Add life to years [full issue]

Add life to years WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • FEBRUARY-MARCH 1982 Cover: Add Life to Years. This poster for World Health Day 1982 was con- tributed by the In- ternational Green Cross. IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English, French, Portuguese, Russian and Spanish, and four times a year in Arabic and Persian. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents Add Life to Years by Halfdan Mahler 3 The controlling elders by Ing K. 4 The World Assembly on Aging by William M. Kerrigan 7 Keeping watch on the water by Lita S. Consignado 8 Solidarity with the aged by Joseph Franceschi 11 Senility: the outlook is bright by Marian Emr 13 Working to the last by Carlos Denton 16 Aging: a statement on health policy by Leo A. Kaprio 20 Where age brings honour by Jitendra Tuli 22 Geriatric medicine — why? by Jean-Pierre Junod 26 Mental health in old age by Theodore Hovaguimian 30 The face of old age: photographs by Jean Mohr 32 They defied old age 36 News Page 38 2 Add life to years by Dr Halfdan Mahler Director-General of the Worlc Health Organization WORLD HEALTH DAY 1982 ging is not simply a physical process but a state of mind, and today we are witnessing the begin- ning of a revolutionary change in that state of mind. In the past, and especially in most industrialized countries, aging implied enforced retirement, loss of physical functions and mental capacity, accompanied all too often with isolating the individual from the normal activities of society. The aged person was considered as suffering from an irreversible form of illness and was treated like a sick child. The image of the aged person as one who is tottering towards the grave, battered by illness and mined by disease, beyond the capacity for loving and incapable of taking care of himself, much less rendering service to others, is false. Recent studies of healthy individuals show that, even at seventy years of age, they can do far more than take care of themselves; they can do a good day's work, use their minds creatively, carry on loving relationships and play an active role in the community. Therefore, the stereo- type of the old as helpless and useless must be discarded. To change the stereotype, the aged themselves must play a more active role. It is up to them to assert their right to participate in the necessary care and health activities they require, as full adult par- ticipants. Health for all by the year 2000, with its emphasis on primary health care, necessarily includes the participation of the aging, who often know best what is needed and how it should be carried out. Aging is a vulnerable period. Older people are at greater risk than any other age-group apart from infancy. A lifetime of exposure to hostile elements in the environ- ment, the ticking down or the irregular ticking of the biological clock make them particularly vulnerable. Therefore, aging Proud of his work, proud of his grandson, this sturdy Indian farmer savours life to the full. (Photo WHO/A. S. Kochar) people require a wide range of preventive, curative, and rehabilitative care. They have special needs in nutrition, in hygiene, in exercise and in immunization. Housing, transport and personal security should be adapted to their particular needs, and in some places already are. Research in all these areas and into the whole social and biological process of aging should receive new impetus. The elderly need prompt clinical care when they are ill, and here the thrust of primary health care can bring about important change by acting as an early warning and first intervention system. However, the entire range of medical and rehabilitative services should be ready to be called into play when required. The theme of this year's World Health Day coincides with that of the United Nations World Assembly on Aging; both stress the urgency of meeting the special needs of the aging while contributing to a profound change in attitudes. The elderly are a group requiring special protection, but also one with a positive contribution to make, particularly if they are integrated within the community. The situation in many developing coun- tries is somewhat different from that in countries where industrialization and urbanization took place many years ago. Today, in many developing countries, there are still living customs which incorporate the elderly into the life of the community and these should be maintained. In fact, in these countries wisdom is still equated with age and the elderly are often considered to be the natural statesmen of the community. However, nowhere in our world is the situation static, and developing countries are undergoing rapid change as they industrialize and large portions of their population move into urban centres. In such situations there is a real danger that the mistakes, made elsewhere, of excluding the aged from the life of the community will be repeated. Just when the most industrial- ized countries are rediscovering the human worth of the aged and trying to allow them to live within the community and outside of institutions, whenever possible, it would be tragically ironic if developing nations were to discard their own traditions which accord a place of honour to the aged. The aged can contribute in many ways. In the realm of art, masterpieces by the elderly are frequent and the aged sculptor or musician is rightly appreciated. But there are many other useful vocations which the aged would like to perform if they are not deliberately excluded. Govern- ments will have to be careful not to establish situations that cut off the aged from the work they want to and are able to perform. But perhaps the main contribu- tion of the aged is a human one: they can add something to those around them by their presence and life experience. Educa- tion is not something dispensed only in schools and based on books; it is the distillation of life's experience. Only some- one who has lived through the momentous events that have marked the twentieth century everywhere and reflected on them can help younger generations understand how we arrived at our situation today and what we can do to make tomorrow better. It is in this spirit of respect for the highest human values and a desire to maintain solidarity with all members of the human family that WHO wishes to see the slogan "Add Life to Years" celebrated and acted upon throughout the world. ■ 3 The controlling elders by Ing K. The Phooyai of Thailand are the revered elders, to whom all important decisions must be referred. They take you each step of the way through life, and may even control the purse strings hen you're dead, will you help me run my new shop from the other side?" Mr Sook asked his mother as she lay dying. The old lady nodded and smiled, because she could not speak by that time. Mr Sook Sangsawang is a very successful radical publisher in Thailand with a reputation for being wise and daring. At the age of 49, he still listened to his mother's advice. The whole family was built around "Grandma", who was always treated with deference. Extended families like Sook's are not uncommon in Thailand where age still stands for wisdom. All Thais, whether they believe in it or not, recognise the revered concept of Phooyai which, literally trans- lated, means 'The Big, or Superior Person'. In practice, this concept means a great deal more; the elders can control your life, taking you through every step and turning along the path. They sit there at the top, apparently being taken care of, and yet themselves taking care of every member of the family under their umbrella. They are the Phooyai, to whom all important decisions must be referred, from whom all guilty secrets must be kept at all costs. In some cases, they also control the purse strings. The same concept dictates that no one whose parents are still living can be classified as a Phooyai. You could be 60 and your children 35, but not one of you would be considered adult as long as your 80-year-old parents are still alive. "Society respects the Phooyai because, in the old days, it was a remarkable feat to survive to the age of 60", explained Khunying Amporn Mesook, President of the Mental Health Association of Thailand (Khunying approximates to "Dame"). "It was a real achievement because you had to be tough, and therefore full of wisdom." When a person reaches 60 in Thailand, this calls for a Sae Yid celebration which was originally a Chinese custom. On your sixtieth birthday, relatives and friends— even long-lost ones—come to your house to congratulate you. There are religious ceremonies and, in wealthy households, open-air movies and theatrical perfor- mances of various kinds. Reaching 60 is something to be proud of and to celebrate. In Thailand, to be elderly is not to lose the respect of younger generations—quite the contrary. And the aged still have plenty to contribute. ( Nor have they lost their sense of humour: the old lady in our first picture retorted: "I'm not a pretty sight. Why do you want to photograph me?") (Photos 1 and 5 WHO ling K.: photos 2, 3 and 4 WHO/J. M. Micaud) "The best part of being a Phooyai is that you don't have to consider other people's sensitivity too much," said Khunying Amporn with a delighted smile. "You don't have to think about consequences—no job to lose, no goals to achieve, nothing is at stake any more. The old can afford to be blunt. For instance, someone asked me to act as the Phooyai for the groom's side and to ask for the hand of a girl from her parents. I refused. Your son is no good, I said". She laughed. "Young people nowadays choose for themselves, of course. Having a Phooyai in the ceremonies is just a gesture to tradition, which is nice. People think that a Phooyai must have investigated thoroughly before asking for the hand of any girl for his own or a friend's son, grandson or nephew." A Thai proverb says, "To find out properly about a girl one must look at the mother, but it is even better to study her grandmother as well." This is because, in the traditional extended family, the girl was probably brought up by her grandmother, while her mother went out to work beside her husband in the rice fields. Apart from child-minding, the grandparents often weave cloth, make baskets, keep chickens, make pottery and cook to supplement the family's income. No chilli paste in the public market would be really successful without a name like "Mother Thong Imm's chilli paste" or "Prepared by the Old Hand from the Intersection". In the case of the flower children who roam the dangerous streets of Bangkok, selling beautifully- sewn garlands of flowers to bored motor- ists waiting in traffic jams, it is often the grandmothers who string jasmine, roses and orchids together for the children to sell. Survival, for more than 70 per cent of Thais, is a family business. The old people contribute to the family's income, and their good work gives them a sense of purpose, a meaning to their existence. Surrounded by members of their own family, they are still productive and still needed, and they do not let themselves sink into a decline. But economic and other factors have made it practically impossible for most farming families to survive on rice cultiva- tion and home industries alone. This has created another variation of the extended family, one half of which remains at home while the other leaves for the towns, notably Bangkok, to find work. This would not be possible without the grandparents' contribution at home. "In matters of relationships between generations, there is a great deal that the 5 West can learn from the East," said Khunying Amporn. "I think it ought to be the duty of members of a family to take care of one another. First the adult looks after the child, and later when the child is grown up and the adult has grown older and weaker, the child should look after the adult. "The incident that made me passionately interested in the problems of old people was the opening of the Bangkhae Home for the Aged, some 20 years ago," she went on. "It was the first of its kind here. The then Prime Minister gave a speech that was—to me outrageous. He said 'I am proud to be here today to open the Home, and so on... I am proud of this milestone because it shows that Thailand is catching up with the Western nations and becoming civilised.' I was so mad, I went right up to him and asked him how he could come out with such a speech—to say that he was proud when he should have been ashamed! We should all be ashamed that there is actually a need for that here. Opening geriatric homes does not make us more civilised... We ought to know that even the Western countries themselves are now having regrets about their isolation of old people." She went on: "Change is inevitable, and not always a bad thing. But with the impact of technology and the accompanying social changes, the trend seems set to isolate and destroy traditional family relationships... Old people have many problems. They need attention, love and understanding from members of the younger generation, preferably from their own family. Bringing up the grandchildren, they can teach them the things that they believe in, while the children bring youth into their lives. This way, it's much warmer for both sides. But although I am a Phooyai, I can sympathise with young people. Getting married and starting a family of their own, nowadays they naturally want to break away from the `compound' and find a life of their own. The economic factor is a big problem, of course, as many families would probably like to take care of their aged, if only they could afford to shoulder the financial responsibility." According to Dr Prasop Ratanakorn, Director of Geriatric Health Services, who had just attended a Regional Intergovern- mental Meeting on the Aging; "Asian societies have suffered from a kind of ambivalence regarding measures for the elderly, as, on the one hand, social values require that families take care of them, and Keeping fit at a Home for the Aged in Bangkok. (Photo WHO/J. M. Micaud) on the other hand, changing social and economic factors are rendering the fulfil- ment of this task increasingly difficult in a larger number of cases. "It is indeed fully realised that the welfare of the elderly is a problem of large enough dimensions to merit serious atten- tion at this stage, before it is too late." Dr Prasop said that, with better methods of contraception, widely practised family planning and improved health services, people now live longer and fewer babies are born. The increase in the over-sixty popula- tion is therefore greater