Cradle And Grave

INTELLIGENT DIALOGUE:

CRADLE & GRAVE

FALL 2008

Many Minds. Singular Results.

Cover photo: Creative Commons/pdam2

Many Minds. Singular Results.

MESSAGE FROM THE CEO “SOMEONE ALIVE TODAY will live to the ripe old age of 150.” Agree or disagree? Two professors have wagered $150 on this very question. No matter which side you’re on, there’s no arguing that fundamental shifts in health trends have us all rethinking long-held beliefs about life and death. In our latest Intelligent Dialogue white paper, “Cradle & Grave,” Porter Novelli has examined emerging global trends in fertility and birth, health and death that have profound implications for businesses, organizations and consumers far beyond the health care industry. Gaining a better understanding of these complex health issues means getting out of your comfort zone. It means leaving behind preconceived notions of the “right” age for a first-time mother. It means facing your own mortality and examining whether you really want to live to be a centenarian, and then honestly asking yourself, “Am I making the choices today that will allow me to live 100 years?” To prepare this paper, our health care industry specialists joined with our public affairs, corporate affairs and marketing professionals to consider what’s changing across the full arc of life, from conception to death. “Cradle & Grave” identifies key trends in fertility, birth, health care advances, disease prevention and treatment, aging and dying. The paper examines how families (and populations) are changing, and how evolving health challenges like diseases of affluence and the obesity crisis will affect modern society. It raises questions about the advent of personalized drug therapies, the promise of longer life expectancy and the threats posed by swelling ranks of elderly and chronically ill people. While some of the trends discussed in “Cradle & Grave” might not be news, integrating the full scope of them into our lives and businesses is a monumental challenge. This paper is intended to help map out the big picture and prompt discussion. At Porter Novelli, we believe ours is a learning culture, and that ongoing dialogue is key. We challenge assumptions and cultivate creative questions, and we invite you to join the dialogue by checking out our blog, PNIntelligentDialogue.com. It’s your forum for discussing the issues raised in “Cradle & Grave,” and for proposing your own questions. Our goal with the Intelligent Dialogue series is to provide perspective and stimulate conversation. This is an opportunity for individuals and organizations to demonstrate thought leadership on issues that affect all of us. —GARY STOCKMAN

TH E PRE S E NT

SCREAM S

FOR ATTE NTION

AN D TH E FUTU RE

WH I S PE RS .

into the old trap of overestimating short-term change and underestimating long-term change. 4 INTELLIGENT DIALOGUE: CRADLE & GRAVE

Many Minds. Singular Results.

Photo: Creative Commons/jonner

No wonder more people than ever are falling

INTRODUCTION

IN THE CURRENT FRENZY of financial uncertainty, fasttalking pundits and finger-pointing politicians, can anyone afford to think more than a year or so into the future?

Photo: Creative Commons/A.M. Kuchling

Nobody knows what may happen between now and next year in the economy, politics or technology, let alone other parts of life. Thoughts about the longer term are crowded out by urgent news of breakthroughs and breakdowns pumped out by the media 24/7. Businesses and consumers are so busy putting out the fires in front of them, they are unable to focus on what’s further ahead. The present screams for attention and the future whispers. No wonder more people than ever are falling into the old trap of overestimating short-term change and underestimating long-term change. This paper is intended to shift the focus and look at some of the long-term changes slowly but surely reshaping the most important things in our world: literally the basics of our life as we know it. They’re gradual changes that we can all see and feel but are too busy and too distracted to notice; they’re eclipsed by breaking news or hot gossip. In keeping with our guiding principles, this edition of Intelligent Dialogue is driven by observation and open-ended curiosity. It raises a lot of questions, because we find dialogue is

Many Minds. Singular Results.

most productive when it’s open and inquisitive. In particular, this edition is driven by three overarching questions:

1. What about life and death has changed? 2. Which long-standing assumptions about life and death no longer hold true? 3. What are the emerging risks and opportunities for societies, businesses and consumers? With our background in social marketing, Porter Novelli believes that now more than ever, when it comes to the life-anddeath issues covered in this paper, our communities need smart leadership through Intelligent Influence. During this period of worldwide financial change, we will be helping our clients take the long view and keep their sights on these critical health issues as they make decisions on how they will move forward. This is an ideal moment to foster serious consideration of the bigger health issues that affect everyone. For smart businesses and brands in particular, life and death issues create opportunities to provide the leadership employees and consumers need— opportunities that enhance both their reputation and their bottom line.

INTELLIGENT DIALOGUE: CRADLE & GRAVE 5

BIG QUESTION

1

WHAT’S HAPPENING

TO HAVE KIDS or not? Now or later? How many? What will it cost? It used to be that babies were the result of “doing what comes naturally.” But now, having children isn’t inevitable, it’s a matter of choice. It’s a complex decision, and in the 21st century, deciding to become a parent involves considerations unknown to previous generations. Though recent figures from the U.S. National Center for Health Statistics show a record number of babies born in the U.S. in 2007, birthrates are trending downward worldwide. The more prosperous people become, the fewer children they have. More years of education, higher quality-of-life expectations, better career opportunities

and effective contraception make for smaller families. In the developed world, births in many countries are below an average of 2.1 per woman, which is the crucial “replacement rate,” or number needed to maintain a population at a stable level. When fertility rates are below 2.1, the population shrinks. This is a radical change from what has happened throughout most of history, when populations of prosperous cultures continually expanded. Today, with its recent baby boomlet, the United States is running at replacement rate, but the European Union (EU) falls well below that, with a birthrate

6 INTELLIGENT DIALOGUE: CRADLE & GRAVE

of 1.5, as do developed countries such as Russia (1.4), Japan (1.22) and Singapore (1.08), and newly developing countries like China (1.77), Thailand (1.64) and South Korea (1.29). In all sorts of ways, traditional expectations of childbearing and family relationships no longer apply.

> WHY ARE WOMEN WAITING TO HAVE CHILDREN? It used to be that people married in their late teens or early 20s, had children and moved into a grandparent role by middle age. Now, growing numbers of people are starting this cycle much later, or they’re skipping over the marriage step, or they’re choosing to become single parents; some

Many Minds. Singular Results.

Photos (from top): Creative Commons/paristempo, Creative Commons/ShutterCat7

TO NUCLEAR FAMILIES?

necessarily mean it’s baby time. Women may still be reluctant to take time out for a child, either because they are unwilling to sacrifice career goals or because they don’t feel financially prepared. Or the delay may be beyond their control if they are having trouble conceiving.

