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Essay: The bitter end
Cheating death
The bitter end Death is not the real enemy. It’s ageing and the disabilities it brings that we should be fighting, says Guy Brown
■
IN GREEK mythology, Tithonus was a handsome mortal who fell in love with Eos, goddess of the dawn. Eos begged Zeus to grant her lover eternal life. Perfidious Zeus made Tithonus immortal, but did not grant him eternal youth. As Tithonus aged, he became increasingly debilitated and demented, eventually driving Eos to distraction with his constant babbling. Tithonus’s fate now threatens us all. We can look forward to an ever-increasing lifespan, but at the cost of progressive enfeeblement, ill health and dementia. Until about 200 years ago, the average human lifespan was about 30 years. People died young, and they died relatively rapidly, mainly from infections. During the 20th century the average lifespan in the world doubled, and people in developed countries now tend to die old and slowly from degenerative diseases brought on by ageing. It was once thought that humans had >;7BJ>:;
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42 | NewScientist | 13 October 2007
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a maximum lifespan that we would hit at some point, as death from disease was eliminated. Many limits have been suggested, but each has been shattered by experience. Average lifespan has been increasing at the staggering rate of 2.2 years per decade (or 5 hours a day) for the last 100 years. There is no sign of this slowing down, even in the countries where life expectancy is highest (Science, vol 296, p 1029). This has profound consequences for humanity. In the UK, for example, if current trends persist, the number of people more than 65 years old is predicted to triple from 4.6 million now to 15.5 million in 2074, while the population aged over 100 will increase 100-fold from 10,000 to 1 million. The future is not just old, it is extremely old. We are voyaging into a new realm of human life that has hardly existed before and about which we know very little. Unfortunately this increase in lifespan has not been matched by an extension of health. The years we gain are mostly spent with disability, disease and dementia. Between 1991 and 2001, life expectancy in the UK increased by 2.2 years, but healthy life expectancy increased by only 0.6 years; people experienced ill health for an extra 1.6 years of their lives. This is because we have not been able to slow the ageing process; much of the increased lifespan is due to increased survival with chronic diseases. In 1980 James Fries, an expert in chronic diseases at Stanford University School of Medicine in California, and others predicted that the diseases and disability of ageing would become compressed into a short period before death as the average lifespan approached the maximum lifespan. But because there doesn’t seem to be a maximum lifespan, this idea of “compression of morbidity” has turned out to be a mirage. Instead, the increase in lifespan is combining with an increase in degenerative disease with age to generate an “expansion of morbidity”. The prevalence of most degenerative diseases, such as cancer, and
vascular and neurodegenerative disease, increases roughly exponentially with age. For example, the prevalence of Alzheimer’s is about 1 per cent at 65 years of age and approximately doubles every five years after that, to around 25 per cent for 85-year-olds. In the US, 46 per cent of people over 85 years of age are thought to have Alzheimer’s. There are an estimated 5 million people with Alzheimer’s in the US today, and as people live longer this number is projected to rise to 12.5 million by 2050 (Journal of Psychiatric Research, vol 36, p 281). Older people also decline physically. They are more prone to chronic diseases such as arthritis and rheumatism, osteoporosis, high www.newscientist.com
alive but uncured, rather than curing the disease, which loses the customer. The situation is not helped by the charities and funding agencies that focus on preventing death rather than disease or ageing. The root cause of the impending Tithonus crisis, therefore, is our failure to tackle ageing. It is tempting to think that ageing is “natural”, but the opposite is the case. Ageing is an artefact of culture. It is very rare in wild animals and was rare in humans until 200 years ago. As the population inexorably ages, maladies that were formerly rare or non-existent become commonplace. If current trends persist, people born in the developed world today could expect to live 100 years, but are likely to spend their last few decades with increasing disability
TOM SULLAM/MILLENIUMIMAGES
“Death, dying and dementia are nowhere on the political agenda”
blood pressure and heart failure, diabetes, varicose veins, ulcers and strokes. They are much more likely to have disabilities such as deafness, blindness and immobility. Of Americans older than 80 years, 74 per cent have a disability. They are also more likely to be forgetful, confused or depressed. Almost
Profile Guy Brown works on the molecular mechanisms of cell death and degenerative disease at the University of Cambridge. He is author of The Living End: The future of death, aging and immortality, published next month by Palgrave Macmillan.
