No Country for Old Age

No Country for Old Age

Joseph E. Davis

The Hedgehog Review: Fall 2018

(Volume 20 | Issue 3)

No matter how we mark its beginning, “old age,” as the English sociologist John Vincent has said, “is always the period of life before death.”1 The Danish philosopher Søren Kierkegaard called it the “evening of life,” a time when life is beyond its afternoon but not yet at its nightfall.2 Old age is a cultural category, configured by kinship networks, economic systems, and basic value orientations, rather than a stage defined in specific biological terms. The end of old age, however, the last stage, is always that end which we call death. Its meaning is in turn shaped by the ways in which death itself is culturally understood.

In our society, to come directly to my point, old age is understood and framed in ways that lead inevitably to its devaluation. Its status is low and arguably is falling. on its face, such a claim might sound preposterous. Surely, the opposite is true. From the Social Security safety net to the Americans with Disabilities Act, from the positive portrayals of older people in popular media to near-record life expectancy, this is unquestionably the golden age of the golden years, a time of “No Limits. No Labels,” to quote an AARP slogan. The scope of identification with the aged is wide, this time of life is treated with public respect, and extensive supports and accommodations for living well are provided. By what blinkered perspective or romanticization of the past can we fail to see this obvious progress?

There is no question that there have been a great many improvements to the material welfare and health of the aged. But these “new positive images of aging,” that, according to the sociologist Stephen Katz, “depict activity, autonomy, mobility, choice, and well-being in defiance of traditional gloomy stereotypes of decline, decrepitude, and dependency,” create their own expectations and obligations.3 These new images deny the last stage of life its own meaning and character. And without those, old age can have no valued standing.

At other times and in other places, traditional ways of life, social classification, and metaphysical order gave shape and coherence to the life course. In our time, all of this structure has become increasingly attenuated or has disappeared altogether: rites of passage and other ritual demarcations; naming customs that link the generations; duty to ancestors; hierarchies that honor old age and wisdom; extended kinship networks; community integration of the elderly; social practices that superintend grief; arts of suffering and dying. We don’t have to become sentimental or idealize past cultural configurations to recognize our relative poverty in this arena. When it comes to old age, illness, and death, little remains to us of common meaning or shared social rituals.

This poverty is a cultural problem. The evening of life is being redefined by imperatives that are not in themselves new, but are increasingly pressed onto the aged. one such force is the concern with the viability of public programs that provide income and health insurance for the elderly. Underlying much of this concern, and the resulting public discussion, are a growing sense of fiscal crisis and calls for cost-cutting reforms. The subsequent formulation of economic priorities and policies on aging is, in turn, amplifying, another force that is engulfing old age: the growing medicalization of the lives of older adults. Efforts to fight rising costs are both informing and working in tandem with pressure to implement prevention efforts and lifestyle changes, to put in place new and inflexible duties of health surveillance and self-management.

The trend toward medicalization dovetails with yet a third force: the commercialization of old age. Commercialization is inciting and informing imperatives to optimize self and body, realized through vast new industries of goods and services, including antiaging interventions. Public policy, medicalization, commercialization: All of these forces and more are generating new standards and expectations of old age and contributing to its devaluation.

But a devalued old age cannot be explained solely by economic, medical, or commercial pressures. The challenge goes deeper. It involves basic cultural orientations—to time, kinship, social organization, the transcendent, and value premises about what it is good to do and good to be. Seeing our circumstances clearly requires us to ask why we regard aging and death as realities to hide, why we can’t cope with our inevitable decline, and why we can’t maintain our sense of self in the face of dependency, disability, and an aging body.

We find ourselves today with a construction of old age built according to an irredeemable cultural logic.4 That logic and its inevitable consequences become clear in various representations of old age and aging that I will examine below: first, in popular culture (specifically, in a popular blog for people over sixty); second, in the gerontological discourse of “successful aging” and in antiaging medicine; and third, in the rhetoric of concern about a growing “epidemic of loneliness.”

Outside Time and Finitude

The last decade has seen the emergence of a plethora of health, fashion, and lifestyle blogs aimed at people over fifty or sixty years of age: Atypical Sixty, Over the Hill on the Yellow Brick Road, Age Is Just a Number, Muddling Through My Middle Age, Second Lives Club, and so on. Typically run by one or two individuals, the blogs and vlogs create an audience and interactive community around the discussion of aspects of living in one’s older years. Many also generate revenue by deftly acting as intermediaries between their audiences and commercial enterprises that support the sites.

