imageBy Jon C. White, MD

I read a statistic the other day that I thought must surely be a misprint. It claimed that two-thirds (approximately 65%) of all people who have ever lived to the age of 65 are alive today. I did some research with the intent of exposing the obvious exaggeration, but instead came up with more disturbing statistics: The number of people who have ever lived on the earth since man first appeared 50,000 years ago can be estimated by mathematical modeling; the total is thought to be 106 billion.

Currently, there are 7 billion people living or about 7% of all who have ever drawn a breath. These extraordinary numbers are a consequence of the exponential nature of population growth. I also confirmed that an estimated 50% to 70% of people who have lived to age 65 are indeed alive today! The fact that 65% of the planet’s 65-year-olds are living now suggests that there is more than just the growth of the population at work. There is also a dramatic increase in life expectancy. In short, population growth is in a very sharp incline and these multitudes are living far beyond what they did in the past. There are sobering consequences to these numbers.

Food for Thought

In the early 1800s, Thomas Malthus introduced the notion that the world’s increasing population would result in a food supply crisis. Fortunately, better agricultural techniques were introduced toward the end of the century and famine was averted. In the 1970s, another population scientist, Paul Ehrlich, opined that the disaster was not averted but only delayed until the 1980s. This time the “Green Revolution” intervened with improved farming techniques such as fertilizers based on petrochemicals and genetically engineered crops. The agricultural yields increased even further and, again, we avoided world food shortages and mass starvation. Both Malthus and Ehrlich are usually associated with global food supplies but their chief concern was more than food; it was overpopulation. They both understood that the population numbers are relentless and, although neither one had the dates right, it just seems to be a matter of time before we have a problem on our hands and again will need to be rescued by another scientific advance.

I manage to stay optimistic about the future of our planet, however, and the source of my optimism can be best explained by a computation done by the two-time Pulitzer prize-winning entomologist, E.O. Wilson. He estimated that if you take all 7 billion people in the world and stack them like logs they would form a cube one mile on each side. You could hide this cube in the Grand Canyon, which is one mile deep and 18 miles wide. If you then look at earth from space the biomass representing all humanity becomes a vanishingly small speck that is all but invisible. The great swaths of green, representing plant life, and blue, which is the water, make up most of the surface of our planet. It seems improbable that this enormous globe with its considerable plant and water resources is not enough to sustain this microscopic speck of biomass hidden in the Grand Canyon. But if the exponential growth of the population is relentless, you may still postulate that this insignificant speck of humanity will eventually outgrow even the earth’s tremendous resources. I like to think not, so again I should explain the source of my optimism. It is estimated that by the year 2050, the earth’s population will be 9 billion and after that some estimates have it declining. At some point, the rate of growth, which has been slowing, will go to zero and will then start to reverse. When the earth’s fertility rate, which has been continuously decreasing, falls below 2.33 children per family, the population will start to shrink and we will stay forever small enough to be hidden in the Grand Canyon.

image So, I am confident that a combination of decreased fertility rates and our scientific ingenuity can and will prevent the earth from running out of resources to support its multitudes, but how about our own microcosm, the United States of America? I’m afraid that our national population-related problems will be more difficult to solve than those of global resources. The greatest threat for us is not our food supply but our health care system.

U.S. Health Care

There are many problems that will be caused by our expanding and aging population, but none is as severe or as imminent as its effect on our already over-burdened health care system. Of course the sheer numbers are daunting. Both the population and the percentage of people who are older and require more expensive care are growing at alarming rates. We recently have closed a few more gaps in the safety net, which should add about 30 million to the rolls of people with health care coverage. The financial effect of this to the nation has not yet been felt, but most health care economists predict that it will be significant. By 2050, it is estimated that there will be another 117 million people in the country. A larger percentage of these people will be older than age 65, nonworking dependents with more expensive health care needs. At the same time, the number of physicians and nurses as a percentage of the population will shrink.

As a nation, we are the victims of better public sanitation and an effective health care system. People are living longer and it is more expensive to care for them as they age. Not only do they have more health problems, but their chronic illnesses and debilities are more expensive than acute illnesses. The Department of Health and Human Services reports that 90% of health care expenses go to treating chronic conditions and 77% of people over the age of 65 years have two or more chronic conditions.

The notion that keeping people healthy will save money is an attractive theory, but unfortunately it is incorrect. It has been shown that healthy people who live longer will spend more money for health care over their lifetimes than unhealthy people. Several studies, including one by Boston College’s Center for Retirement Research, have calculated individual health care spending over a lifetime and have concluded that healthier people should save more for future health-related expenses. Someone who has an unhealthy lifestyle might die of complications of obesity, hypertension or diabetes in his or her 60s, whereas a healthy person is more likely to survive into his or her 90s and require years of care at the end of life to manage dementia, arthritis, fractured hips, pneumonia and other medical consequences of aging.

Does this mean we should not promote healthy lifestyles? Absolutely not. As a profession, we should promote practices that lead to longer lives but we should realize that we are proposing the more expensive alternative and healthy living is not going to solve our financial problems.

The global food shortage problem noted above seems to have an easy solution, but I’m not quite so sanguine about our national health care problem. The dual realities of our expanding and aging population are going to make many things progressively more difficult and health care delivery and financing will be our biggest and most immediate problem. Although I appreciate that there are a lot of concerned and earnest people engaged in important issues such as donut holes, the sustainable growth rate formula, the constitutionality of mandated health care and so on, there is a much larger, more serious problem on the immediate horizon. That problem is how are we going to continue to pay for what we are doing.

Some look at problems and say that the devil is in the details and solutions will be found merely by attending to these details. This time, however, the problem is too big and we cannot temporize by manipulating the details. As the expression goes, just do the numbers. And you can start with 65. I have concluded that the numbers tell us that we need bold ideas, a radical departure from what we are doing now and full commitment to changing how we deliver and finance health care in this country.

Although I consider most of my columns to be opinion pieces, most of what I have written here is not my personal philosophy or politics; it is arithmetic. There are legitimate differences of opinion about the role of the government, the participation of the private sector, the responsibilities of health care recipients, rationing, tort reform and other issues raised by the health care debate. You undoubtedly have opinions about all of them. The numbers, however, are different. They cannot be interpreted, spun or manipulated. We know where they are headed and beyond that I don’t think it’s much of a stretch to conclude that health care is headed for a difficult future.

In this column I am not offering any easy solutions because there are none. There are only difficult ones that require compromises with features that will be difficult to digest for almost everyone. The first step in finding a solution is to recognize the magnitude of this problem as well as its inevitability. There will be some pain for all. As physicians, as citizens and as advocates for our patients, we will be called on to participate in the solution. We can’t afford to stand on the sidelines.

Dr. White is professor of surgery, George Washington University, Chief of Surgical Services, Veterans Affairs Medical Center, Washington, DC.