AI transcript
0:00:04 You’re keeping people alive, you’re not keeping them healthy.
0:00:10 The view that medicine starts with disease is part of the problem because it should start with health.
0:00:16 One in five, one in six Brits are meant to live to 100 according to the government. How do you finance that?
0:00:19 Is your 401(k) set for you to live to 100?
0:00:25 People age really, really adversely and you can be 100 and literally run in 100 meters.
0:00:28 You can look at it on YouTube or you can be 50 and in a wheelchair.
0:00:34 And instead of this being a crisis, it could be the greatest accomplishment of humanity.
0:00:37 Let’s start this episode with a thought experiment.
0:00:41 What would you do if you knew you were going to die today?
0:00:45 And what would you do if it were impossible to die today?
0:00:54 I’d bet that separate from the outcomes that those days would look pretty different because probabilities guide our decisions.
0:00:57 And that is the premise of today’s conversation.
0:01:04 We as humans have extended the aging curve, meaning we are probabilistically living longer and a whole lot longer.
0:01:09 In 1965, the most common age of death was in the first year in the UK.
0:01:12 Now that’s flipped to 87.
0:01:16 And contrary to popular belief, we are still extending lifespan.
0:01:24 So what happens when the calculus is no longer avoiding dying young but perhaps striving to live extremely old?
0:01:26 Plus, what does a life worth?
0:01:33 And how does this impact our society, not just in the health system, but the financial sector, career planning, and even direct design?
0:01:39 Joining us to discuss exactly this are Dr. Andrew Scott, author of The Long Jeopardy Imperative,
0:01:46 a book published earlier this year alongside founding general partner of A16Z by Own Health, Vijay Ponte.
0:01:49 Let’s get to it.
0:01:55 As a reminder, the content here is for informational purposes only, should not be taken as legal, business, tax, or investment advice,
0:02:02 or be used to evaluate any investment or security, and is not directed at any investors or potential investors in any A16Z fund.
0:02:08 Please note that A16Z and its affiliates may also maintain investments in the companies discussed in this podcast.
0:02:14 For more details, including a link to our investments, please see a16z.com/disposures.
0:02:21 You could have named the book Many Things.
0:02:27 The longevity imperative is very specific and very telling, I think, of what message you’re trying to get across.
0:02:30 Let’s start there. Why use the term imperative?
0:02:37 Partly, I’m a macroeconomist and I think we’ve got to sort of face the challenges we have in the world ahead of us.
0:02:44 And this one just drops off the radar. We talk a lot about AI and climate change now we have to adapt and adjust.
0:02:52 But when it comes to this topic, we tend to talk about an aging society and we rarely get beyond talking about adult diapers and care homes.
0:02:55 So I wanted to just sort of elevate this topic right up there.
0:02:59 And the meaning of imperative is vital importance.
0:03:08 And actually, I think that’s got to double play too because it’s not just vitally important for society because we want to avoid a pensions crisis and a health crisis.
0:03:15 It’s vitally important for all of us because for the first time ever in human history, the young can expect to become the very old.
0:03:19 And so how we age is now an incredibly important thing.
0:03:35 Let’s quickly double click on that because you actually compare the criticality of longevity to things like let’s say AI or climate change, other areas or sectors where people widely address as really critical and widely impactful.
0:03:38 Why do you position it there relative to those other areas?
0:03:42 Because I think it’s right up there just as important.
0:03:45 We fear getting old. We fear outcry. Our skills are health.
0:03:51 And so that’s why there’s that longevity imperative. What are you going to do now to age well?
0:03:58 But aging is not a sexy word. I know no one who says, “Yeah, great. We got an aging society,” which is sort of strange.
0:04:04 It’s one of the greatest achievements of the 20th century to get global life expectancy above 70 phenomenal.
0:04:10 Fewer children to mourn, fewer parents snatched away in midlife, more grandparents meeting their grandchildren.
0:04:15 And we say, “Shit, we got an aging society.” I mean, it’s just a really weird way of framing it.
0:04:21 And so people switch off with aging, whereas when it comes to AI and climate change, it’s like, “Oh, this is really important.
0:04:27 If we don’t do this, we’re going to have a bad outcome. It’s going to be crucial for humanity, crucial for my individual future.”
0:04:31 And all of those statements hold for how you deal with your long life.
0:04:35 So that’s why it’s up there. And it’s not just, I think, me being obsessed with this topic.
0:04:41 I can give you very, very hard data about the welfare gains, but also the economic consequences.
0:04:47 If we don’t adapt the pensions crisis, the unsustainable health burden, it really is right up there.
0:04:53 I don’t think anyone really, other than people who’ve looked at the economics, understand the impact this is having on us,
0:05:00 not just as individuals, but as a country and the amount of debt, the amount of expense that comes along with our current healthcare system,
0:05:05 especially which is exacerbated with age. It’s a very hidden, insidious problem.
0:05:08 And so I think imperative is spot on.
0:05:15 Absolutely. And I’d love to dive into how we do need to refashion our economic system, our tax system,
0:05:18 the way that people think about their careers, because you talk about all of that, Andrew.
0:05:25 But before we get to that, let’s maybe take stock of how lifespan and then also health span have changed,
0:05:31 since those are not the same thing. Ground us in how things have changed, maybe over the last 100 years or so.
0:05:38 Yeah. So if you look at the sort of high income countries, the last 100 years, life expectancy has increased about two or three years every decade,
0:05:45 and in lower income countries, even faster. And so global life expectancy is now over 73.
0:05:51 I think it’s worth just pausing at that point. Global life expectancy is over 73.
0:05:56 Around the world, a child born today can now expect to live into an eighth decade.
0:06:04 And actually, that’s based upon no further change. So it’s probably a greater number than that because life expectancy is increasing in many countries.
0:06:11 In high income countries like the UK, the UK government says that 50% of children born today will live to be about 91.
0:06:18 That’s extraordinary. And I start my book with a somewhat dramatic statistic, which is not about average life expectancy,
0:06:27 but what is the most common age of death? And when I was writing the book, I wanted to sort of make it personal and illustrate these demographic trends with my own family.
0:06:33 And I discovered my own family was stunningly average. They hit nearly every single demographic trend completely.
0:06:39 But the most striking one was that when I was born, the most common age of death was children under one in the UK.
0:06:46 And I was a twin and my twin died in the first few days of life. So I thought that was quite rare, but that was the most common age of death.
0:06:51 And today, the most common age of death, I think it’s 87, 88, something like that.
0:06:52 Yeah.
0:06:59 In my lifetime, the modal age of death has shifted. I mean, it’s complicated life expectancy that’s average, mean and median.
0:07:06 But wow, Sam Beckett, the Irish playwright, says we give birth to stride the grave, the light flickers instant, and then it goes out.
0:07:10 Well, the light’s flickering a lot longer now, and that’s what we’ve got to prepare for.
0:07:15 Yeah. I mean, you shared so many interesting statistics. I’ll just share one more. That surprised me.
0:07:26 Based on 2020 data, you said that a newborn girl in Japan has a 99.6% chance of living to 20 and 99% chance of reaching 40 and a 96% chance of making it to 60.
0:07:36 I mean, those are just astounding numbers, which to your point, we’re not millennia away from those statistics, like just the opposite of those a few decades ago.
0:07:40 You said in 1965, we were looking at completely different numbers.
0:07:49 And what’s sort of happening is that there’s a concept of the survival rate, the probability of a newborn reaching a certain age, and it’s sort of rectangularizing.
0:07:56 As you just said, the chances of a child, a female in Japan reaching 60 is now incredibly high now.
0:07:59 And now the chance of getting 70 is getting higher and higher and higher.
0:08:04 So that’s the real sort of shift. We’ve lowered infant mortality dramatically.
0:08:09 We’ve made big steps in improving midlife mortality, although the US has got some problems there of late.
0:08:13 And so, of course, now all the gains are coming at older ages.
0:08:24 And so life expectancy is now being driven by falls in mortality at older ages such that 80% of life expectancy gains in the richer countries is coming from mortality rates coming down after 70.
0:08:28 So it’s just getting further and further along this rectangularization.
0:08:30 Absolutely. And Vijay, I’d love to bring you in here.
0:08:37 As you look at both the bio and health side of things, what gives you confidence that this trend might continue?
0:08:42 Yeah, I think there’s a lot of excitement about studying the biology of aging for a variety of reasons.
0:08:48 I mean, first off, it’s actually kind of shocking how poorly it has been studied and how little time has gone into it.
0:08:59 But the other thing that maybe is at the heart of aging and disease is the fact that many diseases are exacerbated with age, like cancer, Alzheimer’s, type 2 diabetes.
0:09:09 And so given that there may actually be some common precursors that are interesting to go after, either from a therapeutic point of view, but obviously also from a lifestyle point of view.
0:09:14 Even simple things like we know being overweight is a massive co-morbidity for any of those things.
0:09:24 And so part of the challenge will be as a society what we want to handle through the traditional health care model, which is basically a sick care model dealing with disease.
0:09:31 Or what can we do more broadly to actually get to longevity and never sort of engage with the medical model in that way?
0:09:33 Yeah. And of course, you said it’s that through your whole life.
0:09:38 I think for me, that’s why I stress the longevity society, not an aging society.
0:09:41 An aging society says, what do we do with all these old people?
0:09:44 Whereas the real change is the young can expect to become old.
0:09:52 When you’ve only got a 10% chance of making it to 90, you really shouldn’t say think in your 430s and 40s, what can I do now to make sure I’m healthy in my 90s.
0:09:56 But when there’s a 50% chance of making it, my goodness, you’ve got to start doing it.
0:10:02 And we have this diseased focus model, which just doesn’t work as we get older.
0:10:06 Because as VJ says, chronic diseases have this common source.
0:10:08 And I think that’s really interesting.
0:10:11 What is the X that affects all these later diseases?
0:10:13 And it could be aging.
0:10:15 It could be obesity and GLB1.
0:10:17 It could be through exercise.
0:10:21 And of course, that focuses on a really key issue, which is health.
0:10:26 It just strikes me as stunning that we don’t just say, how do we maintain health?
0:10:28 We say, oh, how do we prevent disease?
0:10:31 It just shows you the orientation of the system.
0:10:38 And there’s a quote by W.A. Jordan, which I use in the book, which is sort of health is the concept that the medicine knows nothing about.
0:10:43 And I said this the other day to a cardiologist, he said, no, health is just an incomplete diagnosis.
0:10:46 Something happens and then I’m in, but it is quite striking.
