Image by andrewmalone via Flickr

Join the Civilian Corps for Aging

One of my goals for ElderAuthority.com is to have it be a FREE and SHARABLE repository for grassroots wisdom about all things aging.  We are not there yet.   ElderAuthority receives lots of private comments and thank you’s.  These are great, but we can only share the comments you provide through the site.  One of the greatest gifts you can give your fellow Boomers is the benefit of your experience.

We live in a world with 78 million Baby Boomers who grow older every day.  There will never be enough services, money, doctors, and support groups for all of us–especially those who have limited financial resources. Please comment on the site.  It is an investment in our future quality of life.  Think of yourself as a volunteer in the “Civilian Corps for Aging”.

The shared experience of civilians is every bit as valuable as that provided by professional caregivers, doctors, and specialists.  The professionals focus on what they know.  The rest of us can participate in sharing our unscientific but equally valuable perspective on what works and does not work.  The more contributors, the more valuable the data becomes.  The 3 a.m. Reader who is desperate for some sort of direction RIGHT NOW! may find the civilian website a better resource than anything the busy and booked-up professionals offer.  At the very least, it is a valuable secondary resource.

Real Life Dementia Experience Online

I have been a fan of the Alzheimer’s Association since 2005 when I took on the role of primary caregiver for my two parents with dementia.  My mother had Parkinson’s Disease with Lewy Body dementia (d. 2010).  My father had Alzheimer’s Disease and vascular dementia (d. 2008).   The Alzheimer’s Association taught me everything I know about dementia.  It is a truly great organization.

Yesterday I attended the “Reason to Hope” breakfast, sponsored by the Alzheimer’s Association Michigan Great Lakes Chapter. Reason to Hope  is a community event that raises funds for programs and services critical to the individuals and families living with Alzheimer’s disease and raises awareness of the work of the Alzheimer’s Association.

Gerry Sampson, Chairman National Board of Directors of the Alzheimer’s Association, was the keynote speaker.   He gave an overview on the national resources offered by the Alzheimer’s Association.  I was delighted to learn about a site with a goal similar to that of ElderAuthority.com.  Please check out AlzConnected.org.  

ALZConnected.org

AlzConnected is an offshoot of Alz.org, the national website for the Alzheimer’s Association.  The national site provides data about everything to do with Alzheimer’s disease as well as other dementias.  It even provides a tool, Alzheimer’s Naviagator, which helps readers develop their personalized action plan for themselves or for a loved one with dementia.

• Meet and communicate with others who are affected by Alzheimer’s AND the other dementias.  (I joined and linked up with members with concerns about Parkinson’s)
• Control your privacy settings.
• Share personal updates.
• Ask questions, share ideas, and consult opinions on message boards.
• Join discussions in Spanish. (Alzheimer’s is three times more common in minorities than in Caucasians.)
• Join public or private groups focused on a topic or shared experience. ( I like it that there is a discussion forum for both Caregivers and Spouse & Partner Caregivers.  They ask different questions.)
• Find and share solutions to questions about Alzheimer’s and caregiving. (This is my favorite section.  It contains the dementia equivalent of “Better Ideas for Aging,” that ElderAuthority continually requests.  Guys, we need all the home grown solutions we can find.  They need to be documented and shared. Please!)
• Send private messages to your connections within a secure system.
• Upload and share photos.

The site has been active for about 18 months.  And, yes, people do share their experiences on the site.  I have learned that people do not learn about scary topics until the crisis is upon them.  AlzConnected is the perfect resource for anyone who has just learned that a loved one has Alzheimer’s Disease.

“What you now need to know is that Alzheimer’s is the most expensive health crisis in America and is increasing like no other.” — National 2013 Alzheimer’s Advocacy Forum, Washington , D.C.

Alzheimer’s Association Great Lakes Chapter Advocates with Rep. Sandor Levin, 4/29/2013

Image by cakersandco via Flickr

Letting Go of Attachments in Old Age

Steve Taylor, in Psychology Today points out that, “We fear old age because we see it as a process of loss, of having to let go of things which we depend on for our well-being.  But it’s this very process which actually causes the well-being of our later years.”  Psychological attachments, such as hopes and ambitions which normally support our sense of identity,  fall away.  “At the end of their working lives, knowing that they may not have many years left, old people stop imagining alternative futures for themselves. They stop striving to become something else, and begin to accept themselves and their lives as they are. Rather than living for the future, they become more present-centered.”

