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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Friends, I'm thrilled that today we get to welcome another very special guest to A Health Podyssey, Doctor. Zeke Emanuel, the author of a new book that has just recently hit bookstore and library shelves titled, Eat Your Ice Cream, Six Simple Rules for a Long and Healthy Life. We'll hear all about those rules, and we'll talk about Doctor. Emanuel's wealth of experience across the fields of health and health policy as an oncologist and leading voice on topics including bioethics and health reform. He is the vice provost for global initiatives at the University of Pennsylvania Perelman School of Medicine.
Rob Lott:He was a special adviser in the Obama administration, where he helped draft the Affordable Care Act. He's authored or edited 15 books and hundreds of articles, some of which have appeared in the pages of health affairs. We've got a lot to talk about, so let's get to it. Doctor. Zeke Emanuel, welcome to A Health Podyssey.
Zeke Emanuel:Oh, it's my honor and pleasure to be here.
Rob Lott:Thanks. Well, so let's just jump right in. This book represents a bit of a pivot for you, if I may say so. We've known you largely as a health systems expert and a voice for reforming how health care is delivered by health systems. Your new book is geared at a broader audience, and it provides a lot of, helpful advice along the way.
Rob Lott:What inspired this shift in focus for you?
Zeke Emanuel:Well, it's only partially a shift in focus. I did write a memoir about growing up, mostly to answer a lot of questions of like, what did your mom put in the water or cereal or whatever food people wanted to refer to? So I did write that in 2013. But this is a departure in the sense that it's more directed at patients than at policymakers or physicians or bioethicists. And honestly, there are three paths.
Zeke Emanuel:One is, as you note, I'm a physician and I get a lot of questions about should I take this supplement? What diet should I be on? What exercises should I do? So this book is somewhat an answer to all those queries I constantly get. Unfortunately, it may actually lead to more queries rather than less queries.
Zeke Emanuel:The second is many years ago, Ariana Huffington at a conference asked me a question about why isn't there more wellness taught in medical schools? Why doesn't the health system focus more on wellness? And it's a really good question. I basically said, listen, people aren't making, you know, the insurers, the pharmaceutical companies, the hospitals aren't making a lot of money on wellness. They make their money on treating sick people.
Zeke Emanuel:And plus, wellness is relatively simple. It's six things, I outlined the six things, and I said, not that complicated. And the third and the proximate cause was someone gave me Peter Attia's Outlived book. I had finished my teaching in December 2023, exactly two years ago. And I read the book because the finals hadn't come in for me to grade.
Zeke Emanuel:And I was livid, pissed off, furious, mad at the book. And I sat down and I scribbled 35,000 words in the space of about three weeks, and that was the first draft of the book. And basically, multiple things pissed me off about that. But the idea was that people were getting the wrong information and the wrong understanding of wellness, and there was a better way for people to do it. And I thought I could help lots of people.
Zeke Emanuel:And helping lots of people, if I had to say one common thread across all my work, is really what it's about for me. I tend not to do one on one on one. I tend to like, what's the policy change we can make that'll affect 20,030, maybe 20,000,000 people?
Rob Lott:Great. Well, talked about or you point to a better way, and one way to sort of perhaps sum that up, you write in the book that wellness should be something that exists in the background of our lives, and this approach is, contrary to the outlook of many people like Peter Attia and others, so called wellness, the wellness industrial complex, as you refer to it, which sort of seems to invite and profit from some, obsessiveness, I think, among its acolytes to to put it mildly regarding the latest silver bullet diet or a special supplement. And I'm wondering if you can reflect for us a little bit about what it is about wellness that invites such a fervent response and what you think the antidote to that might be.
Zeke Emanuel:I think there's at this very moment, I think wellness is a a lot of people see it as a refuge from a world that is topsy-turvy and that they don't control and seems to control them. We have a lot of factors that are frankly very similar to what happened between the 1880s and the start of World War I in 1914. We have a lot of income inequality. We have an industrial revolution, then it was a second industrial revolution, electrification, factories, today it's AI. We have a lot of immigrants.
