‘American Dementia’: Author Interview with Dr. Daniel George and Dr. Peter Whitehouse

I’m Dr. Nathaniel Chin, and you’re  listening to Dementia Matters, a podcast about Alzheimer's disease. Dementia Matters is a production of the  Wisconsin Alzheimer's Disease Research Center. Our goal is to educate listeners  on the latest news in Alzheimer's disease research and caregiver  strategies. Thanks for joining us. Today on Dementia Matters, we welcome the  authors of the new book, American Dementia:

Brain Health in an Unhealthy Society. Dr. Daniel  George is a medical anthropologist and associate professor of humanities and public health  sciences at Penn State College of Medicine, and Dr. Peter Whitehouse is a professor of  neurology at Case Western Reserve University

and professor of medicine at the University of  Toronto. In their book, the authors highlight how twentieth century policies focused on reducing  inequity, inequality, opening access to education and healthcare, and protecting the environment  contributed to today’s declining dementia rates; but they also argue the reversals of these  policies in the twenty-first century are sending us on a backwards trajectory. Welcome  to Dementia Matters, Danny and Peter.

Great to be here, Nate. Yeah, thank you Nate. So to start, let's talk about your  book title. How do you both define brain health and what makes our society unhealthy? As the neurologist, I'll take the  first crack. I mean, brain health is all over the place. Centers of Brain Health are  coming up here and there. And we are actually suspicious of that term because - as a good  member of the American Geriatric Society,

I believe that health is… ah - your whole body.  There are things you can do for your brain like learn and education, and hopefully we get  back to that in a minute, but basically it's cognitive health. But it's cognitive health in  the context of health which is, as you know - I agree with the World Health Organization  - it's kind of psychosocial wellbeing, not just the absence of disease. I thought you  were going to ask us, though, about American

Dementia because that's the more provocative  part of the time. Maybe you'll do that next. Yes, before I get to that then - Danny, why don't you tell me, well what  makes our society so unhealthy? Yeah, I think it comes down to one word which  is marketization. I think, in the 1970s, we have really, and we can dig into this  later, but we've really unleashed markets as a way of - a fundamental way of organizing our  flow of resources, the way we take care of people

in this country. And that has led to us also  stripping away safety nets that we had in the mid 20th century. It's - it's kind of led  to losses for workers, stagnation of wages. There's been a whole cascade of circumstances  stemming from the way we organize society in the 1970s that have not served us well societally  or individually or in terms of our brain health. And we're going to touch on how that affects our  cognition and our brain health in a few minutes

but then let's go back to, what do you mean  by American Dementia? Why use that title?

So we were carrying the book under the working  title of Brain Health in an Unhealthy Society. We got advice from a number of interesting  people, including Bill Thomas - you know, come up with something pithy, you  know, to put before them. And so we use this title because it has a double  meaning: it could mean the clinical dementias,

you know, that exist in America, but it's  rather more a cultural critique. We think that the dementia field - not geriatricians  of course - but neurologists and psychiatrists have this sense that we can fix it with drugs  and… but they forget the lessons of the past and they're not planning well for a future which is  based on a lot of false hope and false promises. So American Dementia is a critique but it's not  just of the dementia field, it's of our country.

Our country forgets its past. It doesn't plan well  for the future. And since you need impairments of activities of daily living to define a cultural  dementia as well - look at our society. Look at what we're doing with the environment, that  you already suggested is part of our book. So we're dealing with a cognitive impairment that  the Indian writer calls The Great Derangement, but we've called it American Dementia, and it's  not just America but we are pretty good at it.

And so Danny, what motivated you to write this  book or be a part of this writing with Peter? Yeah, so Peter and I wrote our first book called  The Myth of Alzheimer's, another provocative titled book, in 2008 and the next year, we  obviously all experienced the Great Recession. And, you know, I was personally affected - I was  unemployed for quite a long stretch. I feel like that thrust us into a different era where all of  us were feeling the effects of political failures

to some degree or another. And of course the  Occupy Wall Street movement was birthed in part in Madison, Wisconsin - where you are, Nate. So  that was sort of the water that we were swimming

in last decade. In November of 2016, people will  obviously remember the election that happened that year, but there's some significant things that  happened in the Alzheimer's field, one being the drug solanezumab which is an anti-amyloid  drug sort of spectacularly failed in its phase three trial, despite much hyping of the compound,  and subsequently we learned that dementia rates had been declining in the United States over the  past decade from Ken Langa and his team at the