In old age people learn to adapt to their strengths and weaknesses and quell unreachable aspirations. The process of letting go brings an authenticity which was obscured by exterior influences in younger years.  The natural contentment of simply being blossoms as they  realize that they don’t actually need external things for their happiness.

Trade-offs of Youth and Age

In old age our our health may fail or we may become more frail, but there is also a great freedom and well-being that comes with not caring what anyone thinks.  Along with relinquishing professional identity, physical appearance, and social status comes liberation.    For some, it’s the first time in their lives where they have the chance to fully live without being burdened by the expectations and ideas of others who have impacted them throughout life.

I always tell people that turning 50 is a fabulous milestone because you become invisible.  No one cares what you do, so you might as well do as you please.

By the time we hit fifty, we have learned our hardest lessons. We have found out that only a few things are really important. We have learned to take life seriously, but never ourselves.
* Marie Dressler

Embracing the Good Part of Aging

On June 18th, I will be 59  and a half.  When I first put money into an IRA it seemed impossible that I would ever become old enough to take money out without paying a 10% penalty.  I find myself redefining what success means to me.  Here is my success definition du jour.

• Being part of a diverse community of supportive friends and relatives.
• Having a long, happy marriage.
• Maintaining my health through exercise, nutrition, and social relationships.
• Having enough money to pay the bills, buy decent health insurance, and purchase the occasional perfect gift for those I love.
• Using my creative energies to do work that matters.
• Living in harmony with nature.
• Finding joy in simple things.

George H. W. Bush, who jumped out of an airplane for his 85th birthday, is the poster boy for getting it right.

When grace is joined with wrinkles, it is adorable. There is an unspeakable dawn in happy old age. * Victor Hugo

Image by Andrew Mason via Flickr

Affordable Coaching for Seniors Needed

Health maintenance is a key longevity factor as well as an essential quality of life component for senior citizens.  We have all received the memo that we can influence our health through consistent exercise and good nutrition.

Motivational coaching, personalized feedback, goal setting, and patient education have been used successfully to bring about long-term changes in diet and activity. Delivering these aids by traditional means, such as one-on-one personal training,  is expensive and difficult to scale up.  A personal exercise coach would benefit any senior citizen, but few can afford it.

New Technologies Become Senior Helpers

There are new health technologies that are effective, accessible, and inexpensive.  The following are a few:

• Pedometers are wearable devices that capture step count.  They can increase activity levels by up to 2000 steps per day.
• Internet-based information can communicate and deliver information to individuals at relatively low cost .
• Internet-based interventions have demonstrated reductions in weight through a combination of self-monitoring, education, and motivational messaging.
• E-Coaching: A coach can increase accountability and adherence to an exercise program.

There is a documented association between the quality of the professional–client relationship and outcomes. The psychotherapy literature describes this working alliance as the trust and belief that the helper and patient have in each other as team members in achieving a desired outcome.

Virtual Exercise Coach

Coaching need not be face-to-face.  A coach need not be human at all.  Recent research into the use of animated computer agents has shown that participants can successfully form a working alliance relationship with a nonhuman agent, also known as  a virtual coach.

The virtual coach is  a computer-animated exercise advisor that runs on software installed on users’ home computers. The virtual coach is entirely automated and follows an algorithm-driven script, using simulated face-to-face conversation, including verbal and nonverbal relationship-building behaviors modeled on best practices from studies of patient–provider health communication with the goal of establishing a working alliance.

Virtual Coach Testing

The scripts in a recent virtual coach test were developed through a collaboration involving physicians, computer scientists, and exercise trainers to ensure adherence to best practices.  These strategies include goal setting, shaping, self-monitoring, positive reinforcement, problem solving, education, and social support.

The virtual coach software was integrated with a database containing the participants’ activity data to allow tailored interactions according to each participant’s adherence to step count goals. The interactions all followed a structured pattern, starting with greeting and social interaction, proceeding to review of pedometer step count, feedback and goal setting, tips on activity or diet, and commitment to date of next interaction, and ending with encouragement and farewell.

The dialogue, format, and content of individual utterances were tailored based on each user’s progress in the system–whether they had progressed past baseline, whether they had met their short-term goals, and whether they had just asked the virtual coach a question or asked for help.  Those who had not met their activity target would have a different interaction from those who were on track.

