Dr. Michael Birt on Aging, Caregiving, and Connecting Technologies for Better Outcomes


This is Alan Pitt with Healthcare PittStop. Today I’m joined by Michael Birt, who focuses on promoting healthy longevity. Dr. Birt is based in Seattle but has traveled extensively in support of health and the life sciences throughout Asia, Europe, and the United States, writing and speaking frequently on how connecting technologies can deliver better health outcomes, particularly for older adults and, importantly, for their care providers. He’s also been a senior adviser to the Campaign for Healthy Longevity with the Personal Connected Health Alliance. I got to know Dr. Birt during his time at ASU, where he was involved extensively with innovation for the University. Michael, I want to thank you very much for joining me.

MB: My pleasure. Looking forward to it.


AP: I went through some of your writings on the web, and because it’s a passion of mine as well I wanted to talk about what it means to live well and how we can improve the lives of our elderly citizens. It shouldn’t be that when we retire we just kind of disappear. At a recent conference on designing healthy longevity there was a consensus that aging is a distinctly personal experience and that we age differently. Can you explain that a little bit?


MB:  We need to frame this. The issues we’re facing now in the 21st century are in some ways unique human experiences. In looking back in human history, we just haven’t had to deal with some of the larger issues we’re facing now as we deal with this truly global issue of rapid population aging. People are living longer. But the important parallel phenomenon that goes with that is that we are also experiencing a rapid decline in birth rates. Those work in tandem to change the entire experience around aging.


Historically we tended to have a small number of people who would live into advanced age—and by the way lifespan has not changed over the last several decades or centuries; the longest that someone can live hasn’t changed much. So what we’re talking about here is what percentage of our population lives into advanced age. That’s what’s really changed, that in the 20th century what we were gifted with was about 30 years of added longevity on average to human life, thanks to better sanitation, vaccines, public health, and crucially at the end of the 20th century, interventions and cardiovascular care disease. Cardiovascular care really changed how long people could live.


So we’re living 30 years longer on average thanks to all those interventions—better nutrition of course would fit into that as well. But what’s really key here to what aging looks like in the 21st century is that we’re flipping the entire demographic pyramid on its head. Whereas 5 percent of the world’s population was over 65 in 1950, it’s going to be 15 percent in 2050. And the under-five population mirrors that in reverse. So we have a much older world and many fewer people to take care of us.


AP: I can’t imagine how that shrinking base is going to take care of that enlarging population in need of care. That is the challenge of our time, really, as to how to help those folks age gracefully.


MB: Absolutely. And it’s playing out everywhere in the world, even in places where the cultures are defined by respect for your elders, for example in Asia where I have spent so much of my career: in Japan, China, Korea, Singapore, Taiwan, which are Confucian societies. And the number one Confucian value is to take care of your elders. How do you do that when all the population dynamics are reversed and then add to that, in a country like China, the rapid urbanization of society that has pulled almost a half a billion people into cities, leaving the elderly behind in villages. How, in a Confucian society, do you honor your elders when they’re a thousand miles away?


So, even China, which is where Confucius came from, is dealing with this. They even have a law now where you can sue your children for lack of care under a Confucian system. And then in a place like Japan, what we’re looking at is the rapid aging of society. A baby girl born today in Tokyo will on average live to be well over 90 years old. Well that’s an enormous human society success. What could be better than that? But what we see—and we’re still 20-30 years away from the full drama—is that there are large areas of Japan where 40 percent of the population is over the age of 65.


AP: That’s incredible. As you point out, this is a problem for the developed countries throughout the world. Are there any countries that you think are dealing with this problem well?


MB: Traditionally the countries that have done the best job are the Scandinavian countries, such as Sweden and Norway, and European countries. France has done a good job. But here’s the difference [when you look at] the metrics we use for population aging and demography: Those societies literally had a century to go from 7 percent to 14 percent of their populations over the age of 65. Whereas if you look at countries in Asia—Taiwan or Korea or Singapore—they’re making that transition from 7 to 14 percent in 20 to 25 years.


