Grow Old Along With Me--And 690 Million Other People by 2030

Grow Old Along With Me—And 690 Million Other People by 2030

Widespread success at overcoming the major public health challenges of the past is creating a major public health challenge for the future.

by Beryl Lieff Benderly

At an international meeting of public health experts in Washington, D.C., some years ago, someone asked a physician from sub-Saharan Africa how he would know when public health efforts in the region had succeeded. Without hesitation, but with a twinkle in his eye, he answered: “When people are dying of cancer and Alzheimer’s.”

Though he shocked his listeners, the doctor stated a basic medical truth: People who die of the non-communicable, chronic diseases that are typical of old age in developed countries have not died in infancy, childhood, youth, young adulthood, or middle age of the communicable diseases still so widespread and so lethal in many developing countries. Nor have they succumbed to malnutrition or perished from pregnancy, childbirth, or their consequences.

What’s more, there’s a good chance that people who survive into their 60s, 70s, 80s or beyond have benefited from safe water, reasonably effective sanitation, basic vaccinations, sufficient nutrition, at least minimally adequate medical care, and other public health measures. In many developing countries now experiencing significant economic growth, these prerequisites of healthy living—formerly rare and accessible only to the social elites if at all—are becoming available to unprecedented numbers of people. In these countries, more people and a larger percentage of the population than ever before are reaching the age bracket most vulnerable to the diseases mentioned by the wise and witty African physician.

Longer Life Expectancy

“Average life expectancy has increased—albeit with setbacks—around the
world,” states Priorities In Health, one of three 2006 publications of the Disease Control Priorities Project. In only 40 years, life expectancy in China had essentially doubled to 71 years in 2000. Life expectancy increases during those same four decades have also been dramatic, though smaller, in other developing regions—from 56 year to 71 years in Latin America and the Caribbean, from 47 years to 69 years in the Middle East and North Africa, and from 44 years to 63 years in South Asia, according to Priorities in Health. In Sub-Saharan Africa, life expectancy rose by 10 years, from 40 to 50, by 1990, although, because of HIV, it fell back to 46 years by 2002.

Thanks to these great successes, the less developed countries are experiencing a senior explosion, with their over-65 population slated to increase from 249 million to 690 million between 2006 and 2030. Asia and Latin America and the Caribbean will see the elderly share of their populations more than double over those years, not only because of longer lifespans, but also falling birth rates, which in recent decades have produced fewer young people. By 2050, the world will contain an estimated total of 1.5 billion persons ages 65 years or older, and 80 percent of them will live in countries today considered less developed.

The developed countries of Europe and North America went through a similar demographic transition during the 19th and 20th centuries, but more gradually than today’s most rapidly developing countries. As a result of this growth, the world’s two largest nations, “China and India, will face the challenge of an aging population before they become high-income countries,” according to Disease Control Priorities in Developing Countries, 2nd edition (DCP2), a publication of the Disease Control Priorities Project. And, as the African physician predicted, developing countries with rising elderly populations are already seeing significant increases in the numbers of people living with and dying from chronic diseases such as cardiovascular ailments, diabetes, Alzheimer’s, and others at a time when these countries must also continue to contend with acute, communicable diseases such as HIV/AIDS, tuberculosis, and malaria that still affect large shares of their populations.

New Ways to Die

Low and middle income countries, not surprisingly, account for the overwhelming majority the world’s deaths each year from diarrheal diseases, tuberculosis, HIV/AIDS, respiratory diseases, all other communicable diseases, and perinatal conditions. But strikingly, developing countries already represent substantial majorities of the people dying each year from cardiovascular disease and cancer, the two top killers not only in such developed countries as France and the United States, but also in Brazil and China. Cardiovascular disease also ranks No. 1 in India, with cancer at No. 5.

Source: Alan D. Lopez, Colin D. Mathers, Majid Ezzati, Dean T. Jamison, and Christopher J. L. Murray. 2006. "Measuring the Global Burden of Disease and Risk Factors, 1990—2001." Global Burden of Disease and Risk Factors,ed.,. New York: Oxford University Press. DOI: 10.1596/978-0-8213-6262-4, 1-13.

As these figures show, "chronic diseases have not simply displaced acute infectious ones in developing countries. Rather, such countries now experience a polarized and protracted double burden of disease,” according to Derek Yach, formerly of the World Health Organization, and colleagues. India, for example, has the world’s largest number of diabetics, but it also still loses around 2.5 million children each year to diarrhea, malaria, pneumonia, and other infections. And it is already obvious that the burden of chronic diseases common among the elderly will become very large. “We face a looming global epidemic of Alzheimer’s disease as the world’s population ages,” says Ron Brookmeyer, professor of biostatistics at Johns Hopkins University. Cases of this extremely costly ailment will increase from today’s 26 million worldwide to more than 106 million in 2050, according to Brookmeyer. Asia already bears the brunt of the disease, with nearly half (48 percent), or 12.6 million of the world’s cases, but it will have an even larger share (59 percent), or 62.8 million Alzheimer’s patients, in 2050. According to current estimates, more than 40 percent of the affected individuals will require a level of care similar to that provided in a nursing home. Future treatments may succeed in slowing the disease’s progression and therefore permit affected people to remain independent longer than is possible today, but providing care will still very likely have a substantial impact on health expenditures.

