Aging and Pandemics

Populations change.  Not only do people change--people die and babies are born each day--but the structure of a population changes.  These sequential changes that every population goes through, predicts that we are entering a scary stage.

The theory goes something like this. A hundred and more years ago women gave birth to a lot of children only to see most of them die of infections and famine. Then we saw improved access to clean water, better sanitation and a better diet, which led to fewer diseases and a decline in deaths from infections and famine.  Women started having fewer children and most survived through adulthood. With fewer children being born and increasing survival, we reach a stage in our population where we are today in most developed countries--a very low incidence of infectious diseases and women continue having smaller families. In most developed countries today, women are having so few children that, without immigration, our populations will start to decline.

As a result we have entered the age of gerontology, were we have an aging population and a shrinking younger population.

With an aging population come a wave of chronic diseases--stroke, cancer, diabetes, heart disease, and neurological diseases such as Alzheimer's disease. Medicine,  in the face of such chronic diseases, starts focussing more on monitoring and maintaining health rather than battling infectious diseases. Because of this stability, from now on, populations fluctuate only as a result of wars and epidemics. We cannot predict wars, but we can predict pandemics.

We are at present going through one of the most lethal pandemics in our history. HIV/AIDS has now already claimed over 22 million people. More than 42 million are currently living with the disease and even if a vaccine for HIV were discovered today, over 40 million people would still die prematurely as a result of AIDS.

Despite this threat,  the two pandemics that clinicians seem more worried about--because of their unpredictability--are influenza and antibiotic resistant infections.

After five main pandemics of influenza, history has taught us that there will be emerging influenza pandemics every thirty to fifty years. Studies are showing how dangerous the last avian flu could have been if it became airborne. This type of airborne influenza--or its 144 variants--can devastate populations as the Spanish Flu did at the turn of the century with over 50 million people killed.

The second emerging concern is drug resistant infections. The spread of bacteria, virus or cancer cells that is resistance to drugs is man-made. Although Joshua and Esther Lederberg while at the University of Wisconsin-Madison showed that resistant bacteria has always been present, their increase is brought about by inappropriate and ineffective use of antibiotics. We are carelessly engineering super bacteria. The World Health Organization reports that, as an example, there are 50 million people with multi-drug-resistant tuberculosis, which exist in 49 countries, including the United States.

Although we have entered a tranquil and stable stage in our population--with an aging population where we are mainly dealing with long-term diseases--we do have the threat of pandemics that will dramatically affect this equilibrium. The question is not how, but when.


Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

How Physicians Die

Sherwin Nuland wrote a beautiful book about How We Die.  Similar to other physicians, Nuland got to observe a multitude of deaths. So he knows intuitively as well as scientifically about the dying process. From this vantage point, physicians have a unique perspective about their own morbidity and ultimate mortality which the rest of us non-clinical lay persons do not have.

Ken Murray, a retired family medicine physician and Clinical Assistant Professor at the University of Southern California, has written extensively on this and one of the conclusions that he makes is that physicians would want better quality of their remaining life rather than quantity.

Such assertions have been supported by convincing anecdotal evidence, but only recently did we obtain some proof to substantiate this.

In 2008, Marsha Wittink from the University of Rochester Medical Center, with her colleagues published a study that reported that physicians who initially wanted the most aggressive treatment for their disease, changed their mind three years later. However, although some changed their mind, there were some (41%) who still wanted the most aggressive treatment. It is therefore not clear-cut.

For some people, including physicians, they change their mind when they are dying. Some want a hasty natural ending, others hold on to life at all costs. How true is this if you know you are dying anyway?

The answer came in a study published in 2011 by Hans-Peter Brunner-La Rocca, and his colleagues from the University Hospital Basel in Switzerland. These Swiss researchers talked to 555 heart failure elderly patients about their end-of-life preferences. They repeated the interview again in twelve months and then again in another six months. What they found is that seven out of ten patients initially said they would rather live two years in their current state then live only one year in excellent health. After a year elapsed, this proportion grew to eight in ten and remained the same after eighteen months.

Some people have interpreted this finding as indicating that most people want to live at all costs which becomes more acute the closer you are to death.  However, surprisingly, when the researchers asked patients whether they wanted CPR in a crisis, about a third said no. While another third said they did want CPR—even among patients with "do not resuscitate" orders in their medical files.

In all this uncertainty, the correct interpretation is that most people opt to live despite the physical discomfort. But when the time comes, a third of patients want the natural process to take its course. What this tells us is that we are dealing with a lot of variables and that one policy does not fit all.

The statistics from the Oregon Death With Dignity Act (DWDA) tell us that for the 70 or so patients who go through with DWDA a year, they are exclusively White, are more likely to be better educated (four out of ten have a degree), tend to have cancer (eight out of ten) and have informed their family about their wishes. This is a very privileged and small minority but an important one.

