EP. 109: RETHINKING HEALTH IN AN AGING SOCIETY

WITH LINDA FRIED

Apr 23

WITH LINDA FRIED, MD, MPH

The Dean of the Columbia University School of Public Health discusses the immense challenges that face an aging population and shares her vision of longevity that emphasizes healthspan, happiness, and individual purpose.

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Episode Summary

To many health economists, the growing aging population is the greatest public health challenge facing America. The current fragmented and costly healthcare system is simply incapable of dealing with the complex medical and socioeconomic needs of this population, especially in an equitable way.

Our guest on this episode, Linda Fried, MD, MPH, has dedicated her life to rethinking how we can create better health futures for older adults. Her pioneering research has expanded our notions of aging and longevity in the 21st century. Dr. Fried, a geriatrician and epidemiologist, is Dean of the Columbia University Mailman School of Public Health, Senior Vice President of the Columbia University Irving Medical Center, and former Founding Director of the Center on Aging and Health at Johns Hopkins University.

Over the course of our conversation, Dr. Fried shares how her early experiences as a caseworker drove her to study medicine, surprising lessons from the martial arts aikido, what frailty means in the context of caring for older adults, why America is one of the most age segregated societies in the world, the flaws of over medicalizing health issues, redefining the roles of older adults in society, the importance of meaning and community in sustaining happiness in life, and more.

Linda P. Fried, MD, MPH, is a distinguished geriatrician and epidemiologist renowned for her leadership in the fields of epidemiology and medicine. Currently, she serves as the Dean of Columbia University's Mailman School of Public Health, a position she has held since 2008. Dr. Fried is also a Professor of Epidemiology and Medicine at Columbia University Medical Center. Her groundbreaking work focuses on the science of healthy aging and the role of older adults in society.
Dr. Fried co-founded the International Longevity Center and has been instrumental in designing and implementing initiatives like the Experience Corps, a community-based social program which engages older adults as volunteers to improve educational outcomes for children. She has authored over 500 scientific articles and her research has significantly influenced global health policy.
Her accolades include being named a "Living Legend in Medicine" by the Library of Congress. Dr. Fried's visionary approach continues to shape the landscape of public health and geriatric medicine.
In this episode, you will hear about:
• 2:30 - What Dr. Fried’s early experiences in social work taught her about justice, social inequity, and taking care of another person
• 11:47 - How an awareness of the social determinants of health shaped Dr. Fried as a clinician
• 16:46 - Why physicians need to stop “medicalizing” all aspects of a patient’s life
• 25:00 - How Dr. Fried came to be interested in geriatrics
• 28:19 - Dr. Fried’s dedication to extending “healthspan” as well as “lifespan” in our society
• 31:08 - The clinical definition of “frailty”
• 34:15 - The value that an older population could bring to our society
• 38:49 - The United States’ unique culture of age segregation and how it contributes to poor health outcomes for the elderly
• 45:38 - What the healthcare system and society at large can do to better serve elderly populations
• 50:55 - Dr. Fried’s advice for keeping true to your purpose as a medical professional
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:01] According to many health economists, the growing aging population presents the greatest public health challenge facing America. The fragmented and costly health care system we have now is simply incapable of dealing with the complex medical and socioeconomic needs of this population, especially in an equitable way. Our guests. On this episode, Doctor Linda Fried has dedicated her life to rethinking how we can create better health futures for older adults. Her pioneering research has expanded our notions of aging and longevity in the 21st century. Doctor fried, a geriatrician and epidemiologist, is dean of the Columbia University Mailman School of Public Health, senior vice president of Columbia University Irving Medical Center, and former founding director of the Center on Aging and Health at Johns Hopkins University. Over the course of our conversation, Doctor Friede shares how her early experiences in social work drove her to study medicine. Surprising lessons from the martial arts. Aikido. What frailty means in the context of caring for older adults. Why America is one of the most age segregated societies in the world. The flaws of over medicalizing health issues. Redefining the roles of older adults in society. The importance of meaning and community in sustaining happiness in life, and more.
Henry Bair: [00:02:23] Linda, thank you for taking the time to join us and welcome to the show.
Dr. Linda Fried: [00:02:27] It's a pleasure to be here. Thank you.
Henry Bair: [00:02:30] So we are looking forward to talking about aging in America, but I was hoping we can start with exploring your somewhat non-conventional path to medicine. Can you tell us more about that?
