Global Roadmap for
Healthy
Longevity

Commission for a Global Roadmap for Healthy Longevity

NATIONAL ACADEMY OF MEDICINE

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by contracts between the National Academy of Sciences and AARP; Administration for Community Living, Department of Health and Human Services; California Health Care Foundation; David E. Nathaniel; Gary and Mary West Foundation; Gilbert S. Omenn and Martha A. Darling; The John A. Hartford Foundation; Mehta Family Foundation; National Academy of Medicine Harvey V. Fineberg Impact Fund; National Academy of Medicine Robert Wood Johnson Foundation Culture of Health Program; The Rockefeller Foundation; Sharon Inouye; and Tsao Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-47150-3
International Standard Book Number-10: 0-309-47150-8
Digital Object Identifier: https://doi.org/10.17226/26144
Library of Congress Catalog Number: 2022941587

This publication is available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

Copyright 2022 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academy of Medicine. 2022. Global Roadmap for Healthy Longevity. Washington, DC: The National Academies Press. https://doi.org/10.17226/26144.

COMMISSION FOR A GLOBAL ROADMAP FOR HEALTHY LONGEVITY

LINDA P. FRIED (Co-Chair), Dean, Mailman School of Public Health, Columbia University

JOHN EU-LI WONG (Co-Chair), Isabel Chan Professor in Medical Sciences; Senior Vice President, Health Innovation and Translation, National University of Singapore

ISABELLA ABODERIN, Professor of Gerontology; Perivoli Chair in Africa Research and Partnerships, University of Bristol

ANN AERTS, Head, Novartis Foundation

JOHN BEARD, ARC Centre for Excellence in Population Ageing Research, University of New South Wales

LISA BERKMAN, Director, Harvard Center for Population and Development Studies

LAURA L. CARSTENSEN, Professor of Psychology; Director, Stanford Center on Longevity

MICHELE J. GRIMM, Wielenga Creative Engineering Endowed Professor, Michigan State University

PAUL H. IRVING, Senior Fellow, Center for the Future of Aging, Milken Institute

MEHMOOD KHAN, Chief Executive Officer, Hevolution Foundation

JEANETTE VEGA MORALES, Minister of Social Development and Family, Ministry of Social Development and Family, Chile

MOSA MOSHABELA, Dean and Head of the School of Nursing and Public Health, University of KwaZulu-Natal, South Africa

HIROKI NAKATANI, Visiting Professor, School of Medicine, Keio University

JOHN PIGGOTT, Scientia Professor of Economics; Director of ARC Centre of Excellence in Population Ageing Research, University of New South Wales, Sydney

JENNIE POPAY, Distinguished Professor of Sociology and Public Health, Lancaster University (resigned from commission July 2021)

JOHN (JACK) W. ROWE, Professor, Mailman School of Public Health, Department of Health Policy and Management, Columbia University

ANDREW J. SCOTT, Professor of Economics, London Business School

ERIC VERDIN, President and Chief Executive Officer, Buck Institute for Research on Aging

YAOHUI ZHAO, Professor, China Center for Economic Research, Peking University

Study Staff

MAUREEN HENRY, Study Director/Senior Program Officer (from May 2021)

JOHANNA GUSMAN, Senior Program Officer (March 2021–November 2021)

EMMA LOWER-MCSHERRY, Senior Program Assistant (from May 2021)

SAMANTHA CHAO, Associate Executive Director (from March 2021)

CECELIA MUNDACA SHAH, Study Director/Senior Program Officer (until July 2020)

V. AYANO OGAWA, Senior Program Officer (until January 2020)

PEAK SEN CHUA, Research Associate (until July 2020)

T. ANH TRAN, Research Associate (until July 2020)

C. STEPHEN CHUKWURAH, Research Assistant (until July 2020)

JARRETT NGUYEN, Senior Program/Administrative Specialist (until July 2020)

Consultants

MARGARET HAWTHORNE, Collaborative Consulting

BRIDGET B. KELLY, Burke Kelly Consulting

MEGAN SNAIR, SGNL Solutions

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by JO IVEY BOUFFORD, School of Global Public Health, New York University, and ERIC B. LARSON, Kaiser Permanente Washington. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring commission and the National Academies.

