The Challenge of LongevityAuthor: Prof. Antony H.B. de Bono M.D., M.A. (Oxon), F.R.C.S., (Director United Nations International Institute of Ageing – Malta) SummaryFor the first time in the story of the human race, people are surviving to old age, not in isolated instances, but as substantial parts of whole populations. Due to increased longevity and decreasing fertility, many populations will in the next few decades, see the elderly comprise 25-30% of their numbers, and most will see the numbers of their elderly at least double in the next two decades. The increase in life span that has resulted from improvements in basic hygiene and sanitation, as well as nutrition, together with advances in medicine and in particular the control of communicable disease will be a predominant socio-economic concern for at least the first half of this century with profound effects in every field. Ageing in the WorldIndividual survival to old age has existed for thousands of years. However, until recently any genetic bias towards longevity has been frustrated by the forces of disease and death. Now, however, at first in the more developed countries, but now increasingly in the less developed regions, mass longevity is rapidly becoming the norm. It is no longer individuals but whole populations that are ageing. The consequences of this fundamental and unprecedented demographic change will affect everyone in the next few decades. The Longevity RevolutionThis mass increase in life expectancy is so unprecedented, so sudden, and has such profound consequences that it has been aptly dubbed "the Longevity Revolution". The term "longevity" is preferable to "ageing" because it emphasizes the far more positive concept of added years of life, rather than the stereotypically pejorative term "ageing". This had important psychological consequences. The factors responsible for the Ageing Revolution were improvements in basic hygiene and sanitation, control of communicable disease, better nutrition, and advances in health care. These decreased infantile mortality, then mortality at all ages. Thus for the first time the vast majority were able to survive towards the limit of their genetically determined life span; and were in effect from premature death. At the same time as this increase in life-expectancy was taking place, we have experienced, at least in most developed countries, a fall in fertility rates that are equally unprecedented. The combined effect of decreased mortality and decreased fertility has led to population ageing, that is population were the median age has increased or put another way, where the percentage of the elderly has increased dramatically. There are thus two important demographic concepts: one is the dramatic increase in numbers of the elderly, and the other is an increase in percentage of the elderly. Both these concepts are important and both have different consequences. Thus in some communities, because of mass immigration or of higher rates of fertility, the population is still "young", but this might hide the fact of rapidly increasing numbers of the elderly, though their percentage in the population remains low. In this case the need for care is often masked. Where the mass longevity is combined with falling fertility, the elderly rapidly constitute a growing proportion of the population. This has serious consequences particularly in the economic and financial fields where the ratio of pensioners to wage earners deteriorates, the so-called dependency ratio. Implications of Mass LongevityThe consequences of mass longevity are so widespread that virtually no facet of life will be unchanged. Most people have no idea of the scale of the longevity challenge. Ageing itself is multifaceted in the sense that so many different factors are involved. These are factors that affect the individual, sometimes called "humanitarian" concerns, there are others that affect the community or country as a whole. Time does not allow us to look at all of these; some examples must suffice. Health and LongevityOne of the most important considerations of longevity is that the years added to life should be enjoyed. At the present time the so-called triumph of longevity is marred by chronic disease and disability. Women, who in most countries have significantly higher life-expectancies, have longer periods of disability. The objective of achieving healthy longevity can only be achieved in the context of lifelong health and active ageing. The aim is for people to reach whatever number of years is called old age in as healthy as condition as possible, and then to continue to live in a healthy, active, and involved way in order to age successfully. A working hypothesis of the biological basis for ageing helps explain the importance of this approach. Nature is concerned with the continuation of the species; it is therefore "concerned" that human beings, and indeed other species, should grow optimally to reproductive maturity. After that it is not much concerned, other than to ensure the survival of the young (who take many years to become totally independent). Following maturity, "ageing" starts. This is a highly individual process, only partly dependent (possibly 25-30%) on genetic factors, the rest on environmental ones. "Ageing" is the process of deterioration that affects most organs, systems, cells and molecular structures in the body. During this post-maturity period normal function is maintained by the body by a process of adaptation where the process of deterioration is compensated for at the expense of the "biological reserve" of the body. Eventually this adaptation runs out of reserve and an overt rapid deterioration called senescence occurs prior to death. This model explains why the elderly suffer from multiple conditions and why prompt effective treatment to restore function and mobility is essential. Research has shown the efficacy of good treatment and above all the importance of healthy life-styles as a lifelong commitment. In the past life expectancies were an important measurement of health and longevity; today increasingly we are more concerned with "health-expectancies" that is the prediction of years free from disease or specific disability. Research has shown that as a result of certain measures the amount of chronic disease and disability that the added years of longevity bring, can be reduced both in severity and duration; they can perhaps be eventually compressed into a very brief period of senescence. However health considerations are an important consideration at the present time because of the amount of care required. Thus longevity will require a radical change in our attitude to health matters, away from the traditional "curative" medicine towards healthy promotion and active healthy life-styles. Nevertheless for the time being conditions such as dementia, and in particular Alzheimer’s disease, will impose an enormous burden on individual carers and the community; the incidence of this condition doubles every five years after the age of 65. Moreover the most rapidly growing part of the population is that of the over-80 year olds. The challenge of healthy longevity is indeed