An Ageing World: Lifespan vs Healthspan

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1:00Hello, my name's David Runseman, and this is Past Present Future, the history of ideas podcast. Today we are starting a new series about what it means to live in an aging world. That is a world in which populations are getting older in which people are getting older in which societies are increasingly geared to the interests of the elderly. We're going to be talking about politics. We're going to be talking about psychology. Today we start with a conversation about the fact of longevity itself. I'm talking to the geneticist Adam Rutherford about why people are living longer, whether so-called miracle drugs are going to increase our longevity again, where the limits are, but also about the difference between lifespan and health span. What if we live longer, but not healthier? What gives then?

2:07Adam, before we move on to some of the further reaches of the science of longevity, or maybe I should say the pseudoscience of longevity, because we're going to talk about that too. And the speculative stuff. Let's talk about something that is happening now. We are at the beginning of, or maybe even in the middle of a medical revolution, which is the GLP1 revolution, and if people don't know what those are, we're talking essentially about what get referred to as weight loss drugs, but they are doing a lot more than that. Just tell us what GLP1s are. Before we go anywhere else, just tell us what it is we're talking about. There's small molecules we discovered in the 80s, and then became part of the pharmaceutical regime in the early 2000s. Glucogon-like peptide receptor agonists is what they are. And they effectively stimulate insulin release when blood sugar is high, which is typically after you've eaten a meal, particularly a glucose rich sugary meal. So the fact that they have is to slow digestion, but also stimulate the areas of the brain which control satiation.

3:12So the effect is that overall effect is to curb appetite. And when they were first developed as drugs, they were specifically for treating diabetes. The further outcome, the reason why everyone has taken them and talking about them is because they overall effect is weight loss. The complexities of that are really, they are worth addressing because of the different types. There were some which were developed to be diabetes specific. There were some which developed to be weight management specific. But there are only a handful of them produced by a couple of companies. But the off prescription use, so that includes people who are not obese or don't have diabetes. There appears to be large the anecdotal so far, but mounting evidence that they also have overall health benefits, such as lowering, arstach risk or stroke, or in some cases, neurological phenomena, we don't really know.

4:14Now, when it comes to talking about longevity, it's too early to say whether these are longevity drugs, but they appear to increase lifespan in animal models. What we don't know is whether they're increasing lifespan in the animal models because they're reducing obesity symptoms or because they have some sort of other physiological effect, which directly are addressing lifespan, then longevity issues. So it's a complex messy picture, but I approach this as a scientist and as a skeptic, most of the outcomes appear to be positive, if not fully understood. And at the moment, uptake of these, it's growing very fast. And as you say, some of it is off the books, as it were. But it is still a minority perceived, let's put it like that. But there is talk, given the range of possible benefits here, that this might be a transformative medicine and become, if not ubiquitous, very widespread, if that were affordable, which is always the question, and how it would be funded is the other question.

5:16But it's possible that there's a future quite imminently in which the benefits of these drugs become very widespread. If that were to be the case, I know we don't know yet, but might we be on the cusp of something that does transform? And I'm going to ask you about the difference between lifespan and health span in a moment. I want to focus on lifespan to start with. Does transform life expectancy? I mean, it's got to be possible, is that likely? I mean, the simple answer, and I have to give this answer, as you don't know, is we don't know. We do not know yet. And the way any pharmaceutical intervention is assessed is through clinical trials. And the clinical trials have not been done for off-prescription use. And in terms of longevity and lifespan, people have only been taking it since 2007. The real ramp up has happened in the last five or six years in terms of the volume of people around the world,

6:16taking GLP ones. And we simply don't know, because we have to wait until all those people have died in order to assess the sort of actuarial status of this as a health intervention. In terms of universality of availability, interventions such as vaccines for smallpox or polio or COVID more recently, and things like public health interventions like fluoride have been transformative in terms of the overall health and health economics, which is the tedious but absolutely necessary bit that interacts with the science of medicine. And genuinely, no one knows whether there is a potential for GLP ones to be potentially universally deployed or deployed in a very widespread way, and whether they will have overall positive impacts on populations rather than individuals. So very early days, it may be the case that I genuinely don't know the answer to this.

