GrowthSurvey2008

FALL 2008

CRADLEGRAVE&

INTELLIGENT DIALOGUE:

Many Minds. Singular Results.

Many Minds.Singular Results.

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MESSAGE FROM THE CEO“SOMEONE ALIVE TODAY will live to the ripe oldage of 150.” Agree or disagree? Two professors havewagered $150 on this very question. No matter whichside you’re on, there’s no arguing that fundamentalshifts in health trends have us all rethinking long-heldbeliefs about life and death. In our latest IntelligentDialogue white paper, “Cradle & Grave,” Porter Novellihas examined emerging global trends in fertility and birth, health and deaththat have profound implications for businesses, organizations and consumersfar beyond the health care industry.

Gaining a better understanding of these complex health issues meansgetting out of your comfort zone. It means leaving behind preconceived notionsof the “right” age for a first-time mother. It means facing your own mortalityand examining whether you really want to live to be a centenarian, and thenhonestly asking yourself, “Am I making the choices today that will allow me tolive 100 years?”

To prepare this paper, our health care industry specialists joined with ourpublic affairs, corporate affairs and marketing professionals to consider what’schanging across the full arc of life, from conception to death. “Cradle & Grave”identifies key trends in fertility, birth, health care advances, diseaseprevention and treatment, aging and dying. The paper examines how families(and populations) are changing, and how evolving health challenges likediseases of affluence and the obesity crisis will affect modern society. It raisesquestions about the advent of personalized drug therapies, the promise oflonger life expectancy and the threats posed by swelling ranks of elderly andchronically 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 amonumental challenge. This paper is intended to help map out the big pictureand prompt discussion.

At Porter Novelli, we believe ours is a learning culture, and that ongoingdialogue 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 andstimulate conversation. This is an opportunity for individuals and organizationsto demonstrate thought leadership on issues that affect all of us.

—GARY STOCKMAN

THE PRESENT SCREAMSFOR 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.

INTELLIGENT DIALOGUE: CRADLE & GRAVE4 Many Minds. Singular Results.

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INTELLIGENT DIALOGUE: CRADLE & GRAVE 5Many Minds. Singular Results.

INTRODUCTION

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

Nobody knows what may happen between now and nextyear in the economy, politics or technology, let alone other partsof life. Thoughts about the longer term are crowded out byurgent news of breakthroughs and breakdowns pumped out bythe media 24/7.

Businesses and consumers are so busy putting out the fires infront of them, they are unable to focus on what’s further ahead.The present screams for attention and the future whispers. Nowonder more people than ever are falling into the old trap ofoverestimating short-term change and underestimating long-termchange. This paper is intended to shift the focus and look atsome of the long-term changes slowly but surely reshaping themost important things in our world: literally the basics of ourlife as we know it. They’re gradual changes that we can all seeand feel but are too busy and too distracted to notice; they’reeclipsed by breaking news or hot gossip.

In keeping with our guiding principles, this edition ofIntelligent Dialogue is driven by observation and open-endedcuriosity. It raises a lot of questions, because we find dialogue is

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 anddeath no longer hold true?

3. What are the emerging risks and opportunitiesfor societies, businesses and consumers?

With our background in social marketing, Porter Novellibelieves that now more than ever, when it comes to the life-and-death issues covered in this paper, our communities need smartleadership through Intelligent Influence. During this period ofworldwide financial change, we will be helping our clients takethe long view and keep their sights on these critical health issuesas they make decisions on how they will move forward. This isan ideal moment to foster serious consideration of the biggerhealth issues that affect everyone. For smart businesses andbrands in particular, life and death issues create opportunities toprovide the leadership employees and consumers need—opportunities that enhance both their reputation and theirbottom line.

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TO HAVE KIDS or not? Now or later?How many? What will it cost? It used tobe that babies were the result of “doingwhat comes naturally.” But now, havingchildren isn’t inevitable, it’s a matter ofchoice. It’s a complex decision,and in the 21st century, decidingto become a parent involvesconsiderations unknown toprevious generations.

Though recent figures fromthe U.S. National Center forHealth Statistics show a recordnumber of babies born in theU.S. in 2007, birthrates aretrending downward worldwide.

The more prosperous people become,the fewer children they have. More yearsof education, higher quality-of-lifeexpectations, better career opportunities

and effective contraception make forsmaller families.

In the developed world, births in manycountries are below an average of 2.1 perwoman, which is the crucial “replacement

rate,” or number neededto maintain a populationat a stable level. Whenfertility rates are below2.1, the populationshrinks. This is a radicalchange from what hashappened throughoutmost of history, whenpopulations of prosperouscultures continually

expanded. Today, with its recent babyboomlet, the United States is running atreplacement rate, but the European Union(EU) falls well below that, with a birthrate

of 1.5, as do developed countries such asRussia (1.4), Japan (1.22) and Singapore(1.08), and newly developing countrieslike China (1.77), Thailand (1.64) andSouth Korea (1.29).

In all sorts of ways, traditionalexpectations of childbearing and familyrelationships no longer apply.

