Blackburn J.A., Dulmus C.N. (Editors). Handbook of gerontology: evidence-based approaches to theory, practice, and policy

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ONCLUSION

economic, and political structures and trends, a fully informed discussion of

global longevity, its multiple dimensions, and the various policies, programs, and

interventions. Nonetheless, in this chapter I attempt to do three things. I present

and analyze the demographics of global aging, recognizing that the ongoing

longevity revolution is occurring in complex environments. I identify and discuss

three sets of policy and program challenges. Finally, I argue that evidence-based

approaches to policy and program development as well as clinical intervention

may be ideal, but note the unevenness in research resources and capacities that

can be brought to bear in both developing and developed nations.

To provide an initial comparative perspective, I examine China in comparison

to the United States. In some instances, I also provide a comparative view of

Japan’s response to the fact that 25% of its populace will be 65 years old and older

by 2020 and 38% will be over 60 in 2050 (United Nations, 1999).

THE DEMOGRAPHICS OF GLOBAL AGING

VERVIEW

Today, there are an estimated 6.5 billion persons in the world (U.S. Census Bu-

reau, 2006b). In mid-2005, about 1.2 billion persons resided in the more developed

world, with nearly 15% age 65 or older. This was significantly less than the 5.3 bil-

lion persons 65 or older (about 5%) in the developing world (Population Reference

Bureau, 2005). Of this, 605 million persons are 60 or older; an estimated 483.3 mil-

lion persons (7.46% of the world’s total population) are 65 or older. By 2025, it is

expected that 1.2 billion persons will be 60 or older. In 2050, the number of per-

sons 60 and older is expected to rise to almost 2 billion. At that point, the size of

the older adult population will exceed that of children (0 to 14 years) for the first

time in human history (HelpAge International, 2002).

Approximately 3.3% of the U.S. population of 3.3 million persons in 1990 was

65 or older; 100,000 were 85 or older. By midcentury, the number of persons over

65 had grown to 12.3 million, and by the beginning of the twenty-first century,

the elderly population in the United States had mushroomed to approximately 35

million older adults out of nearly 300 million persons (12%), 4.2 million of whom

were older than 85. The Federal Interagency Forum on Aging-Related Statistics

(2000, 2006) projects that in 2050 there will be 86.7 million persons 65 and older

and 20.9 million who will have reached age 85 or older.

In the United States, the equivalent of one small town (about 7,918 persons)

turns 60 each day (U.S. Census Bureau, 2006a). Regardless of how dramatic this

sounds, the rapidity of aging in the developing world is staggering. In 2000, for

example, the world’s entire elderly population (60 years and older) numbered 600

million, with the population of 374 million elders in developing countries grow-

ing at an astonishing rate of about 795,000 persons per month (Kinsella & Velkoff,

2001). By 2030, 75% of the world’s elders or 1 billion persons will be in developing

countries. In comparison, the number of older persons in developed countries is

likely to reach 362 million in 2030 (HelpAge International, 2002).

Approximately 27.4% of our global population is 0 to 14 years of age. In com-

parison, 65.2% of the world’s people are 15 to 65 years old. Confronted by dra-

matic population aging, Japan, Sweden, and other nations have developed societal

responses that may provide policy makers and professionals in the United States

with an expanded notion of policy and program possibilities.

Global Challenges for an Aging Population 547

According to the Population Division of the United Nations (2002a), the oldest

of the old—persons 80 or older—are increasing in number at twice the rate of the

60+ cohort. Not only will this subpopulation grow rapidly in 2050, those 100 and

older will increase 18 times between 2000 and 2050 (from 180,000 to 3.2 million).

AGING IN DEVELOPING AND DEVELOPED NATIONS

The proportion of older persons to total population in the developing world is ap-

proaching 66%, up from 59% (249 million) in 2000 (Kinsella & Velkoff, 2001). This

trend should continue through the decades ahead as the growth of the 60+ popu-

lation in currently developing nations will dramatically outpace the growth in

today’s developed world. In less than 2 decades, developing nations will lay claim

to 75% of the world’s elderly population, with the number of older persons rising

most dramatically in Asia and Latin America. In fact, individuals 80+ will repre-

sent the fastest growing age segment in the developing world (World Health Or-

ganization [WHO], n.d.).

