situation much as we imagine ourselves doing in dreams. Sadly, for many of us our most commonly recurring dreams recall stressful situations requiring urgent action, such as getting lost as a child or being betrayed by someone like a parent, or reliving situation where they may have behaved shamefully. As dementia takes hold, residents imagine themselves in these situations more and more frequently, and they become stressed, angry and even violent as a result.

Much though I have always admired the nuns and staff at the home we visit, I used to think that they sometimes did not treat all their residents well. Often you hear desperate cries emanating from bedrooms, with nobody seeming to rush to help. On other occasions staff could appear brusque or heartless. Now that we have witnessed late stage dementia ourselves we know better. If such a resident calls for help, it might or might not be possible to mollify them. But the likelihood is that the scenario is repeated only a few minutes later. Short of sitting with somebody 24/7, requiring an infeasible level of staffing, what can they do?

This is the real world described in the best article I have read about dementia, in last week’s Guardian Weekly by Sarah Boseley. The author struggles to help her own mother and writes with compassion and intelligence. It emerges that good practice dementia care has progressed, albeit slowly. My grandmother had dementia in her later years, and, like many, ended up in a cruel home, often chained to a chair to prevent her doing anything silly. What a miserable life that must have been.

But most options involve impossible levels of personal care. The article describes how societies evolve from one where women stay at home to care for elderly relatives, then employ low-cost home help for the task from developing countries, then resort to care homes. Even the best care homes lack resources for the level of personal care needed. So sometimes residents are still restrained, and often they are heavily sedated.

When resources are available, it is obvious that the best choice involves plentiful social interaction. Our own home organises bingo and crafts and prayer and puzzles and many other distractions and brain stimulation, but this can only defer the day when one-on-one care becomes necessary.

Even giving that care is difficult. If I sit with a suffering resident for 30 minutes, it can seem like hours and severely test my ability to find distractions and conversation that achieves more good than harm. Here again good practice has evolved. Before, carers were told to be brutally honest. If a nonagenarian resident is looking urgently for her mum, we were supposed to point out that mum had been dead for fifty years. But good practice now is to minimise suffering. One professional quoted three golden rules: don’t ask questions that may cause distress; listen and only offer information that will make them feel better; do not contradict. I find these helpful, and wish that my volunteer training had included some specific advice for handling such situations. But I can promise you that, golden rules or not, it is not at all easy – and I can always go home when I have had all that I can take. It is a bit like sitting with a three-year-old with toothache or earache – hard work and often depressing.

Boseley also describes some modern concepts for community living for people with dementia, such as a village in the Netherlands that is part of regular society but with external walls that residents cannot get past. To me this sounds brilliant but not scalable: it involves a lot of capital and plenty of training too.

But somehow we will need solutions. More of us are living longer, dementia will only become more common, and we will need more homes with smarter designs. Perhaps better drugs can help – at the moment homes seem to use general sedatives like morphine that surely have side effects. Perhaps more people can join the army of carers: I love the idea of siting care homes with nurseries, and I read recently that in the Netherlands they are even experimenting with using paroled prisoners. I applaud Boseley for a very balanced and well-researched contribution to this urgent debate.

Now, where did I leave that soup?

Poverty in America

The Economist included one of its excellent special reports last week, this time on the subject of poverty in America – meaning the US. I found the report enlightening and thought provoking, but also perhaps with a few gaps.

My first takeaway from the report was just how many archetypes of poverty exist in the US. The report looked into former mining communities in Appalachia and black towns in the Deep South. It also highlighted smaller cities in the rust belt, such as Youngstown, which have lost their only significant employer and seen a drain of resources ever since. Then there is urban poverty, both in struggling cities such as Detroit and in generally thriving ones like New York. In the latter it is possible to get a job, but sometimes not one paying enough to escape a life of constant hustle and rent arrears, mainly due to the lack of affordable housing. Then there are Native American communities, hidden places of suffering out of the public view.

We can add a few more categories. There are many people with outwardly affluent lives but who are riddled with debt and with no feasible way out. Addicts, of opioids or alcohol or anything else, have a similar prognosis. Often, people from these latter categories are hidden in plain view.

While it is hard to get a full picture, I have managed to observe people from many of the categories. Last week I was in Europe, and they exist there too, but somehow I get the sense that the numbers are smaller and the plights usually less desperate.

Other reading tells a similar story. I am still haunted by the book “Evicted”, about the poverty trap in Milwaukee. I also read a long article last week about workers on a tipped minimum wage. While we all read about the regular minimum wage and cheer that it is finally shifting upwards in many cities, we are rarely reminded that workers designated as tipped staff do not qualify; indeed the federal tipped minimum wage has remained unchanged at just over $2 per hour for decades, and over the bridge in New Jersey it is just over $2.50. In a poor town, many folk on that wage will work at a  down-at-heel diner, where tips will hardly be abundant. 

