K242_1Population ageing: a global health crisis?Population ageing: a global health crisis?About this free courseThis free course is an adapted extract from the Open University course K242 Ageing societies and global health: www.open.ac.uk/courses/modules/k242This version of the content may include video, images and interactive content that may not be optimised for your device. You can experience this free course as it was originally designed on OpenLearn, the home of free learning from The Open University –www.open.edu/openlearn/health-sports-psychology/population-ageing-global-health-crisis/content-section-0There you’ll also be able to track your progress via your activity record, which you can use to demonstrate your learning.

Copyright © 2017 The Open UniversityIntellectual propertyUnless otherwise stated, this resource is released under the terms of the Creative Commons Licence v4.0 http://creativecommons.org/licenses/by-nc-sa/4.0/deed.en_GB. Within that The Open University interprets this licence in the following way: www.open.edu/openlearn/about-openlearn/frequently-asked-questions-on-openlearn. Copyright and rights falling outside the terms of the Creative Commons Licence are retained or controlled by The Open University. Please read the full text before using any of the content. We believe the primary barrier to accessing high-quality educational experiences is cost, which is why we aim to publish as much free content as possible under an open licence. If it proves difficult to release content under our preferred Creative Commons licence (e.g. because we can’t afford or gain the clearances or find suitable alternatives), we will still release the materials for free under a personal end-user licence. This is because the learning experience will always be the same high quality offering and that should always be seen as positive – even if at times the licensing is different to Creative Commons. When using the content you must attribute us (The Open University) (the OU) and any identified author in accordance with the terms of the Creative Commons Licence.The Acknowledgements section is used to list, amongst other things, third party (Proprietary), licensed content which is not subject to Creative Commons licensing. Proprietary content must be used (retained) intact and in context to the content at all times.The Acknowledgements section is also used to bring to your attention any other Special Restrictions which may apply to the content. For example there may be times when the Creative Commons Non-Commercial Sharealike licence does not apply to any of the content even if owned by us (The Open University). In these instances, unless stated otherwise, the content may be used for personal and non-commercial use.We have also identified as Proprietary other material included in the content which is not subject to Creative Commons Licence. These are OU logos, trading names and may extend to certain photographic and video images and sound recordings and any other material as may be brought to your attention.Unauthorised use of any of the content may constitute a breach of the terms and conditions and/or intellectual property laws.We reserve the right to alter, amend or bring to an end any terms and conditions provided here without notice.All rights falling outside the terms of the Creative Commons licence are retained or controlled by The Open University.Head of Intellectual Property, The Open University In this free course, Population ageing: a global health crisis?, you will explore two major issues of our time – ageing societies and global health. It provides you with an introduction to ageing societies and their implications for global health – implications that are only just beginning to be fully understood. The course will help you to deepen your understanding of ageing societies across the globe, the different components of the concept of global health, global influences on the experience of ageing, and the need for global cooperation. You will also explore the ways in which population ageing is often framed as a crisis and you will begin to develop your own ideas about the implications of population ageing.This OpenLearn course is an adapted extract from the Open University course K242 Ageing societies and global health.After studying this course, you should be able to:answer the question ‘what is population ageing?’identify the core components of global healthunderstand how population ageing and increasing life expectancy might be seen as a global health challenge.You are going to begin by looking at some important facts and ideas about population ageing that are central to this course.Activity 1 Global population ageing: the issuesAllow about 30 minutesThe video below is about global population ageing. It also addresses the impacts, opportunities and challenges of global population ageing together with ways to overcome these challenges globally.Video 1 Global aging(International Monetary Fund)[MUSIC PLAYING]TEXT ON SCREEN: Rheinhart and Kirkegaard: Retiring Government DebtDoug Irwin: Trade and Exchange PolicyNobelist George Akerlof ProfiledJobs for Middle East YouthF&D Finance and Development  Global ageingThroughout the world and throughout history the young have always outnumbered the elderly.Over the next 40 years this will change. The population over 60 will grow by 1 billion to a total of 2 billion. For the first time in human history, there will be more people over 60 than under 15. 1 in every 5 people will be elderly. In 1950 there were 12 working people for every elderly person. Today: 9. 2050: 4.More money out, less money in. Economic impact: Growth, Savings, Debt, Investment, Consumption, Labor markets, Pensions, TaxationSocial impact:Family composition, Living arrangements, Housing demand, Migration trends, Health carePolitical impact:Voting patterns, Political representationThe elderly bring:Inspiration – values, Work ethic – culture, Leadership – tradition, Wisdom – legacyBut with age comes:Health concerns, Vulnerability, UncertaintyBut with less money how can countries afford looking after the elderly and how will we afford to look after our own health, our education … afford to spend on technology, arts, science? Afford to spend on our children and their futures? We could consider these steps:Integrating aging into all aspects of development, Involving the elderly more in major policy decisions, Fundamental reforms in existing pension systems, Making health care affordable to allAnd we can do this not just because we care for them, because we also care for those to come.Read more about aging in the June 2011 issue of Finance and Development, a publication of the International Monetary Fund. www.imf.org/fanddProduced by Babar Ahmed for The International Monetary FundOriginal music composed by Kenneth LamplAnimation and graphic design: Junko NaganoThanks to Luke Ditommaso and Charles Esser As you watch, think about the following questions. According to the video: What is the age at which someone becomes ‘elderly’?In this video, the ‘elderly’ are those who are 60+. What do you think about this way of classifying people as ‘old’? Is it fair? Using this classification, the video then goes onto show how for the first time, there will be more older people than there of working age people in societies across the globe.What are the benefits of having older people in a population?Some of the benefits of having older people are highlighted – inspiration, work ethic, leadership, wisdom, values, culture, tradition and legacy. Other sources have also identified contributions that older people make to society, for example, caring for those who have a long-term illness or disability, childcare for grandchildren and voluntary work (HelpAge International, n.d).What are the ‘challenges’ of having older people in a population?The video gives an overview of the economic, political and social impacts of population ageing and gives several examples of each. These examples include the challenges this global societal transformation brings, such as less money into the economy and more money out, and the way that older people’s vulnerability and poorer health cause an increase in the costs of meeting their health needs and caring for them. Some of the implications of these impacts – in terms of housing demand, taxation, growth, investment, pensions and migration – may also prove to be challenging. They is because they are not only challenging in themselves, but also because of the extent to which addressing them means there are fewer resources for other essential services for the rest of the population.How can the challenges be addressed? The final part of the video presents some ‘steps’ that can be taken to address these sorts of challenges – integrating ageing into all aspects of development, involving the elderly in major policy decisions, making fundamental reforms to the pension systems, and making healthcare affordable to all.You will be looking into the issues and questions this video raises in more depth and will be referring back to it throughout this course. Population ageing is the term used to describe the process whereby the percentage of older persons in the population is increasing. But this definition throws up more questions, including: What do we mean by older persons?Who belongs to this group? In the video you watched in Activity 1, chronological age is used – and this is a very common way of classifying people as ‘old’. There is no universal agreement about how is choronologically ‘old’, but as you saw in the video, a cut-off of 60 years of age was used. This cut-off of 60 years is frequently used in data collection; so too is 65 years, and in certain parts of the world, such as sub-Saharan Africa, individuals aged 50 or 55 years are included in studies of older people.As you saw in the video too, a worldwide transformation is under way; populations across the world are becoming older, making this a truly global issue. Although 8% of the world’s population was aged 60 years and older in 1950, by 2013 this had reached 12% (United Nations Department of Economic and Social Affairs, 2013). This demographic transformation will gather momentum in the coming years, with some predicting that by 2050, 20% of the world’s population will be aged 60 years and over. Those aged 60 years and older comprise a large range of ages, and the United Nations (UN) uses the cut-off of 80 years to refer to the ‘oldest old’. This is the fastest-growing section of the older population (of those aged 60 years and older). The percentage aged 80 years and older increased from 7% in 1950 to 14% in 2013. By 2050, those aged 80 years and older are expected to account for approximately 20% of older persons (United Nations Department of Economic and Social Affairs, 2013).So far in this course, the focus has been on the extent of ageing at the global level. It is important not to treat the world just as one whole – there are important differences between countries, and you will explore this in the next activity.Activity 2 Ageing across the globeAllow about 45 minutes Look at the graphic below showing the percentage of older people in different countries in 2015 and 2050, and then have a go at answering the questions.

