MR. KOJO NNAMDIIt's a startling statistic. In less than 40 years, demographers say the world will contain more people age 60 and older than children under the age of 15. It wasn't supposed to be this way. Scientists thought that baby boomers and the generations after them would produce a global population explosion. Instead, baby boomers are living longer while their children and grandchildren are deciding not to have big families or any babies at all. These bleak numbers have provoked fears of sky rocketing healthcare costs, social security deficits and the world wide scramble to find appropriate accommodations for seniors.

MR. KOJO NNAMDIBut others say, a grayer globe could produce a more peaceful planet and spark innovations that will ultimately make life better for all of us. Joining us in studio is Phillip Longman, senior research fellow at the New America Foundation. He's also an editor of the Washington Monthly and author of, "The Empty Cradle: How Falling Birthrates Threaten World Prosperity and What to do About it." Joining us by telephone is Michael Gusmano. Michael, is that how your last name is pronounced, Gusmano? Michael's not there. Michael...

MR. MICHAEL GUSMANONo. I'm right here. Hello?

NNAMDIHow do you pronounce your last name?

GUSMANOGusmano, you got it perfect.

NNAMDIThank you, Michael Gusmano is research scholar at the Hastings Center in New York and co-director of the World Cities Project at the International Longevity Center-USA. Phil, many demographers suggest that our biggest worry right now isn't having too many people on the planet, it's having too few. But isn't it true that the global population is increasing?

MR. PHILLIP LONGMANYes, it is. It's increasing roughly by the population size of Egypt every year, but it's a different kind of population growth than we've seen before. United Nations population division says we'll probably go to nine billion people on the planet, up from 6.9 now, but more than half of that increase will be increases in the number of people over 60 worldwide. And, of course, those people have already been born. So it's kind of strange to think about. It's a whole new world. But we have both some increases in life expectancy going on and we also have these great big aging baby boomers or baby boom generations around the globe who are not reproducing themselves. And between those two effects, we have a graying world.

NNAMDIWhy are we getting old so quickly? Those two effects, anything else?

LONGMANThe biggest piece of it is the dramatic decline in birth rates that started in Scandinavia in the 1970s, spread throughout Europe in the 1980s, paused briefly at the Pyrenees in the Alps and then pushed into Southern Europe, swept across former Soviet Union, reached China, Japan and now has spread very rapidly in the developing world. So we have countries like Brazil now that no longer produce enough children to sustain their population over time. Chili, all of the West Indies, places that you don't associate with global aging.

LONGMANIn many cases, these countries are experiencing rates of aging that we've never seen before in human population. Even a country like Egypt that's so much in the news today, right, will age more in the next generation than France did in the last 140 years. And by mid century, one out of five people in Egypt will be over 60, which is roughly the percentage that's in France today.

NNAMDIOn the other hand, the U.S. is on track to grow relative to the rest of the world because it's birth rate is higher than that of almost any other industrialized country. So will we avoid this so called population bomb?

LONGMANWell, we are, on paper, better off than other industrialized nations when it comes to the birth rate. Most of that is the result of our very rapid rates of immigration. Immigrants tend to have higher fertility than the native born population of the United States. But that's changing rapidly, too. For example, in Mexico, we have never seen, in human population, a decline in fertility as fast as this happened in Mexico in the last generation. The absolute number of children in Mexico has been falling for more than 10 years. The same thing is through -- true throughout Latin America. So a lot of the places from which we have imported babies in the past, so to speak, are themselves not having children anywhere near as fast as they used to.

LONGMANAt the same time in recent years, we've seen a reverse of immigration to the United States. So we have maybe as many as 300,000 people going home last year to their native countries. So between that and the sort of convergence of economic standard of living, the United States, I don't think, can count on immigration as much as we have in the past. And this same meme (sp?) if you will, this what it is that's spreading around the world, causing people to not have as many children as necessary to replace themselves is bound to reach these shores.

NNAMDIMichael Gusmano, you and your colleagues at the International Longevity Center are studying the effects of aging in New York, London, Paris and Tokyo. Why those cities and tell us about the World Cities Project?