University of Michigan - this study published in  JAMA. So that created a paradox right where we're in this backdrop of, you know, political failures  and whatnot and yet these dementia rates seem to be falling. So Peter and I are not - neither of  us are political scientists but it does require you to think about political economy. What is the  context that has produced these benefits if not biotechnology? And so that's sort of the genesis  of the questions that we're asking in this book.

And so before we get to some of your thoughts on  that specific topic I do want for you both - and I'll start with you Peter - but can you  share with our listeners how you explain Alzheimer's disease to your family and friends?  And I'm going to ask this question because you don't view Alzheimer's disease as a single  disease that technology can just fix. So how do you share that? How do you explain to people at a  dinner party what you do and what Alzheimer's is?

I think it's easy to just say that the name  - that the concept of Alzheimer's has changed and it's still changing and one of the things that  science over the last 25 years has told us is it's not one thing - it's heterogeneous. And people are  familiar with the idea that diseases can occur in different places. Sometimes people aren't really  - they think of diseases as being discovered by doctors, they're really invented by doctors and  drug companies. And the idea that, you know,

to agree on something being a disease requires  a social process. So you know I'll sometimes use homosexuality as an example of a condition  that the attitudes of which have change and medicine change with it. So basically,  to get the idea that it has changed,

it will change, and it's not one thing - and it  is related to aging. That's the other part that's important to throw in there because with all  these concerns about mild cognitive impairment and subjective cognitive decline, people begin to  wonder just what on earth is this entity anyway. Danny, do you want to add anything to  that before I ask you your next question?

No, I think Peter is nailing down the base tenets  of the myth of Alzheimer's which is it's not one thing, it's heterogeneous, it's syndrome, and  it is intimately related to brain aging processes. And those are the two things we try to convey  that we're not just dealing with polio here, a single pathogen. This is a very complex  challenge. And in fact, if you're talking to older family or friends, they'll know this  as senility right? They hit a different frame

for it, a different schema through which  to understand it. It's only in the last, you know, 30 or 40 years that it's really become  a prominent disease to be cured through a single mechanism drug. And so since that hasn't happened  it has sort of created fertile grounds for people to maybe think differently about what it is  we talk about when we talk about Alzheimer's.

Yeah I appreciate your explanation of not  separating it from aging. Even though we consider Alzheimer's disease to be an abnormal process,  when you acknowledge that it's still a part of getting older, it isn't so easy to just  have a silver bullet that takes care of it. And not to be offensive to our  infectious disease colleagues, but it's not something that we can simply  identify, throw an antibiotic at it and

kill it. It's more complex and requires - I don't  want to say more thought because I know there's a lot of thought that goes into antibiotics,  antimicrobials, but it does require more. Yeah I like to - I like to think of  it as being like a Jackson Pollock painting versus the Mona Lisa. Dealing  with something that's very complex.

(laughs) And so Danny, I'm going to go with you  for this question because you had mentioned, you know there are things that we're not doing well  from a societal standpoint and that that could be, you know, really harming some of the  gains that have been made in reducing dementia rates. What do you think is  wrong with our current approach to

Alzheimer's disease from a non-clinic  standpoint, from a societal-cultural? Yeah, so the model, the story we've told about  Alzheimer's is single gene, single protein, single cure. That has not yielded the silver  bullet that you mentioned, Nate. And you know what has emerged in the writing of this book is  really the fact that the greatest interventions

that we've had have been at the level of political  economy over the last hundred years. That's things like increasing education for people through  the GI bill, through Pell Grants, through the expansion of state universities during the  Cold War and so on, and the cognitive reserve that has sort of precipitated. You have a great episode  that I just listened to about smoking and brain health and obviously the public health campaigns  from the 1960s forward were substantially

successful in reducing smoking rates. It went  from 42% to 14% from the 60s to today. We have the Great Society in this country, which put  health care around more people and allowed for better treatment of vascular risk factors,  hypertension, diabetes, high cholesterol and those sorts of things. And then of course,  the last thing I'll mention is we were able

to delead gasoline in the 1970s. That was through  the Clean Air Act with the EPA which was created, of course, as a result of the fire on the river  of the hometown - my hometown - in Cleveland where Peter also lives now. (laughs) So - but those  interventions -quote unquote - have had a more substantial impact on brain health than anything  that has come down the pharmaceutical pipeline.