0:10:48 Can we speak to that really quickly?
0:10:54 Because something that you and many others have pointed out recently is this trend toward specialization in health care.
0:10:59 And at face value, someone who’s not involved in this world, actually, that sounds pretty great, right?
0:11:07 The fact that for anything that I run into, there’s going to be some specialist who studied this much longer than the average doctor who can solve my problem.
0:11:13 And so just as we’re kind of addressing the state of affairs, can you speak to that specific trend in specialization?
0:11:21 Now, maybe it’s not as compelling as you might think if we’re trying to achieve this idea of longevity.
0:11:23 There’s always a case you made for everything.
0:11:25 I don’t want to sort of criticize specialization.
0:11:34 I think when we come to drug development, we can say that there’s some challenges there because we are seeing a lot of drugs being developed for very serious specific conditions where you can charge a lot,
0:11:37 but you only affect a small number of people.
0:11:39 Brilliant that you affect those people.
0:11:42 But what about the cross-cutting breakthroughs that we really need?
0:11:45 But no, I think it’s a consequence of this sort of disease specialization.
0:11:58 And in particular, as you start to have an older population, I think the real problem of specialization is you’d be spending one morning with a cancer specialist, one morning with a cardiovascular specialist, one with a diabetic clinic.
0:12:00 So you’re going to get massive polypharmacy.
0:12:07 So you have multiple description of drugs where you’ve got no idea how they interact because we haven’t got clinical trials to try and prove it.
0:12:14 And then I think the other challenge we’ve got is that the trouble as you get older is you get all these aging-related diseases.
0:12:18 And fantastic if you can reduce the risk of cancer.
0:12:19 That’s tremendous.
0:12:22 But you’ve still got dementia out there.
0:12:26 You’ve still got diabetes and cardiovascular, all of which will lower the quality of your life.
0:12:36 So if you could do something early that affected multiple diseases, the whole is greater than the sum of its parts, which specialization is not going to give you.
0:12:48 I think Andrew hinted in that the view that medicine starts with disease is part of the problem because it should start with health and to maintain health rather than to fix disease.
0:12:52 Like we all don’t want our houses to be on fire, so we have smoke alarms.
0:12:57 And if we wait until the house is on fire, that’s both unfortunate and also there’s only so much you can do.
0:13:02 In some ways, we ask a lot from acute care and they can do miraculous things.
0:13:09 It’s kind of amazing, but it would be a lot healthier, but also a lot cheaper to be able to address these issues early.
0:13:13 But that has its own challenges and part of it is just not the way the system is built to work.
0:13:20 I think that is the problem because what you’ve got then is you’re keeping people alive, you’re not keeping them healthy.
0:13:21 And that’s the real challenging.
0:13:25 We’re spectacularly successful in keeping people alive.
0:13:31 But as we’re going beyond 70 into 80s and 90s, we slow down the dying process, but not the aging process.
0:13:39 And that’s been a problem because you’re going to spend ever more money on sensible things, but you’re getting not better health outcomes.
0:13:45 In as an economist, there’s various tools where you can put dollar values on health gains and you can add those to GDP and say,
0:13:47 “Look, here are the welfare gains we’ve got.”
0:13:54 And suddenly over the last decade, you’ve seen a really big slowdown in the rich countries in terms of the health benefits they’re getting.
0:13:57 But health expenditure is still rising.
0:13:59 And they’re called new assets.
0:14:03 The health outcomes have been spectacularly bad compared to other countries.
0:14:10 This is a good point to really double click on the fact that I think a lot of people don’t realize the societal impact of just that spend.
0:14:19 There’s been a lot of talk we’re in an election year about inequality between middle class and upper class that a lot of middle class gains and wages have been zero.
0:14:20 They’ve been flat.
0:14:25 But actually, if healthcare could have been kept at the same cost, let’s say 30 years ago,
0:14:27 then the middle class would have seen huge gains.
0:14:31 Basically, healthcare and its rising costs is eating up these gains.
0:14:34 And so it’s not just about keeping us healthy, which would be great.
0:14:37 It’s about the health of the nation and the health of the economy.
0:14:39 So it has really broad reaching impacts.
0:14:40 It does.
0:14:47 And there’s also another link as well, which is something I’m particularly keen on at the moment, which is making a broader case of prevention,
0:14:52 which is that if you could stop people in their 50s having heart attacks, they can carry on working.
0:14:56 And that then generates huge benefits in GDP and taxes and benefits.
0:15:00 And this, of course, is the key thing because you’ve got more and more older people.
0:15:04 If you want to make them work for longer, you’ve got to keep them healthier and productive for longer.
0:15:08 You can’t just say, “Hey, I’ve raised the social security age. Good luck.”
0:15:14 So if we think about these incentives and how these healthcare systems really need to think about where they allocate their resources,
0:15:22 it really is a very multivariate equation. And I’d love for you to break down how these systems actually do decide where to invest.
0:15:29 I know there’s different metrics, whether it’s VSL or Qualey Quality Adjusted Life Year that different groups use.
0:15:35 But then in addition to that, I just wanted to call out one other metric from your book, which is about this idea of action versus prevention.
0:15:43 In 2020, total U.S. healthcare expenditure was $4.1 trillion, which is around $12.5,000 per person.
0:15:48 But of that, only around $363 was spent on prevention.
0:15:52 So I think that really highlights exactly what both of you just spoke to,
0:15:59 which is the idea that we’re not investing in prevention at least compared to the action when something goes wrong.
0:16:03 So could you just speak to how these healthcare systems choose to divvy up the resources?
0:16:07 So what’s interesting globally, we’ve got the same problem. We’ve got a pensions problem and a health problem.
0:16:12 And then of course, if you look within the details of the pension and health system in every country, it’s wildly different.
0:16:22 They’re all going wrong in different ways, but in a lot of them, basically, broadly speaking, the Ministry of Finance hand over a check to the Ministry of Health.
0:16:29 The Ministry of Health’s got that stock of money, it has to decide how to allocate it. And it will look at some health measures.
0:16:39 Again, it varies in my country, the UK, one of the big targets is waiting list for operations, which is just a crazy metric because I can’t really think how that links into health measures very well.
0:16:46 But that’s a big measure. But there’s also this medical concept of a quality, which is a quality adjusted life year.
0:16:58 And so if you have a treatment that saves a child’s life and they can live to 80, you’ve saved 80 years, but you quality adjust the years for the sort of level of health that you get.
0:17:07 And so broadly speaking, you calculate that and then you set a price for every quality in the UK, it’s around £30,000, so it’s about $40,000.
0:17:14 And say, if this treatment comes in less than that price, it’s worth it. If it’s not, don’t do it.
0:17:20 In the US, the budgets are much bigger and it’s more of a commercial decision, I would say, that happens.
0:17:24 And of course, that’s that question of how much you can pass on to the insurer.
0:17:28 But there’s all sort of value based pricing in that as well.
0:17:37 Most of the measures are all very internal to the health system. I think that’s a, for me, a really big issue because with budgets under constraint,
0:17:43 take the UK where the health system actually, they spend a lot more money, but they’re not getting better outcomes.
0:17:47 You’ve got more and more older people who need operations, need the help replacement, etc.
0:17:50 And you can’t say to them, no, I’m not going to do it.
0:17:56 So you haven’t got the money to finance prevention and you’re just stuck forever doing hit replacement operations.
0:18:01 So the case for prevention at the moment is sort of made, will it save me money within the health system?
0:18:05 If I spend this now, will it reduce my operating costs now?
0:18:10 And the problem with that is prevention tends to take a bit of time to come through.
0:18:19 The other problem you’ve got in the US health system is that with multiple health providers, one person’s expenditure could be someone else’s benefit rather than them.
0:18:26 In the UK, it’s a lot easier because we have one health system, the Ministry of Finance pays for everything so they can see the savings.
0:18:34 But this is why I’m very keen to sort of say, oh, hold on a minute, though, there’s another game to prevention, which is these spillover benefits.
0:18:41 In the UK, and I’m sure it’s similar in the US, if you’re 15, you have a heart attack, you’re six times more likely to leave the labor market.
0:18:44 And once you’re out the labor market, it’s very hard to get back in again.
0:18:51 So if you can stop that person leaving, you’ve got this knock-on effect in terms of income, GDP and revenue.
0:18:53 And that’s not currently taking into account.
0:19:01 Very little time is discussed on prevention, nutrition, and also those fields are complex and highly debated.
0:19:04 So there’s the education part, which I think there’s huge room for improvement.
0:19:08 But then, at least in the US, the big question is who’s going to pay for it?
0:19:18 And with existing payers, they unfortunately have to deal with a reality where people may switch payers every two or three years, and prevention is a long-term game.
0:19:26 There’s a big push for value-based care, and I think there’s new models for that and exciting things happening, especially in areas like Medicare Advantage.
0:19:36 But in the end, I think what we’re going to see is high deductible plans and choices like ICRA that will allow actually consumers to be the ultimate payer.
0:19:43 And in the end, we kind of are the ultimate payer in dollars, and we are obviously the ultimate payer in healthcare results.
0:19:45 And so we care about value.
0:19:50 I care about my children’s health and my wife’s health and so on in a way that no insurance company would.
0:19:57 And I think that shift for who’s going to pay and me choosing how my dollars are spent could also facilitate more prevention.
0:20:04 And it’s a really interesting point too, because of course, once you move away from the disease model, the health system and now everything, it’s the air that you breathe.
0:20:07 It’s the British state that you live in. It’s the food that you buy.
0:20:10 And I think you’re going to see it go retail in a very big way.
0:20:13 Of course, not everyone is going to spend and invest in health.
0:20:16 But I do think that’s the logical consequence of prevention.
0:20:23 If the health providers won’t provide it sufficiently, other people will, whether that be wearable devices or whatever.
0:20:26 So I think the health economy just starts to get even bigger.
0:20:32 And I think something that a lot of people don’t realize is that if you look at the determinants of health and especially mortality,
0:20:35 genetics is a large part, it’s like 30 or 40 percent.
0:20:38 All of medicine is basically 10 percent.
0:20:42 And then a large fraction like 40 percent is social determinants.
0:20:44 So if your spouse smokes, guess what?
0:20:49 You’ll either be smoking or you’ll have secondhand smoke where your zip code predicts your health to a large degree.
0:20:54 Those social determinants are a huge part and addressing that should be part of health care.
0:21:01 But right now, the health care really is that 10 percent of providing disease focused care and you’re missing that 40 percent.
0:21:02 I completely agree.
0:21:04 I mean, the socioeconomic determinants are huge.
