1、U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T YiiUNLOCKING THE POWER OFHEALTHY LONGEVITYDemographic Change,Non-communicable Diseases,and Human CapitaliiU N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Y 2024 The World Bank 1818 H Street NW,Washington DC 20433 T

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7、orld Bank.2024.Unlocking the Power of Healthy Longevity:Demograph-ic Change,Non-communicable Diseases,and Human Capital.Washington,DC:World Bank.World Bank.”Any queries on rights and licenses,including subsidiary rights,should be addressed to World Bank Publications,The World Bank,1818 H Street NW,W

8、ashington,DC 20433,USA;fax:202-522-2625;email:pubrightsworldbank.org.Cover design and typesetting:Karim Ezzat Khedr,Creative Director;email:.U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T YiiiContentsTables and Figures Abbreviations and Acronyms Foreword Report Team Preface:Why t

9、his report?Unlocking the power of healthy longevity:Key messages of this report Executive Summary 1.Introduction:Better health throughout the life course is achievable 2.Healthy longevity,NCDs,and human capital:Levers for action across the life course 3.Advancing healthy longevity now:What countries

10、 can do 4.Financing for healthy longevity:Country leadership and key supporting roles for development partners 5.Conclusion:From knowledge to action Appendices Appendix A:Data sources,methods,and analytic processes Appendix B:Supplementary analytic materials Appendix C:Acknowledgments Appendix D:Bac

11、kground papers Bibliography ivvviviiviii1511304260727279868889C O N T E N T SivU N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T YTables and FiguresFigureTitleFigure 1.1Trends in global population change by age and dependency ratio,1950 to 2050Figure 1.2Population and deaths by age

12、in 1990 and 2023 and projections to 2050Figure 1.3Population size by age group in 1990,2023,and 2050 and changes in total fertility rate,selected countriesFigure 1.4Global distribution of climate vulnerabilityFigure 1.5Trends in probability of death at ages 079,5079,and 049 years from 1970 to 2019 b

13、y income regionFigure 1.6Proportion of all deaths attributable to NCDs,by country income category,2019 and 2040Figure 1.7Number of adults living with major NCDs in 2019Figure 1.8Contribution of mortality or disability for selected major causes of death in India at various ages,2017Figure 1.9Number o

14、f people(aged 15+)with NCD risk factors in 2016 and trends in prevalenceFigure 1.10Avoidable mortality as a percentage of total mortality,2019Figure 1.11Projected mortality decline vs.mortality decline at the rate of top 20%of countries,Ethiopian men aged 50-69Figure 1.12Trends in the age distributi

15、on of avoidable mortality by sex in Colombia,1990 and 2030Figure 1.13Levels in avoidable mortality,selected countries by age and sex in Latin America and Japan in 2020Figure 2.1Shares of total wealth,by asset type and income group,2018Figure 2.2Conceptual framework to address NCDs,human capital,prod

16、uctivity,and wellbeing Figure 2.3Survival among British males in 1960,2010,and with hypothetical ideal,including years lived with disabilityFigure 2.4Distribution of critical income values for LMICs in 2019,relative to reference 1990 global valueFigure 2.5Incidence rates of major CVDs in selected co

17、untries by income regionFigure 2.6Education levels and age-standardized death rates from cancers among adults aged 3069 in India by sex,200103(left)and education levels and selected NCD and risk factors among Argentinian adults aged 18 years and older,2013(right)Figure 3.1Levels of excise and other

18、taxes on cigarettes by country income group,2020Figure 3.2Prioritization of HLI-recommended NCD clinical interventions,by country incomeFigure 3.3Coverage of contributory pension systems strongly depends on income level(left)and coverage levels in LMICs have changed little over 15 years(right)Figure

19、 3.4Survival rates and pension coverage,by education in IndiaFigure 3.5Sample HLI dashboards for India and Sierra LeoneFigure 4.1Intersections of demographic change,NCDs,climate change,and pandemicsTableTitleTable 1.1Average annual rate of reduction in mortality between 1990 and 2019 by age(%)Table

20、1.2Projected deaths vs.avoidable deaths in hypothetical scenario and with accelerated performance through-out life courseTable 1.3Economic value of avoidable mortality for 2050 as a percentage of annual income and in US$trillion,by country income categoryTable 1.4Economic value of avoidable mortalit

21、y in 2019 and 2050,globally and compared to the frontier mortality rates,as%of annual income by major disease categoryTable 3.1Full list of recommended NCD interventionsTable 3.2Estimated cost and impact of locally tailored,high-priority NCD package,by country incomeTable 3.3Estimated distribution o

22、f cost of NCD package,by level of health systemTable 3.4Estimated increase in health care workers and facilities with HLI packageTable 5.1Summary of the HLI agenda recommendations and their impactTA B L E S A N D F I G U R E SU N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T YvAbbre

23、viations and AcronymsAARC Average annual rate of changeAARR Average annual rate of reductionACS Acute coronary syndromesAI Artificial intelligenceAIDS Acquired immunodeficiency syndrome ASRHR Adolescent sexual and reproductivehealth rightsBMI Body mass indexCOPD Chronic obstructive pulmonary disease

24、COVID Coronavirus disease(also known as COVID-19)CVD Cardiovascular diseaseCWON Changing Wealth of NationsDALY Disability-adjusted life yearDCP3 Disease Control Priorities,third editionEVAM Economic Value of Avoidable MortalityGDP Gross domestic productGNI Gross national incomeGPGs Global public goo

25、dsGPT Generative pre-trained transformerHICs High-income countriesHIV Human immunodeficiency virusHLI Healthy Longevity InitiativeHNP Health,Nutrition and Population Global Practice(World Bank)HPV Human papillomavirusIDU Injecting drug useLICs Low-income countriesLMICs Low-and middle-income countrie

26、sLTC Long-term careMDB Multilateral development bankMDGs Millennium Development GoalsMICs Middle-income countriesNCD Non-communicable diseaseNGO Nongovernmental organizationODA Official development assistanceOECD Organization for Economic Co-operation and DevelopmentPCI Percutaneous coronary interve

27、ntionPHC Primary health carePPP Purchasing power parityR&D Research and developmentSBCC Social and behavior change communicationSDGs Sustainable Development GoalsSHI Social health insuranceSIDS Small island developing statesSSBs Sugar-sweetened beveragesUMICs Upper-middle-income countriesUN United N

28、ationsUNPD United Nations Population DivisionVLY Value of a life yearVSL Value of statistical lifeVSLr Ratio between VSL and income per capitaWHO World Health OrganizationWPP World Population ProspectsA B B R E V I AT I O N S A N D A C R O N Y M SviU N L O C K I N G T H E P O W E R O F H E A LT H Y

29、L O N G E V I T YForewordThe World Bank has a long history of engaging in population issues,ranging from childhood illness,nutri-tion,fertility,and safe motherhood to the aging process.It supports countries in addressing the implications of the demographic process through analytical work,technical a

30、dvice,and financing to expand health cov-erage,redesign pension systems and social security,and undertake actions that support their economies.This report follows that tradition and analyzes the steps to promote healthy longevity and enhance the quan-tity and quality of human capital through attenti

31、on to the burgeoning problem of Non-communicable dis-eases(NCDs).Research began before COVID and concluded after,drawing upon lessons from the pandem-ic.The report is intended to inform policy and action at the country level.The demographic transformation is a global phenomenon,and the increasing po

32、pulation of the mid-dle-aged and elderly brings with it many challenges which are more acute in low-and middle-income countries where resources are more limited.The increasing number of adults calls upon countries to insti-tute the social and economic measures of ensuring their wellbeing and making

33、them optimally productive.Health must be at the center of these concerns,not only its preservation towards the end but its optimiza-tion throughout the life-course.This report builds on a compendium of analytical papers covering the economics of avoidable mortality,long-term care,behavior change,soc

34、ial protection,and whole-of-government solutions to support healthy longevity.It emphasizes that a great deal of ill health globally is a result of inequitiesespecially poverty and gender inequities that limit or delay access to and use of health care.High out-of-pocket payments for NCDs can plunge

35、households further into poverty or extreme poverty.Women live longer with NCD morbidities.Preserving good health increasingly depends on preventing and controlling NCDs.This is grounded not only in the demonstrated efficacy of fiscal instruments governments can use to reduce the burden of NCDs,such

36、as excise taxes on tobacco,sugar-sweetened beverages,and alcohol,but also on the definition of the system-wide interventions that make healthy longevity possible.The proposals set out in this report are ambitious but firmly grounded in the financial realities of individual countries and emphasize th

37、at such financing should come principally from domestic sources,noting that the poorer countries will need support from external sources.There are existing instruments to operationalize most of the recommendations of the report,and attention to research and development of global public goods is a ne

38、cessary adjunct.The adoption of such policies will involve not only governments but also all of society,particularly people living with NCDs and the full range of development partners.Countries are at different levels of development,but all can commit to the imperative of the life-course approach.Th

39、is implies continuing the commitment to maternal and child health that was so successful for reaching the Millennium Development Goals.It is my hope that the wide dissemination and adoption of the recommendations in this report will contribute significantly to adding both years to life and life to y

40、ears.Mamta MurthiVice President for Human DevelopmentThe World BankF O R E W O R DU N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T YviiReport TeamThe Healthy Longevity Initiative(HLI)was led by Sameera Altuwaijri,Global Lead,Population and Devel-opment at the World Bank.Prabhat Jha

41、 was the lead author of the HLI report and the lead of the HLI sci-entific advisory committee.The scientific advisory committee was composed of George Alleyne,Debapriya Chakraborty,Gisela Garcia,Victoria Haldane,Paul Isenman,Seemeen Saadat,Jeremy Veillard and Daphne Wu.The HLI builds on the Non-Comm

42、unicable Diseases and Human Capital Research Initiative,which was spearheaded by Jeremy Veillard.The HLI was conducted under the overall guidance of Mamta Murthi,Vice President,Human Development,World Bank.Timothy Evans and Muhammad Ali Pate,as former Directors of the Health,Nutrition,and Population

43、(HNP)Global Practice of the World Bank,and Juan Pablo Uribe,as the current Director,helped to initiate and complete the HLI.Monique Vledder,Practice Manager,HNP Global Practice,World Bank oversaw the completion.Alexander Irwin,Christine Ro,Leslie Newcombe,Katherine Ward and Meriem Boudjadja provided

