Ageing and the challenge of non-communicable
diseases in low and middle-income countries
a position paper
We are living in the century of global ageing. Global investment in public
health and wellness has resulted in the triumph of longevity, which is a
worldwide phenomenon. By 2030, for the first time in history those over
60 will outnumber those under 15, with the fastest growth in the
developing world.
This triumph for humanity also presents great challenges, among them
the need for urgent action to address the rising burden of noncommunicable diseases (NCDs) for older people worldwide.
“Health is a fundamental human right, indispensable for the exercise of
many other rights, and necessary for living a life in dignity…Nevertheless,
for millions of people around the world, the full enjoyment of the right to
health remains an elusive goal. This is especially true for older persons,
who are particularly vulnerable to infringements of their right to health”1.
Healthy and active ageing requires investment in age-friendly and
affordable health services. This approach will drastically improve the wellbeing of people over 60.
A whole life course approach to NCDs, which is inclusive of all ages,
should be adopted for any recommendations on detection and diagnosis,
and strategies for prevention, management and treatment as well as more
effective care. Just as it is never too early to start prevention and
promotion efforts counteracting NCDs, so it is never too late.
We challenge the use of discriminatory language and concepts relating to
older age in the NCDs debate. The criteria for setting an age-specific point
for ‘prevention of premature death’ should be subject to review.
Office of the United Nations High Commission for Human Rights: Expert consultation on
older persons and the right to health. Background paper. UN, Geneva April 2011
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Demographic transition - the ageing of humanity
During the 21st century the world will make a historic transition. For the
first time in history humanity will no longer be young, as the number of
people over 60 will outnumber those under 15 by 2030. The enormous
gains in health, economic and human development of the past one
hundred years have produced the triumph of ageing in this century.
This triumph is accompanied by many challenges. Population ageing is no
longer the domain only of the “developed” world, but is occurring most
rapidly in low and middle-income countries, where the global pattern of
falling birth rates and rising life expectancy is most rapid. Already the
majority of people over the age of 60 live in developing countries, a
proportion which is projected to rise to over 80% by mid-century.
Population ageing in developing countries is leaving them less time to
adapt to its consequences. The older population is itself ageing, and
again this is happening most quickly in developing countries, where the
size of the over-80 population is growing faster than that of any other
cohort2.
Progress in global health has benefitted older people, many of whom live
longer and healthier lives. However, for older people as for other age
groups, progress in health has been deeply unequal. In developing
countries, health priorities reflect those prioritised by the Millennium
Development Goals, with a focus on communicable diseases, primary
health care for children and mothers and reproductive health. Despite the
demographic and epidemiological transition increasing the greatest burden
of disease on non-communicable conditions more associated with older
age, addressing older people’s health needs have low (or no) priority in
health policies and programme financing.
Epidemiological transition – the rise of NCDs
The global demographic transition has been accompanied by an
epidemiological transition, shifting from the predominance of infectious,
acute diseases to non-communicable or chronic disease. NCDs include a
wide range of chronic conditions, including cancer, diabetes,
cardiovascular disease, hypertension and also Alzheimer’s and other
dementias. While NCDs have been seen as “diseases of affluence” the
evidence is that risks are often greatest in poor and deprived
communities, worsened by exposure to health hazards over the whole lifecourse.
NCDs and older people
Ageing brings an increased risk of developing chronic disease and
disability. Non-communicable diseases (NCDs) are already the single
largest cause of both mortality and morbidity in most developing
UN Department of Economic and Social Affairs: “World Population Ageing 2009”. United
Nations, New York 2010
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countries3. NCDs account for nearly 90% of the disease burden for the
over-60s in low-, middle and high income countries, and people over 60
accounted for 75% of the 35 million deaths from NCDs worldwide in 2004,
with the majority in low and middle-income countries4. This was
recognised in the UN Secretary-General’s note of September 2010
transmitting the World Health Organization’s global status report on NCDs,
which refers to ageing as the first of four drivers of NCD predominance in
developing countries5.
The links between ageing and NCDs are increasingly visible in low- and
middle-income countries. Two-thirds of the 177 million people with type-2
Diabetes are estimated to live in the developing world6, and the greatest
increase in prevalence of Type-2 Diabetes in older people is expected to
occur in Asia and Africa, where most patients will probably be found by
20307. Large numbers of older people suffering from cardio-vascular
disease, stroke and diabetes are living in developing countries.
Hypertension, often undetected, is widespread in older populations of lowand middle-income countries. In countries such as Cuba (73%) urban
China (63%) and urban India (60%) hypertension prevalence rates
approach the levels found in Europe and north America. Half of China’s
older rural population and nearly one-third of older rural dwellers in India
