Living longer is the best revenge
By Richard A. Knox, Globe Staff
Trim, ruddy, and almost as nimble as ever, Tommy Rawson demonstrates the trademark weaving style that kept him from serious injury in 316 amateur and pro boxing matches (with only 10 losses). Around him in the living room of the sturdy Arlington house he built in 1947 are mementos of a boxing career spanning almost three-quarters of a century: autographed glossies of Rocky Marciano and Sugar Ray Leonard, souvenirs of a 1970 stint as coach of Burma's Olympic boxing team, clippings on Rawson's victory in the 1929 national amateur junior lightweight championship in Chicago, when Al Capone and his entourage watched from the first two rows.
But at 90 years old, Rawson isn't done yet.
As he has for 57 years, he drives to Cambridge Mondays through Fridays to coach Harvard's boxing team from 3 to 5:30 in the afternoon. Rawson works out with his proteges, pushing himself through calisthenics and punching the bag (''If you're going to teach, you've got to demonstrate''), although he had to give up his daily 10-mile run a couple of years ago when his heart got balky. Retirement isn't in his plans. ''Harvard's paying me to stay fit,'' Rawson says. ''Not much, but I'd do it for free. If I stopped, I'd just probably eat and get lazy.''
Is Tommy Rawson the future of aging?
Do such vibrant nonagenarians (and even centenarians) presage a revolution in what it means to be very old? Or are Rawson and other ''successful agers'' just lucky exceptions to a rule of nature that, on a societal basis, will dictate a ruinous spiral of debility and dependency in the early decades of the new millennium, as 78 million baby boomers come into their seniority?
On that question hangs not only the future of a generation but of the entire society's - in fact, the whole world's - economy, politics, outlook, its very soul.
To some, the die is already cast, the glass certainly half-empty. The demographics are ''immutable and effectively irreversible,'' warns that quintessential realist, Federal Reserve chairman Alan Greenspan.
Last year, the proportion of elders surpassed that of children in developed nations, an unprecedented event in world history but merely a harbinger of what's to come. Observes a recent United Nations report: ''With the continuation of fertility decline and increase in life expectancy, the population of the world will age much faster in the next half-century.'' Already, there are as many people younger than 37 as there are above that age in the world's developed nations; by the middle of the next century, the median age will be 46 - truly the index of a mature society. Remarkably, less-developed nations are only a bit behind that curve.
There is little time to prepare for the baby boomers' elder years. Just under a dozen years from now, boomers will start turning 65 at the unprecedented rate of about 9,000 a day. To many economists and perhaps most politicians, that spells budgetary Armageddon. By some projections, two-thirds of the federal budget will be swallowed by retiree benefits in 2030, leading to ''government by, of, and only for the baby boomers,'' as Eugene Steuerle of the Urban Institute in Washington, D.C., alarmingly puts it.
By conventional wisdom, the burden on younger generations will become intolerable. Politics will be poisoned, if not paralyzed, by intergenerational conflict, as greedy geezers place limitless burdens on resentful workers.
Demographers couch the threat in terms of the ''dependency ratio,'' the balance of workers and dependents. Currently, there are four US workers for every elderly or disabled Medicare beneficiary. By 2030, when the youngest boomers will be entering retirement and the oldest will be 84, there will be 2.3 workers per beneficiary. Medicare costs will go through the roof, since the average elder's medical costs are 3.5 times higher than the average working person's. Moreover, medical care for the oldest of the old, those 85 and above, costs six times as much - and their numbers are growing faster than any other age group. Nursing-home costs may triple as a percentage of total government spending.
Is this scenario inevitable? Increasingly, leading authorities on aging don't think so. For as aging transforms societies, they say, aging itself is being transformed into a novel state that will defy history and confound expectations.
Aristotle formulated the notion of acme, the highest point on life's course. In his view, everything before acme is growth and preparation, everything after, decline and decay. ''That really remains the fundamental attitude about aging, at least in the West,'' says David Schlessinger, a geneticist at the National Institute on Aging in Bethesda, Maryland. ''In that view, the phases of life are almost hermetically sealed compartments: infancy, childhood, adulthood, decline.''
Historians now recognize that childhood and adolescence are social constructs as much as biological ones. Until the late 19th century, there was no such thing as a prolonged, protected period of early development and maturation. In just a generation or so, developed nations have stretched ''adolescence'' into the third decade of life, at least for the considerable fraction of the population that completes college.
Similarly dramatic transformation can happen - is happening - in what it means to be old. ''It's pretty well established, and I think it's going to increase,'' says Matilda White Riley of Bethesda, an 88-year-old sociologist of aging who embodies the trend she studies. ''Here's this whole new stratum of older people who are like nothing that has ever existed before. On the whole, they are very competent and very well informed. They're not going to sit back and play golf and bridge all their lives.''