The lesson to take is that each case is unique and there can be no one policy for everyone.We should respect all individual options when it comes to death.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

Dying Priorities

The most divisive issue in America is not the economy, politics, war on drugs, racism, health care or our ongoing military wars across the world. The most recent Gallup's annual Values and Beliefs survey of 2010 reported that doctor-assisted suicide is the most controversial of the issues tested. Equally 46% reported that it is moral unacceptability and morally acceptable.

In contrast, Americans are fairly unified in their opposition to another life-ending choice--suicide--with 77% calling this morally wrong. Taking subordinate position in dividing the nation is gay and lesbian relations, abortion and having a baby outside marriage. 

All these issue drive to the heart of the American ideal of personal freedom.  And yet Americans remain fixated on an issue of doctor-assisted suicide—better known as Dying With Dignity Act (DWDA)—where nationally, in 2011, only 71 people died using this option. In contrast to the 2.5 million Americans that die each year, those that die with DWDA are a very very small minority. They are nearly exclusively White, primarily women, educated, and exclusively people with life threatening disease (mainly cancer.)  

While many people are blessed to be released from life from a final act of covert over-medication, such action is necessarily too late. And while most Americans think a good death consists of dying at home, surrounded by family, and free from pain and suffering—regardless of one’s age, gender, ethnicity, or religious background—one in five people die in an Intensive Care Unit. Death for most Americans is a medical failure rather than a dignified release.

Except for physicians, who tend to shy away from aggressive medical treatment when the prognosis is negative, most Americans tend to undergo a lot of unnecessary, expensive and invasive treatment.

But three of every four Americans do not fear death as much as they fear being in pain at the time of death.  Despite these clearly stated and seemingly universal preferences, too many of the 2.5 million Americans who die in health care settings each year suffer needlessly in pain at the end of life.

And this should be the national issue. Nearly eight out of every ten hospital deaths occurred without a palliative care /formal pain management. More than four out of every five older adults in long-term care facility experienced untreated or under-treated pain at the time of death. While 70 percent of all Medicare decedents, regardless of their age or where they died, received an inadequate amount of pain management.

Sara Imhof and Brian Kaskie predicted in 2008 that "we can only conclude that public policies will fall even further behind the advancement of evidence-based pain-policy guidelines, and the number of Americans who continue to suffer needlessly in pain at the time of death will only increase."

It does not have to be this way. Dying in pain is a national travesty. We need to honor the body’s capacity to let go. In studies that looked at voluntary refusal of food and fluids, nurses report that patients die more serenely then with DWDA. The body knows how to shut itself down. We need to incorporate a dignified exit in our health care system where Americans can at least be protected from a painful death.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

Being Happy Changes You

Why do happy people live longer?

The idea that an optimistic attitude causes people to live longer has been repeatedly observed. Although we identify our longevity to having “good” genes, only recently have we began to understand how our genes are affected by how happy we are.

The best way to study the effect of genetics on longevity is to look at twins. Monozygotic twins, those that split from one egg, have nearly similar genetic makeup. Twins that have a different egg (dizygotic) only share the same level of genotype as with any other siblings.

More than three decades ago, Cook and his associates published a study in 1981 looking at the onset of dementia among monozygotic twins who were both affected by Alzheimer's dementia. In one case study, dementia began in her late 60s, while in the other twin the onset of dementia was at age 83.

Subsequent studies confirm that although monozygotic twins might both have the disease, how they express them and when they express the disease might differ. The difference used to be attributed to the environment. But recent studies blurred the difference between genetics and the environment. 

Twelve years ago, in 2000, Randy Jirtle and Robert Waterlanda from Duke University modified the expression of an agouti gene that which made mice fat, yellow and prone to cancer and diabetes.  These mice did not live very long. The researchers produced young mice that were slender brown and without displaying their parents' susceptibility to cancer and diabetes and lived to an active old age. The effects of the agouti gene had been virtually erased.  

Remarkably, the researchers modified the expression of this gene not by altering the mouse's DNA, but by changing the moms' diet.  Feeding the mother a diet rich in onions, garlic, beets, and in the food supplements often given to pregnant women the researchers provided a chemical switch that reduced the agouti gene's harmful effects. 

These foods--known as methyl donors--enhance or diminish gene activation and gave birth to a whole new science of epigenetics. But can epigenetic changes influence longevity?

In 2012, Jordana Bell of King's College London and colleagues looked at the DNA of 86 sets of twin sisters aged 32 to 80, and repeated with another 44 sets of younger twins aged 22 to 61, and discovered that 490 genes linked with ageing showed signs of epigenetic change. In particular, among these malleable gene expression were four genes that relate to cholesterol, lung function and maternal longevity.

What is phenomenally interesting is that these changes are not just brought about by diet and methyl rich donors, but also by such lifestyle factors such as smoking, environmental pollution, stresses, and attitude.  So we might say that optimistic attitude allows your good genes to shine through while diminishing the effect of  your bad genes. And the effect jumps across generations. If you are long lived, thank your grandparents for being optimistic.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com