Sage Nation

What Israel’s ancient respect for age and its culture of innovation could teach a rapidly aging world

Approaching Rosh Hashana, I am always reminded of how my grandfather used to say that we Jews live longer lives, age-wise – because we count our years twice. Once on the Gregorian calendar, the one the rest of the world lives by, and once on the Jewish calendar, the one that marks time by our story: our exoduses, our exiles, our returns. He believed those two tallies add up, and that this embodies how we carry the wisdom of a people that has been counting, remembering, and starting over each year. In most of modern life, the passing of time is treated as something to outrun. But my grandfather’s arithmetic suggested otherwise – that time, counted honestly, is not subtracted but accumulated. Every year lived adds to a store of memory, story, and understanding that does not simply pass through us, but stays. To grow older, in this accounting, is not a process of loss, but of gain – one that keeps adding to itself, year after year. I reflect on this often as a geriatrician, having the privilege of learning to appreciate age in a way most people don’t get to.

In modern academic medicine, one is careful about how to refer to the people in our care. For example, the American Geriatrics Society and its journal recommend “older adults” or “older people,” rather than “the elderly,” “seniors,” or even “elders.” The reasoning is to use a neutral description of a population defined by its chronological age, rather than using any form of subjective language which may reinforce stereotypes about aging.

Jewish tradition offers a different perspective.

The Hebrew word “zaken” does not simply mean an old person. Jewish tradition gives the word another deeper meaning. In the Talmud, Tractate Kiddushin 32b teaches us the ethics, limits, and definitions of showing honor, specifically concerning Torah scholars, community leaders, and the elderly. Rabbi Yosei HaGelili interprets zaken as zeh shekanah chochmah: one who has acquired wisdom. This is more than a description of age: it evokes someone who is valued for wisdom because of age and often holds a position of responsibility or authority within the community. In this passage zaken and Rabanan are used throughout, translated as elder and sages. A sage is someone distinguished for their wisdom, often a person of sound judgment gained through long experience. I like the word sage. As a geriatrician in my early 40’s, I am lucky that all my patients are older and wiser than I am. Sitting across from them in my office trying to get them to take their blood pressure seriously, I am mostly humbled by their wisdom. These are not just “older adults” to me, these are my elders, my sages.

That distinction matters and, in my opinion, highlights a shortcoming in our modern medical doctrine. Modern medicine understandably tends to approach aging through what is lost: muscle, bone, cognition, independence, physiologic reserve. Geriatrics exists in large part to prevent, delay, and manage those losses. But aging is more complex than decline. It is also an accumulation of experience, relationships, perspective, adaptation, and wisdom.

Earlier this year Israel’s State Comptroller published a sweeping report on the country’s preparedness for an aging population. It received almost no attention. Between the ongoing wars, the political turmoil, and the daily emergencies that dominate the news cycle, a document warning that Israel still lacks a coherent national strategy for millions of aging citizens came and went largely unnoticed. The picture it paints is bleak: fragmented responsibility, declining geriatric capacity, and a long-term care system expanding faster than anyone is tracking its sustainability. As a geriatrician, I could not look away from it. But as someone who does not see fear aging, I also could not leave it there. Because inside the daily reality of caring for Israel’s older patients, is something the Comptroller’s findings don’t capture: Israel may also hold an unusual set of ingredients for getting this right. This is an attempt to hold both truths at once.

It is upon this foundation that I build the claim that Israel has the components to become The Sage Nation: a country that treats the unprecedented aging of humanity not as a demographic problem to manage, but as an opportunity to rethink how people can live longer, healthier, and more meaningful lives, and how in turn society can grow by appreciating such wisdom.

There are at least nine reasons why Israel is uniquely positioned to lead this effort:

1. The generation that built the country is aging with it.

Israel itself is still remarkably young. At its establishment in 1948, only around 4 percent of its population, approximately 30,000 people, were over 65. Today, Israel has approximately 1.3 million people aged 65 and older, about 13 percent of the population. By 2050, that number is expected to approach two million. In a sense, Israel is experiencing something unusual: the institutions created by a young country are being forced to mature at the same time as the generation that built them.

2. Israel is simultaneously old and young.

Israel does not look demographically like much of the aging developed world. Israelis live long lives and are ranked 4th in the OECD for life expectancy. At the same time, fertility remains comparatively high, making it one of the youngest countries in the OECD as well. Its Arab and ultra-Orthodox communities have particularly young population structures, but even the rest of Israeli society retains a younger demographic profile than many peer countries.

That means Israel’s aging challenge is about figuring out how several generations coexist. More and more families report having four generations alive at once. For most of human history, that was exceptional. Increasingly, it will not be. Aging societies around the world will have to learn how to organize families, work, housing, communities, finances and healthcare around this new reality. Israel can be one of the places where we learn how.