than that of the world's total population. This is inevitable, and a world-wide phenomenon. The bur- den on young people in the labour force is growing heavier all the time. "As there are more of them", added Dr Prasop, who is himself over 60 and still busy at the Neurological Hospital, "old people should be used more effectively." He suggested that the approach to the care of the elderly should be integrated into community service. "The elderly who are not disabled or sick could benefit the community by being involved as commun- ity volunteers, or undertaking activities in which they can serve others, particularly when there are opportunities for inter- action with members of the younger generation." Standard information on "Our work for the high in age" which was prepared for distribution to journalists was full of names and the positions they occupy. The Thai government is obviously concerned about problems of the aged. The country's first and biggest geriatric home is in Bangkhae, south of central Bangkok, and houses 489 people, most of them without relatives and the remainder forgotten by their family. "We get few personal visitors here," said an official at the home. "This one is the largest because, naturally, people in Bangkok have to struggle so hard to make a living, and they have no time for their old people." So many loveless lives at the Bangkhae Home, deposited there to reminisce over the past and sit out the years. There are five other homes for the aged, situated in various parts of the country, making a total of about 1,500 institutionalised old people. "Thank goodness there is no need to build any more homes at present," said a member of the staff. "I'm glad that most Thai people still care for their own aged." ■ 6 The World Assembly on Aging by William M. Kerrigan Secretary-General of the World Assembly on Aging hen the General Assembly of the United Nations decided in 1978 to convene a World Assembly on Aging, the basic purpose was to call world-wide attention to the dramatic change which is taking place in the population structures of all the more developed countries, and which will soon affect the less developed ones too: the human race is growing older. All over the world, there are more and more people living beyond the age of 60, 70 and 80 years. Their relative numbers in the total population are also on the increase because of the general reduction of fertility rates. The latter has created a situation where fewer people are born and more are surviving into old age. While there have always been "old people", however defined, as an impor- tant sector of any human society, for the first time in history it is not a selected few but most individuals who have a reasonable chance of surviving into advanced age, often well beyond their period of active and remunerative employment. It is also for the first time —as of today in the industrialized nations and within a few generations in the developing countries—that the elderly constitute a substantial part of the national population. What is even more important is that people all over the world not only tend to live longer but to live better than ever before. Old age is no longer equated with physical frailty and with socio- economic dependence on others, whether they be the younger, active family members or society itself. This change can be directly attri- buted to impressive advances in public health and medical technology over the last few decades which, for various reasons, have preceded similar pro- gress in other areas of development. The result has been a situation where large sectors of the population remain physically and mentally alert and capable of continued involvement in the life of their own societies; however, this involvement is often being denied them by obligatory retirement schemes and by the constraints of the labour market. At the same time, the gradual increase in general life expectancy rates has much increased the relative and absolute numbers of the very old, who do have special needs for care and protection and who represent a grow- ing challenge to the socio-medical services and material resources of each country. Old age needs no longer to be equated with physical frailty and dependence on others. ( Photo Mark Edwards C)) The problem of the aging of in- dividuals and of societies is thus two- pronged: it represents both an oppor- tunity and a responsibility. The preparations for the World Assembly are therefore based on the dual ap- proach of a developmental as well as a humanitarian conception of the issues at hand. The aging of societies as such, in absolute and proportional terms, entails a new set of problems and at the same time a challenge to the "style" of further development to be adopted for societies which will need the active involvement and participation of this sector of the population. Furthermore, the growing number of aging in- dividuals represents not only a resource of skills and knowledge, but also a source of power and influence which cannot but profoundly affect the course of national progress in the decades to come. There is no doubt that the increase and longevity of this population group will entail problems of protection and security which will remain a test of our capacity to attain the humanitarian objectives of modern societies. The World Assembly on Aging, which will take place at the Hofburg Palace in Vienna, from 26 July to 6 August 1982, will be a unique oppor- tunity to confront the world commu- nity with these issues and to call for international action to meet the pro- blems and challenges of the aging. The World Assembly will be preceded by a number of regional and technical meetings, expert encounters and United Nations inter-agency consulta- tions which are now in progress. The World Assembly will consider the formulation of a World Plan of Action on Aging which should provide the framework for future international cooperation and national efforts to meet the problems and challenges of the aging of societies and individuals. The draft Plan will be prepared through a series of regional meetings, inter-agency consultations, and inputs collected from the important group of non-governmental organizations in- volved in this issue, and will reflect the world-wide interest in the issues of aging both as a developmental chal- lenge and as a matter of humanitarian concern. ■ 7 Keeping watch on the water by Lita S. Consignado In certain small villages of the Philippines, elderly people who are well-known to and respected by the local residents are playing active and fulfilling roles as guard- ians of the cooperative-run community water supply year ago, life in Barrio Emma- nuel in the town of Cuenca, Batangas province, a rural community 60 miles (100 km) south of Manila, centered on the batis, a Tagalog term for a spring. This was the community's main water source and it was there that frail-looking but hardy Potenciana Lorca, aged 65, used to go for her laundry and bath. It was there, too, that she drew water for her daily needs. However, since March 1981, Ka Poten (Ka is a term of respect for the elderly), as she is popularly called in this rural community, claims she has not laid eyes on the batis. It was in March that the Emmanuel Barangay Water Service Cooperative, a pro- gramme assisted by the United States Agency for International Development (usAiD) and designed to provide safe and sufficient domestic water to small and medium size rural communities, became operational in this community. It was a boon to the barrio, which had always complained of inadequate water supply. (The barangay is the smallest political unit in the Philip- pines; it may consist of several barrios or villages). "The first time I turned on our faucet after the completion of the project", says Ka Poten, "I felt so good. It meant we will now have a sufficient supply of drinking water. It meant, too, not waking up early to fetch water from the batis. I just have to turn on the faucet and I can have a refreshing bath. During the summer, when no rains ever fall, there's even enough to water the plants." Water used to be such a treasured commodity in this barrio, which has a population of 1,092. "We made gods of the rain, hoping they would drench our farms", relates Ka Poten. "Because of the poor water supply, we developed this instinct to conserve water. I stored water from the rain or the spring in four big tanks. In a tapayan (earthen jar) I stored our drinking water." Plans for the water service coopera- tive started in the barrio two years ago, when the USAID joined in the United Nations campaign to provide "fresh water for all by 1990". The uN has proclaimed 1981-1990 as the Interna- tional Drinking Water Supply and Sanitation Decade to generate urgency for the need to provide people, especi- ally in the developing countries, with safe drinking water. A WHO survey on the coverage of community water supply and excreta disposal services in Carrying water for the family's needs at Emmanuel, in the Philippines. Facing page: Potenciana Lorca, 65, is the elected treasurer of the village cooperative which ensures the supply of water—a treasured commodity. ( Photos WHO/L. Consignado) the developing countries found that some 1,230 million people are without water supply. It is estimated that a majority of all the diseases in the world are associated with water. The water project became a com- munity affair among the residents of Emmanuel. Nine were elected to the board of the cooperative. Ka Poten, being an active resident (and also wife of the barrio captain, 67-year-old Rosalio Lorca), was elected treasurer. She keeps the cooperative's money and makes sure that every centavo is accounted for in the bank. The Emmanuel Barangay Water Service project cost 100,000 pesos (US$12,500). That amount was borrowed by the association from the provincial government which received funds from USAID. The amount is payable in 15 years at four per cent interest. "The loan gives us a lot of head- ache", says Ka Poten, "but coopera- tion among the users assures us that we can make both ends meet. Emmanuel residents are fairly good customers. We had delinquent payers in the first months but once they appreciated the comforts of having individual water connections, they have become con- scientious customers. Today, we can dispense with the collector. The users themselves bring their monthly dues of 22 pesos ($2.75) to the cooperative's office." Like the rest of the board members, Ka Poten gets no financial compensa- tion for the service she renders to the cooperative. She says that helping her neighbours amounts to compensation enough. Apart from her involvement in the water project, she is a fulltime house- wife. She has never been employed outside her home. "I accepted em- broidery work before the war, but the company which provided the job closed its shop. I have not been employed since then." Today, her hands are full with work at home and on the 1.5 hectare rice and corn farm. She still washes clothes by hand, cooks and keeps house for her husband. All her six children are already married. "I guess I'm too old to get rich", she says. "All I want at my age is to see my children happy and eating well." Being the barrio captain's wife, she claims, does not give her additional work. "What is there to being married to a barrio captain?" she asks. "There's a whole council to do the job in his absence. Besides, what is there to do in a small peaceful barrio? The most my 9 Remigio Cueva, 65, as chairman of his community's water board, is particularly proud of the flourishing vegetables he and his wife have grown. ( Photo WHO/L. Consignado) husband does is to reconcile drunks in a brawl." * * * Being the peacemaker in a brawl was also Remigio Cueva's preoccupation when he was barrio captain of Talaga, near Tanauan in the same province, for 16 years. "I have quit being barrio captain," says the silver-haired Remi- gio. "All I do now is make sure that everything is piping well at the Talaga Barangay Water Service Cooperative." Remigio, 65 years of age, is chairman of the board of the usAID-assisted project in this community, a 30-minute drive from Emmanuel. "Water was our barrio's nagging problem", says Remi- gio. "We used to depend mainly on the rains and a few artesian wells. When the rains didn't come, our plants wilted in the summer. Getting water from the wells is too time-consuming and tiring, especially for people as old as I am." Since farmers have always been subjected to the whims of the weather, Remigio has made sure all his life that he had enough supply for his needs. "When I got married and started making a home of my own", he explains, "I built two big water tanks one of which can store about 1,000 gallons of water. I filled them up with rain water through the atip system (water is conveyed to the tank through the roof gutter). That assured our water supply for laundry and cleaning. A separate earthen jar contained our drinking water". It was with particular warmth, therefore, that Remigio and the rest of the people of Talaga (population: 1,951) welcomed the proposal to start a water cooperative. All the residents organized themselves into an associa- tion which owns, pays for, manages and maintains the water system. Remigio was elected to the board of nine members. The job doesn't give him added income, with the exception of the 20 pesos ($2.50) per diem he gets when the association meets once a month. According to this elderly resident, there's much that the Talaga folks should thank the water system for. "It assures us of sufficient potable water supply", he says. "Our houses are more sanitary now and our plants do not wilt in summer. Pig and poultry raising have also sprung up in the barrio". (Indeed, there are now six big poultry raisers in Talaga.) "Our water cooperative, the second to be operated in Batangas Province, we were informed, is among several successfully operated usAID-assisted water projects. But we are not without problems. Our loan, amounting to 256,000 pesos ($32,000) payable in 20 years, demands that we work hard. We have such delinquent member- users, and the 25 pesos ($3.12) that is due each month hurts their pockets. But they have to learn to cope with it. I still think food and water are necessary ingredients for humans to be happy." ■ 1 0 u his is no easy task, since France has around seven and a half million people aged 65 and over. Their proportion of the general population has increased from 11 per cent in 1945 to 14 per cent today. The total of people aged 65 and over will scarcely increase at all in the next