Going Public, in Partnership

Public health is different from the healthcare industry. As explained by the American Public Health Association:

“The health care industry treats people who are sick, while public health aims to prevent people from getting sick or injured in the first place. Public health also focuses on entire populations, while health care focuses on individual patients.”

In Elder Abuse and the Public’s Health, editors Pamela B. Teaster and Jeffrey E. Hall (and contributing colleagues), turn attention to themselves as they recognize elder abuse is a public health problem, given the “burden of EA [elder abuse], its societal costs, and the whole of its consequences for public health.” (2018, 1)

Addressing abuse professionally, elder abuse is public health’s problem. The contributors provide a clarion call to all sector experts. They recognize that elder abuse 

“...is a constellation of problematic behaviors that the field of public health must own, contend with, and help eliminate for practical, ethical, and moral reasons” (1–2) given the “…potential facilitative role that this sector may play in advancing work to measure, monitor, and address [elder abuse] more systematically and robustly at a population level.” (16)

Addressing abuse personally, elder abuse is framed as the public’s health problem. This signals a call to action to all society as elder abuse is “a threat that should not be ignored, dismissed, or left for someone else to handle.” (1)

Empowered and emboldened by ownership and obligation, the experience and foresight of professionals who take aging personally help us engage all of society — even fueling a popular movement. Editor-in-chief of The Gerontologist, Rachel Pruchno, introduced a special issue in her editorial (2017, 1):

“This Special Issue, ‘Aging: It’s Personal,’ is different from anything The Gerontologist has ever published. Gerontologists, like everyone else, experience the positive and negative transitions of aging. Yet often we study issues such as family caregiving, retirement, and illness long before we experience them. Other times, the experiences we have direct our careers. This Special Issue examines how our academic knowledge influences the way we understand our own aging experiences and those of our loved ones and how, in turn, our personal experiences can help identify gaps in gerontological research, theory, and practice.”

The authors attended to several aging issues, with family caregiving the focus of almost half of the 19 articles. Some papers addressed the systemic social harm of how “macrostructural forces and formal health and care systems affect caregiver burden” (1). Spurred by Pruchno’s issue, I hope that The Gerontologist will consider publishing future special issues that focus on elder abuse — including guardianship abuse. Such special issues might be conducted in concert with Gerontological Society of America’s Abuse, Neglect, and Exploitation of Older Persons Interest Group.

Pruchno’s special issue of The Gerontologist takes a hybrid vigor-with-translational-rigor approach by combining professional and personal experiences to research, practice, and life. In a summary titled lessons learned, Pruchno reflects, “Although science tells us about average experiences, these reflections show that real life is sometimes much more complex and much messier.” (4)

The messy complexity of reality underscores the profound contrast between absolute and relative perspectives on aging, the interconnectedness of our collective life experiences (professional and personal), intersectional inequities, societal norms, and existential questions surrounding our human condition.

Professionally, a grounded understanding of our shared life breaks down barriers between disciplines, enabling and empowering experts to collaborate more effectively to combat social harm. Personally, the illumination of our shared lives provides a glimpse and glimmer of a promise of justice that extends to and through all of us, as concerned persons.

Like America’s eagle’s talons, Teaster and Hall’s possessives — public health’s and public’s health — entail an attributive relationship; these possessives gain a purchase on our personal and professional roles and responsibilities; they indicate an ownership that entails obligation and opportunity.

Hall and Teaster (2018, 15) describe elder abuse,

“in three distinct, yet interrelated contexts of perception, interpretation, and action. In each context, a unique argument is made for acknowledgment, acceptance, and ownership of this problem. In reality, [elder abuse] encompasses all three aspects.” (2018, 15)

In framing elder abuse as public health’s problem, Hall and Teaster call on public health practitioners to act, more, in an arena occupied by experts who have worked tirelessly to address and arrest elder abuse for decades.

“From its beginnings as a social problem, ‘elder abuse and neglect’ was shaped as a problem that required professional expertise,” note Joan Harbison and colleagues (2012, 91) when citing the observations of Leroux and Petrunik (1990, p. 653) who observe, “…concern over elder abuse thus far…derives more from professional interest group advocacy than from widespread societal reaction or even a popular movement.”

Since the 60s, confronting elder abuse has been “largely considered the responsibility of social services, aging, or law enforcement agencies…which were recognized as having legitimate authority” note Shalon M. Irving and Jeffrey E. Hall (2018, 20). Other experts include Harbison’s gerontologists, who “supply leadership in the construction of a problem, its theory of explanation and its policies to alleviate the problem” (Harbison, 91). Added, too, are professionals specific to our wealth and health — our “wealthcare” (Jason Karlawish) — experts in financial services sectors and in health care and public health. Our professional circles of support expand to embrace and embolden elder justice.

