Age International submission to the IDC inquiry: Humanitarian crises monitoring: impact of coronavirus

April 2020

Executive summary

1. DFID has recognised that older people “are disproportionately impacted and at more serious risk of severe complications and fatality due to COVID-19”.[1] International responses to COVID-19, however, including from UN agencies, humanitarian actors and international development agencies, are not recognising sufficiently older people as a group at highest risk from the virus and not prioritising them in their response.

2. DFID needs to ensure that the UK’s international response and the financial support offered to partner governments, UN agencies and civil society organisations specifically includes the most at-risk groups within the pandemic and ensures that older people are not left behind in this crisis.

3. Older women and men are experiencing extreme cases of discrimination and human rights abuses in the response to COVID-19 in every part of the globe. Entrenched ageist attitudes are fuelling divisions that allow older people to be treated as being of lesser value to society. The ‘leap-frogging’ of international responses to COVID-19 from the primary health impacts to the secondary economic and social impacts is indicative of an approach that values less those who are at highest risk of death and severe illness from the virus.

4. Older women and men must be treated equally in response to COVID-19. They have the right to high quality healthcare and the right to freedom from discrimination in the same way as every other member of society. Decisions made about treatment should be based on medical need, scientific evidence, and ethical principles. Basing healthcare decisions on non-medical characteristics, such as age or assumed social worth is unethical and discriminatory.

5. It is estimated that up to 30% of displaced people are older people.[2] International actors have raised concerns about the devastation that COVID-19 could cause to people living through humanitarian crises or in refugee camps and Internally Displaced Persons (IDP) camps. Older people caught in humanitarian situations and forced displacement face a much higher risk of serious illness and fatality if they catch COVID-19. DFID needs to ensure its response to COVID-19 in refugee and humanitarian settings includes older people as a high-risk group.

6. The UK government has highlighted the increased vulnerabilities of women and girls during and after the COVID-19 outbreak, however this needs to explicitly include older women. Social distancing measures brought in to respond to COVID-19 has created barriers for older women to access an income, increased their amount of domestic responsibilities and made them more vulnerable to abuse, violence, and sexual violence.

7. Older men and women make vital economic and social contributions to their families, communities, and local economies. Many older women support families and communities by doing paid and unpaid work, domestic work and by providing care. Social distancing measures brought in by countries to respond to COVID-19 are limiting all adults’ ability to earn an income, but older people – especially those living in poverty – are particularly at risk. Social protection measures that provide income support to older people, including universal social pensions, need to be supported by DFID in low and middle-income countries.
    
8. DFID must articulate clearly how it is implementing its commitment to ‘Leave No-One Behind’ (LNOB) as part of the Sustainable Development Goals (SDGs) in the context of COVID-19, with specific reference to older women and men who are at highest-risk from the virus.

Introduction

9. Age International is a UK charity focused on improving the lives of older people in developing countries. Age International is the international arm of Age UK and works together with HelpAge International as the UK member of the HelpAge global network. Our mission is to help older people around the world to overcome poverty, claim their rights and challenge discrimination, so they can lead dignified, secure, active and healthy lives.

Global ageing
 

10. Global population demographics are changing. For the first time in history, persons aged 65 years or over worldwide outnumber children aged under five. By 2050, the number of persons aged 65 years or over globally will also surpass the number of adolescents and youth aged 15 to 24 years.[3]
     
11. Currently 69 per cent of the world’s older population live in low- and middle-income countries,[4] with this expected to increase to 80 per cent by 2050.[5]
     

COVID-19 and ageing

12. COVID-19 is affecting all age groups; however, statistics show that older people have been disproportionately affected. WHO Regional Director for Europe, Dr Hans Henri P. Kluge reported that over 95 per cent of deaths on the continent from COVID-19 occurred in those aged 60 years and over.[6]
     
13. The COVID-19 pandemic is impacting the global population in drastic ways. Although all age groups are at risk of contracting COVID-19, the epidemiological evidence[7] is clear that older people are at higher risk of death and serious illness from COVID-19.[8]

14. DFID has recognised that “in addition to their other vulnerabilities, older people, people with pre-existing conditions, and those with complex needs are disproportionately impacted and at more serious risk of severe complications and fatality due to COVID-19.”[9]

