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January 2002

The elderly, HIV/AIDS and sustainable rural development

by Jacques du Guerny1

This paper was presented at a seminar on Aging and Rural Development sponsored by the American Association of Retired Persons (AARP)

Introduction

The demographic impact of HIV/AIDS on the population pyramid has begun to be explored and scenarios with and without HIV/AIDS have been prepared. They reveal dramatic drops in life expectancy in the high prevalence countries and increases in mortality. The United Nations Estimates and projections have taken into account the impact of HIV/AIDS in their last few Revisions. The US Bureau of Census has also done work in this area and has illustrated the striking aging that can occur by the example of the age-sex pyramid of Botswana, whose shape rapidly evolves from a pyramid to a "chimney" where the upper part of the sides of the pyramid become vertical! The aging of populations that occurred through declines in fertility, followed by lengthening of life at older ages is now occurring in high HIV-prevalence developing countries as a result of HIV/AIDS through the increased mortality of young adults, the lowering of fertility of young HIV- infected females who die before completing their expected fertility and by the first baby boomers of developing countries reaching older ages. This is a very new scenario in which these developing countries are aging and will have a high relative proportion2 of older adults and of elderly under conditions radically different from those of developed countries. It will be aging without the development base needed to meet the needs of the elderly. Furthermore, this novel form of population aging can happen at a very rapid pace, which creates difficult conditions to organise a response, especially for a developing country with insufficient infrastructure, services and resources.

Against such a background, the objective of this paper is to examine briefly how the international community is perceiving and responding to the HIV/AIDS pandemic from the perspective of the elderly, why the elderly have a role to play and under what circumstances can they play it in rural areas of developing countries. The focus is on rural elderly in developing countries, especially, but not only, in Africa.

The perception by the international community of the role of the elderly in HIV/AIDS

The international community is aware and understands that the HIV/AIDS epidemics require multi-disciplinary and multi-sectoral approaches and responses. This is has been reflected in the very concept of UNAIDS and its co-sponsors, who range from the World Bank and UNDP for macro development to organisations with special group concerns like children/youth (UNICEF) or substance abusers (UNDCP), labour force (ILO), health (WHO), education (UNESCO). Of course, no organisation specifically represents the elderly except for the United Nations itself (since it has an Aging Unit), but the United Nations unit has not focused on this aspect of the AIDS issue.

The United Nations has taken a very active role in combating the HIV/AIDS epidemics and this effort has been acknowledged in the Nobel Peace Prize it (with the Secretary General) was awarded in 2001. In June 2001 a Special Session of the General Assembly on HIV/AIDS (UNGASS) was held with a number of heads of state and prominent personalities. One of the interesting aspects of these conferences is that they provide a snapshot of where the international community stands on certain issues, how it perceives them and what it is willing to do about them. The outcomes of these conferences are consensus documents, i.e. reflecting that to which all member states can agree. However, one of the aims of negotiations is to introduce the most specific text possible according to the well known precept "what goes without saying, goes even better when stated3".

With this background in mind, it is worthwhile to examine the report of the Secretary-General of the United Nations which sets the stage for UNGASS4. As stated in the summary of the report, it "examines the spread of the epidemic and reviews its impacts ….It approaches the epidemic from all levels, recognizing that…the mobilization of people and communities is also essential." The summary goes on to stress that "meeting the challenge of HIV/AIDS requires a combination of approaches: strengthening leadership, alleviating the social and economic impacts of the epidemic, reducing vulnerability, intensifying prevention, increasing care and support…".

In the report containing 123 paragraphs, only 3 include the word elderly and need to be quoted:

After presenting the elderly as a burden and a problem, the report discusses the responses to AIDS; the elements of a successful response and, finally, the challenges for an expanded response: the way forward. There is no mention of the elderly in these sections.

How then did the issue of elderly fare at the Special Session itself? In the Declaration of Commitment of HIV/AIDS "Global Crisis - Global Action" (103 paragraphs), there is only one specific mention of the elderly, in paragraph 68, under the heading "To address HIV/AIDS is to invest in sustainable development" which states: "By 2003…. Review the social and economic impact of HIV/AIDS at all levels of society especially on women and the elderly, particularly in their role as caregivers and in families affected by HIV/AIDS and address their special needs…".