> WHY ARE WOMENWAITING TO HAVECHILDREN? It used to be thatpeople married in their late teens or early20s, had children and moved into agrandparent role by middle age. Now,growing numbers of people are startingthis cycle much later, or they’re skippingover the marriage step, or they’rechoosing to become single parents; some


WHAT’S HAPPENING

TO NUCLEAR FAMILIES?

BIG QUESTION 1

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are starting new families as they move onto second marriages, and some aremarrying relatively late and adopting.

The average age for first marriages hascrept up, and it’s not surprising. Youngerwomen are too absorbed in education andcareers to focus on serious dating, and theytend to be financially self-sufficient. Thewomen depicted in “Sex and the City” mayhave been TV-land creations but theystruck a chord all over the world as womenwho enjoyed their independence and weretaking their time in finding a long-termpartner until well into their late 30s or 40s.

Why should women hurry to havechildren when modern life is giving themplenty of reasons and ample means to havethem in their own good time—or not at all?Even settling with a steady partner doesn’t

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

The statistics tell the story of delayedmotherhood but Hollywood brings it tolife, writ large in the personal lives ofcelebrities: Madonna famously gave birthto her first child at 38 (fathered by aboyfriend); her second at 41 (father wassecond husband Guy Ritchie); and then adopted a child at 49. “DesperateHousewives” star Marcia Cross celebrated her first marriage at 44, then gave birth to twins less than a year later. ActressNicole Kidman recently gave birth to herfirst child with second husband KeithUrban at 41, having previously adoptedtwo 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 Mary-Louise Parker.

> HOW OLD IS TOO OLD TO HAVE ABABY? Data across the EU and the U.S. show the average age of first-timemothers is rising. More women at the

In the U.K., child psychiatrist

Patricia Rashbrook made headlines

in 2006 when she gave birth at age

62; she already had three grown

children from a previous marriage.

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.

{ MILLION DOLLAR BABY }

THE COST OF FERTILITY

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upper range of childbearing ability arebecoming mothers.

The average age of EU women givingbirth to their first child rose from 23 to 25between 1990 and 2002. In the biggercountries, first-timers were older thanthat: 28 in France (as of 2001)and 29 in Germany (2003).According to the U.K.’sOffice for National Statistics,more of Britain’s first-timemothers now fall in the 30 to 34 agegroup than in the 25 to 29 age group;and there has been an almost 50 percentincrease from 10 years ago in women over40 having babies. In the U.S., the mostrecent census figures show the average age atan all-time high of 25.2, with more than100,000 births in 2003 to women 40 or older.

Fertility treatments and improved healthcare are certainly pushing up the age atwhich it’s possible to have children.However, “possible” is not the same asprobable, advisable or desirable.

Professor Bill Ledger of England’sSheffield University is one of the fertilityspecialists warning that obesity andsexually transmitted diseases are causing agrowing number of fertility problems.Currently, one in seven couples hastrouble conceiving naturally, and Ledger

warns this could rise to one in three.He advises couples to start trying toconceive younger than 35.

Older parenthood is not just afemale issue; men have their ownfertility problems. There is clearevidence that sperm qualitydeteriorates with age and around a quarter of men of reproductiveage are subfertile (they producesperm but not at maximum

fertility). There are indications that malefertility is decreasing due to severalpossible causes, notably stress, weightissues and diabetes. Researchers arelooking into other possible causes such aselectromagnetic radiation from cell phones

and “gender bending” (endocrine-disrupting) chemicals in the environment.

> WHAT ARE THEFINANCIAL ISSUES OFOLDER PARENTHOOD?First-time parents who are older than the“traditional” age tend to do a lot of soul-searching. Whether their later parenthoodis deliberate, or due to circumstances suchas marriage or fertility problems, they aremore likely to feel the need to rationalizeand justify their situation to themselvesand/or to others. The Internet is provingto be an ideal medium for them tocompare notes and examine the issues.

One clear advantage of older newparents is financial stability—a factor thatseems to be widely accepted and valued indiscussions on the issue. Parents in their 30sand 40s tend to be educated and establishedin the workplace. They’re more likely thanyounger parents to have achieved a certainstandard of living, along with higherexpectations of service, comfort and quality.

Older prospective parents may have tobe prepared to invest significant amountsof money and time in fertility treatmentsor adoption.

On the other hand, these parents mayfind themselves needing to fund theirchildren’s teenage pursuits and collegeeducation at a time when their peers arebeginning to draw pensions. As AARP theMagazine put it: “Midlife parents faceanother challenge: how to stay financiallyhealthy as well [as physically healthy].Many may find themselves working wellbeyond the traditional retirement age justso they can send their kids to college.”

Current assumptions about maternity-planning patterns and family structures areincreasingly out of step with reality.


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.

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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.

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

Are employers that foster a maternity-friendly, postpartum-friendly, family-friendly culture getting ahead of the curvein recruitment, retention and reputation?Or are they merely picking up the tab formore ruthless, lean-and-mean competitors?

The biological limitations of parenthoodhave changed, and so have the sociallimitations. Parents no longer need to be in a traditional couple—some are singlewomen, others are same-sex couples.

There’s a greater willingness to talkabout fertility problems and options. Still, there’s a risk of social backlash whenpeople opt for non-traditional choices. For businesses, how tightly they want toembrace non-traditional choices is not justa matter of inner-focused company policy—it’s a part of brand positioning and identity.

