Physical Environment Enablers
While the physical environment has many aspects, this chapter focuses on those aspects the commission believes are most consequential for realizing its vision and goals related to the physical environment. The key targets for physical environments, along with the recommendation and supporting structures to achieve the physical environment goal, are provided in Figure 5-1.
Characteristics of the physical environment influence the health and well-being of all people across the life course. A considerable body of evidence links the physical environment to health and well-being (Bird et al., 2018). The World Health Organization (WHO) suggests that 24 percent of death and disease can be linked to environmental hazards, including poor water quality, poor water availability, sanitation, infectious diseases, air quality, harmful substances, and climate change (WHO, 2022a). As discussed in the previous chapter, the social determinants of health and the environmental conditions in which people live, work, play, and age have extraordinary impacts on well-being and health. Specifically, how an environment is designed and built can have positive or negative influences on health, social engagement, and access (or lack thereof) to essential services. In response to the WHO Age Friendly Cities Initiative, many places around the world have begun designing “age-friendly cities” and creating opportunities for older adults to age in a healthy and more holistic way (WHO, 2022b).
This chapter focuses on how healthy longevity intersects with key aspects of the physical environment, such as housing, public space and infrastructure, transportation, climate change and environmental hazards, and digital access. The discussion in each section touches on the cross-cutting issues of achieving equity and of best practices and promising interventions for promoting a healthy physical environment. The built environment influences human health in complex
ways and requires a “community-based, multilevel, and interdisciplinary research approach” (Srinivasan et al., 2003, p. 1446). The influence of place reflects a complex interplay among the key targets discussed throughout this report (see Figure 5-2).
The physical environment’s effects on health and well-being are evident across the life course, with negative effects accelerating as people age. The pace of biological aging and risk of chronic disease can often be linked to environmental exposures in early childhood, or even before an individual is born, because these are key periods for human development (Wang et al., 2021). A study in the United States, for example, measured the effects of social and physical environments on birth outcomes and found that measures of traffic exposure (i.e., air pollution) in utero were associated with lower birthweights (Zeka et al., 2008). Low birthweight can have long-term effects, including poor motor skills, poor vision, and chronic health problems (Hack et al., 1995). Investments in the physical environment, including forward-thinking prevention and mitigation interventions addressing climate change, are needed to enhance well-being at all
stages of life (Wang et al., 2021). While this report emphasizes interventions for and needs of older adults, neglecting the cumulative exposures acquired over the life course and the interventions that could be implemented earlier in life will result in missed opportunities for impact and less progress made toward healthy longevity for all. The commission believes that the key targets discussed in this chapter can positively influence people of all ages, setting them up for a more positive trajectory toward longer, healthier life spans.
KEY TARGET: HOUSING
Housing is a primary component of the physical environment that can influence a person’s ability to achieve healthy longevity. The home, together with the built environment around the home, is critical to one’s quality of life and the ability to remain independent. For many, maintaining independent living will be the goal. For those unable to live alone, however, thoughtfully designed elements in group housing can improve quality of life. Regardless of location, numerous inequalities exist in housing for older adults, which are amplified in disadvantaged environments and for those who lack basic water and sanitation. These inequalities play a critical role in influencing a person’s healthy longevity
throughout the life course. Important considerations for housing include universal design; affordability; and health and safety, including basic services such as water, sanitation, and hygiene. Finally, the proximity of a living space to food and resources will also play an important role in influencing healthy longevity.
One means of achieving independent and autonomous living for adults as they age is universal design, defined as intentionally developing environments and products to be easily accessed and used by a wide range of people (Farage et al., 2012). Although employing universal design principles1 at the initial stages of planning and designing housing results in 1 percent or less additional cost, the concept has yet to be widely adopted (Snider and Takeda, 2008), limiting many older people’s ability to perform such activities of daily living as bathing and moving around the home. Policies can encourage the development of accessible housing stock by incentivizing or requiring universal design features for all new homes. Designing homes with features that increase accessibility and independence for those with mobility challenges creates housing stock that is suitable for all members of society, not just older adults.
Availability and Affordability
The availability of affordable housing of adequate size and design and with access to community and social institutions is also a key component of healthy longevity. While many people say they want to stay in their home as they age, which enables more autonomy and continuation of social connections, doing so may pose challenges. For example, if children move out or a spouse dies, houses built for families may be more space than a single older person needs and too much for the person to manage. Depending on housing markets, younger people may be unable to afford to purchase or rent dwellings of the size that their parents could afford, raising questions about intergenerational equity. To address this challenge, policies that make it attractive for older people to downsize as they age are needed. As discussed in Chapter 4, there are also emerging programs pairing older and younger generations to address both the lack of housing available to young people and the need for more assistance for older adults.
Additionally, many older people of lower socioeconomic status are more likely to live in poor-quality housing for much of their younger years, often in environments that are not conducive to social integration and mobility (WHO, 2015). The benefits to their longevity of having them remain in these locations
1 Universal design principles include having a “no-step entry, all living space on one floor, switches and outlets at easily reachable heights, wide hallways and doors, and lever door handles and faucets” (Guzman et al., 2017, p. 1).
will be limited. Understanding specific demands in different areas can help policy makers and community leaders be more proactive in their approaches to this issue. As found in a study in Mexico, for example, housing arrangements in middle age have been found to predict housing needs in older age. Overcoming typical limitations of not having long-term data, the researchers found that typical living arrangements for adults at age 50 predicted their future living arrangements, with the potential to inform public health and other urban design policies (Huffman et al., 2019). As the older population grows, the need for affordable housing will increase, and policy makers need to take this need into account.
Health and Safety
Health and safety risks posed by poor housing conditions in infancy, childhood, and adulthood are similar in magnitude to those posed by smoking and alcohol consumption and can contribute to downstream mental and physical health conditions later in life (Howden-Chapman, 2004). The WHO Regional Office for Europe compiled a list of factors associated with inadequate housing, such as mold, lack of smoke detectors or window guards, overcrowding, indoor cold, traffic noise, and lead or radon exposure (Braubach et al., 2011). It summarized the evidence for the significant health consequences of these factors, which include asthma mortality and morbidity, injury deaths, lung cancer, respiratory problems, and cardiovascular disease, all of which affect people across age groups. Likewise, a German longitudinal study followed households for 25 years and found that, among people aged 64 and older, those living in homes needing minor renovations or major renovations had, respectively, 6 percent and 20 percent more physician visits than those living in homes needing no renovations (Palacios et al., 2021).
Taking a closer look at safety within the home, “falls are the second leading cause of unintentional injury deaths worldwide” and pose a serious risk to older people, who suffer the greatest number of fatal falls relative to other age groups (WHO, 2021a). However, children are another high-risk group for falls, so improving housing design and standards to prevent falls can address a problem that spans age groups. A study of older adults in Nigeria found that “28.4% [of] respondents believed that houses that were dark, ill-ventilated, damp and dilapidated were dangerous to health of the aged living therein. Poor lighting coupled with steep slope of stairs and slippery floor finish had caused falls and collision with objects among 18.2 [percent of] respondents” (Alabi and Fatusin, 2018, p. 174). Potential modifications to prevent falls and address other health aspects of housing conditions are presented in Box 5-1.
