Breathing is the most basic condition for sustaining life. When that self-evident right is neglected because someone has grown old, or left unprotected because someone has stopped working, it cannot be left as a private matter.
Ahead of Senior Citizens' Day on Oct. 2, it is worth asking what our society must guarantee so that older adults can live in health and dignity in a super-aged society. For me, after years of treating older patients, this question arrives first as a patient's face rather than as a statistic. As of December 2024, South Korea's population aged 65 and over surpassed 10.24 million. With one in five members of society now an older adult, the health of older people is not the concern of a single generation but a reality our entire society must face.
Among member countries of the Organisation for Economic Co-operation and Development (OECD), South Korea has the highest relative poverty rate among the retirement-age population of 66 and over, and more than half of those past 75 live below the poverty line. For these older adults, treatment costs and vaccination fees not covered by national health insurance are expenses they cannot bear. In the end, some give up treatment, prevention or both. That choice can become a fork between life and death. Such patients are not rare in clinical practice. Watching an older person who postponed treatment to make a living develop a severe illness, or an entire family sink into the burden of caregiving, is where I feel the greatest helplessness as a doctor.
These institutional blind spots appear across the respiratory diseases that most threaten older people's lives: chronic obstructive pulmonary disease (COPD), influenza and respiratory syncytial virus (RSV) infection. Treatment matters most for COPD, and prevention for influenza and RSV, but all three share the same problem — financial circumstances decide who gets the opportunity.
Older patients in particular can be hit harder by respiratory disease because of physical and immunological aging and multiple chronic conditions. When respiratory status deteriorates, managing existing conditions also becomes harder. As daily functioning declines, the caregiving burden on families can grow. This is why geriatric medicine must view respiratory health not as a matter of the lungs alone but as a matter of whole-body health and daily life.
Based on long clinical experience, COPD is a disease in which financial circumstances can sharply change a patient's chances of treatment. COPD is already lethal enough to rank among the world's three leading causes of death. In South Korea, 12.7% of people aged 40 and over have it, and among those 65 and over, one in four. Prevalence rises with age. With population aging added on, the number of patients is likely to grow. The nature of the lung compounds the problem. Lung tissue that has lost function does not regenerate, and damage accumulates with each acute exacerbation severe enough to require additional medication. As a clinician who has followed patients for years, this is what I find most painful.
A patient who has gone through a single acute exacerbation suffers as if breathing through a crushed straw, and may never return to their previous respiratory state. On top of that come conditions specific to older patients. Existing chronic conditions such as cardiovascular disease or diabetes often worsen along with respiratory status. The government's decision this year to newly include lung function testing in the national health screening program for those aged 56 and 66 is a welcome change in that it opens the door to early diagnosis. Still, institutional gaps remain before patients diagnosed with COPD receive appropriate treatment.
The danger of acute exacerbations is confirmed in research. Patients who have experienced three or more acute exacerbations face a 4.13 times higher risk of death than those who have not, and patients whose exacerbations were severe enough to lead to an emergency room visit or hospitalization face more than a sixfold increase in the risk of cardiovascular events such as stroke or myocardial infarction. For older patients with underlying conditions, such risks can lead to a deterioration in whole-body health. The decline in quality of life from the shortness of breath, depression and anxiety experienced by patients with severe COPD is also reported to be comparable to, or more serious than, that of lung cancer patients. Families caring for patients who have difficulty moving can find their own work constrained. One person's illness shakes the life of an entire household. The resulting social loss amounts to roughly 1.4 trillion won ($1 billion) a year.
International treatment guidelines from GOLD recently recommended biologic agents, which can be expected to improve lung function and quality of life, for high-risk COPD patients who repeatedly experience acute exacerbations despite appropriate standard treatment. The problem is that this treatment is not covered by national health insurance in South Korea, leaving patients to pay the full cost. A new treatment option has been presented for some high-risk patients, but the high price of the drug means they may give it up.
Blind spots exist in prevention as well as treatment. In the case of influenza, immune aging means older adults cannot expect the same level of protection from a standard vaccine as younger people. In fact, 52.4% of patients hospitalized for influenza in the 2024-2025 season were aged 65 and over. The government's expansion of vaccination access for older adults through the national immunization program is a clear achievement. Building on that, it is now time to introduce a tailored vaccination strategy reflecting immune aging and raise the level of protection for older people's health another step.
The same is true of RSV. When older patients with underlying heart or lung conditions are infected with RSV, their existing conditions can sharply worsen and lead to hospitalization. In its 2026 revised adult immunization recommendations, a domestic specialist society recommended RSV vaccination for those aged 50 to 74 at high risk of severe RSV infection and for all adults aged 75 and over. But the adult RSV vaccine is not yet included in the national immunization program, leaving individuals to pay for it themselves.
Care must be taken so that financial circumstances do not become a barrier deciding who gets vaccinated among older adults and people with underlying conditions who medically need prevention. For both influenza and RSV, what matters is ensuring that preventive measures suited to older adults' risk levels and immunological characteristics actually translate into vaccinations.
The Korean Geriatrics Society, the Korean Association of Geriatric Medicine Subspecialists and the Korean Academy of Clinical Geriatrics recently drew up a joint policy proposal on guaranteeing the right to breathe for older adults in a super-aged society, covering both treatment and prevention, and submitted it to the government. The proposal sets out tasks in both areas. On treatment, it proposed evaluating the clinical utility, cost-effectiveness and budget impact of biologic agents for high-risk COPD patients with repeated acute exacerbations despite appropriate standard treatment, and establishing suitable reimbursement criteria. For the most severe patients who are hospitalized repeatedly each year or require long-term oxygen therapy, it called for reviewing the case for reducing out-of-pocket costs or applying special calculation rules for catastrophic illness.
On prevention, it proposed reviewing pilot programs and phased adoption of high-immunogenicity influenza vaccines, starting with those aged 75 and over and high-risk individuals aged 65 to 74, and beginning state support for those aged 75 and over and high-risk individuals aged 50 to 74 for severe RSV infection, then expanding it in stages.
This should not be read simply as a request to widen coverage. Reducing the burden of acute exacerbations, infections and hospitalization through appropriate treatment and prevention is a matter of protecting the lives of patients and their families. The fiscal feasibility and application criteria of each policy should be reviewed on sufficient evidence, but the social value of reducing preventable exacerbations, hospitalizations and caregiving burdens should be weighed alongside immediate spending.
What is needed now is speed. Lung function, once damaged, is hard to restore, and infection can rapidly worsen underlying conditions. Meanwhile, the number of patients keeps rising. No citizen should be left out of needed treatment and prevention because of age or financial hardship. This is not a demand on behalf of one group but a minimum social promise grounded in the universal fact that anyone can grow old and fall ill.
Evidence-based treatment options must be guaranteed for high-risk COPD patients with recurrent acute exacerbations, and influenza and RSV prevention support must be expanded to reflect older adults' risk levels and immunological characteristics. Only then can we come a step closer to filling the institutional blind spots in treatment and prevention. Such change would help patients protect their breath and their daily lives without postponing treatment for financial reasons, and help family caregivers return to their own lives and work. Protecting older people's right to breathe means easing the burden on patients and families and sharing responsibility as a society.
Ahead of Senior Citizens' Day, I want to stress again that ensuring no older adult misses needed treatment and prevention because of financial conditions is the foundation of a healthy super-aged society.
