Crisis creates opportunity. The furor over the US Supreme Court’s decision regarding the Health Care Mandate focuses on access and cost. But these are only tangential to the imperative issue that defines our broken health-care system.

Ours is not a Health-care system. It is a Disease-care system.

It is a system in which all resources are consumed by repair. Repair is a fiscal and scientific black hole with an inverse relationship between cost and benefit.

All the kings horses and all the kings men cannot make America healthy until it embraces a Commonhealth, in which every segment of society is committed to the assurance of our personal and collective potential. This unarguably is our most important national resource.

We must assume individual responsibility. This is of paramount importance. Each of us owns our health. We cannot download it on government or doctors or pills.

The solution is a massive campaign to eradicate health illiteracy. We need health in our classrooms and homes, not in expensive body shops.

Today we know enough to prevent 50% of illness and save trillions of dollars.

Mean-spirited and selfish short-term political posturing demeans our nation’s reach to assure full lives for all Americans.

Carpe Diem!

The words health and function are virtual synonyms. A healthy body is one that is working well. So too, a healthy intestine or leg or brain each is an organ that is performing its dedicated functions in the best functional fashion. We are blessed with much redundant extra function.  We have two eyes, two ears, two lungs, two kidneys, two sex glands, when we really only need one to get by.  I can run a marathon with one lung, I can excrete all my waste material with one kidney, or overpopulate the world with one testicle.

The Darwinian reason for this seeming excess of function streams from the fact that we do not simply live in the idle gear. The environment provides constant challenges beyond merely getting by.  Hence, we understand the survival value of “extra” health.

So, we can surrender half of our original capacity with no apparent functional loss. At 60% loss still no problem with any deterioration of function.  At 30% remaining margin, we start to have symptoms, such as shortness of breath or a pileup of waste materials.  Another 10% debit from our 100%, brings us down to 20%; this results in either profound loss of function or death.

This is therefore a good-news/bad-news story, much like a bank account.  When you have extra cash in the bank, you can be a big spender. However, when you get to a certain margin a little more loss and you become bankrupt. All of the medical encounters and bills are spent in this narrow 20% to 30% margin remaining from our starting functionality.

It makes obvious great sense to preserve function. The way we do that is by good preventive maintenance, thus avoiding the trouble and expense of being sick. Health trumps illness by any possible measure. Western medicine spends all its intellectual and fiscal capital in trying to repair the damage or loss function.  Eastern medicine places its emphasis on retaining health and function.  This makes dominant good sense.

The obvious reason for the Western emphasis on repair instead of prevention is that repair pays well, whereas prevention doesn’t.  Zimmerman’s Law asserts “Nobody notices when things go right.” Such a perverse reality comes under increasing scrutiny. As the costs of Western health (illness) care begin to threaten fiscal solvency of the nations that embrace the repair model, they inevitably look elsewhere for an alternative. The East is the appropriate direction for us to seek answers.

Fortunately, medical science is maturing sufficiently to provide a rigorous science of health. Health is no longer a bland platitude, but a firm format. Health is not simply the absence of disease but a physical state of specified content. The determinants of lifelong health are not to be found in hospitals or pharmacies but in the everyday lifestyle that we pursue. We either choose health or illness.  It’s our choice to choose to act toward better health, or to neglect it.

The ancient Greek precepts of self-knowledge and moderation in all things have been rediscovered. Therefore our current trend to convergence of Eastern and Western precepts is not only of geographical import, but historical as well. The future will decree how effective we will be in the integration of our broadening curriculum for health.

John McCarthy died four days ago. He was 84. His obit in the “New York Times” made specific reference to his generally attributed parenthood of artificial intelligence.

John was my good friend and a terrible patient. For 30 years he resisted my best effort to shape up his dissolute lifestyle. He made 84, despite his derelictions. But a large reason why I recall him as a miserable patient is my fault. Every one of his visits to my office disrupted my subsequent patient schedule, because my encounters with him were so magnificently enriching that I defaulted the length of his scheduled appointment, and thereby made everybody else late.

