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In 2021 Dr. Kiran Rabheru, a professor of psychiatry at the University of Ottawa and a geriatric psychiatrist, found himself at the center of a medical debate. The World Health Organization wanted to officially designate “old age” as a disease, but with more than 40 years of work with aging populations, Rabheru saw this as another example of ageism that needed to be challenged. Dr. Rabheru talks with Yasmin Tayag about how he fought the WHO and about the impact such designations can have on research and our understanding of growing old.
The following is a transcript:
[Phone ringing.]
Natalie Brennan: I’m Natalie Brennan, producer at The Atlantic.
Yasmin Tayag: And I’m Yasmin Tayag, a staff writer with The Atlantic.
Brennan: You’ve reached How to Age Up. Leave us a voicemail after the beep.
[Beep.]
Jennifer Motiff: Hi. I am 60 years old.
Toscan Lahy: Most people think I’m 45, 50, but I’m actually going to be 63.
Marla Mclean: And I am 60-wonderful years old. That’s 61.
Brennan: Yasmin, over the last few weeks, we’ve been asking people to call in and tell us their age and about some of their experiences of aging.
Myron Murray: I’m 75 years old. Thank God I’m Italian, and I don’t wrinkle, so I don’t look my age. I feel 20.
Susan Brown: My age is almost 80, so I am actually aged, not aging.
Doug Rutholm: I’m 88 years young. I’m only 88, and I’m married to a younger woman: only 85. So one of our secrets is youthing. We’re not aging, we are youthing. And we eat well, we exercise, and looking forward to getting older. But we’re getting younger. So that’s it. Bye-bye.
Tayag: Youthing! I like the sound of that!
Brennan: Not wrinkling because I’m Italian … I like the sound of that! But as I was moving through the collection of voicemails, I noticed a pattern. We also received a lot of callers sharing very similar anxieties about the unknowns of what could lie ahead …
Gary Schuberth: And what aspects of aging am I nervous about? Living to a very old age, and not being very healthy.
Jes Chmielewski: I am nervous about feeling older. Just all the aches and pains and failures of organs and body parts.
Jennifer Moffat: The things that make me nervous about aging are just physical breakdown, like, I don’t want to break a bone. I don’t want to get cancer.
Stella K.: I’m really afraid of getting dementia. I mean, it just seems like a terrifying thing, and the older I get, the more afraid of it I am.
Brennan: And Yasmin, you know, we asked about aging, and we heard a lot about disease and decline.
Tayag: Yeah. I mean, I’m not totally surprised to hear that people are worried about getting sick as they age. I mean—I do think culturally we conflate aging and disease. It actually made its way to the center of a debate in the medical field. A few years ago, the World Health Organization tried to connect aging and disease more officially.
Brennan: How so?
Tayag: Well, they proposed defining aging itself as a disease.
Brennan: To make aging a disease?
Tayag: A classified disease. In the ICD—The International Classification of Diseases.
Brennan: What benefit would that have?
Tayag: Well, the idea is that if old age is officially considered a disease, then drugs can be developed to treat it … the way we have drugs to treat diseases like diabetes and cancer. So a lot of it comes down to funding.
Brennan: But how do you treat old age? Aging is … time passing. How do you stop that?
Tayag: You make a good point! And these kinds of details are exactly what I wanted to know more about.
Kiran Rabheru: We don’t have a good clear definition of old age. And that is still up for debate. What is old age?
[Music.]
Tayag: Natalie, that’s Dr. Kiran Rabheru—he’s a professor of psychiatry at the University of Ottawa and a geriatric psychiatrist. He’s been focused on aging populations for over 40 years. And he spearheaded the team that challenged the World Health Organization when it wanted to officially designate “old age” in the ICD. But before we get to that, it can help to know more about Dr. Rabheru and why he’s so interested in aging populations.
Rabheru: That’s an easy one: my grandmother.
Tayag: Oh! Tell me more!
Rabheru: [Chuckling.] My parents were, they were around, but they were busy: setting up a business and so on. And when I was growing up, my grandmother was the main sort of person in my life. She had a huge amount of influence on me. She was not educated. She couldn’t even write her own name. But she was, in my opinion, totally biased, probably the wisest and smartest person I’ve ever met in my life. And every time I see an older person, I see a bit of her in them.
