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Alan Rosenberg: I've been reading your book Why Survive?, and in the introduction, you talk about your childhood and that you came to be concerned about the elderly and aging as a young child. Can you talk a little bit about that and the influences?    
                
Dr. Robert Butler: Well, I was brought up by my grandparents, so obviously, older people became important to me. My grandfather died quite unexpectedly to me, and my family, benignly, I think, sort of covered it up and didn't really explain to me that he had died, and out of that experience, I decided to become a doctor.

Alan: How old were you when your grandfather died?

Dr. Butler: Seven.    
                
Alan: Seven. And you determined then you would be a doctor.    

Dr. Butler
: I absolutely made up my mind.    
                
Alan:  Did you understand back then that you weren't only talking about your grandfather and your grandmother, but you were talking about yourself, as you got older?    
                
Dr. Butler:  No, I wasn't smart enough to relate myself that directly.  I mean, I recognized that something significant had happened to me in my life, that I lost someone of incredible importance to me, my only father really, and I was, therefore, determined--and really it solved my grief in some ways because it became possible to determine I was going to do something that would be meaningful in my life.  

Alan: I've heard it said that specializing in geriatric medicine can be depressing because people feel like the end result is always the same; the ultimate demise of the patient.  Is there any truth to that?    
                
Dr. Butler:  When I had the wonderful opportunity to start the first department of geriatrics in an American medical school, the rotation was required, so students had no way out.  And, of course, in anticipation, they thought "This is gonna be depressing."  But the moment they saw that even modest interventions could make such a difference in the quality of life of the older person, they began to see the satisfaction.  It's not all death.  I mean, there's a long prelude in old age before death occurs, and it's very possible to engage medical students once they're required to take it.  If they only have an opportunity to elect it, they may not do it, but if they can't have a choice and they do it, they find it's quite gratifying.  

Alan:  In England, it's a requirement for all doctors to study.

Dr. Butler: All medical schools in Great Britain have a department of geriatrics, and it's now either the second or the third largest specialty in Great Britain.  We have 145 medical schools, as you say with academic hospitals, university hospitals, and only eleven of them have required geriatric departments.  So we've got a way to go.    
                
Alan:  Why is that?  What is it about America? We're supposed to be an enlightened society.  

Dr. Butler:  Well, I think we're basically enlightened, but some of it is the expenditures that medical students make, so when they graduate, they have about $150,000 of debt. This is a low-tech specialty. You can make in one hour about $600, let's say, being a gastroenterologist, but about $100 being a geriatrician.  So the reimbursement, financial issues.  Then there's so few of us who have pioneered in the field of geriatrics that there aren't very many models for the students to follow. And then third, the general culture's effort and response tends to be youth oriented. So we're just not quite there yet as a society.  When the baby boomers hit Golden Pond, things are gonna have to change.    
                
Alan:  Do you think they will? Are you optimistic?    
                
Dr. Butler:  I'm optimistic that the baby boomers will be transformative.  I don't think they themselves will benefit a great deal because you can't overnight solve the problem of Alzheimer's disease.  You can't overnight have physicians well-trained to take care of older people.  You can't overnight begin to have enough finances to take care of you in your old age. And the boomers, half of them don't even have 401(k)s. The other half have about an average of $50,000 in their savings.  I don't think that means they're very well prepared for old age, and society's not prepared for them.

Alan
:  You've written a little bit about Katrina and 9-11 and how older people were treated after those disasters.

Dr. Butler: Or not treated.    

Alan:  Or not treated. Can you talk a little bit about that?    

Dr. Butler
:  They were invisible in Katrina, and as you know, most of the people that died tended to be older people. They did not have effective evacuation plans in the nursing homes in New Orleans, so we lost a lot of older people we need not have lost. But that was also true at 9-11, at Ground Zero.  We found out that the pet owners did better; that is, the league of animal service was in quickly and took care of animals and rescuing them. The Animal Rescue League.  Whereas older people were often sitting there for 3 or 4 days, sometimes in their own excrement if they were paralyzed and without receiving home health aides, and not having a replenishment of their medications because they were forgotten. They were invisible.    
                
