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Alexandre Kalache

Alexandre Kalache: A policy for ageing well

Creator of age-friendly cities says that this issue is important for the country's development

léo ramosThe lifetime project of 62-year old public health physician and researcher Alexandre Kalache is for the elderly to age while improving their lives . This idea might sound opportunistic given Kalache´s age; however, it must be emphasized that Kalache has focused on this issue for more than 30 years. He was one of the first experts to see the huge challenges that developing countries will face if they do not promptly start to think about and act upon the ageing issues of their populations. “The point is to face what could become a problem as an opportunity to turn this into an important issue of developmental policies,” he says.

In 2050, the world’s elderly population will equal 2 billion people, according to World Health Organization (WHO) estimates. More than 80% of them will be living in countries such as Brazil. In Brazil, the percentage of elderly people will rise from 9% to 18% in just 17 years (2005 to 2022). How can society adapt to such brutal demographic changes? “By starting to think and to plan immediately,” Kalache answers. His insight that this demographic was bound to occur came in 1976, when he was working on his Master’s Degree in social health at London University. He later went to Oxford University for his doctorate, where he also worked as an assistant professor.

Kalache, a physician, studied at the National School of Medicine (Faculdade Nacional de Medicina) at the then Brazil University (Universidade do Brasil), currently the Federal University of Rio de Janeiro (UFRJ). He was a professor of clinical medicine for four years. In the mid 70´s, he went to Europe, where he lived for 33 years; for the last 13 years, he has headed the WHO’s Global Health and Ageing Program. His two children (a son born in Rio de Janeiro and a daughter born in England) and his granddaughter are now adult and stayed on in London. Last month, Kalache retired from his position at WHO and now works as an advisor on global ageing in the president’s office at the New York Academy of Medicine. His ambition is to create an International Center for Policies on Ageing based in Rio, to continue doing research and  improving the quality of life for the elderly. The day after he returned to Brazil, he was at his mother’s big apartment in the heart of Copacabana, the neighborhood where he was born and raised, and gave this interview to Pesquisa FAPESP.

Did you come back to Brazil permanently, to create the International Center for Policies on Ageing?
No. I’m going to commute between New York and Rio with the intention of establishing this center here, which will focus on ageing as a development issue. In other words, how Brazil and similar countries, whose population is ageing much faster than that of more developed countries, can deal with the ensuing challenges.

How is this related to the New York work? 
The center will be connected to the New York Academy of Medicine and to London University. The idea is to set up a group of non-governmental, governmental, academic and even private sector organizations and, under this umbrella organization, to create a consortium focused on creating policies around the concept of active ageing, which we created at WHO. Such as the global movement of age-friendly cities. The Age-Friendly City Program was the major and last activity I developed within WHO. And I want to continue this program though I am now retired from WHO. The time has come to carry out the program. For example, Yeda Crusius, the Rio Grande do Sul state governor, wants her state to become an age-friendly state. I’m going to spend a week there to discuss the development of policies to perhaps turn Rio Grande do Sul into a model state in this respect. I plan to travel all over the state to contact academic groups, NGOs and the private sector. But above all, I am going to organize groups of elderly people from the state and ask them to tell us what difficulties they have to deal with, their suggestions and expectations. This will be a bottom up process.

According to the WHO’s Global Guide for Age-Friendly Cities, 35 cities are currently in the program.
Yes, we started with 35, but this figure has grown – a number of European and Japanese cities joined the program in January alone. Now, with Rio Grande do Sul, this number will increase because we will start with 12 cities from the state under a pilot program and then extend the program to the entire state. I need to tell you the background so that you can understand how this project came about. When I was a child and a teenager, Copacabana was a young people’s neighborhood. I was born at the Arnaldo de Moraes Maternity Hospital nearby; it has now become the São Lucas geriatric hospital. In other words, in my lifetime of 62 years, Copacabana has changed from a neighborhood with lots of children to one with a largely elderly population. No babies are born in Copacabana anymore. The pregnant women who live in this neighborhood have to give birth in the area of Botafogo. Today, Copacabana has more old people proportionally than Japan or Sweden. Who are they? People like my 89-year old mother; people who came here in the 1920s and 1930s, when Copacabana was being developed and urbanized. The neighborhood’s population mushroomed in the 1940s and 1950s. Everybody wanted to live in Copacabana.