44、 editorial and writing support.Karim Ezzat and Danielle Willis provided graphics sup-port and Arlene Lucindo Fitz-Patrick,Jocelyn Haye,and Venus Jaraba provided operational support.Aart Kraay and Roberta Gatti from the Human Capital Index team joined in early consultations on the HLI.Elena Glinskaya

45、,Gustavo Demarco,and Margaret Grosh provided input on social protection and jobs,and Daniel Halim on gender.Iffath Sharif and Gabriel Demombynes,successive Managers of the Human Capital Project,provided key additional input.Additional contributions were provided by Philip OKeefe,University of New So

46、uth Wales,Australia;John T.Giles,Lead Economist in the Development Research Group,World Bank;Susan Horton,University of Waterloo,Canada;Hoyt Bleakley,University of Michigan;and Norbert Rudiger Schady,Chief Economist of the Human Development Network,World Bank.Dean T.Jamison,Lawrence H.Summers,and Je

47、ffrey D.Sachs provided useful comments on development finance.Adalsteinn Brown and Beverley Essue provided input from the Dalla Lana School of Public Health,Univer-sity of Toronto.The work was conducted in partnership with the Disease Control Priorities Project,led by Editor-in-Chief Ole Norheim.Any

48、 errors are the sole responsibility of the report team.The report benefited greatly from a wide variety of workshops(see Acknowledgments in Appendix C).Fund-ing for this report came from the World Bank;the Access Accelerated Trust Fund;the Centre for Global Health Research,Unity Health Toronto,Dalla

49、 Lana School of Public Health at the University of Toronto;and the Queen Elizabeth Scholars Program of the Government of Canada.R E P O R T T E A MviiiU N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T YPreface:Why this report?Governments have increasingly recognized the importance o

50、f human capital,defined as the knowledge,skills,and health that people accumulate throughout their lives,enabling them to realize their potential as produc-tive members of society.Human capital is central to ambitions of greater prosperity and inclusive societies,as well as to the greater human well

51、being to which they contribute.Three major challenges to human capital and wellbeing are climate change,pandemic vulnerability,and demographic transformation.While the first two have received substantial attention,the demographic shifts occurring worldwide have attracted less.This report seeks to fi

52、ll this gap,demonstrating that addressing the major Non-communicable diseases(NCDs)through a life-course approach contributes to healthy longevity and improves human capital and wellbeing.Countries continue to rebuild from the COVID pandemic,crucial in itself and as a portent of the relation-ship be

53、tween infectious diseases and NCDs,and of the need to build resilience in individuals and societies.Simultaneously,the global demographic landscape stands at a crossroads,with rapid declines in fertility and rapidly aging populations holding profound implications for employment,social services,and w

54、ellbeing.This aging of populations has accelerated the rise of NCDs as the leading global cause of death.Projections suggest a global surge in deaths from 61 million in 2023 to 92 million in 2050,as well as related increases in needs for NCD-related hospitalization and long-term care.Beyond mere sta

55、tistics is the grief,hardship,and suffering from death and severe disease.The world finds itself inadequately prepared for the impending NCD pandemic.This report maps out a menu of practical,cost-effective,fiscal and clinical interventions,many of which can be swiftly implemented to yield substantia

56、l benefits.With mortality and spending forecasts extending to 2050,the report underscores the imperative of prolonged interventions to fully realize the impact of a life-course approach.Its principal focus is to galvanize country-led efforts,with accelerated progress through cost-effective,pro-poor,

57、and inclusive interventions.If low-and middle-income countries can achieve am-bitious yet feasible rates of progress,the world could avert 25 million deaths annually by 2050,effectively halving avoidable deaths and meeting the related Sustainable Development Goals.The report proposes a comprehensive

58、,but fiscally realistic,intervention package,building on that menu and on historical successes in reducing mortality among children and mothers and combating infectious diseas-es.It is also important to extend interventions beyond health to encompass broader social protection,labor market,and long-t

59、erm care policies.The report draws on the foundation of the World Banks Human Capital Project and Human Capital Index and synthesizes economic,epidemiological,and implementation evidence,including 18 detailed background papers.It introduces innovative analysis assigning economic value to avoid-able

60、mortality and incorporates insights gleaned from consultations with over 90 experts conducted over a four-year span.It identifies priorities in global public goods to tackle NCDs and improve welfare.People living with NCDs are also increasingly recognized as a potent political force and can help in

61、gaining more attention to NCDs.The billions of individuals grappling with NCDs look to their governments for support in managing their conditions and contributing meaningfully to their families,communities,and economies.Analyses alone will not be enough.Mobilizing support to move from knowledge to a

62、ction is required to real-ize the astounding human and economic benefits of addressing one of the major challenges of the 21st century.The HLI Report Team,August 15,2024P R E F A C EU N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Y1Unlocking the power of healthy longevity:Key mess

63、ages of this reportNavigating global demographic transformationsa call for strategic actionThe world is undergoing a significant demographic transformation,with a rapidly aging population in many countries presenting opportunities as well as challenges.Encouragingly,there has been remark-able progre

64、ss,with global mortality risk of death before the age of 80 dropping from about four in five in 1970 to just over half in 2023.Child mor-tality has seen remarkable declines worldwide.This positive trend,marked by longer and healthier lives,more women working,and smaller families as countries prosper

65、,has contributed substantially to economic growth.However,these favorable trends bring with them a set of challenges.The growing adult pop-ulation,encompassing both the elderly and mid-dle-aged individuals,has impacts that reverberate across societal organization,education,work dy-namics,and health

66、care services.The global pop-ulation is projected to reach 9.7 billion by 2050,stabilizing thereafter.Some nations already grapple with declines in total population;and the majority of countries are experiencing significant declines in the rate of growth of population,and so in the growth of the lab

67、or force.These shifts result from falling fertility rates and reduced premature mortal-ity.The one area still experiencing marked popula-tion growth is Sub-Saharan Africa.Many nations are ill-prepared for the magni-tude and pace of these demographic shifts,which will ripple through labor markets,imm

68、igration,and social policies.Retirement ages and other institu-tional responses to changes in the age structure are lagging behind the rapid increase in adult popula-tions.To navigate this evolving landscape,investing in the health and wellbeing of the working-age pop-ulation is imperative.Early and

69、 effective control of Non-communicable diseases(NCDs),the primary cause of adult deaths,is crucial.The key lesson from centuries of demography and epidemiology is clear:while death in old age is inevitable,death early in life should be rare and death in middle age need not be common anywhere.These d

70、emographic changes intersect with the challenges posed by climate stress and pandem-ic vulnerability.Approximately 40 percent of the global populationaround 3.5 billion peoplelive in areas vulnerable to adverse climate effects that exacerbate poverty,especially among margin-alized groups.There is al

71、so a reasonable proba-bility of another global pandemic in the medium term.Pandemics of respiratory pathogens,like COVID,will disproportionally harm the elderly and people with NCDs.These intersections could markedly amplify intergenerational suffering and economic stagnation.Governments cannot affo

72、rd to delay address-ing these interconnected challenges.Proactive measures and country-driven strategic planning are essential to build resilience.While altering the population structure significantly by 2050 might be challenging,sustaining success in reducing prema-ture deaths and disabilities and

73、enhancing overall wellbeing is achievable.These are potent yet un-derused tools to alleviate poverty.Tackling the NCD challengea strategic imperativeNCDsparticularly cardiovascular diseases,di-abetes,respiratory diseases,cancers,and major depressionalready account for over 70 percent of all deaths i

74、n low-and middle-income countries(LMICs)and a significant portion of disability.NCDs are surging in low-income countries(LICs)due to demographic shifts toward older populations and the influence of key risk factors including to-bacco smoking,heavy alcohol use,and obesity.The share of NCDs in overall

75、 deathsand even more as a share of avoidable deathsis large and rising,contributing also to preventable increases in K E Y M E S S A G E S O F T H I S R E P O R T2U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Yhospitalizations,long-term care(LTC)needs,and poverty traps for famil

76、ies.For example,the world has over 1.1 billion smokers(who will typically lose a full decade of life compared to similar non-smok-ers);1 billion people with hypertension,contribut-ing to cardiac death and disease;and 700 million who are obese,contributing to diabetes.On current trends,the global num

77、ber of diabetics may double from 500 million today to over 1 billion by 2050.LMICs are particularly vulnerable,already bearing the brunt of the NCD epidemic but without ade-quate preparation and resources.Healthy longevity means sharply reducing avoidable death and serious disability throughout the

78、life cycle,as well as increased levels of physical,mental,and social functioning through middle and older ages,and a socially-connected,reasonably pain-free and short period of time before inevita-ble death.It is produced by action throughout the life cycle,starting with infant health and nutrition.

79、Countries face critical choices in responding to their aging populations.Vigorous action,as pro-posed in this Healthy Longevity Initiative(HLI)re-port,can catalyze a virtuous cycle of gains in health,improved wellbeing,and reduced poverty.With the achievement of ambitious yet feasible rates of prog-

80、ress,LMICs could meaningfully extend billions of lives,averting 25 million deaths annually by 2050,effectively halving avoidable mortality and meeting the related Sustainable Development Goals.Recognizing poverty and gender equity in the pursuit of healthy longevityThe poorest within countries are m

81、ost suscepti-ble to NCDs,for example because of higher rates of smoking and obesity.They are also least able to afford treatment costs and cope with income loss.NCDs and their risk factors create intergeneration-al traps of poverty,affecting childrens prospects.So reducing NCDs increases equity.In a

82、ddition,HLI-recommended responses explicitly target pov-erty and gender equity.Women generally outlive men.But partly because of that,they bear high burdens of specific NCDs and experience great-er and longer periods of disability,and they have fewer resources to address these challenges than men.In

83、 addition,women bear disproportionate re-sponsibility for caregiving which can reduce their employment prospects and compromise their own wellbeing.Expanding LTC options to reduce costs and care burdens on women is essential.Leveraging cost-effective interventionsthe HLI agendaThe HLI agenda propose

84、s proven,cost-effective interventions ranging from NCD prevention and treatment to targeted financial protection for the poor and to meet LTC needs.While recommen-dations vary based on individual country circum-stances,they demand increased upfront financing,primarily domestic for most middle-income

