Many older people want to work and contribute to society but cannot because of bad health. Half of that disease could be prevented, dealt with, or significantly delayed by using the technology we have today. More of it will be preventable through the revolution that has already started in diagnostics, big data, and artificial intelligence. There may be insurmountable obstacles to getting politicians to invest in healthy ageing.
The longevity economy
Today, if all older people worked the way older Icelanders do, it would add $3.7 trillion to the global economy every year, without counting the value of unpaid work. It would give older people dignity and fulfilment and empower them even more to volunteer, run community institutions, care for children (freeing up younger adults to work), and do all the other things that build “social capital,” as economists call it.
A failure to invest in prevention for older people will have appalling economic consequences. Pre-COVID numbers suggested that by 2035, forty percent of the G20 workforce will be aged 50 or above (up from 30 percent in 2015). And they will be more needed than ever: the UK, for example, will be short 2.6 million workers by 2030. There are compelling suggestions that much of today’s labour shortage is caused by the withdrawal of older people from work during the pandemic: between 1993 and 2019, labour force participation doubled for the over 65s; it has declined since 2019.
Often these discussions provoke a union leader or populist politician to draw a picture of a ninety-year-old teetering at the top of a fire ladder struggling with a bucking horse. The average person working just two or three years longer would dramatically benefit the individual and collective prosperity. Most retire before their state pensions start, so they would also have more savings throughout retirement.
While older workers will generate 40 percent of all earnings, in proportion to the share of the workforce they constitute, they spend much more than younger households do. Across the G20, which contains many emerging economies with young populations, 56% of total spending in 2015 came from families over 50. The mortgage is paid off; the children are finishing university, and investments may provide returns; why not buy stuff for the grandchildren and live a little? Data suggest that a 0.1% increase in spending on disease prevention could increase spending by older people by 9% per year. That spending, of course, creates jobs and growth across the economy — the global longevity dividend.
“Household savings is the main domestic source of funds to finance capital investment, which is a major driver of long-term economic growth,” according to the Organisation for Economic Cooperation and Development. Those savings are depleted when a household member becomes unwell, especially in countries with no national health system. If granny gets severely ill with pneumonia, you will spend whatever you have got to secure her treatment. Keeping older people healthy leaves household savings at work, creating economic growth.
The politics of medicine
If healthier, more productive citizens will make society much richer, why aren’t our politicians just getting on with doing a better job of preventing the diseases of later years?
We wrestled with this problem throughout a fascinating, three-day meeting on prevention and healthy-ageing organised recently by the International Longevity Centre UK (despite its name, ILC UK works internationally and we were lucky enough to spend three days at the Annecy global health centre run by the Mérieux Foundation). We came up with the same objections to democracy that troubled many ancient Greeks. I spent enough time taking notes to have raided the presentations of almost every expert there but, sadly, not enough to credit those whose data I am using. You can see videos of each day here.
Elected politicians today need to expend a little money and a lot of political capital to realise benefits across the decades ahead. Those politicians are extremely unlikely to be the ones who get to claim the glory for any of the work they put in. One delegate said it was like building a new high-speed railway, but it was even more difficult. The minister commissioning the railway spends but never travels; her successor who sees it through planning objections hears the objections of people who live near the track, but never the thanks of commuters; his successor …. You get the picture … At least each of them gets a photo opportunity, a news segment from atop an impressive piece of earth-moving equipment, a commissioning ceremony at the factory building the carriages, or a meeting with grateful businesses and trades unions.
An ambitious health minister could generate a massive medium-term health bonus by improving the coverage of adult vaccines that we know work; she, though, spends and battles but never gets a political reward. Good flu vaccines are 80 or 90 percent effective at keeping you out of the hospital. They also prevent atherosclerosis and heart disease. The good ones cost a bit more than the cheap ones.
Our health minister must increase vaccine spending, face a few sceptical health professionals, and deal with a Twitter storm of abuse from anti-vaxxers. It is easy to see why 50 new A&E beds look like a more appealing opportunity to the minister’s political adviser. The patients occupying those beds should be furious that the minister’s failure to invest in vaccines put them there; instead, they’re ready to go on camera, being pathetically grateful for the wonderful care they received while on a ventilator.
Once we get beyond flu, things are even more politically challenging. Only 29 percent of Europeans know they can be protected against pneumonia, so fewer than five percent of patients with heart failure, diabetes, or COPD get the pneumococcal vaccine for which they are eligible. Hardly anyone knows about emerging research that shows that rotavirus vaccination in children prevents type 1 diabetes or retrospective research that suggests that a full course of childhood immunisation helps prevent dementia in later life. What is an ambitious politician to do?
Fossilised medical systems force patients onto those ventilators even if funding is forthcoming. In many countries in Europe, a patient who wants a flu or pneumococcal vaccine must go to the doctor to get a prescription; take the prescription to the pharmacy and pick up a vial; then, before the vial gets too hot for too long, go back to the doctor to be injected. No wonder one in four Europeans lives with at least two chronic conditions, but only 45 percent of those with chronic conditions get a flu vaccine.
Every effort to streamline this system triggers pushback from everyone who will lose prescribing, dispensing, or administration fees. Picking a fight with doctors is rarely good for political careers.
Once the disease is established, often diagnosis and prescribing are not enough. Fewer than half of European patients who have been diagnosed and are receiving prescriptions have control of their blood pressure or high cholesterol after three years. Just when taking the pills should be becoming a mindless habit — after three or four years of daily pill taking — it falls quite fast. And we have no idea why. It might be the mechanics of getting prescriptions renewed, refilled and reimbursed. (Yet another part of that fossilised medical system — is there any reason discount supermarkets should not sell 100 packs of cholesterol-lowering medicines for €5? It is certainly less dangerous than the hot dogs and cream pastries they sell in vast quantities). It may be that the pills are reminders of disease and mortality that the pill taker would rather forget. Either way, there are few opportunities for ribbon cuttings or front-page photos and few incentives for politicians to change things.
