9781785045332 by Smakprov Media AB

VERMILION

Vermilion is part of the Penguin Random House group of companies whose addresses can be found at global.penguinrandomhouse.com

Penguin Random House UK One Embassy Gardens, 8 Viaduct Gardens, London SW11 7BW

penguin.co.uk global.penguinrandomhouse.com

First published in the USA by PublicAffairs in 2025 Published in the UK by Vermilion in 2025

The moral right of the author has been asserted.

Penguin Random House values and supports copyright. Copyright fuels creativity, encourages diverse voices, promotes freedom of expression and supports a vibrant culture. Thank you for purchasing an authorised edition of this book and for respecting intellectual property laws by not reproducing, scanning or distributing any part of it by any means without permission. You are supporting authors and enabling Penguin Random House to continue to publish books for everyone. No part of this book may be used or reproduced in any manner for the purpose of training artificial intelligence technologies or systems. In accordance with Article 4(3) of the DSM Directive 2019/790, Penguin Random House expressly reserves this work from the text and data mining exception.

Typeset by Six Red Marbles UK, Thetford, Norfolk

Printed and bound in Great Britain by Clays Ltd, Elcograf S.p.A.

The authorised representative in the EEA is Penguin Random House Ireland, Morrison Chambers, 32 Nassau Street, Dublin D02 YH68

A CIP catalogue record for this book is available from the British Library

ISBN 9781785045332

Penguin Random House is committed to a sustainable future for our business, our readers and our planet. This book is made from Forest Stewardship Council® certified paper.

For Nate, may he live healthy to 100

Chapter

Chapter 4: The Tomato, the Asparagus, and the Carrot

Chapter 5: The Last Acceptable “Ism”

Chapter 6: Wrinkles in Time: Building the Social Superhighway

Introduction

Miyako claps her hands in delight and flies past us, her sandals clacking rhythmically as she runs toward the bridge. She reaches the other end and turns back to look at us, as though in wonder that we haven’t kept pace. Hiro shoots me a sideways look, a combination of amusement and amazement, because it’s not every day that you get left in the dust by an eighty-eight-year-old woman.

It wasn’t a total surprise to us, though. We had traveled that morning to the rural city of Ukiha, about two hours east of Fukuoka in southern Japan, to visit the oﬃces of Ukiha no Takara Co., Ltd., a small food services company specializing in traditional Japanese foods. The company has achieved a modest public recognition for its unusual hiring strategy, as it principally employs women over the age of sixty: Those over the age of seventy-five are called “grandmothers,” and those between the ages of sixty and seventy-five are labeled “grandmother juniors.” It is an unusual hiring strategy to say the least, reflecting the owner’s desire to engage the elders of his community, but it also makes a certain amount of sense from a human resources perspective in a country where 30 percent of the population is over sixty-five and the majority of that group wants to keep working.

On the train out to Ukiha, Hiro, a Japanese journalist who had signed on as my translator, and I strategized about the interviews.

We had plenty of time, since Ukiha doesn’t sit on any of the main train lines and is only served by creaky commuter trains rather than the Shinkansen (bullet trains) for which Japan is justifiably famous. We chugged out of Fukuoka on one train, only to change at a small station where a row of commuter bicycles sat unlocked, unwatched, and untroubled. Our second train eventually deposited us in Ukiha, a town of twenty-seven thousand sometimes called the “Kingdom of Fruits” in recognition of its agricultural traditions.

We were scheduled to talk with three of the grandmothers, ranging in age from seventy-seven to eighty-eight, and I was a little concerned about the conditions of the interview: Would the grandmothers have the energy for a long conversation, would they be comfortable talking with us, and would they be interested in the topic that I wanted to explore with them—the relationships between work, social connection, and health?

I needn’t have worried. Our interview takes place in the cramped kitchen, an enormous pot of potatoes gently bubbling in the background. There are no chairs, and it is hot and crowded, but it quickly becomes quite clear that Hiro and I will tire before the grandmothers. Miyako, Keiko (age eighty-two), and Sakie (age seventy-seven) are full of energy and life, laughing and clapping at each other’s answers and enjoying the novelty of a visitor from afar.