Still, most of society sits on the sidelines, indifferent. Teaster and Hall conclude that elder abuse, “only occasionally becomes concrete, real, and fully present in the eyes of the public…” (2018, 7). This lack of presence, this indifference, is an intentional and instrumental means to mask our mortality and compromise our mores and morality. This compromise is compounded by ageism.

Simon Pemberton observes, “…the greatest level of harms that are probably caused in our society are caused by indifference” in an interview with Lucy Vernall about social harm and the structure of societies (February 8, 2012).

A veil of indifference works two ways: looking inward, it conceals complacency; looking outward, it obscures a fuller understanding of our human condition and potential. Humanity’s fear of mortality is manifested in our terror management (Ernest Becker Foundation) — as described in theory developed and tested by Jeff Greenberg, Tom Pyszczynski, and Sheldon Solomon.

This poses a paradox: on one hand, elder abuse “only occasionally becomes concrete, real, and fully present in the eyes of the public”; on the other hand (as detailed below), over one in six adults have helped a person suffering from elder abuse and “an estimated overall prevalence of elder abuse of approximately 10% appears reasonable” (Lachs and Pillemer; 2015, 1949). Society-wide, the salience and severity of abuse is shrouded by stigma, shame, social norms, and indifference.

Share your concern

Elder-justice experts are not indifferent, nor are they alone. Isolated, coping, and hoping, too, are concerned persons in informal social networks — non-abusing family, friends, and neighbors who desperately struggle to help loved ones from abuse.

Risa Beckman and colleagues learned about concerned persons in informal networks who step up for elder abuse victims through the Cornell University Survey Research Institute omnibus survey, which assessed this population for the first time in 2016. Survey results revealed that when findings were extended to the general population approximately 44 million adult Americans had become involved in helping an elder abuse victim.

As principled actors concerned persons draw the line. It becomes a battle line. Concerned persons position themselves as human shields to protect older adults. At times, concerned persons are collateral damage (Melba A. Hernandez-Tejada; July 17, 2019) in long-running fights over an older person’s well-being. The line can also become a slackline on which concerned persons balance all of life’s responsibilities while navigating dangerous, uncharted territory; sometimes, they hang on by a thread. They cannot weave a secure safety net for seniors, self, and society alone. Our secure safety net must be woven by all citizens.

The NYC Elder Abuse Center—NYCEAC, now the Center for Elder Abuse Solutions (CEASe),

“was launched in 2009 to improve the way professionals, organizations and systems respond to elder abuse, neglect and financial exploitation. It accomplishes this through an unprecedented level of collaboration and coordination…”

In 2017, Risa Breckman and colleagues at NYCEAC started a city-focused pilot project, the Elder Abuse Helpline for Concerned Persons. A permanent program was established the next year. Since then, the helpline has expanded statewide to include the Upstate Elder Abuse Center at Lifespan [of Rochester]. The pilot was funded in part by the Fan Fox & Leslie R. Samuels Foundation. The helpline is funded by the New York State Office of Victim Services (Grants Unit) through its administration of federal Victim of Crimes Act (VOCA) Funds. I serve on the helpline’s advisory board.

The Helpline is now part of the Weill Cornell Medicine Center for Elder Abuse Solutions (CEASe), neé the New York City Elder Abuse Center. As described by CEASe, the helpline is:

“…a NON-EMERGENCY service providing information and support… The Helpline gives callers access to a trained service specialist [who] is backed by a culturally competent, compassionate, and caring team of professionals with many years of experience in the elder justice field.”

Confidence helps concerned persons who reach out, having experienced the betrayal of trust inflicted on a vulnerable adult. Concerned persons trust experts’ ethics, as they confide in you — knowing you trust them. Concerned persons trust experts’ agency, as they have confidence that you can help them and not question their altruistic motives.

The success of the CEASe helpline, showcased through its effective practices and ongoing assessment, serves as a powerful catalyst to improve support for concerned persons nationwide. My experience in 2006, absent such support, underscores the crucial need for resources like CEASe’s helpline. Most concerned persons still face similar struggles without access to a single source of professional help. Without a helpline to call, personally I wasn’t sure where to start when I embarked on my effort to help my grandmother.

Our concern is two-fold. We are concerned: worried, anxious, even traumatized, and it’s our concern, our ownership, and our obligation to act. When we act, we realize that our moral responsibility must be matched by and mesh with society’s ethical ‘response-ability’ — society’s ability to respond with its concern matched by capacity. Otherwise, we feel helpless and hopeless, as do those we strive to help.

