Older people2 are an increasing natural resource. In the past century, the world’s population of people over age 65 has grown more rapidly than other age groups due to rising life spans and declining birth rates. This growth is expected to continue into the future, although the decline in life expectancy across many countries adds uncertainty to predictions made before the COVID-19 pandemic. Today’s older people already make substantial contributions to their families and communities, and with healthy longevity, even more will do the same in the future. Despite the value that older people bring to society, however, governments and the news media characterize global aging as a tsunami that will overwhelm governments and consume resources needed for younger people to thrive. One concern is real: as life spans have increased, so too have unhealthy years of life, which can increase reliance on government health and social service programs while also contributing to individual suffering.
Healthy longevity is the state in which years in good health3 approach the biological life span, with physical, cognitive, and social functioning that enables well-being across populations. By increasing healthy longevity, societies can minimize societal and individual burdens while increasing human and social capital. Promoting healthy longevity for individuals and societies through policies
1 This Summary does not include references. Citations for the discussion presented in the Summary appear in the subsequent report chapters.
2 “Older people” applies to people in the second half of their life, depending on the life expectancy where they reside. As people age, the prevalence of age-related conditions climbs. The onset of age-related chronic conditions is about 10 years later in high-income versus low-income countries.
3 This report uses the World Health Organization’s definition of health: “a state of complete physical, mental, and social well-being.”
and actions can unleash the potential of older people in the near and long terms, benefiting people of all ages and societies around the globe.
Now is the time for a movement toward healthy longevity. In the past century, the number of older people has grown to make up a larger number and share of the global population than ever in the past, and the trend is predicted to continue. While some countries are seeing rapid aging, all countries will need to create structures and climates to support health and promote productive engagement in society among all people.
Age is the greatest risk factor for developing chronic conditions, which are responsible for most mortality and disability worldwide, but science is providing insights into how to delay the onset of aging and chronic conditions. Among the most effective interventions for delaying aging and chronic conditions are addressing negative social determinants of health population-wide, for example by ceasing tobacco use, increasing physical activity, and consuming a healthy diet. Additionally, scientific advances and technologies are enabling the development of promising therapeutics to delay aging processes and support people facing functional or cognitive decline.
A GLOBAL ROADMAP FOR HEALTHY LONGEVITY
This report is a product of the National Academy of Medicine’s (NAM’s) Healthy Longevity Global Grand Challenge. To create a roadmap for healthy longevity, NAM convened an international, independent, and multidisciplinary expert commission charged with creating a roadmap for global healthy longevity to translate demographic change into opportunity.
The roadmap starts with a set of overarching principles for healthy longevity. To operationalize these principles, it then includes long-term goals for longer and healthier lives in 2050 and supporting structures to achieve those goals, together with recommendations for catalyzing change toward healthy longevity (see Figure S-1). These goals, structures, and recommendations span four domains: the longevity dividend (i.e., work, volunteering, and education), social infrastructure, physical environment, and health systems. Within each domain, the commission focused on key targets to catalyze change. The commission selected key targets based on actionability, impact on people across the life course, equity, and importance to (1) improving healthy longevity in the long term and (2) tackling needs of older people in the near term. It focused the report on essential actions in specific sectors with potential to generate multisector, all-of-society transformation. The key targets are not the only areas in need of attention for healthy longevity by 2050; rather, they are starting points. Cross-cutting themes include the need for a life-course approach, equity, social cohesion accompanied by a strong social compact, the role of science and technology, and the need to measure progress toward the healthy longevity goals.
The commission recognized that healthy longevity requires multiple complex systems working together and the political, fiscal, cultural, and other factors that will facilitate, rather than challenge, a future of healthy longevity. Some efforts will need governmental funding, while others will not. All actors in the pursuit of healthy longevity, shown in Figure S-2, will inevitably face competing demands for time and resources. Healthy longevity will require all-of-society involvement, but the commission emphasizes the importance of including older people in designing systems for healthy longevity and of anchoring action in the community.
The commission’s roadmap aligns with other overlapping global efforts currently under way, including the United Nations (UN) Decade of Healthy Ageing and the UN Sustainable Development Goals (SDGs). By strengthening institutional structures that enable good health across the life course, governments can also make progress toward achieving the SDGs.
