The pressure to remain fit, slim, and in control of one’s body does not end with old age—in fact, it only grows more insistent. Friends, family members, and doctors start nagging the aging person to join a gym, “eat healthy,” or, at the very least, go for daily walks. You may have imagined a reclining chair or a hammock awaiting you after decades of stress and, in the case of manual laborers, physical exertion. But no, your future more likely holds a treadmill and a lat pull, at least if you can afford to access these devices. One of the bossier self-help books for seniors commands:
Exercise six days a week for the rest of your life. Sorry, but that’s it. No negotiations. No give. No excuses. Six days, serious exercise, until you die.1
The reason for this draconian regime is that “once you pass the age of fifty, exercise is no longer optional. You have to exercise or get old.” You may have retired from paid work, but you have a new job, going to the gym. “Think of it as a great job, which it is.”2
People over fifty-five are now the fastest-growing demographic for gym membership. A few gyms, like the Silver Sneakers chain, deliberately target the elderly, in some cases even to the point of discouraging those who are younger—on the theory that older folks don’t want to be intimidated by meatballs or spandexed sylphs. If the mere presence of white-haired gym-goers isn’t enough to repel the young, some gyms don’t offer free weights, partly because the sound of falling weights is supposedly annoying to older people and partly because older people, who are more likely to use exercise machines, may see them as a reproach. In the mixed-age gym I go to, membership tilts toward the over-fifty crowd, where “exercise is no longer optional.” The more dedicated may use the gym as only part of their fitness regimen; they run in the morning or bike several miles to get there. Mark, a fifty-eight-year-old white-collar worker, does a 6 a.m. workout before going to work, then another one after work. His goal? “To keep going.” The price of survival is endless toil.
For an exemplar of healthy aging, we are often referred to Jeanne Louise Calment, a Frenchwoman who died in 1997 at the age of 122—the longest confirmed human life span.3 Calment never worked in her life, but it could be said she “worked out.” While he was still alive, she and her wealthy husband enjoyed tennis, swimming, fencing, hunting, and mountaineering. She took up fencing when she was 85, and even at 111, when she was in a nursing home, started the morning with gymnastics performed in her wheelchair. Anyone looking for dietary tips will be disappointed; she liked beef, fried foods, chocolates, and pound cake. Unthinkably, by today’s standards, she smoked cigarettes and sometimes cigars, though antismoking advocates should be relieved to know that she suffered from a persistent cough in her final years.
This is “successful aging,” which, except for the huge investment of time it can require, is almost indistinguishable from not aging at all. Anthropologist Sarah Lamb and her coauthors of a book on the subject4 date the concept of successful aging to the 1980s and locate it throughout the Western world, where it also goes by such names as “active aging,” “healthy aging,” “productive aging,” “vital aging,” “anti-aging,” and “aging well.”5 Lamb reports that
the WHO dedicated World Health Day 2012 to Healthy Ageing, and the European Union designated 2012 as the European Year for Active Ageing.6 In North America and Western Europe, centers for Healthy Aging, Active Aging and Successful Aging abound. Popular cultural and self-help books on the topic are flourishing.7
Among the titles now available on Amazon are: Successful and Healthy Aging: 101 Best Ways to Feel Younger and Live Longer; Live Long, Die Short: A Guide to Authentic Health and Successful Aging; Do Not Go Gentle: Successful Aging for Baby Boomers and All Generations; Aging Backwards: Reverse the Aging Process and Look 10 Years Younger in 30 Minutes a Day; and of course Healthy Aging for Dummies. A major theme is that aging itself is abnormal and unacceptable. As the physician coauthor of Younger Next Year wrote, under the subhead “‘Normal Aging’ Isn’t Normal”:
The more I looked at the science, the more it became clear to me that such ailments and deterioration [heart attacks, strokes, the common cancers, diabetes, most falls, fractures] are not a normal part of growing old. They are an outrage.8
And who is responsible for this outrage? Well, each of us is individually responsible. All of the books in the successful-aging literature insist that a long and healthy life is within the reach of anyone who will submit to the required discipline. It’s up to you and you alone, never mind what scars—from overexertion, genetic defects, or poverty—may be left from your prior existence. Nor is there much or any concern for the material factors that influence the health of an older person, such as personal wealth or access to transportation and social support. Except for your fitness trainer or successful-aging guru, you’re on your own.