Results showed that participants can form a social bond with a computer agent, even though they are aware that the agent does not represent an actual human.  It may be best used as a supplement to other forms of automated applications.

Virtual Coaching for Parkinson’s Patients

Developing effective, automated self-management programs, that offer a relationship and personalized feedback, may prove essential to developing scalable solutions to deal with large populations faced with chronic disease.

A recent  article in the Wall Street Journal, A Virtual Coach Spurs Patients With Parkinson’s, reported that “patients walked markedly farther and faster after a month of daily motivational chats with a virtual exercise coach.” According to the American Journal of Physical Medicine & Rehabilitation, the technology has been used in studies of healthy adults, but this is the first study to involve patients with a neurological disorder.

Virtual coaching has many applications beyond promoting activity. Coaching is increasingly recognized as an important component in the management of chronic conditions, such as diabetes and heart disease, and in the promotion of healthy behaviors, such as adherence to medication.

Future Healthcare Implications

Given the growing burden of chronic disease and the shortage of providers, such applications may prove useful supplements to conventional office-based care. By linking data from home monitoring devices, health practitioners could encourage patients to develop better self-management skills.

Broader changes in the health care payment system, such as the shift from visit-based to outcome-based reimbursement, may promote adoption of this type of care-delivery platform by clinicians. Pay-for-performance initiatives promote provider innovation around care delivery. An online coaching platform could be used, either as an adjunct to traditional care or as a stand-alone self-management program for patients.

Diner Menu via ElderAuthority

Ask for Your Senior Discount

Everyone knows someone over 50 please pass this on!!!!!

Laughter is a Longevity Factor

Researchers in Norway found that near death patients who maintained a good sense of humor increased their odds of survival—by 31 percent!

Caregivers: How much do you laugh?  Invalids: How much do you laugh?

Humor expert Allen Klein gives this advice for increasing the laughter in your life.

Place Laughter Reminders

Hmmm.  I need to do this.  I think I will start with putting pictures of laughing animals on my office walls.  That should give me a hit of oxytocin too. [Search ElderAuthority for a bunch of articles about my favorite hormone.]

Exaggerate Annoyances

Ask yourself “What’s the worst thing that could happen?”—and continue to ask that question until your response becomes absurd.

I have had a phobia about getting lost ever since I got off the school bus at the wrong stop when I was eight years old.   The other day, I got lost while on a walk.  When I tried to articulate anything that was really bad about it, I came up empty.

That’s the great thing about phobias.  They are all in your head.  Laughter can help shake them out.

Carry a Prop

Klein says, “Everyone in my workshop gets a clown nose,”   I like that one.  Bring clown noses to family meetings about caring for your parents.  The emotions in those meetings are not rational.  You need humor triggers to get through it.

State a Fear Out Loud—Then Say ‘Ha Ha’

Most caregivers have money fears.  State your fear out load.  Then say ‘Ho ho,’ or ‘Ha ha,’ or ‘Hee hee.’”  I tried this.  It actually worked–at least for a few minutes.

Find a Laugh Buddy

Ask a friend to practice laughing with you.   You can call each other; text each other;  email each other; send daily jokes;  just show up laughing.   It can’t hurt.  If any of my friends who read this want to be my laugh buddy, send me an email.  Otherwise, I will assign this one to the stalwart husband.

Share a Joke

Adam and Eve said, “Lord, when we were in the garden, you walked with us every day. Now we do not see you. We are lonesome here and it is difficult for us to remember how much you love us.”

And God said, “No problem! I will create a companion for you that will be with you and who will be a reflection of my love for you, so that you will love me even when you cannot see me. Regardless of how selfish, childish, or unloveable you may be. This new companion will accept you as you are and love you as I do, in spite of yourselves.”

And God created a new animal to be a companion for Adam and Eve. And it was a good animal.  And God was pleased. And the new animal was pleased to be with Adam and Eve and he wagged his tail. 

And Adam said, “Lord, I have already named all the animals in the Kingdom and I cannot think of a name for this new animal.” And God said, “No Problem. Because I have created this new animal to be a reflection of my love for you, his name will be a reflection of my own name, and you will call him DOG.” 

