Dr Margaret Chan addresses gerontology congress

Dr Margaret Chan
Director-General of the World Health Organization

The New Normal: Life after Sixty Lecture delivered at the Congress on Gerontology and Geriatrics and the 20th International Seminar on Care for the Elderly
Havana, Cuba

30 March 2012

Distinguished delegates, scientists, colleagues in public health, ladies and gentlemen,

It is a great pleasure to address an audience of experts working in such a critically important field. Your research and experiences are important for advancing scientific understanding of the many dimensions of ageing, especially in areas where uncertainty and controversy prevail.

Your work is important for the health and well-being of historically unprecedented numbers of people, in every corner of the world. Your work is important for health budgets and, indeed, national economies, as the universal aging of populations comes with substantial financial challenges.

It is equally a great pleasure to speak to you in Cuba.

Cuba was one of the earliest proponents of primary health care. It gave the world a model for transforming health systems towards the noble ideals of equity and social justice. This successful experience shaped the origins and direction of the Health for All movement.

Cuba has long been a leader in South-South collaboration, sharing doctors, experiences, and innovations, but also sophisticated biotechnology.

Cuba reformed medical training to suit the distinct health needs of the developing world, including a burning need for doctors willing to work in remote rural areas. This work continues on an ever-greater scale.

Cuba has pioneered and modernized the concept of medical cooperation. As just one example, Cuban-trained doctors, using made-in-Cuba interventions, have restored the eyesight of nearly a million people impaired by cataracts, well beyond the borders of this country.

This is a big contribution to a huge problem. Worldwide, nearly 30 million people are blinded by cataracts. Saving eyesight is the kind of work that makes a difference in our world, especially for ageing populations.

Next week, WHO, born on 7 April 1948 and also in the over-sixties age group, will mark its birthday through the celebration of World Health Day, this year focused on healthy ageing.

The poster commemorating this event features a 69-year-old grandmother from Cuba. She is a retired ophthalmologist. She is very fit, very attractive, and is pictured dancing the salsa.

Cuba illustrates well a conclusion reached in a recent report from the Organization for Economic Cooperation and Development, or OECD. That report concluded that societies that have the least inequality have the best health outcomes, regardless of the levels of spending on health.

In other words, money alone does not buy better health. Good polices that promote equity have a better chance.

Thanks to good health policies, life expectancy in Cuba matches or surpasses that seen in some of the world’s wealthiest countries. And like any country that enjoys a long life expectancy, Cuba must now deal with the considerable health needs, and costs, of an ageing population.

In fact, Cuba is the most rapidly ageing country in Latin America and the Caribbean. On current trends, Cuba will have the oldest population in the Americas by 2050.

Distinguished delegates,

Demographic ageing is now a universal trend, in rich and poor countries alike, and this trend has some historically unprecedented dimensions. According to WHO data, the most rapid growth in the elderly population is taking place in low- and middle-income countries.

The transition is dramatic. In Chile, for example, the life expectancy for a woman was 33 years in 1910. Today, it is 82 years. This is a stunning gain of nearly 50 years of life, largely due to improvements in public health.

A transition towards an older society that took more than a century in Europe is now taking place in less than 25 years in countries like Brazil and China. The window for preparatory action has become much smaller than it used to be.

Worldwide, the proportion of people older than 60 years in the total population is increasing at more than three times the overall population growth rate. Within the next five years, for the first time in history, the number of adults aged 65 and older will outnumber children under the age of 5.

In other words, being in the older age group is becoming the “new normal” for the world’s population. Our “seniors” are now our biggest age group. Today, the majority of middle-aged and older adults have living parents. This, too, is historically unprecedented.

What does all this mean?

Several things are clear. First, these unprecedented trends are placing strains on health systems, health care workers, and health budgets.

Given the nature of the ageing process, people will inevitably experience at least some physical and cognitive impairment as they get older. Many will eventually need institutionalized care.

WHO estimates than more than 35 million people worldwide are living with dementia. This number is expected to double by 2020 and more than triple by 2050. Already now, nearly 60% of the burden of dementia is concentrated in low- and middle-income countries.

