Tag Archives: elderhood

Co-Housing

Not to be confused with co-working, co-ops, or condos, co-housing is its own cultural phenomenon.

This is a major article in the NYT describing a decades-old phenomenon of co-housing, and updating the phenomenon with present day facts:

Co-housing

20211024

CREDIT: 

The most recent manifestation of the communalist impulse is the postvaccine nostalgia for the pandemic pod. People are now telling reporters that they miss the camaraderie of those pared-down social networks, as well as the frequent physical company of the same group of friends, the “transformative power of proximity,” as the psychologist Susan Pinker calls it.

I was late to find out about co-housing, a species of intentional community that dates back 30 years, in the United States, anyway. (It emerged in Denmark in the 1970s.) Forced to characterize co-housing in a phrase, you might say “living together, separately.” Those living together have built a community based on, well, belief in community. But they live separately, in that they own their homes, condo-style.

Co-housing sounds confusingly similar to co-living but has a whole different vibe. Co-housers aren’t transient. They have a much stickier idea of social affiliation, and they’re not about to rent a bedroom in some random complex. To draw even finer distinctions: Co-housing communities are not communes. Residents do not give up financial privacy any more than they give up domestic privacy. They have their own bank accounts and commute to ordinary jobs. If you were lucky enough to grow up on a friendly cul-de-sac, you’re in range of the idea, except that you don’t have to worry about your child being hit by a car as she plays in the street. A core principle of co-housing is that cars should be parked on a community’s periphery.

This, I thought, was an idea with promise. Co-living accommodates precarity; co-housing seeks stability. Podding is a byproduct of the collapse of society; co-housing builds society.

The most recent manifestation of the communalist impulse is the postvaccine nostalgia for the pandemic pod. People are now telling reporters that they miss the camaraderie of those pared-down social networks, as well as the frequent physical company of the same group of friends, the “transformative power of proximity,” as the psychologist Susan Pinker calls it.

I was late to find out about co-housing, a species of intentional community that dates back 30 years, in the United States, anyway. (It emerged in Denmark in the 1970s.) Forced to characterize co-housing in a phrase, you might say “living together, separately.” Those living together have built a community based on, well, belief in community. But they live separately, in that they own their homes, condo-style.

Co-housing sounds confusingly similar to co-living but has a whole different vibe. Co-housers aren’t transient. They have a much stickier idea of social affiliation, and they’re not about to rent a bedroom in some random complex. To draw even finer distinctions: Co-housing communities are not communes. Residents do not give up financial privacy any more than they give up domestic privacy. They have their own bank accounts and commute to ordinary jobs. If you were lucky enough to grow up on a friendly cul-de-sac, you’re in range of the idea, except that you don’t have to worry about your child being hit by a car as she plays in the street. A core principle of co-housing is that cars should be parked on a community’s periphery.

This, I thought, was an idea with promise. Co-living accommodates precarity; co-housing seeks stability. Podding is a byproduct of the collapse of society; co-housing builds society

Out of the 165 co-housing communities around the country, Eastern Village interested me because it’s urban and vertical, while the majority are suburban or at least suburbanish. I wondered whether co-housing could survive the claustrophobia of city living and the resulting need for personal space. My cheeks still get hot with embarrassment when I remember a remark in an elevator: It was a few years after my son was born, and I’d moved back to Manhattan, hoping to find the something I missed in the suburbs. “You’re not from around here, are you?” a man said, after I tried to start a conversation. Oh, right, I thought. People crammed into a box don’t want to talk to a chirpy lady they might have to edge away from. I never did get to know the other families in the building.

There are other, better-known urban co-housing communities around the country, but Eastern Village has the virtue of not being exemplary. For one thing, it was built from the top down rather than the bottom up. Model co-housing tends to be grass-roots: First the group meets to explore its wants and needs, then it finds an architect who designs a community just right for them, and finally it builds. From the time a group of would-be co-housers forms to the time it moves in, two to five years can pass. The idea for Eastern Village, on the other hand, came from a developer. He undertook the daunting task of retrofitting the building, then asked someone better versed in co-housing to go out, put together a group and teach participants how to live together.

The process still took two and a half years, but it struck me as a more replicable model. If co-housing didn’t have to be handcrafted, I thought, maybe it could be scaled up. And this seems the moment to think about how.

Americans may be about to experience three once-in-a-lifetime opportunities to reconsider how they house themselves. The first is the two big spending bills working their way through Congress. If they pass, they could provide billions of dollars to alleviate homelessness and increase affordable housing. The second opportunity proceeds from the shift to working from home: Record numbers of office buildings stand empty and ready for the refurbishing, and they won’t all be refilled

The third force that could push us to change our way of life is a heightened awareness of isolation. In a 2020 survey by the Harvard Graduate School of Education, one-third of Americans described themselves as seriously lonely — up from one-fifth before the Covid pandemic. Loneliness is now understood as a public health crisis, ranking as high among risk factors for mortality as heavy smoking, drinking and obesity.

Contrary to what one might think, the loneliest people in America aren’t the elderly. They’re young adults (close to two-thirds of them, according to the Harvard survey) and mothers of small children (about half). This makes sense: Young people tend to lead migratory lives, leading to weak social ties. Mothers have their children, although almost a quarter of them are raising those children without a partner; the United States has the highest rate in the world of children living with only one parent. With or without a partner, a mother may still have a hard time finding a fulfilling social life, since paid work and unpaid maternal labor take up so much of her time.

The pandemic lockdown exposed women’s solitude, in particular, as a function not just of time but also of space. Afraid to go out into the public domain, all caregivers — the newly full-time ones as well as those who had already put care at the center of their lives — became painfully aware that the private domain can be a very lonely and demanding place.

Under the circumstances, co-housing has the potential, if nothing else, to furnish ideas of how to build for community. After all, you’d never get away with snubbing people in the elevator at Eastern Village

If there is an adage that informs life in co-housing, it’s treat thy neighbor as thy family. Thy extended family, that is, assuming it’s a happy one. And what do happy families do? For one thing, they share stuff. As Rabbi Kimelman-Block led me through what felt like a labyrinth, he opened several overstuffed “sharing closets.” One was full of expensive, space-hogging items like travel cribs and skis. Another was for things being given away.