Unfortunately, the gurus’ instructions are far from unanimous or easy to follow. On the dietary front there’s no more clarity than can be found in the general dietary advice for adults. Should you go with a Paleo diet or one heavy in complex carbohydrates? Should you eliminate all fats that do not originate in avocados or olives? We are widely advised to follow a “Mediterranean diet,” but does that include Greek gyros and Italian charcuterie? Or perhaps we should refrain from eating anything at all. Numerous studies have shown that caloric restriction or intermittent fasting can prolong the lives of rats and other animals, but the debate over its effectiveness in humans goes on,9 despite the fact that most of us would find a semi-starved life not worth living. If I can discern a general rule, it is governed by deprivation: Anything you like to eat—because it is, for example, fatty, salty, or sweet—should probably be put aside now in the interests of successful aging.
As for exercise, here too we find no precise instructions. Some sources, like the book quoted above, specify the rough amount of exercise, such as six days a week for about forty-five minutes per session, and how it should be divided between cardiovascular work and muscle training. But overall, a disturbing vagueness prevails. Often, we are urged simply to “get active” or “get moving,” on the grounds that even the smallest motion can be life-prolonging. “And even if you can’t run a four-minute mile, keep running. If you can’t run, walk—but keep moving.”10 For the sedentary, fidgeting at one’s desk can help, along with parking a block or so from one’s destination. A middle-aged woman reports that “I keep maniacally active because if there’s any down time I sit there feeling guilty I’m not doing anything.”11 Not doing anything is the same as aging; health and longevity must be earned through constant activity. Even the tremors of Parkinson’s disease can be seen, optimistically, as a form of health-giving exercise, since they do, after all, burn calories. The one thing you should not be doing is sitting around and, say, reading a book about healthy aging.
There are bright sides to aging, such as declines in ambition, competitiveness, and lust. In her seventies, Betty Friedan turned her attention from gender to aging, writing a book called The Fountain of Aging and telling an interviewer that as they age, people become “more and more authentically themselves. They didn’t care anymore what other people thought of them, you know, keeping up with the Joneses and ‘Am I going to make a fool of myself?’”12 Another noted feminist, the Australian-born Englishwoman Lynne Segal, found artists often doing their best work in old age, and titled her balanced and richly documented book Out of Time: The Pleasures and Perils of Ageing. I can add from my own experience that aging also comes along with a refreshing refusal to strive, to take on every potential obligation and opportunity that comes my way.
But as even the most ebullient of the elderly eventually comes to realize aging is above all an accumulation of disabilities, often beginning well before Medicare eligibility or the arrival of the first Social Security check. Vision loss typically begins in one’s forties, bringing the need for reading glasses. Menopause strikes in a woman’s early fifties, along with the hollowing out of bones. Knee and lower back pain arise in the forties and fifties, compromising the mobility required for “successful aging.” As we older people mutter to each other in the gym, “It’s just one damn thing after another,” most of these things are too commonplace and boring even to serve as small talk. The U.S. Census Bureau reports that nearly 40 percent of people age sixty-five and older suffer from at least one disability, with two-thirds of them saying they have difficulty walking or climbing.13 Yet we soldier along, making occasional concessions to arthritic joints or torn muscles but always aware that any major cessation of effort, say for two weeks or more, could lead to catastrophic collapse. “You don’t become inactive because you age,” we’ve been told over and over. “You age because you’ve become inactive.”
