|DR. J. K. SEHGAL MEMORIAL ORATION
|Year : 2012 | Volume
| Issue : 3 | Page : 189-195
Aging: The triumph of humanity-are we prepared to face the challenge?
Professor & Head, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Pondicherry, India
|Date of Web Publication||3-Dec-2012|
Professor & Head, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Pondicherry - 605 014
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Advances in medicine have increased the life expectancy resulting in an increase in the geriatric population all over the world, and their proportion will only continue to rise in the coming years. It is known that the elderly bear a significant burden of morbidity, which is why health systems globally spearheaded by the WHO are waking up to the need for better geriatric health services. This includes India, whose health system continues to grapple with the health challenges of communicable and noncommunicable diseases. This article enumerates the various government policies and programs, constitutional and legal provisions available for the care of the elderly, and concludes that they are grossly inadequate to deal with the various physical, psychological, and emotional needs of the aging population. Mainstreaming of geriatric health to address the health needs of the elderly at all levels of health care, both in the public and the private sectors, giving due importance to multidimensional rehabilitative services and terminal care, involving NGOs and voluntary organizations, and stepping up social security in old age are the recommended measures for improving geriatric health in India.
Keywords: Ageing, Geriatrics, Social security, Health
|How to cite this article:|
Singh Z. Aging: The triumph of humanity-are we prepared to face the challenge?. Indian J Public Health 2012;56:189-95
| Introduction|| |
It is an honor and a privilege to deliver an oration in the memory of my illustrious teacher, Dr. [Air Vice Marshal (AVM)], J. K. Sehgal. I express my thanks to Indian public health association (IPHA) head quarter for awarding and IPHA (Delhi branch) for sponsoring this oration.
Dr. (AVM) Jai Krishan Sehgal was born in Multan on 26 th August 1921 and obtained his M.B.B.S. degree from King Edward Medical College, Lahore, in 1944 and joined the Royal Air Force as a commissioned officer in the same year. In 1956, he proceeded to U.K. to study and obtained Diploma in Public Health (D.P.H) and Diploma in Industrial Health (D.I.H) from the London School of Public Health and Diploma in Tropical Medicine and Hygiene (DTM and H) from the School of Tropical Medicine and Hygiene in Liverpool with distinction. For his excellent performance, he was awarded the Warrington Yorke medal.
In the Indian Air Force, Dr. Sehgal served as a consultant in Social and Preventive Medicine, and later as Professor and Head of Social and Preventive Medicine and Dean of the Armed Forces Medical College in Pune. He was a fellow of the Academy of Medical Science, India, and IPHA and various other professional organizations, and a member of the expert group of Indian Council of Medical Research (ICMR). At the time of his retirement from the Air Force in 1980, he was Director for Medical Research for the Armed Forces.
During his career in the Air Force, Dr. Sehgal was deputed to take an active role in the Malaria Eradication Programme and Smallpox Eradication Programme launched by the Government of India in association with the WHO. After his retirement from the Air Force, he was actively involved with Voluntary Health Association of India (VHAI), Delhi branch, and with the Air Force Associations where he helped plan a veterans hospital and old age home for Air Force personnel. He was a teacher par excellence and an able administrator.
Dr. Sehgal died on 8 June 2001 after a brief illness. He is survived by his wife Dr. Hema Sehgal (Pediatrician), two daughters, a son, two sons-in-law, a daughter-in-law, and five grandchildren, all of whom miss him dearly. On behalf of the IPHA family, I pay homage to an excellent human being, outstanding academician, and reputed public health specialist.
| Aging: A Triumph of Humanity|| |
The biggest achievement of the last century was greater longevity that has resulted in an increasing geriatric population worldwide. The incredible increase in life expectancy may be termed one of the greatest triumphs of human civilization. However, it has also posed one of the toughest challenges to be met by modern society. The social, economic, political, epidemiological, and other developments that have underpinned the sustained mortality improvement of recent decades are many and complex. However, the increased control of many infectious and parasitic diseases (e.g., smallpox, guinea worm, malaria, cholera, poliomyelitis, leprosy), the spread of immunization coverage, general progress in improving nutrition, sanitation and water supplies, increased level of education, and considerable expansion of health facilities have all been significant parts of the reduction in mortality and improvement of longevity.
| WHO and Geriatric Health|| |
World health organization has highlighted the issue of geriatric health over the years, with World health day themes such as "Add life to years (1982)" and "Healthy living: Everyone a winner (1986)". The theme "Active ageing-makes the difference (1999)" not only served a wake-up call to the nations of the world to the reality of our increasing elders, but also went on to bust myths about aging: myths that elders are a burden on resources and that they cannot be productive citizens any more, etc. 
| Demographic Transition|| |
The demographic transition in India is predicted to transform the current population "Pyramid" into a "Pillar" by the year 2050. The narrow apex of pyramid constituting older years is expected to widen out almost to the dimensions of the broad base, which is constituted by younger age groups.  The health system has to prepare to face the demands that the "geriatric boom" is going to imply; indeed, geriatric health issues are identified as one of the top five challenges that primary health care will face in the coming years. 
