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Gerontological Policy Issues in Social Medicine
Joaquín González-Aragón, M.D.
Mexican Geriatric and Gerontological Society
México City, México
(Para leer el artículo completo dar click en read more y para traducir eliga Español en la parte principal del Blog)
The role of the sciences and professions in improving the quality of life for countless millions of older persons and in improving the quality and types of services offered to them suggests that the sciences and professions be involved in policy and action programs for the aging. Government at all levels must work together with the medical, health, and social professions to assure that the preventive, remedial, and social aspects of illness within the total health care delivery system are dealt with through basic clinical research in the morphological, physiological, and biochemical changes occurring with aging. Old people need a system that will generate appropriate medical attention both for common treat-able conditions that are insufficiently diagnosed and treated, and for acute and chronic pathological processes that occur in old age because of prevalence of multipathology (Reichel, 1978). The main issues to consider are as follows:
1. The aging process is determined by genetic or intrinsic factors and also by environmental or extrinsic factors (Chebotarev, 1978).
2. There are significant differences between older individuals; aging is a process of differentiation. Because of this, the aging group is heterogeneous in biological, psychological, and social aspects (Shock, 1978).
3. Inside the same organism, the organs age at different rates and in different sequences.
4. Aging does not mean sickness, although it may contribute as a basis to some pathological processes (Reubin, 1978).
Historical Evolution of Sociomedical Services for the Aged
The services for the aged in the developed countries have passed through three phases (Keet, 1979):
1. Preindustrial Phase. The origin or source is of the charity type autonomous, isolated, and generally institutional; the aged usually are supported by community systems, but mainly by the family. Developing countries are in the first stage: The family is still the main party responsible for an elder's wellbeing. Generally, the governments of such countries are not actively interested in the implementation of gerontological programs for two reasons: There exists the myth that the aged are well cared for; there are also more pressing priorities for the government to handle.
2. Industrial Phase. With state support, this system changes to a social welfare system. Charity is not substantial any more. In this phase, the main responsibility for the well-being of older persons lies with the government, and often the family feels liberated. The aged become passive recipients of services. All countries are experiencing some degree of industrial development; this implies a problem of cost, lack of quality, and dehumanization of services, which, on the other hand, are sufficient for only a small sector of the population. In the highly developed countries, the social welfare systems are suffering serious economic hardships and may go into bankruptcy by the year 2000.
3. Postindustrial Phase. The negative effects are depersonalization, dehumanization, and bureaucratization; costly services are the factors that help to develop active participation of the elderly and their families and communities. The formal networks by themselves cannot offer total support and should be reinforced by the informal systems, with the elderly as the main resource. Through this pattern, the developed countries may solve their budgetary problems, and the developing ones, in-stead of constructing expensive formal structures, will move into a postindustrial phase, utilizing the already existent resources.
Guidelines for the Organization of Sociomedical Services
Objectives for the general population. The World Health Organization's (WHO's) declaration of "Alma Ata" states that by the year 2000 all the countries and international organizations should be actively involved in the effort to achieve health care for everyone (Mahler, 1980). This declaration may serve as a means to focus the sociomedical policies of all countries on a multidisciplinary, interdisciplinary effort, which should include better use and a more equal distribution of resources. This combination of humanitarian considerations and socioeconomic aspects is fundamental for the acquisition of better health care.
Objectives for persons over 60 years. Goals for older persons should include independence, self sufficiency, comfort, and biological, psychological, and social well-being (for both sick and healthy elders) in the family milieu. In those cases in which it is not possible to be with the families, appropriate facilities should exist, both for healthy and for sick or frail elders. For those elders who have serious problems, physical or mental, special medical and gerontopsychiatric services should exist.
Aims of geriatric care. Different from the other specialties, geriatrics' aims should be directed to the maintenance of function and to the prevention of chronicity, invalidism, diminishing capacity, as well as of the dependence that accompanies them. (Coni and Davidson, 1980). It should try to avoid pathological approaches. Education, the promotion of a healthy condition, and preventive medicine, as well as early detection, are very important. In cases in which persons have a terminal illness, support and understanding should be provided in a peaceful and supportive atmosphere.