Miyako was born in Ukiha and met her husband there but spent most of her life as a Kyoto housewife. After her husband’s retirement, they returned to their hometown. With her children and grandchildren grown and distant, Miyako became bored and lonely, and felt that she lacked purpose in life. She saw her friends taking jobs, so Miyako entered the workforce for the first time,

joining some of her contemporaries three mornings a week in the Ukiha no Takara company kitchen. It’s an act of courage, the willingness to try such new things so late in life, but it’s one, Miyako assures me, that has been amply rewarded. “I love coming to work, being with my friends. It gives me purpose and meaning to my life that would not otherwise be there.” She credits getting out of the house and joining her friends at work for her remarkable health and energy, and for saving her from a life of isolation and loneliness.

Ukiha no Takara roughly translates as “Ukiha miracle,” and it is tempting to view the boundless energy and joy of the grandmothers as just a little short of miraculous. But I start with this story for precisely the opposite reason, because Miyako’s story is neither particularly miraculous from a health perspective nor even unusual in Japan. Japan has the longest life expectancy of any country in the world, and more importantly, it has the longest healthy life expectancy, the number of years a person can expect to live disability-free and in good health. The average Japanese person can now expect to live over seventy-four years in good health—four years longer than in the United Kingdom and eight years longer than in the United States.1

Japan is also the country in which the highest percentage of people over sixty-five continue to work; roughly 25 percent of the people over sixty-five are active members of the labor force.2 That number is double that of the UK and three times the rate in Germany by comparison. And people across Japan will tell you that the high employment figures and the strong health data are closely related. When I ask Miyako, Keiko, and Sakie whether working has contributed to their remarkable good health, they all laugh like I just cracked a good joke, because for them, and for most Japanese,

it is self-evident that the social connection and purpose that come with work are critical contributors to their vitality and good health.

In 1938, in the depths of the Depression, researchers at Harvard launched an ambitious study to identify the sources of happiness and health, to understand what makes some people thrive and others struggle. The study, which eventually became known as the Harvard Study of Adult Development, started with two distinct groups. The researchers first enrolled 268 Harvard sophomores. These were presumed to be the leaders of tomorrow—and indeed the group included John F. Kennedy and Ben Bradlee, the legendary editor of e Washington Post during the Watergate era—though the researchers were careful to ensure that the study group balanced scholarship students with the scions of the Brahmin families of Boston. The Harvard group was supplemented with 456 boys who came from some of Boston’s most troubled and disadvantaged neighborhoods. These boys were mostly the children of immigrants and were typically saddled with a combination of poverty and limited educational and social opportunity, which stood in sharp contrast to the seemingly boundless opportunity unfolding before the Harvard students.

The researchers had the extraordinarily ambitious agenda of following these 724 men across their lifetimes, through war and migration, marriage and divorce, work and unemployment, and in some cases incarceration, and yet the original founders of the study would have been astonished to see what has happened. Not only did the Harvard team and its successors (which is now in its fourth generation of researchers) successfully follow this group, it

ultimately expanded the study group to include some 1,300 spouses and descendants. Closing in on its ninth decade, the Harvard Study of Adult Development is now the longest-running longitudinal health study in American history. It is extraordinary not only in its longevity but in its comprehensiveness.3 Every year, the researchers collect a treasure trove of data on each participant. Health data of course including blood draws, DNA samples, EKG reports, brain scans, and (in the early days) phrenology studies of the shape and weight of skulls. But that’s just a part of it: They also log employment data; voting records; behavioral information such as smoking and drinking; and the results of extensive biennial interviews with participants, their spouses, and their children.

It is a study that is unprecedented in scope and detail, and what the researchers have found is startling, both in its conclusion and in its clarity. After parsing through eighty-five years of data, the researchers have concluded that there is a formula for a healthy life. It’s not weight, exercise levels, the quality of diet, or even income that most impacts healthy longevity. It is the quality of relationships, the social fitness, you might say, of the people involved. It’s really an astounding thing. We’ve been conditioned to judge our health by a scorecard of numbers: our weight, our blood pressure, our cholesterol level, our caloric intake. But none of that matters as much as our relationships. It all boils down to the idea—as Robert Waldinger, the current director, has said—of “being engaged in activities I care about with people I care about.” If you want to come up with the recipe for successful aging, you need to start with the key ingredient, and that is the nature of your relationships and your social connections. If you want to know how to live a healthy and rewarding life, you start with social health.