The greatest share (54%) of the world’s elderly persons is in Asia. Second is Eu-

rope (24%), where 24 of the world’s oldest populations reside (United Nations,

2002a). Japan, the sole non-European nation with a significant proportion of its

citizenry 65 and older, expects that its elders will represent more than 27% of its

population in 2025, up from 14.6% in 1995 (Ibe, 2000). By 2030, more than 40% of

elderly Japanese will be 80+; demographers expect that Japan will have the

“largest number and proportion of centenarians” by 2050 (United Nations, 2002a,

p. 25). In comparison, the United States is a relatively young country, ranking

32nd in the proportion of older persons to total population. Africa is home to the

youngest aging countries.

Demographers forecast a huge rise in the number of elderly persons in China,

estimated presently to be 88 million out of a population of 1.3 billion of all ages.

By 2020, one-third of all persons in Shanghai, China’s most cosmopolitan and

modernized city, will be 60 and older. By 2050, China will have 331 million older

persons—nearly equal to the total projected population of all persons of all ages

in the United States. For comparison purposes, the older U.S. population, cur-

rently 35 million, will grow to 86.7 million by 2050 (U.S. Administration on

Aging, 2005).

Although the rise in the sheer number of elderly Chinese will be astounding,

Singapore (372%), Malaysia (277%), Colombia (258%), and Costa Rica (250%) will

see extraordinary increases between 2000 and 2030 (Kinsella & Velkoff, 2001).

With few exceptions, the most significant growth in the elderly population will be

in the developing world. The aggregate rate of growth of the total world popula-

tion will be half that of the elderly population in the developing world. Similarly,

the developed nations’ aggregate growth rate for older persons will be less than

half that of their counterparts in the developing world (Kinsella & Velkoff, 2001).

The economic status of older persons in the United States and other OECD

countries is significantly different from the rest of world’s aged. About 9.8% (ap-

proximately 3.6 million) of older persons in the United States were at or below

the poverty line, and 6.7% (2.3 million) of older Americans were between the

poverty line and 125% of it in 2004. As with many women around the world, a

larger number of older women in the United States were impoverished (12.0%)

than older men (7.0%). Similarly, more older persons (17.9%) living alone were

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ONCLUSION

poor than were older persons who were living with their family (5.7%). Older

African American and Latina women who lived alone were also more likely to be

impoverished (U.S. Census Bureau, 2005). In contrast, most elderly persons in

developing countries live lives of impoverishment and deprivation (HelpAge In-

ternational, 2002).

Gouré (2000) and Petersen (1999) are among those who have seen population

aging as generating burdens hazardous to economic and national security. Gouré

cautioned that the ability of developed nations to rebuild an aging military infra-

structure, counter the shortage of active recruits, and otherwise add to military

spending in the United States will be seriously constrained by the anticipated

budgetary requirements of Social Security and Medicare and the exodus of the

baby boomers from an already less than robust workforce. The same scenario is

expected in Europe, China, and India. Petersen’s and Gouré’s observations were

made, of course, prior to 9/11, the war in the Middle East, North Korea’s missile

test in summer 2006, and similar events that reverberated throughout the global

community.

OOMERS AND

GING

Assuming that the United States will remain one of the most powerful sociocul-

tural leaders in this century, envisaging the potential impact of the aging U.S.

baby boom generation (born between 1946 and 1964) may help us to better ad-

dress global aging in the future.

Unlike previous generations, the boomers will likely challenge the chronologi-

cal age-based standard for retirement and “old age”—age 65—set in 1916 in Ger-

many. Significant gains in life expectancy had not yet been realized worldwide

during the 2nd decade of the twentieth century, nor had sufficient evidence been

gathered about whether 65 should be viewed as synonymous with old age or

whether it should demarcate a newly defined “middle age.” In fact, findings from

several recent studies suggest that chronological age-based definitions of aging

and age-based criteria for retirement may no longer command the degree of con-

currence that would legitimize their use. A 2000 survey of more than 3,000 adults

of all ages in the United States concluded that many Americans regard dis-

cernible decline in physical ability, not chronological age, as the defining criteria

for “old age” (National Council on Aging, 2000). A nationwide telephone survey

of 1,000 adults of all ages found that definitions of “old age” appear to depend on

the relative age of the respondent. Older respondents tended to define “old age”

as older than did younger respondents (MetLife Mature Market Institute, 2005b).