New Patterns of Care

“As the world’s population ages, health systems that formerly focused primarily on infectious disease are being asked to deliver new types of care, mostly for chronic diseases and increasingly for mental illnesses,” states DCP2. In the developing world, care of the elderly who can no longer care for themselves has long been a family rather than a government responsibility. In traditional societies, the senior generation generally continues to play an active role in community life as long as health permits, and families often live in multigenerational households that facilitate caring for the infirm. The pattern common in many developed countries, in which older people stop working and live by themselves away from their children and grandchildren or in facilities inhabited exclusively by their contemporaries, is much less common as is the social and emotional isolation that such practices can entail when disease or disability make people less mobile.

Around the world, however, rapid urbanization is shattering traditional ways of life as millions of young rural adults each year seek work in cities, leaving their elders behind in the countryside. In countries such as China and India, where sons traditionally constituted parents’ old age pensions and daughters-in-law their long-term care, today’s smaller families and the movement of the young to cities are challenging governments to provide the services that older rural people need. In most developing countries, rural health care and other services are inferior, and often markedly so, to those available in urban areas.

Even many older persons who have always lived in cities have been severely affected by explosive urban growth, which destroys the traditional low-rise neighborhoods in which they spent their lives. In Shanghai, one of the world’s fastest growing cities, psychiatrists have noted that elders’ moving from traditional housing to unfamiliar and impersonal new high-rise apartment complexes is causing increased depression and complicating the diagnosis of dementias in people deprived of their accustomed community supports.

Meeting the Challenge

Despite the cataclysmic social, demographic, and epidemiological changes shaking many developing countries, few are equipped to adjust to the new realities. Not only are the resources and facilities devoted to elderly care inadequate, but health practitioners trained primarily to treat acute communicable diseases generally lack the expertise to care for older patients with chronic, non-communicable diseases and conditions or to provide the preventive services and to promote the lifestyle changes that they need to remain independent as long as possible. Moreover, experts note that practitioners need culturally relevant methods for diagnosing conditions such as dementia to replace those developed for Western countries, which assume higher educational levels and different cultural patterns than are typical among the elderly in less developed countries. Furthermore, where awareness of Alzheimer’s disease and other dementias is low, severe memory loss or disorientation may be considered “normal” features of old age. They are not seen as symptoms of conditions that may be treated, leaving sufferers without proper care.

“A doctor not trained in the issues that older patients face is not going to know what to do” to provide appropriate care, Dr. Pedro Paulo Marin, director of geriatric medicine at Universidad Catolica in Santiago, Chile, told the Chilean newspaper, El Mercurio. Physiological changes associated with aging require modifications in diagnostic and prescribing practices and can produce confusion and misdiagnoses if health care providers are unfamiliar with older patients. But at present Chile, for example, has only 25 physicians with specialty training in geriatric medicine, although estimates suggest that it needs 50 times that number and will need even more in the future. Officials in some countries are already taking steps to increase the supply of health professionals specially trained in elder care. In June 2007, for example, Morocco graduated its first class of geriatric nurses, who will work in hospitals and long-term care facilities and also provide home-based care.

A Chance to Shape the Future

The currently undeveloped state of services for the elderly in many countries may nonetheless present a valuable opportunity, according to Luis Miguel Gutierrez-Robledo of the Salvador Zubiran National Institute of Medical Sciences in Mexico City. A pioneer of geriatric medicine in his own nation, he has noted that less developed countries now “have the opportunity to develop systems different from those in the more developed countries” and more in keeping with local preferences, circumstances and traditions. For example, “by capitalizing on the lack of infrastructure [developing countries can] produce more home-based rather than institution-based long-term care systems,” he suggests. To assure that the systems they establish do indeed suit the needs of those they serve, it is vital that the elderly be involved in planning their own futures, he notes.¹ Nations would be well advised to start right away designing the new health services that they will need, Gutierrez-Robledo adds.

In his famous poem about growing old “along with me,” Robert Browning lauded life’s latter years, promising that “the best is yet to be, the last of life for which the first was made.” And, indeed, for many millions of people worldwide, the extra years possible today can afford opportunities for pleasures and satisfactions denied to countless previous generations. But they could also mean nothing but extended suffering and disability for elderly people unable to obtain adequate care. The outcome, Gutierrez-Robledo warns, depends on whether rapidly aging nations get to work developing the health services and health promotion strategies that assure that their older citizens remain healthy as long as possible and receive suitable care when they need it. “Appropriate planning now,” he notes, “will decide the future of the elderly in less developed countries during the next 20 to 40 years.”

¹Luis Miguel Gutierrez-Robledo, “Looking at the Future of Geriatric Care in Developing Countries,” Journals of Gerontology Series A: Biological and Medical Sciences 57A, no. 3 (2002): M162-M167.

Beryl Lieff Benderly is a prize-winning Washington journalist and author specializing in health, behavior, and science policy. Her articles appear in major magazines and on the Internet, and she is a regular contributor to the Science magazine website. Her eight books include In Her Own Right: The IOM Guide to Women's Health Issues. She is working on a book about addiction (Oxford University Press, forthcoming).