Social inequalities in aging: evidence from Ecuador Julio Ortega - - PDF document

1 Social inequalities in aging: evidence from Ecuador Julio Ortega William F. Waters Universidad San Francisco de Quito Quito, Ecuador Abstract Population aging is of increasing concern in most countries in the world, including Ecuador, as the number and proportion of older adults increases as a product of demographic and epidemiologic transition. A national survey conducted among older adults in Ecuador provides information that confirms that aging interacts with other social and economic determinants to provide a context of social and economic inequality. We examine factors such as age group, sex, ethnicity and race, and level of education to elucidate the conditions under which certain groups of Ecuadorian older adults confront poverty and inequality. Introduction The norms and values inherent in most cultures dictate that families and communities should provide special care and attention to older adults, who deserve special respect as well as rest and comfort following lifetimes of labor and care for their families. This does not always occur, though, and to the contrary, older adults may live in situations

• f vulnerability, poverty, and poor health in proportions greater than that found in their

respective populations. This situation represents a relatively understudied area of inequalities that may be further compounded by more well-understood factors such as sex, race, and ethnicity. Moreover, because of the demographic and epidemiological transitions, the number and proportion of older adults is increasing dramatically in most countries, further exacerbating the situation at the level of the family, community, and nation. Among the principal determinants of social inequalities or disparities are income, living conditions, level of formal education, geographic distribution (chiefly urban vs. rural residence), race and ethnicity, gender, and access to health services (both physical and financial (Burdrys, 2003; Casas, Dachs, and Bambas, 2001). While poverty is frequently cited as the most important precursor to poor health status (Leon and Walt, 2001), it has also been noted that it is important to understand this complex interrelationship from a life cycle approach (Smith, gunnel, and Ben-Schlomo, 2001). Nevertheless, this approach is not universally used in the analysis of public policies that address poverty reduction and social exclusion (Gacitúa, Sojo, and Davis, 2001). The purpose of this paper is to propose the inclusion of age as a critical factor in understanding social inequalities. We use the case of Ecuador to explore these

• relationships. Ranked near the middle of the UNDP human development scale (UNDP,

2015), Ecuador displays many characteristics of a high-development, middle income

2 country that is rich in human and natural diversity. The case of Ecuador therefore represents a useful case study for understanding age as a decisive factor in social inequalities, particularly when considered in conjunction with the other classic determinants mentioned above. Methods The analysis presented here is based on the Encuesta Nacional de Salud, Bienestar y Envejecimiento SABE I Ecuador 2009-2010 (National Survey of Health, Wellbeing, and Aging, SABE I Ecuador 2009-2010) (Freire et al., 2010). This representative, stratified, multistage sample survey covered all persons 60 years of age or more in the rural and urban areas of the coastal and highland regions of Ecuador, excluding the sparsely populated eastern lowlands and Galapagos. In all, 5,115 persons were included in the survey. Results Population transition in Ecuador While the popular image of population trends in Ecuador is that the country has a young population in accelerated growth, the reality is quite different. On one hand, Ecuador is facing a demographic transition, as the fertility rate is 2.22 for the 2015-2020 period and is projected to be 2.1 for the 2020-2025 period (Freire et al., 2010: 55).while life expectancy at birth is currently greater than 75 years, as compared to 57.4 years for the 1965-1970 period. Consequently, older adults, who now represent less than 7% of the population, will exceed 25% by 2050; in absolute terms, this means that from a total of less than one million according to the most recent (2010 census) they will be more than three million by 2050. This trend alone suggests the challenges that face the national health care and social security systems in the near future. Figure 1 (below) portrays the evolution of the Ecuadorian population pyramid, showing the increasing prominence of the proportion

• f older adults and a relative decline in the proportion of people in the lower age ranges.

The second population trend is the epidemiological transition, first described by Omran (1971) as a global trend and later as a process clearly observable in Latin America (Omran, 1996) and frequently since then (Freire et al., 2014). Briefly, this transition is characterized by: (i) decreasing morbidity and mortality from “traditional” conditions, including transmissible diseases, maternal morbidity and mortality and undernutrition and (ii) a progressive increase in morbidity and mortality attributed to “modern” (especially chronic) conditions associated with extended life expectancy, such as cardiovascular disease, many forms of cancer, diabetes, and hypertension. In countries such as Ecuador, it is eminently clear that these two transitions co-exist, and that the traditional conditions are not being replaced by modern conditions but rather that the two overlap, being more or less prominent in different population groups (Waters, 2006).