And Dog lived with Adam and Eve and was a companion to them and loved them. And they were comforted. And God was pleased. And Dog was content and wagged his tail.

After a while, it came to pass that an angel came to the Lord and said, “Lord, Adam and Eve have become filled with pride. They strut and preen like peacocks and they believe that they are worthy of adoration.  Dog has indeed taught them that they are loved, perhaps too well.”

And God said, “No Problem! I will create for them a companion who will be with them and who will see them as they are.  The companion will remind them of their limitations, so they will know that they are not always worthy of adoration.”

And God created Cat to be a companion to Adam and Eve.  And Cat would not obey them.  And when Adam and Eve gazed into Cat’s eyes, they were reminded that they were not the supreme beings. And Adam and Eve learned humility. And they were greatly improved. And God was pleased. And Dog was happy.

And Cat didn’t give a **** one way or the other.

Gets me every time…Happy Sunday!!

Image by Jake May via Flickr

Image by Digging for Fire via Flickr

Social Security Online Simplifies Life

Wahoo!  Yeehaw!  The bad old days of standing in  line at the Social Security Office are a thing of the past.  The Social Security Administration website now gives you access to your information through “my Social Security” and allows you to make changes from home.  There’s no need to drive to a local Social Security office or wait for an appointment with a Social Security representative.

Set Up a “my Social Security” Account

To create an account, go to socialsecurity.gov/myaccount. You must provide some personal information about yourself and give answers to some questions that only you are likely to know. Then, you create a username and password that you will use to access your personal online account.   You can create an account only to gain access to your own personal information.  You must provide the following information:

- Have a valid E-mail address,
- Have a Social Security number,
- Have a U.S. mailing address, and
- Be at least 18 years of age.

It took me about two minutes to set up my account and get my information.

Services Provided by Social Security Online

Once you have set up an account you can do any of the following:

• Apply for Benefits:  Social Security offers an easy online retirement application.  
• Get Your Social Security Statement: The one that is mailed every year and gets lost in your files.
• Appeal a Decision
• Find Out if You Qualify for Benefits
• Estimate Your Future Benefits
• Check Your Application Status
• Get your benefit verification letter (includes Medicare and SSI);
• Check your information, benefits, and earnings record;
• Change your address and telephone number; and
• Start or change your direct deposit.
• Block Electronic Access to Your Information
• Apply for Medicare
• Learn About Survivors Benefits
• Get a Form or Publication
• Locate a Social Security Office
• File W2′s for you Employees

You can even research baby names!

Access Additional Services

You can also access services for businesses, governments, payees and third parties

View from Office Window of ElderAuthority

A reader sent the attached video of  87-year-old gymnast Johanna Quaas to me.

• Johanna Quaas appeared in her first competition in 1934.
• In 1945 she finished her job training as gymnastics coach.
• She co-authored the gymnastics text book Gerätturnen.
• In 1961, she also coached gymnasts, including two women who were later nominated to start at the 1964 Summer Olympics.
• In 1982, at age 57, Quaas returned to training and won at the VII. Turn-und Sportfest der DDR in Leipzig.
• After the German reunification she also started at all Deutsche Turnfeste since 1990.
• On September 13, 2012 it was announced that Quaas will receive an entry in The Guinness Book of Records as oldest gymnast in the world.

It is time to “Get Up Offa That Thing” and go for a walk, take up swing dancing, or ride a bike.  Spring is finally here!

Family of Canadian Geese, Ann Arbor Bike Ride, Spring 2013

CareZone Logo via CareZone.com

Continued from CareZone: Eldercare Harbinger of Hope (Part 1)

World’s Oldest Social Network

Jonathan Schwartz, the former chief executive of Sun Microsystems and co-founder of CareZone, says, ”The world’s oldest social network is the one you were born into – your family.”  The New York Times calls Care-Zone the “Anti-Facebook”.  How refreshing–a social network that doesn’t blab your private business to the world!

CareZone is a service that enables families to organize care of their loved ones. CareZone provides secure storage of patient information like medical records and prescriptions, plus critical phone numbers and digitized documents associated with care, such as insurance information. There is also a journal feature, for keeping notes on a patient’s condition and a calendar for future appointments and coordinating schedules.

Talent and funding is finally surfacing in private enterprise to solve the overwhelming issues we face as 78 million Baby Boomers age.  Entrepreneurs finally understand the potential profit in solving eldercare problems.

