ARTICLES

 

Surviving Multiple Pandemics. Socio-Economic Impact of COVID-19 among the Elderly in Botswana: A Call for a Holistic Pastoral Approach

 

 

Tshenolo Jennifer Madigele^I; Ronald Tshelametse^II

^IUniversity of Botswana
^IIUniversity of Botswana

 

 

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ABSTRACT

Amid the COVID-19 and HIV and AIDS crises, elderly people have been identified as the most affected and at-risk population group. This paper uses existing studies and research from different disciplines to explore the socio-economic impact of these multiple pandemics among the elderly in Botswana. We propose an elderly-inclined Holistic Pastoral Care intervention in surviving multiple pandemics. The intervention incorporates the inclusion of older people on pandemic outbreaks emergency task forces or other inter-agency platforms and coordination mechanisms at the national level. The paper further calls for deliberate and intentional socio-economic equality and attention for the greatest benefit of the elderly people. In conclusion, the paper recommends to all stakeholders, sustainable, socio-economic, Inclusive Holistic Pastoral Care in favour and targeting the elderly for long-term survival of these Multiple Pandemics of COVID-19 and HIV and AIDS.

Keywords: COVID-19; HIV and AIDS; The Elderly; Socio-Economic Impact; Holistic Pastoral Approach

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Introduction

This paper argues that the COVID-19 pandemic has had a significant socio-economic impact on the elderly population in Botswana, especially those living with HIV and AIDS. The pandemic has exacerbated existing inequalities and vulnerabilities, leading to increased poverty, food insecurity, and limited access to healthcare (Kgosidialwa, 2020: 170). The situation calls for a holistic pastoral approach that addresses not only the physical needs but also the psychological, social, and spiritual needs of the elderly.

The HIV and AIDS epidemic has already taken a toll on the elderly population in Botswana. According to a study by Nkosi et al. (2019:10), older adults living with HIV and AIDS face unique challenges, such as stigma, discrimination, and limited access to healthcare services. The COVID-19 pandemic has further worsened their situation, leading to increased isolation and limited access to essential services. The socio-economic impact of COVID-19 on the elderly population in Botswana is also evident in their reduced income and increased poverty levels. According to a report by the World Bank (2020), the pandemic has led to job losses, reduced incomes, and increased food insecurity among vulnerable groups such as the elderly. This has resulted in limited access to essential goods and services such as healthcare.

The COVID-19 pandemic came at a time when the elderly people in Botswana were battling with the horrendous effects of HIV and AIDS. This exposed the already stretched elderly to multiple pandemics. The elderly people in Botswana are under immense pressure to survive both HIV and AIDS and the COVID-19 pandemic. HIV and AIDS had been highlighted as one of the main challenges of the elderly who are taking care of their grandchildren, whose parents met their demised of HIV and AIDS. The HIV and AIDS scourge was particularly rampant among the sexually active and productive generations leaving behind orphans under the care surviving elderly. Meanwhile, the elderly also succumbed to the scourge as they were primary caretakers of the victims and hence contracted the virus. However, given a lack of public health and social security programmes, older persons are most often the default caregivers whenever AIDS strikes a family in developing countries (May 2003:18-19). According to May (2003:2), even though the HIV and AIDS epidemic has had devastating economic, social, health and psychological effects on older people, its impact remains under-reported in Botswana and has not been appropriately addressed.

Several other scholars have stated reasons why HIV and AIDS have had a significant impact on the elderly population in Botswana but remain underreported (Chandra-Mouli, et al, 2017, Hirsch, et al, 2007, Kuate-Defo, 2004, Negin, et al., 2010). While HIV and AIDS are often associated with younger populations, the disease has also affected older adults in Botswana. The elderly population is particularly vulnerable to the disease due to age-related declines in immune function and an increased likelihood of comorbidities. Additionally, older adults may face social stigma and discrimination related to their HIV status, which can further exacerbate the negative impacts of the disease (Chandra-Mouli, et al, 2017). Despite these challenges, there has been limited research on the impact of HIV and AIDS on the elderly population in Botswana. This lack of attention has resulted in a gap in knowledge about the needs and experiences of older adults living with HIV and AIDS in the country. To address this issue, there is a need for more research that specifically focuses on the elderly population and their experiences with HIV and AIDS (Kuate-Defo, 2004). HIV and AIDS place a burden on older people as carers and put them at risk of infection. Many older people provide home-based care for people living with AIDS but are not directly targeted by prevention and awareness campaigns (UNAIDS, 2019).

