By Joan Hamilton
Illustration by Matt Bandsuch
As the 20th century dawned, hopeful immigrants streamed into Chicago, New York, Boston and other American cities by the millions.
What they found was an often chaotic, dangerous and, certainly by modern standards, unhealthy scene. Horses and mules pulled wagons through muddy streets, and feral dogs fought over garbage. Contagious diseases spread overnight through overcrowded tenements and neighborhoods, often via contaminated water supplies. Charlatans peddled health nostrums better suited to stripping paint than treating people. A quarter of all babies born into this world died before they were 5, and 20 percent of children were orphaned before they reached 18. Overall, life expectancy in the United States was 47.
A mere 100 years later, more than 99 percent of babies born today in the United States make it to their fifth birthday. Life expectancy hit 77 in 2000 and continues to climb. Where did those 30 years come from? Improved sanitation, vaccinations, antibiotics, nutrition and refrigeration all gradually ganged up on the infectious and toxic killers so devastating to infants and children.
However, as the 21st century gains steam, America is grappling with a fascinating and difficult new challenge of life expectancy — one created by all those babies living. By 2030, the nation will experience a near-doubling of the number of people over age 65, to 70 million. The strains that demographic shift portend are profound, particularly in medicine and the delivery of health care. Health-care costs already comprise 16 percent of the gross domestic product and could climb to 20 percent or more in coming decades.
The medical implications of aging are sobering enough, but they’re only part of a fast-changing national profile. The 77 million-strong baby boomers began turning 60 in 2006, and the phenomenon of a huge increase in long-lived retired people even as the percentage of workers declines threatens social programs such as Social Security and Medicare unless the funding and structure of the programs are revamped. Add to that a need for communities to better accommodate elders in term of housing, transportation and urban design, and to make decisions such as whether money should be spent on day care for the young or for the old.
One irony of the dramatic changes we’re facing today is that the aging of the U.S. population snuck up on us about as subtly as a herd of buffalo. Certainly, the culture is already responding in a few obvious ways. Advertising mushrooms for everything from adult diapers to golf course communities to investment ideas for growing those retirement funds. And a slew of disparate, so-called anti-aging medical treatments from Botox injections to Viagra to cosmetic surgery solutions represent big markets that are growing fast.
But at Stanford, psychologist Laura Carstensen, PhD, is determined to marshal the best experts from myriad fields that stand to improve the course of human aging in far more fundamental ways. And in short order. While many academic centers focus on aging and gerontology, she has created a new model for looking at the challenges facing long-lived people throughout their life spans at the now-2-year-old Stanford Center on Longevity. And she is committed to pressuring societies worldwide to shift pervasive views of old people as helpless and infirm to what she believes is a more accurate profile of older people as both able and valuable — not to mention worthy of accommodations science and technology can provide to help them. In that quest, this Stanford professor of psychology is flying around the world sounding the call for comprehensive and speedy attention to the most pressing needs of our aging population.
Carstensen says her energy and optimism are rooted in what the United States has accomplished in the past 100 years. “It was really cultural change that saved those babies in the 20th century,” she says. “At some level, individuals, communities and policy makers accepted the notion that it made sense to pursue the science and embrace the technology that made life safer and healthier for everyone. Otherwise, our society would not have experienced the dramatic increase in life expectancy that it did.”
While she notes that saving babies was not a specific, integrated strategy, she says Americans’ can-do, largely democratic attitude toward things like improving public health for everybody was a model for what we need now. “At the turn of the century, babies were viewed as pathetic little creatures, sick and frail and vulnerable. Society did not view them as a source of hope and possibility as we do now. Much of the world sees old people the same way today, as sick and vulnerable. If we ask, ‘How is the world failing old people?’ you’ll start to get answers. You’ll see us solve Alzheimer’s disease and even hearing loss in the same way that we eliminated rickets or other childhood illnesses that used to afflict those babies.”
