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The signal public health achievement of the 20th century was the increase of the human life span. Now, as that achievement helps raise the proportion of the aged around the world, what once seemed an unalloyed blessing is too often regarded as a burden — a financial burden, a health care burden, even a social burden.
“It’s nuts,” said Dr. Linda P. Fried, an epidemiologist and geriatrician who is dean of the Mailman School of Public Health at Columbia University. “To assume defeat from what every one of us as individuals wants suggests we’re not asking the right questions.”
Findings from the science of aging, Dr. Fried said, should “reframe our understanding of the benefits and costs of aging.”
From her perch at Mailman, a position she has held for four years, Dr. Fried is pushing students, professors and a wider audience to ask the right questions and ponder the right policies for coping with an aging world population.
Dr. Fried’s mandate is to lead a school that will give a new generation the tools to deal with global challenges to public health, including environmental degradation, climbing health care costs and the pressure of rapid urbanization. But she believes that research on aging and health changes “across the life course” are central to designing solutions to public health problems in the 21st century.
The Mailman School is newly energized, with enrollment in the master’s and doctoral programs up 26 percent over the last four years, and grants from the National Institutes of Health up 12 percent in 2011 — a year in which the overall N.I.H. budget declined slightly. Mailman’s curriculum has undergone a major redesign to reflect a new emphasis on health preservation and prevention for every stage of life. Interdisciplinary study will be required of all students. The curriculum, Dr. Fried boasts, is “absolutely unique” among schools of public health, and has generated a great deal of interest. Applications for 2012 admission to the master’s program were up more than 20 percent from the year before.
It would be too soon to call the dean’s job the capstone of Dr. Fried’s career. Petite, energetic and seemingly indefatigable, Dr. Fried, 63, travels extensively, serves on numerous nonprofit initiatives on aging, maintains a house in Baltimore and an apartment in New York, and on occasion dons in-line skates for a spin in Central Park.
She gives the impression of having only just begun a campaign to change people’s thinking, and frequently answers a question by saying that she’d like to take several hours to do it justice.
Dr. Fried has spearheaded a large body of scientific research on aging. She spent more than two decades at Johns Hopkins University studying data collected on the health of more than 5,000 men and women 65 years and older as part of the Cardiovascular Health Study, and later mined data on 1,000 women over 65 for the university’s Women's Health and Aging Study.
She broke new ground in defining frailty in the elderly, developing a simple assessment tool that uses five criteria to test for frailty. She also developed the concept of a “frailty syndrome,” and continues to guide younger colleagues in studies exploring how the frail respond to various stressors. In recent years, she has also collaborated with her husband, Dr. Joseph B. Margolick, an immunologist and H.I.V./AIDS expert, in studying frailty in H.I.V. patients. Dr. Margolick works at the Johns Hopkins Bloomberg School of Public Health and travels most weekends to New York to be with Dr. Fried. The couple has two grown sons.
Dr. Fried’s findings have set new standards for the assessment and treatment of geriatric patients. Her work “has become core knowledge and core teaching in every geriatric program” in the country, said Dr. Christine K. Cassel, president and chief executive officer of the American Board of Internal Medicine and a leading expert in geriatric medicine.
Dr. Fried, who is a native New Yorker, grew up in Stuyvesant Town, attended Hunter High School and went on to study history at the University of Wisconsin. After spending five years variously as a paralegal, social worker and a physical therapist, she enrolled in Rush Medical College in Chicago, graduating in 1979.
After training and fellowships in public health at Johns Hopkins, she was recruited for a fellowship in the geriatrics program at the university’s medical school by Dr. William R. Hazzard, and hasn’t looked back. Dr. Hazzard, now an emeritus professor of medicine at the University of Washington, said that at the time, most physicians were daunted by the challenges that go with the aging process. Dr. Fried, he said, “embraced the complexity.”
Indeed, the frailty syndrome that Dr. Fried describes is at once simple in its constituent elements and complex in the manner in which those elements interact. In a sort of negative synergism, insufficient nutrition can lead to loss of muscle mass, which can reduce strength and walking speed, which in turn reduces overall activity and energy. All of these factors interact to dysregulate the immunological, endocrinological and other systems in the body. Many of Dr. Fried’s papers on frailty have a schematic with arrows showing the negative feedback loops and how they work.
“I’m an intuitive thinker, and I’m very visual,” Dr. Fried said. “There’s a progression; you sweat over something. You try to get at it from 40 different directions. One day it all comes together. Then there are years of study to demonstrate what we know. You know that quote from Michelangelo — sculpting is merely the art of revealing figure in stone. In science, every once in a while you chip away at the marble and what is revealed is exactly what you thought you were going to find.”
Despite the widespread acceptance of Dr. Fried’s work on frailty, some researchers have developed competing tools: Dr. Kenneth Rockwood, a geriatrician at Dalhousie University in Halifax, Nova Scotia, favors using a mathematical index based on as few as 31 and as many as 100 specific deficits, including “activities of daily living” like dressing and bathing.