3 Figure 1: Ecuadorian population pyramids: 1950, 2000, 2010, and 2050.

4 Health Inequalities Related to Age Table 1 and Figure 2 shows the proportion of Ecuadorian older adults who live in different levels of self-reported social condition. The data are at variance with the popular image in Ecuador that families universally take care of older adults, who are cherished and respected as valuable members of society. It can be seen that less than one in four older

5 adults live in very good or good social conditions, while more than one in three live in poor

• r very poor conditions—the latter reflecting extreme poverty or indigence.

Table 1. Social conditions, Ecuadorian older adults, percent.

% Very Good 10.8 Good 12.0 Regular 44.0 Bad 9.8 Indigence 23.4 TOTAL 100.0

Figure 2. Social Conditions, Ecuadorian Older Adults (percent). Table 2 and Figure 3 show that that the socioeconomic conditions of Ecuadorian older adults differ substantially by area of residence. It can be seen that the proportion of respondents who live in very good or good conditions ranges from well over half in the capital city of Quito and nearly half in other highland cities to well under ten percent in rural areas of the highlands and coast. Conversely, the proportion of older adults who live in extreme poverty or indigence is nearly half in highland rural areas but only 4% in Quito and about 13% in other highland cities.

5 10 15 20 25 30 35 40 45 50 Very ¡Good Good Regular Bad Indigence

6

Table 2. Socioeconomic conditions by area of residence (percent). Region Socioeconomic conditions Very good Good Regular Poor Indigence Total Urban highlands 12.7 19.7 52.6 2.1 12.9 100.0 Rural highlands 0.9 4.9 27.4 17.9 48.9 100.0 Urban coast 7.8 11.2 54.3 4.6 22.1 100.0 Rural Coast 1.1 4.2 34.0 22.3 38.3 100.0 Quito 31.8 24.8 37.3 2.1 4.0 100.0 Guayaquil 16.8 10.3 54.8 10.4 7.6 100.0 TOTAL 10.9 12.1 43.8 9.8 23.5 100.0

Figure 3. Social conditions by area of residence, percent. ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡Two ¡other ¡determinants ¡of ¡inequality ¡among ¡older ¡adults ¡in ¡Ecuador ¡are ¡age ¡group ¡ and ¡sex, ¡as ¡shown ¡in ¡Table ¡3 ¡and ¡Figure ¡4 ¡(below). ¡ ¡These ¡graphics ¡show ¡that ¡poor ¡ socioeconomic ¡conditions ¡are ¡associated ¡in ¡particular ¡with ¡older ¡adults ¡as ¡they ¡age. In analyzing differences by sex, it can be seen that higher proportions of women than men live in indigence among respondents under the age of 75. Conversely, higher proportions

• f men than women report living in very good socioeconomic conditions.

¡

10 20 30 40 50 60 Urban ¡Higlands Rural ¡Highlands Urban ¡Coast Rural ¡Coast Quito Guayaquil Very ¡Good% Good ¡% Regular ¡% Bad ¡% Indigence%

7

Table 3. Socioeconomic conditions of Ecuadorian older adults by age group and sex, percent. Age Group Socioeconomic Conditions Females Males Total 60 to 64 years Very Good 15.1 16.3 15.6 Good 7.2 13.1 10.0 Regular 54.7 52.2 53.5 Bad 6.0 10.1 7.9 Indigence 17.1 8.4 13.0 65 to 74 years Very Good 8.7 13.3 10.8 Good 8.2 16.3 11.9 Regular 47.5 37.4 42.9 Bad 8.2 12.2 10.0 Indigence 27.3 20.8 24.3 75 or more Very Good 6.0 10.1 7.9 Good 14.2 14.9 14.5 Regular 44.3 33.2 39.1 Bad 9.0 12.4 10.6 Indigence 26.5 29.4 27.9