You may not be shocked by the idea that social health is important to your well-being and that, conversely, loneliness is a danger to your health. After all, the UK in 2018 created the position of minister of loneliness, a move that Japan followed just three years later. And the US surgeon general in 2023 declared a loneliness crisis, a development that was extensively covered in the American media.4 Yet, despite the attention surrounding the surgeon general’s announcement, the only formal governmental position in the United States created in its wake was the appointment of the sex therapist Dr. Ruth Westheimer as New York State’s honorary ambassador to loneliness, though even that job has remained unfilled since Dr. Ruth’s death in 2024.

When it comes down to actual action and priorities, the reality of how we tackle healthy aging is still very focused on the physical: In much of the West—and really much of the world—healthy living is considered the responsibility of the individual and centers largely on physical care. It is about what I eat, how I exercise, how I sleep, and how I obtain my health care. Vast nutrition, fitness, and health care industries support that view of good health. I’ve seen it myself. In writing this book, I’ve had hundreds of conversations about healthy aging, and people invariably focus on diet, exercise, and health care. If I mention social health and its central role in healthy longevity, people tend to acknowledge its importance and then immediately shift the conversation back to the Mediterranean diet, the ten-thousand-step rule, or the impact of universal health care on public health. Ozempic by itself gets more airtime than social health.

While many people already acknowledge, or at least pay lip service to, the relevance of social connections to healthy longevity, few

would elevate it to the same level of relevance as nutrition, fitness, and health care. Let’s call it the 90/10 rule. In much of the West, 90 percent (though it’s probably more like 99.9 percent) of our effort focuses on our bodily health: diet, nutrition, and exercise. You can fill Yucca Mountain with fad health books alone, as well as build several more waste repositories with the $37 billion that Americans spend each year on exercise equipment—a good chunk of which will be landfill anyway within a short period of time.

It is a big miss, because the evidence shows a critical, even paramount, link between social capital and healthy longevity. The first breakthrough in the area came in 1979 when two researchers—Lisa Berkman of Harvard and Leonard Syme of Berkeley—published the results of a nine-year study of almost seven thousand adults and found that loneliness increased mortality, independent of health condition, socioeconomic status, or behaviors like drinking or smoking.5 Hundreds of studies since have confirmed the close connection between social connection and healthy aging—and the punishing impact of loneliness. And it’s not just among specific populations, like White men from Boston. A 1988 study reported in the journal Science, for instance, tried to get at the universality of the measure by evaluating and synthesizing five studies conducted in different parts of the world: Evans County, Georgia; Alameda County in Northern California; Tecumseh Township in Michigan; Gothenburg in Sweden; and eastern Finland. Not surprisingly, there were enormous health and life expectancy differences between, for instance, a rural county in Georgia and a booming city in Sweden best known for its Volvos and its literary festival. But one thing held true across all the studies and whether the group was primarily White or heavily Black, or whether it was rich or poor, rural or

urban: “People who were more socially connected had less risk of dying at any age.”6

That finding has been replicated countless times throughout the intervening decades. In 2010, Julianne Holt-Lunstad, a professor at Brigham Young University, looked at 148 studies conducted in countries all over the world (including Canada, Denmark, Germany, China, Japan, and Israel, among others) and found that social connection had the same impact on health across all of them. Building on the prior works of Berkman and Syme, Holt-Lunstad quantified the association and found that social connection increased the likelihood of surviving in any given year by more than 50 percent.7 Based on these findings, she concluded that social health, or lack thereof, is of greater health consequence than obesity and equivalent to smoking een cigarettes a day. Other researchers have subsequently found that the effect of social health is equal to or greater than everything from physical inactivity to high blood pressure, cholesterol levels, air pollution, and clinical interventions such as the flu vaccine.8