ten years; on the other hand, the numbers of those who are very old will rise considerably, from 580,000 today to close on 900,000 in 1990. These elderly people will include a high proportion of women, partly because of the huge slaughter of young men during World War I and partly because of the big difference in life expectancy of men and women. At the same time, France has undergone very rapid urbanisation and has seen the break-up of the traditional family unit. All these factors have brought about a big increase in old people, many of whom play no real role in economic or social life. Among the very old, a great many have meagre financial resources and suffer from loneliness, uncomfort- able homes, health problems, and a progressive loss of independence in their daily lives. Coordinating role In order to respond to the problems of the aged and of people living on pensions, I coordinate with Mrs Nicole Questiaux, France's Minister of Na- tional Solidarity, the programming, financing and management of policies relating to this section of the public policies which control resources, ser- vices and equipment. One of the top priorities of this policy is to enable old people to continue living in their own homes. Various activities which we undertake, and which are from the outset complemen- tary, are aimed at delaying the loss of independence; we try to mobilise their physical, mental and social capacities towards a better life style by encourag- ing health education, physical exercise, a balanced diet, and social integration in the form of clubs, group holidays and so on; we try to improve their home conditions and to ensure that they have access to public transport and public buildings. In cases where there is a serious loss of independence, a whole range of neighbourhood services go into action to help the aged, and also to help families where there are people who are more or less dependent. Household helps are enjoying a new lease of life thanks to improvements in their train- Solidarity with the aged by Joseph Franceschi Secretary of State for the Aged in the French V inistry of National Solidarity In a truly healthy world, we have to care for individuals of all ages, from the very youngest to those who have endured the inevitable advance of many long years. It was in response to the needs of the latter that, in May 1981, President Francois Mitterand of France set up, for the first time in history, a Secretary of State with responsibility for the Aged. Vy mission is to ensure that old people derive the most effective benefits from all the services of national solidarity. The first few months were sufficient to confirm the need for such an office: it is clearly desirable that a member of the Government should be fully ready to listen to the aged, and that he should have experts at his disposal to devise and expedite programmes of social and medical activity on their behalf, and to coordinate the broad policy of making resources and social integration available to them. With a large population of old people to deal with, my task is to put into effect an active and innovative policy within the framework of a global programme. 11 ing and in their earnings. Moreover, I recently issued a circular letter which encourages greater use of nursing services in the home. Services in the home Let me develop this point to show that the Secretary of State for the Aged, so far from confining himself to making wordy speeches, is radically attacking the problems. These nursing services in the home are trying to help dependent old people to continue their routine domestic activities—eating, washing, dressing, going to the toilet. In a more specific sense, they provide such nursing care as the changing of dressings, the management of incon- tinence or intravenous feeding. At the same time they help to prevent the problems that affect people who are bedridden, by encouraging muscle use or offering massage when it is needed. These services are available to everyone aged over 60 who suffers from chronic physical or mental disease of a crip- pling nature and therefore of long duration. People with shorter term problems also have access to such services. A salaried nurse heads each team. She is charged with organizing, coor- dinating and following up the different operations. Under her are at least three full-time nurses, enough to deal with 15 to 20 people; other nurses and nursing aides can be included according to need, so as to ensure service for 12 hours a day every day of the year. The nursing staff may be salaried, tempor- ary or paid for each service they offer. These services are coordinated with various other services or establish- ments dealing with old people: household helps, homes for the aged and so on. In this way we can arrange for nurses' visits to take place in an individual's home or in a hostel or in an old peoples' home which has no nursing department. At present there are 3,000 jobs available, and I intend that total to increase to 20,000 over the next two years. A global policy This is just one example among many within our global policy, which requires very considerable financial France's national policy on the aged accords high priority to enabling old people to go on living at home, rather than in institutions. ( Photo WHO 'Jean Mohr) resources. The minimum monthly pen- sion of an elderly person living alone, for instance, has risen from 1,400 francs a year ago to 2,000 francs today, and for couples, from 2,800 francs to 3,700 francs. To ensure better coordination of all the related activities, I have allocated funds to create a first batch of 500 local coordinators in the field. Their main job will be to prevent any further rise in the number of people needlessly housed in collective institutions—at present about half a million. International cooperation The World Assembly on Aging later this year will be a welcome opportunity for a major meeting of ideas. For my part, I hope that it will prove fruitful for the future, and will result in a greatly increased exchange of information, experts, social workers and so forth, so that the principle of solidarity with the aged will become a matter for action on an international scale. ■ 12 Senility: the outlook is bright by Marian Emr enility"—something which most of us fear in old age—is not a normal part of growing old; in fact, it is not even a disease. Rather, "senility" is the word com- monly used to describe a large number of conditions with an equally large number of causes. Of the three to four million elderly Americans who suffer from some degree of senile dementia, some 500,000 have senile dementia of the Alzheimer type (sDAT), the most relent- less and devastating of all. Even when a loving and caring family is available to give support, the victim of SDAT is most likely to spend his or her last days in a nursing home or long-term care institution. Because we don't yet know how to prevent or to cure SDAT, its victims account for a disproportionate share of the US expenditure for long- term care which totalled $22,000 mill- ion in 1980. In 1956, data from the Human Aging Study carried out by the US National Institute of Mental Health (NIMH) questioned the popular misconception that "senility" was an inevitable occur- rence which resulted from a hardening of the arteries of the brain. Using a method for determining average blood flow which had been developed a decade earlier, the NIMH investigators found that the average supply of blood and oxygen to the brain in healthy elderly volunteers was not appreciably less than in healthy persons sometimes as much as 50 years younger. In 1970, researchers in the United Kingdom found that the incurable "senility" caused by a blockage of blood flow to the brain was present in less than 20 per cent of confused elderly patients they examined. By contrast, 50 per cent of the mentally impaired elderly patients they saw showed signs of other physical changes in the brain similar to those described by Alois Alzheimer early in this century. Alzheimer's disease was first des- cribed in November 1906 at a meeting of the South West German Society of Alienists, when Alois Alzheimer re- counted the story of a 51-year-old patient. The woman's problem began with loss of memory and disorienta- tion, later was complicated by depress- ion and hallucinations, and eventually resulted in severe dementia and death. Upon death, the patients brain was found to show severe atrophy (shrin- kage) and the cerebral cortex (outer layer of the brain) was marked by a clumping and distortion of fibres in the nerve cells. Alzheimer called these jumbles of filaments neuro-fibrillary tangles, and they have since become the hallmark of Alzheimer's disease. Emotional problems in old people are often mistakenly confused with irreversible brain disease. ( Photo US National Institute on Aging Because of Alzheimer's findings of this disorder in a middle-aged woman, and because of other reports which followed, Alzheimer's disease is classic- ally considered to be a presenile (pre- old age) form of dementia, despite the prevalence of similar manifestations in the majority of severely mentally im- paired older persons. Studies linking "senility" to Alz- heimer's disease prompted a great deal of interest in investigating the dement- ing disorders of elderly patients. These same studies encouraged physicians to consider normal aging as separate from age-related diseases. The accurate diag- nosis of dementia is often a challenge for physicians. Roughly 20 per cent of severe "senility" is caused by neither Alzheimer type dementia nor vascular disorders. In these cases, older people who appear confused and forgetful may be suffering from any one of 100 reversible conditions which can mimic their symptoms. A minor head injury, a high fever, poor nutrition or adverse drug reactions, for example, can tem- porarily upset the normal activity of extremely sensitive brain cells. If left untreated, such medical emergencies can result in permanent damage to the brain, and possibly even death. In much the same way, emotional pro- blems can be mistakenly confused with irreversible brain disease. Depression, loss of self-esteem, loneliness, anxiety, and boredom can become common as elderly persons face retirement, the deaths of relatives and friends, and other such crises—often all at the same time. To aid physicians in sorting out these reversible disorders, the National In- stitute on Aging (NIA) sponsored a task force to develop guidelines for a thorough physical, psychological, and neurological evaluation prior to the diagnosis of an irreversible brain disor- der such as SDAT. This includes a complete medical check, as well as tests of the patient's mental state, and highly specific tests such as the brain scan. The brain scan is immensely valuable in terms of its ability to identify and accurately locate brain tumours, blood clots, and certain other disorders which can mask themselves as senile dementia. The underlying message of the NIA report is clear: "senility" is not an inevitable part of old age. Unfortunate- ly, this is a message which has not been consistently recognised by laypersons and professionals in different countries around the world. This is further complicated by the fact that conditions often causing the same symptoms as 13 those of irreversible "senility" may be more prevalent among the people of developing nations. Who then are the victims of senile dementia of the Alzheimer type? Is there an "at risk" group who might be most susceptible to this disorder? At the present time, we know of no link between SDAT and sex, race, occupa- tion, place of residence, or even age, since Alzheimer's disease can strike as early as 40. We only know that it is prevalent. Wherever there are old people, there is senile dementia of the Alzheimer type. With no clear-cut pattern to pursue, a number of epidemiologists have become intrigued by the unanswered questions pertaining to dementia. In order to improve current estimates of frequency, the NIA recently arranged to supplement an already established, community-based survey of mental illness to "sort out" persons with presenile and senile dementia of the Alzheimer type who have remained outside of institutions. More recently, the NIA initiated a study to develop a more accurate picture of the natural progression of the disease and attempt to determine specific factors. Through grants to universities and major research and medical centres, the NIA supports scientists from a variety of disciplines who are involved in an intensive search to uncover the cause or causes of SDAT. To date, the most consistent—and many feel, most promising—findings have pointed to changes in the activity of certain chemicals in the brain which comprise what is known as the cholinergic system. A number of investigators have reported that SDAT patients exhibit a significant decrease in the activity of choline acetyltransferase (chAT), the enzyme instrumental in the production of the neurotransmitter acetylcholine. For some time it has been known that the cholinergic system is involved in both memory and learning. The most exciting findings in SDAT patients show a correlation between this change in neurochemical activity and changes in both cognition (such as memory loss and disorientation) and in brain path- ology (particularly the number of characteristic plaques seen at autopsy). If it is true that the cholinergic system is implicated in the development of presenile and senile dementia, then we are closer than ever before to the possibility of treatment. In this regard, many experts have compared SDAT to Parkinson's disease, in which a defi- Senility: the outlook is bright Left "Senility" is not an inevitable part of old age, and millions of aged people—provided they are given the opportunity—remain active and useful members of society. Right Old people who appear confused and forgetful may be suffering from any one of 100 reversible conditions which mimic the symptoms of irreversible disorders, such as senile dementia of the Alzheimer type ( SDAT). ( Photos US National Institute on Aging (31) cient chemical process is involved and the patient's symptoms can be treated by employing restoratives. In tests of drugs and dietary supplements, re- searchers have attempted to increase the amount of choline in the brain, but with disappointing results. Other investigators are attempting to increase cholinergic activity in the brain by preventing the normally fast breakdown of the end product, acetyl- choline. Such studies are beginning to suggest that drugs which block