Ageing, health and society

Shah Ebrahim

Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.

‘Will you still need me, will you still feed me, when I’m 64?’ Lennon and McCartney wrote this line in 1967. Average life expectancy at birth for a man in England was 68, but it is now 75 years and rising at the rate of 2 months every year. The rise in the oldest old has been even more dramatic amongst very old people and is best exemplified by the number of people reaching 100 years of age. In the UK, it is the custom for the Queen to send these people a congratulatory telegram (Table 1Go). The Queen now sends a card by express mail as the telegram service no longer exists. How long before she just sends an e-mail?


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Table 1 Birthday greetings telegrams sent by Queen Elizabeth II to people on their 100th birthday, 1952–2001
 
This issue of the International Journal of Epidemiology contains a series of papers concerned with ageing. For each of us individually, having survived long enough to be reading this, our chances of reaching old age are high. And yet, the myths surrounding ageing are legion. Our commentators make an excellent job of highlighting and demolishing many of them.

Demographic alarmism

The ticking of the demographic time-bomb and associated chaos for public services has been a prevalent theme. Averting the ‘crisis’ of very large numbers of older people has been used as a lever to promote questionable policy changes,1 which have failed. Gee contextualizes current concerns about the ageing of populations with earlier eras of demographic alarmism: fertility control in Canada in an attempt to preserve and improve the ‘White race’; massive western (largely US) funding for birth control to slow the ‘population bomb’ of the rapidly growing populations of the South, which still continues.2 Both were misguided and ultimately such policies fail. In commenting on the impact of demographic change on health and social care, both US and European perspectives highlight the fact that it is not demographic factors that will determine the affordability of care, but rather it is politics and social organization.3,4

While the whole world is ageing, there is marked heterogeneity between countries in the rate of ageing. Palacios suggests, controversially, that the differences in both the numbers of aged and the economic status of different countries may promote migration that would enable the long-term care needs of elderly people in high-income countries to be met and would lead to the economic growth of poorer countries.5 Although it is frequently emphasized that the majority of the world’s elderly people live in low- to middle-income countries, it is the speed with which these populations are ageing that is of greater significance. In the rich North, a century of economic growth change enabled slow and steady development of the infrastructure necessary to support the health and social needs of growing numbers of elderly people. It took over 100 years for Belgium to double the proportion of its 60+ population from 9% to 18%. China will take 34 years and Singapore only 20 years to achieve the same population ageing. Projections suggest that the net world monthly gain in people aged 65 years and over by 2010 will be 1.1 million every month,6 from a current level of about 800 000 every month. In the poor South, it will be difficult to implement adequate support systems, given their economic status and the lack of political will.

A new social contract?

In Latin America, Palloni et al. feel that the chances of achieving successful public policies are bleak, citing the causes as untamed inflationary pressures, recessionary set backs, high unemployment, increasing absolute poverty and growing social and economic inequalities.7 It seems likely that in all countries there will be a need to re-define the role of the state in ‘welfarism’ as suggested by Lloyd-Sherlock, who also emphasizes the changing economic, social and cultural contexts in which social policies for older people are enacted.8 The social contract between individuals, families and the state requires re-definition. But this re-definition needs to be done explicitly, starting with a statement of our social values from which our policies should grow. In the UK, the issue of long-term care has only recently become the subject of review in the form of a Royal Commission.9 While unanimous conclusions could not be reached on who should pay for certain aspects of long-term care, that independent, explicit and reasoned debate has occurred will make for better understanding of our social contract.

Political denial, empowering the disenfranchised

In poorer countries, as both Evans and Gorman note, it is much more likely that politicians will simply neglect to consider their responsibilities to older people or, worse, remain in a state of denial in which it is assumed that traditional values will ensure that ‘the family will cope’.10,11 In an effort to understand the nature of health and social care needs associated with the ageing of populations, the Association of South East Asian Nations (ASEAN) decided to establish a focus on ageing. A field review of policies revealed marked variation, largely determined by the prevailing system of political organization and wealth (Tables 2, 3GoGo).