And they never left.
Their children left and the grandchildren don’t even dream about living in Copacabana: to them, the neighborhood is a thruway; they “drive through” Copacabana. Only the elderly remained. And they remained because this neighborhood has a lot of services. When my father passed away, my mother asked me, “Do you think I should move?” I said, “Think about it carefully, because this is all familiar to you, this is your environment, you have everything nearby: drugstore, taxi stand, restaurants, banks.” Moreover, active old people go to the boardwalk, they socialize – it’s very pleasant. But take note: for each active old person outdoors we have two or three senior citizens who have difficulty moving around, who have non-preventable illnesses, very often not properly managed. They don’t get proper care because very often the physicians themselves are not properly trained to take care of the elderly, even though more and more geriatric specialists are working in Copacabana. Out of every three inhabitants, one is over 60 — a very high proportion. The Higienópolis district in São Paulo also has this profile. There is an acronym for this; these people are called NOEPs, which stands for naturally occurring elderly population. These are populations that, for a variety of reasons, such as the one that applies to Copacabana, elderly people are spontaneously concentrated. Not because of a policy, but by accident.

Is this the reason for choosing Copacabana as the first age-friendly city?
An International Gerontology Congress was held in Rio in June 2005. The event organizers invited me to give the opening speech. They asked me to focus on something new, to attract media attention. That’s when I thought of implementing a pilot project, which I called Age-Friendly Copacabana and launched this idea at the congress. It was a success. The project was mentioned on Fantástico, a Sunday TV show, on the Jornal Nacional evening news, on the Globo Repórter TV special and in the press. As my opening speech was attended by an international audience, many people started asking me, “Why only in Copacabana? Why not in Buenos Aires, Geneva, Shanghai?” I would answer, “And why not?” So we very quickly recruited these 35 cities, which were part of the WHO-run pilot. I set the limit at 35 cities because I wanted to complete the pilot project before retiring from WHO. 35 cities is a big number to work with. We included Shanghai, Tokyo, Moscow, London, New York, Melbourne, Geneva, Liverpool, Nova Delhi, Nairobi, Istanbul, Buenos Aires, Mexico City, Rio…

What did the reports on the pilot study cover?  
First, we conducted a basic survey to see which, according to specialized information, are the main elements that make an environment more age-friendly. Things such as housing, transportation, community participation, access to information, access to medical services, access to social services, engagement in social life, communication issues, adapting to an info-tech world for an ageing population. We focused on these eight issues and conducted qualitative studies, comprised of focus groups, with younger elderly respondents and older elderly respondents, from different socioeconomic levels; groups comprised only of women, groups comprised only of men, mixed groups, and then groups comprised of service providers and caregivers. Then we conducted another study, using the same methodology that focused on eight issues, in the 35 cities. When the reports came back, we put everything together to find the common denominators that would guide us on how to make the urban environment become more age-friendly.

léo ramosWas that the study that resulted in the guide?
Yes. The guide was launched in October 2007. Now the concept is becoming a more widespread international movement.