this breakdown can improve both memory and learning in SDAT victims. Much basic research remains to be done before we can hope to treat the symptoms of SDAT victims with consis- tent success. Some of that research will be designed to determine why the cholinergic system is malfunctioning. In the near future, however, attempts to stimulate or revitalise the cholinergic system may at least alleviate the debilitating symptoms of SDAT. While some researchers have been exploring neurochemical changes in SDAT, others have been looking at the role of trace metals, genetics, and slow viruses in the development of the disease. As regards trace metals, inves- tigators working with experimental 14 animals in 1965 induced the develop- ment of neurofibrillary tangles by injecting aluminium salts. These stu- dies stimulated Canadian researchers, who later reported an increase of 10 to 30 times the normal concentration of aluminium in the brains of individuals who had died having Alzheimer type dementia. Still, there has been a great deal of controversy involving the poss- ible role of this metal in the development of the disease and the role of normal levels of aluminium in the brain. And how does aluminium gain access to the brain, since it is found in all kinds of soil and therefore in airborne dust, to which everyone is exposed? When someone is told that a parent or relative has SDAT-Or any degenera- tive brain disease—there is a great similarity in the response. What can the patient expect for the future? What can I do to help? But inevitably the question that arises is: Is it hereditary? A classic study of patients with senile dementia in Swedish mental hospitals showed that the risk of the condition among relatives was 4.3 times as great as in the general population. Con- ceivably, a gene or a group of genes may be identified as causing or promoting SDAT. What about slow viruses? In the late 1960s, material from several patients with rare familial cases of Alzheimer type dementia produced degenerative brain disease in chimpanzees; this provided the first hint that the dement- ing disorders might be caused by slow- acting transmissible viruses. The changes seen in the animals' brains were not identical to those seen in the brains of SDAT victims. They were, instead, consistent with changes in- duced in similar experiments involving victims of two other disorders, kuru, a central nervous system disorder unique to certain native tribes of Papua New Guinea, and Creutzfeldt-Jakob di- sease, a rare but rapidly progressive dementia. Numerous attempts to re- produce and corroborate these initial findings have been entirely unsuccess- ful. But the theory is not yet ruled out that a hidden virus may be responsible for slowly progressive damage to the brain which produces symptoms of the disease only after a long period of time. Research on SDAT in the United States has increased by more than 200 per cent since the creation of the National Institute on Aging. Two major international conferences spon- sored by the Federal research agencies involved with this subject area did much to stimulate new research on the causes and prevalence of senile demen- tia as well as on possible treatment approaches. We hope that continued studies in US laboratories will maintain the momentum of the past decade. We also recognise that studies in "living laboratories" around the world may answer many questions about the etiology of Alzheimer type dementia. Public awareness of senile dementia as a pervasive problem has increased, leading to and led by the development of a new US voluntary health associa- tion, the Alzheimer's Disease and Related Disorders Association, which has sister organizations in both Canada and the United Kingdom. As a result of increased scientific interest and public awareness, the future looks brighter for the families of people with dementing disorders, who in the past were told to proceed as best they could with no hope and little support. Perhaps the people of other nations will be able to benefit from the successes and learn from the mistakes of US scientists as they discover more about the diagnosis, the process, the treatment and—some day—the cure of senile dementia of the Alzheimer type. ■ 15 miliano Flores, 67, was not able to travel to the capital city of his country in Central America one week in late October because of the pressing needs of the coffee harvest. When the berries ripen on the dark bushes, they must be picked immediately to save them from birds, bugs, and heavy rains which can knock them to the ground. Emiliano, his wife Gloria, 61, five of their children and two young grandsons all of them worked for ten days straight, from sunup to sundown, picking the red berries on his four-hectare plantation located over 60 miles (100 km) from the nearest big city. The two grandchildren missed school, and Emiliano could not keep up his gardening contracts with three wealthy residents of the city; but missing school and work commitments proved to be the only way to ensure the crop's safe removal into a shed behind his rural home. Those gardening contracts, which earn Emiliano a total of US $120 a month, were important to him because they provided regular cash income, but also because two Working to the last by Carlos Denton The elderly people of Central America will have to continue to work until the very last, and those who cannot work will have to live with and be support- ed by their families. This may appear to be a bleak picture yet it could prove to be the right solution for other, and much wealthier, countries 16 Still active and productive at 67, Emiliano Flores not only tends his own coffee plantation, but also manages three wealthy clients' gardens in the nearby city. (Photo WHO/C. Denton) of his clients had registered him with the Social Security Administration, paying the monthly quotas required of all insured persons. As an insured member of the Social Security Programme, Emiliano and his family are entitled to free medical care, and he is assured of a minimum pension when and if he were required to give up work. The pension would provide him with $36 monthly which would not be enough to live on—he would have to depend on his older children for support—but neverthe- less, it would still be an income. Emiliano is a healthy man. Despite a lifetime of physical labour, he complains little except about an occasional back pain and problems with false teeth. All of his teeth had been removed when he was 17 by a local dentist to avoid future pain and trouble; the fee for professional services had been paid by Emiliano's father. Emiliano is typical of a generation of Central Americans born in the first decades of the century who, unlike their forebears, have survived into the third age. The factors which are involved in this new longevity in the Middle American isthmus, which contains six countries with a combined population of 24.5 million, are similar to those in other Third World areas in Latin America, Africa, and Asia. Better nutrition, improved sanitary conditions (especially potable water), and better and more distributed medical services have permitted life expectancy figures to soar as high as 70 for Costa Rican and Panama- nian women. In the other countries the figures are lower, but in no case does a country have a life expectancy figure of less than 60. Few of the aged in Central America end their days as permanent residents in institutions. The norm is for the aged to live on with their families, either as heads of household as in the case of Emiliano Flores, or as dependents of older children. It is most common to find aged women in the latter situation. The increased life expectancy would perhaps have gone unnoticed in several countries except for the fact that this new longevity occurred simultaneously with a decline in the birth rate, precipitous in Costa Rica and more gradual in other nations. The result is that the percentage of the population in the age cohorts of 60 years of age and over has increased. For the small group of the aged who do reside in institutions (there are fewer than 150 "homes for the aged" in the entire isthmus), life is generally grim. Rations are short, living conditions are generally little better than squalid, and recreational pro- grammes are generally non-existent. Trained personnel are in short supply and many of the homes are at least partially staffed by members of religious orders. The latter, although well-meaning and moti- vated, have not been trained specifically to deal with the aged. 17 Although life expectancy figures have improved as a consequence of better nutrition and safe drinking water, all of the Central American nations can be described accurately as poor. Resources of all types are scarce. Per capita income figures in Guatemala, Honduras, and El Salvador are below $500 a year, and in the other three nations, although higher, they are not high enough to assure minimum levels of existence for all the inhabitants. Within the context of the situation described here, the needs of the Central American elderly are not hard to define. Foremost among the priorities is the need to guarantee a viable income to all those who are no longer able to work because of age or disability. Unfortunately this is a need which it is unlikely to be even remotely met in the coming years. The declining economic situation in these countries, caused by ever-worsening terms of trade in the international market place, political strife, and poor economic configurations, have led to other priorities being preferred, including rural electrification, roads, schools, and medical programmes. There is no chance of introducing any type of voluntary retirement programme in any of the nations of the isthmus compar- able to those that exist in the industrialized nations, except among the highest paid civil servants and employees of multinational corporations. The facts are, then, that most of the elderly will have to continue to work in order to support themselves financially, whether it is selling food at the doorstep or cleaning the streets. Second in the order of priorities among the needs of the elderly is adequate medical care. In Central America, there are no more than 25 geriatric physicians for all six nations and about the same number of nurses trained to work with the elderly. Equipment needed for the special care of the aged is generally non-existent. In 1981 it was estimated that the Central American population aged 60 years and older num- bers some 1,100,000 persons. This figure is expected to increase to at least two million in the next two decades. The six nations of the area must start training personnel now to serve the medical needs of the elderly in the future. If it is presumed that a minimum of one per cent of the population aged 60 and over will have to be hospitalized at any given time, then there will be a need for 20,000 hospital beds to take care of them by the year 2000. In fact, the entire region only has 30,000 hospital beds today, and these must suffice Ananias Delgado, still cleaning the city streets at 71... for patients of all age groups requiring hospital care. Since aging is primarily a problem for preventive medicine, medical programmes designed to keep the popula- tion healthy throughout the later years of life are crucial. Dr Carlos Luis Alpizar, one of the three geriatric physicians practising in Costa Rica, works at a hospital for the aged maintained by the nation's social security system. Dr Alpizar, a member of the board of the Union para el Estudio Cientifico de la Vejez en America Latina (ECVAL), believes that the only way Central America will be able to handle the problems of the ever- growing aged population is by preventing —to as great an extent as possible—the emergence of medical problems. By the time many of the aged seek medical help, the condition is so advanced that it is difficult to solve. He and his colleagues have taken a number of initiatives in public education in an effort to encourage young people to care for themselves, and older people to seek medical attention as soon as they detect a problem. A major hazard related to the increase in the elderly population of Central America is the housing shortage. Efforts to solve this shortage have led to the construction of ever-growing numbers of small dwellings, which in many cases occupy no more than 50 square meters of floor space yet are designed for two-generation or nuclear families. If the aged of Central America are to live with their families, making three- generation homes the norm rather than the exception, then planners will have to make provisions for larger dwellings in order to make this possible. In a region charac- terised by shanty towns, the pressures on housing planners are enormous, and it will be no easy task to convince the administra- tors and politicians to think of the needs of the elderly. Dofia Elsa Martinez, 71, is a retired school teacher and widow who lives alone in a provincial capital in Central America. She pays occasional visits to the homes of her three daughters, all of whom live nearby, but finds herself spending a great deal of time alone watching television. There are thousands of women like Elsa Martinez throughout the Central Ameri- can region, although most of them do not have her educational levels. Most are widows, women who spent their lives as housewives caring for now deceased hus- bands and raising children. When the government planners asked Elsa to help organize a day care centre for the aged in her city, she jumped at the chance. The plan was to convert an unused floor of the local social security hospital for ... and Elsa Picado, 76, selling bananas from her own doorstep. ( Photos WHO IC. Denton) that purpose. There were many meetings devoted to setting up the centre, and these involved the aged, government planners, hospital administrators and community representatives. However, the meetings stopped abruptly when it became clear that no finances from the central government would be forthcoming for the project. Elsa went back to watching television, visiting her daughters, and feeling lonely. Day care centres are another priority need in Central America. If the aged are to reside with their families in small living quarters, then the day care centre provides them with a place to go where they can be with others like themselves, can engage in work tasks and can perhaps even earn a little money. Recreation would of course be a major component of the centre's activities. Many of the rural elderly live far from any such centres, but they may live on