Photos (clockwise from top): Creative Commons/SilentObserver, Creative Commons/Mahalie, Creative Commons/miss pupik

are starting new families as they move on to second marriages, and some are marrying relatively late and adopting. The average age for first marriages has crept up, and it’s not surprising. Younger women are too absorbed in education and careers to focus on serious dating, and they tend to be financially self-sufficient. The women depicted in “Sex and the City” may have been TV-land creations but they struck a chord all over the world as women who enjoyed their independence and were taking their time in finding a long-term partner until well into their late 30s or 40s. Why should women hurry to have children when modern life is giving them plenty of reasons and ample means to have them in their own good time—or not at all? Even settling with a steady partner doesn’t

The statistics tell the story of delayed motherhood but Hollywood brings it to life, writ large in the personal lives of celebrities: Madonna famously gave birth to her first child at 38 (fathered by a boyfriend); her second at 41 (father was second husband Guy Ritchie); and then adopted a child at 49. “Desperate Housewives” star Marcia Cross celebrated her first marriage at 44, then gave birth to twins less than a year later. Actress Nicole Kidman recently gave birth to her first child with second husband Keith Urban at 41, having previously adopted two children in her 20s with first husband Tom Cruise. And several stars chose to be adoptive single moms despite their busy careers—actress Angelina Jolie, singer Sheryl Crow and actress MaryLouise Parker.

THE COST OF FERTILITY

{ MILLION DOLLAR BABY

}

In the U.K., child psychiatrist Patricia Rashbrook made headlines in 2006 when she gave birth at age

> HOW OLD IS

62; she already had three grown

TOO OLD TO HAVE A BABY? Data across the EU and the

children from a previous marriage.

U.S. show the average age of first-time mothers is rising. More women at the

She and her husband had spent $20,000 on fertility treatments with Italian embryologist and fertility specialist Dr. Severino Antinori, who has become a controversial (and wealthy) celebrity in the field. According to the American Society of Reproductive Medicine, the average cost of an IVF cycle in the U.S. is $12,400. Would-be parents may try it two or three times, although IVF is not successful for a significant percentage of women. In Europe the average cost is estimated at $4,000 to $6,000.

Many Minds. Singular Results.

INTELLIGENT DIALOGUE: CRADLE & GRAVE 7

IVF TURNS 30

{ ONE

PLUS ONE EQUALS ME

}

The world’s first test tube baby, Louise Brown, has just turned 30, and the IVF (in vitro fertilization) technique used to make her birth possible has spawned an industry now worth $3 billion in the United States alone. The process used at the time has been superseded by ICSI (intracytoplasmic sperm injection), where a single sperm is injected directly into an egg.

The average age of EU women giving birth to their first child rose from 23 to 25 between 1990 and 2002. In the bigger countries, first-timers were older than that: 28 in France (as of 2001) and 29 in Germany (2003). According to the U.K.’s Office for National Statistics, more of Britain’s first-time mothers now fall in the 30 to 34 age group than in the 25 to 29 age group; and there has been an almost 50 percent increase from 10 years ago in women over 40 having babies. In the U.S., the most recent census figures show the average age at an all-time high of 25.2, with more than 100,000 births in 2003 to women 40 or older. Fertility treatments and improved health care are certainly pushing up the age at which it’s possible to have children. However, “possible” is not the same as probable, advisable or desirable.

Professor Bill Ledger of England’s Sheffield University is one of the fertility specialists warning that obesity and sexually transmitted diseases are causing a growing number of fertility problems. Currently, one in seven couples has trouble conceiving naturally, and Ledger warns this could rise to one in three. He advises couples to start trying to conceive younger than 35. Older parenthood is not just a female issue; men have their own fertility problems. There is clear evidence that sperm quality deteriorates with age and around a quarter of men of reproductive age are subfertile (they produce sperm but not at maximum fertility). There are indications that male fertility is decreasing due to several possible causes, notably stress, weight issues and diabetes. Researchers are looking into other possible causes such as electromagnetic radiation from cell phones

and “gender bending” (endocrinedisrupting) chemicals in the environment.

> WHAT ARE THE FINANCIAL ISSUES OF OLDER PARENTHOOD? First-time parents who are older than the “traditional” age tend to do a lot of soulsearching. Whether their later parenthood is deliberate, or due to circumstances such as marriage or fertility problems, they are more likely to feel the need to rationalize and justify their situation to themselves and/or to others. The Internet is proving to be an ideal medium for them to compare notes and examine the issues. One clear advantage of older new parents is financial stability—a factor that seems to be widely accepted and valued in discussions on the issue. Parents in their 30s and 40s tend to be educated and established in the workplace. They’re more likely than younger parents to have achieved a certain standard of living, along with higher expectations of service, comfort and quality. Older prospective parents may have to be prepared to invest significant amounts of money and time in fertility treatments or adoption. On the other hand, these parents may find themselves needing to fund their children’s teenage pursuits and college education at a time when their peers are beginning to draw pensions. As AARP the Magazine put it: “Midlife parents face another challenge: how to stay financially healthy as well [as physically healthy]. Many may find themselves working well beyond the traditional retirement age just so they can send their kids to college.” Current assumptions about maternityplanning patterns and family structures are increasingly out of step with reality.

8 INTELLIGENT DIALOGUE: CRADLE & GRAVE

Many Minds. Singular Results.

Photos (clockwise from top): Creative Commons/moyix, Creative Commons/salimfadhley, Creative Commons/paristempo

upper range of childbearing ability are becoming mothers.

TH E

MORE

PROS PE ROU S

PEOPLE B ECOM E, TH E

FEWE R CH I LDRE N

TH EY HAVE. MORE YEARS OF E DUCATION, higher quality-of-life expectations, better career opportunities and

Photo: Creative Commons/jonner

effective contraception make for smaller families.

Many Minds. Singular Results.

