A Society with Many More Seniors with Walkers than Youngsters in Strollers

GUEST: John Rowe, M.D.
AIR DATE: 09/18/10

I’m Richard Heffner, your host on The Open Mind.

And we’ll deal today – probably, we should do so much more frequently, and much more systematically – with an enormously pressing social, economic and political problem … one that relates to a quickly and dramatically aging society – our own.

Now, key to our conversation is the MacArthur Foundation’s “Research Network on an Aging Society” , which asks us to imagine a society with many more seniors with walkers than youngsters in strollers, when those over age sixty will clearly outnumber those under fifteen … and which asks us to consider what America will have to do to accommodate these new demographic facts of life.

The Chair of MacArthur’s “Network on an Aging Society” – and my guest today – is medical doctor John Rowe of Columbia University’s Mailman School of Public Health.

Earlier Dr. Rowe led Harvard’s program in academic geriatrics, was President and CEO of Mount Sinai Hospital and School of Medicine in New York, and then served as President and CEO of Aetna, the health care organization.

Now, I think we ought to begin today by my asking my guest if we could at least briefly parse the various myths that he and his distinguished colleagues in the MacArthur Foundation “Network” feel that we must dispel before being able to deal successfully with our aging society.

If you’ll let me, Dr. Rowe, what I’d like to do is go through them and sort of parse them as briefly or as importantly, expeditiously as we can.

ROWE: Sure.

HEFFNER: Because you say “We believe myths in this country.” And you were telling me the story of a very distinguished person, who when he got contacts and read the myths said, “I thought they were true.” And I must admit, I thought they were true, too.

But the first one you list is “aging in America is a temporary phenomenon caused by the Baby Boom”. Not true?

ROWE: False.

HEFFNER: False?

ROWE: We got to these myths first of all because we found that as scholars in my … the MacArthur network that I’m involved with … you mentioned … tried to engage with policy makers about the changes that we thought we should consider in this country, we ran into all these myths.

And we’ve … have to demythologize our view of an aging society before we’re able to face the reality and make the needed changes.

This first one that you mention … people think it’s a transient thing related to the Baby Boom. That the Baby Boomers are moving through our population like a swallowed mouse through a snake.

And when they move out (laughter) the end, we’ll be back to where we were. So we don’t really need to reengineer our society.

But the facts are that we’re becoming an aging society because of the Baby Boomers and because, independent of the Baby Boomers, there has a been a very substantial increase in life expectancy in the United States.

And we don’t expect that to turn around and go in the other direction. So once the Baby Boomers are gone, we will have an aging society permanently. In the United States.

HEFFNER: Do you anticipate, incidentally or I should say not so incidentally, that that matter of longer and longer life span will continue on that same route?

ROWE: It’s a very important question. Because if you look at the current projections for our population … the Social Security Administration Census Bureau … they actually predict that the advantages in life expectancy … the incremental increases will be less and less … going out. That it will be diminishing returns, if you will. That we’ve reached close to what we’re going to reach.

We don’t believe there’s any reason to believe that. (Laughter) Look at Japan, they’re quite a bit further ahead of us in life expectancy. So we actually think that continued medical advances … as far as I know we haven’t cured cancer yet … in most cases. Or even changes in basic aging process will result in even greater increases in life expectancy than the government currently projects.

HEFFNER: I hope it’s not impolite of me to say, “How come officialdom makes one judgment and the MacArthur network makes another?”

ROWE: Well, because they have certain rules. And they look at 75 year trends and recent changes and advances tend to get smoothed out. They’re very good scientists and actuaries. I think they’re objective, they’re not politically motivated. But they have a context in which they make their projections and their forecasts and we happen to believe that that limits the likely increases in life expectancy that we’re going to see.

HEFFNER: How far are we going to go? What is your anticipation there?

ROWE: Well, I think that we can easily gain four or five more years in average life expectancy. That would just put us where Japan is now.