Dr. Linda Fried: [00:02:41] So it's a bit of a complicated story, which I actually, when I finished college, worked for five years and had no plan to go into medicine, and probably was the farthest thing from my mind and couldn't have imagined it, but went on an unexpected journey of experiencing many different dimensions of health and wellbeing. And they included, I actually thought I was going to be a lawyer, and so I worked in a law firm for a year as a paralegal. But after that, I worked as a social worker for the Department of Public Aid in Chicago. And from that learned, I had a whole caseload of people on disability coverage and and realized how multifactorial the factors are that affect whether someone becomes disabled or not, and whether they can compensate for that disability. That had a profound effect for me, because in general, the people who truly were disabled, if they had had better resources and opportunities, would have been able to cope with it better. And I was quite profoundly affected by that. I also, uh, had a lot of experiences volunteering in a range of organizations, including a free clinic as a patient ombudsperson, and realized how much the opportunity for people to be healthy was affected by access and the right care. And I also trained for a number of years in Aikido and got really fascinated by the dimension of training and fascination with the body and and how we learn how to manage it.
Henry Bair: [00:04:36] Aikido, as in the martial arts.
Dr. Linda Fried: [00:04:38] The martial art.
Tyler Johnson: [00:04:39] Can you explain for our listeners a little bit more what that is? Many of them may not be familiar with it.
Dr. Linda Fried: [00:04:44] I feel like a digression from medicine big time. But Aikido is a nonviolent self-defense art, which was developed probably 100 years ago by Morihei Ueshiba in Japan. And it's a very disciplined training and it's physical. You work with partners and you learn how to respond to aggression and attacks and join with the attacker and redirect it, redirect the attack so that nobody gets hurt, including the. It's got a strong philosophical foundation to everything I just said, but that's what Aikido is. But that training actually taught me a lot about myself, but it also taught me a lot about how to think about caring unexpectedly, even in the face of assault. Wow.
Henry Bair: [00:05:41] Can you share with us? Because this was even before medical school. So what did that teach you about caring, exactly?
Dr. Linda Fried: [00:05:48] Well, I mean, it's not what I understood when I went into the training, but it's what I understood as I stayed with it for a long time that you could actually, if people were aggressive, learn how to manage the aggression so that nobody got hurt. That's a very caring enterprise. And you could join with the person's aggression and redirect it to a more positive place.
Tyler Johnson: [00:06:13] It's such an interesting philosophical turn for me to think about that. I did this immersive learning experience a number of years ago about restorative justice programs, and it's a similar kind of an approach, right? Where I mean, what I learned, and I'm obviously no expert in this, but what I learned is that our entire judicial system in the United States is set up with the idea being that the point is, it's a complete binary, it's innocent or guilty, and then if the person is guilty, then it is all about retribution. And it's all about exacting, so to speak, your pound of flesh. Right? Whereas restorative justice is not about a binary innocent or guilty, nor is it about retribution. It's all about making everyone involved in the fabric that was frayed, so to speak, whole. Both the person who suffered and the person who imposed whatever the problem was. Which is not to even necessarily say that it's quote unquote right. But it was just such a completely different philosophical framework that it sort of blew my mind to even think about things that way. It was one of those things that it never even occurred to me that there were different ways of having a system of justice, just like it had never occurred to me that there's a way to respond to a physical assault by trying to both honor your own humanity and the humanity of the person who's attacking you. That's really fascinating.
Dr. Linda Fried: [00:07:34] Yeah. So I agree with your analogy to try and answer your question. I had a wide variety of experiences. I'll give you one example. When I was a caseworker for the Department of Public Aid in Chicago, I had on my caseload a gentleman who was in his late 40s and had Huntington's disease, and I would see him once a month because he had pretty advanced Huntington's disease. And his sole basis for support was the welfare he was on. But every month he didn't get his check, which was pretty minimal. And the reason he didn't. I was 22. This is what I learned. The reason he didn't get his check was that he was homeless. And he lived under Wacker Drive in Chicago behind a pole. Which was all he could manage. You know, there's a lot to learn when you're 22 about society's effects on well-being, which are are very important lessons. So I was the beneficiary of of my experiences. And I realized I, I needed to find a career in health. I looked at a million careers and for a variety of reasons, decided I would try and go to med school to try and make a contribution. I thought I would be a general internist and be a primary care physician, and that's how I decided to go to medical school.
