By: Ann Keeling
Longer life – with life expectancy increasing just about everywhere in the world – is often presented as a problem. If so, it is a great problem to have. Of the many questions around ageing societies, one of the most pressing is how can we get the best out of those extra years of life by supporting people to be healthier, more socially engaged and active for longer?
Here are six factors that influence the chances of ageing populations living a healthier old age:
1. Peace and security: Around 15 years ago, as part of my international development work with the Commonwealth, I was invited to attend the opening of a new rural school in post-conflict Sierra Leone. All schools in the area had been destroyed in bitter fighting so this was a big day for the local community who had contributed to the building work and made all the furniture by hand. Peace had only recently been established. As we gathered for the opening, children of all ages kept coming until there were maybe 200, shy but excited, in the crowd. It took me a few minutes to realise that large numbers of the children were resting on makeshift crutches having lost a limb, an arm or maybe both arms in the conflict. It may seem obvious but war, conflict and chronic insecurity rob people of their lives and also rob younger people of a healthy, older future as they carry through life a legacy of disability, dislocation, poor nutrition, poverty and mental illness. The UN report that in 2017, 68.5 million people were displaced by conflict, persecution and generalised violence. In addition, millions live in contexts with chronic high levels of insecurity from violent crime. Age International as part of the Help Age International network, supports vital work to meet the needs of older people in conflict and emergencies since they are often overlooked. Conflict and insecurity vastly reduce the chances of affected populations achieving a healthy, disability free older age.
2. Poverty and inequality: Again, it may seem obvious but despite gains in the last twenty years to eradicate extreme poverty, large numbers of women and men still live in dire poverty, unable to invest in their own healthy future. Economic growth is not being spread evenly as inequality rises both within and between countries. As an illustration, health inequalities within the UK, a country with a national health system, are stark. The UK government’s 2019 Health Inequalities Report found that life expectancy for men varied from 74.2 to 81.3 years depending on the level of deprivation in the areas where they lived. Men from more deprived areas were likely to spend a greater proportion (one fifth) of their lives in ill health. Other compounding forms of inequality – between genders, races, ethnic groups etc – also have a profound impact on health in older age. Most countries lack the data on health inequalities between genders and social groups to use as the basis for policy measures. We will not spread the benefits of healthy ageing until we spread the benefits of economic growth more evenly and reduce inequality.
3. Social determinants of health: Some of the greatest public health successes in recent decades have prevented ill health and risk through population-based policy measures implemented by governments. These include clean water and sanitation; reducing air pollution; anti-tobacco measures including smoking bans and taxation; and seat belt legislation and other road safety measures to reduce death and disability from road traffic crashes. Despite successes in some policy areas and some countries, all those risk factors remain high in some countries. When I visit my son who lives in China I monitor hourly air quality in the city where he lives and would not consider going outside without a face mask when air quality reached unhealthy levels. While I am out in my mask, it is devastating to see young children in the streets, unprotected from air that will damage their chances of healthy lungs in old age. In some countries risk factors for ill health such as tobacco use have been radically reduced and the benefits are measurable in longer, healthier lives. Yet as we tackle some risk factors others have increased exponentially and are proving complex to solve. Obesity has nearly tripled since 1975, with alarming increases in childhood obesity. WHO reports that in 2016, more than 1.9 billion adults, 18 years and older, were overweight or obese. Related to this has come an equally alarming increase in diabetes with approximately 425 million adults(20-79 years) globally now living with the disease. The rise in Non-communicable Diseases (NCDs) such as diabetes, cancer, heart and lung disease and dementia mean large numbers of people enter older age with multiple health conditions and complex health needs, much of which could be prevented or delayed with changes in diet, tobacco cessation, more moderate use of alcohol and active lifestyles. We cannot blame individuals, however, for their ‘unhealthy lifestyles’ if they live in unhealthy physical, social and commercial environments. A healthier diet is not affordable for many and not all cities encourage an active lifestyle. Governments are the guarantors of their citizens’ right to health and population-based policies, when enforced, can change both behaviour and culture to protect health in older age. Government action is urgently needed to disrupt, for example, the commercially driven obesogenic environments that go beyond individual lifestyle choices.
