Dr. John Rowe discusses health in our aging society.
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GUEST: John Rowe
AIR DATE: 12/15/2012
I’m Richard Heffner, your host on The Open Mind.
And there are several compelling reasons why I would focus our attention today on a book I first read a dozen and more years ago.
First, because my friend Jane Brody wrote right at its publication in 1998 that … quote … “Once in a great while an outstanding health book comes along that should be featured on every radio and television talk show and in every major newspaper”…and that Successful Aging by Dr. John W. Rowe and Dr. Robert L. Kahn is just such a book.
Second, because only a few months ago – when asked “What do you plan to read next?” in the Sunday New York Times Book Review’s new “By The Book” interview column with recent authors, former Secretary of State Madeline Albright also chose Successful Aging.
Third… quite honestly…because at 87 I really need to find out much more about aging successfully.
And, of course, because my author guest, medical doctor John Rowe of Columbia’s Mailman School of Public Health – who led Harvard’s program in academic geriatrics, was successfully President and CEO of Mount Sinai Hospital and Medical School in New York and of Aetna, the health care organization, and has long chaired, MacArthur Foundation’s “Network on an Aging Society” – is so expert in the field. And my good doctor friend, I want to ask you … Successful Aging … the book has aged so well, what would you change about it?
ROWE: The book has aged well, Dick, and that’s very exciting for the group of scientists who worked together to, to do this research and bring it to the public’s attention.
But there are two chapters of that book which are wrong. (laugh) … and …
HEFFNER: Whoever says that except a scientist …
ROWE: (Laugh) If I were re-writing or re-publishing the book, there would be two things that I would change. I think the bulk of our work has been supported by additional research and it’s proven the test of time.
But there’s a chapter on menopausal hormone replacement therapy that was written before the famous Women’s Health Study and it’s quite clear now that the combination of estrogen and progesterone … based on that research and follow-up from the Women’s Health Study … while it reduces the risk of getting a bone fracture, it increases the risk of having a stroke or having invasive breast cancer or gallstones or blood clots in the legs or maybe even dementia. And so I would change that chapter.
The second chapter that has to be changed is the one on vitamin supplements. Research over the last several years has fairly conclusively shown that there’s little, if any, benefit to vitamin supplements, particularly high doses of vitamin supplements. Most of us get what we need from our normal diet and unless you have an unusual diet or a medical problem, one way or another, you really don’t need to waste your money on these.
HEFFNER: Well, Jack … you … you so frankly indicated to me (cough) … excuse me … when I said I’d like to do a program about the book that these are two caveats that you had.
What occurred to me then and what still occurs to me is to what extent you feel what we’re learning today, what we’re told today by you docs … not just about aging … but about so many areas of medicine … we have to assume a decade from now … a dozen years from now … they’re going to change their minds.
ROWE: They are. We really only have excellent scientific evidence to answer about 15% of the questions that we are asked. But we have to answer all of the questions. So that when a patient says, “Do you think I should take multi-vitamins?” … in 1998 the hard factual research was not yet there. In the lack of evidence … most physicians said, “Well, we don’t think it can hurt you … (laugh) … you might as well take it. There’s some evidence that people who take it seem to do better than people who don’t … etc., etc.”
Medicine is the application of the scientific method to the improvement of the health status of individuals. And what we are doing is accruing scientific information over time.
And sometimes that means that what seemed right before is wrong now. And, as long as the advice is given in good faith and we make it clear to patients what we really know for sure … and what we think is right. Then I think it’s fine.
HEFFNER: Okay, let’s, let’s turn to the rest of Successful Aging … at my age, I want to know what you mean. What do you mean by “successful aging”?
ROWE: You’re a poster child for successful aging. (Laughter)
HEFFNER: Oh, come on. My wife wouldn’t say that.
ROWE: Well, our definition of successful aging deviated from the research prior to the MacArthur Foundation’s funding our work.
Previously most research on aging was about avoiding a hip fracture or, or a nursing home admission, or so on.
We saw it more broadly. We think avoiding disease and disability is important. But in addition you have to maintain your physical and cognitive function and very importantly … there’s a third piece … and that is you have to maintain “engagement”.
HEFFNER: What do you mean “engagement”?
ROWE: A productive interaction with society, with the community, with a social network. Social networks are so important late in life, Dick, that I would tell medical students, when I was instructing them that if there’s an old man in the next room that you’re going to see as a patient … and you want to know how he’s going to do in the next six months and you have one question, you’re better off asking him how many interactions he has per week with friends and neighbors than asking him if he smokes cigarettes.