In this inter-government consensus, the only role recognised for the elderly is that of caregiver and the association with the traditional role of women leads one to think that countries are mostly referring to elderly women and not men. It should also be stressed that certain roles are assigned to the elderly by others; they are treated as minors. The issue of HIV/AIDS is nowhere seen or presented from the perspective the elderly themselves could have, although they are affected by it (e.g. death of children providing them with support) and enrolled in mitigating the consequences through care, of course, to the sick, raising of orphans, contributing to or ensuring the food security and management of the farm-household 5.

The same governments that extol the virtues, contributions and roles of the elderly in the statements for the International Year of Older Persons (1999) and which will certainly do so for the Second World Assembly on Aging of 2002 demonstrate a completely different view of the elderly when discussing HIV/AIDS. One thing issues such as aging, gender or HIV/AIDS have in common is that they reveal the hidden face of societies, the areas of dysfunction since the reality of the situation usually clashes with the images every society likes to project of itself. One can then only wonder whether the more representative view of the elderly is not to be found in the HIV/AIDS statements rather than in those on aging?!

However, all should not be seen in a negative light. The UNGASS Declaration does provide a potentially very useful framework in which the elderly can play a crucial role, not just in care-giving, but in ensuring the food security of the millions of affected rural farm-households. They can play such an essential function precisely by fitting into the UNGASS promotion of the strategy of investing in sustainable development. In fact, countries with high rates of HIV prevalence might come to realise that they cannot very well do without the contribution of the elderly and that this has yet to be specifically integrated into their anti-HIV/AIDS strategies. As will be shown, this requires a synergy between rural development strategies and those for the elderly.

The role of rural elderly in the HIV/AIDS epidemics

Following the very brief presentation of the population aging process in the introduction, it is useful to be more specific in order to identify some of the important issues concerning the elderly. To bring out the demographic changes that will have an impact on the elderly, one needs to compare the present situation as illustrated by the population pyramid with a projected one in the future. Population projections are generally rather robust since there has been a considerable amount of inertia. Changes over the last few decades have occurred mostly through declines in fertility which meant that the shape of pyramids shrank at their base due to fewer births. The result is that the major projections done by the UN Population Division, the World Bank or the US Bureau of Census were not very far apart. In recent years, population projections have introduced the innovation of producing scenarios "With" and "Without" HIV/AIDS. This means introducing assumptions about mortality for infants, young children and younger adults. It also means reducing both the total number of births per woman and their fertility as women die before completing their expected fertility without HIV/AIDS6 . As the epidemic is continuing to unfold, it is still difficult to be very certain about the assumptions that are being made. The UN has been more conservative than the US Bureau of Census and their respective projection results are thus rather different for the most affected countries (See Table 1). In this table, which shows the impact on the total population of differences in the mortality assumptions on HIV/AIDS, both the UN and the US Bureau of Census have made projections with HIV/AIDS. In the UN projection, the total population continues to grow slightly (9% in 20 years), whereas in the Bureau of census scenario, it declines by 16% over the same 20 year period. Of course, the impact on the age structure will be substantial in the later scenario.

The objective here is not to discuss which of the two projections has the best chance of being closer to the future reality. Population projections are not predictions, but rather illustrations of what if scenarios . The purpose isto highlight some issues facing the rural elderly in high prevalence countries, and for that reason the US Bureau of Census scenarios are selected here. We will first highlight changes in the sex and age structure, not in general, but from the perspective of the elderly at the national level and then try to infer some issues for the rural elderly since we do not have separate projections for rural and urban populations. The conjectural nature of the discussion needs to be stressed. As Stanecki7 has pointed out "AIDS mortality will produce population pyramids that have never been seen before…[and] the implications of this new population structure are not clear". Botswana and South Africa (SA) have been selected to illustrate the scenarios (see Annex I) because they both are very high prevalence countries, Botswana's pyramid was the typical one for Africa whereas that of South Africa was already in transition through a decline in fertility. The onset of the epidemic is earlier in Botswana (the resulting "chimney" effect is more pronounced), but progress is very rapid in South Africa. These points show in the pyramids projected to 2020.

As mentioned, the cases presented have been for high prevalence countries at the national level. Does this mean that other countries will not be affected? Not necessarily as the distribution of HIV/AIDS is not homogeneous throughout space (e.g. the metaphor of the "leopard skin") and there can be considerable differences within a country with areas hardly touched by the epidemic and others badly hit. One can assume that the situation in sub-national areas with a high prevalence will see their population structure evolve in a rather similar manner to that shown in Botswana and South Africa: this could be somewhat offset by internal migration, but it also makes it difficult to set up blanket national policies and programmes.