Impact of COVID-19 for older people in humanitarian contexts

15. Older people are too often excluded by international development actors in their responses to humanitarian crises and now face a deadly combination of being the most at-risk group from COVID-19 and a group often left out of humanitarian responses.[10]
     
16. Refugee and internally displaced populations are likely to experience some of the worst impacts of the COVID-19 pandemic due to limited access to healthcare, the high density of people limiting individuals’ ability to self-isolate and difficulties in accessing water and sanitation facilities. It is estimated that up to 30% of displaced people are older people[11] and UNHCR has identified forcibly displaced older people as facing the highest risk from COVID-19.[12]
     
17. Older people in refugee and Internally Displaced Persons (IDP) camps also face barriers to accessing information if they are being told to self-isolate and may be forced to rely on relatives or local neighbours to relay information to them which may not be accurate. Without having the appropriate health and sanitation information available to them, older people will not be able to protect themselves against COVID-19.
     
18. Humanitarian response plans that do not clearly identify older people as a group at high risk from COVID-19 will fail to recognise the discrimination faced by older people in accessing healthcare, information and advice, appropriate nutrition, basic livelihoods and income support, and psycho-social support. It is crucial that older women and men are considered as equal rights holders at all levels of humanitarian response to the crisis. This follows the Sphere Humanitarian Inclusion Standards[13], recognising that all people affected by a crisis have a right to dignity, and understanding the needs of those who are less visible in times of humanitarian crisis.

Case study: Cox’s Bazar in Bangladesh

19. Approximately 855,000 people live in the 34 refugee camps in Cox’s Bazar, including more than 31,500 refugees aged 60 and older.[14] So far there has been only one confirmed case of COVID-19 however due to the severe overcrowding, poverty and chronic lack of health care facilities, there are huge fears that COVID-19 could quickly spread and spiral out of control in the camps, leading to a colossal loss of life.
     
20. It is almost impossible to practice physical distancing in the camps as there are between 5-8 family members living in one room. Self-quarantine is also challenging as most people do not have access to running water, toilets and bathing facilities in their own homes so have to travel along the narrow pathways within the camps to access these potentially life-saving facilities.[15]

21. According to research undertaken by Amnesty International with older Rohingya refugees in Bangladesh, “the humanitarian response has failed to respect older people’s rights to health, food, water, and sanitation. Many problems stem from not including older people’s views and inputs and from not considering their needs and risks when designing assistance. These same mistakes are being repeated with the COVID-19 response, despite all medical evidence demonstrating that older people are one of the most at-risk populations.[16]”

22. Furthermore, older people interviewed by Amnesty International could not access even the most basic information about COVID-19[17].
     
23. Many older people are suffering from hypertension, diabetes and cardiovascular and chronic respiratory diseases, which are exacerbated by the poor conditions in the camp, making them dangerously vulnerable. There are only three ventilators for all of the camps and there are no treatment centres outside of the camps at this moment. Even if they are available, it is very difficult for Rohingya people to be able to access them.[18] If someone living in the camps becomes acutely ill with COVID-19, it could very likely be a death sentence.
     
24. Age International, through our partner HelpAge International, are running a programme funded by UK Aid to procure medical gowns, surgical masks, gloves, goggles, hand sanitisers and head and shoe covers. We are also preparing teams of volunteers to be able to provide community health care and water and sanitation on a larger scale in the coming weeks and months.[19]

Access to healthcare

25. Older women and men in low and-middle income countries already face significant barriers to accessing healthcare. Older people, particularly in rural settings, often live far from health clinics, are unable to afford the transport there, and lack ID to claim any free healthcare that may be available. They face barriers to accessing information as they are more likely to be illiterate and speak local languages rather than English or French.
     
26. Higher levels of disability among older people present additional barriers to accessing services and information[20]. These may be disabilities related to sight, hearing and communicating, or physical mobility disabilities that prevent them from accessing community spaces where information and services are shared.
     
27. The COVID-19 pandemic poses particular, life-threatening risks to older people, who are more likely to be living with non-communicable diseases (NCDs) and chronic illness[21], such as heart disease, hypertension and diabetes, which makes them more at risk from the worst effects of the virus.[22] Healthcare systems lack resources and specialist expertise in gerontological care, including the prevention, treatment and management of NCDs[23]; illness and redeployment of medical staff due to COVID-19 could deplete this further.
     
