Melting away

Last week I was in Geneva, for a consultation meeting of the World Health Organisation on healthy ageing. A good occasion to write another blog after my 6 months stay over two years ago at WHO where I wrote a blog every week.

Why I had to go to Geneva again? The WHO published a big world report recently on ageing and health with ample information on this topic. The next step is an action plan on what countries and the WHO itself can do to ensure that people in future live longer in good health. We came together with countries and various organisations to discuss this action plan that has to be approved next year during the World Health Assembly.

In the report, WHO makes a distinction between intrinsic capacity and functional ability. Intrinsic capacity is the same as physical capacity and may remain high till the end of life and then decline suddenly. But this capacity can also decline earlier in your life course (because you get one or more chronic diseases for example). Genes, personal factors and luck partly determine what trajectory life has in stock for you. But of course you also can influence it yourself. Prevention is important during your entire life course and in the end also determines how fit you still are. So don't smoke and don't eat processed meat and your intrinsic capacity will probably decline only later in life.

Then functional ability. This is, simply said, what you can still do given your intrinsic capacity. The environment you live in determines how much extra functioning you can gain. This can be due to help by family members, assisting technology, your house being adapted for old age by the municipality, how age friendly the city is you live in and so on. A health system that is aligned to the needs of older people and a good long term care system that supports people who really need it with nursing, washing, shopping etc. also help to raise this level of functional ability. And not to forget, a culture in which elderly are seen as useful members of society and where they are not subject to abuse also helps them to keep doing the things they want. And that is exactly the definition of healthy ageing. To be able to keep doing the things you value, also in old age.

Readers of this blog of two years ago may remember that at this point I usually introduced a film I saw that week and that I connected to the topic of the blog. Therefore I went again to the art cinema la Scala in the nice neighbourhood Eaux Vives where they screened a film by Luc Jacquet, the Oscar-winning director of international smash hit March of the Penguins. He now made a documentary in Antarctica “Ice and the Sky (La Glace et le Ciel). The film looks at the life of one man: French polar explorer and glaciologist Claude Lorius.

His biggest breakthrough was the fortunate discovery that the chemical composition of snow allowed him to calculate the exact temperature on the day it fell, which means that samples from thousands of years ago could be surveyed to get an idea of the rise and fall of temperatures over extended periods of time. He thus found proof for climatologists’ hypothesis that our planet went through hot and cold periods of about 100,000 years each, which in turn allowed him to prove that the rate of climate change over the last 100 years is not a normal variation in temperature, and must thus be caused by man.

Gorgeously choreographed shots, many of them filmed with the help of drones, show Lorius surveying the melting water of glaciers or the burning forests that are the result of climate change. Entirely wordless, they convey the idea that the beauty-filled natural world indeed seems to be slipping away from the old man who first suggested this would happen and who now worries about what kind of world his grandchildren will be living in.

Now what this story about climate change has to do with healthy ageing as defined by the World Health Organisation? Well, just like the ice sheets in Antarctica, your and Lorius' health and intrinsic capacity will melt away in the years to come. But more serious, the intrinsic capacity of our climate is seriously compromised and we will need to do a lot to prevent further worsening. This means burning less fossil fuels and eating less meat (ah, wasn't that also good for your health as well?).

It also means that we will have to work on our functional ability of living on planet earth. We have to adjust to climate change like to old age, by introducing new ways to cope with natural disasters, and by offering long-term care to those who will have to leave the places where they now live and work (New York, Miami, Bangladesh and Netherlands to name a few of places that will have disappeared in 200 years from now).
And just like with respect for the elderly, paying more respect for nature and our planet will also help us to keep enjoying our lives. Elderly abuse and abuse of our planet should both be avoided and we need a different mind set.

Perhaps contradicting myself now at the end: like age friendly environments, we will also need environmental friendly ageing. That means for example not allowing electric bikes anymore for people under 75 and no absurd heating of rooms to 25c or more. Now that would mean a contribution to not melting away for the rest of us!