In a study of retirement by a global financial institution, a sample of nearly

11,500 adults in 10 countries, there were also strong indications that neither age of

retirement nor definitions of old age should be presumed to be linked to chrono-

logical age. It appears that both “retirement age” and “old age” are more com-

monly determined individually and personally, are often dependent on physical

and mental capacity, and may depend on an interest in remaining actively en-

gaged (Hong Kong and Shanghai Banking Corporation [HSBC], 2005). A follow-up

2006 study with a sample of 21,000 individuals and 6,000 employer organizations

in 20 countries revealed a range of attitudes toward retirement and self-assessed

retirement preparedness across countries (HSBC, 2006).

Using the criteria of the Older Americans Act, which defines old age as 60+,

the leading-edge baby boomers became “older Americans” in 2006. However,

Global Challenges for an Aging Population 549

most discussions presume that the first wave of boomers will come of age in

2011, when the cohort begins to reach age 65. At that point, baby boomer num-

bers in the United States will be more than twice the total population of Canada.

This is hardly as dramatic as the number of boomers in developing nations, who

will outnumber older persons in the developed world, in some cases by multiples

of hundreds of millions.

Eighteen years separate the youngest from the oldest boomers, who were born

between 1946 and 1964. Hardly a homogeneous generation, boomers have been

differentiated by several observable differences and similarities. Gillion (2004)

regards boomers born between 1945 and 1957 as distinct from the “shadow

boomers” born between 1958 and 1963. Boomers can also be divided into market

segments. “Younger boomers” born between 1956 and 1964 are purportedly less

concerned about the future and are focused as consumers primarily on their chil-

dren. “Older boomers,” born between 1946 and 1955, are more concerned about

the future, are more likely to try to protect themselves against future losses, but

typically are also more self-indulgent, using more of their resources for vaca-

tions, homes, and clothing (MetLife Mature Market Institute, 2005a).

Within-group differences for individuals born between 1946 and 1964 are not

limited only to the United States. In other countries, political developments, nat-

ural disasters, wars, epidemics, and the dynamics of the marketplace have cre-

ated distinctive points of reference and differing resource expectations.

Boomers in the United States have a higher standard of living than did their

parents. In spite of this, Hughes and O’Rand (2004) observed that boomers are

characterized by more inequality in household incomes, home ownership pat-

terns, and net worth. A MetLife study has estimated that the spending power of

older boomers is about $1 trillion, compared to younger boomers at $1.1 trillion

(MetLife Mature Market Institute, 2005a). Although boomers as a generational

group have a declining overall percentage of persons in poverty—down from 9.5%

in 1993 to 7.3% below the poverty level in 2000—more younger boomers were poor

than their older counterparts. This may seem counterintuitive because of the

spending power of younger boomers (MetLife Mature Market Institute, 2005a).

Trends for U.S. boomers’ standard of living and economic diversity may be the

same in most other developed nations as well. If the findings of two recent multi-

national studies with a U.S. sample are accurate, many adults as a whole and

many boomers as a segment feel that they lack adequate knowledge about per-

sonal finance and investments to be confident about their financial security in re-

tirement. In fact, retirement preparedness and knowledge of levels of financial

capacity necessary in retirement were appallingly inadequate in 20 countries ex-

amined in 2006 (HSBC, 2006). Even well-educated boomers have said that they

need more useful and usable information and guidance so that they can better

plan for their older years in retirement (National Commission for Quality Long

Term Care, 2005). These issues are in sharp contrast to economic security issues

that are largely colored by the extensiveness of poverty among elders in many de-

veloping nations.

GING IN

URAL AND

RBAN

OMMUNITIES

Urban and rural differences among older persons may be most readily observable

by continent or region. Asian elders and older women tend to live in urban areas,

550 C

ONCLUSION

whereas older Africans and older men tend to be residents of rural communities.

About 74% of older persons in developed nations reside in urban settings. This is

in sharp contrast to older adults in developing nations, many of whom now reside

in rural settings, but more than half of whom will likely be affected by a push to-

ward urbanization within less than a decade.