No doubt immortality would be a more alluring goal if we could imagine surviving without disability, but hardly anyone, outside of the narrow demographic slice represented by Silicon Valley billionaires, is interested in an extended life of being fed and “toileted” by caretakers until the next biomedical breakthrough comes along. More modestly, the goal of “successful aging” is often described as a “compression of morbidity” into one’s last few years. In other words, a healthy, active life followed by a swift descent into death. The latter goal may help account for the rise of “extreme” and dangerous sports in recent years, at least among those who can afford ski resorts, snowboarding, or a trip to Nepal. While the poor are chided for unhealthy lifestyles, the rich are applauded for summiting Everest, an enterprise with a 6.5 percent mortality rate14 and costing a minimum of about $100,000, not counting equipment or airfare—although fitness enthusiasts will be happy to know that both gluten-free and vegan diets are now available to climbers.15
But the goals of a healthy, active life followed by a fairly quick death may not even be compatible without the intervention of avalanches and altitude sickness. The truly sinister possibility is that for many of us, all the little measures we take to remain fit—all the deprivations and exertions—will only lead to a longer chance to live with crippling and humiliating disabilities. As a New York Times columnist observed, “The price we’re paying for extended life spans is a high rate of late-life disability.”16 There are no guarantees.
But where there are no guarantees, there are plenty of promises, of which “younger next year” is far from the most extravagant. Skincare products, once content to be “age-defying,” are increasingly claimed to be “age-reversing,” and, we are told by the wellness coaches and websites, a youthful appearance is part of “feeling good about yourself,” which is deemed essential to wellness at any chronological age. Credit for adding beauty—or at least a simulacrum of youthfulness—to the wellness package should go to the new “celebrity wellness” entrepreneurs, starting with actor Gwyneth Paltrow, whose digital company Goop has been dispensing tips on beauty, health, recipes, and shopping since 2008. Actor Blake Lively launched her own “lifestyle company” in 2013, which is about “living a very one-of-a-kind, curated life,” and included home decorating tips.17
The general assumption is that the customers have plenty of time and money on their hands for, among many other things, a $60 “skin-rejuvenating pillowcase with patented Copper technology,” or a $5,000 “radiofrequency” skin-tightening treatment. If you have enough money for such gadgets and interventions, you can presumably buy your way out of the strenuous “younger next year” approach to aging and take a more sybaritic path, one designed not to challenge but to pamper. The celebrity wellness entrepreneur du jour, Amanda Bacon, who is a celebrity only by virtue of her Moon Juice wellness products, offers, instead of exercise regimens, a line of ointments and drinks, heavy on the kinds of exotic and expensive substances that Bacon herself likes to consume: “ho shou wu, silver needle tea, pearl, reishi, cordyceps, quinton shots, bee pollen and chaga.” The theme here is self-nurturance, as reflected in the cost of the items consumed, as well as the time that goes into “curating” and procuring them. As New York Times reporter Molly Young comments:
What Goop (and acolytes like Moon Juice) sell is the notion that it’s not only excusable but worthy for a person to spend hours a day focused on her tiniest mood shifts, food choices, beauty rituals, exercise habits, bathing routines and sleep schedule. What they sell is self-absorption as the ultimate luxury product.18
Not surprisingly, these celebrity-endorsed wellness techniques are not exactly evidence-based, although of course there may be some large-scale double-blind randomized studies of, say, the salubrious effects of pearl consumption, that I am not aware of. But there are other equally passive and sweat-free wellness techniques that claim slightly more scientific credibility, such as “touch therapy.” It is known that human infants and probably those of many other mammals only thrive when held and touched. Extrapolating from that, some wellness purveyors surmise that even adults in modern societies suffer from “touch deprivation”—most of all the elderly ones, who may have lost, or lost interest in, their partners and simply aged out of the dating pool.
Fortunately, touch is easy enough to commoditize in the form of massages or “healing touch” therapies that can be offered by spas, hospitals, and senior care centers. An assisted living center excitedly tells us that touch reduces blood pressure and glucose and increases alertness, while all-out hugs “strengthen the immune system, relieve pain and depression, elevate mood, reduce stress, decrease the heart rate, and may prevent Parkinson’s disease.”19 The hugs can be dispensed by care providers or acquired from the fledgling “cuddling industry,” which offers asexual cuddles for a price.20
In the twentieth century, medical science began to think of aging as a kind of disease as opposed to a normal stage of the life cycle. Women were used to having their lives “medicalized” from puberty to menopause, with pregnancy and childbirth as acute episodes requiring intense medical monitoring and often intervention. But since there was no cure for aging, the elderly were pretty much left to their own devices, once meaning tonics and elixirs rich in alcohol or cocaine, which may have been, at least in the short term, highly effective. Not until the 1960s and ’70s did a researcher come up with a theory of aging at the subcellular level, which in the reductionist biology of the time was the only level that counted as interesting. This was the “telomere theory”: Every time a cell divides, the tips of its chromosomes (telomeres) grow shorter until further cell divisions become impossible.