The problem is we don’t have much time, says Carstensen. “We have to accelerate these solutions and we have only about a 10-year window before the impact of the aging population increase hits hard.”
An embrace of technology and public health efforts was far from uniform around the globe in the last century. Indeed, life expectancy surged in the United States and many Western countries, but in many countries in Africa, the Middle East and parts of Asia, no such will developed to broadly implement public health measures, medicines and other benefits of technology. As a result, birth rates remained high, but life expectancy did not climb. That scenario characterizes volatile, unhealthy populations such as conflict-wracked Sierra Leone, for example, which still loses almost 30 percent of its children before age 5. China and Japan, meanwhile, rapidly grow top-heavy with older people who cannot work.
The United States is aging more slowly than Western Europe, China and Japan, thanks largely to immigration. But plenty of economists and others have been predicting big trouble anyway: In his landmark 1999 book Gray Dawn, Peter Peterson, former chairman of the Blackstone Group, says the financial consequences of soaring populations of old people mean, “If we do not reform tax and spending policies, the benefit outlays for just five programs — Social Security, Medicare, Medicaid and federal civilian and military pensions — will exceed total federal revenues by the year 2030. This would leave zero tax revenue for any other purpose — not even for interest payments, nor for national defense, nor for education, nor for child health, nor for the federal payroll,” writes Peterson. Not all observers agree that the economic impact will be catastrophic, but most agree the structural design of these programs will buckle under the weight of so many older people. Stanford’s Charles R. Schwab Professor of Economics John Shoven, PhD, has written that Social Security’s “financial problems are compounding with daily interest” and that an aging population means we face an inevitable choice: Raise contributions, curtail benefits or both.
“What we have to do today,” says Carstensen, “is re-engineer society so that it supports satisfying, independent and healthy lives for older people.” For example, all signs point to the reality that most people will no longer be able to retire at 65. “Retirement is really a 20th-century invention,” says Carstensen, one that evolved indirectly from Social Security. Previously, people did not retire; they worked as long as they could in a primary job, then they had to pull back and perform other tasks on the farm or for the household until they finally became too sick or weak to do that. In all likelihood, today’s boomers will lack the financial reserves to stop working at 65 and then support themselves for what is now typically almost another 20 years. Ideally, employment should be restructured so people work at their peak levels while they’re able, and move to gradually less-taxing jobs as they age. Achieving that in practice is not a matter of passing a law. It involves changing social attitudes about the value and contributions of older people, changing retirement policies and tax codes, and rethinking certain jobs to make them more accessible to older people.
Carstensen sounds this clarion call in speeches, in frequent press interviews and in her advisory role to numerous projects involving aging, such as the Steering Committee for the National Academy of Sciences Keck Futures Initiative, shaping interdisciplinary solutions on aging. “I topped 100,000 frequent flyer miles for the first time, last year,” she says. On these trips, she exhorts academics in disciplines from economics to medicine to push ahead with research on strategies to get children to eat properly, exercise and stay in school. Such activities help individuals age successfully. And she is using the center’s prominence to engage thought leaders in important conversations.
There is little argument, for example, that medicine falls short in the expertise needed for coping with soaring ranks of elders. In England, for example, which is also aging rapidly, geriatric medicine now represents the second-largest medical specialty. But in the United States we have perhaps 5,000 geriatricians at best, says Robert Butler, MD, head of the New York-based International Longevity Center-USA, a policy and education organization. “Only 11 of the nation’s 145 medical schools have a department of geriatrics,” he says, adding that an even bigger problem is that there are so few geriatricians available to train a new generation of doctors about to confront more and more older people.
Geriatricians aren’t the only physicians in short supply. Overall, studies have predicted a dearth of all physicians in coming decades, with one government report predicting the United States will be short 24,000 physicians by 2020, largely due to the aging population. The American Medical Association has called for medical schools to increase enrollments by 15 percent in coming years. Meanwhile, some medical leaders debate whether medical schools should do more to promote geriatric medicine as a specialty or instead integrate geriatric concerns into the training of doctors in every specialty.