GUSMANOWell, sure. We picked those cities because they're the four largest cities in the developed world. And we know a great deal about them. And they've been compared many times, but until we started looking at them, no one had compared health and the social policy among and within those cities. And they often share information with each other and share innovations and ideas. And so the World Cities Project has been an attempt to better understand how each of these cities which are located within nations that have vastly different social and health policies, are coping with challenges, like, population aging.

GUSMANOAlthough I will say, going back to your first point, I think most of the big claims about the negative consequences of population aging are vastly over blown. Just a simple statistic as Mr. Longman points out, France is significantly older than the U.S. and Germany, Italy, many other countries are older than the U.S. Yet they spend far less than we do in terms of healthcare in large part because population aging in and of itself is a relatively minor factor in terms of how much you spend. The price of medical care, volume and intensity are far more important than just the age of the population.

NNAMDIWhy study urban areas rather than rural ones?

GUSMANOWell, it's a good question. It's largely is because the -- in addition to the trends that you pointed to with population aging, which are quite startling, there's also a trend toward urbanization. And so within the next few years, 60 percent of the globe will be living in big cities and we know very little about the experience of older people living in these places. We put these two trends together and thought it would be interesting to better understand what's happening. And in -- since we've began this project about 10 years ago, the WHO has actually picked up on this and started an age friendly city movement, which helps to sort of raise this issue to the agenda. And I'm very pleased to see that.

NNAMDILike our listeners to join this conversation. If you'd like to do so, call us at 800-433-8850. Do you have elderly people who are isolated, family members who are in need of long term care? How are you facing that problem? And speaking of which, Michael, are children of these elderly people stepping up to take care of them in these big cities or are many of the elderly isolated?

GUSMANOOh, I think there's a lot of evidence that children provide a lot of support, in fact the bulk of the support for older people living in these cities. Now having said that, there are issues because, particularly in the cities that we study, these are very expensive places to live. Children can't always afford to stay in the city and live near their parents. I met a woman, actually, from Washington, D.C. several years ago who was creating an interesting service, where she would pull together all of the health and social service agencies and put them all on one website.

GUSMANOSo that children who are living remotely, but wanted to try to arrange services for their aging parents within the city, could call one number and figure things out. But there's lots of evidence that older people are supporting their children and vice versa so lots of intergenerational transfer still going on even in a place like Japan, which has adopted national long term care insurance.

NNAMDISpeaking of Japan, Phillip Longman, Japan has had some interesting ideas about how to care for its quickly graying population, including exporting them.

LONGMANWell, yes, that's been a subject of very serious deliberation in Japan, whether it would be better to import Philippina nurses to take care of their elderly or to export their elderly to the Philippines. I think this idea's kind of on hold because the older generation in Japan kind of remembers what happened in World War II in the Philippines and is not really anxious to go back there. But Japan does, in many ways, show us the future. This is a country that the average woman only has about 1.3, I believe it is now, children over her lifetime. I would like to say, too, that although Japan doesn't exemplify this, many western countries do, that we have this very rising incidence of childlessness among the next generation of seniors.

LONGMANSo in my generation, the baby boom generation, about almost one out of five us never had children. This is double the rate in the previous generation. So we're looking at huge numbers of elderly who cannot draw on large numbers of extended family to support them. If you look at a place like China, you see that the elderly and the young are geographically separated. So you have horrible conditions of rural elderly in Western China, in many cases selling their blood to make enough money to get by, while their children are in the cities trying to make a new life.

LONGMANAnd that's a pattern you see throughout the developing world now. You see that in Africa, see that in India. And, you know, going forward, the more human population moves into urban areas, and as Michael says, it's a gigantic mega trend around the world now, if there's one iron law we know, the -- governing the birth rate is that when people find themselves living in an urban environment, they have far fewer children than they do when they're living on farms or in a peasant kind of circumstance.

LONGMANAnd so we -- that's part of the reason why -- that same urbanization is part of the reason why we have to anticipate that this downward trend in fertility that's been gathering momentum for 40 years now, is really going to go into hyper drive, particularly in the developed world.

GUSMANOAnd (unintelligible) ...

LONGMANDeveloping world, I'm sorry.

NNAMDIGo ahead, Michael.