My instinct is supported up by the second takeaway from the Economist report. Data confirms the US to be an outlier among rich nations. Despite the official definition for income poverty being much lower than elsewhere, the US has a higher proportion of poor people than its peers. To be classed as poor in the US, you have to be very poor indeed. By the definitions of poverty in most of Europe, over a third of US households would be classed as poor. That is one large contingent of households, of voters, of misery and of lost opportunity.

My next takeaway from the Economist report is that it seems that not enough people care about poverty in the US. Otherwise, why is it so large? Why is that I watch Democratic presidential debates, and there is little discussion of poverty? Instead there is an emphasis on particular programs, such as higher minimum wages, universal healthcare and eliminating student loans.

While all of these would reduce poverty, they are not well targeted. A high federal minimum wage would work in affluent cities, but be wrong in poorer places where the cost of living is lower – there it would probably reduce employment. Universal healthcare would be good, but the bigger issue with healthcare is its overall cost to the economy, due to monopolies and poor incentives. And student loans are irrelevant to most of the poor, and eliminating them would on balance subsidise richer people with better prospects.

Sadly, I reach the conclusion that reducing poverty would be great policy but is currently seen as bad politics. The reasons for this are depressing. The most prevalent is that Republicans have managed to sell the line that a lot of poverty is due to individual laziness or bad character. The Economist report demonstrates plainly that this is rubbish, but the notion makes it hard for Democrats to champion poverty reduction as a goal – they can be painted as promoting handouts for the undeserving.

Then there are other Democratic calculations going on. I suspect that the reason they don’t highlight the tipped minimum wage is that they rely on donations from businesses that exploit it and from the organisation representing the minority of tipped employees who do very well from tips. A more defensible possibility is that they realise that grand federal programs are not the best way to address poverty, yet grand federal programs are all the news media wants to hear about. Lastly, there is the calculation that poor people don’t usually vote.

Perhaps this is a major missed opportunity. The media like grand federal programs, but even more they like grand federal goals, and eliminating poverty would be a powerful one. It is the antithesis of everything the Trump administration stands for. It would lead to many practical policies. And it might enthuse voters. A good argument can be made that poverty drives outcomes that swing voters really do care about such as crime.

The Economist report argues that Lyndon Johnson won an election on precisely that messaging back in the 1960’s. It also shows the good and bad side of what happened next. Civil rights were improved, and programs of Medicare and Social Security lifted a lot of people out of poverty. These policies were good for their time, but they ended up helping older people on average, and the policies failed to evolve to meet other needs. The Economist makes a compelling argument that the primary focus of a new federal goal should be children. That would even help the political marketing, because not even Republicans argue that poor children are undeserving.

It appears that Elizabeth Warren has an almost unstoppable path to the Democratic nomination. She is a master of detail, with a catchphrase of “I have a plan for that”. The problems are that big goals can get drowned out by all the detail, and that many plans feel more like nasty retribution towards the wealthy than anything more worthy. An umbrella goal of eliminating poverty within a generation and child poverty within fifteen years could alleviate those problems. It is positive, exciting and completely differentiated from anything Trump has to say. The many existing plans can fit neatly under the umbrella, while the umbrella helps with prioritisation and also indicates suitable policies locally. Cities need reformed housing support and more housing supply; struggling smaller cities need regeneration plans; the Deep South needs quality education for all. As a result, her campaign can focus on meaningful policies in swing states and districts.

Trump may often seem to be imploding but his message is simple and his base seemingly robust to anything. Warren is a powerful candidate, but is vulnerable to appearing vindictive and geeky. The Economist report on US poverty might have revealed an opportunity to give her a better chance of winning, and then a better chance of implementing good policies. We can all pray for those outcomes. 

Income Envy

One of the judgments around retiring early nine years ago was about money. Did I have enough? I had been well paid, well overpaid really, for fourteen expatriate years, and had paid off all debt and then saved what seemed quite a lot. There was a severance package available, half of a house in England to cash in, and the prospect of starting my pension at 55 if need be. My daughter would soon be off the payroll.

I can’t recall the calculations I made. No doubt there was some fancy spreadsheet. But whatever it said, it was hopelessly wrong. I did not reckon on significant earnings after retirement. I did not think about the prospect of an inheritance from my mum. I didn’t consider income from investments. But most of all, I underestimated my expenses. Part of that was about separating, remarrying and taking on two new kids. A lot of it was about moving to an expensive city like New York. And some of it just did not account for inflation and societal changes.

Luckily, even if almost every line of the spreadsheet turned out very wrong, the bottom line has turned out to be close., at least so far. Once upon I time I saw a documentary where all these rich people were shown obsessed with money and concerned to make more and more. One guy near the end of the show was different and seemed to enjoy his life a lot more despite having only modest wealth. The narrator asked him how much he had, and he responded with a single word – enough.

