Read an Excerpt

AGING AGGRESSIVELY

How to Avoid the US Health-Care Crisis

Balboa Press

Take Charge of Your Health

This book is about growing older, about taking charge of your health, about understanding present health care policies, and about feeling secure and enjoying the process. It is also a clarion call to those of us who are older adults to take advantage of two important facts: we are a significant numerical force in society, and we can and should be certain that our voices are heard in every aspect of social and medical planning. This book was stimulated by, and is a follow up of, the book "Taking Charge of Your Health" by John Burton and William Hall. That book sets the stage, we hope this one fills in some of the details.

The book is divided into three sections. The first (chapters 1–7) describes what we face each day of our aging lives and what we can do to interact with our health care providers in a positive but assertive way. The second (chapters 8–11 and the appendices) is a primer on current health care policy in the United States and internationally, so that we can better understand decisions politicians and physicians are making thus enabling us to make relevant contributions to the process. The third (chapters 12 and 13) offers nuts and bolts suggestions and some personal insight about maintaining a sense of humor, achieving self-fulfillment, and reflecting on our memories while facing the important issues of health, medical care, and end-of-life decisions.

Thomas C. Jones has been a highly respected research physician trained in infectious diseases, international medicine, and public health. He is emeritus professor of medicine at Weill-Cornell School of Medicine, where he did his own internship and residency, and later was one of the most popular professors of parasitology and infectious diseases. He has cared for patients in private practice, on hospital wards, in an army hospital in the Philippines during the Vietnam War, and in the refugee camps of Thailand and along the Pakistan-Afghanistan border. He has published over 200 scientific articles, chapters in the most important medical textbooks, and his own book titled Medical Care of Refugees (Oxford University Press, 1986). He was the first editor of the Brazilian Journal of Infectious Diseases—the first English-language medical journal ever published in South America. His research on toxoplasmosis provided ground-breaking insight into that disease process, and his collaboration with physicians and researchers in Brazil and Haiti brought him international respect among his peers and created a rich environment for study for the medical students, residents, and researchers who worked abroad with funding from his grants. Dr. Jones is in a unique position to address the issues of our faltering health care system and recommend a solution—specifically, what we can do to obtain the care we need and head off a potential health crisis, for our own lives and for our society. Now that he is retired from professional medicine and outside of the mainstream, Dr. Jones's somewhat irreverent view is precisely what makes his opinions relevant today.

As contributing author, John F. Cotton has contributed two chapters (2 and 11) and Appendix B to this book. His views are pertinent based on his many years of experience in state government, originating and administering the details of health care-related federal programs and policies. In addition, his views on how those programs affect quality of life for elders and our real social obligations make his contribution especially valuable.

The editor, Betsy Chalfin, adds another dimension based on her years as a copyeditor for Thomas C. Jones at Cornell University Medical College and at the Brazilian Journal of Infectious Diseases, and from her years of experience as a program coordinator in international refugee relief and as a hospital administrator.

There are a number of familiar quotations that suggest how we should think about aging and we have selected two in particular to set the tone for this book. Dylan Thomas wrote, "Do not go gentle into that good night ..." The second is a quote from the character Old Lodge Skins in the movie Little Big Man based on the book by Thomas Berger. Old Lodge Skins thought it was his time to go to the Happy Hunting Ground so he climbed up into the mountains and waited for Nature to take its course. After waiting awhile, he realized he was still alive and concluded, "Sometimes the magic just does not work!"

Our primary focus here is health care for elders—what is wrong with it and what we can do to make it suit our needs. You will learn that health care is not just about medicine but it is also a complex mix of social attitudes and personal and political will.

There are many examples of special and often discriminatory treatment of elders in our society—like forced retirement regardless of productivity; periodic medical reports required to engage in active sports despite the fact that they are in good health; exclusion from certain social events that are planned for a younger population; or participation in a musical group or chorus that prefers a more youthful public relations image. There is often a lot of fun and peace of mind associated with getting older, but for the situations that fail to meet our needs or expectations, we advocate an aggressive approach to challenge and change them.

When one considers the issue of health care and what can be done to improve it, especially the care directed specifically toward the aging population, we find a number of powerful influences in play. We find that lawyers enthusiastic about generating class-action legal challenges for their own financial gain, regulatory agencies influenced by numerous lobbyists anxious to direct the purchasing power of elders, and politicians elected or removed by the increasingly elder demographic are the powerful sources of potential change of the system—not physicians.