INTELLIGENT DIALOGUE: CRADLE & GRAVE 9

SURROGACY IN INDIA

{ CARRYING

THE WEIGHT OF THE WORLD

}

Thanks to globalization, India has emerged as an option for surrogacy. Centers are springing up in which local women carry the babies of Westerners who don’t want to pay the high costs generally associated with such a proposition in their home countries. India’s sophisticated medical capabilities and low costs make outsourced surrogacy a viable industry, but one that’s prompting outrage from critics who charge that it exploits poor people and is a crass commercialization of an intimate matter. Dr. Nayna Patel, who works at a surrogacy clinic in Anand, India, defends the practice as a win-win arrangement, telling the Associated Press, “There is a woman who desperately needs a baby and cannot have her own child without the help of a surrogate. At the other end there is a woman who badly wants to help her [own] family. If this female wants to help the other one, why not allow that? It’s not for any bad cause. They’re helping one another to have a new life in this world.”

Are employers that foster a maternityfriendly, postpartum-friendly, familyfriendly culture getting ahead of the curve in recruitment, retention and reputation? Or are they merely picking up the tab for more ruthless, lean-and-mean competitors? The biological limitations of parenthood have changed, and so have the social limitations. Parents no longer need to be in a traditional couple—some are single women, others are same-sex couples. There’s a greater willingness to talk about fertility problems and options. Still, there’s a risk of social backlash when people opt for non-traditional choices. For businesses, how tightly they want to embrace non-traditional choices is not just a matter of inner-focused company policy— it’s a part of brand positioning and identity.

> WHAT’S WRONG WITH GETTING A SNEAK PEEK? Fertility treatments and prenatal screening have given would-be parents the option of knowing the sex of their baby before it’s born. In some cultures where males have a higher status than women (such as India and China), this has resulted in a dangerously skewed gender balance. In China, the one-child policy has meant that many parents aren’t willing to let nature take its course. China will have 30 million more men of marriageable age than women in the next decade and a half. The ratio for newborn babies in 2005 was 118 boys vs. 100 girls, up from 110/100 in 2000. In some regions the ratio is as high as 130/100, compared with an average of between 104 and 107 boys for every 100 girls in industrialized countries.

frustration through violence, crime and political extremism, and that rising demand for sex workers could fuel the practice of human trafficking and the spread of HIV/AIDS. Although prenatal gender screening involves the relatively simple technology of ultrasound, its wider social effects are proving to be far-reaching. The effects of more sophisticated genetic-based prenatal screening are likely to be even more radical.

In 1994, the Indian government banned medical practitioners from revealing the gender results of fetal scans. Yet the gender imbalance has only further tipped. In 1991 there were 945 women for every 1,000 men, and the gap widened to 927/1,000 by 2001. These unintended consequences of simple screening are likely to be felt for decades to come. There are concerns that millions of restless young men could vent their

10 INTELLIGENT DIALOGUE: CRADLE & GRAVE

Many Minds. Singular Results.

Photos (clockwise from top): Creative Commons/jenaynay, Creative Commons/Michael_Chavarria, Creative Commons/The LeCrones

Can employers afford to have valuable, talented staff absorbed in a baby chase? What are the opportunities for businesses to offer fertility counseling and assistance as part of occupational health care, in order to attract and retain top-notch midto-senior level professionals?

WHY

S HOU LD WOM E N

Photo: Creative Commons/wilf2

HAVE

H U RRY

TO

CH I LDRE N…

WH E N MODE RN LI FE is giving them plenty of reasons and ample means to have them in their own good time—or not at all?

Many Minds. Singular Results.

INTELLIGENT DIALOGUE: CRADLE & GRAVE 11

BIG QUESTION

2

WHAT’S THE BEST WAY TO DELIVER BABIES?

traditionally surrounded by folklore and mystery. Historically it has been one of the riskiest moments in life. It still is. And while medical science has helped alleviate the risk and pain involved, there are still major open issues.

> IS A HOSPITAL BIRTH THE ONLY SAFE OPTION? There’s a growing tendency for developed countries to treat pregnancy and childbirth as medical issues, requiring highly sophisticated medical care and hospitalization. For a long time this trend was accepted by parents-to-be and the wider society as “doctor knows best” and “this is the way

it happens.” But in fact, it doesn’t happen the same everywhere. Now, as in other parts of medicine, globalization has enabled interested parties to compare practices in terms of medical outcome as well as emotional outcome and cost. This has encouraged challenges to the highly medicalized approach to pregnancy and childbirth that is at its most pronounced in the United States. In the U.S., home births account for just 1 percent of deliveries, and the American College of Obstetricians and Gynecologists has repeatedly stated its opposition to home births, emphasizing that “the safest setting for labor, delivery and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex.”

12 INTELLIGENT DIALOGUE: CRADLE & GRAVE

How much of this is due to the precautionary principle, with the fear of malpractice suits informing medical procedures? How much is due to the medical profession seeking business opportunities? How much is due to the “mission creep” of technology, as implied in the polemical 2007 movie “The Business of Being Born”?

> WHO REALLY WANTS BIRTH BY CESAREAN SECTION? One of the most hotly contested issues is the trend to deliver babies by cesarean section. Although it’s still a serious surgical procedure, it’s no longer a last-resort rarity. Many Minds. Singular Results.

Photo: Creative Commons/premus

CHILDBIRTH IS AN EXPERIENCE

CE SAREAN S ECTION HAS B ECOM E SO

NORMAL

THAT I N SOM E I N STANCE S, IT I S

REGARDE D AS

A WAY OF S LOTTI NG

Photo: Creative Commons/wilf2

CH I LDB I RTH

I NTO A

Many Minds. Singular Results.

B U SY SCH E DU LE .

INTELLIGENT DIALOGUE: CRADLE & GRAVE 13

In the United States, figures for 2007 are expected to show around one in three births by cesarean, compared with fewer than one in 20 in 1965. Cesareans are increasingly common in Canada too, even though the health system is significantly different: 26.3 percent of women delivered by cesarean in 2005–2006, up from 23 percent in 2001–2002. In the U.K., cesarean sections are also increasing and currently stand at around 20 percent.

According to a survey of American women conducted on behalf of the U.S. nonprofit Childbirth Connection, 98 percent of women with primary (planned) cesareans believed there was a medical reason for the surgery. The most common concerns cited were fetal distress, position of baby, size of baby and prolonged labor. However, 42 percent of respondents also felt that due to fear of lawsuits, the current health care system leads to unnecessary cesareans.

As childbirth becomes a less frequent occurrence in developed societies, will each pregnancy and birth become more expensive? Will the medical profession become ever-more intensively involved? Childbirth has become a lot less risky than it used to be in many parts of the world. But is the complete medicalization of childbirth in the best interest of all concerned? Are health care and insurance providers missing an opportunity to offer alternatives that cost less and satisfy more?