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Table 2 Health policies of relevance to health care for elderly people in Association of South East Asian Nations (ASEAN), 1997
 

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Table 3 Social policies of relevance to elderly people in Association of South East Asian Nations (ASEAN), 1997
 
Evans considers it unlikely that international aid donors will create social support systems to replace the traditions destroyed by development money.10 While it is commonplace for donors to consider the effects of funding on women and the poor, similar considerations for old age are currently non-existent, but could be implemented. Non-governmental organizations, which might be expected to play a leading role in such advocacy, are said by Gorman to lack the necessary resources.11 They are however, often better placed to deal with the disempowerment of poor elderly people through community action schemes, such as the community banking and income generation initiatives.12

Avoiding differential challenge

Evans defines the process of ageing as one of loss of adaptability of the individual and of differential challenge, such that older people are faced with greater performance requirements relative to their capacity.10 For example, road crossing timers that are too short for older people to cross the road safely; high steps to get onto public transport; and poor quality housing (Figure 1Go). Many of these problems could be improved by better design, but in the case of disabled access in the UK, legislation was required to ensure that new buildings were designed appropriately. Such design is often of benefit not just to disabled older people but also to mothers laden with shopping and children.



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Figure 1: Profile of physical capacity changes with age indicating a threshold for independent life and possible means of reducing the consequences of age-related changes in physical capacity.

 
A common link running through several of the articles in this issue is the need to ensure income security in old age. Differential challenge due to poverty is the most pressing problem in the countries of the South. Our common stereotype is of intergenerational money transfers flowing from children to parents or grandparents in these countries. However, recent work in Indonesia among poor rural people has demonstrated that the majority of transfers are from older to younger people (Philip Kraeger, University of Oxford, personal communication). Futhermore, the picture is complex, with many elders being without children or any obvious means of immediate support.

Social policies should be complemented by adequate health care policies. Good health care for all ages is likely to play a major role in improving the peak capacity of older people, and reducing the rate of decline of physical and mental function associated with old age, such that we reach thresholds for maintaining independent life at a much later age. When disease strikes, accurate diagnosis and prompt treatment, coupled with rehabilitation, will be needed to move the individual above dependency thresholds. In the UK a National Service Framework—or blueprint—for health services for older people has been implemented which attempts to define the standard of care that should be expected.13 It remains to be seen whether initiatives of this nature will work. Hospital services for elderly people are becoming widespread in China14 and many countries of the South, but without adequate community outreach and support for family carers it is doubtful that they will achieve the aim of allowing older people to maintain independence for as long as possible.

The World Assembly on Ageing, Madrid

Many of these issues—including health, nutrition, protection of elderly consumers, housing and environment, family, social welfare, income security, employment and education—were the priorities of the First World Assembly on Ageing in Vienna in 1982. It is now acknowledged that much of the work proposed never happened.15 Member states of the United Nations, organs of the United Nations and non-governmental organizations, research institutions and the private sector were involved. During 8–12 April 2002 a second World Assembly met in Madrid with the aim of reviewing the outcome of the first World Assembly and then adopting a revised plan of action on ageing ‘that is aligned to the sociocultural, economic and demographic realities of the new century, with particular attention to the needs and perspectives of developing countries’.

At the Assembly, the World Health Organization launched its life course approach to healthy ageing. This builds on the notion that industrialized countries have been able to postpone the onset of disability and disease—and while the latter is certainly true, there is much less evidence to be sure about the postponement of disability. Actions are recommended in three essential areas: health, participation and security (Box 1Go).


Box 1: WHO—Ageing: A Policy Framework (http://www.who.int/hpr/ageing)

  • Address factors that contribute to the onset of disease and disabilities like poverty, low literacy levels and lack of education.
  • Control tobacco use and alcohol abuse throughout the life course.
  • Ensure appropriate nutrition and healthy eating starting at an early age.
  • Promote physical activity at all ages.
  • Create age-friendly, safe environments by making walking safe and implementing fall prevention programmes.
  • Increase affordable access to essential, safe medications and assistive devices such as eyeglasses or walkers.

 

It would be easy to quibble with these rather glib recommendations, but in the face of political inertia it is important to make the point clearly that much can be done, and in some of the areas listed in Box 1Go we have a fair idea of how to proceed. There is clearly a major research agenda for ageing identified by these recommendations: we simply do not know how to promote mental health or physical activity. To make matters worse, it is likely that information gleaned from the rich North is unlikely to be applicable to the poor South.

The World Assembly strategy stresses the need for action, for linkages between ageing and development programmes, and for the needs and perspectives of developing countries to be taken into account. Not surprisingly, public–private partnerships are promoted and measures to promote intergenerational solidarity emphasized. Topics covered by the strategy are shown in Box 2Go. The international media attention for this World Assembly has been muted, and has emphasized ageing as ‘an international problem’16 rather than the Assembly’s more positive slogan ‘a society for all ages’.