The theory had its problems—many types of cells, such as cardiac cells and neurons, do not reproduce or do not do so very often, yet they somehow manage to age. But it also presented a tempting commercial opportunity in the form of drugs that might lengthen and fortify telomeres, although their pharmaceutical promise has not been fulfilled. A host of other chemical agents in the aging process have been identified, each with its own proposed nostrum. Free radicals were popular culprits in the 1980s and ’90s, leading to a brief fad of consuming antioxidants like vitamin E and selenium—to no effect, as it turned out. Methylation, the addition of a methyl group to a protein or nucleic acid, is required for cellular health and is thought to be encouraged by B vitamins such as folate. But the effect of B vitamins on aging is murky at best.21 Or, it has been proposed, mutations can occur in a cell’s DNA, leading to accumulated intracellular damage, and there is no known cure for that.
All of these proposed chemical pathways of aging occur within individual cells, and all are suggestive of the kind of deep trends one might associate with aging—decay and entropy. The analogy is often made to the kind of “wear and tear” that eventually disables a machine or at least its moving parts, except that cells are not machines and their moving parts are molecules or clusters of molecules that are subject to perpetual destruction and renewal. Proteins, the fundamental chemical ingredient of cells, are constantly being torn apart by intracellular digestive enzymes and replaced by freshly constructed ones. Some of the key protein players in cellular metabolism have half-lives only minutes long, meaning that there are plenty of opportunities for errors, as well as opportunities for correcting them. Over time, though, with advancing age, the errors accumulate until the integrity of the cell is compromised. And it is then that things get interesting.
Damaged cells attract immune cells, or, more precisely, damaged cells send out chemical signals that attract the immune cells, which proceed to devour the ailing cells. Some of the immune cells are messy eaters, leaving behind debris or the equivalent of crumbs, which in turn attracts more immune cells. Macrophages in particular are drawn to damaged cells; in fact, their chief “function” in the body, in addition to fighting microbes, is the removal of such compromised cells. Thus the site of cell damage becomes a site of inflammation, where macrophages pile up and attract more macrophages to share in the meal. Inflammation is of course lifesaving when provoked by microbes, but when the target is the body’s own cells or damaged versions thereof, it can lead, however gradually, to death.
In 2000, the Italian immunologist Claudio Franceschi proposed the neologism “inflammaging” to describe the entire organism-wide process of aging. Far from being a simple process of decay originating in individual cells, aging involves the active mobilization of macrophages to deal with proliferating sites of cellular damage. Today Franceschi’s theory is widely accepted, with inflammaging being described, ominously enough, as “chronic smoldering oxidative and inflammatory stress.”22 The hallmark disorders of aging—such as atherosclerosis, arthritis, Alzheimer’s disease, diabetes, and osteoporosis—are all inflammatory diseases, characterized by a local buildup of macrophages. In atherosclerosis, for example, macrophages settle in the arteries leading to the heart, where they gorge themselves with lipids until the arteries are eventually blocked. In Type 2 diabetes macrophages accumulate in the pancreas, where they destroy the cells that produce insulin. Osteoporosis involves the activation of bone-dwelling macrophages, called osteocytes, that kill normal bone cells. The inflammation associated with Alzheimer’s disease was first thought to represent macrophages’ attempts to control the beta-amyloid plaques that clog up the Alzheimer’s brain. But the most recent research suggests that the macrophages, which may indeed be activated by the plaques, actually drive the progression of the disease.23
These are not “degenerative” diseases, not just accumulations of “errors” and cobwebs. They are active and seemingly purposeful attacks by the immune system on the body itself. Why should this happen? Perhaps a better question is: Why shouldn’t it happen? The survival of an older person is of no evolutionary consequence since that person can no longer reproduce—unless one wants to argue for the role of grandparents in prolonging the lives of their descendants. It might even, in a Darwinian sense, be better to remove the elderly before they can use up any more resources that might otherwise go to the young. In that case, you could say that there is something almost altruistic about the diseases of aging. Just as programmed cell death, apoptosis, cleanly eliminates damaged cells from the body, so do the diseases of aging clear up the clutter of biologically useless older people—only not quite so cleanly. And this perspective may be particularly attractive at a time, like now, when the dominant discourse on aging focuses on the deleterious economic effects of largely aging populations. If we didn’t have inflammatory diseases to get the job done, we might have to turn to euthanasia.