Foreword

If you knew you could remain healthy for 10, 20, or even 30 more years, how would your plans change? How would your life change? How would the lives of your loved ones change?

It is well known that people across the globe are living longer. By 2030, for the first time in recorded history, the old will begin to outnumber the young.¹ This demographic shift could result in more vibrant societies worldwide, as older people contribute to their communities and the economy for more years. However, in many cases, these latter years are currently quite challenging and include contention with chronic disease, increasing frailty, a fragmented health care system, and a society that is not currently oriented to care for the aging. As individual life spans have increased, the years of unhealthy life have also increased. Very few countries have made significant progress to prepare financially, socially, and scientifically for longer and healthier life spans.

It does not have to be this way. Mitigating the challenges posed by and for the global aging population will require broad, systematic change and deliberative action across basic and translational science; clinical medicine and health care; personal, social, economic, and environmental determinants; and policy and financing. Innovative solutions are needed to improve overall health, productivity, and quality of life for the aging population.

To better understand the scope of this challenge and identify these innovative solutions, the National Academy of Medicine (NAM) assembled an independent international commission of experts to author this authoritative, evidence-based

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¹ See https://healthylongevitychallenge.org/about-us.

report with recommendations that can be applicable for diverse societies worldwide to guide effective solutions for healthy aging and longevity. The commission assessed the existing and projected risks, challenges, and opportunities presented by global aging, and its deliberations have resulted in a roadmap to foster healthy longevity through strategies related to the social and behavioral enablers of health, health care and public health systems, and science and technology.

This study underscores the fact that humanity needs to fundamentally shift how we are preparing for population aging to maximize the number of years lived in good health—not simply extend the number of years lived. To ensure that additional years of life are meaningful, the report identifies social infrastructure as a necessary foundation. Reducing ageism, improving social cohesion, ensuring financial security, and boosting digital literacy are all critical aspects in ensuring that society is prepared to support individuals as they age. Reimagining the physical environment of our cities and communities, including housing and neighborhoods, improving access to public transportation, and combating climate change are critical to help ensure that people are able to live independently for more years.

Many health systems were developed at a time when life expectancy was approximately 50 to 70 years; since then, health systems have both struggled and not been properly incentivized to adapt to better care for people who are regularly living more than 70 years. Adapting our health systems to be able to care for the health of older people, specifically considering the impact and cost of chronic conditions, providing value-based health care, improving public health, investing in improvements to long-term care and geroscience, and utilizing big data and advanced analytics to better understand and implement preventive care will be critical in ensuring that the additional years individuals are living are universally healthier.

Helping people live longer and more fulfilling lives also makes economic sense. Experts predict that longer lives will contribute to financial growth across many sectors. An explicit focus on reimagining and empowering an aging workforce, supporting education and training across the life span, and broadening options for formal and informal volunteering will ensure that as people live longer, they continue to contribute to both society and the economy.

As we work, collectively, to allow all persons to live longer, with purpose and dignity, we must also ensure that these revolutionary advances are distributed equitably across all populations worldwide. If only some of us are living longer and healthier lives, we have not achieved the necessary goal of improving how we all age.

I am grateful to the commissioners for their tremendous contributions to this report over the past 3 years, while they were simultaneously addressing the impacts of COVID-19 in their home countries. When the pandemic emerged in early 2020, the commission actually paused its deliberations for a year. When the group reconvened, all of the members returned with a better understanding of

the unique vulnerabilities of older adults highlighted by COVID-19, the perverse inequities in populations around the world, and the interconnected nature of our global society.

I would like to thank the members of the International Oversight Board that had authority over the commission’s membership, statement of task, and dissemination efforts; and would like to acknowledge the hard work and dedication of the many NAM staff who have contributed to this effort, most notably Maureen Henry, Emma Lower-McSherry, and Samantha Chao. I would finally like to thank the sponsors of the report itself, whose ongoing support has made this report possible. In addition, I would like to thank a public-spirited donor, wishing to remain anonymous, for supporting the dissemination of this study.