Peter, I mean feel free to add  on top of Danny’s response, but from a clinical perspective how do you  think we're making mistakes when it comes to the approach with Alzheimer's disease and  I would just say all cognitive disorders? I'm going to generalize that to all  of medicine. Well, because I think this is supposed to be the era of  personalized and precision medicine in which we know more about you as an individual  and your biology, which leads us into the field

of biomarkers. I mean, what's happened to  Alzheimer's disease in the last ten years is that there's this attempt to reinvent it as a  purely biological process which to my mind demeans what is really personalized about medicine, which  is understanding an individual patient's story

and tailoring your care to that story. Not to,  you know, a vast panoply of expensive biomarkers that, in some kind of strange way I don't  understand, is going to lead to a pill for you or maybe a panel or a - a cocktail - I love that  expression - a cocktail of drugs designed for you. I think that is dehumanizing and unrealistic and  expensive and I think dangerous. So that's why, as Danny said before, Alzheimer's is really a lens  through which to see bigger issues about how we

frame health. You asked us to define brain health  in the beginning - if you define brain health as purely something that brain scientists are  going to take care of, you're going to restrict not only geriatricians but a whole bunch of  other people from playing a role collectively and that's the message. It's not the individual  people. It's not just the individual patient. Of

course this gets to be attention in medicine too.  Doctors are responsible for individual patients, but we are increasingly recognizing you can't  do primary care without doing public health. And so within that framework of brain health,  I do want to ask you both a personal question before I get to your bigger cultural  recommendations or societal ones. When we think of brain health we think  of lifestyle behaviors. We think of

some decisions that people make. And while  these may not be curative, certainly there's some evidence to say that blood pressure control  can be very helpful to a brain. What excites you, Danny, what do you think about in your research  - as far as at that individual level that Peter's referring to - what do you subscribe to? What  do you think could have a meaningful impact?

Yeah I think, you know, the Lancet Commission  on dementia prevention has really nailed down the fact - that's this very hopeful part of the  story - which is that about 40% of dementia risk factors appear to be modifiable and within that,  I mentioned things like lead poisoning but other -

what we're talking about environmental impacts.  We've learned a lot in recent years and you've - I think - had an episode on this within the last  couple of years, Nate, about air pollution and the effect on inflammation in the brain and vascular  injury, so there's an interesting story emerging there. Another kind of unconventional risk factor  to emerge in recent years has been hearing loss and providing hearing aids for people. That's  a very low-hanging fruit, it seems to me.

But I guess in closing - and I know I've said  more than one here and I apologize for that - but the education story is very exciting to me too.  Not just providing higher education to more people which does appear protective, but encouraging  friends, family members, listeners to engage in playful, purposeful learning that builds  relationships, that builds community because in this marketized era that we've been living in  for the past 40 or 50 years, it's all been about

the individual - this sort of monatic, isolated  individual - and that's deeply alienating. And I think we're all feeling that especially during the  pandemic, but getting back to the community bonds that we've lost through things like education  is a really, really inspiring one to me. And so Peter, moving beyond individuals and some  of these things too that I just asked Danny about. You know, in the book the two of you talk  about a collective resilience to dementia.