John was probably the smartest person whom I had ever known. His early career was as a mathematician, initially at CalTech, then Princeton, then Dartmouth, eventually to MIT where he with Marvin Minsky spawned the world’s first artificial intelligence laboratory. He moved to Stanford in 1962, which was to be his subsequent academic home. Here he founded the Stanford Artificial Intelligence Laboratory, which birthed many of the techie geniuses of Silicon Valley. He invited members of the Homebrew Computer Club, a hobbyist group, to meet at his lab. Among the early attendees were Steve Jobs and Steve Wozniak. The rest is history, as they say.

In 1941, while at Princeton he joined the Communist Party, part of his pedigree since both his parents were members. His romance with this leftist philosophy eventually faded around the Vietnam War, and he became more conservative thereafter; always the consummate optimistic humanist.

John had a special love for chess. While at Dartmouth in the 1950s, he taught his computer to play chess. Around this time, he engaged a group of Soviet scientists in an international tournament, which lasted a year. The Soviets won. This high profile application was eventually expanded to the PR-rich world, where chess masters and Big Blue (IBM) contested. This exposed the world’s attention on the issue of whether the human brain had found its match or maybe even its master.

En route, John’s fascinating life placed him in contact with legends. Alan Turing, Robert Oppenheimer, and other members of the atom bomb group, the big hitters at the Santa Fe Institute, and Nobel laureates were on his phone regularly. I never could figure out how John managed to fit his huge brain inside his average-size skull. His intellect was vast with prodigious memory storage. His awesome brainpower often would penetrate into deep philosophic meanderings that I treasured so much.

We spent endless hours looking into the free will / determinism terrain. But, John’s intellect extended far beyond his own field of science science into history, politics, astronomy, and philosophy. He entertained himself with science-fiction rambles. Each encounter with him left me enriched in a major way. His extraordinary intellect sometimes obscured the pixie within. Often after a sudden childish grin emerged, I wondered whether indeed he might be a leprechaun.

My official role as John’s internist ended in 2000 as I left the practice of medicine. My attention drifted afield until several months ago, another Stanford faculty member off-handedly mentioned to me that John McCarthy was doing poorly, and had had several falls. I bristled at this thought that this great man was faltering. So I called him and invited myself over for a house call. His house was shuttered, the lawn was not mowed. John was down in a darkened room with an oxygen tube tethering him to his bed. A dark omen loomed.

I was agitated. I spoke, ”John if you don’t get your rump out of that bed, you’re going to die.” He didn’t flinch, nor did he make any actual display of distress at my insistence, much as he had filibustered my counsel over the years.
I visited John at his home several times a week for the intervening months, each time feasting on the incredibly rich banter that we created.

One month ago, as I was about to leave, he restrained me and said, “Walter wait a moment.” He managed to straighten himself out of bed, arose, and walked across the room. I was thrilled, as joyous a moment of success in a clinical sense as the resolution of an elevated temperature in a febrile patient, or the reversion to a normal pattern of a disordered cardiac rhythm.

Then yesterday I received a call I had somehow managed to avoid contemplating from John’s daughter. “John died.” I shuddered. But she generously said that my friendship was important to John, and that he had felt a real bond. Whatever small light that I might have brought to John’s candle pales in comparison to what John McCarthy’s friendship meant to me.

I feel a big hole somewhere within.

On Sunday October 16, 2011 Fauja Singh, age 100, completed the Toronto Marathon, an occasion worthy of an entire trainload full of champagne corks popping. Bigger than the Super Bowl, bigger than the World Series, bigger than the America’s Cup, bigger than the four-minute mile. Fauja Singh set the new world standard for the capacity of the human body and spirit.

For decades, I’ve been tracking the prospect of this moment. As a certified champion of what’s good about aging, I have lusted for this time to say “Hallelujah.” I rise to cheer.

Three years ago I was titillated by the fact that Buster Martin said to be 100 finished the London marathon. But the sleuthing of the Guinness record people discovered that he was only 94 — a different brand of Rosie Ruiz.

So the title of 100-year-old marathoner remained vacant until Sunday. Until that moment,the oldest marathoner record was held by Dimitrion Yordanidis, age 98, set in Athens, 1976.