28. Containment measures and pressure on health systems may lead governments in affected lower and middle-income countries to take drastic action that could curtail the rights of older people, among other groups. Decisions about reducing the risk of infection and effective allocation of resources must be in line with human rights standards and principles. Older people have the right to health, including the right to access healthcare and information, alongside others in society.
     
29. Being forced to self-isolate can be dangerous for an older person, particularly when their usual support within the family or community are also being warned to stay at home or maintain social distancing. Older people already face many challenges when it comes to accessing social care, so limiting access to care without putting in structures to support older people will lead to devastating consequences.

Health system strengthening

30. The experience of COVID-19 is demonstrating that countries need strong and effective health and social care systems in order to protect their populations when global health emergencies occur.
     
31. COVID-19 shows the importance of having health systems that are able to manage multi-morbidity (the presence of multiple medical conditions) and the importance of integrated systems that can respond to people’s holistic health needs. Health systems must be strengthened to ensure they are better placed to respond to the complexities of health in older age, including the impact of disease outbreaks like COVID-19 on older people.

Ageism & discrimination

32. Decisions and actions being made in response to COVID-19 globally indicate that lesser value is being placed on the lives of older people in society.[24]

33. COVID-19 is exposing the age discrimination and denial of rights that older people are facing daily in their everyday lives. Across media and social media channels there has been shocking examples of derogatory and dehumanising language[25] suggesting that older people should put others or the economy first and even that the pandemic could benefit the economy through ‘culling elderly dependents’ [26]. As health systems come under pressure, there have been further examples of age discrimination, including guidance in some contexts explicitly encouraging health staff to prioritise younger people[27].
     
34. Older people must be treated as equals in society. They have the right to high quality healthcare and the right to freedom from discrimination in the same way as every other member of society. Decisions made about treatment should be based on medical need, scientific evidence and ethical principles. Basing healthcare decisions on any non-medical characteristics, such as age or assumed social worth is unethical and discriminatory.

35. Whilst older people are among those most at risk of complications from COVID-19, this is not an ‘older person’s disease’. Misinformation fuels the stigma and discrimination that many older people already face. Everybody is at risk from COVID-19, and everyone can help stop transmission.

36. The ageism and discrimination endemic to the COVID-19 response globally has been made possible by the lack of international legal standards that clearly articulate what the protection of human rights means for older people globally. A new UN convention on the rights of older persons is necessary to give governments and other stakeholders clearer guidance on what their obligations and responsibilities are, and to reframe perceptions of older people so their rights are protected equally with others in society.

Income security

37. The impacts of COVID-19 extend far beyond the individual lives of those who die because of the virus. As well as being a health crisis, this is also a social and economic crisis that includes people of all ages. Many older women and men in low and middle-income countries live without a secure and regular income and often live in poverty. However, despite their unreliable income older people are making vital economic and social contributions to their families, communities and local economies.

38. COVID-19 presents a very real social and economic crisis for fragile economies around the world as self-isolation and physical distancing measures taken to protect societies from COVID-19 are also limiting an older person’s ability to earn a living and putting their families and themselves in economic peril. Equally those who cannot afford to stop working, risk contracting COVID-19, which can have severe consequences, particularly for those living with chronic conditions.
     
39. Responses to COVID-19 that limit contact and communication between people without providing sufficient support will have a direct impact on the health and wellbeing of those older people upon whom families and communities depend. Social pensions and other forms of social protection, such as disability grants, are therefore key in providing a regular and stable income for people in old age regardless of their situation. This is particularly important for older women, who are more likely to have had interrupted work patterns due to unpaid care responsibilities and other gender inequalities throughout their lives, such as informal jobs.
     
40. The UK government has been clear in its desire that UK aid should help countries to help themselves. A very successful example of this is the support DFID has given to partner governments in lower-income countries to make social protection systems more inclusive of older people. DFID has worked with the Government of Uganda to deliver a Senior Citizens Grant, which currently supports over 168,000 older people with a cash transfer. This social pension will be a lifeline for many older people, enabling them to pay for food, healthcare and support grandchildren to go to school.

Older women

41. Women comprise the majority of the older population in virtually all countries, largely because globally women live longer than men. While initial evidence points to more men dying from COVID-19 than women,[28], women are disproportionately affected by the social and economic impacts of the virus.
     
