Wednesday, 09 April 2008
The TGB Interview: Dr. Robert N. Butler
I discovered Robert N. Butler, M.D. when I first started researching aging a dozen years ago through his Pulitzer Prize-winning book,Why Survive? Being Old in America. My copy, even in hardback, is tattered and worn now, Post-It noted and marked up to within an inch of its life, as it is one of the “bibles” I regularly use to think about aging and as a reference for this blog.
Dr. Butler, a gerontologist, researcher, psychiatrist and public servant, coined the term “ageism” in 1968, founded the first department of geriatrics at a U.S. medical school at The Mt. Sinai Medical Center in New York City in 1982, and is president and CEO of the International Longevity Center – USA. Throughout his career, he has been an eloquent advocate for the rights of elders.
In his new book, The Longevity Revolution – The Benefits and Challenges of Living a Long Life, Dr. Butler brings his vast knowledge and experience to bear on the wide-ranging and dramatic changes that must be made in politics and society – and the reasons for them - to accommodate humankind’s increased longevity. It is a brilliant, intelligent book that, if I had the funds, I would send to every politician in Washington, D.C. and every reader of this blog.
Dr. Butler made time his schedule to answer my questions for this TGB Interview, and I am most grateful to him.
RONNI BENNETT: What do you mean by the title of your new book, The Longevity Revolution?
ROBERT N. BUTLER: The longevity revolution refers to the fact that we gained 30 additional years of life in the 20th century, greater than had been achieved during the preceding 5000 years of human history. This is revolutionary in character and unprecedented. Just to give one example, in 1776 the average life expectancy in the U.S. was 35. In the year 1900 it was 47 and today 77.
RB: What are a few of the ways global aging will affect the world in the coming decades?
RNB: If we think we have serious issues with Social Security and healthcare, imagine aging of the developing world. Global aging will affect the global economy, character of disease, socioeconomic circumstances, politics and culture.
RB: You suggest in your book that we could lose those gains in longevity you mentioned. How would that happen?
RNB: Were we to have a human-to-human mutation of the bird virus we could lose the longevity we have gained. Furthermore, we predicted in an article in The New England Journal several years ago that because of the rising obesity epidemic in young people, we could reach a point where the younger generation lives fewer years than the older generation.
RB: You state unequivocally that an aging population does NOT account for rising health costs and that excessive medical costs are NOT associated with the end of life. A lot of people don’t believe that…
RNB: It is technology, drugs, so far, that account for the rising health costs not the aging of the population. This could change, of course, with increasing aging. End-of-life care can be expensive whenever end of life occurs. For example, a young person in an automobile accident, a young woman with breast cancer, but in old age per se, the per capita expenditure at the end of life actually declines and the proportion of Medicare that goes to end-of-life care has remained stable for more than the last 20 years.
RB: The federal government has just released some scary statistics on Medicare – that at its current level of payout, spending will exceed revenue by 2019. Do you have a solution?
RNB: The solution to the issue of Medicare is to change the reimbursement system which favors the procedural and technological specialties rather than primary care. It does not adequately support prevention.
The solution to Medicare ultimately has to be reforms in the healthcare system in general. We need new systems of healthcare delivery, more primary care, more prevention, more investments in research and a better trained healthcare workforce to take care of old people.
RB: How can Medicare be improved? Is it a good model for universal coverage?
RNB: Medicare could be a very good model for universal coverage. Administrative costs approximate two percent. The private health insurance industry costs up to 20 percent. This is because of advertising, marketing, claims adjustment and profits.
RB: You advocate development of “a vigorous politics of aging and longevity.” How confident are you that it can happen? What will happen if it does not develop?
RNB: While I favor a vigorous politics of aging and longevity, at the moment we do not have a great exponent comparable to the leadership of the late Claude Pepper. The reason, I think, it may happen is the baby boomers will grow old and then the 65+ population will be 20 percent of the entire population, 25 percent of the adult population and probably some 30 percent of the vote.
RB: With 70-year-old Senator John McCain the presumptive Republican candidate for president, what would you advise voters about considering his age when deciding to vote for him or not?
RNB: I am concerned that there is a storm of ageism being projected against Senator John McCain. Yet there have been great leaders of great age such as Charles DeGaulle in post-war France, Konrad Adenauer in post-war Germany. The issue is not age, the issue is function, that is, intellectual and physical capabilities to carry out the job.
RB: It is obvious that with our longer lives, elders are capable of working beyond the standard age-65 retirement and many want to. Even so, they are shoved out of the workplace and corporate America keeps insisting it needs to outsource jobs to other countries because they cannot find enough qualified workers here. How can those attitudes be changed?
RNB: Some corporations are actually concerned about the impending retirement of the baby boomers. They fear the loss of executive and managerial talent. There is also a concern over the fact that within 15 years, 50 percent of all nurses will have retired. There will also be shortages of air controllers and atomic energy personnel. The opportunities to work longer may be upon us.
RB: We all know that sometimes an idea hardly exists until it is given a name. How did you come to coin the term “ageism”?
