The third age [full issue]

THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION - APRIL 1979 Cover: Wise old age. Portrait of a chieftain in the Philippines. (Photo WHO) IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Lalit Thapalyal World Health appears in Arabic, English, French, German, Italian, Persian, Portuguese, Russian and Spanish. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents The elderly in a changing world by R. Glyn Thomas 3 Enjoying old age by D. Chebotaryov 8 The third age by J. Bland 12 Elderly—and fit by A. Svanborg 16 A worldwide challenge by C. Viedma 20 Fragile: handle with care by S. Hatano 24 News Page 30 The elderly in a changing world "Perhaps we should examine how this ageing population may be helped to maintain good health and to remain alert and active; some might even be recruited as auxiliary personnel for the health services" by R. Glyn Thomas it ithin the group called the elder-ly there are many individuals who may be faced with growing difficulties in coping with the problems of everyday life and changing environment. The planning for the health care of such groups is also made more difficult by a lack of information as to who really are the elderly and what, if any, are their special health problems. The demographic cause of the ageing of populations is a complex one, but it should be recognized that any important and sustained decrease in fertility pro- duces ipso facto an "ageing" of the popu- lation. Consequently, the populations of developing countries which have a young structure will age if their fertility follows a generalized downward trend. Further, this process of ageing of populations will be quicker than that which has already taken place in the industrialized coun- tries. A second major factor is the reduc- tion in mortality during the second half of life. It is reasonable to forecast a fur- ther ageing of populations resulting from a combination of the two processes. A third phenomenon, that of the migration of young people out of, or the elderly into, certain regions or localities, may result in still greater ageing of some pop- ulations. There is a distinct difference between the concepts of individual ageing and the ageing of human populations, although both concepts have only recently received scientific attention. Individual The Third Age. Baby—parent—grandparent: all three generations make their contribution to the life of the community. And all three have certain inalienable rights. (Photo WHO/D. Henrioud) ageing emphasizes irreversible stages of the life span, the understanding of which is dependent on knowledge of the biolog- ical, sociological and psychological processes associated with growth, matu- ration and possible decline of the human organism within the context of physical, psychological and social environments. The ageing of human populations, how- ever, is a more complex phenomenon about which there is little consensus as to how it may be defined. Much of the litera- ture to date, in defining societal ageing, stresses the proportionate increase of older persons within a given population. For policy formulation planning, and in developing new responses to the needs of ageing populations of the world, demographic data should be examined in terms of aggregate numbers, as well as in regard to the proportions of the older populations vis-a-vis other ageing groups. For example, the 60-and-over population while representing only 8.4 per cent of the world's total in 1970 and 9.3 per cent in the year 2000, in numbers represents 304 million and 581 million persons, respectively. This nearly doubl- ing of the older age groups in 30 years has far greater implications than their percentages of the total populations would suggest. Between the years 1970 and 2000, for the world as a whole, all ages are expected to increase by 73 per cent, but the 60-and-over population will increase by 91 per cent while the 80-and- over population will increase by 119 per cent or almost half again as rapidly as the world's population of all ages. For the more developed regions and countries, which have experienced a decline in birth rates, the proportions and numbers of the older population have increased steadily over the past 3 decades. Not surprisingly, it is in these countries that the greatest attention has been given to social policies and practices regarding the elderly, and also to the in- creasing numbers of persons of extremely advanced age. Of the world's population of 3,600 million persons in 1970, slightly less than one-third lived in the more developed regions and slightly more than two-thirds in the less developed regions. Of the world's 304 million persons who were 60-and-over in 1970, about half were found in the more developed regions and the other half in the less developed regions. Throughout the world as a whole, there were some 26 million persons aged 80 and over in 1970. By the year 2000, this same number of per- sons aged 80 and over will be found in the less developed regions alone. The proportion of persons aged over 80 within the 60-and-over population is increasing. Worldwide this group repre- sents 8.7 per cent of the 60-and-over pop- ulation, and by the year 2000 it will represent 9.9 per cent. But in the more developed regions, the proportions are 10.5 per cent in 1970 and 13.3 per cent by the year 2000. This is the age-group which is most frail and vulnerable, and which may require the greatest range of specialized services and facilities. With the ageing of populations is asso- ciated an increasing survival of women over men. In the more developed coun- tries, where ageing has been more pro- nounced in recent years, the world of ad- vanced old age has been characterized as essentially a women's world. There is a higher proportion of 80-and-over women than 80-and-over men throughout the world, and in the more developed regions this disproportion is even greater and will be still more pronounced by the year 2000. Ageing and disease. Until recently there has been confu- sion between the processes of ageing and the disease processes. Old age is not a cause of death. Rather, death is caused by a defined disease or pathological enti- ty. What is known is that ageing is a process of differentiation, both within the human organism and between indi- vidual human beings. A number of physiological changes appear to have a direct relationship to growing old but, despite these changes, a majority of older persons retain their functional capacities notwithstanding their apparent organic decline. Until recently, most of the psychologi- cal and behavioural research on ageing, including the use of tests and measure- ments, were based upon earlier studies of younger persons, particularly children and adolescents. Often the findings as- sumed that any differences identified be- tween these two groups were age-related. This was particularly the case in the areas of intellectual performance, that is, the capacity to learn, solve problems and create. There was a failure to recognize that each age-group is born into and matures in a different social environ- ment, a different cultural and historical period. Hence the limitation of many studies which have failed to develop ap- propriate ways of ensuring that differ- ences between the generations are not considered as age-related differences. In addition, because many of the earlier studies were based upon populations confined to institutions rather than those living in the open community, there was a confusion between disease and ageing. The decline in intellectual functioning is more related to disease than to ageing. Research on intellectual processes sug- gests that only specific functions and re- sponses such as numerical calculations and speed seem to diminish somewhat with age. Verbal capacities continue to increase throughout the life span, and learning is a continuing phenomenon. Because of the great cultural variations throughout the world in regard to the use of symbols and oral traditions, it is im- portant to have studies about the psy- chological processes of ageing within a number of cultures and regions in order The elderly in a changing world Left : Over 100 years old, this Mexican fisherman is still actively at work. By the year 2000, persons aged over 80 will represent nearly ten per cent of the world's elderly—that is, of those aged 60 years and over. ( Photo Len Sirman ©) Right : An old woman in India enjoys the company of her family. Research into the behavioural aspects of ageing too often overlooks that each age-group is born into and matures in a different social environment, a different cultural and historical period. (Photo WHOIP.A. Pittet) to determine what is characteristic of ageing per se, and what behaviours in old age are culturally defined and deter- mined. In the developed world the emphasis has been on institutionalization of the aged. It is a long-held view that older persons needed special care and protec- tion from the stress of community life. There is now, however, an increasing questioning of the appropriateness of this approach. In many countries more than 95 per cent of older persons reside in the open community, making increas- ing use of community health services and facilities. Some less developed regions are now starting to look to special institu- tions to care for the aged, based upon the models of the more developed world, but the more developed countries are begin- ning to provide a full range of alternative settings for "care", based upon the rec- ognition of individual differences and needs within the older population. The problem we are dealing with is ex- tremely complex, and will require a mul- tidisciplinary approach in the develop- ment of services. Furthermore, it is not simply a medical problem, but one which involves social, environmental and eco- nomic factors. Analysing such many- faceted problems calls for constant study of the demographic trends, particularly the marked increase in older age groups and the disproportionate mortality and morbidity rates between the sexes. Recent studies tend to indicate that the elderly can be said to be generally heal- thy, both physical and mentally, but they are often bored or lonely and many have social, vocational and economic prob- lems of much greater importance. The Scandinavian study of 70-year- olds referred to elsewhere in this issue found that