0:21:07 So behavior and environment explain the majority.
0:21:11 But one thing that’s interesting is people kind of resistant to the idea that aging is malleable.
0:21:15 But you just look at inequality and you say, well, we found a way to speed up aging.
0:21:21 These socioeconomic determinants, so it’s proof positive that we can really affect how we age.
0:21:24 And it somehow just doesn’t get into the consciousness.
0:21:29 Yeah. And I think examples that you gave in the book are that on a very small scale,
0:21:35 you are seeing some insurance companies incentivize people who exercise or have healthy habits or get discounts on healthy food.
0:21:38 I’m surprised we’re not seeing that more candidly.
0:21:46 But maybe this is a good transition for us to talk about social implications and the major parts of society that do need to be restructured.
0:21:49 As some of this is somewhat inevitable, right?
0:21:54 There’s things like the health system, the financial sector, taxes and career planning, drug design.
0:22:01 Yeah. And let me just reiterate the very simple idea of the book, which is for the first time ever, you can now expect to become old.
0:22:04 So you’ve got to make sure that you’re healthy and engaged for longer.
0:22:06 You’ve got to invest more in your human capital.
0:22:10 And of course, if you don’t invest in your future, then actually your future isn’t very good.
0:22:13 You run out of money, you run out of skills, you run out of purpose, you run out of health.
0:22:21 But we had never set up our institutions to say, how does Andrew live a life to his 90 that remains healthy and engaged?
0:22:26 So nothing is sort of untouched, including culture and psychology.
0:22:27 But where are the main things?
0:22:29 Well, obviously the health system is huge.
0:22:35 I mean, a shift to a focus on delivering health rather than treating disease.
0:22:37 Work clearly has to change.
0:22:45 And in an early book, The Hundred Year Life, I sort of talked about how we created a three-stage life in the 20th century of education, work, retirement.
0:22:50 But if you just stretch that out to 90, it looks pretty unappealing, pretty miserable.
0:22:55 And I think for me, the very simple notion here is longevity is about having more time.
0:22:58 So the question is, what do you want to do with that time?
0:23:01 And how do you in particular distribute leisure across your life?
0:23:07 And in the 20th century, we fixed retirement age, lived for longer and just took more and more leisure at the end of life.
0:23:09 Governments around the world are saying, no, that doesn’t stack up.
0:23:11 You’re going to have to work for longer.
0:23:16 So I think we may take less leisure at the end of life, but we’ll spread more leisure across life.
0:23:18 We might start work later.
0:23:20 We might take mid-career breaks.
0:23:24 Your last job might be part-time or you might go part-time sometime in the middle.
0:23:30 But your career is going to have, I think, a lot more transition, some chosen by you, some forced upon you.
0:23:34 And that, I think, has big implications for all sorts of different people.
0:23:39 So if you’re a manual worker age 50, you can’t carry on working in a physical job.
0:23:42 How do you transition into something different?
0:23:48 If you’re an investment banker working all those hours, you can’t carry on doing this beyond the age of 45, 50.
0:23:51 Do you take a break, retrain and do something?
0:23:55 And wrapped into this is education, identity, so many things.
0:24:03 But finance comes into it as well because the simple pension industry says, accumulate money while you’re working, run it down when you retire.
0:24:09 But if you’ve got this sort of multi-stage life, accumulation to accumulation becomes much more complicated.
0:24:12 So I think finance has to probably do three things.
0:24:17 One is do long-run saving products that have a much more flexible pattern.
0:24:20 Totally tie financing into health.
0:24:29 And then the other big challenge is that, you know, in the 19th, 20th century, we developed a life insurance industry that paid out if you died young.
0:24:34 But sort of the risk now is not that you die at the average, but most people die above the average.
0:24:41 And there’s now a small chance of going above 100, one in five, one in six Brits, and then to live to 100 according to the government.
0:24:43 How do you finance that?
0:24:52 So that living insurance, how do I provide you a steady stream of income in case you sort of live a really long life is a huge financial one?
0:25:01 Yeah, I think there’s a crisis also that those who have anticipated see it, but I don’t think everyday people think about it this way, which is the shift at least in the United States from pensions,
0:25:06 which have defined payouts to 401ks, which have defined contributions.
0:25:13 That in the context of living to 90 and maybe in time to 100, is your 401k set for you to live to 100?
0:25:15 Is it built that way?
0:25:17 And so what does that mean for when you stop working?
0:25:23 And can you have a health span long enough so you can build a 401k so you can pay for your lifespan?
0:25:26 All these things are things that are going to be fundamental to us.
0:25:29 And by the time we’re there, it’s too late to make changes.
0:25:31 Yeah, and it’s a really complicated problem isn’t it?
0:25:33 You think how long will I be able to work for?
0:25:35 How long will I live for?
0:25:38 How much money do I need my retire and what’s the rate of return going to be?
0:25:41 Those answers are going to differ wildly for different people.
0:25:43 It’s impossible to be precise about them.
0:25:47 So whatever plan you’ve got, you’ve got to have some flexibility in it.
0:25:53 And the key flexibility is investing in your human capital, investing in your health and your skills.
0:25:57 So if suddenly you find you haven’t got enough money, you can carry on working for longer.
0:26:01 But if you haven’t got the skills and haven’t got the health, then you’ve got a really big financial problem.
0:26:03 So I think that’s the other thing about longevity.
0:26:07 The portfolio suddenly becomes not just my 401k.
0:26:09 It is my health and my skills.
0:26:13 And integrating those together is really important.
0:26:18 And I think something you’re calling out is just how this dynamic has completely flipped on its head, right?
0:26:21 Before it was, how do I avoid dying early?
0:26:24 And now it’s, what do I do if I live too long?
0:26:26 That is a really interesting phenomena.
0:26:30 But to your point, the statistics back it up in terms of your probability.
0:26:33 And we do make decisions as humans based on probability.
0:26:38 Maybe on that end of the people who maybe might say, you know what?
0:26:43 I don’t know if I want to live forever or living to 100 doesn’t actually sound so great.
0:26:50 You mentioned pretty repetitively throughout your book this bias that people seem to have around aging and the aging population,
0:26:59 both on a personal level, but then on the societal level of requiring the support of many others who have not sustained their health span.
0:27:04 So can you just speak to this further and talk about how maybe we need to update our priors based on these shifts?
0:27:07 There are definitely some cultural differences here.
0:27:13 China and the U.S. is a one end of the spectrum, but in general, we underestimate the capacity of older people.
0:27:14 That’s ageism.
0:27:18 And the trouble with that is it means we underestimate the capacity of our own later life.
0:27:20 And I enjoy telling a story.
0:27:26 I was teaching some Chinese MBA students this summer and I was showing them the Chinese demographic data.
0:27:29 These students are late 20s, early 30s.
0:27:32 And China’s demographic changes is truly striking.
0:27:38 It’s going from 1.4 billion people to 1 billion, 45% in the movie more than age 65.
0:27:44 So I was sort of showing the data and showing how in 35 years time there’s all these people aged over 65.
0:27:47 And I said to these Chinese MBA students, how do you feel about it?
0:27:48 And they said, it’s a problem.
0:27:49 I said, why?
0:27:52 They said, but there’s all these old people, they’re going to get ill, they need a pension.
0:27:54 And I said, well, who are these old people?
0:27:56 And they said, what do you mean they’re old people?
0:27:57 I said, no, they’re you.
0:28:01 And it was remarkable how the penny dropped like, oh my goodness.
0:28:05 When everyone hears about an aging society with old people, that’s not about me.
0:28:06 I’m going to be fine.
0:28:07 I’m going to be fit and healthy.
0:28:10 And it was quite remarkable how we’re negative about old people.
0:28:14 And we don’t recognize that the big changes the young can expect to become the old.
0:28:18 I think there’s all sorts of reasons for that about why we have that negativity.
0:28:23 But it’s a fundamental problem because you underestimate the capacity of your own later years.
0:28:24 You will under invest in them.
0:28:28 And so you lead to the very sort of outcomes that you fear.
0:28:32 And then there’s just all the sort of problems of ageism that comes with any form ofism,
0:28:37 which is that if you assume that on the basis of a characteristic age, this is what you’re like,
0:28:41 then you’ve got a problem because actually the real thing about aging is diversity.
0:28:43 People age really, really diversely.
0:28:46 And you can be a hundred and literally running the hundred meters.
0:28:50 You can look at it on YouTube or you can be 50 and in a wheelchair.
0:28:54 And I think society has become very focused on chronological age.
0:29:01 I think it’s really interesting in England in 1601, we introduced the Elizabethan poor laws.
0:29:04 And it was look after the poor and the old.
0:29:06 But no one knew how old people were.
0:29:08 There weren’t birth certificates.
0:29:10 There wasn’t much numeracy.
0:29:14 So until very recently, people didn’t know when they were born or how old they were.
0:29:18 The song “Happy Birthday” comes in the 1930s, just kind of.
0:29:25 So what the poor laws said was, okay, old is someone who’s lived a long time and can’t look after themselves.
0:29:28 So the whole test was about, could you be functional?
0:29:30 Then bureaucracy comes along.
0:29:32 So this is a nightmare, this test.
0:29:34 Let’s just say everyone over 65 is old.
0:29:36 And that’s what we do today.
0:29:38 We say everyone over 65 is old.
0:29:43 But of course, the problem that chronological measure of age is measures how long you’ve lived.
0:29:46 And for me, there’s two much more important measures.
0:29:49 One is how many more years you can expect to live.
0:29:50 I’m 59.
0:29:56 And at 59, I have to behave differently from my father and my grandfather at 59 because I can expect more years.
0:30:02 And then of course, the other thing is my biological age, sort of how is my body aging and how am I dealing with it.
0:30:08 And of course, if you have that approach, you start to think, well, actually being 59 doesn’t really tell me much about Andrew.
0:30:11 It’s not that important a piece of information.
0:30:16 But we zoom in on chronological age, we assume everyone over 65 is old.
0:30:19 That is an enormous problem for firms, for instance.
0:30:24 Because whenever I sort of see a presentation of the aging society store and a consultant comes on,
0:30:28 I know immediately they’re going to say, hey, we should invest in care homes and cruise ships.
0:30:33 Because everyone over 65 is going to want a cruise ship or go to a care home.
0:30:36 And you lost the market completely, if that’s the way you think.
0:30:44 Yeah, I was just right before this actually watching a video of Robert Marchand, the French 105 year old cyclist.
0:30:50 He unfortunately passed away at 109, but at 105 he was still cycling, still beating centenarian records.
