Some Thoughts on Aging and Other Medical Problems, Part I

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Christine K. Cassel
Title: Some Thoughts on Aging … And Other Medical Matters, Part I
VTR: 4/11/02

I’m Richard Heffner, your host on The Open Mind. And I remember that some 15 years ago, when I did a program with gerontologist Dr. Mark Williams on what it means to be old in America, I said then that viewers had long indicated they could pretty well tell whatever was going on in my own mind and in my own life simply by taking note of the subjects and the guests I choose for The Open Mind.

And remember, that was all of a decade and a half ago when I invited Dr. Williams to this table. So that you don’t really have to go much further than just look at the ancient on your screen right now and note that some thoughts about aging compose our topic, to know what’s very much on my mind these days. And, of course, why I’ve invited as my guest today a leading expert on geriatric medicine.

Dr. Christine K. Cassel is the new Dean of the School of Medicine of the Oregon Health and Science University, the Editor of “Geriatric Medicine”, the primary textbook used in geriatric care. Most recently she was professor and chair of the Department of Geriatrics and Adult Development at the Mt. Sinai School of Medicine in New York.

Dr. Cassel was the first woman President of the American College and Physicians and is past-Chair of the American Board of Internal Medicine. Important also to the programs we’ll record today is the fact that Dr. Cassel is well recognized by her peers as a “social activist and a policy wonk”. And since I know she has told her medical audiences that “the public would like to hear us” for change advocating on their behalf, rather than in narrow self-interests … let me first ask my guest just where her social activism begins? Is that an unfair question?

CASSEL: It’s not an unfair question at all. I actually have a view that I teach to the medical students called “Responsible Professional Activism” related to the issue that you just said, that as we look around us at health which is a vital value for all peoples, really, and we should be advocates for health. And that doesn’t always mean being advocates for medicine. But being advocates for our patients and for the communities and the nation at large, and how we go about trying to support and foster a healthy population.

HEFFNER: You think there has been a dichotomy made between medicine and health?

CASSEL: Certainly, Dick, that’s actually one of the major issues in this area of the aging of our population that I think is still at odds. The fact that we think of health as something that medicine gives us and yet we don’t do things ourselves that promote health. And the society, if you look around us, is not a society that invests in or values the things that really can create more health for more people.

HEFFNER: Like what?

CASSEL: Like social infrastructure. Like good nutrition. Like exercise. Like education. If you look at the factors that promote health status and also healthy aging, the most important factors, that have the strongest relationship with how long you’re going to live, and how healthy you’re going to be as you age are socio-economic status, level of education and ability to interact with your society. That has nothing to do with medicine. And so, if we really wanted to invest in health, we would deal with poverty, more effectively, we would create green spaces in our cities, we would have “phys-ed” in schools, which is also the first thing to go when they cut the education budgets. And we would make it possible for more young people to get more education.

HEFFNER: You say “we” would. “We” would do this, “we” would do that. What do you mean? You and I want that, who are the “we” who do not?

CASSEL: That’s a real important question. And that’s why we need responsible, professional activism. Because we are a society that believes in the democratic process. And, I think, increasingly in the modern world, that’s something that citizens of the United States value. Citizens of the free world and many, many countries around the world value. We exercise that freedom and those beliefs through the electoral process and through not-for-profit organizations; advocacy organizations and open exchange of ideas, much as is happening right here, right now. In that arena I think that the American society has become very invested in the idea of privatization and free market, the economy; and those things are valuable parts of our society, but we may have left behind some understanding that what benefits each one of us individually maybe somewhat different than what benefits the population as a whole. And we don’t think, we don’t think about the benefits to the community, to the population as whole in a way that we used to.

HEFFNER: Now how do you … you, you made a statement, and I was going to associate that with the question of how do you help teach or train, or make for doctors who will be advocates. Because you had, you had said somewhere … oh, it was in your … in the New York Times interview with you … the piece on you … just after the World Trade Center terrorist event …”the health care system doesn’t work for older people.” Now, I’m … if it doesn’t work for older people, is that a function of the indifference … maybe that’s too strong a word of your profession?

