Hippolyte Fofack
WASHINGTON, DC – US President Donald Trump’s tariff bombardment of the world is likely to be the main topic of conversation among the assembled political leaders, international-finance experts, development practitioners, economists of all stripes, and corporate CEOs who will soon gather in Washington for the annual spring meetings of the World Bank and the International Monetary Fund. The harsh impact of Trump’s tariffs on markets, prices, and, most importantly, individuals will certainly justify their dominance of participants’ public and private discussions. But the looming impact on the world economy of today’s demographic changes, if left unaddressed, will be as harsh – and perhaps more permanent.
The simple fact is that humanity is getting older faster than ever. A globally synchronized decline in fertility rates (expected to reach the demographic tipping point of 2.1 births per woman by 2050), combined with falling mortality rates and rising life expectancy (resulting from advances in public health and nutrition), has accelerated this demographic shift. Both developed and developing countries are graying at an unprecedented pace, with the global population of people aged 65 and older projected to grow by 104% between 2005 and 2030, compared to a mere 21% increase in people under 65.
Longer lifespans are, of course, a positive development, partly because they have for decades been strongly correlated with economic development. But the “silver tsunami” poses unprecedented challenges, not least a dramatic increase in age-related chronic diseases and disabilities, implying major social and economic costs with intergenerational consequences. And insufficient financial resources have constrained efforts – most notably by “geroscientists,” but also by big data and AI entrepreneurs and innovators – to improve healthspans (the period of a person’s life spent in good health).
But the tide may be turning. The Hevolution Foundation, a nonprofit backed by the Saudi royal family, has earmarked $1 billion per year for research on how to increase healthspans. That includes investing in therapeutics targeting the root causes of aging and supporting initiatives aimed at turning scientific breakthroughs into products or treatments that will enable healthier aging. Now the rest of the world must follow suit to co-create a healthier future for the aging world in order to make the United Nations Decade of Healthy Aging a reality that transcends generations and reaps the enormous benefits of longevity dividends.
Old Before Rich
According to the UN World Population Prospects 2022 report, there will be more than twice as many people aged 65 and older as children under five by 2050, at which point senior citizens will represent 16% of the global population, up from 10% in 2022. Compared to other regions, this older demographic is projected to comprise a much higher proportion of the population in Europe and North America (26.9%) and in East and Southeast Asia (25.7%) by the middle of the century, as their populations are expected to peak sooner before beginning to decline in the late 2030s.
But the most rapidly aging societies are in the Global South: between 2006 and 2030, the elderly population in developing countries is expected to grow by 140%, compared to 51% in developed countries. And by 2050, 80% of older people will be living in low- and middle-income countries. While it took more than a century for the share of French people aged 65 and older to rise from 7% to 14%, many developing countries contending with an accelerated compression of aging are set to experience the same increase within a single generation (21 years in Brazil and 26 years in China, for example). This underscores the remarkable demographic revolution that began in the second half of the last century and accelerated in recent decades.
Developing countries are thus increasingly at risk of growing old before becoming rich, raising the specter of elderly poverty and vulnerability in the absence of strong social-safety nets. And while increased longevity at the global level represents a triumph of medical science and social and economic progress, many people aged 65 and older are not experiencing healthy life expectancy. Aging has instead become associated with the onset of disabilities and non-communicable chronic diseases. This is reflected in a fundamental shift in disease epidemiology: ailments such as heart disease, cancer, diabetes, and Alzheimer’s have surpassed infections as the leading causes of death. According to the Global Burden of Disease Study, supported by the World Bank and World Health Organization, age-related chronic diseases will cause a substantial increase in disability worldwide.
The rising health burden of age-related diseases threatens to undermine fiscal sustainability and economic growth. The fiscal implications are already being keenly felt in rapidly aging societies, where extended longevity and the accompanying increase in disability rates are causing health expenditures and pension outlays to skyrocket, while the working-age population is shrinking. The IMF forecasts that, by 2050, global public-pension spending could depress public saving – which is essential for domestic investment and to absorb economic shocks – by more than two percentage points of GDP.
