by Peter Walker
‘Jerry was an extremely humble man and didn’t like to give his studies big titles to increase their profile,’ says Hillsdon. ‘He was more concerned with the quality of the science than anything else.’ Tamara Lucas, whose father grew up alongside Morris in their large, bustling, ever-enquiring extended family in the now barely recognisable world of pre-war Glasgow, agrees: ‘Jerry was very modest. He was never pushy or self-promoting. I never heard him boast about what he did. But his influence is extraordinary – it’s a shame that he’s not as acknowledged as he could be.’
Among the many discoveries built on his work are studies which have shown how remaining physically active is a key factor in warding off mental decline. Again, Morris’s life provides a resonant example. Family and colleagues say that Morris never seemed to slow down mentally. In October 2009 he eventually died, aged ninety-nine and a half. ‘He always insisted on adding the half,’ recalled his daughter, Julie.45 He had spent his last days in a London hospital, severely weakened by pneumonia and kidney failure. But even here Morris remained eager to exchange ideas. Through his oxygen mask he endlessly quizzed staff and fellow patients on what they thought about a then-ongoing strike by postal workers, and a recent rise in prominence for the far-right British National Party. At Morris’s funeral his son, David, had said he never expected the moment to come, as his father had seemingly found the secret of, if not eternal existence, then one that seemed to be prolonged for the foreseeable future.46
Morris’s life and research contain lessons which could bring greater longevity, not to mention hugely improved quality of life, to millions of other people around the world. That governments have not as yet heeded this message is in no way the responsibility of Morris, arguably one of the most prodigious, influential and yet relatively little-celebrated figures of the past century.
Next steps:
Jerry Morris was very much not an athlete. But he was always very active. Try some of his methods, perhaps even walking a mile and a half from a train station, rather than driving, or at least up the stairs when you can. If you have younger children, you could even test out the ice cream–based bribes for particularly long and brisk walks.
4 The Tidal Wave: How Inactivity is Bankrupting Governments
Interviewing a doctor inside the emergency department of a busy inner-city hospital is rarely easy, but Martin Whyte is enjoying what is – by his standards, if that of few others – a fairly relaxed morning at the office. He has just helped examine the newest patient to reach King’s College Hospital, a clearly very weak man in his eighties, with dementia, brought in from a care home. A series of other recent arrivals groan or lie silent behind curtain screens. But almost half the beds are empty, a rare sight at the usually frantic south London teaching hospital. Whyte thus has a brief moment to interrupt his chat with a junior doctor to answer the question I posed about five minutes earlier: what proportion of patients he sees are admitted due to conditions where inactive living can be identified as a factor?
Whyte pauses some more to look around the long, starkly lit, rectangular space, as other staff dart between cubicles or rapidly type notes into portable computer terminals set atop wheeled stands. ‘That is basically my job,’ he says eventually. ‘It’s people who are sedentary. Of course, it’s not everyone, but it’s a lot. And it’s a big range of conditions: diabetes, heart disease, arthritis, dementia. You name it.’1
Whyte’s observation is based on years of first-hand, expert experience, but there is an extent to which he is merely stating the obvious. As the statistics show, in the UK, or indeed in many dozens of other countries, if you are a professional of more or less any sort who deals with the adult public then a relatively high proportion of the people you encounter will live dangerously sedentary lives. The difference for Whyte and his colleagues, of course, is that they witness the moments when these years of inaction manifest themselves on someone’s health, often in sudden and frightening ways.
This is, as we shall see, a phenomenon which, when repeated across populations, threatens to make universal medical systems like those in the UK increasingly unviable, and similarly threatens state care for older people. Make no mistake: just about every expert and policymaker agrees that without significant policy changes the only debate is about when all this will happen, not if.
During my day at King’s examining this front line – this is before coronavirus erupts – I have two expert guides. The first is Whyte, a trim, cheery man in rolled-up sleeves and a waistcoat, who bounds along endless corridors and down several stairwells from his cramped office to the emergency department where, as a consultant, a senior doctor, he works with the accident and emergency team and their rapidly filling allocation of beds. Later I trail after Phil Kelly, another consultant. He is taller, even more lean, and strides back to his office from a ward round at such a pace I have to break into a trot to keep up. Both cheerily note the paradox that having a job tending to the chronically immobile seems to involve ceaseless walking. ‘I’ll be exhausted by the time I finish tonight, but at least I won’t have to worry about being inactive,’ Whyte grins.
Whyte and Kelly are both consultants in general medicine, that is to say the mass of everyday complaints not cordoned off by more specialist areas. Some of the patients they see will end up being moved to other departments, but they and their teams are the first point of contact, and oversee the broadest mass of hospital admissions. A significant percentage of their clientele arrive due to ailments closely associated with inactive lives, and the attendant, if separate, public health scourge of obesity. This could involve heart disease, difficulties in breathing, complications around arthritis, or, Whyte’s particular focus, the rising tide of type 2 diabetes. If this wasn’t alarming enough, more and more of their patients are presenting themselves with several of these lifestyle-induced conditions, and are likely to live with them for ever-longer periods.
