W •~RLD ~ THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION Theme articles Towords a heolthy old age Hiroshi Nakajima A global strate\y for healthy aain~ Alexandre oloche 8. Ilona Kie~ use Resist aid age: exercise! J.N. Morris Men and women age differently Astrid Stuckelberger C°tng with age argret M. Baltes Primary care for the aged Jeon-Pierre Michel Culture and lonf evity Keiko No omuro Those who have vision Nono Apt Healthy ageing in Africa Seyi Lodele Amosun 8. Priscilla Reddy Healthy population ageing Gloria M. Gutman Ageing well Solly Greengross "Ta serve, not to be served" Horoce B. Deets A new lease of life Elza Mario de Souza Jamaica's "senior citizens" Denise Eldemire Cuba's circulos de abuelos Enrique Vega Four months of fruitful and hai,py life Godfred Paul Care for the elderly - by the elderly Doris Moriebel DI. Comogoy Longer, healthier lives Toshihito Kotsumuro 8. Adrion D. Hinman Training for ageing Julian Mamo WHO Interview Growing aid in China Ageing in Lebanon Ablo Siboi 3 4 6 8 10 12 14 16 18 20 22 24 26 27 28 29 30 31 33 34 36 Features Facts and figures WHO publications 37 39 World Health • SDth Year, No. 4 July-August 1997 IX ISSN 0043-8502 Correspondence should be addressed to the Editor, World Heolth Magazine, World Heolth Orgonizotion, CH-1211 Genevo 27, Switzerland, or direcriy to authors, whose addresses ore given at the end of each article. For subscriptions see order form on page 39. HEALTH Front cover: Photo WCC/P. Williams © page 17 World Heolth is the official illustrated magazine of the World Health Organization. It oppeors six times a year in English, French ond Spanish, ond four times a year in Arabic and forsi. The Arabic edition is avoiloble from WHO's Regional Offce for the Eastern Mediterranean, P.O. Box l 517, Alexandria 21 511 , Egypt. The for~ edition is obtainable from the Public Health Commiltee, Iron University Press, 85 Pork Avenue, Teheron l 5875-4748, Islamic Republic of Iron. page 12 page 20 © World Health Organization 1997 All rights reserved. Articles and photographs that ore not subject ta separate copyright may be reproduced for nan-commercial purposes, provided that WHO' s copyright is duly acknowledged. Signed articles do not necessarily reflect WHO' s views. The designations employed and the presentation of material published in World Heolth do not imply the expression of any opinion whatsoever on the port of the Organization concerning the legal status of ony country, territory, city or oreo or of its authorities, or concerning the delimitation of its frontiers or boundaries. World Health • SOth Year, No. 4, July-August 1997 3 Editorial Towards a healthy old age Dr Hiroshi Nakaiima, Director-General of WHO. Photo WHO/ H. Anenden By the year 2020 more than 1 OOO million of the people in the world will be over 60 years old, and more than two-thirds of them will be living in developing coun- tries. In the early 1950s, average life expectancy at birth was 47 years worldwide. In 1995 it was more than 65 years, and in several countries it was almost 80. Change of this mag- nitude amounts to a revolution in both demographic and cultural terms. It has been brought about partly by socioeconomic factors, such as better nutrition and living conditions, and partly by improvements in health care. Not only do we have drugs and treatments to cure diseases that in the past led to premature death, we also have vaccines to prevent many of these diseases, and in some cases even to eradicate them. Further- more, a larger proportion of the world's population has ready access to effective medicine. If the main public health chal- lenge of this century has been sur- vival, that of the next will be quality of life. With the steadily rising number of children who reach adult- hood and adults who reach old age, the most pressing concern becomes that of ensuring that all of them enjoy the highest attainable level of well -being. To help promote a global re- sponse to this major societal con- cern, WHO launched a new programme on ageing and health in 1995. Its perspectives and activities are described in this issue of World Health, together with some of the ways in which society is responding to this new phenomenon of a grow- ing elderly population. Health is generally felt to be of paramount importance for the quality of life, especially in old age, when physio- logical and other difficulties tend to accumulate and the end of life ap- proaches. There are many more ways of protecting and improving health than people generally realize, and these articles provide valuable insights into the possibilities that exist. Investing in health and promoting it at every stage in life, talcing a lifespan approach to health care, will help more than anything else to ensure that people grow old in good health, and continue to enjoy living and contributing to the h_appiness of others. To make people more aware of these opportunities, the theme for World Health Day in 1999-which has been designated by the United Nations as the International Year of Older Persons - will be healthy ageing. • Hiroshi Nokaiimo, M.D., Ph.D. 4 World Health • SOth Year, No. 4, July-August 1997 A global strategy for healthy • ageing Alexandre Kalache & Ilona Kiekbusch The young ond the old enrich each other's lives. Photo WCC/P. Williams © O has restructured its rogramme on the health of he elderly and given it a new name: Ageing and Health. Reflecting rapid population ageing worldwide, this area of health care is becoming a dominant concern as we approach the next millennium. The changes in the programme are re- flected in its new title. It implies that our focus is on ageing as part of a whole life rather than on a static age group set apart from the rest of the population. With this came the adoption of the new perspectives that guide the programme's activities: • approaching ageing as part of the life cycle rather than compart- mentalizing the health care of the elderly; • promoting long-term health: there is increasing awareness of the need to focus on the process of healthy ageing since, whether early or late in life, people have many opportunities to improve their health status as they age; • observing cultural influences: the settings in whjch individuals age play an important part in their health and well-being; • adopting community-oriented approaches: throughout the world, even in the richest coun- tries, the vast majority of older people live in the community and it is at this community level that most of their problems will have to be dealt with - often outside the health sector but usually with implications for health; • recognizing gender differences: there are important differences in men's and women's health and ways of living, and they become more pronounced in later life; • strengthening intergenerational links: emphasis is placed on strategies to maintain cohesion between generations and a com- mon understanding of ethical issues - as populations age, vital issues must be considered such as undue hastening or delaying of death, human rights, long-term care, and abuse. Our focus is on ageing as part of a whole /if e rather than on a static age group set apart from the rest of the population. A global strategy All these dimensions are of central relevance to the programme and are reflected in activities as interrelated elements that to- gether compound our "global strategy for healthy ageing". An activity component of crucial importance relates to the strengthen- ing of the existing information base; a huge amount of information has been generated in recent years, but it needs storing, checking for accuracy and putting into an accessible form for the use of health professionals, policy-makers and the public. Such information also enhances people's capacity for self-help and self-care. The ways in which we dissemi- nate information are important, since they determine our chances of influ- encing behaviour and decision- making among all the people concerned, who include the public, politicians, health professionals and care providers within the family. Effective information exchange in its turn helps us to develop research programmes that are relevant, non- repetitive and health-oriented (as opposed to disease-oriented). All this leads to new training needs, espe- cially as regards transferring special- ized medical knowledge to the primary care level. Primary health World Health • SOth Year, No. 4, July-August 1997 care workers often have only basic training. However, especially in developing countries, they are the ones most likely to be responsible for helping people to "age well" and to provide health care for older persons when needed. This will call for appropriate policies at every level. WHO's work on ageing and health cannot be restricted to an individual programme. In practice, this means that the "ageing" compo- nents of other WHO programmes have to be highlighted and devel- oped. Such an ageing component is present in virtually all programmes - from Mental Health to Nursing, from Primary Health Care to Noncommu- nicable Diseases, from Reproductive Health to Rehabilitation. In this respect, a major role of the Ageing and Health Programme is to act as a catalyst for action. This has been facilitated by the development of a conceptual framework illustrated by the graph below. The graph refers to the concept of functional capacity and the ageing process. For a number of functional capacities (for example, respiratory capacity, muscular strength, cardio- vascular performance) we reach a "maximum" early in adulthood. From there on, there is a decline. However, this decline can be faster or slower depending on a number of individual characteristics, often associated with living conditions and behaviour. For instance, our ventila- tory capacity reaches a maximum at around 25 years of age. A slow decline in this faculty is associated with factors such as physical activity and living in an environment free of air pollution. A fast decline could, for example, be associated with cigarette smoking. A person follow- ing the first "decline" curve will not reach the disability threshold until very late in life, if ever (as death may occur earlier). In contrast, the life- long smoker may develop emphy- sema at the age of 60 and survive many years with a poor quality of life. Thus it is only later in life that the difference between those who experience a rapid decline in func- tional capacity and those who experi- ence a slow one will be clearly manifested. A life-course perspective to maintain the highest possible level of functional capacity O early life interventions to ensure the hi ghest possible functional capacity O adult life interventions aimed at slowing down the decline age O for those in older age above the disability threshold, previous interventions need to be reassessed O for those in older age below the di sability threshold, interventions are aimed at improvi ng the quality of life Maintaining an optimal physical, mental and social capacity from birth to death is a lifetime process requiring interventions by individuals, communities and health services throughout the whole span of life . Graph by WHO/Ageing and Health Programme This conceptual framework has been shared throughout WHO in order to stimulate other programmes and divisions to adopt policies that will: • bring functional capacity to the highest level early in Life, for example, through good nutrition, physical activity and education; s • place as many individuals as possible on the "slow" curve - i.e. slowing down the decline; • reassess interventions which, as a result of ageing-associated changes such as retirement, widowhood and the onset of specific diseases, need to be adapted to the new context; • intervene for those who fall below the threshold of di sability, for example, to restore sight by a cataract operation or mobility by a hip replacement; or where this is no longer feasible (for instance, for a stroke patient with major residual disability) , to intervene in such a way as to ensure the best possible quality of life. By working with other divisions and technical programmes of WHO around the world, and with other agencies in many fields of activity, the Ageing and Health Programme is taking on one of the big challenges of the next century. And for those who feel gloomy rather than celebrative about ageing, some good news. At least in some parts of the world, the prospects for healthy ageing seem good: evidence is now emerging, for instance, that, in spite of living longer, North Americans are enjoy- ing lower rates of disability. A very recent study suggested that if the disability rates prevailing in 1982 had persisted, by 1996 there would have been 1.2 million more disabled elderly people in the USA than in fact there were. • Dr Alexandre Ko/ache is Chief of the Programme on Ageing and Health and Dr /Iona Kiekbusch is Director of the Division of Health Promotion, Education and Communication, World Health Organization, 1 2 1 1 Geneva 27, Switzerland. 6 World Health • SOth Year, No. 4, July-August 1997 Resist old age: exercise! J.N. Morris In Cicero s opinion, "It is our duty to resist old age; to compensate for its defects by a watchful care; to fight against it as we would fight against disease; to adopt a regimen of health; to practise moderate exercise." Good news: across the world, death rates in old age are faJling, life expectancy is rising. The grand question now is whether this increasing longevity will be accompanied by a fall in sickness during old age. That would mean additional years of active, useful, independent well-being for growing numbers of longer-lived survivors. Otherwise, there will be more infirm old people, with their physical, mental and social disad- vantages worsening over a longer span. Already affecting sizeable mj- norities, these infirmities commonly progress as age advances leading to increasing frailty with waning facul- ties, diminishing vigour and capacity for physical effort, weaker muscles, slower gait, joint stiffness, and postural instability. Later, more often in the "old old" (the 75 plus) than in the "young old" (aged 65-74) and frequently precipitated by disease or injury, disability supervenes. Thjs can restrict the essential activities of daily living, is liable to lead to de- pression as well as physical hazards and social isolation, and risks bur- dening individuals, their families and the health and welfare services till the end. The "abuelos" of Cuba (see p.28) exercising on the beach. Exercise strengthens muscles, eases ;oints and improves stability. Photo W HO/Centro /beroomericano de la Tercero Edad, Cuba Can this progression be pre- vented? The answer at present is fragmentary - but encouraging. The prevalent infirmities of age are a compound of biological ageing (a decline in physical fitness begins as early as the 20s); the effects of inactivity and disuse (often stretch- ing back for decades); and disease. The key questions are: can the ageing processes be slowed at aJI by exercise? Can the consequences of inactivity be rectified? And can the major diseases be reduced, post- poned or attenuated? Positive evi- dence is accumulating on all these fronts from research, including controlled trials. Thus, brisk walking has been shown to improve cardiovascular performance and muscular work in people in their 70s by as much proportionately as comparable exercise in the young. Such a rise in "fitness" will counter frailty in getting about, for example crossing a busy road. It is typically assumed that "brisk" means walking at about four kilometres an hour - today 's typical healthy woman aged 75 to 80 finds about three kilometres an hour comfortable. Trials focused specifi- cally on strengthening muscles in frail subjects aged over 90 have been similarly successful. Reiuvenation effect These measures are achieving a "rejuvenation" effect of many years. There is a bonus too in terms of increased capacity for independence and for playing a social role (includ- ing caring for others). With the renewed ability to get about freely, the elderly can enjoy more stimulat- ing environments and keep their minds more active. All this is a reminder of the waste of potential health and well-being that stems from the modern preference for physical inactivity. Exercise certainly can play its part in preventing coronary heart disease, the common diabetes of later life, osteoporosis, and falls and fractures. But perhaps the more obvious unrealized potential of exercise in old age is in the treatment and rehabilitation of the many peo- ple with diseases and disabilities of heart, lungs and joints. It is vital to make the most of the general and local capabi I ities of these patients so that they can cope more effectively. World Health • SOth Year, No. 4, July-August 1997 Improving the walking capacity of people with chronic bronchitis and so relieving their breathlessness, or building up the muscles serving osteoarthritic knees are good exam- ples of this. There are plenty of opportunities here for primary health care teams. 