¡ Figure ¡4. ¡Socioeconomic ¡conditions ¡by ¡age ¡group ¡and ¡sex, ¡percent. ¡

10 20 30 40 50 60 Very ¡Good Good Regular Bad Indigence Very ¡Good Good Regular Bad Indigence Very ¡Good Good Regular Bad Indigence 60 ¡to ¡64 ¡years 65 ¡to ¡74 ¡years 75 ¡or ¡more WOMAN ¡% MEN ¡%

8 Race and ethnicity are important social determinants of health and health inequality throughout the world; in Ecuador, members of the different indigenous groups, in particular, live in poverty in much greater proportions than other groups (Larrea, 2006). As seen in Table 4 and Figure 5, indigenous peoples represented nearly 10 percent of the sample, while Afro-Ecuadorians account for 3%, persons of mixed race (mulatos and mestizos are nearly two thirds of the sample. These proportions are similar to those reported in the most recent (2010) population census.

Table 4. Self-reported race/ethnicity of Ecuadorian older adults, percent. Indigenous 9.8 Afro-Ecuadorian 3.0 Mulato 3.4 Mestizo 63.6 White 13.9 Others 6.3 Total 100.0

Figure 5. Self-reported race/ethnicity of Ecuadorian older adults, percent. Table 5 and Figure 6 (below) show that poor and extremely poor socioeconomic conditions are dramatically higher among indigenous Ecuadorians than other groups, while conversely, less than 2% of indigenous and Afro-Ecuadorian respondents reported living in very good conditions.

10 20 30 40 50 60 70 Indigenous Afro-­‐‒Ecuadorian Mulato Mestizo White Others

9

Table 5. Socioeconomic conditions among older adults in Ecuador by race/ethnicity. Indigenous Afro- Ecuadorian Mulatto Mestizo White Total Very Good 1.8 2.0 2.6 12.5 16.3 10.8 Good 4.7 9.2 7.1 13.9 12.2 12.0 Regular 27.8 47.5 51.8 45.4 47.1 44.0 Bad 12.4 21.7 9.4 9.3 8.1 9.8 Indigence 53.2 19.6 29.2 18.9 16.3 23.4 TOTAL 100.0 100.0 100.0 100.0 100.0 100.0

Figure 6. Socioeconomic conditions among older adults in Ecuador by race/ethnicity. As mentioned above, level of formal education is also associated with inequality. Table 6 and Figure 7 (below) show that this association exists in the case of Ecuadorian older

• adults. It can be seen that persons who live in poor or extremely poor socioeconomic

conditions report far fewer years of formal education than persons in other groups, particularly those who report living in very good conditions. Moreover, with the same levels of formal education, higher proportions of males than females report very good or good socioeconomic conditions.

10 20 30 40 50 60 Indigenous Afro-­‐‒Ecuadorian Mulatto Mestizo White Very ¡Good Good Regular Bad Indigence

10

Table 6. Socioeconomic conditions of Ecuadorian older adults by sex and average years of formal education. Socioeconomic Conditions Sex Average years Very Good Female 12.8 Male 14.7 Good Female 5.0 Male 5.3 Regular Female 4.7 Male 4.5 Bad Female 3.2 Male 3.3 Indigence Female 3.3 Male 3.4

Figure 7. Socioeconomic conditions of Ecuadorian older adults by sex and average years of formal education. Access to public services is another source of social inequality. Table 7 and Figure 8 show that people who report very good or good socioeconomic conditions report in greater proportion that they have access to electricity, sewage, and potable water.

2 4 6 8 10 12 14 16 Very ¡Good% Good ¡% Regular ¡% Bad ¡% Indigence% Female Male

11

Table 7. Socioeconomic conditions by access to electricity, sewage, and potable water among Ecuadorian older adults, percent. Electricity Sewage Potable water Very good 99.9 95.7 98.2 Good 99.8 87.9 94.4 Regular 98.7 63.2 77.6 Poor 95.9 22.5 47.6 Indigence 88.1 19.8 40.4 TOTAL 96.2 55.5 73.9

Figure 8. Socioeconomic conditions by access to electricity, sewage, and potable water among Ecuadorian older adults, percent. Discussion Poverty affects many Ecuadorians, and older adults are no exception. The physical, mental, and emotional effects of aging are part of a process of inevitable deterioration associated with aging. The data presented in the SABE national survey (Freire et al., 2010) show that a substantial proportion of older adults live in poverty and in isolation, and that family and community social networks do not necessarily provide for the needs of older

• adults. Moreover, other determinants of social inequality interact with age to provide a

portrait of older adults that is dramatically different from the generalized view of protection for this group of particularly vulnerable individuals.