Like most U.S. medical schools, Stanford has no department of geriatrics and offers no courses on geriatrics. Instead, it incorporates lessons on caring for aging patients across the curriculum. The medical school’s dean, Philip Pizzo, MD, plans for these lessons to expand. “Understanding aging in multiple dimensions will increasingly be a part of the curriculum for medical students, both during their preclinical and clinical studies,” he says.
And unlike many medical schools, Stanford provides specialty training in geriatrics — three fellowship programs led jointly with the Veterans Affairs Palo Alto Health Care System.
Still, it’s doubtful such fellowships will ever train enough people in the field of geriatrics to make a difference, says Peter Pompei, MD, associate professor of general internal medicine and director for resident rotation in geriatric medicine at Stanford. “So, many of us have shifted to preparing our colleagues for the special needs of this increasing population,” he says.
One way to compensate for thin physician ranks is more team-based care for patients with chronic disease, which afflicts more than 80 percent of older people. In this model, patients meet regularly to share their experiences and ask questions of a team leader, who might be a nurse or social worker. “The key is to give optimism, support and learning,” says Halstead Holman, MD, the Berthold and Belle N. Guggenhime Professor of Medicine. “All structures and training in health care were designed to deal with acute disease, where you approach people with a cure,” Holman says. “We didn’t adapt the system to the new challenge” of preventing chronic disease and keeping patients with it functioning and comfortable. “We don’t need more buildings or more high tech, we need a change in attitudes and behaviors.”
One interesting approach in that vein is Mount Sinai’s new Martha Stewart Center for Living, in New York City, which gives seniors a full medical assessment as well as access to social workers to help with the social and financial challenges they face. The center seeks to create a complete life plan designed to keep them as healthy and active as possible for as long as possible, explains Brent Ridge, MD, an assistant clinical professor at Mount Sinai and a vice president at Martha Stewart Living Omnimedia. “The idea behind our center is to maintain a person’s functionality. We have a very team-based approach with doctors, nurses, social workers and medical students.”
The Center for Longevity supports the development of such models, but it sees needs far beyond health-care delivery. Center affiliates come from every school at Stanford, from law to earth sciences. They are working on a startling variety of projects. Thomas Andriacchi, PhD, professor of both biomechanical engineering and orthopedic surgery, is developing a shoe that shifts the pressure in an arthritic knee so that a wearer of any age can keep exercising and postpone taking painkillers. Meanwhile, Thomas Rando, MD, PhD, associate professor of neurology and neurological sciences and the center’s deputy director, is conducting basic research at the cellular level into the mechanisms of wound repair, a process that degrades in older people. Economists such as Shoven and Alan Garber, MD, PhD, both center affiliates, are looking at big-picture economic impacts of aging on social programs and health-care funding.
Cartstensen’s motivation to address the repercussions of longevity began with a traumatic experience. Early in her 20s, she was in a serious car accident that left her hospitalized for months, convalescing alongside many elderly people. She had a sense that while the health-care system was invested in helping her overcome her injuries, it had given up on older people around her who actually were capable of much more. “They were being conditioned to believe that they couldn’t do things, so they became passive,” she observes.
So today, keeping older people independent is one of her most passionate goals. Carstensen, whose own research has focused on emotions and decision-making over the span of life [see “The positivity effect”], hopes to use the center as a laboratory to figure out the levers and mechanisms for changing the culture and motivating people to act in their own best interests. “We must figure out how to change the mind-set of entire families, spanning generations, so that going forward each member has the best possible chance to be healthy and independent for as along as possible,” she says. And since the cost of dealing with the sheer number of people who are suffering the effects of obesity, poverty, dementia and other debilitating conditions as they age is going to explode, we literally cannot afford to give up.