7 The overall aim is to encourage the elderly to exercise the large muscles regularly, working up gradu- ally to a moderate intensity - feeling warm and breathing a little harder - and sustaining the exercise for half- an-hour or so on most days. Brisk walking and swimming are the most enjoyable and popular activities, and are virtually ri sk-free. They should preferably be undertaken in company and arranged to give structure to the daily routine. Practising Tai-Chi in a pork in Chino. Exercise should be integrated into daily life. Photo Panos Pictures/R. Giling © Stair-climbing is another benefi- cial activity. Like walking and swim- ming it should be habitual in middle age, and should then be continued without question into old age. Gardening and home maintenance and repair are excellent psychologi- cally and physically; they contribute to muscle strength and joint flexibil- ity, to balance and dexterity, and to weight control , although less to cardiovascular fitness. Overall, increased activity will also help to assure optimal nutrition. Some elderly people will wish to join classes and groups, while the many very old who are in residential and nursing homes must not be forgotten. Such group sessions can build confidence, promote sociability and help establish a routine; guid- ance may be provided on exercises to stimulate the pelvic floor for bladder control, and to strengthen bones. Before joining such a class, or if there are any doubts on any aspect, a doctor should be consulted about what exercise is most appropriate for the particular individual. Lower levels of exercise than those de- scribed here will still be beneficial , even quite minimal activity for people who are immobilized by their disability or are housebound. Enterprising local health and leisure services are increasingly engaging in such health promotion. Unfortunately, a lot of apathy must A couple planting flowers in their garden. Gardening is on excellent activity for maintaining psychological and physical fitness . Photo Keystone© be anticipated in response and, judg- ing by past experience, this will be especially true among the less edu- cated and the poor. Special facilities and low prices may not be enough to attract the target groups. Local trials are likely to be necessary to deter- mine how best to attract those who will benefit most, for example, frail elderly women. Improving physical fitness, and enhancing the capabilities that this activates, are a crucial part of the answer to the problem of increasing longevity. The cultural shift that is needed involves the whole of society - and must engage old people them- selves. The Roman author Cicero saw this as a matter of mortality, writing more than 2000 years ago: "It is our duty to resist old age; to compensate for its defects by a watchful care; to fight against it as we would fight against disease; to adopt a regimen of health; to practise moderate exercise." • Professor ).N. Morris is in the Health Promotion Sciences Unit at the London School of Hygiene and Tropical Medicine. He was awarded the new international Olympic medal and prize for research in exercise sciences of the Atlanta Gomes, USA, in July 1996. His address is: London School of Hygiene & Tropical Medicine, Health Promotion Sciences Unit, Deportment of Public Health & Policy, Keppel Street, London WCI E 7HT, United Kingdom. 8 World Health • SOth Year, No. 4, July-August 1997 Men and women age differently Astrid Stuckelberger Women everywhere are living longer than men, but the longevity of women is offset by a higher sickness rate than that of men; women suffer more from non-lethal diseases. Throughout this century, health , social and technological ad-vances have been causing an unprecedented demographic and epidemiological transition whose consequences are becoming ever more apparent. In many countries, people are living longer and enjoy- ing better living conditions than ever before, but differences are emerging between various groups, between women and men, and are particu- larly marked in old age. The basic biological differences between the sexes, especially as regards their reproductive role, have ensured a lifetime chronology specific to each sex and this in turn has led to un- equal social conditions in such matters as opportunities in life, literacy, training, marriage, and paid jobs. The longer life-span, the decline in fertility and the growing complex- ity of family life as a result of di- vorce, widowhood and remarriage all add to the disadvantages women suffer in their old age, leading to more precarious lives than those of men. The "feminization" of old age is already advanced in the developed world, and is growi ng even faster in the developing countries. It is caused mainly by the growing proportion and number of women in the popula- tion as a whole, and their longer life expectancy. Current demographic data give a very clear "statistical snapshot" of the ageing population. In this age group, women now constitute the majority in practically every country in the world. In 1995, UN estimates for the population aged 60 and over (almost one-tenth of the world's population) showed 302 million women and 247 million men. In the developed countries, women aged 60 and over represented over 20% of the total female population while the corresponding figure for men was only 16%. Projections suggest this divergence is accelerating at the global level , but is even more rapid in the developing world. This is largely explained by the fact that among people aged 80 years and over, the proportion of women is increasing faster than at lower ages. Today 61 % of the world's women aged over 80 live in developed Differences in the health of men and women become mare marked as they advance in age. Photo HelpAge lnternatianal/N. Cooper© World Health • SOth Yeor, No. 4, July-August 1997 "Feminization " of old age is advancing rapidly worldwide, mainly because the proportion of women to men is on the increase, as well as women 's life expectancy. Photo WHO/) & P Hubley countries; by 2025 , the majority of them will be living in developing countries . Lower mortality rate Calculations of life expectancy at birth and at 65 years show almost everywhere a divergence in favour of women. Worldwide in 1995, the average figure at birth was 67 years for women and 63 years for men. At one extreme is Japan, where women at birth can expect to live on average for over 83 years and men for nearly 77 years; at the other extreme is sub- Saharan Africa where the average figures are 52 years for women and 49 years for men. Women in all age groups have a lower rate of mortality than men for practically all causes of death. In some countries, however, women show a greater death rate at younger ages, which stems from high levels of mortality linked to pregnancy, childbirth and abortion, the precari- ous social status of women, or the advantages given to sons at birth and during child rearing. Whereas the mortality risks for women are princi- pally linked to their reproductive role and their greater susceptibility to certain infections, especially those that are sexually transmitted, those for men relate mainly to high-risk behaviour, especially work-related or traffic accidents, suicide and such lifestyle risks as smoking and drink- ing. The greater longevity of women is offset by a higher sickness rate than that of men. Although men 's unhealthy lifestyles.:... which are known to increase mortality - may arouse great epidemiological interest in future, the greater longevity of women is also a concern, since they are more affected than men by conditions linked to physical and psychological capacity and the need for care as well as social conditions such as widowhood, poverty and isolation. It is very clear that women's lives, especially in old age, are di- verging from those of men every- where in the world and that their status is evolving at quite different speeds in different parts of the world. Two principal trends can be seen. • In the developed countries, where women have greatly improved their social standing and moved towards more equality with men (for instance in literacy, health care, social security and wages) , they are living longer than men and the gap is widening as their social status becomes more equal. • In the developing countries, where women remain deeply disadvantaged in relation to men, with, for instance, high illiteracy rates, poor earning levels, high fertility and high rates of mar- riage between 15 and 19 years of age, their living conditions as they grow older are highly depen- dent on those of their children and grandchildren. 9 The social conditions of women and men and the very concept of the family are rapidly changing through- out the world. Having played tradi- tional roles with very clear-cut rules and raised their children accord- ingly, the elderly are now gradually being confronted - particularly through the media - with the image of quite different roles, especially in the area of "equal opportunities" for men and women. These contrasts must be taken into account in assess- ing the needs and expectations of the elderly. The tendency today is not merely to record the differences between health data by sex but to examine the reasons for these variations and their implications. Using this comparative approach, it may be found that what benefits one sex can be used to bene- fit the other. For example, a clearer understanding of the factors which influence unequal mortality and morbidity as well as those which contribute to or hinder unequal physical, psychological , social and economic well-being will make it possible to take positive measures in favour of the disadvantaged sex. • Dr Astrid Stuckelberger is Deputy Director of the Swiss Research Programme on Ageing at the Swiss National Science Foundation, and a Scientific Collaborator with the University of Geneva. Her address is: Swiss Research Programme on Ageing, 16 Rue Butini, I 202 Geneva, Switzerland. In India, as in most societies today, the respective social roles of men and women are still very di fferentiated. Photo WHO/ A. Stuckelberger 10 World Health • SOth Year, No. 4, July-August 1997 Coping with age Margret M. Baltes Obviously there is no "gold standard" by which successful ageing can be defined, since the criteria will vary between people. Any theory that postulates one desirable feature of ageing - such as high levels of activity or health or /if e satisfaction - will be inadequate. Ageing successfully does not imply avoiding the problems, changes or losses that come with age. On the contrary, it means continually striving, despite set- backs, to maximize gains and mini- mize losses. We need to consider first of all what is known about ageing and what is known about strategies and mechanisms that might be help- ful in coping with losses. We have at our disposal a large amount of information on this sub- ject, that is shared by gerontologists around the world. In particular, this information shows that there is great variation in the nature and timing of the events of ageing, that people have vast reserves of hidden strengths to draw on as they grow older, and that a continual willingness to adjust and adapt is called for. The piano virtuoso Arthur Rubinstein was a world-famous example of successful ageing. Photo Keystone © Heterogeneity increases with age, as the effects of environmental factors accumulate, making people more and more dissimilar. Thus two seven-year-olds are likely to have more in common than two 70-year- olds. Heterogeneity is also increased by disease, which can cause ageing to proceed in quite divergent ways. With regard to adaptability, or "plasticity", as it is called in our research, the elderly have many latent or dormant reserves that are not used simply because they are not activated by environmental demands. The accumulation of such reserves starts at birth and continues throughout life. Old people tend to live in an undemanding environ- ment, with little stimulation, whereas mental, social, psychologi- cal or economic demands can have the effect of activating these latent reserves. Limiting the goals As one ages, increasing vulnerability needs to be acknowledged and moni- tored. This might require one to change one's expectations and stan- dards, to delegate control, or to acknowledge the uncontrollability of specific events - in short, to accom- modate one's goals as necessary. In this sense, the elderly need to be flexible and in tune with themselves and their environment. Growing old requires self-mastery as well as environmental mastery. What strategies might assist older people to continue to strive to reach their goals? Such strategies must allow a person both to keep on course and to cope with losses that might call for a change of direction. They need to provide for the adjust- ment of goals as well as the means of attaining them. Success can be seen World Health • SOth Year, No. 4, July-August 1997 A man brings his grandchild ta the immunization centre. Family and community involvement helps to ensure an eniayable quality of life in old age. Photo WHO/H Anenden as the minimization of losses and the maximization of goals. The defini- tion of those goals can be subjective or objective and can be measured by different standards. We argue that growth and gains remain possible even into very old age, when increas- ing vulnerability makes it necessary to cope with and adjust to losses. Growing old successfully despite losses is possible when three processes are employed: selection, optimization and compensation. An example of the interplay of these processes in the attempt to maintain a goal and adjust to losses can be seen in the pianist Arthur Rubinstein. Asked in a television interview when he was 80 years old how he managed to remain a renowned pianist at such an advanced age, Rubinstein replied that he attempted to overcome some frailties of his age by performing a smaller number of pieces, so that he could practise them more often. He also alluded to some tricks he used, such as slowing down the tempo before a very fast passage, to give the impression of playing the music faster. Here we can see all three processes working: selection (reduc- tion of repertoire), optimization (more practice of fewer pieces), and compensation (a change in style to retain the appearance of playing fast). Such examples abound in everyday life, and the three processes usually seem to be adopted instinctively. Indeed, selection, optimization and compensation should not be seen only as a matter of intention and rationality. Each of the three processes can be active or passive, internal or external, conscious or unconscious. For instance, they may involve moving to a better place to work or live, or changing one's goals to fit the existing conditions. They may involve the active pursuit of new skills or a gradual acceptance of life without certain skills. By using strategies of selection, optimization and compensation, individuals can contribute to their own successful ageing. Certainly the biology of ageing limits more and more the overall range of possibili- ties in old age. However, the adaptive task of each of us as we age is to select and concentrate on those aspects of life and those goals that are of high priority for us and that involve a convergence of environ- mental demands and individual motivation, skill , preference and biological capacity. • Dr Margret M. Baltes is Professor of Psychological Gerontology at the Freie Universitot Berlin, Beniamin Franklin Medical School, Research Unit of Psychological Gerontology, Nussbaumallee 38, 14050 Berlin, Germany. Making envelopes in Sri Lanka. Being active and striving far gaols are powerful ways to counterbalance the physical losses that go with ageing. Photo HelpAge lnternational/K. Peachey© II 12 World Health • SOth Yeor, No. 4, July- August 1997 Primary care for the aged Jean-Pierre Michel Training courses for non- prof essional primary health care workers should be promoted as widely as possible by local, regional and national authorities. This will undoubtedly contribute to reducing health care costs while at the same time improving the quality of life of the elderly, whatever position they occupy in the community. Since its origins in the United Kingdom in the 1940s, geriatric medicine has progressively generated programmes for the long- term care of the chronically ill. At the same time, geriatrics has deep- ened its fundamental understanding and adapted its attitudes to meet the new needs of a population that is growing steadily older. And it has improved the means by which it makes its scientific, clinical and social findings available to an ever wider body of health professionals with very varied backgrounds and training. All this has been very useful but much more is needed in view of the rapid demographic, economic, social and health changes that are occurring all around the globe. These efforts must essentially be directed towards elderly people living at home. Ethiopian refugees in Sudan. At the start of the 21 st century, more than 60% of people aged 65 and over will live in developing countries. Photo HelpAge International© At the start of the 21 st century, 60% of the people aged 65 and over will live in developing countries. Consequently training must be extended as fast as possible not only to specialists but also and especially to primary health care workers. This generic term is used here to include health professionals working in the community, such as general practi- tioners and nurses who make home visits, as well as social workers, professionals without specific train- ing in care, and others who spend time with elderly people living at home. These include the families and close friends of the elderly sick. The transfer of knowledge that will benefit primary care workers and in particular the non- professional carers is one of the new challenges facing WHO's Ageing and Health programme. Training for non-professionals A consultation was organized re- cently by the International Institute on Ageing, the United Nations and the Maltese Government, under the chairmanship of Dr J. Troisi of Malta. It brought together specialists from Israel, Switzerland and the United States as well as from Malta itself. The members of this group, who work within university, institu- tional and community establish- ments, saw the need for three main areas of training for non- professional primary health care workers . • Health promotion and disease prevention. This involves a better understanding of the various aspects of ageing, whether med- ical, psychological, social, emo- tional or environmental, as well as the ability to foresee the needs of elderly people. This interdisci- plinary work entails a positive interaction between the different World Health • 50th Year, No. 4, July-August 1997 13 A general practitioner advises her patient. Health professionals working in the community must hove a complete understanding of the needs of ageing people. Photo Keystone © Ageing is a many-faceted process, and corers need to take into account all the possible medico/, psychological, social, emotional and environmental aspects. Photo WCC/P Williams © carers and services whose task must be to identify the elderly sick, who are living at home and at risk of physical or mental deterioration or socioeconomic difficulties, so that early and well- targeted action can be initiated. • Acute care. An essential basic understanding of the objectives must be conveyed to ensure that the attitudes and behaviour of the carers are appropriate in cases of acute illness, and that simple evaluation tools (functional, nutritional, mental or relating to social integration) can be used. • Management of chronjc diseases. A sound understanding and coordination of treatments and of the care networks will clearly be indispensable in the long term in order for functional rehabilitation to be effective, and will help to prevent difficulties from becom- ing chronic unnecessarily. Respect for the dignity of the patient, the management of pain and care for the dying will also call for appropriate training of the primary care workers. A tailor-made programme Training for non-professional pri- mary health care workers must be flexible and adapted to local condi- tions and resources. The pro- grammes should be short, and include sessions lasting for one or two days only, so as to allow as many people as possible to participate. Training should be based on interac- tion between experienced health professional s and the participants. Three phases will be desirable: 1. An orientation session based on an exchange of experiences and on an understanding of the district and its networks. The expectations of the participants should be expressed in terms of their personal needs and the problems they encounter in their daily practice. 