To compound their challenges, the elderly population has been identified as the most vulnerable group to COVID-19 due to their weakened immune systems and underlying health conditions. In Botswana, the elderly were also identified as being at a higher risk of contracting COVID-19 and experiencing fatal outcomes (Mokgatlhe et al., 2021:3-4). Mokgatlhe et al, indicates that eighty two percent of COVID-19-associated mortalities were over the age of 50 years (2021:3). The increased number of mortalities is driven by the lack of capacity of the healthcare system to cope. COVID-19 has, therefore, affected the elderly disproportionately. The pandemic has further contributed to increased poverty; discrimination; deterioration of cognitive, mental and physical health; unmet health and other support needs; abuse; vilification and stigmatisation (UNDP, 2020).

The socio-cultural role of caregiving and household duties that is mainly carried out by the elderly, more specially women in the Botswana context, render them more vulnerable in the era of COVID-19. The role has a direct economic impact on elderly people. Caregiving and household duties require the availability of funds (UNDP, 2020). The COVID-19 pandemic is therefore far more than a health crisis, it is further exposing pre-existing disparities and exposing vulnerabilities in all aspects of the lives of the elderly such as economic, social and political. It is therefore imperative for the elderly to be integrated into socio-economic and humanitarian responses to COVID-19 (UNDP, 2020).

On the continent of Africa, people of 65 years and above (WHO, 2018) constitute ten percent (10%) and below of the population; nevertheless, their numbers are growing faster than in any other major world region. In the year 2020, the number of elderly people in Africa was already 74 million, and it is projected that this number will triple to 216 million by 2050. By 2030, the continent will be home to an additional 30 million older persons (UNICEF, 2011). Statistics Botswana (2017) reports that Botswana has a relatively young population, with 5.4% of the elderly aged 65 and above. This means that 179033 people belong to the range of 65 years and above in Botswana.

Faced with these multiple or dual pandemics this paper argues that services extended to the elderly during this era should be intentional in addressing all dimensions of their human existence. The compounded multiple pandemics require deliberate unified action. The Holistic Pastoral Approach (Patton, 1993; Louw, 2005) is emphasised in this paper as a tool that can addresses the physical, psychological, social, and spiritual needs of the elderly. This tool is necessary to mitigate the impact of multiple pandemics on this vulnerable population. According to Madigele et al, (2022:122), pastoral care should be inclusive of all aspects of human life, including emotional support, spiritual guidance, and practical assistance. This approach should also involve collaboration between different stakeholders such as healthcare providers, community leaders, and government agencies. The elderly should be involved in all platforms that aim at controlling and preventing the effect of COVID-19 in Botswana. This paper therefore recommends to all stakeholders a sustainable, socio-economic, Inclusive Holistic Pastoral Care in favour of and targeting the elderly for the long-term survival of these multiple pandemics of COVID-19 and HIV and AIDS.

 

Methodology

This paper uses existing literature on the elderly, their problems, challenges and needs in the Coronavirus 2019 (COVID-19) and HIV and AIDS pandemic. It examines the impact of both COVID-19 and HIV and AIDS pandemics with emphasis on the social and economic priorities for the elderly using Botswana as a case study. The paper further proposes innovative solutions to cope with challenges posed by the pandemics on elderly people in the socio-economic context. The study uses a qualitative approach. Mouton (1996:168) defines qualitative research as a holistic focus on understanding social phenomena in context, rather than explaining them. This is a holistic and humanistic approach that allows for the understanding of human lived experiences without focusing on the specific concepts (Morse et al., 1996:8). The paper also makes use of documents from government institutions, research institutions and general sources. They are then analysed and coded into themes.