42. One in seven women aged 65+ in low- and middle-income countries are in the labour force, taking up paid work to support themselves and their households. Older women are also propping up economies by making substantial contributions in unpaid care and domestic work to their families and communities. Older women provide on average 4.3 hours of unpaid care and domestic work per day. [29]
     
43. Social restrictions brought in to combat COVID-19 are resulting in a loss of income for older women working but an increase in domestic workload, particularly with school closures. Although carrying out work in later life has many positive benefits, the accumulation of a lifetime of intersecting inequalities means that many older women carry out their work and care responsibilities living with disabilities and in poor health, which is increasing their risk of fatality from COVID-19.
     
44. DFID prioritised policies and programmes that support women and girls but have failed to articulate how older women are included in this work. The UK Government will no doubt be keen to take steps to mitigate the impact of COVID-19 on women and girls in its response, however considering the pandemic disproportionately affects older people, they need to explicitly include older women as a group at highest risk. Failure to do so could have catastrophic health, social and economic consequences for families, communities and societies which DFID is working to support.

Violence, abuse & neglect

45. COVID-19 has created social upheaval for every country around the world. This disruption to normal life can lead to increased cases of violence, abuse and neglect towards older people, which can go unrecognised and unreported.
     
46. Cases of abuse and neglect towards older people in the context of COVID-19 have been well documented in the media and are increasing due to ageist attempts to prioritise younger generations in health responses and the measures brought in to limit older people’s access to healthcare. Furthermore, potential lack of information can lead to the misunderstanding that COVID-19 is an older person’s disease and cases of younger people dying can lead to accusations of witchcraft.
     
47. Older women face the same types of gender-based violence as younger women, including physical, sexual and emotional intimate partner violence. However, this is largely being ignored by the international development sector. Women aged 50 plus are routinely excluded from data as internationally comparable data on violence against women and girls stops collecting data on women over the age of 49. As a result, the physical, sexual and emotional abuse that older women face remains hidden, creating the false impression that only younger women experience gender-based violence. All women of all ages are at greater risk of violence and abuse due to the isolation measures imposed to curb COVID-19.

Leave No One Behind
 

48. The ‘Leave No One Behind’ commitment of the SDGs means taking into account, realising the rights of, and empowering women and men of all ages, and ensuring that the rights and needs of those most marginalised are put first. International responses to COVID-19 threaten to marginalise older people and deprioritise their rights and needs over other age groups. The UK Government’s commitment to Leave No One Behind requires it to challenge its own international response, and those of its international partners, to take into account the immediate and longer-term challenges older women and men are facing from COVID-19.

Recommendations
 

49. The UK Government has recognised the disproportionate impact that COVID-19 is having on older people and should insist that its international partners, including UN agencies, multilateral organisations and recipients of development funding, include older people in their responses to COVID-19.
     
50. The UK Government should state clearly that the rights and needs of older people must be protected globally on an equal basis with others in response to COVID-19, and in society at large through the creation of a UN convention on the rights of older persons.

51. DFID’s humanitarian response to COVID-19 must follow the epidemiological evidence and identify older women and men as being at higher risk of death and serious illness from the virus, and require that measures be put in place to ensure that they receive access to information, medical attention and social protection services on an equal basis with others.

52. DFID needs to ensure its efforts to tackle violence against women and girls include women of all ages, especially older women who are at heightened risk of violence and abuse due to measures brought in to tackle COVID-19.

53. The UK Government needs to ensure that its work to “strengthen health systems through our work in-country, as well as through our support to the WHO and other global health initiatives”[30] is age-inclusive and includes gerontological care and expertise.

54. The UK Government needs to ensure that commitments made at the UN High-Level Meeting on Universal Health Coverage in September 2019 are followed through and are fully inclusive of the health rights and needs of older women and men.
     
55. DFID must ensure that older people are included in longer-term efforts to respond to the secondary economic and social impacts of COVID-19. Older women and men, as vibrant actors in their local economies and families, must have access to measures to mitigate the economic impact of the crisis, including minimum income support through social protection measures, such as universal social pensions, as well as access to finance.
     

For further information, please contact:

Zoe Russell

Parliamentary Officer, Age International
zoe.russell@ageinternational.org.uk