What else do families do? Well, chores, preferably cheerfully and collaboratively. And indeed, co-housers are expected to sign up for maintenance and cleanup days. Families also look out for one another. In co-housing that means, among other things, helping keep an eye on all the children. Many communities pay for formal day care. Most important, co-housers eat together. Breaking bread is probably the most effective bonding ritual society has ever come up with, and co-housers take turns cooking for and serving meals to other members. Some communities offer meals as often as six times a week. (Attendance is never mandatory.)

Most co-housing communities are anchored by a large, shared kitchen. It forms the heart of the common house, which may also offer pools, carpentry workshops, dance studios or meeting rooms — you name it, some community has it. In Eastern Village, common spaces have been cleverly tucked around the complex. Wending our way from basement to roof, Rabbi Kimelman-Block and I went through a dining room, a room for table tennis and foosball, a living room with a fireplace and fat leather chairs, a children’s playroom, a lamp-lit quiet room, a game room, a laundry room, an exercise room, a small lending library. The kitchen, though, is a problem. It’s not set up to cook communitywide dinners, in part because the fire marshal insisted that it install a crushingly expensive commercial range, and it went instead with a “warm-up kitchen,” as architect and developer Don Tucker calls it. So Eastern Village is more or less stuck with potluck.

But then again, as my mother liked to say, the perfect is the enemy of the good. We have to make do if we want to make change.

Today, the detached single-family house — the lonesome cowboy model of domestic architecture — dominates the American landscape so thoroughly that it feels as if it were inevitable. As of 2019, there were about 100 million single-family homes in the United States (including mobile and prefab homes), compared to about 40 million multifamily ones. But it didn’t have to turn out this way. Although the home on the farm had been the American ideal since Thomas Jefferson popularized pastoralism, as the country urbanized after the Civil War, many visionaries saw opportunities for a less atomized, more female-friendly lifestyle.

The landscape designer Frederick Law Olmsted, for one, imagined Emerald City-like metropolises with public laundries, bakeries and kitchens, taking some of the burden off housewives. Amenities like sewers, gutters and sidewalks would make streets more appealing for women. Women’s rights activists such as Charlotte Perkins Gilmanand a now-forgotten feminist named Melusina Fay Peirce envisioned Eastern Village-like cooperatives in apartment complexes, complete with communal laundries, sewing rooms, kitchens and dining rooms. Peirce called it “cooperative housekeeping” and thought women should make money at it.

During the early part of the 20th century, however, those reveries retreated into science fiction novels. Many forces converged to rob them of reality, not least the Red Scare, when politicians developed an allergy to anything that seemed to have a flavor of socialism or feminism. Along with builders, they began to promote the single-family dream house, with its Harry Homeowner and his happy housewife.

Today, roughly three-quarters of the residential land in metro areas is set aside for such houses and yards. Hub-and-spoke roads and commuter railways have grown up around them. Elaborate exclusionary zoning codes were written to protect them from the taint of commerce and industry — as well as to keep white, wealthy neighborhoods away from Black and poorer ones. The distance between home and everything else imposed by these laws is the reason most Americans need to drive to shop or work.

Back when the majority of breadwinners were male and made the journey downtown unburdened by domestic concerns, a long commute wasn’t a big logistical challenge. Today, mothers are also making those commutes, but they still have domestic burdens. Working from home improves the situation only if child care is available.

Co-housing arose, in part, as a solution to the work-life problem. In 1969, Hildur Jackson — just one among many co-housing pioneers, but an eloquent one — was living in a house in Copenhagen, a law school graduate unsure whether she should stay home with her two little boys or embark on a law career. “There was no apparent third option,” she wrote in a remembrance. Then she read an article titled “Children Need 100 Parents.”

Ms. Jackson decided to start a six-family community on an old farm in a Copenhagen suburb. The families built homes around two giant lawns, which were used largely for games, particularly soccer. The barn was turned into a common house, and three Icelandic horses were bought for the stables. “We chose to have no borders between our gardens,” she wrote. “We raised chickens, tended a large common vegetable garden and had fruit trees and berry bushes.” Days were set aside for community maintenance. When her husband traveled on business, which he did often, “I never felt isolated,” she wrote. When she had her third child, she had 11 other parents to help.

Co-housing (called “living communities” in Denmark) soon spread throughout Scandinavia and to the Netherlands and Germany; communities are now found all over Europe, as well as in Canada, Australia and New Zealand. In the 1980s, the architects Charles Durrett and Kathryn McCamant, who were married and business partners at the time, began importing co-housing to the United States. (Between the two of them, they have built or been consultants on many of the co-housing communities in the country.) The two got involved in the movement because they wanted children but their lives seemed too hectic: “We would come home from work exhausted and hungry, only to find the refrigerator empty,” Mr. Durrett has written. So they went to Denmark to study another way to build for parenting.

Co-housing is the nonthreatening heir of America’s far more radical communitarian past. And during my many years of self-education, I discovered that communitarianism has often had a feminist face.

Early socialists avowed an egalitarianism so radical that it included housewives. Nineteenth-century progressives, male as well as female, understood wives’ solitary and unremunerated duties as central to their oppression. Socialists set up model villages and touted them as a way to inspire workers to abandon cities, factories and industrial bosses. But they also promised to enfranchise women and free them from the shackles of domestic drudgery.

Robert Owen, the most famous British socialist of his day, and his French counterpart, Charles Fourier, envisioned the collectivization of women’s work in communal kitchens, dining rooms and nurseries, although they seemed to think this would require the construction of vast, ornate (and unrealistic) palaces. Owen’s and Fourier’s followers, known as Cooperators, established close to 50 socialist communities in rural areas in the Northeastern and Midwestern United States in the 1820s to 1840s. The leaders, who were almost always men, rarely put theory into practice when it came to women. As Carol A. Kolmerten, a historian and the author of “Women in Utopia,” a study of American Owenite communities, wrote, it fell to female Cooperators to prepare the food, wash the clothes and teach the little ones. Or, if the women toiled in fields and workshops, they would still cook and clean in the evenings. Wives who had arrived full of hope left, taking their husbands with them.

Male obtuseness was not the main reason these settlements failed. Other realities proved more damaging. Some settlements couldn’t generate enough cash to pay off the loans that paid for the land. Life in the wilderness wasn’t palatial; it involved log cabins and mosquitoes. Refugees from cities didn’t know how to farm. Class differences among members reasserted themselves, leading to factionalism. But the alienation of one-half of the population (the “woman problem,” Owen came to call it) didn’t help.

