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The Situation of Older People in Poor Urban Settings: The Case of Nairobi, Kenya

Alex C. Ezeh, Gloria Chepngeno, Abdhalah Ziraba Kasiira, and Zewdu Woubalem

INTRODUCTION

Urban growth in sub-Saharan Africa continues to be fueled by rural-urban migration, especially of youths and young adults under 30 years of age. For many African countries, this trend dates back to the early 1960s with the attainment of independence in some of the countries. Drawn largely by the expanding urban economies and social amenities in the 1960s and 1970s, which offered opportunities for cash or wage employment and trade, city-ward migration soon became associated with social and economic mobility (Anderson, 2001; Barber and Milne, 1988; Bigsten, 1996; Johnnie, 1988; Nigeria Institute of Social and Economic Research, 1997). Residence in cities quickly became a status symbol for at least the rural residents in many parts of Africa, and this, among other reasons, has continued to propel this pattern of migration and rapid urbanization in the region.

Africa’s rapid urbanization has occurred amidst stagnating economies and poor governance, which have created massive and abject poverty in overcrowded slum settlements across major cities in the region. Recent studies have highlighted huge inequities in social indicators and in health and reproductive health outcomes between the urban poor and other subgroups, including residents of rural areas, with the urban poor recording the worst outcomes (African Population and Health Research Center, 2002; Dodoo, Zulu, and Ezeh, forthcoming; Gulis, Mulumba, Juma, and Kakosova, 2003; Magadi, Zulu, and Brockerhoff, 2003; Zulu, Dodoo, and Ezeh, 2003). Despite the poor outcomes observed among the urban poor in sub-Saharan Africa, cities continue to attract a large influx of migrants from rural areas,



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6 The Situation of Older People in Poor Urban Settings: The Case of Nairobi, Kenya Alex C. Ezeh, Gloria Chepngeno, Abdhalah Ziraba Kasiira, and Zewdu Woubalem INTRODUCTION Urban growth in sub-Saharan Africa continues to be fueled by rural- urban migration, especially of youths and young adults under 30 years of age. For many African countries, this trend dates back to the early 1960s with the attainment of independence in some of the countries. Drawn largely by the expanding urban economies and social amenities in the 1960s and 1970s, which offered opportunities for cash or wage employment and trade, city-ward migration soon became associated with social and economic mo- bility (Anderson, 2001; Barber and Milne, 1988; Bigsten, 1996; Johnnie, 1988; Nigeria Institute of Social and Economic Research, 1997). Residence in cities quickly became a status symbol for at least the rural residents in many parts of Africa, and this, among other reasons, has continued to pro- pel this pattern of migration and rapid urbanization in the region. Africa’s rapid urbanization has occurred amidst stagnating economies and poor governance, which have created massive and abject poverty in overcrowded slum settlements across major cities in the region. Recent stud- ies have highlighted huge inequities in social indicators and in health and reproductive health outcomes between the urban poor and other subgroups, including residents of rural areas, with the urban poor recording the worst outcomes (African Population and Health Research Center, 2002; Dodoo, Zulu, and Ezeh, forthcoming; Gulis, Mulumba, Juma, and Kakosova, 2003; Magadi, Zulu, and Brockerhoff, 2003; Zulu, Dodoo, and Ezeh, 2003). De- spite the poor outcomes observed among the urban poor in sub-Saharan Africa, cities continue to attract a large influx of migrants from rural areas, 189

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190 AGING IN SUB-SAHARAN AFRICA causing urban growth to remain high across sub-Saharan Africa (Govern- ment of Kenya, 2000; Oucho, 1998). Migration to urban areas has generally been thought of as a temporary phenomenon, with migrants maintaining strong ties with their rural origins (Grant, 1995; Gugler, 1991; Trager, 1998). The assumption has also been that they will return to their rural homes upon retirement. However, the presence and the growing numbers of older people in urban areas call for a better understanding of the context of aging in sub-Saharan Africa as well as the situation of older people living in urban areas in the region. These urban areas are characterized by worsening economic and social condi- tions, especially in the sprawling, informal settlements of cities across sub- Saharan Africa. Even though sub-Saharan Africa has the lowest proportion of people age 60 and older, at about 5 percent compared with 10 percent globally, the region has one of the highest rates of growth for this age group, with pro- jections reaching as high as 12 percent of the region’s total population by 2050 (Population Reference Bureau, 2005; World Health Organization, 2002). Recent comparative analysis of Demographic and Health Survey data conducted in the early to mid-1990s in 20 sub-Saharan African coun- tries noted that, on average, people 60 years and over accounted for about 6 percent of the population, with the average for Southern African coun- tries reaching 7 percent (Ayad and Otto, 1997). In Kenya, various estimates put the proportion age 60 and over at about 4 percent (Thumbi, 2005). The 1999 Kenyan census puts the proportion 60 and over at 4.7 percent, signifi- cantly lower compared with the 6.1 percent recorded in the 1989 census (Republic of Kenya, 2001). These differences may result from age misreporting in censuses and surveys, especially for older ages, since inter- viewers generally rely on physical features to estimate age. Little research has focused on older people in sub-Saharan Africa. The limited work that has been done has focused mostly on rural areas, and attention to older people living in urban areas is almost nonexistent. This paper aims to reduce this dearth of knowledge by exploring the living ar- rangements, economic activities, and health status of older people living in two informal settlements in Nairobi, Kenya. The Study Setting Nairobi typifies the current urban population boom and its associated health and poverty problems, characteristic of many sub-Saharan African cities. During the colonial era, restrictive settlement policies on migration to the city maintained the growth within certain limits, with a population of 120,000 in 1948 (Muwonge, 1980). With the elimination of the “pass”