85、 coun-tries(MICs),complemented by external financ-ing and technical support.In addition,substantial concessional financing will be needed for LICs.In the short run,excise taxes on tobacco,alcohol,and sugar-sweetened beverages can mobilize additional revenue.In the long run,enhanced productivity and

86、extended working lives mayother things equalboost incomes and tax revenues.The overarching recommendation is for coun-tries to invest in interventions for NCDs over the life course.The main thrust involves scaling up high-impact interventions,addressing financial pro-tection for the poor and LTC nee

87、ds,and supporting data and global public goods for healthy longevity.Scaling up high-impact interventionsa fiscal,public health,and clinical approachLeveraging fiscal instruments for health across the life course is crucial.Tobacco excise taxation stands out as the single most effective measure,with

88、 sig-nificant pro-poor health benefits and reasonably rapid reductions in premature mortality.Excise taxes on alcohol and sugar-sweetened beverages similarly bring health benefits and can generate substantial revenues for NCD interventions and other pro-poor measures at all income levels.Inte-gratin

89、g cost-effective clinical services into primary health and first referral systems is also crucial and cost-effectiveas well as preventing unnecessary suffering and death.The sooner the integration pro-cess begins and is scaled up,and the higher,better structured,and more sustained the tax increases,

90、the greater the benefits.HLI investments in LMICs are expected to cost about US$220 billion in 2050,constituting about 7 percent of projected public spending on health(but significantly more as a percentage of public spend-ing in LICs).These investments would substantially expand health care capacit

91、y:over 6 million more nurses,0.8 million more doctors,and 1.7 million additional health facilities.It will take time to scale K E Y M E S S A G E S O F T H I S R E P O R TU N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Y3up this expanded capacity,but it is important to hasten the

92、process,primarily to accelerate health benefits,but also because the additional capacity can support expansion of overall health services to the population.Emphasizing the needs of women,who have been relatively neglected in NCD efforts,and disadvantaged social groups is essential.Providing financia

93、l protection and addressing long-term care needsa holistic approachSupporting financial protection from catastroph-ic health expenditure is vital for inclusive healthy longevity,particularly for the poor who are primar-ily in the informal sector.Providing opportunities for skill development and exte

94、nding working lives is crucial.In addition to existing social protection systems,expanding non-contributory or subsidized pensions for the informal sector can enable digni-fied aging and help cover essential costs,including health care.Emphasizing sustainable alternatives to residential LTC,particul

95、arly community-based care,will contain costs,respect dignity and cultural norms,and aid women to remain in the workforce.Promoting data and global public goodsa collaborative strategyIt is essential to create and fund global public goods(GPGs):internationally relevant innovations,in-cluding health t

96、ools,pricing mechanisms,joint procurement,scientific and operational research,knowledge,and pro-poor intellectual property ar-rangements.These GPGs correspond to global chal-lenges including synergies with climate change and pandemic preparedness and response.GPGs can expedite progress on life-cours

97、e health with suffi-cient mobilization of resources from development partners.Expanding open data for accountability and monitoring,which are partly national and part-ly global public goods,is also crucial.Investments in vital registration and statistical systems,cou-pled with the use of healthy lon

98、gevity dashboards,can strengthen national systems,improve program management and evaluation,and facilitate knowl-edge sharing between countries.Moving from knowledge to actiona call for collective effortHealth interventions have been spectacularly suc-cessful in reducing child and infectious disease

99、 mortality.Similarly,NCD interventions could yield remarkable gains reasonably quickly,improving the lives of potentially billions of parents and grandpar-ents worldwide.The HLI agenda requires substantially more spending,begun and scaled up quickly to avoid cost headwinds,and accelerated steps to r

100、educe pre-ventable disease and death.With a minimal“start-er”HLI package of interventions,cumulatively at least 150 million deaths across all LMICs would be avoided by 2050,and about 8 million in 2050 alone.Analysis of the economic value of avoidable mor-tality suggests that this would correspond to

101、 over US$3.2 trillion just in 2050,suggesting a very favor-able benefit-cost ratio of 16 to 1 for all LMICs.This report provides a robust knowledge base,including evidence that significant progress in tack-ling NCDs is possible in nearly every setting,even where delivery capacity is currently limite

102、d.How-ever,a strong evidence base alone is insufficient.Building strong support at top leadership levels in political and other areas is crucial for adopting and advancing the proposed agenda.A coordinated,whole-of-society effort involving governments,the private sector,academia,nongovernmental orga

103、ni-zations(NGOs),foundations,the media,the health community,including people living with NCDs,and the global and national development communities is needed.Multilateral development banks can play a pivotal role in catalyzing country analysis and own-ership and sharing learnings across diverse settin

104、gs.The imperative is clear:acting now on healthy longevity can shape a healthier,equitable,and more productive future for the twenty-first century.K E Y M E S S A G E S O F T H I S R E P O R T4U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T YBOX Summary of Report StructureFollowin

105、g this overview,Chapter 1 details the rapid demographic transformation the world faces from a shift to a much larger and older population of adults,declines in fertility,and changes in the age-structure.Paired with this demographic change,it describes the large and growing burden of NCDs and their k

106、ey risk factors,notably smoking,harmful use of alcohol and obesity.It includes novel analysis of avoidable mortality that combines demographic estimates with economic value.It also compares the very large benefits in lives saved if countries were to accelerate their performance in life-course invest

107、ments to match that of the top fifth of peer countries.Chapter 2 sets out the links among healthy longevity,NCDs,and human capital.It explains why levers for action are needed across the life course,suggesting key levers for action at each stage.It then provides pathways from healthy longevity to en

108、-hanced human capital and wellbeing.Key to the welfare benefits is the relationship between NCDs and poverty.The chapter ends with why tackling NCDs is critical to increasing gender equality.Chapter 3 then addresses the country-level arenas for action in advancing the healthy longevity agenda.These

109、include tackling NCDs with cost-effective,pro-poor interventions,as well as looking beyond the health sector to social protection,jobs,and long-term care strategies.Improving healthy longevity outcomes will necessitate stronger measurement and monitoring sys-tems,and the chapter lays out how healthy

110、 longevity dashboards can contribute to these goals.Chapter 4 presents suggestions for financing from both national governments,which must take the lead on the healthy lon-gevity agenda if it is to produce sustainable progress,and development partners and other external sources of financing.These in

111、ternational sources of financing are crucial,especially but not exclusively to LICs.In both LICs and MICs,they can support country efforts to accelerate the pace of scaling up of NCD and other healthy living investments,as well as in development and uptake of GPGs such as new knowledge creation and

112、dissemination or pooled procurement mechanisms.This chapter also ad-dresses intersections with climate change and pandemic finance,and the substantial role for multilateral development banks.Chapter 5 provides a brief conclusion with key recommendations of the report.The appendices detail the analyt

113、ic methods used and provide additional analyses.K E Y M E S S A G E S O F T H I S R E P O R TU N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Y5Executive SummaryThis report,a product of the Healthy Longevity Initiative(HLI),presents the rationale and recom-mendations for focusing o

114、n the many opportunities presented by healthy longevity.This summary high-lights particular points from each chapter in turn.Chapter 1:Better health throughout the life course is achievableDemographic transformations are reshaping the world,with the global population expected to reach 9.7 billion by

115、 2050.Notably,the number of mid-dle-age and older adults is rising sharply,creating both opportunities and challenges.Reductions in fertility and child mortality have largely driven these changes,along with age-structure effects.These,also known as cohort effects,relate to the relative size of diffe

116、rent age groups.There are important lessons from the last few decades.The world has made remarkable progress in saving childrens lives.From 2000 to 2019,the deaths of 65 million children under 5 were averted in low-and middle-income countries(LMICs).Major global goals,like the Sustainable Devel-opme

117、nt Goals(SDGs),focus on reducing mortality rates,particularly for children and from NCDs.To-day,urgent new global health challenges are emerg-ing,linked to rapid demographic transformation,with a big increase in the size of older age groups and a related rise in cases of NCDs.Population aging carrie

118、s economic implica-tions,potentially slowing growth unless there is in-creased labor force participation and productivity.Countries need careful analysis for policies that bal-ance economic demands,social services,and long-term care costs.Migration policy becomes crucial in this context,depending on

119、 the size and skill com-position of demand,and leveraging the differential stages of demographic transition across countries.Climate change adds an additional layer of com-plexity,particularly for countries facing both aging populations and rapid changes in climate.A key reason for the sluggish pace

120、 of improve-ments in health outcomes among older adults is the growing contribution of NCDs.NCDsincluding cardiovascular disease,diabetes,respiratory disease,cancer,and selected mental health conditionsare responsible for at least 70 percent of deaths global-ly each year and most disabilities.The ma

121、jority of NCD deaths already occur in LMICs,where abso-lute NCD burdens are also rising fastest.By 2050,based on current projections,there will be a rise in overall deaths to 92 million from 61 million in 2023,concentrated among middle-aged and older adults,and most of these deaths will be from NCDs

122、.The world has,over the last three years,largely overcome the COVID pandemic.Yet much of the world is unprepared for the serious and con-tinuing NCD pandemic of recent decades.Death in very old age is inevitable,but the main lesson from centuries of demography and ep-idemiology is that death prior t

123、o very old age need not be common anywhere.This reports analysis of avoidable mortality suggests that about 7 in 10 of all deaths in 2019,or 40 million,could have been avoided at the lowest observed death rates of various countries.Deaths can be avoided by applying the abundant knowledge of cost-eff

124、ective ways to pre-vent,treat,and palliate NCDs,directly and through their major risk factors,most notably smoking,obe-sity and alcohol abuse.This report provides a unique lens on NCDs by strongly emphasizing a life-course approach.Im-plementing this approach will increase good health during longer

125、lives.This will be associated with in-creased human capital(knowledge,skills,and other individual aspects that contribute to productivity)applied over longer working lives,as well as with positive impacts on gender and income equity.If all countries were to accelerate their progress through life-cou

126、rse approaches by matching the rate of progress that the top 20 percent of countries have achieved for each age and sex group,cumula-tively over 500 million lives could be meaningful-ly extended by 2050,and 25 million lives could be saved in the year 2050.This would halve avoidable deaths and help a

127、chieve the relevant SDGs.This reports life-course approach to NCDs aims for not only a longer lifespan but also good health throughout.It introduces the Economic Value of E X E C U T I V E S U M M A R Y6U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T YAvoidable Mortality(EVAM),a n