Zeke Emanuel:Immigrants were pouring in from overseas in many, many countries, not just The US, but also immigrants from rural areas to urban areas where there were new jobs. Obviously, we have a huge immigrant question and issue in the country. There were also a lot of these little wars happening, not the big ones yet, the Franco Prussian War, the Spanish American War, the Russian Japanese War, the Boer War, and today we have Venezuela, Israel, Gaza, Ukraine, Russia, South Sudan. And people feel like the world is out of control. It's affecting them, but they're not able to control.
Zeke Emanuel:And they reassert autonomy and control in the thing they can get their hands on, which is, their body, what they eat. And then there's concern about that. In the early twentieth century, was up in Sinclair, the jungle and all the worries about processed foods. Today, it's the same thing, worries about processed foods, about contaminants. Then it was worry about mandates for smallpox vaccines.
Zeke Emanuel:Today it's worries about all the vaccines that RFK is railing against. And so you have very similar moments. And I think I see wellness as a way of asserting self control. And in that context, people are not experts. And so you have people who think they can make a lot of money off this.
Zeke Emanuel:It's not the big corporations typically. It's people like, you know, David Sinclair, Andrew Huberman, Peter Attia, that are selling things, whether it's a supplement, a newfangled test, private consultations and individualized exercise and diet regimens. And, you know, they're right. Conservatively, the wellness industrial complex in The United States is valued at $1,000,000,000,000 More liberally, depending on what you include, things like Canyon Ranch and all those other wellness spas, the estimates rise to $2,000,000,000,000 So there's a lot of money. It also turns out to be recession resistant.
Zeke Emanuel:When we had the Great Recession in February, the economy's GDP shrank 3%. Surprise! Supplement sales went up 6%. It's not money for big corporations, but it's a lot of money for people who can gain influence, gurus selling all sorts of junk elixirs, this and that, that really have no basis in reality. I guess the latest one is peptides.
Rob Lott:Well, as you just said, wellness waves are not new. We've been through this before in the late 1800s, but I suspect what might be new is the full scale embrace of some of the movement's worst instincts, whether that's sort of chasing novelty cures or sort of wildly extrapolating from limited laboratory findings at the highest level of our government. And I'm wondering how this shift happened in your eyes, and how do we come back from it?
Zeke Emanuel:Well, we do have, you know, RFK Jr. Attacking vaccines, attacking additives in food, which I think is actually the additives in food is right. The vaccines is wrong on almost every single level. And I think, again, he embodies a perfect example of attack on expertise, an attack on people who actually do the science, and manipulation of that scientific language in a very dangerous way and basically creating a lot of misinformation, fear, uncertainty, and doubt. You know, he's inducing people to be cautious.
Zeke Emanuel:And in this context, cautious is I won't vaccinate my children because I don't know, and there might be problems. And I think that is really dangerous. There are real scientific issues here. And when people ask me, I say, Listen, we're going to have a breakthrough. Everyone's going to know about it.
Zeke Emanuel:It's not going to be a question. It's going to be established. And I said, Look, GLP-1s came along. You hadn't heard of them a few years ago. It was clear that they were an amazing therapeutic advance, not only losing weight, reducing heart attack risk, affecting the brain and the reward system.
Zeke Emanuel:You've heard about it, everyone's heard about it, and there's a way of getting them. Whatever you're reading about the latest peptides, if it really was a miracle, everyone would know about it. It wouldn't be hidden. You can't hide those kind of things in the current media marketplace. And so I think people need to not chase the latest shiny object or the fad or listen to people who are talking about data from nematodes or mice.
Zeke Emanuel:You know, do the basics. You don't have to make it fancy. And as I say, chasing things for wellness should not be your life. That is a hollow, empty goal. And at the end of your life, you would realize it's hollow and empty.
Zeke Emanuel:It should be a lifestyle in the back, the things you do regularly, but your focus should be on something bigger. And, you know, frankly, most of the data suggests a focus on something outside yourself actually will make you healthier, live longer, and be happier.