Tyler Johnson: [00:09:06] I'm so touched by your story of the man with Huntington's disease, because it reminds me that, you know, I grew up in looking back on it, I think especially when I was really young, that my family probably would have been what I would now consider to be maybe lower middle class. I think we were sort of house poor, which is to say that I got to go to a good public school. But, you know, our clothes were all from Kmart and our shoes were all from Shopko, and McDonald's was a luxury. And yet we always had food and we always had clothes. We were never poor. Which is just to say that I feel like so much of growing up, and especially I would hope of becoming a doctor, is about making what may have previously been invisible to you visible. Right? Like, it just it would never have occurred to me to think that there's a person who can't claim his. I mean, first of all, of course I wouldn't have even known what that check was growing up. But even if I had known, it never would have occurred to me that there would be a person who couldn't claim it because they didn't have a physical address to which it could be delivered, or didn't, you know, have a bank account with which to cash a check or, you know, whatever the the precise collection of problems was. But I and I don't mean to instrumentalize that man's suffering, but it's just to say that I feel like that's so much of what moral development is about is coming to understand the many different types of suffering that are in the world, especially those that were previously invisible to you.
Dr. Linda Fried: [00:10:32] I think the first time I used my aikido training in real life was also in that General Assistance office for the Department of Public Aid, because a young man who was just completely at wit's end, on the verge of being homeless, part of the Great Migration from the South. And again I was 22, pulled a gun on me out of desperation because he needed some money to survive. And you know, I was able to. Wasn't why I was hired as a case worker because of aikido. I could handle that and get rid of his gun. So nobody got hurt. But these are all background experiences that teach you about the things that drive people over the edge. As in our human experience, which are not often of their making. And are part of the fabric of how we think about taking care of human beings, as physicians can't solve everything. Much of the things that push people over the edge aren't within the remit of medical care, but if we understand them, we can be part of the citizens that get the other parts solved.
Henry Bair: [00:11:47] That is such an important insight, especially for those earlier in their training. The fact that we in medicine cannot fix the underlying problems that led a person to have come to the hospital. When I was in medical school, I did rotate in internal medicine in both academic and community hospitals, but somehow I don't think I grasped any insight into how little was in the control of the patient and the physician until I became a resident. You know, I recall during my first general hospital medicine rotation as an intern proudly presenting a diabetes care plan to a patient I had devised. I had arranged for a new follow up with an endocrinology clinic, ordered outpatient lab draws, and ordered one of those fancy new GLP one agonist medications. Only after I had happily finished telling her all of this to the patient, start telling me that she had no way of paying for these medications or getting to these follow up appointments. I was wholly unprepared to respond. Since then, I have gotten better about asking proactively about whether a patient feels comfortable with a certain co-pay or what kind of social support they have. But even then, I've come to see that patients can sometimes not be as truthful about this. Absolutely not out of malice, but out of either shame or sense that there was nothing we could do to help them anyway, so why bother us about it? It seems that you realize this very early on, and I'm wondering, how did your understanding of the myriad social factors of health, many out of our control, inform your training and daily work as a clinician?
Dr. Linda Fried: [00:13:25] Well, I guess I did come to medical school with a background that told me about how multifactorial the causes of health or illness were, and that if we could prevent them, it would require both direct medical intervention and a lot of societal fixes. So I did have that perspective, even though I might have not have been able to recite it to you in the same way at that time. I also was profoundly influenced by my clinical skills training in med school. I remember reading in the textbook that we used in clinical skills, that 85% of a diagnosis was the history, and I still believe that the right history. And that also is really important, of course, for understanding the human being and being able to with the diagnoses, being able to think about the care that would matter to that person. But you have to have taken an adequate history and learn the person that you're interacting with and what is shaping their health or ill health. I also probably over the years, have appreciated more and more the history of medicine in the United States, which has been since the 18. I was the president of the Association of American Physicians for a while, and had the privilege of reading the archives of Aafp since, uh, since it was formed in 1886. And and I, I learned from that how much you know, that was a moment when a group of physicians worked to put science into medicine, and the only place medicine could start was with disease.
Dr. Linda Fried: [00:15:18] When patients showed up with an illness with symptoms, and to tie that to underlying pathophysiology and unite the symptoms, the manifestations, the signs, and reach for the underlying pathophysiology that was causing that. That's the foundation of what medicine has done heavily to the present is a focus on disease, because that's what we can touch most readily. But what that doesn't tell you is another branch of the origins of US. Medicine was the realization by a number of the founding physicians in the AAP and others that we had to also understand the contextual factors that shape health and disease, and the contextual factors turn out to predict 70% of a population's health. So if we take an adequate history to understand those forces. It's really important both for learning but also for intervention. And so I think those were other things that have shaped my understanding. We tend to focus on the disease because that's within our remit. The contextual factors. We can join with other sectors of society to try and support patients.And then we need, I think, to learn how not to medicalize everything of a patient's life. And because if we do that, if we think everything's medical, we sap our societal energy to actually solve the root causes.