Dr. Fried has welcomed his input. Some years ago she invited Dr. Rockwood to serve on the external advisory board of the Center on Aging and Health at Johns Hopkins. “How many other people invite the guy on the other side to come to their program?” Dr. Rockwood said.
That collaborative approach is a hallmark of Dr. Fried’s work. Numerous colleagues cite her generosity of spirit, her years of mentoring and her ceaseless advocacy for young doctors and researchers, especially women. “I don’t think I would have been chair of the bio-statistics department were it not for her mentoring,” said Karen Bandeen-Roche, at Johns Hopkins Bloomberg School of Public Health.
One Generation to the Next
Dr. Fried credits her study of the “visually beautiful” art of aikido, which emphasizes nonviolence and conflict resolution, with giving her a “sense of my strength” and the tools to help her lead ethically and effectively. Drawn to aikido because of her petite size, she practiced it in her 20s and early 30s and received a black belt.
Dr. Fried was also greatly influenced by her mother, Adrienne Fried Block, a “highly original and analytical thinker.” Ms. Block was a musicologist and feminist scholar who got a college degree in her 30s, began graduate school in her 40s and completed her Ph.D. in her 50s, then went on to teach and mentor for many years. She died in 2009 at age 88. Dr. Fried’s father, George Fried, is 94 — and frail, she says.
The biggest lesson she learned from her mother, Dr. Fried said, is that “no human life should be wasted.”
That impulse pushed her to collaborate with the social activist Marc Freedman and others in the early 1990s to plan and enact a nationwide volunteer program called Experience Corps. The program trains volunteers, 55 and older, to tutor children, from kindergarten through third grade, in economically disadvantaged schools for 15 hours a week. The pilot began with volunteers in five cities in 1996; the program has now expanded to 19 cities, including Baltimore.
For Dr. Fried, the potential for Experience Corps to benefit both children and older adults was not only exciting, but also a testing ground for the psychologist Erik Erikson’s principle of generativity — that one generation seeks, as it moves into old age, to help and pass knowledge on to a younger generation.
Dr. Fried built in health-promoting components, by ensuring, for instance, that tutors had to walk a certain distance to the classrooms where they would meet with children. She also designed the program so that tutors would be randomly assigned to schools, and those people’s health outcomes could be evaluated against those of tutors who had not yet been assigned.
A 2009 study using functional magnetic resonance imaging showed that participants experienced short-term gains in executive function governed by the prefrontal cortex region, compared with a control group. Other studies are being conducted on the longer-term effects of the program.
Challenges on the Horizon
Dr. Fried is still looking for new ways to engage members of an aging population. She and Dr. Laura L. Carstensen, director of the Stanford Center on Longevity, both of whom serve on the MacArthur Foundation’s Research Network on an Aging Society, recently wrote an article together for the World Economic Forum, calling for the development of “infrastructures that tap the real talents and potential contributions that healthy older people can make to societies.” One idea that Dr. Fried has weighed in on, now being developed at the Stanford Center, is a program that would steer people who are close to retirement to volunteer activities that they can continue to pursue in retirement. Dr. Fried also hopes to invigorate the International Longevity Center, newly housed at the Mailman School. The geriatrician Robert N. Butler, who died in 2010, founded the center and had discussed bringing it to his alma mater. With affiliated centers around the globe, the center will be the flagship for research projects that cut across disciplines at Columbia. Subjects will include disease prevention and housing for the aged, and Dr. Fried expects that professors from engineering, architecture and other schools will play a role in the center’s research agenda.
But the basic business of scientific research still draws Dr. Fried. Every two months or so, she hops on an early train from New York’s Penn Station to Baltimore’s Penn Station, hails a taxi to the Center on Aging and Health and proceeds to a meeting room where about a dozen current and former Johns Hopkins colleagues gather at a large table. After asking to see baby pictures and chatting about recent vacations, Dr. Fried gets down to business: discussing the latest research on how the frail respond to various stressors.
Dr. Fried challenges, prods and teases her younger colleagues. She reminds them of the questions, big and small, that they are trying to address. After Dr. Rita R. Kalyani, an endocrinologist, presented her findings on diminished glucose tolerance among the frail, Dr. Fried called the work “breathtakingly exciting.”
Even though financing has run out to support the group’s efforts, they have vowed to keep meeting, alternating between New York and Baltimore. Dr. Fried’s participation is unusual but welcome. “I’m really amazed that she still has the energy and motivation to keep working on frailty,” said Ravi Varadhan, a biostatistician and engineer who is a member of the group.
Dr. Fried wouldn’t have it any other way. “We’ve been working toward this data for 20 years,” she said. “To actually get data that took us 8 to 10 years to design and collect and have it actually be exactly what we had hypothesized, well, that’s always a nice experience.”
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