2. Several sessions devoted to cer- tain basic concepts: - the ageing process; - behaviour and social interac- tion; - the basics of health promotion; problems arising from the most common ailments of old age; a comprehensive evaluation of each situation. During these sessions the trainers will select the themes and place the emphasis on the study of good practical attitudes rather than on scientific know-how. They will foster a deeper understanding of: communication with and behaviour towards aged patients, their families and other carers; the care systems that are avail- able at the local and regional levels; legal and ethical approaches to delicate situations; the management of drug treat- ment. 3. An evaluation session to find out if the objectives fixed at the start of the training have been attained or additional information is required. Training of this kind is vital for all non-professional primary care workers who will for the first time be serving old people in the commu- nity. It is no Jess important for carers already working in thjs field, so as to refocus their understanding and encourage them to review their own attitudes. It will complement the training already given by health professionals working in the com- munity, and will be rounded off by specific training of families and friends who will take over the per- manent care of the very old. It is recommended that local, regional and national authorities should promote such training courses as widely as possible, since this will undoubtedly contribute to reducing health care costs while at the same time improving the quality of life of the elderly, whatever posi- tion they occupy in the community. In support of this action and under the aegis of WHO, a book is being prepared by myself with Professor L.-M. Gutierrez-Robledo (Mexico) and Professor H. Ben- Maiz (Tunisia) spelling out the scientific basis and practical mea- sures involved in the training of primary care workers. • Professor Jeon-Pierre Michel is the Chief of the Geriatric Deportment, University Hospitals of Geneva, Route de Mon·ldee, 1226 Thonex, Switzerland. 14 World Health • SOth Year, No. 4, July-August 1997 Culture and longevity Keiko Nakamura An Asian businessman in New York. Adapting to another culture con modify health risk patterns and affect longevity. Photo Panos Pictures/C. Stowers © I n recent decades, the efforts to achieve health for all, coupled with improvements in living standards, have raised life expec- tancy in many parts of the world. In 1993, there were about a dozen countries where life expectancy at birth exceeded 77 years. By the year 2000 there will probably be 20. Studies made on the health and lifestyles of Japanese, Japanese- Americans living in Hawaii and California, and American Caucasians have taught us that an individual's health is determined not solely by heredity and the physical environ- ment but also by cultural factors that influence lifestyles and social networks. Japan has the lowest rate of mortality from coronary heart dis- ease of all the industrialized coun- tries, while the United States has one of the highest rates. Japanese- Americans are less likely to die from coronary heart disease than white Americans, but more likely to do so than Japanese living in Japan. Among Japanese-Americans, the risk of developing coronary heart disease and dying from it is lowest among those living in traditional Japanese ways. Traditional and non- traditional Japanese culture affects lifestyles differently. The traditional culture involves the intake of fewer fats, particularly saturated fats, and the formation of closer social net- works with friends and neighbours. Adaptation to American culture increases the risk of coronary heart disease among Japanese immigrants. The same increased risk is also observed among Italian migrants to Australia, and among Pacific islanders who have migrated to the United States. A comparative study on the incidence of breast cancer in Japanese, Japanese-Americans, Chinese, Chinese living in A cultural tradition that is positive about three- generation families and places greater value on family ties results in close-knit social networks that support the health of the elderly. Singapore, Chinese-Americans, Indians and Indians living in Singapore showed that differences are associated with the intake of fat, urbanization and related lifestyle changes. Such differences demon- strate the significant influence that acculturation has on people's health. Supportive social network An international study on how elderly people live was conducted in 1990 in Germany, Japan, the Republic of Korea, the United Kingdom, and the United States. Its aim was to elucidate differences in the way the elderly live in differ- ent countries. Marked differences were found in family structure. The percentage of those aged 60 and over who live in three-generation house- holds is considerably higher in · industrialized Asian countries than in Europe or North America. The attitude of the elderly towards living with their children or grandchildren after retirement indicated even greater divergence among the coun- tries in the study. More than 50% of the elderly in the Republic of Korea and Japan agreed that "it is best for the whole family to live together," while fewer than 4% of those in the World Health • SOth Yeor, No. 4, July-August 1997 United Kingdom and the United States agreed. As regards the social networks of older adults in Japan, close relations among family members are more valued than relations with friends or acquaintances. In addition to giving emotional support, family members living together function to ensure the healthy li ving of their elderly rela- tions. Examples include offering a healthy diet by making sure that a variety of foods is available, encour- aging ski lls that promote health, including efforts to prevent injury and choose the most appropriate health resources, and assisting in day-to-day personal care for those who have lost the ability to live independently. A cultural tradition that is positive about three- generation families and places greater value on family ties results in close-knit social networks that sup- port the health of the elderly, both physically and emotionally. Developing new health-support- ive resources by applying advanced technology is one of the marked features of recent health care and health promotion efforts in Japan. Because of the growing numbers of elderly people, communities and health professionals encourage the use of new technology to support the health of the elderly. The use of videophones in home health care is one example. Thanks to the wide- spread installation of ISDN (Integrated Services Digital Network) in Japan, videophones are used in this system to assist the home health care service for the elderly. Patients and their families feel more comfortable because they know they are being taken care of better and have ready access to health profes- sionals. Instruction through the videophone helps to develop the independence of patients and their families. This technology helps people to choose healthier lifestyles, as the information offered supplies examples of how to live a healthier life, including tips on diet, fitness, relaxation, community group activi- ties, housing, food safety and injury prevention. Home monitoring Medical check-up systems using telecommunications are another example of the effective use of new technology. Physical changes, blood pressure, pulse, heart beat, body temperature and body weight are monitored on a small terminal at home and automatically transmitted to a health centre. In addition to allowing health professionals to give appropriate and timely advice on the basis of daily changes in physical condition, the system also helps people learn how to take care of themselves. Society in general can help to create a health-supportive environment by making better use of new resources and stimulating public interest in reorienting the health services. The appropriate application of new technology has great potential for tackling health issues that are central in society. Culture influences people's everyday life by supplying them with norms and standards. It affects peo- ple 's attitudes towards health; social networks that are supportive of Grandmother minds the babies. In Japan, about a third of people aged 60 and over live with their married children and play a big part in the Family's daily life. Photo Keystone/ !. Sirman © IS health are formed through strong cultural links; culture influences the readiness of a society to reorient its mechanisms towards improving health. Because we are living in the information age, we have a better chance to interact with cultures from different parts of the world and to learn from them. The United Nations predicts that those aged 65 and older, who ac- counted for 6.5% of the world 's population in 1995, will account for 15.1 % of it in 2050. The increase will be particularly great in Asia, where the number of elderly people will rise from 5.3% of the population to 15.9%. The challenge of the coming era of increased ageing worldwide and rapid trends away from traditional patterns of living will be to learn from diverse cultural experiences that influence longevity, and then to adapt what we have learnt to individual societies. • Dr Keiko Nakamura is Head of the Urban Health Research Unit, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-ku, Tokyo I 13, Japan. 16 World Health • SOth Year, No. 4, Ju ly- August 1997 Those who have vision Nana Apt The challenge we face in Africa is not just one of providing protection and care for the elderly, but of keeping them involved in the development process of family, community and nation. Any examination of what "el-derly well-being" means in traditional Africa cannot neg- lect the role, aspirations and active involvement of old people in their family and community. In a typical household in any African commu- nity, each person, whether young or old, has a role to play and elderly people are not excluded from pro- ductive and social activities. In my own country, Ghana, the elderly contribute to the social up- bringing of the young and become educators and guides who foster the initiatives of young people. This guidance role is extended to the entire community. In many social and economic initiatives of the young, an elderly person is consulted and - while he or she remains in the background - patronage by the elderly in terms of monetary support, advice and direction is the expected norm. In administrative matters regard- ing fami ly or communal property, elderly people act as consultants. In this role, they are always much involved in important decisions about family or community rights. Ancestral rites ideally forge a cul- tural link through the elderly, as spiritual leaders, with both the living and the dead. In this connecting role, elderly people in the community officiate in ceremonies marking A village elder with his family in Zambia. In Africa, the elderly are the educators and guides who foster the initiatives of the younger generations Photo Keystone/ H. Paul© puberty, marriage, birth and death , and in cleansing ceremonies aimed at ensuring that peace and harmony prevail within the community. This activity naturally extends to resolv- ing conflicts between individuals or groups in the community. African proverbs fulfil an indis- pensable function of expressing, enhancing and codifying cultural beliefs and attitudes. While express- ing wisdom, they are also potential keys to understanding the customs and way of life in the past. Many of them plainly indicate the customary principle of active and responsive ageing. In Ghana, people say: "The hand of the child cannot reach the top of the shelf for the gourd, neither can the hand of the elder get into the neck of the gourd". This neatly expresses the need for young and old to cooperate to achieve a desirable goal. Perhaps the Bambara or Mali best summarize traditional expecta- tions of ageing in African society with this proverb: "A young man's gait is rapid, but he does not know the way; an old man's gait is slow but it made the way." The guidance role A psychological study showed in 1980 that, in traditional societies, elderly people are protected against stigmatization not only by favourable cultural concepts but also by culture itself. In the African application, traditional words used to describe the old are not derogatory. On the con- trary, the common expressions used to describe elderly people in African languages - "elder", "someone who knows", "someone who has vision" - underline the guidance that society expects of them. In other words, with old age go certain roles and responsibilities which stem from the eider's life experience and accumulated wisdom. Thus, the much talked about respect and honour accorded to the old in traditional Africa are guaranteed only in so far as the elderly person is responsive to expectations of societal leadership and guidance. Individuals who have learnt nothing from their life experience that can enhance the life of younger persons in the society forfeit the respect and honour re- served for elders. World Health • SOth Year, No. 4, July-August 1997 17 Once a school, now a home for displaced persons in Angola. In Africa today, political and social strains threaten the traditional role of the aged in the community. Photo WCC/P. Williams © Elderly Africans continue to provide for their household's welfare and the enrichment of the communjty as a whole through their guidance work in social, cultural, economic and political activities. So the traditional African ageing role is a necessary response to the challenge of social and economic well-being, an important role which should not be easily cast aside in modem times. In many coun- tries ageing is widely perceived as a time of decline and loss and, in the Africa of today, moderruzation, in particular education, urbanization and migration, are seen as factors which undermine the traditional participa- tory role of ageing people in the communjty. The challenge we face in Africa is not just one of providing protection and care for the elderly, but of keeping them involved in the development process of family, com- munity and nation. A close relationship at present exists between social roles and elderly well-being, combining in the broadest sense both material and spiritual factors. Three conditions must be fulfilled: elderly people's rights must be truly recognjzed and enforced; those rights must apply to all elderly people, not just to a small minority; and the required material means must be made available for this purpose. Furthermore, creating a condition of genujne well-being of older peo- ple through participation calls for in- depth, long-lasting action, whose basic constituents are training and information. These must be matched by putting into effect well-thought- out measures taken on elderly peo- ple's behalf, particularly with an eye to promoting positive and rewarding social roles. In other words, what is required is grass-roots action to initiate, educate and inform elderly Africans caught up in present mod- em transformations, to reassure them Growing old in Ghana. Older people in Africa ore the holders of traditional wisdom and, as such, ore involved in the development process of family, community and nation. Photo HelpAge lnternationol/K. Peachey © that they are capable of taking indi- vidual, concrete and appropriate action and arriving at new duties and roles. Another psychological study showed that people fall ill when they have to play unrewarding roles for a long time. The author commented that older people in modem times "are often virtually invited by those who are younger to be feeble and helpless, although they have great reserves of vitality latent within them". Africa's younger generation is beginning to move in this direc- tion. A case in point in which I became professionally involved was that of a 72-year-old widowed woman in a village who frustrated all efforts of her son to move her into his own comfortable household in the city. Asked why she did not want to live with her son, she calmly explained that she was not a pet goat that had to be fed and made to sleep at the whim of the owner! She rejected her son 's notion that she was too old to work and that he had enough money to take good care of her in his own household. • Professor Nono Apt is Head of the Social Administration Unit and Director of the Centre for Social Policy Studies, University of Ghana, P.O. Box 27, Legan, Ghana. 