The Growing Geriatric Population
By 2025, globally the geriatric population is expected to rise more than 1.2 billion with about 840 million of these in developing countries.  According to projections by the UN Population Division, there will be two elderly persons for every child in the world by 2050. In India, the Sample Registration System (SRS) (2003) estimated the population of persons above 60 year to be 7.2% of the total population.  The projected geriatric population in the year 2030 will be 195 million which is estimated to rise to 308 million by 2050 constituting about 20% of the total population as shown in [Table 1]. 
The demographic profile depicts that in the years 2000-2050, the overall population in India will grow by 55%, whereas population of people in their 60 years and above will increase by 326% and those in the age group of 80+ by 700%,- the fastest growing group. 
From the above projections, we observe that during the next four decades, the size of the population will grow by about 50%, but the number of older people will increase fourfold. Similarly, the old-age dependence ratio will go up from 15.2% in 2015 to 32.8% in 2050. Consequently, the index of aging (aged-child ratio) will increase from 34.5% to 108.1% during the same period. Therefore, every three working Indians may have to take care of the elderly person by 2050 as compared with about eight working Indians at present. It has been estimated that an Indian 60 years of age today is expected to survive another 15 years. Hence, adequate savings are required to sustain an individual for a longer postretirement period to have a decent lifestyle.
| Health Profile of the Elderly|| |
Declining health status is a major symptom of an individual's aging process. Such deterioration broadly depends on heredity, nature of lifestyle, and the nutritional quality of food consumed. A gradually weaker physical capacity and psychological strength are observed during this time of life. The gamut of health problems that the elderly face is immense. While it is imperative to acknowledge the gravity of each of these problems, today there is an urgent need to prioritize so that resources may be directed cost effectively.
The health problems of the elderly could be broadly grouped as those due to aging process, problems associated with long-term illness, and psychological problems.
Problems due to the aging process
Osteoporosis, senile cataract, glaucoma, nerve deafness, failure of special senses, changes in mental outlook, etc.
Problems associated with long-term illness
- Degenerative diseases of heart and blood vessels
- Cancer, e.g., cancer prostate, cervical cancer
- Accidents, e.g., fracture neck of femur
- Diabetes mellitus
- Diseases of locomotor system, such as spondylitis and arthritis
- Respiratory illness, asthma, chronic bronchitis, emphysema
- Genitourinary problems, enlargement of prostrate, urinary incontinence.
Impaired memory, depression, social maladjustment, suicidal tendencies.
The death rate among the elderly rises steeply with advancing age. The mortality in old age is higher among rural as compared with urban population [Table 2].
Hence, there is a need to address the burning issues of geriatric health to reduce mortality among the geriatric population.
| Are we Prepared to Face the Challenge?|| |
Although there are a number of government policies and programs, constitutional and legal provisions available for the care of the elderly, they are grossly inadequate to deal with the various physical, psychological, and emotional needs of the aging population. The existing provisions are as follows.
1. Pension schemes; Central Government and State Governments' Old Age Pension Schemes benefitting more than four million destitute elderly all over the country
- Nationalized banks pension schemes for its employees.
- Employees pension scheme 1995.
- Indira Gandhi old age pension scheme.
2. Legislation and government agencies: It is important to know about the privileges and benefits available to the elderly through legislation and government agencies so that this information can be disseminated to the elderly as to where they can look for support. The various provisions are as follows. 
a. Constitutional provisions
b. Ministry of social justice and empowerment Various schemes and agencies for welfare of the elderly are as follows:
- In constitution of India, serial 24 in list III of schedule VII deals with the "Welfare of Labor," including conditions of work, provident funds, liability for Workmen's compensation, invalidity and old-age pension, and maternity benefits.
- Article 41 of directive principles of state policy has particular relevance to old-age social security
- Item No. 9 of the state list and items 20, 23, and 24 of concurrent list relate to old-age pension, social security and social insurance, and economic and social planning.
- The right of parents without any means to be supported by their children having sufficient means has been recognized by section (1) (d) of Criminal Procedure Code (CPC) 1973, and section 20 (3) of Hindu adoption and maintenance act 1956.
- Maintenance and Welfare of Parents and Senior Citizens Act 2007.