In Skin in the Game: Hidden Asymmetries in Daily Life, Nassim Nicholas Taleb states succinctly, “The entire point of the book is that in the real world it is hard to disentangle ethics on one hand from knowledge and competence on the other” (2018). With a focus on elder justice, Karen A. Roberto and colleagues note, “community capacity is defined as having two elements, sense of shared responsibility and collective competence” (2015, 22).

Concerned persons “are often the only ones standing between the victim and the abuser, preventing the victim from slipping into total isolation,” note Breckman and Marshall (2017). Experts may also be isolated in seemingly disparate disciplines when deprived of a network to share knowledge and know-how.

Roberto explains (2015, 20):

“Our community capacity model includes and expands upon the successes of multidisciplinary professional teams by distributing knowledge about, and responsibility for, elder abuse prevention and intervention not only across professional boundaries — but within and between neighborhood, familial, and individual boundaries as well — to more comprehensively reinforce the safety net for elder abuse victims.”

Jay A. Mancini, and Karen A. Roberto (2009, 254) observe,

“When dissimilar networks focus on common issues, the odds increase of making positive differences in communities…networks provide the framework for social action because it is through networks that community members develop relationships and feel connected to one another.”

CEASe assumes an adept ambidextrous approach to networks through:

• Informal networks — CEASe provides the readily accessible Elder Abuse Helpline for Concerned Persons staffed by trained service specialists who provide supportive listening for non-abusing family, friends, and neighbors assisting a victim who resides in New York State and, so informed, make appropriate referrals to experts.

• Formal networks — With funding from the US Department of Justice’s Office of Victims of Crime, CEASe helps experts nationwide through the National Elder Abuse MDT [Multidisciplinary Team] Training and Technical Assistance Center, which provides training and technical assistance for all stages of team development, implementation, and formative assessment. In New York City, CEASe’s Enhanced Multidisciplinary Teams (EMDTs) provides, “a team of specialists who provide EMDT coordination, case consultation, technical assistance, trainings, and support on a range of elder abuse-related issues. Specialists include forensic accountants, geriatricians, geropsychiatrists, social workers, civil legal providers, and counselors.”

David Burnes and colleagues view the helpline experience from experts’ perspectives in a paper titled, Informal Network Supporters Make a Difference in Facilitating Use of Formal Support Services (2018, 146). The authors conclude:

“The hidden nature of elder abuse remains a major challenge in the field. Few elder abuse victims ever seek or receive assistance from formal support services (e.g., adult protective services, law enforcement) designed to ameliorate the effects of abuse and prevent re-victimization… Elder abuse victims who had a concerned person in their personal network were significantly more likely to use formal elder abuse support services than victims without a concerned person.”

In a crucible of shared solicitude, such relationships forged among formal and informal concerned persons are transformational, not only transactional. The NYCEAC/CEASe sets an example: the center’s conscious coupling of what is transformational and transactional serves to amplify our collective concern and capacity to serve as catalysts for positive change society-wide.

Our safety net works when we have safety networks — formal, and informal, and in unison

One glimmer of hope for our future is the growing number of people who, through hard-lived experience, have emerged as credible messengers around the issue of elder justice, compelled to change a system that puts our most vulnerable citizens at great risk of abuse. A turnkey is key to engaging society. Concerned persons provide society that turnkey. In concert, they create a new normal to draw greater society in and they signal a collective change of expectations whose achievement is expressed by Cristina Bicchieri in Norms in the Wild (2017, 111):

“Norm creation and norm abandonment thus share common features: people must face a collective action problem, they must have shared reasons to change, their social expectations must collectively change, and their actions have to be coordinated. There are, however, important differences between norm creation and norm abandonment. To create a social norm, normative expectations must be created first, and empirical expectations will follow. To abandon a social norm instead, empirical expectations have to change first, and change in normative expectations will follow.”

Experts’ insights prove invaluable. Informed by Bicchieri’s diagnosis, measurement, and definition of “norms in the wild,” Pruchno’s messy complexity of shared experiences help couple Harbison’s experts and their “concern over elder abuse” with Breckman’s “concerned persons” in informal social networks. Both are emboldened and empowered by Roberto’s “sense of shared responsibility and collective competence.” Teaster and Hall’s public health experts help scale a unified response to elder abuse to “a population level” buttressed by Nerenberg’s public health “approaches to preventing threats.”

Through networked action, institutional change, normative shift, and unwavering accountability, as concerned persons we can scale elder justice society-wide to embrace our shared ownership, obligation, and opportunity.