0:30:56 And so to your point, age very much isn’t a metric, but there are many others to pay attention to.
0:31:04 And so I feel like a lot of listeners at this point are convinced that maybe longevity is more complex and important than I realized prior.
0:31:08 And so on a personal level, they’re probably asking, OK, so what should I do?
0:31:13 Because I can impact this. Maybe starting out there, how would you both think about the 80/20?
0:31:17 The big problem is both when we talk about diet and exercise.
0:31:23 I think the first misconception is that there is a right diet for everybody and a right exercise plan.
0:31:31 And this is so individualized that we’ve seen now lots of companies crop up to try to measure things that will allow you to know what the right diet is for you.
0:31:35 And so it starts with diet and exercise, but I think that’s a lot easier said than done.
0:31:38 It’s really trying to figure out what is important for you.
0:31:45 But from there, I think there are intriguing things on the horizon that are maybe probably more a little bleeding edge.
0:31:48 People take metformin, people take other supplements.
0:31:52 I put that in the 20 or the 5%. I wouldn’t start with that at all.
0:32:01 I think if you’ve optimized your diet and you’ve optimized your exercise and you’re still getting PRs in your 50s of either weights or cardio or whatever,
0:32:07 and you want to go that last bit, that’s one thing, but I think there’s a lot of low-lying fruit, especially for people who are fairly sedentary.
0:32:15 I’m not a medical doctor. I don’t take anything as not prescribed and proven simply because I can’t monitor my own health to know if it’s working.
0:32:20 I was saying this the other day, someone takes lots of supplements and they were shocked and said, “We’ll miss you, Andrew.”
0:32:24 I don’t take any of that and I agree there’s exciting stuff coming along.
0:32:28 It’s always a disappointing thing because people always want the easy answer and there are some easy answers.
0:32:32 It’s exercise, diet, sleep, enjoyment, good company.
0:32:40 At the moment, I would broadly say, although there’s some latest evidence about high-intensity exercise and this way of sleeping, et cetera, and fasting,
0:32:45 broadly speaking, we know what works, what’s changed is our incentive to do it.
0:32:51 I think that’s the message that you’ve got to draw home, not that there’s some secret technique that’s going to change everything.
0:32:57 We have done brilliantly inventing and innovating intervention techniques.
0:33:02 We’ve now got to put the same thing on to prevention and data is going to be really important.
0:33:07 Then I think we’ll start seeing some more personalized medicine coming along.
0:33:14 None of that is going to happen quickly, so we’re left with the stuff that really does make a big difference.
0:33:24 If you look at the evidence on particularly healthy life expectancy, you’re talking about another year or two for each of the things you do in terms of weight exercise, that stacks up quite a lot.
0:33:34 I’ve seen myself and others, it’s not overnight, but you can see gains in the first year and then they compound and then it’s about keeping it going.
0:33:39 I think the maintaining is the hardest part to avoid injury and to build that discipline.
0:33:42 We could also talk a little bit about the sci-fi stuff.
0:33:53 Beyond the 80/20, this is like the 99.9 to 0.1, but the sci-fi stuff is that there are just amazing new discoveries in biology of cells and even organisms.
0:34:00 The so-called Yamanaka factors and many people are searching for what really could be a fountain of youth.
0:34:04 That is way off and I don’t think you’re going to be taking a pill like that anytime soon.
0:34:12 But intermediate things, there’s new pathways that are corresponding to pathways of exercise and there’s drugs in phase two for that.
0:34:18 Even the GOP ones and there’s pros and cons of them may help you get started if you’re obese.
0:34:24 It’s about the coming up with a plan where this is not going to be a fad diet, this is going to be the rest of your life.
0:34:32 The GOP ones are really interesting and I think we’ve still got some way to go to work out exactly what they’re doing.
0:34:39 But what is so interesting is first of all, it looks like it gets people a sense of agency and control so they can do other things.
0:34:41 So it has benefit mental health.
0:34:49 It’s affecting multiple diseases. It’s a bit like one of those biomarkers and some of the effects seem to happen outside of an effect on obesity,
0:34:55 which of course is exactly the sort of thing that we need to have because the body is very complicated.
0:35:00 Aging is not just one process and so there’s unlike to be just one pill we take that does everything.
0:35:06 But I give the analogy with interest rates and the economy, the government changes interest rates to try and control the economy.
0:35:09 It’s not perfect, but it has a pretty big impact.
0:35:14 And so what’s the equivalent and I think that’s a really interesting example of the GOP one.
0:35:16 And then as you say, I think it’ll be lots of other stuff.
0:35:21 I’m particularly taken by stem cells, which you can then just regrow a liver and that’s pretty sci-fi about that.
0:35:27 I think it’s sort of pretty feasible to happen or drugs that treat arthritis. Wouldn’t that be wonderful?
0:35:35 So I think that’s the sort of beginnings of aging better rather than here’s something that’s going to keep us alive to 150.
0:35:44 Yeah, if I’m taking anything away from both of you, it’s just that maybe we are at this interesting juncture where it really pays to think about this.
0:35:54 And I know that sounds really simplistic, but if we take your example, Andrew, of your kind of family tree, that longevity that happened decade over decade was a little bit passive.
0:35:59 It wasn’t passive in terms of there was millions, if not billions of people working toward those longevity gains.
0:36:06 But your father or your grandfather weren’t necessarily thinking, “Let me go test my VO2 max. Let me eat certain things.”
0:36:12 But now we do have more information than ever, especially in, as you said, Vijay, that 80%, right?
0:36:15 We’re not even talking about the sci-fi stuff here.
0:36:19 So there are very clear things that people have agency over.
0:36:28 Are there any other second, third order effects of this “long-jevity revolution” that you don’t think we’ve necessarily touched on yet that really people should be thinking about?
0:36:31 For example, one that you mentioned in your book, Andrew, was menopause.
0:36:39 There’s something that a lot of people don’t think about, but the health impact to 50% of humans is pretty substantial.
0:36:47 Menopause is very interesting because of course there’s a huge impact on women’s later life and women tend to live for longer, but get into ill health before men.
0:36:51 And so successful menopause is really important for later future health.
0:36:56 And it’s an accelerated form of aging and it’s quite rare in the amongst animals.
0:36:58 So humans are quite unusual in having a menopause.
0:37:05 And of course, men’s reproductive ability declines in a general form of age, but women’s doesn’t.
0:37:07 So I think that’s a really interesting area.
0:37:16 And our role models about how we live and what is old and what isn’t old have been formed from centuries and millennia and they radically need to change.
0:37:26 And then the other thing I think it’s important to stress is that we talk about it being more old people, but in many countries, the U.S. as an example used to have a pyramid that was lots of people at the bottom.
0:37:28 Now it’s more like a straight tower.
0:37:30 And so you’ve got age equality.
0:37:36 And because of that intergenerational connectivity becomes incredibly important.
0:37:44 And we design our institutions around a hierarchy, but we’ve got to get much better at that intergenerational mixing.
0:37:48 How do you stop a hierarchy blocking progress for the young?
0:37:52 How do you generally learn from one another and exploit that?
0:37:54 That’s going to be incredibly important.
0:37:57 There’s a virtuous cycle and a vicious cycle.
0:38:02 The vicious cycle is what we’ve been talking about where people are not paying attention to their health.
0:38:08 They can’t work, but they live long enough that they’re very expensive and not contributing to GDP.
0:38:12 The virtuous cycle is where people can maintain health span.
0:38:16 They can continue to work, continue to contribute to their 401(k).
0:38:28 And instead of this being a crisis, it could be the greatest accomplishment of humanity to allow people in their 60s and 70s and 80s to have massive contributions like we’d only expect from people who are younger.
0:38:30 That was an amazing future.
0:38:32 And theoretically, we have all the elements.
0:38:34 We just have to choose to do it.
0:38:36 And it’s sort of mobilizing people to this problem.
0:38:38 I think is the imperative.
0:38:46 If you think about it, the FDA was started before we even had access to penicillin or modern-day antibiotics.
0:38:55 Which I think kind of just speaks to the idea that these institutions, while they do many good things, are really, at least to some extent, a relic of the past.
0:38:58 But that’s exciting because there are clear wins.
0:39:09 Yeah, I often quote Malthus because, of course, Malthus, back in 1799 or whatever, comes up with this very miserable thesis that says populations grow exponentially, our resources grow linearly.
0:39:14 We’ve got too many people and we’re always going to have problems of illness, disease, famine, etc.
0:39:18 And that negativity is sort of shared with the aging society story.
0:39:20 The aging society story doesn’t say we’ve got too many people.
0:39:22 It says we’re just living too long.
0:39:24 We’re out living our religious support this life.
0:39:27 So we’re going to get ill and we’re going to have a pensions crisis.
0:39:31 So it’s interesting to go back and Malthus’ writing on the world population was not even one billion.
0:39:33 Now it’s over eight.
0:39:40 And what Malthus got wrong is he didn’t see innovation, invention, ingenuity, and new institutions that would come with industrial revolution.
0:39:42 And they increased productivity.
0:39:46 We’d invest in health and education, which further increased the quality of life.
0:39:49 And I think that’s a metaphor for this aging society story.
0:39:50 Where’s the invention?
0:39:51 Where’s the ingenuity?
0:39:52 Where’s the innovation?
0:39:54 Where’s the new institutions?
0:39:57 Because we can make this long life healthier and more productive.
0:39:59 We just go start doing it.
0:40:01 All right.
0:40:02 That is all for today.
0:40:05 If you did make it this far, first of all, thank you.
0:40:13 We put a lot of thought into each of these episodes, whether it’s guests, the calendar touchers, the cycles with our amazing editor, Tommy, until the music is just right.
0:40:19 So if you’d like what we put together, consider dropping us a line at ratethespodcast.com/a16z.
0:40:22 And let us know what your favorite episode is.
0:40:23 It’ll make my day.
0:40:25 And I’m sure Tommy’s too.
0:40:27 We’ll catch you on the flip side.
0:40:29 (upbeat music)
0:40:39 [BLANK_AUDIO]
0:00:10 The view that medicine starts with disease is part of the problem because it should start with health.
0:00:16 One in five, one in six Brits are meant to live to 100 according to the government. How do you finance that?
0:00:19 Is your 401(k) set for you to live to 100?
0:00:25 People age really, really adversely and you can be 100 and literally run in 100 meters.
0:00:28 You can look at it on YouTube or you can be 50 and in a wheelchair.
0:00:34 And instead of this being a crisis, it could be the greatest accomplishment of humanity.
