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I would like to share a song called “Drouot” by the French composer and singer Barbara (1987, Chatelet 1987, Vol. 1). It is the story of an older woman selling for auction a few souvenirs from a distant past. It is only as the auction is complete that memories from a long gone lover suddenly come back to her. But it is already too late. How much place is there for regrets and memories as one reaches the end?

In the wicker basket of the auction room,
A forgotten figure of the 1930s,
Had put for auction, among other antiques,
an old jewel, that a lost love had once offered her.

She was there, frozen, superb and heartbreaking,
Her hands, restless and shaking,
Her hands still beautiful, distorted and bare,
As bare as some trees are in November.

Every morning in the auction room,
swarmed a crowed, feverish and impatient,
Made of those who buy to later trade,
The fabulous treasures of others’ distant pasts.

In this old rosewood bed,
Embraced shadows dreamt and waited for each other,
Objects own secrets, things withhold legends,
Yet those objects will talk to those who know how to listen.

The hammer was raised in the auction room,
Once, twice, then, breaking the silence,
She cried, ‘Let me buy them back,
Those things you sell, they are my own past.’

But it was already too late in the auction room,
The hammer hit the table again, covering her voice begging,
She saw, among other antiques,
The last souvenir of her past love taken.

Near from the wicker baskets, in the auction room,
A lady cries her 1930s,
And could see her history pass,
Her past disappearing, her past going.

Because, from the bottom of her memory,
Had reappeared, a long-gone visage,
A loved figure, from the past,
The only one she truly loved as a woman.

Dazed, she walked out of the auction room,
Holding a few notes in her  trembling hands,
Holding a few notes, from the tip of her bare fingers,
A couple of crumpled notes given for her lost past.

Dazed, she walked out of the auction room,
I saw her, her back bent, heartbreaking,
From her longtime gone past, remained nothing,
Not even this last souvenir, that had now disappeared.

barbara

Working in health and more precisely around pharmaceutical products is a complex situation due to the highly controversial actions of the pharmaceutical industry. To sketch things in a slightly over simplistic manner, researchers have to choose side: either you are a pure academic sociologist and generally oppose the capitalist pharmaceutical industry or you collaborate with the industry and take for granted a certain number of assumptions.

I feel I sit between both chairs. On the one hand my research lab displays a sociological orientation working independently from the pharmaceutical industry and my supervisors are not known for their support to the pharma world. On the other hand, my sponsoring institution is a consultancy working directly for the industry. This potential issue had not arisen so far, but since I have started working on theoretical concepts of medicalisation and pharmaceuticalisation, I see the topic has become hotter.

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The efficacy of pharmaceutical treatments is in many ways the centre of disagreement. In his book ‘Limits to Medicine, Medical nemesis: the Expropriation of Health, Illich unwillingly exposed the dilemma. (Illich I. 1976) He argued that many treatments, especially newer ones harm society more than they help. However, he admitted that a number of pharmaceutical discoveries were in fact fundamentally positive, citing infections like malaria or syphilis for which medical treatments were found to be efficacious. To me, by entering the field of comparative health research he puts his argumentation at risk of being falsified due to advancing knowledge and contradictory evidence.

 After having worked in health economics for over three years I understand that measuring efficacy of medical treatments is not a straight forward black or white science. It is necessarily embedded in theoretical assumptions, methodological biases and limitations of a number of sorts. Treatments initially appearing as efficacious in a particular indication can be demonstrated harmful ten years down the line and/or can be proven efficacious later in another indication following complementary investigations. Because of the pharmaceutical industry’s financial interests, the controversy will remain between those defending the product and those opposing it.

When I first entered the medical field of osteoporosis and knew only very partially the existing literature, I started with the reading of pro-pharmaceutical industry publications (including the report I mentioned in a previous post, Hernlund et al. 2013). As most observers, I was sensitive to the argument of a tremendous treatment gap: older people were denied efficacious treatments. So my initial research question was formulated as follow: there are fully recognised efficacious treatments available to treat a well known harmful and costly disease: why are treatment uptake rates low and now declining? This was the argumentation I supported at one of my first conference presentations, the SMi Safe Geriatric Medicine Summit in 2013 in London.