7:16No one does, but it may be, yes, I'm very reluctant to use words like miracle drugs. I would say that GLP ones are pointing in that direction with no obvious major side effects. There are side effects people who take the drugs talk about that there are persistent gastrointestinal issues. So things like constipation diarrhea, nausea vomiting, they appear to be fairly common for people who take them, but these are not so prohibitive that they would not be taken more broadly. And in that recent history of dramatic interventions, vaccines, statins, I suppose, would come in that category too, statins which are now very, very widely used and have had some impact on longevity statistics, is that fair to say? Yeah, pretty significant. And the best case study is probably the UK because statins became available on the NHS. And there are multiple estimates about how broadly the introduction of statins

8:17have increased lifespan, but almost all of them, even the most conservative analysis say that they have increased lifespan. And so that has a really significant effect on health economics, that the introduction of statins, as it didn't, to a certain extent, with smoking cessation advice in the late 20th century and the development of vaccines throughout the 20th century, the impact of increasing lifespan through disruptive medical interventions is frequently not taken seriously or ignored by the economies that rely on longevity and actuarial data. So one analysis, which I think is credible, suggested that multiple years increase in longevity as a result of statins had a really significant impact on the pension industry. And this all relies on the question that you queued up, which is the difference between health, span and lifespan. So I want to come to that, but just to be clear,

9:19when we're talking about increased longevity, we're not talking yet, and we're going to come onto this, about pushing the envelope at the top end, particularly, in the sense that these are not fountain of youth miracle drugs, which are going to lead to people living to be 150. There's absolutely no evidence of that. What we're talking about here is many, many more people who would have died in their 70s, living into their 80s, who would have died in their 80s, living into their 90s, who would have died in their 90s, more people are reaching the age of 100, and it's accelerating very quickly, but it's not that more people are reaching the age of 120. So we're talking about a big expansion of the population in their 80s, 90s and a bit more. That's what we're talking about here. Yeah, that's exactly right. And those are sort of two separate questions. So the people who are interested in super centenarians, so that's the scientific study of people who live to be over 110. And the people who I suppose we'll come on to talk about,

10:20the ones who are fantasizing about literally living forever or for 150 or 500 years or whatever, that's a very different question from what we're talking about with health interventions like statins or GLPs. And I think it's fair to say that most people want to live longer, but the impact of even a year or two years or three years of overall average longevity really does have a significant effect on health economics. There's a very specific reason for that, which is that the majority of an individual's economic burden, health burden, is spent in the last few years of their lives. If you live a relatively healthy life, then you get a sort of bimodal distribution of your health costs. So there's a lot when you're very young, and then there's sort of steady level throughout the majority of your life, and then most of the money spent on keeping you alive is in the last five or 10 years of your life. So if the majority of that cost is towards the end of your life

11:22and we are extending longevity, which effectively means more pension payouts, it means more healthcare through hospital and medical intervention, so drug taking, and it means more cost at end of life in general. So one or two years can make a major difference. If we're talking about people going from 80 to 90 or 90 to 100, that's a huge impact, but actually it's even significant at the level of people, you know, going from 80 to 82 or to 85. So these are really, really serious questions that I don't think we as a society, globally and nationally have really addressed at all. And presumably say this were in some sense a miracle drug or set of miracle drugs. There are still, as he suggests, there are two possibilities, one of which there's a cost, there's a cost to taking these drugs, they will presumably get cheaper as drugs tend to do and they may also get more effective as drugs,

12:23tend to do more targeted and all of that. They could allow people to live longer and also enable them to take fewer other medicines, or they might not, in the sense that they might be very good at treating certain things, which do have mortality risks associated with them, but quite specifically, allowing people to live from 82 to 85, or maybe even from 92 to 95. But in those extra three years, they're not really reducing the overall medical burden. Again, I suspect you're going to say we don't know yet, but do we have a sense, lifespan, health span? That's what we're talking about here. You could live another five years and be healthier in those five years, or you could just have the things that might kill you, bracket it off, but leaving you more or less the same slightly decrepit person you were before, especially maybe if you don't take personal decisions to improve your health, which is another question. Do we know yet, lifespan, health span, where we are? And if it's lifespan and not health span,

13:23that is pretty serious, isn't it? I mean, the burden is going to be big. Well, they have opposite effects, so we should define them. Lifespan is simply the number of years that you live, whereas health span is slightly more, it's a slightly more nebulous concept, which is it's maximizing the number of years that you live healthily. You live well. If I'm sounding very cynical and I'm not an economist, and would never claim to be, but I think we have to have these conversations in a slightly removed way and talk about the economics of it, rather than the impact that this has on people's lives, which is really significant and really personal. But just from this sort of wide view, we have to talk about in slightly cold economic terms. Increasing health span and increasing lifespan have opposite economic effects, because you spend most of your money if you're increasing the number of years that you're living at the end of life, compared to if you're increasing middle age, sort of productive, healthy age,

14:23which is an overall benefit to health costs, and so for the NHS, specifically in this country. And when we don't know whether we're using drugs that are increasing lifespan or health span, then it becomes very difficult to model the future economics of how these drugs become available, how we continue to develop drugs. And then there's other, you know, extremely complicating factors, such as you mentioned at the beginning, that access to, specifically to GLPs is restricted to wealthy countries and wealthy people within those countries, especially countries that don't have fully socialised medicine. So increasing health span has a net positive effect on health economics, and increasing lifespan has a net negative effect. So we face this position, the future is, do we increase the distribution of drugs that have a positive effect on people in keeping them alive, but may have negative consequences for health economics?