Spirituality and health

This is my last day at the World Health Organisation. All good things end. It was a very stimulating time for me and I am a bit sad it is over. Also because WHO receives much attention these days. Just look at the new book by Dan Brown “Inferno” and the latest film with Brad Pitt “World War Zombie”, where in both cases WHO must save the world from a terrible virus (Warning: World War Zombie is a terrible movie, where not even the zombies are acting well). So I am proud having been employed at WHO and to make a small contribution on how to deal with the ‘ageing virus’.

As I am in a bit melodramatic mood, it is a good moment to write about spirituality and healthy ageing. The more so as this week one of the world’s religious leaders, mr Sri Sri Ravi Shankar visited Unaids and we were all invited to attend a session with him. Now I am a little bit suspicious of Indian Gurus as it is often about power, women and so called miracles (the Sai Babas of this world). But this guy (or his Holiness as he calls himself) is quite funny and sincere in his effort to make the world a better place.

The essence of his philosophy is that there is too much violence in the world and that it is caused, among other things, by stress. Caring and sharing are the first things that we forget when we get stressed. And that leads to violence. By means of ‘Art of living’ courses it is possible to learn ways how to cope with stress and how to keep your energy.

At this point there is an overlap with healthy ageing. Remember the FIELDS of ageing I wrote about earlier. Working on Food (healthy food), Intake (some additional minerals & vitamins), Exercise (a lot), Liquids (water), Drugs (avoid medicines where possible) and Stress (enough sleep) can increase your life expectancy. Sri’s list for energy contains many similar items of items that can contribute to a healthy lifestyle. His sources of energy are food, sleep, breath, happy mind and time for yourself with nature.

I can agree with these simple but important messages. It is a bit a pity that he uses the same methods as the traditional guru: a wild black beard, a long dress, mysterious laughing and red velvet chairs. At the end of the session, we even had to do some exercises (but with some humor: feel how many knots you have, you are very naughty). His lessons are that we should pray, meditate, do some exercises and above all take care of our breathing.

When we walked out, a colleague asked me how I liked it. I had to admit that I never pray, never meditate, never take any breathing exercises and that my only spiritual encounters are with wine and whisky. But we agreed that there was much common sense in his words and I will think about how I can include more moments of peace in my own life.

So where is the usual link with the weekly film? Well, I saw La grande Bellezza (the great Beauty) from Paolo Sorrentino. A beautiful Italian film in the style of Fellini about Jep, a 65 year old author not being able to write anymore after he indulges in ‘Bunga Bunga’ like parties in Rome. But when he learns about the death of his first and biggest love something changes.  He feels love again, and perhaps even has the power to start writing again, just when he feels the shadow of death fall across him. Just in time, he may have found the sources of energy again.

This summer, I will also try to regain some energy. Hence, it will be my last blog. I may continue writing, but I will open another blog for that.  Just follow or friend me on Facebook, Twitter and LinkedIn if you want to read more.

And to end with a saying by Sri: Walk lightly on this planet and yet leave such a footprint that cannot be erased for thousands of years! I hope by blogs were light enough and still readable in 3013. Have a nice summer holiday.

Hit old people

Is it allowed to hit frail old people? Most people will agree with me that the answer is no and that you abase yourself if you abuse others. But is it allowed to push them a bit when they are demented and try to run away? And is it allowed to sell frail old people a vacuum cleaner when they can not remember anymore that they already have one? Or is the family member that cares for the older person and deals with all financial matters allowed to use some of the savings to have a well deserved holiday, “because mother really wants me to do that”?

As you understand the possible number of border line cases is substantial and will only grow with the increasing number of older people in the world. It is rather easy to abuse older people, even with good intentions. Sometimes informal carers are so overburdened combining care and work, that they become stressed and do things that they later regret. Not everything can be avoided and arranged but raising awareness is the least we can do. The Dutch government now has a television campaign showing an example of an old man whose model boat was broken by some carer losing patience. The old man is comforted by one of the neighbours trying to find out what happened after hearing the noise.

It is good that the topic is also on the international agenda. Last week I attended a symposium on abuse and neglect of older persons in Europe. It was organized by the European Commission together with the United Nations Human Rights Office. I represented the World Health Organisation, as there are obvious links with ageing, health, care workers, mental health and long term care. But it was also useful for my next job in the ministry, where I will work on long term care and the initiative to come to a new UN convention on older persons’ rights.