Tyler Johnson: [00:17:02] Yeah. You know, one of the things that, as Henry and I have reflected on the most important lessons that we have learned from now, many, many hours of having these discussions with a lot of really wonderful and intelligent and caring people. If we had to distill all of that down, I think that the single most important lesson that we've learned is a corollary, or the root or an outgrowth. I'm not quite sure which of what you're saying, which is that we feel like medicine has gotten to a point, in large part where we try to mechanize medicine, right? So we try to reduce a person to a machine, and we try to understand sort of inputs and outputs. And then what we do, especially I think this is most clear in the hospital where you have a person who comes in because they're sick, and then you're supposed to do some things and then they get discharged, right? That it really is like having this sort of acute machine service, right, where a machine comes in that's broken and you sort of open up the gears and, you know, tinker around with your tools and fix things and then send them back out. But to your point, I think that it takes most medical students not too long on the wards to realize that sometimes. That's right. Right. Sometimes you have the college student who has a wonderful, healthy background and a good, stable social situation, and they just get meningitis and they need antibiotics and that's all it.
Tyler Johnson: [00:18:28] I mean, that's really what it amounts to. But so often what is presenting and what you're fixing is just the, so to speak, the tip of the proverbial iceberg that has to do with all of these things, like what you were referencing earlier, even before you got into medicine, has to do with all of these things about how much money the person has and where the person lives and what the person's social situation is like, and whether they have supportive family or not, and how many jobs they're working. And you know which geographic part of town they live in and what the access to resources is and whether their water is clean. And anyway, I mean, you can make this sort of endless list. And I feel like that epiphany, which most medical students have at some point, is at once liberating and frustrating, liberating because it allows you to understand that it's not you that's failing. When the person keeps coming back into the hospital over and over again, but also frustrating and overwhelming because it does, you know, make it feel like I know that there were times when I felt like, gosh, you know, like, what am I really doing here? Like, what does our work even amount to in the face of what often feels like large elements of society that are broken? Right. It's not just a problem with the lungs or a problem with the gallbladder or whatever. It can feel like it's an entire system that's conspiring against the person.
Dr. Linda Fried: [00:19:50] So our job as physicians is to relieve suffering. And to do our best to create health. And to optimize it. And that is critically important. For the well-being of any human being. But the other part of this, I think, is that we have such a privilege, which I know you both know to be. Privy to the most intimate parts of the human experience. And that it's a privilege. Which of course needs to be protected and honored. And served. But it also needs to be respected in the sense of not medicalizing parts of a person's life which that would not serve. Or turning everything into a medical problem. I think that's really critical. So I probably like you both spent a lot of my time and I'm not in clinical practice anymore, but because I have a different kind of 24/7 job. But I spent a lot of time in my clinical practice running around trying to find samples for medications for somebody who couldn't afford to buy them, or who confessed to me that they were only taking their pills every other day to conserve them because they didn't have the money to buy them every month. So this may be the wrong example because it may not take me to to overmedicalization. But but ultimately I ran around and always trying to find samples to give them other ways to do an end run around the problem. But the core problem is how we provide access to the medicines and care that people need in a humane way, in a humane society. And that requires us as physicians, as people in the health profession. I think giving voice to what society needs to solve.
Tyler Johnson: [00:22:02] Can you just talk just to clarify for our listeners, many of whom may not be familiar with the idea, what does it mean to medicalize a problem, or what's an example of medicalizing a problem that is not actually inherently medical?
Dr. Linda Fried: [00:22:18] So we have a big resurgence in the movement of food as medicine. In a lot of ways that came from the work of Jack Geiger and his colleagues in Mississippi in the 1950s, caring for really indigent people in rural Mississippi. And they found over and over again that people there were hungry, malnourished, even starving, but just generally undernourished and everybody. And so the only way they could figure out how to get them food was to start writing prescriptions and demand that insurers pay for their prescriptions because they couldn't figure out how to solve the food insecurity another way. But it was a problem everybody wasn't experiencing, but it was labeled food as medicine in order to find a way to get food to people. We now have a resurgence of food as medicine in a lot of ways to solve the same problem. Which is a serious one in the US in terms of food insecurity for many people. And sometimes the lack of the right nutritious food, the affordability of nutritious food, access to affordable food is the reason people are sick in the first place. But we can write prescriptions for food as medicine when they finally get sick, and then the food becomes treatment, which we can justify. The challenge with that, while I honor the need to make sure that people who are sick and would benefit from the right nutritious food is critically important, is that it saps the narrative that food is health, and we need not just to find the solution one patient at a time, but we need to find the solution for everybody who's food insecure before they get sick. Before we can claim that they have an illness that needs treatment. That's what I mean by over medicalizing a problem. Because it directs our attention to late in the pathway of becoming ill. We could have prevented those people from getting ill in the first place. If we fix food insecurity at its roots for everybody.