Figure 1 The percentage of the population aged 60 years or older across the world in 2015 and 2050(adapted from Agewatch Index, 2015, based on data from UNDESA Population Division, World Population Prospects: The 2015 Revision)Figure 1 comprises two maps of the world. Using different colours for the percentages, the first shows the percentage of the population aged 60 years and older in 2015, and second does the same for the percentage of the population aged 60 years and older in 2050. The 2015 data shows: 0–9% for most of Africa and the Indian subcontinent 10–19% for most of South America and China20–24% in the USA, Canada and Russia , UK, Spain and most of Eastern Europe25–29% in France, Italy, Austria Switzerland and the Scandinavia30+% for Japan.The 2050 data shows: 0–9% in some Africa and a few Indian subcontinent countries10–19% in a few African, most Indian subcontinent countries and one or two South American countries20–24% in some parts of South America and Africa 25–29% in USA, Alaska, Russia Australia and New Zealand 30+% in Japan, China, UK , most of Europe, Scandinavia and Canada.

In 2015, which of the following countries was the ‘oldest’ in the world in terms of the percentage of its population aged 60 years and older? United KingdomJapanSwedenAustraliaIn 2015, what was the youngest region in the world in terms of the percentage of its population aged 60 years and older?Sub-Saharan AfricaLatin America and the CaribbeanSouth East AsiaOceaniaBy 2050 roughly how many countries are expected to have more than 30% of their population aged 60 years and older?103064The map shows the countries that have the highest number of older people in both 2015 and 2050.TrueFalse

We have already established that population ageing is not about the numbers of older people in the population, but it is about the relative size of the older population to other age groups in society. You also saw in Activity 2 that because a population has the greater percentage of its population aged 60 years and older compared to another country, that does not mean it necessarily has a greater number of older people. Now consider the information on population ageing in Table 1.Table 1 Percentages and numbers of population aged 60 years and older across the globe in 2013(adapted from United Nations, 2013)

Regions	The percentage of population aged 60+	The absolute number of people aged 60+
More developed	22.7%	287 million
Less developed	9.2%	553 million
Least developed	5.3%	48 million

You can see from this that the more developed regions of the world have the greatest percentage of their population aged 60 years and older (22.7%) by far. Yet, the less developed regions have a larger number of older people – nearly double that of more developed regions.Your introduction to ageing societies and global ageing is now nearly complete! There is just one more term that needs clarifying, and that is ‘developed regions’. Regions and countries are classified differently by different organisations. For instance, the World Health Organization (WHO) refers to high-, middle- and low-income countries, whereas the United Nations uses a classification system based on whether countries are developed or developing. As we will be drawing on a range of sources in this course, we will be referring to ‘high-, middle- and low-income countries’ and ‘developed or developing countries’ depending on the sources of our information. You will also come across these differences when you are looking for information yourself.Before exploring the implications of ageing societies for global health, we need to think about what we mean when we talk about ‘global health’ … so onto our next topic!

The first step to understanding global health is to ask what we mean by health. You may already be familiar with the WHO definition of health as ‘a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity’ (WHO, 2006, p. 1). This definition therefore goes beyond ‘scientific’ biological conceptions of health, and emphasises the wide range of contributing factors, such as social and environmental influences on health.This emphasis on the influences on health is also in the concept of global health. Although this concept has increased in popularity over the past decade, its meaning often remains ambiguous, with many using the term undefined. Drawing on the work of Koplan and colleagues (2009), global health can be seen as an area of study, research and practice that focuses on people’s health across the globe, in high-, middle- and low-income countries alike, and recognises that health is influenced by issues that surpass national boundaries.Activity 3 Global health – no boundariesAllow about 30 minutesRead the following two short case studies and answer the question that follows:AdoleAdole lives in compound housing with other female relatives, including her daughter and grandchildren, in Accra, the capital of Ghana. She is 72 and although she has worked for most of her life, she does not receive a pension and now relies on her family to support her. She provides childcare for her grandchildren while her daughter works. She has recently started to experience hearing problems. Although Adole is registered with the National Health Insurance Scheme (implemented in Ghana in 2003), she would not be entitled to hearing aids should she be diagnosed with hearing loss.SelimSelim is a gay German pensioner aged 74, living alone. He was born in eastern Turkey and migrated to Berlin, Germany, with his family for work. Throughout his working life he always managed to find work that enabled him to earn an above average income and live in his own apartment. However, as a gay migrant Muslim man he has found it hard to be accepted by his family and the predominantly Turkish community in which he lives. Although he increasingly finds he has nobody to turn to for support, he is reluctant to use state services.What factors do you think have been influential on Adole’s and Selim’s health? Note them below.You might have thought about family and community support, access to medical care, income and gender. Are there any other factors you have in addition to this list? Your list will show that even though people live in very different parts of the world and have very different lives, their environments share some common features that shape their health and their lives.There is a recognition within the concept of global health that influences on health do not respect national boundaries. This has implications for how health issues are addressed. Work on global health emphasises that there is a need for transnational collaboration in relation to research, and action across all sectors to prevent ill health and promote health for all. Therefore, global health is about:worldwide health improvement (for example, reducing infant and child mortality across the world)reduction of disparities (for example, reducing inequalities between urban and rural areas in different countries)promotion of health equity (for example, ensuring everyone has access to healthcare)protection against global threats that disregard national borders (for example, wars and natural disasters).

