Institutional ageism in global health policyBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4514 (Published 31 August 2016) Cite this as: BMJ 2016;354:i4514
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We welcome Braillon’s response to our original paper , but would like to raise two further points.
First, whilst it is true that health expenditure is generally higher for older age groups, this mainly occurs because lifetime health costs are concentrated in the last months of a person’s life . Numerous studies have demonstrated that the "cost of dying" tends to be lower for people dying over the age of 70 than at a younger age [3, 4]. The concept of premature mortality implies that we shouldn't spend anything on trying to keep people alive beyond age 70, which we consider to be both unethical and discriminatory.
Diagnosing dying and determining appropriate treatments based on the wishes of the patient and family is an important aspect of health care for older people. Unfortunately, some sick older people are not managed by skilled geriatricians, or are cared for in health systems with strong perverse incentives, resulting in over-treatment and inappropriate expenditure. By contrast many older people have potentially remediable conditions that may benefit from treatment and rehabilitation . Foregoing such opportunities by neglecting those over 70 would likely increase institutional care and increase costs of health and social care. This was highlighted in NHS England’s latest figures on historically high rates of “bed-blocking” . In low and middle income countries, access to cost effective interventions is very limited for people of all ages, old and young.
Second, we did not raise the broader issue of allocation of public spending between generations or inter-generational fiscal justice in our paper. Our concern is with the explicitly ageist aspect of premature mortality. We neither attack nor defend current pension policy, nor do we suggest that childhood poverty should receive a low priority. These issues, important in themselves, are of no relevance to our paper.
1. Lloyd-Sherlock PG, Ebrahim S, McKee M, Prince MJ.Institutional ageism in global health policy. BMJ 2016 ;354:i4514.
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Competing interests: No competing interests
Lloyd-Sherlock et al claimed that goals to reduce premature mortality from non-communicable diseases reflects wider ageism (a process of systematic stereotyping and discrimination against people because they are old) in global health policy” but failed to provide evidence.(1)
Indeed, healthcare expenditures increase with age (average spending on 60 year olds is twice as high as the spending for 40 year olds, spending on 70 year olds is four-times as high and 80 year olds have on average six-times higher hospital expenditures than 40 year olds).(2) Moreover, reducing premature mortality may also be likely to reduce morbidity at an older age.
In fact, public health concerns must be about child poverty, first of all. Child poverty has been plateauing in UK since 2004/5 and for the first time in almost two decades it has started to rise in absolute terms (3 see Fig, 4). Child poverty and related social determinants of health negatively affect physical health, socioemotional development, and educational achievement.(5)
Our gerontocratic societies spend more and more to grasp and even extend an already very long end of life. It may get worse as the grasp response, a primitive reflex, correlates with dementia. No ageism since a long time ago Plato claimed, "it is for the elder man to rule and for the younger to submit" (6)
1 Lloyd-Sherlock PG, Ebrahim S, McKee M, Prince MJ.Institutional ageism in global health policy. BMJ 2016;354:i4514.
2 Melberg HO. Are healthcare expenditures increasing faster for the elderly than therest of the population? Expert Rev. Pharmacoecon. Outcomes Res 2014:14;581–583.
3 Pickett KE, Wilkinson RG. The ethical and policy implications of research on income inequality and child well-being. Pediatrics 2015;135 Suppl 2:S39-47.
4 Wickham S, Anwar E, Barr B, Law C, Taylor-Robinson D. Poverty and child health in the UK: using evidence for action. Arch Dis Child. 2016;101:759-66.
5 Hair NL, Hanson JL, Wolfe BL, Pollak SD. Association of child poverty, brain development, and academic achievement JAMA Pediatr 2015;169:822-9.
6 Plato in Bytheway B. Ageism. Buckingham. Open University Press. 1995. p. 45
Competing interests: No competing interests