For sure bad things can happen. The stock market is bound to collapse at some point. One of the kids might need help. One of us might lose our good health. But most of the time, when I think a bit about it, I think I am the guy in the documentary. I have enough, probably, and what a rare blessing that is.

Most of the time, that means I don’t have serious negative thoughts about money. But occasionally I do, indeed more often recently. So I wondered what might have caused that. My answer is not about spreadsheets, but about stories. I have become susceptible to income envy.

I remember when I clearly had the first such twinge. This one did not directly concern money, but ambition. Shell has a system called CEP, in which people are assigned a job level to indicate where their careers could reach, a ceiling if you like. It is a good system, though it has flaws, mainly in how it is executed. I remember the day I found out that someone who had previously been my direct report had been promoted to a level that was higher than my own CEP.

For some reason, this briefly made me envious. It was a sign of being terminally overtaken in some great race. The feeling was quickly usurped by ones of pride and pleasure, but it had been present and was uncomfortable.

Of course, that experience quickly became commonplace, as my career plateaued and those of the many talented people I had tried to coach blossomed. Since then, many of my former reports have risen to impressive levels, inside Shell and outside. Some have thrown me some generous crumbs, and many are still kind enough to remember the help I gave them. I am not envious, even when I observe lifestyles that I never enjoyed and certainly are way beyond me now.  Well, maybe just a tiny bit envious, in weak moments.

My lifestyle is on a steady glide path downwards, yet I choose to live in a city of extremes where others have openly opulent lifestyles and many are on a stratospheric path. There could be a four-box model here, with wealth or the past on one axis, and income or the future on the other. Each box has its own characteristics and its pitfalls. My own box, of high past and modest future, can be a relaxing place to be, but can open up spasms of envy, and also of making unfair judgments on those in other boxes.

A typical New York story occurred recently when I met a choir friend for coffee. She explained that she might have to miss a few rehearsals because her husband had just changed job, from one Wall street firm to another. I expressed the hope that at, even if the new job meant longer hours and more stress, there might at least be the consolation of more money. Oh no, she said, he took a pay cut of $200,000 per annum, to move to a better environment. My jaw dropped. The passing twinge of income envy followed soon afterwards.

We have a good friend who is a Chinese lady in her late twenties. Other friends of ours had played an informal foster-parent role for her when she had lived in England, and we were delighted to inherit that responsibility when she moved to New York. We still give plenty of personal help and companionship to her, and we are delighted to serve and get a lot back in return from her. But within two years she has rocketed from the low past/ unrealized future box to the affluent present / spectacular future box in my model. Two years ago we were stocking her fridge and always paying for dinner. Now she spends more in a month than we do in a year. It is lovely to see it, and she remains the same unaffected young lady she always was, but I have to confess to just the occasional pang of income envy.

The stories with people I know well are always the most poignant, but in New York there are opportunities for income envy of strangers every day. My recent experience of buying a car had few positives, but one big negative was fighting off the envy of recognizing that others were shopping in an altogether more glamorous market than I was.

Occasionally I get some evidence that makes me rethink assumptions. My dentist is a lovely lady who works hard and deserves her success and high income. But, one day while with my mouth wide open in her chair, I started advocating against income inequality, and was quickly reminded that she was still paying off six figures of student debt, in her late forties with two kids in college. Both axes in the model can weigh heavily, and can challenge easy assumptions.

I once had a good friend who was in the same box as me, but in a more extreme place within the box. We called him the poorest rich guy we had ever met. He owned a huge estate, but it offered him no income at all and he lived as modestly as anyone I have ever known. Then we have all encountered the converse, someone addicted to luxury but mired in debt. Appearances can deceive, and models can be complicated.

Like all failings, the first step is to acknowledge it, and nowadays I have learned to recognise the income envy feeling and have found ways to move past it. It can help to cast my eye just a little wider and to observe the many people who are worse off than I am. But for this particular negative feeling, I can do that and then consider a more structural fix.

The fix goes back to that documentary and the magic word “enough”. The envy feeling always starts with a mental reference to a race, and the sense of being overtaken and having no way to overtake back. But if think a bit harder we can realise that there is no such race against others, just our own journey meandering through life. If we can convince ourselves that we have enough, then that journey can be peaceful even if we are overtaken, by one close friend or by a million New Yorkers. They are welcome to their own race; indeed I can wish them all the best and cheer them on from my seemingly diminished vantage point.

For me, that realisation helps every time the income envy twinge comes around, and helps me to find peace. For others, that same realisation could be even more powerful, if it stops the urge to stretch to buy something they can’t afford, just to impress the neighbours, wife, parent or ego. Positions in four-box models are subject to change, after all.