The commission anchored the roadmap in a vision for a realistic and optimistic future with healthy longevity. In that vision, healthy longevity triggers a virtuous cycle (see Figure S-3) whereby it both benefits from and enables a lifetime with meaning, social engagement, learning, and growth. Together, health and productive engagement build social, human, and financial capital. Increased capital, in turn, fuels the systems that support health, social needs, the physical environment, education, and productive engagement through work and formal or informal volunteering, and these systems, collectively, support health and produc-
tive engagement. Major disrupters of this virtuous cycle include ageism, disease, poverty, pollution, and inequity. Societies with healthy longevity are expected to thrive with a new social compact based on social cohesion and equity.
The roadmap provides a path from fear of global aging to a future that thrives on global aging. While much of the focus is on addressing challenges facing older people, many of the interventions to achieve healthy longevity benefit people of all ages. When older people thrive, all people thrive.
The commission faced several challenges in creating an evidence-based global roadmap for healthy longevity. No country has achieved sustained healthy longevity. Moreover, scientific evidence for precisely how to do so is unproven, although empirical evidence and case studies reveal promising pathways, which serve as the basis for the commission’s findings, conclusions, and recommendations. The commissioners emphasized the urgency of proactive experimentation and innovation guided, not limited, by evidence and monitored using metrics, rigorous evaluation, and continuous improvement. At the same time, the commission recognized that not everything important for healthy longevity can be measured objectively. If societies wait for academic evidence and standardization before taking action to achieve healthy longevity, the world will be stuck in the status quo.
The need to address healthy longevity is universal, but the best pathway for moving the agenda forward in every corner of the world is not. To address the challenge of limited evidence, the commission relied on evidence from global reports; multicountry systematic reviews; and when necessary, single studies
representing a small fraction of the global population and individual case studies of promising interventions.
The heterogeneity within communities, countries, and global regions posed additional challenges. Beyond the evidence, political, economic, social, and environmental forces and resources vary widely around the world. This variation is particularly poignant and challenging in a world facing existential crises, such as climate change, a global pandemic, and threats to global political stability that will compete for the same resources needed to improve healthy longevity. In the face of these challenges, the need to access all societal resources is urgent, and older people are currently a largely untapped resource—hence the commitment to initiating change through the roadmap.
THE LONGEVITY DIVIDEND
As life spans increase over time and older adults make up a larger proportion of the population than they have in the past, societies have the opportunity to reap gains if good health is maintained for more of the years of life than has thus far been the case. If longer lives in good health are combined with the structures needed to enable healthier older adults to be productively engaged in life, society and individuals of all ages will benefit. The longevity dividend roadmap (see Figure S-4) describes components needed to initiate change to benefit all.
Increasing longevity means that people in many countries will need to work longer than they do today to avoid national fiscal and economic challenges and to
maintain personal financial security. An immediate counterpoint to this assertion is that older people will take jobs away from younger people, but the evidence suggests that, when older people work instead of retiring, younger people are more likely to have jobs and are less likely to be unemployed.
The commission concludes that healthy longevity will contribute to growth in gross domestic product (GDP), personal savings, and government coffers. Beyond supporting healthy longevity by addressing social and health needs of
people across the life course, governments and the private sector can support opportunities for older people’s productive engagement, including work, volunteering, caregiving, and other unpaid roles in the community and family.
Labor Force Participation
To maintain current standards of living over longer lives in the face of demographic change, people will need to be healthier and engaged longer. The commission argues that increasing workforce participation among people over age 50 in high-income countries by giving people who have the desire or need to work the opportunity to do so is the best way to harness healthy longevity in service to those countries’ economies. This strategy will offset predictions that larger populations of older people will harm economies.
Raising the age at which older people can access pensions increases workforce participation among older people but can force low-income older people to work longer, even in the face of health problems more common among workers with physically demanding jobs. Raising the retirement age may also leave older workers unemployed and ineligible for a pension should age discrimination prevent them from being hired or remaining employed. Alternatively, removing structural barriers (e.g., age discrimination and implicit taxes on wages earned after retirement age) that prevent people from working as long as they want and establishing incentives to encourage people to work have historically increased workforce participation.