15:26Now this is very specifically this drug we're talking about in general, statins have increased lifespan rather than health span, and so that has had a negative health economic effect. And the pension's industry didn't really account for that for complex reasons, but also just because these health interventions occur much quicker than we change economic structures that surround them. You know, the drug development industry and the science industry are there primarily to create new products that alleviate human suffering. And it is the overall structures around those developments, the pharmaceutical and science industries that have to deal with the consequences of these potentially disruptive new interventions. So again, it's a don't know situation, but I think it's really, really significant. And there are scenarios presumably where these things get quite significantly after kilter. They might come back into kilter if that's even a phrase later on, but there, as you say, extensions of two or three years

16:29doesn't sound like a lot can make a huge difference to the overall health economics picture, but also time lags. So maybe the health span will catch up with the lifespan at some future point. Other drugs will be developed that will mean that people in their 90s are less of a burden, but it might take five, 10, 15 years for that to happen. And I think we should be clear about this, even though we're talking the uptake of these drugs in prosperous countries by historical standards, enormously prosperous people, but also we're talking about societies under severe strain, massively indebted, aging populations, public and private health care systems that are overburdened in various ways, including by different kinds of debt. And there are, for all the personal benefits, there are significant risks in aging societies, which is what this series is about, even living with a 10 year lag between lifespan and health span. As you say, we don't know, but we might be on the cost of that,

17:29the strain that this might put for all the benefits on, say, and Britain, the public finances. It's never talked about, but it's real. It's real. And I think it is talked about quietly, but I don't think it's a thing that has been dealt with seriously. I think the people who look closely at these ecosystems are really genuinely worried about this. I mean, we're already in this situation, pre-GLPs and even statins to a certain extent, exemplified most simply by the fact that lifespan has increased hugely significantly over the last 100 years through other health interventions. And as a result, we're still wedded to a pension age of, whatever it is, 64, 65. When most people are perfectly capable of working for much longer than that, but our economic systems are still wedded to this particular model, which was based on actuarial data, which is decades out of date. Now, I have no idea how you change that sort of cultural norm,

18:30but I'm going to be at retirement age in 14 years time, and I'm not financially well off enough to actually properly retire, nor do I want to. You know, I imagine that I've got another 30 or 40 years in me, and before I check out, and I think that many people feel the same, but we haven't yet built a society, which is capable of coping with that increase, that's a really significant increase in lifespan and health span, that predates even discussions about statins. So it is okay, I hate the cliche, and I hate using cliches in general, but we have definitely slept walked into this. It's also happening at a time when uncertainty about the meaning of work, and again, to use a more boring economic phrase of the job market has never been greater. You might want to work for another 40 years. I think some of your younger colleagues are hoping that a job might open up, UCL or somewhere else, would be less than thrilled by that, and in other episodes of this series,

19:32we're talking about this, this very serious, you know, health span increases, people who have jobs hold onto them, and it makes it much harder for people coming up on the rails, but it's also the case, I just want to describe something from yesterday, because I had a sort of vision of the society that we live in. I went to the theatre yesterday, it was a matinee, Alan Ackborne play, Old Vic London, and I significantly lowered the average age of the audience by showing up being someone just about to turn 60, I've never been in a room with so much, grey hair in my life. I don't know what the average age, thousand plus people sell out, chuckling away, but I was looking around, I was really trying to observe it, partly because I knew we were going to have this conversation. There were some very, very elderly people there, and it was fantastic. They needed a lot of help to get to their seats, really old people, serious mobility issues, and then generally in the room, a lot of significantly old people, who 30, 40 years ago wouldn't have been going to the theatre, because they would have been dead.