only one in eight among the subjects had needed a visit by a doctor during the previous three years, and about half of them stated that they "nev- er saw a doctor or a nurse" or at least had not seen one during the last year, whereas only one in four had seen a doc- tor or attended hospital as frequently as once every three months. This is con- firmed by information from the German Democratic Republic, where only one in three of the population aged 65-and-over makes use of well-developed and easily accessible medical services during a given year. These observations indicate rather limited medical problems which could possibly be confirmed, better analysed and understood if studies on the inci- dence of diseases and the prevalence of impairments in the higher age groups were available, but they seem to be non- existent. Mortality surveys do exist, however. On the basis of studies carried out in Denmark, Israel, Norway, Poland, United Kingdom, the United States and Yugoslavia, it has been calcu- lated that, in a population of 100,000, some 900 persons in the age group 65- and-over die annually. Of these slightly more than 500, or approximately 60 per cent, may be expected to die from cancer, cerebral strokes or other cardiovascular diseases. It is certainly difficult to deduce from such statistics what the medical problems of the elderly are, but the im- pression is borne out that the medical problems are not as overwhelmingly great as many believe. Isolated lives The social problems of the elderly, on the other hand, are very considerable. An increasing number of old people complain that they live isolated lives or feel lonely. In the age group 65-69, roughly 20 per cent state that they some- times or often feel lonely, and in the age group 80-and-over this proportion rises to between 30 and 40 per cent. Many fac- tors combine to create this situation, which sometimes exists in spite of fre- quent contacts between the elderly and their children and friends. In the more developed regions, where retirement from the labour force is an ac- cepted social policy, increasing numbers of older persons face economic depri- vation and poverty. There is a myth that older persons cannot continue to work beyond a specific chronological age. While this varies from country to country, for the most part beyond age 65 compulsory removal from the labour force is a social condition of ageing. This is related to another value central to some societies. This is the equation of economic productivity with personal worth. The elderly, who are denied the right to continue to be economically rewarded for work, are denigrated as lacking the ability to carry out socially productive roles. We need to examine the underlying cultural attitudes and as- sumptions about ageing, including how these may be changed to provide a more realistic and meaningful approach to ageing in society. Another important element is that the elderly sometimes lose, even in their fam- ily relationships, the feeling of being needed or being useful. These observa- tions should be seen in the light of avail- able evidence that in general the elderly are not only able to work, but are also able to learn and to adjust to change, even if many find it difficult to adjust to the loss of work. Linked with this, at least in many parts of Europe, is the economic situation created by a reduced income, most often resulting from the loss of the right to work, sometimes from a gradually reduced ability to work, and sometimes from the next generation's tendency to want to take over full responsibility. Cul- tural patterns urge the elderly to "rest and take it easy". Only gradually, and only in a few countries, is the reduced in- come being adequately compensated through pension schemes. These social, economic, vocational and psychological components are pro- bably much more important in creating a difficult life situation for the elderly than the medical components. Nevertheless, the problem is often presented as a medi- cal one, as this is apparently more accep- table both to the individual and to soci- ety. In addition, and possibly because of this acceptability, we have created a ser- vice system which gives both economic and social advantages to those who pre- sent themselves as medical problems. Obviously, if a social or economic prob- lem is presented as a medical one, it should be met and dealt with not as a medical problem but on the basis of its real causes. Information on mortality and morbid- ity in age-specific groups is at present in- adequate. There is a tendency to assume wrongly that the over-65s form a homo- geneous group. The different needs in rural and urban areas are not clearly un- derstood, nor are the changing clinical aspects of multiple morbidity and chang- ing attitudes in regard to family struc- ture. If we compare the situation in the developing and the developed world, it seems essential to maintain the strong family ties that exist in the developing countries and to re-establish those in the developed world which tend to have dis- appeared. Service development has been in the past, and possibly still is, ham- pered by an emphasis on "cure" rather than on "care", and by outdated and inadequate legislation. If we take as the starting point the fact that in Europe there are increasing num- bers of people aged 65 or older to whom we deny the right to work, who we know will in the future meet increasingly fre- quent social, economic, psychological and vocational problems as well as medi- cal problems and sickness, and who will eventually die, most often after a fairly short period of serious incapacity or dis- ease, then we may have a fair basis for our planning. 6 The elderly in a changing world Left: In the developed world, the emphasis has been on institutional care of the elderly; today it is being increasingly questioned whether this approach is appropriate. (Photo Irene Barki, Viva ©) Right: In many developing countries, the view is widely held that the family takes care of its older members. Yet there is increasing evidence of the elderly being left behind when younger people migrate to the cities, or settling un- happily in urban slums. The true situation in these areas of the world requires urgent study. ( Photo WHO/P. Almasy) For these people we need to develop health protection in the broad sense. We should, however, be realistic and face the fact that the prevention and treatment of diseases and impairments will have to be dealt with first. Since we do this fairly well and thus postpone death—then it seems to be our duty to make sure that we also preserve for such people the highest possible quality of life. Perhaps we should examine to what extent this ageing population may be assisted in maintaining good health, in keeping a purpose in life and in remaining alert and active; some might even be recruited as auxiliary personnel for the health ser- vices that we so badly need but have problems in creating because of the shortage of manpower. Most research findings in developed countries stress that while dependency on other persons is a characteristic of each life-stage, there are specific depen- dencies related to growing old. However, many of these may be caused by society's approaches to the ageing, rather than be- ing inherent in ageing per se. The issue appears not to be one of dependence ver- sus independence; rather the capacity and right to "self-care" of one's bodily, psychological and social functions. Dependency is often created by the des- truction of the individual's own capaci- ties; at times, persons working with the elderly tend to take over by making the decisions which are normally made by other adults in the population. In many countries of the less devel- oped regions, there appears to be a conti- nuing view that the family takes care of its elder members. At the same time, there is increasing evidence of migrations from rural villages to urban centres ; the elderly are either left behind by younger migrants or, if they follow their adult children to the cities, they settle in slums and uncontrolled settlements where they have no role, status or identity. How and under what conditions younger people care for older family members in these areas of the world requires study. It may be a myth that such traditional responsi- bilities are indeed carried out in the pre- sent world of rapid technological and social change. The rapid changes which are occurring throughout the world make information increasingly obsolete. Information ex- changes between the elderly and the young often become complex and less relevant, while the elderly often cling to knowledge and experiences which grow out of past identities. In addition, many of the industrial and urban areas of the world have developed a youth-oriented culture which places heavy emphasis on children and the young. Older persons are viewed as obsolete. Part of this nega- tive attitude towards the elderly may be due to an emphasis on the future—the young being symbolic of the future and the old representing that which is past. Educational institutions have tradi- tionally emphasized the preparation of the young for vocations. Only recently have questions been raised about the im- portance of lifelong learning, and about the changing roles of primary, secon- dary, and higher education in regard to preparation for ageing and for the crea- tive use of time beyond family and occu- pational responsibilities. A few pro- grammes exist to prepare individuals and families for retirement, but these are still limited. If it is true that the major problems of the elderly are in the social and economic fields rather than in the sphere of medi- cine, then much close coordination is required between the health, social and welfare services in order to draw up ac- tive social policies that will truly benefit the older generations. ■ 7 Enjoying old age Soviet studies show that people who are pen- sioned off suffer a sharp decline in vitality and may age prematurely. Socially useful employ- ment, however, gives a big boost to their morale by Dmitry Chebotaryov • eople who have retained their spiritual youth in old age interest me much more than the creatures of Mars if they ever came to Earth." This statement by Hungarian writer Gyula Illyes precisely sums up my own view of gerontology. In more than two millennia since the age of Hip- pocrates, the father of medicine, at least 200 theo- ries about the ageing process and an even greater number of "radical" ways of combating it have been put forward. However, it is only under condi- tions where a high level of scientific, technological and economic development prevails in a society that the real possibility arises of increasing the average life expectancy. The ageing of the population, that is, the increase in both the absolute and the relative number of elderly and old people, is a problem that is peculiar to the 20th century. In the Soviet Union, a consider- able rise in life expectancy since the 1917 Revolu- tion (from 35 years in Tsarist Russia up to 1916, to between 70 and 72 years today) is due to the radi- cal social transformation that has taken place and to the improvements in working and living conditions. Now we are entering a period when the greatly increased elderly population calls for fundamentally new methods of combating premature ageing, since we now recognize that man as a biological species can live as long as 90 and even 110 years. Ex- periments with animals have already shown that we can prolong the normal life-span by 25 to 40 per cent. Our task now is to unravel, as quickly as pos- sible, the genetic code of longevity. Present-day biology is already on its way towards solving this problem. I am sure that the next few years will see a qualitative leap forward in the study of the ageing processes. 