PRB

People are living longer and, in some parts of the world, healthier lives. By 2030, 1 billion people will be ages 65 and older. While this is a major achievement of the last century, significant challenges now confront us. Societal aging may affect economic growth, family sustainability, and international relations.

During a PRB Discuss Online, Dr. Richard Suzman, director of the behavioral and social research program at the U.S. National Institute on Aging, answered participants’ questions on the impact of population aging on the global community, and the findings of the NIA’s report, “Why Population Aging Matters.”

July 31, 2007 10:45 AM EST

Transcript of Questions and Answers

Richard Cincotta: Clearly health systems are in for gradual increases in demand for services and shifts in the types of services in demand. What are the most efficient types of public health investments that can be scaled up now, and targeted at people of younger ages, to reduce gereatric healthcare costs in “aging” societies.
Richard Suzman: Our understanding and appreciation of the long range impact of pre natal and early childhood health on adult and old age health has been growing. David Barker of the UK, for example, has some controversial findings that under-nutrition in the first trimester can lead to old age hypertension and obesity. Education seems to be one of the strongest determinants of longevity and healthy life expectancy. Obesity is a major contributor to type II diabetes, and diabetes is one of the costliest high prevalence diseases – it multiplies the cost of treating other disease that diabetics may acquire by 7-15 times! So I would say adequate nutrition in pregnancy, a good education, and prevention of childhood and teenage obesity should be near the top of anyone’s list.
Dr. Mosfequr Rahman: How do the the ageing populations affects in economy of a developing country, where birth rate is still high and population are mostly young aged?
Richard Suzman: As you have defined the issue, probably not very much, though I wonder whether early onset of chronic diseases and early withdrawal from the labor force because of associated disability might not have an impact especially in the high human capital component of the labor force.
Sandra: As family structures change and people live longer and have fewer children, it’s possible that informal caregiving will become less common. How prepared are governments to step in and assume more responsibility for caring for the elderly?
Richard Suzman: Correct, the baby boom cohort is a low fertility cohort. So the current oldest old cohort (those age over age 80 or 85 – where disability levels are heaviest), whose children in part constitute the baby boom generation, have relatively plentiful arrays of children to help care and support them – and the family provides a good deal of long term care. Also, the increases in divorce and childlessness have already weakened the support system for the future elderly. Support will have to come from a mix of public and private sources, informal unpaid and paid. One thing that would help would be to narrow the life expectancy gap between husbands and wives, since the premature death of husbands increases the chances of impoverishment of their widows along with the probability that their widows will be institutionalized when severely disabled. The reduction in the gap between male and female life expectancy has been has been happening over the last couple of decades as male life expectancy has been increasing while female life expectancy has not shown the same improvement, perhaps as a partial result of their smoking histories. I think we need some models to help forecast the demand for long term care. A good deal of the care will probably be provided by immigrant groups to the USA.
Jane: Democratic-era health policy in South Africa appropriately places emphasis on a primary health care approach. This approach tends to focus on improving maternal and child health and managing acute conditions. Which seems to overshadow the health and well-being needs of our older persons. Are there models from similar-situtation countries that one can learn from how to effectively increase the priority given older persons health?
Richard Suzman: Yes, it does seem that South Africa has focused mainly on child and maternal health rather than on aging and chronic disease. Child health and HIV/AIDS obviously require significant attention, but type II diabetes is endemic in many communities as is hypertension. I also don’t know how much attention the WHO report on the Global Burden of Disease http://www.who.int/topics/global_burden_of_disease/en/ ever got in terms of the projection that non-communicable diseases will come to dominate middle income countries. SA is a country that in my view has to wage health battles on at least two major fronts – infectious disease and a growing burden of chronic disease, sometimes even within the same individuals. The question to be answered is whether or not an increased focus on chronic non-communicable diseases of middle and old age is overdue, and whether the timing and resource allocation has been optimal. The most significant focus on the elderly came about with the huge change in the public pension system in which the pension was extended to all population groups, becoming for a while the major income security program. Interesting, one of the more studied consequences has been how some of the resources filter down to children.The NIA funded a report from the US National Academy of Sciences on Aging in Sub-Saharan Africa http://books.nap.edu/catalog.php?record_id=11708 – NIA has hard copies of the report that we can share. We also expect that a report on the demography of aging in this region that we commissioned from the US Census will be published in the next two months. NIA has funded a WHO survey on ageing (aging) in South Africa — http://www.who.int/healthinfo/systems/sage/en/index3.html. We have also funded an aging component in several of the INDEPTH sites including South Africa: http://www.indepth-network.org/. NIA will also be funding research on the impact of HIV-AIDS on the older population – too many of whom become caregivers for their grand children. We recently co- issued with the USA State Department a major report on Global Population Aging that discusses some of the issues: http://www.nia.nih.gov/ResearchInformation/ExtramuralPrograms/BehavioralAndSocialResearch/GlobalAging.htm.
