Persistent social unrest, growing financial inequality and choking urban density might not be traits usually associated with longevity, but despite the troubles currently gripping the city, Hong Kong has the highest life expectancy in the world.

According to the United Nations Vital Statistics Summary and Life Expectancy at Birth for 2016 – the most recent data available – Hong Kong women live, on average, to 87.3 years of age and men to 81.3, beating such places as Japan and Italy, which are renowned for longevity.

“It was surprising,” says Jean Woo, a professor of gerontology and geriatrics at Chinese University. “The whole world had looked to Japan; what is their secret?”

Regions dubbed “blue zones” by Dan Buettner, author of books about places conducive to old age, such as the province of Ogliastra, in Sardinia, and the centenarian-riddled Nicoya Peninsula, in Costa Rica, conjure up images of bucolic villages sitting alongside cerulean waters. Hong Kong, however, benefits from many aspects of its urban density, and Woo suggests the legacy of British colonial rule has left many well-designed Hong Kong neighbourhoods.

“Sha Tin is an example of good design,” says Woo. “It was just swamps before and was purpose-built – they had a blank sheet of paper to design it. There is a river and every­one walks by it, there are green spaces, parks and the public housing is very good.

“Our green space is not empty like a football field, there are things in it. You can socialise, do physical activity and you can rest your eyes. It isn’t just buildings higgledy-piggledy like a maze. It affects air quality as there is good airflow.”

She describes Sha Tin’s Lek Yuen Estate, built in 1975 and com­prising seven residential blocks, as an example of a place that the elderly don’t want to move away from, despite its charmless appearance.

“There is a wet market, little shops, a clinic next door and it is a transport hub,” Woo says. “The elderly don’t get isolated as everyone greets them. They go out every day; they don’t want to stay at home because it is cramped so they get exercise, sunlight and no vitamin D deficiency.”

Woo also points out that the built environment is con­centrated, meaning Hongkongers can walk places, or even go hiking on the city’s many trails.

Dr Kim Mak Kin-wah, chairman of the Hong Kong Society for the Aged, says that the compact environ­ment also has its benefits in emergencies.

“When older people need medical atten­tion, the ambulance arrives quickly and the hospital is only a short distance away,” he says. “Hong Kong is also lucky because we don’t have natural disasters. Or many factories. It is a service-based economy. High-risk situations don’t arise as much.”

Indeed, the 2011 earthquake and tsunami in Japan, which claimed more than 20,000 lives, was a contributing factor to the drop in Japan’s life expectancy.

Dr Jacqueline Yuen Kwan-yuk, a clinical assistant professor in geriatric medicine at the University of Hong Kong, says, “Public health measures like sanitation and clean water have prolonged life, so have medical treat­ments – especially when you look at our major killers: cancer, heart disease and strokes.

“These are illnesses that can affect people even before old age and now we have treat­ments that can cure cancer and remove blockages from arteries in the heart. Smoking has been associated with so many chronic diseases and Hong Kong has taken huge steps to curb smoking rates.”

Woo says Hong Kong has “huge minuses” but the scales begin to tip when other societal aspects are taken into consideration.

“All over the world, income inequality translates to health inequality, so poor people die quicker and their life expectancy is lower. If you look at the United States, this is what happens,” she says. “You are not happy or satisfied because someone has more money than you – the media always highlights wealthy people’s lifestyles and you think, ‘Well, I’m not there yet.’ That is human nature.”

Woo believes income inequality can be ameliorated by education, which allows people to empower themselves.
“If you don’t have any education or money, you don’t get anywhere. If you have education but no money, there is still hope for you,” she says.

Yuen suggests that the high education levels of Hongkongers means they are aware of potential medical issues and take steps to monitor and maintain their health.

Old-school wisdom

According to dietitian Rhoda Ng Yin-chee, the traditional Chinese diet of steamed dishes and fresh vege­tables with no processed products reflects the eating habits of other places known for longevity, such as the Mediter­ranean, where salads and greens feature heavily in local fare.

“For several decades, our economy wasn’t good, so the diet was more plant-based. People only occa­sionally ate chicken, beef or pork, which has contributed to the high life expectancy [of the elderly who grew up on that diet],” Ng says.