8 A village greybeard in the Soviet Arctic. (Photo Len Sirman © ) Top: A lively band of singers and dancers in traditional Georgian costume. Every member of the band is aged over 100. Left: Still at work in the tea-plantation, this old lady is said to be 137 years old. (Photos WHOINovosti) 9 A few years ago, the Soviet Union's Social Gerontology Laboratory, headed by Dr Nina Sachuk, summed up the results of many months of observations made among about 40,000 people who had lived particularly long lives. The study covered practically the whole of the country, and scientists paid particu- lar attention to the so-called "longevity zones" whose inhabitants have long been noted for their enviable good health— the Caucasian Mountains, Abkhazian and Azerbaijan. For the first time they obtained serious data on a whole range of factors -the way of life, heredity, pattern of employ- ment, food and recreation—of those who live to a great age, as well as climatic and natural conditions. What emerged is that, as a rule, people who live long are "children of nature". The overwhelming majority live and work in rural localities, and they rarely change their occupations. Fully half of them have never smoked and have not over-indulged in drinking alcohol. The incidence of divorce is very low among them. And, oddly enough, only 8.4 per cent of them are vegetarians who have vowed to eat no meat—it has long been believed that vegetarianism is a sine qua non for a long lifetime. It was also found that those individ- uals who for one reason or another have been obliged to retire on a pension suffer from what we call "pension diseases" that is to say, a sharp decline in vitality, dissatisfaction with their status and, as a consequence, premature ageing. Socially useful employment, on the other hand, enables older people to retain their form- er role in society and gives a big boost to their morale. Guidelines for the development of the national economy for the period 1976 to 1980, adopted at the Twenty-fifth Con- gress of the Soviet Union's Communist Party, point to the need for "using more fully the opportunities for wider partici- pation of pensioners and disabled per- sons in social labour". The realization of these opportunities is assuming growing importance as a result of the increase in the absolute and relative number of senior citizens. Between 1959 and 1970 the number of pensioners in the Soviet Union rose from 25 to 36 millions. By the end of 1980 this figure is expected to reach 44 millions. Work has therefore begun already on programmes that will coordinate the ef- forts of scientists from various speciali- ties, and will concentrate on comprehen- sive studies of the economic, social, med- ical and other problems caused by the changing age patterns in the population. Making use of the pensioners' working abilities is particularly valuable in certain key branches of production where there 10 Enjoying old age In the Soviet Union, where there are expected to be 44 million pensioners by the end of 1980, efforts are being made to teach elderly people a rational way of life aimed at helping them to positively enjoy their old age. Left : A senior citizen has his pulse-rate checked while he savours a warm bath. Right : Two army veterans discuss the merits of the traditional Georgian knife. The youngster holding the knife is only 99 years old but his friend claims to have already celebrated his 125th birthday. (Photos WHO/Novosti) is a shortage of labour, while at the same time enabling senior citizens to continue their active work after they reach retire- ment age-55 years for women and 60 years for men. In old age, even though the individual has had longer experience and amassed more knowledge, the ability to master new specialities weakens. In particular it proves difficult for ,the elderly person to a come to grips with new job if it involves moving to another locality. On social and economic grounds it is best to em- ploy able-bodied workers of senior ages in jobs that they have already mastered in the same industry, workshop and department. In some specific industries and depart- ments, the Government has ruled that easier working conditions should be laid on for disabled persons and old-age pensioners. They benefit from a bal- anced work and recreation timetable, as well as a more relaxed tempo of work, and can if they wish take up only part-time employment. Every year millions of Soviet pension- ers give up their professional activity for reasons of health, family problems and so forth. Yet studies made by the Geron- tology Institute of the Soviet Academy of Medical Sciences prove that non-work- ing pensioners often do not use their lei- sure time in ways that are beneficial to their health. This is why it is important to teach them a rational way of life aimed at increasing the amount of time they spend on vigorous activity, whether in community work, communal forms of recreation, physical exercise and so on ; this in turn will make it easier for them to improve their life-style and to positively enjoy their old age. These efforts have the support of trade union groups, the health and medical units of industrial enterprises and offices, social security organizations and gerontology research centres. Adopting a sensible diet in old age is obviously important. Special recipes and dishes for the elderly need to be worked out and should be introduced widely in public catering. One way of extending the range of sensible foodstuffs is to design new types of food with low calorie content and a limited quantity of saturat- ed fat, sugar and common salt. Further improvements in the medical and social services will create more favourable conditions for millions of senior citizens in the Soviet Union, so that they can be usefully employed to the greatest possible degree in the sphere of production and public life. This in turn will help to strengthen their physical and psychological health, improve their mat- erial well-being and ensure that all their hard-earned experience and know-how is handed on to the next generation. ■ 11 The third age by John Bland he last issue of World Health was dedi- cated to the younger generation, in the light of the International Year of the Child. It seems fitting to follow this by a searching look at the other end of the human time-scale—the grandparent generation. That children have fundamental rights will be challenged by nobody, while the genera- tion of the parents is the active one, with the responsibility and the dynamism to ensure that its own human rights are safeguarded. But it is all too easy to neglect the rights of the Third Age. What should be a safe harbour after the storms and vicissitudes of youth and adult- hood tends all too often to resemble a scrap- heap. In many parts of the world, in developed and developing countries alike, old men and women are under-utilized, neglected, pushed into the corner. As the so-called "nuclear" family loosens its grip, particularly in urban societies, the ties of kinship slacken and the younger generations tend to forget the grati- tude, the sympathy and the care which they owe to their elders. The rights of the elderly have been en- shrined in many charters, not least in the Universal Declaration of Human Rights which proclaimed specifically thirty years ago—the concept of welfare and financial security for the unemployed, the sick, the disabled, the old and the widowed. Only four years ago, a group of doctors and nurses in the United Kingdom found it necessary to stress that an old person is a unique individual "with a need for creative activity, for privacy and fellowship at appropriate times, and with a right to be consulted and to choose in all matters affecting his (or her) health and welfare." As an increasing number of people enter this age-group within the population, health care for the elderly assumes ever greater im- portance. With improvements in living stan- dards, basic sanitation and the quality of life, the elderly have begun to take up a greater percentage of health workers' time than was hitherto the case. WHO's declared goal "the attainment by all the citizens of the world by the year 2000 Facing page: The sturdy Mexican craftsman typifies the rugged individuality of those who retain their capacity to work even into old age. In turn, the old woman in a Greek village comforting her sick granddaughter symbolizes the positive values that stem from close-knit family ties. (Photos WHO and WHO/J. Mohr) Above: This patriarch in a village in Mali still commands respect and even awe from the younger generation. (Photo WHOIP.A. Pittet) Left: Studies in many countries have shown that only a small proportion of the elderly population need institu- tional care. The accent—as here in a European geriatric clinic—should be on encouraging the old to remain active, and preferably to return to "open community" life. (Photo WHO/P. Boucas) Below: Cartoonist Cork takes a wry look at the wheelchair