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Aging in World Cities
AARP Global Aging Program Idea Exchange with Victor Rodwin and Michael Gusmano / Event
May 2006
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Learn more about the AARP Global Aging Program
AARP Global Aging Program Idea Exchange Series
Washington, D.C.
Victor G. Rodwin and Michael Gusmano of the International Longevity Center-USA, recently visited AARP to present findings from the World Cities Project, a study of aging and senior services in four large world cities: New York, Tokyo, Paris and London. Growing Older in World Cities, a book based on the study, focuses on the evolution and organization of social services and public health infrastructure and how these dynamics contribute to making communities livable for older persons in the urban setting.
Livable communities should address the basic needs of older people with respect to health, safety, housing options, and social services. They should also optimize physical and mental well-being while maximizing independence. Opportunities must be available for social and civic engagement through cultural, religious, recreational, and volunteer activities as well as the availability of paid work. Rodwin points out that it is important to see how these things look and work in specific places, especially cities.
With their varying transportation systems, polarization of the rich and the poor, and diverse populations, cities offer a unique and special case for studying aging and services for older people. Additionally, cities provide a window into two growing global phenomena with one glance: urbanization and population aging. Large cities, like those used in the study, are increasingly becoming models for growing metropolises of the third world i.e. Mexico City and Mumbai. Rodwin emphasized the importance of cities in the study of aging stating, “You cannot talk about aging at the national levels. You must disaggregate by communities and examine the situation in cites.”
In order to use cities as a focal point for studying aging and senior services, a common definition was derived. Various accounts of city definitions exist ranging from the sole inclusion of boroughs and center city areas to the inclusion of rural areas and outlying suburbs and exurbs. Rodwin, Gusmano, and their team developed succinct criterion for cities to make fair comparisons among the four used in the study. Points of analysis used were the combination of urban core and first ring populations and health care resources (e.g. number of teaching hospitals, physicians, etc.). The team found that the cities had numerous similarities but were all different in respect to their pension policies, social welfare net, organization of medical care, and the extent to which they promote productive aging. In New York the life expectancy was higher than the national average, in Tokyo no significant difference, Paris is similar to New York, while London experiences higher life expectancies for women only. Questions raised from this pattern include:
- Does this reflect migration (Healthy people stay in cities, sick people leave)?
- Does it reflect the concentration of academic medical centers (better care)?
- Does it reflect income?
Dr. Gusmano began by looking at the broad spectrum of long-term care policies and aging in place found in each city. More specifically he examined the use and location of institutional and community care services in each city. He found that each city had an emphasis on a different kind of care. Japan and Manhattan had the highest percentage of institutional care options while London and Paris focused more on community care. In each city, institutional care was most prevalent in the outer rings and suburbs while home and community care prevailed in the urban core. High prices of land and real estate downtown may be a key factor in this trend. Overall, each city had developed or is looking to others to develop nursing home alternatives including community-based residential options e.g. assisted living (both public and private), congregate housing, individualized apartments with collective services, and naturally occurring retirement communities. Each of these establishments requires pooling services and resources together to better serve the older population.
National policy plays a major role in these services. Outside of the U.S., most of the funding comes from the central government. However, cities are increasingly filling the financial and social protection gap. Social protections for alternative care are limited across the board. Cities are providing non-means tested assistance to many older persons who would otherwise not have access to services. Gusmano concluded by reemphasizing the importance of looking at aging in an urban context. According to him, nations are becoming more like cities in terms of income inequalities, increasing diversity and the necessity of care for aging citizens. We must learn from cities that are experiencing these aging challenges in order to carefully craft successful solutions in the future.
Discussion
Rodwin and Gusmano have expanded their research into applications that can help cities gage the amount of persons who need assistance and the communities that require help providing it. The “vulnerability index” is derived from approximately nine indicators:
- number of people age 75 years and over
- percent of people (75+) living alone
- percent of people (75+) living below poverty level
- percent of people (60+) receiving disability benefit (Paris)
- percent of people (75+) reporting 1+ disability (NYC)
- percent of people (75+) who are linguistically isolated
- rate of avoidable hospitalizations
- number of vacant lots (NYC)
- number of “walk-ups” (NYC)
These indices are being used to plot vulnerability maps that are examined by researchers and local governments to determine where services are most needed. New York City and Paris currently utilize the vulnerability index. Plans to expand the program are being considered. Audience members offered additional indicators to consider such as lighting and transportation in an effort to make urban communities livable for all.
BioVictor Rodwin is Professor of Health Policy and Management at the Robert F. Wagner Graduate School of Public Service, New York University (NYU). He has served in several capacities at the Wagner School including Director of International Initiative from 1992 to 1998, and Director of Advanced Management Program for Clinicians. From 1983 to 1985 he was Assistant Professor of Health Policy at the University of California–San Francisco. He is the recipient of a Robert Wood Johnson Health Policy Investigator Award on "Megacities and Health: A Comparison of New York, London, Paris and Tokyo," and he co-directs (with Michael K Gusmano) the World Cities Project, a joint venture of the Wagner School, NYU, the International Longevity Center-USA, and the Mailman School, Columbia University. Professor Rodwin has authored or co-authored numerous publications including The Health Planning Predicament: Quebec, England, France and the U.S (UC Press, 1984), The End of an Illusion: The Future of Health Policy in Western Industrialized Nations (UC Press, 1984), Public Hospital Systems in New York City and Paris (NYU Press, 1992), Japan's Universal and Affordable Health Care: Lessons for the U.S.? (Japan Society, 1994), and Growing Older in World Cities: New York, London, Paris and Tokyo (Vanderbilt U. Press, 2006).
Michael K. Gusmano, Ph.D., is an Assistant Professor of Health Policy and Management and Lauterstein Scholar in the Mailman School of Public Health, Columbia University. He is the Co-Director of the World Cities Project, a joint project of the International Longevity Center-USA, New York University and Columbia University. Dr. Gusmano is also the co-editor and author of Growing Older in Four World Cities: New York, London, Paris and Tokyo (Vanderbilt University Press, 2006), which compares the health status and use of health and social services for persons older persons in these cities. His other research interests include politics of health care reform, Medicare, Medicaid and comparative welfare state analysis.