In addition to the term ‘global health’, you may have come across ‘international health’ and ‘public health’. As Table 2 shows, these terms are not be confused with global health. This table will help you to distinguish between these terms; it summarises key differences in relation to their geographical reach, level of cooperation, the extent to which they embrace individuals or populations, their views about access to health and their disciplinary approach.Table 2 Comparison of global, international and public health(adapted from Koplan et al., 2009)

	Global health	International health	Public health
Geographical reach	Focuses on issues that directly or indirectly affect health but can transcend national boundaries	Focuses on health issues of countries other than one’s own, especially those of low and middle income	Focuses on issues that affect the health of the population of a particular community or country
Level of cooperation	Development and implementation of solutions often requires global cooperation	Development and implementation of solutions usually requires cooperation between two nations (binational)	Development and implementation of solutions does not usually require global cooperation
Individuals or populations	Embraces both prevention in populations and clinical care of individuals	Embraces both prevention in populations and critical care of individuals	Mainly focuses on prevention programmes for populations
Access to health	Health equity among nations and for all people is a major objective	Seeks to help people of other nations	Health equity within a nation or community is a major objective
Range of disciplines	Highly interdisciplinary and multidisciplinary within and beyond health sciences	Embraces a few disciplines but has not emphasised multidisciplinary approaches	Encourages multidisciplinary approaches, particularly within health sciences

In essence, Table 2 demonstrates the distinctive breadth of the concept of global health, with respect to its geographical reach (transcends national boundaries), the extent of the cooperation required between different countries (global), its objectives (prevention in populations, clinical care of individuals, health equity for all) and its disciplinary nature (highly interdisciplinary and multidisciplinary). Integral to global health are the transnational factors that influence and shape health (for example, the marketing of tobacco). These transnational influences mean that global health issues often arise because of the way different countries are interdependent. It is therefore important that solutions to global health issues need to be addressed through collaboration between countries across the globe (Frenk et al., 2014). Indeed, when using the term ‘global’ in this course, the emphasis is on interdependencies between countries; as well as taking a comparative perspective of differences between countries.

