Dhruv Khullar writes about the differing opinions about how to approach the so-called “‘marginal decade’ at the end of our lives, when medicine keeps us alive but our independence and capacities bleed away.” He points out that in 1900, the life expectancy at birth was 47 years. But at that time, one in five children died before the age of 10. Now life expectancy at birth is close to 77. Much of this improvement came about rapidly due to improved sanitation, antibiotics, and vaccines that have reduced infant and child mortality considerably.

But in the last six decades, increases in longevity have slowed, to only about seven years, and are more due to extending the lives of of old people, many of whom are in ill health. In other words, Khullar says, “we are prolonging the time it takes to die.” The goal of compressing mortality, i.e., shortening the gap between the end of a healthy life and death, may be slipping away.

If anything, longer lives now appear to include more difficult years. The “compression of morbidity may be as illusory as immortality,” two demographers, Eileen Crimmins and Hiram Beltrán-Sánchez, wrote in 2010. According to the World Health Organization, the average American can expect just one healthy birthday after the age of sixty-five. (Health spans are greater in countries such as Switzerland, Japan, Panama, Turkey, and Sri Lanka.)

I was puzzled by what the statistic that “the average American can expect just one healthy birthday after the age of sixty-five” meant and the article did not clarify. In searching around, I did find this representation of ‘healthy life expectancy’ (HLE) across the globe that says that the healthy life expectancy at birth for the US is 66.1 years which is what Khullar is probably referring to. But that is different from heathy life expectancy at age 65. The CDC has figures for HLE in the US at age 65..

Life expectancy (LE) (i.e., expected years of life at a given age) is the average remaining years of life a person can expect to live on the basis of the current mortality rates for the population. HLE estimates the equivalent healthy years that a person can expect to live on the basis of the current mortality rates and prevalence distribution of health status in the population.
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For both sexes, estimated HLE generally was less in the South than elsewhere in the United States. HLE for males at age 65 years varied from a low of 10.1 years in Mississippi to a high of 15.0 years in Hawaii. HLE for females at age 65 years varied from a low of 11.4 years in Mississippi to a high of 17.3 years in Hawaii. HLE was greater for females than for males in all states, with the difference ranging from 0.7 years in Louisiana to 3.1 years in North Dakota and South Dakota.

What is one to do with this information?

As one gets old, one’s sense of one’s mortality becomes hard to avoid. News of the deaths of elderly family members and friends become common and each one means that a thread in the fabric of one’s life has become severed. But while one hopes that one will live longer, there is the counterbalancing fear that one will become incapacitated or otherwise unable to live the kind of life that is desirable. Ideally, one would like to have good health until one dies. But that is rare and largely outside our control. More often, one experiences physical and cognitive decay until one’s body finally gives out. One can only hope that the gap between the end of a healthy life and death will be short, with enough time to get one’s affairs in order but not so long that the end is drawn out and painful.

There is no doubt that genes play an important role in one’s health and longevity. If one is lucky to have been born with good genes, that is a considerable part of the story. But lifestyle choices also play an important role role and the question is to what extent they are beneficial and should be adopted. There are those like Peter Attia, physician and author of the book Outlive, who think that by taking heroic measures throughout one’s life and adopting a very vigorous regimen, one can not only extend one’s lifespan but also significantly extend the healthy period, and promoting such practices has become a very lucrative industry with hundreds of specialized “longevity clinics”, some charging up to six-figure annual fees.

There is the old joke that getting old is no fun but is better than the alternative. There are those who do not agree and, sadly, it leads them to take their own lives. There are others who will fight that alternative to the end, adopting the view in the poem Do not go gentle into that good night by Dylan Thomas that begins:

Do not go gentle into that good night,

Old age should burn and rave at close of day;

Rage, rage against the dying of the light.

Some experts argue that the benefits for such extreme measures to increase longevity and health are unproven.

