Abstract

Ageing is one of the most significant social transformations of the twenty first century around the globe. The largest age cohort that is expected to grow in the developing countries further in the next three decades is that of the older persons i.e. above sixty years of age. This is a Review paper sheds light on understanding ageing as a natural phenomenon. There are numerous socio-cultural factors impeding in acceptance of this reality. In Pakistan, age inclusive sustainable development goals are desired to tackle unemployment and underemployment institutional care is the need of the hour. Keeping in view the population projections of 2050, there is a dire need to strategize for population aging through policy making and implementation from both public and private sector of the country. In Pakistan the disjuncture of apt measures taken by the stakeholders, can multiple volume and graveness of the issue

Key Words

Ageing, Elderly, Longevity of Life, Old homes, Self-Perception, Vital Ageing

Introduction

Ageing in an organism, marked by the progressive transformation or the decline in one’s ability reducing the capacity to cope with the metabolic stresses (Rogers, Simic, & Guarante, 2019). The classical theories of aging hold the view that extrinsic mortality is the primary evolutionary driving determinant of aging.  The factors of external mortality could be disease, starvation, accident or predation etc. (Johnsonl, Shokhirev, & Shoshitaishvil, 2019).  Ageing in this way is never a cause of death but the age bound  diseases which lowers the immunity of human body and molecular imabalances incurred due to living long. Life span is the number of years any human can live at its maximum whereas, the average number of total years a human is expected to live is termed as Life expectancy. Life span of human beings has stayed constant for about 125 years but the life expectancy are projected differentlly after every decade based on the medical advanvcement pertaining to cope with ageing disorders  (Hayflick, 1998) &  (Hayflick, 1996). Nevertheless, People consider ageing as a certain stage of life rather than a process.

Phenomenon of Aging

Ageing is a subjective phenomenon which varies in its perception from society and individuals. In terms of the societal perspective, generally negative implications are attached to it. It is believed that age affects health and vitality in a negative manner, whereby human aging is a more complex phenomenon (Singh, Demmitt, & Ravi, 2019). However, population ageing is a result of demographic transition resultant of increased life expectancy and declining fertility rates that results in increasing proportion of the elderly (above 60) (World Health Organisation, 2010). It was not until the 19^th century that a threshold age was attached to the concept of ageing i.e. “60 years” (Hamilton, 2011) & (Mullan, 2002). Between 2015 and 2030, the number of people aged 60 and over is expected to increase from 901 million to 1.4 billion (United Nations Depatment of Economics and Social Affairs, 2019).

Ageing is also an individual experience apart from population ageing. Individual ageing is associated with functional loss and illness (Fernández-Ballesteros, Robine, Walker, & Kalacahe, 2013). In terms of ageing as a lifelong process, it spans over the human life whereby it is not only determined by (intrinsic factors) ones genes and age but also by the personal and behavioral events and determined by the (extrinsic factors) socio-environmental factors (Bandura, 1986) & (Bandura, 1997). The image of being aged is two tiered—the individual level and the societal level. In order to gain a comprehensive yet contextual knowledge of ageing, we need to accept its impact on one’s self-perception or self-image. Also, there is a need to understand that how the larger societal population contrasts older persons with the relative stigmatization pertaining to age (Christina, 2005). There is a common paradigm which looks down upon the aged and the ageing phenomenon. Aged people need to be valued and respected. Most of the elderly aspire to honor and thrive for living in their actual age. However, this type of aging is rampant.

Terminologies on Ageing

There are certain terms used in conjunction to aging such as healthy aging, successful ageing, vital aging, productive ageing and active ageing. The terms ‘vital ageing’, ‘productive ageing’ and ‘active ageing’ are synonymously used which implies an ageing period based on vitality and sustained heath, as contributors to society rather than being dependent, ill or disable (Achenbaum, 2001) &  (Butler & Gleason, 1985). The satisfaction achieved out of life, growth and mastery, freedom from disability, longevity of life, and active engagement in life are termed as ‘successful ageing’  (Moody, 2005). The span of life of an individual is termed as longevity (Rogers, Simic, & Guarante, 2019). The term vital ageing refers to a lifelong process that enables to create meanings, achieve potential and enrich life by developing connections and making contributions to the community (Vital Aging Network, 2019).