In the discussion of the video in Activity 1, we talked about some of the advantages that having a higher percentage of older people in a population can bring. These are not the only benefits of population ageing! There is much evidence that population ageing is an outcome of all the efforts that have been made to improve global health over the past decades. In other words, that population ageing is a sign of global health success. Click left and right on the slideshow below to read about some of this evidence.Interactive 1 Population ageing – a global health success?This slideshow contains four figures.The first figure shows a graph with a declining world fertility rate (in 1950–1955 it shows the fertility rate as being at 5, and this declines over time so that at the end of the graph, in the years 2045–2050 it is estimated to be at 2.The second figure is a photograph of two women smiling at the camera.The third figure shows the 17 Sustainable Development Goals. The first box in the goals figure says ‘Transforming Our World: The 2030 Agenda for Sustainable Development’. These goals are: no poverty zero hunger good health and wellbeingquality educationgender equalityclean water and sanitation affordable and clean energydecent work and economic growthindustry, innovation and infrastructure reduced inequalitiessustainable cities and communities responsible consumption and productionclimate action life below waterlife on landpeace, justice and strong institutionspartnerships for the goals.The fourth figure is a photograph of someone testing their blood sugar levels.For a larger version of the third slide, select the following link: Sustainable Development Goals.The video in Activity 1 introduced some of the challenges of population ageing. Once of the most notable challenges is the increased costs involved in meeting the needs of older people, many of whom may be vulnerable or in poorer health. In the next activity, you will take a longer look at these concerns about population ageing and increasing life expectancies.Activity 4 Elderly healthAllow about 45 minutesGlobal health is concerned with the health of all nations, especially health concerns that cross boundaries. In this activity you will discover what concerns population ageing and increasing life expectancy might bring for global health.Listen to Audio 1, an interview with Dr Jay Bhattacharya about disability, elderly health and obesity in the United States. As you listen, think about the following question.Audio 1 Disability, elderly health and obesityINTERVIEWER:I would like to start by noting that when we at PRB write about ageing in the United States we often say that the elderly are leading longer and healthier lives, but the conclusion that you and your co-authors seem to have reached in your recent article in Medical Care, when I read it, said that continued improvements in elderly health should not be taken for granted. Can you explain more about that and tell us what your concerns are, given that what we think we’ve been seeing are improvements in elderly health?DR JAY BHATTACHARYA:We have been seeing improvements in elderly health and that’s part of the great news for people that are older today, and so for the last 30 years there’s been a very sharp, a sharp decline in the rates of severe disability, by which I mean, you know an inability to dress yourself or to bathe yourself, and so on. Those rates have come way down in 30 years among the elderly population, and there are many reasons for that including improved, you know, improved technology, prevention of chronic diseases, improved technology to assist the elderly, and so on. The caveat in what my article focused on is that that same decline which we saw in the elderly population does not hold true in younger populations, in working age populations. In working age populations, actually, you’ve seen increases in severe disability, and so that’s the reason why you might not expect this decline to continue forever. The set of people who are now in their fifties that have seen the increase in disability are going to be 65 in 10 or 15 years, in 15 years, and they’ll be more disabled than the people that are in their sixties now. So it’s not a given that the disability rates will continue to decline forever into the future. The gains have been substantial, and that’s wonderful. The question is can we sustain them in going forward?INTERVIEWER:Define what you mean by working age population.DR JAY BHATTACHARYA:Sure. So in this article we looked at people between age 30 and age 60. We also extended past that in other work to 65 and older, and that we confirmed the well-known finding in literature that there have been large declines in disability rates in the older populations.INTERVIEWER:What do you see as major differences, or what do you see as different kinds of disabilities in, let’s say, the younger part of working age population versus older?DR JAY BHATTACHARYA:So for the most part in my work I focused on severe disabilities so that we’ve used this, we meaning I and my colleagues, we’ve used the same definition of disability that people use for older populations. These disabilities are called activities of daily living limitations, you know the inability to bathe yourself, to dress yourself, and so on, and the goal of my work has been to look at how those rates of disability that are traditionally seen as pertaining mainly to the older population to the extent to which they also pertain in the younger population, and the results are what you’d expect. The rates of those kinds of severe disabilities are much lower in the younger population than in the older population, but those rates have been increasing very sharply over the last 20-30 years, say 25, 20 years, but not in the younger population.INTERVIEWER:And why do you think those rates are increasing?DR JAY BHATTACHARYA:So, let me tell you what I know, and then I’ll tell you what I don’t know. So one obvious idea about this is that disability doesn’t tend to happen to people who are free of, especially in younger populations, doesn’t happen to people who are free of other conditions, chronic conditions. It tends to happen to people who have other chronic diseases, you know, people who have diabetes, severe diabetes, people who have had strokes, people who have had Chronic Obstructive Pulmonary Disease, so one obvious hypothesis is to look to say okay, have the rates of those diseases in the younger populations gone up over time? Another hypothesis is that among the people with those diseases have the rates of disability gone up? So you see the distinction, right, so that the rates of the diseases themselves could have gone up, or the rates of disability among the people who have these diseases could have gone up. The answer that I found in my work with my colleagues is that, in particular, the rise in obesity rates in this population has played a substantial role in fuelling the increase in disability rate, and obesity is associated with lots of other very severe chronic conditions – diabetes, hypertensions, and so on – and you know so that it’s not that obesity directly leads you to get this, but that it may cause other conditions that leads you, that then leads you to be more likely to become disabled. That explains about half of the rise.The other half of the rise is that for some conditions, in particular for Chronic Obstructive Pulmonary Disease, the rates of disability have been going up, so compared to 20 years ago, if you take someone, a patient with Chronic Obstructive Pulmonary Disease, and you compare them with another patient today, that person with Chronic Obstructive Pulmonary Disease today is more likely to be disabled than the person 20 years ago, again using this definition of severe disability.INTERVIEWER:The pulmonary disease, COPD I guess is the acronym, is that mainly caused by