Crossing the Caregiving Chasm

Crossing the Chasm was a 1990′s marketing book by Goeffrey A. Moore.  This book identified the chasm between early adopters of new technologies (the visionaries) and the early majority (the pragmatists).  If a successful firm can create a bandwagon effect in which enough momentum builds, then the product becomes a de facto standard. However, Moore’s theories are only applicable for innovations that force a significant change of behavior by the customer.

Every family caregiver experiences similar challenges such as coordinating schedules, maintaining records, keeping contacts up to date, finding notes when you need them, preserving privacy, gathering resources, and, most challenging of all, finding and coordinating help.  The beginning caregiver is stunned and confused.  The experienced caregiver simply wears out.

We all need a map for caregiving that helps us create a plan.   Once we have a plan, any plan, we heave a sigh of relief and begin doing, doing doing.  Others offer to help, but the weight usually falls on the primary caregiver in every family.

CareZone may be the catalyst that projects the caregiver over the chasm from individual doing to true family caregiving.

Process Change

When a family caregiving crisis strikes, such as Mom breaking her hip and not being able to live alone any more, the response of adult children can range from complete denial to one sibling taking on guardianship and control that alienates the rest of the family and deprives the parent of independence.  Most family caregivers mean well but in the end fall back on the mantra, “I just do the best I can in an imperfect situation”.  Small comfort.

There is a desperate need for tools that can help caregivers centralize and share information while guaranteeing privacy.  CareZone stand out because it uses familiar technology and tools to build accountability into the process.

Technology Drives Accountability

Caregiving is lonely, expensive, and time consuming.  Some caregivers quit their jobs; others refocus their entire lives.  One reason we have not solved this problem is because we have not had ubiquitous, affordable, secure technology platform on which to build in a structure for sharing the load of caregiving.

Enter Smart Phones, The Cloud, Health Records Systems, and CareZone. For the price of a smart phone you can use CareZone’s very private social network to share information within families.

Professional caregivers charge $12 to $30 per hour.   Most of us simply can’t afford that.  While the main CareZone application is free for up to five individuals under care, it will costs $5 a month or $49 a year to use CareZone for five to 10 people. From 10 to 100 individuals, CareZone charges $25 a month.  Hmm, let me see…$25 per hour or $25 per month?

With CareZone, the family actually can take care of its own without turning any family member into a victim. Perhaps the tech savvy 19-year-old grandchild installs the app, inputs key information such as prescription dosages, and sets up family member on their smart phones. Then, the primary family caregiver identifies everyone who might be able to help AND ASKS FOR THE HELP.  Primary caregivers become project managers rather than road kill.

Even the greatest Luddites use smart phones.  Helpers can volunteer for appropriate tasks as well as look up records, calendars, and assignments.  If the assigned person cannot make it to the doctor with Mom, someone else can jump in.  The data is all there.  All you have to do is listen carefully during the appointment and make notes that the rest of the team can access.

Slackers, and we know who they are, have a much more difficult time avoiding responsibility.  Everyone can contribute in some way.  If you live far away, you can send money.  If you have a full time job, you can volunteer to do the bills at night or on the weekend.  If you are unemployed you can be the driver for doctors visits and the family can pay you a fee for each service. Every situation is different.  Every family has to figure it out. Every family can become closer by collaborating with usable tools.

CareZone is a teeny, private start-up, piloted by some very savvy technology leaders who have experienced the problem they are trying to solve.  I am betting they will succeed. It is available for the iPhone and Android (as of this week), in English and Spanish.

This is a video of  CareZone BroadCast which demonstrates how easy it is to use this product.

CareZone Logo via CareZone.com

Seeking Better Ideas for Caregiving

In 2004 the increasing frailty of my parents dramatically changed my life.  After 28 years working in the New York metro area (first in the arts and later in bleeding edge software development), I moved to Dallas, Texas, where I grew into my role as primary family caregiver, a role I maintained for the succeeding seven years.  As I learned about caregiving, I changed my career trajectory to address problems I experienced, and committed myself to figuring out better ways of aging for my parents’ generation, their children, and their children’s children.