situation. of a level of health that will permit them to lead a socially and economically productive life" envisages care of the elderly as an inte- gral part of every country's national health policies. Primary health care is seen as the es- sential tool to bring about this ambitious goal, and the primary health care approach must in- clude care of the elderly among its essential strategies. In turn, the main purpose of care of the elderly should be to maintain elderly per- sons as an integral part of society. As one writer suggests elsewhere in this issue, some of the elderly might well be recruited as aux- iliary personnel for the manpower-starved health services. Initiatives directed towards the welfare and well-being of the older generation are bound to increase throughout every country of the world as these senior citizens are seen to form an increasing proportion of the population. Community health workers will have a partic- ular responsibility in this field, but their activi- ties will not be confined merely to preventing ill health and social breakdown in old age. They will also be helping society as a whole to recognize that old age is not a disease but the fulfilment of every individual's birthright. ■ Facing page, above: An 80-year-old athlete in Hungary gives an impressive demonstration in gymnas- tics for a youthful audience. (Photo WHO I Interphoto) Facing page, below: One of the first trained midwives ever to practise in Sudan, this senior citizen remained actively at work well into old age. (Photo WHO/E. Schwab) Above: Working happily in his garden, this sprightly Romanian is 116 years old—living proof that vitality and creative ability need not end at retire- ment age. (Photo WHO) Right: A sprig of jasmine brings pleasure to an old man in Tunisia. (Photo WHO/E. Schwab) Elderly and fit A major population study among 70-year-olds in an industrial city of Sweden showed that they were generally in good health, and that only three per cent needed care within institutions by Alvar Svanborg n intensive study of elderly peo- ple in the Swedish city of Gothenburg started in 1971/72 with an investigation of a repre- sentative sample of the 70-year-olds. The sample eventually comprised 521 men and 627 women. This wide population study concerns the nature and manifesta- tions of normal ageing processes, the in- cidence and prevalence of disease at higher ages and the occurrence and nature of infirmity in old age. It also looks at the possibilities for preventive activities at higher ages. The first step is a house call to elicit basic personal data and information about housing conditions, economic, social and physical communications, where the person has lived, educational level, previous and present occupations, the person's need for care, and his or her consumption of health care and drugs. The researchers observed and measured the lighting conditions where the person usually sat to read, and carried out a sim- ple test of visual acuity. Later on, the out-patient department of the geriatric hospital carried out thorough medical and ophthalmological examinations, including blood and urine samples, as well as electrocardiogram readings and X-rays of the heart, lungs and breasts. Some of the elderly people received psychological, psychiatric, den- tal, somatic, and audiometric examina- tions and were interviewed intensively about their eating habits. The first follow-up occurred in 1976-77 when the subjects had reached the age of 75, and simultaneously another five-year study began into a further sample of individuals who had reached 70 years of age in 1976/77. At present only limited conclusions can be drawn about the incidence and prevalence of disease in this age group. Although organized care of the old and debilitated and of the chronically ill has existed in most countries at least since the Middle Ages, the increase of medical knowledge and technical re- sources during the 20th century has been mainly focussed on acute diseases in children and in adults in so-called pro- ductive ages, while the basis for clinical work in the elderly population is rather weak. The present knowledge of human ageing processes in general, that is, in gerontology, is also limited, and there is a lack of basic facts which permit a distinc- tion to be drawn between symptoms and signs of ageing processes per se and those of diseases in elderly individuals. A marked absolute and relative increase in the number of elderly people will occur in Sweden and in many other countries up to the 21st century—a fact which em- phasizes the urgent need for better knowledge of the ageing processes. The objectives of the Gothenburg study were to make a survey of the social and medical conditions of the popula- tion, to obtain basic data for planning the care of the elderly, to contribute to the knowledge of normal ageing pro- cesses and of normal criteria within the age group, and to offer the subjects a thorough medical examination. The organizers of the study also felt that more thorough attention ought to be given to present living conditions for the elderly in the community, and to the need for financial subsidies aimed at decreasing the risk of physical inactivity and social and mental isolation. In many cases ageing causes signs that are very similar to symptoms of disease. Over-diagnosis tends to be rather com- mon in this age group because the border line between normal ageing and disease is only a very vague presentiment in the higher age groups. One example of this is' the apparent prevalence of hypertension. Thus 48 per cent of the 70-year-old wom- en said their doctors had told them that they had too high blood pressure. Many were on digitalis treatment because of supposed congestive heart failure. A detailed analysis, however, indicated that many of them were healthy even though they had a higher blood pressure or greater breathlessness during physical exercise than at younger ages. Such dif- ferences between the age-groups consti- tute the main reason for over-diagnosis among the elderly, and underline the need for a better understanding of the nature and manifestations of normal ageing, or more specifically for adequate clinical reference values for higher age groups. In Sweden, the life expectancy at birth for males is about 73 years. Women live longer than men—an average of about 77 years—and one might therefore antic- ipate that they should be healthier and need less medical care than men. But women consume more drugs and consult physicians more often than men. At the age of 70, urinary incontinence, bacteriuria and rheumatic diseases are more common among females but respi- ratory diseases, cardiovascular diseases, cancer and liver diseases are more com- mon among males. Men were thus shown to suffer to a greater extent from life-threatening diseases, which can be Participants in these jazz-ballet classes, aged 80 and over, said they 'felt as if they were in their twenties again". (Photo WHO/E. Mandelmann) 16

fatal within a shorter time. However, they also appear to suffer from a great many less serious diseases. A global judgement of infirmity among the 70- year-olds does not indicate that the high- er consumption of medical care by wom- en results from a higher incidence or prevalence of disease among women. There are obviously many factors which explain why over-diagnosis is more common in the elderly woman than in the elderly man. One is that the old woman more often lives in a situation of loneliness and physical and intellectual inactivity, to the extent where it can in- fluence her basic physical and mental functions. Those who complained of be- ing lonely were significantly more likely to declare that they did not feel fit. The lonely women visited physicians more of- ten and consumed more drugs than other women. The prevalence of diseases known to influence mobility, such as chronic bronchitis and anginal pain, was not specially high among those who felt lonely, nor were other physical definable diseases or handicaps. Social isolation These observations seem to indicate that social isolation and physical inactiv- ity suggest one explanation for the differ- ence in the use made of medical care by men and women. Another explanation is that certain manifestations that might be due to normal ageing such as blood pres- sure and blood cholesterol levels are low- er among young women than among young men but higher in elderly women than in elderly men. This means that there is a greater difference between the old woman and the young woman than there is between the old man and the young man. So long as adequate clinical reference values are not available, wom- en run a greater risk than men of being diagnosed as hypertension or hyper- cholesterolemia cases. Our study also showed that women more often reported symptoms and signs, even those that seem to be due to normal ageing processes. The study also brought to light cases of "under-diagnosis", that is to say it fre- quently detected the existence of pre- viously undiagnosed diseases. On aver- age fewer than 50 per cent of the defin- able diseases observed were previously known to the subjects. This seems to be due to the fact that many elderly people anticipate that certain symptoms are due to normal ageing; they therefore don't even mention these symptoms when they consult their physicians. Another and broader technique for collecting all known medical data about a patient is obviously needed when the elderly are examined than those that are commonly in use. An important finding of the Gothen- burg study was that the 70-year-olds 18 Elderly and fit Facing page: I. and 2. Attending an art-class or just feeding pigeons in the park—the elderly are glad of every opportunity to enjoy life. (Photos Irene Barki, Viva © and WHO/ E. Mandelmann) "Those who complained of being lonely were significantly more likely to declare that they did not feel fit." ( Photo Irene Barki, Viva ©) "Psychological tests did not indicate any marked reduction of intellectual functions at the age of 70." (Photo WHO/ILO) Right: Women tend to live longer than men—but they also consume more drugs and consult physicians more often than men. ( Photo WHO/D. Henrioud) generally were in a good state of health, and that only about three per cent of them suffered from advanced handicaps or disease to such an extent that care within institutions was necessary. Anoth- er