suffer from hypertension8.
Preventable risk factors for NCDs continue into old age. For example, an
average of 66% of older people in seven Latin American cities were found
to be overweight in a 2000 study9. Some non-modifiable risk factors will
also grow exponentially with ageing. By 2050 115 million people
worldwide will have Alzheimer’s disease or other dementias, 71% of whom
will be living in low- and middle-income countries10.
Chronic Disease, ageing and disability
Chronic diseases are thus the main cause not only of death but also of
disability in most developing countries. Disability is strongly associated
with age, especially in poor countries. Poverty and exposure to harsh,
hazardous living conditions over the life course, as well as chronic illness
acquired during the life-course, contribute significantly to disability in old
age.
Sub-Saharan Africa remains the exception, though even here NCDs are accounting for a
rapidly increasing share of mortality and morbidity
4 World Health Organisation: “Raising the priority of non-communicable diseases in
development work at global and national levels”. WHO Presentation 2010
5UN General Assembly sixty-fifth session 13th September 2010: Note by the SecretaryGeneral transmitting the report by the Director-General of the World Health Organization
on the global status of non-communicable diseases, with a particular focus on the
development challenges faced by developing countries
6 World Health Organisation: “Facts related to chronic disease”. www.who.int
7 Wild S, Roglic G, Green A, Sicree R, King H: "Global prevalence of diabetes: estimates for
2000 and projections for 2030". Diabetes Care 27 (5): 1047–53 (May 2004)
8
http://www.alz.co.uk/1066/1066 presentations
9 ECLAC/CELADE: “La situacion de las personas mayores”. Document presented at InterGovernmental Conference on Ageing, Santiago 2003
10 Alzheimer’s Disease International Annual Report 2010 p15
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Disability is predominantly concentrated in older populations. For example
blindness and visual impairment rise exponentially with age. Over 80% of
all people who are visually impaired are aged 50 and older (although they
represent only 19% of the world's population) and again the great
majority (well over 80%) live in the developing world11.
Evidence is also growing of the cost and social implications of the impact
of Alzheimer’s disease and other dementias. In 2010, the global cost of
dementia was an estimated $604 billion or 1% of global GDP. The costs of
informal care are borne especially heavily by poor communities worldwide
and therefore associated with poverty12.
Links between communicable and non-communicable diseases and ageing
also need to be addressed. For example, with increased access to
antiretroviral therapy for HIV, and the growth of new infections amongst
older people, an “ageing” of the epidemic is now occurring. It is estimated
that 14.3% of people living with HIV in sub-Saharan Africa are 50 and
over13 and this figure is rising14. This is a reflection of a pattern that has
emerged in high-income countries, where research has also shown that
older people living with HIV are likely to have other health conditions
(such as hypertension, arthritis, heart disease and diabetes).
Women, NCDs and ageing
The rapid increase of the oldest-old populations and the feminization of
ageing will mean even greater risks of long-term physical and mental
frailty especially amongst women. Worldwide older women represent the
majority of older people, a proportion which increases with age. The
oldest old (80 plus) age group is growing proportionately the fastest of all
age groups. Women’s greater longevity also carries a burden of ill health,
and we are already seeing the concentration of chronic disease in older
women. For women in developing countries who survive beyond middle
age, life expectancy is close to that of women in the developed world15; at
age 65 for example, women in developing countries now have about
three-quarters of the remaining life expectancy of their counterparts in
the developed world.
Older women are at risk of “multiple jeopardy” where social disadvantages
(such as widowhood and reduced family support) combine to exacerbate
age related disabling conditions. Older women are prominent among
sufferers from Alzheimer’s Disease and other dementias, 58% of whom
World Health Organisation: Visual impairment and blindness. Fact sheet www.who.int
ND
12 http://www.alz.co.uk/worldreport
13 Those aged 50 and overare considered as older people in the HIV response. This is due
to the fact that data on the epidemic is often exclusively focussed on those aged 15-49
years
14 Negin J and Cumming R G 2010 HIV infection in older adults in sub-Saharan Africa:
extrapolating prevalence from existing data, Bulletin of the World Health Organisation
2010;88:847-853
15 World Health Organisation: “Women, Ageing and Health” WHO Fact Sheet no 252, June
2000.
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are already living in developing countries, and these numbers are growing
rapidly16. Again there are significant gender differences in disability.
Women are more likely than men to have a longer duration of life lived
with disability.
Responses to NCDs and ageing in the international development
agenda
Combatting NCDs in developing countries makes sense from both a public
health and a development perspective. Since NCDs are both a cause and
outcome of poverty at all ages, combating them is also essential for the
achievement of the Millennium Development Goals (MDGs). Recognition
of the shift in disease profiles from infectious to non-communicable
diseases in disaster settings due to population ageing and increased life
expectancy has led to the inclusion of minimum essential standards and
indicators for response to NCDs in the revised 2011 Sphere Minimum
Standards for Humanitarian Response.17
However, so far progress in introducing NCDs onto the development