Policy makers worldwide have largely failed to bring the quality of life of persons

in rural communities on a par with that of persons in large urban areas. Compared

to more populous urban areas, rural communities tend to have poor (or no) public

works, public health, and social welfare infrastructures as well as weak economic

bases. With more poverty in rural communities, members of younger generations

are less likely to remain in their ancestral villages, raising thorny issues of familial

versus public support of aged rural members that spill over into urban communities.

Rurality is a variable that is typically synonymous with fewer resources and an

outmigrating population. In China, existing household registration mandates dis-

courage intranational relocations by disallowing access to government-sponsored

programs in all but official communities of residence, regardless of how com-

pelling the need for assistance. Elderly Chinese may be discouraged from moving

away from resource-poor rural villages with their relocating offspring. If they

choose to remain in ancestral villages, they must contend with the trials of living

alone, lower standards of living, and fewer services and service providers and may

expect to be without the economic and social support of family caregivers. If they

move, they must adapt to unfamiliar urban environments in which government

support is unavailable.

In Japan, a nation whose aging ratio will be the highest in the world within a

few decades, health and aging policies have recognized the needs of elders and

have provided for locally administered services. However, with younger off-

spring moving to urban areas, the need for formal caregivers and workers is

acute. Unable to convince its own people to move for work to rural communities,

Japan is cautiously opening its doors to a small number of immigrants, who may

be able to fill formal care-giving positions.

ENDER AND

GING

The strength and influence of the world’s older women should come to full bloom

during the twenty-first century. In terms of sheer numbers, women outnumber

men at age 65+, with a sex ratio of 1.0 women to every 0.79 men. The most dra-

matic figures in comparisons of women to men are observable when the 65+

group is further differentiated. For example, women outlive and outnumber men

by 2 to 1 at age 80 and older—the fastest growing age segment in many countries

across the world (United Nations, 2002c). Although men will presumably make

gains in longevity in the decades ahead, women are expected to remain more

long-lived and more numerous than men in all but a small handful of countries.

Ifchildcarewasoneofwomen’sleadingsocialissuesinthetwentiethcentury,

aging-related issues should be one of the most prominent concerns of younger and

older women during the twenty-first century. Older women in developing coun-

tries are more likely to be poor and vulnerable, and the most vulnerable and the

poorest among them are widows. More than 50% of women over 60 are widowed

in many of the least resourced countries (HelpAge International, 2002). In the

United States, older women who are widowed, living alone, and minorities are at

Global Challenges for an Aging Population 551

the highest levels of risk for impoverishment. If they are single, women are placed

at risk by the inequities meted out by the dynamics of our social structures.

Policy makers in the developed OECD countries have begun to focus on younger

women because of the ramifications of global aging for economic competitiveness,

growth, and productivity. International groups with members from developed na-

tions have advocated for both pro-natalist and labor policies that encourage women

to bear more children and enter the workforce (Center for Strategic and Interna-

tional Studies, 2001). Whether such policy directions would be acceptable to

women and would result in altered dependency ratios in aging countries would de-

pend on whether the policies can truly reverse disincentives to marriage inherent

in long-standing labor, employment, and child welfare laws. They would also de-

pend on the resiliency in developing countries and traditional societies of women’s

gender-role expectations, following on the introduction over the past 4 decades of

more liberal Western models. In tradition-bound Japan, for example, growing num-

bers of women no longer accept the curtailment of their newly discovered right to

exercise personal choice and enjoy individual freedom. To the alarm of policy mak-

ers, young Japanese women are postponing or refusing marriage and motherhood.

So dramatic is the decline in fertility rates in Japan that it is referred to as

“women’s revenge” against male chauvinism (Japan Aging Research Center, 2000).

Similar trends have been observed in China and other countries.