CASSEL: My profession could have a lot more effective role in fixing the health care system. That’s an indirect way of answering “yes” to your question. That, if you look at the history of attempts to create a more organized, a more systematic, a more patient-centered health care system in the United States. Every single time there’s been an attempt to do that, one of the major barriers has been the medical profession. Not the only one, there are many different political forces involved in the health care system because it’s such a, a huge industry, and there’s a lot of invested interests involved in it. One of those vested interests is the physicians. And, as a group, they have not supported health care reform in any of its iterations. And many individual physicians will speak out on behalf of patient centered care, improved quality of care, more access to care, universal health care insurance, which we still are the only industrial country that doe not have universal health insurance. And as a matter of fact, we seem to have given up on even trying to achieve it as a value. And yet, physicians as individuals may say “we believe in this.” But organized medicine or groups of physicians who could be very effective in advocating for it, have not done so.

HEFFNER: Well, now, how do you as the Dean, as a new Dean, help create, mold medical minds to participate as you would have doctors participate in these reforms?

CASSEL: Well, the first thing you have do is educate young people that their views are, are part of their citizenship and that citizenship is an important part of being a physicians. That it’s not just … being a physician is not just being a business persona. There are business aspects to it, but at the heart of professionalism is a commitment to this value of health. And, that it goes beyond the individual doctor/patient relationship. And extends to the health of the community.

So, let me give you a good example, that if I’m an Emergency Room doctor and I’m working in an Emergency Room and an elderly person comes in in the winter, suffering from hypothermia, which is not uncommon … particularly among poor people who can’t afford adequate heat. And they don’t realize that they’re getting … their body temperature is going down and they may become comatose and be brought by an ambulance, because of that. Now, I can put that person in the Intensive Care Unit … it is a life threatening condition, if they make it through, if they survive, we can make sure that they are … all their medical conditions are taken care of. And send that person back out to the … wherever they were living, or perhaps they were homeless, with absolutely no investigation or attention to what was the problem in the first place? Which is that they had no money, they had no ability to afford their medications and they had no heat where they live. So that’s the kind of thing, that at the most basic level, that social conditions very often can endanger health and physicians need to be involved. They can’t fix all those things … but physicians are very influential members of most communities and can be an important voice in social policies that can help.

HEFFNER: Now, how often in the American medical school community does one find that point of view being presented? Being pushed?

CASSEL: It’s variable. I think it’s not what most of medical school curriculum is about and … nor it should be. There is a lot of important stuff that young doctors need to learn. But I think among my colleagues there is more and more awareness that all of the wonders of modern medicine are going to be available to fewer and fewer people if we don’t solve these broader problems of access.

HEFFNER: But you know, I’m an old man, and I’ve been sitting at this table for nearly half a century and I have heard many wonderful physicians, many wonderful medical philosophers say what you have been saying. I think that what has happened does not match the intensity of their belief, their conviction.

CASSEL: That’s right. This is not a new message. And … but that’s not a reason we should stop saying it. And that’s one of my major messages when I speak with members of Congress, when I speak with other policy makers at the State level … and with people in the foundation world and other influential citizens. Sometimes we get tired of hearing this message in the United States. It seems impossible to solve and we want to move on to some new thing where maybe we can make some progress. I’m all for picking practical problems that can be solved. And I’m a very pragmatic person in that regard. But I think the voice still has to be there. Because the way politics works is that there comes a moment when you can make progress and you never know when that moment is going to be. If you look at the history of Medicare, for example, passed in 1965, there were attempts since World War II to try to create some kind of national health insurance model. And finally in 1965 all the pieces were in place, for a whole range of complex and very specific reasons to that decade. And it happened. And we got universal health insurance for one segment of our population, the elderly. And that was a good start. So, you couldn’t have predicted that that moment in 1965 would have been the moment that it would happen. But there had to be all of the right pieces in place. So what I’m saying is that those of us who share these beliefs need to keep on the, on the target, keep pointing this out, train another generation of physicians who will care about the same issues and who will see that part of their responsibility is to, at least, give voice to those ideas, and some of them may even become leaders in, in social change.

HEFFNER: All right, now what about us old folks … we, old folks. To what … do I understand correctly that there are not very many geriatric medicine departments in this country?

