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1 The Ongoing Process of Aging and Health in Latin American Middle-Income Countries Cesar González-González Roberto Ham-Chande Introduction As an outcome of recent history Mexico and most of Latin America qualify as middleincome countries. A main pursuing of these nations is to raise its over-all social and economic status, which should be a straight-forward task but it is not because of conflicting ideologies and vested interests that translate into huge socio-economic inequality. Nowadays, Latin America is carrying on a complex dynamics with many unknowns and concerns about its economic, social and political future. Among the uncertainties, arguments and disagreements about how to seek a better future there is an issue which everybody agrees upon. Regarding the future to come we are highly positive about the trends in the demographic and epidemiological transitions, which find its most conspicuous expression in the rapid population aging. The discussion in this paper is that we can profit from the general assertions of population projections and use them as the starting base for planning the unavoidable aging process. It can also be shown that such approach is not restricted to the old-age population, but it is related to the whole age structure of the population. In the same vein, it goes beyond demographics, thus requiring the involvement of other fields of research and policy making in health, social and economic issues. It must also be said that the awareness raised by projections about the aging process have been in mind for some time now. But examining that past we have to accept that economic and social adjustments to this trend have been slow and mostly misleading from what is required for old-age health, social security and well-being. At times it even seems to go backwards by widening the gaps between needs and goals. These suggestions can be confirmed by some scenarios, just assuming the same prevalence for health conditions and disabilities that for the projected population. The result will be projections of people with morbidities and disabilities, whose medical and care costs will surpass any imaginable budget. Under such prospective scenarios based on highly reliable trends, the needs of the elderly population would remain unmet.
2 Life expectancy is increasing albeit cohort analysis is showing that this increment may not be in good health. Health care is limited and eroding. Among the OECD countries Mexico has the lowest investment in health and the highest percentages of out-of-pocket health expenses. By 2000 Mexico spent 5.1% of its GDP on health which increased to 6.2% by 2011. Such figures are insufficient and below the average of other middle-income countries in Latin America. Of the total health expenditure, 46% is government expenditure and 54% is private. Prospective analysis and scenario construction are necessary for public policies to avoid or at least prevent health crisis. It is important to consider conditions as a middleincome country. When today´s elderly were children Mexico was barely emerging into modernity, with important consequences for present socio-economic and health conditions. Looking for an example of how to foresee the close future, working population in the 45 to 59 age bracket and approaching retirement, shows employment handicaps that will preclude them from an suitable old-age income. Less than a half will receive a pension, most of them of a meager amount, thus glimpsing a deprived future in old age. It is frequently asked which experiences from developed countries already aged may allow to identify policies and actions seeking health and wellbeing improvements for our own aging population. Of course medical findings and health interventions are a must. But for socioeconomic determinants the experiences of developed societies diverge from the socioeconomic realm of middle-income countries in Latin America. May be more helpful south-south collaboration, especially in comparatives between Latin American countries. In terms of research possibilities and data availability, it will be suitable to contrast with Puerto Rico (McEniry, 2012) and Costa Rica (Brenes, 2012). It is appropriate to ask if demographic aging will be a hurdle for national development and public health. One obstacle appears in the financing of unfair perked pension systems that are economically and socially unsustainable. They are the burden of an artificial aging of young pensioners undermining investment in education and health for future generations. Besides, the cost of chronic diseases and disability should be added. Health in long-term care will be more expensive than pensions. Aging is a factor that
3 exacerbates the poverty scenario. Solutions to enable economic and social viability face obstacles due to political, financial and union’s vested interests. With a holistic approach and the relationships between demographic, social, economic and health conditions of the elderly, two topics arise. 1) The health-illnessdisability-death process and 2) Health costs and expenditures associated with it. In each issue, we identify the key factors in order to avoid or mitigate population health problems and to promote healthy aging. Data and Methods. We use a descriptive analysis with a comprehensive cohort projections and prospective to understand the aging process, the multidimensional factors and the interactions that determine it. The main purpose is to provide planning inputs. Data comes from the 2010 Census of Population and Housing, the National Survey of Health and Nutrition (ENSANUT) 2006 (and 2012 whenever it is released). Comparisons with Costa Rica and Puerto Rico can be done through existing research. Findings. As Graph 1 shows, population 65+ is 6.3% of the total population and is expected to keep growing to a fourth by 2050. Aging can be seen as a success for public health and for socioeconomic development. However, it is occurring in a context of deep social and economic inequality (Ham, 2003). In Latin America´s middle and low income countries are experiencing institutional frailty, macroeconomic reversals, political upheavals, and, more importantly, only small improvements in alleviating poverty and income inequality. The consequence is that within the aged population, sharp inequalities may continue to prevail or even exacerbate.
