Life, Liberty, Longevity
Life, Liberty, Longevity
The 20th century saw unprecedented advances in longevity, but alarms are sounding with regard to health care costs.
By Michael J. Cowell
Life, liberty, pursuit of happiness–mere words, though enough to kindle a revolution, a new order reverberating down to our present age, with consequences perhaps never intended. Wordsmithing the draft Declaration almost until the fourth of July, its author, in substituting "pursuit of happiness" for his originally drafted "protection of property," changed forever, one biographer asserts, the entire thrust of American revolutionary thought.1 Scholars still debate Jefferson's reliance on earlier philosophers. The words of a personality so enigmatic as to be dubbed American Sphinx2 point to a record ambiguous at best. On one occasion, he claimed to have consulted "neither book nor pamphlet," nor "copied from any ... previous writing."3 Yet on another he acknowledged that the Declaration's authority rested on such "elementary books of public right as Aristotle, Cicero [and] Locke. ..."4
Aristotle's "city"–polis, or civic society–a partnership to enable people to live well,5 was the holy grail for many philosophers. His writings extend this theme with some ambivalency about living together, but just how successfully, two-and-a-third millennia later, we have achieved either the well or the together bit, is a good question. In the 90th chapter of Psalms, David proclaims "the days of our years threescore years and ten, and if by reason of strength fourscore; yet," he adds, "is their success toil and sorrow, for it (presumably life) is soon cut off and we fly away." These two fonts of Western Civilization, Ancient Greece and the Scriptures, often clash, not only with each other, but sometimes with our present day notions of society itself. Nevertheless, civil communities today might be considered meeting both ideals if most of their citizens get past the threescore mark in good health–until time comes for them to fly too. And while long and healthy lives may not guarantee happiness, many might accept them as necessary conditions.
Compared to living well, though, living long, as a pursuit, has relatively recent provenance. The 20th century saw unprecedented advances in longevity, but alarms have been sounding for some time over the cost-benefit relationship of these twin goals. Some economists argue that extending healthy life is a great creator of wealth, while others worry that life-prolonging measures could imperil the very economies that finance them. This article focuses on the more quantifiable wellness part of Aristotle's formulation and the consequences of individuals and entire societies taking these twin–sometimes conflicting–objectives to extremes. It summarizes findings from my 2008 Living to 100 Symposium paper, cites two major behavioral causes of runaway health costs, reasserts a biological underpinning for mathematical expressions of mortality, briefly touches on efforts to measure happiness and concludes with a little personal philosophy on getting old.
Actuaries traditionally had assumed a more or less passive role in recording statistics on sickness and death, twin nemeses of life, good or long. But as early as 1898, Miles Dawson, a New York consulting actuary, suggested that members of this profession would enjoy better than average longevity because we take our own mortality studies seriously.6 Subsequent analyses by John Larus in 1938,7 John Cook and Jack Moorhead in 1990,8 and last year by Philip Lehpamer,9 documented mortality of actuaries at a fraction of that in the general population. Actuaries seem to have discovered at least some secrets of the living long part of the equation.
In 1985 this author suggested that the cure for the ills of health care financing lay in the following simple, commonsense steps for individuals to take on more personal responsibility for their own wellness:10
- Don't smoke.
- Avoid habit-forming drugs.
- Stay lean.
- Monitor blood pressure and cholesterol.
- Eat sensibly.
- Buckle up.
- Exercise regularly.
- Sleep soundly.
- Drink responsibly.
- Manage stress.
At the time, the United States was spending 11 percent of GDP on health care, a larger portion of its economy than any other country. That share has since increased to 16 percent. Stephen Goss, chief actuary of Social Security, predicts that absent major changes to health care delivery this number could hit an almost incredible 40 percent by mid-century.11 The implications of such enormous expenditures on health care for all other aspects of our lives, public or private, are for anyone to speculate.
This author has documented that across countries, longevity does correlate highly to income.12 But the relationship is such that above a threshold for adequate nutrition, good public health and access to medical care–around $20,000 per capita GDP, the current level for such "upper-middle-income" countries as Portugal and the Czech Republic–incremental spending on health care does not appear to purchase added longevity. A longitudinal comparison of the United States to Canada shows that over the past 40 years our northern neighbors have achieved even greater improvements in life expectancy than we, but at a fraction of our per-capita increase in health care costs.13
Better educated and upper income sectors in our society take better care of themselves; hardly surprising. They smoke far less–practically not at all if they have a college degree or higher education–exercise more, eat healthier, and are marginally less obese than those with lower levels of education and income. Also in 1985, this author presented data to support his contention that heavy smokers–the Surgeon General's definition is 35 or more cigarettes a day–could be taking as many as 13 years off their life expectancy.14 Yet, whether analyzed internationally or by state within the United States, income correlates highly to education, and better health goes with higher income. So strong are these interrelationships that, taken together, education and income explain almost half the state-by-state differences in mortality attributed to smoking.
