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Institutional ageism in global health policy

BMJ 2016; 354 doi: (Published 31 August 2016) Cite this as: BMJ 2016;354:i4514

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Re: Institutional ageism in global health policy (response)

We welcome Braillon’s response to our original paper [1], 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 [2]. 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 [5]. 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” [6]. 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.
2. van Weel C, and Michels J. Dying, not old age, to blame for costs of health care. Lancet 1997 Oct 18;350(9085):1159-60.
3. Felder S, Werblow A and Zweifel P. Do red herrings swim in circles? Controlling for the endogeneity of time to death. Journal of Health Economics. 2010 Mar;29(2):205-12.
4. Kaul P, McAlister FA, Ezekowitz JA, Bakal JA, Curtis LH, Quan H, Knudtson ML, Armstrong PW. Resource use in the last 6 months of life among patients with heart failure in Canada. Archives of Internal Medicine. 2011 Feb 14;171(3):211-7.
5. Prince MJ, Wu F, Guo Y, Gutierrez Robledo LM, O'Donnell M, Sullivan R and Yusuf S. The burden of disease in older people and implications for health policy and practice. Lancet 2015 Feb 7;385(9967):549-62.

Competing interests: No competing interests

19 September 2016
Peter G Lloyd-Sherlock
Professor of Social Policy and International Development
Martin McKee, Shah Ebrahim, Martin Prince
University of East Anglia
Earlham Road, Norwich, NR4 7TJ, UK