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Also A middle--income cou untries facee a double b burden of d disease. Onee is the emeerging chronic diseases d as major causses of morb bidity, disab bility and death, and aalso the unfi finished agenda of o infectious diseases. Increasing disability aand functio onal loss aree the most impactin ng effects (W WHO, 20111). In Mexicco in 2010, tthe main caause of deatth for men 65 years an nd older wass cardiovascular diseasse, represen nting 23.8% % of all deaths. This w was followed d by diabetees with 14.2 2%, and mallignant tum mors accoun nting for 13 3.0% of deatths. Similarly y, for womeen in the sa ame age gro oup, cardiovvascular dissease was th he leading ccause of death being 25.1% % of all dea aths, follow wed by diabeetes mellitu us with 17.3% and maliignant tumors with w 10.9%.. Although A inffectious disseases have lost importtance as a lleading cause of death in all age grou ups, and parrticularly am mong olderr adults, theey keep sign nificant preevalence an nd have not been n diluted to the same extent e as theey have in h high-incom me countriess. Thus, infl fluenza
5 and pneumonia are the seventh most common cause of death in this population group, followed by intestinal infectious and an assortment of parasitic diseases. The projected increase in the absolute and relative numbers of the elderly, especially the oldest-old, will impact health care demands. Data from ISSSTE (Social Security and Social Services Institute for Public Employees) corroborate the pressure imposed by aging in the operation and demand for medical services. a) At ISSSTE 2.8 of every 100 people under 65 years old were hospitalized in 2009, while for those 65+ the figure was 8.4, and b) medical appointments among those 65+ increase 32% between 2004 and 2009, meanwhile in the under 65 group it increased by 8%. Moreover, in the same period hospital discharges increased by 26% for the population 65+ and only 14% for those under 65. Estimates from ENSANUT 2012 shows that 56.8% of people 60+ have at least one chronic disease and 22.6% had at least two. Almost half of the budget in public health institutions goes to address chronic no-communicable diseases, mainly diabetes and hypertension (Garcia Peña and Gonzalez-Gonzalez, 2012). In 2012 the percentage of population with self-reported hypertension was 42.2% and for self-reported diabetes was 25.0%. Generally, these diseases are not lethal, but they hamper the normal body function with great impact on the individual, the family and the society. Health outcomes yields dependency and require adjustments from the health system. The World Report on Disability by WHO (2011) states that in low and middleincome countries, diabetes, cardiovascular diseases, mental disorders, cancer and respiratory diseases are the cause of two thirds of the years lived with disabilities. In Mexico, according to estimates by the Ministry of Health, 84% of deaths are due to chronic diseases and injuries and 53% of these are 65+. Results from the ENSANUT 2012 shows that the prevalence of functional limitations, which refers to having at least one limitation among four activities of daily living (walking, bathing, getting in and out of bed and dressing), was about 26.9% with women showing higher rate (29.6%) compared to men (23.8%). The relationship among chronic diseases and disability is well known. Comparing by the presence/absence of chronic diseases in the 65+ population in ENSANUT 2012, those with chronic diseases uses more intensively the health services (morbidity, ambulatory care
6 and hosp pitalization n) and a high her percenttage report difficulty tto perform tthe activitiees of daily liviing. 39% for those with hout chronic diseases and 50% fo or those witth chronic diseases.
