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International Journal of Epidemiology 2002;31:715718

Will you still need me, will you still feed me, when Im 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 1).

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?

This issue of the International Journal of Epidemiology containsa series of papers concerned with ageing. For each of us indi-

vidually, 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: fertilitycontrol 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 hetero-

geneity 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 elderlypeople 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 worlds 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. Projectionssuggest 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 unemploy-

ment, 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 assuggested 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 Com-

mission.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, empoweringthe 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

International Epidemiological Association 2002 Printed in Great Britain

Department of Social Medicine, University of Bristol, Canynge Hall,

Whiteladies Road, Bristol BS8 2PR, UK.

715

EDITORIAL

Ageing, health and societyShah Ebrahim

Table 1 Birthday greetings telegrams sent by Queen Elizabeth II to

people on their 100th birthday, 19522001

1952 1962 1972 1982 1992 2001

255 590 1283 2759 3382 3898

Source: Buckingham Palace Anniversaries Office, 2002.18

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review of policies revealed marked variation, largely deter-

mined by the prevailing system of political organization and

wealth (Tables 2, 3).

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 dis-

empowerment 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 1). 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 justto disabled older people but also to mothers laden with

shopping and children.

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 communi-

cation). Futhermore, the picture is complex, with many elders

716 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

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

Health policy Brunei Cambodia Indonesia Laos Malaysia Myanmar Philippines Singapore Thailand Vietnam

Free primary health care Yes Yesa Yes Yesa Yes Yesa Some Some Yes Yes

Free hospital care Yes Yesa Yes Yesa Yes Yesa Some No Yes Yes

Training in geriatrics No Medicine No Nursing No No No Medicine, Nursing Medicine

nursing

Geriatric services No No No Abandoned University No Some Yes Yes Yes

Community rehabilitation No Amputees No Projects Projects Projects Projects Yes Projects Some

Preventive services Yes No No No No Projects Yes Yes Projects No

Nursing homes Yes No Private and No Private and Private Private and Private and Private and No

Public Public Public Public Public

a User charges currently under investigation.

Source: Ebrahim S. Report to Association of South East Asian Nations Task Force on Ageing , 1997.19

Table 3 Social policies of relevance to elderly people in Association of South East Asian Nations (ASEAN), 1997

Social policy Brunei Cambodia Indonesia Laos Malaysia Myanmar Philippines Singapore Thailand Vietnam

Pensions All citizens Civil Civil servants, Civil Civil Civil Civil servants, Civil Civil Civil

servants Widows servants servants, servants self-employed servants, servants servants

pensions restricted employed

Housing Some No No Very limited: Rural NGOa No Group homes Limited No No

civil servants housing

scheme

Caring

allowances On No No No Tax relief No Tax relief Tax relief No No

application for carers for carers for carers

Disability

allowances On No No No No No Workers No Yes Limited

application compensationTransport None None Subsidized None Subsidized None Subsidized Subsidized None None

fares fares fares fares

Respite care None None None None None None Institutional Institutional None Social

and day and day centres

centres centres

Organizations None Senior None National Senior None Senior Citizens Singapore Senior Senior

for elderly Citizens Front for Citizens Federations/ Action Citizens Citizens

people Association Construction Association Associations Group Association Association

of Elders

a Non-governmental organization.

Source: Ebrahim S. Report to Association of South East Asian Nations Task Force on Ageing , 1997.19

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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 amajor 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 Frame-

workor blueprintfor 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 out-

reach and support for family carers it is doubtful that they willachieve the aim of allowing older people to maintain

independence for as long as possible.

The World Assembly on Ageing, Madrid

Many of these issuesincluding health, nutrition, protection of

elderly consumers, housing and environment, family, social

welfare, income security, employment and educationwere

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 wereinvolved. During 812 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 diseaseand 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 1).

It would be easy to quibble with these rather glib recom-

mendations, 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 1 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, publicprivate partnerships are

promoted and measures to promote intergenerational solidarity

emphasized. Topics covered by the strategy are shown in Box 2.

The international media attention for this World Assembly has

been muted, and has emphasized ageing as an international

problem16 rather than the Assemblys more positive slogan asociety for all ages.

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 countriesprobably through the publicprivate

partnerships proposedwill 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 organ-

ization, 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 improve-ments to the care of older people, to advocate the need for

politicians to take an interest, and as a rallying call to older

people themselvesmany of whom do have votes, money and

informal modes of ensuring intergenerational influence. Almost

everyone will become oldthese are issues that will affect

us all.

AGEING, HEALTH AND SOCIETY 717

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.

Box 1: WHOAgeing: 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 walk-

ing safe and implementing fall prevention programmes.

Increase affordable access to essential, safe medications

and assistive devices such as eyeglasses or walkers.

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References1 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 Epidemiol2002;31:75053.

3 Wiener JM, Tilly J. Population ageing in the United States of

America: implications for public programmes. Int J Epidemiol

2002;31:77681.

4 Walker A. Ageing in Europe: policies in harmony or discord? Int J

Epidemiol2002;31:75861.

5 Palacios R. The future of global ageing. Int J Epidemiol 2002;

31:78691.

6 Kinsella K. Demographic aspects. In: Ebrahim S, Kalache A (eds).Epidemiology in Old Age. London: BMJ Publishing, 1996, pp. 3240.

7 Palloni A, Pinto-Aguirre G, Pelaez M. Demographic and health

conditions of ageing in Latin America and the Caribbean. Int J

Epidemiol2002;31:76271.

8 Lloyd-Sherlock P. Social policy and population ageing: challenges for

north and south. Int J Epidemiol2002;31:75457.

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 Epidemiol2002;31:79295.

11 Gorman M. Global ageingthe non-governmental organization role

in the developing world. Int J Epidemiol2002;31:78285.

12 Randel J, German T, Ewing D, for HelpAge International. The Ageing

& Development Report 1999. Poverty, Independence & the Worlds 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 Epidemiol2002;31:77275.

15 Bosch X. Two billion people older than 60 years by 2050, warns UN

Secretary General. Lancet2002;359:1321.

16 BBC World News. http://news.bbc.co.uk/hi/english/health/newsid_

1913000/1913515.stm

17 HelpAge International. The State of the Worlds 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.

718 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

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 inter-

generational interdependence, solidarity and reciprocity

for social development;

Provision of health care and support for older people,

as needed;

Facilitating partnership between all levels of govern-

ment, 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.