Understanding the Moral Injury of Depictions of Muhammad

Speaking about Muhammad, Speaking for Muslims
Author(s): Andrew F. March
Source: Critical Inquiry , Vol. 37, No. 4 (Summer 2011), pp.
806-821
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Critical Response
Speaking about Muhammad, Speaking
for Muslims
Andrew F. March
The Danish Cartoons as Moral Injury
In a recent article, Saba Mahmood has presented an intriguing
account
of what was at stake morally and emotionally for a large number
of Mus-
lims in the Danish cartoon controversy (Saba Mahmood,
“Religious Rea-
son and Secular Affect: An Incommensurable Divide?” Critical
Inquiry 35
[Summer 2009]: 836 – 62). In doing so, she offers a framework
for thinking
about such instances that takes the place of accounts that
portray the con-
flict as one between a liberal, secular commitment to free
speech and a
religious commitment to combating blasphemy. This account
instead fo-
cuses on forms of Muslim piety in which “Muhammad is
regarded as a
moral exemplar whose words and deeds are understood not so
much as
commandments but as ways of inhabiting the world, bodily and
ethically”
(p. 846). This form of religiosity should be understood as an
assimilative
“modality of attachment” or “relation . . . based on similitude or

cohabi-
tation” along the lines of the Aristotelian concept of schesis, as
opposed to
a communicative or representative relationship to the Prophet
(p. 859).
Importantly,
the sense of moral injury that emanates from such a relationship
be-
tween the ethical subject and the figure of exemplarity . . . is
quite
distinct from the one that the notion of blasphemy encodes. The
no-
tion of moral injury I am describing no doubt entails a sense of
viola-
tion, but this violation emanates not from the judgment that the
law
has been transgressed but that one’s being, grounded as it is in a
rela-
tionship of dependency with the Prophet, has been shaken. For
many
Muslims, the offense the cartoons committed was not against a
moral
interdiction . . . but against a structure of affect, a habitus, that
feels
wounded. This wound requires moral action, but the language of
this
wound is neither juridical nor that of street protest because it
does
not belong to an economy of blame, accountability, and
reparations.
Unless otherwise noted, all translations are my own.
Critical Inquiry 37 (Summer 2011)

© 2011 by The University of Chicago. 0093-1896/11/3704-
0010$10.00. All rights reserved.
806
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The action that it requires is internal to the structure of affect,
rela-
tions, and virtues that predispose one to experience an act as a
viola-
tion in the first place. [Pp. 848 – 49]
Understanding this model helps us to appreciate that not all
forms of
religiosity are chosen or self-conscious affirmations of beliefs
or proposi-
tions (p. 852) and thus that attacks on religious icons may be
experienced
as directly and irreducibly as attacks on racial groups.
Mahmood’s account is a very helpful supplement to much of the
jour-
nalistic and scholarly focus on formal legal and religious
normativity, rac-
ism and Islamophobia, and political manipulation. It also
reflects a deeply
attractive moral sensibility grounded in empathy and humility,
reminis-
cent of the late liberal theorist Judith Shklar’s sense that cruelty

takes many
forms and is the summum malum of which humans are capable.
It is in full
solidarity with that sensibility that I engage with Mahmood’s
arguments.
Which Concept of “Moral Injury”?
Mahmood spends much of her article establishing that the
cartoons
were a catalyst for a genuine sort of pain, one to which we are
not always
sensitive. But is it really the case that in much of the non-
Muslim reaction
to the Muslim reaction(s) was a refusal to accept that Muslims
may have
felt injured or pained by the cartoons or an “inability [for the
idea of moral
injury] to translate across different semiotic and ethical norms”
(p. 860)?1
I think it is actually quite easy to accept the idea that Muslims
felt a genuine
sense of pain at the portrayal of the Prophet in those images. In
fact, if
anything, perhaps Mahmood is too cautious in outlining the
many ways in
which the cartoons were a source of pain for Muslims. I would
submit that
the idea of emotional pain is really no mystery here at all. We
feel pain at all
kinds of things for all kinds of reasons. We attach ourselves to
all kinds of
1. Mahmood quotes a number of commentators who did in fact
express incredulity that

what was motivating many of the protests was genuine pain or
injury. However, I wonder
whether too much is made of these quotations, all of which were
reactions to the violent forms
that many of the protests to the republication of the cartoons
took. Perhaps we should not take
statements of incredulity that acts of violence were purely a
matter of spontaneous moral injury
as evidence that Western publics are uniformly incapable of
appreciating that many Muslims
felt an authentic form of distress.
A N D R E W F . M A R C H is an associate professor in the
Department of Political
Science at Yale University. He is the author of Islam and
Liberal Citizenship
(2009). He is presently at work on research related to speech
crimes in Islamic
legal and moral thought and the Islamic intellectual response to
secularism in
twentieth- and twenty-first-century legal and theological
discourses.
Critical Inquiry / Summer 2011 807
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symbols, figures, persons, and ideas in the assimilative way
Mahmood
describes, as the recent furor over Ground Zero as hallowed

ground dem-
onstrates.2 And, of course, there is no point in asking whether
this pain is
genuine or real. Rather, I believe that there are much harder
questions at
stake which Mahmood’s account doesn’t directly address but
perhaps pro-
vides a provocation to thinking about.
First I am curious whether Mahmood is insisting on this one
single
account of the moral injury involved in the cartoon incident.
Some might
puzzle over her use of Aristotelian concepts to account for
certain Muslim
attitudes towards the Prophet or her reading out of abstract and
formal
intellectual traditions in Islam,3 but I find her account perfectly
plausible.
2. Another good example is an incident that emerged at
Michigan State University in Fall
2005, where I was then teaching. A cartoon published in the
student newspaper on Veteran’s
Day portrayed two soldiers: an octogenarian World War II
veteran and a soldier in the
American army presently occupying Iraq. The veteran was
dressed in commemorative garb,
whereas the active soldier was covered in blood and wielding a
medieval-style cudgel. The
dialogue had the veteran saying, “I liberated a torture camp”
and the active soldier saying, “I
work in one.” This cartoon was published in the wake of the
revelations of atrocities carried out
by US soldiers in Abu Ghraib and, ironically, at the beginning
of the Danish cartoon affair. Of

course, certain conservative student groups protested outside
the newspaper demanding an
apology and the firing of the cartoonist, invoking much of the
same sentiment of “moral
injury” described by Mahmood. For these students, American
flags and soldiers were symbols
of identity and moral attachment inappropriate for use in this
way to make a political
argument.
3. Ironically, the urge to downplay abstract or formal
intellectual reflection about belief
and doctrine in Islamic religiosity has a tradition in Western
Orientalist approaches to Islam
that have tended to avoid serious study of Islamic theology.
In part this flowed from the persistence of nineteenth-century
assumptions about the mar-
ginality of abstract intellectual life in Islam, and about the
greater intrinsic interest and orig-
inality of Muslim law and mysticism. It was also commonly
thought that where formal
metaphysics was cultivated in Islamic civilisation, this was
done seriously only in the con-
text of Arabic philosophy (falsafa), where it was not obstructed
by futile scriptural controls,
and where it could perform its most significant function, which
was believed to be the
transmission of Greek thought to Europe. However, a steady
process of scholarly advance
over the past two decades, coupled with the publication of
critical editions of important
early texts, has turned the study of Muslim theology into a
dynamic and ever more intrigu-
ing discipline. Old assumptions about Muslim theology as either
a narrow apologetic exer-

cise or an essentially foreign import into Islam have been
successfully challenged. [Tim
Winter, “Introduction” to The Cambridge Companion to
Classical Islamic Theology, ed.
Winter (Cambridge, 2008), p. 1]
In raising this I do not mean to insinuate that Mahmood’s
approach to Muslim religiosity
(based on a focus on the daily lived practices of disciplining the
body) inadvertently resurrects
old Orientalist attitudes about Muslims’ lack of intellectual
sophistication in matters of
theology, ethics, law, or politics and their more bodily and
sensuous habitus. However, what I
do intend to deflate is the sense that this attitude towards
Muslim religiosity evidenced in
Mahmood’s outstanding scholarly contribution is in itself
complete without approaches that
examine more formal Islamic intellectual attitudes towards
normativity. The formal, public
contestation of Islamic norms is no less a lived practice for
believing Muslims than the practices
808 Andrew F. March / Critical Response
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(In fact, it is somewhat obvious; Muslims really love the
Prophet and hate
for him to be mocked or disdained.) My concern is whether it

