GUEST: Dr. Robert M. Butler
AIR DATE: 11/14/09
I’m Richard Heffner, your host on The Open Mind.
And I guess one of the most pressing questions before us all today is whether we Americans can afford old age.
Having gotten so long in the tooth myself, of course, my answer is that I very much hope so … but I wouldn’t be all that much surprised if we can’t, or at least don’t!
My guest’s answer, of course, is very much more informed. For Robert M. Butler – physician, gerontologist, psychiatrist, founder of the first Department of Geriatrics in a US medical school … at Mount Sinai Medical Center – is now President and CEO of the International Longevity Center.
In 1976 Dr. Butler won the Pulitzer Prize for his “Why Survive? Being Old In America”. And Public Affairs has just published his “The Longevity Revolution. The Benefits and Challenges of Living a Long Life”.
Well, our last Open Mind conversation came almost a dozen years ago, to be sure, and I would now ask my guest whether I’m correct in detecting a bit more optimism in his new book … more, I’m afraid, than I find in my own thinking about longevity. Bob, more optimistic?
BUTLER: I am more optimistic. As I mention in the book, you know the truth is there’s an extraordinary new body of emerging knowledge, from very diverse schools of economic thought. Conservative University of Chicago, Rand Corporation, Harvard, Yale, Belfast in Ireland, our own International Longevity Center … showing that, in fact, aging, longevity and health create wealth. Now we all know that as societies get richer, assuming they’re a benign government, they’re more apt to provide more benefits for their people.
But that the reverse is true. As societies get older, they’re richer and create more wealth is a relatively new idea. But there are studies, for example, out of Harvard that show those nations that have a five year advantage in life expectancy have a great, more rapid GDP.
And if you want me to tell you why this is all true … I will.
HEFFNER: Please do.
BUTLER: Okay (with a smile).
HEFFNER: Because I wonder and I don’t mean to stop you from telling me why, I wonder then why we’re, we have declined in our place in the world in terms of growing older.
BUTLER: Well, we have declined in life expectancy. That’s sadly true. We’ve fallen from 11th place to 42nd place. But that’s in part due to poverty, to the unavailability of health insurance, race and other factors which are very genuine and must be examined because it’s shocking that people in Jordan live longer than Americans.
When we clearly … we have to have health reform. To go back to the issue of the relationship of health and wealth. Follow a child who’s healthy. If they’re healthy, they’re more apt to be a healthy adult. If they’re a healthy adult, they’re more apt to have had a better education, they’re more apt to have had a better job; they’re more apt to have saved more money, invested more and had a more productive old age.
Now if you add that up collectively, a whole body of people, you can begin to see how individual health relates to wealth.
But the other big thing is what the Japanese call the “silver market”, we call it the “senior market”. Just as there was the youth market in the nineteen sixties that the people profited from, think of it, when you buy financial instruments … you’re thinking about the future, thinking about your first home, your children and your retirement. You’re thinking ahead.
Health care industry, the pharmaceutical industry, hospitality, travel … all of these are very much age related. And, you know, one person’s cost, is after all another person’s job, income, asset.
So as we examine these questions, we see that idea we can’t afford old age is, in fact, an ageist prospect.
HEFFNER: You say “ageist” …
BUTLER: Prospect …
HEFFNER: You’re the one who, who worked up that word …
BUTLER: I did.
HEFFNER: … “ageism”. What do you mean by it?
BUTLER: Prejudice with respect to age. In my original article I pointed out that old people can also be prejudicial towards young people. But that’s not the image that got captured … and when it got into the Oxford Dictionary, it was already, “prejudice with respect to age”.
But we have a lot of discrimination … on the job, in the health care industry. Just one little example in health care. We do not require … the FDA, the Food and Drug Administration does not require older people to be included in clinical trials … although 40% of all drug use is by people who are 65.
HEFFNER: How can that be?
BUTLER: Well, it’s prejudicial …
HEFFNER: How can it be? It doesn’t make sense on any level.
BUTLER: It doesn’t make any sense on any level. I’ve been fighting with the FDA about that since 1975. You can see what a failure I am.
