This multiauthor volume is part of a series of publications focused on the economics of healthy and active aging from the European Observatory on Health Systems and Policies. Following a general introduction of the issues to be considered, the text includes a description of the demographic trends and the status of various inequalities (age, gender, ethnic, socioeconomic, geographic, health) in Europe; a review of the politics of aging, including age-bloc-related voting trends; and a detailed analysis of the prevalent mechanisms underlying the development of age-related policies and programs.

Seven authors of varying seniority are listed, ranging from highly respected senior professors to postdocs, with faculty appointments in academic departments of political science, health policy and management, population health, and social policy in both the United Kingdom and the United States. The volume has a sense of being a hybrid between an edited collection of chapters and a truly cohesive, unified treatment of the subject, leaning toward the latter.

The authors indicate two goals: debunking the common narrative that older persons are “greedy geezers,” which they handle very well, and debunking the view that financing a welfare state is unsustainable given the demographic transitions—a topic that, in my view, would require much more economic and tax policy evaluation than they offer to be considered fully analyzed.

There is a lot to like here, both regarding the treatment of many important aspects of the ongoing demographic and social transitions in aging societies and in the sophisticated analysis of the politics of aging. On the other hand, there are times when I feel the authors press a bit too far on their theme that age per se is not an important or meaningful determinant of many of the problems facing aging societies and thus has little or no utility in setting policy. Such an age-minimalist view that discards age as “just a number” seems counterproductive and a major step backward, as it would basically throw out something that is generally accepted and is straightforward and effective in favor of a much more complex set of policies based on somewhat arbitrary characteristics of individuals.

But let's start with the positives. The treatments of issues such as prevalence and adverse consequences of “ageism”; cross-national differences; the prevalence and impact of inequalities based on race, gender, socioeconomic status, and place among the elderly; and the limited utility of archaic concepts such as the “lump of labor fallacy” and “age-dependency ratios” are all excellent.

There is a very thoughtful analysis of the critical importance of taking a life-course perspective in policy development, including considering the value of all generations and the importance of child care, child poverty, housing, various work benefits, and tax credits. The authors note that achieving healthy aging requires attention to the neediest and to ensuring quality of care across the life span. Healthy aging does not begin at age 65!

The authors include an insightful discussion of the limited utility of the two prevalent social narratives that frame public discourse regarding older persons: on the one hand, they are greedy geezers soaking up more than they deserve or we can afford, to the disadvantage of other generations; and on the other hand, they are a neglected and disadvantaged group that deserves much more than they receive.

As one might expect from these scholars, the treatment of issues related to the politics of aging is a major strength, emphasizing evidence that older persons do not vote as a bloc and that most policies that might be considered “age-friendly” generally do not arise from the electorate but rather are brought to the table by “supply-side” coalitions of policy makers and special-interest groups. The detailed discussion of the dynamics and societal value of win-win versus win-lose (zero-sum) policies and politics is enhanced by descriptions of real-world examples and contrasts of both approaches. While the reunification of the Federal Republic of Germany strengthened intergenerational solidarity, the policies of the Labour government in Britain (2000–2010) had a less positive result.

A major theme of the book is that age per se is not an important or meaningful determinant facing aging societies (or the “age is just a number” argument), which is based on the very reliable observation that with advancing age, healthy individuals without evident underlying disease become much less like each other, not more like each other. This holds true for many biological and physiological factors, such as kidney, lung, heart, and brain function. And while it is true that much of this increased heterogeneity with advancing age can be attributed to various lifestyle factors and social determinants, such as smoking, obesity, environmental exposures, poverty, exercise, and the like, the fact remains that age itself is a major independent predictor of many diseases, such as dementia, and has important clinical consequences for the presentation of diseases and responses to treatments.

The tendency to minimize the utility of age is also seen when policy makers espouse the importance of education, race, geography, or socioeconomic status as a rationale for avoiding the use of a specific age standard for eligibility for benefits such as health insurance, food supplements, or social insurance. In this vein the authors say, “Highlighting this variability among older people matters, because all too often policies that are considered when trying to respond to the perceived threats of population ageing take a broad-brush approach. Whether proposing to deal with fiscal pressures by raising pension ages across the board or resisting calls to expand entitlement to long-term or social care services without acknowledging the huge variation in access to informal care or abilities to self-fund social care, all too often older people are treated like a single homogeneous group” (33). As discussed above, while I fully recognize the importance of identifying the root causes of risk or disadvantage and targeting those who can most benefit from special attention or assistance, at both the population level and the policy level age continues to serve as a very useful predictor and widely accepted criterion.

The limitations of minimizing the relevance of age are perhaps most prominent in the volume's treatment of the experience with the COVID-19 pandemic, when they attribute much of the dramatic excess age-related mortality to social factors. “The risk of hospitalization and death from the virus, then, varied with age and other co-morbidities such as hypertension and diabetes. Again, these reflect inequalities such as class, race, and ethnicity. COVID-19 is clearly more dangerous to older people, but the odds of catching it and having the other co-morbidities that make it more dangerous are all reflective of deeper social inequalities from which age is mostly a distraction” (14).

I disagree. The facts are clear when it comes to COVID-19 and aging. As the authors correctly indicate, within the oldest age groups the risk of morbidity and mortality is strongly influenced by comorbidities such as diabetes and obesity, which are associated with social factors. However, it is also very apparent that there is a dramatic increase in risk among older persons compared to their younger counterparts that is not attributable to social factors; rather, biological causes are at work. Starting in early adulthood and progressing throughout the life course, the immune system of all mammalian species undergoes several functionally important changes. This is due to aging, not education or economic status. One arm of the system—the cellular component, which includes T cells that directly attack infectious agents and B cells that produce antibodies against them—is progressively impaired with advancing age, which is why older persons, regardless of their social status, require a higher-dose vaccine to elicit a clinically protective response from these cells. The other arm of the immune system, inflammation, is excessively upregulated with aging (the so-called “inflammaging”), which results in an adverse release of biological mediators called cytokines that cause damage to end organs such as lungs and the cardiovascular system. This “cytokine storm” was a major cause of age-related increases in morbidity and mortality during COVID-19. The term “immune system” does not appear. To characterize these very well described, clinically important aspects of aging as “mostly a distraction” neglects important opportunities for research that can advance the health of older persons—after all, the title of this book is Ageing and Health. While “age” may be a number, “aging” is an important life-course process with major biological, physiological, clinical, psychological, and social consequences.

Lastly, this volume is focused solely on Europe, which is proper given its origin in the European Observatory on Health Systems and Policies. Nonetheless, it would be useful to read what these experienced policy scholars feel about the relevance of the lessons they learned in Europe to the challenges of aging societies elsewhere, including not only high-income countries that may resemble European nations but also lower-income countries.