Public health and aging.

We wish to applaud the authors of the editorial “Public Health and the Second 50 Years of Life” in the August 2002 issue of the Journal for highlighting the need to bring more attention to public health and aging.1 The Journal editors are to be congratulated, as well, for printing an article that uses the recent publication record of the Journal itself as evidence for the paucity of published public health research that includes older adults. Because public health is in large part responsible for the unprecedented gains in life expectancy seen in the past century,2 we hope that public health will enthusiastically take up the challenge of improving the health and quality of life of older adults. The authors also propose a conceptual framework for public health research in aging. One particularly valuable contribution of the proposed framework is the illustration (in Albert et al.’s Figure 1 ▶) of the authors’ statement “More than likely, some combination of true senescence and greater exposure to risk factors is likely to be responsible for the changes we consider ‘aging.’ ”1 This schematic is especially helpful for making the case for prevention efforts targeting older adults. However, we suggest that the proposed model would have even more usefulness if disability were portrayed not as an outcome, but as a complex process, like aging. The model would then avoid any suggestion that disability is a negative, undesirable end state and, by implication, a circumstance less amenable to public health intervention. This is particularly important because of the growing population of persons with disabilities who are not only aging, but aging with existing health disparities.3 For an expanded research role in public health and aging to take shape effectively, we believe that aging and disability need to be modeled together. FIGURE 1 —Interaction between the components of the International Classification of Functioning, Disability and Health. The authors state that disability is “typically defined as difficulty with household and personal self-maintenance activities severe enough to threaten independent living.”1 This overstates what is, in fact, only some convergence of agreement regarding what constitutes disability beyond the “activities of daily living” and “independence” (“instrumental activities of daily living”)4 used by the authors. In practice, we do not have uniform, standard definitions for disability.5 In May 2001, the World Health Organization completed a project spanning more than 20 years when it approved the International Classification of Functioning, Disability and Health (ICF)6 as a companion to the International Classification of Diseases (ICD). This classification includes a framework that, like the one proposed for aging, recognizes the interaction of multiple, complex processes (Figure 1 ▶). In this classification, disability is more accurately characterized as a nonlinear, multidimensional experience having implications for body function as well as abilities to perform various tasks, from meal preparation to toileting. The disability framework also includes the potential effect on a person’s ability to participate in social roles, that is, attending religious services, working, and being with friends and family. Clearly, the old men in the photograph published with the editorial are involved in social roles that are important to them, yet we do not know if any or all have “disabilities.” We do know they are having a good time. The ICF would allow public health research to map the environment and social participation, as well as function and morbidity. The ICF moreover shares the emphasis of Albert et al on the importance of the environmental and personal factors that can serve as barriers or facilitators for people with and without disabilities. Regardless of disability status, environmental barriers have the potential to rob older people of independence. Bathroom doors too narrow for a walker or wheelchair may be the sole factor forcing an older person from his or her home, independent of other functional issues. Curb cuts can allow both a person who uses a wheelchair and a young, vigorous mother manipulating a stroller to navigate a street. Cognitive decline may outweigh any number of mobility issues. Similarly, social environments that are welcoming or discouraging also serve as facilitators or barriers. An older person with a disability who is welcomed into a community aging program is more likely to participate. Demographic trends alone leave little doubt that public health research should attend to older people. We would assert that the research must involve all older people, including those with disabilities. To that end, public health must appreciate the nuances of “the second 50 years.” Our public health messages promoting increased exercise, better nutrition, and reduced smoking and drinking are of equal value to older people even after they have acquired a disability. Other efforts, such as interventions that target secondary conditions, may need to be tailored to the requirements of specific disabilities. Research that examines the social context of becoming older and research that examines the social context of acquiring a disability share common domains. These are all topics worthy of the prominence given to public health and aging in the recent editorial by Albert et al.