HEFFNER: Well, I wouldn’t put it that way, because the optimism that you express now is … I gather … in your terms, founded on the researches that, as you suggest at the beginning ….
HEFFNER: … have been done and that indicate that you can have a good older life. But how good, Bob? And how old?
BUTLER: Well, I don’t want to be dismissive. The amount of suffering that a significant number of older go through, certainly with Alzheimer’s disease … which is a terrible, terrible infliction and one that we had best do something about pretty soon or it’s going to be devastating and very difficult financially because it’s a terrible, expensive condition.
Twelve to fourteen years of living in that condition … the family burden is tremendous. So I don’t want to sound so optimistic that I’m not realistic about the necessary steps we have to take. But they are do-able. When we can do …
HEFFNER: But why … let me, let me ask the question …
HEFFNER: … and then I’ll go back to the, to the …
HEFFNER: … very interesting matter of how old and what you think … do you feel … as a physician … that there is an end limit to those of us and those who came before us and those who will come after us? Do you really think there’s an end limit?
BUTLER: Well, from the point of view of genes and our genetic make-up, there probably is. We do know probably the wonderful story of Jeanne Calment the woman who lived 122 years. And, you know, but she was an outlier, she’s extraordinary. We do already though have about 80 plus thousand centenarians in the United States.
And one census projection is we could have as many as 840,000 by mid-century. That’s tomorrow.
HEFFNER: You …
BUTLER: … That’s 42 years away.
HEFFNER: You …
BUTLER: 41 years away.
HEFFNER: Is that really the fastest growing age?
BUTLER: It is the fastest growing. Usually they say, “85 plus”, but the truth is that buried within 85 plus is 100 plus. And that’s the most rapidly growing age group.
HEFFNER: Now you mean a good life? Or you mean surviving?
BUTLER: Surviving. Some have a good life, like Jeanne Calment this famous woman who lived to be 122, had a great sense of humor and lived, as I say, a very long, authenticated life. But for some, it’s tough. So we’ve clearly have to do something about dementia. In fact 75 percent of all people who become centenarians remain in good shape through their 95th year. It’s after that that things begin to really happen.
HEFFNER: So you mean I have to watch out for 95?
BUTLER: That’s correct.
HEFFNER: Not so long from now.
BUTLER: I want you …
HEFFNER: Not so long from now.
BUTLER: I want you to stay right in there.
HEFFNER: Bob, is there a … would you put an age to a natural, evolutionary based limit?
BUTLER: Probably 110, plus or minus. That would be under the most perfected, perfect conditions, of course. And some much of what we think of as the diseases of old age really have their origins in childhood. I don’t mean just the genetic things that you’re borne with, but our lifestyle, our behavior …
HEFFNER: You say in the book that about 25 percent of our aging capacity is genetic based.
BUTLER: Right. That means 75 percent is up to us. For example, osteoporosis which is the bone thinning that leads to so many broken hips, particularly in women, is really a pediatric disease. If you bank your bone during your pubescence and adolescence, have adequate supply of calcium and sunshine and vitamin D and don’t drink too much and don’t smoke, you’re not likely to get osteoporosis. It’s a childhood disease, but it manifests itself in old age.
HEFFNER: Now you and I … you not so much because you’re my junior by some years …
HEFFNER: … but we’ve seen an awful lot happen. Is your optimism based upon a sense that we are getting there to an understanding that it’s in our hands, that 75 percent of the matter of survival in a good old age is in our hands?
BUTLER: Yes, that’s what the data show.
HEFFNER: But are we getting there?
BUTLER: Well, we wrote a paper which was very painful a couple of years ago in which we predicted that the 30 year gain in life expectancy which we enjoyed in the 20th century … that we could lose three to five years of that because the rise of obesity. And we wrote a sentence that’s been widely quoted, but very painful. That this could be the first generation to live less long than their parents.
Obesity is a huge problem. And that’s, of course, within that 75 percent that we can do something about. But it’s very tough. Very tough. We’re going to have to undertake enormous changes in culture, in attitudes toward food and the economic aspects. Because you can feel full after you’ve eaten a Bit Whopper, and you can’t afford the kinds of vegetables, fruits and things that you should have to have a healthy life.