Alan:  Is that kind of thinking ingrained in our culture here or are we just neglecting people?

Dr. Butler: I think we're an ambivalent culture.  When you think back on the Puritans, they seemed to help each other.  We had the New Deal in the 1930s when we reached the desperate point of one out of every four adult Americans without a job.  But when things are "reasonably good", then we tend to go back to individualism, rugged individualism--it's all up to you.  We need a better balance, in my opinion, between the solidarity, between the cohesion that you need among people and among generations, on the one hand, in maintaining the incentive and excitement of being entrepreneurial and individual.  But when it goes one way or the other, I think we miss something very vital.    
            
Alan:  But as you said in your book, when we advocate for older people, we're advocating for ourselves 'cause hopefully we'll all become older.  So what causes that denial?  What prevents us from seeing ourselves in older people?    
                
Dr. Butler:  Well, I think I was hit with a ton of bricks, so I couldn't deny. I mean, there I had the father/grandfather-- gone! But others may not have had that experience. Furthermore, there's a tendency to kind of not want to think a good deal about old age because an association with old age is deterioration, dementia, poverty-all of these unpleasant thoughts.  And so if you can kind of let it go and not bother to think about it too much, that's very attractive, but very dangerous because the future belongs to those who prepare for it.  And those that don't at least face it to a degree and do something about it are making a mistake.  I personally think, in our schools, public schools, kids should learn something about the life cycle, about the various stages of life.  Not in a morbid way where they're preoccupied by death or aging, but that they have some sense that there's a flourishing of life and a change throughout the course of life.  And to know that you don't have to be morbidly preoccupied, but you better do a little bit of preparing.  And help your society do some preparing because you can't do it entirely by yourself.    
                
Alan:  This denial, do you think it has more to do with a fear of dying or a fear of losing our good looks?  You know, we're such a youth-oriented society.

Dr. Butler:  Well, I think there is some fear of death, of course, people would like to live, but I think the thought of being dependent, being poor, being ill, not being able to get around,  to be disabled and immobile, I think these concomitants of age are part of what also scares people.  

Alan: You know, I'm 56 years old.  I came of age during the antiwar movement, the anti-Vietnam War movement and the civil rights movement.  I come from a generation that really made major changes or helped major changes to happen in this country.  What are we waiting for?  There's clearly a need for some kind of political action on behalf of older people, on behalf of ourselves.  What do you think we're waiting for?    
                
Dr. Butler:  Well, I'm waiting for you baby boomers to speak up.  Already, you're beginning to see your own parents who have problems, their great care giving needs, which is a terrific responsibility making certain that there's some proper care of an older parent either at home, which is preferable, or in a nursing home.  So, I think that's going to be a wake-up call.  The oldest baby boomers are now 61.  About 10,000 new baby boomers practically every day, who are hitting 61 years of age.  So, suddenly, it's gonna hit them. I'm not gonna be able to deny it any longer.  Then I hope they will effect major changes.    
                
Alan:  You have children.    

Dr. Butler: I do.    
                
Alan: How many?     
        
Dr. Butler: Four daughters.    
                
Alan:  Wow. And how old are they?
    
Dr. Butler: Well, they range in age from 27 to 54.    
                
Alan:  How have you discussed aging with them?    
                
Dr. Butler:  Oh, they couldn't escape. They fully understand, and even my 27-year-old is well aware of the realities of aging. My plan with them and my discussions with them are not really morbid.  They're planful.  My wife and I set up what we call "longevity funds."  Since they're girls, they're going to outlive their husbands.  We wanted to make sure that they had some private funds of their own to assist them.  And I really widely recommend that for the women of America. You should all start a longevity fund.    
                
Alan:  You've spoken very movingly about the recent loss of your wife and your reaction to it.  Was there anything that surprised you about how it affected you?    
                