Next after smoking, lifestyle behaviors most threatening our health are poor diet and inadequate exercise leading to obesity. The seriousness of this problem, not only in the United States but throughout much of the Western world, leads some observers to wonder whether obesity is not becoming the new smoking. In the early 1960s, the Surgeon General classified only 13 percent of U.S. adults as obese, meaning their body mass index (BMI) exceeded 30.15 By 2005, more than one-third of all adults met this criterion. One team of researchers projects that without a reversal in this trend, the life-shortening effects of obesity could lead to a decline in U.S. life expectancy for the first time since the mid-19th century.16 The health threat is especially ominous for children and adolescents. Poor diet and inadequate exercise can lead to such conditions as adult onset diabetes, being attributed for the first time in medical history to habits in children that will affect them over a lifetime. But merely being overweight does not carry the same social stigma as smoking, so that while the problem is similarly more concentrated at the lower end of the socio-economic spectrum, those at the upper end are only marginally less overweight. The healthiest segment of the adult population in this regard is the elderly where, at ages 75 and higher, the obesity rate is less than two-thirds what it is at younger ages.17 It should be apparent that people don't just suddenly lose a lot of weight when they reach 75!
Alcohol abuse, smoking, obesity and their consequences–diseases of the heart and lungs, diabetes, cirrhosis of the liver and cancer–figure prominently in research by Harvard's Global Health Initiative. That group's analysis of U.S. longevity down to the county level shows that the healthiest places to live are Hawaii, the California coast, the Pacific Northwest, the Northern Plains, coastal Southern Florida and along the I-95 Boston-Washington corridor.18 Differentials between these areas and those registering the poorest longevity–across a wide swath from Appalachia through the South Central and Southeast–are as much as eight years for females and 10 for males. Christopher Murray, director of this research, notes that life expectancy in some locations in Appalachia and the Mississippi Valley is more comparable to that in third-world countries. Omitted is any observation that in the most favorable locations, Americans enjoy longevity matching such countries as Norway and Sweden. Murray concludes, though, that while geography is important, it is not so much physical environment, but rather social and cultural differences that define habits such as diet and exercise.
It troubles some people as elitist or classist to have such critical life and health issues weighed in socio-economic and cultural terms, but the statistics–most of which are published by the U.S. Surgeon General–are irrefutable. Education and income, together with geography, do explain much of the variation in the component of life expectancy that cannot be linked to genetics. From long-term studies of twins in several countries, biologists and gerontologists have determined that somewhere between one-quarter and one-half of the statistical variance in individual longevity is genetic.19, 20 My paper emphasizes the remaining one-half to three-quarters that might be considered as subject to our personal choices. The two lifestyles most seriously indicted–smoking and obesity that results from poor diet and inadequate exercise–accentuate the challenges to bringing behaviorally driven health care costs under control.
It might be inferred from this author's analysis that more education and higher incomes are the causes of better health and improved mortality, as well they may be. But irrefutable as the numbers are, as statisticians we appreciate that correlation is not causation, and it could be argued that the prospects of living longer serve as an inducement to spend more time being educated, with its positive effects for the individual and the economy. In either case, so as to forge a more robust link between lifestyle behavior and longevity, my paper retreads the path pioneered by Gompertz and Makeham in the 19th century and our colleagues, Aaron Tenenbein and the late Irwin Vanderhoof in the 20th.21 In their seminal 1980 paper, Tenenbein and Vanderhoof sought to reground actuarial mathematics "in the sub-structure of biology and gerontology" by providing a scientific validation for the constants B and c in Gompertz's famous formulation for the force of mortality, µx = B cx
The B factor reflects biological and behavioral risk, while c encodes genetic information in the human cell measuring decreased ability with age to resist infection and injury that ultimately leads to complete cell failure and death. And while no single longevity gene may exist as such, molecular biologists have identified alleles–a set of gene groupings on the human chromosome–responsible for regulating repair of DNA so as to delay cell failure. Other biologists–and now some actuaries–refer to the decline of vitality with age as frailty. They have developed longitudinal models capable of tracking hundreds of thousands of lives individually, subdividing the population according to multi-dimensional indicators of frailty that their proponents consider better predictors of mortality and morbidity than such parametric models as Gompertz's and Makeham's.22 Leonard Hayflick, a leading authority on aging, believes that cell failure results from loss of molecular fidelity, the cell's inability to maintain the thermal stability required for viability.23 Collectively, this research presages opportunities for actuaries–those, at least, with far deeper understanding of molecular biology than this author professes–to develop ever more precise mathematical tools for predicting life and health expectancy.24
"Well, Doctor Franklin, what have we got ... ?" "A republic, if you can keep it." Ben Franklin's response to Mrs. Powel, Philadelphia, Sept. 18, 1787.