As participants in the health care bureaucracy, the authors learned that physicians alone are unable or unwilling to define the life-enhancing support systems needed for their patients and translate them into appropriate delivery of health care. Ever increasing pressures on health care providers makes this so. These pressures include administrative guidelines and insurance reimbursement requirements that impose time limits allotted for a physician to spend with each patient even though the physician believes more time is necessary for adequate evaluation and care; constant advertising that suggests nearly miraculous effects of a specific prescription medication that misleads patients and prompts them to question their physician's recommendations; and finally, intellectual and financial rewards that drive young physicians toward medical specialization rather than general medicine—each of these pressure tactics work against a physician's need and desire to focus on the overall health status and life quality needs of his or her patient.

There are a number of hidden features affecting the social welfare of elders that must be explored. The plethora of medications prescribed for the aging population is a vivid example. In their book, Burton and Hill quoted the famous physician, writer, and social critic Oliver Wendell Holmes. To paraphrase that quote, "... almost all medications prescribed to patients would do better to be thrown into the sea—a good move for humanity although probably not so good for the fish." The multitude of prescribed medications are supposed to allow a patient to reach old age but the clinical studies, the statistical analyses of these studies, and information on how they apply to special sub-groups are often not available. So, a 75-year-old patient is instructed to take a certain medication to improve his or her chance of survival even though the drug studies were done on specific at-risk groups between 30 and 60 years old. The logical question here is, "Why not focus a study on those over age 70 whom the drug is usually prescribed for?" The answer is almost always that the subgroup analysis of the targeted population would alter the power of the statistical result—in other words, the pharmaceutical companies could not exaggerate the beneficial power of their drug. Up to now, the elder population has had little power to insist on more accurate information—we believe the time has come to change the paradigm. We will discuss specific examples, like the use of statins, in chapter 3. These examples are among the issues the aging population must think about and understand if they are to appropriately manage their health care. Inappropriate use of prescription drugs is also partly to blame for driving up the costs of health care and health insurance.

At a time when the health care system often fails us, insurance companies and health maintenance organizations are really Fortune 500 corporations lining the pockets of government bureaucrats and company CEOs, our population is more rotund and less active, and pharmaceutical companies are bombarding us with advertising to lure us into taking pills and potions for maladies we never knew existed (and likely do not have), we offer a different way to think about life. We are firmly convinced that life must be enjoyed to the fullest up to the end and that the path to thriving requires us to push aside much of medicine and the medical bureaucracy as we have known it and replace it with a vision of the future and the good things life offers us when we aggressively approach the elder phase of our life.

A Social Perspective

The impending crisis in Medicare and, more generally, the financing of health care for all in the United States, calls for clear articulation of what we, as a society, are about. Precisely what is our aim and how do we proceed to whatever goals we aspire? For sure, we must admit that there is no consensus as to what might characterize that aim, but that should not deter us from laying out the prime issues that must shape whatever we hope to do. Most important, this crisis cannot be addressed as a narrow "health care" issue. What we must talk about is the quality of life for all residents of the United States, including elders.

This book is our attempt to address this matter and it reflects our experiences and values. In no way is it intended to convey that this is the only or the best prescription, but we do hope it is coherent and consistent and will contribute to the debate.

What Do We Mean By Health Care For Elders?

To be a bit more precise: What kind of access ought elders have to the myriad of remedies and treatments that are now and will be in the future available for the treatment of the physical and mental ailments that beset all humanity? To a certain degree, answering that question entails recommendations for research on new technology oriented to the problems of aging, but for the greater part it concerns the appropriate delivery of what is generally available to the public as a whole.

Social versus Private Goals

In modern Western society there is widespread acceptance of a predominant public interest and, therefore, an acceptance of the appropriate role for a designated collective (government) that functions in an array of activities to fulfill those public interests; e.g., defending the nation, maintaining highways, fighting fires, educating children, and ensuring food safety. This has not necessarily taken the form of direct government activity—often, public regulation of private collective activities has been the approach. On the other hand, there are uncountable activities for which the consensus is that purely private actions are appropriate; e.g., while present law demands that the operation of a motor vehicle requires having liability insurance in most states, probably no one believes the inclusion of collision insurance in a policy is a matter of public concern. Hence, we must take a stand on what is the public (or social) interest in providing health care for elders.