two per cent needed regular help with personal hygiene, dressing and so forth, and 18 per cent needed domiciliary help. But 95 per cent of the subjects living at home were able to take a bath without any help, 99 per cent managed to go the toilet without aid, and 70 per cent were doing their own laundry. In addition, 11 per cent of the women and five per cent of the men had difficulties in rising from bed ; 14 per cent and six per cent respec- tively had problems in rising from a chair without arms, while eight per cent and five per cent respectively found it hard to walk easily. What emerged from the survey was a general picture of social and medical conditions at the age of 70. It should be emphasized that the majority of the 70- year-olds in Gothenburg were living a very comfortable life under rather favourable physical and mental condi- tions, and seemed to have wonderful op- portunities for enjoying life. The general conclusion from psychological tests that were carried out was that the results do not indicate any marked reduction of in- tellectual functions at the age of 70, with the solitary exception that the sensory- motor speed—the time taken to react to stimulus—was markedly lowered at that age. The better educated persons gener- ally showed less decline during the ageing process. The intake of energy and nutrients was on average satisfactory but showed a fairly large variation. It was significant that individuals whose education level was higher than elementary school derived a higher proportion of energy in- take from proteins, while elderly men liv- ing alone had a lower iron intake than other men. Our study comprises a great number of other measurements which illustrate manifestations of ageing as well as indi- cating the general condition and ability of the subjects. For instance we investi- gated the total composition of the body. The average body weight at the age of 70 proved to be 76.2 kg for men and 66.3 kg for women. A preliminary comparison between these findings and corresponding data from cross-sectional studies of mid- dle-aged individuals in Gothenburg showed that the amount of fat was similar in the two age-groups. Body cell mass seemed to be of the same order of mag- nitude in 70-year-olds as in middle-aged females, but showed a lower value among 70-year-olds than in middle-aged men. Finally it deserves mentioning that the findings indicated very marked varia- tions between individuals, illustrating the great differences in the degree to which ageing processes affect people in this particular age-group. ■ 19 A worldwide challenge By the year 2000, nearly 60 per cent of the world's elderly people will live in the developing countries. If they are to have the health ser- vices they will need, we have to start planning those services today by Christiane Viedma ore and more human beings can expect to live to a ripe old age as we enter the closing decades of the 20th century. Yet "ripe old age" is all too rarely the serene fulfil- ment of a lifetime; instead it tends to be little more than a barren period of lone- liness and poverty, offering neither com- fort nor hope. This unfortunate state of affairs may have its root in current trends towards a breakdown in social structures, and cer- tainly any attempts to improve the situa- tion must be linked to the process of eco- nomic development. Those social prob- lems that old people face today in the in- dustrialized countries are already mak- ing their presence felt in the Third World. Unless we take note of these problems now, the future consequences could well prove to be disastrous. In the developed world, the over-65s are increasing steadily in numbers, and in some countries the total population is rising even though the birth-rate is fall- ing. It is no exaggeration to speak of an ageing population in some parts of the world, where the over-65s already make up 15 per cent—occasionally even 20 per cent—of the total inhabitants. Does this mean that we have hit on some magic formula for prolonging human life? Far from it. Ten years ago, R. E. Burger noted in the Saturday Review that the "miracle" which had made old age possible for so many Americans had also made it more frus- trating. Modern medicine had by then raised the average life-span of the Amer- ican male to nearly 70 years compared with 49 years in 1900. And yet in 1900, on reaching the age of 65, an American could hope to live for another 13 years; in 1969 the comparable figure was 14 years —only one year longer. "We have pro- Old people and the family Old people are nearly always discussed as 'Problems", rarely in terms of family and social solidarity, or of the positive contributions which they can make to other generations, particularly when allowed to function in the setting of their own home. Because old people make little or no contribution to a country's gross national product, they have become "the unwanted generation". It is now increasingly accepted that the particular social and psychological needs of old persons are best provided for in an active and loving family environment, where they have a role to play and where they feel needed and wanted. A dynamic interaction among family members at all ages is what is needed. Psychological experiments have shown that when young persons are exposed to reduced vision, reduced hearing, lack of human contact and monotony, they will after ten days show signs which are considered typical in old persons: apathy, loss of memory, confu- sion. It follows that the most effective way of postponing or reducing the social and mental deterioration associated with old age is to ensure that the elderly have access to prevention and care of physical disabilities in an active social setting, the best example of which is a properly functioning family group. The answer to the health and social problems of old people is not necessarily more geriatric homes, however excellent they may be. We should take a new look at family roles and family functioning, so that social and health care systems will tend to support rather than to atomize family life. Bold innovations are called for in the care for the aged—innova- tions that will emphasize their active participation in family and social life. Selfcare, family care and community care must be organized in a mutually sup- porting fashion. Those whose main concern is with the cost would find that such a strategy would in the long-term prove to be a cheaper solution. Above all, it would be an important step towards a better quality of life, not only for the old, but for their children and grandchildren as well longed life in general, thereby creating a larger group of the aged; but we have not prolonged the life of the aged," wrote Burger. More recently in Europe, there has been such a "boom" in the numbers of people living to 75 or even 80 that the specialists are beginning to speak , of the Fourth Age. Throughout the industrialized world these upward trends in the elderly popu- lation are clearly a social consequence of improved living standards. From the medical point of view, the elderly do face rather special problems. They tend to be subject to chronic diseases and may offer a complicated clinical picture in which several organs are affected simultaneous- ly. Their physical frailty means that they may be more sensitive to certain drugs, and even after they respond to treatment their health needs to be closely watched. Many will need relatively long-term care, and today more attention is being given to terminal care. But in general the health care they need is much the same as for younger people; much more critical are the social and economic difficulties which result from the rapid expansion of this particular age-group. To a certain degree, the elderly share the lot of other non-productive sectors of the population. Cut off abruptly at retirement age from productive employ- ment, they find themselves reduced to the status of a dependent, and in many cases prematurely, since the rate of biological ageing varies significantly from one indi- vidual to the next. This sudden break from occupational activity is frequently Unless we take note of the needs of the elderly now, the future consequences could prove to be disastrous. (Photo WHO/P. Almasy) 20 fattarir.. accompanied by a steady deterioration in health. A study made in the United States five years ago into the limitation of activity due to chronic conditions showed that, for the over-65s, the limita- tion of activity was 25.8 per cent among people who continued working but 40 per cent among those who did not work. The same study showed that this limi- tation varies by over 15 per cent accord- ing to the level of earnings and by over 25 per cent according to the level of edu- cation. In other words, old age is broadly speaking a better time for those who have an adequate income, a better educa- tion and a chance to keep on working. These socio-economic and cultural dif- ferentials, though first determined among the elderly of an industrialized country, are also found in the rest of the world. The position of the elderly is in fact even more precarious in developing countries. Virtually submerged by the enormous problems which communi- cable diseases, malnutrition and poverty impose on them, these countries have so far hardly been able to direct their atten- tion to their old people. With only a few exceptions, social security for the old is employment-linked and appears in the form of a pension or a lump sum paid out when a person stops working. When one thinks of the vast army of unemployed in the big cities of the Third World, or of the countless mul- titudes scattered throughout the rural areas, it is all too clear that such official social security systems as exist only pro- tect a tiny segment of the population. Again, some countries only offer social welfare and pensions to former government employees and exclude all other sectors ; thus even those who are lucky enough to have a job can expect no relief from poverty and need in their old age unless it is provided by their family. This is the case, for instance, in seven countries of South-East Asia and in seven countries of Africa. In one rural African community alone, a physician working for voto estimated that one per cent of the total population consisted of the old and destitute that is, of aged people with no form of income, no