Addressing the impact of chronic disease in an ageing nation

Dr Andrew Penman | September 19, 2011

Population ageing is as inexorable as it is global. Japan is the feature story where aging has been credited with everything from the lost decade(s), to the sclerosis in government. The USA is seen as offsetting the aging impact through migration policy.

Actually, all countries are on an aging journey, though some will reap a demographic dividend along the way. Better to think long term about how to reap the benefits of a “mature” population than to see it as a dead weight on prosperity.

 

The goals of public health formed when infectious disease struck down people early in life. This reduced working life expectancy and eroded returns from education. It made sense then to have a single-minded focus on lengthening life. Five years retirement was a bonus.

 

How different it is now. The average age of retirement in Australia is under 60, and life expectancy at retirement extends well beyond eighty.

 

This world needs different public health goals – goals that retain productive potential well into older age and consign the traditional 65 years cut-off in the demographers’ dependency ratio to irrelevance.  

 

Chronic disease has replaced infectious disease as our greatest disease burden.  It erodes productive potential in later life by limiting function. Also subjectively, when facing chronic disease, we may heavily discount the merits of working for the future gain or reward.

 

Health policy should centre on the preservation of healthy life expectancy. Chronic disease increases with age, but it is possible to defer the onset, and confine its impact to a shorter duration at the end of life – so-called compression of morbidity.

 

Morbidity compression firstly focuses policy on creating circumstances where people live healthy lives. Even if we cannot eliminate all cancer, diabetes, mental illness and heart disease, we can delay onset by many years, which is nearly as good demographically speaking. Policies that encourage unbridled hazardous consumption may be good for economic activity now, but carry a terrible long term price. In confronting obesity and inactivity, we must learn from the hard measures that were required to turn around the tobacco epidemic.

 

Consider cancer – it accounts for a greater disease burden than any other disease and on current trends the numbers diagnosed will double in 25 years. Yet poor lifestyles cause one third of cancers.

 

No-one suggests that a tee-totalling, vegan, marathon-running world is imminent. But some goals seem eminently achievable. Compared to women, men are 80 percent more likely to die from mostly preventable cancers that are common to both. Why the discrepancy? Because women live less risky lifestyles and use health services more effectively. Is it too much to imagine that men might readily achieve what women already have achieved?

 

Healthy life expectancy also leads us logically to re-examine health care. Cancer treatment has increased survival enormously.  Someone with prostate cancer will soon have a life expectancy rivalling peers without cancer. Yet the diagnosis often signals the end of a working life. Sure, people re-evaluate their priorities after a brush with cancer, but abandonment of goals diminishes both an individual and the community. 

 

Access to services for treatment complications such as lymphoedema and dental disease is constrained. There is even less consideration of the measures required – by governments, employers and communities- to restore economic and social relations after cancer onto an even keel. It would be nice to treat cancer more as an incident in an otherwise healthy and vigorous life course and less as a chronic disease. Unfortunately, often it is a premature disruption to life’s course.

 

Of course there is a lot more driving the shifts in retirement and workforce participation than the health system. However, the demographic challenge is sometimes framed as a problem foisted upon us by advances in health. While it is illusory to think that expenditure on health will go anywhere but up, we should have firm expectations about the social returns we expect from health expenditure. Compressing morbidity to a short period within a long and vigorous life would be a handsome return indeed and even the demographers might be mollified.

 

 

As CEO of Cancer Council NSW since 1998, Dr Andrew Penman is determined to not only improve the lives of cancer patients, but to work towards a goal that sees cancer defeated. When he’s not thinking or talking health, you’ll find him practicing Hindi and cooking feasts for family and friends.