The institutions were supposed to turn over, and grown organs made it optional

There is a regional health board I have watched for most of my writing life, and for the better part of that time it has seated the same seven directors. I will not pretend this is scandalous on its face. They are competent people. Attendance is excellent. The minutes are tidy. The chart tells a different story: no seat on that board has been vacated by resignation, by vote, or by death in over two decades.

That last clause is the interesting one. For most of the history of institutions, death did the pruning nobody had the nerve to do. A director's heart would announce its retirement for him. A chair would develop the kind of cough that ends careers, and the seat would open, and the young and the hungry and occasionally the better-qualified would move up a rank. It was cruel and arbitrary, and it worked the way forest fires work — not kindly, but on schedule.

We put out the fires, and I count that to our enormous credit. I spent the early part of my career handing people hearts we grew to fit them. I have written, happily, about clinics that now take the cases the old transplant lists turned away. Nobody on that health board is kept from serving by a failing organ, because we do not let organs fail the way we used to. The therapies the Meridian Longevity Institute made famous (and their Earthside imitators have since made ordinary) do the rest: a director who might once have slowed at seventy now chairs committees at a hundred and ten with the resting pulse of a swimmer.

I want to be clear that this is a success. It is my beat's proudest one. It is also, like most successes in medicine, a problem nobody thought to fund.

The retirement we removed, we never replaced

When we subtracted mortality from the governance equation, we did not add anything back. We assumed renewal would keep happening because it always had, the way you assume your knees will keep working because they always have. They do not consult you about it. One of the board's younger applicants — younger meaning she is in her sixties — told me she has reapplied through four open calls that were not, in any meaningful sense, open. "They thanked me for my interest each time," she said. "The interest is not the problem. The vacancy is the problem."

The fix is not to wish death back onto directors. I have delivered enough honest prognoses to know that nobody volunteers for that one, and I would not ask them to. The fix is to decide, on purpose, what the fire used to decide by accident: term limits that bite, mandatory rotations off, and — this is the part everyone skips — somewhere meaningful to rotate to. Succession written as a designed process with dates in it, not an event we wait on nervously like weather.

A body that never replaces its old cells gets cancer. I have made that comparison before and I stand by it. An institution that never replaces its old leaders gets something similar, and we have not grown the therapy for that one. What we can grow is a calendar. The seven directors meet again next quarter. The agenda, I am told, does not include their own seats.