Tayag: That is lovely. So how did that shape your view of older people? You had, what sounds like, the privilege of getting to know a grandmother. But that hasn’t always been common, right?
Rabheru: So aging, historically: If you go back a century or two, if you look at the numbers, if you were walking on the streets in the year 1800, most people would not have been old. You would hardly see an older person. Most people died by the time they got to the age of 30.
Tayag: Yikes; I would have been long gone.
Rabheru: If you fast-forward a hundred years, if you were walking around the streets in 1900, most people would be no more than 40. So there’s a difference of 10 years in that 100-year span. But if you fast-forward another hundred years, in the year 2000, that number went from 40 to 70. So now, even across the lower- and middle-income countries, most people live to old age. So, on one hand, we’ve increased the lifespan of people. But on the other hand, we have devalued that population.
Rabheru: And therein lies the crux of the matter that we’re talking about, and that is the way people think and feel and behave or act towards the whole aging population.
Tayag: So it sounds like there have been some big, positive improvements for aging, but that may have led to an increase in the disparaging thinking we call ageism.
Rabheru: It’s very subtle, and it’s largely unconscious, and it’s institutionalized. It’s part of our policies and laws, and it’s part of our processes. It’s structures, in every sector, and that’s embedded as an unconscious bias.
Tayag: Sure.
Rabheru: The COVID-19 pandemic really shone a light on the gaps we have in our system, particularly towards older people. And ageism became so much more rampant. The future is not about young versus old. Although our government sometimes tries to pit the old against the young. But it’s about designing a society where everyone, at every age, can live together with dignity and purpose and opportunity.
Tayag: One thing that I think makes those conversations difficult is that we don’t have agreed-upon language to talk about age, and our society’s perspective on aging seems to reflect that. Like, to me, our conception of age seems very rudimentary. Old and young are relative terms. I understand that one of the attempts to assign a definition to old age came when the World Health Organization wanted to classify it as a disease in the ICD. Can you explain what that actually means, and the implications for how we think about age and illness?
Rabheru: Oh, Yasmin, absolutely. I used to teach the course on classification diseases, and classification is really important. It’s not perfect. We have to adapt it as societal values change and our thinking changes, and we gather more data. Biologically, the environment changes, and we need to change the classification system to match it, right? The ICD is not published every year. It’s published every 10–15 years apart. So, once it’s in there, it can change a whole generation of people going through the treatment and through the hospital or clinical system.
Tayag: You know, I’m thinking, for example, of alcohol-use disorder. You know, it used to be seen as this moral failing, a failing of willpower. And then it was classified as a disease, and that seemed to change some of the cultural thinking around it. So that’s an example of defining a disease that really helped the culture find more empathy—and also more investment in the recovery and success of many people. Could you give me an example of a condition that, you know, went through the process of being considered and classified as a disease but is no longer considered to be one?
Rabheru: You know, we’ve gone through “diseases” like homosexuality—classified as a disease. And think about the stigma associated with those terms. We don’t use them anymore. And words matter; it tells people what value you place on that human being.
Tayag: It’s so obvious to me that these official classifications matter. You know, it makes me think of the legalization of marijuana in Canada. where I grew up. My parents were always super strongly opposed to it. But ever since it was legalized, I’ve noticed their tone softening a little. It’s not like they’ve gone and flipped and started using it, but now they talk about it as a thing that some people do, and that’s okay. And it’s been fascinating to watch that shift just because there is some sort of, like, binding declaration of this being legitimate.
Rabheru: Exactly.
Tayag: So I want to talk about disease classification specifically in relation to aging. In December 2021 you found yourself in the middle of some very high-stakes deliberation. Set the scene for me.
Rabheru: It was the most fascinating experience, I’ve got to tell you, Yasmin. As part of my work, I’ve worked with a lot of people, across the world, that lead different organizations in aging. And it came to our attention that the WHO was updating the International Classification of Diseases, the ICD. And part of the changes that they were proposing was to include “old age” as a disease.
Tayag: Wow; just old age.
Rabheru: Just old age, quote, unquote, as a disease. And, you know, look: The WHO is highly respectable. but it’s an unconscious bias. And this is an example of ageism within WHO. Now, in March of 2021, the same organization put out the global report on ageism. To combat ageism.
