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Book review: American Dementia: Brain Health in an Unhealthy Society

By Daniel R. George & Peter J. Whitehouse

Baltimore, Johns Hopkins Press, 2021, pp 404, ISBN 9781421440477

I was asked to supply a review of this book for the publisher, but I thought it would also interest our blog followers. Johns Hopkins University Press have agreed that I can also post it on Dementia Day to Day, so here it is:

Like all good games of football, the book is comprised of two halves. The first, longer part is an analysis of the damage done to population health by neoliberal hypercapitalism, with particular reference to dementia. The second part of the book examines examples of good practice in care and new thinking about how society can respond and celebrate the contribution and wisdom of older people and people living with dementia, using a framework referred to as intergenerativity.

The book title is a play upon describing the present state of dementia research and care in the US but also refers to the state of the nation since the 1970s and the breakdown of the previous social compact to be replaced by unfettered, rapacious market-driven economics and policies. George and Whitehouse refer to the psychology underlying this philosophy as a kind of madness, therefore also a collective dementia. The title of the book suggests that the book may only be of interest to North American readers, but this is not so. There are plenty of other countries where governments are a self-serving class whose main aim seems to be to advance the interests of their chums, with the interests of the majority falling well down the agenda. For example, the criminal financial meltdown of the 2000s, where neoliberal governments bailed out the bankers and speculators who had caused the crisis, whilst imposing austerity upon the rest of the population. Especially upon those most in need of welfare, who have continued to see cuts in benefits and services.

The authors’ argument runs thus: in the time following the New Deal and with the pre-eminence of Keynesian economics, there was a period of social democracy (broadly defined) with investment in social welfare and an active role for government in overseeing this process. From the 1970s, this was challenged and overthrown by the rise of neoliberalism and individualism, with deregulation of markets, globalisation of labour and welfare reduction. Governments now have a limited role, mainly around stimulating ‘enterprise’, a process by which the rich become even wealthier and a large proportion of the population, being economically unproductive, are simply surplus to requirements. George and Whitehouse argue that increases in longevity, and falls in the prevalence and incidence rates of dementia, are largely due to the ingredients of social democracy, and therefore these positive changes cannot be guaranteed in future because of the destabilising effects of neoliberalism (such as greater poverty, precarity of employment, increasing costs of higher education). Indeed, progress is likely to go into reverse, especially for the poorer and marginalised groups of society.

Alongside this, they point out, a humbling fact for any dementia researcher, that despite the vast sums spent on dementia research, the benefits in terms of new treatments are negligible compared to the effects produced by social policies that reduce rather than increase inequality between people. In this analysis, most biologically-based research into dementia is actually a manifestation of neoliberalism. The benefits, for example, of early diagnosis of Alzheimer’s disease or of drugs targeting cerebral amyloid are currently nebulous and questionable for people with the condition, but they are undoubtedly of great benefit for imaging and pharmaceutical companies. Indeed, it may be said that the whole notion of Alzheimer’s disease, as opposed to dementia as part of the ageing process, it to commoditise part of the human condition.

Several chapters develop these ideas but also cover the effects of poverty and environmental scandals, such as the lead-polluted water supply of the city of Flint, Michigan. The effects of excess lead on developing brains will play out over future generations of poorer, largely African-American people. Characteristic of such disasters (hurricanes, floods and covid are all examples) is how emergency contracts are handed out without adequate scrutiny to the friends of people in government, alongside hefty doses of austerity and reduced welfare and services for the masses. And then there is climate change… which of course falls mainly upon the disadvantaged, living in marginal areas liable to flooding, in poor quality housing, and already stressed about financial and work issues.

At about this point in the book, the gentle reader might be excused for feeling profound hopelessness, but fortunately the last few chapters are much more optimistic in tone. Indeed, some of the work described is inspirational. Topics covered include how the quality of long-term care can be improved by improving environments and providing myriad activities, for example participation in the arts; how loneliness can be approached by measures such as volunteering; and how intergenerational education can transform and inspire both children and older people. One message that shines through is the need that we all have to be useful, to contribute, as exemplified by the elderly mentors (many of whom have a diagnosis of dementia) who contribute to intergenerational schooling, e.g. by reading aloud. At times, the writing seems a little utopian, for instance when eulogising about the potential of psychedelic drugs or of driverless cars, but the sentiments are right, and in order to change the world we have to think big.

The message of the book is summarised simply on page 25: the pursuit of a healthier society is the best tool we have for improving brain health. We have to look after each other.