Physician and award-winning author Louise Aronson, a noted Harvard-trained geriatrician, introduces a revelatory way of thinking about aging in her new book ELDERHOOD: REDEFINING AGING, TRANSFORMING MEDICINE, REIMAGINING LIFE (Bloomsbury; June 11, 2019). Sharing stories from her personal and professional life, and drawing from history, science, literature, and popular culture, Aronson offers a new framework for understanding old age and how we approach our later decades. Offering hope about aging, medicine, and humanity itself, Aronson tackles the topic with the precision of a scientist, the compassion of a clinician, and the eloquence of a literary writer. Below is a Q&A with Arsonson.

In ELDERHOOD, you write “Although many of the stories in this book involve people who are old and sick, this book is about life.” Can you explain that a bit?
We age from the moment we’re born, so there’s no way to talk about life without talking about aging and vice versa. Equally important, lives are essentially stories, and a good story depends on a few key things: a clock or limit that forces the action (a wedding or other event, a deadline, a sports match, a school term, or in the case of human lives, death), the most influential stories have moments of high drama when things that really matter are in jeopardy (will the beloved be won back, with the hero be impoverished, will the team win), and how a story ends has a disproportional influence on how it’s seen and remembered (a happy, unexpected, or tragic ending). In a human life, death is the limit, illness and injury bring the jeopardy, and old age is the ending that has an outsized impact on a person’s legacy. Since I work in San Francisco, I’ve had the privilege of caring for people from all continents and many backgrounds, rich and poor, every color and religion and background. At the end of life – both in elderhood generally and when death becomes imminent – people are more the same than different. Elderhood helps us define ourselves and what matters most. The sooner we think about it, and imagine it for ourselves, the more likely we are to live long, satisfying, and relatively regret-free lives. [I should probably admit here that although I have believed this for years, I didn’t really start living it until I entered my fifties. One of my hopes for the book is that it helps people think more clearly and constructively about the trajectories and priorities of their own lives sooner than I did.]

Was there a pivotal moment or experience that made you feel you needed to write this book?
There were three phases in the writing of this book. The pivotal moment came between the second and third. In phase 1, my editor wanted an ‘aging book’ and I recognized I had things to say that I rarely or never came across in other books or the media. In the second phase, I tried to write a particular sort of general non-fiction book. I analyzed other such books and found most had 8 – 13 chapters and were between 250-350 pages long. As I worked on that book, I kept getting distracted by more radical or personal or formally adventurous essays. When I’d nearly finished it, my team read it and said, “it’s good, finish it.” But I knew something wasn’t right. Then one day – a fall Saturday in late afternoon after a phone call with another writer-doctor – I realized that the essays and that first book were all part of the same project, that the problems with old age in medicine are the problems with medicine and the problems with medicine are the problems in society, and that we are all part of the problem and part of the solutions, and that this wasn’t just a book about aging but a book about what it means to be a human being.

You write a lot about how society and the US healthcare system fail the elderly. If you could change one element of the system to better serve those in elderhood, what would it be?
The recognition that elderhood is a distinct, decades-long life stage, just like childhood and adulthood. That would change everything: standards of care and training, the questions that guide medical research and health policy, and the structure and priorities of health systems and institutions.

I should also note that I don’t just think the health care system fails the elderly. For most people the word elderly describes what some have called the older or oldest old. I think the health care system fails all older people, though it fails people more grievously as the move from senior and old through elderly and aged.

What role does the decline of physical beauty--the traditional notion of it, at least-- play in how we treat the elderly and how the elderly feel about themselves? Can it be remedied?
Because youth and physical beauty have been associated with each other across time and cultures, young beauty appears to evoke a primal response in our species. But it’s also true that one group’s beauty is often another’s ugly, that people often become more attractive when we know them better and like them more, and that what society labels beautiful changes. At all ages, some people are beautiful and most are not, though a majority of us in the latter category may be sexy, handsome, cute, pretty, and attractive, depending on who is looking and especially if we see themselves that way and make the most of our assets. Society used to dictate that people over a certain age, usually anywhere from forty to sixty, act, dress and behave in certain narrow ways that were considered sad, ugly, and limited for younger people. No longer. And those changes, which fundamentally simply allow older people to be their full human selves, have only just begun.