So can you define, for our listeners, really  what does that mean? And how does our culture or our governing bodies or our society really  address this and achieve true resilience? So I think, you know as geriatricians,  resilience is an important concept clinically. You can have two older folks that have a  similar problem list but there are some that are just able to adapt to change and that's  the key word - change. How does the individual,

how does the community, how does the culture, for  that matter, respond to change? And I'll echo what Danny said and add to it. I mean, the way I think  is that education is the key to resilience. If you have a broader set of patterns of neural activity  that you can connect with, you can connect with more people. And so this issue that - it is the  learning experience that enhances resilience and Danny and I both have worked in three public  intergenerational schools in Cleveland

where I would recommend to my patients to  consider volunteering in the school. Patients with dementia, patients in Danny's research study had  dementia. But they engaged themselves in the lives of young kids from Cleveland and they enjoyed a  sense of purpose and a spirited engagement in a community. And it's really hard to do studies  on that. I mean, how can you determine that having a sense of purpose in life is critical?  Almost is a silly question to answer - to ask,

let alone answer. But a learning environment  gives you that sense of commitment, collective, resilience, solidarity, and commitment to your own  brain health and to the brain health of others. And in this book, you argue that inequalities of  the twenty-first century may be reversing some of the progress that we're seeing in our reduced  rates of dementia. So Danny I'll start with you,

but I do want Peter to answer as  well, what are these inequalities and how are these inequalities  actually affecting one cognition? Right, so in the 1970s we had, you know, the  crisis of stagflation and oil shocks and basically that led - just like the Great Depression and  the World Wars - to a sort of reorganization

of society. Whereas it was organized around  social democracy in the twentieth century, earlier twentieth century, in the 1970s it was  organized around what we might call neoliberalism, or hypercapitalism, hypermarket logic that  we've already touched on. And, you know, I've already said sort of the effects of that,  but it created massive wealth right - more wealth

than the world has ever seen. But deregulating  markets and sort of liberating capital around the globe also created real volatility which has  led to tens of millions of jobs being outsourced and we saw the housing crisis precipitate  the Great Recession that I mentioned at the outset. Wages have been stagnant for people  in the middle class for 40 years because

workers have sort of lost their footing. The  unions have been broken to a large extent. We've lived the last 40 years in an era where money  has been trickling upwards; the average person's life has not really been getting better. And in  the context of brain health what that's led to is like reversals in vascular health improvements  that we saw throughout the twentieth century. Now 6 of 10 Americans, according to the CDC,  live with a vascular or chronic disease.

80 million are un- or underinsured in the country  - those are people who are not getting help for all of the upstream vascular risk factors and  other risk factors for brain health. You know, we've seen a rise in things like deaths of  despair. We've lost life expectancy in the country four of the last five years. We lost a whole year  and a half of life expectancy last year. And then you know we've cut our public health programs,  we've deregulated industries, and that has led

to a massive lead crisis once again. This time  it's not in our paint or our gasoline, it's in our water, in the water mains that connect us all.  Again, just a direct result of not investing in infrastructure, and not investing in public health  and public good, and sort of just leaving things to the market. And so I think all of those things  portend very dangerously for brain health. And I guess the last thing I'll mention is that we've  seen a trend downwards as well in total years

of education for the cohorts who are now growing  65 and older. So we saw this sort of exponential rise post-GI bill but those numbers are starting  to trend down, especially for men, who are not going to college as much. People are just getting  priced out. We've, of course, underwritten all the debt - the massive debt - through Wall Street.  You know, another result of this marketization of the landscape we're living in, but all  of it does not loom well for brain health.

Well Peter, that's a tough one to follow. I'm not  sure if you want to add to that one or explain,

you know, how specifically these climate  change - because in your book you talk about climate change and poverty in  particular and its impact on thinking. Yeah, actually I was just going to go there,  Nate, to climate change because - I think COVID is trying to teach us lessons about  the importance of public health, but climate change - and I’d call it a climate crisis frankly,  change my language on that - because I thought it,

used to think it was, you know, an issue for my  grandkids. Well, it's an issue - it should have been an issue for generations before ours. It is  the intergenerational ethical issue of the times and I try to connect it to the dementia  conversation by saying, what is the greatest threat to people with dementia? Well, they get  dehydrated easily. They can't get out of the way of floods. They may be blown away in a storm. They  just don't know how to respond. Of course kids are

vulnerable too, so it's an intergenerational  issue. But the reason that climate crisis is the greatest threat to the quality of life  of people with dementia is it's the greatest threat to the quality of life of all of us. So  quite frankly dealing with aging and dealing with dementia is an important issue, but I sometimes  joke that, you know - I know the elevation of