Until now, rural areas have witnessed a more rapid and pronounced aging than the urban ones, e.g. in Botswana the 60+ represented 8.5 % of the rural population in 1991 compared to 4.5 % for urban areas (the exception in Africa is South Africa)8. The data collected are mostly data from before the high impact of the HIV/AIDS epidemic. One has noted a hierarchy in the types of jobs and therefore, deaths of unskilled labour in urban areas tend to be replaced by rural migrants, thus aging the population in rural areas further. As shown by the Kenya Vulnerability Working Group9, infection rates tend to be higher in densely populated areas which are the most productive agricultural areas. The changes in population structure in these areas could thus have impacts on agricultural production. FAO studies have shown the HIV/AIDS impacts on farm-household food security and agriculture: in an agriculture largely based on labour, its strength and draught animals (in the absence of mechanical equipment), shortages result in leaving fields fallow, substituting cash crops by low calorie subsistence ones (e.g. cassava), drops in yields due to reducing tasks such as weeding or loss in knowledge, sale of assets mortgaging the future (sale of draught animals) and pulling children out of school to assist in the farm-household10. FAO has also estimated that in the 25 most-affected African countries, AIDS has killed seven million agricultural workers since 1985. As shown in Table 2, Botswana by year 2000 has already lost 6.6% of the agricultural labour force it would have had without HIV/AIDS. HIV/AIDS could kill 16 million more within the next 20 years11. These projections were made on the basis of the UN population projections and the estimates would be higher with the US Bureau of Census ones (See Table 2). In the case of Botswana, the agricultural labour force would be 23.2% smaller because of HIV/AIDS. One can but wonder what the compensation mechanisms will be and the role of the elderly in these. FAO studies have highlighted the considerable impacts on household food security and on agriculture with the level of loss before the year 2000: the studies were carried out in Kenya, Tanzania, Uganda and Zambia with levels of loss often 2 to 4 times lower than the projections for 2020. One can suppose it could be important, especially as the effects of population decline (fewer mouths to feed, but more importantly, fewer producers of food) are not symmetrical to those of population growth under which agriculture production and food security have taken place until now.

Table 2. Agricultural Labour Force: Percentage Loss from HIV/AIDS

 

2000

2020

Botswana

6.6

23.2

South Africa

3.9

19.9

Source: Marcoux, Alain, SDWP/FAO. Communication. NB .Based on UN and ILO projections

Most of the literature that exists mentions the caring and mitigating roles of the elderly: caring for the sick and raising orphans. Dependency also operates at the household level, not just at the national level, but data for individual members is generally not available. Questions are also raised about the welfare of the elderly as the support expected from their children might be less or no longer available. However, the elderly can show a surprising resilience in such adverse circumstances as deaths of adults in their households because their Body Mass Index (BMI) quickly recovers12. This recovery seems to be due to support received from the extended family such as remittances. Such support might not be possible due to decimation of many extended families in countries such as Botswana with considerably higher HIV/AIDS levels than Tanzania which had an estimated adult rate of 8.09 at the end of 1999 compared to a 35.8 rate in Botswana13. More important, from the perspective of this paper is the finding that the extent to which the health of the elderly is affected depends on a range of factors: their physical well-being; household wealth; availability of remittances; emotional reaction to the death; and developmental characteristics of the area concerned, among others. It should be noted that a number of factors such as wealth, remittances and developmental characteristics are closely related to the degree of rural development.

The elderly, HIV/AIDS and sustainable rural development

After having briefly examined the inter-relations between the rural elderly and HIV/AIDS, the present section discusses the possible role of rural development. Rural development is less fashionable today than a few decades ago because it requires state intervention rather than letting market forces shape in an unregulated manner the life of farmers. Here, as elsewhere, one should avoid the extremes and promote forms of rural development based on partnerships between all key actors.

In fact, many policy-makers prefer to use the expression sustainable development which applies to all sectors, including rural development, as a framework. Since the Rio Conference in 1992, which placed sustainable development on the international political agenda, the emphasis has tended to be on the protection of the physical environment. The human dimension has been recognized, but perhaps more from the perspective of farmers ensuring food security and agricultural production without damaging the environment. To a large extent, production remains the underlying concern. However, nothing prevents one from giving more room to the human dimension within the sustainable development concept. In particular, one can point out that it is not only that development needs to be sustainable from one generation to the next, but that by implication development needs to sustain everyone in society and not to be skewed to the benefit of certain groups, e.g. urban versus rural, agro-industrial farms versus small farmers It is quite possible that the neglect, not to sometimes say the sacrifice in the drive for development, of millions of small farmers in many developing countries is one of the factors which fuels the HIV/AIDS epidemics through the related poverty driven mobility systems14.