Social connection and social fitness are particularly important to health in the second half of life, when we are most vulnerable to the loss of social networks and the rise of social isolation. During my research for this book, I traveled across Spain, reporting on its extraordinary success in longevity. It is already one of the longestlived countries on Earth, and it is projected by some to have the longest life expectancy in the world by 2040. People in Spain, I found, are rather proud of their longevity. The idea of aging healthy to 100 is increasingly popular in Spain, reflected in the civic pride in the growing number of centenarians in the country. It’s a good thing that the Spaniards love their centenarians because they have a

whole lot of them: close to twenty thousand now, a number that is expected to rise to 373,000 within the next forty years.9

As I was crisscrossing Spain, researchers at the Universidad Politécnica de Madrid released a study of super-agers, a group defined as people with memory abilities comparable to those twenty to thirty years younger. Super-agers are a source of endless fascination to some researchers, but it’s a hard group to study, largely because you need a place with lots and lots of old people in order to find a critical mass of them. Spain is a gold mine in that respect, and the Madrid researchers were able to recruit 119 centenarians, roughly half of whom fell in the category of super-agers. The other half had aged normally—though still well enough to hit the 100year mark. The differences between the two groups? There was little difference in diet; the amount of sleep, alcohol intake, or tobacco use; fitness regimens; or even work backgrounds. Equivalent numbers in both groups ate a careful Mediterranean diet, while others subsisted on ultra-processed and fast foods. The only difference researchers were able to identify between the super-agers and their normally aging counterparts was that the super-agers had higher rates of social connection and lower rates of loneliness.

There are a number of reasons why we undervalue the importance of social connection to health and longevity: It’s hard to measure—my Fitbit doesn’t recognize it—and it’s also hard to understand why it matters so much. It’s easy to understand the impact of smoking once you’ve seen a lung X-ray, or to envision how a poor diet raises the risk of stopping your heart once you’ve learned how cholesterol and fats can clog up key coronary pathways, but there simply aren’t such neat diagrams to sum up the multiple ways that social connection supports good health—and how

loneliness undermines it. That’s because social health is a precursor condition: In and of itself it is not a clinical condition, but it impacts a wide range of other conditions, from cardiovascular diseases to hypertension to diabetes and even infectious diseases.

Evolutionarily, humans are social creatures, biologically wired for social connection and common purpose. Throughout our history, the ability of humans to rely on one another—for food, shelter, and common protection—has been critical to survival and human flourishing. Our brains have adapted to expect and need proximity to others, because being outside the group was dangerous and a sign that we would have to perform the diﬃcult tasks of survival all on our own. Our body responds to feelings of loneliness and chronic isolation by flooding our biological systems with stress signals.10 This type of evolutionary response was built up over millions of years, and the relatively few years of our modern society have not dulled it.

Our bodies react to stress with increased inflammation. Stress and inflammation can go up and down with the vicissitudes of life, but chronic stress and inflammation, such as that caused by loneliness, can have a pervasive and negative effect on everything from cardiovascular disease to cancer, diabetes, depression, and Alzheimer’s disease, as well as a variety of mental and cognitive health outcomes.11 Research on the causal links between social health and mortality is still developing, but it is considered likely that inflammation is the common pathway that explains the many diverse health outcomes associated with isolation and loneliness. There is also a correlative effect between social connection and health. At its most basic level, social connection gets people out of the house and moving, a basic signpost of healthy aging. But it’s

more than that: People with better social health markers are more likely to adopt better health behaviors, everything from reduced smoking and drinking to more exercise and better treatment adherence, including the taking of medicines and following health protocols. Social influence plays an important role in this—from a friend or relative urging better self-care to social cues about better behavior around everything from vaccinations to exercise. To be fair, social cues can have negative health impacts as well—witness all the social pressures that developed against taking the COVID-19 vaccine in some communities—but on balance they play a positive and often determinative role in healthy aging.

I live in Washington, DC, but I really began thinking about social health somewhere along O’Reilly Street, a dusty little thoroughfare that passes for the main drag in Presidio, Texas. Perhaps you’re not familiar with Presidio. It’s tiny, a little over three thousand people, and you’re not likely to just blunder upon it. To get there from Washington, I had to fly to Houston, changing time zones from Eastern to Central time; then fly to El Paso, changing time zones again from Central to Mountain; and then drive back three hours, reverting again to Central time. You have to really want to go to Presidio to get there.