Water, Sanitation, and Hygiene
The availability and quality of water, sanitation, and hygiene are essential for all people to cook nutritious food, avoid waterborne pathogens, and maintain a socially acceptable level of hygiene. Less than half the population in 42 countries have basic handwashing facilities in the home (Seghers, 2020). In the Democratic Republic of Congo, Lesotho, Liberia, and Rwanda, only 5 percent of the population have access to these facilities, while this proportion is less than 30 percent in Haiti, Vanuatu, Bolivia, and Timor-Leste (Kashiwase, 2020). This lack of access to basic services can also have negative effects across generations, setting individuals up for challenges across the life course. A study in India, for example, found that pregnant women who spent more than two hours per day fetching water were 33 percent more likely to have a baby born with low birth-
weight (Baker et al., 2018). Those who shared a compound latrine versus those who did not were also more likely to give birth preterm.
While more pervasive in low-income countries, these problems are seen as well in middle-income countries, where they are also associated with poor health indicators. Water supply, sewerage, and access to indoor shower facilities and washrooms were key components of a composite measure of built environment that was applied in Brazil. Using this measure, researchers found positive associations among community dwellers 60 years and older between adverse conditions of the built environment and respiratory, urinary, and gastrointestinal conditions, as well as headaches and visual impairment (Blay et al., 2015). In South Africa, “community level provision of built resources of basic services (i.e., water, sanitation, electricity, housing) has a modest but significant impact on older persons’ subjective well-being” (Ralston, 2018, p. 111). However, individuals with chronic illness did not receive the same benefit as those without such illness, pointing to the importance of providing these basic services to a community before its residents develop chronic conditions.
Housing in Informal Settlements
Housing challenges are amplified in informal settlements, sometimes referred to as “slum” environments. Informal settlements are characterized by lack of access to safe water, sanitation, and durable infrastructure; insecure tenure of individuals in their housing; and a high density of residents (UN Habitat, 2006). The informality of these settlements—when residents are not registered with the municipality—influences the lack of access to the amenities and services important for health (Weimann and Oni, 2019). Inhabitants are also more vulnerable to consequences of urban development projects as well as climate and natural disasters, all of which can displace them.
Residing in informal communities negatively impacts health and health-seeking behaviors. A study of informal settlements in Rio de Janeiro, Brazil, found healthy life expectancy was twice as high in more affluent areas than in the slum settings (Szwarcwald et al., 2011). Researchers who examined residents in two informal settlements in Kenya noted associations with multiple adversities among older people, including mobility issues, lack of access to basic health services for cardiovascular and musculoskeletal conditions, and mental and emotional stress heightened by overcrowded family homes (Aboderin et al., 2017). WHO’s age-friendly communities and cities program, which emphasizes age-focused living standards that meet the needs of older adults, can guide efforts to upgrade or create alternatives to informal settlements. As written, however, the program’s indicators do not capture mental and emotional well-being challenges arising from basic housing quality.
Access to Food and Resources
Chapter 4 highlights the critical interplay among social determinants of health, poverty, and life expectancy. A steepening longevity gradient across cities and regions poses troubling questions about how health, prosperity, and environment have uneven impacts across the social landscape. One key aspect of healthy longevity is a healthy diet of nutritious food. But lack of access to and availability of nutritious food can be a challenge for people across the life course depending on their circumstances, particularly income level and geographic location. For example, the effects of poverty can include food insecurity due to a lack of financial security and challenges in the affordability of nutritious food. In addition to affordability, the length of travel necessary to procure nutritious food can be a barrier.
In the Global North, the concept of “food deserts”—“areas with limited access to affordable and nutritious food”—is recognized for its impact on food security for many households (Jones, 2011). Food insecurity intersects with housing-related factors in important ways. For example, researchers in Ontario, Canada, found that, relative to the overall prevalence of food insecurity among seniors, twice as many older adults living in subsidized housing experienced food insecurity (Pirrie et al., 2020). Additionally, women can be more vulnerable than men to food insecurity; researchers in Portugal found that 26.5 percent of older females reported being food insecure, compared with just 18.9 percent of older males (Fernandes et al., 2018). In higher-income countries, the placement of new housing developments, especially for older adults, near community centers or the introduction of farmers’ markets in underserved areas can partially fill the gap in food access. But without close proximity to these resources, people will rely on transportation. Thus, communities suffering from decades of structural racism or economic disinvestment that leads to a lack of robust transportation options will also be more food insecure (Beatrice et al., 2021; ODPHP, 2022).
The concept of food deserts, even in urban areas, is less relevant to measuring levels of food insecurity in countries of the Global South (Wagner et al., 2019). Because of the fluidity of the informal food economy in these areas, proximity to sources of food can be difficult to assess. Research on the application of this concept in the Global South is limited, but when analyzing access in Nairobi and Mexico City, researchers concluded that “food deserts in the Global South should not be understood through the proxy measurement of supermarket access” (Wagner et al., 2019, p. 13). Households in both cities accessed multiple types of food-sourcing options (Wagner et al., 2019). Additional research is needed to explore the structural drivers of inequities in food sourcing within urban environments in the Global South. However, given the dependence on agriculture for many in these countries, additional threats to food security, such
as climate change, protracted conflicts, and economic stalls (as seen during the COVID-19 pandemic), will continue to be at the forefront and demand attention (Whiting, 2022).
The demographic challenge of population aging also intersects with food insecurity in other ways, as the average age of farmers worldwide is 60 years old (Vos, 2014). In low- and middle-income countries, adults over the age of 55 make up approximately 30 percent of agricultural holders, and agriculture is often their main source of income (Heide-Ottosen, 2014). But, due to age discrimination and the perception of older farmers as unable to learn new skills, they are often excluded from productive resources and training on innovative technologies.
Inequality in access to nutritious food is also seen in low-resourced environments, such as informal settlements or refugee camps in low- and middle-income countries. A HelpAge International study conducted in Kenya found that more than 50 percent of people aged 60 and older living in refugee camps were in need of nutritional support as the result of a lack of access to food rations and a low-diversity diet (Fritsch and Myatt, 2011).
Levers for Empowering Change
Living environments could be redesigned in the near and longer terms to accommodate all ages in society, with attention to affordability, health, and safety. Especially as many countries continue to see a rise in their older populations, it is important to think about how best to accommodate older people with various housing options to promote optimal functionality and healthy longevity. Studies included in a review of evidence assessing housing interventions consistently found that providing housing and supports reduces emergency department visits and hospital stays and can generate a return on investment of USD1.57 in savings for every USD1 spent (Tsega et al., 2017). Multiple approaches can be applied to this end, such as increasing the availability of housing appropriate for independent living and making modifications to increase access to transit and needed services.
Additionally, proximity to resources such as nutritious food can have clear impacts on healthy longevity. Tsega and colleagues (2017) found evidence that access to healthy food among vulnerable populations is associated with lower health care costs and utilization. The ability to access health and social services is an important consideration when developing new housing projects and solutions to promote healthy longevity. Finally, “it is crucial that [older farmers] have equal access to productive resources and training on innovative technologies” (Heide-Ottosen, 2014, p. 21), to benefit farmers and to maintain an adequate global food supply.
Finding 5-1: Housing that encourages independence, social integration, and mobility is a key factor in older adults’ ability to realize healthy longevity, but the availability and affordability of this type of housing are limited, especially for those with limited financial resources.
Conclusion 5-1: To achieve global healthy longevity, safe and accessible housing that allows older people to age in place is critical. To ensure that housing and community design meets their needs, older people need to be included in user-centered design processes when modifying existing or creating new housing. Housing that supports aging in place can be encouraged through universal design standards, embedded health and social services, and “smart” technology adaptations that encourage independence. For some countries, especially those with informal settlement environments, providing housing that has sufficient water, sanitation, and hygiene is a critical first step toward achieving healthy longevity.
Finding 5-2: The proximity of a person’s living space to critical resources such as food can facilitate healthy longevity. Without food security, people are at risk of several comorbidities, such as dementia, depression, and functional dependence. Studies have found a high prevalence of food insecurity in older populations across several countries, affecting women more than men.
