The new age of old age
Alexandre Kalache is a world expert on ageing. With average life expectancy now above 80, he discusses what Australia should do to prepare for the longevity revolution.
Alexandre Kalache is a world expert on ageing. With average life expectancy now above 80, he discusses what Australia should do to prepare for the longevity revolution. ALEXANDRE Kalache's departure from his job as the World Health Organisation's Director of Ageing in 2007 was a moment of bitter irony. In October of that year he turned 62, and despite being fit and energetic with years of good work still ahead of him, he was forced by the organisation to retire.It is policies such as this that, paradoxically, represent the central theme of Kalache's life work: that the retirement structure used by most developed countries was conceived in the 19th century and has ceased to be relevant in the 21st century. It is time for societies to adapt to what he calls the "longevity revolution".When Kalache was born in 1945, life expectancy in his native Brazil was 43 now the average Brazilian can expect to live to 75. Kalache describes this leap in life expectancy in such a short time (mirrored in developed countries including Australia) as "the greatest societal achievement of the 20th century - something to celebrate".But he also warns that "it threatens to become the greatest challenge for the 21st century if we don't have the right policies''.The numbers explain the challenge: by 2050, the number of people aged over 60 will double to more than 2 billion, or 22 per cent of the global population. With life expectancy in more than 20 developed countries already above 80, the economic and social impact on societies of an increasingly healthy ageing populace are obvious. For example, in Australia the cost of aged care is expected to double by 2050.Politically, it also brings opportunities for governments to target the so-called "grey vote" - evidenced in the Gillard government's much-trumpeted aged-care announcement on April 20.For his part, retirement has been a productive time for Kalache. His various positions include being president of the International Longevity Centre in Brazil, a senior adviser on global ageing at the New York Academy of Medicine, and a Resident Thinker on Ageing for the government of South Australia, where he is currently visiting.He also runs campaigns on age-related issues close to his heart, such as making cities more aged-friendly a subject on which he is running a seminar in Melbourne on Thursday. He is evangelistic about the idea that ageing is not just something that happens to the elderly, that it's an integral part of every person's life journey.The ebullient Brazilian grew up in Copacabana, surrounded by older relatives. He pinpoints his grandmother's three-year battle with cancer as the trigger for his later studies in geriatrics."She died at home, living with us. I was 15 to 18 at the time and I was going to be the doctor in the family: like it or not, I was involved in her care and it was fantastic. It gave me the privilege of what it is to care for someone who is at the end of their life."Kalache trained as a doctor in Brazil before moving to the UK in the 1970s. He ended up staying in Europe for 30 years, studying first at the London School of Hygiene, then at Oxford University, where he taught geriatrics. A secondment to the World Health Organisation led to the directorship of what was then the Health of the Elderly program in 1994.The first thing he did was change the name of the department, arguing that the label "elderly" put a segment of the population in a box, making disassociation easier for the rest of society. "I said the program should use the word 'ageing' - it's a much more active word and it involves everybody, because everybody will age. From there the other departments at the WHO started to recognise that they had a role to play in this."Kalache is never more ardent than when discussing the frontiers being forged by those hitting old age now - the "baby boomers" born between 1945 and 1965. He says boomers have transformed every stage of life they've experienced and retirement is proving no different."You talk about the sexual revolution, the emancipation of women in the workforce, 1960s student movements - all this was in our day and age. Now that we are going to old age we are going to invent a new position, a new social construct," he says.Kalache has even conceived a term for this stage of life - "gerontolescence" - by adapting the concept of adolescence for older age.Before World War II, most people moved quickly from childhood to adulthood by starting work younger. After the war, says Kalache, developed societies discovered the "luxury" of having years to make the transition from childhood, with longer periods of education and less pressure to start work, a time we now know as adolescence. "But back in the fifties it was a new phenomenon."In a similar vein, there was previously little transition from work to retirement and old age because most people did not live long enough to experience it when German chancellor Otto von Bismarck instituted the first old-age pension for 70-year-olds in 1881, only 3 per cent of people lived long enough to actually receive it. But as life expectancy has increased, so have the opportunities to move into old age and redefine this phase of life."We are going to age differently. We are starting to see role-models who are active, demanding, who will want to work longer or will want more leisure or will want to take part in society and expect that people will listen to their voices. It's exciting because it's a new stage of human development ? It's going to be a very vibrant transformational period that is going to have lasting influences."Sue Hendy, chief executive of the Council on the Ageing in Victoria (COTA) and a director of the International Federation on Ageing, agrees that baby boomers hold more sway than older people used to, but not because they are demanding different rights than their predecessors."They want respect, to live at home, to live in a world that's friendly and enables them to keep connected, to have civic participation. I don't think that's much different from what previous generations wanted," she says.The difference is that previous generations of older people lacked the numbers that the current generation has today. This one, she says, has the capacity to be more activist, to demand greater attention from policymakers.As part of the $3.7 billion aged-care package launched by the Federal Government, $577 million is new funding. Proposals include introducing means-testing for residential and home care, increasing the number of funded home-care places from 40,000 to 100,000 over three years and directing $1.2 billion over five years towards tackling workforce shortages in the sector. Dementia will also become a national healthcare priority.Importantly, though a user-pays model, the program will exclude the family home from asset calculations.The federal reforms were a response to a Productivity Commission inquiry into aged care. The commission panel, which included former deputy prime