Stayin’ alive

Stayin’ alive
$27 million says Emory and Ga. Tech can save America’s health care

By Stephanie Ramage

Within the universe of my body and yours, deep in our cells, at the ends of our strands of DNA, is a little area like the plastic-coated tip of a shoelace that’s called a telomere. As we age, our telomeres begin to shorten like that plastic area does when a shoelace begins to fray. We’re all born with a reserve of telomeres, but the reserve is used up by the time we’re adults. Some people, says Emory University scientist Cornelia Weyand, use them up faster than others.
“We can look at two 65-year-olds and one can be in very good shape and one in not such good shape,” she says. “And the one in good shape has the longer telomeres.”

Weyand, an immunologist, has studied patients with lupus and rheumatoid arthritis, and she has noticed that many of them age 25 percent faster than other people—that is, their telomeres shorten 25 percent faster than those of healthy individuals. Other scientists before her had already looked at the telomeres of mothers of disabled children.

“What they found is that those women aged more rapidly, too—they had much shorter telomeres,” she says.

What both groups had in common was stress. The stress of having to manage a disease—their own or someone else’s—was literally taking years off their lives. It’s something that we human beings have seemingly known all along without the benefit of microscopes. We have phrases like “frayed nerves” and “aging me in dog years.” There’s also a substantial body of documentation dealing with prisoners kept in traumatic conditions aging so rapidly that, ultimately, their own families barely recognized them, but now science has found the biological root for our intuition: Telomeres are the measuring tape of how much of our lives is being chewed up by our experiences.

This is key information in the impending overhaul of American health. In fact, Emory and Georgia Tech, armed with $27 million in funding, are at the forefront of the most dramatic health movement our country has ever known, a movement that reaches far beyond the walls of hospitals, into the minds of philosophers and onto the streets of cities and small towns. The name for the movement, “predictive health,” is misleading—it bespeaks genomes and fetal screenings, but that’s not what it’s really about. It is, instead, says Ken Brigham, vice chair for research in Emory’s department of medicine, a vision of 70- and 80-year-olds getting around like people almost half their age. After all, he says, it is medically possible to keep someone alive until they’re 120, but why would we do that if that person isn’t healthy?

Health care issues related to aging are sinking the American health care system. And it’s not just that the country’s largest generation, the Baby Boomers, are retiring and being admitted to hospitals for knee replacements and bypass surgeries. Part of the problem is that the Boomers are different from the old folks of the past: Many of them want to continue running marathons or kayaking until their time on this earth is done and that is the kind of challenge an already burdened health care system simply hasn’t faced before. So, while diabetes and cardiovascular disease tot up more victims than ever, doctors are also faced with 60-year-olds asking questions about how to stay strong and competitive for another 20 or 30 years—which is no longer impossible.

Michael M.E. Johns, chairman of the board of Emory Healthcare, addressing the audience at the Emory-Ga. Tech Predictive Health Initiative conference in December, drew a chart for the overhead projector to illustrate the potential of predictive health.

“Typically, this is what our health looks like,” he said, pointing to a line that rose from birth and plateaued around age 30, then began descending in our late 40s or early 50s in a steep downhill run toward death as the quality of our health diminished. “But this is what we are capable of doing,” he continued, showing another graph, this one with a line rising from birth, leveling out around 30 and staying at this optimal level of health until maybe 120 and then—blip—death: “A short period of diminished health before death.”

The death taboo

Ken Brigham, associate vice president of predictive health at Emory, speaks slowly and carefully, like a man who has delivered bad news enough to know how to ease the words into the conversation like a syringe into a vein.
“We do not really have health care,” he says. “What we have is disease care.”

