After COVID-19: what next for older people in China?

The UN Decade of Healthy Aging (2021–30) began under the shadow of the COVID-19 pandemic. The initiative aims to bring together multiple stakeholders to “improve the lives of older people, their families, and the communities in which they live”. For China, a country experiencing a rapid shift in population demographics, the decade is particularly relevant. As the country makes large changes in its response to the pandemic, it is crucial that the future of China’s older population is a priority.

In the past few months, China has seen drastic changes in its COVID-19 policies. The country had become an outlier due to maintaining policies, such as quarantine facilities, lockdowns, mass testing, and strict restrictions on mobility (both within and out of the country), with the objective of preventing SARS-CoV-2 infections. Although the policies aimed to prevent morbidity and mortality, the social and economic consequences have been severe. For older people, who are at greater risk of poor COVID-19 outcomes, the benefits of reduced infection risk have been, for some, counterbalanced by the physical and mental costs of reduced activity and social contact. Additionally, concerns had been raised regarding the level of vaccine protection, especially in people older than 60 years, in whom vaccination rates have lagged. As we argued in a previous Editorial, vaccination of older adults was crucial to enable relaxation of COVID-19 restrictions. Unfortunately, the uncertain level of protection from vaccination in older people remains a concern. Although WHO have acknowledged the recent progress made in substantially increasing vaccination rates, they have also highlighted the inadequate vaccine coverage in people older than 60 years. The impact for older adults of the change in policies combined with inadequate vaccination protection is not, at the time of writing, fully known. However, of the 59 938 COVID-19-related deaths reported in hospitals in China between Dec 8, 2022, and Jan 12, 2023, 90·1% were in people aged 65 years or older.

Although ensuring high COVID-19 vaccination rates in people older than 60 years remains a priority, COVID-19 is not the only challenge faced by China’s older population. The demographic shifts in the country mean that older people must continue to be a top health priority for the foreseeable future. In 2021, the World Bank calculated that 13·1% of China’s population was aged 65 years or older. By 2030, this proportion is predicted to rise to 18·2% and, by 2050, to almost one-third of the population (30·1%). Until recently, older people requiring care were largely looked after by family members. However, a falling birth rate combined with migration from rural to urban areas for younger generations means family care is less readily available. The impact of this shift will become increasingly felt over the next few decades. The path to healthy ageing in China: a Peking University–Lancet Commission, published in December, 2022, highlights key steps to take to prepare for the health needs of an ageing population in China.

As highlighted in the Commission, an important area to address will be training a new generation of health and social care workers. Expansion of high-quality, long-term care, both in facilities and community settings, will be needed to replace reduced family support. Primary care will also need to be strengthened to ensure it can deliver holistic care to a growing number of people with multiple comorbidities. The Commission also includes health promotion as a priority. Although attention has been focused on COVID-19 vaccination, the rates of other vaccinations in older adults are low. For example, WHO recommends seasonal influenza vaccination, with older adults being a top-priority group. However, rates of influenza vaccination in those aged 60 years or older in China have been reported to be around 3·8%. By comparison, the UK consistently reports vaccination rates above 70% in people older than 65 years. Additionally, health inequalities persist, with women and people living in rural area having worse health outcomes than men and those living in urban areas. Health promotion efforts must carefully consider and target both older men and women and to ensure that people living in rural areas are reached.