HEFFNER: Any indication that we are moving in that direction at least in terms of what your profession, the medical profession is doing?
BUTLER: Well, the medical profession has not been as good as it should be in health promotion and disease prevention. But we have an interesting Mayor in a particular city called “New York” who’s really done quite a stunning job in trying to address, trying to address the issues of, of health behavior.
And its beginning to emerge around the country and, and, you know, I’m very hopeful. I’m always hopeful that somehow or other we will arrest our previous behaviors and behave better.
HEFFNER: Bob, what’s the role of government in all, in all of this?
BUTLER: Well, we used to have, under President Kennedy, something called the President’s Council of Physical Fitness and Sport. It still exists, but it has been somewhat dormant. I would love to see it come alive. And to work with the Robert Wood Johnson Foundation with a preventive taskforce and have a national walking movement. What a step that would be.
We have these little step counters … who could be competitive … not with each other … but even within yourself to see if you could walk an average of five miles a day. It’s not so demanding as one might think. If you walk with a friend, or with a family or with a neighborhood and if we’re really get people walking, it would have a tremendous impact on the health of this country. A national walking movement.
HEFFNER: Now, movements take money.
BUTLER: It doesn’t take a lot of money, you don’t have to join health clubs or anything to walk.
HEFFNER: I didn’t mean personal expenditure …
HEFFNER: … not at all … just have a dog, as I do …
HEFFNER: … who makes me walk, walk, walk.
BUTLER: Yeah. Right.
HEFFNER: I mean instead the kind of funds that seemingly only a government can put into getting people to be aware of what it is you’re, you’re suggesting. Or dealing with your profession, the medical profession in a way that it will become the major force behind healthy living.
And why haven’t … hasn’t the medical profession been doing enough, in your estimation?
BUTLER: Well, you know, they have on average eight minutes now with every patient. It’s not much time to do much counseling.
And also, let’s be frank, doctors don’t get paid for keeping you healthy. Hospitals don’t get paid for keeping you healthy. The disincentives are powerful. It’s really when you’re sick that you make money as a doctor and as a hospital.
We really need public health authorities to take this over. We need broad efforts, by not just government, but foundations, family groups, non-governmental organizations who work together to make this major set of reforms. I don’t think it’s going to come. I hate to say it. But I don’t think it’s going to come from the medical profession.
HEFFNER: It …
BUTLER: They maybe the leaders of it, but individually, I don’t think so.
HEFFNER: Eight minutes. Why?
BUTLER: Well, a lot of it, of course, has to do with the insurance issues. The payment structures in our country, especially for primary care doctors … as you may know now, we only have about 30% of our doctors in primary care.
In Europe it’s fifty-fifty. We’re overspecialized. And that’s where the money is made. And the primary care doctors do not get appropriate payment for what they’re expected to do. So they’re under pressure and they see more patients and they see them for eight minutes on average.
HEFFNER: But isn’t this, Bob, seriously, you talk about 25% of our, of our opportunity for old age comes … determined by genetics. 70% in your hands, in my hands …
HEFFNER: Why aren’t we doing the things that can be done. You’re not saying the eight minutes are necessary. You’re talking about an attitude …
HEFFNER: … and, on the part, not only of the public, but of medical people.
HEFFNER: Can’t we do something about this?
BUTLER: Well, we are trying. I think there are seven major things. One, of course, is not to smoke. To be very moderate in the use of alcohol. To have a decent diet with at least five to seven fruits and vegetables every day. To make sure that you have a purpose in life, that’s very, very important. And having relationships … a network of friends, loved ones. That makes a difference. These are the kinds of things we need to do if we want to live longer.
HEFFNER: And the role of government in all of this? To switch suddenly?
BUTLER: It’d be … I think it’d be encouraging, it would be helpful. And I mentioned the Presidents Council on Physical Fitness and Sports could play a large role, the National Institutes of Health could, the CDC, the Centers of Disease Prevention could be spelled out more fully.