 As I went on reading I understood the other side of the controversy alongside the limitations associated with the efficacious characteristics of treatments against osteoporosis as well as the concepts of disease mongering (pejorative way of describing the role of the pharmaceutical industry in the increasing place of health in life). I also acknowledge that I don’t have the knowledge nor the willpower to engage in this endless and highly technical debate. It is for this reason that I have decided to take an almost anthropological stand at the situation and avoid the question of efficacy.

 When anthropologists study the role of shamans or sorcerers in societies (technological or traditional societies – yes there are still such practices in Western countries nowadays!), they do not argue the effectiveness of the spiritual procedure; either because the researcher considers in a slightly cynic way that such beliefs are kinda retarded or because he/she voluntarily chooses a neutral position. Adopting such a position in our modern societies on the topic of pharmaceuticals suggests that I put medicines at the same level as an exorcist procedure. Because I work in an environment completely devoted to the assessment of pharmaceuticals’ effectiveness, it makes it delicate to adopt an external position. Sorry for the comparison, it is as if I was anthropologically questioning the usage of exorcism as I simultaneously worked as priest assistant! It is complex, yet surely not impossible.

Jeanne, my Grand-Mother still lives in her own home despite her increasing frailty. Unlike her mother, it is getting clearer that she will not be able to remain at home until the end. Times have changed and transgenerational family housing is not common anymore. Understandably, people of all ages wish to live independently from others, including relatives.

Not so long ago, if someone was unable to live completely independently and did not have sufficient formal or informal carers to be looked after, the only option was to move to a nursing home. However, things are moving rather quickly in the field of older age housing and more alternatives are now available.

Nursing homes become increasingly reserved for people with great dependency and dementia rather than for “intermediate” older people, if I may say. Costs are a key driver for this transition. It translates into increasing average ages in these institutions but also shorter life expectancy. In France, on average people live less than 5 years in a nursing home. Such institutions have become end-of-life facilities rather than older age homes. So what are the options?

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1. Stay-at-home. Remaining at home longer has been made possible with technological innovation. It is not true of all homes as some properties require the person to be very mobile. Such properties include houses with several levels or isolation from commodities. But many homes are adaptable to older age. Although this is a very new market, there are now advisers who are in a position to counsel home adaptation (Age UK is one). Depending on needs, a home can be made extremely easy to live in, subject to the older person’s budget. Fracture-proof flooring, automatic lighting, smart kitchens, and so on, make a house sufficiently age-friendly to support many more years of independence.

2. Adapted independent housing. When houses are in principle not adaptable for the reasons I mentioned (or other reasons), an alternative and intermediary solution is to move into a readily adapted home. However, it requires the person to possible change town, neighbourhood or city, which bears the risk of socially isolating the person from friends and family. Although this option allows to remain relatively independent, it fails to fulfil the wish of many older people to remain at home. One offer that I came across recently that I find innovative and possibly answering to the significant demand was the “Villa Sully” proposed by the nursing home business GDP Vendôme. Yet, such options remain for the Upper-Middle Class.

3. The Granny annexe. The concept of the granny annexe is semi-independence by moving into a relative’s garden and build an annex into the garden. This solution is in line with the fact that in most cases, carers are family, and these informal carers often have to travel to help (an example). The Granny annexe allows the older person to live by her/himself. The first time I saw this option, I couldn’t help but seeing the Granny annex next to the dog house and felt extremely repulsed by the concept of having an older person in the backyard, but I realised that it was an option that could actually satisfy some people’s expectations.

4. Community living. In the perspective of the 2011 French film ‘All Together‘, an option is for friends or relatives to buy/rent an adapted home to share. This solution allows to put means in common in order to have services of formal care among other. For a long time, and still these days, I thought this was the coolest way of dealing with increasing dependency. I discussed the topic with my Grand-Mother and she explained to me the difficulty of such a project. Her reason for not liking the idea was that friends or relatives all have varying health states and that capable people were afraid of serving as carers. Why would those currently very independent choose to abandon their home?

This last housing option got me thinking quite a bit about independence, denial of one’s needs and the relative absence of rationality in this area. An adult has earned the privilege of independent living in a course of life and seeing this privilege fall can be perceived as an unbearable and unpleasant transition. “If I have to loose this, I might as well go straight to a nursing home”, was Jeanne’s reaction. Above all, the lesson I have learnt is that the solution is plural, that there is no perfect solution and that ideally older people should be offered a number of options to choose from. We now have the expertise and the means to diversify age-friendly housing. As for my Grand-Mother, I hope she will make a decision that makes her happy, rather than one people expect/want her to make.

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