smoking?DR JAY BHATTACHARYA:For the most part, yes. Now the rates of COPD have come down but the rates of the remaining COPD population disability have gone up by disability among the people who have COPD still. And actually, there’s an interesting twist which is that improvements in technology, improvements in medical care for people with chronic disease can actually lead to increasing disability rates among those populations so a set of people today who have diabetes, say, and if you, like, take 50 year olds, 50 year olds with diabetes today are more likely to be disabled than people, 50 year olds, 20 years ago, that’s a fact. People that are 50 years olds today with diabetes are more likely to be disabled than people who were 50 years old 20 years ago.INTERVIEWER:Who also had diabetes?DR JAY BHATTACHARYA:Who also had diabetes.INTERVIEWER:Twenty years ago?DR JAY BHATTACHARYA:Right. Now the reason, an ironic reason for that is that we’re much better at taking care of diabetics, so the set of people who have diabetes are more ill, right, though some of the patients with diabetes would have died off 20 years ago, and those people potentially are alive with disabilities today. So, you know, I’m not sure how to look at that. I mean, so in one sense is good news, in one sense it’s something that we really should be concerned about, you know how do you support populations like this?What two possible health concerns associated with ageing are described in the audio? The audio discussion highlights two main health concerns arising from population ageing in the USA. Life expectancy has increased, but there is a question of whether older people are spending these extra years in ill health or with functional limitations and disabilities. There is the example of how improvements in technologies have increased the survival chances of those with diseases such as diabetes, but this might mean those who have these diseases might be in poorer health or have greater disability than those who had such diseases 20 years ago. Another point raised relates to non-communicable diseases and conditions (those that cannot be transmitted from person to person) such as Type 2 diabetes, stroke and heart disease. Population ageing is associated with a rise in these conditions, but the audio suggests there might be an additional challenge in the fact that younger generations might be more likely to age with these diseases compared to those previously, with obesity being given as a reason.Although the audio discussion is based on ageing in the USA, the questions surrounding the rise in non-communicable diseases, and whether increases in life expectancy means prolonged periods of ill health, are concerns shared by ageing societies across the world. Non-communicable diseases and conditions such as stroke are among the top ten causes of death across the world (World Health Organization, 2014) and of the number of deaths from non-communicable diseases, three quarters of these in 2012 occurred in low- and lower–middle-income countries. So, shared health concerns refer to those issues that are common to many nations around the world.While increased life expectancy can be seen as a success, population ageing is a global health challenge because an increasing percentage of older people in any population means preventing, managing and treating non-communicable diseases, as well as ensuring that additions to life expectancy are spent in good health. This has been referred to as the ‘challenge of success’. It is impossible to talk about population ageing and global health without considering global forces.While global health is concerned with all influences on health regardless of level of operation (for example, individual lifestyles, local environments, national economies), it is particularly interested in global influences. Globalisation is one of the most significant global influences. Through the process of globalisation we are increasingly living in an interconnected and interdependent world (Brown et al., 2006), and this is shaping daily life and consequently influencing our health. It is therefore time to look more closely at globalisation and health. Activity 5 will introduce you to what globalisation is and the types of changes that define it.Activity 5 Our globalised worldAllow about 1 hour 45 minutesPart ARead Reading 1: Globalisation: what is it and how does it affect health? (Lee, 2004).If you have access to a printer, print off the Reading and, as you read, underline or highlight any concepts you do not understand or have not come across before. Using your chosen internet search engine, explore what these concepts might mean in the context of the article. You might want to write these ideas down as comments along the side or at the bottom of the article.Some parts of the reading are quite complex, but reading in depth and exploring further any concepts that you are unsure about will help you to understand the arguments and complete the next activities. You may have picked out the following concepts: Market liberalism and inequities are the belief in free and open markets, which means that governments are discouraged from interfering with the prices of goods and services, and determining supply and demand (for example, through policies such as price fixing, regulations on trading and taxes). Market liberalisation is connected to globalisation, as promoting free markets in turn promotes international trade in goods and services. This, however, can result in inequities, or unfairness, in economic outcomes. For example, without regulations some countries will be at an advantage and others at a disadvantage in terms of whether their industries are able to compete internationally, or even domestically, where goods come in from other countries.Foreign direct investment (FDI) is the flow of investment from one country to another. This might include, for example, a company setting up a related company overseas, or buying shares in an overseas company, or the combining of one company with another company overseas. Examples of FDI could include a large car company with production plants in different countries, a successful fast-food company opening new chains in different countries, a US company buying majority shares in an Indian company, or where two companies from different countries start a joint venture, such as mining. Foreign direct investment is linked to globalisation as it builds connections around the world.Part BIn the reading, Lee (2004) sees that globalisation is best defined by three types of changes. Identify and briefly describe these below.The three types of changes are:Spatial changes: globalisation has caused physical space to contract or disappear altogether as, due to advancements in technology (such as in transport and communication), the flow of people, information, money and goods across countries is increasing. The breaking down of physical boundaries between countries reflects the fact that action in one country can impact other parts of the world; for example, carbon dioxide emissions produced by developed countries results in climate change that causes extreme weather on the other side of the world.Temporal changes: in addition to our experience of space, how we experience time is changing. Technology (for example, phones and aeroplanes) can connect people or take them from one place to another faster than before. On the other hand, life has slowed down in some respects – for example, access to the internet means we can become overloaded with information, which we then spend more time accessing and processing.Cognitive changes: globalisation changes how we see ourselves and other countries. For example, the mass media and communication technology, or increased travel to other parts of the world, brings us knowledge of other countries, and along with it the sharing of ideas and values.