But however benevolent the diseases of aging might ultimately be—at least from a social or economic perspective—they are experienced by the individual as a betrayal. In one of his last novels, Everyman, Philip Roth’s protagonist, who is essentially the same Rothlike, sex-obsessed character who has starred in most of his novels, must face his own physical deterioration. Well into his seventies, retired and largely estranged from his family, he is still hitting on women at least a half century younger than himself. Mostly though, he is aging—tormented by his increasingly unreliable penis and by atherosclerosis, which comes to require heart surgery every year. The setting is increasingly claustrophobic as it moves among waiting rooms and hospitals before returning to the cemetery where the story started, at a family funeral, and where his own body will eventually rest. It is unlikely that Roth knew anything about inflammaging or the cellular basis of atherosclerosis, but he accurately summed up the biological situation when he wrote that “old age isn’t a battle; old age is a massacre.”24
So whatever good deeds immune cells may accomplish in the young, such as fending off microbial infections, their job—or perhaps we should say, their effect in the elderly—is to destroy the organism. The question of why they do these things might be simplified into a more childish form: Are the immune cells “good” or are they “bad”? Friends or foes? For the most part, scientists dodge this question with mumblings about “paradoxical” effects or a “double-edged sword.” Macrophages can save our lives or promote deadly tumors. Neutrophils, which are among the first immune cells to arrive at a site of infection, can slay intruders or start a spiral into chronic inflammation. Scientists sometimes fall back on the language of moral judgment, of “good” and “bad.” For example, a researcher who has contributed to several papers on inflammation attempts to exonerate neutrophils by blaming their occasional bad behavior on other cell types they are in contact with, which are typically other immune cells:
Although neutrophils may often appear to be the “bad” guy in certain inflammatory conditions this is typically due to the influence of other molecules released from surrounding cells. Without this influence the primary aim of the neutrophil is to resolve inflammation, making them overall the “good” guys of the inflammatory process.25
It would take a lengthy trial to determine the guilt or innocence of the immune system or of any cell type within it. In the case of macrophages their contributions to the well-being of the organism are well known: They help sculpt the embryo into a human fetus; they defend the body against microbial invasions; they participate in the process of antigen presentation; they keep the body clear of dead and damaged cells. On the destructive side, they encourage the growth and spread of tumors; they launch the catastrophe of inflammaging; they are frontline killers in autoimmune diseases. If I were a prosecutor in the trial of macrophages I might wind up my case with the autoimmune diseases, which may not prove active malice on the macrophages’ part, but certainly make a case for homicidal negligence. In their defense, macrophages could argue that whatever the deleterious consequences, they are simply doing the kind of things they are expected to do—removing damaged cells, for example. To which the prosecution might counter that macrophages have way too much discretion in determining which cells are damaged enough to die, and may even have caused the initial harm themselves.