HEFFNER: That’s it. Keeping up with the world.
ROWE: Very, very important. But you have to have all three.
ROWE: Avoid disease and disability … and that means don’t smoke and so on, you know. And pay attention to your health and get your blood pressure treated, if it’s elevated, and so on.
Secondly, physical and cognitive function. Exercise is terrifically important.
And thirdly … engagement. And what we did was a series of studies to see what the predictors were of who aged successfully according to our definition and who didn’t.
We found some really interesting things. I’m a bio-medical scientist, so I was collecting blood samples and 24 hour urine collections and I thought the answer was going to be some hormone.
But the social scientists and the psychologists were right. The most important factor, the best predictor in a group of 70 year olds about who was going to do well … x years from then … was self-esteem.
HEFFNER: That’s an interesting one. What is your definition of “self-esteem”?
ROWE: Do you feel that you can influence what’s going to happen in your life?
HEFFNER: Interesting question whether you’re 87 or 27.
ROWE: (Laughter) Absolutely. But if you feel like you’re just a cork floating on the waves, being buffeted one way or another by the wind and the sea and that you really can’t influence what’s going to happen … you have low self-esteem by that definition.
But if you feel that you can take charge and set a course, then you have high self-esteem. That turned out to be a very important predictor.
Another interesting thing was support. It turns out that support comes in two flavors. There’s instrumental support and emotional support.
Instrumental support is somebody saying to you, “Dad you’ve done everything for me all my life, now it’s time for you to relax, I’ll do the dishes, I’ll do the cooking, I’ll do the shopping, I’ll do the cleaning, I’ll get this for you, I’ll get that for you … you just sit there.” That’s instrumental support. That’s actually harmful.
Then there’s emotional support. “You can do it, Dad”
HEFFNER: Gotcha, gotcha. And what do you find we Americans are indulging ourselves in most? Which of those supports?
ROWE: Well, I think over the last 10 or 15 years there’s been a much greater focus on engagement, on civic engagement particularly, on volunteerism. Employers are developing more flexible work schedules for older workers to permit them to continue in a work force even on a part-time basis. Which is an important form of engagement, it’s not just volunteering. Working for pay is engagement.
So I feel very good about that and I think the image, the image that we have of older people has changed. I, I would tell my students about this famous picture of an elderly woman … Whistler’s Mother … pale, grey haired, dark clothes, white cap, looking forlornly out a window … and I’d show them that and I’d say “How old is that woman?” They’d say 88, 90, 92. 67 … that’s what 67 used to look like, that’s not what 67 looks like today.
HEFFNER: You said before that you would tell younger doctors, doctors in training, if you want to know about that elderly gentleman in the next room …
HEFFNER: … ask about his involvements. How well did you teach? Ah, I don’t really mean how well did you teach, but how well have we taught the medical profession to approach seniors …
HEFFNER: … in the most productive possible way?
ROWE: In 1980, when I established the Division on Aging at Harvard Medical School, it was one of the first such programs in the country. There was also one at Mt. Sinai which was the first formal Department of Geriatric Medicine in the country.
Now, it’s very, very common. It’s an important part of the curriculum in many medical schools and for training in internal medicine, they take a Board certifying exam in Internal Medicine, a significant portion of the questions are about old people.
And about the problems of advanced age. So, we are making progress with respect to that. And the other thing is that we are treating older people much more aggressively than we used to before. People would say …
ROWE: … well, people would say I’m not going to dialyze anybody over 65. I’m not going to do cardiac surgery, you know, on patients who are over 75. But now it’s very common and in fact the, the risk of cardiac surgery at age 70 is probably less than 2 or 3 percent because the technology has improved so dramatically.
HEFFNER: Yeah, but that, of course, raises for me the question of whether that doesn’t mean that your profession isn’t focused overly much on simply trying to continue life … come what may … extend life … talk to me about that.
ROWE: Well, it’s not about life span. It’s about health span.
HEFFNER: Is it?
ROWE: It’s about the quality of life and I think physicians take that into account and when they guide families and patients and …
ROWE: … I mean nobody’s doing heart surgery on severely demented individuals, I mean it just doesn’t happen. So it’s really about the quality of life. But you have to understand that, you know, a 65 year old man in this country has an average life expectancy, you know, of … on average … 65 year old man has a life expectancy of another 18 years or so. And if you have a condition which is disabling, it could be corrected by some intervention and the person is functioning well … then there’s really no reason … in fact it’s less expensive to do the procedure (laugh) than to pay for all the treatments that might be needed.