minister Brian Howe, consulted Kalache and incorporated many of the principles advanced by the WHO under Kalache's reign.Kalache says that Australia's aged are well represented by groups such as COTA, and that simply by having a minister for ageing Australia is ahead of the pack."So often, in other countries, ageing is diluted into some other department. It is actually fascinating that [Minister for Ageing Mark Butler] happens to be a young person so often you find the minister, if they have one, is old, because it is about ageing. You know who to call here. Butler is young: he has a long shelf life."Hendy says that Kalache's charisma and passion for the subject, as well as his impressive CV, lend an element of celebrity to the broader discussion about ageing and that this opens doors to politicians, academics and other influential people. He has had several one-on-one meetings with a "warm and enthusiastic" Butler and last Friday met with Jay Wetherill, the South Australian Premier.Kalache's response to the federal government package will no doubt be of interest to both government and the opposition (which has yet to articulate its response to the reforms). He says the initiatives are a "step in the right direction" and show that the challenges are being taken seriously by government."It was a serious methodology that produced the [Productivity Commission] report and then you see the government responding to that report and choosing the most sensitive of all the sections [home care and means-testing]."There has been a process of consultation that is admirable. Not everywhere is it done with this care."But he believes more needs to be done to facilitate self-care and informal care in the community that the emphasis on residential and institutional care and the funding allocated to them is misguided.Kalache draws a picture of four boxes, one inside the other. The largest box, taking in the majority of older people, is self-care in the home. Inside that is a box symbolising informal care at home by family, friends and neighbours.This is followed by community care provided by councils, community centres and the like. The smallest box, proportional to the numbers it affects, takes in residential and institutional care. (Sue Hendy points out that only 6 per cent of people aged over 65 are in residential or institutional care at any one time.)KALACHE says: "When you look at the money and where it's given, it's the wrong way around. Huge amounts go to institutions, a little to paid professionals, a little to the community - especially the mostly women who are behind the scenes holding things together: women who are untrained, unsupported and unrewarded and expected to give their best. And then comes self-care, where people are in control of their health and the process of ageing - well, virtually nothing is given there."A big part of empowering older people to take care of themselves for longer is through health education and promotion, elements that both Kalache and Hendy say are lacking in the government's proposals and the aspects that do deal with health relate to palliative care and access to primary-health facilities by people in residential accommodation, with no mention of those still at home."There's been very little attention paid to health promotion and older people at both state and federal levels," Hendy says. "For instance, we're writing a document for VicHealth because they acknowledge they've done very little on it."At the federal level, Hendy says: "There's a lot of smoke and mirrors. I hope the detail will come."The federal program has been criticised for placing a higher cost burden on recipients of professional home care. An analysis by UnitingCare Ageing of the impact of the program last week found that the cost of home care would rise as a proportion of recipients' incomes, with those on higher incomes paying significantly more.This was recommended by the Productivity Commission and groups including Catholic Health Australia, a large operator of non-profit aged-care services, supported it. Others, including COTA's national head, Ian Yates, decried the higher cost burden. Minister Butler responded by saying that "those who can pay more, should", while those on lower incomes would be protected from large cost increases.Kalache supports the idea that people should foot the bill for as much of their own care as possible, and that the wealthier should pay more. "It expresses the idea of solidarity between all. I always say that if there is one word that rhymes well between longevity, it is solidarity. It is solidarity between the old and young, developed and developing, and then, yes, solidarity between rich and poor."Training is also lacking in the package, Kalache says. The $1.2 billion earmarked for the aged-care workforce is being directed towards improving capacity, skills and conditions in a sector that experiences staff turnover rates of some 25 per cent. But more formal geriatrics training is needed for health professionals, he says."Australia is still training professionals for the 20th century, but they are practising in the 21st century." It should go beyond health workers too if cities are to cater for growing numbers of older people, then everyone from urban planners and architects to lawyers and bureaucrats needs to be better informed about the needs and impacts of ageing people "because we live in an ageing universe".For all the challenges of implementing policies for an ageing population, Kalache says Australia's wealth, small population and relatively uncomplicated bureaucracies make him optimistic about its ability to prepare for the longevity revolution. "And that," he says with a flourish, "is why I spend my time here."Julia May is a Melbourne writer.On Thursday, Dr Kalache will present an overview of the value and practical application of age-friendly communities. This will be followed by a workshop on how older people and others can build an age-friendly Victoria.Venue: Jasper Hotel, 489 Elizabeth Street, Melbourne from 9.30am to 12.30pm.Bookings: 9655 2125 or www.cotavic.org.au/programs-events/Who is Alexandre Kalache?? South Australia's Thinker In Residence, in partnership with Flinders University.? Director of the World Health Organisation 1994-2008 under his leadership, WHO launched the Global Movement on Age Friendly Cities and pioneered the concept of ''active ageing''.? Senior Policy Adviser to the President on Global Ageing at the New York Academy of Medicine.? International ambassador for HelpAge, a global network of not-for-profit organisations with a mission to help disadvantaged older people worldwide.? Adviser to the Permanent Working group on Rights of Older Persons of Mercosur (the leading trading bloc of South America).? Adviser to the World Bank and the European Union on ageing-related matters.? Board member of World Economic Forum Council on Ageing? Board member of the International Association of Gerontology.? Founder and former head of the Epidemiology of Ageing Unit at the London School of Hygiene and Tropical Medicine.? Former clinical lecturer at the Department of Community Health and Cancer Epidemiology at Oxford University.