Aging, suffering, and the inevitability of death: Let's keep it real, and ignore the quacks

My friend Paul Taylor, longtime journalist and former executive at the Pew Trusts, has just published a new book called “This Is Getting Old: Two Boomers and Their Generation at Dusk”. It has two main topics. The first is an often-disturbing analysis of the impact of the “Boomer generation” as a whole, focused on their (our) massive accumulation of money, fighting for society’s resources to be directed to us, and shockingly, away from those who need it most, children. There are clearly many different indviduals in this generation, as well as subgroups (since boomers were born 1946 to 1965, the usual characterizations of us in our youth, activism in the late 1960s, obviously are only about the older part of that cohort). He makes the point that not only did this generation, as many before, get more conservative as they aged, but that only a portion of them were ever progressive. And the contrast between their generosity to their own children and grandchildren, and their parsimony toward most of society’s children is, at least coincidentally (as he states it), or definitely (as I think) about the color, race, and ethnicity of the majority of today’s children. Did I say this was shameful? If not, I do!

The other focus of the book is the aging of his, their, and our generation, focusing particularly on one couple (a terrific, impressive, warm and active couple), but also full of data on what is happening to all of us. Which is the same thing that happened to everyone before us, getting old and eventually dying. We may be dying older, and dying of different things, and (many of us) having more healthy and productive years before we die, but we all die. And for many of us, perhaps most of us, as all through history, that dying will be preceded by a period – which can be short or be many years – of suffering, of being sick, in pain, losing our mental faculties, or all of these. Guaranteed. While billionaires are being quite successful in avoiding (at least for themselves) the other of that famous pair, taxes, avoiding death is, even for them, only a science fiction cryogenic dream for them that has not yet happened. Thank goodness. If there are any people that the future does NOT need preserved for them to deal with, it is the billionaires most assiduously working on it!

So, we need to remember not only the inevitability of death, but the suffering that so often precedes it. We boomers have been watched it in our parents, our older relatives, and, sadly, many of our peers. It is well to remember the myth of Tithonus, who was granted eternal life by Zeus, but not eternal youth. He continued to age, alive and living sicker and more decrepit. A more modern self-deception: a few decades ago, I was the only physician in a health policy class. Each week one student had to make a presentation to the class on a particular topic. The student who addressed the issue of “long term care” did present data, but then added that in their opinion the need for long-term care would decrease because people were taking better care of themselves, exercising and eating better and not smoking. I pointed out that this would obviously increase the need for long-term care, as people would less often die young from heart attacks and more often live older and older (if not eternally, like Tithonus) with more and more care needs. I suspect I even said something like “if you want to decrease the need for long term care, have people smoke, drink, eat poorly, not exercise and drop dead in the 40s and 50s”.

But that student, and others, were young. Somehow, they conflated living a more healthful lifestyle, and having better health in the near and medium term, with not ever confronting getting old, sick, and dying. That is purely wishful thinking. While living more healthfully is a good idea, it cannot prevent the inevitable. And yet, many people, even today, believe this that somehow they can and (more venally and evilly) are selling it to others. Some of these ideas are commonly associated with folks like Secretary of Health and Human Services Robert F. Kennedy, Jr. (how painful to associate that name and that title!) and the MAHA (Make America Healthy Again) movement. Like the MAGA (Make America Great Again) of Donald Trump, the key point is the “again”. In the case of MAGA, it depends on what your definition of “great” is – probably America was if it means slavery, racism, subjugation of women, and constant wars, with military budgets making up the biggest part of public spending, the funding of which comes disproportionately from those with lower incomes.

In terms of MAHA, while there may be a bit less subjective flexibility about defining “healthy” than “great”, there is definite disagreement about the road to health. For example, a recent study by the Edelman Trust Barometer produced the table below. About a quarter to a third
of Americans believe each of these falsehoods, and 70% believe at least one, with a whole bunch of folks who “don’t know”. Edelman calls these claims “false or unproven”, which is generous. To a greater or lesser degree, they are all false. The most dangerous are the claims about vaccines, which are good, and to a large degree the reason that boomers and others are likely to live as long as they are. As a t-shirt I have seen correctly asserts “Vaccines cause adults”!