The blog Sixty and Me, a “community of 500,000 women over 60,” founded by Margaret Manning, stands out not only because the site has a very large following but also because it covers a wider range of topics than most, including health, travel, money, life, mindset, dating, and beauty. Sixty and Me furthers recommends itself with its mainstream tone and advice. There are sites offering fanatical fitness regimes, starvation diets, and dreams of “engineered negligible senescence,” but this is not one of them.

Sixty and Me brims with advertising. Manning dominates her blog, but there are also contributions by various experts, typically with something to sell. While there is some discussion of caregiving, self-care for caregivers, and the need to talk about death, there is little mention of suffering, decline, or death itself. As the gerontologist Harry Moody once observed about marketing to the older demographic, “The appeal is always to turn away from outdated images of maturity in favor of reinvented identity outside of time and finitude.”5

At Sixty and Me, an appeal to emancipation and reinvention informs the picture of good aging. That picture draws on the familiar American ideal of an independent, self-sufficient, and enterprising self. In one popular post, Manning quotes the actor Jamie Lee Curtis, then 56:

If I can challenge old ideas about aging, I will feel more and more invigorated. I want to represent this new way. I want to be a new version of the 70-year-old woman. Vital, strong, very physical, very agile. I think that the older I get, the more yoga I’m going to do.6

Manning notes that Curtis “isn’t afraid of getting older. Instead of seeing life after 60 as a time to take it easy, she is looking forward to the opportunity to make the absolute most of her life.” Manning adds that she appreciates “the fact that Jamie Lee Curtis realizes that, as a celebrity, she has a role to play in challenging aging stereotypes.” Finally, Manning approvingly observes that Curtis “calls attention to the fact that life after 50 is a choice. And indeed, Curtis is already planning for the decades ahead. As she correctly points out, the older she gets, the harder she will need to work to maintain her energy and physical strength.” Make the most of life, live so as to challenge “old ideas about aging,” and treat life after fifty (or sixty or seventy) as a choice: These are the three norms Manning takes Curtis to be living by, and which Manning finds “right on the money,” as did many (though certainly not all) of the blog readers who commented on the article. In this view, later life should not be a time for less engagement or a reorientation away from a view of the world as a task zone, but, rather, a period of continual goal-seeking, work, or other contributive role-taking. The future is open, inviting, ready to reward new initiatives.

This picture of people as independent agents, masters of their lives through volition and choice, is familiar. As social institutions have declined in recent decades, however, there has been an even greater emphasis on self-optimization. In the 1980s, for instance, we framed autonomous persons as “enterprising” people energetically striving, with calculation and efficiency, to project a future and act to achieve their goals.7 The notion that life after fifty is a choice, is anything we want to make of it, brings together the norm of self-optimization—she will not be retiring or taking it easy, but making the absolute most of her life—with two related and widely accepted ideas: that health is an achievement and that body image is an integral component of personal identity. All of these ideas meet in the joint concept of “health and fitness,” which is presented by Jamie Lee Curtis as the decisive blow to the old stereotypes of aging. What will make Curtis a “new version of the 70-year-old woman” is the fit and vital body that she will work ever harder to produce.

Aging well by such criteria requires continuous demonstrations of success through signs of initiative and energy. Appearance—looking healthy, fit, and “put together”—is also crucial: “To look old is to be old.”8 In the comments section of Sixty and Me, people often report on how they look younger than they are. As one reader put it, “I am 70 (even though most folks tell me I look at least 10 years younger…).” Such self-affirmation signals that they are aging well.

In a discussion of “fashion for women over 60,” Manning stresses looking “fabulous without trying to look younger.” one of her fashion secrets is to “embrace your age.” Elaborating on that advice, she writes that

when people try to dress in styles that would be more appropriate for someone much younger, they paradoxically make themselves look much older…. If you “dress age-appropriately,” it often has the effect of making you look younger because people are not distracted by age-inappropriate clothing, and instead can appreciate what great shape you’re in, or how healthy your skin is, or what a stylish haircut you have.9

Again, the measure is the body. Health, fitness, a youthful appearance, entrepreneurial energy: These are not “add-ons,” like fashion or cosmetics; they are something you are. The point of the advice of Sixty and Me is not so much to deny the aging process as to postpone it to some indefinite future. The message is that good aging is living later life as if you were young, though with a necessarily even more exacting regimen of diet, exercise, and risk-reduction practices—and, given that this good aging is a matter of choice and responsibility, with the unspoken implication that problems and failures are self-inflicted.