4. Universal Health Coverage (UHC): UHC is the big talking point in global health in 2019 with a UN High Level Meeting scheduled for September 2019 convening Heads of State and Government to drive commitments on UHC. Bringing the subject to top political decision makers is critical to get their backing for a political choice that has the potential to deliver health services for billions of people who currently lack access to comprehensive services. WHO estimates that 800 million people currently spend over 10% of their family income on health expenditure and 100 million are pushed into extreme poverty each year because of out of pocket health bills. Clearly, people who have no little or no access to affordable, quality health services cannot protect their health and facilitate their own healthy ageing. UHC is critical to make quality health services accessible for older people and also critical to enable people to stay healthy throughout the life course. UHC, however, is the necessary starting point for realising the right to health but on its own will not guarantee equal health outcomes for all ages, genders and social groups. As noted above, governments must tackle the multiple dimensions of health inequality throughout the life course to create the conditions where everyone has a chance of enjoying a healthy older age.
5. Prevention and early diagnosis: Male life expectancy in UK doubled from 40 years in 1850 to nearly 80 years today. Many factors in public health contributed to this increase but two stand out: childhood vaccinations early in life that headed off the death and lifelong disability of diseases such as Polio and also interventions later in life that improved prevention and treatment of heart disease. UHC, as defined by WHO, includes prevention, health promotion, curative services and rehabilitative care. Also high on the global health agenda this year is renewed commitment to primary health care as the critical building block for a strong health system. As populations live longer and the global burden of disease shifts from infectious to Non-communicable Diseases (NCDs) primary health care is where health prevention, early diagnosis and chronic disease management take place most effectively. As noted above, almost half a billion people are living with diabetes but that figure is made all the more alarming knowing that around half (over 200 million people) are unaware they have diabetes. Undiagnosed and untreated diabetes is likely to progress to serious secondary complications such as kidney disease, blindness and circulatory conditions causing foot and limb amputations. This is just one example highlighting the need not only for prevention early in life to increase the chances of healthy ageing but also for health systems that can prevent, diagnose and manage chronic conditions throughout the life course.
6. Mental health, social isolation and loneliness: As societies change and family patterns evolve, older people may no longer be cared for within extended family networks. Longer life should be viewed as an opportunity and the very real contributions of older people to families, communities and economies acknowledged. Older people are more likely to remain healthy if they are valued and included. Age discrimination, is pernicious and erodes life chances and morale and leaves older people more excluded. It is critical that health is understood to include mental as well as physical health and that social structures and communities are designed to reduce social isolation, loneliness and mental health issues for all ages.
Nothing I am saying here is new. We know many of the factors that facilitate healthy ageing but are slow to act. One important reason is that health expenditure is often considered a cost when it is, in fact, an investment in healthy ageing and better health throughout the life course. Short political horizons can tend to discount the longer term benefits and savings that investment in health can bring. Age International, as a member of the Help Age International global network, supports the proposal for a Decade of Healthy Ageing led by WHO to bring together governments, international agencies, health professionals, civil society and the private sector to change thinking, build support for and drive action on healthy ageing.
 UNHCR (2018) Global Trends Forced Displacement in 2017
 UK Department of Health (2019) Health Inequalities Annual Report 2019
 WHO (2018) Key Facts Obesity and Overweight https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
 International Diabetes Federation (2017) Diabetes Atlas – Eighth Edition
 WHO (2017) WHO website www.who.int/healthsystems/universal_health_coverage/en
 International Diabetes Federation (2017) Diabetes Atlas – Eighth Edition
This blog is part of the Prevention in an ageing world programme. To find out more about our work in this space, please click here.
Chair, Age International
Ann Keeling’s 35 year career in global health and social development includes posts in Pakistan, Papua New Guinea, Indonesia, the Caribbean, Belgium, USA and UK. She is Chair of Age International and Senior Fellow with Women in Global Health. Ann was UNFPA Country Representative Pakistan, Head of Gender Equality UK, CEO of the International Diabetes Federation and founded the NCD (Non Communicable Diseases) Alliance.