Well, I'm delighted to have Carol Winograd with us today to speak about aging. Carol, I'd love to hear a little bit about yourself. And then, let's just plunge into a discussion about the way the world is going to be in the future, in terms of older people. >> Thank you, Anne, for inviting me, and I'm delighted to be here. My name is Carol Hunter Winograd, MD, and I am a Geriatrician in the School of Medicine at Stanford. And have been the Clinical Director for Geriatrics for the university. >> What's happening these days demographically and internationally? >> So demographically what's happening is that, the world is getting older. And, more and more people over the age of 65 are living to that age, and fewer and fewer children are being born. Even today, there are more people over the age of 65 in both the developed and developing world than there are children under five years old. And this trend is only going to increase. This slide shows the demographic in United States. And what you can see is that the between the years of 1950 to 2050, that first you have an increase in the number of 15-64 year olds, and then around 2025, it dramatically decreases. Simultaneously, the line on the bottom, which is the the 65 year olds is increasing over that same period of time. And the less than 15 year olds stops increasing in about 1975. And that's shown on the right with the younger people being in red in the graph, and the older people being in yellow. And you can see that, as we move in time, there is less and less red, and more and more yellow. And this dramatic demographic shift in the United States is even more dramatic in other countries. Although around the world, the percentage of older people will increase everywhere. In some places, it will increase more dramatically, and this slide shows that factor. So the dotted line is the increase in aging in the developed world. And the colored lines are different countries in the Middle East, and you can see that they have dramatic increases beginning in 2010 in the numbers of older people who they have. And that the slope of the curve is much higher in these countries than it is in the developed countries. In 2005, 7% of the world was over 65. In 2050, it will be 16%. And that represents 1.5 billion people. >> Is there a distinction to be made, an important distinction in terms of the numbers to be made with regard to women and men? >> That's a very interesting question. I have searched diligently at my friend Google, et al for those numbers, and it is unavailable. I could not find any numbers per se about women, specifically. We have charts that describe in some countries the numbers of men, the numbers of women, and we'll see them in a little while. But total aggregate number of women in the world, I cannot find. >> Well, couldn't we assume that? I mean, in some sense demographic projections would allow us to sort of assume a certain number of both men and women total population. >> Women in the developing world as well as the developed world survive longer. And so, we are certain to see many, many more women and the problems with women are the exact same ones as men have except more exacerbated. This slide shows the same thought in a slightly different way. On the bottom you can see that, the developed countries are in dark purple, and they have a consistent amount of people, in millions over the period between 1950 to 2050. In contrast, the less developed countries have a dramatic increase. And you can see that by 2050, there are way more older adults, that is, those older than 65, in the less developed countries than in the developed countries. Right now, Japan is the oldest country in the world, and it has population over 65 of 27%. By 2050, there will be 70 countries in the world, which will have that percentage of old people. There are three realities that are leading to this dramatic demographic shift. One is decreasing fertility. The second is increasing longevity. And the third is, population increases in Africa and Asia in the developing countries. Replacement fertility is 2.1 children per woman. In 1950, there were 2.8 children per woman in the developed world. And in 2005, there was 1.6 woman in the developing world. In the less developed world in 1950, there were 6.2 children per woman and 1950. And in 2005, it's dropped to 2.9. So in both the developed and the developing world, the fertility rate is dropping dramatically. Korea has the lowest fertility rate in the world, and it is 1.2 per woman, not even close to the replacement of the population. This slide shows the numbers of people per country in different times. On the left is 1950, on the right is 2030. And in each of these pyramids, in the middle to the left of the middle are represented men. And to the right of the middle are represented women, and each line represents five years. So the bottom of the pyramid, let's look at Japan in 1950. The bottom of the pyramid shows the numbers of children who are being born. And Japan had a very low post World War II fertility rate. But you can see that the lines are wider at the bottom than they are at the top, and that's because there are more children alive And then as the children grow older there is a death toll that is taken. And gradually at the very top in the oldest of old there are fewer. And you can look at 1950 in Japan and see that it looks like a pyramid. In 2030 It no longer looks like a pyramid. There's a very small base and it bulges out in the middle. And towards the top and you can see although this is a little hard on the size of this graph that there are more women at the older ages than there are men. If you try to compare the dark purple on the top, the left and the right of what would be the midline, there's more purple on the right. And that reflects more women then men on the left. And, the line across it is median age. You can