Personal efforts to stay fit or engage in work are certainly not to be derided. What is of concern is the language of individual choice and the incitement to a self-optimization understood in terms of “productivity.” There are no grounds here for coping with disability and decline, physical or mental, or for embracing old age as a valued and dignified final chapter in its own right. And in the individualism being promoted there is precious little rationale for interdependence: for the humility, for instance, to accept care or the commitment to provide it. Despite the effort to project a positive image, what is on offer is a construction of old age that can only intensify and perpetuate its low status.

The “New Gerontology”

In the late 1980s, two distinguished medical researchers, John Rowe and Robert Kahn, developed something they called the “new gerontology.”10 Previously, gerontologists had treated age-related alterations in physical and cognitive functioning that were not due to disease or disability as normal and inevitable and unassociated with lifestyle and risk. Rowe and Kahn argued that much of the decline in older age was avoidable, and that with the right choices and the discipline to follow a careful regime of risk reduction, individuals could attain “successful aging,” generally characterized in the gerontological literature as sustained health and vitality in the later years.

Success, in those terms, means living with little disease or disability, maintaining high cognitive and physical functioning, and remaining active and independent for as long as possible. In an important sense, you satisfy the criterion of “successful” only to the degree that you are not “old.”11 If you are frail, functionally disabled, disengaged, or have health risks, such as high blood pressure, your aging is “usual.” That doesn’t sound so bad—but, as many critics have pointed out, the opposite of success is not “usual.” It is “failure.”12

The normative appeal of the new gerontology to individual autonomy and responsibility makes it even clearer that “failure” is precisely what is at stake. Health is a matter of individual choice, and it becomes each person’s moral duty to muster all of his or her energies to be successful. Insufficient initiative, insufficient efforts to stay informed, incomplete compliance with expert advice, and the like are grounds for potential blame, stigmatized as fatalism and passivity, and made the target of interventions by others. Calling, and getting called, to account for any slacking has become a pervasive phenomenon, so common that we offer anticipatory apologies when we know that others know that we have done anything less than prioritize our health and longevity. There are no excuses.

The popularity of the successful aging model and its imperatives has, predictably, contributed to a steep rise in the use of antiaging therapies. If old age is open and indefinite, aging a choice and a technical challenge, then pursuing such interventions for the sake of “success” would seem not only fitting but obligatory.

Antiaging is big business.13 By far the most common and commercially profitable components of this commerce are those interventions that help hide, postpone, or compensate for the effects of aging on the body. Antiwrinkle cream and Botox disguise and conceal; exercise and nutritional supplements stave off decline; Viagra and hormone replacement therapy compensate or reinvigorate. Most such interventions are readily available, including the more compensatory through the growing phenomenon of specialty longevity clinics, sometimes known as antiaging centers or life extension institutes.

Restorative medicine is one aspect of a larger antiaging medicine and science. Interventions that might slow the aging process and extend the human lifespan are being pursued through research into genetics, the biochemistry of cellular senescence, and stems cells. Optimism about this enterprise has been bolstered by successful efforts to manipulate the longevity of nematode worms, fruit flies, and mice. Some now believe that the human lifespan can be extended twenty to sixty years. Even farther out on the edges of longevity research are some provocateurs who claim that aging can be stopped and even reversed. These are members of what the philosopher Mary Midgley aptly calls the “new immortalist movement”14—new in its invocation of science, perhaps, though this movement can claim a long and storied lineage.15

Antiaging research goes further than gerontology in medicalizing aging itself, defining it as a condition of degeneration, a technical failure that can be technically modified. And it promotes interventions, such as hormone treatments, that gerontology rejects as unproven and dangerous, and does so for people who may be without clinical impairment or even elevated risk. Despite their differences, however, antiaging and successful aging push toward a similar framing of old age as undesirable and, at least for a time, preventable. Both treat frailty and disability as indications of failure and emphasize individual choice and effort without regard to the hardships and inequalities many older people actually endure.16 Both promote an evasion of the inevitable confrontations with disability, disease, and death.