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191 THE SITUATION OF OLDER PEOPLE IN POOR URBAN SETTINGS system, in which migrants were required to obtain a permit to reside in Nairobi, and the relaxation of other migration rules following Kenya’s in- dependence in 1963, Nairobi’s growth entered its second phase; its popula- tion reached 350,000 in 1962 and 500,000 in 1971, with an estimated one- third living in unauthorized housing (Muwonge, 1980). The 1999 Kenyan Population Census enumerated the population of Nairobi at 2.3 million (Republic of Kenya, 2001). With economic declines since the 1980s, 60 to 70 percent of the Nairobi population is currently estimated to be living in informal settlements that occupy only 5 percent of the residential land area of the city (Matrix Development Consultants, 1993; UN-Habitat, 2003). This study covers 2 of the more than 40 informal settlements in Nairobi: Viwandani and Korogocho. Although the two communities are similar in many respects, they also have some key differences. Viwandani, which is located very close to the city’s industrial area, is home to many low-income industrial workers, as reflected in the relatively high proportion of men of working age (15-49). In line with its strategic location near the major source of employment in the city (the industrial area), Viwandani attracts some- what more educated residents than Korogocho. However, this means that the population is also more transient, with residents on average having lived there only six years, whereas Korogocho residents have spent an average of 11.5 years in the community. Also, while Viwandani has more than 53 percent of the total population of the two settlements, it has less than a quarter of the population age 60 and over. The two communities also share a number of features characteristic of informal settlements in Nairobi. Most households live in one-room houses that serve multiple purposes, including sleeping, sitting, and cooking and eating. Over 95 percent of the households cook in the same room they use for sleeping. Over 90 percent of the households do not have any organized mechanism for garbage disposal, while fewer than 5 percent have their own toilets. Similar patterns are observed for water supply: over 90 percent of households depend on poor-quality water distributed by vendors or kiosks for which they pay three or more times the tariff charged by the Nairobi City Council to pipe water to middle or upper income households (African Population and Health Research Center, 2002; Matrix Development Con- sultants, 1993; UNICEF, 2002). The social, economic, and environmental conditions prevailing in informal settlements provide a challenge to the well- being of older people living in this setting, given their increased vulnerabil- ity due to declining physical and health status and reduced economic pro- ductivity. It is against this background that this paper seeks to explore the living conditions of the elderly in the informal settlements in Nairobi.

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192 AGING IN SUB-SAHARAN AFRICA Data and Methods The quantitative data are drawn from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) that the African Population and Health Research Centre set up in 2002. The NUHDSS covers a popula- tion of about 60,000 living in about 23,000 households in the two informal settlements. The NUHDSS involves visits to all the households once every four months to continuously update information on pregnancies and preg- nancy outcomes, migration, episodes of morbidity, health-seeking behav- ior, mortality and causes of death, livelihood activities, vaccination cover- age, marital status, and school attendance. Data on 791 persons age 60 and older present at the end of the three waves of observation in 2003 are used in this analysis. Qualitative data are also used to examine the meanings attached to being old by older people themselves and other residents of the communi- ties under study and also to provide a snapshot of older people through the use of case studies. The qualitative research involved focus group discus- sions and in-depth interviews with older persons, as well as focus group discussions with other members of the two communities. The focus group data were collected to provide an overview of the communities’ attitudes and opinions toward older people and aging. They addressed a number of issues relating to community perceptions and definitions of an older person, roles older people play in the community and how these might vary be- tween men and women, support networks available, and general problems older people encounter in urban informal settlements. The focus group par- ticipants were randomly selected and stratified according to age. In the in- depth interviews, different categories of older people (those living alone, those living only with children under age 15, those with physical disabilities or chronic conditions, those who recently lost an adult child, etc.) were purposively selected for interview. The interviews focused on obtaining case histories of their lives and experiences, support networks, and reasons why they continue to reside where they do. Although these qualitative data are rich and deserve fuller exploration beyond the scope of this paper, we have made only limited use of them, generally to underscore the results emerging from the quantitative data and to highlight the lives of specific older people in the form of case studies. Who Are Regarded as Older People in Poor Urban Communities? Although old age is defined differently by various cultures and societ- ies, age 60 is widely used as the cutoff age to define older people. Chrono- logical age, physical features, and social attributes are widely used as char- acteristics that define old age. The concept of defining old age by