IN-HOME DELIVERY

{

SHOULD WE ALL BE GOING DUTCH? }

Among major developed countries, childbirth in the Netherlands is an anomaly. In fact, the attitude of the Dutch toward childbirth has been called medieval. Pain is regarded as a normal part of childbirth, and pain relief is the exception rather than the rule. Indeed, unless there are medical complications, maternity care is a determinedly low-

than 10 percent, which is significantly out of line with the modern trend. Likewise, few countries have the equivalent of the kraamzorg, a program in which a maternity nurse provides after-birth care in the home for a week. It’s standard after all births in the Netherlands and is on the policy list of Britain’s Conservative Party. However, the Dutch example may not be so easy for other countries to emulate. In the small, densely populated Netherlands, most homes are within 10 to 15 minutes of a hospital. If an in-home delivery suddenly turns difficult, medical facilities are within easy reach. 14 INTELLIGENT DIALOGUE: CRADLE & GRAVE

Many Minds. Singular Results.

Photo: Creative Commons/eyeliam

tech affair left in the hands of midwives; a home birth is the default choice. The rate for cesarean sections is less

BIG QUESTION

3

Photo: Creative Commons/Andrew Ciscel

WHAT NEW HEALTH THREATS MUST BE DEFEATED, AND HOW?

PEOPLE ARE ALREADY experiencing

> ARE THE MAJOR

longer, healthier lives than ever before and there’s the prospect of more good news to come. But that doesn’t mean it’s all smooth sailing from here on. For one thing, microorganisms (bacteria, viruses, etc.) have a way of evolving to exploit new opportunities, which could trigger a major pandemic. For another thing, we are facing diseases arising from new lifestyles and from living older.

CONTAGIOUS DISEASES GONE FOR GOOD? Time

Many Minds. Singular Results.

was when contagious diseases were the big killers: plague, smallpox, cholera, etc. Thanks to public sanitation, hygiene, vaccination and antibiotics, their impact has been hugely reduced. But they have not been completely eliminated, and they still hold some nasty surprises.

HIV/AIDS and the virulent staph infection MRSA are relatively new to the roster of communicable diseases. One third of the world’s population is infected with the bacteria that causes tuberculosis. Meningitis continues to lurk and malaria may yet spread further as global warming makes temperate zones more congenial for mosquitoes. Meanwhile, health authorities are keeping an eye out for the likes of SARS and avian flu, and whatever might yet emerge from tropical jungles.

INTELLIGENT DIALOGUE: CRADLE & GRAVE 15

E A R LY P R E V E N T I O N F O R A H E A LT H Y F U T U R E

{ WHAT

A GIRL WANTS

}

According to the U.S. Centers for Disease Control and Prevention, the vaccine Gardasil® prevents the types of genital human papillomavirus (HPV) that cause most cases of cervical cancer and genital warts. The vaccine is given in three shots over six months and is routinely recommended for 11- and 12-year-old girls. It is also recommended for girls and women ages 13 through 26 who have not yet been vaccinated or completed the vaccine series.

HIV/AIDS is typical of what health professionals fear from cunning superbugs. By the time the Centers for Disease Control and Prevention (CDC) in the U.S. recognized HIV/AIDS as a distinct syndrome in 1981, it was already on its way to becoming a devastating epidemic. According to a 2006 report from the United Nations Joint Program on HIV/AIDS, over the last quarter-century, nearly 65 million people were infected with HIV and an estimated 25 million have died of AIDSrelated illnesses. About 33 million—almost half are women—live with HIV today, the vast majority unaware of their status. Scientists are looking for ways to spot other emerging diseases before they become equally—if not more—devastating. About three-quarters of emerging human diseases are “zoonoses,” or pathogens that, like HIV/AIDS, originate in animals and cross into human populations. A number of projects are focused on gathering frontline blood samples across equatorial jungles, watching for changes in behavior and mortality, and coordinating findings through specialists such as the CDC and the virology laboratory at the University

of Montpellier in France. The systematic monitoring of bush-meat hunters may also help prevent future AIDS-like epidemics. Although communicable diseases are not killing huge numbers of people in the old familiar ways—sickness, fever, swelling and pain within weeks or months—they may be wreaking havoc over a longer period, working in the background. Some viruses can cause changes in cells that may lead to cancer. There are clear links between cervical cancer and the genital wart virus HPV, between primary liver cancer and the hepatitis B virus, and between various cancers and the Epstein-Barr virus. Fortunately medical science evolves fast too and a range of new vaccines such as Gardasil has been introduced in recent years that seem to be effective at reducing the incidence of such cancers. Many of the major historical advances in disease control and life expectancy have come from preventing diseases rather than curing them. Vaccination, sanitation, education and nutrition have together done more to save lives from disease than have feats of medical wizardry as seen in “ER” and “House.” The specific illnesses have changed but the principle holds; cures are needed but prevention will continue to be the most effective and the most cost-effective strategy.

> WHAT ARE THE PROSPECTS FOR TREATING CHRONIC AND TERMINAL CONDITIONS? People in developed countries are much less apt to die from contagious diseases anymore. Rather, they tend to succumb to old age or to “diseases of affluence”—those stemming 16 INTELLIGENT DIALOGUE: CRADLE & GRAVE

from behaviors or environments of wealthier societies. This is uncharted territory in human history and raises new challenges. We are seeking medication to tackle the effects of too little physical activity and too much food; we are expecting cures for diseases that were barely encountered a century ago. And they can’t be found soon enough. By some accounts, half the American population is living with some form of chronic illness. Diabetes is a case in point. About 124 million people worldwide had diabetes in 1997, compared with a projected 221 million by 2010. The rate is rising in parallel with obesity, a major cause of type 2 diabetes; the coupling of a severe weight problem with type 2 diabetes is being referred to as “diabesity.” While death from heart disease in the U.S. has fallen by 26 percent and death from stroke by 24 percent since 1999, they are still the first and third causes of death, respectively. And the American Heart Association has warned that the improvement could be short-lived if risk factors aren’t reduced. It’s not just the U.S. that’s grappling with the big killers. The World Health Organization reports that cardiovascular disease is the top cause of death globally, and it’s projected to remain so. An estimated 17.5 million people died from Many Minds. Singular Results.

