A defining feature of the 21st century — globally and in India — will be the rise in the numbers of persons classified on the basis of age as ‘elderly’ (above 60 years) and ‘very elderly’ (above 80 years). India, which has a ‘young’ demographic profile with a youth bulge, will also see a rise in the number of the elderly — from 8.5 per cent of the population now to nearly 20 per cent by 2050. Even at present, India’s elderly population of 105 million outnumbers the total population of many countries.
The age cut-offs for these definitions were set in the labour market economies of a century ago and are no longer relevant at present, when people have advanced to a state of greater fitness and functionality even late in life instead of being frail and feeble. New measures are emerging due to rapid societal changes, such as ‘healthy life expectancy’ and ‘prospective life expectancy’ (how many more years of expected life at a given age, rather than count from birth).
Much of the credit goes to social advances and public health, which kept the body and mind healthy and young for longer periods, rather than to reparative technological innovations that restore damaged body parts to better function or merely replace them. Ageing is no longer viewed as a cataclysmic change that occurs at a pre-determined calendar date and abruptly curtails productivity, but as a multidimensional construct that integrates extended life with increased functionality.
The leaps in longevity can be substantially credited to public health approaches such as better sanitation, cleaner water, wholesome nutrition, better road safety (from helmets to seat belts and drink driving laws), tobacco control, food safety standards, environmental regulations and improved health systems that delivered a wide array of health services, from preventive vaccination to mental health counselling. Countries which coupled economic development to greater social equity reaped better benefits in terms of both total and healthy life expectancies in their populations, compared to countries on a similar scale of economic development but with wider equity gaps within their populations. Gender equity is also critical to healthy longevity in a population.
The vision of public health envisages a long and productive life span between the book ends of ‘birth without danger’ and ‘death with dignity’. Public health aims to achieve this through multi-sectoral policies, creation of strong health systems capable of effective delivery of a wide range of health services, and active engagement of enabled communities in the co-creation of health at the population and personal levels.
Ageing does come with a higher probability of encountering some physical and mental health challenges, though their nature, severity and age of onset can be very variable in timing. This calls for strong health systems which can readily provide a wide range of health services that can prevent, diagnose and treat disorders along with rehabilitative, palliative and counselling support, as needed.
A common feature of ageing-associated health disorders is ‘comorbidity’, in which a person can have multiple co-existent medical conditions. Hypertension and diabetes is a common mix, as is depression with cardiovascular disorders or arthritis with diminished vision and hearing loss. Many of these require chronic care, the cluster now being labelled as ‘multiple chronic conditions’ (MCC), calling for capacity to manage them concurrently with competence and compassion.
Strong primary health care services are especially needed for such integrated care. Though specialist care may be needed on occasion, holistic initial assessment of the person and customised long-term management of co-morbidities are essential to providing the best possible functionality and least risk from multiple treatment modalities. Such care is best provided through primary health services.
It calls for training and deploying a multi-layered, multi-skilled workforce comprising community health workers, nurses, doctors, dentists or dental hygienists, physiotherapists, and mental health counsellors who function as integrated teams. Nutrition of the elderly also requires special attention, with the aged persons, their families and healthcare providers being educated in this area. Mental health services too need to be strengthened to overcome the problems of social neglect, social discrimination and social withdrawal that can darken the later years of life. Built environments and transport systems which facilitate easy and safe mobility, with reduced risk of falls and injury, are also complementary to such care.
A major challenge for accessing the wide range of health services is the financial barrier of affordability, if elderly persons are compelled to purchase these services. Frequently, retirement reduces incomes and creates vulnerability at a stage when more health services are needed. Apart from old age pensions as part of social security, universal health coverage programmes will need to ensure easily accessible health services without financial hardship. Technologies that assist mobility, safety, functionality and well-being among the elderly must also be provided by health services.
We also need to recognise and respond to the threats that operate at the population level to cut short our confident march to healthy longevity. Climate change, air pollution and pandemic threats are among the threats we must contend with and counter if we wish to reap the economic and social benefits of long and productive lifespans. Conflicts and forced migration must be mitigated, as poignantly demonstrated by the recent drop in life expectancy in Syria.
Finally, it must be recognised that healthy ageing is a lifelong phenomenon that starts even before birth, with the mother’s health and nutrition. It extends through childhood and adolescence, where balanced nutrition and regular exercise can shape body and mind, to all stages of adult life where health can be fostered and threats avoided or diminished. While genes do play a role, the remarkable increases in life expectancy across the world in the last 75 years clearly show that gene expression can be favourably altered by the way we live. Public health paves the road, provides the light of ever-growing knowledge and creates supportive structures as we travel on the path to increased longevity, with more years of assured health, fitness, functionality and happiness.