> WHAT’S WRONGWITH GETTING A SNEAKPEEK? Fertility treatments andprenatal screening have given would-beparents the option of knowing the sex oftheir baby before it’s born. In somecultures where males have a higher statusthan women (such as India and China),this has resulted in a dangerously skewedgender balance.

In China, the one-child policy has meantthat many parents aren’t willing to letnature take its course. China will have 30million more men of marriageable agethan women in the next decade and a half.The ratio for newborn babies in 2005was 118 boys vs. 100 girls, up from110/100 in 2000. In some regions theratio is as high as 130/100, comparedwith an average of between 104 and107 boys for every 100 girls inindustrialized countries.

In 1994, the Indian government bannedmedical practitioners from revealing thegender results of fetal scans. Yet thegender imbalance has only furthertipped. In 1991 there were 945women for every 1,000 men, andthe gap widened to 927/1,000by 2001.

These unintendedconsequences of simplescreening are likely to befelt for decades to come.There are concerns thatmillions of restless youngmen could vent their

frustration through violence, crime andpolitical extremism, and that risingdemand for sex workers could fuel thepractice of human trafficking and thespread of HIV/AIDS.

Although prenatal gender screeninginvolves the relatively simple technology of ultrasound, its wider social effects areproving to be far-reaching. The effects of more sophisticated genetic-basedprenatal screening are likely to be evenmore radical.


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.”

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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?

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CHILDBIRTH IS AN EXPERIENCEtraditionally surrounded by folklore andmystery. Historically it has been one of theriskiest moments in life. It still is. Andwhile medical science has helped alleviatethe risk and pain involved, there are stillmajor open issues.

> IS A HOSPITALBIRTH THE ONLY SAFEOPTION? There’s a growingtendency for developed countries to treatpregnancy and childbirth as medicalissues, requiring highly sophisticatedmedical care and hospitalization. For along time this trend was accepted byparents-to-be and the wider society as“doctor knows best” and “this is the way

it happens.” But in fact, it doesn’t happenthe same everywhere.

Now, as in other parts of medicine,globalization has enabled interested partiesto compare practices in terms of medicaloutcome as well as emotional outcome andcost. This has encouraged challenges tothe highly medicalized approach topregnancy and childbirth that is at its mostpronounced in the United States.

In the U.S., home births account for just1 percent of deliveries, and the AmericanCollege of Obstetricians and Gynecologistshas repeatedly stated its opposition to homebirths, emphasizing that “the safest settingfor labor, delivery and the immediatepostpartum period is in the hospital, or abirthing center within a hospital complex.”

How much of this is due to theprecautionary principle, with the fear ofmalpractice suits informing medicalprocedures? How much is due to themedical profession seeking businessopportunities? How much is due to the“mission creep” of technology, as impliedin the polemical 2007 movie “The Businessof Being Born”?

> WHO REALLY WANTSBIRTH BY CESAREANSECTION? One of the most hotlycontested issues is the trend to deliverbabies by cesarean section. Although it’sstill a serious surgical procedure, it’s nolonger a last-resort rarity.


WHAT’S THE BEST WAYTO DELIVER BABIES?

BIG QUESTION 2

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CESAREAN SECTION

HAS BECOME SO NORMALTHAT IN SOME INSTANCES, IT IS

REGARDED AS

A WAY OF

SLOTTING

CHILDBIRTH

INTO A BUSY SCHEDULE.

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In the United States, figures for 2007are expected to show around one in threebirths by cesarean, compared with fewerthan one in 20 in 1965. Cesareans areincreasingly common in Canada too, eventhough the health system is significantlydifferent: 26.3 percent of womendelivered by cesarean in 2005–2006, upfrom 23 percent in 2001–2002. In theU.K., cesarean sections are also increasing and currently stand at around20 percent.

According to a survey of Americanwomen conducted on behalf of the U.S.nonprofit Childbirth Connection, 98percent of women with primary (planned)cesareans believed there was a medicalreason for the surgery. The most commonconcerns cited were fetal distress, positionof baby, size of baby and prolonged labor.However, 42 percent of respondents alsofelt that due to fear of lawsuits, thecurrent health care system leads tounnecessary cesareans.

As childbirth becomes a less frequentoccurrence in developed societies, will eachpregnancy and birth become moreexpensive? Will the medical professionbecome ever-more intensively involved?

Childbirth has become a lot less riskythan it used to be in many parts of theworld. But is the complete medicalizationof childbirth in the best interest of allconcerned? Are health care and insuranceproviders missing an opportunity to offeralternatives 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-

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

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.

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PEOPLE ARE ALREADY experiencinglonger, healthier lives than ever beforeand there’s the prospect of more goodnews to come. But that doesn’t mean it’sall smooth sailing from here on. For onething, microorganisms (bacteria, viruses,etc.) have a way of evolving to exploitnew opportunities, which could trigger amajor pandemic. For another thing, weare facing diseases arising from newlifestyles and from living older.