 

Ageing Population and HIV and AIDS

In Botswana, many older people are providing home-based care for individuals living with AIDS, but they are not directly targeted by prevention and awareness campaigns. This is a significant issue. According to the United Nations Programme on HIV/AIDS (UNAIDS), HIV/AIDS prevention campaigns tend to focus on younger populations to the exclusion of older adults (UNAIDS, 2014). This exclusion is problematic because older adults, particularly women, are at increased risk of contracting HIV due to factors such as sexual violence and lack of access to information and resources (UNAIDS, 2014). Furthermore, the lack of targeted prevention efforts for older adults can lead to a lack of knowledge about the disease and its transmission, which can increase the risk of transmission from those in their care. This is particularly concerning given that older caregivers are often responsible for providing care to multiple individuals living with AIDS (Chirwa et al., 2013:5).

One study found that older caregivers in Botswana faced significant challenges in providing care, including financial strain and lack of support from healthcare providers (Makgoba et al. 2021:3-4). Additionally, many older caregivers reported feeling stigmatised by their communities due to their association with those infected with HIV/AIDS (Makgoba et al., 2021:2). To address these issues, it is essential to include older adults in HIV/AIDS prevention and awareness campaigns. This can be done by tailoring messages and resources specifically for this population and ensuring that they have access to information and resources necessary to protect themselves and those in their care.

Waysdorf maintains that HIV and AIDS affect elderly caretakers of orphans affected by HIV and AIDS in two ways: the elderly are themselves infected with HIV, making them vulnerable to many health and socioeconomic challenges (2002:51). May (2003:5) asserts that over the past decade, the HIV and AIDS epidemic has had devastating economic, social, health and psychological effects on older people, especially in sub-Saharan Africa. Even though these grandparents have become very appreciative and accepting of their roles as caregivers, it is not an easy process.

Alpaslan and Mabutho (2005:277) report that grandmothers might be dealing with the loss of their senses, such as sight and hearing, at the same time that they face health problems such as backache and high blood pressure. All these physical, psycho-emotional stressors may hinder the ability of grandparents to provide care to their affected grandchildren. Alvis, et al, (2023:450) assert that when a parent loses a child to AIDS, it is likely that the mourning process will be hindered because AIDS is associated with antisocial behaviour and is also a disease that is often stigmatised. It is also difficult for grieving grandparents to receive sympathetic social support because of the nature of death, which is usually stigmatised. Meanwhile, as discussed earlier, grandparents will exhibit severe depression with no one to attend to fully. According to Ponzetti et al., (1999:152153), some of them even suppress their feelings of sorrow in order to spare their families from further suffering. Therefore, the deep pains of the elderly remain unknown. Alpaslan and Mabutho (2005:280) add that it is because of the fear of the societal stigma that grandparents reduce participation in social activities.

In Botswana, some governmental support is offered to people who are classified as destitute. This destitute programme is designed to assist individuals who do not have any source of income and are therefore too poor to afford food, clothing and shelter. Even though most family caregivers know that extra assistance is needed, they remain reluctant to apply for the destitute program. The stigma of being classified as destitute has dissuaded them from utilising the destitute programme. Registration for the destitute programme is felt to constitute abandonment and is perceived as a source of embarrassment. The destitute programme is perceived as humiliating and compromises people's dignity and self-esteem. This presents a challenge for intersectional collaboration of various departments to devise appropriate resources for families taking care of the elderly without the humiliating consequences (Shaibu, 2013:366-367).

 

The Socio-Economic Impact of COVID-19 on the Elderly in Botswana

The COVID-19 pandemic has had a significant impact on the elderly population in Botswana, particularly in terms of their socio-economic wellbeing. The pandemic has resulted in increased poverty, reduced access to healthcare, and limited social interaction for this vulnerable group. One of the major impacts of COVID-19 on the elderly in Botswana has been the economic downturn caused by the pandemic. Many older adults have lost their jobs or experienced reduced income due to business closures and reduced economic activity. This has led to increased poverty and financial insecurity among the elderly population (Molomo, 2021:102).

In addition to economic impacts, COVID-19 has also affected the health of older adults in Botswana. The pandemic has led to reduced access to healthcare services, including routine check-ups and treatments for chronic conditions. This has put older adults at greater risk of developing serious health complications (Kebaetse et al., 2020:5). The pandemic has also limited social interaction for older adults in Botswana. Many seniors have been forced to isolate themselves from family and friends to avoid contracting COVID-19. This has led to increased loneliness and social isolation, which can have negative impacts on mental health (Molomo, 2021:105). Furthermore, COVID-19 has highlighted existing inequalities faced by older adults in Botswana. Many seniors lack access to necessities such as food and shelter, which has been exacerbated by the pandemic. Additionally, older women are particularly vulnerable due to gender-based discrimination and unequal access to resources (Kebaetse et al., 2020:4-5).