- National Policy on Older Persons, 1999
- National Council for Senior Citizens, 2011
- Old age and Income Security
- National Institute of Social Defense (NISD)
- Privileges and Benefits
(i) National Policy for Older Persons (1999):
- The Policy is formulated with the objectives: 
- To provide preventive, promotive, curative, and emergency health care to the elderly.
- To train health professionals in geriatrics.
- To develop research related to geriatrics and gerontology.
This policy is to be implemented through home-based health service, community-based health centers, and improved hospital-based support services. The following programs are being provided assistance under this policy.
- Maintenance of old-age homes to provide food, care, and shelter.
- Maintenance of respite care homes and continuous care homes for seriously ill elderly persons who need continuous nursing care.
- Multiservice centers for older persons to provide day care, educational, entertainment, and health care.
- Maintenance of mobile medical care units to provide health care to elderly in rural, isolated, and backward areas.
- Hearing aids.
- Running of day care centers for Alzheimer's disease/Dementia patients.
- Physiotherapy and disability clinics.
- Helpline and counseling centers.
- Regional resource and training centers of caregivers.
- Sensitizing programs for school and college children to take care of elderly.
- Awareness programs for elderly such as self-care.
- Formation of senior citizens associations.
(ii) National Policy for Senior Citizens, 2011
The prime minister has approved the constitution of national council for senior citizens as envisaged in the national policy. The council will advise the central and state governments on the policies, programs, legislative measures, promotion of physical and financial security, health, independent and productive living, awareness generation, and community mobilization for welfare of senior citizens.  The policy on senior citizens lays special emphasis on rural poor, women, and disadvantaged seniors, employment in income-generating activities after superannuation, support and assist organizations that provide counseling, career guidance, and training services. Health-care issues, safety and security, and housing needs of senior citizens will be accorded priority by central and all state governments.
(iii) Old Age and Income Security
The ministry has launched a project called old-age social and income security (OASIS). The project is based on the premise that every young worker can build up enough savings during his or her working life through public provident fund, employees provident fund, and LIC, UTI, etc., which would serve as shield against poverty in old age and reduce the burden of the state.
(iv) National Institute of Social Defense (NISD)
NISD has initiated several training programs for the care of older people.
(v) Privileges and Benefits
- Annapurna scheme
- Under this scheme, free food grains up to 20 kg per month are provided to destitute older persons who are not receiving any pension.
- Income Tax rebate of ` 10,000/- for those who are above 65 years of age under section 88B of finance act, 1992, deduction in respect of medical insurance premium up to ` 20,000/- (sec 80 DDB). Senior citizens do not have to pay tax on income up to 2.4 lakh per annum. There are special counters for senior citizens for filing IT returns.
- Insurance Schemes
- LIC Jeevan Dhara, Jeevan Akshay, Jeevan Suraksha, Bima Nivesh senior citizens unit plan (SCUP), medical insurance scheme, group medical insurance scheme, Jan Arogya Yojana (1996), Varishta Pension Bima Yojana for 55 years and above provide insurance benefits to the elderly.
- Travel concessions
- Indian railways provide 30% concession in all classes and trains, priority for lower birth, separate reservation counters for citizens above 60 years.
- 50% discount on the basic fare for travel in economy class by Air India, Air Sahara, and Jet Airways for senior citizens of above 60 years.
- In Punjab, women above 60 years can travel free in buses.
c. Legal provisions
- Maintenance and welfare of parents and senior citizens act 2007  . Children must provide monthly allowance to parents for food, clothing, shelter, and treatment. The monthly allowance may not be more than ` 10,000/-. State governments are required to open old-age homes. State must ensure in all government funded or aided hospitals to provide special services for senior citizens such as separate lines, special priority for beds for admission, more research work on diseases of older persons.
- Chief justices of all high courts have been advised by Hon'ble chief justice of India to accord priority to cases involving older persons and ensure their expeditious disposal.
d. Health infrastructure: Current scenario
Health infrastructure is an important indicator to understand the health-care delivery provisions in a country. It also signifies the investments and priority accorded to creating the infrastructure in public and private sectors. There are approximately 2000 health institutions across the country for which database is available.  Health infrastructure indicators comprise of two categories, namely educational infrastructure and service infrastructure. Although there has been rapid growth in medical education infrastructure during the last 20 years, the service infrastructure has not expanded correspondingly specially for geriatric population during the corresponding period.
The country has 314 medical colleges, 289 dental colleges during 2010-2011, and 2028 Institutions for Nurse Midwives as on 31 March 2010. The availability of service infrastructure includes 12,760 hospitals having 576,793 beds in the country. 6795 hospitals are in rural area with 149,690 beds and 3748 hospitals are in urban area with 399,195 beds. Dispensaries and hospitals to provide medical care facilities under AYUSH care 24,465 and 3408, respectively, as on 1 April 2010. There are 23,391 primary health centers and 4510 community health centers in India as on March 2009.