Chronic C diseease also im mpacts the family, f thro ough long-teerm care an nd living arrangem ments. Inad dequate forrmal health services, li mited publlic support and nil perrsonal social seervices, com mpel familiees to provid de informal care to the elderly. Heelp from ch hildren and otheer family members beccome essen ntial. On ano other directtion, in thee context of multigen nerational family f arran ngements th hat are pre sented todaay, older peeople play sseveral roles, sin nce simulta aneously theey may be providers p an nd recipien nts of suppo ort and caree dependin ng on their functional capabilitiees (Robles 2 2009, Monttes de Oca 11997). Demographi D ic characterristics also show s a com mplicated siituation forr the elderlyy. Average schooling for f this grou up is 4.6 yeears, 17% haave not acceess to healtth care in an n institutio on, and 45% % does not have a spou use or a parrtner. We W are now working in n the cohortt and prospeective scenaario using tthe recent projectio ons of the National N Population Co ouncil (CON NAPO) and d the latest rresults from m ENSANU UT 2012. A priori, we identify i som me factors p playing a keey role to gllimpse a complica ate scenario o, among th hem the fasst aging pro ocess occurrring in Mexxico, along w with a mixed ep pidemiolog gical regimee, pervasive health risk ks (obesity, smoking an nd drinking g). It must be added a deeep inequaliity, with low w investmeent in health hcare and th he pension n system. All A these fa actors comb bined with have h impairr the qualityy of life of tthe elderly. Factors playing p a po ositive role in favor to a better sccenario wou uld be higheer education n, higher healthcare h access, a healtth infrastru ucture, bett er means in n social security and th he creation of new insttitutions wo orking for an a active agging.
7 Discussion The macro situation is complicated. The accelerated aging is challenging. The heterogeneity, economic inequality, poverty, financial crisis and the low pension coverage, concomitant with low investment in health, the epidemiological transition and changing age structure sketches a complex scenario. Future cohorts of aged people will have more stressful life experiences. Women are increasing their labor market participation, less healthy lifestyles, all typical of the urbanization process. At the same time, smoking, alcohol consumption, obesity and sedentary lifestyle are risk factors that can be prevented, in programs preparing young cohorts for healthier aging. There are limited analyses on what this increase will represent in terms of needs and requirements. This research aims simultaneously to fill that gap and to inform about the challenges that the increase in the elderly population will bring (González et al., 2011). As for the relationship between changes in the age structure and health expenditure, we cannot conclude that health spending will increase by the same proportion as the population increases with aging. An elderly population is not necessarily a sick population. In large part it will depend on the prevention and control of chronic diseases. References. Brenes, G. (2012). “Análisis de las secuencias en el estudio del envejecimiento”. Capítulo del libro “El envejecimiento en América Latina: evidencia empírica y cuestiones metodológicas” de Redondo, N. y Gary, S. ALAP. Brasil. García Peña, C y González-González, C. (2012) “La enfermedad crónica y los costos de la salud al envejecer”. En Luis Miguel Gutiérrez Robledo y David Kershenobich Stalnikowitz Coords. Envejecimiento y salud: una propuesta para un plan de acción. México, D.F. Academia Nacional de Medicina de México, Academia Mexicana de Cirugía, Instituto de Geriatría y Universidad Nacional Autónoma de México. González-González, C.; Sánchez-García, S.; Juárez-Cedillo, T.; Rosas-Carrasco, O.; Gutiérrez-Robledo, LM.; García-Peña, C. “Health Care Utilization in the Elderly Mexican Population: Expenditures and Determinants”. BMC Public Health, 11:192, 2011 Ham-Chande, R. El envejecimiento en México: El siguiente reto de la transición demográfica. México: El Colegio de la Frontera Norte, 2003.
8 McEniry, M. “Early life exposures, life in mainland US and the health of older adult Puerto Ricans”, Paper presented at the V Congreso de la Asociación Latinoamericana de Población. 23 a 26 de agosto de 2012. Montevideo. Montes de Oca, Verónica (1997), “La actividad económica de las mujeres en edad avanzada en México: entre la sobrevivencia y la reproducción cotidiana”. Documento presentado en la reunión de la Asociación Latinoamericana de Sociología, Hotel Continental Plaza, Guadalajara, México, Abril 17-19, 1997. Robles, Leticia (2009), "La relación cuidado y envejecimiento: entre la sobrevivencia y la devaluación social", Papeles de Población, núm. 45, pp. 49-69. World Health Organization & World Bank. (2011). World Report on Disability. Geneva, c2011. xxiii, 325 p.