Global aging is one of the defining challenges of this century. It will fundamentally impact how families, communities, societies, industries, and economies function. This report describes an ambitious all-of-society approach that will be necessary to revolutionize our current approaches to caring for the aging—and in implementing this approach, all of society will benefit. We have the opportunity to start designing more equitable societies that enable all people to live healthier, longer lives. Immediate movement on this work will only benefit us all, sooner.

Victor J. Dzau, M.D.

President, National Academy of Medicine

May 2022

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Preface

One of humankind’s greatest achievements in the past century has been the extension of life span in every society. Coincident with falling birth rates, the world now has more people over the age of 60 than under 5, and in many countries, those over 60 will constitute 40 percent of the population by 2050.

Like climate change, demographic change is unprecedented, and will remain so for the foreseeable future, impacting the way we live, learn, work, and play; and all dimensions of the human experience. It will shape jobs, economies, and national budgets. In some societies, this change is occurring faster than others but will eventually affect everyone during their lifetime. How we now plan for life in the older age most people and societies have never had before will determine whether the outcome is an optimistic one for all, or the negative one many forecast. Fortunately, much can and must be done to ensure that societies are aging societies that are thriving and robust. This is the motivation of this report and the basis for its recommendations.

The commission was formally constituted in 2019 with members from countries representing both the North and South, East and West. Our disciplines range across science, medicine, public health, health care systems, engineering, technology, and policy. We have benefited substantially from expertise shared at our three public workshops on the social, behavioral, and environmental determinants; the health and health care systems needed; and how science and technology can enable our vision for 2050 and beyond, and from input by global economists.

The commission is aligned on the following:

• A recognition that all societies were created for a length of life half of what we will have by 2050.
• Substantial evidence supports the immense opportunity for all from longer lives, but an intentional whole of society transformation will be required to achieve these opportunities and to ensure equity in this achievement.
• The capabilities of longer lives could be a basis for societal thriving if healthy longevity is achieved. Investments in healthy longevity could extend health span for the vast majority and also support the needs we all are challenged by with older age.
• Commensurate with these longer healthy lives, older adults having the opportunities for paid work and volunteering, enabling them to assume roles to contribute to a better future for their community and family, will further contribute to well-being.
• Coalescence around the importance and urgency of this issue that changes everything else—for better or worse, depending on how societies respond.
• Timing to create the changes needed is important; there is urgency to start these changes now so as to not forfeit the opportunities, and to support human needs in our longer lives.
• The observation that unless low- and middle-income countries put aging at the center of their development agendas, these agendas are at substantial risk of not achieving their goals.

Our report envisions what societies could look like in 2050 if we applied all that we know on how societies can remain robust and even thrive because of, not just despite, demographic change. This is the basis of our “Future-Back Vision,” supported with evidence where available, and otherwise with expert opinion.

This will require us to revisit our current life stages, and instead of compartmentalization into phases of learning, working, and then retirement, consider a blended journey, where the elements of learning, working, and leisure are intertwined from early adulthood to as long as these are valued. We are heartened that a significant number of older people globally wish to remain engaged for what they can contribute to society.

This will also require significant investments, but the benefits and returns from this in human, social, and economic capital will more than justify the expenditure. This will be detailed in the chapters that follow. These investments are arguably the strongest protection we have against the fears that demography will dictate destiny.

This report builds on and reinforces recent critical efforts, especially the United Nations Decade of Healthy Ageing (2021–2030). The report aims to provide a roadmap for leaders across societies to extend health span and identify

what actions will be required to ensure the success of their community as they become aging societies. Central to this success would be the need for societies to address their social compact and accomplish equity.

COVID-19 impacted the content, progress, and writing of this report. The commission planned three workshops and had just concluded their second, on Health Care and Public Health Systems for Healthy Longevity in February 2020, before global travel restrictions came into force. This was the last in-person meeting of the commission. The commission paused in April 2020, as members were involved in dealing with the pandemic, and formally restarted in May 2021. During this hiatus, we had a change of the National Academy of Medicine (NAM) supporting staff, initially led by Cecilia M. Shah, V. Ayano Ogawa, Peak Sen Chua, T. Anh Tran, Jarrett Nguyen, Stephen Chukwurah, Bridget Kelly, and Margaret Hawthorne. After the restart, they were succeeded by Maureen Henry, Johanna Gusman, Emma Lower-McSherry, Samantha Chao, and Megan Snair, supported by Morgan Kanarek. We are grateful for your superb leadership, expertise, and contributions.