HEFFNER: And how long will this go on? How long do you want it to go on? How far into an individual’s future?
ROWE: The ideal is the “one hoss shay” of Oliver Wendell Holmes …
ROWE: … so you function at a high level until you get to a point and then it all ends abruptly. What I’m looking for is the compression of morbidity.
That we have a curve which is a survival curve, then we have a health curve under it.
ROWE: And I want to press that health curve right up against that survival curve. I want to squeeze out the period of disablement and I want to enhance the period of active life expectancy.
HEFFNER: You want those two to come together. Right?
HEFFNER: What about pushing the top one down? That means …
ROWE: Well, that may happen. That may happen. There are some very sophisticated folks wrote an article in the New England Journal a couple of years ago, “Will Life Expectancy Decrease in the 21st Century?” …
ROWE: And looking at the obesity epidemic … particularly in youth … and young adults, looking at the emergence of untreatable infectious diseases and pandemics … certainly that could happen.
HEFFNER: What do you think about that? Particularly …
ROWE: It scares me. It scares me.
HEFFNER: … you think that it’s possible that …
ROWE: I, I … I think it’s possible, but I still think it’s possible for us to increase active life expectancy by focusing on the tenants of successful aging … these three pieces.
I also recognize that the best predictor of disability … physical disability is education …
HEFFNER: What do you mean?
ROWE: The more years of education, the less likely you are to be disabled. At age 65, if you have a college degree, you’re one-third as likely to be disabled as if you didn’t graduate from high school.
HEFFNER: Okay. Spell that out. Why?
ROWE: Well, some people think there are direct effects of education.
HEFFNER: But you, you don’t mean that, do you? Physical effects?
ROWE: Well, yes, I mean if people are educated they’re less likely to smoke …
ROWE: … you know, they’re more likely to have a better salary that gives them access to health insurance …
ROWE: … and health care. And so on. There are a variety o ways that you could see that it would … maybe it’s just a proxy for socio-economic status. But it’s really important. And, and so I think we understand some of the drivers that will prolong active life expectancy even more than we’ve seen so far.
And we understand also that it’s … and this is, I think, important … it’s not all genetics … because when you talk like I’m talking with you now about changing things … people say, “Look, no, no man in my family has lived past 52”.
ROWE: (Laugh) You know, as if there’s some internal clock. But our research has shown that that’s not the case. That if you look at the factors that predict successful aging … only about a third of it is heritable. The rest of it is related to lifestyle and exposures and education. And that’s a very positive finding. Because what that tells me is that I’m responsible for my own old age, that there’s not some computer program in me that’s going to drive me to some premature death. And that’s, that’s a very enabling empowering finding and it’s a strong, scientifically based finding.
HEFFNER: I thought when you talked about education that you might say the more years of education and the better education, the more you’re able to be that active person you talked about when we began our discussion. The more able you are to go off into different areas …
HEFFNER: … to study more, to learn more, to do more …
ROWE: I think that’s true. I think, with respect to cognitive function … I’m certain that more educated people read more, or have more intellectual interests or do more crossword puzzles or listen to more music or whatever …
HEFFNER: And therefore keep going.
ROWE: And, and, you know, it’s kind of use it or lose it type of thing. They say education is really important. And, and … so when, so the answer to … in many ways, a successful old life is for society to focus on the earlier part (laugh) of life. And make sure that we give young people opportunity to get education.
HEFFNER: What’s the lifespan now of a man … born, let’s say … we’re doing this in 2012 … we’re doing this program.
HEFFNER: What’s the life span?
ROWE: I, I would say it depends on how much education you get. But if you’re an educated White woman, you know, you’re up around 83/84 years now.
HEFFNER: But you’ve got to be White and a woman.
ROWE: Well, if you’re an uneducated White woman you’re several years less. Education is more important than race. It’s really not about race, it’s about social class.
ROWE: Social economics.
HEFFNER: And all that goes with it.
ROWE: And for men it’s still a couple of years less than it is for women, but men are catching up. They’ve narrowed … there used to be … 20 years ago … there was a 7 and a half year difference between women and men’s life expectancy and that’s sort of cut in half now.