fami- ly or other ties, perhaps disabled, inca- pable of self-sufficiency, and therefore totally dependent for survival on the handouts of private charity. This situa- tion is unfortunately all too common in many parts of the Third World. During the 63rd session of WHO's Ex- ecutive Board, held last January in Gene- va, Dr M. M'Baitoubam, Director of Studies and Training of Medical and Paramedical Personnal of Chad, report- ed that the dispensing of health care to the elderly was something of a novelty for the African Region. He pointed out that, as a result of the rapid economic progress being made by the countries of that Region, the situation risks becoming even more acute as new social structures 22 A worldwide challenge Left : A community health worker visits the home of an aged woman patient in -Tunisia. Until recently many countries have had so many other pressing problems that they have paid little attention to the needs of the elderly. (Photo WHO/E. Schwab) Right: A nurse on her rounds in an old people's ward in India. By the year 2000, there will be 390 million people aged over 65 in the world —and almost 60 per cent of them will live in the developing countries. (Photo WHO/A. S. Kochar) evolve. The "expanded" family, though it still exists in the Third World, is tend- ing to disappear as the development process gains ground, to the point where the elderly can no longer rely on lasting support from the younger generations. Several Executive Board members called on wilo to undertake a study of the "expanded" family in the hope of finding at least a temporary solution to the hazards facing the elderly in the Third World, while Dr John H. Bryant, US Deputy Assistant Secretary for Inter- national Health, offered the view that it was high time to sound the alarm. The el- derly needed services for economic, health and social support, and this was not a problem exclusive to the developed countries. The trend towards an ageing population was irreversible; by the year 2000, there would be 390 million people over the age of 65 compared with 216 million in 1975. In the developing countries there would be an increase of 127 per cent—from 98 million to 223 million. Moreover, by the year 2000 nearly 60 per cent of the world's elderly would be living in those countries, Dr Bryant said. It is essential that these people should have access to social services—and it is today that we ought to start worrying about them. Last November, the General Assem- bly of the United Nations decided at its 33rd session that a World Assembly on the Elderly should be convened in 1982 to launch a global plan of action aimed at guaranteeing the economic and social security of old people, and also giving them a chance to participate in national development. The possibility of celebrat- ing an International Year of the Elderly is also under study. So the international community is already taking note of the fact that the problems of the elderly are of global dimensions. Throughout the Third World, old peo- ple suffer from such chronic diseases as bronchitis or arthritis to an even greater degree than in the industrialized coun- tries. Furthermore, rapid industrializa- tion in certain areas subjects them to even greater psychological stresses as they try to adapt to changing life-styles. The rigours of poverty are yet another burden to be borne. The strategy of Primary Health Care, as formulated by WHO and other world bodies, has underscored how improved health for all people, and particularly for children, cannot be brought about without parallel social and economic progress. This is no less true when we ex- amine the plight of the elderly. The ques- tion we have to ask ourselves is this : Will those children whom we endeavour today to save from misery, physical suf- fering and death be fortunate enough to enjoy their old age too? ■ 23 Fragile: handle with care What is regarded as an inevitable ageing process is not simply a matter of human destiny; it can be postponed by regular activity and training by Shuichi Hatano tumbling on the edge of a tatami mat, old Mrs Toshida fell heavi- ly. She tried to stand but could not, and felt a severe pain in her hip. She was sent to an orthopaedic surgeon who discovered a fracture of the neck of the thigh bone. Mrs Toshida went to hospital, but did not seem to understand what she was do- ing there and talked incoherently in a way that gave her family a great deal of anxiety. She developed a slight fever which proved to have been caused by cystitis, but this was cleared up by treat- ment with antibiotics within a week. Af- ter a successful operation, she learned to stand up and practised walking with the help of parallel bars in the gymnasium. Her clouded mental state ceased to be a problem soon after the physical training started. It took about three months before she could go home, but by that time she could stand unaided and walk with a cane to ensure her balance. The ageing process However favourable the environment, animal tissue cells in culture stop multi- plying after about 50 divisions. But the speed and extent of decay varies between different organic systems and between different individuals of the species. Thus the nerve cells of the brain stop increasing in number soon after birth and continue decreasing throughout our life-span. Because of their highly inte- grated functioning, other brain cells can compensate for this loss and the deficit does not become apparent until old age. The decline of complex functions such as recalling memories of recent origin come to light fairly early, while verbal commu- nication is preserved for much longer. Not only the number of cells but also the functional capacity of an individual cell decreases with age. The amount of stimulation—such as heat or pain— required to provoke signals at the sen- sory nerve endings increases and the speed of transmission within the nerve fibre slows down, hence the weak and slow responses of nerves to external and internal stimuli. Old people are therefore at greater risk of accidents, whether cuts, burns, traffic accidents or a simple fall caused by an unevenness on the floor as occurred in Mrs Toshida's case. However it has been demonstrated that the speed with which nerves conduct stimuli can be increased by training. It follows from this that what is regarded as the ageing process is not simply human destiny; it can be postponed by regular activity and by training. Physiological ageing and pathological processes are difficult to delineate shar- ply. For example, there are few people whose arterial walls remain smooth by the time they reach their seventies, and all atherosclerotic changes may be regarded as pathological. Atherosclero- sis increases with age and is so common- ly distributed in aged populations that it may be considered as a manifestation of normal ageing. Shortage of blood supply to critical organs such as the heart or the brain due to advanced atherosclerosis is a leading cause of death in many coun- tries, and this condition also accelerates the ageing of other tissues by persistently limiting the blood supply. It has been es- timated that we would gain an extra seven years of;life if only we could elimi- nate death from atherosclerotic diseases. Yet we do know ways of preventing the progression of this illness—ways that are all the more effective if maintained from childhood onwards. The loss of elastic fibres in the lung decreases the body's vital capacity. The thin walls of tiny terminal air sacs in the lung diminish with age and the sacs merge together to form a wider space, resulting in a reduced surface area for the exchange of atmospheric gases; this con- dition is called emphysema. Cigarette smoke, atmospheric pollutants or bac- terial and viral infections can also cause bronchitis. Both conditions impair the respiratory functions, but this may pass unnoticed when the body's demand for oxygen is not very high. Gradual deterioration continues in many tissues as well as in the heart, kidneys, liver and endocrine organs. Changes occur in the bones too, whose mineral content decreases. This is partic- ularly true in elderly women as a result of Home visits by a qualified nurse form part of the health services for the elderly in Koganei City. ( Photo Y. Fujita, Tokyo Metropolitan Institute of Gerontology) 24

hormonal disorders and lack of exercise. The bones may become so fragile that they break at a slight injury, and they take much longer to heal than in younger persons. Low respiratory functioning shows it- self during vigorous exercise, when one has to increase the volume of air breathed in order to meet the increased oxygen demand of working muscles. Eventually the margin of safety becomes slim. The older a person, the more serious the consequences of minor respi- ratory infections, which are the com- monest cause of death among the elderly. Angina of effort generally occurs only during physical work or at times of emo- tional tension when the heart has to pump a large volume of blood. An attack of anginal pain which occurs during an ordinary walk will disappear when the patient stops and rests. This pain is in- duced by a slight shortfall in the supply of oxygen to the heart muscles during ex- ercise. It is worth remembering that sen- sations of pain are felt less acutely by the elderly than by young people; even acute myocardial infarction with generally more persistent agonising pain may go unreported by old patients. Similarly the decline in brain function referred to above may only become ap- parent when physical health deteriorates, as in the case of Mrs Toshida. Immune response There may also be a decline in immune response and phagocytosis—the protec- tive biological reactions of the host to combat virulent micro-organisms. The course of an infection will tend to fluctu- ate and recovery may take a long time despite the judicious use of antibiotics; even mild infections may prove fatal. Adverse drug reactions are not infre- quent; digitalis, sedative and psycho- tropic drugs have to be prescribed with care. And the elderly are less capable than their juniors of tolerating drug overdoses. So we see that old people may have ail- ments in various parts of the body without showing symptoms. A series of diseases can result from a single injury and may leave a person permanently bed-ridden or even result in death. Mrs Toshida had to stay in bed for a