And that would be a very, very significant increase. We can do that, I think, by 2050. Social Security Administration thinks we’ll get there by the end of the century.

HEFFNER: And you … there’s a half century gap between your estimates.

ROWE: It’s only 50 years among friends.

HEFFNER: (Laughter) Old friends. Dr. Rowe, what, what … I put this question to Lew Thomas once, years ago.

ROWE: HmmMmm.

HEFFNER: Put it to you. What would you say could be the natural lifespan of homo sapiens?

ROWE: Well, it’s very important to differentiate life span from life expectancy.

HEFFNER: Okay. Educate me.

ROWE: Life span is the maximum period of time that a species can exist. So we now know that there have been people who are 116 and 117 years old. So by definition, the human life span, maximum life span is at least that. And it may increase.

But that doesn’t mean that the average life expectancy for people of the species, or members of the species would be the maximum. It’s a bell shaped curve and … but we could easily get up from our current average life expectancy of 82 up to an average life expectancy that is somewhere between four and seven year more than that. That’s our projection.

HEFFNER: You use an adverb … we could easily get there. What do you mean “easily”? Tell me and I’ll go out and do what I have to do.

ROWE: I, I would … maybe I shouldn’t say that … but I guess what I mean is that I don’t think it’s a long shot.

HEFFNER: In terms of what’s been happening?

ROWE: In terms of the developments in biomedical science. If you just look at cardiovascular disease. We’ve made dramatic increases in life expectancy in the last 30 years. There are millions of Americans alive now who would not be alive if we hadn’t developed stents and coronary artery by-pass grafts and more effective medications for a variety of cardio-vascular ailments and there’s no reason to think that we can’t make progress in Alzheimer’s disease. Cancer. No, no reason at all.

On the other hand, I may be wrong. There are individuals who say increasing obesity, continued emergence of unexpected and untreatable infectious diseases, will actually decrease life expectancy over the next century. We don’t believe that to be the case.

What we’re really saying here is we don’t know that Social Security and the Census Bureau are wrong. And we don’t know that we’re right.

HEFFNER: You’re talking about potential.

ROWE: But if we’re only half right, we going to have a lot more older people faster than we’re currently planning for.

And if you were making policies for the United States and you have to guess what the population’s going to look like, you should have on the table all of the reasonable scenarios that might unfold, so that you can choose some average of them as a best, most likely case scenario.

HEFFNER: I gathered … at the very beginning of our conversation you talked about talking to policy makers …

ROWE: Yeah.

HEFFNER: … and I gather you feel that it is important to do that so that they understand the shifts and changes that they must provide for.

ROWE: That’s right. The, the basic tenet of our work is that the core institutions of our society … the work force, retirement, education … just to name a few, the design of our cities … those core institutions were not designed to support a population that is going to have the age distribution of our coming population.

So if we are going to succeed in emerging as a productive and equitable aging society, we are going to have to re-engineer the core institutions. And that’s going to be facilitated by policy changes.

HEFFNER: Or not.

ROWE: Or not. And, and … and if we fail, if we do nothing, what would failure look like? Failure would be very ugly.

HEFFNER: You know, I said I was going to parse the seven myths …

ROWE: Yes. Yes.

HEFFNER: And I’m not really doing that …

ROWE: We’ve got one down.

HEFFNER: … because I’ve started. One down. But I’ve got to ask you another question, in between. Are we alone?

When we talk about … when, when I wrote the opening copy … and I talked about “we”, “us” … I wondered, should I be saying “the world”, should I be saying “American society”? Where are we?

ROWE: Well, first of all, I think it’s important to differentiate developed countries from developing, or undeveloped countries.

And to put it very concisely … developed countries got rich before they got old, developing countries are getting old before they get rich.

That has a dramatic effect on the degrees of freedom that those societies have to respond to.