Table 1. Population by Age Groups across Pakistan

The unprecedented effects of the globalized health care economy will at some point of time in near future roll back to a developing country like Pakistan as well. The current situation of Pakistan, according to the data extracted from the latest Population census of 2017 represents that almost 7.5% Pakistani population comprises of the older persons. 25% population is based on the youth. However, more than 60% people belong to the productive life span. The increasing longevity of life and prolonged life span are likely to posit serious threats to the health care and employment sector. Pakistan like many other developing countries is going through a demographic transition. Populating boom is resulted from low fertility rate and a consistent improvement in life expectancy (Elahi, 2012).  Lack of awareness has resulted in overpopulation that has worsened with poverty, and hence compromised quality of life for the elderly. Resultantly, advocating the rights of elderly is an imperative; especially equity in health care and social support services. It cannot be achieved unless prudent resource allocation is made to meet the needs of ageing population in managing their health and wellbeing. Longevity of life has opened certain challenges as well, but they could be coped up with modifiable ageing, eliminating disability and mainstreaming the ageing population in productive abilities (Christensen, Doblhammer, Rau, & Vaupel, 2009).

Ageing challenges in Pakistan

Population ageing is the emerging challenge to a country like Pakistan where it is underscored as yet. The gradual shift in population dynamics have led to several changes in demographic factors. Migration, fertility and mortality are the key drivers in demographic process which determines its age and size. According to OEC, the Pakistanis who have migrated for jobs since 1970s are around 8.7 Million (International Labor Organisation, 2015). In a country like Pakistan which has a huge population of around 200Millions people, 8.7 Million migrants are not too much. Fertility in Pakistan has been above replacement for most of its history, with the levels approaching 7 births per woman in the 1960s, declining to around 6 in the 1980s and to its current level of 3.7. The fertility replacement rate is considered high when it exceeds 2.1 (Population Council Book Series, 2013). The average fertility rate of Pakistani women in 2017 is 3.6 (World Bank Group, 2019).  The main cause of the population decline is due to mortality rates. Pakistan has seen a dynamic improvement in terms of life expectancy from 1950s to date. From 1950-1955, when it was 41 years of age, the current statistics determine the average age at 65. The global awareness on health and improvement in medical technology, improved standards of living and better medical care have led to the fact that over next thirty years, by 2050, the life expectancy will reach up to 72 years (Population Council , 2013). The major influence of mortality decline will continue to rise in terms of a large cohort of the aging population in Pakistan.

The world’s attention to this issue was sought for the 1^st time in Vienna in 1982 in a . UN General assembly‘s conference of the theme of aging. By 1991, key principles for older person were adopted by the United Nations pertaining to care, dignity, self-fulfillment, dignity and participation. The 2^nd conference on ageing was arranged by UN in 2002 in Madrid. The projections given by world population prospects suggest that the world’s population is going to be doubled by 2050 and triple by 2100. In 2017, the aging population estimates of the world were 962 Million, which will rise to 2.1 Billion and 3.1 Billion by 2050 and 2100 respectively (United Nations, 2017). Internationally, the largest share of aged population in the world belongs to Europe i.e. 25%. The latest statistics on World Population prospects suggest that by the year 2050, one in every sixth individual will be aged, above 65 years of age in the world which will be 16% of the total world population as compared to the current statistics which is currently one in 11 i.e. 9% of the population  (United Nations, 2019).

Pakistan is one a leading abode to the ageing population, but the dilemma is that most of the ageing population lives in poverty. Since most Pakistanis are dependent on agriculture, there are fewer opportunities limited to agriculture and informal work on which most of them rely for most of their lives. This leaves with very few pensions or a reliable income sources on which they can reply in older age. This often leaves them dependent on their families who often keep on struggling to provide for them. The family structure in the country persisted to be expanded and extended where elderly were responsible for socialization of the younger generation (Chaudhry & Zeeshan, 2019). With increasing pace of urbanization, rural urban and international migration, the familial bonds are weakening. The family ties are loosening into more of the nuclear family setups where people detach from their aged parents either due to employment opportunities and better education. The needs of the elderly differ from the productive age span. Older people who live a lonely life, have disabilities, need to care for their young children or if they are single either widowed or divorced are particularly vulnerable in terms of financial insecurity.