> ARE THE MAJORCONTAGIOUS DISEASESGONE FOR GOOD? Timewas when contagious diseases were thebig killers: plague, smallpox, cholera, etc.Thanks to public sanitation, hygiene,vaccination and antibiotics, their impacthas been hugely reduced. But they havenot been completely eliminated, and theystill hold some nasty surprises.

HIV/AIDS and the virulent staphinfection MRSA are relatively new to theroster of communicable diseases. Onethird of the world’s population is infectedwith the bacteria that causes tuberculosis.Meningitis continues to lurk and malariamay yet spread further as global warmingmakes temperate zones more congenial formosquitoes. Meanwhile, health authoritiesare keeping an eye out for the likes ofSARS and avian flu, and whatever mightyet emerge from tropical jungles.

WHAT NEWHEALTH THREATS

MUST BE DEFEATED,AND HOW?

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Communicable-disease specialists warn thatthere’s a strong chance of more superbugs;microbes and even cancers are developingimmunity to the drugs that have been usedagainst them.

HIV/AIDS is typical of what healthprofessionals fear from cunning superbugs.By the time the Centers for Disease Controland Prevention (CDC) in the U.S.recognized HIV/AIDS as a distinctsyndrome in 1981, it was already on itsway to becoming a devastating epidemic.According to a 2006 report from the UnitedNations Joint Program on HIV/AIDS, overthe last quarter-century, nearly 65 millionpeople were infected with HIV and anestimated 25 million have died of AIDS-related illnesses. About 33 million—almosthalf are women—live with HIV today, thevast majority unaware of their status.

Scientists are looking for ways to spotother emerging diseases before theybecome equally—if not more—devastating.About three-quarters of emerging humandiseases are “zoonoses,” or pathogens that,like HIV/AIDS, originate in animals andcross into human populations. A numberof projects are focused on gathering front-line blood samples across equatorialjungles, watching for changes in behaviorand mortality, and coordinating findingsthrough specialists such as the CDC andthe virology laboratory at the University

of Montpellier in France. The systematicmonitoring of bush-meat hunters may alsohelp prevent future AIDS-like epidemics.

Although communicable diseases are notkilling huge numbers of people in the oldfamiliar ways—sickness, fever, swelling andpain within weeks or months—they may bewreaking havoc over a longer period,working in the background. Some virusescan cause changes in cells that may lead tocancer. There are clear links betweencervical cancer and the genital wart virusHPV, between primary liver cancer andthe hepatitis B virus, and between variouscancers and the Epstein-Barr virus.Fortunately medical science evolves fasttoo and a range of new vaccines such asGardasil has been introduced in recentyears that seem to be effective at reducingthe incidence of such cancers.

Many of the major historical advancesin disease control and life expectancy havecome from preventing diseases rather thancuring them. Vaccination, sanitation,education and nutrition have togetherdone more to save lives from disease thanhave feats of medical wizardry as seen in“ER” and “House.”

The specific illnesses have changed butthe principle holds; cures are needed butprevention will continue to be the mosteffective and the most cost-effectivestrategy.

> WHAT ARE THEPROSPECTS FORTREATING CHRONICAND TERMINALCONDITIONS? People in developed countries are much less apt todie from contagious diseases anymore.Rather, they tend to succumb to old age orto “diseases of affluence”—those stemming

from behaviors or environments of wealthiersocieties. This is uncharted territory inhuman history and raises new challenges.

We are seeking medication to tackle theeffects of too little physical activity and toomuch food; we are expecting cures fordiseases that were barely encountered acentury ago. And they can’t be found soonenough. By some accounts, half theAmerican population is living with someform of chronic illness.

Diabetes is a case in point. About 124million people worldwide had diabetes in1997, compared with a projected 221million by 2010. The rate is rising inparallel with obesity, a major cause of type2 diabetes; the coupling of a severe weightproblem with type 2 diabetes is beingreferred to as “diabesity.”

While death from heart disease in theU.S. has fallen by 26 percent and deathfrom stroke by 24 percent since 1999, theyare still the first and third causes of death,respectively. And the American HeartAssociation has warned that theimprovement could be short-lived if riskfactors aren’t reduced.

It’s not just the U.S. that’s grapplingwith the big killers. The World HealthOrganization reports that cardiovasculardisease is the top cause of death globally,and it’s projected to remain so. Anestimated 17.5 million people died from

INTELLIGENT DIALOGUE: CRADLE & GRAVE16

EARLY PREVENTION FOR A HEALTHY FUTURE

{ 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.

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THE UPSIDE OF CHRONICDISEASE TREATMENT

IS THAT PEOPLE ARE SURVIVINGAND EVENTUALLY DYING

with the disease rather than from it.

The downside is that it can be

expensive and debilitating to live

life on the tightrope of

daily disease management.

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

In 2003, the World HealthOrganization’s “World Cancer Report”forecast an increase in cancer from 10million new cases globally in 2000 to 15million by 2020, mainly due to steadilyaging populations in both developed anddeveloping countries, as well as risingtrends in smoking and the growingadoption of unhealthy lifestyles. Thereport says cancer poses major challengesfor health care systems worldwide, but thatit can be prevented and its impact reduced

through basic research and improvementsin treatment and care.