The politics of health
To get the best value for money, our poor politicians should focus on non-medical interventions too. Those, though, are even less good for her career.
Let’s start at the extreme. Some data suggest that children who grow up bilingual progress to Alzheimer’s about five years later than a monolingual child. It would be one of the greatest bargain health interventions ever, if true. Sketchier data suggest that benefits also accrue to adults who learn a second language later in life. That might be politically feasible in Scandinavia, but do you want to be the French politician who requires universal bilingual pre-schooling or the American one who tells 40 year olds to go out and learn Mandarin?
Let’s be a little less ambitious. Governments must mandate reductions in sugar, salt and fat content because less salt and sugar prevents many chronic diseases, but our tastes change as a herd. If you don’t believe me, ask Coca-Cola: Fanta has 43g of sugar per 330 ml in India but only 23g in the UK. Coke says the difference is to account for local tastes. Still, it may have something to do with pressure by the UK government to reduce sugar content or face further taxes. High sugar is good for sales: refined sugar is highly habit-forming, but Coca-Cola used an average of 17% less sugar in its drinks in the UK in 2018 than in 2015. Voluntary agreements between industry and the four governments of the UK have also led to substantial falls in the average salt content in seventy-six food categories. And consumers did not notice unless they bought a Fanta in Mumbai, got on a plane and bought one in London eight hours later.
Coca-Cola was founded by a Confederate Civil War veteran and its original recipe was even more addictive as it contained cocaine. That Fanta with 23 or 43 grammes of sugar is the brand created by Coca-Cola in Germany to quench Nazi thirsts after December 1941 when Coke syrup from the United States became er… unavailable. So fond were senior Nazis of Fanta, that Coca-Cola Germany got an exemption from sugar rationing. Much of the production up to mid-1945 was produced by slave labourers kidnapped from across Europe by Coke’s Nazi fans. You will have gathered by now that promoting human welfare has always been quite low on the agenda of the soft drinks industry but keeping in with those in power has always had a high priority.
Taxes on addictive convenience foods could fund subsidised access to fresh fruit and vegetables. However, the producers of undifferentiated oranges have limited lobbying budgets. In contrast, the producers of sugary drinks spent $7 million in 2018 in California alone in a successful effort to restrict local taxes on their products.
Treats for politicians
I charge clients a lot for my public affairs consulting, so I should not admit this, but if you have ever trained a dog, you know most of what you need to know about working with politicians and the officials who report to them.
Positive reinforcement is the best way to get a dog to do what you want. Every time the puppy performs outside instead of on the carpet, he gets a treat, a pat on the back, or both. Every time the dog eyeing up the sheep hears a dog whistle and returns; she gets a special toy. If a dog is about to run into traffic or go after that sheep, you may need a short smack and a loud “no”. Be careful, though: negative reinforcement sometimes has unpredictable consequences. Smacking a dog all the time or using a shock collar may turn a friendly and cooperative animal into one who is so scared that he tries to avoid you.
Politicians respond precisely the same way as dogs. It is important to remember that most are a bit more intelligent and sophisticated than the average labrador and got elected because they want to improve the world, however many compromises they had to make to win power. So, while Rover will be primarily focussed on a ball or a sausage, you need to spend a bit more time understanding the motivation and ideas of politicians and fit into their Weltanschauung whenever you can. Talk to a libertarian about preserving individual autonomy; talk to a Conservative about keeping families together; talk to a socialist about community responsibility. With any luck, all paths will lead to healthy ageing policies.
Depending on the country’s civil service system, officials who work for politicians will often have real skills and a deep understanding of health, ageing and economics. However, the effective ones know that their learning will be wasted unless they can think like a politician and package things in a way their political masters will accept.
What does all this mean for getting healthy ageing pushed up the political agenda? We have a lot to offer in the way of positive reinforcement. The average eighty-year-old is four times as likely to vote as the average eighteen-year-old. As discussed above, the eighty-year-old is likelier to have discretionary income to contribute to political parties and campaigns. In some countries, such as the USA, many already belong to powerful political action groups. The challenge is to get the constituency mobilised around vaccinations, not ventilators.
When we need it, we can deliver the slaps too. Opinion research shows that young people do not see a generational tussle for resources with their grandparents. They want to do the right thing; they worry that it’s unaffordable. And without action on prevention now, it will be.
Getting the old or young to vote based on the minutiae of vaccine delivery systems or the speed of change in the content of processed foods is a non-starter. We need to learn from people whose goals we may not share. The National Rifle Association in the United States has managed to stop any meaningful new restrictions on firearms by skilfully mobilising its base — so skilfully that they negate the 80 percent or so of Americans who favour the restrictions. The ins and outs of gun control policy are as arcane as the details of keeping older people healthy. The NRA, though, gives every legislator a rating. A few of its supporters check the details; most look for a good NRA rating. We need a healthy ageing rating.
The nature of effective political action is compromise and refusing to allow the perfect to be the enemy of the good. To work, this score will need to be endorsed by a range of professional groups, groups of older people and consumer organisations. Some commercial entities may even want to join in: health insurers, for example. None will get everything they want; most could get what they want.
The proposal is short on details, but we must find a way of incentivising today’s politicians to do things that will deliver benefits over the decades ahead.