So, how do we rationalize that balance? One way would be to rely on a libertarian prescription for private health care; i.e., let each individual (or family unit) take responsibility for obtaining access to the health care they desire. Why not allow consumers and the private free market to assemble the options in concert, leaving it to the responsible individual to decide what costs and risks are to be taken? The answer is simple: unlike grizzly bears, humans are a social species. (As a political aside, it should be no surprise that the "mama grizzly" is the chosen symbol of a current political faction in the United States. On the other hand, selecting a donkey for a political party is not very encouraging.) Whether or not one accepts the evolutionary view that social behavior was a key factor in the success of Homo sapiens, it is clear that group association has been a dominant feature of all we know about our past. This observation is not to demean the private individual—we are not akin to an ant species and, rightly, we hold in highest esteem the outstanding individual and give greatest praise to individual accomplishments in whatever field of endeavor. But, it is precisely because we humans are such a mix of the individual and the social that questions about appropriate access to health care are so perplexing.

There are at least two reasons why the public interest impinges on health care. First is the social response—instinctively we are moved by the plight of fellow humans we see in distress. When an individual or family is beset by a tragic accident or sickness, there frequently emerges a strong community response to provide assistance. This is highly commendable, but also sad—a system that requires this voluntary humanitarian response is hardly one in which to take pride. Even sadder is the knowledge that many such predicaments do not carry the emotion-evoking weight needed to capture voluntary action. We do acknowledge, however, that society has not been completely derelict. The social instinct has forced at least minimal access to be available to all in the form of the Emergency Room.

Second is the understanding that the well-being of all in society is heavily dependent on the robustness of the health of our fellow citizens. There is little reason to believe there is not widespread acceptance of this concept in general.

The nature of this dependence for elders differs from that of the younger cohorts of the population. There are few who are middle age and older that are unaware of the devastating emotional and economic price that must be paid by untold numbers of caregivers and supporters of the seriously ill or poorly functioning elders. This toll on individuals creates an aggregate that constitutes a high cost to society as a whole. The days of our grandparents—when the relatively small "very old" population could be looked after by extended family in a stable social environment—are long gone. Today there are ever-stronger reasons for a social response.

What Are the Ingredients of Normal Healthy Aging?

To address a sensitive and controversial issue at the outset: in considering the public interest, we decidedly are not advocates of indefinite "life extension" as a goal. In our view, the philosophical, ethical, and economic questions raised by the prospect of indefinite life expectancy presently are well beyond the capacity of a reasonable societal response. To state it clearly, we believe there is no social entitlement to indefinite life extension. In a recent web blog on the predictions, prospects, and promises of technology for producing indefinitely long life spans, one comment by an observer (probably an elder or approaching that) stood out as particularly astute: "I'd settle for a cure for hemorrhoids." We might do well to adopt that as the watchword for our position.

There is one aspect of life extension that is relevant to our considerations. In 1912, premature death was both a private and social concern. At present, it can be argued that premature death remains a private problem but not a social one. If anything, it might be argued that "post-mature" death is the emerging social problem.

What is premature death? For the private concern, the definition of premature is in the eye of the beholder. It is almost a mantra for our generation to assert that we do not want to reach the age or stage of disability that we witnessed in our parents, and others but neither do we want to expire right away. To die tomorrow would be premature. It is rather like giving up smoking—"One more cigarette won't hurt ..." or, from the musical Annie, "Tomorrow is always a day away." We cannot hope to resolve those dilemmas here.

What should constitute premature death from a social perspective? We propose the following: When an individual has completed his or her "fiduciary" responsibilities to family, to other dependents, and to society, then death ought not to be considered premature by society. However, since individual circumstances are not appropriate to public policy, a simpler standard must serve. For lack of a better number, we suggest the wisdom of the authors of the Old Testament of the Bible—three score and ten as a reasonable marker. To be clear, we are not arguing that life beyond 70 years is undesirable for individuals (if that were the case, perhaps we should not be here to make these proposals). We are arguing that the public interest does not call for intervention at this stage as a social goal per se. We also argue that life beyond 70 years of age should be guided by issues of personal comfort, not by proposals related to life extension.

Rather, we advocate as a social aim a lesser version of the end expressed by Oliver Wendell Holmes in his poem, The One Hoss Shay. It would be nice to believe a logical end, as for the Shay, could exist, but in the modern world of technology that is not probable. We are all inexorably pushed toward indefinite life extension. A useful term for our overall concept could be "Healthy Normal Aging." Our touchstone is that absent heroic medical/technical intervention there is a plausible distribution of ages at which death is normal.

---

Excerpted from AGING AGGRESSIVELY by THOMAS JONES, JOHN COTTON, BETSY M. CHALFIN. Copyright © 2013 Thomas C. Jones MD. Excerpted by permission of Balboa Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

---