The emergence of this stratum, in developed nations around the world, depends on two related 20th-century phenomena. One is the global revolution in longevity - ''the absolute triumph of this century,'' Dr. Gary Robert Andrews, an Australian gerontologist, calls it. The other is a more recent but pronounced trend toward healthier aging.
The longevity revolution is more familiar. In 1900, American life expectancy was less than 50 years, but at the close of the century it stands at 76 and climbing. Of all the humans who ever achieved the age of 75, three-quarters are alive today, notes Andrews, who is special adviser to the United Nations on aging.
Initially, gains in life expectancy stemmed largely from improvements in public hygiene and nutrition that increased the likelihood of surviving infancy and early childhood. In the last half of the century, medical and public health interventions have vanquished or greatly reduced the risk of diseases that once carried off adults before they could reach advanced ages.
Beginning with common infections such as pneumonia and rheumatic fever, the trend toward reduced risk had progressed by the 1970s to complex killers such as kidney failure, heart disease, high blood pressure, and stroke. Lately, it has extended to the most complex disease of all: Last year saw a first-ever reversal in the rate and absolute numbers of US cancer deaths, a trend extended last month to lower overall incidence of new cancer cases.
Until recently, trend-spotters habitually stressed the price to be paid for this medical and public health success - the ''failure of success,'' as it's sometimes called. More people, analysts noted, are now living long enough to acquire chronic, late-onset disorders such as heart failure, Alzheimer's disease, osteoporosis, type II diabetes, and arthritis. And that implied gloomy prospects for ever-increasing burdens of disease and debility.
But lately the emphasis has shifted as evidence accumulates that a surprising number of elders are aging ''successfully.'' They're not immune to aches and pains and real physical and spiritual troubles, and millions are gallant survivors of one or more life-threatening diseases. But increasingly, today's elders are escaping - perhaps deferring is a better word - the disabilities that typically have robbed older people of their independence and joie de vivre.
''By essentially all measures, the elderly are healthier than they used to be,'' concluded David M. Cutler of Harvard University and Louise Sheiner of the Federal Reserve System board of governors in a recent survey of the evidence.
This is not merely an optimistic impression. The proportion of disabled elders in the United States, Japan, and several other developed nations has been declining steadily since the early 1980s. It adds up to nothing less than a change in ''the biological rate of aging,'' according to Kenneth G. Manton and his Duke University colleagues, who first documented the trend.
Significantly, disability rates are falling across the entire age spectrum of Americans over 65, and the drop is greatest for the most severe disabilities. Whatever is happening to keep elders in better shape, it is not just operating around the edges but is blunting the disabling effects of severe disease.
Encouraging as it is, the trend won't stop the absolute number of disabled elders from going up, since the over-65 population is growing so rapidly. But it means the number will ''only'' double over the next two decades, whereas it would have tripled if disability rates in the early 1980s had remained unchanged.
Put another way, the declining rate of disability translates into millions of elders who are able to stay out of nursing homes, a trend that has already saved Medicaid around $20 billion in nursing-home costs. And, since disabled elders incur five times higher medical costs than their nondisabled counterparts, a slight but steady decline in disability rates will also save Medicare billions - even if it isn't enough to rescue the program from bankruptcy (which is expected in 2015, by current projections, if nothing is done).
Only in the last year or so have policy experts become convinced that the disability trends are real. Still, Schlessinger, the Institute on Aging geneticist, thinks the change has seeped into popular consciousness. ''When I was a kid, people who were 50 years old were old, and they were thought of as old,'' Schlessinger says. ''That's simply not true now. It's due to better attention to diet and fitness, and to modern medicine, which has meant a lot - at least for those who can afford it.''
The ''critical question'' now, says Dr. Richard Hodes, director of the National Institute on Aging, is how far this propitious trend can be pushed. Is there still room to make further major gains against the leading killers and disablers of older individuals, based on what we already know?
Absolutely.
Take the decrease in heart disease, which Cutler and Sheiner identify as ''the dominant source of improved longevity in the past 30 years.'' Since heart disease deaths have already plummeted by 51 percent over the past 40 years - 22 percent in just the decade between 1985 and 1995 - one might imagine that most of the gains have already been made. Not so. Hodes notes that a major recent study on systolic hypertension - an elevation of the larger number in blood pressure readings, which reflects arterial pressure each time the heart contracts - demonstrated a 50 percent reduction in heart failure among patients treated with a simple drug regimen, 90 percent among patients with prior heart attack.
This is a big deal, since heart failure has become the leading reason for hospitalization among Medicare patients. Until the recent study, doctors regarded systolic hypertension as a normal and inevitable part of aging, not something worth treating. And this is only one example of further inroads waiting to be made in heart disease. There's overwhelming evidence that heart disease and deaths could be greatly reduced by a number of other right-at-hand measures, from more widespread use of daily aspirin and beta blockers following heart attacks to better diet, moderate exercise, and smoking cessation.