 

 

Unpasteurized (ie, raw) milk has in fact caused lots of deaths because of bacterial contamination. Testimonials from dairy farmers who drink it all the time are not valid for urbanites who are consuming it days after milking, when the bacteria in it that would have been killed by pasteurization has had time to multiply, The other false claims may not cause death, but sure can cause suffering; I suffered a lot of dental cavities as a kid before our water was fluoridated. Fluoride is definitely helpful to dental health (excessive amounts can cause unsightly, but NOT dangerous, mottling of teeth). Avoiding acetaminophen in pregnancy can cause pain. And on animal protein: it is not more healthful than plant protein, it is in fact, generally less healthful. As is animal fat (e.g, tallow, lard). 

These false claims are relatively easy to refute, although it is not easy to convince people who believe them that they are wrong; these are two different things. But what of the amazing plethora of other magical health claims, today’s equivalents of snake oil (in promises for great health, not to mention quackery). Early in his book, Taylor writes 

Don’t pick up this book expecting to find the magic formula for staying forever young. I ain’t got one. You’re better off cruising TikTok, where a bustling industry of anti-aging influencers serves up a bottomless banquet of science and quackery. They treat aging as a curable condition, death an avoidable fate. 

Sigh. It would be wonderful if these nostrums could keep you healthy and keep you from dying. But they don’t. That doesn’t keep them from being a “bustling” (and profitable!) industry.

Three points:

1) Natural is not necessarily better or safer. That is a fallacy. Anything that actually has biologic effects can have the ones you want, and the ones you don’t (side effects). If it doesn’t have any biologic effect, it’s not helping either.

2) Don’t be a sucker. Yes, Big Pharma is evil, but there is much better data on whether and how its products work than those of the MAHA-hood.

3) If it sounds to good to be true, it probably is.

We don't need billionaires, we need a healthy population: It is time to move forward

I recently started reading Ricardo Nuila’s book “The People’s Hospital”, about Ben Taub, the largest public hospital in Houston. This will not be a book review (which can be found in many places, such as the NY Times, Washington Post, and elsewhere); I’ve just started it. What affected me was how, even in the first few pages, Nuila’s description of Ben Taub was so like that of Cook County Hospital (now John Stroger Hospital), the public hospital in Chicago where I did my family medicine residency and later practiced and taught for many years. That should not be surprising; the characteristics of large public hospitals in major cities, and especially the circumstances of the people who come to them for their health care (a major focus of the book, per the reviews) are going to be, sadly, very similar. What was most striking, and depressing, to me was the temporal aspect. Nuila is writing about recent years, including the impact of the COVID pandemic, while my years at Cook County were in the 1970s, 80s, and 90s. And yet so little has changed, especially not for the better.

Yes, medicine has changed. What we can (or, maybe more important, could) do for people is more. When I was a resident at County, CT scanners were uncommon, and didn’t exist at our hospital. If a patient needed a CT scan, it could usually be scheduled for after midnight at the private hospital across the street, if they were accompanied by the resident. Who had been up the entire previous night doing admissions. CT scans, and other imaging, are far easier to obtain now. We now have dozens, perhaps hundreds of more antibiotics, and are able to effectively treat many more infections, although bacterial resistance to them seems to grow faster than the antibiotics themselves, both because of overuse and the special breeding capacity of bacteria in hospitals where antibiotics are so pervasive. We can treat, even  cure, cancers we could not touch in the past, although the cost of chemotherapy drugs – a bonanza for not only the pharmaceutical companies but the hospitals that get paid a huge markup from insurers for administering them – makes them often unavailable to those who are poor and uninsured.