The longer people live, the more likely itis they will experience any one of about 80autoimmune disorders that can make lifemiserable. These disorders involve theimmune system mistakenly attacking anddestroying healthy body tissue—“friendly fire,”so to speak. Well-known conditions include:type 1 diabetes, thyroiditis, pernicious anemia,rheumatoid arthritis, lupus, multiple sclerosisand Graves’ disease. According to theAmerican Autoimmune Related DiseasesAssociation, it’s estimated thatapproximately 50 million Americans sufferfrom an autoimmune disease.

Degenerative conditions are anotherprospect, especially dementia—the umbrellaname for progressive degenerative brainsyndromes that affect memory, thinking,behavior and emotion.

Alzheimer’s disease is the most commonform of dementia. According to JohnsHopkins researchers, an estimated 26.6million people worldwide suffer fromAlzheimer’s, a number that’s forecast torise to more than 106.8 million by 2050.Much of this increase will be in rapidly

developing, heavily populated regions suchas China, India and Latin America.

Like battlefield weapons designed towound rather than kill, the chronicillnesses of today can be more devastatingthan acute, sudden-death conditions.People suffering from chronic disease overseveral years represent major costs, bothfinancially and emotionally.

The prospect of many millions morepeople suffering from chronic illnesses andmillions having to look after them is a realand unprecedented threat likely to eclipsethe dangers of terrorists and road trafficaccidents and violent criminals combined.How can governments, insurers andindividuals be adequately prepared for it?


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UP TO THE AGE OF 65,

DEMENTIADEVELOPS IN ABOUT ONE PERSON IN 1,000.

Its incidence rises sharply withage to one person in 20 over age

65. The big threat is to people overthe age of 80, when the incidence of

dementia increases to one in five.That’s riskier than the one in six of

Russian roulette.

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> IS OBESITY THENEXT FRONTIER? Obesityand its complications will cause theuntimely deaths of hundreds of thousandsof people every year for the foreseeablefuture. In 2006, U.S. Surgeon GeneralRichard Carmona called obesity “theterror within” and warned that, “Unlesswe do something about it, the magnitudeof the dilemma will dwarf 9/11 or anyother terrorist attempt.” Are such direproclamations just the nanny state atwork? After all, if obesity is such a bigthreat, why are people living longer?

There’s no getting around the healthimplications of extra pounds. According toU.K. private hospital group BMI, obesity

(defined as a body mass indexgreater than 30) increases therisks of developing diabetes,high blood pressure, angina,heart attacks, highcholesterol, urinaryincontinence, infertility,osteoarthritis, asthma, sleepapnea and cancer.

These illnesses representhuge costs in terms of humansuffering, not to mention medicaland insurance costs as well as lostproductivity and earnings. Obesity is setto become the most critical health issueshaping life and death in the first half ofthe 21st century. Turning the tide willrequire the commitment and collaboration

of public and privateconcerns, ranging

from governmentsto nonprofits tothe food industry.Perhaps a faster,fail-safe solutionwill come fromscience.

A lot of peopleare aiming for a

“cure” for obesity—miracle foods, pills,

injections, surgery, gene therapyand more. Whoever comes up with a safe andeffective treatment that fulfills the classicmarketing imperatives—quick, easy, convenient,affordable—will be sitting on a goldmine.

Might microbes come to the rescue?Researchers at the EU’s Metagenomics ofthe Human Intestinal Tract project(MetaHIT) have found a sharp contrast inthe bacteria population in the guts ofoverweight and thin people. And whenheavy people dieted and lost up to aquarter of their body weight, their gut florachanged too, becoming more like those ofthe lean group. So it may be that certaintypes of probiotics can help reduce weight.

Might genetics solve the problem? In2007, scientists analyzing a large-scalestudy of diabetics found a correlationbetween the FTO gene and obesity.Researchers at Cambridge University inthe U.K. have discovered that the genecodes for an enzyme that modifies DNAcould be activated or inhibited bypharmaceuticals. This opens the prospectof drug therapies for obesity.

For the moment, many people are pinningtheir hopes on surgery. Restrictive surgerycovers procedures that make the stomachsmaller, so that the patient eats less.Malabsorptive surgery changes the body’sability to absorb calories from food. Thetwo most commonly performed operationsare laparoscopic adjustable gastric banding(LAGB), also known as lap banding orgastric banding, and gastric bypass.

Weight problems are no longer simplyaesthetic issues; they represent a majorthreat to public health, although publicperception of the real threat is far short of reality.

What will it take for obesity to betreated seriously as a modern medicalcondition with major public health


THE OBESITY EPIDEMIC

{ NO ROOM TO GROW }

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.

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THE FOOD AND DRINKS

INDUSTRIES

HAVE GROWNTHEIR MARKETSSPECTACULARLY.

While they may not be blamed forconsumers’ 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?

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ACCORDING TO THE MAYO CLINIC, EACH YEAR AN ESTIMATED

100,000AMERICANS DIE from adverse reactions to medications andmore than 2 million are hospitalized.


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implications rather than as a lifestyle issue?The risk is that the cumulative effects ofobesity will overwhelm the capacity ofcommunities to deal with the financial andhealth care consequences.

