INTERVIEW BY IVAN DURAN

HHPR Senior Editor Ivan Duran interviewed Baroness Camilla Cavendish. She is an award-winning journalist, broadcaster, and the author of “Extra Time: Ten Lessons for an Ageing World”. Baroness Cavendish was Head of the Prime Minister’s 10 Downing Street Policy Unit under David Cameron, and she currently sits in the House of Lords. She is a Senior Fellow at Harvard Kennedy School, and a Contributing Editor at the Financial Times where she writes a weekly OpEd column. Baroness Cavendish holds degrees from Oxford and Harvard University.

Ivan Duran (ID): When and how were you first interested in researching the challenges and opportunities of societal aging? And how have your perspectives changed since then?

Camilla Cavendish (CC): Working at the centre of government, it was impossible not to be aware of the potential pressures that aging populations could place upon welfare and health systems. The projections showed that an increasing proportion of public expenditure would go to the population aged 60 years and older unless there was a significant change in pension systems and/or health outcomes.

I was also influenced by watching my parents age, which made me think there must be better ways to do this. My mother suffered from multiple health problems exacerbated by a life of smoking and stress–but refused to be defined by her age and kept working, lying about her age, until she was in her seventies. My father was blissfully free of health problems in his last two decades but his horizons were narrowed too early by his own concept of being “old”–which he wasn’t. My early research into the challenges of aging came from a fairly pessimistic place–I have to be honest. I was concerned that we had not fully contemplated the implications of the demographic shifts, and I was worried about the impact on younger generations. But as I visited different countries and met groups of people who are redefining old age, I became much more positive. People I call "rebels against fate" are refusing to dress demurely, stop work, or be carted off to care homes. Some are the heads of multi-generational households, doing many hours work with grandchildren, while others are starting companies.

My book became an attempt to capture this optimism, and to share with readers the many uplifting interviews I did with people who are finding new ways to cheat the advance of time: through social connection, healthy living, genetics, and neuroscience.

ID: What inspired you to write Extra Time: 10 Lessons for an Aging World? May you tell us a little bit about your book?

CC: I started writing the book after my father died in 2016. I started to think about how his concept of being "old" had whittled down his life too early, because he started to think of himself as "old" in his fifties, although he actually lived in very good health to 86. He started saying "Oh I'm too old" for all sorts of things. He was 58 when my mother left him and he missed our two cats dreadfully, yet he refused to get another cat, on the basis that a cat might outlive him and be left homeless. Yet he lived in very good health much longer than he expected–as many people now do.

I wrote the book to draw attention to this new generation of people in their sixties, seventies, and even eighties, who are living in a healthy "extra time", highly capable and by no means "past it". I wanted to challenge our notions of aging, and explain that it's not old-age that's getting longer, it's middle-age. I have met doctors who had never met many of their older patients until the pandemic, because the proportion of population over 65 with any kind of impairment has been falling for two decades.

I also wanted to set out the monumental demographic shift that is on the way from falling birthrates. There are now 83 countries around the globe where populations are growing slower than replacement rate. This has huge implications for retirement rates, family composition, immigration, and how we look after people if they have no family to care for them. We need to change the way we think about the very notion of family, and build new kinds of networks.

The book looks at everything from these demographic shifts, to the scientific breakthroughs which will prolong our lives, to how older brains learn through to policy levers that governments can pull. It also looks at what we can all individually do to improve our odds of healthy aging: I have become convinced that aerobic exercise is almost a "miracle cure", and have interviewed some extraordinary older athletes.

ID: The pandemic started not long after Extra Time was published. Did you ever imagine that you would experience such a catastrophic event? How has the pandemic impacted your outlooks in terms of global preparedness and political will to prevent and solve health crises?

CC: I launched the American edition of Extra Time in New York at the start of March 2020. In the space of that week what had felt like a distant problem in Wuhan, China became very real indeed. By the time I got to Boston, Harvard was in the process of shutting down and Larry Summers and I were only allowed to have an audience of 23 people when we launched the book at the Kennedy School–I don’t know why it was 23, but I think it was based on some rudimentary calculation of social distance. I flew back to my husband and three children in England on an eerily empty plane. Shortly after landing I got a call from the UK government asking if I would come and advise the Department of Health in the crisis. I was there for the next six months. One of the most upsetting aspects for me was how the pandemic exposed our decades of past failure on public health, in the US and UK especially, this virus exposed vulnerability with obese and poor populations. The UK Prime Minister Boris Johnson himself was admitted to hospital with Covid, and had an epiphany about our need to focus on reducing obesity. More broadly we have seen parts of the global South sadly devastated, and with a continued need to improve global transfers of vaccines. I am very proud that AstraZeneca and Oxford University insisted on providing vaccines at cost–a product in part of the intervention of the UK government to help Oxford scientists achieve their goal of helping the world.