Tayag: It seems a little hypocritical.
Rabheru: In the same organization. Yeah. So we wrote; we got together and we organized a campaign. There were like eight or 10 different organizations that all wrote to the WHO, and collectively we represented millions of people across the world. Our team and the people that I work with immediately thought: Aging is a privilege. That’s not the disease. And you know, look. As a clinician, I know that it’s not always easy. The older people are much more challenging to see and treat because of the multiple medical and psychosocial conditions they have. Having a diagnosis of “old age” would automatically just lead people to put them into that category, that “This person’s just old”—and they move on to something that’s easier to deal with.
Tayag: Well, one of the big questions that the proposal to call aging a disease brought up for me was: Where do you draw the line? Where does aging start?
Rabheru: It’s not the age. Like, Yasmin, if you have a car accident and you can’t walk tomorrow because of a spinal-cord injury, you would have the same level of intrinsic capacity as someone who’s had a stroke at the age of 80. So the number, chronologically, is—not that it’s not important; it is a risk factor, of course. Every organ ages over time. So it is definitely part of the risk factor, of course, but it’s not the main driver of functional capacity.
Tayag: And so what happened next after you wrote to the WHO?
Rabheru: They did, in fact, give us, four hours of their time. It was Thanksgiving Day!
Tayag: Thanksgiving Day?
Rabheru: And we went through it in a systematic, scientific way. And we explained we understand what they’re trying to do, and they want to go after the biological aspects of aging—which absolutely we need to do! There’s no question. There is a lot of pathology that we can reduce the risk of, etcetera. But to call old age a disease is not going to play well in society.
Tayag: Okay; so sounds like it was a worthwhile way to spend your Thanksgiving that year.
Rabheru: Totally, 100 percent.
Tayag: So how did it turn out?
Rabheru: They came back to us a few weeks later saying they’ve met several times, and they’ve decided to change it. We were very happily shocked that they rescinded it. And that was the right thing to do. We were very pleased. Aging is universal and should not be pathologized. And it’s time to reframe aging in a more positive way.
[Music.]
Brennan: Okay, Yasmin, I want to work through some of this tension I’m feeling.
Yasmin: I can see the wheels turning.
Brennan: I’m having a hard time. Because hearing Dr. Rabheru talking about challenging the WHO—it does sound like a win for how health professionals and society in general think about older people. And, as we know, this perception has tangible effects on the care and treatment that people receive. So that’s a win!
Tayag: Yeah.
Brennan: But I’m still trying to work out if treating aging is a worthwhile pursuit or not. On the one hand, I’m like, Okay, if we think about aging as time. And time has a physical effect on our cells—building up damage, getting worn out. I could understand a world where we are working to heal or repair that damage, and if we were able to do that, I am guessing it would relieve some of the anxiety that we heard in so many of the voicemails we received. But at the same time, I’m like, What does treating aging even look like?
Tayag: Well, there are existing drugs that are being repurposed to maybe slow aging.
Brennan: Okay, so what does that mean?
Tayag: Metformin is used for diabetes. Rapamycin is an immunosuppressant. And researchers are trying to determine if those or other existing drugs could slow the passage of time for cells, or clear out old cells, or the molecular junk that time leaves behind.
Brennan: I have Timothy Caulfield in my ear from Episode 1 telling me to assume nothing works! I’m skeptical about the ability to achieve these things. And I’m just immediately wondering if something else is going on here.
Tayag: I mean—a lot of this does come down to money. There’s a hope that there will be more investment in research on slowing aging. Which, in turn, will save money in the long run, because if people get sick less often as they age, it will bring down the costs of health care.
Brennan: Hmm.
Tayag: So that’s one argument for exploring it. There was a report in 2021 from the Medicare Payment Advisory Commission showing that much older people tend to be the most costly to the government, health care–wise.
Brennan: Right. I guess what I am trying to understand is: Although aging is not a disease in and of itself, and it should not be classified as such, it is associated with disease, right? And we could work harder to address the concerns that people have when it comes to aging.
Tayag: Exactly. So aging is a risk factor for disease. But aging itself isn’t a disease. This was something I was really trying to work out, too, when I was talking with Dr. Rabheru.
[Music.]