has to be the
sole account or is even an account distinct from others.
Mahmood con-
cedes that there were certainly many sources of Muslim anger
over the
cartoons, with many kinds of political motivation at stake (p.
842). How-
ever, she occasionally slips into speaking of “the kind of
religiosity at stake
in Muslim reactions to the Danish cartoons” (pp. 852–53, my
emphasis).
The force of Mahmood’s account, on my reading, is its subtlety
and sen-
sitivity to the varieties of religious sensibilities and practices
amongst Mus-
lims. It would be a shame if appreciation for practices of piety
that are not
reducible to political ideology or to Islamic juridical modalities
itself be-
comes a kind of academic orthodoxy whereby we see belief as a
Protestant
concern, thus leading us to assume that authentic Muslim and
other relig-
iosities must lie primarily in the sensorium.
Mahmood’s focus on moral injury derived from an assimilative
model
of relating to the exemplar of the Prophet is an important
corrective, a
crucial part of the entire landscape, just as both formal secular
jurispru-
dence and popular Western attitudes towards Muslims are
crucial pieces
of the puzzle on the non-Muslim side. But this schesis model is
still just one
approach, important as it is. Unfortunately, confusing a certain

refined
academic theory of how to speak about Muslim piety with the
full range of
actual Muslim moral commitments has some bizarre
consequences, as
when Mahmood counsels European Muslims not to look to
European
human rights law to suppress blasphemous speech about the
Prophet.
I fully agree with Mahmood that coercive laws should not be
deployed
to suppress injurious speech and fully agree that looking to
secular Euro-
pean law to protect Islamic religious sentiments contains a
whole set of
paradoxes and dangers. (For that matter, so does the
codification of Is-
lamic law in the positive legal systems of Muslim majority
states.) How-
ever, Mahmood’s account of that paradox is misleading and
potentially
patronizing. She writes that Muslims in Europe were only
attracted to the
legal option because they were “committed to preserving an
imaginary in
which their relation to the Prophet is based on similitude and
cohabita-
tion” (p. 859). Well, who says? Muslims have given a wide
range of argu-
of schesis/habitus which Mahmood so sensitively depicts, and
we ought to be wary of
genealogies of subject-formation through discourse and habitus
that reduce Muslim politics
and ethical life to predetermined outcomes.

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ments for both voluntary and coercive restraints on injurious
speech in
Europe at least since the Salman Rushdie affair, and to reduce
their reli-
gious imaginary to nothing other than this specific desire to
preserve “an
imaginary in which their relation to the Prophet is based on
similitude and
cohabitation” sounds contrived to say the least, particularly
when speak-
ing about a religious community that has such a long tradition
of seeing
law in all of its forms—not just pure forms of sharı�‘a as
articulated by
jurists but also imperfect simulacra of this ideal advanced by
imperfect
secular rulers—as a crucial component of what believers should
expect
and strive for in this world. I believe that Muslims open
themselves up to
awkward interferences in religious matters by secular states in
both Mus-
lim and non-Muslim societies when they seek legal protections
from blas-
phemy; but I don’t think they are irrational or suffering from

false
consciousness when they think they want the legal protections
per se. Both
Islamic law and the law of modern Muslim states have always
insisted on
such legal protections; it makes perfect sense from a religious
standpoint
that this is one thing Muslims might try to achieve in the West.
However, I would suggest further that even the idea of moral
injury is
compatible with many kinds of religiosities, in addition to the
schesis
model Mahmood advances. In fact, Mahmood does not give a
clear defi-
nition of what she means by “moral injury” and specifically
what the mod-
ifier moral is adding to the concept of injury. How does moral
injury differ
conceptually from any kind of emotional pain inflicted by the
criticism
and mockery of others? How does it differ from the kind of
emotional pain
or discomfort inflicted by having to suffer the disapproved
actions of oth-
ers in public? However, in addition to the obvious normative
problems
with endorsing a concept like moral injury for political and
moral guid-
ance in diverse societies (the logic of this concept is precisely
that invoked
by those opposed to even bare tolerance for homosexuality, the
legality of
burning the American flag, or, indeed, equality for minority
religious
groups such as Muslims),4 it is not clear how this concept

provides for the
kinds of distinctions Mahmood wishes to draw between
“violation emanat-
[ing] from the judgment that the law has been transgressed [and
the feeling]
that one’s being, grounded as it is in a relationship of
dependency with the
Prophet, has been shaken.” It seems to me that the idea of moral
injury is
equally at stake in judgments that the law has been transgressed
as it is with the
feeling that one’s being has been shaken. In fact, it is hard to
understand ex-
actly what the objection to the violation of the moral law is,
unless it is some
4. As we have seen ad nauseam throughout the summer and fall
of 2010 in the United States.
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kind of moral injury to the community—which is precisely how
“God’s
rights” (huquq Allah) are often characterized in Islamic legal
theory.
Furthermore, it is far from clear to me why Mahmood needs to
erect

this unnecessary kind of binary between speech that
immediately disrupts
a subject’s structure of ethical affect and speech that would be
character-
ized by that subject as blasphemy or as a violation of a moral
law. Are these
two distinct kinds of injury for the religious subject, or is she
saying that the
vast majority of pious Muslims simply don’t think in terms of
blasphemy
or violations of a moral code at all? (The latter seems unlikely
to say the
least.) In failing to tell a more complete story of how speech is
constructed
as injurious, this account thus erects a series of artificial and
false binaries
between speech that immediately disrupts a subject’s structure
of ethical
affect and speech that would be characterized by that subject as
blasphemy,
between the immediate sense of injury because of the kind of
subject the
religious subject is and the conscious political decision to
protest or endure
speech in this or that instance, and between belief-centered
religiosity and
habitus-centered religiosity. Mahmood’s account thus seems to
have in-
advertently flattened the rich landscape of religious
subjectivity.
For the sake of argument, let us take a quick look at the logic of
com-
bating blasphemy in Islamic juridical discourses. A good source
for this
kind of thinking is the Islamic legal literature on the “objectives

of the Law”
(maqa� �sid al-sharı�‘a). This literature is popular amongst
Islamic legal re-
formers because of the way in which it replaces more formalist,
language-
based methods with morally substantive, purposive ones.
However, it is
also an excellent source for juridical and theological reflections
across the
ideological spectrum on the deeper meanings and purposes of
long-
standing legal norms. Reflections on the laws against blasphemy
and her-
esy are frequently treated as belonging to the sharı�‘a
“objective” (maq�sad)
of “preserving religion” ( �hif �z al-dı�n), one of the five
“necessary objectives”
( �daru� riyya�t) of the Law according to virtually all
scholars.
First of all, this juridical discourse complicates slightly
Mahmood’s pic-
ture of an assimilative, habitus-based relationship with the
Prophet set
against a communicative, proposition-based one. The jurists are
inter-
ested in both. From a short manual on the maqa� �sid al-
sharı�‘a designed for
popular consumption: “Religion consists of divine rules that
God has re-
vealed through prophets to guide mankind to truth in matters of
belief and
to good in matters of behavior and social relations. Religion
constrains
mankind by these rules and brings them into submission to their
commands

and prohibitions so that they may attain the happiness of this
world and the
next. . . . Complete, perfect religion is composed of four
elements: faith (ı�ma�n),
external submission (isla�m), belief in right doctrines
(i‘tiqa�d), and works
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(‘amal).”5 There is no reason, then, to see the pietistic
conception of assimila-
tion to exemplars through daily habits as something that
necessarily gives us a
different understanding of the meaning of the Prophet from
more formal
juridical conceptions. Each rests on the other, and they interact
in complex
and variable ways for different believers at different times.
Let us consider, then, how this kind of legal discourse treats
slanderous
speech about the Prophet. First, what is blasphemy? In the
Islamic juridical
tradition, the crime in question is sabb (or shatm) al-nabı� —
the reviling or
slandering of the Prophet. Thus, implicit in the very language of
how
jurists speak about what is commonly referred to in English as

blasphemy is
the idea of moral harm and injury (as, of course, it is in the
word blas-
phemy, often thought to derive from the Greek for “hurtful” or
“harmful
speech”). Furthermore, jurists do not uniformly adopt a
formalist, deon-
tological, legalistic understanding of the danger of allowing the
Law to be
violated. Their understanding is shot through with not only
substantive
moral and political objectives but also a conception of the
multiple kinds
of moral harms involved. A particularly expansive, yet succinct,
account is
provided by a contemporary scholar seeking to appropriate for
today
views of the jurist-theologian Ibn Taymiyya (d. 1328).
According to this
scholar, blasphemy is punished and the honor of the Prophet is
protected
because
when the honor of the Prophet is violated then respect for and
ag-
grandizement of the Prophet’s mission collapses, and thus so
col-
lapses everything which he achieved. . . . The collapse of the
honor
and glorification of the Prophet is the collapse of religion itself.
This
demands vindication through the killing of the blasphemer. . . .
He
who blasphemes against the Prophet and attacks his honor
[yasubb
al-rasu� l wa yaqa‘ fı� ‘irdihi] is trying to corrupt people’s