18 World Health • SOth Year, No. 4, July-August 1997 Healthy ageing in Africa Seyi Ladele Amosun & Priscilla Reddy Community-based education programmes make older people aware of the ways to stay healthy - and to avoid health risks. Photo WHO/ H. Anenden Community services should be designed in such a way that society can benefit from the experience of older people, while the needs of the elderly themselves are fulfilled. Older people should continue to be fully functioning, active and productive members of their communities. To achieve all this, a healthy ageing process needs to be encouraged and nurtured even from childhood. The number of elderly people in the general population is in-creasing rapidly in many African countries owing to the dra- matic gains in li fe expectancy during the 20th century. In most African countries, in both traditional and contemporary societies, old age is regarded as a blessing, and old peo- ple are respected. Classically, the extended fami ly and the community have constituted the primary source of care for the elderly, but urbanization, moderniza- tion, and political and social strains, such as war, poverty and economic insecurity, are eroding these tradi- tional support networks. Perceptions about older people are being dis- torted, and they are often seen as a burden on the family, using up scarce resources. A sizeable proportion of them today are viewed as unproduc- tive and have become highly depen- dent. As the numbers of the elderly escalate, the question of how to care for them becomes more critical. What can be done to ensure healthy ageing and a good quality of life in old age? What are the correlates of longevity associated with psycho- physical well-being? Attempts to provide answers to these questions no doubt led to the choice of the theme for International Nurses' Day in 1992, which was "Healthy Ageing" , as well as the United Nations' decision to designate 1999 as the International Year of Older Persons. Our knowledge of the determi- nants of healthy ageing in Africa is still in its preliminary stages but is rapidly expanding. A major implica- tion of the increase in life expectancy is the likelihood of an increase in the prevalence of physical disabilities among the elderly. While some physical capabilities deteriorate with age, it is known that a majority of health issues associated with ageing have the potential for successful preventive action. Health care is often hindered in the elderly popula- tion by poor access to health services and limited use of preventive ser- vices. Barriers to access are primarily social and economic. It is becoming more and more necessary for policy- makers and members of the commu- nity to ensure that supportive healthy environments are provided for older people. Ideally, societies should view ageing as a normal process, and as something quite distinct from illness. Longitudinal studies underscore the multifaceted nature of the ageing process; genetic and biological factors influence longevity, as also do social and ecological factors, which in turn help to determine the kind of lifestyle that promotes longevity. Nutrition, physical activity, the extended family and spirituality are known to be major determinants of well-being in the elderly. Dementia, depression, alco- holism, neglect and suicide are some of the most important mental health issues affecting older people. There is also a high prevalence of problems relating to activities of daily living. Health promotion for the elderly should promote the advantages of a World Health • SOth Year, No. 4, July-August 1997 healthy lifestyle, encouraging people to come together to enjoy recre- ational and social activities, to re- duce social isolation, and to foster independence, intergenerational support, self-reliance and good quality of life through well-devel- oped community networks. What can be done? Firstly, older people should have adequate access to community- based health enhancement programmes organized by persons with experience in health education as it relates to such risk factors as hypertension, diabetes, smoking and alcohol abuse. Regular screening should be carried out at these com- munity-based centres, including checking on vision and gait to pre- vent accidents. But in addition to screening for health problems, such exercises should include psychoso- cial factors. Then it is known that, with ad- vancing age, energy expenditure - and therefore energy requirement - generally decreases, because of a decrease in basal metabolic rate and physical activity. Emphasis should therefore be placed on keeping people active and independent, at the same time nurturing a state of health that allows maximum active life expectancy while maintaining high levels of function. Older people should continue to engage in intel- lectual and physical work within their capacity. Thirdly, disease prevention through meal planning is a cost- effective approach to promoting healthy ageing. The ageing process alone has no significant adverse consequences on the caloric intake and nutritional status of healthy elderly individuals, but epidemio- logical data suggest that, in humans, undernourishment reduces the life span. Nutritional intake and nutri- tional status are dependent not only on appetite and the availability of diverse food, but also on physical activity and involved social lifestyles, among other factors. Community health nurses should encourage nutritionally sound habits through the medium of health educa- tion, by promoting and supporting the use of traditional food and cook- ing habits. Fourthly, populations with healthy lifestyles have a signifi- cantly greater life expectancy. Malnutrition is common in the developing world, and it is the result of poverty, alcohol misuse, smoking and other factors such as depressive disorders and social isolation. Health promotion in Africa needs to move beyond simple health education strategies to strategies which advo- cate policies, environments, and resources aimed at promoting a lifestyle that will encourage Africans to age in peace, comfort and eco- nomic security. 19 Finally, social interaction should be encouraged among older people themselves. Social networks can provide facilities for sports and recreation, as well as offering friend- ship and companionship. A closer interaction between older and younger people should be encour- aged through organized visits by schoolchildren to older people within the community. Ageing is a lifelong and natural process which brings about certain anatomical, physiological and psy- chological changes. Older people should be positively encouraged not to lose interest in the joys of life. Community services should be designed in such a way that society can benefit from the experiences of older people, while the needs of the elderly themselves are fulfilled. Older people should continue to be fully functioning, active and produc- tive members of their communities. To achieve all this, a healthy ageing process needs to be encouraged and nurtured even from childhood. • Dr Seyi Ladele Amosun is with the Department of Physiotherapy, University of the Western Cape, Private Bag X 17, Bellville 7 5 35, South Africa. Ms Priscilla Reddy is Programme Leader, National Health Promotion, Research and Development Office, Medical Research Council, P 0. Box 19070, Tygerberg 7505, South Africa. A health centre in Lesotho. The elders in the family have more difficulty than their younger relatives in reaching sometimes distant health pasts. Photo WHO/) & P Hubley A market-place in Nigeria. Traditional food and cooking habits lay a sound foundation for healthy nutrition at all ages. Photo WHO/) & P Hubley 20 World Health • SOth Year, No. 4, July-August 1997 Healthy population ageing Gloria M. Gutman Never before have the nations of the world known such numbers of older persons, especially in the very old category (85 years and over). The Brasilia Declaration on Ageing proposes ways of meeting the needs of today's and tomorrow's elderly. Ageing is very much a develop-ment issue for both developing and developed countries - for both North and South. In July 1996, in collaboration with WHO's Pro- gramme on Ageing and Health, the Govern-ment of Brazil convened an interna- tional meeting in Brasilia to develop an agenda on ageing for the remainder of the 20th century and beyond. A multidisciplinary group of experts from all parts of Brazil as well as from 21 other countries attended the meeting. We heard about Brazil's new National Policy on Ageing and witnessed an action plan for carrying it out being signed by the President of the Republic. In lectures and panel discussions, we heard about the demographic and epidemiological transition that is occurring everywhere in South America, about sociocultural and anthropological aspects of ageing, The ever-growing numbers of older persons pose a new challenge to health services throughout the world. Photo HelpAge International/Pro Vida Chuquisaca © and about research needs, including studies to support policy develop- ment. Never before have the nations of the world known such numbers of older persons, especially in the very old category (85 years and over). The rate of demographic change is also unprecedented. In Brazil, for example, between 1960 and 1980 ferti lity fell by a third and there was an eight-year increase in life ex- pectancy. In Japan, between 1970 and 1994 the proportion of the population aged 65 and over doubled from 7% to 14%. Projections sug- gest that by 2020 more than 25% wi ll be over 65, whjch will probably place Japan in the position of being the world's most aged country. Rapid population ageing brings with it many concerns for govern- mental and nongovernmental organi- zations, including the increased demand for health care, specialized housing, social and recreational programmes, and income support programmes. Another major concern for developed countries is the in- creased prevalence and incidence of the chronic conditions that tend to accompany population ageing. Such problems are compou nded in many developing countries where there is a need to deal simultaneously with high rates of infectious disease (as well as poverty and unemployment) in the younger segments of the population and increased rates of chronic disease in the older segment. The Brasilia Declaration reflects the delegates ' desire to effect change in the direction of more healthy population ageing. It draws attention to the fact that, while ageing is inevitable and irreversible, many of the chronic disabling conditions that are seen today in persons aged over 60 can be prevented or at least de- layed, and that healthy older persons are a resource for their farmly, com- munity and society at large. World Health • SOth Year, No. 4, July-August 1997 Women form a high proportion of older people and are often at a social and economic disadvantage. Photo WCC/ P Williams © It also underlines that ageing is a gender issue: women are dispropor- tionately represented among the oldest old, in unpaid caregiver roles, and among the most socially and economically disadvantaged. And it emphasizes that not just medical but also social, economic and environ- mental interventions must be applied if we are to improve the health of current and future generations of older persons. For rational planning, we must take a life-span perspective - understanding, for example, that the low-income single mother of today is the financially disadvan- taged older woman of tomorrow. The Brasilia Declaration is per- haps most important for articulating ten guiding principles for achieving healthy population ageing. The first nine of these principles apply unjver- sally. The tenth , directed towards Brazil to establish an international centre for ageing, hjghlights the importance of dialogue and technol- ogy transfer between countries and hemispheres to meet the needs of ageing populations - key goals of the WHO Ageing and Health Pro- gramme and of the International Association of Gerontology. • Dr Gloria M. Gutman is a member of the WHO Expert Advisory Panel on Ageing and Health and Co-chair of the North American Region of the International Association of Gerontology, Gerontology Research Center, Simon Fraser University, #2800 515 W Hastings St , Vancouver, Canada V6B 5K3. Brasilia Declaration on Ageing 1-3 July 1996 Ageing is a development issue. Healthy older persons are a resource for their famil ies, their communi ties and the economy. Their usually unpa id and unsung contributions are indispensable for development Ageing is universal, affects every individual and fam ily, community and society. The numbers of older persons are growing steadi ly. There are gender implications; older women are disproportionately represented among the oldest old a nd the most disadvantaged, and they constitute the backbone of careg iving Ageing is a normal dynamic process. It is not a disease. Whi le agei ng is inevitable and irreversible, the chron ic disabling cond itions that often accompany ageing can be prevented or delayed, not only by medica l but also by socia l, economic and environmenta l interventions. There are ma jor inequ ities in ageing reflected in life expectancy, morbidity, premature mortal ity, d isability and qua lity of life. The basic prerequ isites of quality of life include adequate food, clean water, shelter, safety, bas ic economic security and access to prima ry health care. This declara tion takes into account the UN Internationa l Vienna Plan of Action on Age ing, and it is consistent with conventions signed in Cairo, Copenhagen, and Beij ing, with the Ottawa Charter on Health Promotion and wi th Habitat II. The Conf ere nee recommends the following principles for action: l . Addressing the needs of an ageing population must take place wi th in the context of broader social pol icy and issues and take a life course perspective. Interventions should occur at the community level rather than focusing solely on the individual and should be culturally relevant. 2. A ll actions must be in tersectoral and take in to account the biophysical, social, psychologica l, econom ic and envi ronmental determinants of health. Policies across al l sectors must be coordinated and harmon ized 3. Po licies and practices should be developed to address ethica l issues, including equal access to care and services anal equitable distribution of 4. 5 . 6. 7 . 8. 9. 10. resources. To succeed, the approach must develop and build on partnersh ips between governmen ts at all levels, nongovernmental agencies, religious organizations, social movements and the private sector. It must a lso clearly incl ude the active participation of those who benefit from policies and programmes . Fi scally responsible action suggests a two-pronged approach that involves targeting the most vulnerable while at the same time engag ing in disease prevention and heal th promotion. Actions must promote and support family cohesion and intergenerational solidarity. The mul tiple roles of ageing women and the impact of those roles on health and economic security must be recognized and supported by legislation, pol icy and programmes. Education and tra ining are needed at all levels and for all groups concerned with ageing. Th is includes education for sen iors to enhance their capacity for self-help and mutual aid, advocacy and leadership; education of para-professional and professional health and soc ia l service providers that includes gerontology and geriatr ics in the basic curriculum, as well as opportunities fo r specialization and continuing education; practical training of family and social networks; and public education to d ispel myths and stereotypes. Research capacity must be developed in order to assess and define need, develop and evaluate models of intervention, disseminate best practices a nd inform policy. Train ing to utilize existing information and develop new databases is part of research capacity building. Long itudinal databases tha t facilitate the monitoring and determination of outcomes are a pr iority as is training in scientific research methods including quanti tative, qualitative, participatory and action research methods. The emphasis should be on applied research To serve as a resource to support these recommendations, an international centre for ageing should be established in Brazil This centre wi ll serve as a clearing-house for best practice models, as a repository of comparative research data, and a resource for education and tra ining. This centre should also facilitate intercountry collaboration both between countries of the South as well as between North and South countries. 21 22 World Health • SOth Year, No .. 