20:33Let's be frank about this, and they were having the time of their lives, absolutely roaring with laughter at this Alan Ackborne bedroom and a fast and had a vision of what lay behind a society that wonderfully allows these people to have this lovely late retirement going to matinee's in the afternoon, I had a vision of if all of the prescriptions in the room had been laid end to end, what it would look like, and if all of the care that had been involved in getting people to the theatre had been laid end to end, what it would look like, and it scared me. I sort of had a picture of a society which is, for these people, all of them it should be said, looking quite comfortably off, and again, a room of people who were almost all white, I should say, even though we were in South London, their lives are being sustained by a political and social economy, which is great for them, and the costs are so buried, and I'm not saying,

21:34one has to be carefully not to sound like, you're on the edge of a politics which is extremely unpleasant, I have no problem with it, I'm going to be one of them soon, and it was a lovely occasion, but there is a sort of hidden side to this that we almost never see, and we are as a society increasingly geared towards. This as the set of benefits that we are wanting to sustain, and it doesn't feel sustainable. No, I don't think it is at all. We can't have this conversation without talking about the socioeconomics of health, that the single biggest factor in all disease modalities is poverty. And so, going to the old Vic and seeing a bunch of elderly people watching a play, I mean, the theatre is one of the most socioeconomically divisive cultural things that we can do anyway, especially in London, but access to health, the point of universal access to healthcare through socialised medicine

22:36is that those disparities are, we move towards equilibrating them. Does it happen? No, it doesn't, because poverty has massive health effects outside of the structures of the NHS as well, including things, you know, most significantly, diet. We expand this conversation to looking specifically, or questioning specifically, GLPs globally, and looking obesity globally. There is a global obesity epidemic that is unfolding in front of us, but it's incredibly unevenly distributed, and it does relate very significantly to poverty, but if you look at the top three countries in terms of obesity around the world, which is America, India, and China, the health economics and the obesity economics in those three situations are wildly different from each other, and then if you introduce the Middle East, which has a really, really significant obesity crisis emerging, the health economics of that are different and unique further, because the majority of people with obesity in the Middle East

23:38have effective universal access to healthcare, but not through socialised medicine, but through access to extreme wealth. So the uptake of GLPs in order to address obesity in the Middle East is really, really higher. I forget what the actual number is, but I think it's higher than the states where it's about 18 to 20%. But it's not because there was universal access through state intervention, it's just because they're very wealthy. You compare that to China, where the uptake of GLPs is really significant as well, but its distribution is wildly different because it is mostly middle class and wealthy Chinese people taking them. So, I mean, again, it's not a very satisfactory answer for a podcast, but we don't really know what's going on at all. There's another factor, which is, I think, going to be transformative again, which is that the main brands, which is WeGovie and Monjaro, as M. Pick is WeGovie, but for diabetes, they are going to fall off the patent cliff within the next five or six years,

24:41which means that generic versions of the same drugs are going to hit the market, the second the patent expires, which means that the availability for all of these drugs immediately becomes much cheaper. And again, probably a good thing, don't know, but we don't know. Another thing worth mentioning is that the introduction of pills has had a really significant effect. So, when we study the people who don't maintain the treatment, the most significant cause is needle aversion. Now, my understanding is the needles are not, it's not like a giant horse needle, and the actual, injecting yourself is pretty insignificant, but that is given as the main reason for people stopping taking the treatment. So, the impetus became to develop them in pill form, which you can extend a patent on, because it's a different delivery or even elotes of the same drug. But we also know that the pills are not as effective as the weekly injections. The pills are now, you know, readily, but you see them on the sides of buses advertised in around London,

25:43now, which I think has really only begun to happen in the last couple of months. But I think uptake is going to really, really ramp up, both with pill form and then in a few years time with patent expiry. This episode is brought to you by PayPal. You know how a mom's bag has everything? Sunscreen? Snacks? A stapler? The new PayPal app is like that, but for your money, shop, pay, manage your account, and earn rewards all in one place.

26:45And with purchase protection on eligible items, biometric security, and pass keys, you're protected at every step. Download the new PayPal app to get started. See PayPal.com slash protection terms. I want to ask you about maybe the next frontier of this. So this thing is happening now. And as you say, we really don't know what it means. Definitely there are some good things, lots of good things. But there may also be inadvertent consequences, which are hard to sustain with the social and political and economic models that we have. So they could also be transformative in those ways too. And this is a very uncertain time. We are living through very uncertain times. The next frontier might be the availability of new treatments and medicines driven by what is being called by the people who are boosting it, the AI revolution in this. And I think of deep mind, people like Demis Hassabis, at the frontier of this frontier. Demis Hassabis has said his ambition for deep mind. I've heard him give a talk.

27:45He used to have as his slogan, we're going to do two things. First, we're going to solve intelligence. And then we're going to solve everything. His ambitions have been dampened down a bit because he now just wants to solve disease. I think he then he'll solve everything. It's very three stages. Solve intelligence, solve disease, then solve everything. Advances are being made rapidly, very recently, deep mind announced that it was offering at least the possibility for scientists and people developing new medicines to have access to AI generated data, which looked at I think the 9 billion possible single gene mutations for human DNA in order to break down every possible mutation so that everything can be to the single mutation tailored for the particular disease. And we are told by the people who are boosting this, that it could be utterly transformative. Could it? You're looking much, much, just for people listening. That face was not the face of a man.