But this is still a trend. Do you already have any visible results from this movement?
Yes, in New York. I was there in the first week of February and Mayor Michael Bloomberg presented the State of the City – the annual presentation of the budget – focusing on the project Age Family in New York. He set up eight committees, each one focused on one of the themes of the Age Friendly City Guide. The committees include the housing committee, which focuses on housing issues; the open parks committee, focusing on park accessibility issues, or how to make parks more accessible to the elderly. Central Park has roller skating rinks and skateboard facilities; moreover, people go jogging there. This is not age-friendly. The 35-city studies showed that it is necessary to create specific facilities for people who want to jog, skate or ride bikes. Thus, the elderly would also have safe paths to walk on with no fear of being struck down by someone working out. The senior citizens asked that a bench be placed every 200 meters so that they can rest. New York’s Central Park still doesn’t have enough benches. But it has more than São Paulo’s Ibirapuera Park or Rio’s Aterro do Flamengo. So everything is relative and one must respect the perception of the elderly who live in that specific place. For example, the study showed that the elderly in Geneva think that the city is not clean enough. This is hard to explain to any resident who lives on the outskirts of our cities. However, the important thing is to realize how the local elderly feel. The guide has a list with items that have to be checked by the authorities in charge of safety policies, public ways, open spaces, transportation, housing, etc. It is a tool for the development of specific policies for that specific age group and has to the contextualized within local reality. This is why I plan to travel extensively throughout the State of Rio Grande do Sul.

Have you seen any such improvements in Copacabana? 
Two measures were implemented immediately based on this study. The first was to create a police station open 24/7 for the elderly residents. The facility is for solving security issues, such as petty crimes. The second, also based on Age-Friendly Copacabana, will be the opening, in March of a healthcare center, also open 24/7. It will be near a subway station, in a central location.

Did these requests come from the elderly themselves? 
Yes. When elderly residents of Copacabana have health problems and need urgent care, people don’t know what to do. Normally, they are taken to some emergency ward and sometimes, upon arriving there, they are scolded, because an emergency ward is for emergencies. Now we want to set up an Age-Friendly Healthcare Center, based on another WHO study that has been I conducted over the last five to six years. Normally, health care centers are unsuitable places for elderly patients to wait; sometimes there’s nowhere to sit, and the toilets are often precarious. Elderly patients often arrive early, get a password and, after a few hours, the receptionist yells, without any respect, that no more appointments will be scheduled that day. This happens after the person has been waiting for five or six hours. The written signs are unclear, everything is bad. It is like being in an unfamiliar airport where we don’t know our way around. Suddenly, a voice announces something over the loudspeaker and the elderly person doesn’t hear very well. We get upset if this happens. But the elderly person doesn’t. He feels bad, humiliated and guilty because he isn’t able to understand the system. Our objective is to make this system more age-friendly. Therefore, we must train  primary caretakers, from family physicians to nurses and nutritionists, so that these healthcare workers provide better care. This is a serious demographic transition problem. Healthcare workers know everything about child care and very little about elderly care.

Does the application of the program take social differences into account?
From this building in Copacabana, one can see the Pavão-Pavãozinho shantytown; it’s very close to us. All the contrasts and contradictions of Brazil are found in this neighborhood. If you walk 150 meters in a straight line, you’ll walk right into the center of a shantytown, which is the site of one of Rio’s biggest drug trafficking operations. Rio is surrounded by shantytowns and the study also focused on their inhabitants. The study focused on all the neighborhood’s residents.

Is it a fact that a rich senior citizen lives longer than a poor one, even when the latter has full medical assistance?
This is a good topic for discussion nowadays. Michael Marmot from London University is probably the world’s foremost public health expert today. He contributed enormously to this issue when he measured this situation scientifically. Mamort said that if we take one of those red London buses and go from Kilburn, a low-income neighborhood, to Hampstead, a high-income neighborhood, we gain one extra year of life every 200 meters.

So the closer you live to a high-income neighborhood, the higher your life expectancy is? 
That’s right. There is a ten-year difference in terms of life expectancy. Even after we adjust the related data for excess weight, unsuitable diet, alcohol and tobacco consumption, everything that is bad for your health, which are major factors causing chronic illnesses, mostly in adults. We still see this difference in terms of life expectancy. It is not yet clear why this occurs. But researchers suspect it might be related to self-esteem. And this is where the age-friendly city fits in, by enhancing citizenship and self-respect. It is not only at the age of 65 that one realizes the inequalities that occur throughout life. It is tough to reach old age. This is when we realize that the years have gone by and initial hope is transformed into despair. It is important to act upon societies that are ageing, in order to offer some kind of assurance that we will have support when we need it the most – and not only to be familiar with the factors that indicate who is going to die earlier or later. As we age, we aren’t interested in adding more years to our lives, but in adding more life to our years. The question is how to ensure at least a minimally acceptable quality of life in our golden years. This is a huge challenge.

