Being Mortal

When Gawande was in college, he began dating a girl named Kathleen and met her 77-year-old grandmother Alice Hobson. Alice was spirited and independent: her husband died in 1965 of a heart attack, when Alice was 56. She was able to live off his pension and keep her home. Her son, Jim, lived nearby, but she remained completely autonomous. She even mowed her own lawn and fixed her own plumbing.

Gawande eventually married Kathleen, and as the years passed, he started to wonder how long Alice would be able to live independently. She became arthritic and lost weight. When Gawande’s father met Alice, he was surprised to learn she lived alone. Coming from India, Gawande’s father felt it was the family’s responsibility to take care of the aged and give them company.

Gawande’s grandfather, Sitaram, had a traditional old age that seems idyllic. He was a farmer in a rural village in India. Gawande met him on a visit to India when Sitaram was over 100 years old. Sitaram walked with a cane, was hard of hearing, and was very weak. But he was surrounded and supported by family at all times, and he was revered for his wisdom. The family consulted him on all important matters.

In America, Sitaram would likely have lived in a nursing home. If a person can’t use the toilet, eat, dress, bathe, groom, get out of bed, get out of a chair, or walk, then they lack the capacity for physical independence. If a person cannot prepare food, shop, do laundry, manage medications, travel alone, and handle finances, then they lack the capacity to live safely alone. Sitaram could only perform some of the basic measures and a few of the complex ones.

Living with family allowed Sitaram to manage his farm, which he built up from nothing to become one of the richest landowners in the village. Every day he rose before sunrise, and each night he inspected every acre of field on horseback—even at 100. Had he lived in the West, doctors would insist he live in a nursing home, but in Sitaram’s world, he lived how he wanted to live and the family was meant to make that possible. He died at almost 110: he hit his head falling off a bus while he was going to a courthouse in a nearby town on business.

For most of history, Sitaram’s experience was the norm. Elders were cared for in multigenerational systems. One child, often the youngest daughter, remained in their family’s home—this is what happened to Emily Dickinson, who lived in her parents’ house until they died. It was understood in both these cases that parents would keep living in their home, assisted by the children they’d raised.

Now, old age has changed. In the past, surviving into old age was uncommon. In 1790, people 65 or older were less than 2 percent of the population; now they are 14 percent. And thanks to technology and modernity, old age and wisdom isn’t as revered—teenagers have just as much access to certain information as the elderly. As a result, traditional family systems have become more strained, as young people lost freedom about how to live their lives and battles emerged over land and money.

Meanwhile, global economic development has put pressure on young people to move in search of greater opportunity—like Gawande’s parents, who left India for professional opportunity in the United States. Gawande’s father sent money home to help his family in India, but he never went back. Sitaram’s situation was only possible because Gawande’s aunts and uncles did not leave home. And even then, tension emerged between Sitaram and Gawande’s uncles, who didn’t always agree on how to run the farm.

While many believe that they might want the old age Sitaram had, in reality, the historical pattern shows that people generally don’t want this kind of living situation. Elderly parents discovered economic benefits to children leaving as well: they could rent or sell their land instead of handing it down. Rising incomes and pensions enabled people to accumulate savings and maintain economic independence. Retirement began to take shape.

Life expectancy, which was under 50 in 1900, climbed to 60 by the 1930s. Family sizes fell and women stopped having children at a younger age. As a result, more people now see all of their children live to adulthood. With new economic opportunity and fewer children, many aging parents found freedom in separation from their children—a worldwide pattern.

The fact that the elderly and the young both have more choices and independence is a sign of progress. The elderly can choose a retirement community or remain independent in their own homes, like Alice Hobson. But there is one problem with this way of living. Even though people can be independent longer, sooner or later, independence becomes impossible.

In 1992, Alice turned 84. She was in striking health, going to the gym, doing her own shopping, and taking care of her house. Soon, things began to change, however. On a mountain vacation with the family, Alice became confused and went into the wrong cabin. Then the family noticed bruises on Alice’s legs when they visited her—she fell going down the stairs. Soon, she had more falls and a doctor found that she had thinning bones. He gave her medications, but in reality, he didn’t know what to do: Alice was simply getting old, unsteady, and her memory was slipping. Her independence wasn’t sustainable, and it was not a fixable problem.