Henry Bair: [00:24:50] Thank you for elaborating on that. It's making sense now. Your career trajectory and why you eventually stepped into leadership roles in public health. I do want to spend some time delving into your early career work in aging and geriatrics, which even now is among the single least popular subspecialties in internal medicine. What drew you to geriatrics all those years ago?
Dr. Linda Fried: [00:25:15] Well, I was a little slow to the game because I finished a residency in several fellowships in general internal medicine and epidemiology, because I got really excited about epidemiology as the science of prevention and how to keep people healthy and, and started working on actually physical activity and its role in health in a variety of ways. And I became a general internist at Johns Hopkins in the Division of General Internal Medicine and was doing science I was quite excited about and had absolutely no, no thought of going into geriatric medicine and then or interest, quite frankly. But somebody I admired greatly, who was the chief of this new division of geriatric medicine and who I'd been doing a little project with, walked into my office one day and said, Linda, I think you should be a geriatrician. And I liked him very much. But I said, Bill, the answer's no. I'm not interested. And please leave. Don't bother with me with that again. But I, I liked him so much, and I respected him a lot that I went home that night. And I told my husband, you wouldn't believe what Bill tried to talk me into today. And then it just kept bugging me.
Dr. Linda Fried: [00:26:38] So I sat down and started looking at the data, and the data blew me away. This was the late 1980s. We were caring for a gazillion people dying of HIV Aids in the hospital, and I looked at the data and I thought, I never realized this. We have actually created longer lives. At that point we added 20 years to human life expectancy. Now it's 30. And I just was completely unaware of that. And then I thought, oh my God, we're going to have aging populations by the 21st century, which is right now. And our politicians are hanging crape on this amazing success. They're saying, what a disaster. I mean, those headlines were in the paper every day. I thought, this doesn't make much sense. We haven't even asked the question about whether this is worth it or could be good. And I thought, this is such a big deal. This is going to be the HIV Aids of the 21st century. And the answers were providing don't make any human sense to me that we've created something unprecedented in the history of humanity, which is longer lives. And we're not saying, what could we do with this? We're opportunities. I got so captured by that. And then I thought, you know, I really love my older patients. What I learned from it is so fascinating and so cool, and I learned so much about life from them. And I love taking histories. So the next day I changed my career.
Tyler Johnson: [00:28:09] As one does. Why not?
Dr. Linda Fried: [00:28:11] But that's that's how I got into geriatrics and I it's been the greatest thing in the entire world.
Henry Bair: [00:28:17] So you had this revelation that with the incredible advancements in medicine allowing people to live longer than before, we are seeing a host of new problems we've never had to deal with during a population health class in medical school. I remember hearing these statistics showing that our current health care system is absolutely, from an economic perspective, not equipped to handle the health care needs of the aging population. And I was even more struck by how the health economists presented the stats. They're tone. It almost sounded as if they were genuinely scared of this grim future. If we did nothing to rethink our health care system, we were headed for Armageddon.In the coming decades, you have been following these developments and practicing in this clinical realm for many years now, and I'm curious to know what specific issues in aging and longevity have you come to focus on?
Dr. Linda Fried: [00:29:11] Well, I learned a lot from my patients. What I learned from my patients is what I ended up focusing on in a lot of ways, and they're kind of three levels of things. One is going back to the stories I told you before, people want long lives. If. They can be healthy. And if they can realize their goals. People learn to live with disability. They learn to. People are amazingly resourceful and they learn to live with multiple chronic diseases. But they would prefer to have the opportunity to be healthy. And to then experience the value of the longer lives we have created. We have created these. And so a huge part of my career has been about where the opportunities are to not just have a long life, but have to to have a long, healthy life and to extend our health span as well as our life span. And I have, as an epidemiologist, led many large studies to try and see where the opportunities for prevention are. And that's a huge amount of the line of work that I've done. When I was in training in my geriatrics fellowship, I got to listen to senior scientists who at that moment were arguing whether prevention would work in matter in older people. That was an argument 30 years ago. Now we take it for granted because the science has said yes, of course it matters across the life course. And if people arrive at old age healthy, they're tracked to stay healthy. But it works in matters into our oldest stages.
