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.

Do we spend too much on old people?

Japan is the worlds oldest country (apart from Vatican city). Or rather I must say the worlds most rapidly ageing country. Combine low fertility and the highest life expectancy in the world and you have a challenge. In 1965 there were still 9 working people for every 65+ person, in 2050 there will be just 1. That is expensive. The total costs for long-term care in 2012 are 89 billion dollar, a staggering amount for a country with 127 million inhabitants. No wonder Japan has experienced economic stagnation for over 20 years now.

But how about my own country, The Netherlands, just like Japan a country with a separate system for long-term care? We spend in 2013 27 billion euro on long-term care (AWBZ) for just less than 17 million inhabitants. Add a significant part of another 5 billion euro for social support (WMO) that will also partially go to the elderly. 89 billion euro equals 69 billion euro or almost 600 euro per inhabitant in Japan. 30 billion euro is almost 1800 euro per person in the Netherlands. In other words, the Netherlands spends about 3 times more on long term care than the old lady of Asia.

So we spend a lot for our older population and I did not even include the generous pensions. But is it possible to spend too much on health or long term care for old people? After all, both in Japan and the Netherlands, the post war generation efforts were key to the economic miracle. They should be entitled to all support we can possibly give them!

The answer to the first question I think is yes. It is possible to spend too much on older citizens for two reasons. It can be bad for the economy and it is not always good for the individual senior.

Have a look at the graph below that illustrates this argument.

The x-axis shows social spending (includes health care costs and expenditures for older people). The first (red) y-axis shows wealth (measured by any form of income) and the second (blue) y axis shows well-being (measured in terms of health plus other non monetary factors).

The red line shows that wealth (income) first goes up rapidly when social spending increases. Investing in health means that people can remain productive, family members donot have to care for very frail and disabled older relatives, can go to their work and in this way contribute to the welfare of the country. At a certain moment the increase in welfare goes down and turns into a decrease. The fiscal burden of more social expenditures means that the country has to raise more taxes, companies will become uncompetitive and people have to spend their money on social premiums and on cares rather than cars.

The blue line shows that a similar thing happens for well-being. At first more expenditures will help your health and well-being improve, and you will not live in misery during the last days of your life when you really need care. That is good for well-being. However, there is a point where too much care becomes a burden. The adverse effects of too many medicines, unnecessary surgery at the end of life, and too much care when you could still be active will lower your well-being.

The last point of too much care and activity may need some explanation. This week I read an interesting article in the Herald Tribune. There is hard evidence that when parents pay too much for the education of their children (and are too involved in their choices), the study results go down compared to the group where students pay (partially) themselves. That makes sense. There is a real financial incentive to study harder when it is your own money. To some extent the same is true for older people. Too much pampering will take away initiative and will ultimately lower their well-being. Participation can be an important element of happiness.

Back to the graph. Countries can be at different levels of social spending, implying different recommendations for policy. Country A and its older people can still gain by increasing social spending. It is good for the economy and good for people. Country B is in a position where the contribution to economic wealth turns negative, but where more social spending stills leads to higher well-being of citizens. Country C finds itself in a situation where more spending is bad for both economy and people's well-being. Notice that country B has the same wealth and well-being with a lower level of social spending as compared to country C.

Of course, this graph is difficult to make in practice and of course my use of the terms well-being, wealth, health, income is not very accurate. Still, I think it illustrates that it is possible to spend too much on health care and on older people.

And Japan? Actually it also claims to be the oldest country. Already in 660 BC Emperor Jimmu was supposed to found Japan, although it was only in the 8^th century that culture and Buddhism spread to other islands. The year 660 BC is a little uncertain as it was probably chosen to correspond to a large cosmopolitan cyclus in Chinese era. To reach the date of 660 BC, Jimmu and other emperors following him got reigns of 60 to 100 years long. And that does not correspond very well to the average life expectancy of 30 years that was so common before 1800.

Ageing musicians

Dustin Hoffman is 75 years old. The famous actor (Rain Man, Kramer vs Kramer) recently directed his first movie "Quartet". I saw it this week in Geneva. This great film is about a home for retired musicians where a new resident arrives. Reggie, Wilfred and Cecily get a special shock when the new arrival turns out to be their former singing partner, Jean. Her subsequent career as a star soloist, and the ego that accompanied it, split up their quartet and ended her marriage to Reggie. The movie is then mainly about whether the famous four will be able to patch up their differences in time for Beecham House's gala concert. And whether the former star is able to cope with her functional decline, not being able to perform on the same very high level (high standard and high notes). Can she be convinced to start singing again?

Apart from being a must see movie, there are also two lessons from this film for ageing policies.

The first lesson is that it is good to create environments where old people can prosper and use their talents. The home for retired musicians is a great example. There are many activities organised that appeal to them, like dancing classes and music rehearses. But they are also still productive and active. A great scene is where Reggie gives a lecture to young students who come to the home every so often. He compares the opera to present day rap and a young rapper answers by rapping about the opera. Both rap and opera is about the expression of intense emotion through song. And of course there is the gala where they are all performing, raising funds for the financing of Beecham House.