Conclusion 5-2: Given older people’s vulnerability to malnutrition and the comorbidities associated with poor nutritional status, housing options for older adults need to take into account the accessibility of such essential needs as nutritious food.
To measure progress on the goals and recommendations of the roadmap set forth in this report, many existing metrics can be used from related reports and initiatives around the world. Several examples are provided here for consideration when cities or countries are attempting to track their progress toward healthy longevity. United Nations (UN) Sustainable Development Goals (SDGs) 9, 11, and 13 are particularly relevant to efforts linking health and the environment, and using those indicators can provide an established mechanism for measuring progress. The following SDG indicator is especially aligned with this key target of housing (UN, 2022):
- Indicator 11.1.1: Proportion of urban population living in slums, informal settlements or inadequate housing.
While the concept of “food deserts” has limitations with respect to being applied universally, the Global Food Security Index uses 59 indicators to measure food security across 113 countries. Indicators include “affordability, availability, quality, safety, and natural resources and resilience” (The Economist Group, 2022). The index can be downloaded and customized for different areas.
While an abundance of evidence has been generated over the past few decades on the importance of the physical environment and its relationships to health and longevity, questions remain about how a community’s context or the implementation of interventions, such as housing for older adults, may influence the strengths or characteristics of relationships. A study in England found an implementation gap between existing policies and actual housing options for older people in a region with a high proportion of older adults (Robinson et al., 2020). The authors argue that future research should seek to understand whether municipal or sheltered housing can facilitate aging in place for older adults and whether it can reduce the need for people to move into residential care, as well as what the cost savings might be.
KEY TARGET: PUBLIC SPACES AND INFRASTRUCTURE
Like housing, public space and community infrastructure are important to health and well-being from birth until death. Public spaces impact mobility, which in turn influences people’s ability to interact with other people within families, communities, and regions (Webber et al., 2010). Public spaces also represent an opportunity, as the World Bank estimates that one-third of a city’s land area is covered by such spaces (World Bank, 2020). Multiple neighborhood resources, such as parks, places to sit, and public transportation, are positively associated with older adults’ active travel (Portegijs et al., 2020). As discussed in Chapter 4, increased opportunities for social engagement and interaction across generations can positively influence healthy longevity. Intentional design of public spaces can strengthen social cohesion, promote urban health and citizen well-being, and support the local economy (World Bank, 2020). Government leaders and the general public are pressing for intentional design of public spaces that promote healthy longevity. While there are numerous angles to consider when creating and designing public spaces, the commission prioritizes the characteristics most directly affecting health and healthy longevity, including green space, walkability,
and safety. Box 5-2 presents a case study in Lima, Peru, highlighting these three characteristics, in which local government transformed underused parking lots to a vibrant public space.
Green space, including public parks, playgrounds, and residential greenery in urban environments, has positive health benefits across all ages, ranging from improved physical and mental health to reduced mortality (Braubach et al., 2017). A recent systematic review across seven countries concluded that green urban spaces can help people live longer and avoid premature death. The researchers concluded that “interventions to increase and manage green spaces should be
considered a strategic public health intervention” given that all-cause mortality increases as the greenness decreases (Rojas-Rueda et al., 2019, p. e469).
Specific benefits of green space have been demonstrated among different population segments as well, including protective effects on sleep deficiency for people over age 65 and increased physical activity for adults over 60 (WHO, 2016). Another study of older adults in Bogotá, Colombia, found that higher density of public parks was associated with better self-rated health (Parra et al., 2010). Recognizing these benefits, several regional and global agreements and declarations include language about improving access to green space. In particular, SDG Target 11.7 calls for “universal access to safe, inclusive and accessible, green and public spaces, particularly for women and children, older persons and persons with disabilities” (UN, 2022). However, the current distribution of these green spaces within cities is often not equitable, so improving access to these benefits for all populations is an important policy goal for city and country leaders as they consider ways to optimize healthy longevity.
In addition to parks and public squares, community gardens are another form of urban green space that have gained attention recently. The emergence of “urban agrihoods” in the United States represents an attempt to provide an alternative neighborhood growth model, positioning agriculture at the center of mixed-use development. This approach not only increases green space within urban environments but also can encourage mobility and walking while increasing access to locally grown foods. One example is a recent collaboration in Philadelphia, Pennsylvania, that established a community garden program to give older immigrants the opportunity to volunteer, meet community members, and grow food for their families (US Aging, 2022). Community gardens that are accessible to older adults create opportunities for nonstrenuous exercise and social interaction with varying age groups. Community gardens have also demonstrated numerous benefits in the Gambia, including job creation; empowerment of women and youth; and greater levels of food security, nutrition, and health for participants (IFAD, 2019). The International Fund for Agricultural Development supports more than 30 community gardens in the Gambia, with several more to follow, enabling community members to cultivate a diverse array of nutritious foods and create additional income streams. It also reports transformational downstream benefits for the entire rural community—an indication that such programs are beneficial beyond urban environments.
A recent review of the impacts of urban green space demonstrated that such interventions carry positive health benefits, as well as “social and environmental outcomes, for all population groups, particularly those of lower socioeconomic status” (WHO, 2017b, p. 5), thus having a positive impact on health equity. The researchers suggest that the community should be engaged in planning and design at the outset to optimize outcomes, and equity should inform the design and be monitored following implementation. They also suggest that people of all ages who will use a green space be involved in its planning and design, and design
criteria should ensure that the resulting space is inclusive of and accessible to people of all ages. Given evidence that the design and maintenance of green spaces can mitigate health risks associated with living in urban areas, equitable access to green spaces is appropriately central to health-oriented urban planning and policies (Daniel, 2022). Indeed, Target 11.7 of the UN SDGs states that by 2030, countries should “provide universal access to safe, inclusive, and accessible green and public spaces, particularly for women and children, older persons, and persons with disabilities” (UN, 2022).
While much of the 20th century focused on urban design accommodating cars, buses, or trains, cities around the world have recently focused on reorienting their design around people. Australia’s Plan Melbourne centers on the ability of residents to meet most of their daily needs by traveling no more than 20 minutes from home by walking, cycling, or public transit (WEF, 2019). Walkability is the degree to which “the built environment enables the mobility of pedestrians” (Baobeid et al., 2021, p. 2). It is positively correlated with the health of an area’s residents, and cities are increasingly recognizing walkability’s benefits to individuals’ health and to a city’s energy and economy. But city living can pose challenges for older adults, because infrastructure is “typically designed for the working population to enhance efficiency and productivity,” such as short street-crossing times and busy sidewalks with bike, scooter, and pedestrian traffic (Loo et al., 2017, p. 812).
High walkability of an area is beneficial for people across the life course, from children to older adults, and numerous relationships have been found across countries between walkability and physical activity levels (Sallis et al., 2016). Spanish researchers, for example, found that older adults living in highly walkable neighborhoods of Barcelona made more trips and spent more time walking relative to their counterparts in less walkable neighborhoods (Marquet and Miralles-Guasch, 2015). But motivations for mobility, especially among older people, often go beyond physical activity to include access to social support from family members and community networks (Gorman et al., 2019).
Overall, across 19 studies published in English or Chinese, walkability was found to have a preventive effect for diabetes, obesity, and hypertension, as well as dementia, for which diabetes is a risk factor (Cheng et al., 2012). One analysis, for example, found higher walkability to be associated with a lower prevalence of diabetes and obesity in 8,777 neighborhoods in Canada (Creatore et al., 2016). Given that physical activity has a direct correlation with physical health and can indirectly impact social engagement, developing neighborhoods and communities that support walking by individuals of all ages can enable healthy longevity. Even benches that allow people to sit and rest can make a difference for both parents with young children and older adults (WHO, 2022b).