“The lack of wealth meant people didn’t eat as much and did more physical activity as the work was more labour-intensive during those times.”

Shared meals were the norm, so people didn’t feel pressured to finish large portions. Ng has also observed that elderly people who eat with extended family have better nutritionthan those who live alone – some of whom suffer from malnutrition.

Traditional Chinese food culture is in stark contrast to that of the US, says Ng. Despite having the world’s highest gross domestic product, the country’s global ranking for longevity is expected to fall from 43rd in 2016 to 64th place in 2040, according to researchers at the University of Washington’s Institute for Health Metrics and Evaluation.

“A diet high in fat and sugar, with a high proportion of meat and large portion size, is a problem,” Ng says. “People don’t have to make their food; they can go to a drive-through. That might also be why there is obesity – even the drinks are loaded with sugar.”

Improvements in diet could potentially prevent one in five deaths globally, according to a study in medical journal Lancet. Hong Kong, however, is headed in the opposite direction, says Ng, and the popularity of Western cuisines and fast food has led to more cardio­vascular disease, high blood pressure and young people with diabetes. She sees patients in their 30s and 40s suffering from diet-related illnesses.

“I worry that our health status is changing, especially with childhood obesity and kids being more sedentary,” says Yuen. “Hong Kong society is experiencing a high level of stress. Political uncertainty for the future [and poor] work habits [are going to have an] impact on psychological health. We shouldn’t take it for granted that Hong Kong people will live the longest forever.”

Longevity is not contingent on a healthy diet alone. Activities such as playing mahjong, practising tai chi or taking part in festivals offer opportunities for the elderly to engage in social pursuits and combat isolation.

“Tai chi helps maintain balance and muscle strength and has psycho­logical effects to improve well-being,” Yuen says.

Master Chow Chin-ching, who holds tai chi classes at the Chen Style Tai Chi Institute, in Sheung Wan, for students of all age groups, says: “The benefits of tai chi are both mental and physical. Mentally, my students can relax, quiet their minds and focus on their bodies. Physically, tai chi helps with every part of the body, including the hip bones, joints and muscles. It also helps with blood circulation. We say the internal and external parts are moving together, yin and yang.”

His students, many of whom look young for their age, attest that tai chi has helped them with injuries, blood pressure, coordination, mental illness, insomnia, immune systems and hypertension. They also enjoy the social aspect of the classes.

Steven Yuen Yai-mun, a student in his 60s, says: “My balance is better than it was seven years ago. I feel younger now.”

A helping hand

In neighbourhoods with a high concentration of senior citizens, it is common to see domestic helpers pushing elderly people in wheelchairs. While the practice of keeping a maid is uncommon in other longevity hot spots, such as Japan, Hong Kong’s helpers have enabled many elderly to continue living in their own homes.

Mak, who has hired a helper for his mother, says: “The important thing is not the meals she cooks because that is simple, it’s the company. I find them watching TV together. Even if people live close to each other, they pretend to not know each other to create a mental space. Elderly people could be really isolated if not for their maids.”

Mahée Leclerc, marketing manager at HelperChoice, an online platform that connects maids with potential employees, says that of the domestic workers in Hong Kong, 40 per cent take care of the elderly.

“If you have a wheelchair-bound elderly person, the housing is a challenge, especially walk-ups,” says Yuen.

“Retirement homes are HK$6,000 to HK$20,000 (US$765 to US$2,551) per month, depending on the quality. When you hire a helper, the minimum monthly wage is HK$4,630,” says Leclerc. “And it is not part of the culture to put the elderly in a retirement village.”

Despite this, Yuen says, institutionalisation is becoming more common. “As a geriatrician, we try to think of ways to allow the elderly to stay at home because that is what they value,” she adds. “It is part of the culture. You see extended families living in close proximity, caring for each other.”

“If you have a wheelchair-bound elderly person, the housing is a challenge, especially walk-ups,” says Yuen.