Figure I. Estimated Age Wise Population distribution of Pakistan in 2019

The figure above provides a view on the age and gender wise distribution of the Pakistani population. On an average, currently 6.5% Pakistani population comes under the category of the elderly; above 60 years of age which means around 13 Million elderly which is indeed a huge number for a developing country. In terms of healthcare facility, barely lies a concept of retirement or Old Age Benefit programs except for those who were associated with the formal employment sector or have pensionable jobs. In hospitals, the concept of geriatric ward is new which has recently been asserted and the idea is making its place to address the specific age bound needs of this cohort. By 2016, only one provincial government has taken it on its mandate to establish the geriatric facility in the government hospitals (Help Age, 2016).

General Perspectives on Ageing

The two conceptualizations of ageing yet distinct from each other in perspective are; an internal view which stresses the affective role of the elderly generated out of their personal philosophies that holds a positive impact, leading to their improved quality of life and wellbeing. The external view has more of a utilitarian approach which stresses the societal contributions of the elderly as individuals, groups, families, organizations or communities (Lenard, Butler, & Webster, 2003). Ideology behind both is to engage the elderly in social, economic and physical environment where they could direct and engage in various tasks. Knowledge, resources, assets, skills and capacities of the elderly are accentuated rather than needs, deficiencies and problems. The very paradigm of productive ageing hence transcends beyond the functional and physical status of the older persons. It has direct implication on health and helps both in traditional and nontraditional service setting.

Here we need to bring in the notion of ‘ageing stereotypes’ or ‘perceived ageing’. The recent study which was conducted in metropolitan city of Pakistan that I referred was focused on bringing the perception of elder people with specific distinction of age groups. Its highlights show that “Old Age” is perceived as alternate of illness and diseases (Ahmed & Chaudhry, 2015). Not only this, they had a perception of social isolation and ignorance attached to it as well. the research results concluded that in light of existing knowledge, it was reflected that if positive stereotypes exist among OPs then they would have spent this phase of their life actively and healthily while on the other hand if feeling and perception continue to persist in negative direction no matter whatever the background characteristics were or will be, then these life ending years will continue to be the burden the living elderly.

Discussion and Analysis

The following section lays stress on certain points. Firstly, how we as a nation need to stress on the emerging challenges of an ageing population by making a distinction in bio-gerontology and geriatric medicine. Secondly the current and emerging challenge of population ageing in Pakistan. Thirdly, age inclusive sustainable development goals, fourthly unemployment and underemployment in terms of the most productive age cohort, fifthly; institutional care for the elderly, sixthly; current challenges and way forward.

The focus in our society is laid only on the medicinal aspect of ageing rather than the biological aspect which lacks local scholarship. This is where we need to distinguish age from disease, since there lays a general perception which blurs the boundaries of the two, ageing is taken as a resolution to death which is supposedly believed to be accompanied with functional impairment, cancer and cardiovascular diseases. The criterion on which age differs from disease process are four; It occurs in all species, every animal upon reaching adulthood and certin size face it, all members of a species after reproductive success and it happens even if a certain proprtion of a species is removed from the mainstraem populace under specific conditions  (Hayflick, 2000).

When society looks down upon the process of ageing, the very notion of anti-aging emerges and gets widespread (Samples, 2019). We are unable to distinguish between research on ageing i.e. ’bio-gerontology’, ‘the natural process of ageing’ and age bound medicines i.e. ‘geriatric medicine’, which leads to social, political and scientific consequences (Hayflick, 2000). Healthy ageing can be maintained by a balanced and age apt diet, physical activity and a meaningful social life (Psychology today, 2019). Diet not only focuses on meeting the caloric requirement, but also the nutritional a balance. Nutrition holds promises as a preventive strategy against cognitive decline while aging (Vauzour, et al., 2017).  Health systems are generally structured to deal with episodic, acute illnesses and thereby less able to deal with long term and chronic illnesses especially in the developing world (Help Age International & AARP, 2018).