And our disease care—although it has resulted in the best emergency rooms and cancer centers in the world—isn’t doing anything to keep us healthy. In fact, the system itself is sick, in no small part because of the large population of aging Americans. According to the RAND Corporation, U.S. expenditure on health care for those 65 and older is three to four times higher than its expenditure on younger Americans.
“Our current health care system is too expensive and is increasing in terms of demand at an unsustainable rate,” Brigham says. “The health of the American population is not as good as, for example, that of Great Britain, which spends half as much on health care as we do. Our system will change because it has to.”

According to the Organization for Economic Cooperation and Development (OECD), of the 12 most developed nations in the world, the U.S. spends the most money on health care—more than Switzerland, Germany, France, Canada, Sweden, Australia, the Netherlands, Denmark, Italy, Japan or Britain. And yet our life expectancy, about 75 years for males and 80 years for females, is less than that of people who live in Japan, France, Italy, Australia, Sweden, Germany or Britain.

For his part, Brigham believe that the high-stress American lifestyle makes us sick and then leaves us on our own when we’re old. This struck him dramatically while he and his wife were vacationing in Venice.

“You saw old people there walking to do errands and sitting down with young people in the square,” he says. “They were included in daily life—and that has a great impact on depression, which we are finding has a great impact on our physical health.” The idea, he says, is not to create a population of cosmetically-enhanced octogenarians, but to instill real health, which may not look the way we envision it. He recounts a story reported by The New York Times, about four sisters who were in their 90s and very healthy.

“Yet, you look at them and they are old,” he says. “We’re supposed to age and eventually die. There is nothing wrong with that, but to preserve life shouldn’t mean imposing a prolonged death. There is a death at the end, of course, but it should be a low-tech death.”

He recalls his days as a resident at Johns Hopkins University, where doctors were not supposed to let anyone die; to have a patient die was to fail. “We did everything we could to keep patients alive,” he says. “And sometimes, now, I think that is more of a need for the physician than it is of the family or of the patient.”

He explains that Medicare spends a third of its budget on patients in their last year of life—a sign of how hard we fight to hold on. “We do have a death taboo in our society—and that is not all right for the dying person and it’s not all right for us,” he says. “We have to learn that at some point it’s OK. It’s not pushing them off on an ice flow and it’s not euthanasia, but it is a huge shift in our thinking.”

That shift in thinking is why, speaking at the symposium at Emory, Elias Zerhouni, director of the National Institutes of Health, reached out to economists, philosophers, theologians, ethicists and sociologists. The NIH, which provided part of the Emory-Ga. Tech initiative’s funding, is looking for interdisciplinary teams who can contribute meaningful research to predictive health.

“The barriers between the sciences must be removed,” Zerhouni said at the symposium. “The world is going to be less medical-centric than it has been in the past. We will have to have a debate as a society and change the medical compact. We are in a transformative chapter in history. Predictive health will determine our societal health for the next 100 years.”

At the conclusion of Zerhouni’s remarks, people in the audience, mostly medical researchers and doctors, lined up at microphones to ask questions. The last question was posed by a man who seemed agitated as he adjusted the microphone to a higher notch.

“You’re talking about keeping people healthy into their 70s and 80s,” the man said, “but there are some societies, like the Okinawans, who are already doing this. So my question is, why aren’t we studying them? These cultures are healthy, but they are disappearing, and we should be studying them while they still exist.”

The meaning of life

As early as 1974, Victor Fuchs, a health economist at Stanford University, noted in his work “Who Shall Live?” that the difference in health quality between America and other countries is the result of environmental factors, genetics and personal behavior, the latter of which is as likely to be made worse by a higher income as it is by a lower income. He wrote, “Differences in diet, smoking, exercise, automobile driving and other manifestations of ‘lifestyle’ have emerged as the major determinants of health.”

Corey Keyes, a sociologist at Emory, who posed the question to Zerhouni at the symposium, wouldn’t disagree with Fuchs. But, Zerhouni tells The Sunday Paper later, there are things happening in our society that diminish the quality of our lives, which is exactly why places like Okinawa are so important. Extended families and strong connections with friends help people be healthy. In Okinawa, he explains, people have a chi goi—a purpose in life—and they talk about it with their friends and their friends help them stay true to it.