"Early to bed, early to rise," Ben Franklin had preached as far back as 1735, "makes a man healthy, wealthy and wise." More than 40 years on, he was coaching Jefferson in those last-minute adjustments to the Declaration. One can only surmise how much of Franklin's earlier insights were reflected there. The statistical relationships among health, wealth and wisdom are now well established; their correlation to the Declaration's pursuit of happiness appears somewhat more tenuous. It has been proposed that long and healthy lives would be acknowledged by many as conditions necessary to happiness, one implication being that they might fall somewhat short of sufficiency. Numerous attempts have been made in recent decades to quantify this elusive state. One such, by Richard Layard of the London School of Economics, plots happiness quotients for 72 countries against per capita income,25 which explains almost half of the statistical variance in the quotients. And as with health and longevity, higher income does tend to increase the quotient, but above a certain level, income appears to have little effect. Layard offers extensive cultural explanations as to why people in poor Nigeria rate themselves as happy as those in rich Germany, and why, with almost comparable income levels, Mexico's happiness quotient of 88 percent is close to the top of the scale, while at 40 percent, Russia's is barely above the Ukraine at the bottom of the list. It comes as little surprise that Layard's quotients are highest in Western Europe (among the world's most prosperous)–the Scandinavian countries, Ireland, Switzerland and the Netherlands–and also Canada. The United States ranks ninth, just behind Switzerland and ahead of Australia–respectable, but perhaps not where some might expect for a wealthy nation with pursuit of happiness declared as a birthright.
This author's 2008 Living to 100 Symposium paper was a reprise to his 1985 article suggesting that resolution of the nation's runaway health care financing would require individuals to assume much more responsibility for their own wellness. Franklin is invoked because his prescription for health, wealth and wisdom implied just such a personal commitment. And his compatriot, Jefferson, because not even with his prescience would he likely have foreseen a time when the right to pursue happiness, with whatever that entailed, might one day be construed as a government obligation to ensure happiness itself, with financial consequences that can only be a subject of speculation. So concerned is David Walker, the Comptroller General of the United States, about the trends in health care costs outlined here that he has categorized as the most serious threat to our very survival not someone holed up in a mountain cave on the Afghan-Pakistan border, rather our own fiscal irresponsibility.26
So what is it to be, Franklin's republic, which, by taking personal responsibility for that most precious wealth, our health, we may yet manage to keep, or a nanny-state perpetuated by those whose election depends on making promises they cannot keep? The extent to which societies have developed educationally and economically does have a significant bearing on their aggregate measures of health and longevity and, also, to the degree it is quantifiable, the levels of happiness its members admit to having achieved. And yet, even with all the scientific, medical and public health advances over the past century, there are still limits to the extent that any one of us can control the length of his or her years. That's not to say we shouldn't try. We should, all the more so if we expect quality of life in the years bequeathed to us, and a healthy economic life for the nation we pass along to those who follow.
Advocating that sense of personal responsibility for sound physical health essential to sounder fiscal health, this author stands by the 10 basic steps proposed in 1985, to which his 2008 Symposium paper has added two more: live in a healthy, wealthy and wise environment, and stay married! On this last point, as some wags–all male–have observed, staying married, especially to the same spouse, may not guarantee living to 100, though it might make it seem that way! These steps are themselves no guarantee. Indeed, except for death and taxes there are no guarantees, and one of those will not be cheated.
Jefferson's copy of The Æneid in the original Latin was the most dog-eared book in his Monticello library.27 We may only conjecture how he might have read those arcane words of Æneas nostalgically lamenting the destruction of Troy, to the effect that while "there are tears shed over mere things it is the facts of mortality that touch the mind." In the last analysis, this author sees the challenge less a matter of adding years to our lives, rather how to best add life to our years.
The author thanks Professor S. Jay Olshansky for his valuable suggestions on bio-medical topics, Professor Michael C.J. Putnam for his insights into the classics, notably Virgil, Robert Cash for his business perspectives on the issues addressed in this article, and Steven Siegel of the SOA staff for his helpful overview.
Michael J. Cowell, FSA, AIA, began his extensive actuarial career in 1959 and is currently retired. His many professional contributions include serving as SOA general chairman, Education and Examination Committee, 1980-81; SOA treasurer, 1986-90; SOA vice president, 1990-92; editor of The Actuary, 1993-96; and editor, the North American Actuarial Journal, 1998-2000.