You will now look at the different ways that globalisation might impact on health.Activity 6 Globalisation: benefits and risks to healthAllow about 45 minutesListen to Audio 2 by Professor Ilona Kickbusch on the impact of globalisation. Using information from this audio and the article by Lee that you read in Activity 5, start to fill out the table below on how globalisation can affect health. If you have any additional ideas, add these to the table too.  Audio 2 The impact of globalisationILONA KICKBUSCHGlobalisation affects public health at very many different levels. I mean, first of all, globalisation means that our societies, or one could even say our world, is being restructured. The way we live, the way we work, but even the way we think and therefore what in public health we call the determinants of health are being very heavily affected, in terms of who is able to work, what kind of work you can get, how you can live, urbanisation is one of these things that comes with globalisation, so that’s one level.The other level of course is that globalisation means that people and things travel more and more quickly with great speed. We have to see that our food that comes from all parts of the world is safe. Obviously viruses can travel without having any concern for borders, but also if you think of the expansion of the tobacco trade, for example, how smoking is becoming an issue in many poor countries; you have this travelling of things and people. Then of course travelling of things and people also means, for the health services themselves, that things change.One of the great problems for developing countries in a global world is that they lose their professionals, that there is a brain drain in the developing world that doctors and nurses go to countries where they have better working conditions and better income. And so you have this enormous change in both the rich, as we call them even though they don’t always feel rich, both the rich countries and the poor countries and, of course, as always there’s winners and losers of globalisation.Table 3 How globalisation can affect health

Dimension	Benefits for health (direct and indirect)	Risks to health (direct and indirect)
Economic integration
Technological innovation
Increased mobility
Environmental factors