active farms either of their own or belong- ing to their children; they probably work hard at planting, tilling, and harvesting crops. In short, they are continuing the rural agricultural tradition of the region. If, however, they reside in rural areas which have experienced a big exodus of the population either to the cities or to other rural areas, it is quite possible that the elderly are living alone in trying circum- stances. Far from government-backed infrastructures and social programmes, if the elderly in these regions can no longer work it is quite possible for them to suffer from neglect or even slow starvation. The needs of the Central America elderly are, no doubt, little different from the needs of the population of the region as a whole. The elderly require at least some income, medical attention, adequate housing, and activities (whether remunerative or non- remunerative) with which to occupy themselves. There is no way that any of the Central American nations, with the meagre re- sources they have, will be able to create the elaborate and expensive programmes which are to be found in the industrialized nations. Instead, the elderly from this region will have to continue to work until the very last, and those who cannot work will have to live with and be supported by their families. Although this appears to be a bleak picture, in fact working and living in a family situation could prove to be the right solution for other countries that enjoy larger resources bases and greater technical capacity. ■ 19 Aging: a statement on health policy by Leo A. Kaprio Regional Director, WHO's Regional Office for Europe Policies for People Health and development poli- cies express the political will of governments to do something for people, with people. Aging policies reflect the commitment of govern- ments to maintain aging persons within society in a state that gives dignity to them, as individuals, and to the community. Triumph of survival This is not a statement of problems, for it would be a perversity to consider the aggregate results of our increasing success in improving human survival and in regulating fertility as problems. Rather it is a statement which appeals to wise and far- sighted statesmen to foresee what these twin triumphs of twentieth century civilisa- tion imply for life on our planet, now, and in the year 2000. We are entering an age of aging, and the effect of this on our societies should be viewed positively, as a human triumph and not as a human problem. Advancing our humanity Underlying all policies about people is the universal principle that the whole of mankind is devalued when any group of human beings is devalued, for any reason, whether on the grounds of race, sex or age. A general consensus of agreement on this principle has been established among the community of nations over the past three decades. The sustained international effort to advance our own humanity will pass a further historic milepost in 1982 when the United Nations convenes the World As- sembly on Aging. This gathering will mark the beginning of the end of age discrimina- tion in human society. This universal principle and the 10 further principles set out below are proposed as a framework for formulating policies and programmes on aging within overall national plans. Sharing the benefits of societal development All human rights and privileges extend to aging people who, by virtue of a lifetime characterised by war, struggle and hard- ship, have a special claim to a fair share of the benefits flowing from the development of our societies. Beyond material needs, aging people require the same social interaction, emotional support and care as the rest of society. The well-being of people in old age is determined by the conditions of life during their working ages. Inequalities during this earlier phase of life are perpetuated and even aggravated with aging. Thus, the coming generation of aging people will benefit from the continuing efforts of nations to reduce health inequalities and to achieve Health for All by the Year 2000. In short, policies for aging people should not be formulated without reference to the needs of other age groups in the same society, since aging persons share the sufferings of other members of the family. Resources must be allocated preferentially to the most economically deprived people, whatever their age. Individuality of aging persons The population described as aging is not a group with uniform characteristics. Like younger people, aging persons differ one from another. Indeed the variation in individual capability increases with age and, from the health perspective, those aged 60 and over comprise two genera- tions, a younger and generally fit group and an extreme aged group that is especially vulnerable to health impairments. Non-dependence The keystone of policies on aging is the commitment of all sectors of government, of non-governmental organizations, of caring professions and of individuals to programmes aimed at the promotion of health and the maintenance of functioning during aging. Impaired health, aggravated by social and economic disadvantages, diminishes the activities of aging people, reduces their independence, incapacitates them and affects the whole quality of their life. Services should not generate depen- dency, and paternalistic practices which erode independence should be discarded. An explicit objective of health policies should be to help aging persons maintain the maximum degree of independent life in the face of increasing difficulty in perform- ing daily activities. The principle of avoiding dependence applies equally in housing, transportation, social and family welfare policies. Choice All too often, the third age is the age of no consent. Decisions affecting aging citizens are frequently made without the participation of the citizens themselves. This applies particularly to those who are very old, frail or disabled. Such people should be served by flexible systems of care that give them a choice as to the type of amenities and the kind of care they receive. In particular, they should not cede control 20 application of this general principle to the specific area of health means that aging individuals, their families and neighbours would share responsibility for adopting health measures aimed at improving the health and well-being of the community as a whole. Another consequence for health programmes would be that aging people might help young or disabled people, as in the surrogate grandparent projects of some countries. A consequence of housing policies aimed at re-uniting the generations would be the creation of better balanced communities which blend different age and social groups. of their own lives to health, social service and other caring personnel, since aging people themselves usually know best what is needed and how it should be carried out. Home care The policy of the Member States of the World Health Organization, as expressed in the Declaration of Alma-Ata, is for the provision of essential health care based on practical, scientifically sound and socially acceptable methods. This health care should be universally accessible to in- dividuals and families in the community through their full participation. From this policy there stems an unequivocal commit- ment to supporting and caring for disabled persons of advanced age within their own homes. It is clearly predictable that the costs of institutional care cannot be borne by developing countries, and it is therefore essential to establish policies which help aging persons within some socially supported situation. Home care is not only the best economic alternative: it provides more emotional satisfaction. Contrary to widespread belief, a con- siderable proportion of mental disorders in old age are either treatable, partly prevent- able or modifiable by means that do not require elaborate technology nor the place- ment of patients in institutions. Accessibility Public services should be accessible to all generations. This applies not only to health services but to recreational, leisure and educational facilities, all of which need to be progressively adapted to cater to all generations, not only to younger people. Of particular importance is the early develop- ment of leisure, educational and recre- ational activities that help people anti- cipate retirement. Engaging the aging Policies should be directed at promoting cohesion between the generations. The Mobility Aging people, particularly in rural areas, are often unable to use social amenities and public services, because of impaired mobility. A first priority for informal good neighbourliness, or lay and religious volun- teer activity, should be to assist aging citizens to achieve the maximum degree of mobility to enable them to attend village markets, shopping areas, community cen- tres, religious services and, when needed, primary health care facilities. Aging people who need help to keep themselves mobile would benefit from the advice of caring personnel who are trained to assess functional capacity and to offer guidance on adaptations and aids to daily living. Productivity The great majority of aging people of today do not show symptoms of decline in their mental and physical function, but rather enjoy a level of health that permits them to lead a socially and economically productive life. Furthermore, in the de- veloped world, an increasing number of people at all ages are committed to healthier eating habits and life styles, and to the maintenance of physical fitness, mental alertness and a stimulating social environment. These future cohorts of people who retain their health but retire from the workforce represent human resources on a huge scale. No society can afford to leave this experienced and skilled resource untapped when so much needs to be done to improve the quality of life on our planet. Thus more flexibility is required in the distribution of work over the lifespan, and education needs to be viewed as a continuous lifelong process. Public and private employers, trade unions, educational bodies, voluntary agencies and aging self-help groups should organize programmes to provide stimulus, motivation and purposeful life after retirement. Self-health care and family care Aging people and their families should be more involved in their own care. Health educational information on the promotion of health and prevention of disease is required, as are simple handbooks of personal care. Knowledge of locally avail- able services and social support systems represents another important element of prevention and will assist aging people and their families seeking health care. Too often the aged fail to seek care in the belief that ailments are part of the aging process. Public authorities should recognise and support relatives who are caring for frail aging people at home, since this often imposes heavy physical, emotional and financial demands. New orientations are required on the part of care providers to help aging people maintain independence, support self- health care, and prevent disability. Such support to aging people must be provided by practitioners who are knowledgeable on the subject of aging, are interested in aging people and their families, are skilled in working with them and are concerned about the quality of care given. ■ 21 Where age brings honour by Jitendra Tuli Old age. The very words bring to mind images of white hair, stooped shoulders, an uncertain gait, a certain isolation. And yet, old age can also mean a full and active life, a lively spirit, and delightful hours spent with your grandchildren, doing whatever you want to do ri n countries of WHO's South-East Asia Region, the elderly have tradi-tionally enjoyed a privileged place in society. They have been revered and their advice has been sought on matters ranging from the sowing of the next crop, a marriage in the family or the settling of a village dispute, to prescrib- ing a remedy for a stomach ache. From positions of eminence—depending on their socio-economic status—those who are well into their eighties direct many an industrial empire even today. And as for politics, some countries have acquired a reputation not so much for the political complexion of their leaders as for their physical ap- pearance. The rule of gerontocracy could well describe the situation. Keeping in mind the age profile of the population, where more than 50 per cent are aged under 20, the elderly are definitely in a minority, but a minority which still wields a lot of clout. This, despite the battering that the whole institution of old age is getting from what is generally referred to as "pro- gress". Like an old fortress, the elderly too are holding out, bearing the onslaught with courage and determina- tion. And they seem to be doing quite well for themselves. In a village not very far front' New Delhi, we came across Bhag Mal, resting by the side of a dusty road, on a hot and sultry afternoon. He had taken off his sandals, and was fanning himself with the piece of cloth that also served as headgear. On the carrier of his bicycle was strapped a wooden box containing cucumbers, and on the crossbar was a cloth bag, half full of wheat. Before we could ask him anything, the 60-year-old explained that he had been out since 6 a.m., on his rounds, and had just a few more kilograms of cucumbers to sell. The wheat was not for sale; it was what he took in exchange for the cucumbers. Amused that anyone would be interested in him and what he did, Bhag Mal said he had Bhag Mal has been on the road with his bicycle since 6 a.m., calling on regular customers with his cucumbers. Facing page: Roop Chand is headman of Tajpur village and undisputed head of his family. ( Photos WHO/ A. S. Kochar) been working like this since 1947. "That's when I came to this area. Of course, I was much younger then, and could cycle for 20 miles without a break. Now I get a bit tired, but I am sure I can work harder than any of you city folk", he chuckled, pulling at one of his small golden ear-rings, very much in vogue when he was a young boy. He paused to light up a cigarette, with the comment: "Yes, I know it is a bad habit; I have forbidden my sons to smoke." He has eight children—six daughters and two sons. Three daugh- ters and a son are married, while the rest live with him and his wife. "I am the sole breadwinner. At times my youngest son lends a hand, but I would much rather have him complete his schooling. The daughters stay at home and help their mother. I am looking forward to the day I will be able to marry them off. I guess it