We are working on the question of what are appropriate levels of services and research for countries and regions at different levels of development. While I am reluctant to suggest other models right now, I sense that countries such as China and even India are beginning to think constructively about aging issues. Some have the impression that South Africa maybe behind where it should be, while others agree with the allocation. There are obviously many complex trade-offs. I would appreciate your perspective on the issue.
J Kishore: Aging indeed a matter of concern to India because of its huge base of population pyramid. Concerns are related to communicable, noncommunicable disease burden associated with disability burden in terms of physical, mental,social, and economic. Beside these, India is facing social support crisis. Social values are changing and aging people are feeling isolated in this competitive world of younger people. I want to know from respected Richard Suzman that how can we retain our social support to aging people in this situation. What policy and real commitment our government should make to ensure physical and mental health of our aging people keeping our younger population in mind? Thanking you.
Richard Suzman: India is an important case of population aging within a heavily rural society that is experiencing rapid economic growth. With the world’s second largest population, and probably in a few decades, the most populous, its life expectancy has increased dramatically over the last 50 years. Over the last 50 years there has been a very slow growth in the fraction of the population over 50 perhaps from roughly 12-15%. However, according to some population projections, India is very close to a major inflexion point, with the fraction expected to reach close to 35% by 2040. You seem to have a good grasp of several of the issues. I remember on a visit to New Delhi, well over a decade ago, the then Director of the All Institute of Medical Sciences scoffed at the issue of aging , especially the need for long term care institutions, arguing that the family would take care of the elderly in need of care. But even then we knew that this was not happening in urban areas and areas impacted by migration. Even in individualistic and monetized societies such as the USA, most long term care is handled by family members and friends, but caring for some patients, especially those with Alzheimer’s Disease, might best be accomplished in nursing homes or other long term care settings. Nations need long range plans commensurate with their level of development and the forecast population and economic changes, and it is a truism that planning for population aging and the development of appropriate pension and health care benefits needs to be done decades before the growth of large fractions of retired persons and aged in need of care became a resource issue. Despite India’s well known penchant for long run planning, the study of population aging in India has been a rather neglected topic, but today I see several signs of recognition of the problem at least within the highest levels of the governing structures. There are, of course, trade-offs, between investment in education, factories, research and long term care and health, and knowing the best balance is difficult. But we all have a chance of becoming old, and increasing numbers of us will, so in a sense even for the current young, the elderly must always be seen as our future selves. So I will answer your question with the thought that India should set up the research institutions and collect the data needed to be able to plan effectively for its aging.
Michael Vitez: I am interested in three questions: where will people grow old, who will care for them, and how will they pay for that care? Is there anything in your new report that sheds new light on these three questions, or perhaps even provides answers to them?
Richard Suzman: The report Why Population Aging Matters (http://www.nia.nih.gov/ResearchInformation/ExtramuralPrograms/BehavioralAndSocialResearch/GlobalAging.htm), was prepared for a US State Department Summit on aging in which the Secretary of State, Dr. Rice, invited the ambassadors to the USA to attend a morning briefing on global aging. So the focus of the report is international rather than focused on the USA. Across the world there is enormous variation in the urban-rural dimension of aging, the availability of caregivers, the need to monetize caregiving, etc.
Yidana Godwin: What in your view are the positive consequences of aging to global economy given the trend of events now?
Richard Suzman: Bill Nordhaus as well as Kevin Murphy and Robert Topel have calculated that the increase in life expectancy in the USA added trillions of dollars to the GNP!
Andrea Aldinger: As a Director of a local Office for the Aging, I am very interested in your topic. My question is what programs and services do you think we need to be prepared for in the next 10 years? Do you think our state and federal government realize the impact Aging has on communities and how do we get them to realize this is a priority?
Richard Suzman: Demographic processes usually happen over decades, and I think the time scale of concern may be closer to 25-40 years. I think it imperative that wee find ways to prevent and treat disability, especially the disability caused by Alzheimer’s Disease. Obviously the longer one waits to revamp pension programs that are not actuarially sound, the more difficult and traumatic the remedies. So the costs of waiting can be high. Local communities do need to plan in terms of programs and infrastructures (such as transportation and health), but I would assume that there is huge local variation.