28:46You were quite energized by talking about Manjaro and its equivalents. You're looking much grumpy or about this. It's not grumpy. It's just a sort of, I've developed this shrug, which is when these claims are made, I feel very cynical for that. Well, one, those extraordinary claims are kind of absurd. And we know they're absurd because the history of everything has demonstrated beyond any doubt that when you make grand claims like that, then almost always the answer is disappointing, right? To solve disease. I mean, what the fuck is he talking about when saying things like that? To solve intelligence. The biggest problem, I think you and I have talked about this, probably multiple times because it is a real issue for me. I think, Dennis, is the very best of a deeply problematic bunch of engineers. And engineers are not scientists, and scientists are not all biologists.

29:46And I always quote that, you know, the Darwin line from the Descent of Man that ignorance begets confidence more readily than does knowledge. Biology is ridiculously complicated. And yes, strong, enormous data sets is definitely a thing that AI and LLM can do. I work in a related field. I do some work where we're developing similar to LLMs in order to predict disease, coma, but morbidity is based on huge data sets, right? So I'm not saying that we can't understand these data, we can't extract meaningful information from these data. And you know, worth mentioning, we think that the human genome is the most complex data set in the known universe. And we think that the human brain is the most complex entity in the known universe. So we're not dealing with problems that are simply going to be solved by throwing more and more power into them. They're complex because of the exist in the universe and the interactions between the genetic,

30:47so the 9 billion variations of single nucleotide polymorphisms, SNPs, which is what Demis has a business talking about. The number of interactions that those variants that our genomes have with the rest of the universe are infinite. They are literally infinite because we can divide biological and inheritance into two categories, which are genetic, that is what you inherit from your parents and everything else. And everything else includes, you used to talk about it as nature and nurture, but they're not particularly useful terms, but nature means genetics in that original conception, which came from Francis Goulton. And nurture is literally everything else. So it's not simply whether your parents read to you when you were a child or whether you went to a public school or a state school, or whether you ate chips or broccoli. It is those things, but it also includes the randomness of, you know, the orientation of the sperm that hit the egg that sets the axis on which your fetus will grow,

31:49which we know in animals has an effect on them. It is the randomness of your nine months in utero, and it is literally everything else in the known universe. So when people come along and say, we just need more computing power to analyze this complex data set. I don't think they're biologically literate, because biologists just sit there, just every, every biologist I know who has studied either microbiology or evolutionary biology or any complex systems within biology just goes, yet you're not talking about real phenomena within biology. We can't model a single neuron firing with another one, how it connects to another one. We can't model that accurately. We have mapped all of the neurological, all of the cells, in fact, in nematode worms, but that's like 900, rather than 80 trillion, we're talking about inhumans. So, you know, DeepMind did a really amazing thing by crunching the protein structures with alpha-fold.

32:49That was really, really impressive piece of work. We don't really understand how it works because there's the whole black box problem within AI. But I'm not even sure now how significant the impact of that amazing Nobel Prize winning development by them has on real biological systems. Leslie Orgel was a chemist in the 1970s, and he came up with a number of his rules. And Orgel's second law is evolution is cleverer than you. And I think it still stands. I think it still stands in when having these conversations about DeepMind and about these absurd claims, just as a subset, just finished this slight rant. These types of claims are always made at roughly the time when a funding round is happening. And you can map those trajectories for all of these grand claims pretty accurately. So whenever they come out and say in the news reports that, you know, Sam Altman says this, Elon Musk says this,

33:50and to a certain lesser extent, because I think Dennis is credible, Demi says this, it does happen to coincide with a significant funding round. So, you know, I'm super cynical about these claims. So we're not going to solve disease. But what does it even mean? What does it mean to solve disease? If we... I never knew what solve intelligence meant, but partly because intelligence is not a problem. I thought like solve intelligence, it doesn't really... Anyway. This relates to the question... What you just said, what does it mean to solve disease? Does relate to the topic of this conversation, which is what is longevity? But if you look at actuarial data from the 16th and 17th century, which I love doing, the majority, apart from in play gears, of causes of death is old age. Now, we don't really think that death by old age is a thing anymore. There is some conflict within the longevity researcher community about this question of whether... Do we just continue to cure the disease

34:53that kills the majority of people at the older stage that people are currently living at? In which case, is there no cap to human life which just fix every next disease as it comes along? When you look at the super centenarians, which is a population of people over the age of 110, which is roughly 70 or 80 people continuously, they are extremely unusual. Guinness World Records has a member of staff whose sole job is to verify the age of super centenarians. Now, if you make it past the major killers in the West, which is heart disease, obesity related diseases, and then neurodegenerative diseases, if you make it past all, and cancer, sorry, I forgot cancers, if you make it past all of them, then the number of diseases that people die from rapidly decreases, and most super centenarians eventually die of some form of atherosclerosis, which is a sort of peripheral vascular disease. Now, if we suddenly develop a massive cure-all panacea