Dr. Butler:  I wasn't surprised, my reaction. The depth of it was unbelievable.  She had been a major force in my life.  She had been coauthor of books that we did together.  We were very close to one another.  I'll never get over it in the sense that I, everyday think of her and regret her loss.  But two months ago, after--twenty months, I guess of--I don't remember, but a long time since her loss, I have found someone that's very meaningful to me.  So that's it. It doesn't mean that I still don't grieve...        

Alan: Of course not.    

Dr. Butler: ...but it means that I've filled a huge void with somebody who's also an extraordinary individual.    
                
Alan: Well, there's an important lesson there too. I lost my brother at a very young age.  He was my only sibling and my best friend.  When that happens, you feel like you'll never make up the loss.  You never will.  You never replace somebody.  

Dr. Butler: You can't make it up.

Alan: But other things do come in to compensate, and I'm happy to hear that...    
                
Dr. Butler: Thank you.    
        
Alan: You're very welcome.  And that, for older people, I've always imagined that's gotta be the hardest thing, not only losing your spouse, but losing--as your friends start to leave, to pass on. How do you cope?  How do you cope with loss?

Dr. Butler:  Well, you're right, loss and grief are really the almost nearly constant companions of old age.  It's not only the loss of loved ones, but maybe even your hearing if you love music, and your vision if you love to read, and you have the number one cause of visual impairment, the loss of central vision. You cope as best as you can.  You reach out to friends.  You try to develop new relationships.  I think it's very good to go up and down the life cycle tree, to have young friends as well as older friends because that can be very constructive.  I've been very fortunate to have a lot of wonderful mentees in science and medicine, and they take me out to dinner or we do things together.  So it's been terrific to have that set of relationships with much younger people.    

Alan:  For me when my brother died, it was kind of the loss of history. There was nobody to recollect with. There were stories that we knew together that we could talk for hours about them.  There's nobody to share those stories with or nobody to kind of participate in them with me--that's difficult.    

Dr. Butler:  And that, in a way is what, when one loses one's spouse--we used to kid sometimes and say, well, between the two of us, we can get one memory back!    
                
Alan:  Is it possible for a person to literally die of a broken heart?    

Dr. Butler:  There are data out of Johns Hopkins Medical School and Center that suggest that people can definitely have heart problems and other physical ailments as a result of loss.  And there are other data, not only at Johns Hopkins.  It might be overdramatic.  It may not occur and, of course, doesn't occur at all times because, obviously, there are many widows and widowers that remain alive.  But it certainly is devastating and can certainly affect--it's a huge stress and can affect one's heart, one's hormonal system, one's central nervous system.    
                
Alan:  Can you talk specifically about some of the things you did to take care of yourself after your wife's death?

Dr. Butler:   Well as a physician, of course, I should've known, but you have to go through it to realize the amount of stress. I lost about ten pounds, and I had earlier lost ten pounds, I thought on purpose, and so I wound up twenty pounds below my usual weight, which I struggled to regain.  There are data that show that men in particular die at a greater rate after the death of a wife than the reverse.  So that in my case, I knew that since there is a greater likelihood of death, I really went out of my way to take very good care of myself in terms of what I eat, my exercise schedule, my relationships.  So I think being intellectually engaged, passionately engaged, having friends, relationships, and taking good physical care in terms of diet and exercise helped me through this. 

Alan:You have a walking group.    

Dr. Butler
: Yeah!    
                
Alan:  You can go walking with how many people?  

Dr. Butler:  Well, we vary.  It's a very high-powered group.  We have an investment banker, a corporate lawyer, a human rights watch activist, a journalist.  There are maybe, when we're at our max, maybe nine or so of us.  But because we're flying all around the world, maybe five of us at any given Saturday or Sunday morning at 7:30, we walk in Central Park, five or six miles, maybe we go up to Columbia, maybe we go all the way downtown, or even across the Brooklyn Bridge, which is eight miles. Then, of course, during the week, at least for me, what I do is, I use my treadmill at home.    

Alan: You were a doctor at Mount Sinai Hospital for many years, and you retired from that job, and you went on to bigger and--go ahead.    

Dr. Butler: Never retired.    
        
Alan: You never did retire?    
                