The cost of caring for dementia is expected to rise even faster than its prevalence, making it important that societies are prepared to address the social and economic burdens caused by this condition. The costs are already staggering. In 2010, the total estimated worldwide costs of dementia were $604 billion.

Such costs make another point clear. As we all know, people experience multiple pathologies as they age, mostly associated with chronic noncommunicable diseases. With the numbers of the elderly increasing at such an unprecedented rate, who will pay for their health care?

Will care be publicly financed? If family members provide most of the care, how will they be supported? Will governments in these hard economic times be forced to put a ceiling on the amount of coverage they provide or limit the interventions covered?

How do you weigh the costs? Like the costs of hip replacement versus the costs of institutionalized care for someone who can no longer function alone?

In well-educated and well-off societies, this question is compounded by the rising expectations of the public. Many people now approaching traditional retirement ages are doing so with an attitude. They want to remain active and engaged. And they want the medical care needed to do so.

And why not? People who got the right start in life, followed healthy lifestyles, and took good care of their health can expect to remain active during their eighth, even ninth decade of life.

But there will be problems. For many, health will deteriorate. Disabilities set in. Some can be delayed or managed. Others cannot. And every medical intervention or assistive device costs.

Daily care for the frail elderly costs especially much, if not in terms of money, then in terms of the physical and emotional strain on caregivers.

When the “new normal” for a population profile means being over 60 years of age, market forces step in. Sleek and elegant “designer” wheelchairs are on the market, as are so-called “smart homes”. These are high-tech homes that help older people function well and avoid falls, but also use sophisticated electronic devices for monitoring health status, detecting early warning signals, and improving compliance with treatments.

As more and more people enter retirement, we can expect to see more technologies like these. Once again, such advances introduce questions about access, equity, and fairness in distributing the benefits of medical progress.

These questions have become especially sharp at a time of global financial upheaval, rising public expectations for health care, and soaring costs. For example, in most OECD countries, health spending is increasing faster than economies are growing.

Just contrast, for a moment, what a smart home offers when compared with the plight of an older women living in a rural area of a developing country somewhere in Asia. She lives alone in a hut with a bed and maybe a table and some chairs. With her eyesight severely impaired by cataracts, she can no longer cook, sew, tend the garden, or make a productive contribution to society.

The traditional fabric of social support has been ripped apart. Her children and grandchildren have migrated to a city to profit from better employment and educational opportunities. She bides her time, waiting to die.

In my view, we must not let money decide who stays fit and who gets frail too soon. This is not the right approach, for ethical but also for economic reasons.

Fortunately, there are other areas with fewer questions and almost universal agreement.

First, keeping the elderly in their homes, safe and functional, for as long as possible is highly desirable. Everyone wants these people to stay out of hospitals and in the community, to be cared for in their homes, and not in institutions. Doing so requires that the elderly remain socially integrated in their neighbourhoods and that broad-based health care and social services are easily accessible.

Municipal planners may need to look at the built environment with fresh eyes. As I often advise: think creatively but also think simple. Are spaces and pathways available that encourage older people to keep fit and active?

Can facilities be provided to encourage exercise? Some research suggests that the ancient Chinese Tai Chi exercise forms can restore balance in older people.

Is housing modified to compensate for declining functional capacity? Are traffic lights at pedestrian crosswalks timed so that older people can safely cross the street?

Second, everyone agrees on the value of pre-emptive measures that help delay physical and mental deterioration, compressing morbidity into the final years of life.

At WHO, we stress pre-emptive measures that cover the entire lifespan. For example, recent evidence demonstrates that undernutrition during gestation and early life increases the risk for chronic diseases, including heart disease and diabetes, later in life.

To reduce the number of individuals needing costly care, pre-emptive measures need to reach entire populations. Full implementation of the WHO Framework Convention on Tobacco Control would greatly increase the number of people who enter retirement in good health. Full implementation would deliver the single greatest preventive blow to heart disease, stroke, diabetes, cancer, and chronic respiratory disease.

Population-wide measures that reduce salt intake are another sure win.

As I mentioned, many areas of research remain controversial. Some recent research suggests that late-life dementia might be preventable. Though findings are preliminary and still controversial, they suggest that certain factors might be protective, including exercise, education, participating in brain-stimulating activities, and being engaged in a cognitively-challenging occupation.

