PHILADELPHIA REFLECTIONS
Musings of a Philadelphia Physician who has served the community for six decades

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Old Age, Re-designed
A grumpy analysis of future trends from a member of the Grumpy Generation.

Redesigning Old Age

A friend of mine, treated as my contemporary but probably only sixty years old, was recently speaking of a club picnic he unfortunately wouldn't be able to attend. His mother was now living with him, and since she was 84, obviously neither of them could go to a picnic on a sailing vessel. The club committee, listening to this regret, chuckled that of course we shouldn't expect him. My thoughts were somewhat different. Since I'm 86 myself, I was wondering if she was available for a date. And of course I am going to that picnic, why shouldn't I?

{top quote}
Most of the old fatal diseases have been cured, and guess what --People are living longer. {bottom quote}

This little encounter is offered to illustrate how realities change faster than attitudes. But attitudes better start catching up, because some grim financial realities are just safely predictable as the demographics. Biblical prophets declared mankind was destined to live for 70 years, until threesome and ten. But American life expectancy at birth has been average American male can now expert to live beyond 80, women a little longer. But that will be eight decades from now, and must be an underestimate. If life spans continue to extend at present rates, average life expectancy at birth will reach 104 by the time today's newborn reaches 80.

Scientific colleagues feel that's only an unrealistic example of the extrapolation fallacy. To them, the human apparatus is programmed to wear out at age 100, so advancing life expectancy must taper off abruptly between now and then. There's a concept called apoptosis stating that cells will only divide a certain number of times before they quit. Human protoplasm thus seems programmed to reach the apoptosis point a around age 100. If the scientific article start describing big advances in delaying apoptosis then of course the rest of this article will need to be modified. In the meantime when friend or family member dies at the age of 90, it might be an appropriate stance to deplore a regrettable loss of ten years of life potential, before that apoptosis thing would have set in.

Pennsylvania Hopital

Six decades of practicing medicine do confirm these statistical whimsies. But experience does not exactly match present predictions of constantly rising costs of medical care. With no difficulty at all. I can recall several dozen diseases which commonly shortened life expectancy in the past, but which have now largely disappeared Tuberculosis comes first to mind: in my student days we saw several new cases every day, and experienced difficulty finding vacant beds to house them in the several tuberculosis hospitals of Philadelphia. Every single medical student in my graduating class of 1948 had a positive test for "TB" and it seemed almost every class contained one or two students who had to drop out for a year or two to have active TB treated. Typhoid fever offered similar experiences to the generation before me. My teachers would point out a forty-bed ward at Pennsylvania Hospital that in their day as interns had once been reserved for typhoid cases exclusively. I had been practicing for fifty years when it suddenly became simple to treat duodenal ulcers. Ten percent of the population used to have ulcers, which would bleed on perforate or penetrate or stenose and cause thousand of patients to eat disgusting soft tasteless diets taking handsfull of chalky pills. Rheumatic fever and the associated bacterial endocarditis no longer fill our hospitals but I can remember a time when there were always one or two cases lying around. Syphilis is gone poliomyelitis is gone small pox and lots of less common conditions. Pneumonia with a former mortality rate of 10% is now treated with an office visit or two. The death rate from heart attack and stroke is down 50% with a vast backlog of already semi-clogged arteries still waiting to mature: the mortality rate will come down to rest at a much lower level. Fifty percent of the drugs in use today were unknown seven years ago so all that education and re-education is redundant a cost eliminated. In my medical lifetime, I probably discarded two full medical educations. Surely all this progress ought to reduce the cost of medical care.

{Privateers}
Cancer Cells

Looking ahead I can only see three or four major diseases that still lack a cure. Cancer is certainly number one an Alzheimer's Disease is probably number two. Add to that schizophrenia and manic-depressive disorder and when those four are cured, it becomes difficult to state what will cost Medicare very much or shorten life expectancy very much below the promised 100 years. So you can't scare me very much about the future medical costs of medical care. Insurance and administrative costs are something else of course. If the problem of foolish borrowing put Medicare out of business, it;s hard to see how that could be the fault of my profession, unless perhaps something or other undermines our traditional system of ethics.

Where the ethics thing comes in is in the obvious conclusion that we are spending a lot of money treating diseases we crusty old docs once wouldn't have thought were worth our time. We are fast approaching the time when substantially all the medical catastrophic costs are concentrated in the first year of life and the last year of life. Increased life expectancy is a matter of widening the interval between those two years. Medical care between those years consists of treating disease successfully preventing disease and managing complaints we once would have dismissed as 'that's nothing'. But even the cost of doing this kind of medical care should decline: patents should expire equipment should simplify treatment should become standardized or even routine. But we notice people won't leave us alone: our government has just spent $27 billion forcing office computers on doctors who don't see the need to be bothered with them. People persist in using our time to inject botulism toxin into wrinkles and to complain how lonely they are. That is to say the public is beginning to insist on substituting their own view of what they want for what doctors have traditionally thought was worth treating. This is an expensive way to enjoy freedom of choice and it is only a matter of time before bureaucrats figure out the least obtrusive way to curtail it. Only when forces come to an equilibrium will it be feasible to extrapolate future health costs.

What should appall us is the cost of paying for a progressively protracted retirement of so many unemployed people and the absolute impossibility of of paying for it by continuing on our present funding path. Maybe that's what all this obesity means. maybe people are trying to store up enough fat when they are forty, so they can go without eating from age sixty to ninety.

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