Dr. Linda Fried: [00:31:05] That was an argument when I was in training. The other two things I've learned from my patients I've learned a lot. But was that when I was, uh, in my geriatrics fellowship, I read a textbook in a new area, a chapter in a new geriatrics text, which said that frailty was the raison d'etre of geriatric medicine. Taking care of frail older patients was the central responsibility of geriatricians. And I took. Care of many frail older patients. But the astounding thing was that the level of the science at that point was that we didn't have a definition of frailty. The National Institute on Aging said frailty was equal to having disability in two or more activities of daily living. And when I looked at my patients, that's not what I saw. Frailty was, and it wasn't just being old because there were older patients who looked like you and me. They weren't fresh, even really old patients. It wasn't whether they had co-morbidity or multimorbidity. There were plenty of people living full lives who didn't seem frail. So the science really was quite indeterminate about what frailty was, even though it was the raison d'etre of geriatric medicine. And I could see my frail older patients had something biologically going on by which I recognized that they were frail before I even talked to them. I could see it, and it didn't match what people were saying was the case. And so everybody agreed that being frail was a state of high vulnerability and high risk for very, very bad health outcomes.
Dr. Linda Fried: [00:32:53] But the interventions that were being tested, which seemed to work, kept coming up negative in in randomized trials. And I realized it was because we didn't know how to select the patients for the intervention, because we couldn't define what frailty was. So I have spent decades trying to figure that one out through a lot of science for many, many, many years have come to a conclusion with many colleagues as scientists that actually frailty is a clinical syndrome, a constellation of symptoms and signs that cohere in a critical mass. And when they're present, identify a distinct pathobiology of changes within our organism, which actually and the presentation marks people whose biologic and physiologic functioning has become so dysregulated. In our homeostatic mechanisms that we are physiologically functioning at a lower level and are at very high risk. That took decades, but I think. It holds up. And the third thing that I learned from my patients was I had patient after patient after patient in their 60s, 70s, 80s, 90s who came in because they didn't feel well. They knew they were sick. Their primary care doc hadn't been able to figure out what was wrong. And time after time, the reason was they had no reason to get up in the morning. That's what I learned from my patients. And having no reason to get up in the morning, having no sense of meaning and productivity, having no sense of value in the world, and being able to contribute what makes people sick and it makes them die.
Dr. Linda Fried: [00:34:55] And so I also have spent three decades trying to figure out how we solve for that. Because what we have learned is that it doesn't matter how old you are, human beings need to feel like their life has meaning, that it has a purpose, that they can bring value to whatever they want to define as the world around them, and that they need to know that they have left a legacy that will live beyond them. That is something that they believe is of significant value. And what I learned was that we in society, because we devalue aging, our older lives, our own older lives, we devalue. It's not someone else's. It's our own potential future because we are so inherently and socialized to be ageist, that we have not actually recognized the immense value that an older population could bring to us. There's some science now to say what that value is, in addition to the intense generative need that many people have as they get older. To feel like they have contributed to a better world for future generations. That will give them a sense of satisfaction and legacy when they die. And that intense generative goal is very important for successful aging. That as people get older, you know, if you retire at one day, you don't lose all the expertise you have. The science is very clear. It doesn't go away. You know a lot, you've learned a lot. And as people get older, they can unite what they have learned objectively. No master clinician better than you were when you were 25.
Dr. Linda Fried: [00:36:50] You've learned a lot in terms of your subjective life experience, and people learn how to integrate those. Actually at the intersection of those two is what perhaps we think of as wisdom, united with values that people develop with maturity in terms of what matters. As people get older, they have more emotional stability, more skills in terms of complex problem solving, because they have a lifetime of experience in solving problems and actually advanced cognitive capabilities to solve problems that they didn't have when they were younger, and bring that to things we could use at scale, like conflict resolution. Older people are better at conflict resolution, conflict mediation than younger people. I mean, I could go on and on, but there are really fascinating attributes of getting older that as a society, we're just learning about. And you combine that with the fact that people need to have a reason to get up in the morning to flourish. And we have not built. We've neither value the assets that we all acquire as we get older, nor have we learned the necessity of building a social infrastructure that could enable people to stay engaged and contribute in ways that will enable them to thrive. So. There are ways we've learned we could and should do that, and it is part of how we create healthy longevity is all of those dimensions. If we enable healthy longevity for everybody, we will have unleashed the assets of our longer lives for individuals and for society.