My dear friend, Dr. Paul Spangler, my father’s Harvard Medical School classmate, gave up his medical career (he was chief naval medical officer at Pearl Harbor on December 7, 1941) to preach the gospel of fitness, which he did with great vigor. He ran the New York Marathon in 1991 at age 92. He charged me with helping him be the first in 1999 to duplicate this feat when he was a hundred. He didn’t make it, dying at 95 while running his customary 7-mile run in San Luis Obispo. Paul didn’t make it, but his shoe lacings did as I put them in my shoes as I ran that New York City Marathon in his honor.

So I have waited a long time for Fauja Singh.  He was born on April 1, 1911, in Punjab India. After his wife died he moved to London in 1992.  He spoke only Punjabi and cannot read or write (Wikipedia) At age 89, he took up running seriously, running his first marathon in London in 2000 and six others subsequently. His finish time in 2000, 6:54 at age 89, was approximately the same that I took when I ran London in 1997 at age only 68.

Last Sunday, it took him 14 minutes even to reach starting line. So, his corrected completion time was eight hours, 25 minutes, 17 seconds. “The Turbaned Tornado” was featured in advertising by Adidas, along with David Beckham and Mohammed Ali so his name is widely heralded and richly deserved. He holds innumerable age-group records, as did Paul Spangler.

A few years ago, we were at a small race in Palo Alto. I asked Paul what he thought his time was going to be the next day.  And he said, “I’m not sure what it is, but what ever it is, it will be a world record.” Maybe all of us should aspire to the same opportunity. So Fauja Singh joins my personal pantheon of athletes at the top. He has shown the world what a centenarian can do. I hope that his accomplishment will represent what Roger Bannister and Sir Edmund Hillary did — an inflection point — a signal for an avalanche of late blooming centenarian marathoners.

An evidence of this possibility is the record of the age group finishers in the New York City Marathon:

YEAR		AGE	MALE	FEMALE
1970	Ted Corbett (Only entrant over age 50)	50	1	0
1978		70-75	6	0
		75-80	0	0
1988		70-75	36	5
		75-80	9	0
		80-90	4	0
1998		70-75	81	14
		75-80	23	7
		80-90	11	3
		90+	1	0
2008		70-75	111	14
		75-80	28	6
		80-90	10	3
		90+	2	3
2009		70-75	125	23
		75-80	31	3
		80-90	9	3
2010		70-75	144	16
		75-80	36	6
		80-90	10	3
2011			?????	?????

XXX
So, as I contemplate March 20, 2030, I hope that I am still in training for Boston in April.

100 years ago the fledgling American Medical Association (AMA) and the Carnegie Foundation joined in an effort to redress the wretched state of medicine in America. Its scientific value was meager, but more important was medicine’s status as an enterprise, of charlatans and hucksters. The AMA and Carnegie sought out Abraham Flexner, a young Johns Hopkins graduate educator to lead the examination.

The resulting Flexner Report is widely regarded as the single most important document in the history of current medicine. Its scathing content targeted practice, training and process. 91 of the diploma mills were driven out of existence. A new model based on the Johns Hopkins example was made the prototype.

A century after this reformulation an immense gain in medical science is in hand. Yet the medical profession again receives failing grades. It is bankrupting, unfair, dangerous, corrupt, inefficient, inconsistent and irrelevant. It confounds our leaders.  It suffers from total body pain.  Another Flexner type effort is called for.

Thomas Kuhn, the historian from the University of Chicago  observed in his book “The Structure of Scientific Revolutions”  that in order to abet a true revolution two prerequisites must obtain. First, there must be a general agreement among the aggrieved parties that a change is demanded. Appeasement is futile. Second, there must be a replacement paradigm available of sufficient dimension and power to replace the failing model.

For the colonists of 1776 a revolution was mandated. Representatives from Massachusetts, Virginia, Pennsylvania, New York and the other nine colonies together signed a parchment declaring independence, a ringing statement of consensus. Nine years later, again in Philadelphia, a similar group produced the replacement paradigm in the Constitution, endowing democracy instead of monarchy. America was born.