For people in elderhood or headed that way – i.e. for most of us – we have come along at a great moment in history. Suddenly there are beautiful and physically appealing older people in the media, on the street, in our workplaces. There is also an international movement of fifty- and sixty-something women showing their gray or white hair – myself included. These are among the visible manifestations of what is rapidly becoming a new civil rights movement, the aging equivalent of Women’s Rights are Human Rights, Black is Beautiful and We’re Here, We’re Queer. Having gray or white hair are only bad if being old is bad, and if being old is bad we are all in trouble.

Self-image studies consistently show that people who have positive attitudes toward the groups to which they belong (color, gender, sexuality, age, etc.) are happier and more productive. Too often, older people set themselves up for failure. The classic example, “You don’t look your age,” usually received as a compliment, implies that only young people or young-appearing people look good and have value. Not only is that not true, it sets up everyone who doesn’t die young for failure. Of course, the person looks their age. We all do, always. If instead of smiles and thanks, the person saying that was gently told that this is what sixty, seventy, eighty, ninety, or one hundred looks like, old people would feel better about themselves and we’d all have a more accurate view of beauty and everything else in elderhood.

In conventional wisdom, the one positive of aging is the accumulation of wisdom. How does that affect how we view the elderly? Does it bring any negative implications?
Once upon a time, wisdom meant accumulated knowledge, but now we have Google. For some people, that has raised questions about whether wisdom matters in the twenty-first century. I think it both sells wisdom and old age short. If you take an average old person and an average young person, the older one may or may not know more, but changes are very good that they will have higher emotional intelligence, better judgment and clearer values than the younger one. Those attributes can be a definition of wisdom or they also can be seen as among the varied advantages of old age over youth and middle age. Young people routinely do dangerous, illogical things that lead to feelings of guilt, insecurity, shame or regret. Most middle-aged people lament lives of unending busyness and responsibility, without enough time for what they value most. The majority of older people make decisions based on their clear priorities and have more time for what matters most to them. Admittedly, at the extremes of old age, people often live lives of frustration and boredom, but that’s largely because we have created a society that leads to frustration and boredom for most people with debility of all ages and because we refuse to accept that life has stages and sub-stages. If being old has negative implications, it is because we think of old people as adults with challenges instead of as elders. Until the last few centuries we did the same thing with children, treating them as short adults, a notion that seems ludicrous today. Whether or not a person becomes wise with age, they remain a human being. Until we admit that elderhood is both different from adulthood and childhood and a life-stage with its own unique attributes, we will not live in a world where we can look forward to the third phase in our lifelong process of aging.

In 2020, four potential candidates for Presidents will be in their 70s: Joe Biden (78), Bernie Sanders (79), Donald Trump (75), and Elizabeth Warren (71). Everyone ages differently, but in your mind, is there an age that is too old to be President? Is thinking someone too old for a certain job discriminatory, or a rational view of the realities of aging?
I love this question! It brings up critical aging issues and perfectly illustrates why we need to be talking more about elderhood.

First, the unprecedented numbers of older candidates in the 2020 presidential field mirrors larger national trends. For the first time in history, septuagenarians are the fastest growing segment of the American workforce. This has significant implications for what work looks like and means across our new, longer lifespans. In fact, two competing trends are playing out in tandem: blatant ageism in sectors like tech and a recognition by other industries that there is a new type of worker with useful skill sets that could be harnessed to everyone’s advantage.

Second, the several accurate answers to the question offer telling examples of how statistics can be cherry picked to support different agendas. On the one hand, a person’s likelihood of getting sick or dying increases with age, so an older president is at higher risk than a younger one for not completing his or her term. On the other hand, most older people with good current health and functional status will not get seriously sick or die in the next four years. In other words, physical and cognitive ability are better predictors than age in elderhood and the older a person gets, the more age matters. For our older presidential candidates, the risks are real and greater than for the younger candidates and the mostly likely outcome is that a high functioning, healthy seventy-year-old candidate will be fine.

The bottom line is that there almost certainly is a point at which a person is too old to run for president but what age that happens at will vary among individuals. For me, 100 is too old, as is 90. The 80s are the ironically titled gray area. I know huge numbers of people in their eighties who could do the job, and I also know their risk for grave and fatal health events is very high. We change throughout our lives, developing new strengths, weaknesses, realities and priorities. Because most of us will live for decades in elderhood, we all have a stake in this conversation. Discrimination thrives when we don’t discuss important social issues openly, honestly, and fairly. My greatest hope for Elderhood is that it helps us do that for old age.