Ezekiel Emanuel, an oncologist and a health-policy professor at the University of Pennsylvania, derides Attia as an “American immortal” who overcomplicates straightforward advice. “The idea that you’re going to get another healthy decade of life just by doing the things he says is hocus-pocus,” Emanuel, who served as a special adviser to the Obama Administration, told me. “No one’s got that evidence.” Half an hour of daily exercise clearly improves and extends lives, but it’s hard to prove that Attia’s intensive regimens are much more beneficial. By incessantly preparing for the future, the skeptics say, we mistake a long life for a worthwhile one. and that everyone can benefit from adopting some simple, common sense practices such as exercise, eat healthily, sleep well, nurture relationships.

Not all rage against the dying of the light. They accept that there will be a steady decline in the things that one can do and rather than fight against it, come to terms with it and seek out other benefits of aging.

[Eric Topol, a cardiologist and the director of the Scripps Research Translational Institute] said that some of his patients had read “Outlive” and then asked him for prescriptions. “People see him as the expert, so they are going to try something if he says he’s doing it,” he told me. “His followers aren’t going to be able to detect which recommendations are firmly grounded in evidence.” Meanwhile, training dozens of hours a week might take more time than it will ever tack on; good health could even drag out some terminal illnesses. “Peter’s theory of Medicine 3.0 is that you get this long life where you’re healthy, and then you fall off a cliff,” Topol said. “It would be great if it were true. There isn’t any evidence for it.”

Emanuel, the University of Pennsylvania professor, has said that he wants to live to seventy-five. (He is sixty-six.) “Living a long time is not an end in itself,” he told me over Zoom. “If it becomes the focus of your life . . . that is one of the worst mistakes you can make.” It’s not that we shouldn’t exercise or eat well—but “everyone goes through a decline,” Emanuel said. “Spending your life worried about all these tiny things is a waste of time.”

When one has good health, one is more eager to extend it as much as possible, unrealistic as it may be, since life still seems to offer so much. In some ways, going through decline may be part of the preparation for death.

Leon Kass, who served as the chair of the President’s Council on Bioethics under George W. Bush, has written that losing our capacities might be a kind of prerequisite to accepting our mortality: maybe the slowing of body and mind is what makes death tolerable. He quotes Michel de Montaigne, the sixteenth-century essayist. “Inasmuch as I no longer cling so hard to the good things of life when I begin to lose the use and pleasure of them, I come to view death with much less frightened eyes,” Montaigne wrote. “When we are led by Nature’s hand down a gentle and virtually imperceptible slope, bit by bit, one step at a time, she rolls us into this wretched state and makes us familiar with it.”
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I thought about a curious body of psychological research, which suggests that as we age and lose our capacities we tend to grow more content, not less. This finding clashes with popular conceptions of getting older, but seems to hold across continents, cultures, and eras. “I can’t do everything I used to,” a family friend, who is in his eighties and has been married for sixty years, recently told me. “But I wouldn’t say I’m any less happy than I was before.” Lost pleasures, he said, could sometimes be replaced: rounds of golf gave way to brisk walks, and when walking became difficult he spent more time talking to his children and grandchildren. As we grasp that our days are limited, we seem to abdicate our need for control; we may try to close the gap between what we want and what we have. Healthy aging seems to require a shift in mind-set as much as a shift in muscle mass.

Even Attia acknowledges that striking a balance between extreme measures to stay healthy and complete passivity seems to be the key to a good life and death.

Attia tends to argue that individual choices matter not because they are all-powerful but because they are the power that we have. He compares healthy aging to investing in retirement: contribute what you can, whether it’s a daily walk or an extra half hour of sleep, and the benefits may compound over time. “If I’m being brutally honest, I think some people are looking for a reason not to do it because it’s hard,” he said.

He acknowledged that health, like wealth, is unequally distributed; indeed, one of the most powerful longevity “medicines” is money, which can buy people less stress, better education, safer neighborhoods, and higher-quality medical care. For this reason, Emanuel argues that doctors should focus less on “getting rich people from ninety to a hundred” than on improving health in communities where people die young.

The essayist Montaigne quoted above also said that “to study philosophy is to learn to die”. That seems grim but his point was that we need to face our mortality head on without fear.