And I did. Not because I wanted to find out how an O’Reilly ended up in this almost entirely Latino town just across the border from Chihuahua, Mexico, but because Presidio was the first stop of a new season for the Century Lives podcast I host for the Stanford Center on Longevity. The season, which we had dubbed “Place Matters,” was focused on outlier communities, places in the US that

had better health results than the underlying data indicates they should. In the United States, there is an almost arithmetic correlation between county income and life expectancy. Raj Chetty, a social scientist based at Harvard, has done extensive research in the area and demonstrated that the richer the county, the higher the life expectancy and sadly the converse is also true: the poorer the county, the lower the life expectancy.12 That’s not all that surprising and is hardly unique to the United States, but what is astonishing is the level of dedication that almost every county in the US has to this formula. If you make a graph, as Chetty has done, with income on one axis and life expectancy on the other, and then draw a line up and to the right, virtually all of the 3,143 counties in the US cling to that line, as if the line is magnetic and the counties are made of metal. There are a handful of outliers, though remarkably few, and Presidio County is the outlier of all outliers. It’s one of the poorest counties in Texas, among the bottom 5 percent in the entire country, but it still has the tenth-highest life expectancy of any county in the US. When it comes to longevity, there is no other place in the US like Presidio County.13

It’s easy to cross off the things that don’t explain good health in Presidio. It’s not health care. There is little in the way of medical services in town, and the nearest American hospital is in Alpine, a bumpy seventy-mile drive away. It’s not the diet, which was described to me as a traditional Mexican one, heavy on lard, fats, and cheeses, and that’s certainly what I was offered at El Patio restaurant when we stopped in for dinner the first night in town. And it’s not exercise: The principal of the high school is considered the local eccentric because he occasionally rides his bicycle through town. What does explain the high life expectancy in Presidio is social connection— and the intergenerational bonds that tie families and the community

together. Many people live in multigenerational homes: parents, children, grandparents. And if they don’t live in the same house, they live in family neighborhoods: brothers, sisters, aunts, uncles, cousins, grandparents all living on the same block, in and out of one another’s houses all day, the doors unlocked, the kitchens open to anyone who drops in. It’s a community evocative of decades long past, or of societies distant from the US, and it is the wellspring for the remarkable longevity in Presidio.

The story was the same wherever we turned up that season: places as dissimilar as Wayne County, Kentucky; Birmingham, Alabama; and Co-op City in the Bronx. The places were rural and urban, White and Black and Latino, poor and middle-income, and yet they all shared a common trait that residents were more socially engaged and more community-involved than in comparable areas—and were healthier because of it. Social science research is great—who can resist kicking back with a great longitudinal study—but it pales in comparison to seeing the impact of social connection in real life.

That’s the good news. The bad news is that most of the other 3,139 counties are going in the wrong direction when it comes to social health, and you can see it in the life expectancy numbers in the US, and to a lesser extent in the UK. Average life expectancy in the US is only seventy-nine, a number that is lower than Japan, Singapore, and Spain by about six years, and largely indistinguishable from countries like Panama and Jordan, to mention just two nations that have far less resources and wealth than the United States. In a country as big and complicated as the US, gross statistics can mask considerable diversity of experience, but not for life expectancy. Women in the US trail their peers overseas, both in terms of life expectancy at birth and life expectancy at sixty, and the

same is true for men. And it’s not income disparities that explain the difference. Poor Americans lag behind poor people in other developed countries, and our middle class and wealthy also trail behind their respective financial peers—and the same is true if you have access to high-quality health care or if you don’t.

But more important than just life expectancy are the measures of healthy life expectancy, and the US does even worse there, as the average American lives twelve and a half years in poor health, compared to a little over eleven in the UK, ten in Japan, nine and a half in Singapore, and under nine in China.14 Because of this, a person raised in Singapore or Tokyo rather than, say, Chicago has the odds of a better part of a decade more of good health. It’s really a stunning number, and if you are an American like me, it’s a profound indictment of how we live our lives.