> WHEN WILL CURESBECOME LESS LIFE-THREATENING? For all the amazing progress in pharmaceuticals,prescribing drugs is still hit-or-miss. Drugshave been developed to deal withconditions, not individuals; they take aone-size-fits-all approach that can’t accountfor individual body chemistry. Patientsmay be subjected to a range of treatments

before doctors find one thatworks.

In the meantime theside effects of thistrial-and-error processcan be distressing forpatients and riskyfor their health, notto mention a seriouswaste of health careresources.

To reduce the potluckelement of drugs, health careprofessionals are looking topersonalized medicine, orpharmacogenomics. With this approach,before medication is prescribed, geneticanalysis will be carried out to check forrelevant genetic variations—singlenucleotide polymorphisms, or SNPs. Thiswill enable doctors to better predictwhether a drug will provoke an adversereaction or will be likely to do the job.

According to the Personalized MedicineCoalition, this approach has the potentialto offer benefits such as early detection,

more focused therapy, greateremphasis on preventive

medicine and costreduction. The PMCalso believes whenused in research,pharmacogenomicscould reduce thelength, cost and failurerate of clinical trials, and

even revive drugs thatfailed clinical trials or were

withdrawn from the market.

A lot depends on technologybeing developed to read (or

“sequence”) genes fast and affordably. Inthe U.S., the National Institutes of Healthhas set a goal for sequencing an entirepersonal genome at a cost of just $1,000 by2014 (currently, one firm is charging$350,000 to anyone who wants a completepersonal genome sequencing). In a parallelinitiative, the X Prize Foundation in theUnited States has put up a prize of $10million for the first private team that candecode 100 complete human genomeswithin 10 days for less than $10,000 each.

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HOW ABOUT LIVING FOREVER?Mythology, legend, religion and popularculture are full of quests to find ways ofbeating the Grim Reaper: the fountain ofyouth, the elixir of life, the philosopher’s stone.But the human body hasn’t evolved to liveindefinitely; parts of it go wrong (including therepair systems), and an accumulation of faultseventually leads to one part of the systemfailing, with fatal consequences.

> WHAT ARE THELIMITS OF LIFEEXPECTANCY? Althoughthere are a few areas of the world wherelife expectancy is still poor, in general ithas increased steadily. Globally, lifeexpectancy at birth was just 30 years in1900; it had more than doubled, to 62, by1985 and currently stands at around 64.

In most developed countries, life spanshave been steadily increasing for a longtime and look set to continue upward.Consider that in 1850, life expectancy atbirth averaged just 38.3 years forAmerican Caucasian men and 40.5 yearsfor women; by 2004 it was 75.7 for menand 80.8 for women. In the U.K., forevery million born alive in the 1880s, just309,020 were still alive at 65 and only161,164 at age 75; by the 1990s, amajority could expect to reach both 65(830,990) and 75 (612,740).

People are living longer largely becausethey are staying well longer. They are nowin better shape as they age—one reason forproclamations such as “50 is the new 30.”And while it’s true that less healthylifestyles and the rise of obesity meanmany people are not in great condition,they are less beset by infectious diseases

that damage and weaken the body. Thereare fewer accidents and better treatmentsfor injuries such as fractures and lesions.Better nutrition is more widely available,helping bodies stay resilient.

The big imponderable is whether thetrend for gradually increasing life spanscan be projected indefinitely into thefuture. What are the limits? Steve Austad,a professor of cellular and structuralbiology at the University of Texas, isconvinced that somebody alive today willreach the age of 150. S. Jay Olshansky, anepidemiology professor at the Universityof Illinois at Chicago, disagrees strongly.They each wagered $150 on the question,and Olshansky invested the money in afund. If a 150-year-old is alive in the year2150—someone of sound mind and body—Austad’s descendants will get the pot;otherwise, Olshansky’s offspring will win.


HOW OLD DO WE

REALLY WANT TO BE?

BIG QUESTION 4

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> WHAT ROLES CAN PHARMA AND CORPORATIONSPLAY IN FOSTERINGLONGER LIFE? Many factors have come together to make longer lifespans possible. As the data accumulate andresearch goes deeper, we are discoveringwhich other factors can be influenced toextend enjoyable life even further.

One of the most impactful quick wins ona global level is providing sleeping nets topeople at risk of malaria infection bymosquitoes. According to the CDC, 41percent of the world’s population lives inareas where malaria is transmitted. Eachyear, 350 to 500 million cases occurworldwide, and more than 1 million peopledie, most of them young children in sub-Saharan Africa. The big issue: Who pays?

Another victory: statins, drugs thatreduce the amount of cholesterol producedin the body, lowering the risk of heartattack. Currently under debate is whetherstatins will become available over thecounter in the U.S. (an OTC statin isalready available in the U.K.). The FDAhas repeatedly rejected Merck & Co.’sapplications to make Mevacor® availablewithout prescription. Supporters argue thatselling statins over the counter could helpmillions avoid heart attacks.

How about employers encouraging staffto live more healthfully? Corporatewellness has become something of a buzzphrase, but skeptics may see the programsas a trophy-spend to make big companiesfeel good. Is there any hard evidence thatinvesting in wellness benefits the bottomline? The questions are sharpest in theUnited States, where medical costs can eatup as much as half of a company’s profits.And the indications are encouraging.