For medicine, despite much unrest, these two requirements have lain fallow. But now there is a growing agreement that revolution is required. Doctors, patients, labor, industry, Democrats, Republicans, the meek, and the mighty are a chorus of distress.  On a recent Stanford visit Peter Orzag said that in order for America to get on with the rest of its business it must have a major resolution of the health-care mess. The first revolutionary requirement is fulfilled.

But even more importantly, for the first time in history, there is now a sturdy replacement paradigm.  This replacement is health, instead of the ruling mantra of disease. Now we know with precision the determinants of health. Until now, health has been a bland platitude. Albert St. Gyorgy commented that health to people is as water is to a fish, a presumption.

Now we know with precise metrics the determinants of health, just as we know the much more extensively studied determinants of disease.

The exposition of health is immensely empowering. It is empowering exactly because it validates the supremacy of prevention over repair as medicine’s modus operandi. Heart disease, diabetes, cancer, frailty, and AIDS are rarely curable, but are securely preventable by the replacement paradigm of health. And they are vastly cheaper, fairer, and more relevant. Kuhn’s required replacement paradigm becomes “Health instead of disease, prevention instead of repair. I call the new model “Next Medicine.”

The scene is set to fulfill medicine’s transformation, Flexner and Kuhn revisited. Medicine’s mission is the assurance of the human potential. Its current tools of surgery, technology and pharmacy make little dent on the overwhelming confrontations of diabesity (fat children) and aging. Its technology and pharmacology are irrelevant to our society’s needs.  Current medicine fails its mission. It is a square peg for a round hole.

The Centers for Disease Contol (CDC) conjures that ours is the first generation in the history of our republic when the children will live less long than the parents.

Fully 60% of our annual medical expense of over $2.7 trillion is attributable to behaviors that are perverted, and are preventable. Nurture not Nature is the answer. Health illiteracy is our biggest problem. It cannot be addressed by the current model of repair which is now in place, because it pays.  Capitalism is not the problem, but its product is illness instead of wellness. The fee for service model embraces sickness.

Perverse incentives now prevail. We must promote health instead of disease.  We must embrace prevention instead of repair. Health must pay.

Medicine’s primary job harks back to the mission of Asclepius and Hygeia: health. “Doctor” comes from docere, to teach. Learn it. Teach it. Live it. Save trillions.

Medicine needs a new Flexner Report that would recommend classrooms instead of what are now body-repair shops.

 

 

I confess to a long-standing interest in the history of science. Among the nuggets in my treasure drawer is the story of the encounter between Bishop Samuel Wilberforce (“Soapy Sam”) and Thomas Huxley,” Darwin’s Bulldog. This confrontation took place in Oxford’s Natural History Museum, on June 30, 1860, 150-years ago, to a full house. It is generally regarded that this event was a pivotal moment in the clash between religion and science.

A host of notables attended, including Admiral Robert Fitzroy who had accompanied Darwin on the Beagle. The program occurred during the annual meeting of the British Association for the Advancement of Science. Because of the eminence of the Bishop of Oxford and the recent publication of the “Origin of Species,” the stage was set for high drama. The organizers were compelled to change the venue to accommodate the overflow crowd.

Although we have no videotape of the conversations of that fabled meeting, legend has it that Wilberforce took the lead and quipped, “Huxley, I am eager to know whether you are descended from a monkey on your grandmother’s or your grandfather’s side?”

At this jibe Huxley is said to have commented to himself “The Lord has delivered him into my hands.” Then he replied, “I would rather be descended from an ape than a bishop who uses his great gifts to obscure the truth.” The pungency of this remark is recalled to have caused a lady in the audience to faint.

Being a huge fan of Darwin, this story has been precious to me since I first heard it years ago. It came startlingly to life again when I received a wonderful review of my new book “Next Medicine, the Science and Civics of Health” in last week’s issue of JAMA. The prestige of the journal and the academic venue of its author, the Harvard School of Public Health, represent a personal highlight. Within its highly favorable text, Jeffrey Levin-Scherz M.D. labeled my effort to reconstruct a new cheaper, more fair, safer, more honest, more efficient and consistent, more relevant political infrastructure “wishful.” If by “wishful” he means “idealistic,” he is right. I stand convicted of same, and I make no apology. To me the state of my profession is so grim that a full-throated revolution is required for realignment. Churchill commented that a chasm can not be crossed incrementally.