It wasn’t always this way. Until the late 1970s and early 1980s, life expectancy in the United States was more or less equivalent to that of the other advanced economies of Western Europe and Asia. It wasn’t the highest in the group typically, but it also wasn’t the lowest, as it is now. But unobserved except by only a few, about forty-five years ago it began to diverge, with American health measures falling further and further behind those of peer nations. It wasn’t a random development, as Bob Putnam, yet another one of those ubiquitous Harvard professors, described in his book Bowling Alone. 15 In the ’70s and ’80s, all the institutions that brought people together, creating social capital and connection, began to pull apart and decline. Religious activity began its long, slow descent, as did union membership. Participation in parent-teacher associations, which peaked at almost 50 percent in 1960, plunged to under 20 percent by 1980. Club meeting attendance fell by half, as did

engagement in activities as diverse as attending a political rally or joining a sewing circle.

What replaced these group endeavors was a new tide of solitary activities. Putnam famously picked his book title from a story about how people were eschewing league participation in favor of bowling by themselves, but it was really technology that began the process of isolating us from one another. As early as 1950, people who had televisions watched them in huge quantity, about four hours per day, but the impact was muted overall, as only 9 percent of American households had televisions. But over the next three decades, television became more ubiquitous, and we began spending more time watching, pushing out congregational and participatory activities. By 1980, about 99 percent of households had televisions, and we watched an almost unfathomable amount—over seven hours per day. Today, we watch less television, though still almost three hours per day, but those saved hours (and then some) have been plowed right into the internet. Americans spend six hours and forty minutes per day on the internet, roughly forty-seven hours per week or seventeen years of an average person’s adult life. It’s a disconcerting number, though to be fair, it is not entirely unusual now: South Africans, Brazilians, and Filipinos spend over nine hours a day on the internet. But people in many (though not all) of the healthiest countries spend far less time online: Average use in Japan is under four hours per day, and Italy is under three.

While the US was heading in the wrong direction, other countries have been making tremendous strides—unparalleled in human history—in terms of collective health and life expectancy. In the

summer of 1976, my parents bundled up our family—me, my older brother, Michael, and our fat little dog, Chevy—and moved us to South Korea, where my father had been newly posted to the US embassy. Coming from a leafy suburb of Washington, DC, the move was a bit of a shock to my middle school sensibilities, though I loved it. Seoul was noisy, chaotic, and confusing, but also splashed in color and brimming with energy. Korea was just emerging from a postwar malaise that had lasted two decades, and Seoul reverberated with possibilities. It seemed like everyone was selling something: pots and pans, knockoff Adidas runners, genuine Korean “antiques.” Napolean might have disparaged the place as “a nation of shopkeepers,” as he famously said of the British, but it would have been more accurate to call the Seoul of that time a city of “stall keepers,” since most of the commercial action took place in open-air marketplaces scattered across the sprawling city. The place had a proto-capitalist feel to it, though if you squinted really hard you could see the outlines of the major manufacturing powerhouse that it would eventually become. Even in the 1970s, Korea already had a domestic automobile manufacturing sector, led by an obscure company called Hyundai that made rather unattractive and rickety small sedans. For us, Hyundais were an intriguing curiosity, though you would never buy one if you could afford, for instance, an Oldsmobile.

There was (and still is) much to admire in Korea. But it was still largely an isolated and economically underdeveloped society. There was little Western business presence, reflecting how far out of the global business flow it was at the time, and my brother was scandalized that there were no McDonald’s in the country—a sure sign of social and economic backwardness. And that was reflected

in broader social indicators like wealth, education, access to health care—and life expectancy. When we moved to Seoul, life expectancy in Korea was just sixty-three, a full nine years less than the United States at the time.

Little did I realize that our years in Seoul were the beginning of epochal changes, not just the coming flattening in health and life expectancy in the US that I just chronicled, but a surge in life expectancy in South Korea. Today, forty-eight years later, really a snap of the finger in human history, Koreans have added twenty-one years to life—and now can expect to live six years longer than Americans and four more than Brits. These numbers are unprecedented, shocking really, to anyone who studies human demography closely. But perhaps that doesn’t sound all that impressive to you. Try to look at it this way: In less than half a century, the Koreans have added more years to life than they did in all of recorded human history before 1850, when the current boom in life expectancy began.