But there have been other things that have not changed. Indeed, have often gotten worse. This is the main focus of Nuila’s book, the social conditions that so many people, especially poor people, live in that have such a major negative impact upon their health. Calling them the “social determinants of health” is largely accurate, although the “socioeconomic determinants of health” would be more so, but it tends to almost make it sound trivial. It is not trivial. The socioeconomic conditions in which people live have a far greater impact upon health than anything except, perhaps, genetics. Certainly more than medical care, which accounts by most estimates for at best 10% of health, although it is where we as a society spend more than 90% of our health-related money. It has far more impact than all those diet/exercise/lifestyle factors, or vitamin/mineral/“natural supplements” that are promoted by those who are true believers as well as those who see this as their way to cash in.

It is shocking and distressing to me that conditions for poor people are not better than they were so long ago, and are in fact worse. The same groups of people who have always been pushed into this category, especially Black and Latino and Native peoples, and indeed poor white people, have been supplemented by immigrants from all over the globe who our society treats just as badly. And even more, supplemented by the NON-poor, working and middle class Americans who often have trouble getting the health care that they need – and deserve – because of limits imposed by insurance companies and health systems, which all operate as if they were for profit.

It is still surprising to me, because although I intellectually know better, much of my instinctive reaction is deep-seated and believes that history moves in a positive direction and things tend to get better. Said so much more articulately by Dr. King, “The arc of the moral universe is long, but it bends toward justice,” it resonates with me as much as I fear it is not so. My own perspective is generational; grandparents who were immigrants and low-income, parents raised in the Depression and in WWII, myself raised after the war thinking we were now middle-class (we were working class); better off than our parents were growing up. It was in that period that CEO salaries relative to average workers were “only” about 30x as much (not the hundreds of times as much as today), unions were stronger, the civil rights movement was gaining ground. See, e.g., this from the Economic Policy Institute from 2019 showing CEO salaries gained 940%  since 1978 while average worker salary was up only 12%!

But now it is much worse. It is moving backwards, except for the wealthiest – and by the wealthiest I mean the really wealthiest. Midwifed by the Republican party (but abetted by the Democrats), especially since the Reagan 1980s, we have become a society in which not just a disproportionate share (which was always), not just most, but virtually everything goes to the wealthiest. This Oxfam report (January 2023) shows that in the last 2 years, the top 1% has accumulated nearly twice as much as everyone else in the world put together!! This is what it is all about. Yes, there is racism, and sexism, and anti-LBGTQ+ ism, and they are terrible and they often make people’s individual lives terrible, and should be fought against ceaselessly. But it is the gangster capitalism (Noam Chomsky’s term) in which there is literally no limit to the greed and the amount of money a few people have, hundreds of times more than they or their descendants could ever spend.

This is the trend in our world and our nation while the people who seek health care at Ben Taub Hospital in Houston or Stroger Hospital in Chicago or their equivalents, not to mention those who live in places where there are not public hospitals, not to mention those from all the parts of the world to whom coming to Houston or Chicago seems like it would be Heaven, get sick and sicker and die. In fact, contrary to the proclamations of right-wing pundits, all of these problems can be solved with money. It should be the money now being amassed by the richest individuals and corporations, including those in health care (providers and insurers and pharmaceutical and device manufacturers) could, and SHOULD, be used to provide medical care, but more important provide the conditions necessary for health. For EVERY person to have adequate and healthful food, to have adequate and warm housing, to have an opportunity for an education as far as their drive will take them, to have a job to feed themselves and their family. There is enough money to do this, and yet it is being socked away in private pockets so deeply it will never be touched.

In 1850, the Frenchman Frederic Bastiat wrote in “La Loi” that "When plunder becomes a way of life for a group of men, they create for themselves, in the course of time, a legal system that authorizes it, and a moral code that glorifies it." They get to do this because we enable them. Directly, our politicians enable them; while Republicans and Democrats keep our attention focused on “culture wars”, both parties (except for the most progressive Democrats) depend upon and enable them. Indirectly, it is the rest of us, who do not demand that the politicians we elect fight for the interests of the people. If the 10,000 or so Americans worth $100M or more disappeared tomorrow, no one would miss them except (presumably) their families and the politicians who have become accustomed to being owned by them. If they averaged just $100M each, that would be $1 TRILLION ($1,000,000,000,000), but of course that is an underestimate since many are worth billions, or tens of billions.