Like every other caregiver I have ever met, I was not prepared.  When I began to look for help I stumbled and scrambled for solutions until I eventually learned enough to manage competently.   Recognizing how poorly equipped we are as a society to meet the needs of 78 million aging baby boomers I began a quest for “Better Ideas for Aging.”  ElderAuthority.com was founded as a way to collect and share best practices as well as challenge readers to develop and contribute new and better solutions for the problems that are in danger of overwhelming us.

Meeting Basic Family Caregiving Needs

When I realized that caregiving basics could be taught I designed and taught seminars as well as a full semester class on eldercare planning.   For those classes, not finding tools that met my own caregiving needs, I designed a series of Excel spreadsheets to record essential information.  Data collected included the following:

• Important personal information such as Social Security Number, insurance policy information, blood type, personal contacts
• Current and past medications
• Insurance information
• Medical history
• Family health history
• Bank accounts
• Location of important documents
• Passwords
• Contact info for key professionals such as doctors, accountant, banker, attorney

I used these sheets to record my parents’ information and took the sheets with me to all their appointments.  I also used the sheets to capture my own information and kept it in a red folder by the front door.  When I broke my ankle, I only remembered to grab my purse and that red folder on my way out the door to the hospital.

Discarding Unsatisfactory Solutions

At that time no one in my family was using a smartphone and “The Cloud” had not been christened yet.  My system worked as long as I had the discipline to keep information updated.

I found the challenge (time and energy sap) of keeping my four siblings in the loop more exhausting.  Each call and email contained similar types of information, but everyone wanted to discuss, analyze, recommend, worry out loud, and drain my emotions.

How I wished I had a better system.   Periodically some new product would hit the market, but they all seemed just as much trouble as my paper system.  The biggest challenge with any shared technology was that my family members were all reluctant to communicate in any way except the telephone.

This week, a girlfriend was sharing her trials and tribulations as the on-site caregiver for her mother.  She recommended I check out a new social networking tool that she and her brothers were using to provide shared support.

I believe that with this product, CareZone, technology has finally caught up with one of the critical needs of modern day caregivers.

CareZoning Into Modern Day Eldercare

CareZone solves four critical problems with which caregivers have struggled: Privacy, Shared Access, Shared Accountability, and Ease of Use.

It offers the following features:

• Journal: Share thoughts with other stakeholders.
• Uploaded Files: Share any kind of document with others on the team, with separate security for each file.
• To Do’s: Caregiving doesn’t get done without check lists.  Even better, the lists help share the accountability for who does what.
• Helpers: Nope, you cannot do it alone.  Don’t even try.  It will literally kill you. If you don’t have helpers, it is time you found them.
• Calendar: Everyone who needs to know knows when things are scheduled…and who is accountable.
• Notes: Good place for instructions or any other information you want to keep and share.
• Contacts:  Everyone needs access to the same list of essential contacts.  Enter information once and only update it when a new person joins the discussion or team.
• Medications:  Medications change all the time.  Every member of the team needs to be able to view the list up on a smart phone or print it before visiting any medical practitioner.

CareZone: Harbinger of Hope for Eldercare (Part 2) provides a detailed look at why this is a breakthrough product.

Michigan Advocates April 29 2013

ElderAuthority.com is an active participant in Alzheimer’s disease advocacy.  We recognize the urgent need for the funding at the national level to find a cure for this dreadful disease.  Last week’s 2013 Alzheimer’s Forum in Washington, D.C. spread the message to legislators on Capital Hill.

Alzheimer’s Dangerous Message

What you now need to know is that Alzheimer’s is the most expensive health crisis in America and is increasing like no other.

Associated Press – April 4, 2013 “…Alzheimer’s is the most expensive malady in the U.S….”

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Bloomberg – April 4, 2013 “…exceeding that for heart disease and cancer…”

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The New York Times – April 4, 2013 “…skyrocketing at a rate that rarely occurs with a chronic disease.”

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In the past 30 minutes, Alzheimer’s has cost the United States of $11 million and 26 more Americans have developed the disease.

The Latest Alzheimer’s Data

Demand Funding for Alzheimer’s Research

National Institutes of Health (NIH) Alzheimer’s Disease Research funding for a cure is minuscule compared to the amount of Medicare and Medicaid resources thrown at treatment.  We MUST find a cure.

NIH Alzheimer’s Data

Source: Alzheimer’s Association, 2013 Facts and Figures; National Institutes of Health