Aging in Sub-Saharan Africa

Recommendation for Furthering Research

Panel on Policy Research and Data Needs to Meet the Challenge of Aging in Africa

Barney Cohen and Jane Menken, Editors

Committee on Population

Division of Behavioral and Social Sciences and Education

NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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Aging in Sub-Saharan Africa Recommendations for Furthering Research Panel on Policy Research and Data Needs to Meet the Challenge of Aging in Africa Barney Cohen and Jane Menken, Editors Committee on Population Division of Behavioral and Social Sciences and Education

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THE NATIONAL ACADEMIES PRESS •500 Fifth Street, NW •Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Contract No. N01-OD-4-2139, TO#119 between the National Academy of Sciences and the National Institutes of Health and the Na- tional Institute of Aging. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number-10: 0-309-010281-2 International Standard Book Number-13: 978-0-309-010281-0 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); http://www.nap.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. Suggested citation: National Research Council. (2006). Aging in Sub-Saharan Af- rica: Recommendations for Furthering Research. Panel on Policy Research and Data Needs to Meet the Challenge of Aging in Africa. Barney Cohen and Jane Menken, Eds. Committee on Population, Division of Behavioral and Social Sciences and Edu- cation. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engi- neers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its con- gressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PANEL ON POLICY RESEARCH AND DATA NEEDS TO MEET THE CHALLENGE OF AGING IN AFRICA JANE MENKEN (Chair), Institute of Behavioral Science and Department of Sociology, University of Colorado ALEX EZEH, African Population and Health Research Center, Nairobi, Kenya EDWELL KASEKE, School of Social Work, University of Zimbabwe BARTHÉLÉMY KUATE-DEFO, Department of Demography, University of Montreal, Canada DAVID LAM, Department of Economics, University of Michigan ALBERTO PALLONI, Department of Sociology, Institute for Environmental Studies, University of Wisconsin at Madison STEPHEN TOLLMAN, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa ROBERT J. WILLIS, Institute for Social Research, University of Michigan BARNEY COHEN, Director, Committee on Population ANTHONY S. MANN, Senior Project Assistant v

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COMMITTEE ON POPULATION KENNETH W. WACHTER (Chair), Department of Demography, University of California, Berkeley ANNE C. CASE, Woodrow Wilson School, Princeton University, New Jersey EILEEN M. CRIMMINS, Department of Sociology, University of Southern California, Los Angeles BARBARA ENTWISLE, Carolina Population Center, University of North Carolina JOSHUA R. GOLDSTEIN, Woodrow Wilson School, Princeton University, New Jersey BARTHÉLÉMY KUATE-DEFO, Department of Demography, University of Montreal CYNTHIA B. LLOYD, Policy Research Division, Population Council, New York THOMAS W. MERRICK, Center for Global Health, George Washington University, Washington, DC RUBÉN G. RUMBAUT, Department of Sociology and Center for Research on Immigration, Population, and Public Policy, University of California, Irvine ROBERT J. WILLIS, Institute for Social Research, University of Michigan BARNEY COHEN, Director vi

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Acknowledgments This report adds to the empirical and conceptual knowledge of the situation of older people in sub-Saharan Africa and makes practical sug- gestions for further research in this area. The report is based on a work- shop organized by the Committee on Population in collaboration with the Health and Population Division, School of Public Health, University of the Witwatersrand in Johannesburg, South Africa, in July 2004. The report draws on a number of papers commissioned for the workshop, on the comments made by a panel of distinguished discussants, and on the discus- sion by workshop participants. Many people made generous contributions to the workshop’s success. We are grateful to our colleagues, Alex Ezeh, Edwell Kaseke, Barthélémy Kuate-Defo, David Lam, Alberto Palloni, Stephen Tollman, and Robert Willis, who served on the panel that was charged with organizing the work- shop and preparing a document that outlined the priority research areas in relation to aging in sub-Saharan Africa. Belinda Bezzoli, deputy vice- chancellor for research of the University of the Witwatersrand, and Richard Suzman, of the National Institute on Aging, supported the planning of the workshop and participated throughout. We are also especially grateful to the various authors and discussants who prepared papers or presentations in advance of the meeting: Mary Amuyunzu-Nyamongo, African Popula- tion and Health Research Center; Ayaga Bawah, Navrongo Health Research Center; Peter Byass, Umeå University; Samuel Clark, University of Colo- rado at Boulder and University of Washington; Gloria Chepngeno, Univer- sity of Southampton; Mark Collinson, University of the Witwatersrand; Myles Connor, University of the Witwatersrand; Rob Dorrington, Univer- vii