Is this what the expression active ageing refers to?  
The accurate definition of active ageing is the process of improving health, participation and safety opportunities in order to improve the quality of life as one ages. It is an optimization process. The opportunities are always there. At your age, at my age, at the age of 16, or at the age of 5. The earlier and more efficiently we take advantage of these opportunities, the bigger the effects on our health. Participation is the second pillar of active ageing. Good health is the key that allows you to take part in society’s life. In other words, it isn’t only health in the sense of being healthy, but it is to benefit from, to have the energy, to take part in the life of your society, to take a bus when you need to, to have access to a library, go to a show or to the beach when you feel like it; it means  being included and not excluded, as is so often the case with the disabled.

Was it expected that the world’s elderly population would rise from 11% in 2006 to 22% in 2050?
It depends on whom you ask; demographers in general were surprised. People are living longer. When I was born, in 1945, in Copacabana, the neighborhood had a maternity hospital because there were many children in the neighborhood and the life expectancy was 43. In my time, we gained an additional 30 years of life expectancy. Some Latin American countries, which can be compared to Brazil, gained many more years. People from Chile, Costa Rica, Cuba, Uruguay and Argentina have an even higher life expectancy. Life expectancy in Chile and Costa Rica was lower than in Brazil in the 1940s, but now their levels are similar to Europe’s, approximately 78 years and higher than ours, which is 73.2 years. We are living longer, but this has a price. We have to get ready. Otherwise, these people are doomed. A longer life will become a hollow reward. It’s awful to survive in terrible health, with no quality of life. When I was a medical student, the discussion centered on the demographic boom. The total birth rate in Brazil in 1975 was 5.8 children, an average of nearly six children. It has now dropped to 2.

léo ramosIncluding in the poorer states?
The birth rate drop occurred concurrently. When the birth rate of the middle class dropped, the birth rate of the lower-income segment of the population also dropped, in the rural, urban and semi-urban regions, in the Northeast, in the Amazon region, in Rio Grande do Sul – concurrently. We’re talking about 1975. This is a very short time for such a decline. Of course, contraceptives, which didn’t exist before, had an impact. But the fact that Brazil is very open to behavioral changes aided this significant birth rate drop. I realized in 1975 that the population’s ageing would happen much faster in Brazil than elsewhere. Everybody would ask me abroad how I could be so sure of this and I would answer that the country was modernizing itself. The same soap opera that people watched in Copacabana was also being watched on the outskirts of Rio or in the hinterland in the State of Maranhão. A sitcom called Malu Mulher was aired in the late 1970s. It was about a divorced, emancipated, successful single mom who overcame all sorts of difficulties. The values of that middle-class heroine from the Southern part of Rio de Janeiro were widely disseminated. It was natural to think, “If Malu has only one child, why should I have three? Or six, like my mother, or 18 like my grandmother?” These are the types of important elements that change behavior, but people didn’t realize it back then. It took France 115 years to double the proportion of elderly people from 7% to 14%. In Brazil this proportion will double from 9% to 18% in 17 years, from 2005 to the early 2020s. Now, the big difference is that it took the French more than one century to adapt to aging, similar to the situation in other wealthy countries. For France to age it was necessary for the Frenchwoman in the late 19th century to achieve a higher level of education, to resort to rudimentary means of birth control. It was difficult. But little by little, from one generation to the next, Frenchwomen were able to control the number of children they bore and increase life expectancy; so the population of elderly people doubled in 115 years. In Brazil, all of this was compressed into one generation.