Rob Lott:Well, that's a wonderful note and a really simple but seemingly solid way of looking at things. I want to ask a little more about sort of how we got here and how you got here in just a moment, but first let's take a quick break. And we're back. I'm here with Doctor. Zeke Emanuel, author of Eat Your Ice Cream, Six Simple Rules for a Long and Healthy Life, and a long and well respected voice in bioethics and health care.
Rob Lott:And I want to ask a little bit about that history and your experience. I actually have right here with me one of your previous books, Reinventing American Healthcare. Can you see that? Yes. Oh, yeah.
Zeke Emanuel:Of course.
Rob Lott:You published that in 2014, and it's pretty comprehensive take on the Affordable Care Act, how the law was envisioned, how it was being implemented at the time. And toward the end, you made some pretty bold predictions about what you called megatrends for the years ahead. And these included some things like, the end of employer sponsored insurance as we know it, the end of health care inflation. And, some of those, I think you you hit on the the nail on the head and others not so much. I'm wondering when you look back at at what you wrote there, what are you most surprised about?
Zeke Emanuel:Well, first of all, I think I did predict that we would have an end to healthcare inflation. And in fact, for fifteen years, we had a plateau at about 17.5% of GDP going to healthcare. And I think in 2014, and certainly when I wrote it in 2012, I was probably the only person saying that. And people hadn't seen it in the data yet. And I was pretty sure that we were going to have a big impact and it lasted for way longer than anyone thought.
Zeke Emanuel:So I think I was right about that. I was also right about vertical integration and more vertical integration and what I think I call the Kaiserification of healthcare, I got the actor wrong. I said that hospitals would do it and insurance companies would fade away. Hospitals did not do anything of the sort. As a matter of fact, they just continued their way of making money, heads and beds.
Zeke Emanuel:But the insurance companies were like, you know, we're going to go out of business if we don't do something different. So you saw United develop Optum and then get into pharmaceutical benefits management. And so you saw a lot of vertical integration driven by the insurance companies, not by the hospitals. I think the world would have been a lot different and probably better had hospitals taken the initiative, but they're not that weren't that innovative. And I think that was a big disappointment to me.
Zeke Emanuel:The thing I screwed up the most on is medical education and the transformation of medical education. And that's because I didn't listen to my old mentor and co author on many, many articles, Victor Fuchs. All the listeners to this podcast, I suspect, recognize Victor Fuchs as one of the original three health economists in the world, a true giant and visionary. He used to say to me, There's nothing slower evolving in the universe than medical schools. And he's right.
Zeke Emanuel:Look, we still have fundamentally the same medical education we had developed by the Flexner Report. And I've written extensively about the need to shorten medical training. We don't need two years of preclinical work. Most students come in way more advanced than are necessary. We could get everything we need in one preclinical education in one year, things like anatomy, microbiology, and then have two years of clinical rotations, much of which has to be out of the hospital because the hospital is no longer the primary focus of healthcare.
Zeke Emanuel:That's still true today and very slow evolution. Yes, NYU has gone to three years. There are other three year programs around. But getting the AAMC to do anything on this, impossible. Most med schools are not actively doing this.
Zeke Emanuel:And the places that are like Duke and UCLA, they are taking that fourth year charging students for research or a master's degree. I think that is terrible, just adds to that and does not really shorten the training period. So I was wrong on that. Just wrong.
Rob Lott:If you woke up tomorrow and found yourself the head of the AAMC and could make one-
Zeke Emanuel:God forbid. God forbid. What would
Rob Lott:that change be, the change you make tomorrow?
Zeke Emanuel:Yeah, I'd go to three year it would require places to go to three year medical schools and also to go to more competency based evaluation. Frankly, I think we've done a disservice to medical students. I'm now going to speak here probably against the current wave. By going to passfail classes, we have incentivized two dangerous trends. One trend is putting all the emphasis on the boards.