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193 THE SITUATION OF OLDER PEOPLE IN POOR URBAN SETTINGS chronological age in sub-Saharan Africa has severely been criticized (Bledsoe and Fatoumatta, 2002; HelpAge International, 2002; Kimuna and Adamchak, 1999; United Nations, 1991). Social definitions that see old age as both a process and a stage have been recommended instead, as this comes much closer to local perceptions and notions regarding old age. The quali- tative study explored the meanings attached to being old among the study population. Analysis of the data shows clearly that being an older person is perceived both as a process and a stage that a person enters after attaining a certain age or reproductive and other life experiences. Most of the discussants define an older person according to their physi- cal characteristics, their marital or childbearing experiences, their dress, or the sort of lifestyle they lead. In 15 of the 24 focus group discussions, physi- cal attributes, such as having grey hair and wrinkles, using a walking stick, or having a stooped back, were mentioned in defining an older person. Reproductive experience, especially having grandchildren, and personal character, especially manner of dressing, were also said to define an older person. The degree of contribution to community-wide programs or the ability to command respect in the community are other common descrip- tions of older people, often made without much regard to chronological age. These nonphysical notions of who an older person is were mentioned in about two-thirds of the focus group discussions. For some discussants, being an older person is equated with importance in men, the onset of meno- pause for women, and loss of interest in sex for both sexes. Declining physi- cal strength and health status and increased physical and financial depen- dence and vulnerability were also mentioned as characterizing older people. Apart from physical features and reproductive experiences, the roles that older people play in their community, especially in arbitrating disputes and providing guidance and local leadership, are also seen as their defining characteristics. Older people were said to play an important role in the community, for example in settling disputes both at the domestic or family level and at the community level. In about 21 of the 24 focus groups, older people were said to be nonpartisan when settling disputes because of their wealth of experience and knowledge, hence their ability to give valuable advice on various issues. They were also said to play a major role in security matters in the community and to participate and provide leadership in com- munity development initiatives, such as the construction of schools, bridges, and toilets, the provision of water, and ensuring that the community is clean. During calamities or disasters such as fires, older people are said to play a lead role in mobilizing the community. The excerpts below provide examples of the views on older people mentioned above. You may identify an old person by looking at his age and especially for men you may also see their grey hair. Women normally wear head scarves so you

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194 AGING IN SUB-SAHARAN AFRICA may not see the hair. He may also use a walking stick, have impaired vision and may occasionally need assistance from another person (women ages 15-24, Korogocho). Res6: It means being unable to do things for themselves. There is no work you can do. Even in employment you cannot work. It is like being a child. It is like sickness. Res9: An older person is someone who is sickly, has no one to help them. They wake up and stare through the window and pray to God and leave everything to God. I am old and I have nothing. I have nobody to help me. I am sick and I have nobody to give me water or to do anything for me. I am old. Res6: Like me, the way I was last year is not the same this year. I am now incapacitated. I feel I cannot walk. I have aches in the limbs and the back. I feel my whole body paining now. Res1: It is when your body is incapacitated. It does not concern money but when you can no longer work or do things for yourself then you are old (women age 60 and older, Korogocho). Res6: An older person cannot walk and his life is almost over. You will shake while walking. Others have no food and this food we are given by our children while others go without food. That is one of the problems the older people face because you are old and you cannot fend for yourself. When you are sick there is nobody to give you health care. Perhaps you have children but they are poor and they wander around because you never gave them proper upbringing due to your poverty status (men age 60 and older, Viwandani). Res3: They are involved in the administration of the community. Most of them act as chairmen in the community leadership. They attend to community prob- lems like fire outbreaks, shortage of water and village cleanliness, and so on (men ages 25-49, Viwandani). Those who use chronological age in defining older people often men- tioned ages ranging from 35 to 65 and over as the cutoff. Specific ages were given in 13 of the 24 focus groups. Each age group appears to consider anyone in the age groups above theirs as an old person. Discussants in the age group 15-24 were more likely to report age 35 or 40 as the cutoff age. Those ages 25-49 were more likely to mention age 50 or 55 as the cutoff, while most discussants ages 50-59 gave the cutoff as 65. It is interesting that, except for those age 60 and older who feel incapacitated, people do not regard themselves as older. It is unclear the extent to which the negative images often used in describing older people in the slum communities con- tribute to this view. The defining characteristics ascribed to older people as noted above

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195 THE SITUATION OF OLDER PEOPLE IN POOR URBAN SETTINGS suggest that being an older person is not only a function of having attained a certain age, but also reflects certain physical attributes, reproductive ex- periences, and roles performed in the community. This gives a different perspective on who is an older person as seen through the eyes of members of these communities. The different meanings attached to being an older person call for caution in conducting studies that look at older people in such settings. The discussion below, however, focuses on persons age 60 and above in line with the international definition of older persons. STUDY RESULTS Sociodemographic Characteristics of Study Participants Table 6-1 shows the sociodemographic characteristics of older people resident in the two informal settlements. There is a variation in the sex distribution across and within each slum community. There are generally more men than women in the overall population, and this is also reflected in the population age 60 and over. It may reflect historical migration pat- terns in many parts of sub-Saharan Africa, which are largely dominated by male migration. As noted earlier, Viwandani tends to attract more men: 58 percent of the total male population in the two communities resides in Viwandani (statistics not shown in table). A slightly larger proportion (57 percent) of the total population of the two slum communities also resides in Viwandani. However, only 23 percent of the population age 60 and over resides here. This can be attributed to the fact that Viwandani attracts a more youthful population, who work in the adjoining industries. The im- balance in the older population between Viwandani and Korogocho is also reflected in the gender distribution. Whereas only 56 percent of the total older population is male, this proportion rises to 74 percent in Viwandani, whereas the proportion in Korogocho is the same as that of older women. Almost one-third of the total population consists of people from the Kikuyu ethnic group, and the proportion rises to more than one half (54 percent) among the population age 60 and older. Across the sexes, more than two-thirds of older women in the two slum communities are Kikuyu compared with only 43 percent of the older men. The overrepresentation of Kikuyu older women in the two slum communities may reflect a combina- tion of factors, including the fact that Nairobi is almost surrounded by Central Province, which is largely dominated by the Kikuyu ethnic group. It may also be the case that older women from other ethnic groups may be more likely to return to their rural origins in old age or less likely to have migrated to Nairobi in the past. With growing poverty, it is also possible that poor women from Kikuyu-dominated districts surrounding Nairobi may decide to move to Nairobi to beg or carry out petty business and there-