128、ew analysis to better describe the period of life spent in good health,in or-der to inform priority-setting and decision-making.The EVAM quantifies the benefits of healthy longevity.It considers the acquisition and protec-tion of health throughout life,comparing actual and projected mortality rates

129、against a frontier of low observed rates.This comparison enables quan-tification,albeit imperfectly,of avoidable mortality.The EVAM method estimates the economic value of avoiding deaths,emphasizing the potential gains from improving life-course investments.This ap-proach makes it possible to compar

130、e the economic value of various rates of progress toward reducing mortality.It suggests that substantial progress is possible,emphasizing the importance of accelerat-ing efforts to reduce NCDs.Chapter 2.Healthy longevity,NCDs,and human capital:Action across the life courseBy acting across the life c

131、ourse,the world can achieve a more desirable and dignified form of lon-gevity that benefits individuals,households,and societies alike.This report defines healthy longevity as the state of good physical,cognitive,and social functioning for nearly the full lifespan of an indi-vidual.Healthy longevity

132、 is a key component of peoples wellbeing,and thus important in itself as a key objective for development.It is simultaneously a driver of greater equity and social inclusionso-cioeconomic,gender,and intergenerational.The ul-timate vision is for people to live longer,healthier,more productive,and mor

133、e satisfying lives.Some of the health and wellbeing benefits to be had in the future will,rightly,be after retirement.This vision would mean that in their forma-tive years,adolescents and young adults would be much less likely to take up smoking,start drinking to excess,or become obeseall activities

134、 that sig-nificantly increase their likelihood of developing NCDs.In this improved scenario,chronic ill health would be much less likely to mar their lives,lim-iting their employment and income while exacting high health care and associated costs.Nor would avoidable diseases kill them prematurely.Mo

135、reover,family members,usually women,would not have to compromise their own opportunities to provide protracted care.Investments in the life course have proven fea-sible and cost-effective in a variety of countries.But a global scale-up in life-course health will require substantial resources and eff

136、ort.Innovations can make investments more affordable.While it is sig-nificantly cheaper now to save a childs life than it was several decades ago,it is more expensive to save an older adults life.In 2019,to keep up with the top 20 percent of peer countries in reducing mortality in children under 15,

137、LMICs had to spend US$182 per capita,substantially less than the US$342 need-ed in 1990.But to achieve similar performance for adults aged 5069,they had to spend US$255,which is more than the US$198 required in 1990.The rising relative cost to save an adult life em-phasizes the need for more effecti

138、ve interventions through research and development(R&D)and oth-er global public goods(GPGs)to bend the cost curve downward,as has happened for childrens health.Taking a life-course approach to NCDs pro-vides an economic case for what is already clear on moral grounds,and which shone through the world

139、s collective response to the COVID pandem-ic:the lives of older adults are well worth saving.Life-course programs,starting at a young age,to reduce NCDs have a modest positive impact on hu-man capital(more education and on-the-job train-ing)and enable deployment of that human capital over longer wor

140、king lives.Lower NCD burdens also reduce absenteeism and decrease age-related de-preciation of human capital,so increasing worker productivity.Extending working lives will be par-ticularly important as the labor force grows more slowly(or even shrinks)in an increasing number of middle-income countri

141、es.This opens up the possi-bility of increased economic growth,depending on the effectiveness of government policies and of their implementationnot just in NCDs but on labor market and other directly related issues.It depends even more on the evolution of broader underlying determinants of growth,in

142、cluding economic man-agement,education,institutions,and technology.Even more importantly,reducing prevalence,morbidity,and mortality from NCDs also brings about improvements in human wellbeing.This comes not only through higher incomes,but also as a direct consequence of being healthy.In discussing

143、the wellbeing impacts of address-ing NCDs,it is important to bear in mind the equity dimension.People living in poverty and other dis-advantaged groups are more likely to have NCDs.This is partly because poor people are more prone to adopt behaviors that lead to NCDs,such as smoking and obesity,and

144、to have worse mental health.Poor E X E C U T I V E S U M M A R YU N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Y7people are also more likely not to be able to afford,and may be far from,the diagnostic and treatment care they need.In addition,studies show that the combination of h

145、igh medical bills and lost income of a breadwinner creates a high risk of personal and family impoverishment.Addressing NCDs also reduces gender inequal-ity.This is partly because women have heavy specific NCD burdens over their lifetimes,which are usual-ly longer than those of men.It is also,import

146、antly,because of the societal expectation that women will provide care to older household members suffering from NCDs instead of seeking gainful employment outside the household.Women also frequently ex-perience greater barriers to health care for their own NCDs,especially because of their often-lim

147、ited financial means and decision-making power within the household,particularly in LMICs.It is for these reasons the HLI includes a strong,explicit emphasis on gender in its recommendations.In sum,reducing the prevalence of NCDs would also reduce socioeconomic and gender inequalities.The healthy lo

148、ngevity approach to NCDs consistent-ly emphasizes taking account of these inequalities in strategies and interventionswhether in prevention and care of NCDs or in policies related to labor mar-kets,pensions,or long-term care(LTC).Chapter 3.Advancing healthy longevity now:What countries can doCountri

149、es can make major advances toward healthy longevity with well-chosen policies and life-course interventions if implemented quickly.A key general message is the need to substantially accelerate NCD interventions,which have been underused,and to do so early.Delays in adopting interventions will result

150、 in massive and preventable death and disease,both before scaling up starts and in the longer run,because it will inevitably take a long time for scaling up to reach full coverage.A commitment to healthy longevity through a life-course approach can be realized in part by con-tinuing investments in c

151、hild and maternal health and nutrition.To improve health from teen to older ages,Chapter 3 lists a range of 31 cost-effective,ev-idence-based interventions that countries can select from and adapt in view of their unique needs and constraints.The HLI recommended menu of clin-ical health intervention

152、s can largely be delivered through primary health care(PHC)systems,ide-ally in concert with community-based care.These interventions are not only cost-effective but also address equity,reducing financial risk,and feasi-bility of implementation.Countries can draw on and adapt these interventions,depe

153、nding on their specific needs and capacities.Scaling up all of the items in the prioritized list of interventions to cov-er even 80 percent of the population in all LMICs by 2030 would dramatically reduce NCD mortality and would be highly cost-effectiveeven though in practice it would take longer in

154、 most countries to get in place all the financing and capacity needed.For the great majority of countries,adopting all of the measures at once would involve unrealistic in-creases in health expenditure and institutional ca-pacity.Realistically,most LMICs will need to focus initially on a subset of i

155、nterventions and sequence the order and expansion of their coverage.Most countries will likely want to apply“progressive uni-versalism”:limiting costs by concentrating public financing initially on the poor and disadvantaged,then moving toward universal coverage of a set of basic services,and then a

156、dding to that set as financ-ing and institutional capacity permit.The chapter also provides a framework for pri-oritizing NCD interventions based on three other criteria beyond cost-effectiveness:equity,finan-cial risk protection,and implementation feasibility.The list of high-priority intervention

157、includes six population-level prevention measures,all of which are highly cost-effective and relatively inexpensive to implement.The biggest and most cost-effective gains would generally come from“health taxes”particularly taxes on tobacco.These policies are fea-sible to implement even in countries

158、with weak in-stitutional and financial capacity,including in those recently emerging from war or conflict.There is vast evidence that health taxes reduce consumption of these substances that sicken and kill;in the case of tobacco,prolonged smokers lose an average of one decade of life compared to no

159、n-smokers.Yet this fiscal tool is greatly underused worldwide.The high priority package also recommends other clinical interventionsincluding pulmonary rehabilitation and treatment for chronic heart failureand priori-tizes them based on country income level.Overall,fully implementing the high-priori

160、ty package of interventions starting from 2023 to 2050 could avert up to 150 million deaths by 2050,at an incremental cost of US$1.3 trillion(US$9,300 per death averted).The budgetary implications of the package would be more manageable.Total cost(at 80 percent coverage)would in the longer run range

161、 E X E C U T I V E S U M M A R Y8U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Yfrom a relatively affordable 7 percent of projected public spending on health in 2050 in upper-middle income countries,to a much more challenging 20 percent in low-income countries.This cost is based

162、 on the assumption that countries invest in the pack-age constantly every year from 2023 to 2050.Given that programs take some years to reach full opera-tional capacity and the cost to save a life increases over time,it is urgent that countries act now in pri-oritizing,adapting,and implementing the

163、package,so that consequently with economies of scale,scaling up coverage for these interventions remains feasible.The HLI intervention package should be con-sidered a starter or catalytic package that needs to be customized to local contexts.For political econ-omy and institutional reasons,some coun

164、tries will continue NCD interventions not in the HLI list,even if they are relatively less cost-effective.In ad-dition,over time there will be new cost-effective in-terventions(new or newly cost-effective)because of declining prices,including from GPGs.Moving beyond health-specific interventions,pol

165、icies on jobs,social protection,and LTC will also be needed to progress on the NCD and healthy lon-gevity agendas.In terms of employment,countries could call on a range of policies to support older workers who wish to continue working,with resul-tant benefits for their,and potentially,national in-co

166、mes.For those no longer able to work,a critical area of social protection is non-contributory pen-sions,where fiscally feasible,for the large poor pop-ulations in LMICs who have worked in the informal sector.This can help the many older adults and fami-lies facing both low incomes and high out-of-po

167、cket medical expenses,especially in those countries far from achieving universal health care.Additionally,to ensure the healthy and dignified aging of people who require LTC,countries should consider how best to bolster,oversee,and-as needed-partly subsi-dize community and home-based care,with less

168、em-phasis on sparse and expensive residential LTC.For both non-contributory pensions and LTC systems,countries will have quite different needs and capac-ities,and so different approaches.Well-evaluated pilots of both,supported as appropriate by external funding,can help countries assess what makes t

169、he most sense for them before large-scale expansion.Adults who continue working longer contrib-ute to household income.They can also support children and other,needier elders by providing family or community care.As they age,they can re-tain some independencewith many aging in their own homes,with f

170、amily,community,and public support.For older adults,especially women,there is a need for adequate access to health care.Ideally,ill health would be confined to a short period just before the end of their lives.Another urgent area for country action is the strengthening of country data systems that c

171、an help set and measure progress on life-course health.Ex-panding open data sources for widespread use is needed to help countries consider how to improve their performance,including by providing data with which to measure their progress and problems against those of peer countries.Essential invest-