Different panels discussed abuse and neglect in care institutions, in informal and community based care and of the ways how to protect the human rights for older persons. In the last panel, we discussed whether or not we need this new UN convention on older persons’ rights. There is no agreement yet in New York and I may go in August to the next session of the Open Ended Working Group (the official name of the committee that deals with this matter).

Another important issue was how to monitor and improve quality in long term care. That will also contribute to avoide abuse, at least in more formal settings. The OECD has recently published a big study on the topic, entitled “a good life in old age: monitoring and improving quality in long-term care”. The report is about how countries are addressing the challenge to protect life in dignity by frail older people by developing measures to ensure a high quality of long term care. Quality measurement in long-term care lags behind quality measurement in health care (leave alone in other industries) and at the moment it is difficult to make national and international comparisons.

Hitting old people is not good. It is a pity that there are some online games where you can practice exactly that. Read this: “Your friend wanted to take his girlfriend on a romantic ride through park, but he can barely go anywhere with all those stupid old people getting in the way. So he asked you to ride ahead of them and make sure none of them ruin their romantic date. Your aim is to ride your saqway and hit the elderly people to keep them in front of you.” Not really the message we want to give to the young generation, isn't it? As you can see on the picture below, there are other and much better online games available, where you can even play together with old people.

 

The ability to think

This week – in my local Eaux Vives cinema in Geneva - I saw the German movie ‘Hannah Arendt`, directed by Margarethe von Trotta. The film is about Arendt's reporting on the Eichmann trial, the Nazi responsible for organising the deportation of millions of Jews. Her book "Eichmann in Jerusalem," stirred up a firestorm by suggesting that Jewish leaders were in part responsible for the extermination of their own people. But the main theme of her work is that she discovered that Eichmann was not an evil man by nature. As she wrote: "The trouble with Eichmann was precisely that so many were like him, and that the many were neither perverted nor sadistic, that they were, and still are, terribly and terrifyingly normal." Eichmann just followed orders, liked to do that efficiently and did not think about the moral. “This inability to think created the possibility for many ordinary men to commit evil deeds on a gigantic scale. The sad truth is that most evil is done by people who never make up their minds to be good or evil". And that is -perhaps her most well known words - "the banality of evil".

Struck by the danger of thoughtlessness, Arendt spent the rest of her life thinking about thinking. Could thinking, she asked, save us from the willingness of many, if not most, people to participate in bureaucratically regulated evil like the administrative extermination of six million Jews? Only thinking, Arendt argued, has the potential to remind us of our human dignity and free us to resist our servility.

The ability to think is also an important issue in the field of ageing. Apart from the important issue of dementia, it could also be a kind of comfort to know that even if we have less years left, we at least will spend them knowing more about the world. Or that we are better able to cope with other people and not repeating our mistakes of the past. Unfortunately, most frameworks for ageing and health only look at issues like functional decline and frailty and make no distinction between physical and cognitive decline. We still do not know whether ageing means more wisdom and less muscles, nor whether the mind can compensate for some physical decline.

To answer these questions, I think it is important to first make the distinction between cognitive decline and the ability to think. Cognitive decline happens in the form of for example memory loss, lesser ability to play video games and dementia. It is true that this loss of cognitive functions can severely impact your ability to think (clearly). But in a way this loss is much more a form of physical decline (less cells and worse connections in your brain).

The ability to think is a deeper concept and goes much further than just the capacity to think fast and clear. It can be defined as the way to use experience and knowledge gained through the life course to come to deeper insights. The ability to think is not or much less connected to physical or even cognitive functions. By definition, the ability to think can increase over the life course, especially if you have experienced a lot and took the effort to gain knowledge. But not necessarily. There is also something which I call the wisdom paradox: young people are sometimes wiser than old people. The explanation is that those young have experienced more in their short lives and have already studied more than some their older fellow human beings who had more regular and superficial lives, mainly watching television in the evening.

But let's not be pessimistic and assume that most older people have gained some wisdom over the life course. Can old people use this ability to think for compensating some loss of physical functions? Maybe. I can think of not doing things that you better not do at a certain age. Especially men are vulnerable to the illusion that physical decline is something for others (I am no exception with my exhaustive biking up the mountain near Geneva this week on a sunny evening after work). Or to derive more pleasure from other things in life like reading and from the art of thinking itself. I think we need to explore this further and ask older people themselves to give us examples.