China’s one-child policy has also generated ramifications that were unantici-

pated when it was institutionalized decades ago. The oversupply of men in China

has resulted in a dramatic need for the repopulation of rural communities with

women, where multigenerational family caregiving, farming, and other tradition-

ally female responsibilities cannot otherwise be met. However, many Chinese

women are simply unwilling to assume traditional roles and functions. Rather

than remaining in rural communities and acceding to these expectations, greater

numbers of China’s women are migrating to urban areas to pursue lives defined

more on their own terms. The implications of shifts in gender-role expectations

such as the foregoing have generated considerable consternation among national

and international commissions and organizations such as the Commission on

Global Aging and the OECD. They have warned that robust national economic

growth rates, fiscal solvency, raised standards of living, the ability of countries to

meet national security requirements, and the internal stability of governments

will depend on the availability of workers. As new policy directions are consid-

ered and legislated, the traditionally male cards of power and privilege may be

reshuffled to benefit or assure equity for women, who ultimately are most pro-

foundly affected by the aging demographic revolution.

Global aging will not occur in a vacuum. Social, economic, political, climatic,

and other trends and forces, including the impact of extant policy provisions, are

shaping the longevity revolution and the quality of life of older persons and their

families in individual countries and the world community.

GLOBAL AGING POLICY AND PROGRAM CHALLENGES

The aging of the world’s population has enormous implications for every facet of

life in the twenty-first century. Social structures and societal processes will un-

questionably require innovations and adjustments to meet the needs of the first

552 C

ONCLUSION

large multigenerational population of older persons in history. Cross-national

policy and research exchanges and collaboration will be essential, but will suc-

ceed only if there is a high level of interest and commitment by nations with dif-

fering immediate and long-term priorities.

Concerted international efforts to develop global consensus and implementa-

tion activities around policy priorities harkens back to the United Nations’ 1982

Vienna International Plan of Action on Aging. The Vienna Plan failed to stimu-

late governments to address challenges and capitalize on opportunities associ-

ated with population aging. It ignored the countries of the developing world and

was dismissed in turn by the resource-rich and rapidly aging developed nations.

The plan failed to speak to the social and economic development of as well as

human rights implications for older persons (United Nations, 2002b).

The 2002 Madrid International Plan of Action on Aging established a consen-

sus aging agenda for nations worldwide. Issues and recommended action steps in

three broadly encompassing areas presented in the 2002 plan corresponded to the

concerns of older adults in both developing and developed countries. The three

issue areas were “older persons and development; advancing health and well-

being into old age; and ensuring enabling and supportive environments” (United

Nations, 2002b, p. 7).

The Madrid International Plan’s attention to the needs of older persons in de-

veloping nations is consistent with three of the eight United Nations Millennium

Development Goals, all targeted for achievement by 2015. These are (1) the eradi-

cation of extreme poverty and hunger; (2) the promotion of gender equity/em-

powerment of women, (3) and combating HIV/AIDS, malaria, and other diseases

(United Nations, 2005). The Madrid International Plan also embraces the five

broad principles for older persons that are at the core of the 1991 United Nations

Principles for Older Persons: independence, participation, care, self-fulfillment,

and dignity (United Nations, 1999).

There is no shortage of global aging issues requiring the attention of world

leaders. Two considered among the most pressing are the need for economic secu-

rity and long-term care. In each of these, as with most aging-related issues, the

particular vulnerability of women is a constant. A third issue that has been

widely noted over the past decade is active aging. All are addressed in the Madrid

International Plan and are examined in the following section.

CONOMIC

ECURITY

The United Nations Development Program defines “income poverty” as having

individual earnings of under U.S.$1 per day. “Human poverty” is the presence of

illiteracy, poor health, and malnutrition (United Nations, 2000). Countries in

which human poverty is an everyday reality are obviously likely to have popula-

tions plagued by income poverty.

The between- and within-country differences in the distribution, dimensions,

and causes of poverty and hunger and gender inequality can be vastly different

in developed as opposed to developing countries. For example, 9.8% of the elderly

population in the United States is at or below the income poverty line. In sharp

contrast, the majority of the world’s elders are impoverished (United Nations,

2000). Two-thirds of the world’s poorest people live in rural sub-Saharan Africa

and South Central Asia (Population Reference Bureau, 2005). Lacking adequate

Global Challenges for an Aging Population 553

income, older persons experience food, water, and housing insecurity, all of

which can deplete their ability and undermine their motivation to participate

productively in the economic, social, and political sectors of their communities.

This feeds further the cycle of income and human poverty.