In my view, the forces are now aligned to justify Thomas Kuhn’s first requirement for a paradigm shift, namely a growing consensus that things are really bad. His second demand is the availability of a powerful replacement structure to insert for the defective one. For the first time in American political history this requirement is also fulfilled by the new science, which converts health from a bland platitude to a rigorous platform from which policy can and must derive.

Health is a choice informed by new knowledge. I put my trust in it instead of the greed-driven enterprise now in place. Medicine seeks a new punctuation and disruption in its way of doing business. No miracle is required, only a managed evolution to a new less-perverse process in line with medicine’s mission, the assurance of the human potential.

Now, here, we must react to this new imperative reality.

I think Huxley would agree.

Last Friday, the lead sports headline on CNN portrayed the departure of Dean Karnazes from Disneyland on his way on foot to New York. He proclaims this endeavor, “the most intense than I have ever undertaken.” He plans on running 40 miles per day, 14 hours per day, arriving in New York, 12 pairs of running shoes later, on May 11. He is 48 years of age.

I have met Dean numerous times at various marathon events. He is renowned for his 50 marathons in 50 days in 50 states effort, which makes my 40 marathons in 40 years seemed pretty paltry in comparison. Yet, I linger not on that thought. In fact, this highly ballyhooed event with daily TV and blogs with high profile celebrities cheering him on is yet another exhibit of the human potential, which I prize highly.

I immediately recall Annabelle Marsh, a good friend who died in San Francisco in 2008 at the age of 85. At age 61, she ran across America from Boston to San Francisco, 3,261 miles in 112 days, which averages 28 miles per day, and wore out 12 pairs of running shoes en route. She had a wonderful slideshow detailing the highs and lows of this trip, which she shared with her many friends in San Francisco. She was an esteemed member of our 50-plus running crowd at Stanford. Annabelle ran 100 marathons, the last in San Francisco, when she was age 73. But her particular specialty was the Pikes Peak Marathon, which she ran 20 times. I can attest to the rigors of this endeavor as my wife and daughter have both done it, and I crewed for them. We were all blue at the high altitude conclusion.

Through all these years and miles Annabel was lovely, actually beautiful. Her friendship was endless, and she gave any running occasion much class. So, Dean as you head east over the hills, along the way please look around for the footprints left by our dear friend Annabelle Marsh, who ran quietly with grace and dignity and with the courage that you exhibit for which we all honor you both.

You show us what we can do.

