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Bioethics Forum Essay

The Good of the Body

The December 2015 United Nations meeting on climate change was an historic moment for global efforts to reduce harmful carbon emissions. While it gained the agreement about the future good of the planet, it made clear that there is a long and hard road still ahead. Yet another global challenge is showing itself more visibly of late, overshadowed by global warming—that of the good of the body, our health as a species.

A telling place to begin that story is with China’s decision last year to eliminate its one-child limit, rescinding a policy put in place with much criticism in 1980. The initial motive of the policy was to slow or stop the rapid population growth in China, seen as a threat to its goal of eliminating poverty and endangering its fast-rising economic growth. Reduction of population growth, led by the U.N. and various NGOs—and popularized by Paul Ehrlich’s book The Population Bomb–had been an international movement in the 1960s and 1970s. Initially it was heavily focused on developing countries with very high birthrates and pervasive poverty, but it was gradually picked up by environmentalists as well for two reasons. One of them was anxiety about the projected future number of people on earth, dangerously straining natural resources. The other was the disproportionate climate harm done by heavily industrialized affluent countries even with much lower population growth.

With the exception of sub-Saharan Africa and Southeast Asia—where family sizes still remain in the six-to-eight children range–rising affluence, women’s education, and effective family planning programs brought about a significant decline of global birth rates. Not foreseen by the Chinese or others, however, was the possibility that too-low birthrates could threaten economic welfare, leading to depopulation and a declining number of young workers to support a growing number of the elderly. That perception began gradually to emerge in the 1970s and 1980s in developed countries. The success of effective family planning policies and the rising number of working women stimulated that shifting perspective. What came to be known as “low birthrates,” a total fertility rate  (TFR) of, on average 1.5-to-1.8 children per woman, and “low-low” birthrates below 1.5, induced second thoughts, which became common by the 1990s.

Some 32 developed countries have put in place policies to raise birthrates, up from eight in 1986. That has turned out to be more difficult than expected. Many Chinese do not want a second child, and Japan, with the lowest of all birthrates, (1.4 TFR), has made little progress in its efforts to increase procreation. For the past five years there have been more deaths than births in Japan. Other countries trying to turn the tide have not made much progress. In any case, none of the countries seeking to raise birthrates aim to return to earlier excessively high birthrates.

More recently coming to the fore, however, is the great shift in aging that has accompanied population growth.  What came to be called the dependency ratio–the imbalance of productive young workers and more dependent retired–began to loom large toward the end of the twentieth century. Rapidly rising elder health care costs in developed countries as well as generous retirement policies came to be a black cloud on the horizon. Less expected was the proportionate rise in the number of elderly in developing countries. Coming to be called “age compression,” it emerged much faster than it had in rich countries. By 2012 the global ratio of young to old saw the number of those over 60 to be greater than those under 5 for the first time in history.

Some 12 percent of the world’s population is over 60 and it is projected to rise to 22 percent by 2050. Between 2010 and 2050 a 250 percent increase in the number of people in this age group is expected in developing countries, compared with a 71 percent increase in developed countries. In 2010 there were an estimated 524 million people in the world over the age of 65, but that group is projected to grow to 1.5 billion by 2050. Few developing countries are prepared for that change. They already lack good health care for the needs of the young much less for what will be the much greater needs of the old. Government and industry pension and retirement programs are virtually nonexistent. The movement of the young to cities—now holding 50 percent of the world’s population–where jobs are available is leaving millions of the rural old without traditional family care.

There is growing uneasiness even in developed countries. In 1965 in OECD (Organization for Economic Cooperation and Development) countries there were 14 people over age 65 for every 100 younger workers; now there are 28. Whether future population growth will keep that already low ratio from going higher is unpredictable. Nor is the U.S. any better off. The growth rate of the U.S. Medicare program for the elderly is at present slowing down from earlier fast annual cost increases–most likely due to the most recent  recession and some successful cost-control efforts—but it is expected to rise again in future decades as the retirement of the baby boom generation picks up speed. While their proportion in relation to those over 65 is small there are now about 72,000 people age 100 and older, up from 50,000 in 2000. What was rare and worth a special obituary 40 to 50 years ago is now commonplace.

Generally overlooked, however, is the financial status of the elderly. Right off top, some 18 percent of a retirees’ Social Security income is spent on the copayments and deductibles of their Medicare health coverage.  But the worst costs of retirement—home and nursing home care, daily needs for food and shelter–cannot, for most, be covered by Social Security alone. They will need the help of income from pension plans, for people lucky enough to have them (and fewer than 50 percent of today’s retirees do, and personal savings. Baby boomers have been notoriously poor savers, accumulating on average only $30,000 in cash. Short of greatly increased Social Security coverage and relief from health care costs over and above the present Medicare coverage, a fair number will live below the poverty line.

There is another twist to the population and aging story. Old age is now increasingly accompanied by lethal, disabling, and expensive chronic diseases—notably cancer, heart disease, type 2 diabetes, and emphysema, and with Alzheimer’s catching up. Those diseases now plague all rich countries. The marvel of more people living into their 80s, 90s, and 100s obscures the cost to the health care and retirement programs that accompany it. Most notably, developing countries have joined that once exclusive club. Where infectious diseases were once the leading killers in poor countries (and malaria still is), 60 percent of deaths are now due to chronic diseases.

An aggravating feature of what might be called the aging/chronic illness syndrome is that much, though hardly all, of the challenge of chronic illness is that its causes are heavily traceable to lifestyle behavior. Bad diets and consequent obesity and heart disease, smoking, excessive alcohol consumption, and lack of exercise all play a significant role. That distressing feature is particularly apparent of late in poor countries, where they appear some 10 years earlier than in rich countries.  Strategies of prevention are obviously called for, but not easy to put in place. If many people everywhere are not happy to pay high taxes or accept heavy regulation to deal with global warming (and even when they concede the threats), they are even less prone to have government regulate what they do with and to their bodies.

There are many good things going on in coping with population growth, aging, and chronic illness. But all in all we are with the good of the body at the stage that the reduction of global warming and the good of the planet were 30 years or so ago: plenty of scattered ideas, and signs of progress here and there, but little overall policy coherence. What made the greatest difference with global warming was the establishment by the U.N. of the Intergovernmental Panel on Climate Control in 1988 (IPCC) to coordinate scientific research and information, and then, in 1992, the U.N. Framework Convention on Climate Change (UNFCC) to reach policy agreement. A comparable U.N. organization to encompass population growth, aging, and chronic illness would be timely and helpful.

Daniel Callahan is President Emeritus of The Hastings Center and author of the forthcoming book, The Five Horsemen of The Modern World: Climate, Food, Water, Chronic Illness, and Obesity (Columbia University Press).

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