The effect of the financial conditions on the the health

There remains a great deal of diversity in health conditions both among and within national populations.
There is nothing inevitable about the mortality transition—in several African countries, the prevalence of
AIDS has been high enough to cause life expectancy to fall below the levels of 1980. Though none has
so far reached a scale to rival the AIDS epidemic, periodic outbreaks of new influenza viruses or

"emerging infectious" agents remind us that infectious diseases could again come to the fore. Progress
against chronic disease is also reversible: In Russia and some other countries that formed part of the
Soviet Union before 1992, life expectancy for men has been declining, now reaching levels below those
of men in South Asia. Much of the gap between Russian and Western European men is explainable by
much greater heart disease and injuries among the former.
DEPENDENCY AND CAREGIVING RATIOS
Ratios of different age groups provide useful though crude indicators of potential demands on
resources and resource availability. One set of ratios, known variously as dependency or support
ratios, compare the age groups who are most likely to be in the labor force with the age groups typically
dependent on the productive capacity of those working—the young and the old, or just the old. A
commonly used ratio is the number of persons aged 15–64 per persons aged 65 and older. Even
though many in some countries do not enter the labor force until significantly older than age 15, retire
before age 65 or work past age 65, the ratios do summarize important facts, especially in countrieswhere financial support for the retired comes partially or mainly from those currently in the labor force
through either a formal pension system or through the family. While many countries, including China
and most African countries do not have formal pension systems except in specialized sectors such as
the government sector, in Europe public pensions are quite generous, and face dramatic changes in
their dependency ratios. Over the next 40 years, Western Europe faces a drop in the ratio from 4 to 2.
In other words, while in crude terms there are today 4 workers supporting the pensions and other costs
of each older person, by 2050 there will only be 2. China faces an even steeper drop from 9 of working
age to only 3, while Japan declines from 3 to just 1. Even in India, projected to become the most
populous country, the decline is quite steep from 13 to 5.
The dramatically declining number of workers per older person (however determined) is at the crux of
the economic challenge of population aging. The extra years of life that can be considered the crowning
achievement in medicine and public health of the last 150 years have to be financed. The economic
model of the life cycle assumes that people are economically productive for a limited number of years
and that the proceeds of their work during those years have to be smoothed over to finance
consumption during less economically productive ages, either within families or by institutions such as
the state in order to provide for the young, the old, and the infirm. There are only so many ways to meet
the challenge of an extended period of dependency, including increasing the productivity of those in the
labor force, saving more, reducing consumption, increasing the number of years worked most
especially by increasing the age of retirement, increasing the voluntary nonmonetary productive
contributions of the retired, and immigration of very large numbers of young workers into the "old"
countries. Pressures to increase retirement ages in industrialized countries and to reduce benefits are
increasing. But no single one of these measures can bear the full load of adaptation to population
aging, since the changes would have to be so severe and disruptive as to be politically impossible.
More likely will be some combination of these measures.
Population health and the ability to function at work and in everyday life interact with these population
ratios in significant ways. The physical and cognitive capacity to continue to work at older ages is
crucial if the age of retirement is raised. Similarly, caregiving often requires significant physical and
emotional stamina. Further, healthier older populations require less caregiving and medical services.
Just two decades ago, the prevalent view of aging was highly pessimistic. Epidemiologists held that
while modern medicine could keep older people alive, nothing much could be done to prevent, delay, or
significantly treat the degenerative chronic diseases of aging. The result would be that more and more
older people with chronic diseases would be kept from dying, with the consequent piling up of the older
people disabled by chronic disease. Surprisingly, between 1984 and about 2000, the prevalence of
disability in the 65+ population in the United States declined by about 25%, suggesting that in this
respect, aging was more plastic than had been previously believed (Fig. 70-4). All the causes of this
significant shift in disability are not yet understood, but rising levels of education, improved treatment of
cardiovascular diseases and cataracts, greater availability of assistive devices, and less physically
demanding occupations have been found to contribute. One calculation showed that if the rate of
improvement could be maintained until 2050, that the numbers of disabled in the older population could
be kept constant despite the aging of the baby boomers and the older population itself growing older.
Unfortunately, concern is increasing that the rapid increase in obesity rates will negate and perhaps
even reverse this most positive trend. Because of the absence of comparable data in other countries, it
is uncertain whether the same improvement in disability rates (or recent deceleration) is occurring
outside of the United States, but a global network of longitudinal studies on aging, health, and
retirement is now providing data to answer the question.