agenda has been slow. The Millennium Development Goals do not address
NCDs, while the focus of both donor and national government funding in
the developing world remains on infectious and acute diseases18. Although
action on health and poverty are key objectives in the 2002 Madrid
International Plan of Action on Ageing, and ‘Advancing health and
wellbeing in old age’ is the second “priority direction” of the Plan19, there
has been little or no implementation of these objectives by Member
States. Likewise, WHO’s “Age Friendly Primary Health Care” programme
has had limited response in national health priorities20.
There are signs of welcome changes. In most WHO regions action plans
on NCDs are being developed (though the priority given to these plans is
often low, as is the visibility of older people within them). The
commitment of 130 UN member states in 2009 to hold a High-Level
Summit on NCDs in September, 2011 “provides an unrivalled opportunity
to create a sustained rights-based global movement to tackle NCDs,
analogous to the UN General Assembly Special Session on HIV infection
and AIDS a decade ago, which concluded that dealing with the disease
was central to the development agenda…A successful meeting will ensure
that NCDs become central to the long-term global development agenda”21.
An immediate opportunity for integration is provided by the UN member
states meeting in June 2011, three months ahead of the NCDs summit, to
review progress in response to the HIV epidemic. As the UN Secretary16
17
Alzheimer’s Disease International: World Alzheimer’s Report 2009 p8
The Sphere Project Handbook, 2011, page 336
Geneau, R. et al: “Raising the priority of preventing chronic diseases: a political process”
The Lancet vol 376 issue 9753 pp 1689-98 13 November 2010
19 United Nations, ‘Madrid International Plan of Action on Ageing’ paras 48 (a) and (b), NY
2002/3
20 World Health Organisation: Towards Age-friendly Primary Health Care. WHO, Geneva
2004.
21 Beaglehole, R. et al: “Priority actions for the non-communicable disease crisis”.
www.thelancet.com Published online April 6, 2011
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General notes in his report on the implementation of UN declarations on
HIV, ‘since people with HIV live longer as a result of treatment advances,
cancers and other disorders associated with ageing are likely to become
more prominent…underscoring the need…to provide holistic care and
support’22. Furthermore, the draft declaration for the UN Summit on HIV
and AIDS in June 2011 makes a direct link between HIV, NCDs and
ageing. It commits ‘to review models of service delivery to take account of
new evidence about the effects of long-term living with HIV…including
increased risks of cancer, disorders associated with aging such as
diabetes, cardiovascular disease and cognitive impacts…and ensure access
to holistic comprehensive care and support services’23.
Action on ageing in the MDG debate is still a challenge, despite
commitments under MIPAA and the global drive towards ‘health for all.’
Given longevity and the family care associated with NCDs, the financial
implications of care responsibilities on already impoverished families and
caregivers need special recognition if the Millennium Development Goals
are to be realised.
Ageing and older people in the NCD debate
The increased focus on NCDs linked to the development agenda is
welcome, and a tribute to those who have successfully positioned the
issue in recent years. However, it is a concern that the challenge of NCDs
for older people in the developing world remains marginal. This is
particularly surprising given that population ageing is frequently referred
to as a key driver of the global growth in NCDs (for example, in the
preparation documents for the UN High-Level Meeting24).
Nor is this focus new. In 2002 the UN Madrid International Plan of Action
on Ageing recognised the growth in NCDs “in all regions of the world”, and
called for actions to reduce “the cumulative effects of factors that increase
the risk of disease and…potential dependence in older age”25. As we have
seen, the NCD burden is strongly associated with old age, increasing the
risk of long-term disability and dependency.
It is also clear that ageing, associated with poverty, contributes to a
continued growth of the NCD burden in the developing world. A World
Bank report on NCDs in South Asia notes: “Aging is occurring rapidly but
often without the social changes…that accompanied aging in most
developed countries decades ago. Aging due to this transition will, alone,
UN General Assembly 2011 Implementation of the declaration of commitment on
HIV/AIDS and the political declaration on HIV/AIDS: uniting for universal access: towards
zero new HIV infections, zero discrimination and zero AIDS –related deaths, Report of the
Secretary General 28 March 2011
23 United Nations: Draft declaration on HIV/AIDS “Zero New Infections – Zero
Discrimination – Zero AIDS Related Deaths” April 2011
24 UN General Assembly sixty-fifth session 13th September 2010: Note by the SecretaryGeneral transmitting the report by the Director-General of the World Health Organization
on the global status of non-communicable diseases, with a particular focus on the
development challenges faced by developing countries
25 Report of the Second World Assembly on Ageing Madrid, 8-12 April 2002 United Nations
New York, 2002
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increase NCDs because they are more common with increasing age.
However, population aging… is associated with a rapid increase in health
problems such as heart diseases, cancers, diabetes, and obesity—in other
words, unhealthy aging—putting new pressure on health systems”26.
Nevertheless, despite broadly inclusive language about tackling “key
determinants of global health to strengthen chronic disease prevention
and promote improved health for all,”27 mention of the disproportionate
impact of NCDs on older people is strikingly absent from much of the