Zeke Emanuel:Now, if you can't differentiate students, everyone's pass, some have a few high passes, and you end up putting all the emphasis on one test. I, as not a great standardized test taker, think that's a stupid approach. You miss a lot of talent that way. The second thing I would say is it also encourages students not focusing on the core material, but instead focusing on how can they differentiate themselves. So you get a lot of kids who are doing research and you're going to get those really smart medical students doing a lot of AI generated papers that are not creative, original or anything, but are easy to do.
Zeke Emanuel:That is not helping anyone. It's not helping the medical literature. It's not helping the students themselves. So I think we're not doing a good job by students basically focusing only on one test and then upping the floor of what you need to get a good internship, residency, and fellowship. So those are things that I would try to reverse.
Rob Lott:All right. Let's switch gears to one of your other writings from back in the day, also in 2014. You published a widely read article in The Atlantic under the headline, quote, why I hope to die at 75. And if I might very briefly quote just a little piece of the introduction, you say, Death is a loss. It deprives us of experiences and milestones, all the things we value.
Rob Lott:But here is the simple truth that many of us seem to resist: living too long is also a loss. It renders many of us, if not disabled, then faltering and declining a state that may not be worse than death but is nonetheless deprived. And obviously, when you published this piece, it made a bit of a splash. And now here we are, and you're closer to 75 than you were at the age you wrote the piece. And I'm sure you've heard a lot of feedback along the way and wondering if that central point you make still rings true.
Zeke Emanuel:Absolutely 100% true. And as I say in the book, we're all going to die. You know, trying to postpone it and postpone it is not the right answer. I don't know about you, but I can state pretty clearly for me, and I think a lot of people agree with me, the most horrid situation that I could imagine being in is my body's working fine. The heart's pumping, there's no cardiac disease.
Zeke Emanuel:My vasculature is good, my livers are working, my lungs working, kidneys are functioning fine, but my brain isn't. And I've got cognitive impairment and dementia. That is hell. I don't want to live like that at all. And so if that's the case, then you have to look at the data and say, well, when is that likely to be the outcome?
Zeke Emanuel:And again, if you look at the data, the level of dementia cognitive decline is very low through middle age and then shoots up really fast at 75. And between 80 and 85, about a third of those people have clear cut dementia and a lot have mild cognitive impairments. That is what motivated that article, that you don't want to be in that third who are living with dementia and everything in the body is going well. Plus, over the last few years, I've had, in part because of the book, an opportunity to be with and talk with a lot of 90 year olds and a lot of people who have moved over into the centenarian stage living past 100, even a few super centenarians over 110. And one of the things you notice and they notice quite clearly is first, energy level goes way down.
Zeke Emanuel:Almost everyone after 90 will tell you their energy is going down. They need to nap. They can't do as much. They're slowing down. My mother is 92.
Zeke Emanuel:Her mind is very sharp. But she shuffles around, not able to walk really independently. She has to have a walker. She's very deaf, and so it's hard to communicate with her. She's not happy.
Zeke Emanuel:And even people who can hear, can talk, I've met a lot of, as I say, older people, and their limit for talking to someone is maybe half an hour, forty five minutes. I just met a guy at I did a talk at the Harvard Club in New York, 97 years old, still working on documentaries. He also told me he still has a scoop of ice cream a day. And he came up to me after the sort of public announcement. He said, You know, it's really slowing down and harder to do the things in a day that I do.
Zeke Emanuel:I have to have to nap every single day. Now he was very sharp and pretty amazing at 97. God willing, everybody who gets to that age, it's just not the case. We have a bell shaped curve. Most people are 97, still working, still doing very, very, very rare.
Zeke Emanuel:And the idea, I hear this all the time, Oh, Aunt Sally, she's 94 and she's sharp as a pack. Well, I have my doubts. And the main thing is she's probably sharp as a tack in the things that she's used to talking about, her grandchildren, making this for her group of friends or whatever. But taking on novel activities, doing something new, traveling the world, much less. And when you see the people who are doing that, you know, you recognize they're rare.