few days, and she suffered both mental deterioration and a bladder infection— both of which were luckily overcome. Pneumonia may develop without the usual fever, or a patient may suffer from 26 Fragile .. handle with care Left : Some of the jobs willingly undertaken by senior citizens in Japan, such as trimming trees in the public parks, require quite strenuous effort. ( Photo Y. Fujita, Tokyo Metropolitan Institute of Gerontology) Right : Grandfather is pleased and proud to "mind the baby" while the parents are out at work; an undemanding task but one which under- lines an elderly person's sense of belonging to the family. (Photo WHO) dehydration without complaining of thirst, until the point where circulatory failure sets in. Rapid physiological regu- lation and adjustment is difficult because of multiple functional loss coupled with slow and weak neural or endocrine re- sponses. All these factors mean that careful ob- servation and prompt medical attention are essential all the time in caring for the frail elderly, and indeed can save lives. Variation between individuals In young people, physical and intel- lectual standards can broadly speaking be determined according to age, and these standards will be generally appli- cable throughout a given population. Old populations, on the other hand, vary widely. A man of 45 may be bed- ridden and speechless after suffering a cerebral haemorrhage, while a man of 80 may be the very vigorous prime minister of his country. Attempts have therefore been made to compute indices for bio- logical ageing which would serve instead of chronological age. Here again it is dif- ficult to draw a distinction between pathological frames of reference and those for normal ageing processes. Thus chronic diseases such as cerebrovascular disease, rheumatoid arthritis or chronic obstructive lung disease often play a major part in determining a person's life- style and life expectancy. Yet it is to a large extent possible to prevent these chronic diseases. The moral to be drawn from this is that we ought all to live a healthy kind of life that will prevent chronic diseases before it is too late. A study made of Japanese citizens aged 70 years in different parts of the country showed some interesting varia- tions. The middle-class elderly living in Koganei City, a residential suburb of Tokyo, were taller on average and had a higher mean cholesterol level. Their handgrip was noticeably strong. About half the men in the study were college or university graduates, and usually had formed part of the upper middle-class before their retirement. Rural populations in Tsumagoi and Yachiho, upland areas about 1500 to 4500 feet (500 to 1500 metres) above sea level, were short and stout. This may have been due to their high carbohy- drate and low animal-protein diet. Their blood haemoglobin content was highest among the people studied, because of their long-term exposure to low oxygen 27 pressure, and their serum cholesterol was lowest. A large majority of them had been only to primary school. Elderly populations in Hiroshima and Nagasaki were representative of ageing groups in provincial cities, and showed average values in between those from Tokyo and those from upland rural areas. Most again had been only to pri- mary school but some were high school graduates. Inmates at the Tokyo Metropolitan old people's homes were the shortest and leanest, that is, with the poorest body- build, and their handgrip was the lowest. Many of them came from a poor socio- economic class, and more than half the men and women had not even completed primary school education. Their serum cholesterol, however, was higher than the rural people, possibly reflecting the quality of the meals served in the homes. According to one Japanese study, the higher socio-economic groups such as top executives of big companies enjoy a long life expectancy, with a much reduced risk of death from stroke and without an increased risk from heart dis- ease. In our own experience, obese and well-nourished people were likely to live longer among the inmates of old people's homes. A similar experience was report- ed in the Hisayama population; deaths from cardiovascular diseases were more frequent in the obese elderly, but respira- tory or gastrointestinal diseases were more frequent among lean individuals— who therefore suffered from a higher total mortality rate. Social support for the frail We are following up various groups of the population to try to identify the bio- logical and social determinants of a heal- thy and long life in the elderly. The best possible protective environ- ment where an old person can live re- spected and loved by the family is his or her own home. However social support is obviously desirable for bed-ridden or chair-ridden people or those who have no younger relatives to care for them. In 1976 the Ryokuju-en nursing home was opened in a western suburb of Tokyo, which was partly financed by four adjoining municipalities. Its services are open to the community at large. Thus day care is available for handicapped citizens as well as for the elderly. Meal- times become a social gathering where everyone is welcome to enjoy a chat and a good laugh. There are special aids for the bed-rid- den at bath time, and transport is laid on to bring old people to the centre from home. They enjoy a gossip, a rest if they wish, and a bath as well as a lunch before bring driven back home. For the home- bound elderly it amounts to a special holiday treat. Fragile : handle with care Left: A grandmother enjoys a traditional meal with her daughter. The best possible protective environment, where an old person can live respected and loved by the family, is his or her own home. (Photo WHO/E. Schwab) Right: Employment of the healthy elderly in Japan. The task of wrapping up chopsticks is not arduous but it affords the old man a quiet satisfaction. (Photo Y. Fujita, Tokyo Metropolitan Institute of Gerontology) The centre has recruited retired nurses from the four municipalities to work part-time, teaching other members of the family how to assist in the daily life of a bed-ridden person—ensuring cleanliness, moving the patient, and preventing or if necessary treating bed-sores. The local authorities subsidize these periodic visits by the nurses. Prevention of stroke The bed-ridden form some four per cent of the Japanese population aged 65 and over. About half of these cases are the result of strokes. We hope that in the future the total number of bed-ridden will be reduced by prevention of stroke, and by early and continued rehabilita- tion techniques. What about the large majority of the elderly who are healthy? A group of such people got together in Tokyo and created a "cooperative" to organize jobs for the elderly. They have been careful not to compete with young workers—and thus inadvertently pull down wage levels—by appearing to supply cheap labour from the ranks of unemployed old people. But many jobs are highly appreciated by the community—for instance, extra tuition given to schoolchildren during the holi- days by retired teachers. Some jobs require quite strenuous labour, such as trimming the trees in public parks, which is carried out under the guidance of a professional gardener. Requests pour in for various kinds of manual labour, and the old people un- dertake these at their leisure. Work like this helps to give them a sense of partici- pation in the community, and maintains their mental and physical fitness as well as their appreciation of life. It is only in recent times that Japan has been faced with a rapid explosion in the size of the elderly population. In 1950 the over-65s represented only 4.8 per cent of the total inhabitants. By 1975 it was 7.9 per cent and in the year 2000 it will reach 14.1 per cent. Such an expansion oc- curred over the centuries in Europe, so countries there were able to develop the necessary services step by step. In Japan we hope that our experiences will offer guidance to other parts of the world which will have to meet the rapidly grow- ing needs of the elderly. The situation I have described here does not apply just to one corner of the Far East. Upward trends in the size of the aged population will make them- selves apparent as soon as any country succeeds in introducing birth control, upgrading nutrition, and improving maternal and child health. There will be more old people, with their wide variety of health conditions, interests and requirements. This is a global problem, and all of us must participate in solving it, now and in the future. ■ 4100 004 000 000 000 000 *00 000 ...... ... 00• 000 000000 00* 00• *0• 000 000 0410 000 000 000 000 *00 000 0410 000 000 000 000 000 00* 000 *00 0041 MOOS 000 000 000 000 000 Professional and managerial In addition, the report states groups in developing coun- that excessive drinking is tries have shown a "special linked to certain forms of vulnerability" to alcoholism, heart disease and cancer, and the report says, because is also associated with low- "drinking often becomes a ered resistance to infection, Soo 000 000 000 *00 000::: 000 000 M oo. eikol000 000 ". 