But how to compensate for the loss of cognitive functions that will have an impact on our ability to think? Memory loss is not something you enjoy and can compensate easily by doing other things in life. Fortunately, there are many new tools to help old people. LinkedIn wil help you remember the (names of) people you meet in your life, Outlook reminds you of your appointments and smart phones give you access to all information you need to have. While getting rid of the need to remember routine things in life, we can use our remaining brain power to really think when we are old. Well, hopefully.

Back to Hannah Arendt. She was a good philosopher but missed some important issues. Seldom I have seen a film where a woman was smoking that much. It is true that the dangers of smoking were less well known in her time, but a women with such an ability to think should have known better. Tobacco is evil and smoking is a banality. I am afraid that there are still many Eichmanns working in the tobacco industry.

 

Only God forgives

This week I saw the movie “Only God forgives” (or in Italian even nicer “Solo Dio Perdona”), an emotionally breathtaking, aesthetically brilliant and immensely violent thriller set amongst US expatriates in Bangkok. It is directed by Nicolas Refn, the Danish filmmaker who also directed the Pusher films and Drive. The story is about two gangster brothers in Bangkok. One of them, Billy, is killed after he murdered and raped an innocent girl and the victim's father revenges. The other brother, Julian, does not revenge his brother after knowing what he did. His inability brings two terrifying people into the movie: one is Julian's mother Crystal, the mafia Godmother, enraged at Julian's pathetic disloyalty. The other is the mysterious police officer Chang, who roams the streets armed with a sword: a sharia-samurai of justice. What follows is a deeply disturbing film with dream-like scenes of green light corridors, dragon heads, karaoke bars, torture, deep red blood and much death.

It is a bit of a transition, but death also features prominently in the World Health Statistics 2013 that were recently published. Did you know that every day about 800 women die due to complications of childbirth and pregnancy? And that 80% of deaths from malaria occur in just 14 countries? And that children in low income countries are 16 times more likely to die before reaching the age of five, than children in high-income countries? It can all be found in the publication and statistics at www.who.int/gho

One of the striking tables in the summary is about causes of death among children aged under five. In the first 27 days almost a third of deaths occur, most of them from preterm birth complications and birth asphyxia. Pneumonia accounts for a serious 18% of overall deaths under 5 and diarrhea for another 10%. In fact malaria (7%), HIV (2%) and measles (1%) are not even that big killers anymore for kids. 

There is also good news. The world has made progress in reducing child deaths by 40% from nearly 12 million in 1990 to less than 7 million in 2011. The number of countries where at least 1 in every 10 children die before their fifth birthday has more than halved, from 53 in 1990 to 24 in 2010. Many more children can still be saved with simple and cost-effective care.

In the World Health Statistics there is also information on causes of death in older people. They differ of course from the children, but are also quite different in the old age group itself, depending on how old you are. The very old (80+) die mainly from heart disease (in almost 50% of cases) and for the rest from cancer (13%), COPD (13%) and lung infections (6%). The not so very old (60-70) die also but less often from heart diseases (38%), more often than the very old from cancer (22%), less from COPD and lung infections and more often from the bigger group of other diseases. And obviously all elderly groups suffer much less deaths related to traffic incidents, violence and hiv-aids. On the good side, we can see from the statistics that life expectancy is increasing (worldwide from 64 years in 1990 to 70 years in 2010). And also that some countries are already pretty old (in Japan and Germany half of people are over 45). 

What do the World Health Statistics say about causes of death in Thailand? Is it really as terrible as is shown in the movie “Only God forgives”? Unfortunately, the tables do only breakdown by region and not by country. Looking at another source, http://www.worldlifeexpectancy.com Thailand is not doing better or worse on violence than other countries in the world. 

Of course also people experiencing death or violence are victims. I used one of the lunch breaks for a quick visit to the Red Cross museum that was reopened after a large renovation and modernization. It is more interactive now and you can walk around with an audio guide like in many other museums now. Interesting is that you can sit opposite to an eyewitness and hear his or her story. The tales are mostly about a natural disaster or genocide. Many people have experienced death or torture from a short distance. In some cases the guilty had to face trial, sometimes they escaped and sometimes they received forgiveness, like in South Africa. So not only God, but also people can forgive.

