Looking Forward

            Once the 1918-1919 influenza pandemic finally came to an end—after killing somewhere between 50 and 100 million people worldwide—Americans did their best to forget about it. Later tragedies such as AIDS and 9/11 figured prominently in much American fiction, but influenza was seemingly forgotten by American writers: Katherine Anne Porter’s short story, “Pale Horse, Pale Rider” and William Maxwell’s novella, “They Came Like Swallows,” are rare exceptions. Historians and journalists writing about the 1918 flu have hypothesized that the pain and suffering inflicted by the flu paled by comparison with that attributable to World War I, which came to an end at the same time, even though ten times more Americans died of the flu than died in combat. Or perhaps Americans were so optimistic about scientific medicine, which was just coming into its own in the twentieth century, that they chose to ignore medicine’s great failure, its inability to diagnose, treat, prevent, or cure influenza. Maybe Americans simply repressed this traumatic episode that killed people in the prime of life, leaving families without a means of support and children without a mother or father. Will the Covid-19 pandemic similarly be forgotten, or will it have a profound and enduring effect on us as individuals and on us as a society?

            The pundits are already speculating about the long-lasting effects of the pandemic on the real estate market and on the work place, on professional conferences and the movie industry. But what I would like to address is the life lessons we should take away from this devastating and unexpected year. The first is that our lives are tenuous. We in the developed world have come to expect a long healthy life, especially if we are white and middle class. Life expectancy at birth in the US is just under 79 years; if you make it to age 65, you can expect to live another 20 years. Covid-19 showed us that we should not take those years for granted: while 80 percent of the Covid deaths have been in people aged 65 or older, that means that 20 percent have been in people under 65. As of the end of December, 2020, 346,000 Americans had died from the disease, which translates to 69,000 younger people. There’s nothing like awareness of our own mortality to concentrate the mind and encourage us to live life well and to the fullest. This is the first lesson and the one we are perhaps most likely to forget.

            The second lesson is that what matters most to us as human beings is our relationships with other people. That’s what made “social distancing” so painful; it’s why eliminating family visits to nursing homes was so devastating; it’s why Zoom, FaceTime, and other video chat programs have been such a lifesaver. We need to cultivate our friendships, to nourish them, to work to improve them. The pandemic made us believe that other people are the enemy, which runs counter to our essence as social creatures.

            The third lesson that I want to emphasize is of a different sort: it is that to make decisions about most anything important and certainly to make medical decisions, we need to understand something about risk. How to behave during the epidemic was all about how to evaluate risk, how to think about risk. Just because most people who don’t wear masks and who go to group gatherings won’t get sick doesn’t mean that these are safe activities. It means that you markedly increase the chance that you will contract the virus if you go around without a mask or attend a group meeting. And understanding risk is more complicated still: how much you increase your risk depends on how widespread the virus is in the surrounding community. If very few people in the vicinity of where you live are sick, then your likelihood of getting the disease is low, even if you fail to take precautions. But as the virus begins to circulate more widely, then precisely the same behavior pattern that was only slightly unsafe before will become far more dangerous. 

            Understanding risk is tricky because the epidemiological measures designed to protect individuals, whether wearing a mask, practicing social distancing, or getting vaccinated, are not perfectly effective. Some people who wear a mask will nonetheless contract the virus; ditto for people who stay six feet away from others. Individuals who received either the Pfizer or Moderna vaccination in the clinical trials were one-twentieth as likely to get sick as those who received a placebo. But that means that just how safe you can feel if you are vaccinated  (even if the effectiveness holds up in a much larger population than was tested in the trials) also depends on how widespread the virus is: while vaccination lowers your relative risk of getting sick, if the number of infectious people in the community suddenly increases, say by a factor of ten, your chance of getting the disease also goes up by a factor of ten, even if you've been vaccinated. Grasping the concept of risk is essential—not just to dealing with an infectious disease, but also to deciding whether to undergo screening for prostate cancer, whether to take medication for borderline high blood pressure, and whether to invest in the stock market. 

           Americans, along with people across most of the globe, have lost much from our encounter with the corona virus. We have also gained something: an appreciation for life’s fragility, a recognition of the importance of relationships, and a deeper understanding of risk. It is up to us to remember, both those we have lost and what we have learned. 

Why We Work

With Labor Day rapidly approaching, I began wondering about older people in the workforce. Just how many people over 65 work? What about over 75? How is this changing? And what does work mean for older individuals?

Of course 65 is an arbitrary way to define old age. Most people who turn 65 are not old in any meaningful sense—they are certainly nowhere near the end of life: they can expect to live another 19.1 years. For women, life-expectancy at age 65 is still greater, or 20.3 years. Even age 75 is no longer very old, with a life-expectancy of another 12.1 years.  Moreover, as I pointed out in my last blog posting, roughly half those years are “disability-free.” But Social Security kicks in at 65 and so does Medicare, so this continues to mark the conventional threshold between working and retirement.