So that … so there’s a convergence. And actually the reason for that is that men’s life expectancy has continued to increase and for about 15 years women’s life expectancy went sideways in this country, which is known as the “smoking” effect. When smoking became much more common in women, it was quite unusual …
ROWE: … and then it became much more common and that had an adverse effect on survival. But now both curves are going up again.
HEFFNER: What do you … I remember asking Lew Thomas …
HEFFNER: … what he thought … is there a natural end to it all?
HEFFNER: And he said “Well, I’m not going to answer your question, but I’ll say 125.”
ROWE: Yeah. Well, Lew Thomas was a very smart man. And I would support that. I think first of all that we have to understand that every species has a given life expectancy.
ROWE: There are no dogs who live to be 100 years old. Okay. And it just … you know … and there are no mayflies that live more than a couple of hours, maybe or a day. And, you know, and giraffes and elephants and unicorns … every species has an established life expectancy. The question is … when we see this increase in life expectancy in the humans … is that just removing premature death that was due to disease and unfit living conditions and poor nutrition … (laugh) … you know. And are we approaching “the limit”. So, some difference between how long people are living … their life expectancy and what is the human life span?
The oldest documented person was around 122 … a woman in France. That seems to me to be a reasonable limit based on the studies I’ve seen. Maybe it’s 125. I don’t think it’s 150. And I don’t advocate the anti-aging notions and potions and creams and lotions that come … that are very, very common. A friend of mine Jay Olshansky says that longevity salesmen have been around a long time, perhaps it’s the second oldest profession …
HEFFNER: (Laughter) Barnum and Bailey … P. T. Barnum knew, knew about that. But, you didn’t answer the question except you’re saying maybe about 120, 121 …
ROWE: Yeah … 125. You know, you get a lot of arguments from a lot of people about this … but see my focus is on what’s the active life expectancy … not what’s the ultimate human life span.
And, and it’s quite possible, now we have shown in, in animal studies and in cell studies and in yeast and in worms that we can increase life span in those animals, by genetic engineering. So it’s not completely out of the question that we could increase life span. But we have so many issues (laugh) about improving healthy life expectancy that that’s where I think we should focus at this point.
HEFFNER: And Successful Living … you maintain your definition? It hasn’t changed since you were beginning your geriatric studies …
ROWE: No. We’ve been very pleased. You know we put this concept together, we tested it scientifically, it was watertight. Since that time many centers of successful aging have been established at US universities, the Federal government has grant programs on successful aging. Most of these focus on the definition that we use, or a course modification of it, but it seems like its held the test of time.
HEFFNER: Jack, are other peoples, and we just have a couple minutes left … are other peoples around the world as interested as we are … as you and your colleagues are in this question of successful aging?
ROWE: In many ways we’re behind them.
ROWE: Oh, there were … geriatric medicine was a specialty in the United Kingdom long before the first program was started here in the United States.
HEFFNER: How come?
ROWE: Well, maybe we’re a little more too focused on high tech, rather than high touch … on cure rather than care. We’ve had to learn that lesson in American medicine.
HEFFNER: Are we changing now?
ROWE: Yes. I think so.
HEFFNER: And are the medical schools, in your estimation, keeping up with that …
ROWE: I think so, definitely. No question about it. And we see significant numbers of medical schools being developed that are … their mission is to establish primary care providers rather than just, you know, high tech specialists.
HEFFNER: And you feel the primary care providers are well enough briefed, well-enough educated now …
ROWE: Whether we, we’ve …
HEFFNER: … in successful aging.
ROWE: … that’s right. We can’t rely on geriatricians. We’re just not going to train enough of them and there’s not enough interest in the US of being a geriatrician. One of the reasons is finances. You do a special training in geriatrics, your income goes down because all your patients are on Medicare (laugh) as opposed to some of them having private insurance. So there’s no financial incentive.
But we are at the point where we should be able to train all health care providers in the US … physicians and nurses and others … to be competent in the diagnosis and the management of the common problems of old age. That’s what the practice of primary care is going to be in the future. It’s going to be the common problems of old age.
HEFFNER: Well, as a man who’s accustomed to the common problems of old age, which you kids don’t know about really, yet, I want to thank you Dr. John Rowe for joining me today on The Open Mind.
ROWE: Thank you, Dick.
HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. Meanwhile, as another old friend used to say, “Good night and good luck.”
And do visit the Open Mind Website at thirteen.org/openmind to reprise this program online right now or to draw upon our Archive of 1,500 or so other Open Mind and related programs. That’s thirteen.org/openmind.