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

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 of 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 1

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 of 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). 2

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

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 4

adults live in very good or good social conditions, while more than one in three live in poor or 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). 50 45 40 35 30 25 20 15 10 5 0 Very ¡Good Good Regular Bad Indigence 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

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. 60 50 40 30 20 10 0 Urban ¡Higlands Rural ¡Highlands Urban ¡Coast Rural ¡Coast Quito Guayaquil Very ¡Good% Good ¡% Regular ¡% Bad ¡% Indigence% ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡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 of men than women report living in very good socioeconomic conditions. ¡ 6

Table 3. Socioeconomic conditions of Ecuadorian older adults by age group and sex, percent. Age Group Socioeconomic Conditions Females Males Total 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 60 to 64 years Indigence 17.1 8.4 13.0 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 65 to 74 years Indigence 27.3 20.8 24.3 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 75 or more Indigence 26.5 29.4 27.9 ¡ Figure ¡4. ¡Socioeconomic ¡conditions ¡by ¡age ¡group ¡and ¡sex, ¡percent. ¡ 60 50 40 30 20 10 0 Very ¡Good Regular Bad Indigence Very ¡Good Regular Bad Indigence Very ¡Good Regular Bad Indigence Good Good Good 60 ¡to ¡64 ¡years 65 ¡to ¡74 ¡years 75 ¡or ¡more WOMAN ¡% MEN ¡% 7