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Getting Old Fast

Populations in most poor countries are aging rapidly — with ominous consequences

Theirs are the new faces of the ill and dying in poor regions of the world: not a child with A distended stomach but a retired Tanzanian schoolteacher with both legs amputated from diabetes, an Indian matron trying to lose weight after heart-bypass surgery and a Brazilian grandfather immobilized by strokes.

Longevity is increasing nearly everywhere on the planet, and with it comes chronic disease. In fact, many public health experts predict that developing countries, still struggling against infectious diseases, malnutrition and lack of clean water, soon will be engulfed by an epidemic of chronic diseases, including heart attacks, strokes, diabetes and cancers fueled by smoking and bad health habits. Already, the World Health Organization says, chronic diseases are the leading cause of deaths in almost all countries, and take twice as many lives as all infectious diseases (including HIV/AIDS, tuberculosis and malaria) combined. Poor countries are “getting old before they get rich,” notes demographer Adele Hayutin, PhD, who directs the Global Aging Project at the Stanford Center on Longevity.

The world is turning grayer, and at a rapid clip. Today, global life expectancy at birth is almost 68 and that figure is expected to top 75 by mid-century. While the HIV/AIDS epidemic has reduced life expectancy across sub-Saharan Africa to 46, it’s on the march nearly everywhere else. The developing world is benefiting from the same medical advances and immunizations that dramatically boosted life spans in the West and Japan during the 20th century. Their populations are aging at rates two to three times faster than the West’s industrialized nations. Today, life expectancy stands near 71 in Indonesia, 72 in Brazil, 73 in China and 74 in Vietnam, according to the United Nations. By 2050 all four countries will be closing in on a life expectancy of 79 or 80.

Even poor people around the globe benefit from new cancer treatments and drugs for high blood pressure and high cholesterol, says epidemiologist Ali Mokdad, PhD, chief of the Behavioral Surveillance Branch of the U.S. Centers for Disease Control and Prevention and a frequent adviser to developing countries. “The elderly is the fastest-growing population almost everywhere,” says Mokdad, a native of Lebanon. “The sad part is that some countries are still dealing with infectious disease problems and now they have to face this chronic disease problem as well.” Mokdad counsels public health authorities in developing countries to focus on behavior to prevent the chronic killers — cardiovascular disease, diabetes and cancer — from exacting an even higher toll.

Not just numbers

A 2005 WHO report, Preventing Chronic Diseases: A Vital Investment, puts a face on some of the elders and near elders struggling with chronic diseases in developing countries, telling the stories of real people. Among them: Menaka Seni, 60, a plump Indian widow with diabetes and high blood pressure trying to change her diet and lifestyle after heart-bypass surgery; and Roberto Severino, 52, a heavy smoker and drinker with high blood pressure living in a shanty in the outskirts of São Paulo, Brazil, with his seven children and 16 grandchildren. A series of strokes starting at age 46 has paralyzed his legs and left him unable to speak. The former public transit agent now is dependent on his family.

Question of priorities

The notion that poor countries should begin shifting limited resources from mothers, babies and AIDS victims to the chronic-care needs of elders is fraught with controversy. On one side are the U.N., the WHO and many public health experts in academia who argue that a chronic-care catastrophe is looming. They issue exhaustive reports and exhort governments, foundations and the medical community to stamp out smoking and encourage healthier diets to prevent an explosion of heart-related death and disability in the world’s neediest countries.

But skeptics say reining in chronic disease involves changes in behavior that are much harder to effect than traditional public health strategies built around vaccinations and improvements in water and sanitation. “For 25 cents, you can immunize against four or five childhood diseases. That is enormously cost-effective,” says David Katzenstein, MD, a Stanford professor of infectious disease who runs an AIDS prevention project in Zimbabwe. Changing people’s behavior is harder and less cost-effective, especially when “huge economic interests, whether they’re McDonald’s or tobacco companies or Coca-Cola,” are encouraging those unhealthy habits, he says.

This reality explains why so many public health programs in poor nations leave out prevention or treatment of chronic disease. For instance, chronic diseases are absent from the Bill & Melinda Gates Foundation’s priority list of 10 target diseases afflicting people in poor countries. The foundation says it focuses on conditions that cause the greatest illness and death in developing countries, represent the greatest inequities between rich and poor countries, and receive inadequate attention and resources. The global health program’s targets include HIV/AIDS, malaria, tuberculosis, malnutrition, acute diarrheal illness and lower respiratory infections. But the foundation plans to double the $1 billion it spends each year on global health. “The foundation is exploring grantmaking opportunities in a number of new areas, such as tobacco control in developing countries,” says Gates public affairs officers Karen Lowry Miller.

The WHO’s 2005 Preventing Chronic Diseases report underscores how large the toll already is from heart disease, stroke, cancer, chronic respiratory diseases and diabetes. To those who argue that a heavier chronic disease toll is inevitable given aging populations, the WHO gave this answer: Death is inevitable, but it “does not need to be slow, painful, or premature. Most chronic diseases do not result in sudden death…. Chronic disease prevention and control helps people to live longer and healthier lives.”

When push comes to shove

Richard Suzman, director of the National Institute on Aging’s Behavioral and Social Research Program, says the global spurt in life expectancy was a crowning achievement of the 20th century. Now, as developing countries seek to catch up, “the big issue is how they are going to deal with chronic disease, which by definition lasts a long time, given the fact that their health budget is going to be a very small fraction of ours,” Suzman says. He predicts the answer will involve settling on the most cost-effective approaches to prevention and developing new treatments.

Societies can and do adapt to changing needs. Before the advent of Medicare in the mid-1960s, a third of American elders lived their last days in poverty. Today, the elderly have the lowest poverty rate of any age group in the United States. But the challenge will be greater for poor countries. The triumph of increased longevity will be hollow if it means many more people experiencing prolonged disability and painful deaths like Jonas Justo Kassa, a retired Tanzanian schoolteacher also profiled in the WHO’s Preventing Chronic Diseases report. Kassa lost both legs to diabetes and spent his final days in a wheelchair in a village near Mount Kilimanjaro. A few weeks before his death at age 65 in May 2005, the retired teacher told a visitor from the WHO, “I now feel doomed and lonely. My friends have left me. I am of no use to them and my family anymore.”






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