35:54for atherosclerosis and related diseases, then would we then see the super centenarians increase in age to, I don't know, 120s, and then they all die of something else, and then we cure that, and we keep going, we keep going, we keep going. The answer is we don't know, we don't know the answer to that. The super centenarians in some way are not a very useful scientific population because they're so unusual. But yeah, it relates to the question of curing all diseases, because, I don't know, do we just keep finding diseases that old people die from, or if you do solve disease in the way that it's been phrased, then everyone lives forever, in which case we've got a whole new set of problems, boredom being the most significant one. There are lots of things I want to ask you about that. I mean, one is, so you say in the 1617th century, apart from in play-years, the communist cause of death was old age. But that's partly because old age started much earlier,

36:56and old age was an answer given when they didn't know, so you could die of old age in your forties. It's also a time of astonishing levels of infant mortality. I mean, we are now living in societies where death really is, and we're going to do a podcast episode about this, where death really is overwhelmingly correlated with what we now call old age, which wasn't true in the 16th and 17th century. Old age might mean 40, 50, 60, 70, for the people who survived, not one, two, three, four, five, and other things would take them along the way, and there weren't many people in their 70s in the 17th century. There were quite a few, but not that many. So we are still in a very different world in the sense that it's all being bunched among the over 70s, increasingly soon, probably will be the over 75s, and onto the over 80s. And then if the scenario is the one that you described, which is because we have a real fixation on extending life, we want to keep people alive, we probably spend more time thinking about that,

37:57if you go into, and then H.S. Hospital, and you look at the effort that's made to keep people alive, it's hard not occasionally to think, should we be spending more time about thinking about quality of life as well, because it looks miserable often, and I think it is miserable often, but life is extended. If the focus is on the extension of life, we'll find the things that kills the old people, and we'll focus on getting rid of them, so they can live another. The lifespan, health span, lag is gonna become massive. I mean, so even if we don't know where we are in these various revolutions, there must be a risk that it's gonna make what's going on with the GLP's seem insignificant, that we do work out the ways to get people from 85 to 90, 90 to 95 to 100, and that's where the money goes, the research goes, the effort goes, and we're keeping these people alive, and they want to stay alive, because humans want to stay alive, but the health costs are astonishing. It's not the only scenario, it should say,

38:58but it does seem to me like a really possible scenario. It's an incredibly difficult situation to both understand and manage. So if you think about this in terms of chemotherapy for cancers, there's a constant debate within the medical community, so within practicing doctors and the healthcare providers, about when to stop chemotherapy, which is expensive and painful, and affects the quality of your life really significantly. If you look at something like maintaining people's life and their tenacious grip on the end of life through interventions like chemotherapy, where the quality of life is very poor, then it sort of, well, it prompts a conversation about our relationship with death, and our acceptance of, well, I don't know, embracing end of life, rather than infinitely extending it. I don't think we, I mean, this is a different, this is for a different conversation, but I don't really think that we necessarily have

39:59a very good relationship with death. You know, the Elb Woody Allen joke is, I'm not afraid of death, but I just don't want to be there when it happens. I mean, I think that's a conversation you're going to have with a more philosophically minded person in this series. Listeners should go back to Susano Sullivan and your conversation with her about overdiagnosis, because I think that is another really significant, it has a really significant relationship with issues about quality of life and health span. And as you say, the divergence of health span and lifespan in terms of impact, if I sound very do-mongri about this, it's a close to intractable problem. It's important that we're having it. I'm glad that you're addressing this in the series, because I think it's just one of those conversations that doesn't happen very much, and governments and societies are not in any way prepared for this future that we're finding very difficult to understand. It feels to me like there's another lag here, which is this is happening very quickly.

41:01So you can tell different stories with different arcs. As you said, there's a 100-year-plus story astonishing extensions in longevity, just life expectancy. There's a 200-year story in some ways, even more astonishing. The 19th century story, amazing, because I'll for all the beginning of the industrial revolution, life expectancy went down, and it was very low, and then through the 19th century, through the 20th century. But there is the more recent thing that's going on, which we've been talking about, and we may be just on the cusp of that accelerating quite quickly, which will produce these lags. But the things that need to adjust do not adjust at that speed. The pension industry is struggling. You'd think the pension industry would have a very strong incentive to adjust, because it doesn't want to go out of business. But the pension industry can't adjust in time. Governments can't adjust in time. Well-fair states and welfare systems can't adjust in time. And then there are cultural and social attitudes. We are right in the middle of a time.