According to the Wellness Council ofAmerica, the results from effectivecorporate wellness programs areencouraging. At Michigan furnituremanufacturer Steelcase, the averageinsurance cost for high-risk employees is75 percent higher than it is for low-riskemployees; staff that followed thecompany’s health promotion program andlowered their risk factors cut theirinsurance costs by an annual average of$618. Other results outlined on theWellness Council’s Web site point in thesame direction:

• For DuPont, each dollar invested inworkplace health promotion has yielded$1.42 over two years in lowerabsenteeism costs.

• The Travelers Corporation reports a$3.40 return for every dollar invested inhealth promotion, yielding totalcorporate savings of $146 million inbenefits costs. Sick leave was reduced by19 percent during the four-year study.

• The Stay Alive & Well program at LasVegas–based Reynolds Electrical &Engineering has cost about $76 peremployee during the two years it hasbeen in operation, while savings haveaveraged almost $128 per participant.

Increasingly, businesses are seeing notonly a moral and reputational imperative forfostering better health among employees,

but also a business case. This harks backto the paternalistic business leaders of the19th century such as William HeskethLever, founder of Lever Brothers (nowpart of Unilever). Is there a case forwellness expertise becoming as much acore business competence as financialcontrol and stock management?

> WHAT’S NOT TOLIKE ABOUT LIVINGINTO THE TRIPLEFIGURES? As conventionalwisdom has it, getting old is better thanthe alternative. But up to what age doesthat adage apply? What tips a long lifefrom being a blessing to being a burden?

As significant numbers of people live toa ripe old age, what will happen to those—the majority—who haven’t had the meansor the foresight to make their twilightyears comfortable?

It may well be that technology andscience have once again advanced farfaster than our moral and social capacityto deal with the benefits they offer. If thetragedy of times gone by was that toomany people died of relatively trivialillnesses while they were still quite young,with a lot to live for, it’s likely to be theother way around in the future: People willbe able to survive serious illness, perhapslong after they’ve lost the things that make

ELDERS IN FINANCIAL CRISIS

{ POOR AND PROUD }There’s a significant risk that

people who run out of financial

resources in old age will be

comparable financially to maturing

teenagers, but in reverse and with

no “age of majority” in their future:

They’ll have the desire to

participate in society and a sense

of entitlement but—unlike teens—

increasingly less prospect of

independence.

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A GROWING NUMBER OFCHRONICALLY ILL AND

VERY OLD PEOPLE

IN WEALTHY COUNTRIESwill need to be looked after athome. It’s projected that by 2011,two thirds of the workforce indeveloped countries will becaregivers part-time. What are theprospects of full-time salary earnersbeing willing or able to becomepart-timers, staying home to care foraging relatives?


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life worth living: mobility, mental acuity,social life and family.

As the baby boomers move beyond their60s and start swelling the ranks of theelderly, nursing homes, retirement homes,health systems and government assistanceprograms must be ready to meet thechallenge of looking after much largernumbers of people—especially if many areunable to pay for care.

In Japan, where the balance of old toyoung is shifting faster than in mostcountries, people are looking totechnological solutions. The MachineIndustry Memorial Foundation estimates

that Japan could save $21 billion in elderlyinsurance payments in 2025 by usingrobots to monitor the health of olderpeople rather than human nursing care.

In theory, the increase in olderconsumers represents lucrativeopportunities for astute entrepreneurs:equipment that can be used by lessdexterous hands, stylish apparel thataccommodates older body shapes, foodand beverages that help older consumersstay nourished and entertainment thatstimulates them, not to mention all theservices they need. The big potentialobstacle is their financial resources: Willenough of the elderly have money to

spend, or will this group be too cash-strapped to comprise a worthwhile market?

Science and technology have given usthe means to extend life, but it’s beyondtheir scope to provide the reasons or themeans to live longer lives.

Can businesses and organizations step into make those extra years a normal part oflife—a part that’s truly worth living?Stacking supermarket shelves and acting asmuseum guides are a reasonable start butlet’s hope they’re not the last word inpurposeful activities for older people.

How will business and governmentrecognize and meet the exponential needs foraffordable, good-quality eldercare options?

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.

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SO MANY ASPECTS OF LIFE aredifferent from those in previous centuries.It’s inconceivable that death hasn’tchanged too. And so it has in manyrespects. It happens later. It’s more likelyto happen in a hospital or a care facilitythan at home. It’s more likely to be alonely event. The mortal remains are farmore likely to be hefty than slight. And formost people, death is now a far less visiblepart of life.

> WHAT IF WE CANPLAN HOW WE’LLDIE? Society has evolved with somebasic assumptions about how long peoplelive, and about work, families andcommunities. Longer life spans andgrowing numbers of older peoplechallenge those assumptions profoundly.

The biggest thing that will have tochange is the current tendency to put little


HOW IS MODERNDEATH DIFFERENT?

BIG QUESTION 5

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coherent, detailed preparation into the finalyears of life. After all, who knows when theend will come and what will cause it? Lackof planning often results in unnecessaryexpense, stress and distress for all involved.