GUSMANOIf I could just add to that quickly. I mean, some of these trends are problematic. Some of them are the sort of byproduct of some very positive things. One of the reasons it is increasingly difficult to rely exclusively on family caregivers, for example, to provide support for older people is that more and more women are able to enter the workforce and so some of this is a result of expanding educational and employment opportunities for women. In fact, the big push in Japan nearly a decade ago now, for the adoption of long term care insurance, was, in fact, women's groups who were saying, we want public support for publicly paid community based homecare so that this burden does not fall exclusively on daughters-in-law.

NNAMDIGot to take a short break. But we are interested in your phone calls. What do you think our country and other countries need to do to deal with the aging of citizens? You can call us at 800-433-8850 or send us an e-mail kojo@wamu.org. You can also send us a tweet at kojoshow or join the conversation at our website kojoshow.org. We're talking about our aging globe and what you think needs to be done about it. I'm Kojo Nnamdi.

NNAMDIWe're talking about the aging world population. By the year 2050, the world will contain more people age 60 and older than children under the age of 15. We're talking with Michael Gusmano, research scholar at the Hastings Center in New York and co-director of the World Cities Project at the International Longevity Center in -- International Longevity Center USA. Joining us in studio is Phillip Longman, senior research fellow at the New America Foundation. He's also an editor at the "Washington Monthly" and author of "The Empty Cradle: How Falling Birthrates Threaten World Prosperity and What To Do About It." Has the world been through this kind of population cycle before, Phillip Longman?

LONGMANWe can't know with great certainty because we don't have the data. But in late antiquity, in, like, Rome and Greece, people certainly experienced life as one in which people weren't having enough children. Caesar Augustus was alarmed by what he saw, at least as the birth dirth of Rome, that he slapped on bachelor taxes, that he forbade people from serving in the Senate unless they were married and had children. We have satirists, like, Juvenile who were poking fun of people were in the rent-a-baby business so that when Caesar was in town, you know, you could show up with your kid.

LONGMANWe know from writers in late-Greek classical period, that they very much interpreted their decline, vis a vis Rome, as one in which men had become too selfish to have children. All kinds of writers on that theme. So it does look like in the absence of some kind of very powerful prenatal cultural norms, humanity does have a tendency towards what demographers called sub-replacement fertility. Historically, you know, patriarchy has been how human beings have solved this problem.

LONGMANWe kind of find ourselves at a moment when patriarchy is not acceptable as commonly understand, and yet we haven't really figured out some other way to sufficiently reward parents for the sacrifices they make on behalf of their children and on behalf of society. Until we figure that out, we're gonna have a problem.

NNAMDIMichael Gusmano, you talked about the fact that aging, in and of itself, is not what is driving up the cost of health care in these countries, but we've also heard about the alarming obesity epidemic spanning the globe. So what will these coming generations of elderly people look like healthwise?

GUSMANOWell, I think this is a terribly important point, and others have written about this as well, including Phillip, which is that one of the happy stories about population aging over the last several decades has been the so-called compression of morbidity. The idea that we're not just getting older, but we're healthier, and the years in which we spend in poor health and disability have been compressed into fewer years toward the end of life.

GUSMANOUnfortunately, when you look at the trends in obesity which are alarming and look globally like a pandemic, there is a very real possibility that the next generation of older people may be quite a bit sicker than the current generation of older people. Indeed my former colleague, Robert Butler, wrote a piece several years ago arguing that there was even a threat to increasing life expectancy. We've seen almost continual increases in life expectancy, particularly in the developed world, but in the developing world as well. And we may actually see declines if we don't address that problem.

NNAMDIPhil, if our elderly populations are increasingly disabled, according to a recent Rand Corporation study published in health affairs, more than 40 percent of Americans aged 50 to 64 already have difficulties performing ordinary activities of daily life, such as walking a quarter mile or climbing ten steps without resting. If our elderly populations are so increasingly disabled, does this mean they won't be able to work longer?

LONGMANWell, I think, and I'm sure Michael agrees, that there's a lot we can do to promote more productive aging. But we also have to get real about what we're up against. You often hear people making this facile point that, oh, baby boomers are gonna live longer than any other generation in history, therefore they should work longer, raise the retirement age. We're not looking at another next generation of seniors that is gonna be physically capable of doing what many people are expecting of them.

LONGMANAnd, you know, we also have the ongoing trend of people's job skills becoming obsolete as the economy becomes more complicated and high tech. So we have to really be serious about this. And I also would second Michael's point about the U.S. health care system, that it is -- we have comparatively favorable demographics, but our health system is so inefficient that we can't afford to grow old even a little bit, unlike countries like the UK that has a much more efficient system.