000 000000 000 Problems related to alcohol on the rise Alcohol-related problems are increasing not only in industrialized areas but also in developing countries, ac- cording to a report made to the WHO Executive Board at its meeting last January. The report, presented by the WHO Director-General in re- sponse to a World Health Assembly resolution, warns: "The evidence of increasing damage in a large number of developing countries sug- gests that alcohol-related problems constitute an im- portant obstacle to their socioeconomic development and, in addition, are likely to overwhelm their health resources unless appropriate measures are taken." At the same time, the report adds, "There are currently available techniques of pre- vention and treatment which, if widely and consistently applied, could alleviate this damage." Giving a few examples of the magnitude of the prob- lem, the report shows how health services are expe- riencing an increasing burden from alcohol-related health problems. In Brazil, first ad- missions with a diagnosis of alcoholism trebled between 1960 and 1970. In Chile, 30 per cent of the budget for medical and psychiatric services is spent on medical care of alcoholism and its consequences. In Yugoslavia, 50 per cent of all male ad- missions to psychiatric hos- pitals in 1972 had "alcohol- ism" as their first diagnosis. In France, it was the first diagnosis for between 25 and 45 per cent of male admis- sions to general medical wards. The number of patients admitted to hospitals in England and Wales with a relevant primary or secondary diagnosis of alcoholism or alcoholic psychosis increased 20-fold over the last 25 years. The report attributes the rise in alcoholism not to "some- thing innate in the individual", which is "one conventional explanation of alcoholism", but largely to the degree to which the population is exposed to drinking. Alcoholism and related problems are thus seen not as a private but a public concern, increasing in pro- portion to the supply of drink. During the war years in France, for instance, when the supply of alcohol was low, deaths from cirrhosis dropped markedly. Photo WHO/E. Mandelmann " . . Alcoholism: not a private but a public concern . . ." "For France, as a whole, the decline in cirrhosis mor- tality among middle-aged males was of the order of 50 per cent", the report points out. "In Paris, where there was less possibility of circumventing the rationing system, the decline was more than 80 per cent." The trend was reversed and was fol- lowed by "an equally rapid increase when alcohol be- came again available" in post-war years. symbol of prestige and suc- cess", and also because of the stresses and strains that go with the heavy responsi- bilities borne by the scarce key personnel. The impact of alcoholism on "highly trained and key personnel represents a devastating loss for a country where such resources are scant and vital to national development." The low cost of drink is another factor in the growing problem of alcoholism. "The real cost of alcohol has gone down in most parts of the world, despite increased taxa- tion", the report notes, and adds: "The production of alcohol has moved rapidly from a village to a national basis and, in some cases, to a multi-national basis. The consequences have been a marked increase in the amount of alcohol con- sumed." According to world figures, production increased by 20 per cent for wine from 1960 to 1972, by 60 per cent for distilled beverages, and by 80 per cent for beer. "In 25 countries with fairly complete statistics, annual per capita consumption of al- cohol increased by between 30 and 500 per cent." The report lists crime, traffic accidents, absenteeism and, as a consequence, low pro- ductivity, as among major alcohol-related problems. "Studies of the relation- ship between alcohol-related problems and crimes", it says, "implicate alcohol in 13 to 50 per cent of rapes, 24 to 72 per cent of assaults, and 28 to 86 per cent of homicides." The report warns: "The diversion of scant health care resources to deal with alco- hol-related problems—traf- fic accidents or injuries from drunken brawls burdening casualty departments and operating theatres, cirrhosis patients occupying beds, deli- rium tremens demanding emergency care—may put a serious strain on medical services that are already over- burdened." and with tuberculosis. It has been indicated that excessive drinking by pregnant women may be associated with de- velopmental retardation of their progeny. In many de- veloping countries, the diver- sion of family income to a parent's excessive drinking may seriously contribute to secondary poverty and mal- nutrition in children. To counter excessive drink- ing, and to stem the rise of alcohol-related problems, the report calls on countries to support measures, nationally and internationally, that put health ahead of economic interests. The regulation of alcohol production, the control of imports, and the limiting of sales outlets are among legis- lative measures that have proven effective, the report says. It advocates other mea- sures, such as compulsory attendance at rehabilitation centres as a condition of continued employment in certain cases, the detention of drunk drivers and random road-block tests to determine the alcohol content in the blood of drivers. "An essential aspect of any country's response", the re- port points out, "is the polit- ical determination to promote and to adhere to policies that are bound to be controver- sial, and that will need to contend with powerful inter- est groups. Some of the poli- cies to be recommended from a health point of view will inevitably have implications for the alcohol industry..." Kuwait faces sharp rise in salmonellosis Encouragement of beast- feeding and better education with regard to artificial baby foods are seen by Kuwaiti health authorities as a possi- ble solution to the rising incidence in the country of salmonella infections in in- fants and young children. Salmonella is a genus of micro-organism which cau- 30 ses, besides typhoid and paratyphoid, other illnesses characterized by gastro-en- teritis (inflammation of the stomach and intestines) and sudden onset of abdominal. pain, diarrhoea, nausea, vo- miting and fever. Dehydra- tion, especially among in- fants, can be severe. The number of reported cases in Kuwait of gastro- enteritis associated with sal- monella other than S. typhi (the salmonella that causes typhoid) rose from 258 in 1972 to 1,153 in 1977. The total for the first ten months of 1978 was 1,150 as com- pared with 704 for the same period in 1977. In addition, 846 salmonella carriers had been detected up to the end of October 1978. (Carriers are persons who can harbour the disease-causing organism without suffering its ill effects but who can nevertheless transmit the disease to others.) An analysis of the Kuwait figures for 1978 showed that the cases of gastro-enteritis were mostly reported in the age groups 0-1 (729 cases) and 1-4 years (219) while the carrier rate was highest in persons 15 years and older. Nakajima new WHO Regional Director Dr Hiroshi Nakajima, of Japan, has been appointed Director of WHO's Western Pacific Region and is due to take office on 1 July 1979 on the retirement of Dr Fran- cisco J. Dy. The appointment was made by the WHO Executive Board on a re- commendation of the Re- gional Committee for the Western Pacific. Dr Nakajima will head the Regional Office in Manila. Each Member country of WHO belongs to one of its six regions. The Western Pacific Region consists of the following 15 countries: Aus- tralia, China, Democratic Kampuchea, Fiji, Japan, Lao People's Democratic Re- public, Malaysia, New Zeal- and, Papua New Guinea, Philippines, Republic of Ko- rea, Samoa, Singapore, Tonga and Viet Nam. Born in 1928, Dr Nakajima took his medical degree (1955) and Ph. D. in medical science (1960) from the Tokyo Medical College. Between 1956 and 1958 he did postgraduate work in neuropsychiatry and pharma- cology at Paris University. In 1958, he was appointed scientist at the National Ins- titute of Health and Medical Research in France and later rose to the position of Chargé de recherche (Principal Scientist). He left France in 1967 to become Director of Research and Development of Nippon Roche K.K. in Japan, and then Director of Research and Administration. Dr Hiroshi Nakajima. Photo WHO Dr Nakajima has been serving WHO since 1974 when he was appointed Senior Scientist in the Divi- sion of Prophylactic and Therapeutic Substances. Fol- lowing reorientation of the Division's programme, he was appointed, in 1976, Chief Medical Officer of the unit of Drug Policies and Management—the position he now occupies. Dr Nakajima is well known in the Regional Office in Manila and the countries of the Western Pacific Region through his work in deve- loping an inter-country pro- gramme on drug policies and management. Author of more than 60 scientific articles and reviews, Dr Nakajima is proficient in three languages in which his work has appeared—Japa- nese, English and French. He also reads Chinese. Dr Nakajima is married and has two children. New unit has data on African populations The Regional Institute for Population Studies, a UN FPA-supported project located at the University of Ghana in Accra, has estab- lished a Research Coope- ration and Publications Unit (RECPU), says a press note. The Unit has set up a communication link between persons and institutions working in the field of population studies in or about Africa and maintains contact with more than five hundred persons. It makes available to interested individuals or institutions such information as: names, addresses, areas of interest and current acti- vities of persons working on population studies, the status of on-going projects, surveys and field studies, censuses and their results, and oppor- tunities for funding of pro- jects. Information is also available on future meetings and conferences and train- ing programmes in demo- graphy and related fields or- ganized in Africa or acces- sible to Africans. The Unit publishes a news- letter called African Demo- graphy. Further information can be obtained by writing to G. Simon, RECPU, RIPS, P.O. Box 96, Legon, Ghana. In the next issue The May issue of World Health will have no single theme but will deal with topics as varied as a better life for diabetic patients, leprosy in India, and tra- ditional practices affecting the health of women (in- cluding female circumcision). Authors of the month Dr. R. GLYN THOMAS is the Regional Officer for the Develop- ment of Community Services at WHO'S Regional Office for Europe in Copenhagen. Academician D. CHEBOTARYOV is the Director of the Gerontology Institute at the Soviet Academy of Medical Sciences, and an expert on ageing problems at the UN Centre for Social Development and Humanitarian Affairs. Mr J. BLAND is the Editor of World Health. Professor A. SVANBORG heads the Department ofGeriatric and Long- Term Care Medicine at the Uni- versity of Gothenburg, Sweden. Mrs C. VIEDMA is the Deputy Editor of World Health. Dr S. HATANO is at the Tokyo Metropolitan Institute of Geron- tology. WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to "World Health" as follows: US$* Sw.fr.* One year 12.50 25. Two years 22.50 45.- Three years 30. 60.— One year: Two years: Three years: I enclose cheque/postal order in the amount of Name: Street: City: Country: * or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland Pr in te d in S w itz er la n d Im pr im er ie s R eu n ie s S. A . La u sa n ne Old age should be the con:-entEd fulfilment of eery individual's birthright (Photo WHO, T. Farkas)