42:02It's not always been true, I think. But we're right in the middle of a time where extending life expectancy is a central value of our societies. And keeping people alive is a thing that's almost become taboo to question, see the debates around end of life care, and indeed assisted dying. But the changes we're talking about might be happening quite quickly. And the real challenge is social, economic, political, but also cultural and moral systems that don't adjust at that speed. They just don't. And the strains are going to get bigger, not smaller. I'm not so do me as you in the sense, there are obviously massive benefits happening around these things too. But that thing seems to me the thing that we are just not talking about. Things are out of whack in time span terms. And it's partly a historical question, I think. The science and economics to it. But this also, what this podcast is about, the history of ideas. The history of ideas, ideas change at different speeds.

43:06But we're in the middle of something that is changing pretty quickly. I think it's always persistently a problem as a speed of scientific development compared to not just as a societal, but things like legal frameworks change much slower than they're driven by technological change. Effectively always playing catch up. And yes, I think to what you're describing is really significant. As you're speaking, I was wondering whether when Jonas Salk was developing the polio vaccine and distributing it, I would have been the guy saying, should we be doing this? This is going to have a massive, massive effect. So in hindsight, I would never think that at all. You'd have looked at that little first penicillin culture and you'd gone, really? Are you sure about this? Do we want to do this? Are you sure? Yeah. I mean, who's going to pay for all those people who are still alive at the end of this? No, quite. Or the eradication of smallpox. Or it also relates to another conversation that you have, which is about fertility rates.

44:08And those dropping off a cliff, because as countries like Japan and South Korea now have massively aging populations, which will appear to be only increasing. And your timescale question in that, those situations is really significant, because changing birth rates happens incredibly slowly. But increasing in longevity for those populations is happening on a, you know, it's increasing per year. So again, no idea. When I say, no idea, it's not that I don't know. Obviously, I don't know what the solutions to these problems are, but I think that what I'm trying to say is they're very difficult to model. So they're very difficult to model in pure scientific senses about things like specific drug interventions, like GLPs or even vaccines. It's very difficult to model them because they are unprecedented in their potential. But then they're very difficult to model with the things that you're talking about as well. So there's the sort of societal, moral, ethical, legal,

45:10all of those things that are going to have a massive impact as well. So, you know, we started with me saying, I don't know, and not I don't know, as in I don't know myself, but we don't know, and we don't really know how to deal with them. And one view that is still widely held, I think it's less widely held than it would have been 20 or 30 years ago, which is the view that these things are indeed impossible to model, it's very uncertain. You would have to be insane to say, don't cure polio because of the costs. And the view would be the market will work it out. That's why we have market systems. The market is actually over time quite good at working out how to reconcile these different things. And that seems to me to be false, short, medium, and long term. The market does certain things in relation to these things, but actually I don't believe that for some of the things that we've been talking about, the market is a particularly good measure for working out what we should do.

46:10And the fact is you say that the pension industry and other industries with all their incentives have a tendency to put their head in the sand about these questions is evidence of that. So people who sort of say, well, the patent system and all that, it's there for a reason. And so the drugs will get cheaper and that will incentivize people to come up with new things. In the end, over time, these things will be worked out by costs and prices, what people are willing to pay, what people are willing to pay for life extension. And maybe they'll come up with more people work out, it's not worth it. I don't believe that. I don't think I ever believed it, but I think now I think I'm not even sure that many people believe it. I don't believe it either. Maybe we should get someone on who does believe it. There are people, I know there are people who absolutely still do believe it. Well, the NHS is such a different system to what exists in, for example, in America. I think it's almost impossible to make comparisons between them. To the extent that in some work that I've been involved in recently where we're trying to make AI-driven predictions

47:11about morbidity based on large medical data banks in multiple countries, UK, Biobank here, but also all around the world. But we actively exclude the United States because their healthcare system is so different and so driven by socioeconomic factors that they would be such a massive outlier in the data set as to be a distinct case study. So we don't even include the US in our modeling, which seems like such a weird thing to say in the 21st century. But we have to because of the health economics of that nation. So I'm not really raiding myself in from saying we don't know. I wonder whether, when we look back in 50 years time or 100 years time that we will be having discussions about a changing relationship with mortality as well as a changing relationship with work because we're building a very middle-heavy society. We're not handling young people particularly well