Decisions to continue working at later ages are driven by what people need, want, and are healthy enough to do and whether employers will retain, train, or hire them. Pension eligibility, the need or desire for more income, and satisfaction and accomplishment in work can keep people in the workforce. Conversely, people leave the workforce earlier than planned because of poor health, job loss without replacement, family caregiving responsibilities, and physically grueling work environments. Employers can make employment more attractive than retirement by allowing people to transition incrementally into retirement. Governments can eliminate mandatory age-based retirement, provide incentives for job retraining, and reduce cost barriers to working longer.
The commission encourages a choice-based approach to increasing workforce participation, given the evidence that removing barriers and providing incentives to work are effective. In contrast, increasing the pension eligibility age, though effective, can increase disparities and penalize those who may be unable to work for the reasons stated above. The commission acknowledges that many people globally are ineligible for pensions and even social support and health care benefits because they work in the informal sector and, increasingly in high-income countries, in the gig economy. The commission believes that society-wide healthy longevity will not be achieved if large numbers of people
are ineligible for pensions and other benefits because they work outside the formal economy.
Also important to the longevity dividend and intergenerational cohesion is formal and informal volunteering, which brings meaning, purpose, and satisfaction to older people. Volunteering by older people also contributes to value in society, and evidence suggests that it improves health and well-being among volunteers; for a large, national school-based program, it was also found to be beneficial for students. Many older people wish to contribute to society, often motivated by a desire to help younger generations.
Volunteering also brings tangible value to society. One analysis estimated that the value of paid work and a subset of all volunteering by people over age 50 in Europe and the United States was 29 percent and 40 percent, respectively, of GDP per capita. The value of these contributions is actually greater because the analysis did not include the value of household activities or caregiving for an adult in the same household.
In light of the above findings, the commission points out that expanded efforts by private- and public-sector organizations to actively encourage volunteering, especially in roles that strengthen intergenerational cohesion and the social compact, would bring value to societies.
Lifelong Education and Retraining
Education from early ages has multiple positive effects on healthy longevity, including health and financial well-being. Experts predict that in a future characterized by healthy longevity, people will undergo multiple career transitions across their working lives, which will necessitate multiple cycles of education, retraining, and upskilling. Current education and training systems are not designed to meet the needs of middle-aged and older workers, so restructuring will be necessary. Examples of structures that can strengthen education opportunities include pedagogical approaches appropriate for people of all ages and multiple modalities to suit different learning preferences.
SOCIAL INFRASTRUCTURE FOR HEALTHY LONGEVITY
The importance of social determinants of health has increasingly been recognized, but across many countries, spending focuses on other priorities, such as health care, and not on unmet social needs. Because of the scope and scale of unmet needs, the commission identified key targets for social infrastructure that impact healthy longevity and challenges posed by aging societies (see Figure S-5).
Prosocial Strengths of Older People
Advancing age is associated with increased motivation to contribute to other people, younger generations, society, and the greater good. Moreover, older people’s experience, knowledge, and emotional stability hold the potential to build the social and human capital needed to create and perpetuate healthy longevity. Efforts to foster social connections and build cohesion start in local communities, where informal caregiving for family members, neighbors, and acquaintances is the norm.
Ageism and Age Discrimination
Ageism—the only “ism” that all people will experience if they live long enough—affects every aspect of life for older people. Structural and individual age discrimination is a barrier to healthy longevity and productive engagement. Successful efforts to combat ageism around the globe have used multipronged, multisector approaches, such as those combining law, policy, and media. Intergenerational collaboration has been an essential component of several successful programs.
The common characterization of older people as isolated and alone overstates the reality. Most older people have strong social and family ties that keep family members connected and engaged in supporting adult children and grandchildren. Other activities, through religious and community organizations, work, and volunteering, are also important to social connectedness. At the same time, many older adults experience loneliness. An estimated 20–34 percent of older adults in China, Europe, Latin America, and the United States identify as lonely. Some lack social networks, which can lead to isolation and loneliness whose effects on mortality and health risks rival in magnitude those of smoking, alcohol misuse, and obesity. During the COVID-19 pandemic, advice in some countries intended to keep people safe from illness inadvertently increased exposure to these risks. Evidence-based programs to reduce loneliness and strengthen family, community, and social ties can be scaled and replicated, and these programs can be complemented by digital tools and multigenerational communities that hold promise for helping to combat loneliness.