Given the huge and growing burden of dementia, any potential protective factors deserve further study.

Older people face multiple pathologies and multiple needs, including social needs. As populations age, close collaboration between the medical and social services becomes imperative.

We may need to change models of service delivery in radical ways. To prolong healthy lives for the elderly, we need to shift the focus from providing good care for a single disease to providing good health in the face of multiple diseases.

The tendency in medical practice continues to move towards greater and greater specialization, when what we need now is a more generalist approach. The boundaries between primary care and specialist care need to soften.

Health systems and medical education must be reoriented to meet the challenges of multiple morbidities. For ages, health systems were designed, and doctors were educated, to manage usually brief, acute episodes of infectious diseases.

Dramatic changes are needed to cope with the long-term demands of detecting NCDs early and managing them efficiently and effectively, often for a lifetime. Prevention, early detection, and prompt treatment must receive the highest priority.

We look to Cuba, and this congress, for leadership in adapting medical training to the vast array of new challenges that go hand-in-hand with these unprecedented trends.

What everyone wants to see is people living better as they live longer.

Distinguished delegates,

Medicine is one of the few areas of technical innovation where new products, like the next generation of antibiotics, a new vaccine, or a new medical device, are nearly always more sophisticated and much more costly.

This is certainly not the case with other areas of technology, like flat-screen TV’s or computers and mobile phones, where devices become increasingly easy to use and cheaper to buy.

Late last year, a study concluded that technologies for the treatment of cancer now carry costs that are unsustainable, even in the wealthiest countries. Some experts estimate that nearly half of the increase in health spending since 1960 can be attributed to the growth of sophisticated medical technologies.

With the ageing of populations, this trend towards ever greater sophistication and ever-higher costs comes up against a brick wall. It cannot be afforded. It cannot be sustained. Innovation must come to terms with the economic reality.

In a sense, the need to cope with demographic ageing turns the tables. In its drive to extend essential care to poor people living in poor places, public health has long sought to simplify technologies, so they can be used in households or by non-specialized health staff, and cut the costs, with no compromise of safety, quality, or efficacy.

In forging ahead to care for the elderly, the health and medical professions will need to define the best innovations in terms of their ability to reduce costs and simplify care while also promoting health and postponing or assisting disability.

In the view of WHO, devices that improve the quality of life for the elderly, that help them retain their dignity as well as their independence and social engagement, belong in the same category as other essential medical products, like medicines and vaccines, and should be treated as such.

For all these reasons, WHO has launched a new initiative designed to boost targeted technology development for ageing populations in the developing world. The initiative aims to stimulate innovation for new products and get prices down for existing products through technology transfer to low- and middle-income countries.

Health programmes often find the stimulus for innovation by first diagnosing the problems and then defining smart ways to overcome them.

Identifying unmet needs that stand in the way of healthy, active, and independent lives is the starting point for this initiative. Devices and products need more than just an affordable price. Existing technologies need streamlining and simplifications that make them useable by health care workers who lack specialized training and sophisticated skills.

Examples of badly needed products range from age-friendly mobile phones, to joint prosthetics for arthritis treatment, from cheap and robust hearing aids, to simplified diagnostic tests that can be used by non-specialist practitioners, thus expanding the capacity to detect and treat early.

Let me illustrate the importance of such efforts with a single statistic. Of the estimated 346 million people worldwide who suffer from diabetes, more than half are unaware of their disease status.

For many of these people, the first contact with the health services will come when they start to go blind, need a limb amputation, experience renal failure, or have a heart attack.

Distinguished delegates,

I have a final comment.

As we seek ways to cope with these unprecedented trends, these unprecedented demands and needs, we need to look to innovation for some answers. And I mean the right kind of innovation.

Innovation does the most good when it brings clear social benefits and ensures that these benefits are evenly and fairly shared.

If we have learned anything from the economic turmoil of the past few years, it should be this: innovation must respond to societal needs and concerns, and not be driven by greed.

I am sure this congress will yield multiple examples of the right kind of innovation.

Thank you.