Brodie, Fawn M., "Thomas Jefferson–An Intimate History," New York, W.W. Norton & Co., 1974, p. 122.2
Ellis, Joseph J., "American Sphinx," New York, Vintage Books division of Random House, Inc., 1998.3
Fischer, David Hackett, "Liberty and Freedom," New York, Oxford University Press, 2005, p. 124.4
Peterson, Merrill D., "Thomas Jefferson and the New Nation," New York, Oxford University Press, 1970, p. 90, cited in Randall, Willard Sterne, "Thomas Jefferson–A Life," New York, Henry Holt and Company, 1993, p. 273.5
"The Politics," Aristotle, 1280 b 1, 1281 a 1, trans. Carnes Lord, Chicago, 1984, University of Chicago Press, p. 99.6
Cook, John H. and Ernest J. Moorhead, "Mortality Experience of Members of the Society of the Actuarial Society of America and the American Institute of Actuaries," Transactions of the Society of Actuaries, Vol. XLII, 1990, pp. 35-58.7
Larus, John R., "Mortality Study of Fellows of the Actuarial Society of America," Transactions of the Actuarial Society of America, Vol. XXXIX (1938), pp. 24-32.8
Cook and Moorhead, ibid.9
Lehpamer, Philip, "Mortality Experience of Fellows of the Society of Actuaries," Class of 1975, The Actuary, Vol. 4, No. 5, October- November 2007, pp. 24-26. 10
Cowell, Michael J., "The Cure for Health Care," The Actuarial Digest, August 1985, p. 5 et seq.11
Remarks by Stephen C. Goss, ASA, MAAA, Chief Actuary, Social Security Administration, at Society of Actuaries Symposium on Living to One Hundred, Session 3A, "Social Insurance Methodologies and Implications," Orlando, Fla., Jan. 8, 2008. 12
Cowell, Michael J., "Health, Wealth and Wisdom–Living Long, Living Well," Proceedings of the Society of Actuaries Symposium on Living to One Hundred, Orlando, Fla., Jan. 9, 2008, Charts 3a, 3b.13
Ibid., Chart 6.14
Record of the Society of Actuaries, Vol. 11, No. 4A, pp. 1899-1926.15
Health United States, 2006, Office of the Surgeon General, Washington, D.C. 2006, Table 73. Body Mass Index (BMI) is weight in Kg./ (Height in Meters)2 or equivalently, 703 x weight in lbs./ (Height in inches) 2. 16
Olshansky, S. Jay, Douglas J. Passaro, Ronald C. Hershow, Jennifer Layden, Bruce A. Carnes, Jacob Brody, Leonard Hayflick, Robert N. Butler, David B. Allison and David S. Ludwig, "A Potential Decline in Life Expectancy in the United States in the 21st Century," The New England Journal of Medicine, Vol. 352, No. 11, March 17, 2005, pp. 1138-1145. 17
Health United States, 2006, ibid.18
"Eight Americas," Ashley Pettus, Harvard Magazine, Vol. 109, No. 3, January-February 2007, pp. 9-10.19
Browner, Warren S., Arnold Kahn, Elad Ziv, Alex Reiner, Junko Oshima, Richard Cawthon, Wen-Chi Hsueh and Steven R. Cummings, "The Genetics of Human Longevity," American Journal of Medicine, Vol. 117, December 1, 2004, pp. 851-860.20
Stallard, P. J. Eric, "Trajectories of Morbidity, Disability, and Mortality among the U.S. Elderly Population: Evidence from the 1984-1999 NLTCS," North American Actuarial Journal, Vol. 11, No. 3, July, 2007, pp. 16-53.21
Tenenbein, Aaron and Irwin T. Vanderhoof, "New Mathematical Laws of Mortality," Transactions of the Society of Actuaries, (1980) Vol. XXXII, pp. 119-183.22
Hayflick, Leonard, "Biological Aging is no longer an Unsolved Problem," Society of Actuaries Symposium on Living to One Hundred, Session 3, Orlando, Fla., Jan. 8, 2008. 24
Cowell, Michael J., discussion of Stallard, P. J. Eric, "Trajectories of Morbidity, Disability, and Mortality among the U.S. Elderly Population: Evidence from the 1984-1999 NLTCS," North American Actuarial Journal, Vol. 12, No. 1, Jan., 2008, pp. 95-98.25
Layard, Richard, "Happiness–Lessons from a New Science," London, The Penguin Press, 2005, pp. 32-35.26
"America's Red Ink," David M. Walker, U.S. Comptroller General, The Washington Post, Dec. 24, 2006, p. B-6.27
Spiegelman, Willard, "An Epic Undertaking," The Wall Street Journal, Dec. 27, 2007, p. W 12.