Photos (clockwise from top): Creative Commons/Mel B., Creative Commons/Jaye_Elle, Creative Commons/Andy McLeod

Communicable-disease specialists warn that there’s a strong chance of more superbugs; microbes and even cancers are developing immunity to the drugs that have been used against them.

CH RON IC DI S EAS E TREATM E NT TH E U PS I DE OF

I S THAT PEOPLE ARE

S U RVIVI NG

AN D EVE NTUALLY DYI NG with the disease rather than from it. The downside is that it can be expensive and debilitating to live life on the tightrope of

Photo: Creative Commons/Jimee, Jackie, Tom & Asha

daily disease management.

Many Minds. Singular Results.

INTELLIGENT DIALOGUE: CRADLE & GRAVE 17

In 2003, the World Health Organization’s “World Cancer Report” forecast an increase in cancer from 10 million new cases globally in 2000 to 15 million by 2020, mainly due to steadily aging populations in both developed and developing countries, as well as rising trends in smoking and the growing adoption of unhealthy lifestyles. The report says cancer poses major challenges for health care systems worldwide, but that it can be prevented and its impact reduced

developing, heavily populated regions such as China, India and Latin America.

The longer people live, the more likely it is they will experience any one of about 80 autoimmune disorders that can make life miserable. These disorders involve the immune system mistakenly attacking and destroying healthy body tissue—“friendly fire,” so to speak. Well-known conditions include: type 1 diabetes, thyroiditis, pernicious anemia, rheumatoid arthritis, lupus, multiple sclerosis and Graves’ disease. According to the American Autoimmune Related Diseases Association, it’s estimated that approximately 50 million Americans suffer from an autoimmune disease.

Like battlefield weapons designed to wound rather than kill, the chronic illnesses of today can be more devastating than acute, sudden-death conditions. People suffering from chronic disease over several years represent major costs, both financially and emotionally.

Degenerative conditions are another prospect, especially dementia—the umbrella name for progressive degenerative brain syndromes that affect memory, thinking, behavior and emotion.

The prospect of many millions more people suffering from chronic illnesses and millions having to look after them is a real and unprecedented threat likely to eclipse the dangers of terrorists and road traffic accidents and violent criminals combined. How can governments, insurers and individuals be adequately prepared for it?

Alzheimer’s disease is the most common form of dementia. According to Johns Hopkins researchers, an estimated 26.6 million people worldwide suffer from Alzheimer’s, a number that’s forecast to rise to more than 106.8 million by 2050. Much of this increase will be in rapidly

18 INTELLIGENT DIALOGUE: CRADLE & GRAVE

Photos (clockwise from top): Creative Commons/Subewl, Creative Commons/Sam Blackman, Creative Commons/brykmantra

cardiovascular disease and strokes in 2005, accounting for 30 percent of global deaths.

through basic research and improvements in treatment and care.

Many Minds. Singular Results.

U P TO TH E AG E OF 65,

DE M E NTIA

DEVE LOPS I N ABOUT ON E PE RSON I N 1,000. Its incidence rises sharply with

Photo: Creative Commons/lanuiop

age to one person in 20 over age 65. The big threat is to people over the age of 80, when the incidence of dementia increases to one in five. That’s riskier than the one in six of Russian roulette.

Many Minds. Singular Results.

INTELLIGENT DIALOGUE: CRADLE & GRAVE 19

> IS OBESITY THE NEXT FRONTIER?

Obesity and its complications will cause the untimely deaths of hundreds of thousands of people every year for the foreseeable future. In 2006, U.S. Surgeon General Richard Carmona called obesity “the terror within” and warned that, “Unless we do something about it, the magnitude of the dilemma will dwarf 9/11 or any other terrorist attempt.” Are such dire proclamations just the nanny state at work? After all, if obesity is such a big threat, why are people living longer? There’s no getting around the health implications of extra pounds. According to U.K. private hospital group BMI, obesity

(defined as a body mass index greater than 30) increases the risks of developing diabetes, high blood pressure, angina, heart attacks, high cholesterol, urinary incontinence, infertility, osteoarthritis, asthma, sleep apnea and cancer. These illnesses represent huge costs in terms of human suffering, not to mention medical and insurance costs as well as lost productivity and earnings. Obesity is set to become the most critical health issue shaping life and death in the first half of the 21st century. Turning the tide will require the commitment and collaboration

THE OBESITY EPIDEMIC

{ NO

ROOM TO GROW }

of public and private concerns, ranging from governments to nonprofits to the food industry. Perhaps a faster, fail-safe solution will come from science. A lot of people are aiming for a “cure” for obesity— miracle foods, pills, injections, surgery, gene therapy and more. Whoever comes up with a safe and effective treatment that fulfills the classic marketing imperatives—quick, easy, convenient, affordable—will be sitting on a goldmine. Might microbes come to the rescue? Researchers at the EU’s Metagenomics of the Human Intestinal Tract project (MetaHIT) have found a sharp contrast in the bacteria population in the guts of overweight and thin people. And when heavy people dieted and lost up to a quarter of their body weight, their gut flora changed too, becoming more like those of the lean group. So it may be that certain types of probiotics can help reduce weight.

World Health Organization figures for 2005 show that approximately 1.6 billion adults worldwide were overweight and 400 million were obese; the WHO forecasts as many as 2.3 billion overweight adults in the world by 2015, more than 700 million of whom will be obese. Just how much have our waistlines expanded over the decades? In 1951, a survey found that the average British woman’s waist measured 27.5 inches. By contrast, the U.K.’s 2004 National Sizing Survey (SizeUK) found that the average waist had increased to 34 inches. While there was no comparative data for men in 1951, the SizeUK data found an average male waist of 37 inches in 2004.

20 INTELLIGENT DIALOGUE: CRADLE & GRAVE

For the moment, many people are pinning their hopes on surgery. Restrictive surgery covers procedures that make the stomach smaller, so that the patient eats less. Malabsorptive surgery changes the body’s ability to absorb calories from food. The two most commonly performed operations are laparoscopic adjustable gastric banding (LAGB), also known as lap banding or gastric banding, and gastric bypass. Weight problems are no longer simply aesthetic issues; they represent a major threat to public health, although public perception of the real threat is far short of reality. What will it take for obesity to be treated seriously as a modern medical condition with major public health

Many Minds. Singular Results.