Whyte introduces me to two medical terms which sum up this worrying new trend – co-morbidity and polypharmacy. The first describes patients with this series of interlinked, chronic medical issues. Co-morbidity, Whyte notes, used to be the preserve of older people. ‘You’re seeing that now at a much younger age – middle age rather than old age,’ Whyte says. ‘They’ll have the burdens of diabetes, heart disease, stroke, osteoarthritis, blood clots – and around ten to fifteen years earlier than used to be the case, because of the impact of inactivity and weight. And one thing often begets another.’
Polypharmacy is simply what follows for such people: an indefinite future of permanent, multiple medications, a bind for them and a desperate financial strain for the health service. ‘The minute someone’s told they’ve got diabetes, they’re on about five drugs,’ Whyte says. ‘It’s the same with heart disease. And that’s an expense. It’s a tidal wave that’s engulfing the NHS.’
We are just seventy years from the creation of the NHS, one of the world’s earliest universal healthcare systems. The first year of the service, 1948, saw a health budget of about £370 million, or around £10.5 billion at modern prices.2 Seven decades later, with a population that has grown only by about 25 per cent, the sum has swollen to £114 billion.3 How did we get to a point where even this isn’t enough?
Mortality and morbidity
As we saw in Chapter 2, the best estimates of the global death toll from illness linked to inactive living put it at beyond 5 million people a year, possibly significantly more. It forms part of a wider shift in healthcare focus from infectious viral and bacterial illnesses and onto so-called non-communicable diseases, or NCDs, which are often linked to lifestyle or environment. To an extent, this focus has shifted back with the sudden arrival of coronavirus. But even here NCDs play a key role, given an emerging link between conditions like diabetes and high blood pressure and poor coronavirus outcomes.
Academics gauge the impact of NCDs using a tool called Burden of Disease, which simply multiplies the risk an ailment poses to an individual by the extent of its spread.
This system has been used to devise what public health officials call the ‘four by four’ threat – a list of the four most damaging NCDs around the world, and the four primary risk factors behind them. The ailments are much as you would expect: cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes. As for the risk factors, these are equally predictable: tobacco, alcohol, obesity and inactivity.
Given the extent of inactivity and the amount of ill-health it causes, what overall impact does all this have on health services? The brief answer is: an extremely significant one. As well as risking the financial sustainability of many health and care systems, there are even worries for the future integrity of entire national economies.
There is a vital if counterintuitive point to make here. A significant element of these interlocked crises comes not from a failing but from a success – how good modern health services are at keeping people alive. Callous as it might sound, in financial terms the issue is less the sheer number of people who die, rather the millions who spend years or decades facing increasingly poor health, while often requiring regular medical check-ups and an arsenal of drugs.
It all comes down to the difference between mortality – people who die – and morbidity, a ubiquitous term in public health circles which simply describes the independence, good health and quality of life, or otherwise, of those who remain alive. This latter term gives its name to co-morbidity, the interconnected series of long-term medical conditions in individual patients which occupies so much of Martin Whyte’s professional life at King’s. And morbidity, particularly co-morbidity, is a lot more expensive than mortality.
The brutal truth is that dead people don’t cost the taxpayer much. I once asked a professor of epidemiology to privately outline what would be the ideal lifespan of a citizen purely from the point of view of government economic efficiency. He replied: someone who works diligently and pays taxes their entire adult life, and on the day of their retirement, collapses and dies instantly from a massive heart attack (ideally, he added, with a demise so instantaneous and obvious that the bereaved family don’t even bother to call an ambulance).
This is actually not so far from what used to be the case for many people only a few decades ago. As recently as 1961, UK male life expectancy was only sixty-eight,4 giving the average man around three years in which to kick back and claim the state pension before he was no longer a drain on the public purse. The more basic medical care of the era, plus factors like a male smoking rate of about 70 per cent,5 meant many people died fairly rapidly, without a prolonged period of illness or decrepitude. Heart attacks were particularly relevant here. The current UK death rate from cardiovascular disease per head of population is less than a third of what it was in 1961.6
It’s worth stressing the perhaps obvious point that people living longer lives is, of course, a good thing. The only issue is the fact that so many millions experience longer periods of poor health, with this extension happening on both sides of the timeline – as well as living longer, people increasingly develop chronic conditions at an earlier age.
The UK is a prime example of this phenomenon. Life expectancy has shot up in recent decades, even if it appears to be stagnating in some poorer areas of the country. For men it is now a shade over seventy-nine, with the female equivalent at nearly eighty-three.7 However, what is known as healthy life expectancy, the period during which you can live without some sort of age-related impairment, is notably smaller and has either been rising less quickly than overall life expectancy (for men) or falling (for women). The gap between the two figures – which roughly translates as the period during which someone is likely to require medical assistance or a form of care – is now 16.5 years for men, and 20.9 years for women.8 Of Britons over seventy-five, almost a third say they have heart and circulatory problems, and 30 per cent report musculoskeletal conditions like arthritis or back pain.9 This health gap affects a huge number of people. Slightly under 20 per cent of the UK population, or about 12 million people, are now aged sixty-five or over, with more than 1.5 million of these eighty-five or above.10
This combined shift in both mortality and morbidity is happening around the world, with medical advances meaning many fewer people are dying from infectious diseases. There are, of course, other significant factors at play, for example changes in food production and consumption which now mean, for the first time in human history, that more people are dying from excess than malnutrition.