Dr. Butler: No. The "R" word is a very bad word because if you're retired, the implication is you're really no longer a part of the society, and you're not a going concern.  No, I decided that our world, not just our country needed a think and do tank that really addressed this remarkable change with 30 additional years of life.  In one century, the 20th century, that gain being greater than what had been attained the preceding 5000 years of human history.  So I felt we needed to have a think tank that really began to look at some of the issues in a blunt, straightforward, non-denying manner.  I did not retire, and I do not recommend to anybody retirement.  I say they should retire to something.  I don't care what it is.  Could even be a voluntary activity. Golf is not enough.  You can only play so much golf.  But I think it's important to be productively engaged, to do something that's meaningful, something to get up for in the morning.  In fact, in studies we did at the National Institutes of Health when I was a young research scientist there many years ago, we found those people who had something to get up for, something that was important in their lives, a passion, actually lived longer and better.

Alan:  We're sitting here at the International Longevity Center.  America is behind the curve in terms of dealing with aging and older people. What can we learn from other cultures, other societies?    
                
Dr. Butler:  Well, one of the great things is the issue of long-term care.  As we see the baby boomers reach Golden Pond and when they're really gonna need all sorts of care, including nursing home, in-home care, community-based care, then you have to look to the Netherlands or Germany or Japan or Sweden to see what a major public entitlement this is that makes it possible for people to have dignified care right up to the end of life.  We're not there yet.  We only have four million, roughly, private long-term-care insurance policies in action.  Otherwise, people have to humiliate themselves and spend down their income in order to have access to Medicaid, which was originally set up to assist the poor. It was not really set up to be a long-term-care policy, but that's what it's become for a lot of middle-class Americans.

Alan:  You talked a little bit about dignified care and about how in other countries people receive dignified care.  Could you expand on that a little bit?  What is dignified care, and how do we learn from other cultures?    
                
Dr. Butler: In my mind, it's being respectful of the patient.  It's being collaborative with the patient, and not in a power relationship where you are the authority figure and the patient is somehow less than you.  But also, it's a matter of time, and one of the things that's so happened with managed care in the United States is the physician may literally have no more than twelve minutes to be with a patient and have to dispatch all sorts of orders and presumably listen to what the patient is concerned about, and may not really provide the kind of time/dignity that would be required of an egalitarian, warmhearted, compassionate relationship.  

Alan
:  What can a patient do to make sure that they get the best out of their doctor?

Dr. Butler:  One of the things that patients could do is to write out everything they want to make sure gets covered in the session, so they don't walk away later and say oh, I forgot to ask Dr. Jones about this pain I've been having in my left side. Second, is to bring in all the medications in a brown bag.  And if you're taking the next-door neighbor's medication, bring that in too, including herbals, including vitamins and other supplements,  so that you can really give the doctor a chance to analyze what you've been taking, and to maybe tell you you shouldn't be taking this, or that this interacts badly with that.  So that's the second important thing. The third, I think, is, you can actually be direct.  I really want more time with you.  Maybe we need to have a follow-up visit.  Maybe we can use e-mail to be in touch with each other, so we can follow-up with some questions I have.  So there are a variety of different approaches, I think, that can at least expedite or expand the relationship with the doctor.    

Alan: You mention several myths of aging in your book.  I'd like to touch on a few of them.  The number one is that older people are "serene."  

Dr. Butler:  Well, if they're living a tumultuous time and they're engulfed in poverty, and they don't know where their next meal is coming from, or maybe they can't any longer pay the mortgage, they're not certainly living a serene life.  

Alan: Another myth: automatically assume that certain older people are senile.

Dr. Butler
: Well, dementia and Alzheimer's disease is one whale of a condition, which no one welcomes, but we're now talking about 5% of people in nursing homes, maybe another 5% have some degree of Alzheimer's disease. You know, a good 85% to 90% of people, even through their 80th year, are in fine shape including their intellectual condition, so we don't want to start a myth that everybody's senile because they get older.

Alan: Older people are inflexible.    

