Our Undue Focus on Long Life

Americans are living longer but not necessarily better.
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Earlier this week data published in the Journal of the American Medical Association indicated that the life expectancy of people in the United States has increased over the past two decades by three years, to 78.2. This means that the average American today enjoys an extra 1,100 days of life. However, the news is not all good. For example, the U.S. still lags behind most of the world's other rich nations on a number of health indices, including rates of heart disease, lung cancer, and diabetes. Moreover, during the same period, the U.S. ranking in healthy life expectancy fell from 14th to 26th. As one news outlet put it, "although we are living longer, we are not living better."

The statistics surrounding life expectancy are important, and in general it is highly desirable that we find ways to prevent needless deaths. No one wants to die before their time, particularly if we are paying this price for something so trivial as an extra daily nut fudge sundae. On the other hand, the idea of "living better" deserves serious examination. What do we mean when we say that someone is living well or living poorly?

Especially galling is the fact that much poorer countries, including Chile, Portugal, and Slovenia, are actually doing better in terms of their citizens' mortality rates.

It is tempting to compare metrics on waistlines, blood glucose levels, or relative risk of developing cancer, in part because we love the competitive spirit behind such rankings. We love to think, for example, that the U.S. leads the world in number of patent applications, justifying our claim to be the most innovative nation on earth (in fact, we're number 3). Likewise, we take great comfort in the notion that the U.S. has the highest per capita income in the world (actually, we're somewhere between number 5 and 10). Many of our national pastimes are competitive sports with clear winners and losers, and we carry our love of competition right through to the hospital and into the cemetery.

So telling us that our ranking in preventing premature deaths has fallen from 14th to 26th really gets under our skin. We want to be number one, or at least moving up in the rankings. Regardless any absolute increase in life expectancy, we are inevitably disturbed to discover that we are falling further behind. Especially galling is the fact that much poorer countries, including Chile, Portugal, and Slovenia, are actually doing better in terms of their citizens' mortality rates. And some Americans, such as those living in Appalachia, are actually no healthier than Bangladeshis.

What could be the reason? One possibility is that we are not spending enough money on health and healthcare. But this is a difficult argument to sustain, in part because the U.S. pays out far more than any other nation on earth, outspending our nearest competitors by more than 50 percent. If the way to obtain health is to spend money on healthcare, then the U.S. should rank as the number one healthiest country on earth by a substantial margin. But we don't. This suggests that health is not a commodity that can be purchased like automobiles or gallons of gasoline.

And this is certainly true. While there are some broad positive correlations between economic standard of living and health status, it is clearly not the case that wealth causes health. In fact, some very wealthy people have died quite young. Consider Christina Onassis, reputed to be the wealthiest woman in the world, who died at age 37. By contrast, some very poor people have lied to a ripe old age. For example, Mother Teresa, who took a vow of poverty as a young woman and lived without a dollar to her name throughout most of her life, lived to be 87.

To some of us, it seems initially something of an affront to be told that there are things we cannot purchase. Yet a moment's reflection shows this necessarily to be the case. An obvious example is time. Even the richest person on earth cannot buy an extra year, hour, or even second. To be sure, a rich person has an advantage in obtaining the best medical care and might be first in line for an organ transplant if needed, but again, health is not simply a matter of purchasing power. Rich, poor, and everyone in between soon come to the same end, from which no investment portfolio can protect us.

Beneath our appetite for competition and our desire to be number one lurks a deeper desire, the impulse to be in control. And above all, we want to control our fate, to feel secure in the knowledge that we all get what we deserve. Work hard in the marketplace and you will be rewarded with a secure, well-paying job and lush retirement. Eat right, exercise, and avoid bad habits such as smoking and alcohol abuse and you will lead a long and healthy life. Show us what it will take to get back on top, doc, and we Americans will rise to the challenge.

The problem, however, is that the mist of health statistics often obscures the mountain we are really trying to climb. It is true that U.S. life expectancy lags behind that of a number of other nations. It is true that if we could lower rates of smoking and obesity, we could probably bump these numbers up. But a more sober analysis reveals that life expectancy is a pretty poor indicator of health. We are attracted to it because it is straightforward to measure and makes it relatively easy to keep score. But we cannot tell from a person's life expectancy how well they are actually living.

Suppose through some wonder of modern biomedical science we could suddenly double our life expectancy by staying in bed 20 hours per day, or giving up all solid foods, or never again reading a book. Would we do it? To say that we are willing to pay any price in order to increase the length of our lives is to say that we have forgotten what it really means to live. The Struldbruggs in Jonathan Swift's Gulliver's Travels are immortal specimens, but they are also miserable human beings, whose unending lives prove to be not blessing but curse.

Before we spill too much ink bemoaning the U.S.'s declining standings in the world life expectancy race, we should devote a bit more time to reflection and conversation around what really makes a good life. Though Wolfgang Mozart and Martin Luther King died before the age of 40, they managed to lead extraordinarily productive and admirable lives that enriched the rest of mankind. By contrast, many of us may realize our ambition to become nonagenarians or even centenarians and yet contribute too little that really makes a difference. By this standard, our fiercest competitor is right here at home.

The real measure of a life is not how long it lasts. The real measure of a life is what we make of each and every day. We have exactly the same number of minutes per day as the Gateses and Buffetts of the world. How effectively are we making use of this time? I suspect that the best way to lead a truly full life is not by straining every sinew to keep our hearts beating to the last possible moment, but instead by bringing ourselves and others as fully to life as possible. And I won't be surprised to learn someday that living deeply also does far more than diet and exercise to keep us going as well.

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Richard Gunderman, MD, PhD, is a correspondent for The Atlantic. He is a professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the Radiology Department, at Indiana University. Gunderman's most recent book is X-Ray Vision.

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