But even if you look just at developed countries. Western Europe is way ahead of us because we had a Baby Boom, that was a young group that was diluting the older population, so we didn’t get to the point that we, in the field, use as defining an aging society.

That’s when there are more people over age 60 than there are people under age 15.

Germany was there in 1981.

HEFFNER: Thirty years ago.

ROWE: Yeah. So that what you see is throughout Europe … Western Europe … a whole series of decisions about various policies … some of which worked and some of which didn’t.

Japan, the oldest society in the world … lay ahead of us. Japan has done a number of things to cope with that. Those would really work well for us if we were Japanese. But we’re not.

HEFFNER: So it’s not as simple as picking up what they’ve done.

ROWE: And we have a total fertility rate … the number of children born to a woman, on average, which is close to the replacement rate. Whereas Japan’s is very low and many European countries’ is very low. So the dynamics are different.

So what we have to do … in looking at these countries that have aged ahead of us … is we have to see what’s generalize-able, what is relevant, what might work in the US and what might not work in the US.

We can’t just wholesale take a, a set of policies from some successful country like Sweden or Norway or Denmark and try to put them into the US. It wouldn’t fit.

HEFFNER: Myth, number two. Not moving along as fast as I would like to (laugh). Physical and mental capacity inevitably decline with biological aging. Tell me that’s not true.

ROWE: Well, we can …

HEFFNER: I dare you.

ROWE: … we can just keep the camera on you. (Laughter)

HEFFNER: No, no, no.

ROWE: It’s clear that it’s not true. Yeah. Let’s … we can deal with this very quickly and that is that … in addition to a very significant increase in life expectancy over the last several decades … you know … it’s now 82 … beginning of the twentieth century it was 47 (laughter).

There’s also been a consistent parallel increase in active life expectancy. That is disability free life expectancy. So the period of morbidity …

HEFFNER: MmmHmm.

ROWE: … of frailty has been compressed to the very end of life. And so … and that’s very important from a policy point of view because that means that these older individuals are going to be able to work, or volunteer, be productively engaged in society. They’re not going to be physically dependant.

HEFFNER: You haven’t been talking to many politicians, have you? Because the politicians …

ROWE: I’ve been trying ….

HEFFNER: … but the politicians are going to have to be the ones who say “Social Security doesn’t begin at this age, it begins …

ROWE: Well, they’ve started some of that. And it … the issue is that they see this as a problem for the next generation of politicians because they have …

HEFFNER: (Laughter)

ROWE: … more pressing problems and it’s not popular to do these things. And you know, they think it’s a long range issue. But the facts are that there’s something called “institutional lag” that … core institutions of society don’t change quickly. They get dragged along and they change very slowly.

HEFFNER: Do …

ROWE: So, there’s really an urgency. We actually have to start preparing now.

HEFFNER: The 65 year old “fix” for retirement was a function of the way we functioned when those laws first went into effect.

ROWE: Actually it was from Bismarck …

HEFFNER: That far back?

ROWE: That far back.

HEFFNER: Okay … well, it was Bismarck …

ROWE: Bismarck wanted to do something for the elderly and he got his Secretary of the Treasury, whatever that term would be in Germany and his demographer together and he said, “Well how much money do we have? And okay what age would I have to pick in order to be able to give everybody over that age a benefit?”. And they got together and they said, “65”. So be it.

HEFFNER: From your studies, what would you say the answer would be today? Not in Germany, not …

ROWE: Yeah.

HEFFNER: … from Bismarck, but with us.

ROWE: In the United Sates. Well, I would certainly start at 70. I mean I wouldn’t … I’m not a politician, I’m not trying to get re-elected.

HEFFNER: That’s all the more reason for me to ask you … as an expert …

ROWE: But certainly … and France just announced yesterday that they were increasing their retirement age from 60 to 62 and …

HEFFNER: A hell of a lot of trouble there …

ROWE: … howling about that. But it’s inevitable.