Photo: Creative Commons/gotplaid?. Creative Commons/memekode

Might genetics solve the problem? In 2007, scientists analyzing a large-scale study of diabetics found a correlation between the FTO gene and obesity. Researchers at Cambridge University in the U.K. have discovered that the gene codes for an enzyme that modifies DNA could be activated or inhibited by pharmaceuticals. This opens the prospect of drug therapies for obesity.

TH E FOOD AN D DRI N KS I N DU STRI E S

G ROWN TH E I R MARKETS HAVE

S PECTACU LARLY.

Photo: Creative Commons/moyix

While they may not be blamed for consumers’ obesity, they are clearly a crucial part of the problem. How can the health of these industries align more effectively with the interests of public health?

Many Minds. Singular Results.

INTELLIGENT DIALOGUE: CRADLE & GRAVE 21

ACCORDI NG TO TH E MAYO CLI N IC, EACH YEAR AN E STI MATE D

100,000 AM E RICAN S DI E

Photo: Creative Commons/subewl

from adverse reactions to medications and more than 2 million are hospitalized.

22 INTELLIGENT DIALOGUE: CRADLE & GRAVE

Many Minds. Singular Results.

implications rather than as a lifestyle issue? The risk is that the cumulative effects of obesity will overwhelm the capacity of communities to deal with the financial and health care consequences.

> WHEN WILL CURES BECOME LESS LIFETHREATENING? For all the

In the meantime the side effects of this trial-and-error process can be distressing for patients and risky for their health, not to mention a serious waste of health care resources. To reduce the potluck element of drugs, health care professionals are looking to personalized medicine, or pharmacogenomics. With this approach, before medication is prescribed, genetic analysis will be carried out to check for relevant genetic variations—single nucleotide polymorphisms, or SNPs. This will enable doctors to better predict whether a drug will provoke an adverse reaction or will be likely to do the job. According to the Personalized Medicine Coalition, this approach has the potential to offer benefits such as early detection,

more focused therapy, greater emphasis on preventive medicine and cost reduction. The PMC also believes when used in research, pharmacogenomics could reduce the length, cost and failure rate of clinical trials, and even revive drugs that failed clinical trials or were withdrawn from the market. A lot depends on technology being developed to read (or “sequence”) genes fast and affordably. In the U.S., the National Institutes of Health has set a goal for sequencing an entire personal genome at a cost of just $1,000 by 2014 (currently, one firm is charging $350,000 to anyone who wants a complete personal genome sequencing). In a parallel initiative, the X Prize Foundation in the United States has put up a prize of $10 million for the first private team that can decode 100 complete human genomes within 10 days for less than $10,000 each.

Photos (clockwise from top): Creative Commons/SMercury98, Creative Commons/MASH DnArt, Creative Commons/jurvetson

amazing progress in pharmaceuticals, prescribing drugs is still hit-or-miss. Drugs have been developed to deal with conditions, not individuals; they take a one-size-fits-all approach that can’t account for individual body chemistry. Patients may be subjected to a range of treatments

before doctors find one that works.

Many Minds. Singular Results.

INTELLIGENT DIALOGUE: CRADLE & GRAVE 23

BIG QUESTION

4

HOW OLD DO WE

REALLY WANT TO BE? Mythology, legend, religion and popular culture are full of quests to find ways of beating the Grim Reaper: the fountain of youth, the elixir of life, the philosopher’s stone. But the human body hasn’t evolved to live indefinitely; parts of it go wrong (including the repair systems), and an accumulation of faults eventually leads to one part of the system failing, with fatal consequences.

> WHAT ARE THE LIMITS OF LIFE EXPECTANCY? Although there are a few areas of the world where life expectancy is still poor, in general it has increased steadily. Globally, life expectancy at birth was just 30 years in 1900; it had more than doubled, to 62, by 1985 and currently stands at around 64.

In most developed countries, life spans have been steadily increasing for a long time and look set to continue upward. Consider that in 1850, life expectancy at birth averaged just 38.3 years for American Caucasian men and 40.5 years for women; by 2004 it was 75.7 for men and 80.8 for women. In the U.K., for every million born alive in the 1880s, just 309,020 were still alive at 65 and only 161,164 at age 75; by the 1990s, a majority could expect to reach both 65 (830,990) and 75 (612,740). People are living longer largely because they are staying well longer. They are now in better shape as they age—one reason for proclamations such as “50 is the new 30.” And while it’s true that less healthy lifestyles and the rise of obesity mean many people are not in great condition, they are less beset by infectious diseases

24 INTELLIGENT DIALOGUE: CRADLE & GRAVE

that damage and weaken the body. There are fewer accidents and better treatments for injuries such as fractures and lesions. Better nutrition is more widely available, helping bodies stay resilient. The big imponderable is whether the trend for gradually increasing life spans can be projected indefinitely into the future. What are the limits? Steve Austad, a professor of cellular and structural biology at the University of Texas, is convinced that somebody alive today will reach the age of 150. S. Jay Olshansky, an epidemiology professor at the University of Illinois at Chicago, disagrees strongly. They each wagered $150 on the question, and Olshansky invested the money in a fund. If a 150-year-old is alive in the year 2150—someone of sound mind and body— Austad’s descendants will get the pot; otherwise, Olshansky’s offspring will win.

Many Minds. Singular Results.

Photo: Creative Commons/jonner

HOW ABOUT LIVING FOREVER?

> WHAT ROLES CAN PHARMA AND CORPORATIONS PLAY IN FOSTERING LONGER LIFE? Many factors

ELDERS IN FINANCIAL CRISIS

{ POOR

AND PROUD

There’s a significant risk that people who run out of financial

have come together to make longer life spans possible. As the data accumulate and research goes deeper, we are discovering which other factors can be influenced to extend enjoyable life even further.

resources in old age will be comparable financially to maturing teenagers, but in reverse and with no “age of majority” in their future:

One of the most impactful quick wins on a global level is providing sleeping nets to people at risk of malaria infection by mosquitoes. According to the CDC, 41 percent of the world’s population lives in areas where malaria is transmitted. Each year, 350 to 500 million cases occur worldwide, and more than 1 million people die, most of them young children in subSaharan Africa. The big issue: Who pays?