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196 AGING IN SUB-SAHARAN AFRICA TABLE 6-1 Sociodemographic Characteristics of the Overall Population and Older People Age 60 and Above, Nairobi Demographic Surveillance System, 2003 Total Population Population 60+ Women Men Total Women Men Total Ethnic Group Kamba 20.2 27.2 24.2 8.9 15.4 12.5 Kikuyu 33.6 29.1 31.1 67.4 43.3 54.0 Luhya 13.9 13.2 13.5 2.9 10.9 7.3 Luo 18.3 16.1 17.1 2.6 8.6 5.9 Other 13.9 14.3 14.1 18.3 21.8 20.2 Education No education 9.8 5.1 7.1 69.1 38.2 51.9 Primary 67.7 59.8 63.1 30.0 55.6 44.3 Secondary+ 22.4 35.1 29.8 0.9 6.3 3.9 Marital Status Currently married 51.4 57.7 55.2 20.1 76.5 50.8 Formerly married 13.4 4.4 8.1 75.5 21.5 46.1 Never married 35.2 37.9 36.8 4.5 2.0 3.1 Residing with Spouse Yes 96.7 65.6 77.6 70.2 52.8 56.0 No 3.3 34.4 22.4 29.9 47.2 44.1 Number of Cases 23,021 30,525 53,546 350 441 791 Percent 43.0 57.0 44.2 55.8 SOURCE: African Population and Health Research Center (2002-2003). fore more likely to reside in the slums. The large disparity between older men and women from the Kikuyu ethnic group is not reflected in the overall ethnic distribution of the total population in the two slum communities. Kikuyu women account for only 34 percent of the total female population, similar to Kikuyu men, who account for 29 percent of the total male popu- lation. Across other ethnic groups, older men are more predominant than women in both slum communities. Slightly more than half of the older population have no education, and less than 5 percent have attained secondary or higher education. The dis- parity between the sexes in terms of level of education is very wide: more than two-thirds of the older women have no formal education compared with only 38 percent of the older men. Older men are almost eight times more likely than older women to have secondary or higher education.

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197 THE SITUATION OF OLDER PEOPLE IN POOR URBAN SETTINGS Korogocho Population 60+ Viwandani Population 60+ Women Men Total Women Men Total 6.3 7.6 6.9 25.0 32.9 30.8 67.9 45.7 56.8 64.6 38.0 44.9 3.0 10.9 6.9 2.1 11.0 8.7 3.0 10.9 6.9 0.0 3.7 2.7 19.9 25.0 22.4 8.3 14.6 13.0 69.6 42.3 55.9 66.0 28.8 38.6 29.7 51.7 40.8 31.9 64.4 55.9 0.7 6.0 3.4 2.1 6.8 5.6 18.6 71.2 44.8 29.6 90.2 73.1 77.9 26.7 52.4 59.1 8.0 22.4 3.5 2.1 2.8 11.4 1.8 4.5 77.8 64.2 67.1 38.5 29.3 30.4 22.2 35.8 33.0 61.5 70.7 69.6 302 304 606 48 137 185 49.8 50.2 25.9 74.1 Among older women, about one in five is currently married compared with 77 percent of older men. An overwhelming majority of the women (76 percent) are formerly married, the majority of these being widowed, and 5 percent have never been married. For the older men, only 21 percent are formerly married, reflecting the higher propensity of widowed and divorced men to remarry, often to much younger women. Widowed or divorced older women, in contrast, rarely remarry and may end up living alone or with their children or other adult relatives. Among the currently married, older women are more likely to reside with their spouse than are men, and this is true of residents of Korogocho more often than Viwandani. While almost two-thirds of the currently mar- ried older men in Korogocho live with their wives, only 29 percent of those living in Viwandani do so. Also, while more than three-quarters of cur- rently married older women in Korogocho live with their spouses, fewer