Bethesda. It's about 300 feet. Why do I know that?  Because somebody's going to invent the cure for Alzheimer's disease just as the NIH is flooded,  and besides the only person that could afford the cure for Alzheimer's disease would be Bill Gates  or Jim or Bezos or whoever is the most wealthy. It's just - it's just we've got to put what  are really important issues for people's health in front of them and not find ourselves in these  fantasy worlds. That's what they are - that we can

find a magic bullet. Maybe there's a magic bullet  to cure the climate crisis. I don't think so. Well in the book, you mentioned an “eco-psychosocial” model of health. So can  you tell us about the key features of this model and really how do we implement these  things into our current health system? So I invented that word. Danny  has his own neologisms at times. But there's no geriatrician worth his or her  salt that doesn't know about George Engel's

biopsychosocial model. This is kind of like  your model with the infectious disease expert. Yes, the infectious disease  expert prescribes an antibiotic, but if the person is living in poverty or can't  afford to take the prescription or whatever else, you know, it's not going to work. So we know  that with vaccines. I mean getting vaccines into people is the hard part, not necessarily  developing them. So why eco- instead of bio-?

That's the substitution. Well, it's not molecular  biology. It's not reductionist biology. It's not that the doctors need to know their pharmacology  better. Yes, diseases have a biological element at the level of the individual patient. Eco says,  quite frankly, the doctors got the biology wrong. We need to have a biology behind medicine which  is ecological, that's environmental, that's, for that matter, evolutionary. I mean  this linear model of - there's a gene.

There's a protein. There's a drug. There's a  Nobel Prize. There's a lot of profit to be made. It's linear cascade from genomics to economics  is just driving medicine crazy. That resonates with what I was saying before. That's what's  - that’s why the lessons for dementia about thinking of things in the broader ecological  frame rather than narrow reductionistic - I'll use that word again - biology is a key to  seeing why we have an American dementia.

Danny, what are the most promising  “socialceutical” - as is quoted in the book - interventions improving the  well-being of people affected by dementia? Yeah, that's sort of a tongue and cheek phrase  that we use, but I like it because it juxtaposes really nicely with pharmaceuticals and it goes  to show you how powerful the social networks, connecting through the arts - all of the things  that we've talked about before - how vital those

are to dementia care. So I just took my medical  students, over the last month, to a nursing home just off our campus and we did Time Slips.  And I know you've had Anne Basting on recently. Time Slips is a sort of creative, improvisational  storytelling activity. We went to the locked unit, and the skilled nursing home and the students  basically facilitated four sessions with, you know, several dozen people who had  fairly advanced dementia. And the students,

they go into it just thinking of these folks as  difficult patients right? That's what they've encountered in their clinical years. But then  they emerge from it seeing these folks having creativity and spontaneity and wit and  cleverness because the arts, the storytelling, that socialceutical brings something out. It  connects to something quintessentially human that is still there. And as Anne says, it transfers  us from the pressure to remember to imagination.

And so you often see this with music and  with pet therapy and gardens - dance as Peter likes to point out. All of these things  are really brilliant ways of bringing, you know, people who don't have diagnoses  of dementia together but when you do engage

folks with dementia in these activities there can  be something really powerful that happens. And if you had a drug that could do that  for people, that could bring a room of ten elders to life with the way Time Slips  does, it would be a billion dollar drug. And so that's where I have seen the most hope  and vitality in my work in dementia care.

And social prescribing is a real phenomenon. I  mean in the UK particularly. This idea that you don't have to write a prescription for  a pill, you can say to them, you know, exercise or dance. So that's one manifestation  of this concept that Danny invented. And of course what I love  is what are the side effects of art therapy and pet therapy and dance and  being social? A good time and feeling good. But I would say this - you called them therapy.

This is part of the dehumanization. You like - I  don't know what you like but - you like to dance. You like music. You know most people like arts,  so why is it that we have to make it a therapy? So we can take human beings, dehumanize  them, and then rehumanize them by therapy. Let's just say they're human beings and they  like art, music, and let's just do it with them.