I feel there are three reasons I am invited to advocate for elder justice: I am the grandson of a famous philanthropist who was abused by her only child; I am a concerned person who acted to save my grandmother from abuse by my father; and, due to the efforts of many, I was successful. Most people don’t have a famous grandmother; most people do not act against abuse; and, if they do, they seldom share such success. As concerned persons, when we decide to act, we need to know society has our back. Otherwise, we feel helpless and hopeless, as do those we strive to help.

With a rising tide countrywide, concerned citizens are advancing awareness and action with inter-action, harnessing Roberto’s “actions of formal and informal networks to improve response to [elder abuse]” (2013, 23). By taking proactive steps to prevent abuse, concerned citizens as “pre-sponders” strengthen protective environments for older adults and persons in their circles of support. Contextual support flourishes in networks nationwide for both concerned persons and persons of concern: here, older adults who are subject to harm.

Standing in stark contrast, the realm of guardianship will remain resistant to similar advancements. The very premise of guardianship, rooted in presumptions of incapacity rather than potential, undermines the foundation of the strengths-based future we wish to build together through trust.

Guardianship, despite its noble intention to protect vulnerable individuals, can infringe upon citizens’ constitutional and humanitarian rights even in the absence of blatant abuse or exploitation. For example, this can happen in the denial of legal representation, equal rights, and due process, effectively stripping individuals of their right to participate in decisions that significantly impact their lives.

Guardianship can also foster abuse and exploitation that is enabled and abetted by entrenched power imbalances, limited resources, inadequate oversight, minimal accountability, lack of transparency, court cronyism, and even outright corruption. In this environment, guardianship may be employed strategically as a weapon and a shield, allowing bad actors to steal citizens’ net worth, self worth, and lives. Once imposed, the near-irrevocable nature of permanent and plenary guardianship leaves persons under its authority and their advocates perpetually fighting a losing battle against a system that was created to safeguard citizens, but in practice has protected a shockingly high number of bad actors, who commit criminal acts with little fear of being held accountable. Reform, then abolition of guardianship, will address Nerenberg’s first and second- level threats to individual rights and abuses of power at the primary, proactive level by reducing or eliminating the risk factors inherent to guardianship.

In their deeply personal narratives, the New York State senators’ witnesses starkly revealed states’ lack of responsibility and response to the injustice of guardianship. The hearing amplified witnesses’ voices. Yet countless similar pleas across the nation remain unheard as society turns a deaf ear to cries for help.

Compelling personal narratives delivered by the New York State senator’s witnesses starkly illuminated the human cost of guardianship injustices. Their testimony underscored the urgent need for a comprehensive reevaluation of guardianship, particularly its effectiveness at preventing and addressing abuse through the courts. Witness accounts revealed systemic patterns of neglect and inadequate responses, raising concerns about potential violations of fundamental rights and prompting calls for swift reform. However, until effective reform is implemented, individuals under guardianship, their immediate support networks, and our future selves will remain at risk, bearing the brunt of the current system’s shortcomings.

As “guardianship manifests society’s greatest responsibility held in trust” (Luhmann 2017), the inclusion of court-appointed guardians in Mosqueda’s Abuse Intervention Model’s “trusted other” domain will help address the betrayal of trust in guardianship as a white-collar crime that “has the capacity to undermine the trust in the entire sociopolitical system,” observes Sally S. Simpson (2013).

What the New York senators learned is reminiscent of the findings of Congressman Pepper’s 1987 congressional hearing on guardianship. As reported by the Los Angeles Times (September 25, 1987),

“Rep. Claude Pepper, 87, chairman of the House Select Committee on Aging’s health subcommittee, opened a hearing today on problems in guardianship procedures with a litany of state inadequacies — including the fact that advanced age is a cause for guardianship in 33 states. ‘I wonder if they’ll get me,’ Pepper said. ‘I’m 87. I have to be on the alert.’”

Reporting on the best and worst states to retire in 2023, ranked (July 31, 2023), Bankrate, a consumer financial services company, analyzed five categories: affordability, overall well-being, the cost and quality of healthcare, weather, and crime. A comprehensive survey accounting for guardianship abuse and exploitation would likely present a starkly different narrative, revealing that some states are advancing guardianship reform and replacement, other states are not safe for retirees to live and die in.

Through their diverse approaches to guardianship and its abolition, states provide opportunities to strengthen our social contract, fostering deeper trust and responsibility between individuals and society. In the spirit of functional federalism, national networks can help coordinate individual initiatives by states—all compelled by concerned persons.