CASSEL: You understand exactly correctly. There are, I believe, three possibly four departments of geriatric medicine in the United States. In European countries and in Japan there are … almost every medical school has a department of geriatrics.

HEFFNER: How do you explain this?
CASSEL: I think it’s denial.

HEFFNER: Denial?

CASSEL: Well, we’ve all heard about the youth orientation of American culture. And I think that that’s also true for American medicine. In the 1970s, when the National Institute on Aging was first founded, when the Institute of Medicine of the National Academy of Sciences put out its first report on aging, it said that this is … that the population is aging, there are both scientific and sort of health systems issues that the American health care world doesn’t address to meet this aging population. And there are models in other countries that we could look to. Well, America doesn’t like to look overseas for its models. And so, we’ve sort of been very slow on getting going on that. I do think, though, that now at the beginning of the 21st century that’s going to change.

HEFFNER: What indications are there?

CASSEL: There are several indications. The underlying reality of the aging of the population has outstripped every ones expectations and all the experts predictions. We have seen, in the 20th century, from 1900 to the year 2000 almost a doubling of the life expectancy of Americans. And we aren’t the longest lived people on the planet. Quite the contrary, the United States is number 14 or 15 nationally, depending on how you measure it. And in many other countries people live much longer than they do in the United States. But the fact of the matter is that the whole world population is aging, the United Nations just announced that and will have major ramifications for how populations of people and societies are structured around the world. But here in the United States we wanted to look only at youth and at staying young. That’s our idea of successful aging. And yet the, the number of people over the age of 100 is actually statistically the fastest growing portion of the population. We’ve just seen the death of the Queen Mother in England, we have celebrated occasions of major figures in the United States who are celebrating their 100 birthdays. That used to be distinctly rare. And it’s no longer so rare.

HEFFNER: Frequently at this table there’s been a discussion of rationing, or saying “this person is so many years old, let us not invest more of our limited, admittedly limited, though vast resources, on keeping this person going. What’s ;you own fix on that.

CASSEL: Well, let’s, let’s talk about that in two different ways. The first is that the, the reality of the aging population is that most of us can expect to be reasonably healthy well into very old age. And so we are no longer talking about the expectation that at the age of 70 or 80 that, you know, it’s time to hang it up. Quite to the contrary. So the investment …

HEFFNER: I was hoping you’d say that …

CASSEL: [Laughter] And it’s absolutely true. And that’s a dramatic change from even just twenty or thirty years ago. So our society hasn’t yet figured out how quite to deal with that. And that’s what we call sometimes “successful aging”. Now that’s where the social factors that I mentioned are so important. Because people who have higher incomes and higher educational levels are the ones who are more likely to be healthy as they age. So that ends up being a real issue of health care disparities. But as far we can tell, doesn’t have a whole lot to do with access to medical care as we know it. It may have to do with healthy lifestyles. So there’s a lot that all of us can do individually to help ourselves age in a more productive and healthy way. Now, having said that, it’s also true that especially in recent years, modern medicine has a huge amount to offer in terms of things that can prolong life but more important, perhaps, things that can improve quality of life. Everything from fixing visual and hearing problems to joint replacements to keep people active and moving around, to new technologies that may help make organ replacement more available to older people.

HEFFNER: To what end, Dr. Cassel?

CASSEL: Well …

HEFFNER: To what end?

CASSEL: If we value life …

HEFFNER: Yeah.

CASSEL: … and meaningful life, those lives can continue to be meaningful. Now there comes a time, and one of the things that modern medicine with all of its wonders has not done, is to create immortality. And we may have forgotten about. And that’s another area that’s just as important, that we recognize that we are all mortal, that we will die and that the deep traditional role of the physician in caring for the dying has sort of been forgotten with all of this excitement about what modern medicine can do to extend life. I firmly believe that physicians are smart enough to keep both ideas in their minds at the same time. But I think our medical system hasn’t really supported that.

HEFFNER: You say the “medical system” hasn’t really supported that. Doesn’t that go, wouldn’t it go too much against the American grain, to support that?

