What Is the Price of Long Life?

Is the cost of prolonging life poor health? That provocative question was at the heart of a March 1 panel discussion on aging and longevity in New York City offered by the 92nd Street Y: The Long Life: Genius or Nightmare. Moderated by S. Jay Olshansky, professor in the School of Public Health at the University of Illinois at Chicago, the panel also included:

• Dr. Ezekiel Emanuel, oncologist and bioethicist who wrote the lightning-rod essay for Atlantic Magazine about why 75 is a good age to die
• Dr. Nir Barzilai, director of the institute on aging research at the Albert Einstein College of Medicine
• Dr. James Kirkland, director of center on aging at the Mayo Clinic in Rochester, Minn.

When Aging is Seen as a Medical Problem

Modern medicine sees aging as it did prior “predators,” deadly infectious diseases, Olshansky said. Researchers historically look for preventions and cures, one disease at at time. Except now, medicine is looking to “fix” biological aging itself.

Olshansky sees the quest for longer life as a Faustian bargain, because our attempt to prolong life comes at the cost of poor health. To gain one year of longevity, he said, we add six to seven months of unhealthy life. Chronic illness can leave people bedridden, exhausted from medication or immobile.

Olshansky lobbed hardball questions to the panelists with the zeal of a tennis pro.

“Is a cure for cancer genius or nightmare?” he asked.

Emanuel maintained that longevity needs to be balanced with the amount of time you might be living with toxicity from treatments, such as chemotherapy.

“Our goal should be to give people a chance to live a complete life. I think that’s about 75,” he said. At that age, in addition to physical limitations, frailties and chronic illness, most people experience cognitive disability such as memory loss, distraction and difficulty staying on task.

Barzilai agreed, saying, “The longevity dividend is great when health span is better.”

Lifespan Vs. Healthspan

All the panelists reiterated that we need to focus on healthspan rather than lifespan.

“We are tired of prescribing better wheelchairs and walkers and incontinence devices,” said Kirkland.

But even if we cure cancer, it adds three years of life, not the decades some might imagine. In addition, Olshansky noted that if we succeed in curing chronic diseases, such as cancer, we will see dramatic increases in Alzheimer’s disease.

Emanuel pointed out that if science is able to add five years of life to the average lifespan, “you’ll add five years at 75. You’ll go from 75 to 80, not 35 to 40.” So we are increasing the age at which people have less physical and mental capacity, not offering a fountain of youth to people in their prime.

Barzilai argued that 75 is a chronological age, and we need to look at biological age. He spoke about his 100-year-old patients, some of whom are still artists and painters. “For me, 100-years-old is precious,” he insisted.

“You haven’t sampled all 100-year-olds,” Emanuel fired back. “Don’t say it’s average.”

After Emanuel’s essay on aging came out, David Brooks, a New York Times columnist, cited research showing that years between 82 and 85 were the happiest of life. Brooks asserted that Emanuel would be missing the best years of his life if he died at 75.

At the panel, Emanuel addressed that idea. “You aren’t surveying people who live in nursing homes; you have a biased sample,” he said. “I don’t assess my life by happiness. I ask if it’s fulfilling.”

Compression of Morbidity

When it comes to aging, the ideal, in current thinking, is a concept called “compression of morbidity.” Theoretically, this would mean that we live longer — but the bonus years are good years, and the bad times of frailty, sickness and suffering are compressed. In fact, “We have had an expansion of morbidity, not a compression of morbidity,” Emanuel said. “Every year we add morbidity.”

Aging Intervention

But Barzilai said that we have extended health span with drugs that are not used for aging per se, such as Metformin (a diabetes medicine), which may prevent cancer, cardiovascular disease, diabetes and possibly Alzheimer’s.

Again, Olshansky questioned whether that is a good thing: “Why make people live longer if it’s a strain on the environment and population growth. I’m a population scientist. There are 7 billion people currently on earth, and we will have 9 to 10 billion people midcentury.”

With decelerated aging come problems with who is entitled to resources, from public monies to liver transplants. Olshansky asked about issues of fairness and equity — will longevity be an option only for the rich?

Some drugs could be cheap, but even generic drug prices could be jacked through the roof if they were proven to ward off aging, panelists replied. And, Emanuel wanted to know, how would you test a drug that prevents aging?

Today, Barzilai said, the only successful approach to stop aging is to kill the patient. And drug development seems far away. For example, people with dwarfism live longer, he said, because something interferes with their growth hormone, but the most commonly touted “anti-aging” remedy is growth hormone.

The Big Question

Olshansky stated something all age researchers, and the rest of us, know: “If you exercise and eat right, you will still grow old and die, whether from heart disease, cancer or stroke.”

Here, Emanuel, who has said he will not be taking Metformin or antibiotics or flu shots and will not submit to preventive tests, screenings or interventions after age 75, had the last word of the evening: “What does it mean to have a fulfilled life? None of us wants limitation, aches and pains. There is a virtue to a deadline and not putting it off and off and off. It focuses the mind. Cancer patients say getting cancer is the most important thing [they’ve experienced]. It allows them to focus on the essential things. We have to make our big decision on how to live our life.”