On the other hand, secular socialists accounted for only a small fraction of America’s intentional communities. Millenarian Christians — Shakers, Mormons, the Oneida Community and Anabaptist offshoots like the Amish and the Hutterites — built many more, and theirs tended to last longer, as Lawrence Foster writes in “Women, Family and Utopia.” Perhaps that’s because when their leaders broke down the walls of nuclear families to create communal ones, they did so to strengthen their members’ attachment to God and commitment to building his kingdom on earth.

What is remarkable about some of these religious communes is the degree to which they defied the gender norms of their day, in some cases going further than the socialists. The Shakers weren’t feminist in a way contemporary Americans would recognize. They didn’t question the gendered division of labor: Women worked in the kitchens and did the weaving, while men did the farm labor. But women’s work wasn’t seen as inferior to men’s. Both helped sustain the community; therefore both were equal in God’s eyes. More important, Shaker leaders were as likely to be female as male.

In the Oneida Community, a sect that eschewed what its leader called the gloominess of “the little man-and-wife circle” and replaced it with nonmonogamy, women were able to participate without restriction in every aspect of life — religious, economic and social.

Collectivizing domestic labor gave groups incentives to come up with labor-saving household devices. The Shakers patented a water-powered washing machine that cleaned clothes by churning them, an improvement on previous devices. Oneidans may or may not have invented the lazy susan (the point is debated); in any case, they used it to reduce the labor required to serve food in a communal dining hall. With the same goal in mind, they came up with, among other things, an industrial potato peeler and a mop wringer.

These old-time religious communes hold lessons for us moderns. “From a feminist viewpoint the major achievement of most communitarian experiments was ending the isolation of the housewife,” wrote Dolores Hayden in her classic study of feminist communalism, “The Grand Domestic Revolution.” “A second achievement was the division and specialization of household labor.”

A

fter the tour, Rabbi Kimelman-Block roped in whoever was around to talk to me. We gathered on Eastern Village’s xeriscaped roof, its communal green space. Most people brought drinks. I ate Ethiopian takeout. Professions ranged from Realtor to social-justice activist. Eastern Village has 110 residents, 30 of them college age or younger. The ones I met were mostly middle-aged, though one couple bought in when they were in their 70s.

Parenting was the leading answer to my question about why they’d chosen co-housing: Kids aren’t stuck in their apartments; they can run downstairs. Neighbors’ kids or older members were almost always around to babysit, and for a while, there was a somewhat more formal day care arrangement. Adults benefit from the ad hoc interaction, too. Instead of planning dinner or drinks weeks in advance, on any Wednesday or Saturday, a sociable soul can find a neighbor to share a snack or a beer with.

One unexpected comment came from Adrienne Torrey, a curly-haired middle-aged woman with a relaxed manner. “Co-housing attracts a lot of introverts,” she said. That hadn’t occurred to me, but inclined to introversion myself, I immediately saw the logic. Who needs a community more than those who have a hard time spontaneously cobbling one together? Or — my next thought — than new parents stranded by their change of circumstance? By contrast, as soon as you show up in co-housing, you are swept into a round robin of meals and festivities and cleanup days.

The most controversial topic that evening was meetings. Almost all co-housing communities make big decisions by consensus. One member complained that arriving at unanimity is cumbersome and unnecessary. The rest disagreed. However long consensus takes, everyone feels heard and learns the art of compromise. That, I’m told, may be the most important key to successful group living.

I

f co-housing offers solutions for so many of the problems from which America’s mothers suffer, if we are now uniquely positioned to put at least some of its lessons into effect — thanks to the pandemic’s unintentional consciousness-raising and the possibility that Congress will pass the Biden administration’s plans to rebuild the economy — what’s stopping us?

During one of my several conversations with Charles Durrett, I asked what he would identify as the biggest obstacle to building co-housing in the United States. “Our culture,” he said promptly. “We tend to think of ourselves as independent pioneers. We’re not a cooperative kind of culture.” But he grew up in a tight-knit neighborhood, he said, and his neighbors “played a huge role in my well-being.”

But planning departments, regional as well as municipal, don’t help. Typical American zoning laws frown on multifamily complexes unless they’ve been exiled to poorer parts of town. Even accessory dwelling units, such as mother-in-law apartments, are unpopular, lest they be rented to “undesirables.” Those are the most notorious restrictions; they’re not the only ones Mr. Durrett has had to fight as he tried to build co-housing.

City planning laws simply don’t envision communities focused on residents’ helping one other and keeping children safe. One city demanded two-car driveways for each unit, a waste of space and money in a community that keeps cars far from houses. When a town insisted that to accommodate the number of people in a proposed community, it would have to pay for a $1 million fire truck, Mr. Durrett asked the officials what the fire department’s most common call was. “Pick up and put back,” they told him, meaning putting seniors who have fallen out of their beds back into them. “We can do that for ourselves,” he said. Finding people who can put other people back in bed is precisely what co-housing is good at.

The other challenge, of course, is that not all people want to share their lives. People have to be willing to sacrifice time (all those meetings, the grounds maintenance) and the luxury of self-absorption (the small talk expected from those on their way to the mailroom). Co-housing may consume emotional energy that would otherwise go to keeping other social circles — work colleagues, college buddies, fellow parents at our children’s schools — spinning in the air. “Living in co-housing is not easy,” said Ann Zabaldo, the person hired by Eastern Village’s developer to recruit and educate its future occupants about the art of co-housing. But, she added, “it is so much richer, like drinking deeply from the well.”

Communal living by itself will never solve any one major social problem, be it loneliness or sexism or anything else. Although much more communal architecture can (and should) be built, you can’t mass-produce community. People have to be able to see the benefits before they’ll make the necessary commitments.

But life is changing in ways that may make collaborative coexistence more attractive. Rents are on the rise. People are getting used to the sharing economy. And then there’s that bottom-line truth exposed by the pandemic: Take away child care, and women stop working for pay and don’t start again, like the nearly two million of them who have dropped out of the labor force since February 2020. Something must be done.

In the past few years, states and cities around the country have started reconsidering single-family zoning or dared to vote to put an end to it. Last month, Gov. Gavin Newsom of California signed into lawbills to limit single-family zoning and permit construction of buildings with up to 10 units near public transit.