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viii ACKNOWLEDGMENTS sity of Cape Town; Alex Ezeh, African Population and Health Research Center; James Fairburn, University of KwaZulu-Natal; Michel Garenne, French Institute for Research and Development (IRD); Victoria Hosegood, London School of Hygiene & Tropical Medicine; Gillian Hundt, University of Warwick; Kathleen Kahn, University of the Witwatersrand; Benoit Kalasa, United Nations Population Fund; Edwell Kaseke, University of Zim- babwe; Abdhalah Ziraba Kasiira, African Population and Health Research Center; Paul Kowal, World Health Organization; Barthélémy Kuate-Defo, University of Montreal; Rodreck Mupedziswa, University of the Witwatersrand; Randall Kuhn, University of Colorado at Boulder; David Lam, University of Michigan; Murray Leibbrandt, University of Cape Town; Frances Lund, University of KwaZulu-Natal; M. Giovanna Merli, University of Wisconsin; Tavengwa Nhongo, HelpAge International; Alberto Palloni, University of Wisconsin; Karen Peachey, consultant; Dorrit Posel, University of KwaZulu-Natal; M. Omar Rahman, Independent Uni- versity, Bangladesh; Vimal Ranchhod, University of Michigan; Kalanidhi Subbarao, The World Bank; Negussie Taffa-Wordofa, African Population and Health Research Center; Ian M. Timaeus, London School of Hygiene & Tropical Medicine; Margaret Thorogood, University of Warwick; Stephen Tollman, University of the Witwatersrand; Eric Udjo, Human Sci- ences Research Council; Servaas van der Berg, University of Stellenbosch; Victoria Velkoff, U.S. Census Bureau; Robert Willis, University of Michi- gan; Martin Wittenberg, University of Cape Town; and Zewdu Woubalem, African Population and Health Research Center. The Committee on Population was extremely fortunate to be able to enlist the help and cooperation of the staff and faculty of the Health and Population Division, School of Public Health, University of the Witwatersrand, in Johannesburg, South Africa. Particular thanks are due to Stephen Tollman for his invaluable assistance facilitating the meeting and to Dereshni Ramnarain for her assistance in ensuring that the meeting ran smoothly and successfully. In Washington, DC, several members of the staff of the National Acad- emies made significant contributions to the report. We thank Kirsten Sampson Snyder for her help guiding the report through review, Christine McShane for her skillful editing, and Yvonne Wise for managing the pro- duction process. The project took place under the general direction of Jane L. Ross and Barney Cohen. On behalf of the panel, we thank them for their efforts. This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with proce- dures approved by the National Research Council’s Report Review Com- mittee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published