1. I am  energized to blog again, after Obama’s State of the Union address. I guess that re-energizing the people is the purpose of this message.
2. In my case, at least, it worked. On the 26^th of January 2011, I was nestled in the satisfaction that the recent publication of my seventh book, Next Medicine: The Science and Civics of Health, was accomplished.  I’m very proud of it. In my view, it is my effort to “capture the moment”, to “carpe the diem”.
3. As a devoted participant and observer of my profession for many decades, I feel that it is my solemn duty to address what I and most others identify as a huge problem in its ranks, I acknowledge fully my part in its problems. After all, it happened on my watch. But I relish the opportunity to pay back, hopefully in full measure, by proposing what I see as “A,” if not “The” solution.
4. First, in my book I list the symptoms of current Sick Medicine: cost, injustice, danger, corruption, inefficiency, inconsistency, and finally irrelevancy. The first six of these problems are huge in and of themselves, and are interconnected with the others.  In many of these domains the practices of Current Medicine are clearly perverse.  The cost of health care insurance is the largest cause of personal bankruptcy.
5. But it is the last symptom, irrelevancy, that is central to all the others. What I mean by irrelevancy derives from my nominated Mission Statement of Medicine: “the assertion and assurance of the human potential.”  If we can agree on the truth of this job description it is immediately apparent that Current Medicine is not congruent with the latter part of this mission, “the assurance of the human potential.” It is a square peg for a round hole.
6. In Next Medicine. I address the centuries’ long events which led medicine to its current operational format. Until Louis Pasteur of just 150 years ago, medicine was the province of scripture and shamans. Pasteur changed all of that. He showed that metaphysical objects were not the cause of mankind’s big assaults. Instead a bug was.
7. Rapidly medicine achieved a robust legitimacy for genuine human good.  Medical science was born. It achieved subsequent great success in addressing the acute infections which dominated our death certificates till recently.
8. This success led to a changed landscape. In less than a century, no longer did we linger and die from acute infections, but from chronic illnesses of diverse origins and courses. Further, the new Riders of the Apocalypse are not the ones where current medicine was appropriate. The twin tools in medicine’s black bag.
9. Surgery and pharmacy, the legacy of an earlier era, are irrelevant to the behavioral origins of today’s killers. We are therefore faced with a huge anachronism, facing today’s problems with yesterday’s treatments. The current killers are not curable. Heart attacks, strokes, diabetes, arthritis, much cancer are palliated, but not cured. Yet Current Medicine has become addicted to the great financial rewards, which are inherent in the old paradigm.
10. Zimmerman’s Law says “nobody notices when things go right.”  Health, although invaluable, doesn’t pay.  Or at least the way Current Medicine is practiced.  Health promotion and disease prevention are not billable items.

Therefore we need a new direction, a drastic cure, we need a system transplant.  We need a total reconceptualization of our system with different personnel, from subspecialists to expanded primary care providers at different levels, we need different personnel training, recognizing that the intensive care in the hospital should not be the primary locus of M.D. training. The home and community should be. The payment for medical care should not be fee-for-service, but pre-paid. We should reformulate so that health is the product we are selling rather than disease. We need a health care, not a disease care system.

This is the message of Next Medicine.

I am certain that these two terms, EWAS and GWAS, are unfamiliar to almost everyone.  They certainly were to me as recently as Wednesday of last week, during the never-varying time for the weekly Grand Rounds of the Department of Medicine at Stanford Medical Center. The speaker was Atul Butte, my friend and colleague. Atul is the poster-boy of the hundreds of gene jockeys who hang out at Stanford, all of whom have been aggregated by the rich history of gene discoveries made here. A number of Nobel Prizes attest to the eminence of their research.

I have challenged Atul on numerous occasions because of his total immersion in the search for understanding of the central role of the gene, sometimes referred to as “The Holy Grail.” My intellectual challenge favors the environment in which the gene operates. My shorthand for this perspective is, “It ain’t the cards you’re dealt that matter so much as the way you play the hand.” The gene in its environment goes by the other term, epigenesis, which is increasingly recognized by scientists as the more-likely determinant of health.

Meanwhile the geneticists and the huge industry that has grown-up to support them, have been furiously pursuing a vague protocol that presupposes that genes are connected to diseases. This has generated the term, Genome-Wide Association Study (QWAS). Billions of dollars have been invested and spent, and trillions of pieces of information are available online to display these supposed connections.

Atul has been the leader of the parade of these studies. This last Wednesday morning at Grand Rounds he humbly acknowledged the poverty of these results, as he estimated that perhaps 6% of the major diseases could be explained by current gene analyses, through the GWAS.  The remaining 94% remains to be accounted for.

One of the principal diseases under study has been type 2 diabetes. Many thousands of gene analyses have yielded virtually nothing. The cover stories of both Time and Newsweek recently asserted that heredity is not destiny. Thus, these articles are another acknowledgment of the role of the environment,

Now we well know the causes of type 2 diabetes, which primarily are too much food and too little exercise. One of the highest incidences of type 2 diabetes in the world is with the Pima Indians of Arizona.  When these folks pursue their very physically-active lives south of the border, in Mexico, they have no diabetes. But as soon as they cross north of the Rio Grande, they find McDonald’s and a far-more leisurely life.  They soon thereafter develop diabetes. Their genes certainly have not changed during their trip north, but their lifestyle did.

