When should you die?
By Daniël Erasmus
Jumping jacks. We have all done them. At school. In preparation for sports. And for those of us that can remember breakfast exercise programs on the television, we have done them in neon track pants and matching sweatband.
The Jumping Jack was named after Jack Lalanne. Jack can in many ways be considered the father of the modern concept of fitness. He was the first person to start a health spa or gym, he was one of the first people to promote healthy eating and exercise as a path to a longer and better life via television. He was also the first person to host a morning exercise program as part of the breakfast show. Queue the neon track pants and sweatband.
Jack’s philosophy was that if you looked after your body you would live a good life and die at a ripe old age. Jack did just that. He passed away in 2009 at the age of 96, having performed amazing feats of strength and endurance well into old age.
Today the fitness industry and marketing around healthy living is bigger than ever. We are made to believe that if we do this and (don’t) eat that, we will be able to match Mr. Lallene. So why are we still seeing so many people die a slow and agonising death? As a healthcare actuary, I am constantly faced with increasing disease burdens and having to price for the ever-increasing cost of healthcare related to ageing.
Research has indicated that mortality improvements have slowed down in recent years; in some populations the trend has even reversed. This means that for those populations, people born 10 years ago will become older than those born today.
In many ways, the developed world seems to have gotten worse at dying while getting better at living. We seem to believe that life is a uniform good in terms of volume and that more is always better. In the developed world we now have more people dying in hospital at older ages than ever before. Contrast this with data from just a generation before where the elderly predominantly died at home among friends and family.
Atul Gawande put it best in his book Being Mortal: Medicine and What Matters in the End. “Death is the enemy. But the enemy has superior forces. Eventually, it wins. And in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knows how to fight for territory that can be won and how to surrender it when it can’t, someone who understands that the damage is greatest if all you do is battle to the bitter end.”
This makes me think of a talk I heard at the International Actuarial Convention in Washington in a few years ago. It was opening night and the keynote address was being delivered by Professor S. Jay Olshansky. He called himself a thinker and in true American fashion noted, “Basically I am a really smart guy.” He considered if we would ever reach an average age of 100 as a species. For some time, he talked about the dangers of linearly extrapolating longevity trends and that there are several factors at play… Suddenly he stopped, turned to the audience and said: “I do not think that we will ever reach an average age of 100, it would really suck if we did. It would be like a car being driven way past its warranty, eventually everything breaks.”
And herein lies the dichotomy of the Jack Lallane philosophy and the emerging results in terms of longevity and healthcare. To use another quote from Atul Gawande, “Our ultimate goal, after all, is not a good death but a good life to the very end.”
New technologies are constantly pushing the boundaries of what is possible in terms of healthcare and “fixing the parts on the car that break”. But there are many pieces at play in terms of “a good life to the very end”. One of which is dying with dignity and on terms that resemble the life lived. As an actuary, I think it is time we start to think about when that is, rather than simply how long will we live.
I recently delved into this question and looked at the primary factors related to the quality of life at advanced ages. Using our rich healthcare data, as well as information from the life insurance, investment and financial industries I constructed a quality index termed the Quality Adjusted Aging Index (QAAI).
The index can be expressed via a decay function to determine a Maximum Quality Adjusted Age (MQAA). This is the age by which the QAAI is expected to rapidly decrease in each consecutive year with a near zero probability of it stabilising. It is the age by which you will no longer be living a good life. Put simply, you want your age at death to always be smaller than your MQAA.
The aim of the QAAI is to consider the value of cross-sectional collaboration across industries to help people live better lives. The applications and possibilities for such an index are multiple and very exciting. For one it forces us on the insurance side to think “how do my policyholders live, right to the end” rather than just thinking “date and cause of death”. If you would like more information on the index, how it is constructed and how it can be leveraged in the market please contact us.