Under the paradigm embraced by both successful aging and antiaging, old age has no value in itself. “Old” signifies bodily decline, while “success” involves a ceaseless battle to defeat degeneration, and hope is always invested in the prospect of overcoming limits through self-reliance and technological interventions. There is no space here for stillness or release, no sense of value or consolation in the evening of life. Even cultivating spirituality is framed instrumentally in terms of promoting “better physical and mental health in old age.”17 An imperative to defeat aging and even death can only consign these realities to fear, shame, and avoidance.

Further, and for the same reason, situating aging in a framework of success and failure, or victory and defeat, helps undermine the social basis for care and solidarity. Fear and avoidance contribute to the isolation and marginalization of the old, infirm, and dying. It is already difficult for those with little experience of aging or infirmity to empathize with it, and those younger and of good health are often and understandably motivated to avoid the idea of their own decline and death. Representations of old age that add censure and shame to greater dependence and loss of one’s powers can only make matters worse.

An Epidemic of Loneliness

There is no sugarcoating the experience of aging, in our day or any other. For instance, in a sermon on the “infirmities and comforts of old age,” first published in 1805, the seventy-five-year-old pastor of a Congregationalist church in Massachusetts provides a sober description of old age as “a time when strength faileth.” As we age, he observes, we experience a decay of our bodily strength: “Our customary labor becomes wearisome…pains invade our frame…our sleep, often interrupted, refreshes us less than heretofore…our food is less gustful…our sight is bedimmed, and our ears dull of hearing.” Along with this decline, the pastor notes, we often experience a gradual loss of companions and social visits and an increase in isolation. Moreover, to our disadvantage, “we contrast our present with our former condition” of active powers, and “not only the remembrance of what is past, but the forethought of what is to come, aggravates the calamity of the aged man.”18

In The Loneliness of the Dying, the sociologist Norbert Elias argues that, over time, these weakened bonds and other common features of the later years have been compounded by increased individualization and the isolation of the “ageing and dying from the community of the living.” In contemporary society, Elias argues, older people are “pushed more and more behind the scenes of social life,” a process that intensifies their devaluation, emotional seclusion, and loss of social significance. A physical and institutional sequestering and a pervasive cultural tendency to “conceal the irrevocable finitude of human existence” have made it harder for them and those around them to relate to, understand, and interact with one another. The aged and dying are less likely to receive the help and affection they need, and more prone to different forms of loneliness and painful feelings of irrelevance. “Never before,” Elias writes, “have people died as noiselessly and hygienically as today in [more developed] societies, and never in social conditions so much fostering solitude.”19

In recent years, the loneliness of the aged has received increasing public attention, sometimes under the rubric of an “epidemic of loneliness.” While this “epidemic” does not solely afflict those in later life, much of the discussion of it, including proposed responses, tends to focus on the elderly. Popular articles and books identify a number of social changes as contributing factors. Among these are high divorce rates, including a steady uptick in the rate of after-fifty “gray divorce,” smaller families and extended-family networks, more single-member households, and fewer opportunities for social activities.

Contributors to the public discussion frame loneliness itself as a kind of medical condition or disorder: It is something one “suffers from,” that is partly heritable, that has characteristic “symptoms” and “risk factors,” can become “chronic,” and needs to be “treated.” Like other animals, such as fish, mice, and prairie voles, we “evolved to be social creatures,” these writers remind us. Consequently, literally fatal consequences can result from our “perception of isolation from others—of being on the social perimeter,” to quote “social neuroscience” popularizers John and Stephanie Cacioppo. Our “perceived social isolation,” the two neuroscientists write, “can still put us in self-preservation mode,” a “hangover” from our evolutionary past that is now “at odds with thriving in a modern society.” Like a lack of social ties, identified by Rowe and Kahn as a threat to health, loneliness is found to have detrimental effects on “long-term health and well-being.”20 For example, Vivek Murthy, a former US Surgeon General, reports that loneliness and isolation are “associated with a reduction in lifespan similar to that caused by smoking 15 cigarettes a day and even greater than that associated with obesity.”21

