By Dana Goldman
The time is ripe for a new frontier in medicine.
Pitting himself against the ‘American immortal,’ Ezekiel Emanuel famously wrote an account in The Atlantic about why he hopes to die at age 75. His argument focuses on the decline (both mental and physical) that — he posits — inevitably occurs with age: there is despair, depression, and the social and economic costs on families, the healthcare system, and society-at-large. Why put your family through this when you have already lived a full, vibrant life up until 75, he asks?
In seemingly complete contrast is the ‘Silicon Valley immortal’—venture capitalists, researchers, and inventors who have put millions of dollars into research to slow, compress, or stop aging entirely. Recently written about in The New Yorker, these entrepreneurs envision a future in which aging is voluntary and death escapable. They are seeking the magic combination of genes, supplements, and pharmaceuticals that will mean they can stay in their prime.
It isn’t just Silicon Valley elites though. Last year the National Academy of Medicine launched a Grand Challenge for Healthy Longevity. They hope to raise $25 million to advance research aimed at improving human longevity and quality of life.
Though ostensibly at odds with each other, both Emanuel and the so-called American immortals are in many ways focusing on the same problem: today, aging is synonymous with more disease and more disability.
It’s true that over the last fifty years advances in medicine have improved outcomes and extended lives. Diseases once considered death sentences are now livable chronic conditions: people are living long lives with heart disease, diabetes, and many types of cancer. But, this success has coincided with increased rates of disability, and these trends are expected to continue. In previous research my colleagues and I have estimated that by 2030, 34 percent of individuals aged 65 and older will be living with disability. Furthermore, though life expectancy continues to increase, years of life with disability are increasing too– from an estimated 7.4 years in 2010 to 8.6 years in 2030.
The more appropriate question then – and the inherent disagreement between the person who wants to live to 75 and the person who wants to live forever – is whether investment in research in delayed aging and prevention is of value today.
To answer this, let’s first look at life expectancy. In many ways, the fatal flaw in Emanuel’s argument is its short-sightedness. Had he opined on aging in 1915 instead of 2015, chances are he would have said he wanted to live to 55, theoretically missing out on 20 years of life he now values. As a society had we thought like this we would have missed out on innovation and improvements in medicine and public health that has now made living to 75 in good health very doable. Or longer for that matter. A recent survey found more than a quarter of individuals 85 years of age or older report having excellent or very good health and more than half report no health based limitations in housework or work.
Furthermore, cost-effectiveness analyses of medical innovation have shown significant positive value. The improvements in treating HIV and Hepatitis C are two noteworthy examples. Even in cancer, which many point to as the war that hasn’t been one, the value to society from improved survival rates is high.
Yet, it would be myopic to not recognize that the trends in rates of chronic disease and disability point to diminishing returns for this current disease-based model. I would argue, in order for progress to continue we have to change the paradigm, and Silicon Valley is yet again leading the way in this regard.
Rather than focusing on specific diseases in isolation, delayed aging takes a comprehensive approach to alter the biological aging process and the onset of aging associated diseases. In practice this means having the body and mind of someone who is years younger than the majority of today’s population at one’s chronological age and spending a larger proportion of one’s life in good health and free from frailty and disability.
Experimental studies involving animal models have already succeeded in accomplishing this in the laboratory. By manipulating genes, altering reproduction, reducing caloric intake, modulating the levels of hormones that affect growth and maturation, and altering insulin-signaling pathways, scientists have managed to extend the healthy lifespan of invertebrates and mammals. In addition, there is evidence that centenarians (whose longevity is at least partially heritable) often have delayed onset of age-related diseases and disabilities, which suggests that they senesce (grow old biologically) more slowly than the rest of the population. The quest from Silicon Valley is to extend these successes to humans.
Our research shows the payoffs to society could be well worth it. Using the Future Elderly Model, a policy simulation tool developed with support from the National Institute on Aging, we examined what would happen if the promise of some of the more optimistic biological experiments with animals could be replicated in humans. We found that people could live more than two years longer (equivalent to a decade of demographic progress), but — even more importantly — we could reduce disability at the same time.
Appropriately valuing these health gains suggests over $7 trillion in benefits to society. Adding in the cognitive and social benefits from a healthy older population would only increase the returns. Thus, even if the likelihood of success is low, it is clear that this scientific quest is worthwhile.
We also don’t need to wait for a biological breakthrough. Recent studies in cancer, diabetes, heart disease, and stroke have shown that as much as 20 to 40 percent of the risk factor for these diseases can be accounted for by lifestyle factors- a healthy diet, regular vigorous exercise, limited alcohol intake, and abstaining from smoking. If elderly Americans were to simply adopt a healthier diet and lifestyle, putting them on par with the health status enjoyed by their western European counterparts, our projections estimate it would save as much as $1.1 trillion in discounted total health expenditures over 45 years. A health system focused on delayed aging would couple evidence-based prevention strategies and public health investments with bio-innovation to lengthen the years lived healthy and disability free, thereby compressing sickness to the very end of life.
Of course, the increase in the elderly population also adds substantial cost to public programs, leading to the question of whether we can afford the investment. According to our delayed aging scenario, we projected delayed aging would add nearly $420 billion to the entitlement deficit in 2060, 70 percent of which would come from increased outlays for Medicare and Medicaid.
Changing the eligibility requirements of some of these programs, for example increasing the retirement age for social security, may be a viable option to achieve fiscal balance. This type of policy solution may be especially warranted given the cognitive and mobility benefits that the elderly may realize from delayed aging. However, it is important to recognize the effect these sorts of policy changes may have given the social, health, and economic disparities that currently exist. Lower socioeconomic groups continue to lag behind in health and life expectancy measures compared to their high income counterparts. A future in which delayed aging increased the health of all socioeconomic groups would make these increases in eligibility ages more palatable, but policymakers should be aware of the disparities that exist and prioritize access to new innovations and interventions so disparities are not inadvertently increased.
I’ve written about healthcare’s short-termism problem before, but it is particularly relevant here, as delayed aging necessarily requires prioritizing a long-term view of health. Given the current payment models in healthcare, as well as our collective inability to prioritize future gains over immediate rewards, this change is no small feat. To quote The New Yorker article mentioned earlier, “…as a species, we stink at mobilizing against a deferred collective calamity (see: climate change).”
The time is ripe for a new frontier in medicine. Given the recent advances in genetics, we might be closer than we think in unlocking the mysteries of human aging. Emanuel might want to hold off before he punches out at 75.