formidable. Social AspectsEconomic development, all over the world, has brought about profound social change, not least in urbanization and the erosion of the extended multi-generational family. Both these factors affect ageing. With population ageing the numbers of carers will inevitably diminish, and the "burden of care" increase. Indeed in most places this will pass from the family to the community. AccommodationAccommodation is another extremely important area for concern. While there is no doubt that the best place for the elderly of whatever age is with their own families, this is increasingly difficult or impossible. Suitable and appropriate alternative accommodation must be provided. The growth of "granny flats", sheltered housing of all types, and ultimately nursing homeless and extended care for people who require long term 24 hour care is in a period of evolution. Most would agree that the outdated idea of large institutions should be avoided if at all possible. Economic and financial aspectsVitally important areas of concern are the economic and financial aspects of longevity. These are of profound importance both for the community or state, and for the individual. In most developed countries pension schemes have operated for years; most of these are unfounded, that is they are not paid out of the yield of a dedicated fund, but rather largely from, the contributions deducted from current wage-earners. This is known as pay-as-you-go. It was very convenient when the number of personas was relatively low and the number of wage-earners high. However this situation has changed and is still changing dramatically. In the next decade or two not only will the number of pension years grow rapidly, but also the number of production workers will diminish. Countries are realizing that this type of pension is not sustainable. They are quietly cutting back on future commitments and encouraging self-funded investment insurance. This is obviously not as secure as state pensions and requires close regulation; the control of inflation is also of paramount importance. The amount of liquidity tied up in pensions is considerable and affects the economy as a whole; though it has been argued that it has a stabilizing net effect. Other issues to be considered are retirement age: while some ministries try to encourage early retirement in the (often false) hope that this will bring down unemployment, ministries next door are urging that the retirement age is raised to 70 or more. Obviously flexible and imaginative opportunities for the elderly to continue to be productive and engaged are important. What is needed once again is a radical fresh look at traditional practices in the light of the radically new situation that longevity will cause. Malta and World AgeingMost people are unaware of the fact that when, in 1532, Quintinus wrote his description of Malta, he pointed out that one of the remarkable things was that most people seemed to live past the age of eighty years. This at a time when life expectancy was barely forty years. Malta first raised the question of ageing at the United Nations in 1969. Many years later, in 1982, the United Nations called a World Assembly on Ageing which met in Vienna. Again Malta played a leading role as I had the honour to chair the 23 nation Advisory Committee which debated the Draft Plan of Action on Ageing, and later at the World Assembly itself I chaired the Main Committee which comprised delegations from 130 nations and which debated the final Plan of Action. The rules of the United Nations governing global meetings had to be changed in an unprecedented way to allow this to happen. In spite of considerable turmoil and the Cold War this Plan of Action on Ageing was unanimously adopted; a result that had never before occurred at such a Global meeting. Malta offered to host the United Nations International Institute on Ageing and thus the Institute known as I.N.I.A. was set up eleven years ago. Since then our main task has been to train personnel principally from the less developed regions in various fields concerned with ageing. Indeed I.N.I.A., and Malta, has achieved worldwide renown in the field of ageing because of this. I.N.I.A. has a three-pronged strategy. It organizes Core Training Courses for participants from all over the world in four topics: Social Gerontology, Health and Longevity, Economic and Financial Aspects of Ageing, and Demography. Tutors from the U.K., U.S.A., France, Canada and Australia among other countries help with the courses. The second element is the organization of in site or on-site courses in the countries themselves. The aim of this is to build up capacity in that country and focus on specific local issues and solutions. Courses of this type have been organized in countries round the world. The third element which is the ultimate objective, is to help and sustain the establishment of Training Centres in countries and regions to cope with the challenge of training their own people to face the growing demand for trained personnel in all fields concerned with ageing. As example of this is the recent agreement with the Chinese National Committee on Ageing to set up such a Centre in Beijing. The training courses are enhanced by a widespread network and distance learning programmes. Malta has maintained its advocacy role in international ageing. In 1998 I was asked to give a paper on "Ageing in the Commonwealth" to the Commonwealth Ministers of Health Meeting in Barbados, and last year the Prime Minister raised the question of Ageing at the Commonwealth Heads of Government Meeting in South Africa. ProposalsThe question of ageing is an important one for Malta, and even more so for the Greater Malta which includes the much wider community. Network On-lineFar greater use could be made of modern electronic communications not only for the diaspora to keep in touch with elderly relations and family but to exchange ideas about their own communities throughout the world. Cyberspace needs to be more fully exploited in terms of meeting the challenge of mass longevity, for instance by dedicated Websites. Comparative StudiesMaltese communities abroad provide an ideal opportunity to compare matched groups of the elderly with those in Malta, particularly to study the effects of different environmental factors on those with relate gene pools. This would make a significant contribution to our understanding of a number of important conditions which are very prevalent in the Maltese elderly such as diabetes, obesity, and hypertension, both major risk factors. Other studies might include the incidence of cancer of the lung which has a very high incidence in Malta. ConclusionsLongevity will be a paramount socio-economic concern during the next few decades. The rapid increase in the over eighty population poses increased challenges. There is much to be gained by the exploration of how a genuine and on-going exchange of ideas and information with the Greater Malta Community can enhance the quality of life for all the elderly, and at the same time make a worthwhile contribution to world ageing.
    
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