3. Israelis live long, but longevity is not the same as healthy longevity.

The State Comptroller’s new report illustrates a remarkable change. Between 1975 and 2023, male life expectancy increased from 70.3 to 81.4 years, and female life expectancy from 74.6 to 85.5 years. Yet older Israelis also carry a substantial chronic disease burden. Data comparing older Israelis with their European counterparts found that Israelis reported more chronic conditions than average, more mobility limitations, and a greater number of difficulties with both daily living activities and instrumental daily living activities, even after adjusting for age, income, education, and other socioeconomic factors. Israel has one of the highest rates of adults eligible for chronic nursing care, and older Israelis visited the doctor more frequently and used more weekly medications than their European counterparts.

This may be interpreted, in part, as a success of an effective public healthcare system. Israel’s universal healthcare system provides broad access to care and, so far, has demonstrated that a country can absorb an unusually heavy chronic-disease burden in its older population without that burden translating into abandonment or institutionalization. The lesson for other aging societies is that even a system facing high morbidity can be organized to provide ongoing support. Whether that infrastructure can keep pace, however, is a separate and increasingly urgent question.

4. Israel has quietly built a remarkable infrastructure for aging at home.

One of the most interesting features of Israeli aging is how much long-term care takes place in the community.

Israel’s Long-Term Care Insurance Law created public support for people who need assistance with activities of daily living while remaining at home. Despite the very high chronic disease burden and the large number of people requiring chronic nursing care, Israel continues to show impressively low institutionalization. Less than 3.5 percent of older Israelis reside in any type of long-term care setting, a rate lower than in most OECD countries, and even among those who are disabled, well above 80 percent live in the community. This is made possible largely by a system that traces back nearly four decades: Israel adopted a social insurance approach to non-professional home care in 1980, funded by a small employee payroll contribution, and formally implemented it as the community long-term care insurance law in 1988. Depending on need, support can include personal care, housekeeping, day programs, emergency call systems, and other services. Most notably, this system supports full-time live-in aid for those who are eligible. The system for employing live-in foreign caregivers has also enabled many highly dependent older Israelis to remain in their own homes. This matters because aging in place is increasingly an aspiration across the developed world. Israel already has decades of experience with both its possibilities and its shortcomings.

5. Community and family remain part of the care infrastructure.

Formal healthcare is only one component of aging; informal support networks play a paramount role in how people age. Israel has developed supportive-community programs and a broad network of social clubs and community services. Its small geography and sophisticated telemedicine capabilities create additional possibilities for delivering care outside hospitals and clinics.

Family remains particularly important in all elements of Israeli society. For those who are more familiar with Israel, this is sometimes a first remark, but we should resist romanticizing this. For example, strong families do not eliminate loneliness. Israeli older adults still report substantial loneliness, and expectations about whether families or formal services should provide care differ considerably among communities. This opens opportunities to address the root causes of feelings of isolation and loneliness.

6. Israel contains multiple cultures of aging within one small country.

As aging is the culmination of a life lived, the cultural, religious and ethnicity of a person’s life becomes increasingly important.  Israel features a diverse tapestry of Jewish, Arab, Druze, Christian, religious and non-religious, immigrant and non-immigrant populations, with different sociodemographic backgrounds and experiences, as wells as different family structures, expectations, resources, and attitudes toward aging. Crucially, the reverence for our elders expressed in this piece is shared by many of these different groups, offering a unique foundation for ongoing intercommunity partnership.

Israel’s diversity therefore creates an opportunity to develop culturally responsive models of aging that may have lessons far beyond our borders.

7. Israel’s older adults offer a living laboratory of resilience.

We tend to define aging by vulnerability. I think we need to become equally interested in resilience, reflecting the ability to withstand stressors. This has become the focus of my academic research. Today’s oldest Israelis carry extraordinary biographies: immigration, the Holocaust, wars, state-building, and repeated societal upheaval. Fewer than a third of older Israelis are Israeli born, making Israel’s aging story inseparable from its national story.

Famously is the notable Jerusalem Longitudinal Study by researchers at the Hebrew University of Jerusalem who have followed for now three decades a group of people born in 1920 and 1921 to see how surviving the Holocaust affected their health as they grew old. This is only one example of the many unique “stressors” affecting Israel’s older adult population. These remaining survivors along with their peers found themselves throughout the years handling austerity, immigration, losing loved ones in wars, needing to run to bomb shells from rockets from Lebanon, Gaza and Iran. Yet, they continue to adapt and to build. During the recent war(s) the JDC Eshel released this remarkable video urging older adults to assist the younger generations to deal with the expected stress. Watch it. It’s remarkable.  JDC-Eshel is a leading non-governmental organization and social research incubator in Israel that plans and develops services for older adults.

That does not mean adversity is somehow beneficial, nor that resilience should become an excuse for inadequate services. It means that if medicine studies only what older people lose, we are studying only half of aging. Understanding why some people remain resilient despite enormous stress may teach us something fundamental about how humans age.

8. Israel has the raw materials for extraordinarily sophisticated aging innovation.

This is where the central idea of this article – “Sage Nation” – intersects with Israel’s better-known identity as the “Startup Nation.”