A wholesale revision of zoning codes could lead to a new built environment, one that would nudge us toward a new mind-set. We should build co-housing on a large scale. But even if we don’t, we could start reshaping the contours of our hyperindividualist and antimaternalist landscapes so as to encourage solidarity and fellow feeling rather than aloofness: Co-housing communities are centered on their greenswards; we need more parks. Co-housing puts people before cars; towns and cities should do the same. Co-housers live together, meaning they are around in case of need; the least inspiration we can take from that is to make our housing stock more varied, less focused on the nuclear family, so that members of extended families and groups of friends can be there for one another, too.

If this sounds not unlike the best-designed urban neighborhoods in America, well, maybe it’s not. But the pandemic has sparked a flight from cities and a demand for more suburban housing, and the boom in the market right now is in exurbia — low-density, lower-cost suburbs on the outer edges of metropolitan areas. As these neighborhoods are built, in all likelihood old design habits will prevail. But there’s no harm in imagining, and fighting for, a land-use philosophy focused on making life more pleasant for parents and children — and for the introvert in all of us.

I

n the 19 years since I had my first child, I have spent a lot of time thinking about how my life might have been different if I’d known about Hildur Jackson’s “third option.” What if there had been tens of thousands of co-housing communities in America instead of a couple hundred? Maybe I would have moved into one rather than back to unfriendly Manhattan.

If I had to single out one feature of cooperative living I find particularly attractive, it would be regular, spontaneous contact with people of all ages. I had my children later in life, and my parents weren’t healthy enough to spend as much time with their grandchildren as all of us wanted, and then, as happens, they died. I’m nostalgic for an intergenerational experience I never had.

A few weeks ago, I watched my teenage daughter spend an entire meal talking conspiratorially to two of my best friends. How often do American teenagers open up to their parents’ friends? What would it have been like for her to be able to do that throughout her childhood with surrogate aunts and uncles and grandparents? The three of them sat just out of earshot, making it hard for me to eavesdrop, which I’m sure was the point. But the sight of them gossiping made me think that maybe, despite the blank suburban streets and the chilly city elevators and my never quite figuring out where we should live, I’d done something right.

Judith Shulevitz (@JudithShulevitz) is a cultural critic and the author of “The Sabbath World: Glimpses of a Different Order of Time.” She still lives in New York City.

The Dying Algorithm

CREDIT: NYT Article on the Dying Algorithm

This Cat Sensed Death. What if Computers Could, Too
By Siddhartha Mukherjee
Jan. 3, 2018

Of the many small humiliations heaped on a young oncologist in his final year of fellowship, perhaps this one carried the oddest bite: A 2-year-old black-and-white cat named Oscar was apparently better than most doctors at predicting when a terminally ill patient was about to die. The story appeared, astonishingly, in The New England Journal of Medicine in the summer of 2007. Adopted as a kitten by the medical staff, Oscar reigned over one floor of the Steere House nursing home in Rhode Island. When the cat would sniff the air, crane his neck and curl up next to a man or woman, it was a sure sign of impending demise. The doctors would call the families to come in for their last visit. Over the course of several years, the cat had curled up next to 50 patients. Every one of them died shortly thereafter.
No one knows how the cat acquired his formidable death-sniffing skills. Perhaps Oscar’s nose learned to detect some unique whiff of death — chemicals released by dying cells, say. Perhaps there were other inscrutable signs. I didn’t quite believe it at first, but Oscar’s acumen was corroborated by other physicians who witnessed the prophetic cat in action. As the author of the article wrote: “No one dies on the third floor unless Oscar pays a visit and stays awhile.”
The story carried a particular resonance for me that summer, for I had been treating S., a 32-year-old plumber with esophageal cancer. He had responded well to chemotherapy and radiation, and we had surgically resected his esophagus, leaving no detectable trace of malignancy in his body. One afternoon, a few weeks after his treatment had been completed, I cautiously broached the topic of end-of-life care. We were going for a cure, of course, I told S., but there was always the small possibility of a relapse. He had a young wife and two children, and a mother who had brought him weekly to the chemo suite. Perhaps, I suggested, he might have a frank conversation with his family about his goals?

But S. demurred. He was regaining strength week by week. The conversation was bound to be “a bummah,” as he put it in his distinct Boston accent. His spirits were up. The cancer was out. Why rain on his celebration? I agreed reluctantly; it was unlikely that the cancer would return.

When the relapse appeared, it was a full-on deluge. Two months after he left the hospital, S. returned to see me with sprays of metastasis in his liver, his lungs and, unusually, in his bones. The pain from these lesions was so terrifying that only the highest doses of painkilling drugs would treat it, and S. spent the last weeks of his life in a state bordering on coma, unable to register the presence of his family around his bed. His mother pleaded with me at first to give him more chemo, then accused me of misleading the family about S.’s prognosis. I held my tongue in shame: Doctors, I knew, have an abysmal track record of predicting which of our patients are going to die. Death is our ultimate black box.

In a survey led by researchers at University College London of over 12,000 prognoses of the life span of terminally ill patients, the hits and misses were wide-ranging. Some doctors predicted deaths accurately. Others underestimated death by nearly three months; yet others overestimated it by an equal magnitude. Even within oncology, there were subcultures of the worst offenders: In one story, likely apocryphal, a leukemia doctor was found instilling chemotherapy into the veins of a man whose I.C.U. monitor said that his heart had long since stopped.

But what if an algorithm could predict death? In late 2016 a graduate student named Anand Avati at Stanford’s computer-science department, along with a small team from the medical school, tried to “teach” an algorithm to identify patients who were very likely to die within a defined time window. “The palliative-care team at the hospital had a challenge,” Avati told me. “How could we find patients who are within three to 12 months of dying?” This window was “the sweet spot of palliative care.” A lead time longer than 12 months can strain limited resources unnecessarily, providing too much, too soon; in contrast, if death came less than three months after the prediction, there would be no real preparatory time for dying — too little, too late. Identifying patients in the narrow, optimal time period, Avati knew, would allow doctors to use medical interventions more appropriately and more humanely. And if the algorithm worked, palliative-care teams would be relieved from having to manually scour charts, hunting for those most likely to benefit.

