Aging, illness, and health policy: implications of the compression of morbidity.

Abstract

AGING, ILLNESS, AND HEALTH POLICY: IMPUCATIONS OF THE COMPRESSION OF MORBIDITY JAMES F. FRIES* The national illness burden has shifted over recent decades from acute to chronic illness and from younger to older individuals [1,2]. The problems of chronic illness mix with and finally give way to senescent problems. Our future population will contain substantially more older individuals, as the birth cohorts of the 1920s and 1930s now approaching their seniority are larger than previous cohorts, and average life expectancy also is increasing. These commonly made observations lead some to postulate a dark future of increasing dependency, worsening health, and spiraling health care costs. The ability of society to pay everincreasing costs for ever more vegetative existence has been called into severe question. However, these somber predictions are not rooted in current knowledge of chronic disease and senescence, and they are not necessarily accurate. There is a much more hopeful paradigm, that of the "compression of morbidity" [1—10]. Rather than assuming that disease is fixed and the life span indefinitely extensible, the compression of morbidity thesis notes that the species' life span is finite and that the onset of chronic disease is relatively easily delayed. Thus, the period (in each individual life) from onset of chronic infirmity to death may be shortened, with both individual and social benefit. A central question to be addressed is whether it is easier to prevent mortality or to prevent morbidity. The data reviewed in this discussion demonstrate that it is far easier to reduce sickness rates than to reduce death rates. This work was supported in part by a grant from the National Institutes of Health (AM21393). ?Department of Medicine, HRP Building, Room 109C, Stanford University School of Medicine, Stanford, California 94305.© 1988 by The University of Chicago. AU rights reserved. 003 1-5982/88/3 103-058 1$1 .00 Perspectives in Biokgy and Medicine, 31, 3 ¦ Spring 1988 \ 407 The basic syllogism of the compression of morbidity is that, since the age of first chronic infirmity can be postponed but the life span itself is genetically fixed, the period of infirmity can be shortened. In more general formulation, the theorem holds that, for the average person, (a) if morbidity may be defined as that period from the onset of the first irreversible chronic disease or aging marker until death, (b) if the date of occurrence of that marker can be postponed until later in life, and (c) if the rate ofsuch postponement can be greater than the rate ofincrease in adult life expectancy, then (d) morbidity for the average person can be compressed into a shorter period of time. Interest in this paradigm has been high, in part because the implications both for health policy and for demographic predictions are substantially different from those often suggested. Further, the concept puts emphasis on prevention rather than cure, postponement rather than palliation, and personal autonomy rather than paternalistic care. Summarizing and extending previous work [1—10], this paper first discusses theoretical, conceptual, and semantic issues, then discusses the available data bearing on the hypothesis, and finally presents a general analysis of the national morbidity and of strategies for its reduction. More detailed explication of similar data has been presented elsewhere [10]. Conceptual Issues In the first three quarters of the twentieth century, there seems little doubt that total morbidity for the average person increased. Health advances over this period were characterized by sharp reductions in infant mortality, major increases in average life expectancy from birth (from 47 to 74 years), decline and virtual elimination of most of the acute infectious causes of death prominent early in the century, and concomitant major increases in chronic and morbid diseases such as atherosclerosis, neoplasia, and osteoarthritis. A dramatic reversal of previous trends in the incidence and prevalence ofchronic illness began in the mid 1970s, proving previous predictions false [10]. Mortality from heart disease, the most important single health problem, began to decline rapidly. The results of these dramatic changes in mortality have not yet been extended into broad understanding of their effects on morbidity. Among the central conceptual issues surrounding chronic illness and aging, six are particularly worthy of emphasis here. THE FINITE HUMAN LIFE...