religion and
by means of that to also corrupt their worldly existence.
Whether or
not they succeed, the person trying to corrupt another’s religion
is
therefore seeking to “sow corruption on Earth.”6 Defaming
religion
and casting ugly aspersions on the Prophet so that people will
have an
aversion towards him is amongst the greatest of corruptions.
Further-
more, blasphemy is a form of sacrilege against the Prophet and
an
5. ‘Abd Alla�h Mu �hammad al-Amı�n al-Na‘ı�m and Yu�
suf al-Bashı�r Mu �hammad, Maqa� �sid
al-sharı�‘a al-Isla�miyya (Khartoum, 1995), p. 26.
6. This phrase “fasa�d fi‘l-ar �d. . .” is taken from a verse in
the Qur’an often used to establish
capital punishment for those who rebel against the state or
provoke such rebellion through
propaganda or incitement. It has served as a very flexible and
supple legal tool in the hands of
Islamic governments, including most recently the Islamic
Republic of Iran, to justify charges of
treason against political and ideological dissenters.
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affront7 to God, His Prophet and His believers. It is an attempt
on the
part of infidels to subvert the Islamic order, to humiliate
believers, to
remove the glory of religion and debase the word of God . . . all
of
which are amongst the most grievous forms of “corruption on
Earth.”8
If that seems a bit too academic or rehearsed, consider a letter
to the editor
of the New Haven Register applauding Yale University Press’s
decision not
to reprint the cartoons: “The cartoons portray outright lies and
distor-
tions. . . . When it comes to God and his divine wisdom in
appointing
prophets there are boundaries that cannot be crossed. . . . For
Muslims,
Muhammad was a mercy sent by God to the entire world. To
portray him
as less than that is blasphemy and it is incumbent upon those
who have
intelligence to direct the majority away from such contemptuous
acts.”9
Surely such statements are as relevant as that of the young
British Muslim
Mahmood quotes (p. 846), and while Mahmood may then
interpret such
an utterance not primarily as a belief-statement but rather as a
kind of
discursive practice by which Rasheed cultivates a certain ethical
subjectiv-

ity or state of affect this might be news to Rasheed.
My point here is absolutely not to suggest that all Muslims
wounded by
the cartoons share and endorse all of these more absolutist
politico-legal
views. Rather, my concern is with the concept of moral injury
as a herme-
neutic for helping us to understand the particular way in which
pious
Muslims not necessarily attracted to juridical methods were
injured by the
Danish cartoons. For the jurists, scandalous and mocking speech
about the
Prophet is nothing other than a moral injury, for it is an attempt
to corrupt
the entire social, psychological, and affective edifice on which
morality
rests. Thus, it remains to be shown just how Mahmood’s
account moves us
beyond a blasphemy model for understanding what was at stake
in the
cartoon controversy.
There is another account of the reaction to the cartoons that is
also
perfectly compatible with the idea of moral injury. It is found in
a concise
way in Slavoj Žižek’s remarks on the cartoon controversy:
The Muslim crowds did not react to the Muhammad caricatures
as
such. They reacted to the complex figure or image of the West
that
7. A� dha� is more commonly used for harm or injury but out

of concern for the theological
complexities arising from the idea that God could be harmed or
injured by human actions I will
translate it as an “affront to.”
8. Yu� suf A �hmad Mu �hammad al-Badawı�, Maqa� �sid
al-sharı�‘a ‘ind Ibn Taymiyya (Amman,
2000), pp. 455–56.
9. Jamilah Rasheed, “Excluding Cartoons a Step toward
Justice,” New Haven Register, 18
Sept. 2009, p. A4.
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was perceived as the attitude behind the caricatures. Those who
pro-
posed the term “Occidentalism” as the counterpart to Edward
Said’s
“Orientalism” are right up to a point: what we get in Muslim
coun-
tries is a certain ideological vision of the West which distorts
Western
reality no less, although in a different way, than the Orientalist
vision
distorts the Orient. What exploded in violence was a web of
symbols,
images and attitudes, including Western imperialism, godless

materi-
alism, hedonism, and the suffering of Palestinians, and which
became
attached to Danish cartoons. This is why the hatred expanded
from
the caricatures to Denmark as a country, to Scandinavia, to
Europe,
and to the West as a whole. A torrent of humiliations and
frustrations
were condensed into the caricatures. This condensation, it needs
to be
borne in mind, is a basic fact of language, of constructing and
impos-
ing a certain symbolic field.10
There are at least two interpretations of this account. One, in
fact, I would
suggest is the same kind of schesis-based account Mahmood
advances in
her article. Only here, the object of assimilation is not the
Prophet but the
community of Muslims. The other interpretation is an honor-
based ac-
count. In other words, for Žižek the cartoons were not an assault
on the
Prophet’s honor but on Muslims’ honor. Mahmood does not
deny that
such an honor-based response to the cartoons was present in
much of the
popular reactions. However, what she does not address is
whether such a
motivation also counts as a form of moral injury. Since she does
not give a
definition of moral injury, we cannot know, but I see no reason
for dis-
counting this emotion as a legitimate form of moral injury. How

could it
be otherwise if we understand the social bases of individual and
group
self-respect to be moral goods? In short, I am not sure what
work the
concept of moral injury does for us in her article.
There are two responses available to Mahmood at this point.
One is to
deny that many Muslims operate with anything other than her
“lived re-
lationship” and “embodied piety” conception of religiosity. But
that is
clearly invalidated by any sincere and open-minded survey of
Muslim
public discourse, even in the West. The other is to accept that
these other
sources of injury—the juridical/blasphemy source and the
identitarian/
honor source—are indeed kinds of moral injury equally salient
and real as
the kind she is interested in exposing but that the latter kind is
particularly
worthy of our moral concern. That is, she might argue that we
should be
more concerned about pious Muslims for whom the cartoons
represented a
10. Slavoj Žižek, Violence: Six Sideways Reflections (London,
2008), p. 51.
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disruption of their attachment with the Prophet and thus more
troubled
by their pain than about the pain of Muslims reacting out of
injury to a
comprehensive politico-religious conception or out of
communal honor.
But I simply don’t see why this is the case. As a fellow citizen,
I am
concerned about the pain both of those for whom slandering the
Prophet
represents an attack on a conception of religious objectives and
of those for
whom slandering the Prophet amounts to an intercommunal
provocation.
Personally, I certainly was troubled by the way in which
“doctrinal Mus-
lims” and “identity Muslims” were pained by the cartoons. For
that mat-
ter, I am also concerned about the subjective pain felt by
conservative
Christians witnessing the gradual replacement of their
conception of mar-
riage with a new, fairer one more inclusive of all kinds of love
and attach-
ment. I was troubled by the pain felt by my students who were
outraged by
the Abu Ghraib cartoon in the Michigan State student
newspaper. I dis-
agree with them, and I don’t want their views inscribed as law
or informal

morality in a diverse society, but that does not mean that I
cannot empa-
thize with the injury they feel.
In fact, in an odd paradox, is Mahmood herself not possibly
reinforcing
some of the “liberal, secular” assumptions about violence and
blasphemy
in advancing her account? By diverting attention away from
those Mus-
lims who have a more intellectualized and politicized account of
what is
wrong with blasphemy and mockery, as well as from those
Muslims of-
fended on community honor grounds, towards the more
sympathetic and
anodyne (to a liberal, secular sensibility) feelings of pious
Muslims who are
not interested in an “an economy of blame, accountability, and
repara-
tions” (p. 849), is she in fact siding with those who think that
blasphemy
and mockery have no claim in the modern world if they are
motivated by
a religious doctrine or a group identity? Is she in fact agreeing
with those
who suggest that religious doctrine or community honor are not
good
grounds for feeling wounded and therefore that we must instead
invoke a
secular conception of subjectively authenticated harm and pain?
If not,
then it would be interesting to hear an account of how the moral
injury she
outlines in her article is more troubling or worthy of concern
than the

moral injury felt on doctrinal-religious grounds or community-
identity
grounds and how her model of religious subjectivity raises any
serious
challenges at all for liberal secularism (outside of France, that
is!).
What Was the Injury in the Danish Cartoons?
A robust concept of moral injury should be able to provide an
account
of what the injury at stake is. Mahmood is dismissive of two
lines of argu-
ment: that it should be within the power of pious Muslims in the
modern
��129.8.242.67 on Tue, 31 Dec 2019
03:03:57 UTC��
world to ignore the doodles of a few cheeky Danes and that the
cartoons
were protected political speech because there are real concerns
about the
relationship of religion and violence. The first “naturalizes a
certain con-
cept of a religious subject but also fails to attend to the
affective and em-
bodied practices through which a subject comes to relate to a
particular

sign—a relationship founded . . . on attachment and
cohabitation” (pp.
841– 42). The second involves seeing the cartoons as
“statements of facts,”
that is, as relying on a conception of Muslims as state security
threats
should they get their way on the cartoon issue (p. 854).
How, exactly, does “attend[ing] to the affective and embodied
practices
through which a subject comes to relate to a particular sign—a
relation-
ship founded . . . on . . . attachment and cohabitation” refute,
however, Art
Spiegelman’s dismay that “dopey cartoons” provoked violent
demonstra-
tions?11 Surely Mahmood does not mean to suggest that having
a relation-
ship of attachment and cohabitation with the Prophet is a
suitable
explanation for the countless complex questions we need to
answer in
order to explain various kinds of political action. Mahmood
confuses here
the idea that Muslims may have objected to the cartoons in good
faith or
been genuinely hurt by them prior to consulting a proper
religious author-
ity with the idea that their political and moral agency is entirely
predeter-
mined by their religious subjectivity. Talal Asad seems to have
made the
same error: “it becomes difficult for the secular liberal to
understand the
passion that informs those for whom, rightly or wrongly, it is
impossible to