www.newscientist.com
a quarter of non-institutionalised Americans over 85 are thought to be severely depressed. Medicine has become very good at eliminating acute causes of death such as infections, but the downside of this success is that people live long enough to suffer from degenerative disease. What’s more, many acute forms of death have been converted to chronic ill health or disability. Heart attack has become heart failure; stroke has become vascular dementia. Diabetes, AIDS and even some cancers have been converted from acute causes of death to chronic disabilities. Another unfortunate factor is that it is much more profitable for pharmaceutical companies to develop drugs that keep patients
and deteriorating health, and face a 25 to 50 per cent chance of dying with dementia. Imagine the consequences if this nightmare becomes a reality. Imagine the psychological consequences of expecting to develop dementia. Imagine the economic consequences of providing one-to-one roundthe-clock care for decades on end for millions of demented or disabled people. Yet we are doing absolutely nothing about it. Death, dying and dementia are nowhere on the political agenda. We are too afraid to think about the three Ds, and that suits the politicians fine because they are not easy problems to solve. We need to stop turning a blind eye to the multiple miseries at the end of life and attack ageing and the diseases of ageing head-on. Research funding needs to be redirected here rather than aimed simply at preventing death. We have to develop alternative routes to drug development for therapies that don’t make economic sense for the pharmaceutical and biotech industries to pursue. Hospices ought to be as ubiquitous and well-funded as maternity hospitals. The aged should be reintegrated into society or whatever society they want and they should be able to choose how they die. Last but not least, we need a new attitude to death. Death is not the enemy; it is an integral part of life. It is ageing and its diseases that we should be fighting. The Tithonus scenario means that attacking them will be at least as important in the 21st century as efforts to tackle terrorism and global warming. ● 13 October 2007 | NewScientist | 43
The bitter end Death is not the real enemy. It’s ageing and the disabilities it brings that we should be fighting, says Guy Brown
■
IN GREEK mythology, Tithonus was a handsome mortal who fell in love with Eos, goddess of the dawn. Eos begged Zeus to grant her lover eternal life. Perfidious Zeus made Tithonus immortal, but did not grant him eternal youth. As Tithonus aged, he became increasingly debilitated and demented, eventually driving Eos to distraction with his constant babbling. Tithonus’s fate now threatens us all. We can look forward to an ever-increasing lifespan, but at the cost of progressive enfeeblement, ill health and dementia. Until about 200 years ago, the average human lifespan was about 30 years. People died young, and they died relatively rapidly, mainly from infections. During the 20th century the average lifespan in the world doubled, and people in developed countries now tend to die old and slowly from degenerative diseases brought on by ageing. It was once thought that humans had >;7BJ>:;
CWb[b_\[[nf[YjWdYo <[cWb[b_\[[nf[YjWdYo
-+
,+ <[cWb[^[Wbj^ob_\[[nf[YjWdYo CWb[^[Wbj^ob_\[[nf[YjWdYo ,'
'/.'