Financial Security in Retirement
The commission encourages providing basic financial security for older people where current supports are inadequate or nonexistent. Designing for societies of longer, healthier lives requires resources to support the financial needs of older people. Healthy longevity requires financial security for older people because they have few options for improving their financial security, especially when in poor health. Societies can adopt successful models for providing financial support to older people, some solely government-funded and others involving incentives to encourage private savings. The latter programs likely will require universal access to secure banking systems and investment opportunities.
Technological advances have left many older adults behind, although digital literacy among older people will increase over time as people who have used digital technology from childhood enter older ages. The public and private
sectors, including civic organizations, can support digital literacy for all people. An emphasis on user-centered design will make future digital interfaces more user-friendly, and lifelong digital training opportunities and affordable digital access will narrow the digital divide for older people.
The physical environment is the locus for many of the social determinants of health. The physical environment can enable or impede healthy longevity by affecting social engagement and cohesion, safety, physical activity, and access to essential needs. Within the physical environment is a complex interplay of multilevel environmental risks, including those associated with climate change, access to services and community institutions, the built environment (i.e., spaces, buildings, products created or modified by people), and the natural environment. The commission’s roadmap for the physical environment is shown in Figure S-6.
Safe and affordable housing is critical to quality of life; health and safety; and for older people and people with disabilities, the ability to remain independent. For many older people, living independently in their community is a personal goal. Key considerations for housing include universal design; affordability; health and safety; and water, sanitation, and hygiene. Including people in the codesign of housing is important to ensure that it suits their needs. Finally, the proximity of a living space to food and resources plays an important role in healthy longevity. Investments in housing can contribute to healthy longevity and provide a return on investment.
Public Spaces and Infrastructure
Public spaces and community infrastructure affect mobility, which influences people’s ability to interact with other people within families, communities, and regions. Multiple neighborhood resources, such as parks, places to sit, and public transportation, are valuable for all residents, and for older people, they encourage active travel. Intentional design of public spaces can strengthen social cohesion, promote urban health and citizen well-being, and support the local economy. Because of their links with healthy longevity, the commission emphasizes the need for green space, walkability, and safety.
Transportation is fundamental to the ability to move around, access services, and engage in social activities and work. The availability of public transportation, particularly important in low- and middle-income countries, has significant impacts on people of all ages. Limitations in public transportation options can impact everything from a person’s ability to stay engaged in the community to access to health services, which have negative effects on health. Driving a personal vehicle is an important mode of transportation, but loss of physical and cognitive capacity renders many older people unable to drive. The level of access to transportation options can be limited by infrastructure and personal financial resources. Improved options for transportation include universal design in cars; innovative design of railways and buses that removes barriers to getting on and off and sitting; installation of bus shelters, benches, and street lighting at stations; and provision of mobility aids for crossings at bus stops to enhance safety.
Interactions with businesses, health care systems, and educational institutions are increasingly becoming digitized. Many advances in social infrastructure
and the physical environment are contingent on access to reliable internet and familiarity with digital devices. Benefits also include the ability to work remotely and social engagement. Inequity in access to modern, high-speed internet is a major differentiator among population groups, but, at the same time, digital access raises concerns about privacy and cybersecurity, including internet scams. The commission agrees with the many calls for expanded access to high-speed internet, especially in rural areas.
Climate Change and Environmental Hazards
The ongoing impacts of climate change constitute an urgent environmental challenge, as healthy longevity is not possible without a healthy planet. Recent studies predict that the frequency of extreme weather events will increase over the next three decades, with effects across the life course but disproportionate and near-term adverse effects on older people and people with disabilities. In addition to climate change, environmental stressors such as exposure to air pollution have greater adverse health effects on older people, particularly those already suffering from respiratory illness. The commission echoes the United Nations’ best practices for engaging older people in disaster risk reduction strategies, providing financial support and social protections following emergencies, and reintegrating older adults back into normal life.