48:12and we're extending lifespan without addressing the economic costs. It is the case that there is a culture, a Silicon Valley culture, which is increasingly focused on that idea of pushing the envelope at the top end. Where can we go to? 120, 150. Brian Johnson is the poster boy for this, but he's just announced that he's done quite significant harm to his health by trying to live forever. But is it possible to say leaving aside the ethics of it and everything else and the complexity of it? But the fact is you say the number is stable of the people over 110. We might be able to soon get that number stable above 120. But the ambition, the idea that it's just our little minds, we're not imaginative enough to think seriously that it should be possible, the human body should be sort of fungible enough that we ought to be able to imagine and then work towards achieving 200 or 400. Leaving aside all of the sorts of questions we talk about here

49:15and just the question of imagination, is it nonsensical to imagine that? I just want to get a sense from you as to whether it's just not even worth thinking about because it's sort of not who we are, what our bodies are. I'm not sure it's a purely biological question or I'm not sure that the biological aspect of this question is the interesting one. So I know Brian Johnson is an absurd outlier. I can never quite work out whether he's taking the piss or not because he does seem to have some sort of slightly bribe self-awareness about the absolute absurdities of the things that he's doing. The question that I want to ask is why? Why do you want to live to be 120 or 200 or never die as his, as Brian Johnson's campaign, I don't know if they still have that, as they're slogan, but to defeat death? It seems like such a peculiar, psychologically problematic thing to sort of state.

50:18Of course, as you said earlier, as I said earlier, everyone wants to live longer and live without pain and live productively and live an enjoyable life, all those sort of bentomite principles. I'm not saying that there should be some sort of cutoff point where we go, yeah, I just want another five years, because in five years' time, you say, well, I just want another two years. So this isn't a binary, but I genuinely don't know why you'd want to live for 200 years. I did a radio four program a few years ago where I interviewed super centenarians. And I went to the, I went to the 113th birthday party of Henry Allingham, who was the oldest living British person at the time. And he died soon after that. One of his great, great grandchildren said something, which I found very striking, which is that his grandchildren, some of his grandchildren had died of old age. Now, what a weird thing to, what a weird existence to see, you know, you should, it's always awful when parents outlive their children.

51:21But for the super centenarians, they were out living their grandchildren and seeing their great grandchildren as elderly people, because they were that old. Now, is this the model that the tech bros are trying to emulate? Is this what they want to see, or does everyone just live forever, live for 200 years? Productively, we do not psychiatrically diagnose remotely. I do not psychiatrically diagnose a tool, because that's not what I qualified to do. But it seems like such a psychologically problematic set of beliefs to have, to hold. Brian Johnson does not appear to me to be a psychologically healthy person. He's not someone I would like to spend time with or share ideas with. And I don't think that many of these people contribute positively to society more broadly. I note as well, it's really worth noting that earlier reference, I made to biology being more complex than we ever anticipate amongst all of these guys.

52:23I think they're all exclusively men. There isn't a biologist present. I don't know where they get their information from. I know that Brian Johnson has a team of doctors and biologists around him to support his quest for eternal life. But you just never get biologists saying this kind of shit. And again, it's that it's the Darwin phrase that I use, but also it is just a sense that a real sense that comes. I think culturally from studying biology for many, many years, which is that we don't understand this stuff. And I don't mean we don't understand, I don't understand genetics. I don't mean that in the way that my milkman doesn't understand genetics. I don't understand genetics because I've studied it so long. And bacteria do things that genuinely surprise people who've been studying evolution for decades. We discover new phenomena within living biological systems that make us go.

53:24This is both the most rewarding subject to study and also the most frustrating. Biology has a four billion year head start on us trying to understand it. So when these guys stand up and say, yeah, we're going to fix disease. And we're going to fix intelligence or solve intelligence or whatever it is. I'm looking at them going, I don't know what you're talking about at all. I don't know what you're talking about. It's like you're speaking a different language. It's like you read science fiction, morality tells in science fiction, and you miss the morality bits of them. A reminder that our two new PPF online courses are available now. One, that the companies are series on the great political essays, the other are recent series on the lives of the philosophers. These courses are available for anyone who wants to use them in any way. They would like to use them. If you would like to explore them, just go to our website ppfideers.com and click on courses.

54:28And a reminder that our most recent PPF plus bonus episode, which we called podcast university and in which I explain some of the thinking behind those courses, but also more broadly about the relationship between what we do on this podcast and the idea of education. That's available now. You know what to do if you would like to hear it. Sign up to PPF plus. Click on the link in the show description. Go to our website. Five pounds a month, 50 pounds for the year, all of our bonus episodes. There are lots and lots. Two new ones every month. Add free listening, automatic sign up to our newsletter, and you'll support the work that we do. Next time in this series, a conversation that in many ways flows on naturally from the one that you have just been listening to. Today we were talking about longevity. Next time I'm speaking to the doctor and writer Richard Coker about the meaning of death. Do join us for that.

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