This actually is the Center of Disease Control and Prevention, but it rarely uses the “P”, it just says CDC. But we really have to get into a preventive mode in this country. It’s awful to have 10 year old children, which I see, with old age diabetes, it’s outrageous.
HEFFNER: Bob, let me go back to the beginning of today’s discussion and the question of doing something about this longevity revolution. And the fact, as you indicate, that the gap between ourselves reaching old age and many, many, many other countries is growing, to our detriment.
This talk about “Death Panels” when the Congress has been considering health reform measures … you think that’s nonsense, I know. But do you think … are you so certain that we can afford to go ahead as our friend Dan Callahan says, and I’ll be talking to Dan Callahan at this table later today, when he … I frequently say to him … “you’re not speaking as an ethicist, you’re talking as an economist”.
But he is talking about reality, he’s talking about dollars. Do you think, in terms of dollars, we can keep going the way we are going with medical inventions, trying to keep people alive at all costs.
BUTLER: Well, you’ve just said it, medical inventions. It’s not aging yet that has to do with the rising health costs. All economists agree to that. It’s new innovations, it’s new drugs, it’s new diagnostic efforts. Those are what have caused the rising health costs. And we could control them better by having cost effectiveness panels that compare a new introduction with the old. “Is it really that much better? Or are we wasting money? Do we need to spend that kind of money on things that may not do that much?”
There’s an awful lot of waste, an awful lot of things that doctors do which is not tried and true at all. But somehow got into their own habit-form. We’ve got to change all that by having means of effective control of the kinds of technologies we introduce. It’s not just age.
HEFFNER: But, let’s, let’s accept the fact that both of us …
HEFFNER: … all of us … are going to and they … effectively, we hope … against waste, against inefficiency. But the fact is there is much by way of scientific advance, there is much by way of technological advances that have helped us extend age.
The Death Panel notion … comes from this idea that at some point we have to say, “Hey look, in terms of what we can afford, it’s your time to go.”
I used to kid Dan, I’d say “Dan, our old friend Heffner is laying on the street, just hit by a truck, and he’s so old in the tooth by now, do we just let him go?”. That’s too crude a way, but I have to put to you, perhaps in almost as crude a way … do you not see that we have to come to some agreement about the costly technological improvements that we are making. Aside from waste.
BUTLER: Well, the real story behind the so-called Death Panels, was an attack upon something that did make sense. That is the opportunity for a doctor and family and patient to discuss together exactly how much care do you want to have?
For example, for myself, if I do not have my intellectual function, I do not want to be kept alive. In most cases in my clinical experience, most patients feel that way. That’s the “death panel” that they have ridiculed, but it really is based upon some real concerted effort to have real discussions as to what people really want to do at the end of their lives.
HEFFNER: How do we go about that, wisely and decently?
BUTLER: In a frank discussion. John or Robert or Richard … Richard?
HEFFNER: Richard, yes.
BUTLER: Richard … what are your plans, what would you like to do, would you like me to do everything possible to keep you alive regardless of circumstances … and you don’t need to answer now, but you might say, no, I really don’t want to that … or yes, I do. And we would act accordingly.
And there are papers that can be signed which have to do with health arrangements for end of life. And that is a legal and appropriate basis and I think would do a lot to cut down costs.
But the other thing I want to point out … because a lot of it has to do with the social structure in which we live. If you go to Europe, health costs are not as great as in the United States.
They spend like eight to ten percent of their gross domestic product on health care. We spend sixteen and approaching seventeen percent. And we don’t cover everybody, where as in Europe, they cover everybody.
So some of this is within the broad social structure in which we live and our attitudes with regard to how we want to shape our health care system …
HEFFNER: And the profit motive? In terms of medicine and pharmaceuticals? And medical technology? Are those factored into this difference? In the use of resources?
BUTLER: Well, they certainly count. I mean 16% of our GDP … out of every health dollar you spend in the United States … every dollar you spend on health, eighty cents only actually to health. Twenty percent of it goes to administrative costs, the clerks that are in every doctor’s office filling out forms, to selling, to marketing, to profits. Do we really need to do that?