CASSEL: Well, that I don’t believe is true. I think that, as I go around the country and talk to people about this new field of medicine called “palliative care” which attends to pain and suffering and dignity as people die, as people face the end of their lives. It … everyone understands what that’s about. Everyone has been through the experience with a family member or a friend of someone dying. And they know when it happens well and when it happens badly. And they can tell the difference. So this is a universal human experience. And while medicine may not want to acknowledge it, medicine still, unfortunately, too often sees death as a failure, rather than as a natural part of life.

HEFFNER: Do you think that’s true of most, or many of your medical students?

CASSEL: The students can hear the message about the care of the dying being part of their role. And they’re very interested in that. The problem is that very few of their faculty have been talking to them about it. So that by the time they finish their medical school and their training and they go into practice, in a hospital environment or a practice environment, where people are uneasy talking about death, and they’re aren’t systems in place, because the health care system is a part of this problem, to support the care of the dying, then they’re going to want to ignore it and they’re going to be uncomfortable talking with patients and families about it. Unless they’ve been trained to have those conversations and to find personal satisfaction and meaning in that kind of health care.

HEFFNER: Now, let me go back to this question of … before we get to palliative care … to what you might consider … you … and end limit … not for an individual … what can we hope for in terms of the modern medical miracles … in terms of knowing how to substitute a artificial organ for a real one. What do you assume is the natural lifespan. Is there such a thing in your estimation?

CASSEL: Well, I, I think that’s an open question now. We used to think that the natural lifespan was about 70, which is actually the Biblical …

HEFFNER: MmmHmmm.

CASSEL: … limit. And that was actually the average life expectancy of Americans around the time that Medicare was created, interestingly enough. And then, of course, when people began living much longer than that, all of the predictions of how … the costs of Medicare went through the roof. Now, the average life expectancy of Americans is in the late seventies. Woman continue to have a survival advantage of six or seven years over men, so aging in many ways has become a women’s issue, which is an interesting dimension of it. But it … what the limit will be remains to be seen. We, some demographers … we’ve got a of debate among scientists about this. Some demographers believe that around 85 or 90 will be about as far as we can push average life expectancy on a population level. Others think that it’s … that we could get well past a 100 if we had all … if we identify risk factors, we treat hypertension, we get rid of overweight and diabetes and some of the things that lead to what’s considered premature death. I think the jury’s out on that. I don’t, I don’t know what the answer is. But, I do know that if we … that so many of these factors are related to socio-economic status and education, that if we don’t address that level, among the younger population, then, we’re not going to see more of an aging population.

HEFFNER: Of course, the, the whole matter of a natural limit, as you say, Biblically … three score and ten … it is so difficult not to think in terms of the machinery simply running down …

CASSEL: Right.

HEFFNER: … and running out.

CASSEL: Right. And that’s … that leads to another part of the health care system that … really has to be included in this, which is the system for chronic care. Because for all of the good news about many, many more years of active life and aging successfully, if you will, the rising tide does lift all ships equally. And at some point at the end of life for many of us, there’s going to be a period of disability. We haven’t yet found the cure or the prevention for Alzheimer’s disease, for example. One of the most devastating age related diseases that there is. And many, many people will have to suffer with declining cognitive function or physical immobility from other kinds of disorders. And we can keep people alive for a number of years and that’s where you get to this question of what is the chronic care system out there that can help families take care of people and help them age gracefully and with dignity. That’s not in any Medicare insurance plan. That’s not what our communities are set up to do and that’s not what our social policies support.

HEFFNER: Is there any indication that we are thinking along those lines.

CASSEL: Not enough. And that’s, I think, where the real shift needs to occur in this century, as we think about aging productively. We need to think about supporting people and creating access to health care that helps them get old and stay active. But, in addition to that, nursing home care, home care, community based care for people who are disabled … there is going to be a huge need in our society. Right now that’s paid for only by Medicaid and by people paying … families out of their pockets.

HEFFNER: Clearly there are so many other issues we need to discuss. If you will stay where you are. We’ll end this program as we must, and do another one. Okay.

CASSEL: Fine. Thanks.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. If you would like a transcript of today’s program, please send four dollars in check or money order to: The Open Mind, P. O. Box 7977, F.D.R. Station, New York, New York 10150

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.