More than half of the world (55 percent) lives in urban settings, and by 2050, that proportion will increase to 68 percent (UN, 2018). The United Nations reports that meaningful sustainable development will be critical in low- and middle-income countries, where the pace of urbanization will be especially rapid. Urbanization has played a key role in shaping human interaction, infrastructure, and living styles. With this increase in urbanization in recent years, it is even more important for cities to develop sustainable and feasible transit solutions for residents in ways that encourage community interaction and connection. At the same time, intentionally designing roads and sidewalks for improved walkability is taking place in many locations, with important benefits for people of all ages. The neighborhood of Yonsei-ro in Seoul, South Korea, for example, undertook a transformation that involved widening sidewalks at bottlenecks and developing more connections to subways, public squares, and shopping malls (Kaw et al., 2020). Consequently, the number of traffic accidents was reduced by more than 50 percent in the year following implementation, and the number of visitors increased by nearly 29 percent.
Safety, which promotes healthy longevity, includes reducing risks of becoming a victim of crime, being injured as a pedestrian, and falling. As with so many other aspects of healthy longevity, people with lower versus higher incomes are less likely to live in safe environments. Public spaces in low-income areas are often unsafe for reasons that range from increased traffic exposure to elevated crime rates. Safety in public spaces is relevant for all people but is particularly important for older adults, who are especially vulnerable to feeling unsafe and less likely to be mobile than younger people. Even if physical infrastructure such as roads and sidewalks is present, older adults will not be as active as needed to benefit their health if they do not feel safe going out.
A recent qualitative study of older adults living in a high-crime neighborhood, for example, found that many reported feeling “trapped” in their apartments, which directly affected not only their physical activity but also their ability to create and maintain social relationships (Portacolone, 2017). In a study of senior housing in Stockholm, researchers found that all criminal incidents described by residents of senior housing took place near their housing (Ceccato and Bamzar, 2016). It is important to note, however, that location and cultural context influence perceptions of crime among older adults. In South Africa, for example, 65 percent of older adults reported feeling unsafe on the street, compared with only 9 percent in Ghana (Lloyd-Sherlock et al., 2016). The effects of crime on fear have a strong association with mobility beyond the home. Where older adults fear crime, they are less likely to leave their home, limiting the physical activity and social connection that promotes healthy longevity.
Leveraging Opportunities for Community Design
While redesigning cities to improve public infrastructure and add various elements can be resource-intensive and time-consuming, the occurrence of a disaster, small or large in scale, offers an opportunity to return to a “better normal,” provided that aspects of safe housing, green spaces, walkability, and social cohesion are incorporated into recovery planning before a disaster occurs. Following the 2012 earthquake and tsunami affecting eastern Japan, for example, authorities and private-sector businesses partnered to redesign a more resilient public housing community, detailed in Box 5-3.
Levers for Empowering Change
“Given the complexity of the built environment, understanding its influence on human health requires a community-based, multilevel, and interdisciplinary research approach” (Srinivasan et al., 2003, p. 1446). Many international reports call for efforts similar to those proposed in this report, and considering these reports in concert and not in competition can maximize the effect of interventions. For example, WHO’s Global Network for Age-friendly Cities and Communities, established in 2010, seeks to stimulate and enable cities and communities around the world to become increasingly age-friendly (WHO, 2022b). It provides con-
nections between cities and communities to enable the exchange of information, assist in identifying innovative and evidence-based solutions, and offer a global database of age-friendly practices that members can access.
Individual choices regarding mobility are shaped by the built environment. Urban and transportation planners can create well-designed, mixed-use, compact cities of the future wherein trip length between origins and destinations is short enough to promote active travel (e.g., walking and cycling). Pedestrian-friendly infrastructure—tree-lined streets, quality sidewalks, supportive bus stops (e.g., with benches), traffic aids at crossings, and crosswalks—has the potential to improve perceptions of safety in neighborhoods. Intentional incorporation of evidence-based factors that promote well-being in the design of holistic physical environments can support healthy longevity for all people, including older adults, as described in Vision 2050 (see Chapter 2).
Finding 5-3: Intentionally designed public spaces and built environments can play an important role in influencing healthy longevity. Creating opportunities for mobility, walkability, access to green space, and social engagement can enhance the lives of older people and reduce mortality and morbidity.
Finding 5-4: Public infrastructure, such as sidewalks, bike lanes, and well-lit streets, can influence the usability of an area and adults’ perception of safety. Interventions can facilitate more active travel, such as walking and cycling, and reduce sedentary behavior.
Conclusion 5-3: Opportunities exist to translate evidence into action in designing public spaces and infrastructure to promote social cohesion and intergenerational connection, thereby improving health outcomes and enhancing the lives of older adults.
Again considering the SDGs and the efforts that have been made to achieve them over the past several years, Target 11.7 specifically focuses on universal access to safe, inclusive green and public spaces. The corresponding indicator can help inform progress toward this target (UN, 2022):
- Indicator 11.7.1: Average share of the built-up area of cities that is open space for public use for all, by sex, age, and persons with disabilities.
Additionally, as the importance of walkability for a city or community has become increasingly recognized, measuring walkability and understanding factors
that may impact the mobility of older adults is also important. Accordingly, Alves and colleagues (2020) have proposed a Walkability Index for Elderly Health, which associates the adequacy of public spaces for older adults with the physical health benefits of walking. This index also can help urban planners and the general public identify age-friendly walking routes that take older adults’ needs into account while also providing access to the amenities that young people and families are seeking.
Generally, the return on investment for various interventions related to age-friendly cities and improved public infrastructure needs to be better understood. This will enable government leaders at all levels to select the right set of interventions for their culture and context. For example, what is the impact on elements of healthy longevity of introducing bike lanes, or safe streets, or park benches? Another area that could benefit from greater understanding is how best to link age-friendly efforts around the world to existing urban policies and design changes being implemented in cities and countries (van Hoof et al., 2021). Some researchers have also asked whether the established standards for age-friendly cities are outdated and should be reconsidered, given technological advances and new agile approaches to design.
Experts note the importance of codesigning interventions with intended older adult users to learn and share knowledge and experiences at the individual and municipal levels. At the same time, translational research is needed to ensure that the findings of such efforts are generalizable and applicable in real-world settings. Codesigning future studies and translating research into practice will ensure that the right stakeholders are being engaged in the design process to accelerate insight.
KEY TARGET: TRANSPORTATION
Adequate transportation, or the lack thereof, has significant impacts on people of all ages. Transportation encompasses public transit—buses, trains, subways, and light rail—and travel by personal, shared, or hired cars (e.g., taxis or rideshare). Limited transportation options can have impacts ranging from impairing a person’s ability to stay engaged in the community to impeding access to needed health services, which clearly has negative effects on health, especially for those residing in remote neighborhoods (Syed et al., 2013). People’s access to multiple transportation modes can be limited by their financial resources as well as by inadequate infrastructure. However, new designs and innovations can positively impact the physical environment within a community, often at reasonable cost, to promote healthy longevity as people age and depend on different transport methods. This section explores how public transit, driving, and automated vehicles may improve healthy longevity.
As one of the most widely used forms of transportation worldwide, public transit is widely accessible across income levels because it does not require an upfront cost to purchase a vehicle or the ability to drive. In 118 countries, there are fewer than 200 vehicles per 1,000 people (NationMaster, 2022), emphasizing the critical nature of public transit. Public transit has particular importance for those living in low- and middle-income countries and for people with low incomes living in high-income countries who depend on public transportation and walking to meet their needs.