0:00:37 Let’s start this episode with a thought experiment.
0:00:41 What would you do if you knew you were going to die today?
0:00:45 And what would you do if it were impossible to die today?
0:00:54 I’d bet that separate from the outcomes that those days would look pretty different because probabilities guide our decisions.
0:00:57 And that is the premise of today’s conversation.
0:01:04 We as humans have extended the aging curve, meaning we are probabilistically living longer and a whole lot longer.
0:01:09 In 1965, the most common age of death was in the first year in the UK.
0:01:12 Now that’s flipped to 87.
0:01:16 And contrary to popular belief, we are still extending lifespan.
0:01:24 So what happens when the calculus is no longer avoiding dying young but perhaps striving to live extremely old?
0:01:26 Plus, what does a life worth?
0:01:33 And how does this impact our society, not just in the health system, but the financial sector, career planning, and even direct design?
0:01:39 Joining us to discuss exactly this are Dr. Andrew Scott, author of The Long Jeopardy Imperative,
0:01:46 a book published earlier this year alongside founding general partner of A16Z by Own Health, Vijay Ponte.
0:01:49 Let’s get to it.
0:01:55 As a reminder, the content here is for informational purposes only, should not be taken as legal, business, tax, or investment advice,
0:02:02 or be used to evaluate any investment or security, and is not directed at any investors or potential investors in any A16Z fund.
0:02:08 Please note that A16Z and its affiliates may also maintain investments in the companies discussed in this podcast.
0:02:14 For more details, including a link to our investments, please see a16z.com/disposures.
0:02:21 You could have named the book Many Things.
0:02:27 The longevity imperative is very specific and very telling, I think, of what message you’re trying to get across.
0:02:30 Let’s start there. Why use the term imperative?
0:02:37 Partly, I’m a macroeconomist and I think we’ve got to sort of face the challenges we have in the world ahead of us.
0:02:44 And this one just drops off the radar. We talk a lot about AI and climate change now we have to adapt and adjust.
0:02:52 But when it comes to this topic, we tend to talk about an aging society and we rarely get beyond talking about adult diapers and care homes.
0:02:55 So I wanted to just sort of elevate this topic right up there.
0:02:59 And the meaning of imperative is vital importance.
0:03:08 And actually, I think that’s got to double play too because it’s not just vitally important for society because we want to avoid a pensions crisis and a health crisis.
0:03:15 It’s vitally important for all of us because for the first time ever in human history, the young can expect to become the very old.
0:03:19 And so how we age is now an incredibly important thing.
0:03:35 Let’s quickly double click on that because you actually compare the criticality of longevity to things like let’s say AI or climate change, other areas or sectors where people widely address as really critical and widely impactful.
0:03:38 Why do you position it there relative to those other areas?
0:03:42 Because I think it’s right up there just as important.
0:03:45 We fear getting old. We fear outcry. Our skills are health.
0:03:51 And so that’s why there’s that longevity imperative. What are you going to do now to age well?
0:03:58 But aging is not a sexy word. I know no one who says, “Yeah, great. We got an aging society,” which is sort of strange.
0:04:04 It’s one of the greatest achievements of the 20th century to get global life expectancy above 70 phenomenal.
0:04:10 Fewer children to mourn, fewer parents snatched away in midlife, more grandparents meeting their grandchildren.
0:04:15 And we say, “Shit, we got an aging society.” I mean, it’s just a really weird way of framing it.
0:04:21 And so people switch off with aging, whereas when it comes to AI and climate change, it’s like, “Oh, this is really important.
0:04:27 If we don’t do this, we’re going to have a bad outcome. It’s going to be crucial for humanity, crucial for my individual future.”
0:04:31 And all of those statements hold for how you deal with your long life.
0:04:35 So that’s why it’s up there. And it’s not just, I think, me being obsessed with this topic.
0:04:41 I can give you very, very hard data about the welfare gains, but also the economic consequences.
0:04:47 If we don’t adapt the pensions crisis, the unsustainable health burden, it really is right up there.
0:04:53 I don’t think anyone really, other than people who’ve looked at the economics, understand the impact this is having on us,
0:05:00 not just as individuals, but as a country and the amount of debt, the amount of expense that comes along with our current healthcare system,
0:05:05 especially which is exacerbated with age. It’s a very hidden, insidious problem.
0:05:08 And so I think imperative is spot on.
0:05:15 Absolutely. And I’d love to dive into how we do need to refashion our economic system, our tax system,
0:05:18 the way that people think about their careers, because you talk about all of that, Andrew.
0:05:25 But before we get to that, let’s maybe take stock of how lifespan and then also health span have changed,
0:05:31 since those are not the same thing. Ground us in how things have changed, maybe over the last 100 years or so.
0:05:38 Yeah. So if you look at the sort of high income countries, the last 100 years, life expectancy has increased about two or three years every decade,
0:05:45 and in lower income countries, even faster. And so global life expectancy is now over 73.
0:05:51 I think it’s worth just pausing at that point. Global life expectancy is over 73.
0:05:56 Around the world, a child born today can now expect to live into an eighth decade.
0:06:04 And actually, that’s based upon no further change. So it’s probably a greater number than that because life expectancy is increasing in many countries.
0:06:11 In high income countries like the UK, the UK government says that 50% of children born today will live to be about 91.
0:06:18 That’s extraordinary. And I start my book with a somewhat dramatic statistic, which is not about average life expectancy,
0:06:27 but what is the most common age of death? And when I was writing the book, I wanted to sort of make it personal and illustrate these demographic trends with my own family.
0:06:33 And I discovered my own family was stunningly average. They hit nearly every single demographic trend completely.
0:06:39 But the most striking one was that when I was born, the most common age of death was children under one in the UK.
0:06:46 And I was a twin and my twin died in the first few days of life. So I thought that was quite rare, but that was the most common age of death.
0:06:51 And today, the most common age of death, I think it’s 87, 88, something like that.
0:06:52 Yeah.
0:06:59 In my lifetime, the modal age of death has shifted. I mean, it’s complicated life expectancy that’s average, mean and median.
0:07:06 But wow, Sam Beckett, the Irish playwright, says we give birth to stride the grave, the light flickers instant, and then it goes out.
0:07:10 Well, the light’s flickering a lot longer now, and that’s what we’ve got to prepare for.
0:07:15 Yeah. I mean, you shared so many interesting statistics. I’ll just share one more. That surprised me.
0:07:26 Based on 2020 data, you said that a newborn girl in Japan has a 99.6% chance of living to 20 and 99% chance of reaching 40 and a 96% chance of making it to 60.
0:07:36 I mean, those are just astounding numbers, which to your point, we’re not millennia away from those statistics, like just the opposite of those a few decades ago.
0:07:40 You said in 1965, we were looking at completely different numbers.
0:07:49 And what’s sort of happening is that there’s a concept of the survival rate, the probability of a newborn reaching a certain age, and it’s sort of rectangularizing.
0:07:56 As you just said, the chances of a child, a female in Japan reaching 60 is now incredibly high now.
0:07:59 And now the chance of getting 70 is getting higher and higher and higher.
0:08:04 So that’s the real sort of shift. We’ve lowered infant mortality dramatically.
0:08:09 We’ve made big steps in improving midlife mortality, although the US has got some problems there of late.
0:08:13 And so, of course, now all the gains are coming at older ages.
0:08:24 And so life expectancy is now being driven by falls in mortality at older ages such that 80% of life expectancy gains in the richer countries is coming from mortality rates coming down after 70.
0:08:28 So it’s just getting further and further along this rectangularization.
0:08:30 Absolutely. And Vijay, I’d love to bring you in here.
0:08:37 As you look at both the bio and health side of things, what gives you confidence that this trend might continue?
0:08:42 Yeah, I think there’s a lot of excitement about studying the biology of aging for a variety of reasons.
0:08:48 I mean, first off, it’s actually kind of shocking how poorly it has been studied and how little time has gone into it.
0:08:59 But the other thing that maybe is at the heart of aging and disease is the fact that many diseases are exacerbated with age, like cancer, Alzheimer’s, type 2 diabetes.
0:09:09 And so given that there may actually be some common precursors that are interesting to go after, either from a therapeutic point of view, but obviously also from a lifestyle point of view.
0:09:14 Even simple things like we know being overweight is a massive co-morbidity for any of those things.
0:09:24 And so part of the challenge will be as a society what we want to handle through the traditional health care model, which is basically a sick care model dealing with disease.
0:09:31 Or what can we do more broadly to actually get to longevity and never sort of engage with the medical model in that way?
0:09:33 Yeah. And of course, you said it’s that through your whole life.
0:09:38 I think for me, that’s why I stress the longevity society, not an aging society.
0:09:41 An aging society says, what do we do with all these old people?
0:09:44 Whereas the real change is the young can expect to become old.
0:09:52 When you’ve only got a 10% chance of making it to 90, you really shouldn’t say think in your 430s and 40s, what can I do now to make sure I’m healthy in my 90s.
0:09:56 But when there’s a 50% chance of making it, my goodness, you’ve got to start doing it.
0:10:02 And we have this diseased focus model, which just doesn’t work as we get older.
0:10:06 Because as VJ says, chronic diseases have this common source.
0:10:08 And I think that’s really interesting.
0:10:11 What is the X that affects all these later diseases?
0:10:13 And it could be aging.
0:10:15 It could be obesity and GLB1.
0:10:17 It could be through exercise.
0:10:21 And of course, that focuses on a really key issue, which is health.
0:10:26 It just strikes me as stunning that we don’t just say, how do we maintain health?
0:10:28 We say, oh, how do we prevent disease?
0:10:31 It just shows you the orientation of the system.
0:10:38 And there’s a quote by W.A. Jordan, which I use in the book, which is sort of health is the concept that the medicine knows nothing about.
0:10:43 And I said this the other day to a cardiologist, he said, no, health is just an incomplete diagnosis.
0:10:46 Something happens and then I’m in, but it is quite striking.
0:10:48 Can we speak to that really quickly?
0:10:54 Because something that you and many others have pointed out recently is this trend toward specialization in health care.
0:10:59 And at face value, someone who’s not involved in this world, actually, that sounds pretty great, right?
0:11:07 The fact that for anything that I run into, there’s going to be some specialist who studied this much longer than the average doctor who can solve my problem.
0:11:13 And so just as we’re kind of addressing the state of affairs, can you speak to that specific trend in specialization?
0:11:21 Now, maybe it’s not as compelling as you might think if we’re trying to achieve this idea of longevity.