The table below shows how globalisation can impact health, including what you may have gathered from the audio and reading, as well as some additional points you may have thought of.Table 3 How globalisation can affect health – completed

Dimension	Benefits for health (direct and indirect)	Risks to health (direct and indirect)
Economic integration	Rising living standardsInvestments in education and health	Economic recessions likely to impact globally, threatening living standardsIncreasing gap between poor and rich nationsCompanies in high-income countries exporting health-damaging products (for example, tobacco and fast food) to low- and middle-income countries
Technological innovation	Decline in production costs – cheaper food and medicines, for exampleICT communications can support education and economic developmentImproved management of global health risks as can respond quicker	Digital divide – poor do not have access to innovationMore effective marketing of health-damaging products (such as tobacco)
Increased mobility	Economic migration boosts poor countries’ incomeTravel promotes cultural exchange and innovationMigration of healthcare professionals fills gaps in receiving countries	Easier spread of infectious diseases (perceived threat from low- and middle- to high-income countries)Financial burden of high-income countries providing care for ‘unhealthy’ migrant population from low- and middle-income countriesMigration of healthcare professionals results in understaffed systems in origin countries
Environmental factors	Better housing, amenities and transport as national incomes rise	Energy-intensive production and consumption (air and car travel) increases pollution and climate changeDepletion of natural resources, decline in open spaces and biodiversity
Cognitive factors	Transfer of ideas regarding healthcare provision	Change in lifestyles resulting from advertising and marketing of health-damaging products

In this last activity you explored how globalisation can impact the health of all groups in societies across the world, including older people. Now look at some examples of how the global forces you identified can influence the health of older people specifically: International migration of healthcare professionals can meet the growing demand for healthcare in countries experiencing population ageing, such as the UK, but it can result in a lack of a specialised workforce available in low- and middle-income countries to meet the needs of a growing older population.Access to healthcare among older populations is partly determined by government policy, which is influenced by global forces. For instance, in low-income countries such policies are influenced by international organisations, such as the International Monetary Fund, and debt repayment programmes, and this can determine how services such as healthcare are funded. This influences the affordability of such services for older people.Nonetheless, when considering the health and wellbeing of older people, it is not just important to consider how global forces affect older people, but also, as you saw in Activity 4, attention must be given to the younger generation and their experience of ageing. Our behaviours and circumstances in earlier periods of our life can influence our health and wellbeing in later life. A good example is the influence that globalisation is having on our lifestyles. Globalisation has resulted in a greater availability of products like tobacco and fast food, leading to potentially detrimental lifestyle changes. International advertising and the expansion of branded products and chains of restaurants into different countries are all important in influencing individual behaviour. Hence, another challenge that population ageing poses to global health is tackling global forces that contribute to non-communicable diseases and conditions in later life, and might also result in increases in life expectancy not being spent in good health.

Figure 2This photograph shows a row of international flags from all over the world.

The last component of global health that you will consider in this course is global cooperation – this refers to the call for the cooperation and collaboration of different sectors within and between countries (Brown et al., 2006) to increase access to healthcare, ensure wellbeing and health of populations, and to monitor disease and control outbreaks.You have seen how population ageing and increasing life expectancy are global phenomena, how both these phenomena are creating concerns for the health of populations and how these concerns are shared between countries. In addition, the health of older populations is influenced partly by global forces, such as globalisation, which creates interdependencies between countries. This all suggests that global cooperation, not just between governments but also with the media, non-governmental organisations and private companies, is vital to address the potential global health challenges of population ageing and increasing life expectancy. For example, through the coordination and collaboration of research activities across companies around the world, knowledge about the prevention and treatment of non-communicable diseases and conditions could be built more effectively and efficiently. Global cooperation is also required to address the global influences on lifestyle that are resulting in non-communicable diseases and conditions in later life. Encouraging behaviour change will only have so much impact; addressing global influences, such as the expansion of fast-food products into a country, are pivotal and this sort of action demands cooperation at a global level.Now that you have studied this free course, Population ageing: a global health crisis?, you will understand some of the key issues in the debates about whether population ageing is a global health crisis or not.You have seen that population ageing means that the percentage of older persons in the population is increasing, and while this is a global phenomenon, the percentage of older people is much higher in more developed countries than it is in less developed countries.Population ageing: a global health crisis? has introduced you to the three core components of global health:shared health concernsglobal determinants of healthglobal cooperation.Importantly too, you will have engaged with the argument about whether population ageing is a global health success or not. Integral to this debate are the challenges population ageing pose for global health, not least in terms of how these challenges are shaped by global forces beyond the control of nation states. Last but not least, you will have a sense of the nature and extent of the global cooperation required in addressing these challenges.Population ageing and global health are constantly in the news. Don’t stop at this point – use your new understanding to develop your knowledge of the issues we have introduced you to in this course!This OpenLearn course is an adapted extract from the Open University course K242 Ageing societies and global health.