It happens that Stanford is home to some of the nation’s leading thinkers about virtually every consequence of long life. When James Fries, MD, Stanford professor emeritus of immunology and rheumatology, first became an advocate for health promotion programs for seniors in 1980, he says it was a controversial notion. At the time, Fries explains ruefully, urging seniors to change their lifestyles was not only considered “too little too late” and a waste of time, some in medicine viewed the exercise and nutrition ideas he advocated as potentially harmful to society. As scientists worked to unravel and treat disease, the presumption was that life expectancy might very well keep increasing indefinitely. Therefore, “the danger was expanding decades of misery,” Fries, an affiliate of the center, says. “Some people accused me of ‘blaming the victims of aging’ for even suggesting that seniors should exercise to improve their quality of life.”
But Fries’ argument was just the opposite. He believed that life expectancy was not going to keep going up indefinitely. The improvement in life expectancy that occurred in the last century occurred not because old people keep getting older — maximum life span has changed very little in the last 100 years — but because so many more children and young people made it to mid- and later life. What Fries was seeing as a specialist in arthritis, however, was that patients who exercised regularly and took care of themselves felt better and were more mobile and independent much longer than patients who didn’t. He believed the goal should be to “compress morbidity,” meaning delay the onset of debilitating conditions such as loss of muscle strength and mobility, heart disease and other problems, thus shortening the period people would be weak and enfeebled as they grew older, but not necessarily prolonging their lives. The compression-of-morbidity hypothesis has become the basis for many health promotion programs across the country. Right now, Fries is involved in a Medicare-sponsored clinical trial of 85,000 seniors to test health promotion strategies that rely on exercise and improved access to health information. The trial assesses the cost of these approaches and their success at postponing disability. If Medicare can achieve significant cost savings over the next few decades, he says, the tailing off of the baby boom population around 2050 could again restore the worker-to-elder ratio that can keep the system in better balance.
Professor of immunology and rheumatology Kate Lorig, DrPh, who has pioneered new care models for arthritis patients, says she has seen a slow but important change across medicine. “We’re now assuming all patients are going to live a long life. We’re not giving up on people. We want everyone to have the best quality of life for the longest possible time.” Like more and more medical specialists addressing an aging population, she believes it’s critical to start early: “You can’t convince a kid that he or she should exercise so they don’t get arthritis in 50 years. In fact the idea of doing anything for the ‘disease of the month’ doesn’t make sense to me. A healthy life begins with prenatal care and establishing good nutrition in schools. You have to do everything with a healthier lifestyle in mind.”
As one navigates through the longevity world, the ways in which the medical, financial and even motivational dimensions of aging overlap are inescapable. Sometimes, they collide in the political arena. Last October and December, the Stanford Center on Longevity sponsored a series of working meetings between leading health-care economists, psychologists, political scientists, political lobbyists and pollsters, aimed at offering hard data and innovative thinking to reform health care.
The center’s Health Security and the Presidency Project will work to break through the impasse over U.S. health-care policy. “Financial security is a linchpin for healthy and successful aging,” explains Jane Hickie, senior research scholar and director of public initiatives at the center. “We determined that health care, both access and cost, represents one of the biggest threats to that security for millions of older Americans. However, it’s one of those issues in politics that candidates tend to tiptoe around — because specific proposals can generate a predictable, divisive response from the opposition as soon as you take a stand.” For example, many economists say that there is no way to keep Medicare solvent without raising taxes and decreasing benefits. The center is working with experts to develop polling data to unearth what specific trade-offs the electorate would be willing to make. “This data could provide some political cover for real action,” notes Hickie.
Most longevity experts say that with the exception of a few specific locales such as Florida, which has an enormous senior citizen population, communities and states have barely begun to appreciate, much less plan for, the coming demographic changes that threaten to undermine their economies and social fabrics.
Clearly, Carstensen’s evangelizing is just beginning. But one promising sign is that she’s starting to get a few exploratory calls from Ivy League schools interested not only in aging, but in the Center on Longevity model — an approach focused on using academic research and technology to make life better for everyone, old and young alike.