Early in his massive work on the history and philosophy of immunology, The Immune Self: Theory or Metaphor, Alfred Tauber states that “the immune self has come to be viewed analogously to a living entity.”26 His use of the passive voice conceals who has come to see the “immune self” in this way—he himself or immunologists in general? But the larger question is, what does it mean to say that some part or parts of the body act as a “living entity”? Certainly the cells of the immune system are in constant communication, and are capable of rather dramatic forms of cooperation. For example, if a macrophage needs to expand its supply of cell-killing digestive enzymes, all it has to do is gobble up a neutrophil and add the neutrophil’s stockpile of enzymes to its own. So the immune system seems to qualify as a “system,” but does it possess the autonomy we expect to find in a “living entity”? If so, we should probably call the nervous system a kind of living entity too, since it is capable of plotting and carrying out the death of the organism—in the form of suicide by gunshot or poison—on its own.
But what kind of an entity is it? Is it a second, shadow self, assuming the word “self” has not been so degraded by its metaphorical uses as to be meaningless? The best analogy I can come up with would be that it is a symbiont—living in a symbiotic relationship within us, sometimes saving our lives and sometimes destroying us. All we can say for sure is that its agenda does not always concur with ours, and there does not seem to be any command-and-control center within the organism to bring these agendas reliably into harmony. There are many small measures, to be sure—checks and balances, anti- and pro-inflammatory chemical messages—but there is ultimately no one in charge.
The danger is that the inflammatory forays of the immune system can easily tilt into lethal cascades. A plaque composed of macrophages can suddenly block a coronary artery. Alzheimer’s disease, which is an inflammatory disease of the brain, can cut off the neuronal circuits controlling breathing. Where there is an inflammation, body cells are damaged, and the damage lures more inflammatory cells to the site. Macrophages get less efficient with age, slower and less effective as phagocytes and defenders against microbial invasions. But the effect may be to make them even messier eaters than they were in their youth, and hence more prone to inadvertently call for more macrophages as backup. Chronic, “smoldering” inflammations can easily ignite into conflagrations.
We all know how this ends, though for the most part we prefer not to think about it. When the organism dies, as signaled by the cessation of the heartbeat and respiration, not all body cells die simultaneously, though many begin to ail within minutes or hours. Their mitochondria swell, their disabled proteins are not replaced, their cell membranes start to leak. Macrophages and other phagocytes, which are not wholly dependent on the bloodstream for nutrients, may last slightly longer and perhaps enjoy a brief orgy as they rush around devouring damaged cells, but they too soon succumb to the lack of oxygen from circulating blood. Bacteria from the gut—collectively known as the microbiome—find their way through leaky membranes to the rest of the body and begin the process of putrefaction. Next come the insects, including beetles, flies, and, should they be in the neighborhood, butterflies. Maggots are the hallmark of decomposition; Shakespeare remarked that “we fat [fatten] ourselves for maggots” and was amused by the fact that even kings are eventually eaten by these little worms. Mercifully perhaps, the corpse may be attacked at some point by larger scavengers—crows, vultures, rats, hyenas, jackals, and dogs—which at least serve to clean up the mess. To the heroes of the Iliad, this was the ultimate humiliation they could wish on their enemies—to be eaten by dogs and crows, to descend from the status of warriors and predators into prey.
So much, then, for the hours—and years—you may have devoted to fitness. The muscles that have been so carefully sculpted and toned stiffen when calcium from the dead body leaks into them, causing rigor mortis, and loosening only when decomposition sets in. The organs we nurtured with supplements and superfoods abandon their appointed functions. The brain we have tamed with mindfulness exercises goes awry within minutes after the heart stops beating. Soon after, reports a forensic anthropologist, “the brain liquefies very quickly. It just pours out the ears and bubbles out the mouth.”27 Everything devolves into a stinking pool or, what may sound even worse, a morsel in a rat’s digestive system.
If this sounds offensive, let me remind you that we inhabit an entertainment culture that is thickly populated with the “undead,” the “walking dead,” and other borderline creatures that resemble decaying corpses. Their mouths, always open to expose rotting teeth, are bloody gashes, their eyes are set deep in their sockets, their jowls may be beginning to melt down toward their necks, and of course, they are lurching toward us in search of a meal. This obsession is odd, given how meticulous our society is about the disposal of corpses. We are unlikely to trip over dead bodies on the sidewalk, but it is hard not to encounter them while relaxing in front of movies—as if we needed reminders of the postmortem future of the flesh.