Population Ageing in Pakistan

Population aging is driven by three demographic drivers: birth, migration and mortality. However, there is a constant and substantia

l increase in aging population expansion since 1950s due to increased life expectancy (United Nations, 2019).  Increased longevity of life and declining fertility are the key drivers which have added this cohort of population. Passing by the streets and roads, we often see older people sitting on the foot paths, facing issues crossing the road, walking, engaged in labor and moving around which reflect a helpless image of the elderly in a society where we are living in. On the contrary, we can observe a different scenario while moving around an elite sector of an urban setting where most of the older persons appear to be fortunate enough since they are able to afford the caretakers or their families are affluent enough to take care of them.

The issue of ageing population is going to be serious in future in the entire world, but it will have its own repercussions in our country. Currently, the largest segment of Pakistani population is comprised of youth. As per the statistics shared by UNICEF, we have around 60% population who belong to this segment. Pakistan has a total of 60.4 % population from age 15-65 years currently (United Nations Population Fund, 2019). The seriousness of the issue will turn to be massive within three to four decades in Pakistan when these youngsters will reach a certain ageing, where they will termed as the senior citizens, older persons or the elderly which is marked at 60 as per the International standards. Currently 3.1 Million people in Pakistan enter the labor force, out of which 2.1 Million are from youth which will continue by 2050 (Hussain, 2013). The following figure is a projection of the population cohorts in Pakistan by 2050, population ageing will resultantly double the growth of the older persons to 12.5%. The question is raised on the emerging challenges and our preparation to address them.

Figure 2. Population Projection of Pakistan for 2050: 309,639,864

Age Inclusive Sustainable Development Goals

The journey to age equality on the International day of older persons, 2019 takes into accounts the sustainable development goals and 2030 agenda. Promotion of active participation of the older persons is the key to all inclusive and comprehensive development since its takes into account the economic, political and social dimensions by reducing inequalities (United Nations Depatment of Economics and Social Affairs, 2019). Keeping in view that Pakistan belongs to the developing countries, which are facing multilateral challenges in terms of management of population outburst and limited resources, even then according to the Human Development Index, Pakistan is ranked in the medium category as per the indicators. Currently we are facing grave challenges related to the basic subsistence needs of our population. Amongst the marginalized segment of our population, children, women and elderly, the most neglected segment of the society are older persons. At the state level, both in terms of planning & policy, are unable to initiate any intervention programs to cater their needs or to provide them with a dignified livelihood.

The Sustainable Development Goals comprising ageing are sub themed on universal health coverage, lifelong proactive and learning and adaptive labor policies, social protective measures and the care sector (United Nations Department of Economics and Social Affairs, 2019). Health issues are prominent in Pakistan thus non-contagious diseases are often ignored hence our health sector is inadequately equipped to provide care to the elderly. In order to understand the health of the elderly, we need to have geriatric specialists who are not yet present in most of the public sector hospitals of the country. According to Help Age International, a country like Pakistan, which is prone to natural catastrophes such as droughts, floods and earthquakes in recent years, faced emergencies. At such times, the older people are at most risk since they need assistance in reference to their specific needs” (Help Age International).

Unemployment and Underemployment

The dilemma is that more than half of this youthful segment of the society is unemployed, or we may say unproductive in economic terms. If they continue to stay dependent on their families, parents or siblings or they keep on getting attached to the part time, ad hoc based menial jobs (under-employment), they will never be able to get financially sound and stable. This in turn is leading to delayed age of marriage or even staying single throughout their lives to avoid sharing responsibilities attached to their families. The statistics show that more unemployed segment of the youth is more educated than the non-literate. Also, lack of vocational training institutes and the aptitude towards it has worsened the employment situation.

Reference to the context of unemployment and the allied challenges of the youth, there is a dire need that the government and the nongovernment stakeholders step forward and work together; partake to share their contribution in an articulated framework of policies that ensure maximum utilization of resources and synergy. There is a collective need to invest on our youth through better coordination of the public and private sector which will not only improve support but will also identify wherever there is a gap to address (Sathar, Kamran, Maqsood, & Hussain, 2016).