will happen when it is destined to happen", he adds uncomplainingly. To Bhag Mal, the biggest boom in life, and something that he always prays for, is good health. "If I were to ask for anything, it would be that I should never depend on anyone, not even my sons, for anything. I would like to work till the last day of my life, cycling like this, going about my work, minding my own business." He volunteered to take us to Tajpur, a village close by. "You will find many old people there. In fact, there are four brothers who are well over 60, and they all put in more hours of work in the fields than their sons or even grand- sons." A great-grandfather at 66, Pandit Roop Chand is the headman of Tajpur village, and the undisputed head of his family. Puffing away on his "hookah", he vigorously presides over the affairs of his household, farm and dairy. With six sons and three daughters, most of them married, Roop Chand proudly informs us that all his sons are educated, and that one of his grandsons is a graduate. "But whenever they have any problem, they come to me for advice", he adds, without any trace of vanity. He is quick to explain that although his children are certainly 23 more knowledgeable, they do not have his experience. "What they know is from books, but I have lived my life and can tell them about things that can never be found in any book." He still puts in a 12- to 14-hour working day, with his children lending a hand when they are on vacation. He is realistic enough to see that, while farming alone may not be sufficiently interesting or paying, a mere job in the city is not enough to keep his sons gainfully or happily employed. What worries Roop Chand most is the fact that many young people have moved from the village and more are waiting to do so. "If they had their way, they would like to sell off the land that their forefathers tilled and stay in some small shack in a congested slum in the city. I cannot understand this." Kesarbai spends the twilight years of her life mostly praying. At home she is looked after by her sons, her daughter- in-law and their children. This is the blessing of the joint family system in India, where the elders are taken care of by the young when they are unable to take care of themselves, either physi- cally or financially. The children have been of immense emotional support to Kesarbai since her husband died more than a decade ago. Even so, the days hang heavy for the 75-year-old Kesarbai. After all, how much time can she spend praying? Always fond of the open air, she is driven every evening to a park where she sits under the lengthening shadows of the nearby temple and tells her beads. Her grandchildren play around her. Just when the sun is about to set, she returns home for a light meal and a good night's rest till it is morning again, and the beginning of another prayerful day. Bharat Singh, 75, still has not got used to the spectacles he has had to wear after a cataract operation some time ago. He maintains that, apart from his eyes, there is nothing else wrong with him He displays a strong set of teeth and narrates how a new barber in the village once asked him where he got his dentures from. "I told him, from heaven!" Though he can no longer go to the fields, he still gets up early and tends to the cows. He milks them, feeds them and gives them a good rub-down. Occasionally he takes them out to graze. Otherwise this job is usually handled by one of the grandsons. Typical of his generation when it comes to hospitality, Bharat Singh insisted that we have a cup of tea with him and his family. He mentioned that he would normally have offered milk but, knowing that we were city folk, he was offering tea. "In my young days, we had tea only when we were ill." When asked what he did for relaxa- tion, the old man pointed out that he enjoyed his "hookah". At times, he listens to the transistor radio, which never ceases to amaze him, and he particularly enjoys religious dis- courses. As for the cinema, he felt that it was strictly a waste of time and money, and could never understand why the young were so keen on it. Had he ever been to the cinema? "No, never, nor do I want to go", he said firmly. Zamrudpur village, in New Delhi's prosperous Greater Kailash area, stands out like an island, surrounded by the realities of 20th century urban development. Here, though mud huts and thatched roofs are conspicuous by their absence, time seems to stand still in the narrow lanes. One wizened resident told us: "I remember very clearly when we first got electricity, and then piped water." He also remembers, as a child, going out with his father and grandfather to their fields. Where the fields were, there are now large houses and multi-storeyed apartment houses. "But, if you want to know more about the village and how it was many years ago, you should meet Dalipo. She is the oldest inhabitant of this village." As it turned out, Dalipo, a frail but stately figure, could well be one of the oldest inhabitants in Delhi. She was wearing the traditional long skirt, loose blouse and the "odhni" or head covering, and her wrists and ankles were covered with heavy silver jewel- lery. Though a bit hazy about her actual date of birth, she is very definite that she was over 25 years old when World War I broke out in 1914. She remembers, because her husband was sent by the "Angrezi Raj" (the English rulers) to fight across the seas, and that is where he died. She remembers getting some medals and a letter from the British Government, lauding her hus- band's services. Later, she married, as was the custom, the younger brother of her late husband. They have two sons and two daughters, and Dalipo today presides over a family which has over 40 members, including grandchildren and great-grandchildren, many of whom have graduated from univer- sities and are pursuing vocations vastly different from the ones she knew. Nearing a hundred years of age, by her own reckoning, Dalipo says she still did many household chores until about three years ago. But then she started losing her eyesight and today is barely able to see. "Apart from this, I am perfectly fine, except that at times I feel giddy." She points to her left ear, and a circular wooden piece which she is wearing. It was given to her by a traditional doctor, and she feels it has helped her, "The giddy spells are not so bad now", she explains. Speaking of the "good old days", Dalipo remem- bers buying silver and gold at ridiculously low prices, and pulses and other food at "reasonable" rates. She cannot understand why things are so expensive now. Women, particularly elderly women, have always enjoyed a special status in Indian society. Whether in the home or outside, they have contributed signifi- cantly to the country's socio-economic progress. Today, loved and respected by her own family and the neighbour- hood, Dalipo is consulted regularly by all and sundry, whether for household remedies, or to patch up tricky personal problems. What has been the biggest Bharat Singh may have to wear spectacle but—he insists—his teeth are his own! Dalipo, one of Delhi's oldest in- habitants, poses with one of her great- grandsons. The recipe for a peaceful and conten- ted life, says Amid Chand, is "hard work, a lot of hard work." ( Photos WHO IA. S. Kochar) 24 difference between what was and what is? Dalipo ponders for a moment and says, "Well, earlier we used to eat a lot more of coarse grains, and we were much less selfish." According to her, this is as good a formula as any for peaceful, contented and healthy living. Amid Chand, with his spectacles, loincloth and slightly stooped should- ers, looks very much like a very famous and revered Indian. "Yes, I know who you mean", he says, smiling toothless- ly. The children in the village also notice the resemblance. Amid Chand, who believes he is over 70, still works in the fields, takes the cattle out for grazing and generally looks after his small land-holding, given to him by the village committee. His sons and grandsons work in the city and, according to Amid Chand, come to the village "when they want a change". As for him, he is very happy staying in the village where he was born and brought up. Had things changed much over the years? "Well, yes. We now seem to have more of everything —more people, more vehicles, more goods—and even more flies." What he would like to see more of, however, was a sense of discipline and duty on the part of young people. Addressing himself to a group of young villagers, he said they all seemed to be waiting to go away because they felt that life was better in the cities. "What they do not realise is that they can live a happy, peaceful and contented life right here, where their fathers and great- grandfathers have lived. What this requires is hard work, a lot of hard work." He adds: "But the rewards, too, are great." A fighting spirit and an ability to take things as they come and to work hard are the qualities that seem most marked in the rural elderly in this part of the world. And this probably accounts for the fact that, though economically poor, they certainly more than make up for it in their rich values, their warmth and their ability to separate the chaff from the grain, and to make good use of both. ■ 25 Geriatric medicine — why? by Jean-Pierre Junod 26 Beyond the age of 80, diseases may show themselves in unusual ways. So we need to know, not only the health or mental aspects of a patient's condition, but also his or her personal and social circumstances Cir he greatest wrong that has been done to geriatric medicine is the fact that for many years people avoided mentioning it. Whereas medicine was taught, geriatrics "went without saying". There is some point therefore in defining the essential aspects of geriatric care. Prevention Because many of the ailments of old age develop during earlier life, it is possible, by health education, to elimi- nate such risks to health as alcohol abuse, smoking, lack of exercise and a badly balanced diet. Information on health is especially necessary as people prepare for retirement. Besides helping the aged to overcome the enforced idleness that gives rise to so many health problems, this kind of prepara- tion can also prevent domestic acci- dents, which are so common among old people and which can be serious. Conditions whose symptoms are erroneously ascribed to aging, include low blood pressure, anaemia, distur- bances of heart rhythm, heart failure, reactivated tuberculosis, and depres- sion, as well as adverse drug reactions. It is essential to prevent relapses in order to retain the benefit of treatment regimens which involve considerable effort and expenditure, for example rehabilitation following stroke. We know that the old people most at risk are those aged 80 and over who live alone, whose financial resources are limited, who have recently been in hospital and who, for various reasons, slip through the medical and welfare network. So, while respecting the freedom of every individual, preventive action has to rely on the initiative of the health care team to identify those at risk. Detection Medicine that is merely concerned with allaying symptoms does not suf- fice for the aged; skilful diagnosis remains the keystone of geriatric medicine. Science can assist us in many ways in diagnosis. For example, physiology provides us with information on nor- mal aging, and teaches us to what extent it modifies the pattern of symp- Geriatric units should not only treat the elderly patients; they offer the best means of motivating those who are 'to provide the elderly with health care. Facing page: If physicians knowingly return a patient to an impossible life, can they in all conscience say that they have fulfilled their duty? ( Photos J.-F. Chretien a toms, the treatment, and the course of the disease. Psychology advises us what steps are needed to protect the patient's personality. From clinical practice we learn how to diagnose several asso- ciated conditions in an individual, the symptoms of which may be obscure, if not downright misleading. Diagnosis is difficult in geriatrics because the same individual may suffer from several diseases. Those admitted to hospital frequently exhibit some three to five simultaneous conditions. So whenever we arrive at what is apparently an adequate diagnosis, we ought to ask ourselves whether other diseases might not also be responsible for the observed symptoms. Thus, each old person should have the benefit of a constructive and sensible assessment. Once we know whatis a matter of old age and what stems from illness, our knowledge still has to be brought to bear on the somatic and mental aspects of the patient's condition. These varied care needs resulting from a multiplicity of conditions make geriatrics an inte- grated form of medicine. It is the discipline par excellence for learning how to solve the problems of the whole patient. Treatment The concurrent administration of more than three drugs is seldom effective. Thus, we have to draw up a plan of treatment, and to decide which condition should have priority. Drugs constitute only a small part of therapy. Other forms of treatment, such as occupational therapy, phy- siotherapy, social services and psy- chotherapy, are perfectly effective as long as the team providing the care knows their use and their limitations, and as long as its members adapt treatment to the realities of old age. It is not enough to prescribe therapy; we have also to understand its long- term consequences. Consider the posi- tion of a patient who has been cured: what is the point of sending him or her out of the hospital and back to an impossible situation at home? Can the medical staff really feel they have carried out their duty if they wash their hands of such a patient and leave it to someone else to try to improve that situation? Those who are returning home need to be taught to forget the hospital routine, but to continue with their treatment. Might it not be appropriate to assess the value of hospitalization in 27 terms of the patients' fitness to resume life in society? Are not those patients the best cared for who return home from hospital less isolated and less confused? For those who have to stay in institutions, we should make every effort to improve the facilities for their humane accommodation and treat- ment. Approaches such as these cannot be improvised. If those who provide care are to ensure the satisfactory continua- tion of what they have done, they have to plan ahead. Finally, if a person is going to die, we should try to provide the best possible physical, psychologi- cal and moral support right to the end. Prognosis It is a commonplace in geriatric practice that a patient's condition should never be diagnosed as "old age". It has taken us a little longer to find out that "old age" cannot be offered as a prognosis either. Let us not forget that the labels which we attach may kill the patient. In our daily dealings we are often unaware which patients are going to progress favourably and which will derive little or no benefit from the treatment proposed. It seems reason- able therefore to give everyone the benefit of the doubt, to offer everyone the best possible prognosis. What form of treatment? Outpatient geriatric medicine helps to keep old people in their natural environment, a priority activity for which highly motivated teams need to be properly trained. The concerted intervention of other services may often be needed—home helps, meals on wheels, and volunteer visitors, for instance. Keeping the patient at home may be encouraged in some instances by va- rious supporting facilities, among which courses for senior citizens, old people's clubs and day centres are in the forefront. Apartments where medical and welfare facilities exist very often make it possible to avoid or delay institutionalization. It might be a good idea in the future for apartments with such facilities and the institutions themselves to be in the same complex, Those who return home need to be taught to forget the hospital routine—while not for- getting to continue with their treatment. 