remain silent when confronted with blasphemy, those for whom
blasphemy
is neither ‘freedom of speech’ nor the challenge of a new truth
but some-
thing that seeks to disrupt a living relationship.”12
The fact that people claim to have “no choice” but to act or
respond in
a certain way does not make this true. The claim that “I can do
no other” is
not a factual claim but rather a figure of speech (“I can do no
other without
great effort or cost to my aims”) or socialization to the point of
mystifica-
tion. In fact, people often do experience a certain distance
between their
selves and some of their constitutive beliefs or practices; the
latter change,
are debated, and are replaced. How a pious Muslim “must”
respond (emo-
tionally and physically) to an insult to the Prophet is not a
natural fact or
even one predetermined by the discursive tradition that creates
her or his
form of religious subjectivity. Rather, it is an evolving product
of many
11. Art Spiegelman, “Drawing Blood: Outrageous Cartoons and
the Art of Outrage,”
Harper’s Magazine (June 2006): 47.
12. Talal Asad, “Free Speech, Blasphemy, and Secular
Criticism,” in Asad et al., Is Critique
Secular?: Blasphemy, Injury, and Free Speech (Berkeley, 2009),
p. 46.

��129.8.242.67 on Tue, 31 Dec 2019
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inputs, including the ongoing discourses and debates within the
religious
community.
Put differently, when secular political theorists (as well as
theologians)
refer to religion as involving belief, this should not be
understood tenden-
tiously and simplistically as only referring to “privatizable”
belief about
theological matters that neither break my leg nor pick my
pocket (the
nature of Christ, who exactly was God’s final prophet), but also
beliefs
about action in the common social world. The proposition
“insults to the
Prophet Muhammad must be avenged in some way” is a belief
statement,
as are the range of arguments that explain and justify it. It is no
part of
critical inquiry of any form or persuasion to object to one
narrative on the
grounds that it “naturalizes a certain concept of the religious
subject” by
merely offering an alternative but equally dogmatic
naturalization of the

religious subject.
Similarly, it is easy to see what is meant by those who seek to
defend the
cartoons as political speech. It does not mean to suggest, pace
Mahmood,
that anyone who defends the cartoons as political speech is
endorsing as
fact what the cartoons were supposedly stating. Rather, what is
being sug-
gested is that the Danish cartoons (like the cartoon from the
Michigan
State student newspaper) were not simply gratuitous offenses
akin to a
noose at a multiracial high school or, say, a picture of a pig
with the name
“Muhammad” written on it. In both of those cases, it is clear
that no
valuable political speech is being voiced beyond “we hate
African-
Americans” or “we think your so-called prophet is like the most
impure
animal in your religion.” In other words, in banning or even
discouraging
speech that might contain political commentary not in itself a
violation of
human dignity, however injurious to some sensibilities that
commentary
may be, there are costs, costs that we are cautious in imposing.
Besides, what were the cartoons suggesting as fact? Were they
simply
suggesting that Muhammad was a terrorist plain and simple?
Maybe, and
it certainly matters that many Muslims took the cartoon as
suggesting this.

But why is this an occasion to leave all of our interpretive
habits at the
door? Is it even possible that the infamous bomb-in-the-turban
cartoon
was a satire on jihadis, not on Islam at large? Is it even possible
that the
cartoon may thus be read as equivalent to What Would Jesus
Bomb? bum-
per stickers— effective mockery of outlandish political
ideologies which
seek to justify their violence in the name of religious founders?
Presumably Mahmood regards as sufficiently obvious both what
was
injurious about the cartoons and why they needed to be
responded to. But
so much more of interest can be discussed here and she is so
well-placed to
contribute to that discussion that it is a pity she did not say
more on it. For
��129.8.242.67 on Tue, 31 Dec 2019
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her “attachment-and-cohabitation-with-the-Prophet” Muslims,
what ex-
actly was so injurious? That Muhammad was portrayed visually
at all? That
he was portrayed by non-Muslims? That he was portrayed in a

mocking or
irreverent fashion? That he was portrayed as a terrorist? That
non-
Muslims were getting away with it?
More troubling for Mahmood, I believe, is that her account
seems
somewhat self-contradictory. If pious Muslims truly inhabit a
closed
world of attachment, assimilation, and cohabitation with the
Prophet or,
in Asad’s terms, experience a “lived relationship,” then how is
their being
so easily shaken by outsiders? What specific actions of
outsiders have the
capacity to rock one’s world in this way? Importantly, accounts
that focus
either on the idea of transgression of a boundary or violation of
honor do
not have this problem. Here it is easy to see why the speech of
others injures
or enrages.
Mahmood’s account, alas, is strangely apolitical and strangely
context-
averse. If a jihadi website has a silhouette of the Prophet
departing for
battle, while that website defends the kinds of acts insinuated
by the car-
toons, is that not a source of moral injury for the pious Muslims
Mahmood
is describing? If a jihadi website proudly proclaims that the
Prophet him-
self engaged in the kinds of acts jihadis are trying to justify—
indeed that
they are also trying to emulate the Prophet and assimilate their

behavior
into his!—is that not also a source of moral injury for
politically quietist
“attachment-and-cohabitation-with-the-Prophet” Muslims? Why
does it
not seem to invoke the kind of reaction that the Danish cartoons
did?
The psychology of offense and moral injury is a complex issue,
and I do
not propose any answers here. But it is clear that the internal
religious
attitudes of pious Muslims toward the Prophet alone do not
explain why
the Danish cartoons invoked the response that they did. There is
a complex
set of political and social contexts involving the identity of the
perpetra-
tors, the geopolitical moment, and the visual form of the speech
act, all of
which need to be taken into account in addition to the apolitical
and
ahistorical nature of pious assimilation and cohabitation with
the Prophet.
That is, there is more to the story than Muslim piety per se. For
those, like
Mahmood, interested in using the concept of moral injury not
only for
descriptive purposes but also for ethical ones, I think something
more
needs to be said about this psychological dimension of offense
and injury.
What I think emerges from these reflections is that the pain
involved,
the brute injury, only partially explains what was wrong with

the Danish
cartoons. All kinds of acts on the part of others are liable to
cause pain.
How do we know when that pain is something which we are
willing to
tolerate? How do we know when the imposition of
psychological pain is a
��129.8.242.67 on Tue, 31 Dec 2019
03:03:57 UTC��
morally necessary byproduct of political action? How do we
know when
the causes or catalysts of pain are morally troubling regardless
of what aims
those inflicting the pain are trying to pursue in the world?
Mahmood is trying to bring our attention to a kind of pain that
she feels
is excluded by liberal, secularist rationality. But is she right?
We live in a
society, largely thanks to that kind of secular mentality, where
people are
self-authenticating sources of knowledge about their own pain,
where ev-
eryone is able to “identify their harms.”13 In fact, Mahmood’s
account is,
above all, a symptom of the power of this secular ethos; for she
herself

brings our attention only to the subjective injury felt by persons
(a thor-
oughly secular consideration) and not to a radically alternative
morality
whereby entities such as God, the Prophet Muhammad, or a
sacred text
themselves have moral claims on human action. Rather than
claiming that
the sacred itself ought to be an object of protection, she chooses
to remain
on the moral terrain of modern secularism by directing attention
to the
moral-emotional costs born by certain persons as a result of
speech. Even
she refuses to slip the bars of secular ideology.
The resistance that Mahmood is encountering in the case of the
Danish
cartoons is not to the idea that some pious Muslims were
genuinely hurt by
the cartoons (why else would Jyllands-Posten have published
them?), or
merely to the idea that Muslim pain of any kind matters (of
course, this is
what many in the West have a problem with), but rather to the
idea that
such pain alone—without a deeper and broader account of why
that pain
is in this context an injustice—stands out from amongst the
countless
possible sources of moral injury and emotional pain that all
citizens of
complex, morally diverse, postmodern societies encounter when
they walk
out the door, turn on the television, or open right-wing Danish
newspa-

pers. The problem is not that our liberal, secular societies
cannot recognize
and appreciate religious pain (if anything religion is still
assumed to be a
more authentic reason for moral consideration than many
secular convic-
tions, at least in the United States), it is that subjectively felt
religious pain
is no longer a trump card in a world that takes race, gender,
ethnicity, and
class as equally important sources of identity and moral
motivation.
A Politics of Witnessing?
In her conclusion, Mahmood avers that “for anyone interested in
fos-
tering greater understanding across lines of religious difference,
it would
be important to turn not to the law but to the thick texture and
traditions
13. Asad, Formations of the Secular: Christianity, Islam,
Modernity (Stanford, Calif.,
2003), p. 6.
��129.8.242.67 on Tue, 31 Dec 2019
03:03:57 UTC��

of ethical and intersubjective norms that provide the substrate
for legal
arguments. . . . Ultimately . . . the future of the Muslim
minority in Europe
depends not so much on how the law might be expanded to
accommodate
its concerns but on a larger transformation of the cultural and
ethical
sensibilities of the majority Judeo-Christian population that
undergird the
law” (p. 860).
Certainly such understanding across religious difference should
be fos-
tered, and it is certainly true that there is a deplorable tendency
in the
Euro-American public sphere to simultaneously assert that
Muslims are
disingenuous in claiming injury and also that Muslims are in
urgent need
of being injured so as to be disrupted from their archaic and
dangerous
attachments. But what “transformation of the cultural and
ethical sensi-
bilities of the majority Judeo-Christian population” do we wish
to see
exactly—that they purify themselves of racist attitudes towards
fellow cit-
izens of Muslim cultural backgrounds, that they not misuse the
secular
license to insult religion as an alibi for creating a hostile
environment for
fellow citizens of Muslim cultural backgrounds, or that they
actually com-
mit to never offending distinctly religious sensibilities held by
Muslims by

not transgressing against the sacred? Mahmood may object to
these kinds
of distinctions on the grounds that pious Muslims might not
wish to dis-
tinguish between injury to the Prophet and injury to the Muslim
commu-
nity, but for her purposes in calling for a transformation of the
Euro-
American attitude towards Muslims while also exploring the
possibility of
a critique of secularism this is the precise question that I
believe she needs
to answer.
In calling on European Muslims to develop the tools to better
“trans-
lat[e] practices and norms across semiotic and ethical
differences” even
without demanding legal remedies, I take Mahmood here to be
calling for
a version of what John Rawls referred to favorably as
“witnessing”: “it may
happen that some citizens feel they must express their
principled dissent
from existing institutions, policies, or enacted legislation. . . .
In this case
they . . . feel that they must not only let other citizens know the
deep basis of
their strong opposition but must also bear witness to their faith
by doing so.”14
Hopefully, we will someday live in a society where brute anti-
Muslim
prejudice is regarded as in the same bad taste as racism, anti-
Semitism,
sexism, and homophobia, where self-respecting people are

embarrassed to
be caught voicing ignorant and hostile statements about
Muslims. I am not
sure whether in such a society The Satanic Verses or the Danish
cartoons
14. John Rawls, “The Idea of Public Reason Revisited,” The
Law of Peoples (Cambridge,
Mass., 1999), p. 156 n. 57.
��129.8.242.67 on Tue, 31 Dec 2019
03:03:57 UTC��
would fall afoul of this sensibility, but many far more vicious
forms of
expression presently circulating in Western societies directed at
Muslims
certainly would. In the meanwhile, things are getting worse,
with neofas-
cist, nativist groups gaining strength in Europe15 and anti-
Muslim speech
(so often expressed as “resistance to creeping shariatization”)16
becoming
the go-to jingoistic gesture of the American Right. (Indeed, with
incidents
like the Swiss minaret ban, one burka ban after another in
Europe, and the
Park 51 fiasco, we cannot say that crude anti-Muslim racism is
now, if it

ever was, only freely expressed by extreme right-wing groups.)
Defeating
these groups is a political project that will require a coalition of
the reli-
gious and the secular.17
I believe that this political project is in the first order about
creating a
political culture that finally accepts the fact that Muslim
communities are
long-term stakeholders in Europe and America and where
Muslim com-
munities see public evidence of this attitude. For me, then, the
cartoons
were above all a political act potentially harmful to the long-
term project of
creating a public space where Muslims feel safe, valued, and
equal. Con-
tributing to this culture will invariably require of Muslims at
times a lan-
guage for expressing their interests and values that is more
secular than
some might like. But that is not primarily because of the
arbitrary disci-
plinary rationality of modern secularism or some “Protestant”
conception
of religion as only a matter of private belief but rather because
of (in
Mahmood’s words) the “thick texture and traditions of ethical
and inter-
subjective norms that provide the substrate for legal arguments”
presently
in circulation in Europe, that is, because of the sensibility of
Muslims’
fellow citizens in Europe. However, what Mahmood’s timely
article re-

minds us is that we must leave space for Muslims to bear
witness in what-
ever language they wish to the ways in which those ethical and
intersubjective norms affect them without the suspicion that
every expres-
sion of Islamic religiosity is a dagger aimed at the heart of
European freedom.
15. See, for example, Dominic Casciani, “Who Are the English
Defence League?” BBC News
Magazine, 11 Sept. 2009,
news.bbc.co.uk/2/hi/uk_news/magazine/8250017.stm, a report
on a
relatively new group calling itself the English Defence League.
16. See, for example, “The Islamification of England,” BNP
Reform 2011, 2 Feb. 2011,
www.bnpreform2011.co.uk/?p�375
17. Indeed, there are many Muslim religious intellectuals who
agree with this, including
Tunisian Islamist Rashid al-Ghannushi and the Mauritanian-
Saudi scholar Abd Alla�h Ibn
Bayya. Both argue that to the extent Western societies are
hospitable to Muslims at all, this is
not due to Abrahamic fraternity or residual regard for religion,
but secular humanism. It is
often precisely a Rawlsian or Habermasian form of liberal
secularism that allows these religious
scholars to argue that Western secularism is not a metaphysical
doctrine that conflicts with
Islam.

��129.8.242.67 on Tue, 31 Dec 2019
03:03:57 UTC��
National Institute on Aging
National Institutes of Health
U.S. Department of Health and Human Services
Global Health and Aging
2 Global Health and AgingPhoto credits front cover, left to right
(Dreamstime.com): Djembe; Sergey Galushko; Laurin Rinder;
Indianeye;
Magomed Magomedagaev; and Antonella865.
3
Preface
Overview
Humanity’s Aging
Living Longer
New Disease Patterns
Longer Lives and Disability

New Data on Aging and Health
Assessing the Cost of Aging and Health Care
Health and Work
Changing Role of the Family
Suggested Resources
Contents
Rose Maria Li
1
2
4
6
9
12
16
18
20
22
25

4 Global Health and Aging
5
Preface
The world is facing a situation without precedent: We soon will
have more older people than
children and more people at extreme old age than ever before.
As both the proportion of older
people and the length of life increase throughout the world, key
questions arise. Will population
aging be accompanied by a longer period of good health, a
sustained sense of well-being, and
extended periods of social engagement and productivity, or will
it be associated with more illness,
disability, and dependency? How will aging affect health care
and social costs? Are these futures
inevitable, or can we act to establish a physical and social
infrastructure that might foster better
health and wellbeing in older age? How will population aging
play out differently for low-income
countries that will age faster than their counterparts have, but
before they become industrialized
and wealthy?
This brief report attempts to address some of these questions.
Above all, it emphasizes the central
role that health will play moving forward. A better
understanding of the changing relationship

between health with age is crucial if we are to create a future
that takes full advantage of the
powerful resource inherent in older populations. To do so,
nations must develop appropriate
data systems and research capacity to monitor and understand
these patterns and relationships,
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well-being. And research needs to be better coordinated if we
are to discover the most cost-effective
ways to maintain healthful life styles and everyday functioning
in countries at different stages of
economic development and with varying resources. Global
efforts are required to understand and
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existing knowledge about the prevention and treatment of heart
disease, stroke, diabetes, and
cancer.
Managing population aging also requires building needed
infrastructure and institutions as soon as
possible. The longer we delay, the more costly and less

effective the solutions are likely to be.
Population aging is a powerful and transforming demographic
force. We are only just beginning
to comprehend its impacts at the national and global levels. As
we prepare for a new demographic
reality, we hope this report raises awareness not only about the
critical link between global health
and aging, but also about the importance of rigorous and
coordinated research to close gaps in our
knowledge and the need for action based on evidence-based
policies.
Richard Suzman, PhD
Director, Division of Behavioral and Social Research
National Institute on Aging
National Institutes of Health
1
John Beard, MBBS, PhD
Director, Department of Ageing and Life Course
World Health Organization
Preface
Figure 1.
Young Children and Older People as a Percentage of Global
Population: 1950-2050
Source: United Nations. World Population Prospects: The 2010
Revision.