HEFFNER: But you do think, that without question, one could have answered the question … near the question that Bismarck raised … at 70. And you feel in terms of our physical capacities.

ROWE: Yeah, sure. And if people aren’t able to participate, they shouldn’t. But, but they, they should have an incentive to participate actively in society and stay in the work force as they can. And, and … one of the important things about this is that … because we’re focusing on the elderly … but when we get to the next myth, we’ll shift off that.

But it’s not just about having a lot of old people. The key … the unit of analysis here is not the old people. It’s the society.

China has a lot of old people. But it’s not an aging society and it won’t be until 2040, because it has a lot of young people.

What we’re talking about is the fact that there are more old people than there are young people.

And so there aren’t going to be the people to produce the good and services (laughter) that are going to be used and needed by this larger elderly population unless some of those elderly people participate in that development, in that productivity.
HEFFNER: And are, for all practical purposes, not in retirement.

ROWE: That’s right.

HEFFNER: Now, the, the … the myth number three … this is what you just addressed yourself to … aging mainly impacts the elderly.

And you and your colleagues are saying “Oh, no, it’s not that simple.”

ROWE: Not aging of society. Aging of individuals. But aging of society is about the society. And in fact the elderly might not be the most interesting group. In Europe …

HEFFNER: They aren’t …

ROWE: What happened in Western Europe … in order to pay for the entitlements for this rapidly growing elderly population, they didn’t’ raise taxes … you didn’t generate revenues that way … they reduced the education budgets in many countries. So it turns out that it was the youth that were most influenced.

HEFFNER: Do you see signs that that is happening here?

ROWE: Not yet.

HEFFNER: But that’s not a foreign idea. I don’t mean to pun on that.

ROWE: I don’t think there are any. Yeah. So we have to think about the whole society and we have to get … more solidarity so that the generations relate more effectively to each other.

HEFFNER: When Larry Aber was here and he studied what we’re doing for our younger children …

ROWE: Yes.

HEFFNER: … he was so concerned about the fact that we are not helping our young … we’re not recognizing the need to be of aid to our young, as we are to the elderly. Is that …

ROWE: This is … is … very important issue … it comes up all the time. The advocates for the different age groups.

And the language that’s used is interesting because the advocates for children talk about “investments in children’” versus “expenditures for the elderly”.

HEFFNER: You don’t like that.

ROWE: I’m, I’m all for investing in children, including my grandchildren. But the facts are … and there are many programs … like Head Start and Early Head Start … they are obvious winners and we should strengthen them, sustain them.

But it doesn’t mean that there are not other periods in life where it’s particularly important to invest. In fact data show that successive investments and efforts say for prevention in smoking and dietary and life style exercise, etc. kinds of interventions are much more effective if they’re done throughout the life course, not just early in life.

In the Diabetes prevention study, which was a lifestyle intervention in different age groups … a group that was most responsive to the intervention was the elderly.

People think, “Well, the horse is out of the barn, and these old people aren’t going to risk …” But there’s a lot of what we call “plasticity” in the aged body and in aged populations.

And, and so we’re interested in making investments across the life course. That’s what we’re interested in.

HEFFNER: You know, I hear what you’re saying. And as part of …

ROWE: Good, I’m glad.

HEFFNER: … and as part of, part of the …

ROWE: (laughter)

HEFFNER: … elderly cohort I certainly hear that. But it makes … it, it … it’s sort of counter-intuitive to think that way. You think of young people, you think of investment.

And you want us to think of investment in terms, terms of the old fogies like me, too.

ROWE: Well, in 60 year old people who are going to live another 20, 25 years.

HEFFNER: Okay, now you’re talking about 60 year old people.

ROWE: I’m talking about people of all ages. Because there are age appropriate interventions in all different stages, not just young individuals. It’s not consistent with the scientific evidence.