The story of life expectancy in Korea is truly extraordinary, but the fascinating thing is that it is not quite unique. Sixty years ago, life expectancy in Singapore was only sixty-six, about four years less than in the US and five years less than its former colonial overseers in the UK. In many ways, Singapore was an even less likely candidate for great strides in health and longevity than Korea. The city had prospered in the first decades of the twentieth century as the “Gibraltar of the East,” a British fortress built to deter Japanese expansionism. That did not work out quite as the British planned, and the city swiftly fell to the Japanese in the early days of World War II. Tens of thousands of civilians and captured soldiers died under a brutal Japanese occupation, and the city’s infrastructure was decimated. What emerged after World War II was a bleak, hollow,

and mistrustful city, eager to see the backs of the British who had failed them so miserably, but deeply uncertain of its ability to survive on its own. Soon after the end of World War II, the British colonial government initiated a gradual transfer of power to local rule—a long, ugly process marked by ethnic tensions, economic jealousies, and disagreement about what to do with a territory that was more than a city but less than a country. Finally, in 1963, the issue was decided in favor of joining the newly created Malaysia, which combined Malaya, Singapore, North Borneo, and Sarawak into an independent federation. It went poorly. The new federation was riven with the same unresolved rivalries that characterized the end of the colonial period, and after just two years, the Malay central government took the unprecedented step of kicking Singapore out of the federation, thereby creating one of the smallest and most ill-prepared countries on Earth.

Accidental countries tend not to flourish, and very few observers thought the fledgling nation of Singapore would survive. Even Lee Kuan Yew, the country’s leader at independence and for many decades afterward, declared the country at independence “a political, economic, and geographic absurdity.”16 Unemployment was rampant. Of its 1.9 million people, 1.3 million lived on the city’s fringes mostly in squatter huts lacking modern sanitation, electricity, and water. It was not even a recipe for survival, let alone success. Yet over the last half century, Singapore has flourished: economically and demographically. The country has added eighteen years to life and is now not only one of the longest-lived countries in the world, but, in combination with Japan, it’s the place where you would live if you wanted to have the longest and healthiest life.

Japan, Spain, and Italy have all followed similar, if not quite as dramatic, arcs, adding roughly fifteen years to life in each instance and being among the world’s leaders in both life expectancy and healthy life expectancy. What knits these countries together is not just their extraordinary success in extending healthy life—there are, after all, other countries that have similar if not quite equal health results—but how they have done it. All these countries—sometimes intentionally, sometimes not—have put social health at the centerpiece of their public health strategies. They have done that through a cultural revolution in how to imagine the second half of life. All of these societies have rejected an outdated notion of the threestage life: education to roughly twenty, work until sixty-five, and then retirement until death. Instead, these societies have arrived at a common place of a more fluid life course, one in which there is no magic cutoff between the years of health and productivity and the era of old age. The years past sixty-five, it is believed, should be part of productive adulthood and not just a long, steepening decline into death. Long-life health means shifting the concept of aging and realizing that traditionally “old” people can now stay productive as long as they are afforded the opportunities to stay engaged, learn, and remain vital parts of their community. It is, to borrow a phrase from the Stanford Center on Longevity, a new map of life, a new set of rules for how we conduct our supersized lives.17

Reconceiving the life course is critical but not suﬃcient. Cultural and mindset changes are the necessary first step, but building a social health infrastructure is also important in keeping older adults connected and flourishing. Want to improve your nutrition? Or your cardiovascular fitness? There are things that society can provide to make that easier, but essentially, you can do it on your

9781785045332

LESSONS ON AGEING FROM THE WORLD’S HEALTHIEST COUNTRIES

KEN STERN

Praise for HEALTHY TO 100

HEALTHY TO 100

HEALTHY TO 100

LESSONS ON AGEING FROM THE WORLD’S HEALTHIEST COUNTRIES

VERMILION

Introduction