Avati and his team identified about 200,000 patients who could be studied. The patients had all sorts of illnesses — cancer, neurological diseases, heart and kidney failure. The team’s key insight was to use the hospital’s medical records as a proxy time machine. Say a man died in January 2017. What if you scrolled time back to the “sweet spot of palliative care” — the window between January and October 2016 when care would have been most effective? But to find that spot for a given patient, Avati knew, you’d presumably need to collect and analyze medical information before that window. Could you gather information about this man during this prewindow period that would enable a doctor to predict a demise in that three-to-12-month section of time? And what kinds of inputs might teach such an algorithm to make predictions?
Avati drew on medical information that had already been coded by doctors in the hospital: a patient’s diagnosis, the number of scans ordered, the number of days spent in the hospital, the kinds of procedures done, the medical prescriptions written. The information was admittedly limited — no questionnaires, no conversations, no sniffing of chemicals — but it was objective, and standardized across patients.

These inputs were fed into a so-called deep neural network — a kind of software architecture thus named because it’s thought to loosely mimic the way the brain’s neurons are organized. The task of the algorithm was to adjust the weights and strengths of each piece of information in order to generate a probability score that a given patient would die within three to 12 months.

The “dying algorithm,” as we might call it, digested and absorbed information from nearly 160,000 patients to train itself. Once it had ingested all the data, Avati’s team tested it on the remaining 40,000 patients. The algorithm performed surprisingly well. The false-alarm rate was low: Nine out of 10 patients predicted to die within three to 12 months did die within that window. And 95 percent of patients assigned low probabilities by the program survived longer than 12 months. (The data used by this algorithm can be vastly refined in the future. Lab values, scan results, a doctor’s note or a patient’s own assessment can be added to the mix, enhancing the predictive power.)

So what, exactly, did the algorithm “learn” about the process of dying? And what, in turn, can it teach oncologists? Here is the strange rub of such a deep learning system: It learns, but it cannot tell us why it has learned; it assigns probabilities, but it cannot easily express the reasoning behind the assignment. Like a child who learns to ride a bicycle by trial and error and, asked to articulate the rules that enable bicycle riding, simply shrugs her shoulders and sails away, the algorithm looks vacantly at us when we ask, “Why?” It is, like death, another black box.

Still, when you pry the box open to look at individual cases, you see expected and unexpected patterns. One man assigned a score of 0.946 died within a few months, as predicted. He had had bladder and prostate cancer, had undergone 21 scans, had been hospitalized for 60 days — all of which had been picked up by the algorithm as signs of impending death. But a surprising amount of weight was seemingly put on the fact that scans were made of his spine and that a catheter had been used in his spinal cord — features that I and my colleagues might not have recognized as predictors of dying (an M.R.I. of the spinal cord, I later realized, was most likely signaling cancer in the nervous system — a deadly site for metastasis).
It’s hard for me to read about the “dying algorithm” without thinking about my patient S. If a more sophisticated version of such an algorithm had been available, would I have used it in his case? Absolutely. Might that have enabled the end-of-life conversation S. never had with his family? Yes. But I cannot shake some inherent discomfort with the thought that an algorithm might understand patterns of mortality better than most humans. And why, I kept asking myself, would such a program seem so much more acceptable if it had come wrapped in a black-and-white fur box that, rather than emitting probabilistic outputs, curled up next to us with retracted claws?

Siddhartha Mukherjee is the author of “The Emperor of All Maladies: A Biography of Cancer” and, more recently, “The Gene: An Intimate History.”

Senior concierge services

“Elder concierge”, or senior concierge services, are blossoming as baby boomers age:

CREDIT: New York Times Article on Senior Concierge Services

https://www.forbes.com/sites/robertpearl/2017/06/22/concierge-medicine/amp/

The concierges help their customers complete the relatively mundane activities of everyday life, a way for the semi- and fully retired to continue to work.

Facts of note:
“Around 10,000 people turn 65 every day in the United States, and by 2030, there will be 72 million people over 65 nationwide.
Some 43 million people already provide care to family members — either their own parents or children — according to AARP, and half of them are “sandwich generation” women, ages 40 to 60. All told, they contribute an estimated $470 billion a year in unpaid assistance.”
“elder concierges charge by the hour, anywhere from $30 to $70, or in blocks of time, according to Katharine Giovanni, the director of the International Concierge & Lifestyle Management Network”

Organizations of note:

“One start-up, AgeWell, employs able-bodied older people to assist less able people of the same age, figuring the two will find a social connection that benefits overall health.
The company was founded by Mitch Besser, a doctor whose previous work involved putting H.I.V.-positive women together in mentoring relationships. AgeWell employees come from the same communities as their clients, some of whom are out of reach of medical professionals
until an emergency.”

The National Aging in Place Council, a trade group, is developing a social worker training program with Stony Brook University. It wants to have a dedicated set of social workers at the council, funded by donations, who are able to field calls from seniors and their caretakers, and make referrals to local service providers.
The council already works with volunteers and small businesses in 25 cities to make referrals for things like home repair and remodeling, daily money management and legal issues.”

Village to Village Network, has small businesses and volunteers working on a similar idea: providing older residents and their family or caretakers with referrals to vetted local services.
In the Village to Village Network model, residents pay an annual fee, from about $400 to $700 for individuals and more for households. The organization so far has 25,000 members in 190 member-run communities across the United States, and is forming similar groups overseas as well.”

=========== ARTICLE IS BELOW ============

Baby Boomers Look to Senior Concierge Services to Raise Income
Retiring
By LIZ MOYER MAY 19, 2017

In her 40 years as a photographer in the Denver area, Jill Kaplan did not think she would need her social work degree.
But when it became harder to make a living as a professional photographer, she joined a growing army of part-time workers across the country who help older people living independently, completing household tasks and providing companionship.
Elder concierge, as the industry is known, is a way for the semi- and fully retired to continue to work, and, from a business standpoint, the opportunities look as if they will keep growing. Around 10,000 people turn 65 every day in the United States, and by 2030, there will be 72 million people over 65 nationwide.
Some 43 million people already provide care to family members — either their own parents or children — according to AARP, and half of them are “sandwich generation” women, ages 40 to 60. All told, they contribute an estimated $470 billion a year in unpaid assistance.

Seven years ago, Ms. Kaplan, 63, made the leap, signing up with Denver-based Elder Concierge Services. She makes $25 to $40 an hour for a few days a week of work. She could be driving older clients to doctor’s appointments, playing cards or just acting as an extra set of eyes and ears for family members who aren’t able to be around but worry about their older relatives being isolated and alone. Many baby boomers themselves are attracted to the work because they feel an affinity for the client base.
“It’s very satisfying,” she said of the work, which supplements her photography income. Like others in search of additional money, she could have become an Uber driver but said this offered her a chance to do something “more meaningful.”
“We see a lot of women,” Ms. Kaplan said, “who had raised their families and cared for their parents out there looking for a purpose.”