'//'
42 | NewScientist | 13 October 2007
(&&'
IEKH9;0E<
-&
a maximum lifespan that we would hit at some point, as death from disease was eliminated. Many limits have been suggested, but each has been shattered by experience. Average lifespan has been increasing at the staggering rate of 2.2 years per decade (or 5 hours a day) for the last 100 years. There is no sign of this slowing down, even in the countries where life expectancy is highest (Science, vol 296, p 1029). This has profound consequences for humanity. In the UK, for example, if current trends persist, the number of people more than 65 years old is predicted to triple from 4.6 million now to 15.5 million in 2074, while the population aged over 100 will increase 100-fold from 10,000 to 1 million. The future is not just old, it is extremely old. We are voyaging into a new realm of human life that has hardly existed before and about which we know very little. Unfortunately this increase in lifespan has not been matched by an extension of health. The years we gain are mostly spent with disability, disease and dementia. Between 1991 and 2001, life expectancy in the UK increased by 2.2 years, but healthy life expectancy increased by only 0.6 years; people experienced ill health for an extra 1.6 years of their lives. This is because we have not been able to slow the ageing process; much of the increased lifespan is due to increased survival with chronic diseases. In 1980 James Fries, an expert in chronic diseases at Stanford University School of Medicine in California, and others predicted that the diseases and disability of ageing would become compressed into a short period before death as the average lifespan approached the maximum lifespan. But because there doesn’t seem to be a maximum lifespan, this idea of “compression of morbidity” has turned out to be a mirage. Instead, the increase in lifespan is combining with an increase in degenerative disease with age to generate an “expansion of morbidity”. The prevalence of most degenerative diseases, such as cancer, and
vascular and neurodegenerative disease, increases roughly exponentially with age. For example, the prevalence of Alzheimer’s is about 1 per cent at 65 years of age and approximately doubles every five years after that, to around 25 per cent for 85-year-olds. In the US, 46 per cent of people over 85 years of age are thought to have Alzheimer’s. There are an estimated 5 million people with Alzheimer’s in the US today, and as people live longer this number is projected to rise to 12.5 million by 2050 (Journal of Psychiatric Research, vol 36, p 281). Older people also decline physically. They are more prone to chronic diseases such as arthritis and rheumatism, osteoporosis, high www.newscientist.com
alive but uncured, rather than curing the disease, which loses the customer. The situation is not helped by the charities and funding agencies that focus on preventing death rather than disease or ageing. The root cause of the impending Tithonus crisis, therefore, is our failure to tackle ageing. It is tempting to think that ageing is “natural”, but the opposite is the case. Ageing is an artefact of culture. It is very rare in wild animals and was rare in humans until 200 years ago. As the population inexorably ages, maladies that were formerly rare or non-existent become commonplace. If current trends persist, people born in the developed world today could expect to live 100 years, but are likely to spend their last few decades with increasing disability
TOM SULLAM/MILLENIUMIMAGES
“Death, dying and dementia are nowhere on the political agenda”
blood pressure and heart failure, diabetes, varicose veins, ulcers and strokes. They are much more likely to have disabilities such as deafness, blindness and immobility. Of Americans older than 80 years, 74 per cent have a disability. They are also more likely to be forgetful, confused or depressed. Almost
Profile Guy Brown works on the molecular mechanisms of cell death and degenerative disease at the University of Cambridge. He is author of The Living End: The future of death, aging and immortality, published next month by Palgrave Macmillan.
www.newscientist.com
a quarter of non-institutionalised Americans over 85 are thought to be severely depressed. Medicine has become very good at eliminating acute causes of death such as infections, but the downside of this success is that people live long enough to suffer from degenerative disease. What’s more, many acute forms of death have been converted to chronic ill health or disability. Heart attack has become heart failure; stroke has become vascular dementia. Diabetes, AIDS and even some cancers have been converted from acute causes of death to chronic disabilities. Another unfortunate factor is that it is much more profitable for pharmaceutical companies to develop drugs that keep patients
and deteriorating health, and face a 25 to 50 per cent chance of dying with dementia. Imagine the consequences if this nightmare becomes a reality. Imagine the psychological consequences of expecting to develop dementia. Imagine the economic consequences of providing one-to-one roundthe-clock care for decades on end for millions of demented or disabled people. Yet we are doing absolutely nothing about it. Death, dying and dementia are nowhere on the political agenda. We are too afraid to think about the three Ds, and that suits the politicians fine because they are not easy problems to solve. We need to stop turning a blind eye to the multiple miseries at the end of life and attack ageing and the diseases of ageing head-on. Research funding needs to be redirected here rather than aimed simply at preventing death. We have to develop alternative routes to drug development for therapies that don’t make economic sense for the pharmaceutical and biotech industries to pursue. Hospices ought to be as ubiquitous and well-funded as maternity hospitals. The aged should be reintegrated into society or whatever society they want and they should be able to choose how they die. Last but not least, we need a new attitude to death. Death is not the enemy; it is an integral part of life. It is ageing and its diseases that we should be fighting. The Tithonus scenario means that attacking them will be at least as important in the 21st century as efforts to tackle terrorism and global warming. ● 13 October 2007 | NewScientist | 43