The elderly in Botswana are forced to retire at the age of 65, irrespective of health, physical ability, psychological readiness/ability, spiritual orientation, and economic status. Although this is the case, they are awarded low or no pension provisions. At the age of 70, they are given a pension that amounts to 430 Pula per month (43 USD). The government of Botswana so far does not account for the 5-year gap, which can be hard for the elderly who do not have any economic support. More than 80% of the elderly Batswana report that they are not able to afford food several times a year (Hassan et al., 2016:4).

Based on the above findings, an adequate pension fund should be allocated to the elderly people in Botswana. It is imperative to come up with measures that fight against ageism in the labour market. The potentiality of elderly workers should be recognised, and the work environment should be age-friendly. The automatic retirement age of 65 years should be set aside or be engaged alongside capability assessment. As much as the government social welfare performs assessment prior to assisting the elderly, their approach seeks only to identify the extremely poor and bundles up the rest. It is within this rest that we observe mammoth economic inequalities. A more robust assessment strategy/tool must be developed that can to a large extent attend to individual socioeconomic needs.

Meanwhile, elderly people are generally physically unfit and suffer from respiratory illnesses, heart disease and high blood pressure (Promislow et al. 2020:1-4). This positions them among the most vulnerable group in the COVID-19 pandemic and hence the high death rate of COVID-19 among those aged 70 or higher (Garg, et al. 2020:460; Promislow et al. 2020:1-4). There is currently no information on the impact of COVID-19 on the elderly people in Botswana circulating in public media outlets. Neither is there specific content on the risk of stigmatising and the narrative around the pandemic nor tailored information on COVID-19 to older persons in rural areas using community structures and local languages. Thus, older persons are not fully informed about the disease, prevention, protection, and treatment measures.

The country's COVID-19 Task Team has created communication channels that are only intended to share information and authoritative updates or messages with minimal impact on elderly people in Botswana. The latter have never been engaged to share their concerns and needs during the COVID-19 era. It is rather unfortunate that the State of Public Emergency (SoE), which started on 2 April 2020, is monocratic. The government of Botswana unilaterally makes decisions with regard to COVID-19 measures and prevention. It has, however, been established that "the top-down approach to policy implementation and addressing complex social issues generally contributes to the ineffective translation of policy into practice" (Masiya et. Al., 2021:79-80). We duly recommend a more inclusive approach.

One of the things that the top-down approach is failing to acknowledge is that most young and reproductive adults have left their elderly parents in rural areas due to urbanisation, industrialisation, and civilisation. It is, however, in the rural areas where most people face greater barriers to accessing basic needs, including healthcare and clean water. Those staying in farmlands found themselves more vulnerable because the government of Botswana could not provide infrastructure to such areas (UNDP, 2020:1, Omorogiuwa, 2017:647).

To contain the spread of COVID-19, people who were affected and infected were advised to social distance, and isolate and others were quarantined. People were quarantined in institutional settings in the form of hotels, guest houses, or other facilities adapted specifically for quarantine purposes. This transition had a negative psycho-economic impact on elderly people who would find themselves alone for long periods of isolation. They were not prepared to deal with the direct and indirect impact of the crisis. Some elderly people shared their spaces with their grandchildren and other relatives. Therefore, social distancing was not easily implemented.

 

The Compounded Socio-Economic Impact of the Multiple Pandemics on the Elderly in Botswana

The familial support system is already in jeopardy due to HIV and AIDS. The COVID-19 and regulations around it have further aggravated the spirit of individualism that was already wavering because of migration, urbanisation, industrialisation and civilisation (Omorogiuwa, 2020:648). In Botswana, specifically, many young and reproductive adults succumbed to HIV and AIDS leaving behind their children under the care of their parents (May 2003:5; Shaibu, 2013:365). The elderly, therefore, find themselves as parents again when they must deal with the realities of ageing, grieving, loss of economic independence, and social isolation due to stigma and discrimination (Shaibu, 2013:365). In addition to these challenges, in the COVID-19 era elderly people's physical, mental, and cognitive well-being may be negatively affected by long periods of isolation (Omorogiuwa, 2020:649). Lack of social support is also "associated with shorter survival in community-dwelling older persons of Botswana" (Clausen et al., 2007:456). These periods make it even harder for elderly people to access adequate care and support services, work, social protection, and food (Omorogiuwa, 2020:649). The requirement to apply for a travel permit to seek for services may further be a hindrance to attaining health services. We propose that the elderly be exempted from having to apply for permits or be automatically granted these permits, as often, their reason for travel will be of authentic and substantial nature.