0:11:23 There’s always a case you made for everything.
0:11:25 I don’t want to sort of criticize specialization.
0:11:34 I think when we come to drug development, we can say that there’s some challenges there because we are seeing a lot of drugs being developed for very serious specific conditions where you can charge a lot,
0:11:37 but you only affect a small number of people.
0:11:39 Brilliant that you affect those people.
0:11:42 But what about the cross-cutting breakthroughs that we really need?
0:11:45 But no, I think it’s a consequence of this sort of disease specialization.
0:11:58 And in particular, as you start to have an older population, I think the real problem of specialization is you’d be spending one morning with a cancer specialist, one morning with a cardiovascular specialist, one with a diabetic clinic.
0:12:00 So you’re going to get massive polypharmacy.
0:12:07 So you have multiple description of drugs where you’ve got no idea how they interact because we haven’t got clinical trials to try and prove it.
0:12:14 And then I think the other challenge we’ve got is that the trouble as you get older is you get all these aging-related diseases.
0:12:18 And fantastic if you can reduce the risk of cancer.
0:12:19 That’s tremendous.
0:12:22 But you’ve still got dementia out there.
0:12:26 You’ve still got diabetes and cardiovascular, all of which will lower the quality of your life.
0:12:36 So if you could do something early that affected multiple diseases, the whole is greater than the sum of its parts, which specialization is not going to give you.
0:12:48 I think Andrew hinted in that the view that medicine starts with disease is part of the problem because it should start with health and to maintain health rather than to fix disease.
0:12:52 Like we all don’t want our houses to be on fire, so we have smoke alarms.
0:12:57 And if we wait until the house is on fire, that’s both unfortunate and also there’s only so much you can do.
0:13:02 In some ways, we ask a lot from acute care and they can do miraculous things.
0:13:09 It’s kind of amazing, but it would be a lot healthier, but also a lot cheaper to be able to address these issues early.
0:13:13 But that has its own challenges and part of it is just not the way the system is built to work.
0:13:20 I think that is the problem because what you’ve got then is you’re keeping people alive, you’re not keeping them healthy.
0:13:21 And that’s the real challenging.
0:13:25 We’re spectacularly successful in keeping people alive.
0:13:31 But as we’re going beyond 70 into 80s and 90s, we slow down the dying process, but not the aging process.
0:13:39 And that’s been a problem because you’re going to spend ever more money on sensible things, but you’re getting not better health outcomes.
0:13:45 In as an economist, there’s various tools where you can put dollar values on health gains and you can add those to GDP and say,
0:13:47 “Look, here are the welfare gains we’ve got.”
0:13:54 And suddenly over the last decade, you’ve seen a really big slowdown in the rich countries in terms of the health benefits they’re getting.
0:13:57 But health expenditure is still rising.
0:13:59 And they’re called new assets.
0:14:03 The health outcomes have been spectacularly bad compared to other countries.
0:14:10 This is a good point to really double click on the fact that I think a lot of people don’t realize the societal impact of just that spend.
0:14:19 There’s been a lot of talk we’re in an election year about inequality between middle class and upper class that a lot of middle class gains and wages have been zero.
0:14:20 They’ve been flat.
0:14:25 But actually, if healthcare could have been kept at the same cost, let’s say 30 years ago,
0:14:27 then the middle class would have seen huge gains.
0:14:31 Basically, healthcare and its rising costs is eating up these gains.
0:14:34 And so it’s not just about keeping us healthy, which would be great.
0:14:37 It’s about the health of the nation and the health of the economy.
0:14:39 So it has really broad reaching impacts.
0:14:40 It does.
0:14:47 And there’s also another link as well, which is something I’m particularly keen on at the moment, which is making a broader case of prevention,
0:14:52 which is that if you could stop people in their 50s having heart attacks, they can carry on working.
0:14:56 And that then generates huge benefits in GDP and taxes and benefits.
0:15:00 And this, of course, is the key thing because you’ve got more and more older people.
0:15:04 If you want to make them work for longer, you’ve got to keep them healthier and productive for longer.
0:15:08 You can’t just say, “Hey, I’ve raised the social security age. Good luck.”
0:15:14 So if we think about these incentives and how these healthcare systems really need to think about where they allocate their resources,
0:15:22 it really is a very multivariate equation. And I’d love for you to break down how these systems actually do decide where to invest.
0:15:29 I know there’s different metrics, whether it’s VSL or Qualey Quality Adjusted Life Year that different groups use.
0:15:35 But then in addition to that, I just wanted to call out one other metric from your book, which is about this idea of action versus prevention.
0:15:43 In 2020, total U.S. healthcare expenditure was $4.1 trillion, which is around $12.5,000 per person.
0:15:48 But of that, only around $363 was spent on prevention.
0:15:52 So I think that really highlights exactly what both of you just spoke to,
0:15:59 which is the idea that we’re not investing in prevention at least compared to the action when something goes wrong.
0:16:03 So could you just speak to how these healthcare systems choose to divvy up the resources?
0:16:07 So what’s interesting globally, we’ve got the same problem. We’ve got a pensions problem and a health problem.
0:16:12 And then of course, if you look within the details of the pension and health system in every country, it’s wildly different.
0:16:22 They’re all going wrong in different ways, but in a lot of them, basically, broadly speaking, the Ministry of Finance hand over a check to the Ministry of Health.
0:16:29 The Ministry of Health’s got that stock of money, it has to decide how to allocate it. And it will look at some health measures.
0:16:39 Again, it varies in my country, the UK, one of the big targets is waiting list for operations, which is just a crazy metric because I can’t really think how that links into health measures very well.
0:16:46 But that’s a big measure. But there’s also this medical concept of a quality, which is a quality adjusted life year.
0:16:58 And so if you have a treatment that saves a child’s life and they can live to 80, you’ve saved 80 years, but you quality adjust the years for the sort of level of health that you get.
0:17:07 And so broadly speaking, you calculate that and then you set a price for every quality in the UK, it’s around £30,000, so it’s about $40,000.
0:17:14 And say, if this treatment comes in less than that price, it’s worth it. If it’s not, don’t do it.
0:17:20 In the US, the budgets are much bigger and it’s more of a commercial decision, I would say, that happens.
0:17:24 And of course, that’s that question of how much you can pass on to the insurer.
0:17:28 But there’s all sort of value based pricing in that as well.
0:17:37 Most of the measures are all very internal to the health system. I think that’s a, for me, a really big issue because with budgets under constraint,
0:17:43 take the UK where the health system actually, they spend a lot more money, but they’re not getting better outcomes.
0:17:47 You’ve got more and more older people who need operations, need the help replacement, etc.
0:17:50 And you can’t say to them, no, I’m not going to do it.
0:17:56 So you haven’t got the money to finance prevention and you’re just stuck forever doing hit replacement operations.
0:18:01 So the case for prevention at the moment is sort of made, will it save me money within the health system?
0:18:05 If I spend this now, will it reduce my operating costs now?
0:18:10 And the problem with that is prevention tends to take a bit of time to come through.
0:18:19 The other problem you’ve got in the US health system is that with multiple health providers, one person’s expenditure could be someone else’s benefit rather than them.
0:18:26 In the UK, it’s a lot easier because we have one health system, the Ministry of Finance pays for everything so they can see the savings.
0:18:34 But this is why I’m very keen to sort of say, oh, hold on a minute, though, there’s another game to prevention, which is these spillover benefits.
0:18:41 In the UK, and I’m sure it’s similar in the US, if you’re 15, you have a heart attack, you’re six times more likely to leave the labor market.
0:18:44 And once you’re out the labor market, it’s very hard to get back in again.
0:18:51 So if you can stop that person leaving, you’ve got this knock-on effect in terms of income, GDP and revenue.
0:18:53 And that’s not currently taking into account.
0:19:01 Very little time is discussed on prevention, nutrition, and also those fields are complex and highly debated.
0:19:04 So there’s the education part, which I think there’s huge room for improvement.
0:19:08 But then, at least in the US, the big question is who’s going to pay for it?
0:19:18 And with existing payers, they unfortunately have to deal with a reality where people may switch payers every two or three years, and prevention is a long-term game.
0:19:26 There’s a big push for value-based care, and I think there’s new models for that and exciting things happening, especially in areas like Medicare Advantage.
0:19:36 But in the end, I think what we’re going to see is high deductible plans and choices like ICRA that will allow actually consumers to be the ultimate payer.
0:19:43 And in the end, we kind of are the ultimate payer in dollars, and we are obviously the ultimate payer in healthcare results.
0:19:45 And so we care about value.
0:19:50 I care about my children’s health and my wife’s health and so on in a way that no insurance company would.
0:19:57 And I think that shift for who’s going to pay and me choosing how my dollars are spent could also facilitate more prevention.
0:20:04 And it’s a really interesting point too, because of course, once you move away from the disease model, the health system and now everything, it’s the air that you breathe.
0:20:07 It’s the British state that you live in. It’s the food that you buy.
0:20:10 And I think you’re going to see it go retail in a very big way.
0:20:13 Of course, not everyone is going to spend and invest in health.
0:20:16 But I do think that’s the logical consequence of prevention.
0:20:23 If the health providers won’t provide it sufficiently, other people will, whether that be wearable devices or whatever.
0:20:26 So I think the health economy just starts to get even bigger.
0:20:32 And I think something that a lot of people don’t realize is that if you look at the determinants of health and especially mortality,
0:20:35 genetics is a large part, it’s like 30 or 40 percent.
0:20:38 All of medicine is basically 10 percent.
0:20:42 And then a large fraction like 40 percent is social determinants.
0:20:44 So if your spouse smokes, guess what?
0:20:49 You’ll either be smoking or you’ll have secondhand smoke where your zip code predicts your health to a large degree.
0:20:54 Those social determinants are a huge part and addressing that should be part of health care.
0:21:01 But right now, the health care really is that 10 percent of providing disease focused care and you’re missing that 40 percent.
0:21:02 I completely agree.
0:21:04 I mean, the socioeconomic determinants are huge.
0:21:07 So behavior and environment explain the majority.
0:21:11 But one thing that’s interesting is people kind of resistant to the idea that aging is malleable.
0:21:15 But you just look at inequality and you say, well, we found a way to speed up aging.
0:21:21 These socioeconomic determinants, so it’s proof positive that we can really affect how we age.
0:21:24 And it somehow just doesn’t get into the consciousness.
0:21:29 Yeah. And I think examples that you gave in the book are that on a very small scale,
0:21:35 you are seeing some insurance companies incentivize people who exercise or have healthy habits or get discounts on healthy food.