Rabheru: It’s a risk factor. Aging is a risk factor—in fact, the strongest risk factor—for cognitive impairment or dementia, barring, you know, all other illnesses. So, if you have a stroke or a genetic predisposition, that’s different. But if you’re healthy and you’re getting older, the biggest risk factor is aging. One in three people by the time you’re 80 will have some form of dementia, regardless of any other conditions. And the biology of that should be explored to mitigate it.
Tayag: Being a science journalist, I’m always looking at new research going on. And it does seem like there is continuing research that still treats aging like a disease, even though the World Health Organization decided not to classify it that way. One thing I saw recently was an effort to delay or stop menopause altogether, which is complicated, right? Because, on the one hand, the symptoms of menopause can be really tough to deal with. And not to mention, the way that postmenopausal people are treated in society. And so I can understand why there’s a desire to delay menopause or stop it altogether.
Rabheru: Mmhmm.
Tayag: But, on the other hand, menopause is a part of aging. It’s just a normal life stage.
Rabheru: Exactly.
Tayag: And it’s in these sorts of questions that I’m not really sure where to fall.
Rabheru: The solution depends on what your agenda is; like, where you put your values. So for example—if your values are coming from the financing side of things, the aging industry, the anti-aging industry, is huge.
Tayag: Oh yeah, I have been victim to a lot of face creams.
Rabheru: There might be things that you can do from a scientific point of view, from a medical point of view, to make the person’s life better. But to completely alter the course of a human being: Just because you can doesn’t mean you should, right? We don’t really understand the medium- and long-term implications of doing some of those things. And the science is advancing so quickly with AI and with technology, but the long-term ramifications of what it does to humans and our society are not well studied.
Tayag: Okay, so we don’t know if reversing or stopping aging is even going to work, and you’re saying it’s something that maybe we shouldn’t pursue. Yet we still have this problem of people assuming that old age means they will get sick. But, you know, I think a lot about my grandfather-in-law. He’s 96 years old and walks two miles every other day!
Rabheru: Good for him.
Tayag: He’s my hero. He’s awesome. And so, he’s definitely old in numbers, but I would never think of him as unhealthy. Nobody would.
Rabheru: Or worth less!
Tayag: Or worthless, exactly.
Rabheru: The older population is growing. We have, you know, we’re going to—we’ll have billions of people by the year 2050 who are older. And that’s a resource; that’s not a burden. If we keep them safe and healthy and happy, they can provide support for the world.
[Music.]
Brennan: Okay, Yas, I have to admit when I hear those statistics about risk for diseases as you age. I do pretty immediately tense up. Disease does still sound so inevitable to aging.
Tayag: I hear you. I mean when I think about my family’s heart-health trajectory, I feel like it’s inevitable that I’m going to get all the same diseases as my parents as I get older.
Brennan: Oh my god, I hope my dad isn’t listening right now, because I had slightly high cholesterol this year, and I couldn’t bear to tell him after years of me pestering him about this. [Laughter.] Here I am on my little lentil-and-sweet-potato high horse, and I still had slightly high cholesterol. Meaning the same genes that came for his heart might just come for mine.
Tayag: You know, I have been on this same spiral lately!
Brennan: Yeah.
Tayag: But have you heard of the concept of healthspan?
Brennan: I have not.
Tayag: It’s what comes to mind when I think about my grandfather-in-law. And all the other older people who called in telling us how they’re thriving and living their best lives. Healthspan is the idea of extending the period that a person is healthy. And that’s different from lifespan, which is about how long you actually live.
Brennan: Okay so, instead of trying to live longer, until 105, it’s about making it longer in your life without disease?
Tayag: Exactly. Just like: staying healthy for as much of your life as possible, no matter how long you live. Which is the case for a lot of older people.
Brennan: Okay—how do we do that? How do we extend healthspan?
Tayag: So we don’t know how to guarantee an extended lifespan yet. But we do know how to increase healthspan: Eat well, exercise, sleep a lot, connect with people. It’s all the stuff we’ve been talking about this season.
Brennan: And did Dr. Rabheru have any more advice, too?
Tayag: Well I thought you might ask. So I asked Dr. Rabheru what his advice to his patients is.
Rabheru: So for many, many years, I have given the same prescription to every single patient I see.
Tayag: That’s after the break.