In discussions of loneliness and how to “solve” this problem, virtually the entire focus is on its harmful consequences for health and longevity. These appear to be the values that really matter, and the evidently urgent need to address the epidemic flows from concerns with this harm and the costs it imposes on society. Health and longevity are the ends to which remedial action is directed and by which outcomes are evaluated. Even in discussions that include exhortations to build strong connections and communities, loneliness and isolation are treated as individual conditions, and references to community easily coexist with talk of genetic hardwiring, the role of the prefrontal cortex, and the ways in which neural mechanisms might generate feelings of loneliness. Readers are reassured that researchers are hard at work “deepening their understanding of [loneliness’s] biological underpinnings.”22 The hope, it seems, is that we can get rid of that “hangover” and stop feeling so much distress in the face of loneliness and social isolation. A psychoactive drug for loneliness might be a start, on which possibility, John and Stephanie Cacioppo note, “animal research is shedding light.”23

Health consequences are a legitimate concern, of course, but this medicalized discourse of loneliness barely touches on the actual social conditions and vulnerabilities of the aged. Little or nothing is said of their practical challenges in everyday life, their loss of social significance, their isolation from the community, or their abandonment. In fact, the definitions of the “epidemic” often downplay if not effectively deny that the social fabric and our mutual dependence are even at issue. Many of the recommended strategies to reduce loneliness place the burden on the lonely themselves. Typical advice is often some form of self-help: “take a class,” “get a dog,” “volunteer”; build your confidence with social skills training; seek out behavioral therapy. With therapy—highlighted for its positive “impact”—the aged lonely can be helped to see that their low self-worth, perceived isolation, or feelings of being unwanted are probably just cognitive misapprehensions that need to be “restructured.” once this restructuring is accomplished, the aged can better match what they want in social life with what they have and get on with aging with more success. The status quo can now appear in a new, more uplifting light. The larger world and the incomparable meaning of people for people need scarcely be acknowledged. The aged, ostensibly the subject of concern, disappear.

More Than a “Pitiful Appendage”

The psychologist Carl Jung once observed that “a human being would certainly not grow to be seventy or eighty years old if this longevity had no meaning for the species. The afternoon of human life must also have a significance of its own and cannot be merely a pitiful appendage to life’s morning.”24

If old age is to be more than a “pitiful appendage,” then we need a way of relating to ourselves, the life course, and death that gives getting older genuine significance. Current constructions of old age in individualistic terms of self-reliance, the fit body, productive accomplishments, or an imperative to deny or defeat aging technologically cannot but deepen our predicament and the need to render it invisible. This is what makes the cultural logic of these constructions irredeemable. They leave us in a cul-de-sac, hemmed in by a predatory commercial culture, a punishing ideology of health, fewer and weaker social ties, an ethic of active striving and mastery, and a mechanistic picture of ourselves. Moving beyond the devaluation of old age requires other orientations and other practices for which we must look elsewhere—to other societies, past or present, and to older traditions.

We know, from history, theology, philosophy, and anthropology, that there are other possibilities. The temporal orientation need not be toward an open, this-worldly future, but toward wisdom, narrative, memory, and, for people of faith, a future that is eternity. The social orientation of the evening of life need not be individualistic, but toward family and the localization and strengthening of social relations. Similarly, the view of the life cycle need not take its bearings from youth and middle age but from roles and identities appropriate to old age, with their own norms and rewards. These norms and rewards need not be defined in terms of active striving and productivity, but in terms of release, such as from social climbing, and a more contemplative attitude toward the world. Surely, in the last stage of life, health and longevity need not continue to be treated as ends in themselves. Rather, they might be set within a larger framework of limits, a recognition of our vulnerability and dependence, and the ethic of a well-lived life. There are other possibilities, and if we are to free ourselves from the iron cage to which our cultural logic consigns us, we must look to them for direction.

