By 2050, nearly 150 million people are expected to be living with dementia. At present 58% of people with dementia live in low and middle-income countries (LMICs), but by 2050 this will rise to 68% (ADI). Improved access to basic healthcare, decreasing fertility rates, and increasing life expectancy are some of the factors which are contributing to an ageing population in countries that have had youthful populations, for most of their history. While ageing does not cause dementia, it remains the biggest risk factor.
For High-income (HI) countries such as Sweden, Australia, and Japan ageing population is not a new phenomenon. These countries have had the chance to build comprehensive care programs through years of skill and knowledge development. While funding in research remains a challenge to be addressed, governments in these nations can channel resources into ensuring that people living with dementia can access high-quality care. Well-developed care programs also take the wellbeing of the caregiver into account.
The case is not the same for LMICs. In lower-income countries like Zambia, dementia is largely a taboo and the social structures to support a person affected by dementia are underdeveloped. In middle-income countries like India, the World Health Organization finds that nearly 65% of healthcare expenditures are out of pocket due to a lack of welfare provisions from the state. Arguably, this is not the case for all countries within this category. For example, Indonesia is one of the 27 WHO Member States which has adopted a national plan to address the economic and societal challenges of dementia. However, in general, the lack of good dementia care is largely prevalent in LMICs.
How can governments prepare to ensure that citizens can age well and continue to live an active and healthy life after a diagnosis?
To find an answer, SCI spoke with Dr Alexandre Kalache, a medical epidemiologist specializing in the study of ageing. A former director of the World Health Organization, he is currently the President of the International Longevity Centre-Brazil and co-President of the Global Alliance of International Longevity Centres. Dr Kalache has worked extensively in the field of ageing and related issues from both an academic and policy perspective. Together with Dr Louise Plouffe, Dr Kalache developed the WHO Global Age-Friendly Cities project and subsequently the Global Age-Friendly Cities Guide in collaboration with other partners. The research protocol was implemented in 33 cities around the globe (WHO).
Dr Alexandre Kalache (Source: ILC Brazil)
For Dr Kalache, the first step is to understand the unprecedented rate at which the demographics are changing. When we talk about statistics, it is difficult to comprehend the real impact on the ground. Using the example of Brazil he says, “Life expectancy after WWII was just 43 years. Today it is 77. That is extremely fast growth achieved in just 74 years. It took France 145 years to see the same kind of doubling between 1845 and 1990. The problem is that countries like France first achieved economic prosperity and then became ‘old’. Countries like Brazil are seeing the opposite, where the population is ageing before the economy has matured. This results in the government being unable to channel resources into welfare as the primary concerns are always related to the economically-active part of the population.”
He continues, “In Brazil, specifically, we don’t have a plan for dementia. Even privately-owned care providers are scarce. Today, 1.2 million people in Brazil are living with dementia. By 2050 it will be 6 million.”
But even if the wellness of older people is a genuine concern in LMICs, the fact remains that there aren’t enough resources that governments can dedicate to improving care. How, then, can they ensure active and healthy-ageing?
“Regardless of whether the country is lower or high-income, when it comes to diseases, prevention is always better, and more cost-efficient than cure. In the case of dementia, simple risk reduction measures have been shown to cut down the risk of cognitive decline. The words ‘dementia’ and ‘Alzheimer’s ‘ carry a lot of weight. Without proper education, people may not understand the full impact or challenges of the disease. Consequently, talking about risk-reduction measures would be futile if large parts of the population don’t see the importance of it. However, we can always think of a way to strategize the implementation of any policy. If we take the example of smoking, most people today understand its negative impact on heart-health. We also know that smoking is a risk factor for dementia. Thus instead of telling people that smoking may contribute to cognitive decline, it can be simplified as ‘what is good for your heart is good for your brain’. Since cardiovascular health receives much more attention in the media and education, people are more likely to be aware of it and take steps to ensure better heart health which would contribute to better brain health.”
Speaking about the effectiveness of implementing new policies, Dr Kalache says, “Change may be slow but it is not impossible. The key is to raise awareness, to make people realize that what doesn’t affect them today, may affect them in the future. Thirty years ago, over 45% of adult men in Brazil were smokers. Thanks to education, extensive campaigning, and control measures such as where one can smoke, today less than 10% of people smoke. What has been especially effective is using children as agents of change. Children are more receptive to new ideas and more likely to participate as changemakers without even knowing. When you teach small children about the harmful effects of smoking, they don’t fear to shout words such as “poison” when they see someone smoking. With determination, drive, and intervention, we can create the same level of awareness about brain health. Of course, in this case, it would be to end the stigma and create a dialogue around it.
If we look at the status of dementia-care, we understand the gaps in skill and competency development between and within societies. How can we close this gap?
“One word that goes well with longevity is solidarity. We share the same world and have the same goals. If we don’t collaborate, forge alliances for the better and think about the future together, then we are going to pay a huge price.
The first kind of collaboration we need is intergenerational. I am privileged to have had all the opportunities to age well. I now have to put in all I can so this generation can age well too. We need to inspire, guide, and be mentors. We need to involve the youth in this discussion instead of alienating them as we have traditionally been doing when we talk about ageing. Older people need to share their knowledge and support younger people who can share their skills and talents. Everybody needs to participate in the conversation and feel like they have a voice; that they can make a difference.
The second kind of collaboration we need is academic. The world is developing fast and we are not investing in people, we are leaving them behind. Good knowledge needs to be accessible no matter where you come from. If people aren’t educated, they are not going to benefit from new technologies that are changing the way we work. For example, if lower-income individuals don’t know of sustainable technologies and how they can benefit from it, they will continue to use conventional means of income largely dependent on deforestation and unsustainable fishing. The same applies to cognitive decline and brain health. Individuals need to be empowered with the knowledge to make better decisions.
The third and final kind of collaboration we need is between the public and the private, local and global. Currently, the only group of people that do not have a convention is older people. Women, children, refugees, all have conventions. We need a convention for the rights of older people because they have set frameworks that call for the dedication of resources for their development, a restructuring of rules and regulations and greater support to ensure their dignity and wellbeing. Many LMICs advocate for the establishment of such a convention, however, HI countries are the ones that vote against it. The reasons for this are two-fold: one, developed countries already have established structures to ensure adequate care for the elderly. They don’t ‘feel the need’ to invest in further resources. Two, a convention would also urge these countries to channel resources in the development of elderly care in LMICs which may not be their priority. However, without support from groups in a position of privilege, it won’t be possible for resource-poor countries to participate in achieving this shared goal to improve the lives of the people on whose backs our countries were built on.”
SCI understands the value of collaboration and aims to bring together experts from the sectors of finance, society, care, research, and business and discuss and forge partnerships to address the challenges the dementia diseases pose to society at Dementia Forum X. Dr Kalache was a participant at this year’s Dementia Forum X. We thank him for his valuable insights and work in improving the state of elderly and dementia care globally.