ID: You have been described as “the woman charged with shaking up social care”. What do you think about these remarks? May you tell us about your work as Member of the House of Lords? How is it different from your previous work as Head of the Policy Unit in 10 Downing Street?

CC: Yes, the Guardian described me that way because I was charged with writing a report for the government about how to reform social care and its links to the National Health Service (NHS), in the light of what we had learned in the pandemic. Sitting there in daily meetings, receiving the latest news about deaths in care homes caused by the rapid discharge of elderly patients who were asymptomatic but had Covid, was harrowing. The emergency showed up all the gaps in the wiring between different parts of the health system in the UK, and above all the lack of join-up with social care services which were already threadbare before the pandemic in some cases. Significant change is needed in the way we commission, regulate, and provide if we are to provide high standards of care for all.

Heading the Downing Street Policy Unit meant working daily with the Prime Minister to develop policy and drive his priorities through Whitehall. The Unit shadows all Whitehall departments. This is very different from my work as a peer in the Lords where I debate and vote on legislation in my particular areas of expertise–a much more remote role although it comes with the enormous privilege to listen to colleagues who include high-ranking judges, former politicians, and campaigners with a deep historical perspective, which is a luxury sometimes lacking in the day-to-day rush of 10 Downing Street.

The House of Lords debates the Assisted Dying Bill on Friday 22 October 2021.

ID: In spite of wide opposition, why did you author the UK government’s “Sugar Tax”? What other policies would you consider for promoting a healthy longevity?

CC: The sugar tax was part of a range of policies we developed when I headed the Policy Unit to combat childhood obesity. The figures were horrendous: one in 10 children were arriving at primary school already obese and one in five were leaving obese at the age of 11. The prime minister David Cameron became convinced that this was crippling the life chances of some of the poorest children in our society. There was substantial opposition from people who were worried about the government intervening in private life and acting as a "nanny state". But we believed that a tax was necessary because voluntary efforts had not been effective. In the end the tax has been shown to have reduced sugar consumption in drinks by 30%. Other policies I would consider include banning the television and online advertising of junk food, which is seen by many children despite some regulations already in existence; ending the two-for-one promotions of unhealthy food, which encourages people to buy too much; and helping primary care doctors to do "social prescribing" of exercise, dance classes, healthy food, and even cooking workshops. We need a revolution!

ID: In just a century the global average lifespan doubled, which is a major outcome of advances in healthcare and public health policies based on prevention. Nowadays there is a rising trend of aging-associated diseases and conditions as an increasing share of disease and death. With this in mind, how should institutions across the spectrum tackle this health challenge?

CC: One of the biggest issues for this century will be whether we can close the widening gap between the rich and educated, who are living longer and more healthily than ever before, and the less fortunate. One of the most shocking things my research confirmed is just how drastically the futures of the rich and poor, the highly skilled and the less skilled, are diverging. Only Japan has begun to really effectively address these questions, with widespread public programs on preventative health.

Not everything is bleak. One of the statistics in the book which people often question, is that the incidence of dementia is actually falling not rising. The data we have from countries like Denmark, Sweden, and the UK suggest that the risk of getting dementia is a fifth lower than it was 20 years ago. In the year 2000 the average age for receiving a diagnosis of dementia in the US was 80.7; by 2012 it had crept up to 82.4–even the doctors had gotten better at spotting it. This doesn't mean that more people won't get dementia, because the total number of older people is growing. But our own individual risk is falling, and we can take steps to reduce it further through diet and exercise.

So our challenge is whether we can reduce the "Twilight Zone" at the end of life, when we may spend too many years in poor health. In some of the longest-lived islands around the world we see people who do not experience this long stagnation before death; genetic breakthroughs are also showing ways around this.

ID: In a report published in February you urged to “start addressing the whole care continuum: from prevention, through medical intervention, rehabilitation, maintenance, and social care support”. How do deep, widening inequities in social determinants of health such as the wealth gap may complicate your proposal both short and long-term? And how may the public and private sectors guarantee an equitable right to healthy aging?