Notes

1. John Vincent, Old Age (London, England: Routledge, 2003), 132.
2. Søren Kierkegaard, Three Discourses on Imagined Occasions, ed. and trans. Howard V. Hong and Edna H. Hong (Princeton, NJ: Princeton University Press, 1993), 56.
3. Stephen Katz, “Growing Older without Aging? Positive Aging, Anti-Ageism, and Anti-Aging.” Generations 25 (2001–02): 27.
4. I borrow this phrase from John Vincent, who uses it in the narrower context of antiaging medicine: John Vincent, “What Is at Stake in the ‘War on Anti-Ageing Medicine’?,” Ageing and Society 23 (2003): 682.
5. Harry R. Moody, “From Successful Aging to Conscious Aging,” in Successful Aging through the Life Span: Intergenerational Issues in Health, ed. May L. Wykle, Peter J. Whitehouse, and Diana L. Morris (New York, NY: Springer, 2005), 64.
6. “This Jamie Lee Curtis Quote about Aging Is Right on the Money,” Margaret Manning, Sixty and Me, 2015, http://sixtyandme.com/jamie-lee-curtis-quote-about-aging/.
7. Nikolas Rose, Inventing Our Selves: Psychology, Power, and Personhood (Cambridge, England: Cambridge University Press, 1998), 154. on the related notion of persons modeling themselves on the concept of a “brand,” see Joseph E. Davis, “The Commodification of Self,” The Hedgehog Review 5, no. 2 (Summer 2003): 41–49.
8. John A. Vincent, “Ageing Contested: Anti-Ageing Science and the Cultural Construction of Old Age,” Sociology 40 (2006): 689.
9. “Fashion for Women over 60, Look Fabulous without Trying to Look Younger,” Margaret Manning, Sixty and Me, 2013, http://sixtyandme.com/fashion-after-60-how-to-look-fabulous-without-trying-to-look-younger/.
10. John W. Rowe and Robert L. Kahn, Successful Aging (New York, NY: Pantheon Books, 1998).
11. Of course, the older you get, the more likely you are to fail. See studies in Peter Martin, Norene Kelly, Boaz Kahana, Eva Kahana, Bradley J. Willcox, D. Craig Willcox, and Leonard W. Poon, “Defining Successful Aging: A Tangible or Elusive Concept?,” The Gerontologist 55 (2015): 14–25.
12. Martha B. Holstein, and Meredith Minkler, “Self, Society, and the ‘New Gerontology,’” The Gerontologist 43 (2003): 787–796.
13. Arlene Weintraub estimates the size of the antiaging industry at $88 billion; see Selling the Fountain of Youth: How the Anti-Aging Industry Made a Disease Out of Getting Old—and Made Billions (New York, NY: Basic Books, 2010), 3
14. Mary Midgley, “Death and the Human Animal,” Philosophy Now 89 (March/April 2012): 10–13.
15. In the words of Norbert Elias, “The dream of the elixir of life and of the fountain of youth is very ancient. But it is only in our day that it has taken on scientific, or pseudo-scientific, form.” Norbert Elias, The Loneliness of the Dying (New York, NY: Continuum, 1985), 47.
16. Michael A. Flatt, Richard A. Settersten Jr., Roselle Ponsaran, and Jennifer R. Fishman, “Are ‘Anti-Aging Medicine’ and ‘Successful Aging’ Two Sides of the Same Coin? Views of Anti-Aging Practitioners,” Journals of Gerontology, Series B: Psychological Sciences and Social Sciences 68 (2013): 952.
17. Moody, “From Successful Aging to Conscious Aging,” 60.
18. Joseph Lathrop, The Infirmities and Comforts of Old Age (Springfield, MA: Brewer, 1805), 4–6.
19. Elias, The Loneliness of the Dying, 2, 12, 40, 85.
20. John Cacioppo and Stephanie Cacioppo, “Loneliness Is a Modern Epidemic in Need of Treatment,” New Scientist, December 30, 2014, https://www.newscientist.com/article/dn26739-loneliness-is-a-modern-epidemic-in-need-of-treatment#.VRKpX2TF9Cw.
21. Vivek Murthy, “Work and the Loneliness Epidemic,” Harvard Business Review, October 12, 2017, https://hbr.org/cover-story/2017/09/work-and-the-loneliness-epidemic.
22. Katie Hafner, “Researchers Confront an Epidemic of Loneliness,” New York Times, September 5, 2016, https://www.nytimes.com/2016/09/06/health/lonliness-aging-health-effects.html.
23. John Cacioppo and Stephanie Cacioppo, “Loneliness Is a Modern Epidemic.”
24. Quoted in Moody, “From Successful Aging to Conscious Aging,” 55.
25. Joseph E. Davis is Research Associate Professor of Sociology at the University of Virginia and moderator of the Picturing the Human colloquy at the Institute for Advanced Studies in Culture. He is editor (with Ana Marta González), most recently, of To Fix or to Heal: Patient Care, Public Health, and the Limits of Biomedicine (NYU Press).