In addition to being carbon-efficient and accessible, public transit systems generally require physical activity (walking, climbing stairs) for access to stations or transit stops. A longitudinal study of adults aged 40–69 in the United Kingdom found that people who switched from commuting by active or public transit to commuting by car experienced increases in body mass index (BMI), while those who switched in the reverse direction saw decreases in BMI (Flint et al., 2016). Well-designed public transportation can support mobility across the life course, especially for people of all ages with physical disabilities.
However, there are numerous challenges to widespread availability and use of public transit. These include geographic disparities in stations, which influence equity within a city and may increase the distance of first- and last-mile travel to and from those stations for those who live in less favorable neighborhoods. Public transit is also less available outside of urban areas and can be difficult to access for those with physical or cognitive disabilities. Interventions that make public transportation more accessible to older people and others have been piloted and implemented in multiple countries. A transportation welfare project in South Korea, for example, targets rural areas that lack public transit and charges the equivalent of just USD0.09 for a taxi ride (Sang-Hun, 2021), an approach that addresses the “first mile–last mile” challenge for older adults who had a long walk to and from a bus or train stop. Authorities found that the program enabled people in remote villages to travel outside their village twice as often as previously. Similarly, the Freedom Pass in London, which allows free access to extensive public transport for older citizens, was found to provide access to goods and services (Green et al., 2014). As a way to tackle chronic loneliness, bus travel provides a sense of belonging and visibility, as well as opportunities for meaningful social interaction. Thus, where good public transit is widely available and not stigmatized, it can be a major contributor to well-being. Other examples include
- the addition of bicycle lanes and bus rapid transit within urban environments (Stankov et al., 2020);
- free bus passes to increase use of public transit among older people (Webb et al., 2016); and
- shareable mobility scooters for city residents with long distances to walk between their homes and public transportation, addressing first- and last-mile challenges (Portland Bureau of Investigation, 2020).
Driving is a common mode of travel for older people, especially in high-income countries, where it is the most prevalent mode of transportation among more affluent older people. In contrast to other modes of transportation, it has negative consequences, such as pollution and congestion (Green et al., 2014). For many older adults, driving allows them to spend more time away from home, stay engaged in their communities, and score higher on measures of successful aging (Houser, 2005). But, driving is not an equitable form of transportation. In Los Angeles, low-income older adults residing in inner-city neighborhoods have lower access to private vehicles relative to more advantaged population groups (Loukaitou-Sideris et al., 2018).
Moreover, driving is not always an option as people continue to age. Among older people, reduced functional capacity associated with sensory and musculoskeletal deficits can force older people to stop driving. “[O]lder men and women, ages 70–74, could expect to not be driving and instead be dependent on alternative transportation for the last 7 to 10 years of their lives, respectively” (O’Neill et al., 2019). When older people stop driving, their mobility decreases when they lack other transportation, with negative effects on their health. A systematic review found driving cessation to be associated with greater rates of mortality and depression, as well as premature admission to assistive-care facilities (Chihuri et al., 2016). Pooled data from five of the studies linked driving cessation with nearly double the rate of depressive symptoms in older adults.
Autonomous Vehicles and Other Emerging Solutions
Emerging technologies such as autonomous vehicles (AVs) will likely play an important role in meeting the growing demand to support the travel needs of an increasing older adult population. Once AVs are broadly available and their safety issues resolved, they have the potential to significantly improve the ability of older adults to travel around their communities (Harper et al., 2016; Shergold et al., 2015). Studies have highlighted reluctance to use AVs among older people, a tendency that increases with age (Becker and Axhausen, 2017). Training and awareness programs targeting older adults may help overcome reluctance. Shared AVs may provide a good option for neighborhoods that are designed for aging in place and have higher proportions of older adult residents (Carnemolla, 2018).
Like housing, discussed previously in this chapter, emerging AV technologies can be made more friendly for older adults through incorporation of such aspects of universal design as low-floor vehicle designs for easy entry, comfortable seat-
ing, automated journey planning, and the use of audio-visual technologies (Metz, 2000). In addition, integrating currently older people or “future elders” into the design process can ensure consideration of the unique needs of the aging population throughout the conceptualization, prototyping, and validation of AV designs. In addition to AVs, next-generation assistive technologies can support mobility and active lifestyles for older individuals, enabling them to travel both within and beyond their neighborhoods and communities (Marston and Samuels, 2019).
Other potential solutions involve interdisciplinary approaches. As the older population continues to grow, more than 80 businesses in Japan have devoted themselves to the principle of Mobility as a Service transport, which allows for shared ride services in addition to other options through a smartphone app (Doi, 2021). Most of these options are focused on operating in rural regions of Japan with less access to established mass transit infrastructure. In Shobara, a depopulated town in the mountains, new bus stops have decreased the distance older adults must walk to reach a stop. To make this system viable, the town has introduced smaller vehicles and a reservation system to reduce unnecessary use (Doi, 2021).
Levers for Empowering Change
Many opportunities exist to incorporate designs friendly to older adults in transportation systems, whether based on individual driving or public transit. Options include universal design in cars; innovative design of railways and buses that allows older adults to board, alight, and be seated more comfortably; installation of bus shelters, benches, and street lighting at transit stops and stations; and provision of mobility aids for crossings at bus stops (to enhance perceptions of safety). The frequency of services for multimodal linkages can be optimized, and the accessibility of point-to-point services can be enhanced. In addition to increased provision of public transportation links, rideshare companies such as Uber and Lyft, where available, have revolutionized point-to-point transportation for older people, and these services can also be augmented by such innovations as mobility scooters and reservations for specialized routes. These options can address some of the first- and last-mile gaps in public transportation. Finally, economic incentives in the form of travel subsidies have been shown to increase use of public transit.
Finding 5-5: Safe and accessible transportation options can give older adults the opportunity to enjoy independent mobility around their community instead of avoiding social activities and becoming isolated and lonely. In areas where public transit does not meet the last-mile needs of the population, such innovations as rideshare programs and autonomous vehicles are opportunities to increase safe mobility for older adults.
Conclusion 5-4: As older adults begin to make up a larger percentage of populations, countries and cities need to enhance available transpor
tation options other than driving. Public transit systems would benefit from older adult–friendly designs and augmented first- and last-mile opportunities to ensure that people of all ages are able to maintain their independence and mobility.
UN SDG Target 11.2 is related to transportation, so using the corresponding indicator of progress can help cities think about ways to advance efforts toward these goals (UN, 2022).
- Indicator 11.2.1: Proportion of population that has convenient access to public transport by sex, age, and persons with disabilities.
For additional metrics to consider, McKinsey & Company developed elements of success in 2021 after studying the transportation systems in 24 cities across the globe (Knupfer et al., 2018). They selected five aspects of transportation systems for comprehensive assessment: availability, affordability, efficiency, convenience, and safety and sustainable development. For example, availability includes such indicators as the share of the population or workplaces living or located less than 20 minutes’ walking distance from a railroad station, or the number of bicycles used in public rental systems per million people. Indicators for safety and sustainability include such measures as the number of public-road traffic accident fatalities per million people per year, or the concentration of nitric oxide in the air in molecules per cubic centimeter.
With respect to transportation, much research has been directed at mobility options and building of mobility environments that are accessible for older adults, but how legislative and institutional approaches to providing various transport options are best used remains unclear (Lin and Cui, 2021). The latter findings could be paired with findings on the optimal combination and use of policies to promote equity and social inclusion for a more synergistic impact.