Tyler Johnson: [00:38:49] I feel like this is an interesting intersection between what we were talking about earlier, in the sense that there are these larger cultural lenses that we bring to problems that we don't even realize that we're using, and also the need to see people fully as people. You know, it wasn't until when I was in my early 20s, I lived in Mexico for a couple of years. One of the things that struck me immediately, culturally, is that in the place where I was living in Mexico, many people lived in multigenerational family units, either within the same home or with. There would be a sort of like a complex of homes or multiple homes on a street where, you know, different levels of an extended family lived. And so you would have grandparents and sometimes great grandparents and multiple aunts and uncles and, you know, grandkids or great grandkids, whatever you want to say. But anyway, all of these people who all lived relatively close and had this kind of a this sort of a free flowing, intergenerational culture, and that was so striking to me because I grew up in a place where, I mean, I loved my grandparents, and I think I had a good relationship with my grandparents. But, you know, they had their home and my aunts and uncles had their homes, all of which were, you know, at least a car ride, if not a plane ride away from where we lived and going to any of their homes was an event, right? We would go to my grandparents once a week or once a month or whatever.
Tyler Johnson: [00:40:15] But I bring this up to say that I feel like we live in a culture in the United States that prioritizes certain things, right? It prioritizes efficiency, profit maximization, sort of maximizing the quote unquote utility of people as workers and making money and, you know, certain other kinds of things, but does not value, at least why, in a widely shared way, does not as much value those intergenerational relationships and dynamics. And I think that part of what I sort of extrapolating from some of what you've said is that I think one hypothesis we could come to is that frailty is not merely a reflection of biological processes run amok, but is also a reflection of maybe blind spots in our culture that we end up atomizing people who are older, who don't, quote unquote, contribute efficiently to the economy or whatever, and they're sort of sidelined. Right? They're they're sort of living in an apartment somewhere alone because they don't fit within the sort of the framework that our wider cultural values dictate in the way that maybe younger people who can, quote unquote, work harder, even though really they just are working in a different way, can do which is just sort of back to the public health point that we were making earlier, that part of the if you were going to try to solve that problem, part of the solution to that is a cultural one and a value based one, as much as it is a medical or a pathophysiologic one.
Dr. Linda Fried: [00:41:48] I think your analysis is spot on. The US is now the most age segregated society in the history of the world.
Henry Bair: [00:41:58] How do we measure that?
Dr. Linda Fried: [00:42:00] So it's not my own science, but the way it's been looked at is whether generations live in proximity to each other. And in fact, older people are increasingly living in segregated areas. But we also zoned segregation. So we zone senior housing into the outskirts of a community away from the life of the town or the city. That's one measure. We have segregated by life. Course, you go to school for increasing amounts of time. You work. You've retired. Well, it doesn't match the realities of what people necessarily want or what would actually cause societal flourishing in the age of longevity. But generations are highly segregated in a lot of ways. The countervailing evidence is strong, just as you just said, Tyler. We could think about this different ways. For example, there's lots of assumptions that if older people are working for pay, that that limits the jobs for young people. The evidence is absolutely the contrary. It's so contrary that economists have given it a name. It's called the lump of labor fallacy because in fact, if older people have jobs, then there's a stronger economy which generates more jobs for younger people, because older people and younger people don't compete for the same jobs in general, and older people have more money to spend, which also then strengthens the economy and can defer drawing on pensions. I mean, the story is longer than that, but that gives you somewhat of the overview. And people need each other across generations, just as you were saying, we need each other across generations in so many ways, including, you know, the hands up from old to young for upward mobility. You know, so there are a lot of ways in which that kind of age segregation harms everybody on the work side. There's strong evidence that intergenerational teams are more creative, innovative and productive than single generation teams. So there's also a bunch of assets we haven't learned how to use very well.
Henry Bair: [00:44:26] Yeah. So it really sounds like it doesn't really matter from what lens you take it, however you want to slice it. Addressing the issues of frailty, addressing issues of aging and longevity benefits a population from a medical sense. Sure, yes, you can reduce the effects of disease from an economic productivity aspect. It also does benefit to be paying more attention to the well-being of older adults. And then lastly, from a more philosophical, ethical, moral perspective, it also does help human flourishing to be focusing more on on well-being in older populations.
Dr. Linda Fried: [00:45:04] I add one other thing to that. Of course, if we set our goals optimistically. In the era of longer lives to creating healthy longevity, not just longevity. What would happen is to accomplish that. We would change medicine, and we would change public health so that we were everything we were doing was about people's health futures as well as their health present. And if we did that. The byproduct would be that we would resolve health disparities.
Henry Bair: [00:45:37] Well, that kind of brings me to my next question, which is, you know, you've spent so much time looking into, as you mentioned, the three areas, right? You mentioned, uh, number one, the importance of prevention, preventative health and older populations. Number two, definitions of frailty. And then number three, the importance of meaning and purpose, improving well-being.So I guess to posit one question, what are some of the most impactful and realistic pragmatic things we could try to do to start addressing some of these issues? You mentioned that you had been looking into what are what are the gaps we can fill in preventative health and in improving or addressing frailty of populations? And what are some of the things that we can actually do or can realistically do today as a society or even as like just within health care system?