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198 AGING IN SUB-SAHARAN AFRICA than 40 percent of their counterparts in Viwandani do so. These patterns of gender and slum location differentials in coresidence also exist in the gen- eral population, with 96 to 98 percent of currently married women in the two communities coresiding with their husbands compared with only 71 and 61 percent (not shown) of the currently married men in Viwandani and Korogocho, respectively. One plausible explanation for these gender differ- entials may be differences in reasons for rural-urban migration between men and women: married men may migrate to the city in search of jobs, leaving their families behind, while the women may migrate to join their husbands in the city. The sociodemographic profile of older people living in urban informal settlements as described above may have implications for their well-being. For example, older women who are largely uneducated and unmarried may face more severe forms of poverty, isolation, and vulnerability than men, and they may be more likely to be excluded from formal employment in the past and social support systems in the present, such as the country’s con- tributory pension scheme. We use the case study of an in-depth interview with an 82-year-old woman to highlight the vulnerability women face in the urban informal settlements (Box 6-1). Living Arrangements The living arrangements of older people greatly affect their social, eco- nomic, and health status and overall well-being. Older people who live alone may lack the necessary social capital and networks to survive in urban in- formal settlements. Table 6-2 shows the living arrangements of the study group. Overall, 47 and 38 percent of older men and women, respectively, live alone in one-person dwelling units in the two slum communities. In both Korogocho and Viwandani, 7 and 10 percent of the older women, respectively, live only with children under age 15 compared with about 1 percent of the men in each of the slum communities. This finding supports earlier reports suggesting that older women, who may be more vulnerable economically and socially, are often more likely to shoulder the burden of caring for orphaned grandchildren or relatives (Ntozi and Zirimenya, 1999). Among older people who reported being currently married, older men are about 2.5 times more likely than older women to live with only a spouse or with a spouse and children under age 15. The greater proportion of older men living with a spouse may reflect the higher likelihood of widowed or divorced men remarrying, often to much younger women, compared with widowed or divorced women. Overall, close to one-half of older women live with at least one other adult (other than the spouse) who is age 15 or older compared with only a third of the men. Across the two slum communities, there are substantial variations in

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199 THE SITUATION OF OLDER PEOPLE IN POOR URBAN SETTINGS BOX 6-1 Case Study 1: Female Living Alone, Viwandani She is 82 years old and has been living alone for the past year after her two adopted children were admitted to a boarding school, which also serves as a rehabilitation center. She ran away from her matrimonial home 20 years ago to escape physical abuse from the husband who had married two other wives after she could not bear children. She settled in this community and did various casual jobs until she decided to become self-employed as a hawker of secondhand clothes in the streets of Nairobi. She stopped the business after hawkers were banned from op- erating in the streets, and she has not been employed since. She was also finding it difficult to continue hawking after she was hit by a vehicle and her leg was seriously injured. She owns the house she currently occupies but the house has burned down a couple of times. About 10 years ago she decided to adopt a set of twins from a woman who had planned to abandon the children after delivery. Her adopted children got into bad company and became delinquent, refusing to go to school. To salvage the situation, she took the children to a rehabilitation center, where all their expenses and upkeep are taken care of by a reli- gious group running the center. The children do not come home to visit her even during holidays, but she does visit them once in a long while. She relies on well-wishers, including neighbors and relief organiza- tions, to provide her with food and water. A religious organization also provides her with free health care. She is able to do household chores with little difficulty. One disadvantage of living alone, according to her, is that there is no one to assist her at times of difficulty. Living alone, how- ever, also has its advantages because she is catering only to her own needs. According to her, “If you feel hungry, you feel the hunger alone. If you cook food, you cook your own which you know it is enough for two days or one only.” living arrangements. More than half of older people in Viwandani (54 per- cent) live alone compared with only 40 percent in Korogocho. In Viwandani, 60 percent of older men live alone in one-person dwelling units, compared with only 36 percent of the women in the same community. While 12 per- cent of the older men in Korogocho live with only a spouse, less than 4 percent of those in Viwandani reported living with only their spouse. Com- pared with estimates for Nairobi from the 1999 census in which only 16.8 percent of the older people live alone, those in the two informal settlements (43 percent) are 2.5 times more likely to live alone. This suggests that older

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203 THE SITUATION OF OLDER PEOPLE IN POOR URBAN SETTINGS hold. She has been married twice and came to live in Nairobi from the rural areas after separating from her first husband in 1989. Her only sur- viving child lives in the same community with his family. She worked as a domestic servant after moving to Nairobi and stopped only after she de- veloped difficulty walking due to pain in her legs. The pain has limited her movements, including performing daily activities such as bathing and using the toilet, which she does with great difficulty and requires assis- tance during days when the pain is most severe. She cannot afford to follow up on treatment for her legs and the little money she gets goes toward buying food for her household. For her livelihood, she sells water on behalf of someone and is paid in kind. She also doubles up as an herbalist selling traditional medicine meant to treat eye infections. The grandchildren also contribute to the household income, especially during school vacation, when they do manual labor, including working as domestic servants. Her household also relies on handouts from well-wishers in the community. The inter- viewer found her contemplating her next move because of a notice is- sued to her and her neighbors to vacate their dwelling units, which were to be demolished due to being too close to electricity main grid lines. Her wish is to start up a business selling vegetables outside her doorstep and joining a welfare group that would advance her credit to expand on the business. She longs for the day when her grandchildren have finished school and will be able to take care of her. One of the biggest challenges to the economic well-being of older people in the urban informal settlements is the informality of their economic activi- ties. A majority of the residents work in the informal sector, and even those who have formal employment often lack job security despite working in high-risk jobs. The case in Box 6-3 highlights the complex linkages between economic activity, health status, and aging among the urban poor. Health Status Table 6-4 shows 30 percent of older women and 18 percent of the men reported being sick during a two-week period preceding a visit to their households between January and April 2003. A look at the main illnesses reported by these older people show few differences by gender and slum location. Overall, musculoskeletal illnesses account for 57 percent of the