Concierges are not necessarily social workers by background, and there isn’t a formal licensing program. They carry out tasks or help their customers complete the relatively mundane activities of everyday life, and just need to be able to handle the sometimes physical aspects of the job, like pushing a wheelchair.
Medical care is left to medical professionals. Instead, concierges help out around the house, get their client to appointments, join them for recreation, and run small errands.
While precise statistics are not available for the elder concierge industry, other on-demand industries have flourished, and baby boomers are a fast-growing worker population.
Nancy LeaMond, the AARP’s executive vice president and chief advocacy officer, said: “Everyone assumed the on-demand economy was a millennial thing. But it is really a boomer thing.”
Ms. LeaMond noted that while people like the extra cash, they also appreciate the “extra engagement.”
A variety of companies has sprung up, each fulfilling a different niche in the elder concierge economy.
In some areas, elder concierges charge by the hour, anywhere from $30 to $70, or in blocks of time, according to Katharine Giovanni, the director of the International Concierge & Lifestyle Management Network. Those considering going into the business should have liability insurance, Ms. Giovanni said.

One start-up, AgeWell, employs able-bodied older people to assist less able people of the same age, figuring the two will find a social connection that benefits overall health.
The company was founded by Mitch Besser, a doctor whose previous work involved putting H.I.V.-positive women together in mentoring relationships. AgeWell employees come from the same communities as their clients, some of whom are out of reach of medical professionals until an emergency.
The goal is to provide consistent monitoring to reduce or eliminate full-blown crises. AgeWell began in South Africa but recently got a grant to start a peer-to-peer companionship and wellness program in New York.
Elsewhere, in San Francisco, Justin Lin operates Envoy, a network of stay-at-home parents and part-time workers who accept jobs like grocery delivery, light housework and other tasks that don’t require medical training. Each Envoy employee is matched to a customer, who pays $18 to $20 an hour for the service, on top of a $19 monthly fee.
The inspiration for the company came from Mr. Lin’s work on a start-up called Mamapedia, an online parental wisdom-sharing forum, where he noticed a lot of people talking about the need for family care workers. He decided to start Envoy two years ago, after his own mother died of cancer, leaving him and his father to care for a disabled brother.
The typical Envoy employee works a few hours a week, so it won’t replace the earnings from a full-time job. But it nevertheless involves more interpersonal contact than simply standing behind a store counter.
“It’s not going to pay the rent,” Mr. Lin said. “They want to be flexible but also make a difference.”

Katleen Bouchard, 69, signed up with Envoy three years ago, after retiring from an advertising career. She gets $20 an hour working a handful of hours a week with older clients in her rural community in Sonoma County, Calif. She sees it as a chance to be civic-minded. “It’s very easy to help and be of service,” Ms. Bouchard said.
Companies like AgeWell and Envoy are part of the growing on-demand economy, where flexibility and entrepreneurship have combined to create a new class of workers, said Mary Furlong, a Silicon Valley consultant who specializes in the job market for baby boomers. At the same time, many retirees — as well as those on the cusp of retirement — worry that market volatility may hit their savings.
The extra income from the job, Ms. Furlong said, could help cover unexpected expenses. “You don’t know what the shocks are going to be that interrupt your plan,” she added.
Other organizations are looking to help direct older residents to vetted local service providers.
The National Aging in Place Council, a trade group, is developing a social worker training program with Stony Brook University. It wants to have a dedicated set of social workers at the council, funded by donations, who are able to field calls from seniors and their caretakers, and make referrals to local service providers.
The council already works with volunteers and small businesses in 25 cities to make referrals for things like home repair and remodeling, daily money management and legal issues.
Another group, the Village to Village Network, has small businesses and volunteers working on a similar idea: providing older residents and their family or caretakers with referrals to vetted local services.
In the Village to Village Network model, residents pay an annual fee, from about $400 to $700 for individuals and more for households. The organization so far has 25,000 members in 190 member-run communities across the United States, and is forming similar groups overseas as well.
“We feel like we are creating a new occupation,” said Marty Bell, the National Aging in Place Council’s executive director. “It’s really needed.”
Twitter: @LizMoyer

DeathEd

I recently did a post on “elderhood” ( http://johncreid.com/2017/02/elderhood/ This post is a follow-up to that.

CREDIT:
https://www.nytimes.com/2017/02/18/opinion/sunday/first-sex-ed-then-death-ed.html?emc=edit_th_20170219&nl=todaysheadlines&nlid=44049881

First, Sex Ed. Then Death Ed.

By JESSICA NUTIK ZITTER•FEB. 18, 2017

FIVE years ago, I taught sex education to my daughter Tessa’s class. Last week, I taught death education to my daughter Sasha’s class. In both cases, I didn’t really want to delegate the task. I wanted my daughters and the other children in the class to know about all of the tricky situations that might await them. I didn’t want anyone mincing words or using euphemisms. Also, there was no one else to do it. And in the case of death ed, no curriculum to do it with.

When Tessa heard I’d be teaching sex ed to her fellow seventh graders, she was mortified. My husband suggested she wear a paper bag over her head, whereupon she rolled her eyes and walked away. When the day arrived, she slunk to the back of the room, sat down at a desk and lowered her head behind her backpack.

As I started in, 13 girls watched me with trepidation. I knew I needed to bring in the words they were dreading right away, so that we could move on to the important stuff. “Penis and vagina,” I said, and there were nervous giggles. A pencil dropped to the floor. With the pressure released, I moved on to talking about contraception, saying no, saying yes, pregnancy, sexually transmitted diseases, even roofies. By the end of the hour, hands were held urgently in the air, and my daughter’s head had emerged from behind her backpack.

Sexual education programming was promoted by the National Education Association as far back as 1892 as a necessary part of a national education curriculum. As information spread and birth control became increasingly available, unwanted pregnancies dropped, and rates of S.T.D.s plummeted. In this case, knowledge really is power.

I believe that this is true of death, too.