current dialogue. In citing the burden of disease, some articles explicitly
exclude those over 6028. References to older people are often incidental to
discussion of global population ageing as a contributory factor to the
overall burden of NCDs29. Data on NCDs focuses on early onset and
emphasises the need to prevent “premature” death (i.e. death below the
age of 60). For example a recent WHO paper says:
“Sixty percent of all deaths in the world are caused by NCDs. Eighty
percent, or 38 million, of these deaths are in people from low- and
middle-income countries. Nine million people die from NCDs every year
before they reach their sixtieth birthday. And most of these ‘premature
deaths’ occur in low- and lower middle-income countries. In these
countries, 47% of all NCD deaths occur in those under 60 years old”30.
There are frequent references to the concentration of NCDs in the
“economically productive” populations in developing countries but almost
none to the burden of NCDs in old age31.
The neglect of ageing and older people in dialogues on NCDs is so
prevalent as to suggest a possible strategy among those leading the
debate, perhaps as a means to motivate decision makers to take action on
NCDs by a focus on people at “productive ages”32. It has been suggested
for example that conceiving NCDs as diseases of old age is a “negative
myth” hindering intervention33. Just the opposite is the case, as we have
Engelgau, M. et al: Capitalizing on the Demographic Transition: Tackling
Noncommunicable Diseases in South Asia” World Bank February 2011 p X
27 Geneau, R. et al: Raising the Priority of Preventing Chronic Diseases: a Political Process,
The Lancet (2010) 376: 1696
28 Mbanya, et. Al: “Mobilising the World for Chronic NCDs”, The Lancet, 377 February 12,
2011, p. 536 (“The 9 million deaths such diseases cause in people younger than 60 years
of age each year…represent nothing less than a development emergency in slow motion”)
29 Alwan, et. Al: “Monitoring and Surveillance of Chronic Non-communicable Diseases:
Progress and Capacity in High-Burden Countries” The Lancet November 11, 2010, p. 53
(‘the ageing of the populations of these countries will lead to a substantially increased
overall number of deaths”); WHO: Preventing Chronic diseases, a Vital Investment (2005)
p. 51
30
World Health Organisation: MDG side-event on NCDs (New York, 20 September 2010)
background paper
31 See for example Information Note on a Joint WHO/FAO Expert Consultation on Diet,
Nutrition and the Prevention of Chronic Diseases: “the growing epidemic of NCDs, which
contributes to the increasing loss of economically productive life years, affects economic
growth and places an increasing burden on the healthcare sector”. FAO Rome April 2003
32 See for example WHO: Preventing Chronic Diseases, a Vital Investment (2005), p.37
(“It is often assumed that chronic disease deaths are restricted to older people, but this is
not the case”).
33
Geneau, et al op.cit.
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seen, but it may be thought necessary to focus attention on younger,
“productive” generations in order to emphasise high-priority issues for the
development agenda such as economic impact of NCDs . This is both a
denial of the rights of older people and ignores the fact that many poor
people in developing countries continue to work productively well into old
age.
The invisibility of older persons in the NCD debate is an example of how
ageing populations continue to have a marginal place in development.
Conversely a focus on a whole life course approach to NCDs which is
inclusive of older people presents opportunities for innovative solutions
which both keep people healthy and active longer, and have beneficial
social and economic impacts. For example, a strategy “with greatest and
most immediate impact is to address risk factors in adulthood, and
increasingly the elderly. Risk factor behaviours can be modified in these
groups and changes seen within 3-5 years. With all populations ageing,
the sheer numbers and potential cost savings are enormous and
realizable”34.
Why prevention and management of NCDs in old age makes sense
Global demographic change and population ageing are a call to action.
“Population aging does raise some formidable challenges, but…also bring
some new opportunities, because people…have different capacities and
needs. The key is adaptation on all levels”35. Including older people in
programmes combating NCDs – both management and prevention –
makes sense for individuals, but also for families, societies and
economies. People who age in better health can remain productive for
longer, continuing to make significant contributions to their families and
communities. There will be reduced need for family support, and
particularly for the emergency care which often causes financial as well as
health crises in poor households. There will be an increasing need for
long-term care, especially for people entering later old age with chronic
illness. However, effective support to both formal and informal carers will
ensure the continuity of this vital assistance to frail older people, with all
its societal and economic benefits. In the era of global ageing, helping
people to age as well as possible will not just be sensible policy, it will be
indispensable.
Darnton-Hill, I. et al: “A life course approach to diet, nutrition and the prevention of
chronic diseases” Public Health Nutrition: 7 (1A) 2004 pp101-121
35 Bloom, D. et al: Population Aging: facts, Challenges and Responses. Harvard University
Program on the Global Demography of Aging Working Paper 71 May 2011
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HelpAge International’s position – key messages
Investment in public health has resulted in the triumph of longevity, which
is now a global phenomenon. However, progress in health provision for
older people has been deeply unequal across the world. Increased
longevity also leads to challenges – global ageing is one of the key drivers
of the exponential growth of NCDs.