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204 TABLE 6-3 Working Status, Reasons for Not Working, and Other Economic Indicators, Nairobi Demographic Surveillance System, 2003 (in percentage) Total Population 60+ Korogocho Population 60+ Viwandani Population 60+ Women Men Women Men Women Men Percentage Currently Working 51.5 62.1 52.3 63.1 46.9 59.9 Type of Work: Petty trading 72.7 50.2 71.9 57.0 78.3 34.2 Formal employment 20.8 22.9 21.3 16.1 17.4 39.0 Informal employment 6.6 26.9 6.9 26.9 4.4 26.8 Reason for Not Working: Too old/retired 62.7 54.5 62.5 52.7 64.3 63.6 Sick/ill 19.1 15.2 18.8 16.4 21.4 9.1 Other reasons 18.2 30.3 18.8 30.9 13.3 27.3 Household Receives Remittances 30.1 15.2 29.7 17.8 32.4 9.4 Receives Social Security (e.g., NSSF) 2.2 10.2 2.3 4.3 2 23.4 Number of Cases 356 442 306 305 50 137 SOURCE: African Population and Health Research Center (2002-2003).

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205 THE SITUATION OF OLDER PEOPLE IN POOR URBAN SETTINGS BOX 6-3 Case Study #4: Man with a Disability (Blindness), Viwandani The subject is a 61-year-old man living with his wife and two school- age children. He moved to Nairobi during the preindependence period and has lived in this particular slum community for close to 25 years. He was employed as a plant operator in one of the neighboring industries. His eyesight started deteriorating after an industrial accident at work that exposed his eyes to dangerous chemicals. His employment was termi- nated on health grounds when it became apparent that he was almost totally blind. He has been unemployed for about 10 years. He made sev- eral attempts to save his eyesight, including undergoing about five eye operations. The hospital expenses of these surgeries cost him all his savings and put him in debt. After exhausting his savings and losing his job at the factory, he was resigned to fate. He has undergone rehabilitation and training on the use of the white cane and is now able to move around his neighborhood unaided and is even able to walk to the main road and take public trans- port. He is also able to perform most household chores, such as washing clothes, lighting the stove, cooking, and washing utensils. He likes to be independent and does not want to stay idle, so he prefers to do most of the household chores, even though his wife and children are always ea- ger to assist. He owns the structure that his household currently occupies in addi- tion to two others in the community that have been rented out. Most of his income comes from the rental structures. His wife also runs a business selling vegetables in the market. He prefers life in the city, which he be- lieves is better than in the rural areas, since his parents left a piece of land too small to farm, and the brothers he left behind have already taken it over and refused to share it with him. illnesses reported by the women in both slum communities but for only 35 to 47 percent of the illnesses reported by men. Men are more likely to report respiratory illnesses, with one in four in Viwandani reporting this compared with only 15 percent of the women in Korogocho and Viwandani. Equal proportions of men and women in Korogocho reported gastrointesti- nal illnesses, reflecting the common environmental conditions affecting health in this particular slum community. In contrast to Korogocho, no woman in Viwandani reported gastrointestinal illness, although 10 percent of the men in the community reported it. Between 10 and 18 percent of the men and women reported illnesses associated with the central nervous system. Although there are indications

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206 TABLE 6-4 Health Status and Treatment-Seeking Behavior Among Older People, Nairobi Demographic Surveillance System, 2003 (in percentage) Total Population 60+ Korogocho Population 60+ Viwandani Population 60+ Health Status and Care Seeking Women Men Women Men Women Men Sick (past two weeks) 29.6 18.1 28.8 19.6 34.7 14.6 Type of Illness: Musculoskeletal 57.1 43.8 56.8 46.7 58.8 35.0 Respiratory 15.2 22.5 14.8 21.7 17.7 25.0 Gastrointestinal 5.7 7.5 6.8 6.7 0.0 10.0 Central nervous 13.3 16.3 12.5 18.3 17.7 10.0 Other 8.6 10.0 9.1 6.7 5.9 20.0 Sought Care for Illness 44.8 47.5 42.0 45.0 58.8 55.0 Number of Cases 356 442 306 305 50 137 SOURCE: African Population and Health Research Center (2002-2003).

