How To Prepare For An Aging Planet

Dr. Alexandre Kalache often uses personal stories to give texture to the themes found in his more than four-decade-long work in the field of population aging. He observes that when he was born in Brazil 74 years ago, the country’s life expectancy at birth was 43 years. Today, it is 77.

This staggering increase in longevity in Brazil is occurring in most countries around the world. People are living longer and having fewer children in almost every region — vastly increasing the proportion of older adults on the planet. Kalache, a medical epidemiologist, saw the beginnings of this trend early in his career and has spent his professional life studying the individual and societal decisions necessary for people to achieve and maintain quality of life as they age. 

"We are privileged to live at this time of a revolution in longevity. It will be a tragedy for humanity if we mess it up,” he said.

The longevity expert who pioneered the concept of age-friendly cities and communities at the World Health Organization came to Boston for a week last month, meeting with state leaders in aging and speaking about his work. Kalache is a member of the board of directors of the newly launched Age Friendly Foundation, which brought him to Boston. The intense agenda of his visit included keynoting at Revolutionize, the inaugural conference hosted by the foundation and the Boston chapter of the Aging 2.0 global network.

While in Massachusetts, Kalache spoke to a class at the Harvard T.H. Chan School of Public Health and visited three other universities — MIT, Fitchburg State and Lasell. He additionally met with both the editorial board of the Boston Globe and various groups working on aging issues, and participated in a working meeting with members of Gov. Charlie Baker’s cabinet.

Kalache took an interest in the initiatives taking place in Massachusetts after he learned of Gov. Baker’s aspiration to make the state a Silicon Valley for innovation in aging. Last year, Baker issued a challenge to all state players to transform the “age-tech” that benefits older people.

The worldwide demographic shift is profound. From 1950 to 2050, the global population is projected to increase 3.7 times. But the number of people 60 and older is expected to multiply 10 times; the number of people 80 and older is projected to increase 27 times -- from 14 million in 1950 to close to 400 million in 2050.

“It is the speed of this change that is astonishing,” Kalache told a class at the Harvard T.H. Chan School during his visit.

Kalache, who lives in London and Rio de Janeiro, is co-president of the Global Alliance of International Longevity Centres (ILC-GA). He directed the World Health Organization’s (WHO) global program on aging for 12 years from the organization’s headquarters in Geneva. During that time, he initiated the global age-friendly cities movement. More than a thousand cities — including Boston — have now formally joined this program, with many hundreds more unofficially adopting its agenda.

Kalache doesn’t view human aging as purely an individual endeavor. He strongly believes that it requires the full cooperation of all segments of society -- from government and business to educational, civil-social and grass-roots organizations.

“Longevity is no longer the privilege of a few. It has become the realistic expectation of the many. It is arguably the greatest social achievement of our time, but we can easily turn it into a disaster if we don’t open our eyes and fully prepare,” he said.

Massachusetts has already made progress preparing for this demographic shift on several fronts. The state was the second in the nation to join the AARP Network of Age-Friendly Communities.

“Many of the ingredients exist for Massachusetts to be a global leader in the response to the longevity revolution -- impressive political will, an engaged private sector, first-class universities and a critical state-wide mass of cities that are already contributing to the age-friendly movement,” he said in an interview. “We are certainly not starting from scratch.”

Before he began his talk at Fitchburg State, Kalache invited the 100 or so audience members to first contemplate their own futures.

“Close your eyes and imagine how you will spend the evening of your 85th birthday,” he said.
“Who will be celebrating with friends and family?” he asked. 

A few dozen people raised their hands.

“Who will be doing something that you have always wanted to do -- now that you perhaps have resources and time -- like taking a cruise, writing a book or traveling to somewhere distant and exotic?”

A few more people raised their hands.

“Who is going to be in a geriatric hospital?” he then asked. “Who’s going to be in a residential care unit? Who does not think that you’re going to make it to 85?”

No hands.

“It is inconceivable that all of you will be disease-free at 85, be it dementia, stroke, hypertension, diabetes, whatever,” he said. For this reason, Kalache prefers to emphasize “active aging,” rather than “healthy aging.”

“No matter where we live, how we live or how old we are, we all need to build reserves in each of the four foundational pillars of active aging: Clearly our health is important, but so, too, is our commitment to lifelong learning, our participation in society (full citizenship), and our security (protection and care) as we age.”

“We still have a long way to go on this journey. We must view the world anew -- with an age-friendly lens. We need to commit to user-led, rather than user-centered, design -- whether it is the design of environments, services or products. Human emotion must be placed at the core of age-friendly design.”

During his Massachusetts trip, Kalache remarked on the parking meters whose instructions are listed at waist level, in tiny print. He also observed the speaker’s dais at the top of a few steps, without a wheelchair ramp and took note of the restroom a flight up, not reachable by elevator. None of these were “age-friendly,” but neither were they accessible to many other members of society. Once you see the world around you using an “aging lens,” he said, everybody benefits.

Kalache’s first action at WHO was to change the name of the program he was hired to direct — from “Health of the Elderly” to “Aging and Health.” The distinction has become central to his message: “Aging is a relational process, not a condition. Our old age is defined by the accumulation of our life experiences and their consequences, for better or for worse. A life-course approach to aging is fundamental. But too often, science still only recognizes old age by its association with an interminable list of diseases that will arrive, one after the other.”

Kalache worked at the World Health Organization until 2007, when he turned 62. He wasn’t ready to leave, but he had reached the organization’s mandatory retirement age. The irony wasn’t lost on him. “A longer life is often accompanied by a greater number of losses and changes of direction. I am privileged. I am resilient. I was able to further define my message and deliver it to an even broader global audience after I left WHO.”

Kalache sees inequality in aging as the biggest challenge of all.

“It has never been so good for some to get older,” he said in Fitchburg. “But it’s punishment for millions. You may reach 70, 80 … 100 -- but often in ill health, with no access to services, without reserves, bypassed by innovations which you cannot afford.”

Life expectancy itself varies dramatically depending on where you live — not only by country, but by neighborhood. In Rio, a single cinder block wall can separate a luxury apartment building from a favela, or shantytown. The average life expectancy for Brazilians who live on the wealthy side of the wall is 20 years more than it is for their fellow citizens on the poorer side, he said. “The only difference in many U.S. cities is that the 20-year divide is usually not a wall, but a short bus ride.”

“Developed countries became rich before they aged,” he told the Harvard class. “Developing countries are aging faster within the context of prevailing poverty and increasing inequality.”

"Addressing aging inequality has to be at the forefront of the efforts in Massachusetts,” he said later. “Despite its wealth and its impressive historical gains, the U.S. is now experiencing a declining life-expectancy and higher rates of premature mortality, mental illness, drug deaths and homicides relative to more equal developed nations.” This, despite spending nearly one-fifth of its vast GNP on health.

“The benefits of a more equitable society are very widespread. International research shows that improved equality creates significant gains even for the richest or best-educated third of the population.” Policymakers must find pathways to understand the needs of older adults who often aren’t heard. “Failing that, the modern plagues -- loneliness, drug abuse, obesity, suicide – will continue to affect many more millions.”

“We must not fall into the easy trap of talking [only] to middle-class, articulate, successful older people,” he said. “We have to listen to the voices of those who have been excluded.”

Policymakers cannot create successful programs without incorporating the ideas from the people they’re meant to help, he said.

“There is one principle that we must have in mind all the time: Nothing for us without us.”

Kathleen Burge is a freelance writer and editor, and a former reporter for The Boston Globe.