see that the median age is 22. In 1950 the median age is 52 in 2030. And that means that half of the people are older than 52 and half of the people are younger than 52. So you can drop increases the population as a whole is aging. Japan is the example on this graph of the oldest country. The next one down is called the middle-aged country and that's the United States. So you can see that in the United States in 1950, we weren't quite a pyramid. We were a little bit lower in the young people and again, the very the narrow part is during World War II. And then it gradually increased and was a little bit wider at the top. But now in 2030, the United States is much wider. So it both has more people and more older people and the median age here went from 30 to 39, not that dramatic a change as in Japan and the youngest country here represented by Pakistan. You can see that it's a very sharp pyramid, very narrow pyramid, meaning that there's a very high death rate at every. Every age, and here in Pakistan you also have a widening of the graph so that you can see that there are more people, and that it is dramatically different at the top. You have a nice, purple pyramid, triangle at the Very top in 2030. We have a very nice triangle at the top in 2030. And virtually none in 1950. So even the youngest of countries is showing this phenomenon. And again, there's more on the right then on the left, meaning more women than men this is an example of Japan over time. So you can see that the triangle of 1950 gradually changes into the, if you will Box of 2050. So it's not an instantaneous change, but it is a gradual change. And as each period goes on and the graph becomes more top heavy, the median age Increases. This slide shows Japan in 2055 and really demonstrates the dramatic increase in women in this country. That the top line is those over 85 and you can see. How many old women, very old women there will be in Japan in 2055 and the international phenomenon is that the over 85 year olds is the fastest growing population. Population in the world. So, all the countries will be having more and more very old people and centenarians. Although, Japan is ahead of everybody else. >> And the majority of those people will be women. >> And the majority of those people will be women, as you can easily see in this this graph. This slide shows the drop in fertility. The bottom line is the replacement rate of 2.1. And you can see that towards the right, which is later years, many of the countries drop down towards that direction. Israel is the lowest one. This slide represents the Middle Eastern countries. The same phenomenon on the curves elsewhere, but this is just for example. So you can see that Israel fertility rate was not as high as some of the others. Iran and Afghanistan, and that now, where that line is, the vertical line, is where we are today. And we are just at the point in Afghanistan where the fertility rate is dropping but the Saudi Arabia fertility rate has already already dropped several years ago. So this is just a demonstration of even in the poorest developing countries, the same phenomenon is happening. This slide shows the workforce growth in developing countries. And you can see that in the Afghanistan and the Palestinian territories the red line is the growth in the work force population between 2005 and 2030, and you can see that in many of these developing countries the work force is, is increasing. However, that's the red line. The dark blue line is those same countries from 2030 to 2050. And you can see that even though there's a large population that is of working age, it is much smaller in the next 20 years than it is between 2005 and done in 30. So this is the shrinking workforce which will happen. The red lines represent what's called the demographic dividend. So in many countries there will be more workers, but the problem here is that these are young people in countries that have poor infrastructure structures, and these are countries where education and jobs are limited. And so this demographic dividend is also a demographic challenge at the same time. This slide shows the percentage of young adult 15 to 29 in various parts of the world in 2005. The red is the highest percentage, and you can see that this is the population that is in Sub-Saharan Africa and in parts of the Middle Middle East. And going down orange is in Northern Africa and some sub-Sahara Africa, and some in China and India. This, and in Latin America. This is where the population is. Demanding of infrastructure resources, education and jobs. And these are the countries also where they are least readily available. And these young people, as they age to 2050, will represent huge numbers of elders who also have not had the benefits of good infrastructures their entire life. So the population in the world as these young people age becomes more and more problematic. Because of where they live. >> Well, Carol, you've presented some numbers that can be really surprising if not shocking and I remember in our conversation you mentioned that even you were rather impressed by the numbers that you were uncovering. What most shocked you or what comments do you have about? >> What surprised me when I really looked at it more in depth, although I knew the facts before that, but the dramatic numbers really impressed me. Is that the vast bulk of the population is growing in places that can't handle the numbers. And can't handle them when they're young and are even less likely to handle them when they're older. And that this is also the circumstances that leads to protest and violence. That when young people have no resources and have no options, then this is much more likely to be an explosive situation and this looks like this could become very problematic and dangerously so I don't want to be a bring a terrible prophecy. But the numbers game