When I was out in Brisbane a couple of weeks ago, I had the privilege of taking part in an international panel discussion on the ongoing debate between longevity and health span. Here are some thoughts which came out of the session.
There is a phrase that has been sitting uneasily with me for some time now.
It appears in different forms across the longevity debate, in policy conversations, in health innovation circles, and in the growing marketplace of anti-ageing aspiration. It is the assumption that the goal of ageing is to remain intact: mobile, cognitively sharp, independent, productive, self-managing. The longer we can preserve that state, the more successful we are judged to have been. The moment it begins to fray, we start to speak the language of failure, decline and burden.
I understand why this framing has become so influential. We are, after all, living longer. Globally, population ageing is one of the defining demographic realities of our time: the World Health Organization notes that by 2030 one in six people in the world will be aged 60 or over, and by 2050 the number of people aged 60+ will reach around 2.1 billion. The UN Decade of Healthy Ageing has quite rightly challenged governments, systems and communities to respond with greater seriousness, urgency and imagination.
But I think we need to pause and ask a more searching question. What, exactly, do we mean when we speak about healthy ageing?
WHO’s own formulation is, in fact, more generous than many of the public narratives built around it. Healthy ageing, it says, is not the same as being disease-free. It is about developing and maintaining the functional ability that enables wellbeing, and it places enormous emphasis on environment, relationships, social policy and the opportunities people have to do what they value. WHO is also explicit that there is no “typical” older person, and that much of the difference in later life is shaped by cumulative inequality across the lifespan.
That is important. But in practice, the conversation too often narrows. Functional ability becomes shorthand for a particular type of bodily and cognitive competence. “Health span” starts to mean the number of years in which a person can perform independence in the way our systems most easily recognise and reward. And from there it is only a short step to what I would call functional fundamentalism, namely the quiet belief that health is synonymous with capability, autonomy without support, and uninterrupted productivity.
I think that is too thin an account of what it means to live well.
There is, of course, much to admire in the modern longevity movement. The life-course emphasis is right. The argument that we should prevent avoidable disease earlier, reduce chronic illness, and use the best of science and technology to delay unnecessary suffering is compelling. Recent work in The Lancet Healthy Longevity has reinforced the importance of a life-course approach, showing that many of the conditions we associate with old age are shaped by factors much earlier in life. OECD commentary likewise underlines the value of prevention, reablement, integrated care and community-based support if we are to respond well to demographic change.
I do not contest any of that.
What I do contest is the moral narrowing that can creep in when prevention becomes a cultural ideal rather than a public health tool. If we are not careful, we begin to imply that dependency is a personal or systemic embarrassment; that needing support is somehow evidence that one has fallen out of the circle of full citizenship; that frailty, dementia, chronic pain or reduced mobility make a life less whole.
Yet we would never say that a disabled life is therefore a lesser life. We would never claim that the presence of impairment automatically diminishes personhood, meaning or belonging. So why do we allow ourselves, so often, to speak as though the onset of frailty in older age marks the beginning of a life of lesser worth? Because it is clear to me that we do.
This is where the longevity debate needs greater ethical depth. A longer life is unquestionably a gift. But the value of that gift is not measured only by how long the body can mirror youth. It is also measured by whether a person can remain connected, purposeful, held in relationship, and assured of dignity even when life becomes more fragile. The literature on healthy ageing increasingly recognises this wider horizon: not merely disease avoidance, but the interaction between individual capacity and the social world around us; not merely years added, but environments that enable people to continue to be and do what matters to them.
And that, for me, is where prevention itself must be re-imagined.
We too often reduce prevention to a list of behavioural injunctions: eat better, move more, drink less, sleep well. All of that matters. But it is profoundly incomplete. Prevention must also mean preventing the erosion of agency. Preventing loneliness. Preventing unnecessary fear. Preventing people from disappearing from public life because pain, stigma, inaccessibility or poorly designed systems have quietly shrunk their world.
Take physical activity in later life. We can speak easily and sometimes glibly about the need to “keep moving.” Yet for many people inactivity is not a moral lapse but the outcome of pain, arthritis, poverty, inaccessible space, fear of falling, grief, or a loss of confidence. In that context, a walking aid, a more navigable neighbourhood, a community group, good pain management, or relational support from a care worker are not second-best interventions. They are acts of prevention in the deepest sense, because they prevent diminishment. The WHO’s healthy ageing framework and OECD analysis both point to the importance of supportive environments, housing, integrated services and community care in enabling people to age well.
This is why I have always been uneasy with the false divide between health and social care. Ageing does not happen in the body alone. It happens in homes, in streets, in families, in communities, in the stories a society tells about worth and usefulness. It is shaped by income, transport, housing, friendship, grief, language, technology and whether care is present when support is needed.
It also changes how we should think about innovation. AI, predictive analytics and personalised medicine will undoubtedly deepen our ability to anticipate disease, stratify risk and tailor interventions. I welcome that. Used well, such tools may help people avoid serious illness and live with greater confidence for longer.
But the purpose of innovation matters enormously. If technology is used simply to identify future loss, to rank bodies by resilience, or to chase a fantasy of biological purity, then it will reinforce the very anxieties it claims to solve. If, however, it helps us ask how a person can continue to live meaningfully with the trajectory they have; how support can be personalised, adaptation anticipated, and relationships strengthened, then it becomes an instrument of freedom rather than fear. Even within the wider healthy ageing literature, the most promising work stresses integrated, person-led models over narrow disease management alone.
We should also be brave enough to say that healthy ageing has to include how we die.
One of the more thoughtful recent contributions to this debate, again in The Lancet Healthy Longevity, argues that the quality of dying should be understood as part of the healthy ageing agenda rather than outside it. I think that is profoundly right. If ageing policy can speak confidently about active later life but hesitates at dependency, decline and mortality, then it remains half-formed. Dignity is not only a goal for the vigorous years. It is the thread that should run through the whole of life, including its final chapter.
So perhaps the challenge is this:
The real test of a society is not whether it can help a privileged minority live to 100 in near-perfect condition. The real test is whether all of us can age without fear, need support without shame, adapt without exclusion, and remain valued regardless of function.
That is a more demanding ambition than the promise of optimisation. It requires us to confront ageism, redesign communities, invest in care and support, and expand our understanding of health beyond the merely clinical. It calls us to resist the temptation to make human worth conditional upon durability.
In the end, I do not think the most important question is how we can preserve intactness for as long as possible. It is this: Can we build a society in which a person remains fully human, fully seen, and fully valued even when intactness is no longer available? That, to my mind, is where the real work of healthy ageing begins.
No one expresses this better than the poetic genius which is Mary Oliver in her poem, ‘I Worried.’
I worried a lot. Will the garden grow, will the rivers flow in the right direction, will the earth turn as it was taught, and if not how shall I correct it?
Was I right, was I wrong, will I be forgiven,
can I do better?
Will I ever be able to sing, even the sparrows
can do it and I am, well,
hopeless.
Is my eyesight fading or am I just imagining it,
am I going to get rheumatism,
lockjaw, dementia?
Finally I saw that worrying had come to nothing.
And I gave it up. And took my old body
and went out into the morning,
and sang.
Donald Macaskill