172、ments include supports for national vital events,registration systems,and improved statistical ca-pacity.There is also a need for healthy longevity dashboards:an innovative data visualization tool tailored to countries that aims to help turn data into action.It synthesizes key indicators to improve

173、management and evaluation,and enables and en-courages countries to draw on available data to as-sess their performance in relation to others.Chapter 4.Financing for healthy longevity:Country leadership and key supporting roles for development partnersThe NCD and other aspects of the healthy longevit

174、y agenda are ambitious,and the necessary financing will be considerable.But these investments will de-liver strong returns on investment,contributing to human capital while reducing poverty.The time for action is now,as delaying NCD-re-lated interventions will result in increased NCD death,disease,s

175、uffering,and worsening poverty.While some interventions can affect change quickly,most NCD programs take some years to establish the financial and institutional capacityand need-ed political supportfor adequate national cover-age.Strong country ownership is essential.And it is at the country level w

176、here the bulk of the financing will need to be mobilized.To extend the high-priority package of recom-mendations to all LMICs would cost up to US$220 billion in 2050.The cost would be reasonably afford-able,at 8 percent of projected public expenditures on health in 2050 for lower-middle income coun-

177、tries,6 percent for upper-middle income countries,and 20 percent for LICs.The corresponding benefits of life-course investments are largecorresponding to over US$3.2 trillion in economic value of avoid-E X E C U T I V E S U M M A R YU N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T

178、Y9able mortality in 2050.Thus,the benefit-cost ratio is very favorable,at about 16 to 1 overall for all LMICs.Countries need to customize interventions to vari-ous contexts and over time.The overall cost-benefit ratio of the HLI is sufficiently high to suggest that various combinations that include

179、most of the HLI interventions should be attractive investments.The political economy of investments over the life course suggests that each country would have to consider the benefits and demands from its citizens.Most interventions will require long-term efforts to attain full coverage.Reassuringly

180、,longer-term costs would fall somewhat through economies of scale plus benefits from investments in GPGs(health technol-ogies,good practices,and other“tools”at the global or regional level with benefits beyond borders).External assistance could play an important role in accelerating expenditures and

181、 policy actions in the early years of scaling up NCD programs.The external financing would be available to support countries efforts at determining priorities,institu-tional reforms,and to kick-start the scaling up of life-course investments.Development partners(external donors and partners of devel

182、opmentbilateral and multilateral organizations,foundations,and NGOs)can also help in analysis and technical assistance.Development partners have enormous scope for increasing their financial assistance.Currently just 2 percent of all official development assistance for health(ODA)goes to NCDs.Develo

183、pment part-ners as well as countries should work closely with foundations,academia,and NGOs.The private sec-tor also has a major role to play in research,produc-tion,financing,and technical capacity.Stewardship of the private sector should be encouraging while still taking account of diverging incen

184、tives.The HLI comes at a time when there is mo-mentum for a strengthening the role of multilateral development banks(MDBs).MDBs are well placed to use their financial,technical,and institutional resources,their cross-country experience,and their close relations with both finance ministries and healt

185、h ministries to encourage and support coun-try-owned NCD and broader healthy living initia-tives and programs.The World Bank Group stands ready to apply its full set of relevant instruments to implementation of the HLI,tailored to specific country circumstances as a part of its growing sup-port for

186、health and social protection.Experience from NCDs suggests three priori-ties for planning responses to future pandemics:(i)reducing NCDs,given that much of COVIDs very large death tolls occurred among those with pre-ex-isting chronic disease and that NCD sufferers are also likely targets for future

187、viruses;(ii)improving data systems for both emergencies and routine diseas-es,including nationwide systems to monitor deaths and detect outbreaks;and(iii)the close link between NCDs and the impact of pandemics adds a strong ar-gument in favor of a cost-effective global adult vacci-nation program to

188、expand routine antigen coverage and to provide surge capacity for future pandemics.While climate investments are essential for planetary health,they are also complementary to life-course investments.Synergistic investments,such as expanding green transportation in urban settings,can reduce carbon fo

189、otprints and increase incentives for physical activity.Ending harmful subsidies for fossil fuels,which represent about 7 percent of global gross domestic product(GDP),can free up major amounts in government budgets that can be used for health as well as climate change mitigation and adaptation and o

190、ther priorities.GPG investments are a powerful lever for im-proving health throughout the life course and for amplifying the equity impact of such efforts.They are much needed to bend downwards the cost curve(reduce costs)and improve results for developing countries.GPGs relevant to NCD prevention a

191、nd management include knowledge-sharing networks,sharing of intellectual property,and global pro-curement mechanisms for health commodities,as well as relevant scientific breakthroughs for NCD treatment.Our broad definition of GPGs also in-cludes technical assistance to countries on uptake of GPGs.T

192、his includes possible expansion of the role of artificial intelligence(AI)in global health.AI tools could help identify new treatments and spur efficiencies in delivery and quality assurance of life-course investments.Careful cross-country regula-tion and transparent governance will be required to c

193、urb disinformation and other harmful AI practices and share benefits equitably.Development partners should give high priori-ty to investing in and fostering the uptake of GPGs for healthy longevity as an important complement to their financing at country level.Financing to date for GPGs for elders a

194、nd other adults has been grossly inadequate.While most financing for NCDs at country level will come from the countries them-selves,this is not the case for GPGs.Rather,GPG support is a critical area where multilateral and bi-lateral development partners,foundations,NGOs,academia,and public health g

195、roups can spur trans-E X E C U T I V E S U M M A R Y10U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Yformation.MDBs are considering how they can best give higher priority to participating in the develop-ment and application of such GPGs.GPGs have helped to foster incredible im-p

196、rovements in child survival and have driven the significant decrease in the cost of saving a childs life.They could help to do the same for adults.Drawing on the lessons from those improvements and applying the same energy to a life-course ap-proach to address NCDs has the potential to con-tribute t

197、o putting the world on a path to a more equitable and healthy future.Chapter 5.From knowledge to actionPrevention and control of NCDs amidst demo-graphic transformation is a grand challenge for the first half of the twenty-first century,commensurate in scale to climate change and global pandemics.Th

198、e overall recommendation is for countries to invest in life-course investments for NCDs,with related reforms of labor markets,pensions,and long-term care.The former covers three areas:(i)scaling up high-impact interventions;(ii)address-ing specific social protection and long-term care needs;and(iii)

199、supporting data and global public goods for healthy longevity.More detailed recom-mendations are provided in the various chapters and are summarized above.Acting on these recommendations would con-tribute to three linked key outcomes:(i)reduced death and disease from NCDs and improved well-being;(ii

200、)reduced poverty and gender inequality;and(iii)improved productivity,choice,and equity in work.If all countries improve their performance to match their best-performing peers,this could avert up 25 million deaths in the year 2050,halve avoid-able deaths,and achieve many of the SDGs.At both country a

201、nd global levels,building strong support at top political and other leader-ship levels for adopting and advancing the agenda is required.That will take a strong and coordinated whole-of-society effort that includes,within govern-ments,ministries of finance,planning,social pro-tection,labor,and gende

202、r among others,as well as championing by health ministries.That effort should go far beyond governments and external partners to include academia,NGOs,foundations,the media,civil society,the private sector,and the broader global and national development and health communities including people living

203、 with NCDs.The challenge facing all who recognize the feasibility and impor-tance of healthy longevity is moving from knowledge to large-scale,sustainable action and impact.E X E C U T I V E S U M M A R YU N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Y11Introduction:Better health

204、 throughout the life course is achievableDemographic transformations are rapidly reshaping the world,with the global population expected to reach 9.7 billion by 2050.The number of middle age and older adults is rising sharply,creating both opportunities and challenges.The core of meeting the needs o

205、f people involves increasing good health during longer lives.Over the last few decades,the world has witnessed extraordinary improvements in human welfare.The proportion of the worlds population living in poverty fell from over 50 percent in 1950 to below 9 percent in 2019,driven by particularly fas

206、ter de-clines in poverty from about 2000 onward(World Bank 2022).In 1970,one in seven of all newborns died before their fifth birthday.By 2020,only one in 25 did.From 2000 to 2019,the world made ex-traordinary human development gains,particularly in reducing poverty and child mortality.Concerted glo

207、bal action on child mortality and extreme pover-ty was catalyzed by the UNs Millennium Develop-ment Goals(MDGs).The first MDG goalto halve extreme poverty between 1990 and 2015was reached ahead of schedule.Countries participation in the MDG process may have resulted in saving the lives of as many 17

208、 million additional children,beyond what would otherwise have been achieved(McArthur and Rasmussen 2018).From 2000 to 2019,the deaths of 65 million children under five years of age were averted in LMICs.The economic value of this achievement is staggering,correspond-ing to US$45 trillion(Chang et al

209、.2024).The eminent epidemiologist Sir Richard Doll summarized that the main lesson from 200 years of demography and epidemiology is that,“while death in old age is inevitable,death before old age is not”.As he conveyed,death early in life should be rare,and death in middle age need not be common any

210、where.By necessity,any definition of old age will be arbitrary.For purposes of this report,we define old age as above 80 years.Currently,global life expec-tancy in 2023 is 73 years and it is expected to in-crease to 77 years by 2050(assuming the setbacks from the COVID pandemic do not change the pre

211、-pandemic trajectories).While the median age of death in low-income countries(LICs)by 2050 is expected to be only 59,it will rise in upper-mid-dle-income countries(UMICs)to about 80 years(Appendix B Table B4).Healthy longevity is produced across the life course.This entails avoiding death and seriou

212、s disability in middle age,enabling a high level of mental and social functioning through middle and older ages,and includes a socially-connected and reasonably pain-free,short period of time be-fore death(OKeefe and Haldane 2024).Moreover,there is evidence of avoidable disability at every age inclu

213、ding past age 80.From 1970 to 2023,the global risk of death before age 80 fell from 79 percent to 54 percent,driven by improvements in mortality at younger ages:below 50,mortality risks fell from 30 percent to 11 percent,driven specifically by reductions in child mortality.Even between the ages of 5

214、0 and 79,when NCDs are the major causes of death,the risk of death fell from 71 percent to 46 percent.Much of the stunning reduction in child mor-tality has been related to communicable diseases.There have also been some improvements on adult communicable diseases,notably tuberculosis and HIV/AIDS.T