KEY TARGET: DIGITAL TECHNOLOGIES
In the 21st century, access to digital communications is imperative for all people. Interactions with businesses, health care systems, and educational institutions are now built on an internet foundation. Many of the advances described in this and the earlier chapters in housing, social engagement, and transportation are also contingent on access to reliable internet and familiarity with digital devices. The COVID-19 pandemic highlighted the importance of internet-based communication within families and social groups at a time when in-person gathering was deemed
unsafe. Unfortunately, inequity in access to modern, high-speed internet across populations is significant (Garcia-Escribano, 2020). One area of inequity is the pronounced digital divide between older adults and other age groups. “The UK Office of National Statistics estimated that in 2020 around 92% of the population as a whole used the internet, compared to only 54% of people aged 75 years or older” (The Lancet Healthy Longevity, 2021, p. E601). For older adults, the adoption and use of internet- and other technology-based systems is influenced by the availability of broadband internet and also by discomfort with using technologies that did not exist during most of their adulthood (see Chapter 4). Considering the intended users of digital technologies during the design and development process and jointly designing systems with users will improve usability to older people and support efforts to reduce ageism, health inequities, and the digital divide.
A digital technology access divide also exists between high- and low- and middle-income countries. The World Bank reports that only 50 percent of the population in low- and middle-income countries uses the internet, compared with 89 percent in high-income countries (World Bank, 2022). Public- and private-sector involvement is imperative to improving access, including cost reduction, which will be necessary for technology to support the achievement of healthy longevity.
Access to high-speed internet is integral to a functioning society today, and thus is an essential component of infrastructure. While researchers and policy makers appear to understand the extent to which broadband benefits health and equity, disparities remain in access to the technology. “From economic stability, to education, to social supports, to civic agency, broadband and the digital services it enables are intrinsically tied to collective health and equity outcomes” (Tomer et al., 2020, p. 3). The World Bank has estimated that in 2019, more than 56 percent of the world’s population was using the internet, but only 1.2 billion people, or 15 percent of the world’s population, had fixed broadband subscriptions (World Bank, 2022). According to the latest research in the United States, 38 percent of households earning less than USD20,000 per year lack a broadband subscription, a gap that greatly impacts equitable access to and adoption of mobile health technologies and other online systems (Sieck et al., 2021). Rural areas are notably unable to access reliable broadband internet services. “For example, while broadband use in the capital cities of India, the Kyrgyz Republic and Moldova and are at the same level as some Organization for Economic Co-operation and Development (OECD) members, usage in these three countries’ rural areas is among the lowest in the world” (World Bank, 2021).
Reliable internet access also impacts multiple aspects of life. During the COVID-19 pandemic, reliable access had far-reaching effects on a person’s ability to access mobile health technology, work in office settings, continue education during remote learning, and stay connected to social networks. Investments in broadband impact the economy, with one study showing that doubling broadband
speed can result in a 0.3 percent addition to gross domestic product growth, and even more modest increases in speed can positively impact household incomes in middle- and high-income countries (Ericsson et al., 2013). Katz (2009) found that if 12 Latin American countries were to add 11 million broadband lines, it would generate at least 378,000 jobs (Katz, 2009).
The digital divide in access to infrastructure is seen within and across countries. The International Monetary Fund (IMF) has noted that this is also the case for businesses in different regions of the world. Only about 60 percent of businesses in sub-Saharan Africa use email, compared with 85 percent of businesses in Europe and Asia (Garcia-Escribano, 2020). Many disparities exist in the United States:
The majority—13.6 million—of digitally disconnected households across the United States live in urban areas, but the gaps in rural areas are an even larger share of the total rural population. Researchers consistently find those least likely to have broadband in America are communities of color and low-income communities, suggesting that systemic barriers remain in place. (Tomer et al., 2020, p. 4)
Even when rural areas have broadband access, they often face slower speeds, potentially limiting economic growth. Box 5-4 outlines examples of opportunities for increasing access to broadband.
Information and Communications Technology
Information and communications technology (ICT) systems include the components, devices, and systems necessary for organizations and individuals to interact in the digital world. The proliferation of these systems over the past decade has created opportunities for improving the lives of older adults, ranging from improved social connections to health care augmentation (described more in Chapter 6). In an Israeli study of adults aged 65 and over, for example, researchers found that individuals who used computer-based applications, such as web pages and real-time chat rooms, reported a lower level of loneliness compared with nonusers (Pearlman-Avnion et al., 2020). Another example is the European Union-funded project Eldergames, which was initiated to reduce the natural process of cognitive decline associated with aging (Gamberini et al., 2008). The study found potential benefits of cognitive training performed via videogames offered by the older adult game system. Other similar findings indicate that videogame platforms paired with cognitive training can help reduce cognitive decline and depressive symptoms for those with mild Alzheimer’s disease (Fernández-Calvo et al., 2011).
While less common than computers, interactive robotic systems have been developed to assist older individuals with their mental and physical needs. For example, PHAROS—a robotic system developed to enhance older adults’ physical activity by recording their exercise performance, categorizing the exercise performed, and recommending physical exercise periodically—showed high accuracy of exercise detection among its older users (Costa et al., 2018). Several studies have examined the benefits of socially assistive robots for older adults. The use of robotic animals as therapy for patients with severe dementia avoid the potential negative health effects of real animals, such as allergies and infection (Hung et al., 2019). However, experts have raised ethical concerns about the use of robotic applications for older people. Unresolved issues “include a potential reduction in human contact; an increase in feelings of objectification and loss of control; loss of privacy and personal liberty; and tendencies toward deception and infantilisation of older people” (Share and Pender, 2018, p. 51). These ethical concerns need to be considered from the design stage.
Privacy, Cybersecurity, and Usability Concerns
An additional concern with regard to digital technology is online privacy, “understood as a person’s right to be protected from unauthorized disclosure of their personal information when online, and from unauthorized publicity, scrutiny, use, or surveillance of their digital information or activities” (Quan-Haase and Ho, 2020). Cybersecurity threats—criminal activities carried out via computers or the internet—remain a concern as more older adults using digital devices increases the number of people at risk (Age UK, 2015). Americans over the age
of 50 reported more than USD1.8 billion in cyberfraud losses in 2020, nearly 30 percent higher than losses in 2019, and the same age group also saw a 61 percent increase in cybercrime complaints that same year (FBI, 2020).
Older adults are targeted by multiple types of fraud for reasons including cognitive decline, social isolation, and lack of knowledge regarding fraud prevention (Shao et al., 2019), especially when using the internet with a limited understanding of the technology. Qualitative interviews in India found that cybercrime had profound impacts on older adults, who often lost their life savings or money set aside for emergencies. As a group in which the majority are not working, older adults are also less able to recoup such losses, and they become even more wary of technology (Tripathi et al., 2019). Researchers suggest that older people need the skills, awareness, and tools to understand when and how to share private information, while frontline staff in banks and law enforcement agencies need training to support these victims when such crimes do occur.
Still another concern relates to older adults’ lack of confidence in comprehending or accessing digital devices that result from inadequate user-centered design of software and hardware interfaces (Wang et al., 2019). The decline in visual acuity that commonly accompanies aging impedes the use of ICT if visibility enhancement features are lacking or of poor quality. Furthermore, modern software interfaces and internet platforms require incremental updates and iterations to adapt to user preferences, resulting in fluid interfaces that transform without warning, often rendering previous user knowledge irrelevant (Wang et al., 2019). Designing digital interfaces that account for the limited functional ability common among older adults, along with instructional material clearly explaining the steps needed to access functionalities, could help overcome some of these limitations.