We don’t do that in Switzerland. We don’t do that in The Netherlands. We do not do that … and they have free systems, so I’m not talking about government in Great Britain or Canada. I’m talking about freely practicing physicians who simply have the concept of a non-profit insurance arrangement in their countries.
HEFFNER: What happened to us that didn’t happen to them?
BUTLER: Well …
HEFFNER: Or what happened to them that hasn’t happened to us?
BUTLER: Well, some of it, I think, derived directly from the war. That is to say they went through a terrible conflagration in World War II and out of that they had to build some kind of system for care. And they took this non-profit approach. We’ve never confronted on our own land a terrifying war such as the Europeans did. We also chose, but very much free enterprise. I respect much of that. But some of it also goes against us. This free enterprise system.
HEFFNER: What kinds of cultural changes do you see as possible?
BUTLER: Well, you know, they like to talk about socialized medicine. We’ve had that since the 1920’s … it’s called the Veterans Administration, which is a pretty darn good system. We have the Geisinger Hospital … we have Mayo Clinic, we have Kaiser Permanente. We do have models which are not based upon profit motive. Some of them, like Cleveland Clinic, where the doctors are directly paid by salary … those doctors are not suffering. They get a decent income. That’s the way it could be. It does not have to be the way it is today.
HEFFNER: And the difference between then … our own “then” and now in terms of the attitudes towards professionalism versus profit on the part of the medical profession? How do you change that?
BUTLER: It’s not going to be easy. I have to say, when I arrived as a young scientist at the National Institutes of Health in 1955, nobody thought about patenting a discovery they made, you just never thought of it. Somehow, you were there … I mean it may sound romantic … but we were there, we thought, to do good. And that was it.
So different today. Now we have professors at great medical centers receiving money, ghost written articles in scientific journals … it’s outrageous what’s happened. A real weakening of the fiber and the quality of American medicine.
HEFFNER: What about medical teaching? Medical education. Does it recognize, can you generalize and say those, what is it, a couple of hundred medical schools in this country recognize what it is we’re talking about and are attempting to make some changes from the podium there.
BUTLER: Well there are 145 medical schools …
HEFFNER: 145 …
BUTLER: … in the United States. That includes osteopathic and allopathic, but osteopathic schools are very fine schools, too. Only 11 have departments of geriatrics … out of 145 … 11 … that’s pretty small.
Now maybe another 30 or 40 have some programs on aging … it’s much better than it was in 1975 when I was had the privilege of starting the National Institute of Aging.
But it’s not good enough. And it’s not appropriate that we don’t have doctors well trained to properly take care of old people. No one should graduate from medical school, no one should graduate from a residency program and not understanding the basic aspects of aging … that you can have an appendicitis without any pain in your abdomen. That you can have a heart attack without any chest pain. That you can have hyperthyroidism, where you’re supposed to be more excited and the person appear apathetic.
There’s so many different ways in which diseases present. Doctors may eventually learn it, but they learn it on the backs of older people.
And they need to know about nursing homes. Only about 20% of doctors have ever been in a nursing home. So we have a whole transcendent need, transformational need to get doctors better prepared to take care of us an increasingly growing older population.
The Baby Boomers are on the march and they’re averaging 63 now and in two years they’ll be on Social Security and Medicare. And we’re not prepared. We’re just not prepared.
HEFFNER: In the few seconds that we have left, I gather in all of this that you’re not so much pushing for the specialists, as you are educating all doctors …
HEFFNER: … in principles.
BUTLER: Well, including specialists. I mean they need to know the special extras. I mean ophthalmology … when I was a kid, when they used to do cataracts … they would put big bags on either side of the head … the person was blind-sided, they became confused, they had confusion … now it’s magical. Relatively speaking how simple it is to do a cataract extraction compared to the past. So I don’t mean the specialists don’t need to learn these things, too. But we certainly have to have primary care doctors well prepared.
HEFFNER: Bob Butler, you make me look into the future with, ah … joy. Thank you so much for joining me today.
BUTLER: Thank you for having me.
HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. Meanwhile, as an old friend used to say, “Good night and good luck.”
N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.