Now that's a point well taken Peter. I  appreciate that because the words we use matter and I certainly think you're  right by incorporating therapy. All right, well I'm going  to incorporate that, Peter. (laughs) You know, I wanted to end by asking - for  both of you, and I'm going to start with you Peter and I'll end with you Danny - what would  you want your reader to do next after reading

this very thought-provoking book? What is the  intention, the goal? What should a reader do? I have two quick thoughts. I mean, in some sense,  it's to open the mind and the imagination to new possibilities. I think we need that in the world  in general, frankly, and I think that's another

example of how doing that with our own minds, our  own thought processes, could be helpful. The other thing which is a little bit more esoteric in some  sense, but I think it's critical, is I go back to the mission statement of this intergenerational  school where people with dementia and kids learn together. The mission of the school is lifelong  learning - which is kind of a no-brainer, so to speak, for an intergenerational school -  but it's also spirited citizenship. I believe,

and Danny believes, that democracy is threatened  around the world. That the gains we've made when we acted socially and democratically - you  know, social democracy - are huge and we are losing that unless people say that the best  thing they can do is to be a spirited citizen and to get out there and make sure that people's  rights to vote are not taken away or whatever.

So I mean it is that, in that broader sense, a  mission. It's a political statement that - take care of your brain, take care of other people's  brains, and take care of society for our children. Yeah, and to that I would add, you know, we sort  of joke in the book that it's not a self-help book, it's an other-help book. What Peter's  alluding to is spot on. And if we think about the initial framing of what american dementia is - you  know, the inability to remember things from the

past or project forward in a meaningful way. You  know, from a policy perspective, you could imagine things like universal health care being one very  clear population-level intervention that would help brain health. You can imagine free tuition  for higher education which has been talked about for the past decade, or free vocational training  for people as being a brain health intervention. You know, a job guarantee and a living wage which  has been talked about since Martin Luther King

but we haven't realized yet. Just lowering stress  and anxiety and precariousness in people's lives. And then of course tackling the lead crisis is  another major way to look forward. But then I'll just end by also alluding to the fact that one of  our chapters is called “Occupy the Nursing Home”, and it gets to what you were asking about  before, Nate, about socialceuticals. And we would charge any reader to think about, what  are your passions? What are your talents?

What are the hobbies that you bring  - that bring you joy and purpose, and could you imagine bringing those into a  nursing home to make quality of life a bit better for people? One of my medical students was an  aspiring Broadway performer before she came here. She's now going to start playing  show tunes and doing, you know, doing piano and singing in the locked dementia  unit where we did Time Slips. Other people could

absolutely imagine doing things like that. We are  very talented, innovative, resourceful species, so I would encourage anybody to think about  how they could go into these assisted living environments and really add to the purpose  and quality of life of people living there.

Well I want to thank you both, Dr. Daniel George  and Dr. Peter Whitehouse, for being on Dementia Matters and I want to encourage our listeners  to pick up their copy of American Dementia: Brain Health in an Unhealthy Society, where they  can learn much more than what we discussed today and really challenge what we're thinking about.  And I love that call to action - find your passion and spread it. So with that, thank  you both for being on the podcast. You're welcome.

Yeah, thank you for having us today. and I'm going on to another  discussion of media. So Nate, I'll teach you some more about geriatrics  later on. Don’t build trust in those biomarkers. (laughs) (laughs) Thanks for listening to Dementia Matters.  Be sure to follow us on Apple Podcasts, Spotify, Google Podcasts, or wherever you get your  podcasts to be notified about upcoming episodes. You can also listen to our show  by asking your smart speaker

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The Wisconsin Alzheimer's Disease Research  Center combines academic, clinical, and research expertise from the University of Wisconsin School  of Medicine and Public Health and the Geriatric Research Education and Clinical Center of the  William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin. It receives funding from  private university, state, and national sources, including a grant from the National Institutes  of Health for Alzheimer's Disease Centers.

This episode of Dementia Matters  was produced by Rebecca Wasieleski and edited by Caoilfhinn Rauwerdink. Our musical  jingle is "Cases to Rest" by Blue Dot Sessions. To learn more about the Wisconsin Alzheimer's  Disease Research Center and Dementia Matters, check out our website at adrc.wisc.edu.  You can also follow our Facebook page at Wisconsin Alzheimer’s Disease Research  Center and our Twitter @wisconsinadrc.

If you have any questions or comments, email  us at dementiamatters@medicine.wisc.edu. Thanks for listening.