HEALTH AND SOCIOMEDICAL SERVICES FOR THE AGED
Taking into account the above-mentioned guidelines, we turn to aspects related to the conservation of health (defined by WHO as a state of bio-logical, psychological, and social well-being, and not only as the absence of disease) and linked to cultural, social, and economic factors and patterns (such as nutrition, activities, and the environment). It is important to consider that in the elderly, the biological situation is affected by involuntary processes on which the pathological conditions are based. Among the issues that should be enhanced in the pursuit of an active, independent, and productive life are the following:
1. Adequate epidemiological and longitudinal health services and clinical research.
2. Health education and its promotion for the aged.
3. Adequate medical services.
4. Special education and training in all professions and occupations related to aging.
5. Adequate physical, psychological, family, and social environment.
6. Informal support networks (voluntary sector, family, community, the elderly).
Adequate Epidemiological and Longitudinal Health Services and Clinical Research
Adequate health services and clinical research are essential to ensure health care. There is a need for knowledge of pathological processes that occur during old age, such as cerebrovascular diseases, senile dementia, osteoporosis, and so on. Medical care of the aged has achieved much progress over the past several decades, and the outlook for the future is positive. However, governments must recognize that with the increase in an aging population there is a need for expanded resources and support for research and care. The availability of information is the cornerstone for the establishment of sound policies and must exist at all levels: local, regional, national, and international (United Nations Interregional Seminar on the Aging, 1979). Areas such as mortality, mobility impairments, and the like should be explored in order to promote the health programs needed. The most adequate studies are longitudinal ones, although their long range or duration could present problems; the other and more usual studies are the cross-sectional ones. In both types, the data should be standardized and the surveys adapted to regional differences in order to facilitate the extrapolation and better use of the information. Research in biological, psychological, clinical, and environmental medicine is fundamental for the development of health programs.
Health Education and Its Promotion for the Aged
Health education should be promoted by all available means to all ages and to all levels of population, stressing the importance of life styles, self-care, and preventive measures in order to ensure the participation of persons of all ages, their families, and the community at large in dealing with clinical problems (Hunter, 1973).
The concept of gerontohygiene is closely related to the practice of self-care and healthy life styles, and includes the following issues: adequate nutrition (we must recognize that this factor is linked to cultural, socioeconomic, and personal f actors, and that the availability of nutrients and ability to obtain them may vary); physical activities (since physical and mental activity is beneficial, we should avoid sedentary programs); harmful influence of substances such as alcohol and tobacco, as well as obesity; dental, hearing, and visual care; general personal hygiene norms; and avoidance of exposure to the elements. The main points of preventive medicine are closely related to education and, therefore, should go hand in hand with a program of sound health habits.
These points include the following:
1. Education in the area of accident and trauma prevention is needed. The environment should be safe, avoiding risks such as wet floors or stairs inappropriate for impaired persons.
2. Education directed toward early detection of problems or illness should be emphasized. For this, it is important to have periodical medical checkups and an awareness of any physical change that could imply major future medical problems (e.g., weight loss, persistent diarrhea, bleeding, visual alterations, coughing, and the like).
3. Special attention should be given to pathology associated with the aging process (diabetes, hypertension, heart conditions, etc.). If people could recognize the symptoms related to these problems, they might cooperate more with the health professionals responsible for their care. Education in the rehabilitation process may take place after the medical problem is arrested.
In order to promote health education programs more effectively, mass media may be used. It is crucial to coordinate and get the cooperation of the organizations that have access to them. Programs may use television, radio, and newspapers in order to emphasize the link between life style and certain maladies.
Adequate Medical Services
All primary care services should include facilities necessary for older persons. Specialized medical services should exist beyond the primary level; such services must be provided by properly trained personnel who have been prepared in the knowledge and techniques relevant for aging. Geriatric services are already established in developing countries (Junod, 1980), but geriatric medical services in developing countries are inadequate or nonexistent. Usually, the elders receive the service when they are sick, which leads to overuse of the specialized services. This demand cannot be reasonably satisfied by the limited human and economic resources available, and therefore special attention should be devoted to the revision of the conceptual framework and gerontological policies. The following scheme may be helpful in this aspect:
1. Primary level: Training of sociomedical personnel (at all levels) in the field of gerontology.
2. Secondary level: Promoting special geriatric services in the general hospitals.
3. Third level: Geriatric hospitals, day care facilities, home care, longrange medical units for chronics and invalids, and psycho-geriatric hospitals, as they exist in the developed countries (Picton, 1979). These structures are of particular importance to maintain a connection and flow between the home and the geriatric institutions. The housing units should be appropriate in order to avoid institutionalization. It is evident that home care and day care facility programs should be created in order to help the informal systems pursue their task (Jiménez Herrero, 1978).