The contrast between listening to the consequences of violence in the museum (learning from violence) and watching a violent movie for fun cannot be bigger. I guess that eradicating violence from films and videogames is not possible and maybe not even desirable. However, it may help to put “Only God forgives” in perspective by visiting the Red Cross museum and by reading the World Health Statistics. 

Selfish care

Last week I saw the great Gatsby, a movie directed by Baz Luhrmann and starring Leonardo DiCaprio. I wrote last week that the World Health Assembly is bombastic, but this movie over tops the Assembly easily. Mr Gatsby holds staggeringly sumptuous parties in his mansion. The 1920s come alive in the movie with all-singing and all-dancing effects, and with Jay-Z's audacious music. Digital panoramas of New York make you dizzy. Fortunately, the story is less complex and easy to follow. Mr Gatsby was years ago in love with Daisy who now lives just across the bay from Gatsby, with her boorish wealthy husband Tom. Gatsby left her many years ago to first make a fortune with illegal deals in the prohibition years so that they would be rich before they started to live.

The parties he now organises are nothing more than an attempt to win her back, but she never shows up. After arranging a meeting through Daisy's cousin Nick, who happens to live next to him, he finally meets her again and a competition follows between the two lovers. But that is maybe not most important. What the movie is really about is that getting rich first is not always the right strategy. And that over-consumption, selfishness and low moral standards do not make you happy in the end.

The individualization and demoralization of the 1920s is perhaps the very start of the trend in the second part of the 20th century that is still continuing today. This week in Herald Tribune there was a great article by David Brook: "What our words tell us". The Google database that contains 5,2 mln books between 1500 en 2008 gives some interesting insights. Researchers looked at how frequently words were used between 1960 and 2008 and discovered the same two main trends. First, individualism has increased as was shown by the increased use of words and phrases such as personalised, preferences, self, standout, unique, 'I come first' and 'I can do it myself'. On the other side of the coin there was a much lower use of words like community, collective, share, united and common good. The second trend, demoralization is also on the rise, reflected by the decreased use of words like virtue, decency, conscience, honesty, patience, compassion, courage, bravery, faith and wisdom. The word humility was even 52% less used.

Brook himself identifies a third trend, governalization and I think he is right. I am sometimes surprised how often our politicians are in the news and how much importance is attached to what they say and do. Politics and media are more connected than ever before.

The overall story according to Brook is that over the last 50 years society became more individualistic and less morally aware. This led to social breakdowns which government tried to address, sometimes successfully and sometimes impotently. And perhaps the government could be smaller when the social fabric of society was more tightly knit.

For long-term care we also had and still have to cope with these trends, both in the Netherlands and probably also increasingly world wide. People have become more individualistic and rely less on their family and social networks. The government has stepped in with big schemes and now provides or finances much long-term care to people. The government is judged by the people on the ability to deliver and care has become a right rather than a shared responsibility. The public sector and those delivering the care also have to face people that are attaching less value to morals. In less kind words, people who are probably less decent, honest and modest when using care.

In the Netherlands we will attempt to reverse the trends by delivering less public services and by asking people to rely more on their social networks when they get old. I mentioned that in previous blogs. We also try to increase their moral standards, among others by asking them to report on inefficiencies in the care system (last week an internet based reporting point was opened). Not so much much by focusing on dishonest behaviour, but rather by together addressing inefficiencies in the care sector. However, much is of course related to 'careless' acts.

And what can we learn from the movie? Well, Gatsby did not get his love again. He was killed by the guy whose wife he killed by reckless driving with his sports car after a binge in New York. At the end Nick tells him that 'You can’t repeat the past, old sport'. We will see whether in Holland we can at least change the past, when it comes to long-term care.