Ditto for cancer. Far too few Americans are screened for colon cancer, breast cancer, uterine cancer, or prostate cancer, even though study after study shows that current technology saves lives by identifying these cancers when they are curable. Even less fancy are measures such as cholesterol and blood pressure screening, or influenza vaccinations.
''The emergency rooms of my hospitals in January and February were choked with older people suffering from the flu,'' notes Dr. John W. Rowe, president of Mount Sinai/NYU Medical Center in New York and coauthor, with psychologist Robert L. Kahn, of the recent book Successful Aging. ''We spent more money taking care of those people than it would have taken to vaccinate every old person in New York. But only 45 percent of eligible people get a flu shot, because Medicare has never been oriented toward prevention.''
When it comes to new anti-aging discoveries and treatments, the prospects have never been more enticing.
Just as societies gird for the greatest onslaught of people ever to cross the threshold of old age, scientists feel on the verge of understanding - and knowing how to do something about - some of the most daunting age-associated diseases, such as cancer, Alzheimer's, osteoporosis, obesity, diabetes, and arthritis.
In cancer, one group of researchers is hot on the trail of drugs to choke off the blood supply that solid tumors need to grow and spread. Others are decoding the perverse genetic signals that tell cells to become malignant or the normal ones that keep malignancy in check.
Alzheimer's is one of the most formidable challenges, but the first modestly effective drugs are on the market, and Hodes is bullish about more dramatic progress. ''The past 10 years have seen an explosive expansion in our understanding of the molecular and cellular basis of Alzheimer's,'' the Aging Institute director says.
Meanwhile, researchers have made important discoveries about the aging human brain that open unexpected possibilities. Contrary to long-established dogma, the cerebral cortex, the outer layer of gray matter responsible for thinking, does not inevitably degenerate with age. The underlying ''white matter,'' which nourishes neurons with the chemicals they need to function, does - but this is good news. It means that neurons might be rejuvenated if researchers can find ways to restore their ''neurochemical environment'' to youthful levels, as Yale University neuroscientist Amy Arnsten puts it. In fact, she and her colleagues are seeing positive results in aged monkeys from several experimental drugs designed to do just that; human trials may be a couple of years away.
Other bright spots abound. In the past year, scientists have shown they can grow neurons, muscle cells, bone, cartilage, and other tissues at will, starting with various types of ''stem cells,'' the protean cells that can blossom into all the 210 (or more) different tissues in the body, depending on which genetic switches are flipped. Recently, scientists have found that such embryonic processes are turned on in aging or in stressed tissues in the heart or elsewhere.
''You might think what's going on is that tissues in trouble are trying to regain some of the flexibility and adaptability they had during embryonic development,'' says Schlessinger. ''It makes regeneration of specific tissues an imaginable possibility.''
These provocative advances are occurring even before the Human Genome Project has provided researchers with a whole new tool kit: a set of the entire genetic instructions for a human being. When that occurs, early in the next decade, scientists expect they will fish out the genes responsible for many specific diseases of aging - and possibly even those that determine longevity or programmed senescence.
The aim of all this is not to engineer immortality (or make 120-year life spans commonplace) but to ''compress morbidity'' - that is, to sustain good physical and mental function and shrink sickness and debility - to an absolute minimum. No one can say how, when, or to what degree this will happen. But there is confidence that it will, to a meaningful extent, and that it will occur in time to benefit millions now alive. ''Disease by disease, we're going to start to make a difference,'' Rowe predicts.
''The fact that we have such large numbers of older people creates all kinds of pressures on social structures, and those pressures are going to persist,'' says Matilda Riley, who is social scientist emerita at the National Institutes of Health. Both the problems and the possibilities are endless, encompassing medical care and health promotion, housing, lifelong education, computer-based communications, financial supports, work-force and retirement issues, and individual versus social responsibility.
But one choice is fundamental, say some philosophers of aging. Societies can continue to segregate old people, physically and psychologically, and thereby foster an us versus them mentality that will stymie accommodation. Or they can look for ways to promote what Riley and her 90-year-old husband and colleague John W. Riley Jr. call ''age integration,'' the breaking down of age barriers.
This isn't just a nice idea; it appears to have real effects on longevity. The New England Centenarian Study has found that those who live to 100 are much more likely to stay in contact with younger generations. ''We must fight ... marginalization and ghettoization'' of older people if we want them to stay healthy and engaged with life, write Dr. Thomas T. Perls and Margery Hutter Silver, codirectors of the Centenarian Study and coauthors of Living to 100, a recent book on their findings.
Age integration is ultimately in everybody's interest. After all, old age is the burgeoning minority group we all (if we're lucky) are destined to join - and much sooner than we ever imagined when we were young and heedless.
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