0:21:38 I’m surprised we’re not seeing that more candidly.
0:21:46 But maybe this is a good transition for us to talk about social implications and the major parts of society that do need to be restructured.
0:21:49 As some of this is somewhat inevitable, right?
0:21:54 There’s things like the health system, the financial sector, taxes and career planning, drug design.
0:22:01 Yeah. And let me just reiterate the very simple idea of the book, which is for the first time ever, you can now expect to become old.
0:22:04 So you’ve got to make sure that you’re healthy and engaged for longer.
0:22:06 You’ve got to invest more in your human capital.
0:22:10 And of course, if you don’t invest in your future, then actually your future isn’t very good.
0:22:13 You run out of money, you run out of skills, you run out of purpose, you run out of health.
0:22:21 But we had never set up our institutions to say, how does Andrew live a life to his 90 that remains healthy and engaged?
0:22:26 So nothing is sort of untouched, including culture and psychology.
0:22:27 But where are the main things?
0:22:29 Well, obviously the health system is huge.
0:22:35 I mean, a shift to a focus on delivering health rather than treating disease.
0:22:37 Work clearly has to change.
0:22:45 And in an early book, The Hundred Year Life, I sort of talked about how we created a three-stage life in the 20th century of education, work, retirement.
0:22:50 But if you just stretch that out to 90, it looks pretty unappealing, pretty miserable.
0:22:55 And I think for me, the very simple notion here is longevity is about having more time.
0:22:58 So the question is, what do you want to do with that time?
0:23:01 And how do you in particular distribute leisure across your life?
0:23:07 And in the 20th century, we fixed retirement age, lived for longer and just took more and more leisure at the end of life.
0:23:09 Governments around the world are saying, no, that doesn’t stack up.
0:23:11 You’re going to have to work for longer.
0:23:16 So I think we may take less leisure at the end of life, but we’ll spread more leisure across life.
0:23:18 We might start work later.
0:23:20 We might take mid-career breaks.
0:23:24 Your last job might be part-time or you might go part-time sometime in the middle.
0:23:30 But your career is going to have, I think, a lot more transition, some chosen by you, some forced upon you.
0:23:34 And that, I think, has big implications for all sorts of different people.
0:23:39 So if you’re a manual worker age 50, you can’t carry on working in a physical job.
0:23:42 How do you transition into something different?
0:23:48 If you’re an investment banker working all those hours, you can’t carry on doing this beyond the age of 45, 50.
0:23:51 Do you take a break, retrain and do something?
0:23:55 And wrapped into this is education, identity, so many things.
0:24:03 But finance comes into it as well because the simple pension industry says, accumulate money while you’re working, run it down when you retire.
0:24:09 But if you’ve got this sort of multi-stage life, accumulation to accumulation becomes much more complicated.
0:24:12 So I think finance has to probably do three things.
0:24:17 One is do long-run saving products that have a much more flexible pattern.
0:24:20 Totally tie financing into health.
0:24:29 And then the other big challenge is that, you know, in the 19th, 20th century, we developed a life insurance industry that paid out if you died young.
0:24:34 But sort of the risk now is not that you die at the average, but most people die above the average.
0:24:41 And there’s now a small chance of going above 100, one in five, one in six Brits, and then to live to 100 according to the government.
0:24:43 How do you finance that?
0:24:52 So that living insurance, how do I provide you a steady stream of income in case you sort of live a really long life is a huge financial one?
0:25:01 Yeah, I think there’s a crisis also that those who have anticipated see it, but I don’t think everyday people think about it this way, which is the shift at least in the United States from pensions,
0:25:06 which have defined payouts to 401ks, which have defined contributions.
0:25:13 That in the context of living to 90 and maybe in time to 100, is your 401k set for you to live to 100?
0:25:15 Is it built that way?
0:25:17 And so what does that mean for when you stop working?
0:25:23 And can you have a health span long enough so you can build a 401k so you can pay for your lifespan?
0:25:26 All these things are things that are going to be fundamental to us.
0:25:29 And by the time we’re there, it’s too late to make changes.
0:25:31 Yeah, and it’s a really complicated problem isn’t it?
0:25:33 You think how long will I be able to work for?
0:25:35 How long will I live for?
0:25:38 How much money do I need my retire and what’s the rate of return going to be?
0:25:41 Those answers are going to differ wildly for different people.
0:25:43 It’s impossible to be precise about them.
0:25:47 So whatever plan you’ve got, you’ve got to have some flexibility in it.
0:25:53 And the key flexibility is investing in your human capital, investing in your health and your skills.
0:25:57 So if suddenly you find you haven’t got enough money, you can carry on working for longer.
0:26:01 But if you haven’t got the skills and haven’t got the health, then you’ve got a really big financial problem.
0:26:03 So I think that’s the other thing about longevity.
0:26:07 The portfolio suddenly becomes not just my 401k.
0:26:09 It is my health and my skills.
0:26:13 And integrating those together is really important.
0:26:18 And I think something you’re calling out is just how this dynamic has completely flipped on its head, right?
0:26:21 Before it was, how do I avoid dying early?
0:26:24 And now it’s, what do I do if I live too long?
0:26:26 That is a really interesting phenomena.
0:26:30 But to your point, the statistics back it up in terms of your probability.
0:26:33 And we do make decisions as humans based on probability.
0:26:38 Maybe on that end of the people who maybe might say, you know what?
0:26:43 I don’t know if I want to live forever or living to 100 doesn’t actually sound so great.
0:26:50 You mentioned pretty repetitively throughout your book this bias that people seem to have around aging and the aging population,
0:26:59 both on a personal level, but then on the societal level of requiring the support of many others who have not sustained their health span.
0:27:04 So can you just speak to this further and talk about how maybe we need to update our priors based on these shifts?
0:27:07 There are definitely some cultural differences here.
0:27:13 China and the U.S. is a one end of the spectrum, but in general, we underestimate the capacity of older people.
0:27:14 That’s ageism.
0:27:18 And the trouble with that is it means we underestimate the capacity of our own later life.
0:27:20 And I enjoy telling a story.
0:27:26 I was teaching some Chinese MBA students this summer and I was showing them the Chinese demographic data.
0:27:29 These students are late 20s, early 30s.
0:27:32 And China’s demographic changes is truly striking.
0:27:38 It’s going from 1.4 billion people to 1 billion, 45% in the movie more than age 65.
0:27:44 So I was sort of showing the data and showing how in 35 years time there’s all these people aged over 65.
0:27:47 And I said to these Chinese MBA students, how do you feel about it?
0:27:48 And they said, it’s a problem.
0:27:49 I said, why?
0:27:52 They said, but there’s all these old people, they’re going to get ill, they need a pension.
0:27:54 And I said, well, who are these old people?
0:27:56 And they said, what do you mean they’re old people?
0:27:57 I said, no, they’re you.
0:28:01 And it was remarkable how the penny dropped like, oh my goodness.
0:28:05 When everyone hears about an aging society with old people, that’s not about me.
0:28:06 I’m going to be fine.
0:28:07 I’m going to be fit and healthy.
0:28:10 And it was quite remarkable how we’re negative about old people.
0:28:14 And we don’t recognize that the big changes the young can expect to become the old.
0:28:18 I think there’s all sorts of reasons for that about why we have that negativity.
0:28:23 But it’s a fundamental problem because you underestimate the capacity of your own later years.
0:28:24 You will under invest in them.
0:28:28 And so you lead to the very sort of outcomes that you fear.
0:28:32 And then there’s just all the sort of problems of ageism that comes with any form ofism,
0:28:37 which is that if you assume that on the basis of a characteristic age, this is what you’re like,
0:28:41 then you’ve got a problem because actually the real thing about aging is diversity.
0:28:43 People age really, really diversely.
0:28:46 And you can be a hundred and literally running the hundred meters.
0:28:50 You can look at it on YouTube or you can be 50 and in a wheelchair.
0:28:54 And I think society has become very focused on chronological age.
0:29:01 I think it’s really interesting in England in 1601, we introduced the Elizabethan poor laws.
0:29:04 And it was look after the poor and the old.
0:29:06 But no one knew how old people were.
0:29:08 There weren’t birth certificates.
0:29:10 There wasn’t much numeracy.
0:29:14 So until very recently, people didn’t know when they were born or how old they were.
0:29:18 The song “Happy Birthday” comes in the 1930s, just kind of.
0:29:25 So what the poor laws said was, okay, old is someone who’s lived a long time and can’t look after themselves.
0:29:28 So the whole test was about, could you be functional?
0:29:30 Then bureaucracy comes along.
0:29:32 So this is a nightmare, this test.
0:29:34 Let’s just say everyone over 65 is old.
0:29:36 And that’s what we do today.
0:29:38 We say everyone over 65 is old.
0:29:43 But of course, the problem that chronological measure of age is measures how long you’ve lived.
0:29:46 And for me, there’s two much more important measures.
0:29:49 One is how many more years you can expect to live.
0:29:50 I’m 59.
0:29:56 And at 59, I have to behave differently from my father and my grandfather at 59 because I can expect more years.
0:30:02 And then of course, the other thing is my biological age, sort of how is my body aging and how am I dealing with it.
0:30:08 And of course, if you have that approach, you start to think, well, actually being 59 doesn’t really tell me much about Andrew.
0:30:11 It’s not that important a piece of information.
0:30:16 But we zoom in on chronological age, we assume everyone over 65 is old.
0:30:19 That is an enormous problem for firms, for instance.
0:30:24 Because whenever I sort of see a presentation of the aging society store and a consultant comes on,
0:30:28 I know immediately they’re going to say, hey, we should invest in care homes and cruise ships.
0:30:33 Because everyone over 65 is going to want a cruise ship or go to a care home.
0:30:36 And you lost the market completely, if that’s the way you think.
0:30:44 Yeah, I was just right before this actually watching a video of Robert Marchand, the French 105 year old cyclist.
0:30:50 He unfortunately passed away at 109, but at 105 he was still cycling, still beating centenarian records.
0:30:56 And so to your point, age very much isn’t a metric, but there are many others to pay attention to.
0:31:04 And so I feel like a lot of listeners at this point are convinced that maybe longevity is more complex and important than I realized prior.
0:31:08 And so on a personal level, they’re probably asking, OK, so what should I do?
0:31:13 Because I can impact this. Maybe starting out there, how would you both think about the 80/20?
0:31:17 The big problem is both when we talk about diet and exercise.
0:31:23 I think the first misconception is that there is a right diet for everybody and a right exercise plan.