It is well past time to take that, both in taxes and in other changes in public policy, and use it for the people.

Other countries invest in the public's health and welfare. We invest in creating billionaires. ???

It’s not just Donald Trump. It would be nice to think it was, and that, if it was far from perfect, everything was much better in the US before him. Maybe it was; certainly many of the horrible things that he and his administration have done were not done by previous administrations, of either party. These include total denial of climate science (or any science), overt (not subtle) racist appeals, gutting most of the federal agencies responsible for the quality of our life (not to mention survival of our planet) in areas such as health, environmental air and water quality, education The administration has replaced of most of the protections we have had with the most rapacious policies we have seen. Oh, yes, and destruction of our relationships with our allies, and moving ever closer to war with – almost anyone, although his friendship and authoritarian bromances with many of the world’s most autocratic leaders might limit that.

And it’s not just his supporters, as nice as it would be to think that they are just stupid (as long as they do not remain the majority, or the effective majority given the intrinsic inequities of the Electoral College). While the most of them may be stupid and have no understanding of where their own self-interest lies, or are at least more committed to racism than their self-interest, there are a minority of them who are smart (if not wise) and very rich people who have been quite pleased with the direction of (most) of the administration’s policies. That is why they fund it.

And it is not even the Republican Party, as much as that party has, at least for 4 decades, been the party of giveaways to the richest, destruction of the environment, bellicosity which has led to several horrible and pointless wars, appointment of right-wing Supreme Court and lower court justices who manage to convince themselves that they know what the “founders” would have thought 250 years later about issues that they could not imagine, and of course racist approaches to almost everything.

But the most important general trend in the United States over the last 40 years, while it has sometimes been accelerated by Republican administrations, has continued under the Democratic administrations of Carter, Clinton, and Obama. It is the increasing, ever increasing – and incredible, at this juncture -- concentration of wealth in the hands of a few, to a degree that has not existed since the days of the “robber barons” of the late 19^th century. A recent article in the Guardian, ‘The US has the most billionaires in the world – but here's what it doesn't have’ documents what citizens of other industrialized have that we don’t: low-cost, or even free, college education, universal health coverage, guaranteed paid vacation and paid parental leave. And more. And, of course, we also do not have what the article refers to as an “inhospitable climate for billionaires, one in which they actually have to pay taxes commensurate with their income and wealth. Our climate is definitely hospitable for them. And, thus, if you are both a billionaire and a completely selfish immoral person, you should be happy with US policies. If you are neither, or only one, you should not be.

There is obviously no disconnect in between these two things, the hospitable climate for billionaires and the limited programs that benefit our people. In the 1950s, as our economy and that of the rest of the world, rebuilt from World War II (ours rebuilt faster because, after the bombing of Pearl Harbor, there was not actual war fought on our territory), under the Eisenhower administration, employment, wages, and unionization increased. The wealthy were wealthy, but regular people, workers, found unprecedented economic success, buying houses, cars, and sending their children to college. CEOs made about 30 times what the average line worker made – a lot more. Of course, the growth was not equitable; minorities and particularly African-Americans were still marginalized, but even many of them got decent jobs.

 In the 1960s, mainly under the Johnson administration, the federal government developed programs to help Americans at a level not seen since the New Deal of the 1930s. In addition to passing laws like the Civil Rights Act and the Voting Rights Act, it developed programs to aid the neediest in our country, both Medicare and Medicaid, and the “War on Poverty”. That “war’s” programs are often derided, by the right, as a failure, demonstrating the fatuity of “throwing money at problems”, but in fact this narrative is incorrect. While the US did not “end” poverty, it decreased poverty a whole heck of a lot. Expansion of programs such as Aid to Families with Dependent Children (AFDC) and food stamps and the Fair Housing Act kept millions of children in homes, with food. The development of HeadStart made a real difference in early childhood education. As with most social service programs, the failings were almost entirely the result of not doing enough, not spending enough, and not a result of doing and spending too much.