Absent meaningful reform and a shift toward a multisectoral and multidisciplinary approach to extending healthspans and lifespans, the silver tsunami will only exacerbate macroeconomic imbalances and further depress domestic consumption and investment, putting countries at risk of secular stagnation. A 2022 study shows that aging has been one of the most important sources of downward pressure on price levels and per capita output in Japan, where people aged 65 and older already account for 30% of the population.
Maximizing Longevity Dividends
Various countries have tried to mitigate the looming costs of rapid population aging by adopting policies aimed at boosting fertility rates and improving the long-term sustainability of pension systems. Measures to reverse the trend of declining births – namely, targeted financial incentives – have largely failed, highlighting the persistence of small-family norms once they become entrenched. Pension reforms, such as raising the eligibility age, increasing the contribution rate, and reducing benefits, have fared slightly better.
But pushing people to extend their working lives will not necessarily sustain high productivity or bolster fiscal sustainability if these extra years of work are dominated by declines in physical and mental capacity. Globally, disability-adjusted life years, a metric that includes years of life lost to a state of poor health, increased by 32% between 1990 and 2019, and is expected to have increased by 55% between 2004 and 2030. These policies could even have the opposite effect, dragging down overall labor productivity and undermining fiscal sustainability as age-related public spending continues to rise, relative to tax revenues.
The United Kingdom’s National Health Service, for example, lacks sufficient home care for the country’s aging population, forcing 855,000 older people into hospitals each year – with huge economic costs and dire health consequences. In the United States, where sustained immigration has partly offset the costs of aging, public-health expenditures have been one of the fastest-growing line items. The Congressional Budget Office projects that total health-care spending will rise from 16% of GDP in 2007 to 37% in 2050.
The more sustainable solution would be to focus on increasing healthspan, thereby compressing morbidity into a shorter period at the end of life. Medical research has identified aging – the accumulation of a wide variety of molecular and cellular damage that over time leads to a gradual decrease in physical and mental capacity – as the predominant risk factor for most of the chronic diseases that drive morbidity and mortality rates. This suggests that “geroprotection” (slowing biological aging, a goal that has long fascinated humankind) in healthy people could help maximize longevity dividends.
In November 2023, the Hevolution Foundation hosted the first-ever Global Healthspan Summit in Riyadh, Saudi Arabia, in part to highlight enormous progress in geroscience (which studies how aging enables chronic disease) and the growing number of possible interventions to slow the physiological processes of aging. Among the major breakthroughs presented at the GHS were the identification, using invertebrate models, of conserved molecular pathways that affect aging; the, mammalian studies that have generated a more detailed understanding of age-associated pathologic changes; and interventions that can extend lifespan while also improving aspects of healthspan.
Perhaps the most promising developments discussed at the GHS concerned medicines. Senolytic drugs, for example, have the potential to eliminate senescent cells that accumulate during aging and contribute to the emergence of age-related disorders and chronic diseases. Delegates were equally excited about rapamycin, the first drug that has been shown to decelerate consistently the early development of age-related diseases in experimental animals. The Hevolution Foundation is supporting more research to understand how rapamycin induces autophagy, a cellular process that degrades damaged or superfluous components, and to develop strategies for testing the drug in humans. It is also helping investigate other longevity-promoting agents.
The Centenarian Secret
Troves of biometric data from centenarians point to the importance of pursuing this avenue of research, with a growing body of evidence suggesting that age-related diseases are rare and delayed among the oldest living people. A study of younger centenarians (aged 100-104 years), semisupercentenarians (aged 105-109 years), and supercentenarians (aged 110-119 years) found that the older the age group, the later the onset of chronic disease and cognitive and functional decline. This supports the hypothesis that as the limit of lifespan is approached, morbidity is compressed into a shorter period, and healthspan begins to approximate lifespan.
The lives of famous centenarians such as the late former US Secretaries of State George Shultz and Henry Kissinger provide further anecdotal support for the idea that people who live to extreme old age are more likely to enjoy the benefits of extended healthspans. Shultz, the first of the two to join the exclusive centenarian club, had an extremely productive life. In an insightful essay, written to mark his 100th birthday, he reflected on the importance of trust to strong families, racial integration, conflict resolution, and foreign affairs – a valuable lesson for strengthening social cohesion and creating the cooperative international environment required at this critical juncture.