Consequently, Atul and his buddies are expanding their bandwidth. Hence, the new term,  EWAS, short for Environment-Wide Association Study.

I have been fortunate to have intuited that this field would eventually emerge.  Though there are few gene studies pertaining to exercise, it’s obvious that exercise will not affect the presence or absence of the genes themselves, but rather their expression, their activation.  This fact effectively yields the basic reason behind the glaring but under-explored fact that exercise is good for everything. The work of Frank Booth in Kansas has been particularly productive, since his award-winning work has helped us understand how cellular and molecular mechanisms respond to exercise both anatomically and physiologically.

Now the field of genetic research is being validated, because of the expansion of its view to include the role of environment in gene expression within the realm of the EWAS. We can only hope that some of the glamour of the nonproductive GWAS will be transferred to its new derivative, EWAS. This is where the real action is going to be.

Medicine, like other cultural fields, contains a feature called structural lag, in which a latent period of lack-of-progress is followed by a new era in which grand comprehensive insights may flourish.

I am immensely cheered by the prospect.

Sometimes, as an intitial assessment of a person, I ask, “Who you think you are going to be when you are 80, or 90 or 100?”  The common answer, “That’s not a reasonable question, because I don’t think I’ll still be here at those ages, or maybe I might still be here, but I’ll probably be in a forlorn nursing home with an oxygen tube in my nostril, while endlessly contemplating the Styrofoam squares in the ceiling.”

I reply, “If you say you’re going to be dead or in a nursing home when you are old, you will be,” because aging is a self-fulfilling prophecy.  Every day, in every way you’re acting or reacting or not acting in such ways as to guarantee the accuracy of your prediction

Norman Cousins, the great literary humanist, proclaimed the many health benefits of optimism and commented, “Nobody is smart enough to be a pessimist.”  There is absolutely no question that depression is hazardous to your health, and the answer to depression is not pills, but a major attitude adjustment.

Martin Seligman has written extensively on the hopeless helpless syndrome.

When you give up on life, life gives up on you. But who you will be at 90 has other dimensions. Ben Levine, who used to be one of our outstanding medical residents at Stanford University, is now the director of the important Dallas Bed Rest Study. In it, healthy volunteers are recruited for a study protocol in which they are put to bed while a variety of measurements are carried out. The group’s conclusion: 2 weeks of bed rest is biologically equivalent to 30-years-worth of aging.

The Native Americans used to think that it was dishonorable to die in bed.  Now we know why.

All of us are our own forecasters in one way or another, guided by experience. One of our principal guides is the health history of our parents and grandparents, and the projection of their stories onto our own future trajectory. For me, my 4 grandparents died in their 60s and 70s of diabetes, cancer and pneumonia.  This was pretty much expected of them in the 1930s; my dad died at 74, like his parents. And I’m still mad at him for exiting so early. But Mother lived to 95, widowed for 22 years, the last survivor of 12 children.  She died healthy, with no medicines or symptoms. Mother was confused about being so old. She didn’t know how to act her age, but who does at 95?

Mother lived to be 95 not because her parents were long-lived; they weren’t. And she certainly did not live that long because of health advisories from her physician husband and physician son, because she perversely disregarded anything we ever said to her. Mother lived to 95 because he was designed to live till 95 and beyond.  She fulfilled most of her biologic pedigree.

One of mother’s assets was her vanity. She insisted on wearing shoes with a small heel, which made her tottery and subject to falls, of which she had several.  But she disregarded any comments that were made about these.  And she kept falling.

I know that she didn’t plan to live to 95, but more and more of us are reaching that age and beyond, and more of us will — as the years accumulate.  Just like the four-minute mile, and climbing Mount Everest, once it is done, it becomes progressively easier for the rest of us who seek to up-regulate our expectations and our prophecies

That’s why I wrote the book “Dare to be 100,” I claimed that achieving this new reality depended essentially on 2 prerequisites, guts and smarts  — the  smarts to recognize that 100 is really our birthright, and the guts to have the courage to get of bed each morning and say YES! to life.

Such is the exhortation of the dawn.