Although rural development, per se, is not necessarily sustainable it does draw attention to the human factor in development. If one then defines sustainable development in a balanced way between development and sustainability on one hand and within sustainability between the environmental and the human dimensions of the term, one can see that it can enrich the concept of rural development. All that needs to be done is to add the word sustainable: sustainable rural development (SRD)!

Ministries of Agriculture have often been slow in reconsidering their policies and programmes in the face of HIV/AIDS15. This is changing, but it represents quite a challenge when the staff of ministries is also paying its toll to the epidemics thus partly disabling the ministries themselves. It means adapting to geographic differences of HIV prevalence as well as thinking through the future with more concern for immediate and future farm-household food security rather than focusing mostly on agricultural production. This role of SRD in assisting households in their caring function and mitigation of impacts should take specifically into account assisting the contribution of the elderly, but SRD can also play other crucial roles. Caring and mitigating the HIV/AIDS impact is an obvious immediate concern, but it is a reactive role, coping with the results of past infections. Just as important, but as yet largely unexplored, is the longer term role of SRD in reducing the future vulnerability of both farming systems and of farm-households16. As has been shown, the labour force could not only be decimated but also change its age and sex structure (see the South African pyramid with and without AIDS in Annex I). The projected changes could jeopardize both food security and agriculture production. If the resilience of the farming systems and farm-households is not protected and increased, rural populations will continue to be vulnerable to HIV infection because many would have to continue to migrate to cities under the worst conditions were they are open to abuse and exploitation, turning to sex work, etc. Even those remaining in rural areas (for example, women headed farm-households battling to retain their land, to produce food or pay debts) might have to trade sex for food or other commodities. SRD can contribute significantly to prevent the setting up of such vicious circles. As the younger adults would often not be in sufficient numbers to carry out the essential tasks, the elderly will increasingly need to be called upon.

SRD planning needs to analyze the essential tasks to ensure food security of the communities and farm-households with their energy requirements and calendar distribution in order to identify the bottlenecks and the interventions required, including for the elderly. For example, a considerable amount of time and energy is spent collecting fuel and water, traditional tasks of women, but we have seen how there could be a shortage of women of age to do these chores. Providing solar based forms of energy for cooking and other tasks in semi-arid areas can also help to avoid longer term destruction of the environment and may discourage the use of cattle dung for fuel rather than as fertilizer. Water harvesting techniques and better irrigation techniques (e.g. drip techniques) of home gardens can be encouraged; this may help to provide indispensable food and the elderly would be able to tend to this type of agriculture.

Many studies have shown the impact on the farm-household nutrition of HIV/AIDS reflected in a decline in cash crops or in remittances (due to shortage of labour or death of migrants to the city) which enable the purchase of food; changes in diets towards poor quality ones based on cassava and the like. The elderly still have an important knowledge about the local plants and their uses for food. It is important to use this knowledge to improve the diets17 of the household members. This knowledge needs to be systematized and transmitted to the children. Extension workers can play an important role in such an area. Some of these indigenous plants might also have potential commercial value and research needs to be conducted on them as they have often been neglected (in French, they are called plantes orphelines, the orphan plants!). Assistance in introducing small draught animals which can be handled by elderly and children instead of the heavy oxen which require a lot of strength is also necessary18.

More generally, as Richards19 points out "the HIV/AIDS crisis is an intensifying regressive crisis…ill-thought out and top-down modernization of agrarian institutions must be resisted in favour of support for long-term grassroots cultural and ethical innovation." Gandiya20 complements this recommendation by stressing that "technologies for resource-deprived households must not be too demanding...[and] must enable a household to meet basic human needs without having to go outside of the home for what it can produce on the farm". Many concrete examples are provided in these papers just mentioned. In such a context one can clearly see that the elderly can play a crucial role.

There are many other areas where the elderly can contribute. Just one is mentioned here. The raising of orphans is often mentioned. The issue is not just to feed and raise orphans, but also how it is to be done. The transmission of indigenous knowledge is one, but protecting the rights of the orphans, particularly their rights to land and various assets is also very important. Elderly have often a good knowledge of these rights and the local common law systems. They are in a good position, especially with institutional support to protect the rights of the children. The elderly are thus at present a largely invisible resource which needs assistance and empowerment in order to fulfill its considerable and indispensable potential in areas of crisis. This opens an area for research and technical assistance from inside the countries and internationally.