So the velocity of the change creates an entirely different magnitude [as regards] policy and societal and cultural issues that countries like Norway, Sweden, France, the United States, and Canada haven’t had to face because it’s [happening in] one generation literally. Then [add to that] the precipitous decline in birth rates. To give you an example, the city of Shanghai has a less than 1.0 birth rate and needs 2.1 as replacements. So the economics of success—urbanization, cultural values, education of women—has had a huge impact. These are all positive things but they play out differently, and it’s very difficult to control those kinds of macro societal issues.


AP: I’ve been reading Thomas Friedman’s Thank You For Being Late. In it he discusses the human ability to adapt, which is largely linear, and the logarithmic or Moore’s Law effects of technology. And there’s this separation—I’ll call it the “delta of discomfort”—that is developing, where changes that we make are much greater than our ability to adapt, and they cause all sorts of problems. Friedman suggests that this is a bad thing, but it may be that he has some hope for the future that technology will be able to come to the rescue somehow, correcting this delta of discomfort. Do you see any of that in the technologies you’ve seen, ways, processes to take care of the elderly with this burgeoning top-heavy half?


MB: What we’re seeing is a kind of hockey stick curve when people talk about technology adoption. I think we’re still very early in some of these 21st century technologies. But let me provide two very different examples of what would cause reason for hope.


One is low cost robotics and all the different ways it will create ways to assist people in aging in place. And that’s a global undertaking. One of the really exciting elements here is that issues of aging are global but now so are the technologies in response. And there’s a high velocity of response to this as well. Very exciting. So that’s one element.


The other—and I come from Seattle so I’m going to plead guilty to having been influenced—but I think what we’re seeing with organizations like Amazon, Microsoft, Google, Facebook, for those of us on the West Coast, is the impact that’s just starting but very powerful of artificial intelligence, natural language processing, machine learning, all aimed at—the buzz word is “frictionless computing.” So rather than a smartphone, where this will really take off is when it’s just ambient. It’s analog; you experience it just as you do as a human being living your life. It’ll just be part of that.


There’s one early example of this that I’ve had some direct experience of through my role in the Personal Connected Health Alliance. I know the groups that are working on it , and at the HIMSS, (Health Information Management Systems Society) meeting in Orlando in February, Amazon Web Services and Merck launched the challenge around using Alexa, the voice activated platform, for new ideas for dealing with type 2 diabetes.


I thought that was a brilliant place to start because continuous glucose monitoring, of course, has been around forever, and screens and smartphones are a big part of the app world for that. But with type 2 diabetes the major issues are peripheral neuropathy and vision loss. Well a smartphone is all about touching a glass screen, so it’s not a good solution for people with advanced type 2 diabetes. But with voice activated systems, where you could talk to your clinician, you could talk to your caregiver remotely, telemedicine in that context becomes a much more ambient embedded kind of service that I think will suit people. Then you don’t have the issue of whether they wear their device or not or if they put it in a drawer. It’ll just be there. The data and the responses will be part of that experience. I think those are areas where I see technology really offering something.


AP: It’s interesting you mention this. I have the “3 R’s” for telemedicine: 1) a return on investment; 2) relationship—our community has to show that we care about you, that we’re involved with you—and building on that relationship with frequent, human interaction—Alexa’s great but human interaction is an opportunity; and 3) reassurance, because when we’re aging, when we’re sick, we’re all worried, whether we’re the patient or their family or even the less experienced provider. We all have issues of anxiety that reassurance can ease. Have you seen opportunities where telemedicine really brings that degree of connectedness to those folks aging at home?


MB: I think we’re just beginning. You know those three R’s that you mentioned, as you know telemedicine held this great promise some time in the past then slowed down and now is regaining momentum. I can feel it when you go to an ATA meeting; it’s a different feel than it was 5 or 10 years ago when it seemed pretty moribund.