A whole life course approach to NCDs, which is inclusive of all ages,
should be adopted for Summit recommendations on detection and
diagnosis, and strategies for prevention, management and
treatment as well as more effective care.

Diseases particularly prevalent in old age, ranging from blindness to
Alzheimer’s disease and other dementias need to be addressed with
urgency.

Governments should ensure the right of older people to age-friendly
prevention, diagnosis and treatment, as well as home and
institutional care services.

Health systems should recognise the strong interconnections of
NCDs and communicable diseases, working towards an integrated
health approach which addresses the spectrum of people’s health
needs and the interactions between them.

The explicit objectives on ageing, poverty and improved health (in
line with MDG goals) contained in the 2002 Madrid International
Plan of Action on Ageing shoul be implemented by the Member
States.

Action on the health consequences of rapid demographic change
should be a key element of international development targets after
2015.

The use of discriminatory language and concepts relating to older
age in the NCDs debate must be challenged. We call for a review of
the criteria for setting an age-specific point for ‘prevention of
premature death’.

Strategies against NCDs should recognise that inclusion of older
people in prevention, promotion and management strategies will
substantially reduce the health costs arising from rapidly ageing
populations

The economic and social contributions of older people should be
recognised, and “productive ageing” should be enabled by
strategies supporting the health of older populations
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
The following specific and measurable strategies to reach older
people should be considered:
o
Use WHO’s age friendly primary health care guidelines as a
key tool in all programmes combating NCDs
o
Include modules on older people’s health in health
professional training
o
Develop primary prevention, screening and treatment
programmes which are inclusive of older people
o
Develop social networks for community-based support of
older people, both as recipients and providers of care
o
Implement the NCD Alliance/Lancet recommendation to
ensure access to affordable essential drugs to treat NCDs as
part of primary health care programmes
o
Ensure continuity of treatment for older people with NCDs in
emergency responses
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