215、he picture for NCDs is quite different.For example,annual rates of progress in reducing mortality from most cancers and ischemic heart dis-ease have been much slower than for childhood dis-eases and from infections(Wu et al.2024)(Appen-dix B Table B7).And urgent new health challenges are emerging,li

216、nked to rapid demographic transfor-mation and rising NCDs.Sustainable Development Goal(SDG)3 calls for ensuring healthy lives and promoting wellbeing,including a specific indicator to reduce NCD mortality at ages 3069 by one-third by 2030.While the goal is laudable,given current progress,it is unlik

217、ely to be achieved on time.These extraordinary transitions are best un-derstood by examining changes in past and future demography and in the major NCDs.C H A P T E R 112U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Y1.1 Demographic shifts affecting life-course healthThe rise of

218、 NCDs has occurred against the back-ground of sweeping demographic changes un-derway over the last 100 years,and,importantly,changing trajectories in the size and structure of populations by 2050.The global population is expected to grow from the current 8 billion to approximately 9.7 billion in 205

219、0 before plateauing at just over 10 billion,and eventually declining by 2100(UNPD 2022).Figure 1.1 shows the trends from 1950 to 2050,indicat-ing that the number of children below the age of 15 peaked around 2020,and by 2040 they will be outnumbered by 5079-year-olds.The number of young adults aged

220、1549 will rise substantially and will not peak until the turn of the century.The num-ber of people aged 80 or more is rising sharply and will do so until 2100.Dependency ratios(the ratio of the sum of the population aged 014 years and those aged 65 and above to the population aged 1564)have fallen s

221、harply globally.In all regions,except in low-in-come countries in Sub-Saharan Africa,dependency ratios will continue to increase between now and 2050,driven by falling fertility and aging.Figure 1.2 depicts the overall change in population and deaths by age and sex group worldwide in 1990 and 2023 a

222、nd projections to 2050.It shows that the“inverted V”of mostly children and young adults in 1990 has already yielded to rapid growth of popula-tion at older ages by 2023.Between 1990 and 2023,there were 2 billion additional adults aged 1569,and another 1 billion will join this age group by 2050.The p

223、opulation at ages 7079 alone will reach 0.7 billion by 2050.Concurrently,by 2050,on existing projections,there will be a vast increase in overall deaths to 92 million from 61 million in 2023.In 2050,there will be about 30 million deaths of people below age 70,the same number as in 2023.By contrast,a

224、t ages 7079,deaths are expected to rise from 13 to 20 million.As deaths increase,so will the huge bur-dens from those sickened and from demands on care in homes or facilities.FIGURE 1.1 Trends in global population change by age and dependency ratio,1950 to 2050Source:UNPD(2022).Note:HIC=high-income

225、country;LIC=lower-income country;LMIC=lower-middle-income country;UMIC=upper-middle-income country.C H A P T E R 1U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Y131.2 Falling fertility,reduced mortality,and cohort effects shape the future populationFor most of human history,popu

226、lation growth has been slow because high fertility was countered with high mortality rates,particularly in child-hood.Thus,it took most of 200,000 years of human history to reach a population of 1 billion(around the year 1800),and another 130 years to reach 2 billion.However,from the 1950 to 2050,th

227、e global population will approximately quadruple,growing from 2.5 billion to 9.7 billion.Broadly,demographic changes can be thought of as two phases.The first arises from reduced death rates,particularly in childhood,and reduced fertili-ty,which collectively increases labor supply of work-ing age ad

228、ults,reduces the dependency ratio,and in-creases economic output.The second phase results from reduced family size,which reduces growth in labor supply and increases the dependency ratio.Much of the world,with the exception of Africa,is already in the second phase(Bloom et al.2024).Three main factor

229、s determine changes in the worlds population size and structuredeclines in fertility,increases in life expectancy,and age-struc-ture effectsand how they vary by country.In 1950,women worldwide had an average of five children and a quarter of children born would die before their fifth birthday.But th

230、is fertility is now FIGURE 1.2 Population and deaths by age in 1990 and 2023 and projections to 2050 Source:UNPD(2022)Note:Crude mortality(deaths per 1,000 population)fell from 10 in 1990 to 7.6 in 2023 and will rise to 9.2 by 2050 due to a greater contribution of deaths at older ages(which have hig

231、her death rates)in 2050 than in 2023.C H A P T E R 114U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Yhalved.The transition to lower fertility has been fast-er in many LMICs than in the US or Europe.For example,the reduction from six children per wom-an to three took the US over

232、80 years(from 1840s onward)and even longer in the UK.But Bangla-desh achieved this same halving over 20 years(from 1982 onward)and China took only 11 years(from 1967 onward and even prior to the start of its“one child policy”)(Roser 2014).Today,women in many LMICs,such as Brazil,Chile,China,and Thai

233、land have fewer children than do women in the US.Reductions in fertility have been driven by favorable changes in empowerment of women(as measured by expanded access to education and contraceptive technologies,and greater participa-tion in the labor market),and declines in child labor and child mort

234、ality.Increases in life expectancy have largely aris-en from reductions in infectious diseases includ-ing those common in childhood.Improvements in nutrition,water,and sanitation have complement-ed public health innovations.Prior to about 1950,much of the improvement in child and young adult mortali

235、ty arose from general improvements in water and sanitation,and public health practices includ-ing basic understanding of the modes of transmis-sion of common infections.However,since 1950,the major improvements have arisen from biomedi-cal innovations,such as use of antibiotics,vaccines,insecticides

236、 for malaria control and related technol-ogies(Jha et al.2005).Since about 1960,reductions in adult mortality also arose in many countries due to smoking cessation and more widespread simple treatments for heart attacks(Norheim et al.2015).The third factor in population aging consists of age-structu

237、re or“cohort”effects.In 2030,the number of adults aged 5059 years will reflect the death rates faced by the cohort born between 1970 and 1980 as they aged.Generally,mortality declines have preceded fertility declines,creating a cohort of living children who would have otherwise died in infancy or ea

238、rly in life at the death rates of ear-lier generations.This has led to the so-called“baby boom”generation,or a“bulge”in the age structure which works its way through the population.When members of this bulge reach reproductive age,this creates a second,smaller boom in births.Thus,even if total ferti

239、lity rates are at replacement(meaning a woman has about 2 births to replace biological mother and father),this bulge effect,sometimes called population momentum,carries on for gener-ations.Indeed,population momentum is expected to drive much of the growth in total population in LMICs through 2100(Bl

240、oom et al.2010a;Bloom et al.2010b;Bongaarts and Johansson 2002).Impor-tantly,reductions in adult mortality from NCDs have little impact on population growth because most families have completed their childbearing by the ages when adult mortality substantially rises.The remarkable and rapid reduction

241、 in fertili-ty paired with reduced mortality and cohort effects will substantially change the demographic profile of the world by 2050,but variably so.Six country ex-amples illustrate this diversity(Figure 1.3).Nigeria,the most populous country in Africa with over 210 million people,is expected to n

242、early double its pop-ulation to 375 million by 2050 and to 546 million by 2100.This is driven by currently high fertility(over 5 children per woman),and with fertility expected to stay high.Moreover,the successive of cohorts born in Nigeria have their own population momen-tum.Fertility rates are exp

243、ected to decline to only 3 by 2050.Thus by 2050,much of Nigerias popula-tion will be aged 1549,which includes prime eco-nomically productive years.Uzbekistan is expected to similarly grow in population size,with a larger proportion at ages 1549 years.By contrast,fertility rates are notably below rep

244、lacement in Colombia and cohort effects imply that the number of adults aged 1549 years will fall but the number of adults aged 5069 and 7079 years will rise sharply.Thai-land shows similar patterns,with modest declines in its population aged 5069 and increases at ages 7079.China and Japan can both

245、expect net depop-ulation by 2050 because the decline in numbers of younger and middle-aged adults does not offset the increase at ages 7079 years.Appendix B Figure B2 provides these graphs for the 25 most populous countries plus other se-lected countries.C H A P T E R 1U N L O C K I N G T H E P O W

246、E R O F H E A LT H Y L O N G E V I T Y151.3 Implications of future demographic changeIn the past,population growth was the major con-cern for global demography.While Africa faces ongoing challenges to reduce fertility,much of the world has seen population growth rates decline.Population aging is inc

247、reasingly becoming the main concern.Future vast demographic changes up to 2050 are,for the most part,not avoidable;for exam-ple,pro-natalist policies are unlikely to substantially reverse the large decline in fertility in many coun-tries(Brainerd 2014).Societies have moral,political,and social ob-li

248、gations to all their people;and as the world ages rapidly,governments,global institutions,academic and civil society have obligations to try to improve the welfare of the far larger number of adults that nearly every country will have by 2050.Indeed,a key theme of this report is that this rapid demo

249、-FIGURE 1.3 Population size by age group in 1990,2023,and 2050 and changes in total fertility rate,selected countriesSource:UNPD(2022).C H A P T E R 116U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Ygraphic change represents an opportunity to im-prove wellbeing,as well as gender

250、 and income inequalities.An important opportunity exists for government action to achieve healthy longevity,al-lowing individuals to live more years in good health and stay productive and independent for longer(World Bank 2021).Population aging can slow economic growth if it is not accompanied by an

251、 increase in labor force participation and productivity(Bloom et al.2010a;Onder and Pestieau 2014).Population aging can im-pair long-term economic growth through a reduc-tion in employment and labor productivity,higher dependency,and lower savings and investments.An aging population needs additional

252、 resources for so-cial services,associated mostly with health systems and long-term care costs and pensions(Arajo and Garcia 2024;Rofman and Apella 2020).The effect of population aging on economic growth ultimately depends on how population aging affects the size and productivity of the labor force,

253、capital intensity and returns to capital,consumption,and asset accu-mulation and if careful public policy can enable lon-ger,economically and social productive lives(Lee 2016;Lee and Mason 2017).While future scenarios will vary by country,the dramatic changes in the size and structure of the populat

254、ion are likely to profoundly influence all societies by creating large numbers of working-age adults in some countries,which could drive eco-nomic growth,including by expanding savings,but also by leading to more older adults who require care(described in Chapter 3)and by influencing migration.Final

255、ly,future demographic changes will interact closely with climate change.Economic growth:The effects of a changing age structure can increase economic growth if defined as the“demographic dividend.”For any specific coun-try,the possible dividend is driven not by popula-tion growth alone,but also by m