0:31:31 And this is so individualized that we’ve seen now lots of companies crop up to try to measure things that will allow you to know what the right diet is for you.
0:31:35 And so it starts with diet and exercise, but I think that’s a lot easier said than done.
0:31:38 It’s really trying to figure out what is important for you.
0:31:45 But from there, I think there are intriguing things on the horizon that are maybe probably more a little bleeding edge.
0:31:48 People take metformin, people take other supplements.
0:31:52 I put that in the 20 or the 5%. I wouldn’t start with that at all.
0:32:01 I think if you’ve optimized your diet and you’ve optimized your exercise and you’re still getting PRs in your 50s of either weights or cardio or whatever,
0:32:07 and you want to go that last bit, that’s one thing, but I think there’s a lot of low-lying fruit, especially for people who are fairly sedentary.
0:32:15 I’m not a medical doctor. I don’t take anything as not prescribed and proven simply because I can’t monitor my own health to know if it’s working.
0:32:20 I was saying this the other day, someone takes lots of supplements and they were shocked and said, “We’ll miss you, Andrew.”
0:32:24 I don’t take any of that and I agree there’s exciting stuff coming along.
0:32:28 It’s always a disappointing thing because people always want the easy answer and there are some easy answers.
0:32:32 It’s exercise, diet, sleep, enjoyment, good company.
0:32:40 At the moment, I would broadly say, although there’s some latest evidence about high-intensity exercise and this way of sleeping, et cetera, and fasting,
0:32:45 broadly speaking, we know what works, what’s changed is our incentive to do it.
0:32:51 I think that’s the message that you’ve got to draw home, not that there’s some secret technique that’s going to change everything.
0:32:57 We have done brilliantly inventing and innovating intervention techniques.
0:33:02 We’ve now got to put the same thing on to prevention and data is going to be really important.
0:33:07 Then I think we’ll start seeing some more personalized medicine coming along.
0:33:14 None of that is going to happen quickly, so we’re left with the stuff that really does make a big difference.
0:33:24 If you look at the evidence on particularly healthy life expectancy, you’re talking about another year or two for each of the things you do in terms of weight exercise, that stacks up quite a lot.
0:33:34 I’ve seen myself and others, it’s not overnight, but you can see gains in the first year and then they compound and then it’s about keeping it going.
0:33:39 I think the maintaining is the hardest part to avoid injury and to build that discipline.
0:33:42 We could also talk a little bit about the sci-fi stuff.
0:33:53 Beyond the 80/20, this is like the 99.9 to 0.1, but the sci-fi stuff is that there are just amazing new discoveries in biology of cells and even organisms.
0:34:00 The so-called Yamanaka factors and many people are searching for what really could be a fountain of youth.
0:34:04 That is way off and I don’t think you’re going to be taking a pill like that anytime soon.
0:34:12 But intermediate things, there’s new pathways that are corresponding to pathways of exercise and there’s drugs in phase two for that.
0:34:18 Even the GOP ones and there’s pros and cons of them may help you get started if you’re obese.
0:34:24 It’s about the coming up with a plan where this is not going to be a fad diet, this is going to be the rest of your life.
0:34:32 The GOP ones are really interesting and I think we’ve still got some way to go to work out exactly what they’re doing.
0:34:39 But what is so interesting is first of all, it looks like it gets people a sense of agency and control so they can do other things.
0:34:41 So it has benefit mental health.
0:34:49 It’s affecting multiple diseases. It’s a bit like one of those biomarkers and some of the effects seem to happen outside of an effect on obesity,
0:34:55 which of course is exactly the sort of thing that we need to have because the body is very complicated.
0:35:00 Aging is not just one process and so there’s unlike to be just one pill we take that does everything.
0:35:06 But I give the analogy with interest rates and the economy, the government changes interest rates to try and control the economy.
0:35:09 It’s not perfect, but it has a pretty big impact.
0:35:14 And so what’s the equivalent and I think that’s a really interesting example of the GOP one.
0:35:16 And then as you say, I think it’ll be lots of other stuff.
0:35:21 I’m particularly taken by stem cells, which you can then just regrow a liver and that’s pretty sci-fi about that.
0:35:27 I think it’s sort of pretty feasible to happen or drugs that treat arthritis. Wouldn’t that be wonderful?
0:35:35 So I think that’s the sort of beginnings of aging better rather than here’s something that’s going to keep us alive to 150.
0:35:44 Yeah, if I’m taking anything away from both of you, it’s just that maybe we are at this interesting juncture where it really pays to think about this.
0:35:54 And I know that sounds really simplistic, but if we take your example, Andrew, of your kind of family tree, that longevity that happened decade over decade was a little bit passive.
0:35:59 It wasn’t passive in terms of there was millions, if not billions of people working toward those longevity gains.
0:36:06 But your father or your grandfather weren’t necessarily thinking, “Let me go test my VO2 max. Let me eat certain things.”
0:36:12 But now we do have more information than ever, especially in, as you said, Vijay, that 80%, right?
0:36:15 We’re not even talking about the sci-fi stuff here.
0:36:19 So there are very clear things that people have agency over.
0:36:28 Are there any other second, third order effects of this “long-jevity revolution” that you don’t think we’ve necessarily touched on yet that really people should be thinking about?
0:36:31 For example, one that you mentioned in your book, Andrew, was menopause.
0:36:39 There’s something that a lot of people don’t think about, but the health impact to 50% of humans is pretty substantial.
0:36:47 Menopause is very interesting because of course there’s a huge impact on women’s later life and women tend to live for longer, but get into ill health before men.
0:36:51 And so successful menopause is really important for later future health.
0:36:56 And it’s an accelerated form of aging and it’s quite rare in the amongst animals.
0:36:58 So humans are quite unusual in having a menopause.
0:37:05 And of course, men’s reproductive ability declines in a general form of age, but women’s doesn’t.
0:37:07 So I think that’s a really interesting area.
0:37:16 And our role models about how we live and what is old and what isn’t old have been formed from centuries and millennia and they radically need to change.
0:37:26 And then the other thing I think it’s important to stress is that we talk about it being more old people, but in many countries, the U.S. as an example used to have a pyramid that was lots of people at the bottom.
0:37:28 Now it’s more like a straight tower.
0:37:30 And so you’ve got age equality.
0:37:36 And because of that intergenerational connectivity becomes incredibly important.
0:37:44 And we design our institutions around a hierarchy, but we’ve got to get much better at that intergenerational mixing.
0:37:48 How do you stop a hierarchy blocking progress for the young?
0:37:52 How do you generally learn from one another and exploit that?
0:37:54 That’s going to be incredibly important.
0:37:57 There’s a virtuous cycle and a vicious cycle.
0:38:02 The vicious cycle is what we’ve been talking about where people are not paying attention to their health.
0:38:08 They can’t work, but they live long enough that they’re very expensive and not contributing to GDP.
0:38:12 The virtuous cycle is where people can maintain health span.
0:38:16 They can continue to work, continue to contribute to their 401(k).
0:38:28 And instead of this being a crisis, it could be the greatest accomplishment of humanity to allow people in their 60s and 70s and 80s to have massive contributions like we’d only expect from people who are younger.
0:38:30 That was an amazing future.
0:38:32 And theoretically, we have all the elements.
0:38:34 We just have to choose to do it.
0:38:36 And it’s sort of mobilizing people to this problem.
0:38:38 I think is the imperative.
0:38:46 If you think about it, the FDA was started before we even had access to penicillin or modern-day antibiotics.
0:38:55 Which I think kind of just speaks to the idea that these institutions, while they do many good things, are really, at least to some extent, a relic of the past.
0:38:58 But that’s exciting because there are clear wins.
0:39:09 Yeah, I often quote Malthus because, of course, Malthus, back in 1799 or whatever, comes up with this very miserable thesis that says populations grow exponentially, our resources grow linearly.
0:39:14 We’ve got too many people and we’re always going to have problems of illness, disease, famine, etc.
0:39:18 And that negativity is sort of shared with the aging society story.
0:39:20 The aging society story doesn’t say we’ve got too many people.
0:39:22 It says we’re just living too long.
0:39:24 We’re out living our religious support this life.
0:39:27 So we’re going to get ill and we’re going to have a pensions crisis.
0:39:31 So it’s interesting to go back and Malthus’ writing on the world population was not even one billion.
0:39:33 Now it’s over eight.
0:39:40 And what Malthus got wrong is he didn’t see innovation, invention, ingenuity, and new institutions that would come with industrial revolution.
0:39:42 And they increased productivity.
0:39:46 We’d invest in health and education, which further increased the quality of life.
0:39:49 And I think that’s a metaphor for this aging society story.
0:39:50 Where’s the invention?
0:39:51 Where’s the ingenuity?
0:39:52 Where’s the innovation?
0:39:54 Where’s the new institutions?
0:39:57 Because we can make this long life healthier and more productive.
0:39:59 We just go start doing it.
0:40:01 All right.
0:40:02 That is all for today.
0:40:05 If you did make it this far, first of all, thank you.
0:40:13 We put a lot of thought into each of these episodes, whether it’s guests, the calendar touchers, the cycles with our amazing editor, Tommy, until the music is just right.
0:40:19 So if you’d like what we put together, consider dropping us a line at ratethespodcast.com/a16z.
0:40:22 And let us know what your favorite episode is.
0:40:23 It’ll make my day.
0:40:25 And I’m sure Tommy’s too.
0:40:27 We’ll catch you on the flip side.
0:40:29 (upbeat music)
0:40:39 [BLANK_AUDIO]
What if the biggest challenge of our time isn’t living longer, but living better?
In this episode, we’re tackling one of humanity’s greatest accomplishments—and perhaps its most overlooked challenge: longevity. As more people live past 100, our systems—healthcare, finance, career planning, and even our cultural perceptions of aging—need a fundamental overhaul.
We’re joined by Dr. Andrew Scott, author of The Longevity Imperative, and Vijay Pande a16z’s Bio & Health general partner, to explore how a shift from “sick care” to “health care” could transform our lives. Together, we discuss the implications of longer lifespans, from the individual choices that can improve our healthspans to the economic and societal shifts required to sustain a healthier, more productive aging society.
Join us as we reimagine the future of aging, where living to 100 can be more than survival—it can be a life well-lived.
Resources:
Find Andrew on X: https://x.com/profandrewscott?lang=en
Find Vijay on X: https://x.com/vijaypande
Learn more about The Longevity Imperative:
https://profandrewjscott.com/the-longevity-imperative/
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