28 Outpatient geriatric medicine helps to keep people in their natural environment. Over a cup of tea, a social assistant at the Geneva Geriatric Hospital helps two short-stay patients to prepare for normal life "back home". ( Photos J.-F. Chretien so as to avoid a succession of upheavals for sick old people. Establishments exist whose purpose is to take those patients whose health is too poor for them to live anywhere else. These should have the appropriate medico-social facilities, that is, they should not merely provide shelter, but should also include care. Any acute illness or unclear clinical situation will require hospitalization. Given that general hospitals are admit- ting more and more elderly patients, they need geriatric units, whose pur- pose should not be to treat all elderly patients, but to indicate the best diagnostic and therapeutic approaches for all, and the best means of mobilising those who can provide care. The future General hospitals will admit an increasing number of old people in the future. The activities of geriatric spe- cialists within general hospitals enable the needs of aged patients to be better assessed, and they also help to mobilise the health care team as a whole. Geriatrics can even help to re- juvenate medicine, since there is a continuous drive in medicine to provide better care for the greatest number! What geriatrics and medicine have to learn together is how to diagnose better and earlier, how to provide more effective treatment, how to lend better support to those providing therapy and to the patient's family circle and friends. We need a better understand- ing of the social and psychological needs of the aged; we need to improve and to make better use of the available institutional services within and out- side hospitals, to make urban com- munities more aware of their duties, and to contribute more to the develop- ment of gerontology and geriatrics as sciences. Once again, we cannot be effective unless we carry out a varied pro- gramme of research; clinical studies directed towards the diagnostic, thera- peutic and prognostic features of the diseases observed; anatomical and clinical studies; therapeutic studies of the use of drugs and other approaches to the treatment of diseases of the aged (indications, dosage, adaptation of treatment, tolerance, side-effects, and so on); and medico-social, psychologi- cal and institutional studies aimed at a better understanding of the needs of the aged as a group, a better appreciation of the expectations of the teams providing care, and a better analysis of the results. The youthfulness of geriatrics as a discipline is what gives it its best chance. The mission of geriatric medi- cine is to throw into relief certain truths which it is dangerous to continue to ignore. ■ 29 Mental health in old age by Theodore Hovaguimian 30 CT he problems of old age are often tackled from a preconceived viewpoint: well-meaning people only recognise the handicaps which old people face and fail to see all the means that exist to meet such people's needs. The prevalence of mental illness is at its highest during the last decades of life. But if an estimated 18 to 25 per cent of old people suffer from a resultant diminution of their mental health, it would be very risky to blame that morbidity entirely on the aging process alone. We might just as well, for instance, blame all the mental troubles of children growing up in urban slums simply on the fact that they are young. Our century has seen a sharp rise in the number of survivors beyond the age of 60 years; where there used to be just a few venerable individuals with a well- defined social role to play, today the elderly can represent as much as a sixth of a country's total population. The scale and speed of this demographic change has far outstripped the slow adjustments that society makes as it tries to integrate this new age-group. This gap has given rise to a high degree of vulnerability among the elderly who, like other sub-groups living on the margins of society and with limited resources, have become a high-risk group in the domain of mental health. In view of their large numbers, it is clearly a priority for any public health policy to seek to protect their health. Reflecting society itself, the mental health services—like the health ser- vices in general—are still ill-prepared to meet that challenge. Traditionally centred upon the early stages of human development and their consequences for the young adult, psychiatry knows little about the psychopathology of advanced age and serves it badly, often falling back on rather pathetic attempts to deal with irreversible mental con- ditions. Yet it is hardly necessary to spell out that the shattering of the human spirit is not a normal conse- quence of growing old. We do know that the cumulative decay of the neurons may in the end Who can tell why some people enjoy a happy old age—like the greybeard singing for his living in India—while others sink into loneliness and depression—like this sad old woman in a European city? What is clear is that spiritual weariness is not a normal consequence of growing old. ( Photos WHO I A. S. Kochar and IPP/G. Tannenberger overhaul the compensatory capacity of the brain, and can cause six or seven per cent of old people to show a general mental deterioration: dementia. Re- cent researches in neuronal aging offer a good hope of finding preventive and therapeutic solutions. But the aging of the brain does not alone explain dementia. How can we be sure that old people who seem intellectually enfee- bled have not been harmed first and foremost by the increasing complexity of society or by the environmental hazards they face? The criteria which enable us to distinguish physiological changes of the mental functions through age from pathological changes have yet to be clearly defined, and means of measur- ing such changes are vital if we are to judge the effectiveness of pharmacolo- gical agents which affect the brain. Depressive states, which are frequent and severe at this stage in life, may often mimic dementia, yet they can be reversed by the use of anti-depressant medication and support measures. A revision of the existing psychogeriatric classifications, with a view to obtaining diagnostic criteria for the use of clinicians as well as of health personnel working in the community, is indis- pensable for early detection of mental disorders. Depression seems to be the lot of one in four persons aged over 60 in industrialized countries, and its symptoms at that age are more resis- tant to treatment and lead more frequently to suicide; the specific symp- toms of depression in old age are related to biological factors but also to multiple losses (of one's job, earning power, health or close relatives), some of which can be avoided or better compensated for in an environ- ment which is both preventive and protective. Acute infectious diseases at an ad- vanced age can take a form in which mental aspects predominate. An infec- tion, metabolic or nutritional pro- blems, respiratory or cardiac com- plaints, intolerance of drugs—all these often take the form of mental con- fusion that is completely reversible provided it is recognised and treated in time Faced with finding solutions to all the diverse problems of advancing age, such medical disciplines as geriatrics and gerontopsychiatry are now in the process of a major overhaul. The same is true for nursing care, the social services and the participation of local communities; comparative stu- dies of the health services are helping us to identify the best conditions for treating elderly patients and showing us how to adapt the training of health personnel and the structure of services accordingly. Many of the topics mentioned here already form the subject of studies undertaken by WHO. By pinpointing the faults in our present responses to the needs of old people, we confront both a risk and a hope. The risk is that we may see the fate of our aged grow worse if nothing is done: the hope is that we may truly be able to add life to years. ■ 31 The face of old age Photographs by Jean Mohr

As old as the Suez Canal The United Kingdom's oldest in- habitant, Miss Jeanette Thomas, died in January this year at the age of 112. Her birth certificate was signed in the Welsh town of Llantrisant on 2 December 1869 — in the same year that the Suez Canal was inaugurated. A dressmaker, she was still sewing up to the age of 102, and still read her daily newspaper until she was 107, when her eyes began to fail. Accord- ing to a friend, "she was never confused in her mind, right up to the moment that she closed her eyes for the last time." The oldest inhabitant of the UK, also a woman, is now a mere youngster of 110. ( Photos WHO/Jean Mohr) 35 They defied old age... ichelangelo was in his sixties when he finished his famous paintings in the Sistine Chapel in Rome, and in his mid-seventies when he completed his work in the nearby Pauline Chapel. Another great Italian painter, Titian, was still at work at around the age of 90—and still de- veloping his artistic style. In our own time, the Spanish artist Pablo Picasso, who died in 1973 at the age of 91, was still energetically at work in his last years. Composer Giuseppe Verdi was in his 74th year when he wrote his great opera Otello, and 80 when he followed it with Falstaff—full of intensity and humour. Confucius, the Chinese philosopher whose ideas have deeply influenced the civilisations of eastern Asia, continued his teachings up to his death in 479 B.C., at the age of 72. In a tribute to famous men who defied old age, the American poet Longfellow wrote: Cato learned Greek at 80: Sophocles Wrote his grand Oedipus, and Simon- ides Bore off the prize for verse from his compeers, When each had numbered more than four-score years... Chaucer at Woodstock with the night- ingales, At sixty wrote the Canterbury Tales; Goethe at Weimar, toiling to the last, Completed 'Faust' when eighty years were past. Among politicians, we may quote Sir Winston Churchill, whose career until his sixties had not fulfilled his early promise. It was only after he was appointed Britain's Prime Minister for the first time at the age of 65, in 1940, that he became a world figure. Before him, William Ewart Gladstone became British Prime Minister for the fourth time in 1892 (although then Queen Victoria privately referred to him as "an old, wild and incomprehens- ible man of 82'/2"). In recent times, Jomo Kenyatta be- came President of Kenya when he was 71, and held that office until his death in 1978, aged 85. But none of us needs to look back in history to recall aged people who have continued fruitful and creative into their seventies, eighties, or nineties. To be- came famous is the fortune of only very few of us, but it is surely the birthright of all of us to enjoy a rich, full and productive life to the end of our days. Are all of us doing all we can to make this possible for the old people whom we know? ■ 36 Detail from the Pauline Chapel in Rome, completed by MICHEL- ANGELO when in his mid- seventies. Pablo PICASSO was still ener- getically at work up to his death at the age of 91. Jomo KENYATTA, President of Kenya for 14 years until his death at 85. Sir Winston CHURCHILL was 65 before fate chose him to lead the British in World War II. Johann Wolfgang von GOETHE — past 80 when he completed Faust. The Chinese sage CONFUCIUS — a teacher all his long life. Artist TITIAN — still developing his style when he was nearly 90. A scene from Otello, composed when Giuseppe VERDI was 73. (Photos Len Sirman C)) 37 eels •oo::: 0.. ..41 000 1100 00• 0041 000000 000 000 000 000 000 000 000 000 000 00• 000 000 000 000 000 0016 000 000 000 000 000 000 000 000 000006 000 000 000 000 000 041* 000000 000 000 000 000 000 000 009 060000 000 000 000 000 000 000 Considering all Pd heard, I decided to either quit or smoke True. I smoke True. the low tar. low nicotine cigarette . Think about R. As Females Out-live Males, Aging Seen Essentially to be a 'Woman's Problem' At no other time in human history have there been so many persons on earth aged over 60 as there are today. They totalled 307 million during the seventies. Their numbers are growing and are expected to increase to 580 mil- lion by the end of this century. The demographic shift "began really at about the time of World War II, and now a good many nations around the world have as much as 14 or 15 per cent of their population over the age of 65", according to Mr William Kerrigan, Secretary-General of the UN World Assembly on Aging. As women live longer than men —from 2 to 4 years in develop- ing, and from 8 to 10 in developed countries—then the majority of senior citizens are, at one and the same time, women and widows. Photo WHO/E. Mandelmann Only now are concerns of older women being brought out publicly. "The group from say 60 to 70, or 65 to 75, might be called the 'young old', and from 75 on- wards... the 'fragile elderly'", he said during an interview at the United Nations, New York. The latter is "largely a women's group", all of which points to