Interventions to Improve Access to and Use of Digital Technologies
While all countries will need to balance trade-offs when implementing programs to narrow their own digital divides across generations, an analysis focused on countries in Latin America highlights seven key elements that should be included in any new efforts (see Box 5-5).
Levers for Empowering Change
Whether through expanded broadband access, videogame platforms, interactive robots, or use of technology in everyday life to access transportation, evidence shows that narrowing the digital divide between older and younger generations can have positive effects on quality of life, connection to social networks, and healthy longevity. To realize the goals of Vision 2050, however, these advances need to be delivered with equity as a central focus, ensuring that disparities in access are not worsened across various groups or countries. To
support affordable and universal access, for example, IMF suggests ensuring that internet investments are complemented by universal access to electricity and subsidies for groups that might otherwise not enjoy access to those investments (Garcia-Escribano, 2020).
Concerns about the expanded use of technology among populations that are largely unfamiliar with hardware and software can be expected to persist. Due diligence with respect to protecting privacy and preventing cybersecurity threats needs to be part of this continued expansion. Given the increasing age of retirement in many high-income countries, retirement benefit packages can teach vulnerable older adults cybersecurity practices related to the use of ICT and online
services and transactions. Similar training programs need to be made available for economically inactive vulnerable retirees to protect them from online scams and predators. Similarly, it will be important to equip future software technologies with fail-safe designs that can identify vulnerable users and implement extra layers of protection accordingly to minimize cybersecurity vulnerabilities.
Finding 5-6: Access to broadband internet is integral to many aspects of society. Low-income and rural households are especially likely to lack broadband access, which greatly influences their equitable access to other resources and their ability to work remotely and stay connected to social networks.
Conclusion 5-5: Broadband is essential infrastructure for achieving Vision 2050. Improving broadband access across socioeconomic demographics will require a combination of public and private incentives and investment. Increased attention to user-friendly functionalities for older adults and additional instructional support need to accompany these investments to ensure equitable access.
The UN SDG indicator for Target 9.c is specifically related to measuring the access to ICT in all countries (UN, 2022):
- Indicator 9.c.1: Proportion of population covered by a mobile network, by technology.
Another useful indicator for digital access could be whether a country has policies in place that promote inclusive and equitable digital access for older adults. In virtual health care, for example, many countries managed to scale access to those services but often to the detriment of underserved groups (including older adults) unless a specific policy to ensure their inclusion was in place.2
As technology advances (e.g., introduction of 5G wireless), research into who is using ICT systems and how they are using them will be important to support public–private partnership investment decisions. Research also has the potential to identify the factors that influence the adoption of digital systems by
2 Personal communication with Ann Aerts, Novartis Foundation. Broadband Commission working group on Virtual Health and Care, chaired by Novartis Foundation and WHO (report to be released June 4–5, 2022).
users in general, with specific attention paid to older adults. The advancement of knowledge can then be used to further improve these systems through the design process and by introducing appropriate training to support their broader adoption.
Given the association between lack of connectivity among older adults and other adverse social determinants of health, understanding how to steepen the technology adoption curve for older adults can help inform insight into ways of advancing healthy longevity. Implementing programs and then evaluating changes in organizational capacity across senior centers, libraries, nonprofit organizations, and long-term care facilities and their partnerships with industry and government can guide future action to facilitate the adoption of technologies among older adults (OATS, 2022).
While COVID-19 demonstrated how rapidly some services could be shifted online, it remains unclear how technologies affected access to health and social services for older adults. An umbrella review encompassing more than 100 studies found none that examined technologies used to facilitate first-contact access to care, and the researchers argue that more research is needed to understand both positive and negative consequences of this online shift for care access and identify those most likely to be excluded (Kunonga et al., 2021). Additionally, authors of a study in South Korea suggest that future research should focus on developing standards for understanding the digital divide in smart environments, not limited to PC-oriented environments, given the explosion of smart technologies over the past decade (Jun, 2020).
KEY TARGETS: CLIMATE CHANGE AND ENVIRONMENTAL HAZARDS
Climate change is an existential threat to all people, regardless of their age. 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 (Gamble et al., 2013). 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 (Simoni et al., 2015). Health-promoting physical environments can enable healthy longevity throughout the life course, yet across the globe, factors in the current built environments in many urban and rural settings pose multiple barriers to, and opportunities to improve, healthy longevity (see Figure 5-3). These factors will become increasingly important as threats due to climate change increase in frequency and severity. Key components of the environment impact healthy longevity, either positively or negatively, at all levels. Figure 5-3 shows that the effect of the built environment on health and well-being does not occur on a single societal level. As discussed in Chapter 4,
many of the key factors shown in this figure align with the UN SDGs, which also support healthy longevity. Successful solutions will require initiatives that, like the SDGs, bridge all levels of societal action and synergistically affect an individual’s health trajectory.
Climate change promises to intensify exposures to extreme weather events and more extreme temperature variations. These changes, in part, can also contribute to increased opportunity for infectious disease spillover from animals to humans and increasing incidence of new diseases in regions where they have previously not been endemic. As Rodó and colleagues (2021) point out, “climate change can both facilitate zoonotic spillovers and have an effect on transmission chains” (p. 576). In addition to COVID-19, several other infectious disease outbreaks occurring in recent decades have been due to spillovers from animal populations to humans. Climate change is believed to play a role by altering species’ range and density, in addition to increasing urbanization and crowded living situations in many countries, all of which affect human exposure to these diseases (Baker et al., 2021). To address this increasing globalization of health risks and to better understand and predict outcomes from the human–animal–ecosystem interface, many experts argue for a more comprehensive application of the One Health concept (Destoumieux-Garzón et al., 2018). Destoumieux-Garzón and colleagues (2018) describe One Health as a global strategy arising from the need for an approach that is “holistic and transdisciplinary and incorporates multisector expertise in dealing with the health of mankind, animals, and ecosystems” (p. 2). Effective surveillance and management of these new and reemerging threats to promote longevity among all populations will require “breaking down the
interdisciplinary barriers that still separate human and veterinary medicine from ecological, evolutionary, and environmental sciences” (pp. 1–2).
Finding 5-7: The built and natural environments where people live affect their health either positively or negatively. Harmful exposures throughout the life course, such as exposures to heavy metals or cancer-causing chemicals, affect the speed of biological aging and timing of the onset of chronic conditions later in life. The consequences are amplified by the cumulative effects of multiple exposures.
Conclusion 5-6: Because environmental exposures and health are closely linked, countries need to take rapid action to reduce harmful exposures and increase opportunities for people to live in healthy environments. Efforts to reduce the level of cumulative harmful exposures across the life course are necessary to promote good health and make progress toward healthy longevity.
Extreme Weather Events and Changes in Ambient Temperature
Extreme weather events caused by climate change have disproportionately adverse impacts on older adults. Migration due to coastal flooding, tsunamis, hurricanes and cyclones, and other extreme weather events often produce “climate refugees,” and the phenomenon is increasing annually. Overlapping vulnerabilities, particularly for older people and those with disabilities, are exacerbated in humanitarian emergencies.
An analysis of the impact of ambient temperatures on years of life lost in low-, middle-, and high-income countries illuminates the systematic association of both extreme heat and cold with life expectancies (Watts et al., 2018). As the intensity and duration of heat waves increase, the risk to older adults will also increase, manifesting in both morbidity and mortality during heat waves. Susceptibility to dehydration and declining physiological homeostasis mean that extreme heat poses a considerable threat to the health of older adults (Schols et al., 2009). Additionally, older people are vulnerable to extreme events such as heat waves due to chronic conditions, and those with limited means may lack good ventilation or air conditioning systems. For older adults aged 65 and over living in São Paulo and Mexico City, for example, exposure to high mean apparent temperature (representing the temperature on the day of death) was associated with a higher risk of mortality (Bell et al., 2008).