Although the averages are satisfactory on a national basis, they vary widely within the country. There is also mal-distribution of health manpower between rural and urban areas. There is concentration of 73.6% doctors in urban areas where only 26.4% of population live.  There are 11 qualified physicians per 10,000 population in urban areas as compared with only 2 per 10,000 in rural areas; 60% of hospitals, 75% of dispensaries, and 80% of doctors are located in urban areas. The health manpower and bed mal-distribution adversely affect the availability of essential medical services for the elderly in rural areas as there is preponderance of elderly population in those areas.
3. NGO'S and geriatric care
The voluntary sector was the first to respond to the problems of the elderly in India. Their intervention has brought to public notice the different kinds of hardship faced by the elderly. Ministry of social welfare provides financial assistance to the voluntary organizations for running old-age homes, day care centers, mobile Medicare, units, setting up multiservice centers, and disseminating knowledge and information in the field of the care of the old; some of the NGOs active in this field are HelpAge India, Geriatric Society of India, Centre for the Welfare of the aged, etc. Seven hundred twenty-eight old-age homes, 398 day care centers, and 40 mobile medical units are functioning across the country for the welfare of the senior citizens. Six million old people benefitted through 3084 projects of HelpAge India.
4. Role of family
The family network, since it is closest to the elderly patient, is important in helping them to remain both active and independent. Families can help assess if there is a problem by observing warning signs such as falls, short-term memory problems, weight loss, periods of disorientation, and difficulties in performing normal daily activities. The family is also the main source of emotional strength and companionship.
| What Needs to be Done?|| |
- We have to "mainstream" aging and not keep it a "segregated" issue.
- Health-care systems will need to shift their emphasis away from acute care to managing chronic diseases and to disease prevention such as falls. If the chronic diseases are properly managed, aging populations do not need to look forward with dread to years of suffering.
- Ensure adequate numbers of competent health-care providers at different levels, giving primacy to districts with poor health-care outcomes through timely and transparent Human Resources for Health (HRH) policies.
- Geriatric health problems must be addressed at all three levels of prevention. This includes health promotion measures (such as avoidance of alcohol and smoking, physical activity, immunization for influenza, tetanus, and injury prevention); screening for noncommunicable diseases, such as diabetes, hypertensions, cancers, psychiatric disorders, nutritional anemia, and tuberculosis; and rehabilitation and caretaker support.
- For chronic diseases and conditions such as Alzheimer's disease, arthritis, depression, Parkinson's disease, much remains to be learnt about their distribution in the population, associated risk factors, and effective measures to prevent or delay their onset.
- Not enough is being done in scientific and medical research in aging. There is ample scope of research into preventive geriatrics, epidemiology, and treatment of degenerative and other diseases of old age. There should be some mechanism to ensure cooperation between research and implementation.
- There is gross lack of expertise such as geriatricians, other doctors, and trained community health workers, which leads to many errors with far-reaching costs for individuals and society. here is lack of financial support for geriatric training and resources.
- Joint approaches and strategies are required to design and build a robust old-age income security system.
- More efforts are needed to extend the services to rural areas. There should be an integrated approach to the formulation and development of projects, for example, an old-age home can have an orphanage attached to it. These two segments can play complementary and supplementary roles.
- There should be more community participation in the programs of the elderly.
- Greater and more specific encouragement needs to be given to voluntary organizations working for the care of the aged. They should be involved in social sector planning and legislation process from the beginning.
- Media should play a positive role for highlighting the problems of the aged, availability of various government schemes for the older population, contribution of NGOs, and creation of positive perception of the senior citizens in the society.
| Conclusion|| |
The steady increase in life expectancy being witnessed around the globe is not a catastrophe, but rather a laudable success and triumph of humanity brought about by advances across the entire front of medical knowledge and practice.
Societies will need to consider how older citizens can obtain long-term care that provides the requisite medical attention, while also keeping costs under control. Health-care systems also need to address ageism. Politicians and health systems, however, may face the heat from the elderly population for change of health policies and programs in their favor sooner rather than later. Instead of being grateful for what crumbs are thrown to them, the next generation of older people will be much more articulate and demanding. They will know their rights and will be much more active consumers than older people have traditionally been. People will not stand age discrimination. Our policy makers and health planners must be prepared to meet this challenge.
| Acknowledgement|| |
I am thankful to Dr. Nateshan Bhumika, Assistant Professor, Community Medicine, Pondicherry Institute of Medical Sciences for assisting me in the literature review and preparing this oration.
| References|| |
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[Table 1], [Table 2]
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