Newsletter and IYOP Initiatives Australian Coalition '99

THE "OLD" REVOLUTION

By
Professor Antony H B DE BONO

Many Commonwealth countries are having to put into place policies to take care of the rapidly increasing numbers of their older citizens. For one institution, however, it is not a new phenomenon. Over the past decade, the International Institute on Ageing (United Nations - Malta) has been training scores of people in its international courses on ageing. In the following article the Institute's Director, Professor Antony de Bono, examines the ageing revolution in Commonwealth countries.

For most Commonwealth countries, the unprecedented increase in the number of people reaching the age of 60 has become a matter of growing concern. The impact of mass longevity, which has been due to improved sanitation, hygiene, access of clean water, improved nutrition as well as control of killer infectious diseases and advances in health care, will affect every Commonwealth country.

This enormous impact will have economic and developmental consequences, as well as profound social and health implications. Unfortunately, the massive effect both on developed and developing communities is not being fully recognised or understood, although governments need to take urgent action.
The more developed members, such as Australia, Canada, New Zealand and the United Kingdom, have experienced this longevity revolution for a number of decades. Their social and health infrastructures are, however, beginning to feel the strain as not only are they experiencing mass survival, but their birthrate is relatively low and the population of the 'old-old'- those over 80 years of age - is growing fastest of all. Thus the dependency ratio between the number of economically productive workers and those they support is getting more burdensome, and the demands for health and welfare expenditure is growing at the same time.

The other members of the Commonwealth are only now experiencing the full effect of the demographic change due to longevity. However, now that the earliest mass survival cohorts have reached 60, the ageing phenomenon will be rapid and massive. The true extent of the problem is often obscured by the fact that because birth-rates remain high, the proportion of the old in the population has remained relatively small - but in absolute numbers there is, and will be, a massive increase. The seriousness of this situation is compounded by the lack of social and health infrastructure to cope with this new challenge.

The first great international global meeting was convened by the UN in 1982 as the UN World Assembly on Ageing'. All the Commonwealth countries took part. This World Assembly agreed, by consensus, on the Vienna International Plan of Action on Ageing which covered comprehensively the various aspects of ageing both from a humanitarian point of view, and a development and economic one. The Year of Older Persons, coinciding with the rapid growth in the number of older people in the less developed Commonwealth countries, will serve to increase awareness and concern. Indeed, the recent Commonwealth Health Ministers Meeting in Barbados, for the first time held a roundtable on the health aspects of ageing. It explored innovative ways of providing the increased care that will be required in an effective way, but in one which the countries can afford, based on the care in the family and community, rather than hospitals and institutions.

Demography
A prerequisite for policy planning must be reliable demographic information. This has been extremely difficult to develop in the Less Developed Countries (LDCS) for a number of reasons. However, such is the vast range of socio-economic development, not only between, but also within, these countries that only specific and focused research can supply this urgently needed information; generalisations and largely anecdotal evidence are not very helpful. Indeed, they are often counter-productive. Ageing is not a disease, and each cohort reaching 60 does so in a relatively fitter condition.
International organisations quite understandably strive to have universal standards that can be compared and contrasted. Thus a definition of 60 years and over defines an old person. However, a 60-year-old in a highly developed country may not be truly comparable with one from a least developed country who has suffered a lifetime of privation, disease and malnutrition. In the former country the 60-year-old would be considered relatively young, while in the poorer country 60 might be 'very old'.

Implications for health care
The increased prevalence of a number of diseases and of chronic disability is a feature of ageing, even though the majority of the elderly are relatively fit for their age.

However, it is clear that increasing morbidity and disability are a feature of ageing, particularly among the 'old-old'. The measurement of health expectancy, that is, years without disability or DFLE (disability free life expectancy), has evolved over the past 10 years, and more recently been further refined. This is known as 'disability adjusted life expectancy and takes into account risk factors, diseases and their associated disability. The economic restraints that have to be faced by every country, but even more so by the LDCS, inevitably evokes the question of priorities. However, the reality of the new demographic fact, should perhaps trigger a total reappraisal of health care delivery systems which, while endeavouring to cope with the extra care burden of the elderly in a cost-effective manner, could certainly be useful for the community as a whole.

Gender differences
In many countries, particularly in the developed ones, life expectancy at birth is greater for women; this tendency for the sex ratio to increase in older ages creates many social problems for older women who are often alone and widowed. Women are very much in the forefront of ageing, not only because of their relative longevity, but also because they are overwhelmingly the carers. In this respect educational policies and other discriminatory practices of the past will have to be reversed if women are to be in a position to contribute from a position of equality in a future modem health scheme.

Conclusions
After a time lag of several decades, the global phenomenon of mass longevity has now at last reached most of the developing countries, which will see a doubling of the elderly population over the next two or three decades. The experience of the More Developed Countries (MDCS) has shown that this additional population will very substantially increase demand for health care, particularly of a long-term nature.

Although a great deal of knowledge and experience can be obtained from these experienced MDCS, there is a marked dearth of reliable data from properly conducted surveys in the developing countries. Such data is a vital and essential prerequisite to any policy reforms in health care delivery that the health care for the elderly augmentation will necessitate.

There is a very wide range of stages of socioeconomic development among the developing countries of the Commonwealth, thus each country will of course adapt and adopt policies in keeping with its economic development and priorities, as well as its perceived needs and cultural environment.

Reproduced with permission of Professor de Bono.

Professor de Bono was Chairman of the UN World Assembly on Ageing Advisory and Main Committees which were responsible for debating the 'UN Vienna Plan of Action on Ageing, 1982'. He is a cardiovascular surgeon by profession. The article is the abridged version of a paper prepared for the Commonwealth Health Ministers Meeting held in Barbados in November 1998.

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