I am a doctor who practices both critical and palliative care medicine at a hospital in Oakland, Calif. I love to use my high-tech tools to save lives in the intensive-care unit. But I am also witness to the profound suffering those very same tools can inflict on patients who are approaching the end of life. Too many of our patients die in overmedicalized conditions, where treatments and technologies are used by default, even when they are unlikely to help. Many patients have I.C.U. stays in the days before death that often involve breathing machines, feeding tubes and liquid calories running through those tubes into the stomach. The use of arm restraints to prevent accidental dislodgment of the various tubes and catheters is common.

Many of the patients I have cared for at the end of their lives had no idea they were dying, despite raging illness and repeated hospital admissions. The reasons for this are complex and varied — among them poor physician training in breaking bad news and a collective hope that our technologies will somehow ultimately triumph against death. By the time patients are approaching the end, they are often too weak or disabled to express their preferences, if those preferences were ever considered at all. Patients aren’t getting what they say they want. For example, 80 percent of Americans would prefer to die at home, but only 20 percent achieve that wish.

Many of us would choose to die in a planned, comfortable way, surrounded by those we love. But you can’t plan for a good death if you don’t know you’re dying. We need to learn how to make a place for death in our lives and we also need to learn how to plan for it. In most cases, the suffering could have been avoided, or at least mitigated, by some education on death and our medical system. The fact is that when patients are prepared, they die better. When they have done the work of considering their own goals and values, and have documented those preferences, they make different choices. What people want when it comes to end-of-life care is almost never as much as what we give them.

I am a passionate advocate for educating teenagers to be responsible about their sexuality. And I believe it is past time for us to educate them also about death, an equally important stage of life, and one for which the consequences of poor preparedness are as bad, arguably worse. Ideally this education would come early, well before it’s likely to be needed.

I propose that we teach death ed in all of our high schools. I see this curriculum as a civic responsibility. I understand that might sound radical, but bear with me. Why should death be considered more taboo than sex? Both are a natural part of life. We may think death is too scary for kids to talk about, but I believe the consequences of a bad death are far scarier. A death ed program would aim to normalize this passage of life and encourage students to prepare for it, whenever it might come — for them, or for their families.

Every year in my I.C.U. I see dozens of young people at the bedsides of dying relatives. If we started to teach death ed in high school, a student visiting a dying grandparent might draw from the curriculum to ask a question that could shift the entire conversation. She might ask about a palliative care consultation, for example, or share important information about the patient’s preferences that she elicited during her course. High school, when students are getting their drivers’ licenses and considering organ donation, is the perfect time for this. Where else do we have the attention of our entire society?

Last week, my colleague Dawn Gross and I taught our first death ed program in my daughter’s ninth-grade class at the Head-Royce School, a private, progressive (and brave) school in Oakland. In the classroom, we had some uncomfortable terms to get out of the way early on, just as I did in sex ed — death, cancer, dementia. We showed the teenagers clips of unrealistic rescues on the TV show “Grey’s Anatomy,” and then we debunked them. We described the realities of life in the I.C.U. without mincing words — the effects of a life prolonged on machines, the arm restraints, the isolation. Everyone was with us, a little tentative, but rapt.

And then we presented the material another way. We taught them how to play “Go Wish,” a card game designed to ease families into these difficult conversations in an entertaining way. We asked students to identify their most important preferences and values, both in life and as death might approach. We discussed strategies for communicating these preferences to a health care team and to their own families.

We were delighted by their response. It didn’t take them long to jump in. They talked openly about their own preferences around death. One teenager told another that she wanted to make sure she wasn’t a burden to her family. A third said he was looking forward to playing “Go Wish” with his grandfather, who recently had a health scare.

Dawn and I walked out with huge smiles on our faces. No one had fainted. No one had run out of the class screaming. The health teacher told us she was amazed by their level of engagement. It is my hope that this is only the first step toward generating wide public literacy about this phase of life, which will eventually affect us all. The sooner we start talking about it, the better.

Aging Science

Aging Science is probably a misnomer. The field of Aging Science, if it can be called that, seems to be dismissed by the average scientist – and, sadly, many who plow fields here are thought to be quacks – people marketing magic potions and miracle cures.

Putting this cultural bias aside, a better truth seems to be that “aging” is actually a collection of highly specialized areas of biology, very specific age-related diseases, and a variety of issues related to healthy aging.

This post explores some of the issues, some of the people out there who are evangelizing the field, and some of the science that sustains them:

==================== Issue #1 – Biology of Aging =========

Stem Cells
DNA
Mitochondria
Caloric Restriction
Cellular Senescence
Genomes (Human Genome)
Longevity
Immune Response
Animal Models
Theories of Aging
Telomeres and Telomerase
Biomarkers of Aging
Oxidative Damage

==================== Issue #2 – Diseases of Aging =========

Alzheimers Disease
Stroke
Prostate Cancer
Osteoarthritis
Breast Cancer
Diabetes
Depression
Age-related Macular Degeneration
Osteoporosis

==================== Issue #3 – Healthy Aging =========

Healthy Aging
Smoking Cessation
Hearing
Alcohol Abuse
Oral Health
Immunization
Nutrition

Sadly, there is much cynicism out there when it comes to nutrition. One reason why: The Women’s Health Initiative (WHI) was a 15-year project involving 161,808 women aged 50 to 79. WHI caused many women (and men, for that matter) to question the value of maintaining a healthful diet.

Nonetheless, most physicians and nutritionists still emphasize the importance of keeping your daily fare rich in vegetables, fruit, and whole grains and spare in processed sugar and saturated fats.

==================== Issue #4 – Progress =========

Apparently, the average human age advances about 1-2 years per decade.