Leo Estrada: Can you foresee an international organization—like WHO—taking on the task of global aging and seeking regional solutions?
Richard Suzman: So far, international organizations such as WHO have given very little attention to global aging though the UN’s Population Division has been more attentive to the issue.
XinQi Dong: Elder mistreatment is a pervasive public health issue, yet there are still vast gaps in our existing knowledge. 1) What is your vision on the current and future plans to address these issues? 2) What funding resources or initiatives from NIA that might deal with this topic that spans multiple disciplines? 3) What are your thoughts on the specific role of population-based research studies in addressing these issues?
Richard Suzman: Abuse of the elderly or their neglect is as terrible as the mistreatment of children. We don’t know the extent of this problem since we have no reliable statistics. The National Institute on Aging (NIA) therefore commissioned a report from the US National Academy of Science on the topic: http://books.nap.edu/catalog.php?record_id=10406. In order to improve the quality of data on the problem the NIA issued a one time call for proposals that would help develop the needed methodology that would enable the provision population data on the issue:
http://grants.nih.gov/grants/guide/rfa-files/RFA-AG-06-009.html and will be funding a number of the proposals. We will provide the results to other agencies along with technical assistance, but do not ourselves expect to conduct such surveys.
Van: How does population aging affect national management of health systems?
Richard Suzman: In many ways. The demand for geriatricians relative to pediatricians increases. The growth of the chronic disease burden increases relative to the burden of perinatal and infectious diseases (see the Global burden of Disease http://www.who.int/topics/global_burden_of_disease/en/, eventually becoming the major burden of disease. Studies in the USA have found that demographic aging is a far smaller cause of increasing health costs than the spread of better but more expensive new technology
Dr. Mosfequr Rahman: In USA Aging is really a matter as elderly population increase rapidly. What initiatives have been taken by the government to solve the problems of elderly in USA?
Richard Suzman: Well, there have been major health and retirement benefit programs set up including the Social Security System for public pensions, the Medicare system for health and the provision for tax treatment of saving for private pensions. The US government also established federal institutions such as the Administration on Aging (https://www.acl.gov/programs) to address the service needs of the elderly and the National Institute on Aging within the National Institutes of Health to address research needs http://www.nia.nih.gov/. Overview: NIA, one of the 27 Institutes and Centers of NIH, leads a broad scientific effort to understand the nature of aging and to extend the healthy, active years of life. In 1974, Congress granted authority to form NIA to provide leadership in aging research, training, health information dissemination, and other programs relevant to aging and older people. Subsequent amendments to this legislation designated the NIA as the primary Federal agency on Alzheimer’s disease research. Mission: NIA’s mission is to improve the health and well-being of older Americans through research, and specifically, to: Support and conduct high-quality research on: Aging processes, Age-related diseases, Special problems and needs of the aged, Train and develop highly skilled research scientists from all population groups, Develop and maintain state-of-the-art resources to accelerate research progress, Disseminate information and communicate with the public and interested groups on health and research advances and on new directions for research. Programs: NIA sponsors research on aging through extramural and intramural programs. The extramural program funds research and training at universities, hospitals, medical centers, and other public and private organizations nationwide. The intramural program conducts basic and clinical research in Baltimore, MD and on the NIH campus in Bethesda, MD.
Ayman Zohry: In a globalized world ageing should not be a big economic issue. I understand that it is a big social issue but I think we still have hundreds of millions of young people in the developing countries who can satisfy the needs of the economic sectors in the developing world. This will narrow the gap between the north and the south. I believe that Migration Without Borders is an effective remedy of ageing in the north. What do you think of this?
Richard Suzman: I think that global ageing is a huge economic issue. It is partially manageable for those in the vanguard though increased immigration, but there are long term consequences of increased immigration, and while the use has been more open to immigration, Europe has been less open.
Allison: The health care system in the U.S. is seriously flawed. What is being done to respond to the growing needs for quality health services as people age?