Kissinger also had a very productive (if controversial) lifespan that was largely free of morbidity and disability (apart from some cardiac difficulties). He wrote and co-authored many articles and books, including one on AI in 2022. A few weeks before his death at 100, Kissinger met with Chinese President Xi Jinping in Beijing in a bid to thaw Sino-American relations at a time of growing geopolitical uncertainty and great-power rivalries.
But centenarians are few and far between. They account for just 0.03% of the US population and an even smaller share of the global population, as most live in advanced economies. Research shows that, on average, one-fifth of a person’s life will be lived with morbidity, often creating highly stressful conditions for them and their loved ones, in addition to the implied social and economic costs. Spending 20% of one’s life in poor and deteriorating health can be an exceedingly long time, and that period is only rising as life expectancy increases.
That is why investing in medical research and innovation to bolster healthspans globally is the most important mission of our time. These investments could narrow the life-expectancy gap between the world’s richest and poorest countries (estimated at nearly 20 years) and raise overall life expectancy. And in places where health-care costs are fueling poverty, the welfare benefits of expanding healthspan will be even more pronounced. In the US, for example, medical bills pushed eight million people – most of them uninsured – into poverty in 2018. The risk of medical impoverishment is even greater in the Global South, where high poverty rates increase vulnerability to health-related shocks.
Beyond increasing the years of healthy living, investment in healthspan research can help reduce lifespan inequalities by leveling the wellness playing field, regardless of geographical and socioeconomic variables. After all, healthspan and lifespan are two sides of the same coin, and interventions that extend the former will also increase the latter.
Creating a healthy-aging future for all will also likely yield substantial socio- and macroeconomic benefits. For most countries, expanding healthspans by one year could increase GDP by about 4%. Simulations based on US data show that delaying aging could increase life expectancy by 2.2 years, generating around $7.1 trillion in economic value over 50 years. Extending healthspan is not just a moral imperative. It is also smart economics.
Biological Data Mining
Despite the consensus among geroscientists and other participants at the inaugural GHS that slowing biological aging was a realistic goal, they lamented the severe underinvestment in anti-aging research. Limited financial support is one of the biggest constraints for innovators seeking to develop therapies that target the root causes of aging. Fortunately, through its initial investment in the Hevolution Foundation, Saudi Arabia has already begun to accelerate the global shift from lifespan to healthspan by supporting life sciences and medicine innovation focused on biological aging, rather than diseases.
This includes grants and early-stage investment to foster independent research and entrepreneurship in healthspan science (from basic aging biology to geroscience and clinical trials); increase the number of safe and effective treatments entering the market; shorten the timeline of drug development; and increase accessibility to therapeutics that extend healthy lifespans. On the last day of the inaugural GHS, the Hevolution Foundation pledged $100 million in research grants to fuel breakthroughs in the field of aging science. The Foundation has made several more pledges since, bringing its total commitments to date to more than $400 million.
The Hevolution Foundation is also supporting the development of platforms and technologies to harness the power of big data, AI, and machine learning to develop a better understanding of individual risk factors and more precise interventions. For example, researchers using data from the University of Michigan Health and Retirement Study found that education has long-term health benefits, helping older people keep dementia at bay and their memories intact. Another study of diverse datasets provided new insights into the genetic underpinnings of aging-related verbal memory performance. Researchers are also leveraging big data to identify and understand the functions of previously unknown mitochondrial genes, with an eye to developing treatments for Alzheimer’s, diabetes, and other chronic diseases.
The increasingly data-intensive approach to geroscience and gerontology has made it possible to address some of the challenges that have impeded progress in the field. Researchers are using these methods to quantify biomarkers of aging; to compile an index of frailty; to develop a genome-wide scan for depressive symptoms in older adults; and to calculate how genetic and environmental factors contribute to age-related cognitive changes. Applying these new technologies and computational tools to vast reams of biological data, coupled with breakthroughs in our understanding of human biology, may also encourage interdisciplinary collaboration.
Such an integrated research model could revolutionize the study of aging, which is driven by codependent multivariate factors, including genetics, behavior, and contextual influences such as socioeconomic status and family adversity. The goal would be to understand individual risk factors, identify the role of genes in diseases, and eventually foster the development of patient-specific interventions to address genetic and lifestyle issues.