Implementation of geriatric services in developing countries (González Aragón, 1977). There is a possibility that instead of constructing new geriatric hospitals, some kind of geriatric unit or service may be organized in the already existing general facilities. This possibility may be explored by the policy makers, since it is relatively easy, it costs little, and people are already familiar with those existing services (first level). On the other hand, it is also important to consider the benefits of receiving integrated sociomedical services. If a sound geriatric unit exists, then the other medical specialties may be relieved of many geriatric patients; often they are not receiving the best services available in medical-surgical units. The extra medical and supportive services that are part of the unit (such as domiciliary aid and day hospital services) will help to reintegrate the elders into their community, avoiding the intensive bed occupation of the general hospital. The construction of special geriatric hospitals may be considered only after other alternatives have been explored. (We do not think this is a viable alternative at this point for the developing countries.) For these elders for whom the only alternative is institutionalization (probably about 4.5% of theelderly), adequate long-term care must be made available.
Special Education and Training in All Professions and Occupations Concerned with Aging
All professions and occupations concerned with the promotion of f unction and the prevention of increasing loss of capacity among the aging must have courses relevant to aging in addition to core curricula in their training. Gerontological education should be implemented (1) at all levels during childhood (with school children); (2) at the preprofessional level for all the biological, psychological, and social careers; (3) at a postdegree level; (4) as continuing education for medical and para-medical personnel, as well as other members of the muitidisciplinary team (Johnson, 1980). All helping professions should also have available to them special education and training related to the aging processes, since the majority will be providing close and continuing care for the elderly.
Adequate Physical, Psychological, Family, and Social Environment
All governments should be concerned with the quality of environments and should recognize the close relationship between such environments and their impact on both health conditions and the processes of aging. To guarantee and support the social participation of the elderly, it is necessary to optimize an integrated approach concerning the environment of the aging individual. The coordination with and support of the family are important f actors in the provision of social health services and also help assure access to sociocultural and economic well-being. In developing countries, deficits in nutrition, recreation, health education, and health and sanitary services are so prevalent that aging is something of a privilege. This aspect adversely affects the morbidity and mortality rates. We must also mention the pervasive poverty problem that obstructs access to health care and keeps marginal groups (such as the elderly) marginal.
Informal Support Networks
Communities, volunteer groups, organizations, families, and senior citizens themselves should be involved in the health care system. It is necessary, however, to create resources to support those who provide sup-port systems for the older persons. A partnership between governments and these informal networks must develop if one does not already exist. It is also essential that the governments recognize their role in develop-ing informal support networks for the aging if they do not exist.
Voluntary organizations. Volunteer organizations are classical developments of industrial areas. These altruistic activities have an enormous potential for aid to the elderly, since they are flexible and spontaneous, and therefore can give rapid solutions to diverse situations or problems (Moore, 1977). Their success may be maximized if adequate coordination with the formal networks is established through intermediate organizations. These kinds of organizations must be adapted to the particular cultural contexts of the different developing countries. They can increase the supply of services in the areas of transportation, recreation, and communication without extra cost. Voluntary organizations of which the senior citizens themselves are members constitute one of the most promising developments. The ones in existence in the highly developed areas are very good examples, since they contribute to the self-satisfaction of the members on the one hand, and supply important services to the community on the other. This social activation of the elderly people characterizes a healthy society.
The family. In the developing countries, the family is still the principal resource for the elderly's well-being. However, the transformation and changes suffered by this system throughout the world must be recognized. The trend is toward a reduction in the role of extended families and an increase of nuclear units.