the fact that aging is essentially a "woman's problem". Most women have been de- pendent all their lives, valued primarily as homemakers. They married men older than them- selves, as is still expected of them in most societies. If they worked, they earned less than men, saved less, and as a consequence, their retirement income is less. In seeking re-employment, say in their mid-forties, after children are grown, they are often con- sidered as "over the hill". Among the problems they face are those of loneliness, feelings of inadequacy as individuals, insuf- ficiency of income, and lack of health care. At times they are depressed, and their depression is mistaken for senility. These too, admittedly, are the problems of older men—with an important difference: they afflict women much longer. The concerns of older women are just beginning to be brought out in the open, forming a part of the agenda of the UN Assembly, which is set for Vienna from 26 July to 6 August. In support of efforts to raise consciousness world-wide to the needs of older persons, WHO selected "Add Life to Years" as its theme for this year. In the United States, women's concerns were aired for the first time last December at the third White House Conference on Ag- ing. There were no discussions at two similar conferences held previously. According to Miss Tish Som- mers, President of the Older Women's League, older US women make up 59 per cent of people aged 65 and over, who are estimated at 27 million today. In the group aged over 75, they outnumber men by two to one. Thus, more older women than men end their days living alone. "There are nine bridegrooms to every bride over age 65", she told conferees, many of whom wore badges saying "senior power"— "despite the larger number of women in this age bracket". Although an estimated 10 per cent of its citizens are aged over 60, the phenomenon referred to as the "greying" of populations is not, of course, confined to the developed world. Figures from the UN Division for Economic and Social In- formation show that by the end of this century the number of elderly in Africa will double, to reach 42 million—growing at a faster rate than the rest of the popula- tion. By the year 2000, Asia will be the home for nearly half of the world's elderly. Some 280 million aged 60-plus, out of a total of 580 million world-wide, will live in that region. And in Latin America, there will be almost 19 million over age 60. The total population is expected to increase by 65 per cent, while the 60-plus will jump to 82 per cent. Despite Advertising, Sports and Smoking Just Don't Mix Well A sporting life and a smoke go well together, so cigarette man- ufacturers suggest in advertise- ments designed to appeal to young adults. Team spirit, or rugged individualism, both desir- able qualities, are achievable with a cigarette in hand, the ads— subtly or strongly hint. Studies in France and Switzer- land, presented recently in Venice at a meeting on smoking and youth, however, point to the contrary—that a majority of those who engage in sports do not smoke. In fact, despite the image advertising conveys, smoking is detrimental to perfor- mance on the field, and endan- gers it. The meeting was spon- sored by the Italian League Against Cancer and co- sponsored by WHO. In the French study, carried out by Prof. J. C. Labadie, of the University of Bordeaux II, 60 per cent of the 400 athletes surveyed were found to be non-smokers, and the other 40 per cent light smokers. Generally, the more in- dividualistic a sport, the less likelihood that the athlete smokes, the study shows. For example, while from 40 to 50 per cent of those who play football or rugby smoked, none of the cycl- ists surveyed did. Furthermore, Prof. Labadie says, 75 per cent of athletes participating in sport at an in- ternational level are non- smokers. And, none of those selected for France's last Olympic games smoked. In the Swiss study, some 8,000 army recruits, aged 19, were put through a 12-minute run. Ac- cording to Prof. Theodore Abelin, Department of Social and Preventive Medicine of the Uni- versity of Berne, non-smokers covered 2.6 kilometers in that time, while the best distance for smokers—those who light up an average of 10 cigarettes daily— was shorter, just 2.3 kilometers. During the 1970s, females aged 16-18 in 14 countries were found—for the first time ever—to smoke as much as, or more than, males in the same mid-teenage group. The countries are Bel- gium, Canada, Denmark, Federal Republic of Germany, France, Greece, Italy, the Netherlands, New Zealand, Norway, Switzer- land, Sweden, the United States, and Uruguay. These are among findings of a preliminary WHO survey of 22 nations aimed at correlating smoking and young age groups. Carried out by Dr Roberto Masi- roni and Mr Louis Roy, of WHO's International Clearinghouse on Smoking and Health, the survey is limited to information available from reporting countries. Only five developing countries are in- cluded. The numbers of youth sampled varied, ranging from 500 in the case of Ethiopia, to 2,000 for Nigeria, and to 100,000 for Canada. With a few exceptions, the survey showed that smoking is on the rise overall for both male and female youths, and that the older they are the more they smoke. The exceptions: In Canada and the United States, the smoking rate for male youths is beginning to decrease. In Sweden, thanks to full-fledged campaigns, rates for both sexes have declined sub- stantially and continuously, be- ginning in the early 1970s. In another study, which deter- mined the prevalence of respirat- ory illnesses in a sample of some 3,000 youths from 12 to 19, Prof. Arja Eskola, Finnish Cancer Re- gistry, Helsinki, found smokers twice as likely to catch cold, and four times as susceptible to ton- sillitis, as non-smokers. But the plain truth is that the majority of athletes do not smoke. There is recognition world- wide of the need to counter the rise in smoking among youths, WHO says. Yet, "it is surprising to note that only a handful of countries have collected informa- tion on the prevalence of smoking in youth". WHO is calling upon public health authorities—particularly in the Third World—to compile data on which to base anti- smoking campaigns. A Thai Study Shows Students' Ability to Perform Vasectomies To reduce population growth, vasectomy is one fertility regulat- 38 WORLD HEALTH for readers everywhere 1982 Subscription Rates US$ Sw. fr. One year 15.— 25. Two years 27. 45.- Three years 36. 60. ORDER FORM Please enter my subscription to "World Health" as follows: One year ❑ Two years ❑ Three years ❑ I enclose cheque/international postal order in the amount of : Name: Street: City: Country: World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. World Health is also distributed through the network of international bookstores and subscription agencies. For payment in national currencies, please contact your usual bookseller. ing method, among others, that is provided for under Thailand's National Family Planning Pro- gramme. While available in a city like Bangkok, such sterilization services, however, are virtually non-existent in rural areas. In those parts of the country few, if any, qualified physicians are found, and without their skills vasectomies cannot be perfor- med—so runs conventional thinking. A study of 463 vasec- tomies, however, has shown otherwise—that medical stu- dents can do the job with a competence equalling that of a physician. In the study, 29 third-year medical students from the cap- ital's Chulalongkorn Hospital Medical School were put through a special programme in vasec- tomy techniques, set up by Thai and WHO officials. As part of training, each student performed 20 vasectomies supervised by a surgeon. Then, ten were selected at random, to operate on their own. Patients went under local anaesthesia. Of the 463 vasec- tomies performed in the com- parative study, 276 were carried out by students, and 187 by surgeons. The work of each group was assessed twice seven days and three months later by an examiner, unaware who performed the surgery. According to WHO's Chron- ic/e,"The operation was perfor- med successfully in all cases. Post-operative complications of bleeding or infection were not significantly different in the two groups." So encouraged are officials with these results that they have launched a new three-year pro- gramme aimed at training students not only in techniques of vasectomy, but also in tubal ligation, that is, in methods of both male and female steriliza- tion. And, if proven successful, this programme may be made a part of the regular medical school curriculum. Since medical graduates are required to spend at least two years in rural areas, the availability of Thailand's steriliza- tion services is bound to spread. In the next issue By air, sea or road, millions of people will make jour- neys this year on business, to enjoy a holiday or for family reasons. The April issue of World Health looks at some of the health haz- ards that all this travelling entails, and suggests some simple precautions that would-be travellers can take before, during and after their journey. Briefs Aging. Despite long-held beliefs, senile dementia is neither inevitable nor untreatable, research carried out by the U.S. National Institute on Aging indicates. Its director, Dr Robert Butler, in an interview with Medical World News, says: "Twenty-five years ago, it was thought that senility is something everyone gets... and that there's nothing you could do about it. But now we know that's not true. It's not inevitable with age, it's not a result of hardening of the arteries though many people, including some doctors, still think so. A significant number of cases are reversible if other conditions are looked for, diagnosed, and treated." (For related story, see page 13.) Ending Smallpox Vaccinations. China and India, among the world's most populous countries, have ended routine smallpox vaccinations of their citizens. In so doing, the two countries have complied with a recommendation made in May 1980, when the disease was officially declared eradicated from the world, namely that "smallpox vaccination should be discontinued in every country, except for investigators at special risk". All told, as of last November, 144 countries are no longer vaccinating. Only five (Burma, Chad, Egypt, Kuwait and Tunisia) still are. The vaccination policy is not known for seven other countries (Albania, Algeria, Gabon, Romania, San Marino and the two Koreas). When vaccination is halted world-wide, some US $1,000 million will be saved yearly, WHO estimates. 'No Time to Lose.' Aptly titled, this new, two-part film makes the point that time is overdue for a change in attitude towards the world's rapidly-growing 60-plus age group. It shows a worker facing mandatory retirement at 55 in the developed world and it depicts the threat to the extended family system posed by socio-economic change in the developing world. The film's theme: Decisions are needed now to add life to years for the 580 million senior citizens projected for the year 2000. Available in English, 16 mm, colour, 45 min: French, Spanish versions to come. Can be ordered from the WHO film unit in Geneva. People. Appointed as Director of WHO's Division of Non- Communicable Diseases, Dr Igor Glasunov (USSR), a staff member since 1968. He is now responsible for these units: cancer, cardiovos- cular diseases, human genetics, immunology, occupational health, and oral health. Appointed as Director with responsibility for coordination of strategy to meet WHO's goal of "Health for All by the Year 2000", Dr Hakan Hellberg (Finland). He was formerly Director of his country's Department of Primary Health Care, Helsinki. Salt and Egyptians. With between 15 to 18 grams going into daily meals, Egyptians rank "among the largest consumers of salt in the world", according to WHO's Regional Office for the Eastern Mediterranean. "An excessive intake of salt is now widely suspected as one of the possible causes" of hypertension, which was rare in the country before the mid-fifties, with one study showing that 22 per cent of Cairo bus drivers suffer from it. As a result of rapid socio-economic change, Egypt "is well on the way towards the pattern of industrialized nations, where cardiovas- cular diseases are by far the most common cause of death", the Alexandria office says. Tobacco-Sponsored Tournaments. In a letter to Mr Neil Macfarlane, Minister of Sport, ten top British physicians have called for an end to the sponsorship of sporting events by tobacco companies. They write of their concern that tournaments held under the sponsorship of tobacco interests tend "to establish a paradoxical link between smoking... and enjoyable participation in healthy sports". Another concern: that through such sponsorhip a form of advertising in itself the companies circumvent the country's ban against cigarette advertising on radio and, particularly, on television. Among those signing, the Times of London reports, are presidents of eight medical colleges, including Sir Douglas Black, President of the Royal College of Physicians. (For related story, see opposite page.) Authors of the Month Dr Halfdan MAHLER is the Director- General of the World Health Organiza- tion. Miss ING K. is a freelance journalist specialising in development topics and writing for newspapers in Thailand and elsewhere. Mr William M. KERRIGAN is Assistant Secretary-General of the UN and Secretary-General of the World Assembly on Aging, which will take place in Vienna later this year. Miss Lita S. CoNsiGNADo is a freelance writer and Editor of Asiana-Pilipina, a magazine for rural women in the Philip- pines. Mr Joseph FRANCESCHI is Secretary of State for the Aged in the French Ministry of National Solidarity. Miss Marian DAR is a Public Information Specialist with the US National Institute on Aging, Bethesda, Maryland, USA. Dr Carlos DENTON is Director of the Institute for Social Studies in Population (IDEsPo) at the National University, Heredia, Costa Rica. Dr Leo A. KAPRIO is the Regional Director, WHO'S Regional Office for Eur- ope, Copenhagen. Mr Jitendra TULI is the Public Informa- tion Officer for woo's South-East Asia Region, based in New Delhi. Professor Jean-Pierre JUNOD is Director of the Geriatric Institutions of Geneva. Dr Theodore HOVAGUTMIAN is depart- mental head at the Geriatric Institutions of Geneva, and a consultant with WHO'S Division of Mental Health. 39 rie s Re un ie s S. A. L au sa n ne "Hard work keeps you ./oung:" a gi -izzled farmer in Mexi:-,.o defies cld age. 'Photo WHO/P. Larsen)