The home is located in the English countryside and has all kinds of adjustments to make life easier for the old artists. That is is of course a good thing. But creating age friendly environments should not be restricted to old peoples homes. On the website agefriendlyworld.org there are many examples of how to make the whole world a better place for older fellow citizens. Examples are reserving hours at swimming pools, extending walk signal times at pedestrian crossings and making sure that people know each other. In the WHO global network - also on this website - a growing number of cities and communities worldwide are striving to better meet the needs of their older residents.

In fact I find the term age friendly a bit degrading and implying that the rest of us must adjust to older people. Some things get worse when you age (biking in the mountains is a good example as I noticed on Thursday), but some things may also get better, like wine. Wisdom, patience, less ego and openness to other people to name just a few things. Age friendly is also about using the special gifts and skills of older people.

The second lesson for policy is about convincing old people. However wise and patient, they can also be very obstinate and conservative like everyone else. It is never too late to stop unhealthy life styles (although this is a bit ridiculed in the film when two 80+ are caught on smoking and reprimanded by the main nurse. Another old guy replies, how much longer will they live, a week?). And convincing them to become more active also requires an active attitude of people. In the film the three musicians try to convince Jean that she should take part in the show. Inviting her for a nice diner does not help, but telling her that her former competitor would then get the final act is the trigger that does the job. 
 

There is an increasing interest in using principles from behavioral economics and psychology to persuade people to change their health-related behaviors, lifestyles, and habits. The popular word is “nudging”. How to nudge people toward particular decisions or behaviors related to health or health care? We live in a world that’s fueled by immediate gratification with little regard for future consequences. Many people are short-sighted: why forgo the instant ecstasy of that second or third serving of chocolate cake when the rewards of restraint are so distant? Simply telling people that certain lifestyle choices have a negative or positive effect on the quality or longevity of their life simply falls on deaf ears. It is better to try influencing decisions in a subtle and indirect manner. The picture below is a funny example of nudging. I am sure it is possible to find many examples of nudging that can - for example - make older people more active.

And finally, although the film wants us to believe that musical skills decline with age, there is in fact ample evidence that you can perform on a high level till a very high age. Just look at the Rolling Stones. Yes, Keith Richard has arthritis. Fortunately, there’s no evidence that playing any instrument wears joints out quickly. Musicians get arthritis, just like the rest of us. He may be comforted by the adage that says that life is short but art is long.

The ultimate age

How old can we eventually get? What is the real maximum age limit? What do we need to do to reach that age? To answer these questions (yes, I am ambitious this week) we first need to dive into some fundamental science.

This week I visited with my family the European Organisation for Nuclear Research, better known as CERN, in Geneva. CERN is home to the world’s biggest and most powerful particle accelerator, the 27km Large Hadron Collider (LHC). This is a machine to accelerate two beams of particles in opposite directions. When particles collide, the energy released produces many new particles, as energy turns into matter in accordance with the equation by Einstein E=MC² .

The interesting thing is that many of these new particles age extremely fast. They were there during the very beginning of the universe, but then decayed in a split second and were never seen again. The LHC simulates the conditions directly after the big bang and detects these very old particles before they decay again. What we learn is a deeper understanding of these particles and of the beginning of the universe.

On the other hand, there are particles that are extremely stable. The protons and neutrons that form the core of our atoms decay very slowly, if ever. Protons may have a half-life of 10³⁴ years which is a long, very long time. That means that they have virtually disappeared after about 1000 half lives when the universe is 10⁴⁰ years old. The bigger stuff, the different atoms we are made of (and which were mainly created when stars collapsed) will of course also have vanished by then.

So the simple answer to the question how old we can get is when all protons have disappeared, say after 10⁴⁰ years. Of course we will have to overcome some other obstacles, for example that star formation will cease after 100 trillion years (10¹⁴ ) and that planets will be out of orbit after 10¹⁵ years, but there is enough time to solve that.

Of course it is highly unlikely that we will ever achieve that. There are other physical laws that facilitate our decline. The extremely weak force of gravity (compared to other fundamental forces) has a significant impact on us, at least on the surface of the planet we are now living on. Sagging breasts, hunchbacks and weaker muscles are all preys of the force of gravity.

We also have to find a solution to the limited replacement of the giant particles in our body that are known as cells. Between 50 and 70 billion cells die every day in the average human being due to apoptosis (programmed cell death in multi cellular organisms, derived from Greek - meaning falling leaves from trees). How often each cell in your body is replaced depends very much on what type of cell it is. Anyhow, the process is vulnerable to ageing and is at present an important determinant of our maximum age.

Whatever the precise maximum age will be that we can eventually achieve, immortality is not something to aim for. In 10¹⁰⁰ years from now, the universe will be a very cold, empty and dark place. Even black holes will have evaporated by then. But maybe even this can be seen as a challenge.

As is written on the Lutheran church in Geneva: “To venture the unlimited you have to leave behind your limits”.