Health systems will need to change to increase the efficiency and affordability of health care. As shown in Figure S-7, the commission’s roadmap encourages shifts across all health systems to support healthy longevity.
The health of older people is heterogeneous. Most people over age 65 live independently, and only a minority have severe functional limitations. At the same time, by age 65 most people have multiple chronic conditions that affect their health. Aging processes increase the risk of chronic conditions, as well as functional and cognitive decline. These health conditions and impairments affect the ability to recover from infection and other health threats, as was demonstrated during the COVID-19 pandemic by the disproportionately high mortality rate among older people.
Public health systems that promote population health across the life course will be critical to preventing or delaying chronic conditions. However, prevention spending across countries is disproportionately low compared with the need and with other health spending. In 2015, on average, approximately 2 percent of
health spending by Organisation for Economic Co-operation and Development countries was for prevention.
The most effective strategy for prevention of population-wide chronic conditions involves addressing adverse effects of social determinants of health and unhealthy environments. Also effective is changing the context by making the healthy choice for behaviors with the greatest impact on health the easy choice. Preventing chronic conditions is most effective when public health agencies undertake multifaceted campaigns that include limits on advertising, public health and education messaging, taxes, financial incentives, and targeted community-based programs. Prevention focused on one disease at a time is less effective than efforts targeting the shared risk factors for biological aging and chronic conditions.
Effective prevention will require disaggregated data on health risk factors and health outcomes to enable “precision” public health strategies that include assessing risks to subpopulations and narrowly targeting interventions to groups that will benefit the most.
Achieving healthy longevity also will require strengthened public health systems and close collaboration with other organizations responsible for addressing health and social needs, including social service agencies, environmental safety agencies, employers, and labor unions. Programmatic components of public health systems with important roles in healthy longevity include interventions at the population and individual levels designed to reduce underlying risk factors for both aging and chronic conditions, as well as data and analytics systems for surveillance, precision public health, population-wide interventions, and evaluation.
The commission argues that integrated, person-centered care (including behavioral health care) is the most appropriate care delivery model to maximize health for people across the life course and is essential for older people with multiple chronic conditions. Care focused separately on discrete conditions can actually harm older people, whereas care centered on an older person’s goals provides a yardstick against which clinicians can measure the appropriateness of care options. Achieving healthy longevity will require that health policies and financing shift away from acute care and infectious disease models toward models that address chronic conditions and the need to create environments that maximize functional capacity.
Primary care is the most efficient mechanism for delivering high-quality, cost-effective care around the globe. The commission asserts, then, the critical importance of primary care that is as affordable and accessible as possible.
Physiology changes with age, as do health outcomes. Therefore, all providers who care for older people need basic training in geriatric medicine if they are to deliver high-quality care. Geriatric care models and guidelines have proliferated
with some evidence of success but with differences in desired outcomes and approaches (e.g., disease self-management versus caregiver support), making it difficult to compare results across studies. Barriers to the adoption and implementation of geriatric care models include the large number of competing models, the single-disease approach that dominates health care systems and financing, and the limited evidence of scalability.
Resolving these barriers will require long-term, transformational change. The commission contends that a number of structures need to be established for health care systems to promote healthy longevity, including
- integrated, person-centered care, as described by the World Health Organization (WHO), delivered by a provider who is responsible for coordinating a person’s care across settings and, when possible, by an interdisciplinary team;
- mechanisms to promote collaborative relationships with social service providers, which can help address social determinants of health at the individual level;
- comprehensive and shared health records that include a care plan based on the person’s goals, preferences, and values;
- health care systems that leverage data systems to inform individual and population care, monitor quality, and identify effective therapeutics and interventions for patient subpopulations;
- primary care systems that focus on prevention and care by carrying out essential screening, addressing risk factors for chronic conditions, implementing evidence-informed interventions to address health behaviors, and maintaining functional capacity;
- over time, the potential use of precision medicine to tailor the most effective therapeutics to individuals; and
- palliative care and hospice for people with high symptom burden and/or advanced illness, and structures to provide hospice care for those with late-stage illness.