Someone who has seen these trends at first hand is Jonathan Valabhji, a consultant in diabetes at another leading London teaching hospital, St Mary’s, who is also the NHS’s spokesman on the condition. ‘What we have seen is a massive change over the last few decades in terms of the type of illnesses that we’re dealing with, and the demographic,’ he says. Twenty years ago, Valabhji notes, his clinic for people with complications from diabetes saw relatively few old patients, for the simple reason that few survived for extended periods. ‘In that era, people were having their index cardiac event – their heart attack – and dying, or at least not surviving very long after,’ he says. ‘Now we’re not seeing that. They now happen later, and people are surviving longer, even into their eighties or nineties. That’s changing the burden of disease. I’m using my clinic as an example, but it’s playing out right across the sector. The net effect of all of those things is that we’re seeing people live longer lives, which is a huge achievement, but they’re developing conditions like diabetes with another twenty years to live, or much more than that. So we have a somewhat older population with multiple, long-term conditions.’11
Type 2 diabetes is often used as an example of the difficulties caused by modern, lifestyle-connected diseases, and for good reason. In the UK, one in six hospital patients have it,12 as against one in sixteen of the general population.13 What are likely to be conservative estimates of the medical costs put it at £2.1 billion a year in the UK, with an additional £7.7 billion in societal costs due to conditions such as amputations and blindness.14
Type 2 diabetes is particularly notable as a condition still generally associated with middle-aged and older people, but where the age profile has reduced. In England and Wales, there are now nearly 7,000 people under twenty-five living with it.15 Back at King’s, Martin Whyte is discussing his experiences in another element of his job, running a diabetes clinic as part of an academic role in Surrey, just outside London. ‘I see this in the clinic all the time,’ says Whyte. ‘It used to always be the case that if you had someone in their twenties with diabetes they’d have type 1. Now you can’t take that as a given. We do see lots of type 2 diabetes now, and you even hear about it in paediatric clinics. And there’s loads of people in their twenties and thirties.’
Whyte says he sees many middle-aged people being admitted at King’s who had believed they were healthy, but turn out to have been incubating a series of conditions, including diabetes. ‘We often see the first presentation of what has clearly been there chronically, but is only just being unmasked,’ he says. One of the very modern-day complications of such cases, he adds, is that some of the people who did not know they had type 2 diabetes arrive after spending months consuming large amounts of high-sugar energy drinks to try to cope with the tiredness it brings, which has just made the condition even worse.
We cannot stand still
It can be difficult to put into figures the total additional costs imposed on health services due to inactivity, not least as it is so often just one of a series of risk factors harboured by people. A study by Public Health England concluded it costs the NHS £455 million per year, while stressing this only covered direct costs and was thus a significant underestimate.16
Seemingly more realistic was a paper by the US government’s Centers for Disease Control, which sought to work out the healthcare costs of inactivity while also accounting for the parallel risks of obesity. Merging data from more than 50,000 patient interviews and cost surveys, it found healthcare spending for inactive and insufficien
tly active people was on average 12.5 per cent higher, and was still 11.1 per cent more when body weight was taken into account. Overall, it said, inactivity totalled just over £100 billion extra per year in additional costs.17 A 2016 study in The Lancet came up instead with what it called a ‘conservatively estimated’ total cost of £42 billion to medical services worldwide from activity, as well as an extra £11 billion in lost productivity.18
Such figures are almost too significant to properly appreciate. As another metric, Whyte estimates that around a third of all the emergency cases he sees have ailments connected to inactivity, a proportion that rises to around half if you combine this with the interlinked issue of patients who are also overweight or obese. ‘It is a major, major problem,’ he says. ‘Absolutely – there’s no doubt about it. And the increased pressure is noticeable every year.’
Added to this, Whyte says, is the fact that even if sedentary living might not be the direct cause of someone’s ailment, it is likely to have worsened it: ‘If you’re looking at metabolic and cardiovascular conditions – and there’s a huge overlap between diabetes and cardiovascular disease – inactivity is clearly a factor. Equally, with lung disease, normally when you’re active you’re taking deep breaths in and out, you’re clearing, you’re ventilating. It’s almost like opening the windows and getting the dust out of a room – it cleans everything through. So if you’re not active, if you’re not getting that ventilation, things will settle in the lungs. You can get what’s called atelectasis, which is where the lung just becomes a bit floppy, and sits down on itself. And the body doesn’t like stasis. The body likes to be constantly moving, so if you have atelectasis you’re much more likely to get infections.’