Available at: http://esa.un.org/unpd/wpp.
Overview
The world is on the brink of a demographic
milestone. Since the beginning of recorded
history, young children have outnumbered
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the number of people aged 65 or older will
outnumber children under age 5. Driven by
falling fertility rates and remarkable increases in
life expectancy, population aging will continue,
even accelerate (Figure 1). The number of
people aged 65 or older is projected to grow
from an estimated 524 million in 2010 to nearly
1.5 billion in 2050, with most of the increase in
developing countries.
The remarkable improvements in life
expectancy over the past century were part
of a shift in the leading causes of disease
and death. At the dawn of the 20th century,
the major health threats were infectious and
parasitic diseases that most often claimed
the lives of infants and children. Currently,
noncommunicable diseases that more commonly
affect adults and older people impose the
greatest burden on global health.
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chronic noncommunicable diseases such as
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changes in lifestyle and diet, as well as aging.
The potential economic and societal costs of
noncommunicable diseases of this type rise
sharply with age and have the ability to affect
economic growth. A World Health Organization
analysis in 23 low- and middle-income countries
estimated the economic losses from three
noncommunicable diseases (heart disease,
3
stroke, and diabetes) in these countries would
total US$83 billion between 2006 and 2015.
Reducing severe disability from disease
and health conditions is one key to holding
down health and social costs. The health
and economic burden of disability also can
be reinforced or alleviated by environmental
characteristics that can determine whether
an older person can remain independent
despite physical limitations. The longer people
can remain mobile and care for themselves,
the lower are the costs for long-term care to
families and society.
Because many adult and older-age health
problems were rooted in early life experiences
and living conditions, ensuring good child
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In the meantime, generations of children
and young adults who grew up in poverty
and ill health in developing countries will be
entering old age in coming decades, potentially
increasing the health burden of older
populations in those countries.
With continuing declines in death rates among
older people, the proportion aged 80 or older
is rising quickly, and more people are living
past 100. The limits to life expectancy and
lifespan are not as obvious as once thought.
And there is mounting evidence from cross-
national data that—with appropriate policies
and programs—people can remain healthy
and independent well into old age and can
continue to contribute to their communities
and families.
The potential for an active, healthy old age
is tempered by one of the most daunting and
potentially costly consequences of ever-longer
life expectancies: the increase in people with
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dementia patients eventually need constant
care and help with the most basic activities
of daily living, creating a heavy economic and
social burden. Prevalence of dementia rises
sharply with age. An estimated 25-30 percent
of people aged 85 or older have dementia.
Unless new and more effective interventions

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disease, prevalence is expected to rise
dramatically with the aging of the population
in the United States and worldwide.
Aging is taking place alongside other broad
social trends that will affect the lives of older
people. Economies are globalizing, people are
more likely to live in cities, and technology
is evolving rapidly. Demographic and family
changes mean there will be fewer older people
with families to care for them. People today
have fewer children, are less likely to be
married, and are less likely to live with older
generations. With declining support from
families, society will need better information
and tools to ensure the well-being of the
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Overview
Humanity’s Aging
In 2010, an estimated 524 million people were
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population. By 2050, this number is expected to
nearly triple to about 1.5 billion, representing
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more developed countries have the oldest
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older people—and the most rapidly aging
populations—are in less developed countries.
Between 2010 and 2050, the number of older
people in less developed countries is projected to
increase more than 250 percent, compared with
a 71 percent increase in developed countries.
This remarkable phenomenon is being driven

by declines in fertility and improvements in
longevity. With fewer children entering the
population and people living longer, older
people are making up an increasing share of the
total population. In more developed countries,
fertility fell below the replacement rate of two
live births per woman by the 1970s, down from
nearly three children per woman around 1950.
Even more crucial for population aging, fertility
fell with surprising speed in many less developed
countries from an average of six children in
1950 to an average of two or three children
in 2005. In 2006, fertility was at or below the
two-child replacement level in 44 less developed
countries.
Most developed nations have had decades to
adjust to their changing age structures. It took
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population aged 65 or older to rise from 7
percent to 14 percent. In contrast, many less
developed countries are experiencing a rapid
increase in the number and percentage of older
people, often within a single generation (Figure
2). For example, the same demographic aging
that unfolded over more than a century in
France will occur in just two decades in Brazil.
Developing countries will need to adapt quickly
to this new reality. Many less developed nations
Figure 2.
The Speed of Population Aging

Time required or expected for percentage of population aged 65
and over to
rise from 7 percent to 14 percent
Source: Kinsella K, He W. An Aging World: 2008. Washington,
DC: National Institute on Aging
and U.S. Census Bureau, 2009.
5
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security of older people, and that provide the
health and social care they need, without the
same extended period of economic growth
experienced by aging societies in the West.
In other words, some countries may grow old
before they grow rich.
In some countries, the sheer number of
people entering older ages will challenge
national infrastructures, particularly health
systems. This numeric surge in older people is
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populous countries: China and India (Figure 3).
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will likely swell to 330 million by 2050 from 110
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of 60 million is projected to exceed 227 million
in 2050, an increase of nearly 280 percent from
today. By the middle of this century, there
could be 100 million Chinese over the age of 80.
This is an amazing achievement considering
that there were fewer than 14 million people
this age on the entire planet just a century ago.
Figure 3.
Growth of the Population Aged 65 and Older in India and
China:
2010-2050
Source: United Nations. World Population Prospects: The 2010
Revision.
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Humanity’s Aging
Living Longer
The dramatic increase in average life expectancy
during the 20th century ranks as one of
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babies born in 1900 did not live past age 50, life
expectancy at birth now exceeds 83 years in
Japan—the current leader—and is at least 81
years in several other countries. Less developed
regions of the world have experienced a steady
increase in life expectancy since World War
II, although not all regions have shared in
these improvements. (One notable exception
is the fall in life expectancy in many parts of
Africa because of deaths caused by the HIV/
AIDS epidemic.) The most dramatic and rapid
gains have occurred in East Asia, where life

expectancy at birth increased from less than 45
years in 1950 to more than 74 years today.
These improvements are part of a major
transition in human health spreading around
the globe at different rates and along different
pathways. This transition encompasses a
broad set of changes that include a decline
from high to low fertility; a steady increase
in life expectancy at birth and at older ages;
and a shift in the leading causes of death and
illness from infectious and parasitic diseases
to noncommunicable diseases and chronic
conditions. In early nonindustrial societies, the
risk of death was high at every age, and only a
small proportion of people reached old age. In
modern societies, most people live past middle
age, and deaths are highly concentrated at older
ages.
The victories against infectious and parasitic
diseases are a triumph for public health
projects of the 20th century, which immunized
millions of people against smallpox, polio,
and major childhood killers like measles. Even
earlier, better living standards, especially
more nutritious diets and cleaner drinking
water, began to reduce serious infections and
prevent deaths among children. More children
were surviving their vulnerable early years
and reaching adulthood. In fact, more than
60 percent of the improvement in female life
expectancy at birth in developed countries
between 1850 and 1900 occurred because more
children were living to age 15, not because more

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the 20th century that mortality rates began
to decline within the older ages. Research for
more recent periods shows a surprising and
continuing improvement in life expectancy
among those aged 80 or above.
The progressive increase in survival in these
oldest age groups was not anticipated by
demographers, and it raises questions about how
high the average life expectancy can realistically
rise and about the potential length of the human
lifespan. While some experts assume that life
expectancy must be approaching an upper limit, Be
rn
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Figure 4.
Female Life Expectancy in Developed Countries: 1840-2009
Source: Highest reported life expectancy for the years 1840 to
2000 from online supplementary
material to Oeppen J, Vaupel JW. Broken limits to life
expectancy. Science 2002; 296:1029-
1031. All other data points from the Human Mortality Database
(http://www.mortality.org)
provided by Roland Rau (University of Rostock). Additional
discussion can be found in
Christensen K, Doblhammer G, Rau R, Vaupel JW. Aging
populations: The challenges ahead.
The Lancet 2009; 374/9696:1196-1208.
Living Longer
data on life expectancies between 1840 and 2007
show a steady increase averaging about three
months of life per year. The country with the
highest average life expectancy has varied over
time (Figure 4). In 1840 it was Sweden and
today it is Japan—but the pattern is strikingly

similar. So far there is little evidence that life
expectancy has stopped rising even in Japan.
The rising life expectancy within the older
population itself is increasing the number and
proportion of people at very old ages. The
“oldest old” (people aged 85 or older) constitute
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12 percent in more developed countries and 6
percent in less developed countries. In many
countries, the oldest old are now the fastest
growing part of the total population. On a
Figure 5.
Percentage Change in the World’s Population by Age: 2010-
2050
Source: United Nations, World Population Prospects: The 2010
Revision.
global level, the 85-and-over population is
projected to increase 351 percent between 2010
and 2050, compared to a 188 percent increase for
the population aged 65 or older and a 22 percent
increase for the population under age 65 (Figure 5).
The global number of centenarians is projected
to increase 10-fold between 2010 and 2050. In
the mid-1990s, some researchers estimated that,
over the course of human history, the odds of
living from birth to age 100 may have risen from
1 in 20,000,000 to 1 in 50 for females in low-

mortality nations such as Japan and Sweden.
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than current projections assume—previous
population projections often underestimated
decreases in mortality rates among the oldest
old.
9
The transition from high to low mortality
and fertility that accompanied socioeconomic
development has also meant a shift in
the leading causes of disease and death.
Demographers and epidemiologists describe this
shift as part of an “epidemiologic transition”
characterized by the waning of infectious and
acute diseases and the emerging importance of
chronic and degenerative diseases. High death
rates from infectious diseases are commonly
associated with the poverty, poor diets, and
limited infrastructure found in developing
countries. Although many developing countries
still experience high child mortality from
infectious and parasitic diseases, one of the
major epidemiologic trends of the current
century is the rise of chronic and degenerative
diseases in countries throughout the world—
regardless of income level.

