The price of success – and how can we ensure that we can afford to pay it?


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Talking to a Sri Lankan friend about his 80-year old mother, who has been living alone ever since his father passed away 4 years back, brought back memories of my own mother who passed away at the age of 76 in 2008. As my Sri Lankan friend was worried about his mother’s living arrangements (he is happy to have her move in with him, but she prefers to stay alone in the house that has been her home for 46 years), I began to muse about my own father who lives alone at 85 years. He is in reasonable health for his age, and is largely independent, except that he needs oxygen support every night while sleeping as his lungs have lost significant capacity due to fibrosis, and his eyesight has deteriorated considerably. I was feeling guilty for not taking care of him in his old age. Again, it is his decision not to move in with any of his children, as he wants to stay in the apartment which he is familiar with and to be ‘independent’. We have appointed a care-taker who stays with him all day, while my sister and brother-in-law who live just a kilometer away give him company in the nights. Still the guilt feeling is no less.

The fact is that the situation in which my friend and I are in is not an exception. It is no longer unusual even in South Asia, where we used to pride ourselves in the family-based social support system, which has all but vanished in the West. Parents here can no longer count on their sons/daughters to stay with them and take care of them in their old age; in fact, the reverse is becoming true in many cases: some couples (or even elderly singles) are helping their children’s professional careers, by taking care of their grand-children (we have heard that old age is a second childhood; but in these case it is also a second parenthood of sorts!); they may enjoy it, and this does make them feel more wanted and needed, but it could easily become a burden. As the economic landscape is changing in South Asia, fundamentally altering our societal norms as well, we too are losing the traditional systems of taking care of the elderly. At the individual level, this is a price we pay for professional and economic success.

That is just one result of demographic transition; before we get into other important implications, let us understand this term. Simply put, it refers to changes in age-sex composition of a population over time, as a country ‘develops’. Though there are several stages of demographic transition, which affects the proportion of all age-groups, we often simplistically call it the “aging” of a population. How can a whole population be “aging”? Isn’t aging an individual phenomenon? Well, what we mean is the increasingly larger proportion of older people in a population. This is basically the result of increased longevity and reduced fertility that usually accompany economic growth. As more and more people live longer and we produce fewer children, it stands to reason that we would end up with proportionately more elderly. The stage of transition of a given country and the pace of change depend on the speed and effectiveness with which public health and population control programs were undertaken. Generally the more developed a country is, the farther along in demographic transition it is. Sri Lanka has been experiencing a much rapider transition than countries of similar economic level, because of its very successful public health measures and faster fertility reduction. At a societal level, demographic transition and its implications are a price that Sri Lanka has to pay for its remarkable health gains over the past decades.

Demographic transition affects every sector of the economy, and is usually accompanied by what is called epidemiological transition: a shift of disease pattern from predominantly infectious diseases and maternal & child health to non-communicable diseases (NCDs). Having effectively addressed most of the former, Sri Lanka is facing a growing burden of heart disease, cancer, diabetes, asthma and other chronic diseases, associated with lifestyle and with old age. NCDs are often erroneously labeled as “rich man’s diseases” (apart from the gender-insensitive usage, the label ignores the fact that NCDs do affect the poorer population as well). An increase in mental health problems and injuries is also seen with urbanization and economic growth. Because of the exceptional pace of the Sri Lankan demographic transition, this country is dealing with these two transitions with a much smaller resource base than most developed nations. Again, a price of unusual success!

As NCDs become more predominant, one consequence is the increased cost of health care, as they are more expensive to diagnose and treat compared with the infectious diseases (another reason perhaps why they are called “rich man’s diseases”). On the other hand, the poorer people afflicted by NCDs find it much harder to access treatment and care. Another important characteristic of the Sri Lankan situation is that NCDs disproportionately impact the male life-expectancy - possibly because of higher rates of smoking and alcoholism among males than among females, but also because of differential health-care seeking patterns. One factor that contributes to lower utilization of health care by the males in Sri Lanka is the fact that outpatient services in the public sector close at 4 pm, making it more difficult for working men to seek care. While women are said to have a biological edge over men in terms of living longer anyway, the difference between female and male life expectancy in most other populations is 3-4 years, while in Sri Lanka it is unusually high (8 years).