The presidential COVID-19 Task Force Team was primarily established to advise the government on what measures to take to deal with the pandemic. It is composed of Professor Kereng Masupu who is a veterinarian and Public Health Independent Consultant, Dr. Mogomotsi Matshaba, A Paediatrician and Assistant Clinical Professor of Paediatrics from Baylor College of Medicine and Deputy Director and Professor Mosepele Mosepele, a Senior Lecturer in Internal Medicine of Infectious Diseases in Faculty of Medicine, University of Botswana (Chida 2020:4). Their other mandate is to provide regular COVID-19 updates and announcements of major shifts, such as declaring of zonal lockdowns. Even though the Task Force Team is made up of various stakeholders, there is no representation of the clergy, businesspeople, non-academics, non-government organisations the elderly people or HIV and AIDS practitioners. This is concerning. Here we propose the task force should include other stakeholders in the pastoral holistic care approach.

The Task Force Team further lacks a multi-disciplinary approach to addressing complex issues around COVID-19 in Botswana. This pandemic has affected all aspects of human life and hence is to be understood in the broader context in which they are taking place. Engaging people from different disciplines can help in ensuring that problems and solutions are framed from different lenses. Further integration of disciplines may help to minimise the negative impacts of COVID-19 on the socio-economic well-being of individuals within the community. Engaging a multi-disciplinary is a long-term and sustainable approach that can facilitate a holistic approach to health and wellbeing. We propose the multi-disciplinary approach should also rope in the experiences and expertise of HIV and AIDS practitioners with the participation of Gerontologists.

There is a need for a multi-sectoral approach to effectively manage these multiple pandemics. The element of state control, one-sided communication and an umbrella approach is an impediment to sustainable development. For the socio-economic issues of the elderly to be addressed effectively, churches, faith-based groups, non-government organisations, community-led organisations and other stakeholders should be included in the COVID-19 response team. These are some of the groups that are close to the community. They could reach "vulnerable populations thereby ensuring ownership and effectiveness in the implementation of prescribed interventions" (UNDP, 2020:1). Furthermore, elderly people should be consulted and be involved in decision-making at all levels during the COVID-19 era. The HIV and AIDS pandemic was relegated to the back bench as approaches to combat COVID-19 were developed. This aggravated the acute state of the elderly.

 

Holistic Pastoral Care Approach

The Holistic pastoral approach that is proposed in this article is not new; it was used by David Livingstone during his missionary work in Batswana. Health and Christianity were initially inseparable entities. During those times, medicine was used to address the physical impact of illness, while the Church addresses the symptoms of illness through spiritual comfort. Attending to the multifaceted nature of illness i.e., spiritual, physical, and social, makes it impossible to address healing from only one perspective (Louw 2005:15-17).

Although the Holistic Pastoral Approach put more emphasis on individualistic treatment of the problem, it is also characterised by extending care to all aspects of the human dimension (Patton 1993:5; Louw 2005:15-17). It gives attention to the uniqueness of human beings in terms of problems, needs and character to avoid an all-in-one or "umbrella approach" in addressing the needs of vulnerable people. The approach also highlights that since all beings have been created in the image and likeness of God, they have been bestowed with God-given dignity that shall be realised. With this approach in use, elderly people should be allowed to make use of their inner potential to find solutions to their problems (Rensburg, 2010:4-5). In that manner, therefore, the elderly people should be respected, valued, and included in all strategies, implementations and decision making processes during the COVID-19 era. Through emphasis on the connection of the body, soul and spirit, the approach highlights the importance of interconnection and interrelatedness of dimensions of human existence (Patton 1993:5; Louw 2005:15-17). Therefore, any model that fails to address a person fully is limited. The collaborative response to a good life, health and wellness is mandatory.