Photos (from top): Creative Commons/Ed Yourdan, Creative Commons/Unhindered by Talent

Another victory: statins, drugs that reduce the amount of cholesterol produced in the body, lowering the risk of heart attack. Currently under debate is whether statins will become available over the counter in the U.S. (an OTC statin is already available in the U.K.). The FDA has repeatedly rejected Merck & Co.’s applications to make Mevacor ® available without prescription. Supporters argue that selling statins over the counter could help millions avoid heart attacks. How about employers encouraging staff to live more healthfully? Corporate wellness has become something of a buzz phrase, but skeptics may see the programs as a trophy-spend to make big companies feel good. Is there any hard evidence that investing in wellness benefits the bottom line? The questions are sharpest in the United States, where medical costs can eat up as much as half of a company’s profits. And the indications are encouraging.

They’ll have the desire to participate in society and a sense of entitlement but—unlike teens— increasingly less prospect of independence.

According to the Wellness Council of America, the results from effective corporate wellness programs are encouraging. At Michigan furniture manufacturer Steelcase, the average insurance cost for high-risk employees is 75 percent higher than it is for low-risk employees; staff that followed the company’s health promotion program and lowered their risk factors cut their insurance costs by an annual average of $618. Other results outlined on the Wellness Council’s Web site point in the same direction:

but also a business case. This harks back to the paternalistic business leaders of the 19th century such as William Hesketh Lever, founder of Lever Brothers (now part of Unilever). Is there a case for wellness expertise becoming as much a core business competence as financial control and stock management?

•

For DuPont, each dollar invested in workplace health promotion has yielded $1.42 over two years in lower absenteeism costs.

wisdom has it, getting old is better than the alternative. But up to what age does that adage apply? What tips a long life from being a blessing to being a burden?

The Travelers Corporation reports a $3.40 return for every dollar invested in health promotion, yielding total corporate savings of $146 million in benefits costs. Sick leave was reduced by 19 percent during the four-year study.

As significant numbers of people live to a ripe old age, what will happen to those— the majority—who haven’t had the means or the foresight to make their twilight years comfortable?

• •

The Stay Alive & Well program at Las Vegas–based Reynolds Electrical & Engineering has cost about $76 per employee during the two years it has been in operation, while savings have averaged almost $128 per participant.

Increasingly, businesses are seeing not only a moral and reputational imperative for fostering better health among employees,

Many Minds. Singular Results.

}

> WHAT’S NOT TO LIKE ABOUT LIVING INTO THE TRIPLE FIGURES? As conventional

It may well be that technology and science have once again advanced far faster than our moral and social capacity to deal with the benefits they offer. If the tragedy of times gone by was that too many people died of relatively trivial illnesses while they were still quite young, with a lot to live for, it’s likely to be the other way around in the future: People will be able to survive serious illness, perhaps long after they’ve lost the things that make

INTELLIGENT DIALOGUE: CRADLE & GRAVE 25

A G ROWI NG N U M B E R OF

CHRONICALLY ILL AND

VE RY OLD PEOPLE I N WEALTHY COU NTRI E S

26 INTELLIGENT DIALOGUE: CRADLE & GRAVE

Photo: Creative Commons/Isaac bowen

will need to be looked after at home. It’s projected that by 2011, two thirds of the workforce in developed countries will be caregivers part-time. What are the prospects of full-time salary earners being willing or able to become part-timers, staying home to care for aging relatives?

Many Minds. Singular Results.

PLANNING FOR THE FUTURE

{ LUST

FOR LIFE

}

Loneliness and the loss of family and friends are part of the cost of living longer. Few people have the financial means or the foresight to plan as carefully as one Swedish advertising executive, who, in his 40s, found a top-quality nursing home overlooking the sea in a beautiful location. He put his name on the long waiting list, set aside money in an investment fund, and invited 100 of his friends to do the same. “I hope I never have to go into a nursing home, but if I do, at least there may be one or two people I know in there with me,“ he explained. life worth living: mobility, mental acuity, social life and family. As the baby boomers move beyond their 60s and start swelling the ranks of the elderly, nursing homes, retirement homes, health systems and government assistance programs must be ready to meet the challenge of looking after much larger numbers of people—especially if many are unable to pay for care.

Photos (clockwise from top): Creative Commons/fredesorensen, Creative Commons/Tim & Selena Middleton

In Japan, where the balance of old to young is shifting faster than in most countries, people are looking to technological solutions. The Machine Industry Memorial Foundation estimates

Many Minds. Singular Results.

that Japan could save $21 billion in elderly insurance payments in 2025 by using robots to monitor the health of older people rather than human nursing care. In theory, the increase in older consumers represents lucrative opportunities for astute entrepreneurs: equipment that can be used by less dexterous hands, stylish apparel that accommodates older body shapes, food and beverages that help older consumers stay nourished and entertainment that stimulates them, not to mention all the services they need. The big potential obstacle is their financial resources: Will enough of the elderly have money to

spend, or will this group be too cashstrapped to comprise a worthwhile market? Science and technology have given us the means to extend life, but it’s beyond their scope to provide the reasons or the means to live longer lives. Can businesses and organizations step in to make those extra years a normal part of life—a part that’s truly worth living? Stacking supermarket shelves and acting as museum guides are a reasonable start but let’s hope they’re not the last word in purposeful activities for older people. How will business and government recognize and meet the exponential needs for affordable, good-quality eldercare options?

INTELLIGENT DIALOGUE: CRADLE & GRAVE 27

BIG QUESTION

5

SO MANY ASPECTS OF LIFE are

> WHAT IF WE CAN

different from those in previous centuries. It’s inconceivable that death hasn’t changed too. And so it has in many respects. It happens later. It’s more likely to happen in a hospital or a care facility than at home. It’s more likely to be a lonely event. The mortal remains are far more likely to be hefty than slight. And for most people, death is now a far less visible part of life.

PLAN HOW WE’LL DIE? Society has evolved with some

Photos (clockwise from top): Creative Commons/tempophage, Creative Commons/orla_keating

HOW IS MODERN DEATH DIFFERENT?

basic assumptions about how long people live, and about work, families and communities. Longer life spans and growing numbers of older people challenge those assumptions profoundly. The biggest thing that will have to change is the current tendency to put little

28 INTELLIGENT DIALOGUE: CRADLE & GRAVE

Many Minds. Singular Results.

coherent, detailed preparation into the final years of life. After all, who knows when the end will come and what will cause it? Lack of planning often results in unnecessary expense, stress and distress for all involved.

the other hand, if handled properly, the information may enable people to take greater control and plan more appropriately.