Box 2: International Strategy for Action on Ageing. 2nd World Assembly on Ageing April 2002 (http://www.un.org/ageing/coverage/

  • Empowerment of older persons to fully and effectively participate in the social, economic and political lives of their societies, including through income-generating and voluntary work;
  • Provision of opportunities for individual development, self-fulfilment and well-being throughout life as well as in late life, through, for example, access to life-long learning;
  • Guaranteeing the economic, social and cultural rights of older persons as well as their civil and political rights, including the elimination of all forms of discrimination on the basis of age;
  • Commitment to gender equality in older persons through elimination of all gender-based discrimination, as well as all other forms of discrimination;
  • Recognition of the crucial importance of intergenerational interdependence, solidarity and reciprocity for social development;
  • Provision of health care and support for older people, as needed;
  • Facilitating partnership between all levels of government, civil society, the private sector and older persons themselves in translating the International Strategy into practical action;
  • Harnessing of scientific research and expertise to focus on the individual, social and health implications of ageing, in particular within developing countries.

 

The notion that a World Assembly is capable of providing a blueprint that is relevant to such diverse member countries is rather surprising and it seems likely that the interests of the powerful countries—probably through the public–private partnerships proposed—will prevail despite initiatives like this. The complexity and breadth of topics covered by the Assembly may be its undoing given the short attention span of politicians. By contrast HelpAge International, a non-governmental organization, has adopted a more focussed strategy, emphasizing the discrimination against older people in health care, legal services and education.17 However, the importance of international meetings is in the symbolism and hope they provide to those who are attempting, often in small ways, to make improvements to the care of older people, to advocate the need for politicians to take an interest, and as a rallying call to older people themselves—many of whom do have votes, money and informal modes of ensuring intergenerational influence. Almost everyone will become old—these are issues that will affect us all.

References

1 World Bank. Averting the Old Age Crisis. Policies to Protect the Old and Promote Growth. Oxford: Oxford University Press, 1994.

2 Gee EM. Misconceptions and misapprehensions about population ageing. Int J Epidemiol 2002;31:750–53.[Free Full Text]

3 Wiener JM, Tilly J. Population ageing in the United States of America: implications for public programmes. Int J Epidemiol 2002;31:776–81.[Free Full Text]

4 Walker A. Ageing in Europe: policies in harmony or discord? Int J Epidemiol 2002;31:758–61.[Free Full Text]

5 Palacios R. The future of global ageing. Int J Epidemiol 2002; 31:786–91.[Free Full Text]

6 Kinsella K. Demographic aspects. In: Ebrahim S, Kalache A (eds). Epidemiology in Old Age. London: BMJ Publishing, 1996, pp. 32–40.

7 Palloni A, Pinto-Aguirre G, Pelaez M. Demographic and health conditions of ageing in Latin America and the Caribbean. Int J Epidemiol 2002;31:762–71.[Free Full Text]

8 Lloyd-Sherlock P. Social policy and population ageing: challenges for north and south. Int J Epidemiol 2002;31:754–57.[Free Full Text]

9 Royal Commission on Long Term Care. With Respect to Old Age. London: Stationery Office, 1999.

10 Evans JG. The gifts reserved for age. Int J Epidemiol 2002;31:792–95.[Free Full Text]

11 Gorman M. Global ageing—the non-governmental organization role in the developing world. Int J Epidemiol 2002;31:782–85.[Free Full Text]

12 Randel J, German T, Ewing D, for HelpAge International. The Ageing & Development Report 1999. Poverty, Independence & the World’s Older People. London: Earthscan Publications, 1999.

13 Secretary of State for Health. National Service Framework. Older People. London: Department of Health, 2001.

14 Woo J, Kwok T, Sze FKH, Yuan HJ. Ageing in China: health and social consequences and responses. Int J Epidemiol 2002;31:772–75.[Free Full Text]

15 Bosch X. Two billion people older than 60 years by 2050, warns UN Secretary General. Lancet 2002;359:1321.[Medline]

16 BBC World News. http://news.bbc.co.uk/hi/english/health/newsid_1913000/1913515.stm

17 HelpAge International. The State of the World’s Older People. 2002. http://www.helpage.org. Accessed 16 April 2002.

18 Buckingham Palace, Anniversaries Office, London UK (+44 20 793 04832).

19 Ebrahim S. Report to Association of South East Asian Nations Task Force on Ageing. Jakarta: ASEAN Secretariat, 1997.

20 Ebrahim S. Health of Elderly People. In: Detels R, McEwan J, Beaglehole R, Tanaka H (eds). Oxford Textbook of Public Health, 4th Edn, 2002, Vol. 3, Ch. 11.8, p. 1712.