is way beyond what I think anyone is really expecting. And when you add to that the other problems of climate change, loss of crop land, loss of adequate water, then you have a recipe for bad things to happen potentially. >> And as the populations now, the younger populations grow older, unless governments make some dramatic decisions and changes, I suspect we're going to find an older population over the next 50 years or whatever, that's similar to the older population that we have now. That is, particularly in developing countries, we find women who are older, illiterate to a great extent, living in rural areas, perhaps isolated. It will take some dramatic policy changes to change that situation, which seems to be very much the situation now, in poor countries. Relating, particularly, to women. >> The situation in poor countries is that way. The difference is going to be is that the numbers are going to be even greater. So I think of women as having six different challenges in addition to the challenges that the men might have in those same countries. So the first is that the women in general are much poorer. That they are outside of the formal economy in most places. And that the developing countries, are very poor social security investment. Indonesia is 10% of salary, and China is 20% of salary. But that's much more so in the formal economy, which is in either government or industry. And women are much less likely to be in those sectors of the economy. And the women are in the informal economy which tends to pay less at every, stage and not have old age benefits. So the informal economy of child care and of home care, management of the home is not considered within the statistics that are looked at for economics, and the contribution that women make is not considered a valuable economic asset. And women are therefore both considered more useless economically and in fact are more poor because they don't have access to the formal economy. >> What are those other factors? You mentioned six factors that were described under women. >> The second factor is that they tend to be rural, and in the rural parts of the world, there are less resources. What is happening worldwide, is that the young adults, their children, are migrating to the cities for work and the migration is because there are better jobs and also the employers are putting the jobs in cities because they have a better competitive advantage in the cities. So both women and men are migrating to the cities leaving the older women in the rural communities and this leads to the third which is they are often alone. Either because the children have migrated, or because they are divorced, or because their children have died of HIV/AIDS, which is very common in Sub-Saharan Africa. There's a loss of a middle generation, and older women are often in the rural communities taking care of grandchildren while their parents are working in the city. And there are many single family households, 40% of women in the developing world are married, a small number whereas 70% of the men are married and, of course, the women are much more likely to survive their spouse and become widowed. Women are also the face of both the informal and the formal care system. The women are the ones who are taking care of not only the children, but those who are disabled and those who are old. And so, they have tremendous demands on them. Even though they have little resources. >> And your further major points, you said you had six following them. >> So we have three, which is- >> Have poverty? >> We have rural and we have alone. And the fourth one is poor education, so when there is education, mostly it goes to the boys. That the girls for a variety of reasons, that we know in terms of preferential treatment, in terms of biology at in puberty are much less likely to go to school. And this leads to an illiterate at times and In any case, an uneducated population of women who have less options for economic gain. The fifth is chronic poor health, so again the preferential feeding and education of boys leads to malnutrition in young women, and the numerous births that they have, further compromises their nutritional health, and that compromises their overall health. And these problems of young adult health issues only get exasperated as the woman grow older because they have less and less access to health care and nutrition because they are living alone in rural areas where the resources are limited. And women spend a longer part of their life, over the age of 65, disabled than men do. The only country that I have the data for is Canada, which is a clearly developed country. And what I'm going to say is probably even worse in developing countries because of the poor chronic health of women in those locations. So, in Canada, of those women who are over the age of 65, they have an expected life expectancy of 19 more years, so once a woman is 65, she is statistically likely to live another 19 years. In contrast, when the men age 65, they are statistically likely to live about 15 more years. Now, what is really interesting and disturbing is that within those years, the men spend fewer years being disabled. Let me explain that. So the men are expected to live another 15 years. Of which about seven of those are as somebody disabled. In contrast, the women who are going to be living a little more than 19 years, have nearly ten years of disability. So the women have more than half of the years remaining when they will be considered disabled in Canada compared to the men who have 40 percent of the remaining years and this in the developing countries, although I do not have the data to prove it, is expected to be much worse. And six, is simple being female, and the same problems that young women have in terms of discrimination, violence against women, are there. The slings and arrows of outrageous