It’s very likely that for most people thelast years of life will now involve morecare and more expense than they did forprevious generations. And whatever theindividual cases may be, there’s enoughdata to know the final trajectories thatmost people’s lives will take. Dr. JoanneLynn, a geriatrician at the Hastings Center,an independent, nonprofit bioethicsresearch group, has identified the threemost common end-of-life scenarios, basedon extensive numerical data:

• The quickest is long years of active lifeending with several months of steep declineand death; in the United States this istypical of cancer deaths, which peak at age65, and is the fate of around 20 percent ofAmericans. This scenario typically requireshospice support at the end.

• Those with long-term chronic illnessessuch as organ failure go through years ofgradually declining health with occasionalbouts of severe illness and requireconsistent disease management. Eventuallyone of the bouts of severe illness will causesudden death, which is the case for abouta quarter of Americans. Chronic heartfailure and emphysema are the mostcommon illnesses of this scenario, withdeath peaking at around age 75.

• The third scenario is set to become themost common: gradual long-termdecline and loss of functions, requiringyears of personal care. At worst thismeans a long, frustrating andhumiliating decline for the individualand an exhausting and potentiallybankrupting ordeal for the family.Approximately 40 percent of Americans,generally past age 85, fall into thiscategory. And the numbers will rise.

In the future, a combination of geneticscreening, medical examination and actuarialdata will make it possible for most people topredict how and when they are likely to die—certainly with far greater chances of accuracythan were previously possible. This couldmean a fundamental change in people’srelationship with their own mortality.

Knowing about one’s death well inadvance is typically perceived as morbidand scary, even a risk to mental health. On

the other hand, if handled properly, theinformation may enable people to takegreater control and plan more appropriately.

> WHY SHOULDDEATH BE A TABOOSUBJECT? The billionaireinvestor and philanthropist George Soros,explaining his foundation’s Death inAmerica project, wrote: “In America, theland of the perpetually young, growingolder is an embarrassment, and dying is afailure. Death has replaced sex as thetaboo subject of our times. Only ourpreoccupation with violence breaksthrough this shroud of silence.”

In a world where so much hope andeffort and ingenuity go into creating lifeand hanging on to it, dying can seem likefailure. It means no more second chances,at least in the prevailing mind-set of thedeveloped world. Will this mind-set bealtered by the growing number of baby

boomers heading toward their finalcurtain? After all, boomers changedsociety’s views of youth, of parenthood, ofmiddle age; it’s likely they will also changesociety’s views of old age and dying.

According to Hospice Net, an independent,nonprofit organization, death was once anintegral part of family life. People died athome, surrounded by loved ones. Adultsand children experienced death together,mourned together and comforted oneanother. Today death is lonelier.

Most people die in hospitals or nursinghomes, where they receive the extensivemedical care they need to give them thebest chance of extending life as long aspossible. Their loved ones have lessopportunity to spend time with them andoften miss sharing their last moments. Thedying have become isolated from theliving; consequently, death has taken onadded mystery and, for some, added fear.

Death has become removed from thenormal experience of people in Westernsocieties. It is denied for as long aspossible. It’s assumed that people don’twant to think about it, so the wholesubject becomes more taboo.

The risk is that death becomes theelephant in the room, causing unnecessarytrauma for both the dying and the living.Sheer demographics, not to mention goodsense, will force more consumers toacknowledge the elephant, which willcreate opportunities for thought leadershipfrom businesses and organizations.

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CONCLUSION

MANY OF THE ASSUMPTIONS previous generationsheld about life and death are no longer accurate—butgovernment policies, politicians, organizations, businesses andindividuals still take them as fact. Outdated assumptions drivethe choices people make: whether and when to marry, havechildren, save or consume; how much to invest in family,friendships, work, health and hobbies. They remainprogrammed into systems and cultures and mind-sets untilthey clash with the changes brought about by education,demographics, science, technology and business.

People are aware of most of the changes cited here, eitherthrough the media or direct experience, but awareness ispiecemeal; there are lots of little patches of information. Andit’s tough to integrate the scope of the changes into a bigpicture. The result is that many stumble half confused, half indenial from one predictable crisis to the next.

The issues touched on here are not peripheral or trivial;they’re big, and they cry out for coherent, consistentIntelligent Dialogue. They span the interests of governments,corporations, advocacy groups and individuals: Theyincorporate a need for change in public policy, finance,science, business and behavior.

With our roots in social marketing and our activeinvolvement in all these areas, we at Porter Novelli are excitedby developments in all these fields. We relish the challenge ofconnecting the dots. And we’re alarmed to see how muchdiscussion around these topics is reactive and partially informed.

“Cradle & Grave” is intended to prompt discussion andfoster thought leadership across disciplines. We work withsmart people in great organizations, and we’re lookingforward to helping them create change and shape the future.

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WHAT PORTER NOVELLI UNIQUELY OFFERScan 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 set-

piece 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.

The Porter Novelli INTELLIGENT DIALOGUEPrinciple

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

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

Porter Novelli Worldwide75 Varick Street, 6th floorNew York, NY 10013www.porternovelli.com

Join the dialogue by visiting www.pnintelligentdialogue.com

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