The Longevity Paradox: Medicine Meets Silicon Valley
'For without friends, no one would choose to live.' - Aristotle
Jeffrey Benabio, MD, MBA
Last year, Bryan Johnson, a 46-year-old tech founder, spent 2 million dollars on a regimen that included monthly plasma transfusions from his teenage son. Why? Well, we live in an age when the wealthy inject themselves with young blood, undergo elaborate hormone replacement protocols, get infusions of NAD+, and gobble metformin pill-packs to optimize their biological age. The sell is seductive: Death is evitable. Aging is curable. And with enough money, one can live to be old and healthy.
The venture capital bets might be recent, but the yearning is ancient. Herodotus wrote in the 5th century BCE about special waters the long-lived Macrobians drank and bathed in — waters that not only extended life but left their skin "glossy and smooth." Later, Alexander the Great, in his conquests, was said to have been on a quest to find the "Water of Life." He died at 32, which is probably why his product isn't a popular supplement on Amazon today. Lucas Cranach's "The Fountain of Youth," painted in the late Medieval period, shows old and infirm patrons swimming in magical waters and emerging vibrant and young on the other side. Perhaps those waters had rapamycin-producing Streptomyces growing in it — which is a top seller today.
The Fountain of Youth by Lucas Cranach d.Ä.
Behind the tempting pitch to live forever lies an uncomfortable question: Is this medicine? Should we be testing testosterone on an athletic 23-year-old? Or continuously monitor glucose for a healthy adult with no signs of diabetes? Few doctors would order these for patients, and fewer payors would pick up the tab if they were ordered. This is the disconnect between medicine and entrepreneurs.
"The medical system is so patronizing," said a young venture capitalist on a popular startup podcast I was listening to. He was complaining about how doctors resist ordering MRIs or specialized tests because we doctors "think patients are idiots." We do not. He's missing the point that, as a healthy 30-something, medicine is not resourced to help him with wellness requests. Who should pay for his requested MRI? Who would interpret the results? We physicians cannot keep up with the demand for services from those who need us acutely. We've no plan for absorbing a new generation of the "worried well" — better named the "ambitious well" — while also caring for their boomer grandparents.
We have a critical shortage of primary care physicians; one that will only worsen as our population ages. The Association of American Medical Colleges projects a shortage of up to 40,400 primary care doctors by 2036. What happens if a portion of that workforce begins dedicating their time to monitoring biomarkers and fine-tuning supplement regimens for patients who are not sick?
Healthcare resources — physicians' time, diagnostic equipment, laboratory services — are finite. Every hour we spend with a healthy person seeking optimization is an hour not spent with a patient who is ill. For every primary care physician giving up their practice for a cash-paying longevity clinic, there will be 2000 or so patients who now have to be redistributed onto already burdened practices. When healthy 35-year-olds can get same-day MRIs at boutique practices while my father-in-law waits nearly 2 months for an MRI to characterize a renal mass seen on ultrasound, we've failed.
Caring for cash-paying patients who can sit with you for an hour is preferable to the daily grind of 15-minute appointments for patients who actually need an hour of your time. Why shouldn't docs get to choose? For one thing, our training is publicly funded. Taxpayer dollars pick up the tab for more than $20 billion in graduate medical education every year. It seems not quite right that this education doesn't at least in part serve the public who funded it.
Despite these concerns, we should acknowledge the import of the longevity movement. Prevention is indeed better than cure. Early intervention can avert costly medical problems. And individuals have a right to pursue health optimizations they value, using their own resources.
The question is, how should longevity medicine relate to our broader healthcare system and societal priorities? I think transparency is essential. Longevity interventions should be clearly labeled based on the strength of supporting research. It's the standard we adhere to every day in practice. We also need to be clearer about necessity versus enhancement. Insurance coverage and public resources should prioritize interventions that address or prevent disease. Enhancement services should be demarcated as distinct from necessary medical care.
Physicians working in longevity medicine might also acknowledge some societal obligations. Perhaps consider devoting a portion of their practice to underserved populations or contributing to research that benefits the broader public, not just those who can afford boutique services. We also surely must address the structural factors that push physicians toward concierge practices. If doctors are fleeing due to administrative burden and time constraints, improving those would help ensure care remains accessible to all.
Lastly, we might recognize that the best determinants of longevity operate at the population not the individual level. Clean air and water, safe neighborhoods, access to nutritious food, and strong social connections likely do more to improve the health and longevity of a population than any supplement or monitoring device.
Realizing the promise of longevity medicine requires more than scientific breakthrough; it demands clarity about how these advances should be distributed and what values should guide their application.
As physicians we face a choice: Should we allow longevity to become another domain where privilege determines outcomes? Or could we build a system where the benefits of extended healthy life are available to all?
Since Herodotus and after nearly 2500 years of searching, we still haven't found the water of life. Or maybe Aristotle actually discovered it just a few years later: gymnastics, moderation in food and drink, and good friends. It's hard to raise a series A with that pitch though.
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