Only 20% of the world’s inhabitants have adequate social security protection,

and less than 50% have any protection (Van Ginneken, 2003). Social security pro-

grams may insure no more than 10% of each country’s total population in such

developing regions and countries as Southeast Asia, Mexico, and sub-Saharan

Africa. In China, a rudimentary “iron rice bowl” government protection program

was established to offer five basic guarantees to needy elders in their advanced

years: food, clothing, health care, housing, and funeral services (Wang, 2005). A

number of factors, including elders’ official, permanent household registration

versus their actual community of residence, determine whether these guarantees

can be accessed. Chinese residing outside of the communities in which they have

their permanent household registrations tend to be marginalized and are unable

to access health and social services.

In 1994, the People’s Republic of China began the transition from the “iron rice

bowl” to a “porcelain rice bowl” program. The iron rice bowl program was a

socialist-based assurance of employment, with all of the accompanying benefits.

In contrast, the “porcelain” program relies on private insurance, “social pool-

ing,” and individual retirement accounts to encourage the accumulation of ade-

quate retirement resources. As with any option that depends on the private

sector or personal responsibility, poor planning, an unfortunate circumstance,

or a misstep can shatter the porcelain rice bowl and its promise.

The Madrid Plan recognizes that most national programs devised to eliminate

poverty have typically ignored older persons. Noting the longevity and the nearly

universal vulnerability of older women, it calls for the eradication of poverty and

concomitantly emphasizes the magnitude of the importance of assuring gender

equality in social protection schemes. The plan stipulates that a commitment to

income security, social protection and social security, and poverty prevention

programs is now crucial in an undeniably aging world. Consistent with the Mil-

lennium Goals, recent international discussions on the policy directions of

poverty programs no longer cast effective antipoverty programs as solely in the

realm of social welfare, but subscribe to the wisdom of reorienting economic de-

velopment programs so that they empower the poor as a group.

In many countries around the world, the question that is debated is the wis-

dom of full to partial privatization of social security programs, not whether social

security programs should exist. More important at this time is whether and how

private-sector-based investment options should supplement traditional programs

and whether the age of entitlement should be raised, scheduled benefits should

be reduced, or scheduled revenues should be increased—the latter three being

obvious mechanisms by which an entitlement program can be stabilized for the

long term (Goss, 2005). The fundamental issues for policy development include

the following:

• Goals of a social security program

• The roles of the market and the state

• Mechanisms that might assure the sustainability of social security protection

• A financing scheme that would best achieve long-term program goals

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ONCLUSION

• The kinds and levels of benefits and their terms

• Whether and how social security programs might be better linked to social

and economic growth and social entrepreneurship

These questions continue to be examined by OECD, the World Bank, and many

other financial institutions.

In the United States, political perspectives and commitments around the fu-

ture of the Social Security program are deeply divided and are driven by ideolog-

ical convictions and economic interests. In June 2006, the U.S. Senate Budget

Committee alarmed national aging organizations with its approval of Republican-

introduced Senate Bill 3521. This bill would significantly modify federal budget

laws, enabling the privatization of Social Security and the imposition of crippling

cuts to the Medicare program. The bill calls for two commissions, each composed

of nine members of the ruling party and six minority members. One commission

is directed to study and propose unrestricted changes to Social Security,

Medicare, and Medicaid. A second “sunset commission” is authorized to evalu-

ate, summarily eliminate, or otherwise modify federal programs. These commis-

sions may be mechanisms to facilitate the intentions declared in June 2006 by

President Bush and members of the House Ways and Means Committee to priva-

tize Social Security after the fall elections.

Pension systems and disability insurance require a much longer discussion

than is possible in this chapter. They are complex topics and are best discussed as

part of a comprehensive financing strategy that typically would include several

pillars: savings, pensions, social security, and perhaps continuing employment.

Unfortunately, pension and disability insurance programs in many countries are

swiftly eroding and are frequently unreliable. In the United States, for example, a

growing number of employers have ended or are in the process of or are planning

to freeze or end underfunded defined benefit pension plans just as discussions

are raging about the future of Social Security (Arnone, 2005). Recognizing the

fragility of pension programs, the Madrid Plan articulated the importance of en-

suring that pension schemes are characterized by fiscal integrity, solvency, and

transparency. To that end, the OECD’s (2006) recent guidelines adhering to the

“prudent person” rule for pension fund management, that is, the care and skill

with which investment fund decisions are to be made and risks are to be man-

aged by individuals with fiduciary responsibilities, are particularly timely.