“This gives your life meaning,” he says. “Having a lifelong group of friends gives your life meaning. But, it’s almost impossible to do this today. We are all relocating. It’s work-related. Either we are torn away from our families and friends because we have to move to a new city or we are working so much that we don’t have time for friends. This isn’t healthy. It causes loneliness and depression and there have been many studies that show a link between depression and illness.”

Simply put, our health has taken a back seat to our productivity.
“We feel we have to be so productive, so work-driven—too many bits and pieces of our economy are invested in that productivity and we are paying for it with our health and that is costing us more in the long run,” he says, drawing an “S” curve on a notepad. He points to the spot where the lower curve meets the upper: “We’re here—we’re at the critical point where we’ve got to change dramatically to undo the damage that’s been done.”
He explains that Okinawans in their 80s and 90s climb up and down mountains every day. He attributes this to their diet and their daily routines. “The Okinawans only eat until they are 80 percent full,” he says. “Which we know is healthier than eating until you are 100 percent full, so caloric restriction is built into their culture.”

Their foods are also high in nutrients and they grow all of it themselves. There was a time, I suggest, when most Southerners grew their own food.
“Yes, but who has time to do that now?” he counters. “Now, having a garden is a luxury. It’s something the affluent do. Also, where can people do it? Now, over half the world’s population resides in cities.”

And those cities are increasingly unlivable, he says. With so many people piling into urban areas and bringing their cars with them, the commute is eating up the time we should be spending with our families and friends.
Andrew Dannenberg, at the CDC’s National Center for Environmental Health (NCEH), agrees.

“How you build the world around you affects your health,” says Dannenberg, who is associate director for science in the NCEH’s Division of Emergency and Environmental Health Services. “The simplest part of this is sidewalks—just building sidewalks encourages people to walk, which reduces obesity. Being physically active lowers stress, which can decrease depression and alleviate illnesses. Having green space, having benches in public areas where people can rest and talk. Every day, when communities are being built, decisions are made about how they will look. Those same kinds of decisions should be made regarding their impact on health.”

At Georgia Tech, Larry McIntyre points to work being done by architects, designers and information technologists to address Dannenberg’s concerns, but the biggest obstacle he sees for overhauling the way we manage health in this country is insurance reimbursement. The topic hits close to home. As chair of Emory and Ga. Tech’s joint department of biomedical engineering, McIntyre has taken a lot of pride in the schools’ nano-medicine centers devoted to cancer, cardio-vascular disease and DNA repair. Nano medicine refers to the ability to pick up the tiniest markers of disease long before any symptom is present.

“But that’s not the way that insurance reimbursement works,” McIntyre says. “An insurance provider wants to know there was pathology—that there were already problems and symptoms that prompted a doctor to have tests run. At our nano-centers, we’re able to pick that up before there are symptoms, but right now, patients won’t be reimbursed for those tests. Yet, we know that the sooner you find cancer, for example, the better your chances for recovery.”

It will take a while for the insurance industry—and, in fact our whole culture—to catch up. McIntyre believes it will take a couple of decades to revolutionize our ailing health care system.

In the meantime, says Emory’s Weyand, we can take care of our telomeres.
“You can naturally replenish your telomeres, otherwise you’d run out of stem cells,” says Weyand, who believes that things as simple as diet, exercise and sleep can help, but that avoiding infections is crucial. “I remember my grandmother sending me out to be exposed to childhood infections,” she says, “but now we think that every infection the body has to deal with shortens the telomeres.”

By the time we’re 75, the body is under intense stress, she says. And that makes sense, since, in the past century alone, we Americans have doubled our typical lifespan. “Nature designed us to live to about 40 or 50 years old,” she says. “After that, we’re living on borrowed time.” SP

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