Richard Suzman: It is not clear that one can talk about the health care system in the USA – since there are many sub-systems that dare not well integrated. Medicare is a huge program while the Veterans system also takes care of substantial numbers of older people. One gap in Medicare – the lack of outpatient prescription drug coverage was recently remedied by the introduction of Medicare Part D, which now seems to be functioning quite well. Long Term Care in nursing homes still has major gaps that are only partially remedied by private insurance coupled with Medicaid for those who have exhausted their financial assets. Our researchers have found major geographical disparities in expenditure and quality (sometimes inversely related), and worrisome racial and ethnic gaps remain. Several institutions such as the Center for Medicare Services, the Agency for Health Research Quality, and the National Institute on Aging (NIA) sponsor research to help improve the quality of care. The NIA also sponsors research on basic medical and social issues to improve the health and care of older people – imagine how lives and families would benefit if we found a treatment or cure for Alzheimer’s disease.
Laura: How do you think the aging population will affect the workforce born after the baby boom generation and what implications might this have on the need for foreign workers?
Richard Suzman: A short and penetrating question, but not one with a simple answer. The post baby boom generation will have a problem in that the baby boom had few children and so the numbers of kids per aging parent will be fewer imposing a heavier burden – in comparison the baby boomers formed a rich support for their parents –many of whom who are still alive are in the oldest old age group. The same holds true for worker non-worker ratios. So labor will be scarcer. The USA has taken a very different path from Europe because of out much higher levels of immigration. Immigrants to the USA on average also have high fertility levels. I expect the demand for foreign workers to increase from present already high levels.
Osvaldo Soto: I wonder if developed countries are doing something to help high birth rate countries to lower their birth rate? ANd if they do, what are they doing and how much money are they spending on this issue?
Richard Suzman: This is not my area of expertise, but certainly programs aimed at increasing the education level of women usually have just that impact.
Gavin Kasper: Resources, Resources, Resources. Obviously the population has been changing, but do allocations associated with particular cohorts keep up with those changes, and if not, where are the “gaps”?
Richard Suzman: Longer lives ( a wonderful dividend of progress) have to be financed somehow. Some of the biggest policy questions of our time involve the long run financing of Social Security and Medicare (in budgetary terms 4-5 times bigger than Social Security). Quantifying actual public and private expenditures for different generations is an ongoing research area that the NIA is supporting. Education is one of the largest investments that families make, and probably on of the best investments that cohorts of young and middle aged can make for their future is increasing investment in the right kinds of education since the economic return to education is important to increase productivity and economic growth—that will provide the support for a large fraction of older people. I am biased, but I would also recommend increased support for research to prevent, delay or treat aging related diseases such as Alzheimer ’s Disease and to reduce disability – plus more research on how to help those who want or need to be able to work at older ages, do so.
Peter Lachmann: It is universally agreed that ageing occurs at different rates and we recognize a condition called progeria. Nevertheless there is no metric of ageing – which invalidates a lot of discussion about it. Can you define the “mini-Methuselah” as the unit of ageing?
Richard Suzman: I do not think that demographic or economic research on population aging has been held back or invalidated by this issue in biology—ratios among age groups or between those in the labor force and those outside of the labor force, do have some problems, but provide reasonable crude but useful approximations at the population level.
Wolfgang Gasser: Could you imagine that demographic saturation*, predicting a direct link between birth rates and death rates, is a possible explanation of the extremely low fertility rates in regions such a Beijing or Hong Kong? And if actually a further reduction in deaths leads to a further reduction in births, would this fact entail social and political implications? * http://members.lol.li/twostone/demography/critical_analysis.html
Richard Suzman: This is not an area I have thought about much so I turned to my Colleague, John Haaga, our Deputy Director who has published authoritatively on this topic (J. Haaga “The Biology of Behavior and the Study of Human Fertility: A Review Essay,” Population and Development Review 29: 2003:505-517). He comments: A feedback loop from population density to fertility rates has often been discussed, especially in the early decades after World War II when fertility declines outside Europe and North America were most apparent in some island nations like Mauritius and city-states like Singapore and Hong Kong. A more subtle version is that fertility is discouraged when young people have a very hard time finding their own apartments in expensive cities, as in Italy. But density effects, if they exist, are not simple. Some of the lowest fertility rates in the world are found in countries that are not especially densely populated (Bulgaria, Russia). Below-replacement fertility has persisted for decades in regions like Catalonia and Emilia-Romagna, long before they were densely settled by modern standards. The modern fertility decline began in two countries (Eighteenth-century US and France) and was much delayed in England – the historical pattern is not explainable by urbanization or crowding. Many bird species respond directly with lower fertility to cues about population density – but humans and other mammals do not. Lower mortality rates would contribute to further population aging, which of course has a lot of social and possibly political consequences. John G. Haaga, Deputy Director
O. U. Ozidi: What is the correlation or orderwise between a Health care outfit, situated in a rural area and the professional level of attention granted to such outfits.