“Retirement homes are HK$6,000 to HK$20,000 (US$765 to US$2,551) per month, depending on the quality. When you hire a helper, the minimum monthly wage is HK$4,630,” says Leclerc. “And it is not part of the culture to put the elderly in a retirement village.”

Despite this, Yuen says, institutionalisation is becoming more common. “As a geriatrician, we try to think of ways to allow the elderly to stay at home because that is what they value,” she adds. “It is part of the culture. You see extended families living in close proximity, caring for each other.”

Planning for the inevitable

Among the numerous factors that give Hongkongers their longe­vity edge could be cases where patients are kept from dying.
“There is a culture of keeping the elderly alive at all costs; they don’t care about the quality of life or their choices,” Woo says.

“We have people going in and out of the hospital to an old age home where the average age is 80 to 90 and they are dependent for years. With our life expectancy, what is a desirable [age to die]?”

There is also a sense of denial when dealing with issues of the elderly in Hong Kong, Woo says. “The health workers, doctors, social workers and students tend to go into the youth and family field, like ageing is a dirty word – it is very negative.”

With longevity comes a host of social issues that Hong Kong might not be prepared for.

“We now have more than 1.2 million elderly people. Within a generation that number will increase by 150 per cent to roughly 2.5 million,” Mak says. “The consequences of that are not recognised.”

As the number of working-age people supporting the social-welfare system declines, non-governmental organisations will play an ever greater role in delivering services to the masses. Currently, charities such as HandsOn Hong Kong send out volunteers to provide food and other basic essentials to elderly people living in private homes. They also play board games with the seniors to improve their cognitive functions and give mobile phone literacy lessons.

Among the primary issues facing the elderly is dementia, says Mak. The disease was one of the top 10 causes of death in the SAR in 2017, according to the government’s Health Facts of Hong Kong report. Mak describes cases of seniors disappearing, trying to find their childhood neighbourhoods, and says there is a need to prepare family members to have photos on hand and tell bus drivers not to let wandering seniors ride for free.

Another concern is the welfare of the carers.

“Looking after an elderly person means you can’t take a break or go on a holiday,” Mak says. “It is demanding finan­cially and could damage relationships. We need to empower the family to understand moods, forget about the little things and look at the basic individual and relationship.”

Living with purpose

In The Little Book of Ikigai (2017), scientist Ken Mogi defines the Japanese word “ikigai” as the “pleasures and meaning of life” and “the reason for getting up in the morning”. While it might sound like a New Age catch­phrase, the importance of purpose is well known to medical researchers.

The book describes a seven-year study – conducted by the Tohoku University School of Medicine, in Sendai, Japan, and published in 2008 – that analysed answers from more than 50,000 people aged between 40 and 79. The subjects were asked whether they had ikigai. It was found that the mortality rate among those who answered “yes” was significantly lower.

“Traditionally, the Chinese family is close, and Hong Kong people are willing to learn tai chi because they want to be healthy so they can look after their grandchildren,” says Chow. “They can take them to school while the parents are at work and play with them.”

“It is an important gauge,” Yuen says. “When they lose interest and are not engaged in activities that give them a sense of purpose, that signals they are in decline. We often see the phenomena of two spouses – one caring for the other – and when one dies the other follows soon after.”

Yuen describes a study at a nursing home where residents were asked to care for a plant. Those given these responsi­bilities lived longer, independent of the health conditions they were suffering from.

Given that about one-third of Hong Kong’s population will be elderly by 2064, their productivity and ability to give back to the community might be crucial; not only for society but also for their sense of purpose.

“The elderly want to be respected, have flexibility and learn more things. To contribute is much more important to them than how much they are paid,” Mak says. “They can now do things they could not afford to do when they were paying their mortgage, and have aspirations that are completely different.”

In Japan, sprightly elders often take up second careers as booksellers, artisans or baristas. Similarly, given that many Hongkongers who reach retirement are active and healthy, the age at which we consider individuals to be “old” might itself be outdated.

“Sixty used to be old. Now it is not,” says Mak. “They are capable of looking after themselves and making contribu­tions to society. We have to [take another look at] the whole concept of different stages of life and not brand people ‘elderly’ too quickly.

“This is how we can empower them to contribute.”