It’s very likely that for most people the last years of life will now involve more care and more expense than they did for previous generations. And whatever the individual cases may be, there’s enough data to know the final trajectories that most people’s lives will take. Dr. Joanne Lynn, a geriatrician at the Hastings Center, an independent, nonprofit bioethics research group, has identified the three most common end-of-life scenarios, based on extensive numerical data:

•

•

Photos: Creative Commons/markhillary

•

The quickest is long years of active life ending with several months of steep decline and death; in the United States this is typical of cancer deaths, which peak at age 65, and is the fate of around 20 percent of Americans. This scenario typically requires hospice support at the end. Those with long-term chronic illnesses such as organ failure go through years of gradually declining health with occasional bouts of severe illness and require consistent disease management. Eventually one of the bouts of severe illness will cause sudden death, which is the case for about a quarter of Americans. Chronic heart failure and emphysema are the most common illnesses of this scenario, with death peaking at around age 75. The third scenario is set to become the most common: gradual long-term decline and loss of functions, requiring years of personal care. At worst this means a long, frustrating and humiliating decline for the individual and an exhausting and potentially bankrupting ordeal for the family. Approximately 40 percent of Americans, generally past age 85, fall into this category. And the numbers will rise.

boomers heading toward their final curtain? After all, boomers changed society’s views of youth, of parenthood, of middle age; it’s likely they will also change society’s views of old age and dying. According to Hospice Net, an independent, nonprofit organization, death was once an integral part of family life. People died at home, surrounded by loved ones. Adults and children experienced death together, mourned together and comforted one another. Today death is lonelier.

> WHY SHOULD DEATH BE A TABOO SUBJECT? The billionaire investor and philanthropist George Soros, explaining his foundation’s Death in America project, wrote: “In America, the land of the perpetually young, growing older is an embarrassment, and dying is a failure. Death has replaced sex as the taboo subject of our times. Only our preoccupation with violence breaks through this shroud of silence.” In a world where so much hope and effort and ingenuity go into creating life and hanging on to it, dying can seem like failure. It means no more second chances, at least in the prevailing mind-set of the developed world. Will this mind-set be altered by the growing number of baby

Most people die in hospitals or nursing homes, where they receive the extensive medical care they need to give them the best chance of extending life as long as possible. Their loved ones have less opportunity to spend time with them and often miss sharing their last moments. The dying have become isolated from the living; consequently, death has taken on added mystery and, for some, added fear. Death has become removed from the normal experience of people in Western societies. It is denied for as long as possible. It’s assumed that people don’t want to think about it, so the whole subject becomes more taboo. The risk is that death becomes the elephant in the room, causing unnecessary trauma for both the dying and the living. Sheer demographics, not to mention good sense, will force more consumers to acknowledge the elephant, which will create opportunities for thought leadership from businesses and organizations.

In the future, a combination of genetic screening, medical examination and actuarial data will make it possible for most people to predict how and when they are likely to die— certainly with far greater chances of accuracy than were previously possible. This could mean a fundamental change in people’s relationship with their own mortality. Knowing about one’s death well in advance is typically perceived as morbid and scary, even a risk to mental health. On

Many Minds. Singular Results.

INTELLIGENT DIALOGUE: CRADLE & GRAVE 29

CONCLUSION

held about life and death are no longer accurate—but government policies, politicians, organizations, businesses and individuals still take them as fact. Outdated assumptions drive the choices people make: whether and when to marry, have children, save or consume; how much to invest in family, friendships, work, health and hobbies. They remain programmed into systems and cultures and mind-sets until they clash with the changes brought about by education, demographics, science, technology and business. People are aware of most of the changes cited here, either through the media or direct experience, but awareness is piecemeal; there are lots of little patches of information. And it’s tough to integrate the scope of the changes into a big picture. The result is that many stumble half confused, half in denial from one predictable crisis to the next.

30 INTELLIGENT DIALOGUE: CRADLE & GRAVE

The issues touched on here are not peripheral or trivial; they’re big, and they cry out for coherent, consistent Intelligent Dialogue. They span the interests of governments, corporations, advocacy groups and individuals: They incorporate a need for change in public policy, finance, science, business and behavior. With our roots in social marketing and our active involvement in all these areas, we at Porter Novelli are excited by developments in all these fields. We relish the challenge of connecting the dots. And we’re alarmed to see how much discussion around these topics is reactive and partially informed. “Cradle & Grave” is intended to prompt discussion and foster thought leadership across disciplines. We work with smart people in great organizations, and we’re looking forward to helping them create change and shape the future.

Many Minds. Singular Results.

Photo: Creative Commons/fredesorensen

MANY OF THE ASSUMPTIONS previous generations

The Porter Novelli

INTELLIGENTDIALOGUE Principle

WHAT PORTER NOVELLI UNIQUELY OFFERS can be summed up in two words: Intelligent Influence. The basis for Intelligent Influence is Intelligent Dialogue. As yesterday’s mass media morph into today’s interactive media, people expect to talk back at journalists and opinion leaders. Yesterday’s way was setpiece monologues broadcast to passive audiences by powerful brands and media owners. Today’s way is fluid, evolving dialogues conducted across multiple, linked channels. Ongoing dialogue is now possible and is truly the best basis of dynamic long-term relationships. Easy sound-bite answers are seductive; they give a comforting but illusory sense of resolution. Instead, we need to cultivate open, questioning minds that ask smart, creative questions. Smart questions spark Intelligent Dialogue, open up thinking and tap into the power of many minds.

PORTER NOVELLI

was founded in Washington, D.C., in 1972 and is a part of Omnicom Group Inc. (NYSE: OMC) (www.omnicomgroup.com). With 100 offices in 60 countries, we take a 360-degree view of clients’ businesses to build powerful communications programs that resonate with critical stakeholders. Our reputation is built on our foundation in strategic planning and insights generation and our ability to adopt a media-neutral approach. We ensure our clients achieve Intelligent Influence, systematically mapping the most effective interactions, making them happen and measuring the outcome. Many minds. Singular results.

CONTACT: Marian Salzman, Chief Marketing Officer, Porter Novelli Worldwide, 75 Varick Street, 6th floor, New York, New York 10013; 212.601.8034; [email protected]

Porter Novelli Worldwide 75 Varick Street, 6th floor New York, NY 10013 www.porternovelli.com