LONGMANSo this is the real subtext about healthcare reform, you know. It's not just getting more people access to an already broken system. You have to get this delivery system seriously more efficient.

NNAMDIHere -- here is Mindy in Columbia, Md. Mindy, you're on the air. Go ahead, please.

MINDYHi. What I'd like to ask if it's time for our nation to consider ways to significantly compensate stay-at-home -- it used to be the stay-at-home mothers, stay-at-home caregivers, for what they're providing as a service in care giving of aging parents.

NNAMDIWhat do you think about that, Michael Gusmano?

GUSMANOWell, you know, it's an interesting question and countries around the world have debated this. One of the things that happened in Japan when they passed national long-term care insurance, was they explicitly decided not to include a cash benefit to caregivers, which was something the Germans had done in their system, and indeed it's the most popular option. Because the concern was that if caregivers were being paid, there would be increased pressure for them to continue their traditional role.

GUSMANOHaving said that, there are a number of studies showing the enormous economic value of caregiving -- informal caregiving and the fact that we don't provide adequate support for family caregivers, that we don't provide, in the case of children, we don't provide much subsidy in terms of daycare. You know, in the mid-1990s we reformed welfare and put in a work requirement, but there wasn't necessarily the subsequent help that people needed if they had children, so they had to go to work.

GUSMANOBut could they afford daycare in terms of making it affordable to raise a family to have more children if that's a desired goal. You need to think about what sorts of support needs to be in place to make that happen.

NNAMDIThank you for your call, Mindy. Do you have elderly family members who are isolated or are need of long-term care? How are you facing the problem? Call us at 800-433-8850. We got this e-mail from Dee in Falls Church saying, "Can you ask your guests a little bit more about what cities and suburbs are doing to make them more livable areas for aging residents?" What could our DC suburbs like Falls Church do, Phil Longman?

LONGMANWell, I think we need to do a lot to begin with to overcome this autodependency that we have, I mean, already a very significant share of the population is either too poor or, for one reason or another, doesn't have access to automobiles. But we're now looking at is, you know, this explosion of seniors coming soon, and we need to have greater transportation options for them so that they can live in their own homes and not live in institutions.

NNAMDIMichael, how are we addressing these challenges policywise in the U.S.? We are facing a growing number of people of Alzheimer's disease and dementia. How are we addressing these challenges policywise in the U.S. and how have you found different countries tackling this health care challenge?

GUSMANOWell, in terms of Alzheimer's disease and forms of dementia, I would have to say we're not doing particularly well at all, and I'm not sure that most other countries are doing very well either. This is a -- a major issue. Although, just to go back to the transportation point, one of the things that we have found in all of our world cities, one of the things that makes them age friendly, and places where older people do rate relatively well compared to other parts of their countries, is the fact that they all have fairly good and often subsidized transportation systems for older people.

GUSMANOBut with regard to Alzheimer's and dementia, among other things, we have terrible policies in place for ensuring that older people receive appropriate palliative care and that we're addressing this early. It's a significant issue that I don't think any countries in the world are addressing particularly well at the moment.

NNAMDIAre there care facilities, Phil, and caregivers to accommodate this growing number of people with dementia and Alzheimer's?

GUSMANONot -- well, I mean, beyond Alzheimer's and dementia, just in terms of the statistics that we were talking about earlier in terms of growing trends of disability and the need to keep people at home. We don't have enough primary caregivers, and we don't have enough social caregivers, and as expensive as, for example, the Medicaid Homecare Program is currently, it could be much more expensive if we actually paid a decent living wage to the people who provide the kind of social care assistance with bathing and dressing that our current population of older people requires.

GUSMANOSo, there's a lot of money at stake here, and one of the disappointments beyond some small efforts nested within health reform was that there was virtually no discussion of the need to really seriously address long-term care, both for people living in the community, and people who ultimately require institutionalization.

NNAMDIOn to Anne in Potomac, Md. Anne, your turn. Go ahead, please.