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207 THE SITUATION OF OLDER PEOPLE IN POOR URBAN SETTINGS that depression and dementia are less common in Africa, there might be gross underreporting given the fact that the occurrence of neurovascular disorders, dementia, and depression increases with age. Again, since the reports are generally obtained from the household respondent, who may not necessarily be the older person, such proxy reports on such illnesses as depression may be poor (Alverado-Esquivel et al., 2004; Heun and Hein, 2005; Prince, Acosta, Chiu, Scazufca, and Varghese, 2003). Although older women are more than 1.5 times as likely as older men to be sick, they are not any more likely to have sought care during an illness episode. In gen- eral, treatment seeking is quite low among older people, with less than one- half of the sick receiving treatment. A major health challenge faced by older people is the increasing preva- lence of noncommunicable diseases often requiring constant long-term care. These illnesses have the potential of affecting every aspect of their lives, including their families, as some spend all household resources on medica- tion, often at the expense of other basic needs. The case in Box 6-4, a diabetic octogenarian, highlights the situation of older people in dealing with chronic illnesses. Interaction of Living Arrangements, Health, and Economic Status Table 6-5 looks at the health and working status of older people in the two slum communities by their living arrangements. In Korogocho where the sample is large enough, older women and men living alone are more likely to report being sick than those who live with a spouse or children (or both) or those living with other adults. While 37 percent of older women living alone reported being sick, only 23 percent of those living with other adults reported an illness. Similar patterns are also observed for men, with those living alone being more than two times as likely to report an illness as those living with at least one other adult. Data on treatment-seeking behavior by living arrangement suggests that older women and men living alone may have less access to treatment when ill compared with those living with at least one other adult. Among older women and those in Korogocho, those who live with at least one other adult (other than the spouse) reported higher levels of seeking treatment during an illness episode compared with those who live alone. The number of cases is too small to explore treatment-seeking behavior in other forms of living arrangements. From the qualitative data, lack of transport fare and absence of health personnel at the health facilities were often cited as major hindrances to seeking health care in hospitals. This may partly explain why older people living alone are less likely to seek care even though they are sicker. In addition, the table shows that in both slum communities and for

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208 AGING IN SUB-SAHARAN AFRICA BOX 6-4 Case Study #5: Man Living Alone, Korogocho The subject is almost 90 years old and has been living alone for the past 5 years. His three children moved out of Nairobi to different parts of the country, and his wife moved in with their son to help look after her son’s children. The wife visits him in the city frequently. He pays some- one to come twice a week to do household chores for him, such as clean- ing and cooking. He used to run businesses that were able to sustain him and his entire family. He had even employed a number of people to help him manage the businesses, including all his children. However, after he was diagnosed to be diabetic, a lot of funds were diverted to treating his ailment, forcing all his businesses to collapse. This also contributed to his children leaving the community to earn a living elsewhere. He owns the structure that he now occupies, including six other dwelling units (rent- able rooms) that are rented out; some of these units were unoccupied during the time of the interview. He is currently under medication and has to buy all the drugs him- self, sometimes assisted by his children. His ailment has depleted his resources and assets and he is on a special diet according to doctor’s advice. He says “I may want medication but it is expensive at these pri- vate clinics, so I wonder what to do. This is what finishes our money. Medicine is expensive. The amount you pay for government hospital wards and the health services is as much as you pay to private clinics for one or two pills. Especially for us diabetics, one tablet costs twenty shil- lings. To get a packet of ten tablets is two hundred shillings. Yet you must buy the medicine, you have no choice.” The diabetic condition has af- fected his eyesight and he has undergone an operation to remove cata- ract from his eyes. His view is that without money one cannot access health care. He prefers to seek treatment in government-run facilities as opposed to pri- vate clinics or hospitals. He argued that health facilities should have spe- cial services for older people to treat particular ailments and also special diets if they are admitted as inpatients. Older people should also be cared for by the government by providing them with food, shelter, or a monthly allowance. He considers an older person to be someone with disability who requires constant care. On special services for older people, he said “I think old people should be separated from the rest. They should have their own hospital. It should be based on a certain cutoff age. If the old have their own ward in a hospital, it would be good because they will be fed as old people. As it is now, when patients are being fed on bones, even the old people are given the bones to eat.” When asked what his greatest wish was, he says he wished to be reunited with his children and that the children would come back to live with him. He acknowledges that this is not possible because the children have settled down wherever they are, and there will be nothing to keep them going should they decide to move back.

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209 THE SITUATION OF OLDER PEOPLE IN POOR URBAN SETTINGS TABLE 6-5 Health and Economic Status by Living Arrangement, Nairobi Demographic Surveillance System, 2003 Lives with Lives with Lives Spouse/ at Least 1 Alone (N) Children (N) Other Adult (N) Those Who Reported Sick Korogocho Women 37.1 (116) 25.0 (40) 23.3 (150) Men 27.8 (126) 16.1 (62) 12.7 (118) Viwandani Women 41.2 (17) — (2/5) 33.3 (24) Men 13.4 (82) 0.0 0 19.1 (47) Sought Treatment by Gender: Women 40.0 (50) — (6/12) 48.8 (43) Men 47.8 (46) — (4/10) 50.0 (24) Sought Treatment by Slum: Korogocho 41.0 (78) 40.0 (20) 48.0 (50) Viwandani — (10/18) — (2/2) — (9/17) Currently Working: Korogocho Women 73.2 (97) 63.2 (19) 55.0 (140) Men 80.6 (98) 90.9 (22) 73.4 (128) Viwandani Women 78.6 (11/14) — (1/3) 55.0 (20) Men 94.0 (50) — (3/3) 80.0 (40) both men and women, older people who live alone are more likely to con- tinue working to support themselves than those who live with at least one other adult. This is further evidence that older people who live alone may face greater vulnerability than those who live with other adults. Compared with their female counterparts, older men are more likely to be currently working irrespective of their living arrangement. CONCLUSION Differences do exist between the two slum communities, Viwandani and Korogocho, both in terms of the share of older people living in the particular slum and also in the sociodemographic characteristics of the older population. Older people are more likely to reside in the Korogocho com- munity, although Viwandani has a larger share of the total population of the two communities. This may result from the fact that Viwandani tends to attract a more youthful population seeking employment because of its proximity to the city’s industrial zone. With regard to the currently mar- ried, more than two-thirds of those in Viwandani do not reside with their spouses compared with only one-third in Korogocho.