Even with longer, healthier lives, long-term care, services, and supports will remain crucial for people with impaired capacity. Long-term care provides the care and functional support necessary to enable people with functional limitations to live with meaning and dignity. Long-term care is best provided in the setting preferred by the person, to the extent possible.
Family caregivers are more common than paid caregivers, but little is known about the adequacy of care provided by family or informal caregivers, except that many have minimal knowledge of how to care for an older person with functional limitations. While most people who receive care express gratitude for their care-
givers, abuse and neglect by caregivers is a concern globally, often associated with caregiver burden. The commission stresses the importance of establishing programs that support families and family caregivers and making formal care provision available where needed, thereby supporting the intersection between formal and family care.
Nursing homes are facility-based long-term care settings that provide care for the most impaired and vulnerable adults. Nursing homes have a troubled past in many countries, rife with allegations of abuse, neglect, and exploitation. The outsized effects of COVID-19 on nursing home residents highlight deficits in care quality and the challenges of keeping vulnerable people safe in institutional settings. These impacts have renewed calls to redesign long-term care systems while avoiding past challenges and meeting the needs of residents.
The commission points to the need for structures to ensure quality long-term care that addresses all human needs, not just personal and health care needs. For example, long-term care policies and funding that prioritize care delivery in the setting of the person’s choice show respect for individual autonomy and the importance of maintaining dignity, with attention to care quality and the risk of abuse, neglect, and exploitation.
Health Care Workforce
WHO’s World Report on Ageing and Health summarizes the inadequacy of geriatric training globally. A study of medical schools in 36 countries found that 27 percent of medical schools, including 19 percent in high-income countries, 43 percent in economies in transition, and 38 percent in other countries, provided no training in geriatric medicine. Medical trainees learn siloed, disease-based care, not the comprehensive biopsychosocial approaches needed to provide high-quality care to older people, especially those with complex needs. Other health care workers, especially those who provide direct services in low- and middle-income countries, also lack the training they need to provide high-quality care for this population.
A critical component of the care workforce for older people consists of those who provide personal care and other supports to people needing long-term care within and outside of facilities. This workforce is overwhelmingly female, often part of the informal economy, and typically very low wage. The commission believes that improving the future of long-term care will require training, safety protections, and adequate pay for these workers.
Geroscience, Technology, and Big Data Innovation
Data, scientific advances, and technological innovations in health are forging new frontiers in aging and therefore need to be considered in the design of future health systems. Governments and health systems now have access to an
unprecedented amount of data on many facets of people’s lives and health. Harnessing the power of big data may enable targeted interventions matched to a community’s specific public health prevention needs or to a person’s individual care needs. However, these capabilities carry the risk of perpetuating historical biases or resulting in action based on statistical noise if data are not transparent and analyzed and evaluated with care.
Geroscience4 is in the early phases of developing new and repurposing old therapeutic interventions to delay biological aging and prevent or slow the progression of chronic conditions. The development of effective interventions to change individual behaviors will require targeted epidemiologic, behavioral, and social science research. Academic institutions and biotech companies are already investigating targets for efforts to slow the aging process and prevent or delay chronic conditions, with potential interventions including new pharmaceuticals, intermittent fasting, use of stem cells, and regenerative medicine.
Wearables and passive monitoring hold promise for providing large datasets that can be used in conducting research or in tracking subclinical symptoms that can indicate health problems so measures can be taken to slow or prevent their progression. Smart home technology can provide the capability for unobtrusive monitoring to detect changes in biological function or falls, contingent on appropriate attention to concerns about privacy and including users in the codesign of products to ensure acceptability.
Older people currently contribute much to the world, and unleashing their potential through healthy longevity will enable them to contribute much more globally while allowing them to spend more of their later years in good health. Contributions and commitment from countries, communities, and people of all ages will be needed to realize the vision of a world of healthy longevity. If these efforts are successful, the possibilities are endless.
4 The goal of geroscience is to describe the age-related biological mechanisms that cause chronic conditions and functional decline, and to develop preventive and therapeutic interventions that can slow the aging process and prevent or delay the onset of chronic conditions that increase morbidity.