ANNEYes. I just wanted to make a comment regarding the long-term care non-provision of monetary compensation for family members who are forced in a way to take care of their parents. My father passed away this past year, and now I'm living with my mother who does have Alzheimer's. But I have found it's impossible to find daily activities in the community for me to bring her to, or to have her picked up by an organization. So I'm almost feeling like I'm trapped in the house with her because she can't go anywhere by herself.

ANNEAnd, you know, looking at her she seems absolutely normal, but yet she can't remember what she did five minutes ago. So you can't just let her out loose in the community by herself. And I really don't know where to go for help.

NNAMDII had a similar experience caring for my elderly mom some years ago. But here is Phillip Longman.

LONGMANYes. Well, my heart goes out to you, and so many people are in your situation, and there's many things we can do. But I think it's also important to attack this problem from the other end as well, right? So when we go to recraft our health care delivery system, we have to understand that most of the poor health that most Americans are experiencing, are in the nature of long-term chronic disabilities. We have a health care system that's pretty good at dealing with people when they get to the point where they have an acute problem, right?

LONGMANThey need to go to the emergency room. We can do amazing things. People can be shot through the head and we can save them. But what we don't have is a system that has much prevention built into it and much disease management built into it. Most of these problems are long-term and chronic, and that argues for a system that has a lot more clinics in the community, a system that has a much broader view of what the determinants of health are, social isolation is a major cause of morbidity and mortality.

LONGMANSo just getting folks out of the house and keeping them stimulated is a great way to put all Alzheimer's and other mental decline. So, you know, these are some of the pictures of things we have to do. Attacking the problem on the other side, also would include, in my world at least, not just thinking about how we can compensate people for taking care of the elderly, but also how can we compensate parents better for having children in the first place?

LONGMANBecause ultimately that's what's driving this squeeze is this dramatic decline in the number of children which is causing this imbalance between young and old, put the middle generation in this terrible spot where we are now.

NNAMDIAnne, in the short term you might want to contact your local chapter of the Alzheimer's Association of Greater Washington, which I know provides support groups and other kinds of assistance to caregivers such as yourself. But thank you very much for you call and good luck to you.

ANNEThank you very much.

NNAMDIMichael Gusmano, and you Phillip Longman, is there a place or a population that has a healthy, functioning system for taking care of its elderly and anything you've been studying so far, Michael Gusmano?

GUSMANOWell, I certainly think Japan, of the four countries that I've looked at closely, is probably the best in the sense that they have both national health insurance so that the kind of devastating economic consequences of high health care costs are not there, and they have, with their national long-term care insurance system, at least the financing mechanism in place. On the other hand, there is a sort of a dreadful shortage in Japan just as there is in all of these other places of people that actually delivered the care.

GUSMANOWe talked earlier about sort of importing people from other countries into Japan and how it gets tied up with immigration policy, and that's certainly true. I do think New York is quite notable in the sense that the vast majority, although it's gotten in trouble for this recently with concerns about fraud, but the vast majority of Medicaid homecare dollars that are spent in the U.S. were actually spent in New York City.

GUSMANOThe state pulls down an enormous amount, and has a fairly rigorous sort of vigorous infrastructure of both senior centers and Medicaid home care. But it's really just scratching the surface of what we really need. I haven't seen an ideal system. The U.S. is a real outlier with regard to acute health care and health insurance coverage. When it comes to the long-term care issue, most of us are in the same boat.

NNAMDIWe're running -- running out of time very quickly, and I know you, Phil, have talked about the Amish here. But some people have argued that an older global population will bring a more peaceful planet. Can you talk about that in the 40 seconds or so we have left?

LONGMANWell, that's what some folks call the geriatric peace. We're rapidly on the cusp of seeing a middle aging of the Middle East. For example, people can remember how much Europe calmed down between the '70s with (word?) and the Weather Underground and all these folks were running around blowing up train stations to what Europe is today. So there is some thought that a middle-aged planet will have a middle-aged concerns and they'll be mellow.

NNAMDIThis is obviously a discussion that we're going to be continuing. Phillip Longman is senior research fellow at the New America Foundation, editor at the "Washington Monthly," and author of "The Empty Cradle: How Falling Birth Rates Threaten World Prosperity and What To Do About it." Michael Gusmano is research scholar at the Hastings Center in New York and co-director of the World Cities Project at the International Longevity Center USA. Thank you both for joining us, and thank you all for listening. I'm Kojo Nnamdi.