CC: The report published in February set out a blueprint for the government to join up the care continuum much more effectively. I want clinicians and government to be far more ambitious about older people, not consign them to decline too early. Some countries are much more effective at rehabilitating people after surgical procedures, for example. Others are showing what can be done through a proper focus on preventative health. Even 90-year-olds can be helped with balance training, physiotherapy, and above all social connection, which study after study shows is vital for retaining a sense of purpose and good health. The Harvard Study of Adult Development, one of the longest longitudinal studies in the world, has categorically shown the importance of relationships in later life and there is not enough attention paid to this.

Social determinants of health are a vital part of the equation: we know that stress and poverty through the life course has detrimental and lasting effects. To take a UK example, a man born in Blackpool can expect only 53 years of healthy life, while a man born in Buckingham expects 68. That's wrong. Sometimes it simply feels overwhelming to try to deal with all of this. Michael Marmot's healthy cities initiatives are one impressive response. I am a member of the UK Parliament's All Party Parliamentary Group (APPG) for Longevity, which has urged the government to set a target of increasing healthy life expectancy by five years by 2035 for every member of the population.

ID: What benefits and caveats do you see in changing the status quo of aging as inevitable and immutable to a manageable, preventable, and even reversible process?

CC: It is vital to change the conversation about aging. Too many people underestimate how long they have to live, which leads to them not saving enough or indeed being ambitious enough for their lives. The view that aging is an immutable process reduces our incentives to maintain our biological fitness. Looking around the world it is possible to see that true biological aging may be a much more positive process than Western aging, which is so influenced by junk food, long commutes, and stress. We have already shown, for example, that we can reverse type 2 diabetes through fitness programs. Some of the conditions we think of as inevitable are in fact reversible. However, I would hate to see us blaming people for falling prey to disease: not everything is within our power, many of us will be unlucky, and we need society to be compassionate and properly caring. We need to learn from societies which still have deep respect for older people for their wisdom and experience. Too often it feels as though the West is a cult of the young, which is impatient and dismissive of the old.

ID: The age of retirement and eligibility for pension benefits has increased in developed countries such as England and the United States partly due to an increase in life expectancy. How may this policy avert a pensions crisis and cuts to social funding? Is this type of policy enough? What other policies could be implemented to avert these situations?

CC: Most developed countries have gradually started to increase the age of eligibility for pension benefits in line with increased life expectancy. Although this is politically extremely difficult, because it means breaking a contract, it is vital for the public finances and also because the age of retirement sends a profound signal to people about what is "old". In the UK everyone gets a free bus pass when they turn 60, although many are still holding down jobs. In the US it is entirely normal to call people "seniors" at ages which are now quite young. If current trends continue, some of us living in Europe, parts of Asia, and North America could spend a quarter of our lives retired.

It is notable that people stop working considerably later in countries like New Zealand and Iceland than in North America and Great Britain. Some researchers suggest that we should define people not by how many birthdays they've enjoyed in the past, but how many years they have left. If we define old age as having 15 years or less left to live, we wouldn't call many baby boomers old until they hit 74. Nevertheless, there is a need to take account of the gap between different groups in healthy life expectancy. It would be cruel to expect people to keep working until 75 if they are in manual jobs or in ill health. Evolving lifespans may require a more nuanced approach to government signals: fixed retirement ages do not necessarily fit any longer. Our current welfare systems are currently set up to pay out too much to people who simply live longer, which undermines the whole force of the social safety net.

ID: On a more personal note, as a woman how do you envision women in leading the transition toward and the opportunities of a healthier, more longevous world? What are some disproportionate or unique challenges to women in society as they age?

CC: Although the life expectancy gap is closing between men and women in many advanced countries, women still live longer on average and sadly many also suffer musculoskeletal problems and pain. I've been struck by research which suggests that women can be more adaptable to changing economic circumstances, both in terms of taking up part-time work and doing more realistic planning for retirement than men who can, apparently, view retirement as a golden time to play golf. It's certainly true that many women feel they become invisible after 50 as they face more discrimination in careers like broadcasting and film. The actress Meera Syal recently told me that actors who played her husband five years ago are now being cast as her son. This is changing, but not fast enough. I believe that both sexes have a powerful part to play as role models of what Extra Time can look like. Queen Elizabeth ll recently turned 96, and there are now so many politicians, professors, and rock stars who defy the stereotype.

A Healthier, More Longevous World: A Conversation With Baroness Cavendish

INTERVIEW BY IVAN DURAN

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