Now patient engagement in the behavioral sciences is converging with telemedicine. That is the exciting new dimension. That relationship with your clinician or caregiver or nurse practitioner—whoever it might be—is important, but what is the value added that’s going to be provided through better behavioral responses?

For example, one of the things I like about Alexa is that if you’re feeling down or isolated, you can just ask “Alexa about what your doctor said. Talk to or even about her and she simply wakes up. So all the different ways you as a clinician could begin building more personal responses with feedback to that person specifically is what I think is really exciting.


And that comes back to the aging issue where we think of people as being the same as they get older. We lump them together as if everyone over 65 were the same. But in fact we become more different as we age. We know genetically we start out differently but the way we live our lives—the phenotypic experience of our life—plays out in ways by the time we’re 65 that make us fundamentally different. Some are going to live to be 90 and be healthy—look at Lee Hartwell at ASU, my colleague and co-founder of our center; he’s in his late 70s and still rides his bike to work every day; he couldn’t be more fit and engaged—whereas others at 60 are already multiple co-morbidities. They almost just stop their lives.


AP: I’ve been blessed. My father retired at 78 as a physician and my mother is a professor of art—a quadriplegic—and she’s still teaching at 77 down at the University of Arizona.


Do you have any advice for the sandwich generation, that parent with aging parents who, maybe because of career demands, is at a distance from their aging parent? What can they do today to leverage some of the technologies you’ve seen to help their aging parents?


MB: There are two elements that I’m very closely involved with. One is a nonprofit group in California called the Atlas of Caregiving. They come out of the quantified self movement and have gone into caregiving and are very good at the data research and ethnographic study of caregiving. I’m an advisor and #Susannah Fox—you may know her as CTO of HHS—is another adviser of this group.


What they’re developing now is a kind of combination analog-digital care map where in seminars and groups they get caregivers together and walk them through a mind mapping process that helps people literally map out how they give care to people and who gives care to them—looking at distance, time, frequency—so that you end up with a map of what your care life looks like. That provides a very visual beginning for then helping people build strategies and tactics to deal with caregiving. Caregiving is demanding, so this helps people better understand, first of all, why they’re so tired, why they’re stressed. But then there are also solutions embedded in them.


The other involves AARP. They just launched a great campaign about men. Their public policy institute did a study and 40 percent of informal family caregiving in the United States is now provided by men.


AP: Really?


MB: That is the almost universal response because we think of caregiving as being a female job or occupation. But the world of aging and sandwiches and blended families—the complexity of life in the 21st century—now means men take on that role. I’ve been a caregiver to a wife, to a mother, to a brother; that is not an unusual experience now.


AP: That’s really reshaping the social norms because I don’t think most men think of themselves as caregivers.


MB: And that is the number one finding of that study. Men don’t even use the word caregiver for themselves. They just do these jobs for this person. And so what it means is that men are very poorly equipped to deal with the stress and finding the solutions—the problem solving skills that women are culturally much more trained in. So AARP has launched a campaign together with the Ad Council and DDB, an advertising company, to begin reaching out to men to provide better tech tools—strategies to help men identify themselves as caregivers.


These problems are so big. Rand recently came up with a study showing that $422 billion a year is what the U.S. economy loses because of the cost of informal, unpaid family caregiving. So it’s now at a point where we just need to become more resourceful, and technology has to be a part of that since there are fewer young people. So the delta, as you put it, that delta has to be technology.


AP: You bring up an interesting point that we’re going to have to figure out ways to virtually bring together not only patients and their family members but also their care givers with other caregivers, maybe in support networks virtually, so that they can draw strength from each other because it is going to be a difficult job.


Michael I really want to thank you for your time today. I appreciate the advice, in particular for families grappling with this. There’s a lot more to be explored in how we’re going to take care of our aging families and ourselves as we age. Thank you very much.


MB: My pleasure, Alan. I hope you get it right. I’ll follow up with a few links for you.


AP: You bet. Thank you.

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