256、acroeconomic man-agement,labor and capital markets,savings rates,trade policies,and,importantly,by human capital accumulation(which Chapter 2 describes in some detail).For many LMICs where the 2050 population may have higher portions able to work and save,specific policies can expand economic growth

257、.The countries that can(i)combine effective policies to create jobs while expanding publicly financed health insurance,(ii)adopt additional efforts to promote human capital(especially for women),and(iii)en-sure safety nets for the poorest are more likely to see the demographic dividend yield broader

258、 benefits.These include policies to support competitive labor and capital marketsequipping workers with hu-man capital and building infrastructure and careful-ly designed trade policies(Bloom 2020).For exam-ple,despite concern in the US that national health insurance would reduce employment,the Cana

259、dian experience showed that the introduction of health insurance from 1961 to 1975 actually increased em-ployment and wages(Gruber and Hanratty 1995).Conversely,countries that do not generate sufficient jobs for large cohorts of young adults are prone to social,political,and economic instability as

260、oc-curred in Tunisia and other settings(Bloom 2020).Given concerns about slowing global econom-ic growth over the next decade,there are challenges for countries to make these investments in an era of reduced government revenue and lower real per capita income.This raises the concerns about coun-trie

261、s becoming old before they become rich.While it took 115 years for France to transition from“young”to“old”(defined as the proportion of people aged 65+doubling from 7 percent to 14 percent),in some countries this transformation is happening in less than 20 years(Arajo and Garcia 2024).Fast aging is

262、not in the future,it is already here.Migration:The 2023 World Development Re-port,Migration,Refugees and Societies,identified about 184 million people across the world,including 37 million refugees who do not have citizenship in their country of residence.The report concluded:“Rapid demographic chan

263、ge is making migration increasingly necessary for countries at all income lev-els.High-income countries are aging fast.So are mid-dle-income countries,which are growing older be-fore they become rich.The population of low-income countries is booming,but young people are entering the workforce withou

264、t the skills needed in the global labor market.These trends will spark a global compe-tition for workers”(World Bank 2023e,p xxiii).The report outlined advance planning for matching migrant skills from countries of origin to destination countries.It argued that origin coun-tries should manage migrat

265、ion for development,including facilitating knowledge transfer by their diaspora and building skills that are likely to be globally relevant.For this report,a major consider-ation,identified in Chapter 3,is the need for long-term care and health care workers.Climate change:Over 3.5 billion people,or

266、about 40 percent of the worlds population,already live in settings highly exposed to climate change(Figure 1.4)(World Bank 2023e).Highly urban-C H A P T E R 1U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Y17ized populations in coastal or mountainous regions are especially vulner

267、able to the effects of climate change.By 2050,an additional 2.5 billion people,primarily in Africa and Asia,will be exposed(In-tergovernmental Panel on Climate Change 2022).Additionally,an estimated 2.8 billion people will be living in countries facing extreme ecological threats in 2050,compared to

268、1.8 billion in 2023 9 Institute for Economics&Peace 2023).Effects of climate change include heat stress,drought,water shortages,sea level rise,and extreme weather events such as hurricanes and floods.Many of the impact-ed LMICs countries also face large burdens of aging populations,including higher

269、rates of mortality at ages 5069.In particular,Small Island Developing States face an existential crisis of rising sea levels,aging populations,and high NCD burdens(Box 4.1).Climate change also affects NCDs through in-creasing exposure to heat stresses,and in worsening respiratory health.Their possib

270、le mitigation is fur-ther discussed in Chapter 4.1.4 Progress in reducing mortality Over the last five decades,survival to age 80 world-wide improved substantially.In 1970,nearly four in five(80 percent)of those born worldwide could die before age 80 years.By 2023 this risk of death fell to 54 perce

271、nt(Figure 1.5).Death rates before age 50 years have declined even faster,falling from about 30 percent to 12 percent,and at these ages,the fast-est decline was in LICs,where death rates substan-tially dropped from about 1997 onwards,driven by extraordinarily fast declines in child mortality.Annual r

272、ates of mortality decline from 1990(which was the start of several major efforts on global maternal and child health)to 2019 were 3 percent among children below age 15 and about 1.5 percent between ages 15 and 49(Table 1.1).For both age groups,nearly every income region matched or exceeded the annua

273、l progress in high-income coun-tries(Appendix B Table B2).By contrast,the annual rates of decline in 5069 and 7079 age groups were only 1 percent,with far greater progress in high-in-come countries than in LMICs.Thus,in the past few decades,LMICs have been able to achieve at a faster rate the kinds

274、of childrens health improvements that wealthy countries saw in the early twentieth centu-FIGURE 1.4 Global distribution of climate vulnerabilitySource:ND-GAIN(2021).C H A P T E R 118U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Yry.By contrast,the faster improvement in mortality

275、 at older ages in wealthy countries has yet to occur in LMICs.These annual rates of improvement help inform plausible targets for the future.Thus,while significant alterations in future population size and age structure are probably not possible,improving wellbeing throughout the lifecy-cle is possi

276、ble.Consider the expected ages at which the 131 million children born in 2023 worldwide(of whom 118 were born in LMICs)would eventually die if 2023 age-specific death rates were to continue.Among all births,approximately 15 million would die before age 50 years(6 million before age 15),losing severa

277、l decades of good life.Fully 24 million would die at ages 5069,losing about two decades of good life,and 29 million at ages 7079,where the loss of life years is smaller.Thus,securing a future for all the children born today requires attention not only to the nearly fully avoidable deaths early in li

278、fe,but also the sub-stantial avoidable proportions of death in middle age.Chapter 2 expands in greater detail on better health throughout the life cycle.A historic perspec-tive on progress in mortality from 1970 onwards at different ages helps set the stage to understand avoidable mortality.FIGURE 1

279、.5 Trends in probability of death at ages 079,5079,and 049 years from 1970 to 2019 by income regionAges 0 to 79Ages 50 to 79Ages 0 to 49Source:UNPD(2022).C H A P T E R 1U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Y19TABLE 1.1 Average annual rate of reduction in mortality betwe

280、en 1990 and 2019 by age(%)Country income categoryAge 0(until age 14)Age 15(until age 49)Age 50(until age 69)Age 70(until age 79)World3.31.41.51.3Source:UNPD(2022).1.5 The epidemiological shifts reshaping life-course healthThe rapid demographic changes underway are ac-companied by a shift in most LMI

281、Cs such that NCDs are the leading cause of deaths.These chang-es arise both from agingcreating larger number of adults who are at the ages where NCDs strikeand also from exposure to key risk factors,such as smoking,alcohol abuse,and obesity.Importantly,NCDs are distinguished from many infectious dis

282、-eases of childhood in being life-long conditions that require ongoing treatment.Globally,NCDs cause 41 million deaths each yearaccounting for nearly three-quarters of all deaths(WHO 2022a).Five major NCDscardio-vascular diseases,diabetes,respiratory diseases,can-cers,and mental health conditions(of

283、 which major depression is the leading cause)account for the vast majority of these deaths and for three out of four years lived with disability worldwide(WHO 2020b).Most NCD deaths occur in LMICs,and the propor-tion of all deaths caused by NCDs is set to rise in each LMIC category(Figure 1.6),inclu

284、ding in LICs.FIGURE 1.6 Proportion of all deaths attributable to NCDs,by country income category,2019 and 2040Sources:Original calculations for this publication,based on WHO(2020b).Hundreds of millions of people are living with NCDs today.Figure 1.7 shows how widespread cer-tain NCDs are,with over 2

285、50 million suffering from depression and over 1 billion from cardiovascular disease(predominantly ischemic heart disease and stroke)and diabetes.These burdens are rising rap-idly,and fastest in LMICs.For instance,the greatest increase in diabetes prevalence is expected in mid-dle-income countries(MI

286、Cs).On current trends,the number of diabetics globally will double from 0.5 billion today to over 1 billion by 2050(Interna-tional Diabetes Federation(IDF)2021).C H A P T E R 120U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T YFIGURE 1.7 Number of adults living with major NCDs in

287、2019Sources:IDF(2021);IHME(2019).Note:NCDs=Non-communicable diseases.Morbidity and risk factors for NCDs:This report emphasizes mortality as the main metric to use in prioritizing diseases and assessing prog-ress.Mortality comprises most of the composite mortality and disability measures,such as dis

288、abil-ity-adjusted life years(DALYs),particularly among lower-income countries.According to the World Health Organization(WHO),about two-thirds of all DALYs globally are due to mortality,but pro-portions are higher in LICs(WHO 2020b).Impor-tantly,mortality does not capture all illnesses,most notably

289、excluding depression(Menon et al.2019);key conditions that disable,notably depression and other mental health conditions,should be priorities for disease control in every country(Menon et al.2019).However,the correlation between premature mortality and morbidity is strong for most diseases of public

290、 health importance,with only some excep-tions(Norheim et al.2015).Moreover,measuring mortality will be far less uncertain than trying to measure disability and mortality.Nonetheless,mortality does not capture all ill-nesses.A deeper examination in India of the contri-bution of life years lost to mor

291、tality and to morbid-ity noted that 29 percent of overall health loss was due to morbidity,but this proportion approached 90 percent for childhood malnutrition and depres-sion(Figure 1.8)(Menon et al.2019).Thus,the public attention and intervention programs need to target selectively the conditions

292、that are dominat-ed by mortality,as proposed in the HLI investment package(Chapter 3).C H A P T E R 1U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Y21FIGURE 1.8 Contribution of mortality or disability for selected major causes of death in India at various ages,2017Source:Origina

293、l calculations for this publication based on Menon et al.(2019).Note:YLL=years of life lost due to premature mortality,YLD=years of healthy life lost due to disability.Neglecting key risks factors for NCDs contrib-utes to avoidable mortality.Smoking,obesity,exces-sive alcohol consumption,and insuffi

294、cient physical activity are strongly predictive of NCD mortality and cause morbidity by themselves(WHO 2022b).Figure 1.9 shows the prevalence of the selected risk factors globally and trends in prevalence in recent decades(WHO 2020c).It is particularly import-ant to raise cessation rates by the worl

295、ds 1.1 billion current smokers(GBD 2019 Tobacco Collaborators 2021).Without major increases in quitting,there will be few health gains from reduced smoking be-fore 2050(Jha and Peto 2014).Considering the key risk factors shown in Figure 1.9,there has been some progress in reducing smoking and alcoho