Richard Suzman: I don’t fully understand your question.
Bashir Ahmad: What can be said about future course of longevity, given that reserach on both historical and contemporary populations belies the existenence of a biologically fixed maximum for the human life span.
Richard Suzman: That it will be of great interest, and we will not know the outcome for a long time! There has been a heated debate surrounding the issue of a fixed maximum for both the maximum life span and the human life expectancy, with Jim Fries and Jay Olshansky on the arguing for limits and Jim Vaupel arguing that no limits are in sight. Vaupel’s paper in Science showing a steady increase for the country with the best life expectancy over the last 160, was truly remarkable. Perhaps more important for policy analyses, are projections of life expectancy and health expectancy over the medium term. Tuljapurkar et al’s paper in Nature. 2000 Jun 15;405(6788):789-92., suggested that many industrialized governments might be under-predicting future gains in life expectancy.
Prof. Adeniyi Osuntogun: Given the fact that people live longer, should the retirement ages from employment be revised upwards?
Richard Suzman: Increased life expectancy is a wonderful benefit but the added years have to be financed somehow. In industrialized countries life expectancy has increased while the age at retirment has declined so that in some cases work life and life in retirement are about equal. There are also data showing that health has improved at least in some countries. A wonderful cross national study by Jon Gruber and David Wise and a large team found that in many industrialized countries it was the mainly the public pension age that affected when people retired. Increasing the age of retirement or more correctly the age at which one can get full benefits is one solution that many countries are taking. If this is done, provision must be made for those with major disabilities etc. The NIA has set up a major study known as the Health and Retirment Study (HRS) to explore many of these issues: http://www.nia.nih.gov/NR/exeres/C80ADCEA-DE6E-4EF0-8D75-FD32AAE9BE6A.htm.  We have also initiated a large scale global enterprise to support studies such as the HRS across the world and there are now ones in England, about 15 EU countries, Mexico, and some Asian countries.
Mike Swift: While most people see suicide as an issue among younger people, suicide rates are high among elderly men. In your view, is mental health given enough attention as a dimension of aging?
Richard Suzman: In the USA suicide is highest within the older population among older white men. However, as a general cause of death within the older population it only ranks about 17th. However, depression, an underlying cause of suicide, is a very large cause of disability and is probably under diagnosed.
Ernest Ball: Compare population forecasts of US, EU regions, vs Moslem world for year 2050 or similar, using predicted growth rates.
Richard Suzman: You can find the answer in UN publications
Kidza Yvonne Mugerwa: Could you please say something about the behaviourals social and economic effects of sging on people who live in societies where you are not expected to live long as evidenced by the fact that there is not national plan for your sustainance (e.g in societies that have been hard hit by HIV AIDS – where you have very old people having to look after grand children and great grand children because their parent have died of AIDS
Richard Suzman: Some countries in Africa probably fit the bill of the sitiuation that you describe. South Africa luckily does have a national pension plan that provides some subsistence, but others do not. We asked the National Academy of Sciences for a report on some of these issues: http://www.nia.nih.gov/NR/rdonlyres/23F2B4E8-F7EB-41D7-86D6-4921A3F3669E/0/Pagesfrom2006AgingInSubSaharanAfrica.pdf. The NIA is also supporting the development of data on the matter in a few countries such as S Africa and Ghana (via a WHO survey known as SAGE). We were going to include Zimbawe but the wretched conditions in that country made research impossible.
Marie Sims: is the ageing of the moslem countries differing a lot to non muslim countries
Richard Suzman: I am not sure that it makes sense to answer this question in general as opposed to considering countries from the same region and at the same level of economic and social development and also level of population aging, but which differ in religion. That said, no big difference comes to mind. However, this is probably an under-researched issue. There are data on countries such as Indonesia, but I have not seen any recent surveys out of Middle Eastern countries, except for Israel (the study included the moslem population—but no analyses are yet available).
Victor Hull: What level of federal funding do you believe will be required to address the growing number of people with Alzheimer’s Disease, and do you believe that level can be achieved in today’s budget environment?
Richard Suzman: Senator Mikulski has a bill in the US Senate on I think just this issue. Some have called for doubling the budget. However, given my position, I am not in a position myself to make recommendations. This is one of the major thrusts of the US National Institute on Aging and there has been considerable progress in the hunt for understanding the disease and finding solutions. The biggest cost comes in mounting large scale clinical trials. The greater the budget the more trials one can start, though the science base posing new approac