Evidence from the multicountry Global Burden
of Disease project and other international
epidemiologic research shows that health
problems associated with wealthy and aged
populations affect a wide and expanding
swath of world population. Over the next
10 to 15 years, people in every world region
will suffer more death and disability from
such noncommunicable diseases as heart
disease, cancer, and diabetes than from
Figure 6.
The Increasing Burden of Chronic Noncommunicable Diseases:
2008 and 2030
Source: World Health Organization, Projections of Mortality
and Burden of Disease, 2004-2030.
Available at:
http://www.who.int/healthinfo/global_burden_disease/projection
s/en/index.html.
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health problems in adulthood and old age stem
from infections and health conditions early in life.
Some researchers argue that important aspects of
adult health are determined before birth, and that
nourishment in utero and during infancy has a
direct bearing on the development of risk factors for
adult diseases—especially cardiovascular diseases.
Early malnutrition in Latin America is highly
correlated with self-reported diabetes, for example,
and childhood rheumatic fever is a frequent cause of
adult heart disease in developing countries.
Research also shows that delayed physical growth in
childhood reduces physical and cognitive functioning
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rarely or never suffering from serious illnesses or
receiving adequate medical care during childhood
results in a much lower risk of suffering cognitive
impairments or physical limitations at ages 80 or
older.
Proving links between childhood health conditions
and adult development and health is a complicated
research challenge. Researchers rarely have the data
necessary to separate the health effects of changes
in living standards or environmental conditions
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to his or her birth or childhood diseases. However,
a Swedish study with excellent historical data

concluded that reduced early exposure to infectious
diseases was related to increases in life expectancy.
A cross-national investigation of data from two
surveys of older populations in Latin America
and the Caribbean also found links between early
conditions and later disability. The older people in
the studies were born and grew up during times
of generally poor nutrition and higher risk of
exposure to infectious diseases. In the Puerto Rican
survey, the probability of being disabled was more
than 64 percent higher for people growing up in
Lasting Importance of Childinfectious and parasitic diseases.
The myth
that noncommunicable diseases affect mainly
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the project, which combines information about
mortality and morbidity from every world region
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diseases. The burden is measured by estimating the
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based on detailed epidemiological information. In
2008, noncommunicable diseases accounted for an
estimated 86 percent of the burden of disease in
high-income countries, 65 percent in middle-income
countries, and a surprising 37 percent in low-income
countries.
By 2030, noncommunicable diseases are projected

to account for more than one-half of the disease
burden in low-income countries and more than
three-fourths in middle-income countries.
Infectious and parasitic diseases will account for
30 percent and 10 percent, respectively, in low- and
middle-income countries (Figure 6). Among the
60-and-over population, noncommunicable diseases
already account for more than 87 percent of the
burden in low-, middle-, and high-income countries.
But the continuing health threats from
communicable diseases for older people cannot
be dismissed, either. Older people account for a
growing share of the infectious disease burden in
low-income countries. Infectious disease programs,
including those for HIV/AIDS, often neglect
older people and ignore the potential effects of
population aging. Yet, antiretroviral therapy is
enabling more people with HIV/AIDS to survive
to older ages. And, there is growing evidence
that older people are particularly susceptible
to infectious diseases for a variety of reasons,
including immunosenescence (the progressive
deterioration of immune function with age)
and frailty. Older people already suffering from
one chronic or infectious disease are especially
vulnerable to additional infectious diseases. For
example, type 2 diabetes and tuberculosis are well-
known “comorbid risk factors” that have serious
health consequences for older people.
11
poor conditions than for people growing up in good

conditions. A survey of seven urban centers in Latin
America and the Caribbean found the probability
of disability was 43 percent higher for those from
disadvantaged backgrounds than for those from more
favorable ones (Figure 7).
If these links between early life and health at older
ages can be established more directly, they may have
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countries. People now growing old in low- and middle-
income countries are likely to have experienced more
hood Health
Figure 7.
Probability of Being Disabled among Elderly in Seven Cities of
Latin
America and the Caribbean (2000) and Puerto Rico (2002-2003)
by Early Life
Conditions
Source: Monteverde M, Norohna K, Palloni A. 2009. Effect of
early conditions on disability among the
elderly in Latin-America and the Caribbean. Population Studies
2009;63/1: 21-35.
distress and disadvantage as children than their
counterparts in the developed world, and studies
such as those described above suggest that they are
at much greater risk of health problems in older age,
often from multiple noncommunicable diseases.

Behavior and exposure to health risks during a
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Exposure to toxic substances at work or at home,
arduous physical work, smoking, alcohol consumption,
diet, and physical activity may have long-term health
implications.
Are we living healthier as well as longer lives, or
are our additional years spent in poor health?
There is considerable debate about this question
among researchers, and the answers have broad
implications for the growing number of older
people around the world. One way to examine
the question is to look at changes in rates of
disability, one measure of health and function.
Some researchers think there will be a decrease
in the prevalence of disability as life expectancy
increases, termed a “compression of morbidity.”
Others see an “expansion of morbidity”—an
increase in the prevalence of disability as life
expectancy increases. Yet others argue that, as
advances in medicine slow the progression from
chronic disease to disability, severe disability
will lessen, but milder chronic diseases will
increase. In the United States, between 1982
and 2001 severe disability fell about 25 percent

among those aged 65 or older even as life
expectancy increased. This very positive trend
suggests that we can affect not only how long
we live, but also how well we can function with
advancing age. Unfortunately, this trend may
not continue in part because of rising obesity
among those now entering older ages.
We have less information about disability in
middle- and lower-income countries. With the
rapid growth of older populations throughout
the world—and the high costs of managing
people with disabilities—continuing and better
assessment of trends in disability in different
countries will help researchers discover more
about why there are such differences across
countries.
Some new international, longitudinal research
designed to compare health across countries
promises to provide new insights, moving
forward. A 2006 analysis sponsored by the U.S.
National Institute on Aging (NIA), part of
the U.S. National Institutes of Health, found
surprising health differences, for example,
between non-Hispanic whites aged 55 to 64
in the United States and England. In general,
people in higher socioeconomic levels have better
health, but the study found that older adults in
the United States were less healthy than their
British counterparts at all socioeconomic levels.
The health differences among these “young”
older people were much greater than the gaps
in life expectancy between the two countries.
Because the analysis was limited to non-
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the generally lower health status of blacks or
Latinos. The analysis also found that differences
in education and behavioral risk factors (such as
smoking, obesity, and alcohol use) explained few
of the health differences.
This analysis subsequently included comparable
NIA-funded surveys in 10 other European
countries and was expanded to adults aged 50 to
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reported worse health than did European adults
as indicated by the presence of chronic diseases
and by measures of disability (Figure 8). At all
levels of wealth, Americans were less healthy
than their European counterparts. Analyses of
the same data sources also showed that cognitive
functioning declined further between ages 55 and
65 in countries where workers left the labor force
at early ages, suggesting that engagement in
work might help preserve cognitive functioning.
Subsequent analyses of these and other studies
should shed more light on these national
differences and similarities and should help guide
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13
Source: Adapted from Avendano M, Glymour MM, Banks J,
Mackenbach JP. Health disadvan-
tage in US adults aged 50 to 74 years: A comparison of the
health of rich and poor Americans
with that of Europeans. American Journal of Public Health
2009; 99/3:540-548, using data from
the Health and Retirement Study, the English Longitudinal
Study of Ageing, and the Survey of
Health, Ageing and Retirement in Europe. Please see original
source for additional information.
Figure 8.
Prevalence of Chronic Disease and Disability among Men and
Women Aged 50-74 Years in the United States, England, and
Europe:
2004
The Burden of Dementia
The cause of most dementia is unknown, but the
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memory, reasoning, speech, and other cognitive
functions. The risk of dementia increases sharply
with age and, unless new strategies for prevention
and management are developed, this syndrome
is expected to place growing demands on health

