It's the nightmare of any parent entrusting the care of an infant to another: The child unable to speak or defend herself will be harmed or abused, and no one will know what really happened.
There is, at the other end of life, a similar nightmare, this one for children: That an elderly parent in a nursing home, crippled by illness and confused by dementia, will be harmed or abused and never be able to tell his story.
For two years, that's been the nightmare of the family of William Neff, an Alzheimer's patient in a Bucks County, Pa., personal-care facility who died six days after prosecutors say he was savagely kicked or stomped by a night attendant. Last week, the attendant was charged with criminal homicide, and four other health-care workers were charged with covering up the horrific incident.
A scathing grand jury report accompanying the indictments urged state legislators to change the way Pennsylvania regulates personal-care facilities. As well they should. Regulators gave the Alterra Clare Bridge home a clean bill of health last year while prosecutors were forging ahead with the well-publicized investigation into Neff's death.
To see this as only a story of inept regulators and the horrors of nursing homes, however, misses the larger, more important point: As the number of elderly people with Alzheimer's increases, how can we safely take care of them? And when it's our turn, who will take care of us?
"Of course, you want to make sure the regulatory system works and there are background checks of workers," says Judy Riggs, acting vice president for public policy of the Alzheimer's Assn. "But none of that is going to make a difference if we don't make these jobs worth doing."
And this society simply doesn't value those who do the hard and sometimes dirty work of caring for the most vulnerable among us be they very young or very old. Surely that's because those jobs traditionally have been women's work done at home.
But this kind of conventional thinking is inadequate before the crushing demands and responsibilities of caring for elderly people with Alzheimer's. These aren't endearing infants who take long naps. These are people who can be incoherent, unreasonable, even abusive, trying the patience of a Mother Teresa. Without creative approaches to recruiting, training, retaining and valuing those who care for them, today's crisis will pale in comparison to what's coming.
And today's crisis is real. The employment vacancy rate in nursing homes is 11.7 percent; the annual turnover of certified nursing associates is a whopping 76.1 percent. A study released last year found that more than half the nation's nursing homes failed to meet even a rock-bottom minimum level of staffing.
Meantime, the aides themselves are so poorly paid that 18 percent of those employed in nursing homes and 19 percent who work in private homes live below the poverty line.
Worse, the number of people who need long-term care will increase just as the employment pool shrinks. By the year 2010, the nation will need 780,000 more long-term care workers, most of whom will take care of patients with Alzheimer's or other forms of dementia. But the traditional pool of workers women between 25 and 44 will grow by only half that amount.
This has all the hallmarks of a public-policy disaster, but because of our societywide denial, the fight against elder abuse lacks a voice in the halls of power.
The Elder Justice Act the first comprehensive national legislation to address elder abuse was introduced last month in Congress, but with the current preoccupation with Iraq and other needs deemed more pressing, it's going nowhere. At least the bill, sponsored by Sen. John Breaux, D-La., recognizes that staffing is critical to preventing abuse and neglect, and suggests grants and tax incentives to boost recruitment and training.
Who will care for us? Perhaps the tragedy of William Neff may propel the Pennsylvania legislature to take its role more seriously, too. But the response cannot stop there. Those who work in long-term care are undervalued because those who "live in long-term care are undervalued.
"We have to realize that we are all in this together," says Jason Karlawish, an assistant professor at the University of Pennsylvania's Institute on Aging. "It can't be yet another reason to say why you'll never go to a nursing home. We're all going to need long-term care if we live long enough."
Jane Eisner is a columnist for The Philadelphia Inquirer.