Most of us over 65 were raised in an era dominated by a concern for excessive population growth. Paul Ehrlich made himself and that issue famous with his 1968 book, The Population Bomb. An organization called Zero Population Growth (ZPG) drew thousands of supporters who believed that not only did the developing countries have a problem but so did the United States. The Ehrlich warnings were dire, even apocalyptic, with projections of deadly food and natural resources shortages. Malthus was not wrong, just too early. As it turned out those disasters did not happen, at least not from population growth as the dominant force.
But the advent of global warming, picking up rapidly in the 1980s, brought about a renewed interest in population growth and the accompanying food and water shortages that collaterally go with it. There is still a core of policy analysts on global warming who see it as a major issue. It certainly is in some parts of the world, notably in sub-Saharan Africa and some Muslim countries, but world population growth is now sharply declining, with most countries at, near, or below the 2.1 children fertility replacement level. By 2015 it is projected that world population growth will be nearly at an end.
Yet coming along and too little noticed is that the global aged population is increasing, Only recently, for instance–for the first time in human history–the number of those over 65 became larger than those under 5. The fastest growing aged populations are now in developing countries. Globally, the elderly population is projected to rise 147% between 2006 and 2030, an increase of 500 million. For a fine analysis of aging in developing countries, see a 2013 report by Richard Jackson and colleagues, U.S. Development Policy in An Aging World (Center for Strategic and International Studies).
Of particular importance for low income countries is the rise of chronic disease–cancer, heart disease, diabetes, stroke, and Alzheimer’s–that goes with aging. The cost of caring for those with such conditions is the largest and fastest growing part of America’s health care, a function of our own aging society. Poor countries, already beset with continuing infectious disease (AIDS, malaria), must now find ways to pay for those chronic conditions as well. Many of them cannot even pay for the least expensive screening and treatments that are routine in industrialized countries. It is also widely agreed that they cannot for the foreseeable future pay for the panoply of expensive technologies that are central to advances care of the chronically ill.
There is still another disturbing feature of chronic illness in developing countries: it now begins on average shortly after age 40, about 10 years earlier than in developed countries. That trend means that many people will not only be costly for health care systems during their middle years, but will often enter their elderly years (assuming they make it there) with advanced chronic disease. To add to this generally dark story, it is exceedingly likely that the citizens of poor countries will, by means of cell phones and Internet availability, be aware of the kind of chronic illness care provided in rich countries that will be well beyond their grasp. That will hurt.
A question that troubles me for which I have no good answer is this: is it better in a poor country to have the benefit of surviving childhood (100 years ago about half would have made it to 5) but dying in middle or old age from chronic illnesses that their countries cannot pay for? I suppose the answer should be yes, although that would not relieve the sting of death of those who know that, if they had the good luck to be born elsewhere, they might go on living.
China recently announced that it was ending, or radically reducing, its one-child policy. Like a number of western countries that in recent years have had what are called low-low birthrates, well below the replacement level (Germany, Spain, Italy, Greece, and Russia), China decided they have many drawbacks, the most notable being a change in the dependency ratio, with two fewer younger workers to be taxpayers and family caretakers for the elderly. In addition China has seen a large migration of rural young workers to the cities, leaving behind elderly parents stranded in rural regions that have poor health care, mainly private and out-of-pocket, and no pension programs or government social security at all.
Our American story of the elderly, still being played out, is going to be dwarfed by the changes taking place rapidly in developing countries, in numbers and challenges. Indeed, many commentators have noted the speed of the change in the poor countries, occurring over only a decade or two–called the “compression of aging” and leaving governments little time to develop solid, much less affordable, policies. Developed countries, by contrast, have had many decadesand much more money to put in place their health care and economic systems.
Daniel Callahan, 83, is cofounder and President Emeritus of The Hastings Center and the author of the recently published “Medical Progress and Global Chronic Disease: The Need for a New Model” in the Brown Journal of World Affairs.