A growing body of evidence points to the association between air pollution and negative health effects. Findings suggest that even slight increases in
particulate matter linked to car emissions, soot, and smoke in both urban and rural areas are contributing to negative respiratory symptoms and early deaths among older adults (Friedman, 2022), as well as neuropathology and stroke, Alzheimer’s disease, and Parkinson’s disease (Block and Calderón-Garcidueñas, 2009). A recent study across the United States revealed that 18,000 older adult lives were lost prematurely from 2016 to 2018 as a result of particulate matter (Weinstock-Platzman, 2019).
Additionally, findings based on animal studies suggest that prenatal and early-life exposure to traffic-related air pollutants is associated with memory impairment, as well as mental and behavioral conditions such as depression. One study found that early exposure to air pollutants in Mexico City negatively affected cognitive functioning in children who had no additional known risk factors, compared with children living in a low-pollution region (Woodward et al., 2018). Adverse physical outcomes are seen as well, as older people in South Africa who lived close (1–2 km) to mine dumps, which have been shown to be associated with air pollution, were found to have significantly higher incidence of “asthma, chronic bronchitis, chronic cough, emphysema, pneumonia, and wheezing” (Nkosi et al., 2015, p. 1).
Interventions to Address the Effects of Climate Change
Recognizing this impact, many countries and cities have taken more intentional action to reduce their levels of air pollution. In Ghana, where nearly 12,000 people die from air pollution each year, city officials in the capital of Accra worked with Norwegian officials and local public health professionals to illustrate the links among air pollution, mortality, and health care costs, providing needed information to citizens on clean air policies (CCAC, 2021). The initiative has now garnered increased engagement from the Ministry of Transport for the use of health assessment tools and is continuing to expand knowledge of these linkages among health care workers. It also has raised awareness within communities of the need to reduce waste burning and develop green public spaces. Environmental staff in Ghana can now “continuously monitor particulate matter and black carbon in multiple areas of [Accra], and produce quality and reliable data to more accurately identify sources of air pollution” (CCAC, 2021).
Heat waves also represent an urgent concern for city planners and policy makers. Some cities offer centrally located cooling centers or provide air conditioners for those in need to keep older adults safe at home. Larger-scale efforts to reduce the impacts of heat in cities include the use of green roofs, water management, and open spaces. Mitigation efforts of Frankfurt, Germany, one of the country’s warmest cities, are highlighted in Box 5-6.
Levers for Empowering Change
As climate-fueled disasters grow in intensity and frequency alongside rapidly aging populations, governments need to develop systems for locating and evacuating vulnerable older people when necessary. In particular, technology-enabled alerts and plans can be used to monitor the status of and provide aid to older people. To this end, civil protection services often maintain registries of vulnerable older people. Additionally, the United Nations recommends best practices from several countries, including engaging older adults in preparedness and disaster risk reduction strategies, providing them with financial support and extended social protections following emergencies, and specifically developing recovery strategies geared toward reintegrating them into normal life following disasters (UN, 2020). Numerous examples during the past two decades have demonstrated the dire outcomes that occur when preparedness for vulnerable populations is not carefully carried out in advance.
The lack of global and robust response to climate change has also widened a divide between younger generations’ galvanization around the climate crisis and the perceived inaction of older generations (Milfont et al., 2021). The commission agrees that collective action and solidarity with those most vulnerable to and affected by the consequences of climate change are needed. In the context of healthy longevity, extreme weather and changes in ambient temperature, along with air pollution, are among the most concerning and immediate environmental hazards requiring national and local attention.
Leveraging existing efforts and stakeholders and leaning on multilateral organizations can help countries and cities address the effects of climate change in their own contexts. The Climate and Clean Air Coalition, facilitated through the United Nations, brings stakeholders together across countries and sectors to improve air quality and protect the climate in the decades ahead.3 The Coalition’s focus is on rapid action to realize benefits across the areas of climate, public health, energy efficiency, and food security.
Finding 5-8: While the impacts of climate change demand action for all populations around the world, older adults are often faced with overlapping vulnerabilities that make them especially likely to experience adverse events related to extreme temperatures, natural disasters, and air pollution. Older adults suffer some of the most adverse consequences of climate change and extreme weather events through exposure to air pollution, flooding, and extreme heat and cold waves. Studies across countries have found associations between high temperatures and increased risk of mortality and morbidity.
Conclusion 5-7: In their climate change planning and mitigation efforts, cities and countries need to consider the amplified impacts on older adult populations, as well as necessary monitoring and response actions. Systems for locating and evacuating vulnerable older people when necessary, as well as embedded designs in buildings and public spaces that reduce temperatures, could help augment other efforts.
In terms of metrics, UN SDG Target 13.1 is highly relevant to climate change and environmental hazards, and Indicator 13.1.3 can help measure progress related to climate emergencies (UN, 2022):
- Indicator 13.1.3: Proportion of local governments that adopt and implement local disaster risk reduction strategies in line with national disaster risk reduction strategies.
For tracking air pollution and its potential health effects within smaller regions or jurisdictions, WHO updated its global air quality guidelines (AQGs) in 2021. This update provides new recommendations on AQG levels and interim targets for PM2.5, PM10, ozone, nitrogen dioxide, sulfur dioxide, and carbon monoxide, and also ties the changes to reductions in health effects (WHO, 2021b).
While numerous studies have provided evidence that older people are more affected by climate change impacts, on average, relative to younger populations, older adults remain less amenable to making critical changes to reduce emissions and address other sustainability issues related to climate change. Research is needed to characterize the attitudes of older people on these issues and learn how they might be persuaded to engage in more “legacy thinking” (Frumkin et al., 2012), including potential levers for incremental attitude change and specific communication strategies for raising their awareness about climate change impacts. Finally, further research is needed to inform collaborative adaptation planning that would engage older populations with local governments and a broad coalition of partners in designing solutions to keep older people safe (Rhoades et al., 2018).
Countless studies around the world have demonstrated important linkages between various factors in the environment and the health of individuals and populations. Critical facets of everyday life can act as barriers to and facilitators of healthy longevity and can influence the length of time a person is healthy at any point along the life course, not just in old age. Many cities and countries have acknowledged these connections and are modifying their public services and urban designs to create opportunities for growing populations to live longer and healthier lives. But these changes need additional evaluation and implementation in varying contexts, especially in low- and middle-income countries, to advance understanding of how they can be optimized to have the greatest effect on achieving healthy longevity for all. The commission believes that to achieve the goal of creating physical environments and infrastructures that support functioning and engagement for older people, the key targets of housing, public infrastructure, transportation, digital access, and environment need to be intentionally designed, properly resourced, and shaped for healthy longevity.
Recommendation 5-1: Governments and the private sector should partner to design user-centered and cohesion-enabling intergenerational communities for healthy longevity. Initiatives should include
- at the city level, developing and implementing mitigation strategies to reduce the negative effects of the physical environment (e.g.,
- at the neighborhood level, promoting and measuring the impact of innovation and policy solutions for healthy longevity, intergenerational connection, and cohesion;
- at the home level, updating physical infrastructure to address affordability, insufficiencies, and inefficiencies in housing stock, as well as support autonomy and social connection;
- making broadband accessible and reducing the digital divide (e.g., usability of and willingness to adopt technology) within the context of each community; and
- designing public transportation options, including solutions that address first-/last-mile transportation needs, that can be provided to companies, foundations, and local governments for implementation.
air pollution and climate events such as flooding and hurricanes/typhoons) on older adults;
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