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.

Fluoridation: Dental health for all

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Fluoridation of the water supply is one of the great public health benefits of the 20^th century. It is also one of the persistently more controversial. Ideological opposition (to “the government” doing anything) has mixed with paranoia (they are poisoning us) to create a pretty sustained grass-roots movement, one that has blocked this effort in many places in the country. Now, according to Lizette Alvarez’ article in the NY Times “Looking to save money, more places decide to stop fluoridating the water” (October 14, 2011), saving money has been added to these arguments. The threat is that communities which have had the benefits of fluoridated water will lose them. This is apparently the what is happening in Pinellas County, Florida (the Clearwater/St. Petersburg area), as well as in Fairbanks, Alaska.

The situations in Florida and Alaska may well be different, however. The decision in Fairbanks is apparently tied to the relatively high levels of naturally-occurring fluoride in the water there, which would make fluoridation an unnecessary cost. In Florida, however, the decision seems to be driven by cost as well as the same issues I note above. “I’m in opposition to putting a medical treatment into the public drinking water supply without a vote of the people who drink that water,” said Norm Roche, a newly elected Republican county commissioner who spent 10 years doing policy research for the county Water Department and who led the turnaround effort. “We had a dozen to 15 doctors, dentists, dental hygienists and chemists here who want us to continue this practice but who could not agree themselves on how best to use fluoride.” The article does not further define what Mr. Roche means by “how best to use”, leaving us to imagine if this is an issue of putting it in the water vs another method (fluoridated toothpaste, fluoride treatments at home, fluoride varnishes by health providers) or disagreement as to whether it should be used at all.

In fact, the medical and dental community are pretty much in agreement that fluoride is good for preventing tooth decay, and that dental caries are a major cause of disability both medically and socially. It is hard for a child with a toothache to concentrate at school, not to mention the teasing that can come from having a mouthful of rotting teeth. This latter continues into adulthood; people with bad teeth (or no teeth) are seen as less smart and less competent, and are less likely to be hired in most jobs.

Fluoride works. In my “middle years”, my Chicago dentist had a pretty good idea of my age because he knew when the water in New York City, where I grew up, was first fluoridated. My “6-year molars” were covered with filled cavities (necessitating, all those years later, a lot of restoration work by him), while my “12-year molars”, which erupted after fluoridation, were almost cavity-free.  I sure remember getting all those cavities filled, before dentists had high-speed drills or used anesthesia for such a simple, common procedure. My childhood self would certainly advocate for fluoride to prevent that discomfort!

There are, indeed, side effects to high levels of fluoride, whether naturally occurring or otherwise. The main sign of “fluorosis” is “marble teeth disease”, with “grotesque” brown staining of the teeth. It was an investigation into this condition in Colorado Springs in 1909 that led to the discovery both that the cause was high fluoride levels in the water, and that these teeth had virtually no decay (“The Story of Fluoride”, from the National Institutes of Dental and Craniofacial Research). This led to work that identified a level of fluoride that could be added to drinking water that was sufficient to prevent decay but too low to produce this condition.

After spending most of my life in New York and Chicago, one of the most dramatic things to catch my attention early in my stay in San Antonio, Texas, were the young children with stainless steel teeth, whose mouths distressingly reminded me of “Jaws”, the James Bond villain (albeit without the points!). I soon learned two things: 1) the stainless steel teeth were the result of having a great pediatric dental program at our dental school which could fix the mouths of children whose “baby teeth” had all rotted out, allowing them to be both pain-free and able to eat, and 2) the water in San Antonio was not fluoridated, which was a major cause (in combination with other behaviors, such as use of sugared drinks in baby bottles, feeding sugared soft-drinks to young children beyond the bottle years,  and “bottle propping” which leaves the milk – and milk sugar – in the baby’s mouth) of the decay the led to the need for such repair. While only a small percentage of children in San Antonio had such stainless steel teeth, a very large percentage had significant and disabling tooth decay.

I also discovered that efforts to pass fluoridation had been defeated in San Antonio on at least two occasions in the past few decades. The opposition was largely from right-wing, John Birch Society, anti-government groups, but also included those who were from the other end of the political spectrum but believed in “natural” health, and thus opposed addition of fluoride. In 2002, an initiative spearheaded by the Mayor of San Antonio, finally led to passage of fluoridation for that city. During this campaign, virtually all the major politicians, all the dentists, physicians, and public health people, and most of the foundations and money were for the initiative. Nonetheless, it passed by only 52% of the vote. The good news here, I guess, is that it is an example of the power of regular people, not very well funded, to resist change being imposed on them. Unfortunately, it was contrary to their health interests.

As I note, the opposition was not solely from the right. During my time in San Antonio, I frequently attended open meetings of a group of progressives in a local Mexican restaurant. Primarily mainstream liberal Democrats, and including the late San Antonio New Deal mayor and newspaper columnist, Maury Maverick, the group was diverse, including socialists and “Greens” and even libertarians, whose interests in lack of government restrictions and privacy invasions gave them common cause. These last two groups, the Greens and libertarians, were opposed to fluoridation. The national Green presidential candidate, Ralph Nader, on a stop in San Antonio, even came out in opposition to the initiative. As a health care provider, I did my best to argue for the benefits of fluoridation, but was unable to win them over.

One argument made they made (at least the libertarians) was that “fluoride might be beneficial, but the government should not put it in our water supply”. Parents could use fluoridated toothpaste or fluoride rinses on their children’s teeth, or bring them to the dentist for fluoride varnish. Well, they could, but often they didn’t, and it was the children who would suffer the caries and their long-term consequences. Indeed in the ‘90s a new syndrome, dubbed “yuppie baby carie syndrome” was identified in children of well-off parents who made their infant formula with bottled water. (The causes of caries from bottle propping and unfluoridated water are well-described in the Wikipedia entry on “Early Childhood Caries”.) Of course, the spread of bottled water to a much wider socioeconomic group makes this even a bigger potential problem. Indeed, some water from natural springs contains minerals, sometimes including fluoride, while the bigger mass-products products from Coke – Dasani – and Pepsi – Aquafina – are municipal tap water that has been “purified” and thus do not.  (This does not even begin to touch on all the environmental costs of bottled tap water, from plastic bottles to transporting tap water from one part of the country to another, but that’s another story.)

San Antonio, and more recently San Diego, are victories for fluoridation, while many cities, such as Wichita, remain unfluoridated, and others, such as Pinellas County and Fairbanks are going the other way. If Fairbanks has sufficient natural fluoride, then supplementation is an unnecessary cost. For those communities without adequate natural fluoride, it is a big mistake.

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