4, July-August 1997 Ageing well Sally Greengross An innovative programme already active in many European countries involves older people as "senior health mentors" in convincing their contemporaries about the importance of following healthy lifestyles. Ageing Well Europe is an innov-ative pan-European health promotion programme for and with older people. It seeks to pro- long active, independent life by advocating and maintaining good health, and reducing illness and disability among people of 50 and over. The programme is backed by WHO, the European Union and many national governments and health authorities. Many of the Ageing Well projects actively in- volve older people as "senior health mentors" . These are specially trained individuals who can offer support and advice to their contem- poraries and encourage them to adopt healthier lifestyles. This type of "peer counselling" is widely recognized as a successful way of passing on valuable information, and, perhaps even more importantly, of changing attitudes and enabling people to take a more positive atti- tude towards ageing. The Ageing Well Europe pro- gramme is a practical response to a number of key developments in health policy: firstly to the WHO health-for-all target of Healthy Ageing, secondly to the European Union's new responsibilities in the field of public health, and thirdly to the lead taken by a number of gov- ernments and health authorities in adopting health targets and recogniz- ing the importance of maintaining health and preventing disease. What does this mean, though, in practical terms? The WHO target for life expectancy in the European Region as a whole is at least 75 years, with a sustained and continu- ing improvement in the health status of people aged 65 years and over. To achieve this, cou~tries in the Region with lower life expectancy figures will need to bring them up to at least 70 years, and reduce the differences in life expectancy between different geographical areas, different socio- economic groups and the sexes. This will involve increasing the number of years that people aged 65 and over live free from disability and degenerative diseases; encouraging the participation of older people in community life; encouraging them to change their lifestyles in order to prolong the period of healthy ageing; and providing appropriate services and support for those who are unable to remain independent. Currently there are Ageing Well projects in nine European countries working to: • meet the needs of local commu- nities with individually designed projects; • involve older people in planning and carrying out projects; • develop partnerships with rele- vant bodies such as government departments, the commercial sector, local health and social service authorities, health promo- tion agencies, older people's organizations, research institutes and the media; • spread good practice by exchang- ing information and ideas at European level so that successful initiatives can be taken up on a wider scale. Innovative projects Examples of some of the innovative and influential work going on in projects across Europe include: People aged 50 and over can look forward to a healthy old age - provided they adopt healthy lifestyles Photo WHO/Zafar World Health • SOth Year, No. 4, July August 1997 Older people are not passive observers. Today they are increasingly _vocal in expressing their views and participating in the shaping of their society. Photo Panos P,ctures/L. Toy/or© • Rotterdam, the Netherlands. Volunteers over the age of 55 have been recruited as senior health mentors who, after 32 days of training, are able to work in the local communities offering infor- mation about local services and general advice on how to main- tain good health. • Madrid, Spain. A survey in the Aranzuela district of Madrid revealed that older residents wanted workshops and courses in which they could find out more about how to maintain good health and deal with problems like loneliness and depression. Volunteers are trained to act as health advisors to their peers, and the service has been extended to include visiting vulnerable el- derly people in their own homes. • United Kingdom. Ageing Well has developed a number of pro- jects in Scotland where specially trained health mentors are work- ing with health professionals to make the dangers of coronary heart disease better known. In the south of England, several pro- jects publicize the importance of exercise and encourage older people to attend specially de- signed exercise classes. In the north of England, an Ageing Well project concentrates on taking vital health promotion messages to older people in isolated rural communities, and focuses particularly on messages about mental health. The nine countries at present in- volved in the Ageing Well Europe programme are France, Germany, Greece, Ireland, Italy, the Netherlands, Portugal, Spain and the United Kingdom. An enormous variety of projects are developing, each responding to the needs of the particular community they serve. The programme has established links with Australia, Canada, Israel, Japan, Ukraine and the United States, and regular exchanges of information take place between the participating nations. 23 Besides the projects highlighted above, there are a number of other interesting initiatives. In Germany, the Ageing Well programme is concentrating on assisting existing self-help groups to raise awareness about osteoporosis and what can be done to prevent it. In Italy, two regional health promotion projects have been launched offering infor- mation courses to older people on a wide range of subjects including nutrition, home accidents, exercise and activity, medication, getting advice from your pharmacist and how to get the best out of your doctor. In the Netherlands, the Ageing Well group has received funding from the Ministry of Health, Welfare and Sport to carry out a two- year evaluation of Ageing Well projects at local level, covering local financing, local partnerships, and the numbers and types of older people involved. In the United Kingdom, the original nine pilot projects are now being evaluated and several new projects have joined the net- work; the Ageing Well programme won a major award in 1995. Ageing Well is about adding life to years and years to life, and the partners and participants believe that the best people to put this philoso- phy into practice are the senior health mentors themselves. Evalua- tions of many of the projects indi- cate that the programme, through the use of these mentors, has in- creased health knowledge among indi victuals, convinced people of the importance of following healthy lifestyles, improved self-confidence and motivation, and enabled partici- pants to play a fuller social role. In taking this forward and developing more Ageing Well projects in other countries so that we can learn from each other's experience, I truly believe that we are making a very important contribution to WHO's "healthy ageing" target. • Lady Greengross is Director General of Age Concern England, Astral House, l 268 London Rood, London SW 16 4ER, England 24 World Health • SOth Year, No. 4, July-August 1997 "To serve, not to be served" Horace B. Deets Founded in 1958 by a retired high school teacher, the American Association of Retired Persons seeks "to enhance the quality of /if e for all by promoting independence, dignity and purpose." she was first alarmed and then out- raged to discover that retired teach- ers had no affordable group health insurance available to them. Dr Andrus knocked on the doors of over two dozen insurance compa- nies before she finally found one that was willing to take what was then considered to be a tremendous risk. That group health insurance policy, the first of its kind in the United States, was an instant success. As she worked to build and strengthen the NRTA, she discovered that the Celebrating Independence Day. In the USA, older people are ;oining forces to enhance their quality of life and achieve their own independence, dignity and purpose. Photo Keystone/5. Grandadam © Wen Dr Ethel Percy Andrus - a high school teacher and principal from the state of California - retired from her job, she quickly realized that the pensions received by teachers were grossly inadequate, not just in California, but throughout the United States. In response, she formed the National Retired Teachers Association (NRTA) in 1947 to unite many individual state organizations into a cohesive national federation that would work on behalf of retired professionals. During this period, problems facing her constituents - health care, economic security, consumer protection - were not limited to retired teachers. She began to hear from older people who were not retired teachers but who wanted, and needed, the same bene- fits that NRTA had won for its members. So on 1 July 1958 Dr Andrus founded the American Association of Retired Persons (AARP) to meet the needs of the ageing population. Through AARP and NRTA, she spread her philosophy that the retire- ment years should be seen as an opportunity for new growth and involvement with society - not as a time for withdrawal from life. Her vision was that ageing Americans could maintain their personal dignity and continue their social usefulness by recognizing their own individual worth through a commitment to service. This was expressed in the motto she developed for the Association: "To serve, not to be served" a motto which still defines AARPtoday. Her vision has turned AARP into the leading organization for elderly people in the United States. It is a non-profit, non-partisan organization independent of the government, and it serves its members and their famiiies through information pro- grammes, legislative advocacy, research, and community services. These activities are carried out by a network of local chapters and expe- rienced volunteers throughout the United States. While AARP has changed and evolved over the last three decades, its commitment to service has been constant and unwavering. From the beginning, it was apparent that the Association was an idea whose time had come. The membership grew slowly but steadi ly, reaching one million in 1967. By 1986, AARP had 20 million members, and people were joining at the rate of 3000 per day. Lowering the membership age to 50 brought even more members, and today more than 32 million Americans enjoy the benefits of membership. Diverse pattern Given this pattern of growth, the AARP has become a very diverse organization. Its members range in age from 50 to well over 100, and more than half are under 65. More World Health • SOth Year, No. 4, July-August 1997 Tourists attending an open-air conference in Texas. Ageing means enriching life, not withdrawing from it. Photo Keystone /Pivonka © than one-third of the membership still work; 55% of the members are women and 45% are men. In addi- tion, the Association currently has more than 50 OOO members in 152 other countries, and most of these are not Americans. AARP has always been an orga- nization run by volunteers. Its Board members are volunteers and, over the years, hundreds of thousands of volunteers at the local level have been involved in a wide range of community service programmes to improve the quality of life for older Americans and their families. These programmes include the organiza- tion of tax assistance to older Americans, voter education, safe driving, assistance for widowed persons, financial and retirement planning, and older worker projects. In addition, AARP has endeavoured to address the unique concerns of older women, diverse population groups and people with disabilities. It also publishes Modern Maturity, the largest circulation magazine in the United States with over 22 mil- lion copies, and the monthly AARP Bulletin. The services available to mem- bers include: health, car and home insurance; a travel programme and a motoring plan; an investment pro- gramme; an AARP credit card; a purchase privilege programme; and a pharmacy service. Using mushroom dyes to prepare colourful handicrafts. There ore many ways to achieve a new interest and involvement in society. Photo Panos Pictures/S. Spragu © 25 The Association is also active in international affairs, serving in consultative status with the Economic and Social Council of the United Nations. It is currently help- ing to prepare for the United Nations International Year of Older Persons in 1999. The future is reflected in the Association 's new vision statement: AARP excels as a dynamic presence in every community, shaping and enriching the experience of ageing for each member and for society. This statement tells members - and the world - that this Association is more than just an organization to serve older Americans. It is con- cerned about people as they age, not just when they are older, and under- lines that community is to be defined as a global community. Building on that vision, AARP states that "we seek through education, advocacy and service to enhance the quality of life for all by promoting indepen- dence, dignity and purpose." Over the years, AARP has been asked many times by individuals from other countries to start, or assist with starting, similar organiza- tions abroad. We are happy to help but recognize that each country and each culture has its own organiza- tional patterns and social needs. The AARP model may not be completely applicable in other parts of the world, but its commitment to service and its ideal of productive ageing have won worldwide respect. In the words of the founder, Dr Andrus: "The human contribution is the essential ingredient. It is only in the giving of oneself to others that we truly live." • Mr Horace B. Deets is Executive Director of the American Association of Retired Persons, 60 1 E Street, N. W, Washington DC 20049, USA 26 World Health • SOth Year, No. 4, July- August 1997 A new lease of life Elza Maria de Souza Recounting their old memories to young people is giving the elderly pioneers who built Brazil's capitol city a new status and a new lease of life. Particularly in old age, many people enjoy going back over old memories. Recounting their memories and experiences to the younger generations helps to keep older people integrated within the community. With this in mind, an intergenerational reminiscence integration project was started in Taguatinga, one of the satellite cities of Brasilia. The project works with the pio- neer people who migrated from different regions to the middle of Brazil in the late 1950s and early 1960s to build Brasilia, the new capital. It started two years ago as a pilot project with 17 elderly people, 10 teachers and more than 300 pupils aged between seven and 16 years old, in two schools situated within the catchment area of one health centre in the city. The elderly people living in the neighbourhood are invited to go once a week to the schools, one person for each class- room, for a one-hour interviewing session with the pupils. The teachers work as facilitators of the groups. The former pioneers talk about their lives, their childhood and their move to Brasilia, including all kinds of details such as toys and games, school days, starting work, courting, and marriage. Emphasis is given to their descriptions of the place when they first came here, their impres- sions and their general feelings about the city now and then. The pupils write down the histories and Pupils show a keen interest in the old lady's story. The Reminiscence Pro;ect hos brought about a better understanding between generations. Photo WHO/M. de Souza make drawings to illustrate them. It is still a very young project but its importance is already visible. The people involved in the project have modified their views of their elderly neighbours and have started showing them more respect and recognition. The exchanges have resulted in a better understanding between the generations, reducing the power of stereotypes and prejudice on both sides and preventing social isolation. This can best be understood through the comments of the students them- selves. "When my teacher told us about the project, I was rather upset. I thought I didn't have anything to say to an older person. That was a terri- ble mistake - I've learned so many things that now I don ' t feel like leaving the project." "Before taking part in the project, I didn't enjoy being with older persons. Now I think it's fantastic to talk to them." "Before joining in the project, I thought elderly people were terribly boring. But now I enjoy spending time with them." For the teachers, the venture brought new meaning to their work. It gave them the opportunity to consider the special role of older people within the educational com- munity. As for the elderly participants, the response has been surprisingly enthusiastic. In their own words: "I was born again! " "Now I greet people in the street." "The reminis- cence process is a good way to prevent depression . I felt isolated before taking part in the work." "Until now, I didn ' t know that I could still be useful." As this project of reliving and recounting old memories results in feelings of reciprocal warmth, trust and a sense of being valued, and offers a chance to develop cultural and educational activities as well as social integration, it can safely be assumed that it is promoting a posi- tive impact on individual and social health. • Or Elza Mario de Souza, a geriotricion, is the medical coordinator of the Reminiscence Pro;ect, SQS l 158/. GAP 208, 70.772-000 Brasilia, OF - Brazil. World Health • SOth Year, No. 4, July-August 1997 27 Jamaica's ''senior citizens'' Denise Eldemire Politicians should consider older people as more than ;ust potential voters. Their health must be put on notional agendas. Photo Keystone/ Comeropress/ L. Smillie © Concerned activists in Jamaica lobbied hard for five years to bring to fruition a notional policy for the ageing, which is also integrated with policies for families and for women. Five years ago a concerned group in Jamaica began a campaign to put ageing policy onto the national agenda, a campaign which has resulted in a national policy being enacted. This small Caribbean island state of 2.5 million persons shares with others many "developing country" characteristics while also experiencing the ageing of its