It turns out that a substantial and rising proportion of the population continue to work after their 65th birthdays. US Census Bureau projections for 2014 are that just under one in five people over age 65 will be working, a 36% increase in just 5 years.  For the 65-74 year old group, it will be slightly over one in four, and for those over 75, it will be a little under 10%. Roughly half of those people who continue to work will do so pretty much full time; about one-third will work 15-34 hours a week, with the remainder working 14 hours or less. 

The US is not the only developed nation to see a marked increase in older workers. England has experienced a surge of older workers, with numbers topping a million this spring: in 2013, 57% of people who reached the official retirement age said they planned to continue working, compared to 40% a year earlier. 

Some of the change is a direct consequence of the recession. The value of retirement plans that were tied up in the stock market took a huge hit, and with it came the realization by many people that they didn’t have enough money saved up to retire at 65. They also stood to lose employee-sponsored health insurance—along with their main source of identity. 

What I found fascinating is that there’s a lot of advice available for prospective retirees about where to live, how to save for retirement, and how to make your money last after you do retire but not much, as a recent article in Time pointed out, about how to make the most of the post-65 period, with or without a job. The pundits encourage everyone to be eat well, remain active and to nurture close personal relationships before they turn 65 in the hope of remaining healthy but are silent about what to actually do with their lives if they succeed..

My personal advice—and I wrote about this in my book, The Denial of Aging: Perpetual Youth, Eternal Life and Other Dangerous Fantasies, in the chapter “Making the Most of the Retirement Years,” is to concentrate on finding meaning in life. If work gives you a sense of meaning and if you’re able to keep at it, then do it. If work doesn’t give you a sense of meaning or if you can no longer continue what you’ve been doing, then it’s best to find something else that gives you that all-important sense of being part of the human community and making a contribution to the world. And it’s the job of the rest of us to make sure there are ample opportunities to do just that.

The One-Hoss Shay

Oliver Sacks turned 80 last week. The noted neurologist and raconteur wrote an inspiring piece in the NY Times in honor of the occasion, in which he says he looks forward to being an octogenarian. He recognizes that he has a fresh perspective by virtue of his experience—he is what used to be called a “wise old man,” before such a phrase became politically incorrect. His hope is to have a few more years doing what he says matters most, loving and working, and then to die “in harness,” or “fully engaged” with life. In other words, he is hoping to be like the remarkable buggy that was constructed so well that it didn’t fall apart for 100 years, immortalized by Oliver Wendell Holmes (who like Sacks was a physician and a writer) in 1900:

      Have you heard of the wonderful one-hoss shay,
      That was built in such a logical way
      It ran a hundred years to a day,
      And then all of a sudden it—ah, but stay,
      I’ll tell you what happened without delay…

And many verses and decades later:

      There are traces of age in the one-hoss shay,
      A general flavor of mild decay,
      But nothing local, as one may say.

But then, after 100 years:

      What do you think the parson found,
      When he got up and stared around?
      The poor old chaise in a heap or mound,
      As if it had been to the mill and ground!
      You see, of course, if you’re not a dunce,
      How it went to pieces all at once,
      All at once, and nothing first,
      Just as bubbles do when they burst.

Of course, when the buggy fell apart, it did so in entirety—taking the deacon who was riding it down as well. Given no warning that the buggy was about to collapse, the deacon could not protect himself. But for people, living long and well and to the fullest, and then dying all at once, as Oliver Sacks hopes his fate will be, seems like the best alternative. The question is, how often does that wish come true?

Over 30 years ago, James Fries predicted that we would see the “compression of morbidity,” or a progressive shortening of the time between the development of age-related disability and death. In a recent review, Fries offered evidence that this is exactly what has happened, with modest increases in life expectancy between 1982 and the present along with a significant decline in rates of disability. Others disagree, arguing that people are living longer than they used to and are spending those added years frail and debilitated. 

The crucial issue is what we can anticipate today when we reach 80, not whether or by how much matters have improved. And the current reality, according to Medicare data, is that 54% of people over 85 have at least 4 chronic diseases and 25% have more than 6. Not only do the oldest individuals have many diseases, but these illnesses translate into problems walking and dressing and bathing: 56% of people over 80 report a severe disability. 

Chronic illness and disability are thus the norm for octogenarians, at least by the time they reach 85. Remaining vigorous and then dying quickly is simply not the reality for many older individuals. This does not mean that they cannot live life to the fullest, but it does mean that for the majority of octogenarians to stay engaged with life, we need to find ways to enable them to derive meaning from their existence. We have to take steps to assure that they can maintain and nourish relationships with others, whether by enhancing transportation to enable them to overcome difficulties with mobility or by teaching computer skills to allow them to communicate remotely. We have to facilitate their desire to contribute to society, whether through part time, flexible employment opportunities or by creating oral history projects in which they can participate. 

Designing medical interventions that allow us to remain robust into old age and then die of sudden death may be as flawed a quest as creating Holmes's perfect buggy. It may be as replete with unintended consequences as striving for immortality (more about the perils of aiming for immortality in a later post). Our challenge as a society is to find ways to support older people in their quest for meaning--even if they are not built like the one-hoss shay.