Israel is already one of the world’s centers of technological innovation. This makes it a particularly interesting open laboratory to address the challenges and questions of aging. Israeli medicine has long been required to improvise within a universal healthcare system with finite resources. Constraint creates pressure for innovative solutions that are practical, scalable and inexpensive.

This is not just a theoretical strength but has already been demonstrated in primary care. Already over a decade ago, an OECD review concluded that Israel’s efforts have produced one of the most sophisticated programs to monitor the quality of care in primary care across OECD countries, built on data collected systematically across the entire population rather than by sampling. Other countries have followed suit since, but that is exactly the kind of population-scale, longitudinal data infrastructure that would now let innovative AI-driven tools be developed and tested at national scale rather than in isolated pilots.

Israel is now emerging as a major international AI hub. This growing AI technology signals an interesting opportunity for understanding aging. Aging is multidimensional – biological health interacts with cognition, mobility, psychological wellbeing, social relationships, environment and economic circumstances. In geriatrics, we sometimes describe this as n=1 medicine: two 85-year-olds with the same diagnoses may be entirely different people requiring entirely different interventions. Until recently, comprehensively measuring that complexity was difficult and acting on it at scale was harder still. AI may change that. For the first time, we increasingly have tools capable of integrating large amounts of multidimensional information: medical records, medications, cognition, mobility, function, social circumstances, patient priorities and potentially information from the home itself. Israel has the technological ability with less red tape.

Few countries combine universal healthcare, highly digitized health systems, academic medicine, dense communities, a small geographic footprint and a technology sector accustomed to experimentation. Those ingredients create possibilities extending far beyond “technology for seniors.” Israel can provide something particularly valuable: a compact living laboratory for aging. Imagine homes that identify changes in mobility before the first fall. Healthcare systems that detect declining resilience before disability appears. AI that helps clinicians understand the biological, cognitive, functional and social dimensions of an individual rather than merely accumulating diagnoses. Telemedicine that allows expertise concentrated in major centers to reach people in their homes. The opportunity is not simply to build better technology for older people. It is to use technology, medicine, community, and data to fundamentally rethink what aging can look like.

9. Perhaps most importantly, Israel has not solved this problem.

The State Comptroller conclusions provide an important counterweight to Israel’s many advantages. More than a decade after the government formally identified population aging as a strategic national challenge, the Comptroller found that Israel still lacks a funded, multi-year national plan with clear objectives, measurable targets, and a single body empowered to coordinate implementation across government. Responsibility remains fragmented among the Ministries of Health, Welfare and Social Equality, the National Insurance Institute, health plans, and other agencies; roughly 70% of government bodies working on aging described cooperation among them as only moderate or worse, while 90% said that information and data are not shared sufficiently.

The healthcare system itself is not keeping pace: despite the expected growth of the older population, the number of geriatricians has barely changed, while geriatric hospital beds per 1,000 people aged 75 and older fell by 16% between 2020 and 2023. Prevention is another missed opportunity: health plans focus much of their activity on people who are already sick or frail rather than systematically preserving health, cognition, and function before decline occurs.

Beyond healthcare, preparation for retirement, continued employment, volunteering, and efforts to address loneliness remain insufficiently coordinated and lack clear national goals.

Even Israel’s extensive long-term-care system faces questions of sustainability: the number receiving long-term-care benefits more than doubled from 180,000 to 392,000 while expenditure rose from approximately NIS 7 billion to NIS 21.1 billion. These decisions the Comptroller notes were made without accompanying actuarial analysis by the National Insurance Institute’s actuary.

This strain is not new, and it predates the current Comptroller’s report by nearly a decade, with private expenditure in the form of supplementary insurance making up the difference. Socialized universal healthcare is one of Israel’s most-cited strengths, but it is worth being precise about what that means today: universal coverage of a defined basket of services, increasingly supplemented by private spending that not everyone can afford.

From Start-Up Nation to Sage Nation

I always say to my geriatrician-colleagues abroad this “Israel is a great place to grow old, but Geriatrics as a field still has plenty of room to grow here.”

The paradox, then, is striking.

Israel possesses many of the ingredients for exceptional aging such as longevity, strong families and communities, universal healthcare, rich longitudinal data, technological ingenuity and a culture accustomed to solving difficult problems with limited resources but has yet to bring together those ingredients into a coherent national strategy and infrastructure. That gap is not only Israel’s greatest challenge in aging; it may also be its greatest opportunity.

The 20th century challenged Israel to build a country for a young population and a young state. The 21st century presents a different challenge: combining the audacity of a young country with the accumulated wisdom of an old and resilient civilization, building a society in which longer life is not merely possible, but healthy, meaningful, and worth living. The world is aging. Israel has a chance to not merely age with it, but to help learn how to do it better.

So, as we enter a new year on the Jewish calendar, one more year added to my grandfather’s count, I hope the vision of a Sage Nation is one we keep building toward. 

Shana Tova.