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210 AGING IN SUB-SAHARAN AFRICA A large proportion of older people living in the informal settings live alone contrary to findings from other studies (for example, Bongaarts and Zimmer, 2001) in which most older people, especially those in rural areas, live in large households. Older men are more likely to live alone compared with women, who were more likely to reside only with children under age 15. Coresidence of older women with young children normally referred to as skipped-generation households could reflect the high incidence of mor- tality in the middle age groups due to HIV/AIDS. Women were more likely to report not being currently married, whereas the majority were formerly married, with a few having never married. This may reflect the combined effect of higher life expectancy for women, higher remarriage among men, and age differences between spouses (African men usually marrying younger women). Older women living in informal settlements are more likely to be vulnerable to poverty as a result of their low participation in employment, which is worsened by their low educational attainment. The informal sector is the major employer to the majority of residents in the slums of Nairobi, hence they are left out of the contributory pension program, which is accessible only to those employed in the formal sector. Less than 10 percent of older people in the two slums were receiving any form of pension. Lack of social security in old age could be a reason for the continued participation of a high percentage of older people in employment coupled with the cash economy of urban settings. The declining health and physical status of older people together with a competitive employment market that discriminates on age reduces the chances of older people find- ing well-paying jobs, as reflected in the nature of their employment, which is mainly petty trading. Although old age signifies an increase in the need for health care, there is low utilization of health care services among older people living in the two slum communities. Less than half of those who reported an illness in the two weeks preceding the visit to their households sought care for their ailment. Older people living alone were also more likely to report being sick compared with those living with a spouse or other adults, but they are less likely to seek treatment in a health facility. This paper has provided an overview of the sociodemographic charac- teristics, living arrangements, health, and economic status of older people living in two slum communities of Nairobi. The paper has highlighted a number of vulnerabilities older people in urban informal settlements may face. Unlike other older people, those in urban informal settlements are more likely to live alone in single-person households. Consequently, they are unlikely to benefit from the type of support and care traditionally pro- vided to older people by extended family. The majority of them, despite being old and fragile, continue to be engaged in one form of economic activity or the other, especially for those living alone. The small sample, however, could not permit a fuller assessment of how the living arrange-

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211 THE SITUATION OF OLDER PEOPLE IN POOR URBAN SETTINGS ments of older people affect other aspects of their well-being. Given the unique challenges faced by older people in the urban informal settlements, a more detailed analysis of their situation across various cities in sub-Saharan Africa is needed to facilitate the development of comprehensive policy and action to improve the well-being of older people living in urban informal settlements. ACKNOWLEDGMENTS The authors acknowledge support for the Nairobi Urban Health and Demographic Surveillance System from the Rockefeller Foundation (Grant no. 2004AR037) and the Hewlett Foundation (Grant no. 2004-9699). This analysis and the qualitative data collection were supported in part by the National Institute on Aging (Grant no. P30 A9017248-0351) through the University of Colorado’s Population Aging Center (Subaward no. 0000047604) in collaboration with Jane Menken. REFERENCES African Population and Health Research Center. (2002). Population and health dynamics in Nairobi informal settlements. Nairobi, Kenya: Author. African Population and Health Research Center. (2002-2003). Nairobi urban health and de- mographic surveillance system. Nairobi: Author. Alvarado-Esquivel, C., Hernandez-Alvarado, A.B., Tapia-Rodriguez, R.O., Guerrero-Iturbe, A., Rodriguez-Corral, K., and Martinez, S.E. (2004). Prevalence of dementia and Alzheimer’s disease in elders of nursing homes and a senior center of Durango City, Mexico. BMC Psychiatry, 18(4), 3. Anderson, J.A. (2001). Mobile workers, urban employment and “rural” identities: Rural- urban networks of Buhera migrants, Zimbabwe. In M. Dedruijn, R. Van Dijk, and R Foeken (Eds.), Mobile Africa: Changing patterns of movement in Africa and beyond. Lieden, The Netherlands: Brill. Ayad, M.B., and Otto, B.J. (1997). Demographic and health surveys comparative studies: Demographic and socio-economic characteristics of households. Calverton, MD: Macro International. Barber, G.M., and Milne, W.J. (1988). Modeling internal migration in Kenya: An econometric analysis with limited data. Environment and Planning A, 20(9), 1185-1196. Bigsten, A. (1996). The circular migration of smallholders in Kenya. Journal of African Eco- nomics, 5(1), 1-20. Bledsoe, C.H., and Fatoumatta, B. (2002). Contingent lives: Fertility, time, and aging in West Africa. Chicago, IL: University of Chicago Press. Bongaarts, J., and Zimmer, Z. (2001). Living arrangements of older adults in the developing world: An analysis of DHS household surveys. (Policy Research Division Working Paper No. 148). Available: http://www.popcouncil.org/pdfs/wp/148.pdf [accessed October 2005]. Dodoo, F.N., Zulu, E.M., and Ezeh. A.C. (Forthcoming). Urban-rural differences in the socio- economic deprivation: The sexual behavior link. Social Science and Medicine.

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