popu- lation. Already in 1995 more than 9% of the population was aged 60 and over while Jess than 32% was aged under 15. Usually referred to here as "Golden Agers" or senior citizens, the elderly vary widely in health and functional capacity and there is also a great variation in available re- sources. In order to put senior citizen issues on the national agenda, both the strengths and the problems of this group need to be highlighted, and so too do the relevant statistics. For example, politicians are always interested in what percentage any group forms of the voting popula- tion. The seniors in Jamaica (10% of the total population) constitute 23% of voters. Policies for the aged reflect the commitment of governments to maintaining ageing persons within society in a state that gives dignity to them as individuals and to the coun- try as a whole. Politicians need to be convinced of this concept, since underlying all social policies should be awareness of the universal princi- ple that the whole of mankind is devalued when any group of human beings is devalued for any reason. Our lobbying efforts stressed that policies for older persons must be integrated with policies for families and for women. The issue was not dealt with in isolation, but was perceived within the overall eco- nomic, societal and cultural context of the nation and of the action pro- posed. As a consequence, the sub- stantial contributions that senior citizens can make to a society won the attention of policy-makers, particularly since facilitating such contributions would not cost large sums of money. Changed perceptions The media played an invaluable role in bringing the issue to public atten- tion. Lobbyists recognized that part of the national agenda had to be a change in society's perception of old age, so as to highlight the positive. Public figures and political leaders, especially those already sympathetic to the issue, were enlisted to help present this positive view. The United Nations principles of individuality, non-dependence, choice, and cohesion among the generations were the driving force for the national policy, together with such concepts as productive ageing, active retirement, self-care and healthy lifestyles. Throughout the campaign the emphasis was on well- being rather than welfare, while the elderly were viewed as a resource and a challenge rather than as a problem or a burden. Jamaica began a programme of "Golden Age" clubs back in 1976, and the work and activities of senior citizens in these clubs became the foundation for successful ageing campaigns. Many politicians be- came convinced of the affordability of supporting these activities, and the clubs also provided the mecha- nism for involving other organiza- tions, the private sector and church groups. The Ministry of Health published information highlighting the problem of chronic disease among older persons. Above all, although the whole process was slow - lasting five years - it was the potential saving in secondary care costs that appealed to the policy- makers. • Or Denise Eldemire is with the Deportment of Community Health and Psychiatry, University of the West Indies, Mono, Kingston 7, Jamaica. 28 World Health • SOth Year, No. 4, July-August 1997 Cuba's ,ir,ulos de abuelos Enrique Vega Cuba is already well advanced in the demographic transition to an ageing society. Currently, over 12% of its population (more than 1.3 million) are aged 60 years and over. Life expectancy for a child born today is 76 years, which is among the highest on the American continent. By the year 2020, one in every five Cubans will be an old person. The policy-makers have understood for some time now that promoting healthy lifestyles and preventing disability are of funda- mental importance for the country 's health policy and economic develop- ment. Yet perhaps the most interest- ing initiative in health promotion in Cuba was started neither by policy- makers nor by health professionals. Instead it is a movement that was started by individuals in the commu- nity for themselves. A decade ago the cfrculos de abuelos (grandparents ' groups) began as a neighbourhood social support network. Today some 20% of elders in Cuba belong to such a group, where older people can go to find companionship and feel at home. Whenever neighbourhood family physicians need help with a vaccination campaign or with a breastfeeding education programme, the cfrculos de abuelos are where they find willing and able resources. That was not the original aim: the first cfrculo (formed in the early 1980s) consisted of older persons who were fed up with hearing the simplistic message that physical activity is good for you. They wanted to know exactly what was involved, so they asked the local family doctor and a physical educa- tion instructor to orient them. This modest initiative started a national movement, and thousands of such groups are now active throughout Cuba. The "circufos de obuefos", the octive community network of older people in Cubo, teoch their members how to monoge their own heolth more efficiently. Photo WHO/Centro lberoamericano de la Tercero Edad Each group works out its own activities. A multidisciplinary team provides guidance and support; it includes a physical education teacher, a social worker, a commu- nity nurse and the neighbourhood family doctor. Exercise programme The cfrculos meet within walking distance of the homes of their mem- bers, in a private house or a park, at the local clinic, or on a beach. For many of the groups, the exercise programme has become the core activity that brings them together. It is based on the belief that a physi- cal fitness programme should consist of enjoyable social activities that enhance the physiological, psycho- logical and social well-being of the participants. Consequently there is a wide range of activities , reflecting the motivation and interest of each group. In 1991 a group of 200 elderly people were interviewed when they first joined a circulo and a second time after a year of participation. At the start of the programme, 85% were suffering from a chronic dis- ease such as arthritis, hypertension, diabetes, asthma or emphysema. At that time 72.6% of men and 85.2% of women had never partici- pated in an exercise programme before, and 82% were taking at least one form of medication on a daily basis. A year later the study showed that the members of this group were managing their chronic illness better and were taking less medication than a year earlier. In fact 35% of the members no longer needed medica- tion and 22% were using a lower dose. In addition, 89% of those who at the beginning of the year had seen loneliness and depression as an important problem in their lives now saw this as less of a problem. The findings of the many other studies that have been done on these groups have been similarly positive. The most important lesson to be learnt from the circulos de abuelos is that neighbourhood networks pro- vide the best means of promoting the health of the elderly. • Or Enrique Vega is Deputy Director of the Centro iberoamericano de fa Tercero Edad, Calle G y 27, Ciudad de La Habana, Cuba. World Health • SOth Year, No. 4, July-August 1997 29 Four months of fruitful and happy life Godfred Paul Training those who will care for frail elderly people. Photo WHO/ATCOA II Death, which is considered terrible by many people, was welcomed by my mother with full knowledge that she had lived a full life", says Dr Maribel C. Dizon. Her mother, Professor Emy E. Cosme, died at 66 with happiness and a sense of fulfil- ment. A professor at Tarlac State University in the Philippines, she had to stop working for health rea- sons. She was an insulin-dependent diabetic and nearly died in 1993 as a result of an enlarged heart caused by diabetes. Because of her illness, her family had to face other challenges, particularly with regard to her mem- ory and mental health. It was during this critical period that Dr Dizon learned about the Asia Training Centre on Ageing (ATCOA) and its activities, includ- ing the workshop on care for demen- tia. "Through the things learnt in the workshop, my concern and under- standing - coupled with love for older people - increased, especially towards my mother. Once I applied some of the knowledge and skills I gained from the workshop, I noticed a number of changes in my mother: Depression: This was alleviated by strengthening and maintaining a deep sense of love and belonging. Her spirits improved. Aggression: The whole family ensured that she was informed and consulted on matters of importance, and that her advice was sought and valued. This made her relax. Communication: This was im- proved by the family using short sentences in communicating and giving her sufficient time to answer. The result was positive interaction. Wandering: We listened to her complaints, and became more flexi- ble in our own views. We touched her, combed her hair, told her stories, and in general tried to rechannel her behaviour into the activities she enjoyed best. "Now I can say that, wherever my beloved mother is, the last four months of her life were fruitful and _happy, as a result of my participation in ATCOA's training programme. The excellent training materials make it easy to share the information with family and friends. My mother was able to receive the best care within the family". Besides the training courses, ATCOA develops multimedia train- ing materials based on the needs in developing countries. These are used throughout the world by age-care trainers. Recently, ATCOA has been asked by some governments to study and make recommendations on welfare services for older people in their respective countries. It also provides consultancy services and arranges training programmes on request by government and non- governmental organizations in the reg10n. Dr Maribel is now busy inform- ing people about ATCOA and en- couraging them to improve their knowledge and skills in age care. She emphasizes: "Understanding and care for older people should start in the family. It will then change attitudes in the community". • Mr Godfred Paul is Training Adviser with the Asia Training Centre on Ageing {ATCOA), Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand The Asia Training Centre on Ageing (ATCOA) is an initiative of HelpAge International in response to the challenge posed to the Asia Pacific reg ion by the ageing of its popu lation. Its aims are to improve the knowledge, understanding and skil ls of individuals and groups who work at all levels in age care throughout the Region. Based at Chiang Mai University in Thailand, ATCOA is a regional resource for train ing in all aspects of ageing, focusing on practical responses. The centre offers a programme of high quality training courses in areas such as the ageing process; residential and commun ity ca re; policy issues; environment and bu ilding design for older people; and ageing and disability 30 World Health • SOth Year, No. 4, July-August 1997 Care for the elderly - by the elderly Doris Mariebel DI. Camagay Mang Ben weaved his way in the darkness over the wooden planks. He cursed himself for not bringing a tlashlight. It would be easy to fall through the boards into the sea below and, after a slight drizzle, the boards were slip- pery. Finally, he came to a flimsy structure, precariously wedged between other precarious structures along the shoreline in Manila. As he entered, he saw his friend Pedro lying on a straw mat in the one-room home, while his wife and neighbours sat on the fringes of the mat, concern written on their faces. Ben unzipped his bag and pulled out his stetho- scope, thermometer, blood pressure gauge, blood sugar device ... Mang Ben is 73 years old and has had only minimal formal education. His patient, like Ben, is a member of a community-based programme for the elderly. Both are old friends and active in the programme, but Ben has been trained to be a "community gerontologist". I work as a geriatri- cian with an organization called the Coalition of Services of the Elderly (COSE). In the course of the past year, I have trained members of the programmes for the elderly to be- come community gerontologists. The community gerontologists receive an initial orientation on diseases common to elderly people, and on remedies including herbal medicine and local practices. After this initial training, they meet once a month to discuss difficulties, suc- cesses and failures. At their gradua- tion, they are presented with a medical bag containing the "tools of their trade." They are encouraged to keep a file on all the elderly (whether members or not) in their respective urban areas. Recently, I have helped the community geron- tologists to open a small clinic in the heart of the commercial district of Quezon City. Since the majority of elderly patients do not absolutely need the services of a professional physician, the community gerontolo- gists act as a filter for the one physi- cian who is available to treat them. In addition, since they are elderly themselves, they are more able to empathize with the specific illnesses of elderly patients. Founded in 1989 with the en- couragement and support of Help Age International, COSE set for itself three main objectives: A community gerontologist takes the blood pressure of an elderly lady in the Philippines. Photo WHO/ COSE • to encourage any group already working with or interested in the elderly to exchange services so as to be of better value to this most important sector; • to intensify existing respect for the elderly as well as to increase public awareness about the looming crisis in care for the elderly; • to invite, support and train lead- ers for community-based pro- grammes of the elderly, especially (but not exclusively) in urban poor areas. Since its foundation, COSE has established 35 community-based programmes for the elderly in the greater Manila area as well as in other major areas of the Philippines. We define these programmes as community organizations of elderly people (aged 55 and above), gener- ally in urban poor areas - known here as "squatter areas" - which will have income-generating potential, health care, a social life of their own and an insurance system. The insur- ance system is, in fact, a burial fund. A surprising number of elderly people worry not so much about dying as about the expenses incurred for those left behind. By contribut- ing the equivalent of 40 US cents per month, the elderly are guaranteed the $ 300 necessary for a dignified wake and burial. The elderly are the fastest growing population group in Asia, including the Philippines. Economically, culturally and humanly speaking, it is clearly the best solution to keep the majority of the elderly active and healthy in their own community for as long as possible. • Dr Doris Mariebel DI. Camagay is Medical Officer with the Coalition of SeNices of the Elderly, Inc. (COSE), 14-C Manhattan Street, Cubao, Ouezon City, Philippines . World Health • SOth Year, No. 4, July-August 1997 31 longer, healthier lives Toshihito Katsumura & Adrian D. Hinman With the highest life expectancy in the world, Japan has to face the challenge and meet the cost of caring for its burgeoning elderly population. Photo Keystone/!. Sirman© In the 21 st century, a physically active lifestyle will be a main contributor to maintaining a high quality of /if e in old age, and help us to see our later years as a time of we/I-being. I n 1950, the average life expectancy in Japan was just over 50 years of age. Now, less than a half a century later, this figure has increased to over 75 for men and over 80 for women, giving the coun- try the highest average life expectancy in the world. Japan is becoming the focus of much atten- tion, as researchers try to determine what has enabled its people to attain such longevity, and as other coun- tries search for solutions to the problems inextricably linked to an increasing life expectancy, such as caring for the elderly, and the costs associated with that care. As the number of people over 65 years of age in the Japanese popula- tion has steadily increased, so too have the costs of medical care. Elderly citizens who are bedridden or suffering from dementia comprise a large portion of those requiring medical care. So the search is on for ways to maintain and promote health, particularly for over-65-year- olds, in an effort to improve the quality of life for the elderly as well as to curb health care costs. Given this trend of longevity in Japan, one of the primary goals of the WHO Collaborating Centre for Health Promotion through Research and Training in Sports Medicine is to find cost-effective methods of increasing the quality of life for the elderly and reducing the number of those who are bedridden or suffering from debilitating di seases. A signif- icant portion of our research here has focused on the benefits of physical activity for the aged. Physical activ- ity and exercise promotion can be carried out with very few resources, and are therefore more cost-effective - as well as more enjoyable - than most other types of preventive medicine. Disease prevention It is often said that remaining physi- cally active contributes to the main- tenance of good health, but what role does exercise actually play in pre- venting di sease and slowing down the effects of ageing? Our research has focused on the effects of aerobic and other forms of exercise in pre- serving good health throughout life. The benefits of exercise include strengthening muscles and joints, increasing flexibility and improving balance and agility, all of which are known to deteriorate with age. As strength and flexibility improve, the likelihood of injury to joints, bones and muscles decreases. Further, as people remain longer in better physi- cal condition, they will also remain 32 more independent of crutches, walk- ers, wheelchairs and human help. Maintaining a physically active