Islamset - Aging inequitably in South Africa

South Africa is both a developed and a developing country. Its population aged 65 and over numbers 1.7 million, which is 4.3% of the total. This is similar to the demographic pattern in developing countries. For the purpose of analysis, four population groups are distinguished in South Africa: African, White, Coloured (of mixed descent), and Asian. These groups are at different stages in the demographic transition: 9.3 % of the White population are aged 65 and over, compared with 3.3% of the African, and 3.4% of the Coloured and Asian populations. The average life expectancy of Whites is from eight to ten years longer than for Africans and Coloureds, and five years longer than for Asians. Although the White population can already be called old, the African population is expected to remain young until the middle of the next century owing to high fertility rates.

Trends in demography and quality of life

By the year 2035, the population aged 65 and over is expected to reach 7.4 million, which will be 6.4% of the total. The composition of the aged population at present is 55% African, 35% White, 8% Coloured and 2% Asian. By 2035 the proportions are likely to be 73%, 15%, 9% and 3% respectively.

Unequal access to the country's resources has been a dominant feature of South Africa's history. Older Africans, Asians and Coloureds have lived through the full 40 years of apartheid rule and are today disadvantaged in most areas of their lives in comparison to their White counterparts. Their disadvantage, especially in the case of Africans, is particularly evident in the areas of education, income and health.

From 1990 to 1991, a survey was made of 4400 equally represented Africans, Asians, Coloureds and Whites aged 60 and over (1). It found that 80% of the Africans living in rural areas and 50% of those in urban areas had no formal education. More than 80% of the Africans and Coloureds and 70% of the Asians, but only 26% of the Whites, received the means-tested social old age pension (a scheme by which the equivalent of about US$ 120 a month is paid to the elderly).

On all the indicators of self-assessed health status, urban Africans suffered a greater degree of health impairment and disability than the Asians, Coloureds and Whites. The major reported problems affecting all groups were hypertension (45% of the total sample), back pain (42%),arthritis (36%), and cardiovascular disease (29% )

Most of the Africans (93%) lived in multigenerational households, as did 90% of the Asians and 87% of the Coloureds, compared with only 17% of the Whites.

Although health services are widely available in urban areas, they are frequently lacking or inaccessible to older Africans and Coloureds in the rural areas, owing to a combination of transport difficulties and professional barriers.

Significant numbers in all groups reported emotional distress, symptoms of stress and feelings of restlessness. The African subjects, especially those living in urban areas, reported by far the highest levels of depressive symptoms. In all groups these were higher for women than for men, especially in the case of Africans in urban areas, where the proportion was 16% to 6%. Whites reported high levels of loneliness. Most of the Africans (93% ) lived in multigenerational households, as did 90% of the Asians and 87% of the Coloureds, compared with only 17% of the Whites.

The family remains the most important source of social support for the majority of older non-White South Africans. However, the old age pension plays a part in this, as Africans who receive it and share it with their families enjoy special status in the household. Nine out of ten elderly South Africans feel they are shown respect by their families, but the number is less than four out of five for urban Africans.

Two thirds of the Whites and half of the urban Africans, Asians and Coloureds in the survey owned their homes. Although 91% of the rural Africans owned their homes, two thirds of these properties were traditional huts. Urban Africans were the least satisfied with their accommodation and living arrangements, citing the cost of housing and cramped living space as the two main reasons for dissatisfaction.

Levels of satisfaction with life in general followed a similar pattern, with Africans being the least satisfied. There was a strong correlation between lower levels of life satisfaction, increasing age and socioeconomic disadvantage. Unfavourable living conditions and poor health also contributed to lower levels of life satisfaction. Most of the factors seen as contributing positively to the quality of life were related to basic needs: satisfactory health, favourable living arrangements, economic security, and psychosocial well-being - particularly in terms of feeling in control of one's life and having some degree of personal independence. Basic needs figured most prominently for the Africans. For Asian, Coloured and White subjects, social integration and psychosocial well-being were more prominent.

In sum, the factors which all older South Africans found to affect their quality of life

Older Africans, Asians and Coloureds have lived through the ful1 40 years of apartheid rule and are today disadvantaged in most areas of their lives in comparison to their White counterparts.

were, in order of importance, health, housing and living arrangements, income security, and psychosocial well-being. This reflects the worldwide trends reported in the literature and in Dr Darnton-Hill's article.

Nutrition

Another factor which can contribute directly or indirectly to the quality of life of the elderly is nutrition. The multidimensional survey did not include questions on nutritional status, but 7% of the African subjects mentioned in response to other questions that lack of food was a serious problem for old people. The data that are available on nutrition indicate different trends in the four population groups. Studies on the elderly in urban areas have shown that for Africans a low proportion of food energy was supplied by fat intake (27% ), while for Whites the proportion was high (37% ). The figure for Coloureds was in between, at 32.4%. Elderly Africans were found to consume almost twice as much dietary fibre a day as elderly Whites.

Overnutrition appears to be more of a problem for the health status of elderly South Africans than undernutrition. There appears to be a trend among urbanized Africans, Asians and Coloured of all ages towards adopting a Western dietary pattern. Western eating habits among older urban Africans appear to be accompanied by an increase in chronic diseases related to lifestyle, whereas the diseases of poverty remain predominant among their counterparts in rural areas. Obesity is common among African and Coloured elderly people in both rural and urban areas. However, a condition called "healthy obesity" has been discerned in this community, since it appears that the condition is not always accompanied by higher levels of hypertension, hyperglycaemia and hyperlipidaemia (2).

The prevalence of diabetes mellitus in rural Africans aged 60 and over rose from 1% in 1965 to 7% in 1990. In a recent health and nutrition survey on a sample of 200 Coloureds aged 65 and over in the Cape Peninsula, an urban area, the prevalence of diabetes was found to be 29%, which is one of the highest rates reported for this age group in the world (3). The same study found the prevalence of hypertension to be 72%. A quarter of the cases of diabetes and over a third of those of hypertension had not been diagnosed or treated before the time of the survey.

Although it is not yet clear whether or how eating habits affect the quality of life of older South Africans, nutrition-related diseases and disability will certainly reduce their enjoyment of life and ability to cope. The prevention and management of these diseases will be an important challenge for South Africa's restructured health system.

South Africa has been at the forefront in the development of sophisticated tertiary medicine, but its new National Health Plan is shifting the emphasis from curative care to the primary health care approach. This should benefit the elderly, but the Reconstruction and Development Programme does not make health of the elderly an explicit priority.

Ferreira M et al. Multidimensional survey of elderly South Africans, 1990-91: key findings. Cape Town. University of Cape Town. 1992.
Walker ARP et al. Obesity in black women in Soweto, South Africa. Journal of the Royal Society of Health. 1990, 110: 101-103.
Charlton KE, Levitt NS. The prevalence of diabetes mellitus. In: Charlton KE et al., eds. Food habits, dietary intake and health of older coloured South Africans. Cape Town. University of Cape Town, 1995.