The Challenge of Matching Health with Longevity

 

Abhaya Indrayan

Biostatistics Consultant, Max Healthcare

Formerly Professor at University College of Medical Sciences, Delhi

 

The World Health Organization supported Global Burden of Disease initiative regularly publishes estimates of how long people live (expectation of life at birth) and how many of those years are lived in good health (healthy life expectancy) for all member countries. In India, life expectancy was 67.3 years in 2021 but the healthy years only 58.1 – a gap of more than 9 years lived in poor health. In Japan, where the life expectancy was the highest at 84 years, this duration is about 11 years. These estimates suggest that at least one-eighth of life is spent with some kind of disability. In fact, it is much more since healthy years are adjusted for severity in this calculation. For example, a year lived with a hip fracture counts as 0.75 years in good health, while a year of blindness counts as only 0.2. When the sick duration is considered in full, nearly one-fifth of life suffers from some functional limitation, and only the other four-fifths is in good health. The period with functional limitation is increasing over time in many countries as the incidence of chronic diseases is increasing with age and rapidly expands in old age where it may be even more than half of the remaining life. Can we shorten the period spent in poor health so that the healthy years nearly match the longevity?

 

What does it mean to be healthy?

Health ideally is complete physical, social, and mental well-being as defined by WHO but medically this is the state when the body, mind, and soul are able to adjust to the aberrations occurring due to factors such as infection, stress, and injury, including those caused by environmental conditions. Called homeostasis, this process of adjustment goes on all the time in our body such as shivering in the cold and widening of pupils in the dark. Our functional performance is optimum when homeostasis is going on well. Social, mental, and environmental factors also contribute to this optimization. Factors such as physical degeneration, stress, and injury sometimes cause severe aberrations beyond the capacity of homeostasis and give rise to ailments that need external help in terms of treatments.

Much of old age across the world is spent in some kind of infirmity, mostly due to degeneration, with enormous social and economic cost. This takes away the happiness, makes one dependent for healthcare, requires frequent visits to the hospitals, and spend substantial resources on treatment. The suffering is not limited to the self but extends to the family and the society. The paradigm of adding life to the years opposed to years to life has been widely discussed without much progress on the ground.

My father lived for 96 years with no apparent ailment requiring treatment. Although he performed his daily routine himself, he was frail and not able to walk normally at the fag end of his life. Degeneration was there for everyone to see. None expected that he would do as much as he was doing in his young age when he actively participated in freedom movement, but was he healthy? He probably met familial and societal expectations for his age, but his abilities were surely restricted. Frailty in old age causes severe restrictions but is rarely counted as disease by the society, not even by medical profession.

 

Can we choose the cause of death

Most health programs focus on reducing deaths from all causes. Since death is a certainty, there is no way to eliminate all diseases – people will die of some ailment. The causes compete with one another – if one declines, the other increases. There is a need to realize that death can only be postponed, not denied, and it needs a cause.

Since all causes of death cannot be eliminated, we have to choose one we prefer over the others. Someday the medical science will give a choice to decide how one wishes to die – by cancer or heart attack or any other condition. A disease such as cancer, and possibly mental conditions such as Alzheimer, often inflict more suffering for longer duration for the self, family and the society than cardiac ailment. Though many would question, there is a case to promote sudden death by cardiac diseases in old age but do all we can to stop the diseases that cause functional disabilities for long duration. Some of us may like to see a day when everyone dies suddenly in old age with minimal suffering. However, there is a con side to this. Sudden death means no time to meet the near and dear ones, share the blessings and advices, say goodbye to them, and settle the accounts. A wiser course could be to realize imminence of death in old age and do all this in time without waiting for the last day.

 

From death to burden of disease

The health systems should work on minimizing the duration of ill health rather than trying to control deaths by certain causes as is currently done. To address the duration and intensity of suffering from ill-health, the focus must shift from mortality to morbidity, particularly in countries where most deaths occur in old age. Since morbidity has not received much attention yet, the data on duration and severity of conditions is scarce. The Global Burden of Disease group estimates these for various ailments, but the data are sparse and the estimates are somewhat guesses. Better statistics and their close examination can help devise targeted strategies to ameliorate the suffering. Interventions that address the conditions such as musculoskeletal infirmities, sensory impairments, and vision loss need priority in old age than postponing mortality through ventilators, defibrillators and heart-lung machine. Research should focus on duration and severity of morbidities rather than merely presence or absence of disease.

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Reducing the burden of suffering

Suffering during the period of ill-health can be reduced by convenient and accessible health care, particularly in old age. Compassionate healthcare can ameliorate the suffering and reduce the intensity and duration of pain. Returning to our erstwhile family system, where elders were seen as assets, not burden, can be a big game changer. Suffering can be turned into pleasure when the family and friends gather around and raise the occasion to provide care and respect. The present trend does not give credence to this happening any time soon as most of us are moving in the reverse direction.

Healthy lifestyle with no tobacco, nutritious diet, and staying active can also reduce the period of suffering but the evidence suggests that this can increase longevity and not reduce the unhealthy period. Sufficient details are not available yet regarding the type and amount of these preventive activities that would reduce the period and intensity of ill-health opposed to death.

Medical science may soon strive to separate risk factors that contribute to morbidity and death early in life, particularly by cardiac ailments, from those that cause sudden death in old age. The former to be fiercely controlled but the latter to be promoted to help us leave the word swiftly in old age with dignity.