Conclusion

In their strategies against HIV/AIDS, the international community has perceived the elderly as being mostly a burden. In view of the present and, especially, projected dramatic impacts of the epidemics in very high HIV prevalence countries or areas, the elderly will increasingly constitute an unrecognized resource in sustaining the national, sub-national, community, farm-household and individual levels, including themselves. Far from being a burden, they will be an indispensable resource and many will not be able to "rest" after working all their lives.

For their contribution to be as effective as possible, the rural elderly will need support from rural development policies and programmes. The priority given to agriculture production over the welfare of rural populations is put into question by the impact of the HIV/AIDS epidemic. It is thus urgent to review the priority given to rural development (as taking into account the welfare of rural populations) and to rethink the most appropriate strategies for sustainable rural development in the new context of the HIV/AIDS epidemics. With the assistance of sustainable rural development which would promote both human and production factors as well as concerns for the present and the future, the elderly have the potential of being the linchpin in holding together farm-households, ensuring their food security and the survival of orphans, even giving them a better chance in life.

Annex I

Age/sex Pyramids for Botswana and South Africa, 2000 - 2020

Endnotes

1Farmer, formerly Chief of the Population Programme Service, FAO and FAO Focal Point for both Aging and HIV/AIDS. The opinions only engage the author.
2Normally, there should also be increasing absolute numbers of elderly as in developing countries each younger cohort is larger than the previous one until fertility declines impact sufficiently. N this case, it does not happen due to HIV/AIDS mortality.
3"Ce qui va sans dire, va encore mieux en le disant", Talleyrand at the Vienna Conference of 1815 dismantling the Napoleonic Empire and reshaping Europe.
416 February 2001, A/55/779.
5The expression of farm-household is preferred by the author to that of household as the farm and the household are integrated in a single unit in most rural areas of developing countries.
6In simpler terms it means that i) who die at 30-34 years (the peak age for women) would still have continued having children had they not died so young; ii) women infected by HIV, due to illness, are less apt to have children.
7Karen A. Stanecki The AIDS Pandemic in the 21st Century - The Demographic Impact in Developing Countries. Paper prepared for the XIIIth International AIDS Conference, Durban, July 2000.
8Stloukal, Libor Rural ageing in developing countries: evidence from national population censuses taken in 1985-1996. FAO Population programme Service.
9Quoted in FEWS Net Project and CARE: HIV/AIDS and Food Insecurity: Breaking the Vicious Cycle
10FAO Sustainable Development Web site: www.fao.org/sd/PE3_en.htm www.fao.org/sd/wpdirect/wpre0129.htm
11FAO: HIV/AIDS: a rural issue. And a communication by Marcoux, Alain, SDWP, FAO.
12Ainsworth, Martha and Dayton, Julia: The impact of the AIDS epidemic on the health of the elderly in Tanzania. World Bank, July 2001.
13UNAIDS, ECA AIDS in Africa, country by country. In African Development Forum 2000. October 2000.
14See for example FAO studies in the areas of poverty, HIV/AIDS as well as papers of the UNDP South-East Asia HIV and Development project on the relations between mobility and HIV/AIDS (www.hiv-development.org).
15Reference of forthcoming FAO paper *****
16For a more detailed discussion of, see Jacques du Guerny Agriculture and HIV/AIDS, EASE International, Copenhagen and published electronically on www.hiv-development.org . It should be noted that this paper is designed within the framework originally developed in Early Warning Rapid Response System: HIV vulnerability caused by mobility related to development. July 2000. www.hiv-development.org/publications/EARLY%20WARNING%20RAPID%20RESPONSE%20SYSTEM.asp
17Josep Gari/FAO research project: personal communication, October 2001.
18Munyombe et al. HIV/AIDS in Livestock Production in the Smallholder Sector of Zimbabwe. In AIDS and Smallholder Agriculture. SAFAIDS, 1999. See also in the same publication: Rugalema,G. It is not only the loss of labour: HIV/AIDS, loss of household assets and household livelihood in Bukoba District, Tanzania.
19Richards, P. HIV/AIDS and African Agriculture: does technology have to change? SAFAIDS, 1999.
Gandiya, F. Some Technological Requirements for Resource-deprived Households in the Smallholder Farming Sector. SAFAIDS, 1999.



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