By Kathryn Kietzman
The field of public health in the United States has evolved from an industrial era focus on sanitation and housing reforms to today’s more comprehensive approach that includes epidemiology, maternal and child health, environmental health, occupational health and global health. Aging cuts across all 21st century public health concerns including bioterrorism, natural disasters, climate change and infectious diseases—but has the public health field come of age? While trends suggest the demographic imperative of population aging is finally capturing the attention of policymakers and planners, is it too little, too late?
Public Health Tools Don’t Necessarily Reach All Populations
The success of early public health interventions has contributed greatly to reductions in morbidity and premature mortality, in turn, increasing population longevity. These advancements are the result of a range of effectively implemented public health tools, including population surveillance and monitoring, health protection through environmental, occupational and food safety, health promotion and disease prevention. But it is important to note that not all older members of our society reap the benefits.
There are notable and egregious disparities in the health and well-being of our aging population. In 2015, the National Academies of Science, Engineering and Medicine released a disturbing report providing evidence that disparities in life expectancy are increasing in the United States. Between 1980 and 2010, researchers found a 12.7-year difference in life expectancy between the wealthiest and poorest men in our society, with the wealthiest men living to 89, and the poorest living only to 76. Disparities between women were even greater: the wealthiest women lived to 92, while the poorest lived to 78.
These glaring disparities indicate that a 21st century public health response requires increased attention to social determinants of health, including race, ethnicity, gender and class, which affect health outcomes throughout the life course. As noted by Steven P. Wallace in 2014, such inequities are avoidable and disparities could be reduced by taking a more upstream approach to healthcare, before the onset of disease or disability. The good news is that our public health delivery system is set up to do just that.
Prevention Efforts Must Include Elders
Public health is rooted in primary, secondary and tertiary prevention efforts that significantly contribute to increased longevity. Primary prevention aims to prevent injury or disease, through, say, immunizations. Secondary prevention aims to detect and treat an injury or disease early on, slow its progression or prevent recurrence. Tertiary prevention aims to ease the impact of long-term chronic disease or disability by optimizing function, quality of life and life expectancy. Yet many disease prevention and health promotion efforts have not been designed to reach the most disadvantaged and vulnerable older adults. And, while investments in younger populations and primary prevention activities are essential to the health of all, additional investments in secondary and tertiary prevention efforts with middle and older-age populations are crucial.
Chronic disease and disability have tremendous implications for population health—not only for those directly affected, but also for those providing care: family caregivers, health and social service professionals, provider systems, and local, state and federal governments. Consider the prevalence of Alzheimer’s disease and other dementias—a public health crisis affecting a sizeable segment of our population and projected to grow exponentially. This disease’s trajectory has profound effects on family members. In response, the clarion call for public health now extends beyond the primary prevention of disease, disability and premature death to include the development and testing of population- and systems-level interventions that have the potential to better manage chronic disease and disability and improve quality of life.
As the implications of population aging become clear, public health professionals are beginning to identify places where public health intersects with aging. Federally Qualified Health Centers, which emerged in the mid-1960s, were intended to ensure that underserved communities would have access to healthcare and social services. While these safety net providers have traditionally focused on the acute healthcare needs of children and young families, many are beginning to respond to the reality that their patients are living longer, with increased disability and multiple chronic conditions.
Another example of public health and aging intersecting is more livable and “age-friendly” communities. We now know zip code more accurately predicts health than genetic code. In response, public health is investing heavily in addressing these geographic disparities. Many of these efforts include the concerns of older adults, who benefit from physical environments that facilitate walking and social engagement, through design that accommodates mobility limitations and optimizes access to opportunities for social and civic engagement.
New Narratives Needed
However, the predominant narratives emerging from public health’s increased awareness of the significance of population aging tend to skew from one extreme to another. One narrative construes population aging as largely positive—preventive interventions early in life lead to healthy aging and opportunities to contribute to population health and wellness through continued productivity. The opposite narrative portrays aging as a time of increasing deficit and decline—while living longer, we are more likely to be living with multiple chronic conditions and disability, to be a burden to our families and to society, and to become dependent on under-resourced and ill-prepared public programs.
While both are valid constructions for portions of the aging population, most aging adults fall in between. A more nuanced narrative would better help to advance public policy that addresses the needs of an aging population, one in which aging is presented as the “new normal” from which the field of public health can craft a more reasoned response to the diversity inherent in any definition of population aging.
So, does our 21st century reality demand a recalibration, a new definition of public health? Perhaps not. If the principles and the practice of primary, secondary and tertiary prevention are more fully exploited, and effective interventions are designed to be appropriate for, and accessible to, all segments of the population, we can better serve an aging population and achieve better outcomes. One major hurdle is getting the public health community—and better yet, society at large—to dispel its inherent ageism and embrace the notion of prevention at any age and at every stage. The Leaders of Aging Organizations provides some hope through its recent launch of a robust, long-term effort to examine ageism and reframe the narrative perpetuated by the media, advocacy organizations, experts in aging and the general public.
Another hurdle is getting policymakers and program planners to take a longer view and recognize the payoff that will come from investing resources in multiple stages of prevention across the life course, resulting in reduced rates of morbidity, improved quality of life and healthier and more productive communities. One important step is the implementation of multi-sectoral and evidence-based collaboration models, such as Sickness Prevention Achieved through Regional Collaboration (SPARC), that leverage existing community resources to build robust networks organized around specific prevention efforts.
As noted by Lynda Anderson and colleagues, opportunities to address the health and social care needs of an aging population abound, especially through evidence-based community programs that improve function and quality of life. But we still have work to do. Prohaska and colleagues identify a need to increase efforts to translate research about effective interventions into community-based programs. They also recommend additional research that better represents minority and disadvantaged older populations.
With a little tweaking, the tried and true tools of public health should work just fine. We just need to ensure that the tools are appropriate and made accessible to all members of our increasingly diverse aging population.
ASA Board member Kathryn G. Kietzman, Ph.D., M.S.W., is a research scientist at the UCLA Center for Health Policy Research in Los Angeles.
Editor’s Note: This article appears in the July/August 2016 issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store or Join ASA.