lifestyle from a young age also appears to help to prevent the onset of osteoporosis later in life. Our longitudinal studies on both physically active and sedentary people suggest that regular aerobic exercise confers the added advan- tage of reducing risk factors for heart disease, such as atherosclerosis. In Japan, the number of elderly people suffering from dementia as a result of cerebrovascular disease is greater than the number of those suffering from dementia caused by degenera- tive diseases of the nervous system, such as Alzheimer disease. Thus, by helping to prevent atherosclerosis, regular physical activity may also help to reduce the risk of cerebrovas- cular disease and, in many cases, the resultant onset of dementia. Besides strengthening the mus- cles, joints and bones and combating age-related diseases, physical activ- ity improves the quality of life of the older population, enabling people to remain independent and active for much longer. We are also studying the effect of regular exercise on mood and general mental health. Exercise is often done in groups, making interaction easier among people who might otherwise become isolated. For elderly people who have retired or have reduced the amount of time they spend working, a regular habit of exercise provides their everyday life with consistency and purpose, and can help to fill the vacuum which is often experienced after retirement. Government support In the last few years, the Japanese Government has promoted physical activity among its citizens as a means of preserving health. In July 1993, the Tokyo Metropolitan Government opened its Health Promotion Centre, and in March of this year, the Japanese Ministry of Health and Welfare published the report of the Committee for Health Promotion through Physical Activity World Health • SOth Year, No. 4, July-August 1997 Making tofu in the Kyoto oreo. Encouraging physical activity as a means to prevent diseases opens the way to an active and independent life for many elderly people. Photo Panos Pictures/}. Holmes © throughout Life. This report gives information on the frequency, dura- tion and specific types of exercise that are beneficial for elder individu- als, and also provides guidelines on exercise for younger people which will help them to maintain their health throughout their lives. It was written and published with help from our centre, and we will produce an English version later this year. In order to study the effects of physical activity on health in more depth, we investigate differences in the mental and physical health of people involved in different levels of exercise, ranging from those who lead a sedentary life to full-time athletes. While determining the benefits of exercise, we also focus on possible negative effects , such as over-training, so as to make a recom- mended exercise "prescription" that will enable people to live not only longer but better. We work closely with the Tokyo Metropolitan Health Promotion Centre in educating people on health maintenance through physical activity and proper nutrition. The Tokyo Metropolitan Health Promotion Centre holds 13-week practical instruction pro- grammes for Tokyo citizens during which participants and instructors work to develop an individualized exercise plan to suit the participant's lifestyle and current physical fitness level. Through periodic physical exam- inations and investigative research during the programme and in the following years, we monitor changes in physical health that have resulted from the participant's adopted exer- cise regimen. The goal is to generate enthusiasm for physical activity, as well as to develop a specific routine to be followed. The success of the Tokyo Metropolitan Health Promotion Centre has led to the growth of other centres throughout Japan, and may inspire similar government-sponsored health pro- motion centres in other countries. In the 21st century, as advances in medicine continue to be made, average life expectancy wi ll proba- bly continue to increase, as will the percentage of the population consist- ing of people aged over 65 . A physi- cally active lifestyle will be a main contributor to maintaining a high quality of life during those later years. Perhaps more importantly, the effects of keeping active will help us to see old age as a time of well- being. • Dr Toshihito Katsumura is Director of the WHO Collaborating Centre for Health Promotion through Research and Training in Sports Medicine, and Director and Professor of the Department of Preventive Medicine and Public Health, Tokyo Medical College, 1-1 Shin;uku 6-chome, Shinjuku-ku, Tokyo 160, Japan. Dr Adrian D. Hinman is Assistant to Dr Katsumura. World Health • SOth Year, No. 4, July-August 1997 Training for ageing Julian Mamo The Malta-based International Institute on Ageing has already trained more than 950 persons from 96 developing countries during the past seven years and looks forward to training even more in the years ahead. I NIA - the International Institute on Ageing- based on the Medi-terranean island of Malta, is very much an institute about people. Set up in April 1988 through a unique collaborative arrangement between the United Nations and the Malta Government, INIA receives some support from both and generates more in its main mission to provide training for personnel from develop- ing countries. An ambitious under- taking with a vast target audience for a small institute, INIA set about its task with enthusiasm, embarking on what has become a regular pro- gramme of international training each year since 1990. Considered as extended members of the Institute's "family", INIA's students - some of them experts in their own right - are sensitized to ageing issues through a highly participative and intensive two-week programme before return- ing home to spread the message. Colonel S.M. Zaki was one of INIA's pioneers. After a distinguished military career he "retired" to found the Pakistan Senior Citizens Association and to serve as its Vice President. Conscious of the great potential for a growing number of Pakistani elders to follow a healthy retirement, he Students from all over the world visit Malta to attend the International Short-Term Training Course in Geriatrics. Photo WHO/ International Institute on Ageing, Malta subsequently wrote a guide for other elderly people entitled "The Life- Style for Senior Citizens". This was reviewed in one of INIA's quarterly editions of its journal, Bold. Later he carried out a mission for WHO in Pakistan to investigate the situation of elderly persons. Dr Mladen Davidovic also at- tended INIA's first course, on geri- atrics, in 1990. He went on to become head of the Clinical Institute for Geriatric Medicine in Belgrade and recently contributed to another INIA publication, Age Vault. He plans to hold an international semi- nar on "clinical medicine in later life" in collaboration with INIA in 1998. INIA course tutor, Professor Nana Apt from Ghana, who writes in this issue of World Health , discussed education on ageing and gender at a recent INIA conference tackling the Population and Development issues of Ageing following the Cairo Conference bearing that name. She had attended an INIA course in Malta in October 1995. Writing in a conference publication produced by the Institute called "Meeting the Challenges of Ageing Populations in the Developing World", she de- scribes the plight of elderly African 33 women who are disadvantaged economically and socially, and stresses the need for continuing training and education into later life. In 1989, she set up the African Gerontological Society (Ages) and recently became the first representa- tive of the African continent on the INIA board. INIA's Director, Dr George J. Hyzler, has planned a full series of events for 1997 to involve more people, including missions to Panama and Mexico besides four regular short-term courses in Malta. He also plans to host a new course for physiotherapists and occupa- tional therapists for the first time this year in collaboration with the World Federation of Occupational Thera- pists and the World Confederation for Physical Therapy. An example of the active ageing professed by his Institute, Dr Hyzler is himself a retired government minister and served in his country's parliament for 33 years, as well as being a medical practitioner. The Institute has already trained more than 950 persons from 96 developing countries during the past seven years and looks forward to training even more in the years ahead. It maintains contacts with its "extended family" through an information network and through its journal Bold. Many of its present activities are focused towards the UN International Year of Older Persons scheduled for 1999. • Dr Julian Mamo is Deputy Director of the International Institute on Ageing, United Nations -Malta, I 17, St Paul Street, Valletta VLT 07, Malta . 34 World Health • SOth Year, No. 4, July-August 1997 WHO Interview Growing old in China Dr Zhu Han-Min, Head of the WHO Collaborating Centre for Community Health Care for the Elderly in Shanghai, was interviewed by Christopher Powell of WHO's Health Communications and Public Relations Unit. World Health: Can you tell us what the work of your Institute involves? Dr Zhu: The Shanghai Geriatric Institute is, among other things, a WHO Collaborating Centre for community health care for the el- derly. It depends directly on the Shanghai Health Bureau, which in turn is an arm of the Ministry of Health. I am also Vice-President of Hua Dong Hospital in Shanghai, where I take a particular interest in the health of the elderly. The Institute itself was founded in 1987 and its main purpose is to undertake research into the mechanics of ageing, to find out how the process of ageing can be delayed. We are trying to determine approaches to the prevention of sickness in the elderly that are suited to our eco- nomic level and our domestic customs. WH: Why do we need new approaches? Dr Zhu: The fact is that the popula- tion of Shanghai is ageing very rapidly. The percentage of people aged 65 and over is more than four times as large now as it was in the 1950s. In China, the family has always traditionally cared for the elderly, and in former times 90% would stay with their family, in an environment with which they were familiar. Now our society is chang- ing and, with the development of nuclear families, a: gap is forming between the generations . Old people Maintaining the family bonds. Keeping active and well integrated in society is a source of fulfilment and good health. Photo Panos Pictures/ C. Stowers© themselves are less ready to stay with the family while the younger generation are finding it difficult to accept older people in their homes. This is why the social sector is strengthening education efforts to try to counter this gap, not least by encouraging the "young elderly" to care for the "old elderly" in the community. WH: What practical measures are there in place to help the elderly? Dr Zhu: The two main approaches are to develop education, especially in the fields of lifestyles and nutri- tion, and to encourage older people to have regular check-ups, at least once or twice a year, so as to identify diseases and treat them early. These approaches are adopted at all three levels of the health services - munic- ipal, district and community. The staff at all levels go to visit the elderly in their community, since hospital consultations are costly and most old people cannot afford them. The health services are trying to develop home care as much as possible. Our staff also do social work, arranging activities for the elderly such as exercise, short jour- neys, lectures, gardening and paint- ing, as well as helping them to acquire self-help health skills. WH: Is the situation the same for elderly women as for elderly men ? Dr Zhu: The proportion of elderly women is always higher than that of men. A very interesting thing is that, in our cities, the average life ex- pectancy is longer in females than in males, but the active life expectancy is shorter in females than in males. For different reasons the women World Health • SOth Year, No. 4, Ju ly-August 1997 suffer more from chronic diseases and a loss of ability to manage the tasks of daily living; this seems to be due to the traditional cultural back- ground. The man who is retired at home tends to have a less stressful life while the women continue to be exposed to many demands, and this affects their active life expectancy. WH: Do the elderly have a prefer- ence for traditional treatment and traditional medicine? Dr Zhu: Many doctors prefer to offer traditional therapy because it's not expensive, while Western medi- cine is very dear. Older people tend to be poor and the cost of living always seems to be rising after retirement, so they prefer traditional medicine. If the simple way has a good effect we use it; you don't always need modem pharmaceutical treatment to bring about improve- ments. WH: What can you do to maintain the psychological health of older people ? Dr Zhu: This is very important in elderly health care. When men and women are retired, there is often an imbalance in some area, especially in the male. This might show itself in depression, or anger with other family members. We are trying to establish a new approach in primary prevention to correct such imbal- ances. For instance, we organize the old people for education, for visits or for forms of entertainment. Again, these activities are organized at the municipal and community level. And they are all free. Of course, health care itself and medical ser- vices are free, at any of the four types of medical facilities - those run by the government, by the work- place from which they have retired, by the cooperative in the countryside or by the insurance scheme. The community or district hospital is available if there should be a health crisis. WH: Does the effect of the one-child family policy pose a problem, since there will be fewer younger people to care for the elderly? Dr Zhu: Yes, there will be a big problem. We have always expected younger persons to care for the older ones. In the 1950s and 1960s, fertil- ity was encouraged and this resulted in a "baby boom." After that, fertil- ity was restricted through the one- child family principle and fell to a low level; there was no longer the replacement factor. In about 80% of Fascination of ploy in Chino. Developing social networks is essential for sustaining autonomy in old age. Photo Keystone/ M. Rutschi © 35 families , the elderly live at home with the younger generation. Furthermore, the nuclear family is rapidly growing in our cities. In the next century there will be a situation where one son or one daughter may have to care for four or even six elderly people. The older ones may stay at home but the younger ones cannot stand it! WH: So what is going to be the solution ? Dr Zhu: We believe that the best way is to develop health care based on the community, so each and every community will create a community service centre capable of catering for old people who may have lost the ability to cope with daily living. When the younger persons go out to work, there will be nobody left at home to offer care, so the commu- nity centre will be able to arrange the necessary care. WH: ls the government doing enough to help the older generation? Dr Zhu: Certainly. There is a real political commitment on the part of the government. In Shanghai, we have two policies to deal with the problems of ageing. Firstly, we have to protect older people's rights. Secondly, we have to convince the younger generation that they must assume their responsibilities as carers for the previous genera- tions. • Dr Zhu Hon-Min , Professor of Geriatrics, is Vice-President, Hua Dong Hospital, Shanghai Geriatric Institute, Shanghai Municipality, No. 22 1, Yon An West Road, Jin An District, Shanghai, Chino. 