ONG

-T

ERM

ARE

Informal care by families is the primary mode of long-term care worldwide. In

the United States, family members provide 80% of all long-term care of older per-

sons informally. About 44 million family caregivers offer millions of hours of as-

sistance valued at $257 billion annually for an average of 4.3 years. (For a

comprehensive review and analysis of family caregiving in the United States, see

Chapter 16 by Montgomery, Rowe, & Kosloski.)

Christakis and Allison (2006) found that caregivers in the United States suffer

from health problems, depression, and, in the case of spousal caregivers, in-

creased risk of dying prematurely. Many informal caregivers, an increasing num-

ber of whom are baby boomers, are twice as likely to be in poverty. Family

caregivers must frequently modify employment arrangements in order to care for

Global Challenges for an Aging Population 555

their relatives. Employment laws do not provide adequate relief to family care-

givers, whose care commitments can extend beyond a year or two and be 24 hours

a day. Support services are often not available and are frequently not affordable,

accessible, or of acceptable quality. Lacking other care-giving alternatives, 9% of

caregivers leave their job and 17% take leaves of absence.

The OECD (2005) recently examined the long-term care policies and programs

in 19 of its member countries. A number of countries have laws that provide fam-

ily caregivers of persons of all ages with varying types of assistance and benefits.

Among the earliest to recognize and respond to the long-term care needs of their

citizens, Sweden and Norway in the 1980s began to offer assistance to elders to

enable family caregivers to sustain their roles in the workplace. The Scandinavian

programs include institutional and home-based care options as well as cash ben-

efits to caregivers. In Germany and France, social benefits are provided to help

informal caregivers. Germany’s long-term care insurance program pays for ser-

vices provided by informal caregivers, home- and community-based services, and

institutional care. Informal caregivers who provide significant assistance to frail

and vulnerable elders also receive contributions to their pension funds.

In 1999, as a part of the Older Americans Act reauthorization process in the

United States, the National Family Caregiver Support Program (NFCSP) was en-

acted, becoming the first U.S. national policy specifically dedicated to the special

needs of caregivers of older persons. Federal funds allocated by formula and

matched by the states have underwritten five sets of NFCSP services, ranging

from information and assistance to caregiver education and respite. Unfortu-

nately, as Montgomery, Rowe, and Kosloski note in their chapter, funding levels

for the program have never been robust enough to meet documented needs.

China’s emerging long-term care dilemmas and the factors that constrain its

capacity to respond to those needs are unique. Following Confucian precepts, the

family unit traditionally embraced filial piety and provided care to its elderly

members. However, changes in the structure, composition, and expectations of

the family have been in process since the Revolution in 1948. As of 2006, about

36% of China’s elders are “empty-nesters.” Sixty-four percent live with adult chil-

dren, who presumably could be caregivers in the years ahead if these younger

adults are not outnumbered by multiple generations of aged relatives, which

would impose a tremendous care-giving burden.

Overpopulation resulting from China’s adoption in the 1950s of the Russian

“Hero Mother” model was followed in the late 1960s by the infamous one-child

policy, which spawned the 4-2-1 problem. There is much discussion and great

consternation in China over the anticipated emergence of a narcissistic society

and the loss of filial piety as a fundamental value. This fear may be warranted as

the sole, doting focus of four aged grandparents and two aging parents is the

family’s singular child (hence, 4-2-1). The reality is that China’s one-child policy

has significantly weakened the potential capacity of the Chinese family to pro-

vide long-term care support to its elders.

The Westernization of the Chinese lifestyle, from low- to high-fat diets to high

levels of tobacco consumption, the replacement of physical activity with televi-

sion watching as the most common activity among elders (Chang, 2005), and

trends such as the nearly wholesale replacement of bicycles with cars as the pri-

mary mode of transportation, have given rise to a higher incidence of chronic dis-

ease. This does not bode well for the future with filial piety a vanishing ethic and