HEFFNER: Yes, but the scientific evidence I understand … and you, as a doctor, certainly can say, “Ah, yes or no.” But the incredible investment that we make in medical matters comes to such a large extent at the end of life. At the very end of life.

ROWE: Well, there is a body of evidence that indicates that a very substantial portion of medical expenditures are in the last year of life.

What year of life would you expect them to be? The fact is people get sick and they die. And when they get sick, really sick all of a sudden and they show up in the Emergency Room, you don’t know whether they’re gong to die or not, so you spend the money. You do the operation, you put them in the ICU, you put them on the respirator. Some of them make it, some of them don’t. The ones that don’t make it had a lot of expenditure in their last year of life. It reminds me …

HEFFNER: Would you consider that an investment?

ROWE: I think that’s not an investment, but that’s not what we’re talking about here. We’re talking about disease prevention programs. Health maintenance programs. I don’t think … I don’t think we should conflate care at the end of life with the problems of an aging society. Ahemm, this is not about “death panels”. This is about …

HEFFNER: Well, I was just going to say it is, in a sense.

ROWE: I don’t believe so.

HEFFNER: We’ve got to argue this, this point …

ROWE: We, we could … and it’s your show.

HEFFNER: No, no, I don’t mean … I don’t mean now.

ROWE: (Laughter)

HEFFNER: At some point.

ROWE: Fine, I’d be happy to.

HEFFNER: We have to argue that out.

ROWE: Ah …

HEFFNER: Other myths. After not being pitted against each other, policymakers … Myth 5 … must choose between investments in youth or the elderly …

ROWE: Yeah, but …

HEFFNER: … although they have sort of said …

ROWE: Yeah, no. I’ve addressed that. But now I want to give you an example because think there are win-win scenarios.

So back in the early nineties in South Africa, they established a pension program for retirees. And it turns out that they studied how the families did and how the individuals did. And in families in which older women were residing in the households in which their granddaughters were also in the household … in those families … when the older women were given the pensions, the granddaughters were taller and heavier and did better in school.

HEFFNER: So there is some use for the old.

ROWE: (Laugher) So these are transgenerational effects. These are win-win effects. There are volunteer programs in something called the Experience Corps … is now in 20 cities and 200 schools … older people volunteering for K-3 kids, often underprivileged kids in inner cities.

In Baltimore, scientists at Johns Hopkins studied this. Not only did they find that the kids did better with the help. And that the older people felt better about themselves and enjoyed it. But they actually did MRI images of the brains of the older people before and after a year of volunteering and they showed improvements.
HEFFNER: That’s what you mean by win-win.

ROWE: That’s win-win. So you make the investment in the program which is a volunteering program for older people who are volunteering to help younger people.

It’s not one generation versus the other. It doesn’t have to be.

HEFFNER: I’ve got to meet the rest of your panel because I have to see whether they’re all as optimistic, by nature, as you are.

ROWE: I’m not an optimist.

HEFFNER: Okay.

ROWE: And I’m not a pessimist. I’m an “empiricist”. The data support these policies.

HEFFNER: Let me go … move quickly because we have one minute left and we’re not going to finish this. The biggest public problems facing an aging America stem from Social Security and Medicare and Medicaid.

ROWE: And that’s all we hear about. But the fact is that if we fix Social Security and we fix the Medicare issue, which is seven times … the unfunded … likely balance in Medicare and Medicaid is seven times that of Social Security.

If we fix both of those, and we don’t re-engineer our society, so that we can have a productive and equitable society … we will not solve this problem.

HEFFNER: Dr. Rowe, no matter what number I’m at … you’ve got to come back because we’re at the end of our program. But I, I must say, and I hope it’s not just because I’m an old man, because everyone has an old man or someone who’s about to be or will, in the long run, be an old man … around … please … thank you for joining me today and do come back.

ROWE: It’s a pleasure to be with you. Thanks very much.

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.”

And do visit the Open Mind website at www.theopenmind.tv

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.