Dr. Butler:  Not so. They are good learners.  There are many studies that demonstrate that. They're very dependable on the job.  They do better than a lot of younger people, who maybe after a weekend can't quite come in on Monday morning.  They are innovative, and they keep learning.

Alan:  Do you find a resistance among older people to learn about computers, to learn about the new technology?  

Dr. Butler:  Well, actually, the fastest-growing age group in terms of learning the computer is the 65-plus age group.  Of course, they didn't grow up in that age, so they do have to work harder at it.  But they take courses, and they do become computer literate.

Alan:  Older people are unproductive.

Dr. Butler
:  Wrong!  As I mentioned, many of them are quite famous who remain longer.  In the theater, in your own work of acting and career, think of all the wonderful actors who are, in fact, older.  Scientists who are quite remarkable.  Nobel Prize winners who get their Noble Prizes well into their 70s and 80s.  Teachers in public schools and in private schools when they're allowed to continue to practice their teaching art, if they haven't been arbitrarily retired, which is, of course, one of the things that stultifies productivity is arbitrary retirement.  

Alan
: Another myth is that older people seek to disengage.    

Dr. Butler: That's an old theory.  Not true.  Older people want to be engaged.  They like to be involved with other people, whether it's in church or synagogue or in a union movement or whatever it may be. So they are involved, and they like to be connected, and it's necessary to be connected.    
                
Alan: Well, this isn't one of the myths you mentioned, but I'd like to talk about sexual behavior and sexual desire as one gets older. How does it change?    
                
Dr. Butler:  Older people can be mighty sexy!  The idea that they have no interest, that they're not capable, and they can't be satisfied is just not true.  Now, there are people aren't really interested in sex, never have been; that's fine.  Those who do have problems, largely men in terms of erectile dysfunction, fortunately, there now are mechanical aids, so to speak, with the famous Viagra and Cialis and Levitra, but it'll not provide an aphrodisiac.  They do not provide intimacy.  They are simply a mechanical aid, but they can do a lot to reignite a relationship, if they happen to have had that problem to begin with.

Alan:  I want to read from your book a little bit.  I sometimes teach acting in Los Angeles, and they're beginning students, and so I always tell them rather than being focused on results, they should learn to walk through the world as an artist.  Learn to be compassionate.  Learn how to internalize things.  You wrote towards the back of your book: "After one has lived a life of meaning, death may lose much of its terror. For what we fear most is not really death, but a meaningless and absurd life."  Could you talk a little bit about that, what it means to walk through the world as an artist and make your life a work of art?    
                
Dr. Butler:  Well, you should, you should definitely recognize the aesthetic and the enriched emotional side of yourself, and despite the fact that my whole career has been intellectual and around science, I think nonetheless, you have to have that artistic side.  But also, you review your life at the end of life.  You try to come to terms with it. You have things you feel guilty about almost inevitably.  You have a brother or sister you may not have talked to for eighteen years.  This is the time to make amends, to atone for whatever you may feel you did not do, and to really be able to forgive others and yourself, and to find meaning in life.  That meaning may be as modest as concern for a grandchild, which is what happened to me with my grandfather, or it may be a larger effort that you can take on behalf of society--global warming or whatever--that can make a difference.

Alan
:  Do you feel like things have changed measurably since you were a child for older people?

Dr. Butler:  Well, we have Social Security, thank goodness.  We have Medicare, we have a national institute on aging.  We have efforts to try to solve the problem of Alzheimer's disease.  We have at least some well-trained physicians who know how to take care of older people.  So there has been some progress.

Alan: Two things everybody should do now that they've turned 50, or to prepare for the coming years. Two pieces of advice.

Dr. Butler:  Well, one is to open their hearts to the reality that they better do some planning.  Number two, I would look around at my relationships and see that I can build up and down the life's tree, young and old friends and relationships, and build upon them.  Can I add a third?    
        
Alan:  Sure. Please.    
                
Dr. Butler: I think you better find a good doctor and a nice place to live.    
                
Alan: Well, thanks. That's great advice for everybody.  I really enjoyed this conversation.  Thank you so much for spending this time with me.


Dr. Butler
: Thank you!