296、l abuse but there have been few advances in increasing physical activity,which contributes to the growing burdens of obesity and diabetes.While heavy alcohol drink-ing and smoking are concentrated in men,obesity and inadequate physical activity are more prevalent in women.Obesity is driven in part b

297、y the effects of weight-gain during pregnancy(or menopause),but more complex factors also operate.For exam-ple,low-income families may be working multiple jobs to make ends meet,with little time for person-al healthand with womens additional responsi-bilities,they would be particularly disadvantaged

298、.In some countries with more rigid gender norms,women may find it difficult to exercise unless they can access and afford women-only spaces for fitness.Smoking:Smoking remains the leading avoid-able risk factor for adult mortality globally,caus-ing over 7 million deaths or about one in ten of all de

299、aths.Smoking contributes to nearly all of the major NCDs,not only lung cancer.The hazards of smoking are uniquely high.Half to two-thirds of smokers are killed by their addiction.Most smokers who start early in adult life and continue to smoke are eventually killed by their tobacco use.This is becau

300、se during middle age,the death rates among smokers are about three-fold higher than those of similar non-smokers every year(when controlling for differences between smokers and non-smokers in heavy alcohol use,obesity patterns,or differenc-es in educational or economic status).Therefore,up to two-th

301、irds of the mortality among smokers would not occur if they had non-smoker death rates.Most of this excess risk arises from diseases commonly caused by smoking.This includes dis-ease such as lung cancer,emphysema,heart attack,C H A P T E R 122U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N

302、G E V I T Ystroke,cancer of the upper digestive areas,bladder cancer,tuberculosis,and various other conditions.Every million cigarettes smoked causes approxi-mately one death(Jha 2020).Smoking cessation is effective in reducing the increased risks of developing smoking-related dis-ease.Smokers who s

303、uccessfully quit before age 40 avoid nearly all increased mortality risks of contin-ued smoking,and even those who quit by age 50 or 60 gain back some of the lost years of life(Jha and Peto 2014).Moreover,the gains arise reasonably quickly,just within a few years of cessation(Cho et al.2024).Finally

304、,given the long delay between smoking onset and disease and the far more rapid benefits from ces-sation,it is particularly important to help the worlds 1.1 billion current smokers to quit.Cessation among current smokers will reduce mortality substantially by 2050.By contrast,efforts to prevent youth

305、 from taking up smoking will yield benefits only beyond 2050(Jha and Chaloupka 1999).Obesity:The WHO estimated in 2016 that global obesity prevalence had nearly tripled since 1975with more than 1.9 billion adults,18 years and older,overweight and of them 650 million suf-fering from severe obesity(WH

306、O 2021b).Body mass index(BMI)is the most widely accepted marker of overweight and obesity in adults,and it is calculated as the weight in kilograms divided by the square of height in meters.For adults,WHO defines overweight as a BMI greater than or equal to 25,and obesity as a BMI greater than or eq

307、ual to 30(WHO 2021b).Obesity is a major risk factor for NCDs such as cardiovascular disease(mainly heart disease and stroke),diabetes,and some cancers(in-cluding breast,prostate,and colon cancer)(WHO 2021b).Obesity is also associated with mental health conditions,including depression,and is associat

308、ed with raised blood pressure,increased levels of blood cholesterol,and decreased levels of high-density li-poprotein(Shekar and Popkin 2020;Romieu et al.2017).An increase in BMI of 10 units doubles mor-tality from cardiovascular disease(Armas-Rojas et al.2021).In general,however,morbidity burden st

309、arts at BMI levels regarded as“normal”and the risk of cardiovascular disease and colon cancer increases linearly as BMI rises from about 20kg/m2(weight in kilograms per height measured in meters squared).Obesity is a result of impaired energy homeo-stasis:too much energy is consumed and too little i

310、s expended.In addition,undetermined hormonal FIGURE 1.9 Number of people(aged 15+)with NCD risk factors in 2016 and trends in prevalenceSource:WHO(2018);WHO(2019);WHO(2020c);GBD 2019 Tobacco Collaborators(2021);Guthold et al.(2018).Note:aged 18+;*in 2019;*from 2000 for Obesity,Heavy episodic drinkin

311、g,and Current smokers;from 2001 for Insufficient physical activtyC H A P T E R 1U N L O C K I N G T H E P O W E R O F H E A LT H Y L O N G E V I T Y23and neurological factors lead to stored fat inducing a metabolic state that maintains obesity.As a result,some researchers believe that the source and

312、 nature of calories is irrelevant.However,others claim that caloric source is important,especially if foods trig-ger increases in blood glucose that lead to excess fat deposition(Foster et al.2003;Schwingshackl and Hoffmann 2013).There is agreement that globally there has been a shift in food consum

313、ption,with populations opting for energy-dense foods with higher sugar and fat content.The processes of glo-balization and trade liberalization play a role in nu-trition transition,especially in LMICs where they influence modern food supply chains and introduce sophisticated marketing to create an e

314、nvironment that promotes obesity.Concurrently,there has been a global reduction in physical activity.Moreover,many LMICs,such as India,are contending simul-taneously with both malnutrition and obesity.The health care costs due to obesity are increasing across the world,but precise data from LMICs ar

315、e scarce.For example,Brazil projects a doubling of obesity-re-lated health care costs from US$5.8 billion in 2010 to US$10.1 billion in 2050(Rtveladze et al.2013).Childhood obesity is also increasing world-wide and there is evidence that obesity in child-hood tracks through to adulthood(Simmonds et

316、al.2016).Childhood obesity may derive from ma-ternal and household factors(Mahmoud 2022).Malnourished and stunted children are at greater risk of becoming overweight or obese as adults if they are exposed to obesity-inducing diets or if they adopt sedentary lifestyles.Prevention of childhood obesity

317、 centers on good maternal nutrition in the prenatal period and breastfeeding,coupled with regulatory and fiscal measures to limit the intake of processed and high-calorie foods(WHO 2017a).At the individual level,the efforts to prevent and control obesity focus on behavioral changes that are difficul

318、t to sustain once elevated body weight is maintained physiologically(Kelly and Barker 2016).At the national level,fiscal policies,including taxes on unhealthy foods and taxes on sugar-sweetened beverages have been shown to reduce consumption,especially in children.The corollary is to subsidize healt

319、hy foods.Regulatory policies such as front-of-package warning labels have also been adopted to reduce the consumption of ultra-processed foods(Shekar and Popkin 2020).Changes in school feed-ing programs are another approach to changing family food habits(Shekar and Popkin 2020).There have also been

320、national policies promoting exercise by modifying urban design but the effectiveness of these interventions is unknown.Recently,drugs originally developed to treat type-2 diabetes have been approved for weight loss(Garvey et al.2022).This injectable mimics the glu-cagon-like peptide 1 and reduces th

321、e amount indi-viduals eat during meals as well as snacking between meals.In randomized trials,one such drug(sema-glutide)caused a 15 percent weight loss within one year but the majority of the weight returned after cessation of treatment(Wilding et al.2022).New-er drugs of this class,including some

322、to be taken orally,are under development,but the current high costs are a barrier to widespread use.Drug therapies are likely work better if complemented by individual behavioral change coupled with a whole-of-govern-ment or whole-of-society approach that tries to re-duce diets rich in processed and

323、 energy-rich foods.Alcohol:The excess morality from NCDs due to alcohol is heavily concentrated in men.Alcohol consumption is an established risk factor for select-ed cancersspecifically esophagus,liver,upper air-ways,colon and rectal and,in women,breast can-cer(Rumgay et al.2021).Alcohol consumptio

324、n is a risk factor for stroke,in part because higher alcohol intake uniformly raises blood pressure.In China,where stroke deaths are more common than isch-emic heart disease deaths,alcohol accounted for 8 percent of ischemic strokes and 16 percent of intrace-rebral bleeding strokes(a type of stroke

325、particularly sensitive to blood pressure).The effects of alcohol on myocardial infarction were less certain(Millwood et al.2019).In meta-analyses among populations most-ly of European descent,stroke incidence rose steadily with increasing amounts of alcohol consumed,and the effects on ischemic heart

326、 disease were also high-er among drinkersonly slightly higher in drinkers whose usual intake was quite low,but approximate-ly flat at higher ranges of consumption(Wood et al.2018).Thus,while earlier studies showed apparently protective effects for ischemic heart disease,they are likely due to method

327、ological limitations,and no clear“safe”level of drinking exists.However,the absolute increases in risk vary by age,sex,and population.Thus,the key guidance is to avoid heavy alcohol use including binge alcohol use,which is strongly related to cancer risk and which most significantly increases blood

328、pressure and stroke risk.Blood pressure:Blood pressure is a fundamental aspect of cardiovascular health that exerts an impact on mortality.Hypertension is a major risk factor for cardiovascular diseases,which accounted for 32 per-C H A P T E R 124U N L O C K I N G T H E P O W E R O F H E A LT H Y L

329、O N G E V I T Ycent of all deaths in 2019 worldwide(WHO 2020b).High blood pressure damages arteries by promoting the build-up of plaque and narrowing of blood ves-sels.This,in turn,increases the risk of blood clots,heart attacks,and strokes,all of which can be fatal or lead to severe disability.Hype

330、rtension coexists with other health conditions such as diabetes and obesi-ty,further exacerbating the mortality risk.Reducing blood pressure and blood cholesterol paired with aspirin can be remarkably effective in cardiovascu-lar disease(CVD)control among the very large pop-ulation of adults with va

331、scular disease(Yusuf et al.2014).These interventions are considered as part of the recommended clinical package in Chapter 3.Between ages 4069 years,decreasing systolic blood pressure by 20 millimeters of mercury halves death rates from stroke,ischemic heart disease and other vascular causes(Lewingt

332、on et al.2002).Efforts to lessen blood pressure-related mortality involve life-style modificationsincluding a healthy diet,regular exercise,and stress managementas well as medica-tion when necessary.This is particularly challenging in resource-constrained settings where access to infor-mation,health

333、 care facilities,and nutritious foods as well as adherence to treatment plans affect outcomes.1.6 The economic value of avoidable mortality Major global goals,including the SDGs,emphasize reducing mortality rates for various age groups,particularly substantial reductions in child mor-tality and a one-third reduction in mortality from NCDs at ages 3069 by 2030.While progress on child mortality rema