The other side of longevity: more years of life, but also greater inequality

This phenomenon affects all developed countries and is likely to become more pronounced with the spread of costly medical innovations – from artificial intelligence applied to medicine to personalised therapies – which are more readily accessible to those with greater financial means. From this perspective, longevity ceases to be merely a health indicator and becomes an indicator of a society’s ability to distribute opportunities throughout the entire lifespan.

Francesco Landi, a professor at the Catholic University of Rome and director of the Geriatric Internal Medicine Unit at the A. Gemelli University Hospital, has proposed a paradigm shift that is set to have significant implications for public policy.

“The greatest inequality in longevity does not concern those who die earlier, but those who start ageing earlier,” he said, summarising years of research into so-called biological age.

According to Landi, ageing is not simply a matter of the passage of time: two people of the same chronological age may have vastly different physical and cognitive conditions. Analysing over 25,000 people who underwent ‘Longevity Check-up’ programmes, the research team observed that indicators such as muscle strength and cognitive abilities begin to decline as early as between the ages of 45 and 50. Even more striking is the enormous variation between individuals of the same age: some people in their fifties perform at a level normally seen a decade later, whilst others retain abilities typical of much younger people.

This is the basis for one of the conference’s central arguments: inequality in old age is often the result of processes that begin many decades earlier. “Inequalities begin long before old age,” Landi emphasised, citing education, diet, physical activity, the environment, social relationships and prevention as key factors. From this perspective, the significance of policies on ageing also changes: it is no longer simply a matter of caring for older people, but of investing early on in people’s health throughout their lives.

Landi’s presentation also extended the concept of prevention to the environmental context. Analyses comparing people living in different parts of Italy show that greater exposure to fine particulate matter (PM2.5) is associated not only with respiratory diseases, but also with higher blood pressure and cholesterol levels – factors that directly affect cardiovascular ageing.

The environment, therefore, becomes a source of inequality in its own right: living in more polluted neighbourhoods means accumulating a greater risk of frailty over time. The prevention strategies identified appear, at least in part, to be well known: a balanced diet, physical exercise, managing cardiovascular risk factors, quality of sleep and mental health. But the geriatrician’s message is that these measures must become an integral part of the entire life cycle, not just old age.

Another recurring theme that emerged during the conference concerns moving beyond a form of medicine focused exclusively on diseases. According to the experts, the real objective should be the preservation of functional capacity – that is, the set of physical and cognitive abilities that enable people to maintain their independence and quality of life. From this perspective, frailty does not correspond to the presence of a specific illness, but to the progressive loss of the ability to carry out daily activities. It is a paradigm shift that is also reflected in the World Health Organisation’s definition of health, understood not simply as the absence of illness but as the maintenance of functional capacity over time.

Barbara Hanratty, a lecturer in Primary Care and Public Health at Newcastle University, has called for a shift in focus from years of life to years lived independently. The research presented shows that the years gained as a result of increased life expectancy do not necessarily correspond to years spent in good health. In the UK, for example, a 65-year-old woman can expect to live for another twenty years or so, but the number of years lived without disability varies greatly between social groups: those living in the most deprived areas experience frailty and dependence much earlier than their more affluent counterparts.

Hanratty emphasised that frailty is also a social phenomenon. Poverty, isolation, weak family networks and loneliness increase the risk of losing independence and of having to rely on health and care services. The scientific literature also links social isolation to increased mortality, cardiovascular risk and cognitive decline. Hence, according to the researcher, there is a need to integrate health policies with social policies and to identify situations of vulnerability at an early stage – not only clinical but also relational.

A second line of research has focused on the relationship between life course and economic circumstances in old age. Michel Oris, a research professor at Spain’s Higher Council for Scientific Research, has shown that poverty amongst older people is not the result of a single event, but of the accumulation of disadvantages throughout their entire lives. ‘The accumulation of advantages is an accumulation of opportunities; the accumulation of disadvantages is an accumulation of risks,’ he observed, explaining how each stage of life can either reinforce or mitigate the inequalities that manifest themselves in old age.

There are numerous turning points: childhood, level of education, entry into the labour market, unemployment, separation, illness and widowhood. Each of these stages can undermine a person’s ability to accumulate income, pension contributions and wealth, thereby increasing the risk of poverty in old age.

Education emerges as one of the most important factors: a low level of education continues to increase the risk of poverty even decades later, regardless of individual countries’ economic progress. At the same time, welfare systems play a vital role in breaking the cycle of disadvantage, particularly when they are able to protect people during the most challenging transitions in their working lives.

Whilst public debate tends to focus on the financial sustainability of pension systems, Monica Paiella, Head of the Analysis and Research Division for the Pension and Social Security System at INPS, has proposed a shift in perspective. “The question that is usually asked is whether pension systems can afford longer life expectancy. I would like to focus on the complementary question: whether individuals can afford their own longevity,’ she said, explaining how the sustainability of public finances and the adequacy of pensions are two closely linked but profoundly different issues.

This line of thinking has given rise to the concept of ‘longevity fragility’: a condition that arises when a long period in retirement is combined with a low pension and limited financial resources. “A long retirement with an adequate income is a success story; a long retirement with a low pension is longevity fragility,” explained Paiella.

Using INPS administrative data on private-sector employees born between 1940 and 1950, Paiella has shown how the average duration of a pension masks very different realities: 23 per cent of deceased pensioners received their pension for over twenty years, whilst around 30 per cent retired on a pension of less than 12,000 euros gross per year – less than 1,000 euros a month. Women are particularly vulnerable because they live longer on average but start their retirement with significantly lower pensions than men, due to more fragmented careers and lower pay.

Hence the proposal to use administrative data not only to pay out pensions, but also as a preventive tool. “The authorities can inform, identify and protect,” concluded Paiella.

Another cross-cutting theme concerned the capacity of public policies to have effects that extend far into the future. Analysis of data from the European SHARE project has shown how educational reforms, pension systems and maternity leave continue to influence health, income and labour market participation even many years after their introduction. Extending compulsory schooling, for example, has had positive effects not only on educational attainment but also on earnings throughout a person’s working life. Similarly, pension reforms alter patterns of retirement, whilst family policies affect women’s careers and, consequently, their future pensions. This finding reinforces one of the messages that emerged most clearly during the two-day event in Venice: longevity cannot be addressed through measures limited to old age, but requires coordinated policies throughout the entire life cycle.

Although the speakers came from very different disciplines, their contributions showed a strong convergence of views. For geriatricians, the priority is to preserve functional capacity before disability sets in. For economists, it is essential to identify at an early stage those most at risk of economic vulnerability. For demographers, the key is to break the cycle of inequality. For social policy researchers, healthcare must be integrated with welfare and prevention. In all cases, the starting point is the same: the inequalities observed at the age of eighty are the result of processes that began many decades earlier.