Although families continue to satisfy the emotional needs of their elderly members, each day it is increasingly difficult to solve their economic problems and meet the increasing costs of services and other needs (Shanas, 1979). An assessment of the reasons why some families neglect their elderly should be made in each country as a basis for deter-mining what resources are needed and to prevent a breakdown in elder-family relationships. Individualized services, education, nutrition and housing programs for the aged should be designed and implemented with the collaboration of, and where possible within the context of, the family and the community (Kral, 1980).
The community. All members of the community must share responsibility for the well-being of the aged; we must remember that each one of us will be among the elders of the future. By the year 2000, every community should have the basic human services (both medical and social) that would guarantee a dignified life for all. These services must be appropriate for and accessible to the aged.
The elderly as a resource. The aged must recognize their rights and responsibilities; in order to acquire biological, psychological, and social well-being, they have the right to good medical services, but they must also participate in their provision. (All these concepts should be incorporated early in life in order to ensure their practice later on.) Active participation and advocacy issues should be initiated by the elderly themselves. Education is a very important factor for the eiderly's preservation of their social status.
ECONOMIC FACTORS AS HEALTH FACTORS
Although experts mention health as the fundamental area for elderly people, solving their main economic problems is a first priority. In order to deal with health problems in a holistic and comprehensive way, we must take into account that poverty contributes heavily to many of those health problems. This is a crucial point to be evaluated by the experts in policy making for the year 2000. When the demographic explosion and socioeconomic development are balanced, the probability of better health care and well-being is higher. In a country in which sound economic development takes place, a better biological, psychological, and social environment may be achieved. With such a balanced approach to development, the elderly may have a better future. Insufficient re-sources in the public sector, excessive polarization in the distribution of governmental investments, and the increase in budgetary deficits are the causal f actors of the imbalance prevalent in Latin America and in other areas of the Third World. The picture seems bleaker because these countries also lack an integrated planning program. The rapid increase in population demands more productivity through the development and use of new technology. All these factors, if they are well planned, may generate full employment; that, in conjunction with a high educational level, governmental stability, and social activation, is crucial for the well-being of all in the population, including the aged.
We are unable to predict what the next decades will bring to the world, since there are serious problems even in the highly developed countries. Only through a planned national development that takes social and cultural values into consideration may we arrive at a progressive condition with justice for all, and justice for the aged in particular.
REFERENCES
Chebotarev, D. F.: Biology of human aging and disease. In: XI International Congress of Gerontology, Tokyo, Jopan, Abstráete. 1978.
Coni, N., &Davidson, W.: Lecturenotesongeriatrics (2nded.). London: Black-well Scientific Publications, 1980.
González-Aragón, J.: Menean aging program of the Mexican Geriatríc and Gerontological Society. Unpublished manuscript, 1977.
Hunter, W. W.: Preparation for retirement. Ann Arbor: Instituto of Gerontology, University of Michigan, 1973.
Jiménez Herrero, F. La asistencia geriátrica en la planificación, organización, y función de la medicina preventiva hospitalaria. Revista Española de Gerontología y Geriatría 13:323, 1978.
Johnson, R. H.: Foundations for gerontological education. Gerontologist 20, 1980.
Junod, S. P.: La organización hospitalaria y extrahospitalaria de las instituciones ginebrinas de geriatria. Revista Española de Gerontología y Geriatria 15: 353, 1980.
Keet, J.: Role ojthe aging in thefamily: Social community and voluntary aging as support services. Background paper for the United Nations Interregional Seminar on the Aging, Kiev, May 1979.
Kral, V.: Psychosocial problems of the aged: A shared responsibility. Journal of
the American Geriatrics Society 28:65, 1980.
Mahler, H.: People. Scientific American 243:67-77, 1980.
Moore, S.: Working for free: Practical guide for voluntarles. London: Serever House, 1977.
Picton, W.: Asistencia geriátrica en el Reino Unido: Desarrollo en el sector Lam-beth. Revista Española de Gerontología y Geriatría 14:48, 1979.
Reichel, W.: The geriatríc patient. New York: HP Publishing Company, 1978.
Reubin, A.: The normality of aging (DHEW Publication No. NIH 78-1410). Bal-tímore: Department of Health, Education and Welfare, 1978.

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