Institutional Care for the Elderly

When it comes to care and nursing facility to the elderly, the general idea is related to the normative order of the society where children and families are expected to look after them. Apart from the institution of family, barely lies any room for acceptance of any formal, institutional health care facility for the elderly. However the increasing population ageing and the upcoming challenges are going to be intense. All the stakeholders need to understand and ensure their active participation for both informal and formal care and nursing of the elderly both at government and non-government level. Currently, old homes are established by the government, only in a few major cities of Pakistan which are limited to provision of the facility to a few people. Most of the facilities are not designated solely for the elderly such as Edhi welfare have 18 centers across Pakistan but they are meant for the destitute and needy people across all age groups. Initiatives taken by Bahria town, Saylani welfare trust and several others are also pretty limited in numbers and limited to main cities.

The 1st clause from article 14 of the constitution of Pakistan is based on ‘inviolability of dignity of man’ that ensures to safeguard their basic right across all age groups (National Assembly of Pakistan, 2012). However, the very right is not enforced the way it has been constituted. Also lack of policy making on the national level can bring social catastrophes in future. The situation is alarming and we need to seriously address the challenges posed by ageing. On one hand, medical sciences have contributed to the longevity of human life in most parts of the world including Pakistan where an average human being lives up to 67-68 years. On the other hand, we have not yet planned for their physical, economic and socio-cultural needs of the time.

Way forward: Vital Ageing

There is a need to foresee that the rush to urbanization has turned our cities to slums rather than metropolis. Affording a respectable or decent living of the older persons in cities is getting difficult day by day. Health, hygiene and nutritious food aside, we only focus on the medicines. Here we need to understand that there is difference between medicines in general and the ones pertaining to geriatrics. In a country like Pakistan where ageing is perceived to be an illness or disease exactly like that of pregnancy, it is extremely challenging to educate the masses on the notions of active and vital ageing. Though this notion was and continues to prevail in some of our rural areas and also in the educated middle class of the country.

On one hand the world is stressing on the significance of physical health care of people. Medical science in advanced countries are working with human stem cells to slow down or even mute the process of ageing for longevity of life, yet on another hand a country like Pakistan is still in a dilemma of accepting this reality. The unprecedented effects of the globalized health care economy will at some point of time roll back to a country like Pakistan as well, where we already have a lot to face in terms of demographic transition. Having the largest chunk of ageing population seems more of a threat rather than a blessing for resource deficit rather poorly managed country like ours. In this scenario, we need to understand the psychological wellbeing of the older persons as well. Apart from the physical well-being of the individuals, psychological well-being counts a lot. In fact, it is the psychological wellbeing of the individuals which affects positively. their physical health. Rather than keeping our social institutions of intact and generating a sense of belongingness among our elderly, we are facing a lot of issues pertaining to broken families and ultimately isolation.

The study leaves us with a question mark on our perceptions or cultural portrayals of different ages of our lives. How a natural process that could have been perceived as a life cycle stage is challenged by associating it negatively based on the socio-cultural myths and the harsh economic realities which in turn deteriorate our self-image, self-esteem and rather than associating ourselves with the notion of productive ageing we establish a negative self-image pertaining to the old age. An older person could only live with full vitality if he has a positive image of the life he spent; successful ageing, has a high self-esteem, was engaged in productive labor or work in past, was skillful. Only then, he will conceive of ageing positively and will then be able to participate productively both in his private and public sphere. The very notion has been discussed by the geriatric paradigm of internal and external experiences that focus on the familial and societal domains. In an environment where they are continued to be underscored or considered un-productive, they will never be able to create their space as vital individuals.

Conclusion

For a country like Pakistan, where the idea of care homes for the older persons is tabooed, planning and managing for such individuals is extremely challenging. The idea of destitution is all that emerges when we start planning in this domain. Rather than facing the real cultural face by examining our ground social realities, we are still living in the fool’s paradise where we have not opened up our eyes to the emerging challenges of the older persons in near future.  Apart from considering ‘ageing’ an agenda presented by the development paradigm, we need to revive raise our collective consciousness which was always pro-vital ageing. Where having elderly in the family was a blessing rather than a curse, where they were always revered and looked forward to while making significant decisions. Entrusting them with positive self-image and shedding the polluted perceptions of ageing will serve to reinstate the idea of vital ageing. On the contrary, if the situation persists, where no measures are taken up for planning of the future needs of the elderly, the future of this particular segment of the society appears dark and gloomy.