36 Ageing in Lebanon Abla Sibai In Lebanon today, older people have to live with the trauma of the recent past. Many of them need the support of social seNices. Photo Panos Pictures/M. McEvoy © In 1970, the United Nations esti-mated the proportion of the popu-lation in Lebanon who were aged 60 and older at 7.4%, and in 1985 they estimated it at 7.8%. The figure for 1995 was 8.3%. As a small country which has only recently emerged from 16 years of war and foreign intrusions be- tween 1975 and 1991 , Lebanon has made only a few limited studies of its increasing numbers of elderly people. Usually they either remain "invisible" within the total popula- tion studied or are not seen as a group that is worthy of the attention of researchers and analysts. Social security systems for meeting their needs are lacking, and there are no technical and administrative units responsible for planning specific services for them. Health professionals, including social workers, receive no formal training in the care of the elderly, and no reliable data exist on the supporting role of the family. While cultural and ethical values still protect the majority of the older people of Lebanon, it is likely that changes in family structure, the declining numbers of children and the increasing numbers of women who go out to work have weakened the family as a care institution. Incessant warfare brought with it stressful experiences and events that had a devastating impact on individ- uals and on society as a whole, disrupting normal patterns of daily life, the family and the social struc- ture. Deaths in the family, injuries, destruction of property, kidnappings and associated threats were widely experienced by the entire popula- tion, but older people tended to feel more deeply the loss or threatened loss of their autonomy and well- being. Many were left homeless and jobless while their savings were eroded, resulting in chronic financial strain and deprivation. Often they received none of the support that they might have expected from younger relatives, who were more likely to have migrated out of the country. Studies have shown that constant exposure to the stresses of war has a long-term impact on the health of middle-aged and elderly people. For both men and women, the risk of early death, particularly from cardio- vascular disease, is significantly higher and this is especially true for those in the lower social and eco- nomic categories. When fighting first flared up in 1975, the majority of Lebanon's present elderly popula- tion were in the prime of their pro- World Health • SOth Year, No. 4, July-August 1997 During Lebanon's years of war, securing water, food and shelter became overwhelming burdens for many old people. Imagine what it was like for a 70-year-old living in a l Oth floor apartment with no electricity- therefore no lifts - to have to carry up water and ordinary supplies for years on end. ductive life; they are still suffering from the consequences. During those years of war, tasks of everyday life such as securing water, food and shelter became an overwhelmjng burden. To under- stand this we only have to imagine what it was like for a person aged over 70 to live in a lOth floor apart- ment with no electricity - therefore no lifts - and to have to carry up water and ordinary supplies for years on end. Clearly, there is need for positive social action in Lebanon in support of the elderly who today still carry with them the traumas of the recent past. More broadly, society in gen- eral should take note that wars and civil strife can break out almost anywhere, and that people in the older age groups are frequently among the "invisible" yet most vulnerable of the victims. Raising public awareness about the plight of these victims should be placed firmly on the agenda of the interna- tional community. • Dr Abla Siboi is a lecturer in the Faculty of Health Sciences, the American University of Beirut, Beirut, Lebanon. World Health • SOth Yem, No. 4, July-August 1997 37 Facts and figures Research looks at safety of oral contraceptives More than 70 million women around the world, including 38 million in developing countries, use oral contraceptive pills. Most of these pills are "combined" oral contraceptives which contain a combination of the hormones estrogen and progestogen. The doses of the hormones have been reduced since contraceptive pills were first introduced in the 1950s. Most oral contraceptives today are low-dose combined pills. Oral contraceptives prevent pregnancy very effectively and, for the vast majority of young healthy women, taking the pill involves much less risk than becoming pregnant and giving birth. In 1986 researchers started to evaluate the safety of low-dose combined pills in 21 centres in 17 countries (12 developing and 5 developed) . Their findings on the risk of stroke and heart attack became available recentty. Oral contraceptives and stroke Stroke is caused either by bleeding from a blood vessel in the brain (haemorrhagic stroke) or by obstruction of a blood vessel in the brain (ischaemic or thrombotic stroke) . In the survey, women over 35 years who used combined oral contraceptives had a slightty increased risk of haemorrhagic stroke, though this did not apply to women under 3 5. Most of the risk was concentrated in women who had a history of hypertension ( l 0-15-fold increased risk) or who smoked. In the case of ischaemic stroke, women who used the pill showed a small overall increase in risk. Once again, however, the risk was mainly in older women, smokers and those with high blood pressure. As with haemorrhagic stroke, the risk of ischaemic stroke was considerably increased in women with a history of hypertension. Stroke is rare among women of reproductive age so the extra risk due to using oral contraceptives is very small in absolute terms. In European women under 35 years of age, for instance, the extra risk is about one case per 200 OOO users per year. This small risk can, of course, be reduced further by not smoking and by avoiding the pill altogether if you have high blood pressure. Oral contraceptives and heart attack The research showed there was very little, if any, increased risk of heart attack among women who used oral contraceptives and had no predisposing risk factors for cardiovascular disease (e.g. high blood pressure, smoking, diabetes). However, among pill users who smoked or had high blood pressure, the risk went up noticeably. For instance, pill users who smoked at least 10 cigarettes a day had a risk of heart attack 20 times that of women who neither smoked nor used the pill. Like stroke, heart attack is rare in women under 35 years (less than one case per million women per year) and increased risk from using the pill is negligible. However, in women under 3 5 who both smoke and use the pill the incidence of heart attack is about 40 cases per million women per year. In women over 35 who smoke and use the pill it is as high as 500 cases per million women (or one woman in every 2000) per year. Healthy young women should not fear to use the pill on health grounds. But the rise in risk among some subgroups of women is a reminder that the pill is not safe for every woman. Potential pill users must be screened so that women already in the higher risk groups can be advised to use another form of contraception. Pill users who smoke should be strongly encouraged to stop smoking. This summary is based in part an issue 39 of Progress in human reproduction research, the newsletter of the UNDP / UNFPA/WHO/ World Bank Special Programme of Research, Development and Research Training in Human Reproduction. For further information, or for a subscription to the newsletter, contact: Special Programme of Research, Development and Research Training in Human Reproduction, WHO, l 2 l l Geneva 27, Switzerland. Health expectancy is more important than life expectancy As people live longer, the risk of noncommunicable disease grows. The World Health Report 1997 describes some of the hazards of living longer, as follows: • Of more than 15 million deaths from circulatory diseases in 1996, 7.2 million were caused by coronary heart disease, 4 .6 million by stroke, 500 OOO by rheumatic fever and rheumatic heart disease, and 3 million by other forms of heart disease. • An estimated 691 million people have high blood pressure. • There are some 6 million deaths from cancer each year, half are them due to cancers of the lung, stomach, colon-rectum, liver and breast. • At least 15% of all cancers are due to chronic infections such as hepatitis B and C viruses (liver cancer), the human papilloma virus (cervical cancer), and the Helicobacter pylori bacterium (stomach cancer) . • New cancer cases in developing countries are expected to at least double in the next 2 5 years. • Tobacco causes 3 million deaths a year. Smoking accounts for one in seven cancer deaths. • The number of people with diabetes is expected to more than double from 135 million now to 300 million by 2025. • More than 50 million people suffer from different types of epilepsy, 2 9 million have dementia, and 4 5 million are affected by schizophrenia. • Rheumatoid arthritis is estimated to affect 165 million people. • There are 160 million cases of occupational diseases each year. Later death is of course a benefit but it is essential to reduce the suffering and disability that longer life often brings. "Increased longevity without quality of life is an empty prize," says the report. "Health expectancy is more important than life expectancy." 38 The effects al violence are growing Around 300 OOO people are murdered and 800 OOO more kill themselves each year. Wars, conflicts and violence between individuals have been putting life and health at risk for as long as diseases. But violence in all its forms has increased dramatically in recent decades. During 1993, at least 4 million people died as the result of intentional or unintentional injury (8% of all deaths). In many countries, up to four in every l O deaths among males aged 15-34 are due to murder or suicide; in some countries the figure is seven out of l 0. Homicide rates among 15-34-year-olds have more than doubled in the last five years. In Latin America and the Caribbean violent deaths average 1250 a day. In half of the countries of the region, murder is the second leading cause of death in young people aged 15-24. In the United States 65 people are killed each day and more than 6000 wounded in acts of interpersonal violence. Suicide is a deliberate act carried out by a person who expects it to result in death. Worldwide, suicide is most common among men and gets more likely with age. Consequently, men over 65 years who live alone are the group with the highest risk. Recently, however, there has been a rise in suicide rates among young people (both male and female) . Many suicide deaths are not reported as such for religious, cultural or other reasons. Experts believe that many deaths attributed to accidents are disguised suicides. Violence against children can take the forms of physical abuse, sexual abuse, emotional abuse and neglect. These are worldwide problems and studies suggest that the rate of child abuse and neglect of children under five years could be between 13 and 20 per l 00 OOO live births. Surveys of adults in several industrialized countries suggest that l 0%--15% of children are victims of sexual abuse - most of them girls. Violence against women is also worldwide and often goes unreported. In some countries, domestic violence is the leading cause of injury among women of childbearing age, and up to 35% of women's visits to emergency treatment centres are for that reason. The prevalence of violence against pregnant women ranges from 7% to 20% and it is more common than many other conditions routinely screened for during pregnancy. So many health workers ... in some places Developed countries have on average 250 physicians for every l 00 OOO population, compared with just 14 per l 00 OOO in the least developed countries. The developed countries have around 7 50 nurses and midwives for every l 00 OOO people, while the least developed countries have about 20. The workforce accounts for some 70% of the recurrent health budget in many countries. The above three items ore based on information from The World Health Report 1997. World Health • SOth Year, No. 4, July-August 1997 Micronutrient malnutrition Worldwide, millions of people are malnourished. More than 800 million people cannot meet basic needs for energy and protein, over 2000 million lack essential micronutrients, and many millions more suffer from diseases caused by unsafe food or unbalanced diet. More than half the young children who die in developing countries are malnourished. This does not mean that they starve to death but that poor nutrition lowers their resistance to killer diseases. It is at the stage when the human body is developing that malnutrition has its most severe effects. Apart from the 6.6 million malnourished children under five who die each year, 17 4 million more are underweight and 230 million have stunted growth. Four main types of malnutrition are the most damaging. Protein-energy malnutrition This is a lack of essential protein and energy from carbohydrates. A malnourished mother is likely to have a baby with low birth weight, while children with protein- energy malnutrition do not grow as well as others. This kind of malnutrition is an underlying cause of almost one-third of deaths among children under five years. Iron deficiency This is the commonest type of micronutrient malnutrition. It causes anaemia, especially in women of reproductive age and young children. Many women spend much of their lives short of iron but during pregnancy, when the body needs extra supplies, iron deficiency can cause extra harm. It increases the baby's risk of low birth weight, anaemia and protein-energy malnutrition, and lowers the mother's chances in case of haemorrhage or sepsis at childbirth. Iron deficiency can be countered by eating iron-rich foods such as meat and fresh fruit and vegetables. Drinking tea or coffee with meals, or soon afterwards, should be avoided since it reduces absorption of iron. The usual way to make sure that pregnant women have enough iron is to give iron supplements, often in the form of tablets. Iodine deficiency This is a public health problem in 118 countries. As a result at least 30 OOO babies are stillborn each year and more than 120 OOO are born mentally retarded, physically stunted, deafiTiute or paralysed. The answer is to iodize salt supplies. WHO's goal is that 90% of salt consumed will be adequately iodized by the year 2000. Vitamin A deficiency One child in every four in developing countries is at risk of vitamin A deficiency. One in five children with the deficiency is at increased risk of death from common infections, and one in 50 is blinded or suffers serious sight impairment. Some countries have organized twice-yearly distribution of vitamin A capsules to infants and young children. Foods rich in vitamin A are dark-green leafy vegetables, orange coloured vegetables and fruits, and liver, eggs and milk products. World Health • SOth Year, No. 4, July-August 1997 39 WHO publications Publications con be ordered from Distribution and Soles, WHO, 121 1 Geneva 27, Switzerland. Osteoporosis and the risk of fracture The health problems caused by asteaparosis can be serious, though recognition I of this has been surprisingly recent. Even today, many general practitioners are unaware of just how serious the disorder can be among women after the menopause. Even among specialists there is no clear consensus on the criteria for screening or even on the efficacy of treatment methods. The report of a WHO Study Group describes how common osteoporosis is and how it is caused. It evaluates various techniques for measuring bone mass, mineral density, and turnover of bone tissue, and looks at the various factors that con make the disorder better - or worse. The report also discusses the risks and benefits of different types of treatment. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: Report of a WHO Study Group (ISBN 92 4 120843 OJ is No. 843 in the WHO Technical Report Series. The report costs Sw.fr. 22. -/US $19. 80 (Sw.fr. 15.40 in developing countries}. Preventing blindness through primary health care A round 148 million people are either blind or have significant visual Mimpairment. Most of these people are in developing countries and much of their visual incapacity could have been prevented or can be cured. Strategies for the prevenffon of blindness in naffonal programmes explains how national programmes con prevent blindness and utilize resources efficien~y in doing so. It describes how national programmes can develop and strengthen services for eye health, how they con do this through a primary health care approach, and how they con recruit and train personnel and provide adequate supplies and equipment. This book was first published in 1984. The second edition published this year has been revised to include recent advances in eye health core. Half of the book is devoted to the major diseases and conditions that cause blindness in developing countries-trachoma, vitamin A deficiency, onchocerciasis, cataract, eye damage, glaucoma and diabetic retinopathy- and ways of controlling them. There is also a chapter on childhood blindness. Strategies for the prevention o f blindness in national programmes (ISBN 92 4 154492 9} costs Sw fr 28 -/US $25 20 (Sw.fr 19.60 in developing countries) How to recognize and treat malaria Malaria con be cured and prevented, yet it is an enormous health problem in many parts of the world. Often people do not seek treatment early enough, either because they do not realize the danger or because they think they have some other common infection. Malaria: a manual for community health workers shows how the damage done by malaria can be reduced, even with minimal resources. People must be encouraged to seek help immediately if they have a fever; their treatment should be carefully explained to them and, if necessary, supervised. This practical book explains how malaria is transmitted, gives a step-by-step description of the correct treatment for different age groups, and advises on what to do if standard treatment fails. The manual explains simply and with illustrations what community health workers should do to control malaria. Special attention is given to the treatment of malaria in young children and pregnant women. Malaria: a manual for community health workers {ISBN 92 4 154491 OJ costs Sw.fr. 16. -/US $ 14 40 {Sw.fr. 11 . 20 in developing countries). Do you have something to say? If you have commen ts, ideas or suggestions on any o f the topics covered in thi s issue , please w rite to the Ed itor, World Health , World Hea lth Organization, 12 1 1 Geneva 27, Switzerland . Letters should be not more than 250 words in length. Letters will not necessarily be acknowledged. The Editor reserves the righ t to edit material selected for publication. In the next issue Did you enjoy this issue? Why not take out a subscription to World Health and enjoy reading about the world's major health issues six times a year. 1997 subscription prices are listed below. The financing of health care involves a set of policies that have im portan t implications for equity, efficiency and sustainability in the health sector. The September-October 1997 issue of World Health will show approaches that are being tried in different countries th at attempt to conta in costs wi thou t jeopardiz ing the qual ity o f ca re, mobilize resources w hi le protecting access to care and obta in the best possible outcome from health investments. WHO also offers its popular "Health Horizons' subscription, a combined subscription (at a reduced rate) to World Health and the quarterly World Health Forum. 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