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ix ACKNOWLEDGMENTS report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of the report: Ronald Angel, Department of Sociology, Univer- sity of Texas at Austin; Channing Arndt, Department of Agricultural Eco- nomics, Purdue University; Yael Benyamini, School of Social Work, Tel Aviv University; Peter Byass, Department of Public Health and Clinical Medicine, Umeå University; Benjamin Campbell, Department of Anthro- pology, Boston University; David Canning, Department of Population and International Health, Harvard School of Public Health; Julia Dayton, con- sultant; Gary V. Engelhardt, Center for Policy Research, Syracuse Univer- sity; Bibi Essama, Westat; Monica Ferreira, The Albertina and Walter Sisulu Institute of Ageing in Africa, University of Cape Town, South Africa; Gary Fields, Department of Economics, Cornell University; Kathleen Ford, De- partment of Epidemiology, University of Michigan; Lucy Gilson, School of Public Health, University of the Witwatersrand; Mark Gorman, Depart- ment of Economic and Social Affairs, HelpAge International; William T.S. Gould, Department of Geography, University of Liverpool; Ellen Idler, In- stitute for Health, Rutgers, State University of New Jersey; Benoit Kalasa, advisor, United Nations Population Fund; Peter Lloyd-Sherlock, Faculty of Social Sciences, University of East Anglia; Monde Makiwane, Child, Youth, Family and Social Development, Human Sciences Research Council, Pretoria, South Africa; Douglas L. Miller, Department of Economics, Uni- versity of California, Davis; Akim Mturi, School of Development Studies, University of KwaZulu-Natal; Sendhil Mullainathan, Department of Eco- nomics, Harvard University; Laura Rudkin, Department of Preventive Medi- cine and Community Health, University of Texas; Joshua Salomon, Depart- ment of Population and International Health, Harvard University; Gigi Santow, independent researcher; Doreen Tempo, Department of Social Policy and Social Work, University of Oxford; Joseph R. Troisi, II, Depart- ment of Psychology, Saint Anselm College; Etienne van de Walle, Depart- ment of Sociology, University of Pennsylvania; Stig Wall, Department of Public Health and Clinical Medicine, Umeå University; Alan Whiteside, Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal; Alun Williams, Centre for Human Ageing, University of Queensland, Australia; Martin Wittenberg, School of Economics, Univer- sity of Cape Town; Zewdu Woubalem, African Population and Health Re- search Center; and Zachary Zimmer, Policy Research Division, Population Council. Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions

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x ACKNOWLEDGMENTS or recommendations nor did they see the final draft of the report before release. The review of this report was overseen by Allan G. Hill, Depart- ment of Population and International Health, Harvard School of Public Health. Appointed by the National Research Council, he was responsible for making certain that an independent examination of this report was car- ried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final context of this report rests entirely with the authoring committee and the institution. Jane Menken, Chair Panel on Policy Research and Data Needs to Meet the Challenge of Aging in Africa Barney Cohen, Director Committee on Population

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Contents Executive Summary 1 PART I: REPORT 1 Aging in Sub-Saharan Africa: Recommendations for Furthering Research 9 References, 46 PART II: PAPERS 2 Aging in Sub-Saharan Africa: The Changing Demography of the Region 55 Victoria A. Velkoff and Paul R. Kowal 3 Demographic Impacts of the HIV Epidemic and Consequences of Population-Wide Treatment of HIV for the Elderly: Results from Microsimulation 92 Samuel J. Clark 4 The HIV/AIDS Epidemic, Kin Relations, Living Arrangements, and the African Elderly in South Africa 117 M. Giovanna Merli and Alberto Palloni xi

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xii CONTENTS 5 Older Adults and the Health Transition in Agincourt, Rural South Africa: New Understanding, Growing Complexity 166 Kathleen Kahn, Stephen Tollman, Margaret Thorogood, Myles Connor, Michel Garenne, Mark Collinson, and Gillian Hundt 6 The Situation of Older People in Poor Urban Settings: The Case of Nairobi, Kenya 189 Alex C. Ezeh, Gloria Chepngeno, Abdhalah Ziraba Kasiira, and Zewdu Woubalem 7 Labor Force Withdrawal of the Elderly in South Africa 214 David Lam, Murray Leibbrandt, and Vimal Ranchhod 8 HIV/AIDS and Older People in South Africa 250 Victoria Hosegood and Ian M. Timaeus 9 Interactions Between Socioeconomic Status and Living Arrangements in Predicting Gender-Specific Health Status Among the Elderly in Cameroon 276 Barthélémy Kuate-Defo 10 Survey Measures of Health: How Well Do Self-Reported and Observed Indicators Measure Health and Predict Mortality? 314 Randall Kuhn, Omar Rahman, and Jane Menken APPENDIXES A Workshop Agenda 345 B About the Contributors 351