Stephen Hawking, not really at the World Health Assembly

This week the Sixty-sixth World Health Assembly is taking place from 20 to 28 May. Officials from 194 Member States have begun their annual review of the activities of the World Health Organisation and will set new priorities. Many NGOs and industry representatives are present attempting to influence them and around 3000 people try to find their way in the vast premises of the Palais des Nations in Geneva. I used to be there as member of the Dutch delegation, busy to keep high civil servants and sometimes even the minister happy with their programmes, meanwhile trying to follow all agenda topics and meeting friends from the global health community. But this year I was more relaxed and could look from the other perspective as staff member of the World Health Organisation

The Health Assembly discusses many health topics like specific diseases, health coverage, women and children’s health, as well as the budget and management matters of WHO. The official opening of the assembly is bombastic, in a huge plenary hall and with much formal ceremony. After that the delegates split in two still very big rooms to discuss proposed resolutions. There are also many side events during breakfast, lunch and late afternoon sessions. I did organise one myself on Wednesday evening about the outcomes of the long-term care meeting in The Hague. With so many people around it is possible to compose great panels and we had a well visited session with among others high level representatives from the USA (assistant secretary), Brazil (vice minister) and Japan. Even better, they had good stories.

There are always impressive moments during the Assembly. Negotiations on important topics can be tough and can last till deep in the night. I still remember 2008 when I was once from 8 in the morning till 4 in the night at the palais. A small drafting group was composed when the big group with all countries could not find a compromise and had to go on with the other items on the agenda. The drafting group was working the whole week to find an acceptable text for everybody and I had to be there on the last difficult evening before closure of the assembly. The topic concerned was very political: how to make medicines affordable to everybody but also ensure that pharmaceutical companies have enough incentives to innovate (and to make profits).

Also interesting are the guest speakers on Tuesday. In previous years I have listened to Desmond Tutu, Bill Gates and Queen Noor, to name a few. This year they invited the president of the World Bank Jim Yong Kim. His speech was rather impressive, calling to end poverty by 2030. Bringing effective health services to all people is one essential element to achieve that. He concluded by saying that we face a moment of decision and that the question is not whether the coming decades will bring sweeping change in global health, development and the fundamental conditions of our life on this planet, but that the only question is what direction that change will take: Toward climate disaster or environmental sanity; toward economic polarization or shared prosperity; and toward fatal exclusion or health equity.

The point of health equity (no big differences in health due to your income or social status) is not just something for poor countries. Remarkably, it was the United States in the session on universal coverage that stated that health care is a right and fundamental in the next development agenda (now being prepared for the period after 2015). They also admitted that they have much to learn from the successes of other countries and that they are late in the progress. Despite of Obamacare many Americans do not have health insurance and can be ruined by catastrophic health expenditures when they fall ill.

Another touching moment was the session on disability. There are 1 billion people in the world with some form of disability and almost everybody will experience some form of impairment during their lives. People with disabilities have the same health care needs as others, but are 4 times more likely to be treated badly and 3 times more likely to be denied health care. Half of them cannot even afford health care. Of the 70 million people in the world that need a wheelchair only 10% have access to one. Staggering figures and it is good that there will be a special session during the UN General Assembly on disability on 23 September 2013.

But it became even more staggering when concrete people explained how they dealt with their disability. First Stephen Hawking, the famous physicist, spoke in a video address about his motor neuron disease but how he could still be successful in his work and personal live. But also that he realised that he was very lucky guy !!! as he had access to first class medical care and the resources to have all kinds of support. Many millions of people do not have that and are denied access to health rehabilitation, support, education and employment. They never get the chance to shine.

But shining did the next speaker, Alexandre Jollien, a rather unknown young Swiss philosopher with a disability. He had a moving story about that at home he does not really feel disabled but that as soon as he moves out of the house he is confronted with his disability and everybody considers him a disabled person. He explained, as only French speaking philosophers can do; a disabled person is not a disabled person and that is why we call him disabled. But we change from day to day and that is also the case for the disabled. He concluded by thanking The Director General sitting next to him, Margareth Chan, who is not Margareth Chan and that is why we call her Margareth Chan for the chance of speaking here and by saying that having a disability is nothing to be ashamed of.

The World Health Assembly can be crippling as well for its participants. Long days of sitting together with many people in a cramped room, sleeping in dusty hotel rooms, rich diners but also long intervals without any food & drinks. This year was a of course a bit better for me although flying home now I do not completely feel like Fred Lafeber anymore, who is not Fred Lafeber anyhow.