 Study another free courseThere are more than 800 courses on OpenLearn for you to choose from on a range of subjects. Find out more about all our free courses. Take your studies furtherFind out more about studying with The Open University by visiting our online prospectus. If you are new to university study, you may be interested in our Access Courses or Certificates. What’s new from OpenLearn?Sign up to our newsletter or view a sample. For reference, full URLs to pages listed above:OpenLearn – www.open.edu/openlearn/free-coursesVisiting our online prospectus – www.open.ac.uk/coursesAccess Courses – www.open.ac.uk/courses/do-it/accessCertificates – www.open.ac.uk/courses/certificates-heNewsletter ­– www.open.edu/openlearn/about-openlearn/subscribe-the-openlearn-newsletterBrown, T. M., Cueto, M. and Fee, E. (2006) ‘The World Health Organization and the transition from “international” to “global” public health’, American Journal of Public Health, vol. 96, no. 1, pp. 62–72.Frenk, J., Gomez-Dantes, O. and Moon, S. (2014) ‘From sovereignty to solidarity: a renewed concept of global health for an era of complex interdependence’, The Lancet, vol. 383, no. 9911, pp. 94–7.HelpAge International (n.d.) ‘Ageing in the 21st century’, Helpage.org, New York, United Nations Population Fund (UNPF) and London, HelpAge International [Online]. Available at http://www.helpage.org/resources/ageing-in-the-21st-century-a-celebration-and-a-challenge/ageing-in-the-21st-century-infographic (Accessed 6 January 2017).Koplan, J. P., Bond, T. C., Merson, M. H., Reddy, K. S., Rodriguez, M. H., Sewankambo, N. K. and Wasserheit, J. N. (2009) ‘Towards a common definition of global health’, The Lancet, vol. 373, no. 9679, pp. 1993–5.Lee, K. (2004) ‘Globalisation: what is it and how does it affect health?’, The Medical Journal of Australia, vol. 180, no. 4, pp. 156–8.United Nations Department of Economic and Social Affairs (2013) World Population Ageing 2013, New York, United Nations.World Health Organization (2006) Constitution of the World Health Organization [Online]. Available at www.who.int/governance/eb/who_constitution_en.pdf (Accessed 6 January 2017).World Health Organization (2014) The Top 10 Causes of Death [Online]. Available at www.who.int/mediacentre/factsheets/fs310/en/ (Accessed 6 January 2017).This free course was written by Mary Larkin.Except for third party materials and otherwise stated (see terms and conditions), this content is made available under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 Licence.The material acknowledged below is Proprietary and used under licence (not subject to Creative Commons Licence). Grateful acknowledgement is made to the following sources for permission to reproduce material in this free course: Every effort has been made to contact copyright owners. If any have been inadvertently overlooked, the publishers will be pleased to make the necessary arrangements at the first opportunity.TextReading 1: Lee, K., (2004) ‘Globalisation: what is it and how does it affect health?’, Medical Journal of Australia, vol. 180, no. 4, pp. 156–8, February 2004, Medical Journalists Association. With Kind permission from Professor Kelley Lee.FiguresCourse image: Globe © Nasa Visible Earth: Image created by Reto Stokli with the help of Alan Nelson, under the leadership of Fritz Hasler. Illustrated Figures and text © Open University.Figure 1: Adapted from: Agewatch Index (2015) based on data from UNDESA Population Division, World Population Prospects: The 2015 Revision.Figure 2: © ARENA creative/Shutterstock.com.Keep on learning section figure: © Konstantin Chagin/iStockphoto.com.TablesTable 1: Adapted from United Nations (2013) ‘UN marks World Mental Health Day by focusing on well-being of ageing populations’, UN News Centre.Table 2: Adapted from Koplan J. P., Bond, T. C., Merson, M. H., Reddy, K. S., Rodriguez, M. H., Sewankambo, N. K. and Wasserheit, J. N. (2009) ‘Towards a common definition of global health’, The Lancet, vol. 373, no. 9679, pp. 1993–5.AVVideo 1: International Monetary Fund.Audio 1: Disability, Elderly, and Obesity, (2008) used with permission from Population Reference Bureau.Audio 2: © The Open University.Interactive assetsSlideshow: slide 1 image: Adapted from www.economist.com (2009). Data UN Population Division.Slideshow: slide 2 image: © Tauanga City Libraries Staff - HC  is licensed under a Creative Commons Attribution-Noncommercial 3.0 New Zealand License.Slideshow: slide 3 image: © United Nations.Slideshow: slide 4 image: Carsten Koall/Stringer/Getty Images.Don’t miss outIf reading this text has inspired you to learn more, you may be interested in joining the millions of people who discover our free learning resources and qualifications by visiting The Open University – www.open.edu/openlearn/free-courses.

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