But the money the government was spending needed to come from somewhere. And relatively more equitable taxes was more than the wealthiest wanted to pay. Of course, most people didn’t and don’t want to pay taxes, but the billionaires had a lot more clout to get what they wanted. So they got tax breaks for themselves and their corporations, and huge expenditures for “defense” (the US spends more than the next 10 countries together), really just another way this country subsidizes its corporations, and this became the order of the next four decades. Beyond not taxing the wealthiest, the US has subsidized them.  This is well-described by Paul Krugman in his recent piece “Why Do the Rich Have So Much Power?” (7/1/2020). Every penny spent on helping the neediest, or kept by the average American, is another penny not in the pocket of billionaires who are apparently possessed by the desire to have endlessly more despite the fact that they will not be able, in their lifetimes and those of their descendants, to buy enough mansions, private islands, planes, and yachts to spend it all.

Then comes a major crisis, like the COVID-19 pandemic. It hits everywhere in the world. Not equally, of course, the poor and the old and minority communities and the disenfranchised are hit the hardest. But a great deal of the first wave was in developed countries. Some were hit particularly hard, like Italy and Spain, and then France and Germany. Some responded aggressively and limited the damage, like the Scandinavian countries (except Sweden). But the US has responded abysmally poorly, with the most infections in the world – 25% of all COVID-19 cases in a nation with 4% of the world’s population. And tens of millions of unemployed people. And hungry people. And, increasingly, homeless people. Because we have not only, over the decades, purposely decimated our public health infrastructure, we have purposely inadequate social infrastructure of any type. While, in this pandemic, the people of other developed countries get cash bailouts, and expansion of the social support systems that we never had, the US expanded (for a little while, we don’t want to go too far!) unemployment insurance and gave folks one-time $1200 checks. Thus the NY Times can report that “Europeans get paychecks. Americans scrounge for food” (7/3/2020). And, thus, as reported by Robin Wright in the New Yorker “To the World, We’re Now America the Racist and Pitiful”. They used to envy us; now they pity us.

Some years back, I was amazed to hear the chair of one of the highest-income departments say they couldn’t afford nurses, and could only have medical assistants in their clinic. Since my department was one of the lowest income, and we did have nurses, I initially didn’t understand. But then it came to me.  Our group hired the nurses and medical assistants we needed to run a quality practice, and paid what was left to our physicians. Their department paid their doctors (i.e, themselves) what they thought they deserved, and then looked to see what might be left to pay staff. A different approach. There are a couple of ways, generally speaking, a society can  allocate resources: one is to spend what is necessary to meet the needs of the people, with the remainder going to profit, or savings, or (if this is the goal) to enhance the wealth of the rich. The other is, well, the opposite – give the rich what they want and see what is left over.

In ancient Egypt, we are told, Joseph advised the Pharaoh to stash away reserves of food when times were good in case they were needed in the future. As the 7 years of plenty wore on, there were certainly those who must have said “Enough!” But then came the 7 years of scarcity, and the Egyptians were glad that they had saved. We haven’t, on purpose, because our purpose has been to make the richest richer and preparing for real problems that might befall the rest of us was not really high on the agenda.

We have not been meeting the basic needs of our people in the best of times. Poverty and racism are key social determinants of health, and for too many of us, our pre-existing health was marginal. We do not have affordable, universal health care. And we have cut resources for public health planning and preparing for a crisis, such as that we face today. For most Americans, that is a double hit, and for the poorest and worst off, it is unconscionable. This needs to change, and it needs to start immediately. Equitable taxation, meeting the needs of our people, and planning and preparation for the future.

Or, I guess, we can just keep funneling money to the billionaires.