fortune affect women at all stages of their lives. And the effects from the earlier years which we know about in terms of problems with childbearing and violence. These problems don't go away once a woman gets older. She simply has to learn to live with the sequelae of these events. And then they accumulate and interact, one with the other, to lead to further problems. And women are socially dependent in many countries, and legally dependent in many countries, and so they do not have access to personal resources such as land or money, to be able to improve their situation. And this systematic, pervasive, lifelong discrimination leads to a very trying and challenging old age. >> I think that you and I are moving toward the end of our lives. It's not an easy time of life for anyone probably. We're, no doubt, luckier than many others. We've had a litany of shocking surprising numbers. And now an analysis that would really suggest very difficult challenges. What I'd like to do however, is to ask you first of all, are you hopeful? If so, why? How can we move into this future as a world community and take action that will either avert some of these possible outcomes or alleviate some of the problems? What do you think? >> I think that there are small and increasingly larger experiments going on all over the world, and community organizing and women's groups that are doing things for young adults and middle-aged adults that will have a very important impact on the role and lives of older women in the coming years. One of the major aspects of many of these are an increase in recognition of the importance of women. The important that they play in terms of providing the glue and infrastructure for society in the informal parts of the economy. Which, if they were not there, there would not be no formal economy. So they're beginning to be recognized as a resource, as an untapped resource, and as a mentor, and a repository of life experience and wisdom. The grandmothers caring for the children provide the history of the nation. And this is a very important lifeline and soul line for culture. And with culture being maintained, there is an integrity in this society that is likely to counter-balance the tendencies for chaos and disruption. Many of these programs are creating economic opportunities in the part of the economy that has traditionally been the informal part of the economy. And that part which is not included in the national international statistics. Such as livestock raising, and basket weaving, and making materials, and making jewelry. These kinds of small Industries that do not take a great deal investment are in increasing around the world being supported by both large groups and banks in the microfinancing world, and also small programs like the Global Funds for Women and the American Jewish World Service projects in various communities around the world focused on woman's work. And as these groups begin to create economic viabilities by these kinds of activities, they become stronger and they become less marginalized. Interestingly, in some of the communities after the tsunami, the women were given ownership of the homes that were rebuilt. And in those communities where they had the ownership of the homes, their status dramatically improved and the violence against them decreased. So, there are mechanisms by which some changes policy innovations can make a difference. I just finished talking about the self-help programs. There are other programs that are coming from outside of the communities. The Daniel Fund is one that has been developed by the United Nations, which is. It's organized under the United Nations and it is a fund that raises capital for private sources and NGOs to finance projects that older women have control over, so that they become the masters of their own fate and the ones who receive the economic benefit of those investments. There is an organisation called INSTRAW, which is also a UN organization which is the International Research and Training Institute for the Advancement of Women. This group is addressing the stereotypes and the concepts that have led to the discrimination, and they are looking at the actual, and potential contributions that women can make to their societies that can be better documented, and better appreciated. Another aspect is using modern technology to improve the economics and the lives of women. Two examples. One is training in computer work and the second is mobile phones. All over, particularly Africa, the mobile phone has become the mechanism by which commerce as well as communication is transpires and women have as much access to this technology as the men do and in fact are using this access to their benefits. So, I expect that this will increase. In Gaza, for example, the United Nations is training women to use computer technology and they are offering that for two reasons. One is it provides an opportunity for potential employment in a very difficult situation and it also allows the women to communicate with their family members who are overseas. So women are beginning all over the world to gain both mobile phone and computer technologies which can be used in the rural communities where many of them reside, and I think this is a very hopeful sign, and this is a very hopeful change that may dramatically improve the lives women as they age. Modest investment in women and their economic activities can be greatly multiplied in terms of benefits for themselves, and their families. This includes the microfinancing loans. This includes things like heifer international purchasing animals for families. Making cottage industries like bakeries or laundromats. These small investments can be dramatic in changing the status of the women within the community. Because once they have money, their role is very different and their dependency and their discrimination decreases.