In mid-2021, Dr. Jennie Popay stepped down from the commission, and Drs. Andrew Scott and Yaohui Zhao were appointed to the commission. The report greatly benefited from Dr. Popay’s contributions, especially as co-chair of the Workshop on Social, Behavioral, and Environmental Enablers for Healthy Longevity, and endorses her strong vision on the importance of enhancing equity to achieve healthy longevity.

During the hiatus, the co-chairs continued discussions with each of the commissioners through video conferencing, and when the commission was formally reconstituted, commissioners made every effort to join meetings despite time zone differences. When recurrent COVID-19 waves hit countries at different times of the year, commissioners continued to contribute despite the demands of their day jobs.

We are deeply indebted to the dedication of this superb team, who shifted seamlessly from life prior to COVID-19 to organizing the third public workshop in June 2021 on Science and Technology for Health Longevity as a virtual global meeting. To say that everyone went above and beyond what would normally be expected is no exaggeration, dedicated to the shared conviction that the world needs to be, and can be, better prepared for this unprecedented demographic change of population aging.

The development of a vision for a successful future of aging societies, which is powered by longer lives with health and meaningful engagement, purpose, and dignity, involved substantial review of the evidence supporting this goal. This has created a shared optimism that this positive future is quite possible for all, but dependent on visionary and committed leadership aligned across all sectors toward individual and societal thriving through healthy longevity. This will require initial actions, some evolutionary and some transformational, as proposed in this

report, and then sustaining progress to 2050. With these actions taken, the aging of society could be the basis for both a longevity dividend for our economies and a previously unimagined Third Demographic Dividend for societies.

The commission is grateful to all who made this report possible: our International Oversight Board, NAM, participants of the three workshops, input from experts around the world, and the reviewers.

We would like to especially honor Dr. Tadataka “Tachi” Yamada, a global health giant in academia, industry, and philanthropy who was a driving force in the creation of this commission. His legacy will live on in all of us and this report, which we hope will reflect his appreciation of the power of science and knowledge to make this a better world for all.

Linda P. Fried and John Eu-Li Wong, Co-Chairs

Commission for a Global Roadmap for Healthy Longevity

Dedication

The commission dedicates this report to Tadataka “Tachi” Yamada who passed away in August 2021. Tachi was a driving force in the development of the National Academy of Medicine’s (NAM’s) Healthy Longevity Global Grand Challenge. He co-chaired the work that led to the creation of the Grand Challenge and co-chaired the Workshop on Science and Technology. We thank him for his immeasurable contributions to NAM.

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Acknowledgments

The commission would like to thank the members of the International Oversight Board: Victor Dzau, Jo Ann Jenkins, and Keizo Takemi, co-chairs, and members Nancy Brown, Dame Sally Davies, Terry Fulmer, William Hait, Roman Macaya Hayes, Rahul Mehta, Chorh C. Tan, Mary A. Tsao, Edwin Walker, and Sir Andrew Witty (through October 2020).

Numerous individuals and organizations made important contributions to the report and provided evidence for the commission’s analysis and deliberation. The commission wishes to express its gratitude for each of these contributions, although space does not permit identifying all of them here. In particular, the commission would like to thank the fellows who helped with this project:

The commission would also like to thank the many experts who provided information to support its deliberations and analyses. In particular, the commission acknowledges the speakers who participated in the public information-gathering workshops and provided additional input as described in Appendixes C–D.

The NAM staff also deserve recognition for their efforts to make this report possible, including Morgan Kanarek, Salman Chaudhry, and Radhika Hira. The commission would also like to thank Sara Sakowitz for her research support.

Finally, the commission would like to thank AARP, Washington, DC; the Ministry of Health, Singapore; the National University of Singapore; the National University Health System, Singapore; and the National Research Foundation, Singapore, for hosting the public workshops.