Zeke Emanuel:They're doing something very unusual. I'm just talking to a friend who's trying to finish a book at 88, and he was asking me about going to Norway because it happens to be a country I visit a lot because I have a research project there and know a lot about. Yeah. He's very unusual. Very, very unusual.
Zeke Emanuel:And we shouldn't all think we're going to be like that. So we have to plan for what's the likely progression and not what we dream about. Can exercise, you can prepare all the wellness to get to the dream, but recognize that's unlikely and be honest about it.
Rob Lott:Well, before we wrap up, I want to come back to your new book. And in that you cite the wisdom of Benjamin Franklin quite a lot. In addition, I know that you've taught a Coursera open course about Benjamin Franklin, his life and legacy. And I'm curious if you thought about Ben Franklin and his role in American Life. Was he perhaps our first wellness influencer?
Rob Lott:And would also, would he have blurbed your book if he were alive today?
Zeke Emanuel:A 100. He would have blurbed my book. I have no doubt about it. He would have been very happy that someone was writing this. I hesitate to call him an influencer for a very specific reason.
Zeke Emanuel:He has no conflict of interest. One of the great things about Ben Franklin is, you know, he's one of the greatest inventors of all time. He still you know, you look at the list of inventors online, he's in the top five. You've got Thomas Edison up there. But Franklin is one of the top.
Zeke Emanuel:He has at least 10 different inventions, you know, musical instrument. He invented as a little kid, as a adolescent, swim fins. He invented, obviously, bifocals. He did that, by the way, at 79 years of age. He invented the Franklin stove.
Zeke Emanuel:He invented the lightning rod, critical to preventing lots and lots of fires in cities and lots of damage and deaths. But he invented many, many things. And what's interesting, and I think no one really knows this, is he never patented a single one. And he also never copyrighted any of his writings. And the reason is, he said, Look, I find things in the world, I improve them, and I put it out in the world.
Zeke Emanuel:And I'm going to put my inventions out in the world, other people are going to improve them, and mankind is going to be better for it. And he was very focused on improving the world, improving Philadelphia where he lived, improving The United States, and improving the whole globe. And he didn't seek to make money on that. He didn't seek to enrich himself on that. Yes, he did print Poor Richard's Almanac and he charged for that and he charged for the Gazette.
Zeke Emanuel:But these were the kinds of things any average person in America could purchase. And he did not just pile up money. He didn't think getting money was the end of anything. It was simply a means to do things. As a matter of fact, he is the guy who invented retirement for working people.
Zeke Emanuel:He retired at 42. And everything we know about him, except the poor Richards Almanac, happens after he retires. And what is retirement to him? It's not lazing around on the New Jersey shore going with a nice Madeira wine. For Franklin, it was simply being able, comfortable enough to ignore the business worries of life and focus on the important things of life: scientific discovery, inventions, civic improvements, the politics and making The United States possible.
Zeke Emanuel:And so that's what he thought was valuable. Making more money, being an influencer to make money like all of these guys? Nah. And I say, I'm not here. I'm not selling you a test.
Zeke Emanuel:I'm not selling you a supplement. I'm not selling you a private consultation. I got no conflicts of interest in this wellness space. I'm trying to give people the right information so they can change their life and live as healthy and long as they want to.
Rob Lott:Well, there you have it, folks, perhaps a bit of a reincarnation of Ben Franklin here today and the Health Podyssey with us. Doctor. Zeek Emanuel, I had a great time talking to you. Thanks so much.
Zeke Emanuel:Thank you for having me. And I love that last question about my great hero. And anyone can take that course that I've done for free.
Rob Lott:Awesome. Well, listeners should sign up for that now and or purchase or borrow Doctor. Emanuel's new book, Eat Your Ice Cream, on bookshelves now. Of course, if you enjoyed this episode of A Health Podyssey, subscribe, recommend it, leave a review, and tune in next week. Thanks, everyone.
Zeke Emanuel:Thank you.