RNB: In my own neighborhood, housing for older people was acquired and my neighbors were up in arms: “We don’t want all those older people around.” There was no term to explain this prejudice and so I decided, analogous to the terms sexism and racism, we could use a new useful term which I called “ageism”.
RB: In the 40 years or so since you coined the term ageism, have you seen improvements in prejudice against elders?
RNB: There may have been some improvements in age discrimination. For example, there is an Age Discrimination in Employment Act which has virtually ended mandatory retirement. There have been some improvements in nursing homes and I think some greater sensitivity about age. But we are a long way from having conquered the prejudices regarding aging.
RB: How have myths and prejudices regarding the nature of aging affected our culture generally?
RNB: Life has to be based on hope and expectation of a positive future. When that future is removed as in the case of old age it builds dissatisfaction, disappointment and depression. This obviously affects our culture.
RB: For most of the history of mankind, in most cultures, elders were revered for their knowledge and experience. How did that change?
RNB: When older people were relatively rare, adoration was easy. As they became more common, especially when impaired, they were experienced as a burden.
RB: As you point out, only 11 U.S. medical schools have departments of geriatrics and schools cannot fill the first-year geriatric residencies that are available. What does this mean to an aging population? Will the quality of healthcare for elders decline? Has it already? What is the solution?
RNB: The care of older people is not what it should be and it could get worse. We have to build new ways of providing care not only including the development of trained geriatric physicians but also geriatric nurse practitioners, home health aides, social workers and others.
RB: Is there any way to change young physicians’ preference for specialties in dermatology and cosmetic surgery over geriatrics? Why do so many more young physicians go into geriatrics in Britain than in the U.S.?
RNB: The reason young physicians go into dermatology, cosmetic surgery and other procedural specialties is, in part, economic. On average, a medical student graduates with $150,000 in debt. We have to change the financial incentives to encourage people to go into geriatrics. South Carolina has created a debt relief programs for those who go into geriatrics. Senator Barbara Boxer of California has introduced legislation to do so on a national level. Payment structures in Great Britain are much better.
RB: What can elders do personally to help ensure their health and that they get the best medical care possible day to day?
RNB: It is never too late to develop good health habits and it is always too soon to stop. Older people can engage in important physical fitness program not only aerobic in character, but particular muscle-building. For example, the status of the quadriceps or the thigh muscle is one of the best predictors of frailty.
RB: In the past, I’ve written about “responsible aging” on my blog and was pleased to see your reference to it in your book. Would you explain your sense of the phrase?
RNB: The last data I have seen is that older people contribute about 33 hours a year, a little more than an hour a week in voluntary service. Older people, of course, have many burdens to deal with, particularly taking care of a spouse or a grandchild. Even so, I would like to encourage older people to play a greater social role, contributing to society in general.
RB: What is your view of Aubrey deGray and others who believe human life can be extended for up to 200 years. Is this a worthwhile goal?
RNB: I think the extravagant claims for longer life by people like deGray are questionable, indeed. We do know that it is increasingly likely that we will be able to slow aging while at the same time delay the onset of diseases. This means that we should devote new financial resources to understanding the basic biology of aging, but we should not get carried away.
RB: Would you explain why good neonatal and pediatric care are important to aging societies?
RNB: Many of the diseases of old age really had their origins early in life due to genes, the environment and behavior. Therefore, we need a lifespan perspective with regard to health promotion and disease prevention and the way in which we provide medical care including the importance of neonatal and pediatric care.
RB: One of your most radical proposals is for family planning along with population reduction and stabilization to meet the challenges of aging societies. Many people will recoil. How can you convince them otherwise?
RNB: It was not long ago that people were concerned about the “population crisis”. There has been considerable success, particularly in Europe and Japan. Indeed, more than desirable.
I do not favor the situation in Japan and Europe where birth rates are below the replacement level. I do favor stabilization of population. It gives us greater control over the financing of health and pension benefits and provides for better quality of life rather than overburdening facilities with huge population growth. Furthermore, we know that population size is not directly related to economic prosperity. Think of prosperous, small countries like Switzerland, Singapore and Norway.
RB: What needs to change for your proposals to deal with an aging society to succeed?
RNB: I think we need a transformation of both the culture and personal experience of growing older for proposals to deal with an aging society to succeed. We need to overcome denial and take a good direct look at what we need to change.
RB: Are you optimistic that governments will make the changes necessary to deal with global aging?
RNB: I am always a guarded optimist and I do think the baby boomers, a very large generation, may be transformative. I am not sure they will be able to benefit as much themselves but that they will contribute to improved quality of life for the generations that follow.
RB: What can individuals, especially those who are elders now, do to contribute to the needs of an aging society?
RNB: Older individuals themselves can contribute directly through civic engagement through the kinds of work that is being undertaken by Marc Freedman of Civic Ventures and by Jack Rosenthal at ReServe. In other words, older people should continue to contribute to society.
[At The Elder Storytelling Place today, Mage Bailey celebrates the arrival of spring in Play Ball.]