Contents

SUMMARY

1 INTRODUCTION

2 VISION FOR HEALTHY LONGEVITY IN 2050

3 A LONGEVITY DIVIDEND

4 SOCIAL INFRASTRUCTURE FOR HEALTHY LONGEVITY

5 PHYSICAL ENVIRONMENT ENABLERS

6 HEALTH SYSTEMS

7 A GLOBAL ROADMAP FOR HEALTHY LONGEVITY

APPENDIXES

A SUMMARY OF THE GLOBAL ROADMAP FOR HEALTHY LONGEVITY

B COVID-19 AND OLDER ADULTS

C REGIONAL AND ECONOMIC INTERVIEWS

D PUBLIC WORKSHOP AGENDAS

E COMMISSIONER AND STAFF BIOGRAPHIES

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Boxes, Figures, and Tables

BOXES

1-1 Myths About Aging

1-2 Statement of Task

2-1 Principles and Goals for Achieving Healthy Longevity

3-1 South African Peer Support Intervention

4-1 Providing a Platform for Older Women to Voice Concerns

4-2 Strategies for Combating Ageism: Public Awareness Campaigns and Intergenerational Contact Interventions

4-3 The Intergenerational Self-Help Club Development Model

4-4 Explorations in Intergenerational Living

4-5 Case Examples of Social Protection Programs in Kenya, Bolivia, and Mexico

5-1 Successful Models of Housing Modifications

5-2 Case Study: Transforming Plaza 31 in Lima, Peru

5-3 Case Study: Tago-Nishi Disaster Resilient Community

5-4 Case Study: Equitable Access to Broadband

5-5 Elements to Consider When Implementing Policies and Programs to Narrow the Age-Based Digital Divide

5-6 Case Study: Climate Mitigation Efforts to Keep Frankfurt Cool

6-1 The Noncommunicable Disease Cost Tally

6-2 Costa Rica and Social Determinants of Health

6-3 WHO Framework Convention on Tobacco Control

6-4 An Older Person’s Experience of Care: The Current State

6-5 Case Study: Disintegrated Care for Cancer

6-6 Costa Rica’s Primary Care System

6-7 Key Characteristics of Geriatric Care

6-8 Quality Concerns About Family Caregivers for People with Dementia

6-9 Examples of Home Care Support in East Asia

6-10 Case Study: Wraparound Services in Canada’s Senior Villages

6-11 Case Study: Tago-Nishi Disaster-Resilient Community

FIGURES

S-1 A roadmap for achieving healthy longevity

S-2 Relevant actors for an all-of-society approach to healthy longevity

S-3 The virtuous cycle of healthy longevity

S-4 Longevity dividend roadmap

S-5 Social infrastructure roadmap

S-6 Physical environment enablers roadmap

S-7 Health systems roadmap

1-1 World population pyramid: 1950, 2020, and 2050

1-2 Singapore population pyramid: 1950, 2020, and 2050

1-3 Nigeria population pyramid: 1950, 2020, and 2050

1-4 The virtuous cycle of healthy longevity

3-1 Longevity dividend roadmap

3-2 Labor force participation at ages 55–64 and average labor market exit age for Organisation for Economic Co-operation and Development countries

3-3 Civilian labor force participation rate by age, 1996, 2006, 2016, and 2026 (projected)

3-4 Labor force participation rates among those aged 65+ by country income level

3-5 Normal retirement age for men entering the labor market at age 22 with a full career

3-6 Estimates of willingness to pay for job amenities by age group, expressed in proportion to respondent wage

3-7 Value of contributions by age group in the United States and Europe

4-1 Social infrastructure for healthy longevity roadmap

4-2 Conceptual framework for structural and social determinants of health

5-1 Physical environment enablers roadmap

5-2 The determinants of health and well-being in the physical environment

5-3 Examples of factors in the urban physical environment and their potential impacts on healthy longevity

6-1 Health systems roadmap

6-2 Years of unhealthy life after age 60

6-3 The health impact pyramid

6-4 Percentage of older people living in nursing homes

7-1 A roadmap for achieving healthy longevity

7-2 Relevant actors for an all-of-society approach to healthy longevity

TABLES

3-1 Factors Associated with Workforce Exit, Organisation for Economic Co-operation and Development Countries

A-1 Summary Table of the Global Roadmap for Healthy Longevity

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