The Denial of Aging

  • Muriel R. Gillick
Harvard University Press: 2006. 328 pp. $25.95, £16.95, €24 0674021487 | ISBN: 0-674-02148-7

US citizens spend $6 billion a year on anti-ageing nostrums. This reflects a general failure in society to acknowledge the realities of old age, believes Muriel Gillick, associate professor of ambulatory care and prevention at Harvard Medical School. Americans, she asserts, squander resources on quackery and on futile but expensive treatments for people approaching the end of their lives, and risk not leaving enough money for more beneficial care.

In the first part of her book The Denial of Aging, Gillick systematically dissects various medical and social provisions for older people in the United States. By linking each critique to a telling case history, she shows how even the best intentions of bureaucrats and politicians fail through not being implemented as part of an informed and coherent sociomedical strategy. Some of the problems are familiar enough to Europeans, notably the impossibility of providing seamless care from budgets separated into 'social' and 'health' elements, with a range of providers all trying to cherry-pick the easy bits and play pass-the-parcel with the rest.

The central problem, however, is one of philosophy: what are we trying to do for older people, collectively and individually? Governments simply want them — or at least those who have not funded their own pensions — to go away. The recent flaccid response of the British government to a critique of UK research into ageing by the House of Lords Select Committee on Science and Technology could be interpreted as anxiety not to encourage anything that might lengthen the lives of the improvident.

Forever young? Rather than face up to old age, many US citizens try to delay it for as long as they can. Credit: D. LECORRE/ALAMY

British geriatric medicine has always concentrated on the quality of life, rather than its length, and older people in Britain are more worried by the prospect of 'being a burden' than of being dead. US medicine, by nature of its funding structure and the legal and social pressures under which it labours, is more than appropriately preoccupied with prolonging life at any cost. There is a gap in medical resources and philosophy between this frenzied use of high technology and the resigned fatalism of palliative care. Between the life-support machine and the morphine pump, there is a lot that can and should be done for ill older people, but appropriate prescription requires the setting of individualized goals and an individualized appraisal of quality of life. Wilful and determined older people can demand and obtain the care they need, but many are simply rolled through a system created by piecemeal legislation and the profit logic of privatized providers.

Quacks flourish, but Americans also look to real science to relieve them from the terror of senescence. In consequence, biological gerontology has been tainted by a Californian dream of indefinite longevity. Perhaps eternal life seems a better idea in California than it might in Brixton. But even if the Colorado River keeps flowing and the San Andreas fault holds together, it is an idea doomed by the second law of thermodynamics and is a dangerous distraction from more important issues. All developed countries face a new demography of increasing life expectancy and falling birth rates. What we should concentrate on is the prevention and prompt alleviation of disability so as to maximize the productivity of the ageing population and the self-sufficiency of individuals. This calls for a new collaboration between biological and medical gerontologists working towards common and explicit objectives. Postponing the onset of disabling disease and slowing the background loss of adaptability that makes pathogenic events more challenging may not necessarily increase life expectancy, but should increase disability-free life expectancy.

Rather than adjusting the institutions of society to a new trajectory of life, politicians are tempted by the plausibly easier option of demographic engineering. Gillick suggests that increasing the permeability of the Mexican border might alleviate a looming shortage of care workers in the United States. This may seem like a quick fix, but it would be damaging to Mexico and have little effect on longer-term demographic prospects for the United States. Immigrants grow old too, and their children will not be content to be cheap labour. Immigrant labour is even less of a good idea for areas where population density has outgrown both its water supply and its social tolerance, such as southeast England. Ageing populations in the West should create their own destiny, not prey on the underdeveloped world.

Gillick's book raises important issues in a lucid and accessible style. The reader cannot help feeling that the problems of ageing and longevity could be effectively dealt with by informed and intelligent political leadership. But if we had that, no one would have invaded Iraq.