20 40 60 80 100 120 Very ¡good Good Regular Poor Indigence Electricity Sewage Potable ¡water

12 Place of residence, level of education, access to services, and sex have been shown here to be critical issues in inequality. In particular, though, race and ethnicity are extraordinarily strong determinants of inequality. An associated study (Waters and Gallegos, 2014) shows that aging presents specific and dramatic challenges to indigenous

• lder adults; even in in communities characterized by strong networks of social solidarity,

family and community do not always compensate for conditions of social and economic vulnerability in older adults. These findings suggest that in the context of increasing numbers and proportions of

• lder adults in Ecuador, as in virtually every country in the world, two concerns will

increasingly stand out. First, public policy in the area of health care and other services will require close attention. For example, in Ecuador as in many countries, long-term health care is an essentially unknown category. Further, in places where members of different ethnic and racial groups live side-by-side, the provision of culturally- and linguistically appropriate social services will be critical to addressing issues of inequality. Second, counties like Ecuador must confront increasingly complicated public finances, since on a per capita basis, older adults require greater expenditures in, for example, pensions and health care. Conversely, if these issues are not addressed, problems of social inequality in aging will persist or even be exacerbated. References Budrys, G. 2003. Unequal Health. Lanham, MD, USA: Rowman & Littlefield Publishers. Casas, J.A., Dach, N., Bambas, A. 2001. Health disparities in Latin America and the Caribbean: the role of social and economic determinants. Washington, DC: Pan American Health Organization. Freire, W.B., Rojas, E., Pazmiño, L., Fornasini, M., Tito, S., Buendia, P., Waters, W.F., Salinas, J., Alvarez, P. 2010. Encuesta Nacional de Salud, Bienestar y Envejecimiento: SABE I Ecuador, 2009-2010 (National Survey of Health, Well-being and Aging: SABE I Ecuador, 2009-2010). Quito: MIES Aliméntate Ecuador, Universidad San Francisco de Quito. Freire, W.B., Silva, K.M., Ramírez, M.,J., Waters, W.F., Larrea, A. P. 2014. The double burden of under nutrition and excess body weight in Ecuador. American Journal of Clinical Nutrition. doi: 10.3945/acjn.114.083766. Gacitúa, E., Sojo, C, Davis, S.H. 2001. Social Exclusion and Poverty Reduction in Latin America and the Caribbean. Washington, DC: World Bank.

13 Larrea, C., Montenegro, F. 2006. Ecuador. Pp. 67-105 in Hall, G., Patrinos, H.A. (eds.) Indigenous Peoples, Poverty, and Human Development in Latin America 1994-2004. Washington, DC: World Bank. Leon, D., Walt, G. (eds.). 2001. Poverty, Inequality, and Health. Oxford, UK: Oxford University Press. Omran, A.R. 1971. The epidemiologic transition: a theory of epidemiology of population

• change. Milbank Memorial Fund Quarterly 49:509-538.

Omran, A.R. 1996. The Epidemiologic Transition in the Americas. Washington, DC: Pan American Health Organization, University of Maryland at College Park. Population Pyramid. 2017. Ecuador. https://www.populationpyramid.net/es/ecuador/2015/ Smith, G.D., Gunnell, D, Ben-Shlomo, Y. 2001. Life-course approaches to socio- economic differentials in cause-specific adult mortality. Pp. 88-124 in Leon, D., Walt, G. (eds.), Poverty, Inequality, and Health. Oxford, UK: Oxford University Press. UNDP (United Nations Development Program). 2016. Human Development Report 2016: Human Development for Everyone. New York: UNDP. Waters, W.F. 2006. Globalization and Epidemiological Overlap in 21st century Ecuador. Globalization and Health 2 (8). www.globalizationandhealth.com Waters, W.F., Gallegos, C.A. 2014. Aging and identity in Ecuador´s indigenous

• communities. Journal of Cross-cultural Gerontology 29: 371-387.