The seriousness of this issue can be understood better when one considers the challenges faced by elderly women forced to live alone and fend for themselves – often under more severe financial stress given their lower levels of labor-force participation, resulting in less financial security in their old age. Modernizing the Sri Lankan health system to meet the new challenges posed by NCDs, while consolidating the past gains with regard to infectious diseases, maternal and child health and addressing some unfinished agenda (like under-nutrition) is going to require significant reorganization and additional investment. In a way, the transition is an opportunity for the Sri Lankan health sector to leapfrog to international standards.

Demographic transition is an insidious phenomenon that takes decades and its impacts are not felt dramatically (unlike disasters like floods, tsunamis, earthquakes and other such events). Almost like climate change, it creeps up on us, and in the absence of an immediately visible crisis, inadequate attention gets paid to it by policy-makers and planners. But being ill-prepared to handle the implications of the transition would surely have serious consequences in the medium to long-term, for the economy, and for the future effectiveness of the health system.

It must be emphasized that demographic transition is not all bad news; it throws up opportunities as well as challenges. Nobody in their right minds would argue that it was a mistake to increase life-expectancy or to reduce fertility; reversing these steps is certainly not the prescription for addressing the transition – that would take us backwards in the development continuum. What is important would be to put in place policies and programs as to make full use of the positives while ensuring that the country is better prepared for the future implications. Doing so will enable countries like Sri Lanka to manage the transition and its impact much better. In other words, let us shape the transition, rather than let it shape our destiny!

One positive perspective that is often cited is the prospect of reaping a “demographic dividend” or “demographic bonus”, when a country is going through the transition; this refers to the benefits to the economy that could be obtained by leveraging the relatively large labor-force that is still available before the country moves into the final stage of the transition that comes with a shrinking labor-force. This is possible precisely because demographic transition does not happen overnight; notwithstanding the relative fast pace of change in Sri Lanka, it still does allow sufficient time for us to take necessary action if the policy-makers and planners have the foresight to think long-term. The window of opportunity is still open, though some experts fear that it may not last longer than a decade or two; if taken advantage of, the “demographic dividend / bonus” could add significantly to the economy. Et voila! We have the answer to the question posed in the title of this blog.

For more information on Tackling Non-Communicable Diseases. check out the Feature Story.


Join the Conversation

Vijay Jagannathan
February 22, 2011

I read the blog with great interest. The development literature hasn't paid enough attention to the issue of how quickly demographic transition affects urbanization patterns. Yes, the world is rapidly urbanizing, with over half the global population now residing in cities. However, the infrastructure being built for this large populations may end up in a lot of over-investments and unnecesary loss of farm lands close to cities. In Japan for example, as populations have aged cities no longer need housing on the same scale, and there has been a dramatic shift from spatially dispersed communities towards more 'compact cities'.

Homira Nassery
February 22, 2011

This is an excellent article that takes the personal and elevates it to the policy level Sundar. I particularly like the implications of NCDs and aging on urban planning pointed out in the comments, which is an angle few people are aware of right now. In addition, the lower uptake of health services by working males is an important health systems issue that should be addressed by balanced planning, but with the focus on MCH (which is valid too), men's health needs are falling by the wayside as donors tend to flock in the same direction simultaneously. Plus, men should be educated in MCH issues as they are usually the decision-makers in the household. Even though we're talking about it, and the NCD summit in September should bring more focus to it, I fear that the real impact of NCDs and the aging transition will be underestimated as you suggest.

Ram Bansal
February 23, 2011

Price of success is sacrifices not only by the individual but by all those linked to him/her in many ways. Leaving the elderly at home for taking up cherished profession is one price that is being paid by many youths and their parents.

Sundararajan S. Gopalan
February 24, 2011

I agree with your comment. Also to be borne in mind is the unplanned nature of urbanization in many of our developing countries, which allows little or no room for incorporating important elderly-friendly features like accessibility, recreational parks, safer walkways, greater public transportation (as the older people are less likely to be able to drive their own cars), and housing that has features such as anti-slip tiles in the bath-room, better lighting, louder door-bells, and such things.

Sundararajan S. Gopalan
February 24, 2011

Thanks Homira. Good point that the men should be involved in MCH issues as well as NCD issues. The problem is that men are generally careless about health. But in Sri Lanka the problem is compounded by the fact that all outpatient services close at 4 pm and therefore working men cannot seek health care without taking the day off.

Sundararajan S. Gopalan
February 24, 2011


February 24, 2011

What are Sri lanka doing to combat clinical waste? Can you report back on this? As this also should be a priority in disease prevention

September 25, 2012

Why is it that the poorest have the most kids?