How can this challenge be overcome?
For us, health care professionals and researchers, for the authorities responsible for urban development, planning, social security, communication, info-tech, the solution is to adapt to a world that is ageing very fast. In 2050, countries such as Brazil will be home to more than 85% of the world’s two billion senior citizens.

More than 80%?
Around 85%. This means 1.7 billion people. And this population will be living in developing countries. The big difference in France is that first they got rich and then they aged.

What is the senior citizen population in Brazil nowadays?
Around 18 million. And this number will rise to 33 million in 2022. We can’t wait until 20% of our population consists of the elderly. We must adapt and develop policies now. We need to seriously and courageously discuss Social Security issues and retirement age, which must be reviewed.

The definition of senior citizen is a person who is 60 or older. Isn’t this definition outdated when we come across people in their 60s who are still mentally and physically fit? 
This is an outdated UN definition and poorer countries don’t want it updated. Any worker who has spent his life carrying weight above his capacity, who has never been properly fed, who was undernourished in childhood, suffered from repeated infections and worked 12 hours a day, will not make it to the age of 60, much less to the age of 75, in the same mental and physical shape as that of a New Yorker.

Doesn’t this prove that the environment is more important than genetics?
Only 20% to 25% of a successful old age is due to hereditary or genetic factors. Environment and lifestyle are the two factors that really determine the successful old age. Lifestyle doesn’t mean only doing sports or eating properly. There are three other personality factors that are very important, namely, optimism, self-efficacy and self-esteem. It is important to have an optimistic nature. Self-efficacy, meaning people who are able to deal with their resources properly, is equally important. The person might have few resources, but you have to deal with these – including health – properly. And self-esteem – liking yourself – is also important. These three factors reflect on the future in some way and might be the key to understanding the social determinants of health. If someone has always been treated badly by society, this person will lack self-efficacy or self-esteem. It is hard being an optimist in this kind of situation. And this ends up influencing not only how many years a person will live, but also the quality of this person’s life.

What are the latest findings on anti-aging procedures in the medical field? 
During the 13 years in which I headed the WHO program, I never opened any mail that focused on anti-ageing issues. I threw this kind of correspondence into the rubbish.

Because nothing that allegedly avoids ageing has been proven, nothing has been shown empirically, or based on data or evidence. There is nothing in this respect that has convinced me or other serious researchers whom I respect. Actually, there is a contradiction of terms… Anti-ageing? If there is any alternative to this, then I certainly prefer to get old, if the only choice is to die young. Things like these orthomolecular treatments, for example. They are very profitable for those who sell this illusion and provide a lot of hope to those who believe in such treatments. It’s much easier to believe in a magic pill that you swallow in the morning than to go for an hour-long walk every day.

What is your opinion about the recent international study showing that people who get to 70 in good physical shape are as mentally happy and healthy as people in their 20s? 
There’s nothing strange about this, because elderly people who reach 70 in good shape normally eat properly and benefit from their resources more effectively; they gain the so-called self-efficacy. But many other senior citizens don’t achieve this self-efficacy.

Why are you so intensely focused on working with old people? Isn’t this a task for young people?
I had fantastic elderly people in my family. My father’s family is half Syrian and half Lebanese, with those intense values. My mother descends from Italians and Portuguese, a true Mediterranean heritage. I never watched TV when I was a child. The elderly people in my family were very passionate people who remembered and told stories from Lebanon, Greece, and Italy – traditional stories. This fascinated me; I loved being with them. And they really spoilt me. They were very caring and I was never mistreated by them.

Have you always wanted to be a researcher?
I always wanted to work in the field of public health, without necessarily working at a hospital or going into private practice. It was so interesting – when I first arrived in London and became acquainted with that society, full of old people, which was not the same here in Brazil at that time, neither in Copacabana nor Brazil. And I thought to myself, “Incredible; it must be great to get old here, with so many available services.” Two months later, I caught myself thinking: “It must be awful to get old here, there’s no family life like the kind I had with all those old family members integrated with us, and here so many people are alone, depressed… ”

The Global Age-Friendly Cities Guide can be downloaded