[Music.]
[Midroll.]
Tayag: Dr. Rabheru, I have one last question for you. As a person who is aging yourself, like all of us are, what is one piece of advice you think we could all benefit from?
Rabheru: Well, I’ll tell you—so, for many, many years, I have given the same prescription to every single patient I see. When you leave my office or clinic or hospital, when you go home, here’s my prescription for you. It’s the rule of 20s. So: I need you to give at least 20 smiles a day. Okay? Because as soon as you’re smiling, it changes the way your brain works. Second is to do 20 minutes of activity of some sort; and I usually say walking, because physical activity is really important for health, right? But try and get 20 minutes of walking. And thirdly: Socialize for 20 minutes a day. And not just with the person you’re living with; that’s fine too, but try and do something outside of yourself. So, those are three basic things you can do, and then all the treatment I give you will be much more effective.
Tayag: I love it; the 20 rule. I’m going to do this today. It seems easy enough. I’m smiling a lot after this conversation, and so I smiled a lot. I’ve talked to you for way more than 20 minutes, and I guess I just have to go on a walk later. Dr. Rabheru, thank you so much.
Rabheru: Likewise, Yasmin; thank you.
[Music.]
Brennan: Yasmin, I do think that a really important part of this conversation is making sure we highlight the aspects of aging that people are excited about. When we asked listeners for those voicemails, we didn’t just ask what people were nervous about as they aged.
Sue: What are you looking forward to? Well, the biggest thing is no more shoulds. I’m tired of shoulds. You should do this. You should do that. I don’t care about shoulds anymore, and the freedom of doing what I want when I want to.
John Shuey: What are you looking forward to as you age? Well. Staying mobile and fit and able to get around. And I really do get around. I, despite my age, I can shovel snow for two hours. I ride bikes 35 miles at a time. I just, I basically feel like I’m 40. Is there someone in your life who has made you excited to get older? And yeah. It’s this girl from high school. I married her, and we have a great time together.
Lynn Clark: I wanted to leave this message for all the women who are nervous about aging. At age 30 I started my own business. I’ve raised two children and was widowed by age 59. At age 60, I started weight-resistance training and cycling. I am slowly backing out of my company towards full retirement. I moved part-time to another state, something I wouldn’t have dreamed of when I was younger.
Susan Anthony: I do stand-up comedy. I do all sorts of weird and wonderful new sports, whatever really takes my fancy. And I kind of enjoy that, and I can just, like, head off in whatever direction I feel like. And all of it is about just that desire to continue to grow. The next question you had was: Who do you hope to be like when you are older? That phrase that I think Clint Eastwood is known for—“Don’t let the old man in”—and I think that’s really where the secret lies. I see so many people who just let the old person in, and I don’t want to do that. And so I admire anyone who really doesn’t allow that to happen.
Tayag: Don’t let the old man in.
Brennan: Or, maybe better: Change your idea of what the old man is like!
Tayag: Right. My dad is on a 70+ senior basketball team, and I like the old man they let in. Like, they are just always looking forward to the next game, the next tournament, and just getting to hang out. And they’re still so excited for what’s to come.
Brennan: Yeah, I think for me it’s like: healthspan, lifespan … I want to extend my curiosity-span.
Tayag: Zest-span.
Brennan: Joie de vivre–span.
Tayag: Exactement. Looking forward–span.
[Beep.]
Myron Murray: I want to see ’em land on Mars. I want to see ’em land and live on the moon. I want to see all the new things that are gonna come and we’re going to get to see.
[Music.]
Tayag: That’s all for this episode of How to Age Up. This episode was hosted by me, Yasmin Tayag, and co-hosted and produced by Natalie Brennan. Our editors are Claudine Ebeid and Jocelyn Frank. Fact-check by Ena Alvarado. Our engineer is Rob Smierciak. Rob also composed some of the music for this show. The executive producer of audio is Claudine Ebeid, and the managing editor of audio is Andrea Valdez.
Brennan: Next time on How to Age Up:
Tayag: Looking to the future doesn’t always feel easy when climate issues loom large.
Sarah Jaquette Ray: It’s not about taking shorter showers. It’s really about kind of setting up your brain when you consume this information.
Tayag: How to age up in a world affected by climate change. We’ll be back with you on Monday.