Throughout history, the Christian Church has often been looked upon as an important source of care, particularly for vulnerable people, such as elderly people. In Botswana, the Church has demonstrated a remarkable resilience in its capacity to continue service delivery in societal transformation especially on the health sector (McGilvray 1981:5-6). In that regard, given a chance, the Church working side by side with other stakeholders and the elderly could contribute significantly to the resilience of national health system in Botswana.

The notion of the Holistic Pastoral Approach that is found within the Church cycles calls for holistic caring services, collaboration, networking, and communal involvement. The Holistic Pastoral Approach is often implemented through various ministries and programs within the Church, such as counselling services, support groups, and outreach initiatives. These efforts aim to provide individuals with the tools and resources they need to address their physical, emotional, and spiritual needs in a holistic manner (Koenig, 2012:78). The approach further demands attention to diverse dimensions in which the elderly people and the community should be involved. It also fosters empowerment of people's life skills. In our case, the elderly people will be empowered so that they can take on a role in their own transformation and wellbeing during this era. Their stories should be heard; they should be further represented during decision-making processes. Moreover, from a psychological perspective, there is a need for making use of innate resources of the elderly people, such as spiritual and religious resources, to alleviate human distress and suffering (Clinebell 2011:26).

 

Recommendations

The elderly population is particularly vulnerable to these diseases, and they require a holistic approach to care that considers their physical, emotional, social, and spiritual needs. The church has an important role to play in providing this care through its pastoral ministry. In the context of HIV and AIDS and COVID-19 affecting the elderly in Botswana, a Holistic Pastoral Approach is essential for providing comprehensive care that meets their unique needs. In view of above discussions, elderly people in Botswana have been severely affected both socially and economically by the dual pandemics. Control and preventative measures to address the spread of the virus, including lockdowns, exacerbated the socio-economic consequences of HIV and AIDS, and affected and infected elderly. Overlooking the fact that the multiple pandemics are far more than health issues resulted in further failure to address the elderly people holistically based on all dimensions of human existence.

All stakeholders, therefore, are urged to collaborate, and the elderly people are urged to be involved in dealing with matters that concern them during these crises. It is also imperative that an adequate pension fund be allocated to the elderly people in Botswana; the automatic retirement age of 65 years be coupled with capability assessment; an assessment strategy/tool that can to a large extent attend to individual socio-economic needs to be developed. There is a further need to come up with strategies and policies that can foster the reduction of inequalities across the life course and in older age. Information on the impact of COVID-19 and HIV and AIDS on the elderly people in Botswana should be made easily accessible to the concerned group and such should be multilingual. Elderly people should be engaged to share their concerns and needs during the COVID-19 and HIV and AIDS era to create an elderly-inclusive forum. They should be consulted and be involved in decision-making at all levels during the COVID-19 and HIV and AIDS era. Furthermore, there should be a representation of the clergy, businesspeople, non-academics, non-government organisations, the elderly people, Gerontologists and HIV and AIDS practitioners on the on the Botswana COVID-19 Task Force Team. Given the complexity of the challenges of the elderly in this multiple pandemic era, there is a need for a multi-sectorial approach in order to effectively manage this pandemic. There is also a need for multidisciplinary cooperation to promote coherence of care, which increases the quality of care and life of the elderly people.

 

Conclusion

HIV and AIDS and COVID-19 pandemics are not just health concerns, but also socioeconomic and human security catastrophes. Elderly people are the most vulnerable people in society amid combined forces of the HIV and AIDS and COVID-19 pandemics. Their vulnerability is due to to social and structural factors. Botswana's government has failed and continues to fail the elderly people in the context of HIV and AIDS and COVID-19.

It is erroneous to be unipolar in the face of multi-pandemics. We argue that Botswana should develop as a matter of urgency Gerontologic Multi pandemic policy in the face of HIV and AIDS and COVID-19 and beyond. The elderly people should be allowed to inform policy change and service provision because they know their challenges more than anyone else and are arguably the most affected in this multi pandemic of HIV and AIDS and COVID-19. Their experiences could subsequently inform all efforts for future pandemics. We conclude by recommending to all stakeholders to adopt a Gerontic sustainable, Socio-economic, Inclusive Holistic Pastoral Care for the long-term surviving of Multiple Pandemics of COVID-19 and HIV and AIDS of our elders. Our elders, our past present and future.

 

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