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population ages. Dementia prevalence estimates
vary considerably internationally, in part
because diagnoses and reporting systems are not
standardized. The disease is not easy to diagnose,
especially in its early stages. The memory
problems, misunderstandings, and behavior
common in the early and intermediate stages
are often attributed to normal effects of aging,
accepted as personality traits, or simply ignored.
Many cases remain undiagnosed even in the
intermediate, more serious stages. A cross-national
assessment conducted by the Organization for
Economic Cooperation and Development (OECD)
estimated that dementia affected about 10 million
people in OECD member countries around 2000,
just under 7 percent of people aged 65 or older.
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form of dementia and accounted for between
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cited in the OECD report. More recent analyses
have estimated the worldwide number of people
living with AD/dementia at between 27 million
and 36 million. The prevalence of AD and other
dementias is very low at younger ages, then nearly
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65. In the OECD review, for example, dementia
affected fewer than 3 percent of those aged 65 to
69, but almost 30 percent of those aged 85 to 89.
More than one-half of women aged 90 or older
had dementia in France and Germany, as did
about 40 percent in the United States, and just
under 30 percent in Spain.
The projected costs of caring for the growing
numbers of people with dementia are daunting.
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Disease International estimates that the total
worldwide cost of dementia exceeded US$600
billion in 2010, including informal care provided
by family and others, social care provided by
community care professionals, and direct costs of
medical care. Family members often play a key
caregiving role, especially in the initial stages of
what is typically a slow decline. Ten years ago,
U.S. researchers estimated that the annual cost
of informal caregiving for dementia in the United
States was US$18 billion.
The complexity of the disease and the wide
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people and families dealing with dementia, and
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and social impact. The challenge is even greater
in the less developed world, where an estimated
two-thirds or more of dementia sufferers live
but where few coping resources are available.
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suggest that 115 million people worldwide will
be living with AD/dementia in 2050, with a
markedly increasing proportion of this total in
less developed countries (Figure 9). Global efforts
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ways of preventing such age-related diseases as
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Source: Alzheimer’s Disease International, World Alzheimer
Report, 2010. Available at:
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Figure 9.
The Growth of Numbers of People with Dementia in High-
income

Countries and Low- and Middle-income Countries: 2010-2050
The transition from high to low mortality and
fertility—and the shift from communicable to
noncommunicable diseases—occurred fairly
recently in much of the world. Still, according
to the World Health Organization (WHO), most
countries have been slow to generate and use
evidence to develop an effective health response
to new disease patterns and aging populations.
In light of this, the organization mounted a
multicountry longitudinal study designed to
simultaneously generate data, raise awareness of
the health issues of older people, and inform public
policies.
The WHO Study on Global Ageing and Adult
Health (SAGE) involves nationally representative
cohorts of respondents aged 50 and over in six
countries (China, Ghana, India, Mexico, Russia,
and South Africa), who will be followed as they age.
A cohort of respondents aged 18 to 49 also will be
followed over time in each country for comparison.
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has been completed, with future waves planned for
2012 and 2014.

In addition to myriad demographic and
socioeconomic characteristics, the study collects
data on risk factors, health exams, and biomarkers.
Biomarkers such as blood pressure and pulse rate,
height and weight, hip and waist circumference,
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and objective measures that improve the precision
of self-reported health in the survey. SAGE also
collects data on grip strength and lung capacity
Figure 10.
Overall Health Status Score in Six Countries for Males and
Females:
Circa 2009
Notes: Health score ranges from 0 (worst health) to 100 (best
health) and is a composite measure
derived from 16 functioning questions using item response
theory. National data collections con-
ducted during the period 2007-2010.
Source: Tabulations provided by the World Health Organization
Multi-Country Studies Unit,
Geneva, based on data from the Study on global AGEing and
adult health (SAGE).
17
Figure 11.
Percentage of Adults with Three or More Major Risk Factors:
Circa 2009

Notes: Major risk factors include physical inactivity, current
tobacco use, heavy alcohol consump-
tion, a high-risk waist-hip ratio, hypertension, and obesity.
National data collections conducted
during the period 2007-2010.
60%
50%
40%
30%
20%
10%
0%
18-49 50-59 60-69 70-79 80+
Age Group
and administers tests of cognition, vision, and
mobility to produce objective indicators of
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activities of daily living. As additional waves
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later years, the study will seek to monitor health
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well-being.
A primary objective of SAGE is to obtain reliable
and valid data that allow for international
comparisons. Researchers derive a composite
measure from responses to 16 questions about
health and physical limitations. This health score
ranges from 0 (worst health) to 100 (best health)
and is shown for men and women in each of the six
SAGE countries in Figure 10. In each country, the
health status score declines with age, as expected.
And at each age in each country, the score for males
is higher than for females. Women live longer than
men on average, but have poorer health status.
The number of disabled people in most developing
countries seems certain to increase as the number
of older people continues to rise. Health systems
need better data to understand the health risks
faced by older people and to target appropriate
prevention and intervention services. The

SAGE data show that the percentage of people
with at least three of six health risk factors
(physical inactivity, current tobacco use, heavy
alcohol consumption, a high-risk waist-hip
ratio, hypertension, or obesity) rises with
age, but the patterns and the percentages
vary by country (Figure 11).
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important contributions will be to assess
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and future disability. Smaller family size and
declining prevalence of co-residence by multiple
generations likely will introduce further
challenges for families in developing countries in
caring for older relatives.
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of health care spending in both developed and
developing countries in the decades to come.
In developed countries, where acute care and
institutional long-term care services are widely
available, the use of medical care services by

adults rises with age, and per capita expenditures
on health care are relatively high among older age
groups. Accordingly, the rising proportion of older
people is placing upward pressure on overall health
care spending in the developed world, although
other factors such as income growth and advances
in the technological capabilities of medicine
generally play a much larger role.
Relatively little is known about aging and
health care costs in the developing world. Many
developing nations are just now establishing
baseline estimates of the prevalence and incidence
of various diseases and conditions. �
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from the WHO SAGE project, which provides data
on blood pressure among women in six developing
countries, show an upward trend by age in the
percentage of women with moderate or severe
hypertension (see Figure 12), although the patterns
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the countries. If rising hypertension rates in
those populations are not adequately addressed,
the resulting high rates of cerebrovascular and
Assessing the Costs of Aging
and Health Care

Figure 12.
Percentage of Women with Moderate or Severe Hypertension in
Six
Countries: Circa 2009
Note: National data collections conducted during the period
2007-2010.
50%
40%
30%
20%
10%
0%
18-49 50-59 60-69 70-79 80+
Age Group
19
cardiovascular disease are likely to require costly
medical treatments that might have been avoided
with antihypertensive therapies costing just a
few cents per day per patient. Early detection
and effective management of risk factors such as

hypertension—and other important conditions
such as diabetes, which can greatly complicate the
treatment of cardiovascular disease—in developing
countries can be inexpensive and effective ways of
controlling future health care costs. An important
future payoff for data collection projects such as
SAGE will be the ability to link changes in health
status with health expenditures and other relevant
variables for individuals and households. This will
provide crucial evidence for policymakers designing
health interventions.
A large proportion of health care costs associated
with advancing age are incurred in the year or so
before death. As more people survive to increasingly
older ages, the high cost of prolonging life is shifted
to ever-older ages. In many societies, the nature
and extent of medical treatment at very old ages
is a contentious issue. However, data from the
United States suggest that health care spending at
the end of life is not increasing any more rapidly
than health care spending in general. At the same
time, governments and international organizations
are stressing the need for cost-of-illness studies on
age-related diseases, in part to anticipate the likely
burden of increasingly prevalent and expensive
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particular. Also needed are studies of comparative
performance or comparative effectiveness in
low-income countries of various treatments and
interventions.

The Costs of Cardiovascular Disease and Cancer
In high-income countries, heart disease, stroke,
and cancer have long been the leading contributors
to the overall disease burden. The burden from
these and other chronic and noncommunicable
diseases is increasing in middle- and low-income
countries as well (Figure 6).
To gauge the economic impact of shifting disease
��
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Organization (WHO) estimated the loss of
economic output associated with chronic disease in
23 low- and middle-income nations, which together
account for about 80 percent of the total chronic
disease mortality in the developing world.
The WHO analysis focused on a subset of leading
chronic diseases: heart disease, stroke, and
diabetes. In 2006, this subset of diseases incurred
estimated economic losses ranging from US$20
million to US$30 million in Vietnam and Ethiopia,
and up to nearly US$1 billion in China and India.
Short-term projections (to 2015) indicate that
losses will nearly double in most of the countries
if no preventive actions are taken. The potential
estimated loss in economic output for the 23
nations as a whole between 2006 and 2015 totaled
US$84 billion.
A recent analysis of global cancer trends by the
Economist Intelligence Unit (EIU) estimated that
there were 13 million new cancer cases in 2009. The

cost associated with these new cases was at least
US$286 billion. These costs could escalate because
of the silent epidemic of cancer in less well-off,
resource-scarce regions as people live longer and
adopt Western diets and lifestyles. The EIU
analysis estimated that less developed countries
accounted for 61 percent of the new cases in 2009.
Largely because of global aging, the incidence
of cancer is expected to accelerate in coming
decades. The annual number of new cancer cases
is projected to rise to 17 million by 2020, and reach
27 million by 2030. A growing proportion of the
global total will be found in the less developed
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cases will occur in Asia.
Assessing the Costs of Aging and Health Care
Health and Work
In the developed world, older people often
leave the formal workforce in their later years,
although they may continue to contribute to
society in many ways, including participating
in the informal workforce, volunteering, or
providing crucial help for their families. There
is no physiologic reason that many older people
cannot participate in the formal workforce, but
the expectation that people will cease working

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