==================== People: Aubrey de Grey =========

Aubrey de Grey is a bearded Brit. He took a $15 million inheritance from his mother – 15 years ago – and decided to plow it into the anti-aging field. Many new outlets have given him an audience over these years, including 60 Minutes and TED. I personally am not clear on what he has to show for this 15 year investment of his time:

Aubrey de Grey theories about RHR and LEV:

Wikipedia about Aubrey de Grey

RHR is Robust Human Rejuvenation

LEV is Longevity Escape Velocity

TedTalk on YouTube here:

Aubrey de Grey YouTube

TedMed talk here:

TedMed 2009

Regenerative medicine and gerontology are the two fields

======= more ======
Pro-aging trance
The “pro-aging trance” is a term coined by Grey to describe “the impulsion to leap to embarrassingly unjustified conclusions in order to put the horror of aging out of one’s mind”.[34] According to de Grey, the pro-aging trance or “pro-aging edifice”[35] is a psychological strategy which people use to cope with aging, and which is rooted in the belief that aging is not only immutable and unavoidable, but desirable in some sense, as part of the natural or divine order that should not be perturbed. De Grey refers, in this regard, to the general public’s ambivalence towards aging. For example, he states that SENS research is often misunderstood or misrepresented as likely to lead to prolonging, rather than postponing, the period of decrepitude characteristic of old age — a belief that de Grey calls the “Tithonus error”, in reference to the myth of Tithonus. He describes this “pro-aging” stance as a rational response to the perceived inevitability of aging (compare related ideas and experimental findings in terror management theory[36]). However, de Grey believes that defeating aging is feasible and that the pro-aging trance represents a huge barrier to combating aging.[37]

Funding of SENS Research Foundation
In 2011, de Grey inherited roughly $16.5 million on the death of his mother.[38] Of this he assigned $13 million to fund SENS research, which by 2013 had the effect of roughly doubling the SENS Research Foundation’s yearly budget to $4 million. Other donors who have given millions to the Foundation include investor Peter Thiel.[38] The foundation also has yearly funding drives that have been successful with some significant donors offering matching grants for members of the public who donate.[39][40]

The seven types of aging damage
Main article: Strategies for Engineered Negligible Senescence
De Grey proposed the following types of aging damage:

Mutations – in Chromosomes causing cancer due to nuclear mutations/epimutations:
These are changes to the nuclear DNA (nDNA), the molecule that contains our genetic information, or to proteins which bind to the nDNA. Certain mutations can lead to cancer, and, according to de Grey, non-cancerous mutations and epimutations do not contribute to aging within a normal lifespan, so cancer is the only endpoint of these types of damage that must be addressed.
Mutations – in Mitochondria:
Mitochondria are components in our cells that are important for energy production. They contain their own genetic material, and mutations to their DNA can affect a cell’s ability to function properly. Indirectly, these mutations may accelerate many aspects of aging.
Junk – inside of cells, aka intracellular aggregates:
Our cells are constantly breaking down proteins and other molecules that are no longer useful or which can be harmful. Those molecules which can’t be digested simply accumulate as junk inside our cells. Atherosclerosis, macular degeneration and all kinds of neurodegenerative diseases (such as Alzheimer’s disease) are associated with this problem.
Junk – outside of cells, aka extracellular aggregates:
Harmful junk protein can also accumulate outside of our cells. The amyloid senile plaque seen in the brains of Alzheimer’s patients is one example.
Cells – too few, aka cellular loss:
Some of the cells in our bodies cannot be replaced, or can only be replaced very slowly – more slowly than they die. This decrease in cell number causes the heart to become weaker with age, and it also causes Parkinson’s disease and impairs the immune system.
Cells – too many, aka Cell senescence:
This is a phenomenon where the cells are no longer able to divide, but also do not die and let others divide. They may also do other things that they’re not supposed to, like secreting proteins that could be harmful. Cell senescence has been proposed as cause or consequence of type 2 diabetes.[41] Immune senescence is also caused by this.[citation needed]
Extracellular protein crosslinks:
Cells are held together by special linking proteins. When too many cross-links form between cells in a tissue, the tissue can lose its elasticity and cause problems including arteriosclerosis and presbyopia.[25][42]

References on Aging Science:

Other Resources

American Federation for Aging Research and their “InfoAging Series”
http://www.afar.org/infoaging/

Biology of Aging

http://www.afar.org/docs/migrated/110930_Infoaging_Guide_Stem_Cells_Web.pdf
http://www.afar.org/docs/migrated/110930_INFOAGING_GUIDE_DNA_Web.pdf
http://www.afar.org/docs/migrated/110930_INFOAGING_GUIDE_MITOCHONDRIA_Web.pdf
http://www.afar.org/docs/migrated/110930_INFOAGING_GUIDE_CALORIC_RESTRICTION_Web.pdf
http://www.afar.org/docs/migrated/110930_INFOAGING_GUIDE_CELLULAR_SCENESCENCE_Web.pdf
http://www.afar.org/docs/migrated/110930_INFOAGING_GUIDE_LONGEVITY_Web.pdf
http://www.afar.org/infoaging/biology-of-aging/immune-response/
http://www.afar.org/docs/migrated/111114_ANIMAL_MODELSFR.pdf
http://www.afar.org/docs/migrated/111121_INFOAGING_GUIDE_THEORIES_OF_AGINGFR.pdf
http://www.afar.org/docs/migrated/111121_INFOAGING_GUIDE_TELOMERESFR.pdf
http://www.afar.org/docs/migrated/111213_BIOMARKERS_OF_AGING-web.pdf
http://www.afar.org/docs/120710_Human_Genome(FR).pdf
http://www.afar.org/docs/130114_Oxidative_Damage(FR).pdf

Healthy Aging

http://www.afar.org/docs/migrated/110930_INFOAGING_GUIDE_SMOKING_Web.pdf
http://www.afar.org/docs/migrated/110930_INFOAGING_GUIDE_HEARIN_Web.pdf
http://www.afar.org/docs/migrated/110930_INFOAGING_GUIDE_ALCOHOL_ABUSE_WEB.PDF
http://www.afar.org/docs/migrated/110930_INFOAGING_GUIDE_ORAL_HEALTH_Web.pdf
http://www.afar.org/docs/migrated/110930_INFOAGING_GUIDE_IMMUNIZATION_Web.pdf
http://www.afar.org/docs/120712_Nutrition(FR).pdf

NIH’s National Institute for Aging: http://www.nia.nih.gov

Report on six types of disabilities and frequency among older Americans: NIH NIA on Disabilities

Report on Screening Tools and Technologies: NIH on Screening Tools and Technologies

List of all screening tests: Screening Tools List

Kuslansky G, Buschke H, Katz M, et al . Screening for Alzheimer’s disease: the Memory Impairment Screen versus the Conventional Three-Word Memory Test. J Am Geriatr Soc 2002;50:1086-91. – See more at: http://www.nia.nih.gov/research/cognitive-instrument/three-word-recall-three-word-memory-test#sthash.ewEmCsZ6.dpuf

Nir Barzilai, director of the Institute for Aging Research at the Albert Einstein College of Medicine in New York
Brian K. Kennedy, CEO of the California-based Buck Institute for Research on Aging

Cochran Regimen for Anti-Aging