More Than a Money Problem
Financial constraints are not the only barrier to slowing down the aging process. Four especially salient obstacles were identified at the inaugural GHS. First, medical research and investment priorities have been heavily skewed toward disease models, and must be rebalanced to reflect today’s population pyramids and the enormous challenges posed by the silver tsunami. While the disease model has led to increased life expectancy, it has done so at the expense of healthspan. The survival of modern health-care systems depends on combining disease models – which remain important – with delayed-aging models to prevent the onset of aging-related diseases.
Second, effectively targeting aging implies a shift away from the current disease-by-disease approach to medical treatment and toward a more integrated method. Many older people suffer from multiple interacting morbidities that are ill-served by one-dimensional care. Embracing novel therapeutic models for multiple chronic diseases and, more importantly, focusing on prevention efforts – particularly those that promote early intervention – would significantly ease the social and economic burdens of aging populations and maximize longevity dividends.
Third, as health-care systems begin to combine disease models with delayed-aging models, it will be crucial to devise clear methodological guidelines for designing clinical trials involving older adults with multimorbidity. The development of effective treatments that can prevent the onset of multiple chronic diseases associated with aging, or simultaneously target multiple age-related diseases, creates enormous growth opportunities for the pharmaceutical industry and, in turn, new challenges for regulators. Close collaboration between the industry and regulators could produce gold-standard treatments for aging populations, revolutionizing health-care services and transforming economies.
Finally, and perhaps most challenging of all, is the required change in mindset. For centuries, older people have been seen through the prism of the age dependency ratio (the share of young and elderly people relative to the working-age population). But to secure a better and more productive future for all people in our rapidly graying world, we must change humanity’s perspective on aging. Societies must view this growing cohort as a valuable asset and direct more resources toward anti-aging research and innovation.
Moreover, increased intergenerational dependence will bring economic benefits. The sustainability of pension systems depends on reforms that raise the retirement age and extend healthspans. This is especially important because the accelerated compression of aging in developing countries will reduce international migration, which for years has partly offset the effects of population aging in advanced economies. Continued employment of older workers could also sustain corporations on a long-term growth trajectory by enhancing mutual learning, bridging the digital divide between generations, and reducing the loss of institutional knowledge.
At a societal level, younger people could end up spending several decades engaging actively with their grandparents and great-grandparents, which would have significant implications for the transfer of knowledge and values in a new world of overlapping generations. The first step toward realizing these longevity dividends is to debunk negative myths about senior citizens and overcome ageism. The second half of life should be viewed with the same hope, expectation, and rigor as the first half.
A Manhattan Project for Aging
Time is of the essence: the number of elderly people afflicted by irreversible age-related chronic diseases is rising sharply. According to the National Council on Aging, nearly 95% of Americans aged 60 and older have at least one chronic condition, while around 80% have two or more. Much of the damage is usually done by the time these chronic diseases and disabilities are diagnosed, making them difficult to treat.
Failure to act now would only compound the challenges facing graying societies. Catalyzing the shift to more healthspan-related research initiatives and interventions that could prevent or delay the onset of age-related chronic illness requires global commitments and a proactive multi-stakeholder partnership. This community of policymakers and experts should approach the task of building a healthier future with the same spirit and sense of urgency that drove the Manhattan Project in the race to develop the atomic bomb ahead of Nazi Germany. Saudi Arabia has provided a major boost to these efforts. But more must be done to shift morbidity to the end of life and to extend people’s productive years, enabling them to remain economically active into old age.
Life is still a one-way street – there is no changing that. But when an individual is thriving, life is always worth living. Our goal should be to ensure that every person’s journey on Earth remains bright and productive for as long as possible. To that end, we must use Saudi Arabia’s large-scale investment in healthspan research to galvanize more support globally for this agenda. To paraphrase a saying often attributed to the playwright George Bernard Shaw, “We don’t stop working because we grow old; we grow old because we stop working.”
*Hippolyte Fofack, a former chief economist at the African Export-Import Bank, is a fellow with the Sustainable Development Solutions Network at Columbia University, a research associate at Harvard University’s Center for African Studies, a distinguished fellow at the Global Federation of Competitiveness Councils, and a fellow at the African Academy of Sciences.