Dr. Linda Fried: [00:46:27] So I think my number one thing as, as somebody who ended up spending half her career in medicine and half in public health is that I think medicine needs to recognize that medicine cannot be successful without strong public health system. Medicine and public health are the two sides of a health coin. The US population has sunk to the bottom of peer nations in the last 30 years in terms of health status. The bottom of 35 peer nations of developed wealthy countries. Much of that is due to a disinvestment in public health. Medicine cannot be successful in its goals unless medicine advocates for a reinvestment in public health. If 70% of a population's health comes from what we do as a society to enable people to be healthy, which is what public health leads. But the US puts only 2.5% of its health dollars into public health. You can see that we're getting what we're not paying for. We need to reinvest in public health and medicine needs to lead the charge not to take over public health. Not to medicalize public health. But to make sure that there is strong public health in every community, to deliver health at every age and stage of life, across the life course, to deliver the conditions for people to be healthy. That enables medicine to complement that with clinically tailored, individualized prevention. But you need both. I'll give you one quick example. When I became the dean of the School of Public Health in 2008, I met with Tom Frieden, who at that point was New York City's health commissioner. He later went on to be the head of the CDC. Like me, he was he's a physician with an MPH. He said to me, Linda. New York City has been trying for 25 years to lower smoking rates.
Dr. Linda Fried: [00:48:41] And we have focused exclusively for 20 years on educating clinicians to work with their patients, which is really important to prevent smoking and to quit smoking. And then he showed me New York City's data. With all of the city had invested in educating clinicians on this. The rates were flatline. They never budged. But we know it's really important for clinicians to know how to counsel their patients. And then he showed me the data that as the city started to empower the health department to actually lead smoking campaigns, to educate the public broadly, to make smoking no longer the norm. Through a whole variety of approaches to make it so that you couldn't smoke in restaurants. That was pretty radical then in other public places to actually add taxation to it, to do community based programing. What you see is that with every additional layer of intervention, the smoking rates over ten years halved in New York City. You need both medicine and public health to have a healthy population. Neither one alone is sufficient. But the disinvestment in public health in the US, which is so extreme, which started 40 years ago, we critically have to turn around not just because of the next pandemic. And to be prepared for it, not just because the health impacts of climate change are threatening the health of Americans all over the country. And we need a public health system ready to protect people's health at a community and population level. But because chronic disease prevention and the issues of health and aging require strong public health as well as the right medical care. So if I were going to say one thing to the medicine community in the US, it's that we need to demand reinvestment in population level prevention. Or medicine can't succeed.
Tyler Johnson: [00:50:55] So we've spent a lot of our conversation today talking about policy level things, philosophy, ethics, lenses through which to see big societal problems. But we like at the very end of every episode, to bring it to focus the microscope right back into an individual clinician. A lot of the people who listen to our show are either at some point in their medical training or maybe even contemplating medical training, or are, you know, attendings who are still open enough to learning and growth that they hopefully are listening to, try to learn. So all of that is to say, if you could, with all of the knowledge and experience that you've accrued over your lifetime in medicine, though, I know you're not directly clinically practicing right now, but nonetheless, if you could go back to, you know, somebody just starting their internship or a medical student who's just starting their time on the wards and give them your sort of most important thoughts about what you wish you would have known at that point that would have made you a better doctor. As you came up through your training, what would you tell them to close us off?
Dr. Linda Fried: [00:52:01] It's. It's a big question. I have to reach back. Um, I think I go back to something that you said before, Tyler, which is. That. It is critically important that we maintain as doctors our connections to the reasons why we went into medicine, and not allow a system that keeps paring back our ability to enact those reasons from doing that. Being a medical student and being a resident is a time of high stress to acquire the the skills for for specific capabilities to deliver medical care. But there's a point at which I think you need to re widen your lens back to the reasons why you went into medicine in the first place, and to reincorporate that and to not lose that because it's, first of all, you're a better doctor. Secondly, it's nourishing of one's own humanity, which is the reason you got there in the first place, and you learn and grow a lot more.
Tyler Johnson: [00:53:18] Well on that beautiful and winsome note. We thank you so much for bringing your many years of experience and expertise and stories to our program, and we know that listeners will benefit greatly from all that you've shared. Thank you so much for being with us.
Dr. Linda Fried: [00:53:33] Thank you for the opportunity to join you and for your great questions.
Henry Bair: [00:53:39] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.theDoctorsArt.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:53:58] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:54:12] I'm Henry Bair.
Tyler Johnson: [00:54:13] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.