II.Social ills138.Although economic factors figure prominentlyamong th - PDF document

A/58/153/Rev.1ST/ESA/284 II.Social ills138.Although economic factors figure prominentlyamong the causes of vulnerability, as explained inchapter I, many other factors often contribute to andreinforce economic disadvantage. Coping capacity isreduced, not only by a lack of financial assets andincome, but also by limited access to health servicesand limited or no access to education. Health andeducation are therefore important contributors to andsignificant factors in determining earnings capacity andpersonal development. A/58/153/Rev.1ST/ESA/284 Assessing vulnerabilities: youth illiteracy The lack of access to education constitutes one of the majordimensions of poverty and limits economic, social, cultural and politicalopportunities for poor people. Youth illiteracy remains alarmingly high inmany regions, in particular among young women.Regionally, the illiteracy rates for young women are the mostsevere in sub-Saharan Africa, where in many countries the proportion isover 40 per cent, and in some even over 70 per cent. Illiteracy rates foryoung men often exceed 30 per cent. Source: UNESCO, Institute for Statistics, 2002. in school. Of those, 94 per cent are living indeveloping countries. Just over one third of the totalare in sub-Saharan Africa, another one third in Southand West Asia and 13 per cent in East Asia and the143.Not all children enrolled in primary school todaywill remain in school long enough to reach minimumlevels of literacy and numeracy. Although illiteracy hasdecreased in all regions, during the period 1995 to1999 in sub-Saharan Africa and South Asia, only 61per cent of primary school entrants reached grade five,generally considered as the minimum required for basicliteracy. In many countries, children enrol in primaryschool at a late age. Educational systems that have highrates of enrolment in primary school at a higher agealso tend to have high dropout rates prior to grade five.Leaving school before grade five and failing to attainminimum levels of literacy have a profound impact onthe entry of children into adolescence and youth and ontheir subsequent ability to find decent employment.Although primary school enrolment has continuouslyincreased over the past five decades, the number ofilliterate young people has remained largely constant,mostly as a result of population growth.144.In addition to the questions of increasing primaryenrolment rates to achieve universal enrolment andretaining children in school through at least grade five,__________________ United Nations Educational, Scientific and CulturalOrganization, Education for all — Is the World onTrack?, EFA Global Monitoring Report (Paris, 2002). United Nations Children’s Fund, The State of the World’sChildren, 2003 (United Nations publication, E.03.XX.1),table 4.there is the question of educational quality. Millions ofchildren are taught by committed but untrained andunderpaid teachers in sometimes overcrowded,unhealthy and poorly equipped classrooms. In somecountries, the high number of children repeatinggrades, whether resulting from attendance orperformance problems, is a serious drain on thecapacity of educational systems. In addition, somecountries do not have enough primary school teachers,particularly the least developed countries, whereclasses with 100 pupils are common. It has also beenargued that in sub-Saharan Africa, where womenrepresent less than half of the teaching staff, a strategyfor facilitating girls’ access to education would be toincrease the proportion of women teachers, whichwould help girls to improve their learning process andlead to an improvement in women’s participation in alleconomic and social sectors. Children, particularly inrural areas, have to walk many kilometres beforereaching a school, making them vulnerable to variouskinds of abuse by peers and adults.145.Related to the issue of quality of education is thequality of pupils’ health. There is evidence thatchildren with poor health face greater learningchallenges owing to illness, which causes absenteeism,and perhaps an inability to concentrate in classrooms.The implication is that they are likely to grow up to bepoorly educated in addition to being in poor health.Such children can be expected to face problems lateron, including the probability that they will havedifficulty in finding decent-paying work and willtherefore have lower earnings than their healthycounterparts. Therefore poor health in childhood can A/58/153/Rev.1ST/ESA/284 have a significant impact on the child’s educationalattainment, which can in turn affect his or her futureearning capacity as well as the ability to cope with146.Sources of vulnerability for children in terms ofphysical health and well-being begin before birth, asthe health of an infant begins with the health of themother. Poor maternal health and nutrition contributeto low birth weight in 20 million newborns eachyear — almost 20 per cent of all births. Low birth-weight infants have a higher risk of dying beforereaching their first birthday and are at greater risk forinfection, malnutrition and long-term disabilities,including visual and hearing impairments, learningdisabilities and mental retardation.147.At least 30 to 40 per cent of infant deaths are theresult of poor care during pregnancy and delivery.Those deaths could be avoided with improved maternalhealth, adequate nutrition and health care duringpregnancy, and appropriate care during childbirth. Thewell-being of children is also linked to the literacy andeducation status of mothers: children of mothers withno education are more than twice as likely to die or bemalnourished compared to children of mothers with asecondary or higher-level education. Even thoughneonatal mortality has declined, the rates of declinehave been much slower than those for infants andchildren below 5 years of age. Nevertheless, of the 8million infants who die each year, possibly half diewithin the first month of life. That is largely a result ofthe slow progress achieved in maternal health.148.Malnutrition affects 150 million children under 5years of age, or one third of all children below that Although underweight prevalence declined from32 per cent to 28 per cent in developing countries over__________________ Safe Motherhood Inter-agency Group, Safe MotherhoodFact Sheets, available from http://www.safemotherhood.org/resources/publications.html UNICEF, Progress since the World Summit for Children:A Statistical Review (United Nations publication, SalesNo. E.01.XX.20). Source data from over 35Demographic and Health Surveys carried out between1995 and 1999. World Health Organization, Strategic Directions forImproving the Health and Development of Children andAdolescents (WHO/FCH/CAH/02.21). “A world fit for children”, final document of the specialsession on children, in Official Records of the GeneralAssembly, Twenty-seventh Special Session, Supplementthe past decade, with the most progress in East Asiaand the Pacific, worldwide about 183 million childrenweigh less than they should for their age; some 67million children are “wasted”, that is, below the weightthey should be for their height; and 226 million arestunted. Children in some regions are particularlyvulnerable: half of all children in South Asia areunderweight, and in sub-Saharan Africa, where one ofevery three children is underweight, the nutritionalstatus of children is worsening. Being underweight andwasting are only the most obvious forms ofmalnutrition; micronutrient deficiencies affectapproximately 2 billion people worldwide, and 250million pre-school children are clinically deficient invitamin A, essential to the functioning of the immunesystem.149.Disease affects malnourished children, who havelowered resistance to infection and are more likely todie from such common childhood ailments asdiarrhoeal diseases and respiratory infections. Forthose who survive, frequent illness saps theirnutritional status, locking them into a vicious cycle ofrecurring sickness, faltering growth and diminishedlearning ability. Nearly 12 million children under fivedie each year in developing countries, mainly frompreventable causes, and over half of those deaths areeither directly or indirectly attributable to malnutrition.Although global deaths of children under 5 years of agehave fallen from 20 million to 12 million annually overthe last four decades, during the same period deaths ofchildren under age 5 in sub-Saharan Africa almostdoubled, from 2.3 to 4.5 million per year. Five majoryet preventable diseases — pneumonia, diarrhoea,malaria, measles and HIV/AIDS — account for abouthalf of all childhood deaths. Other preventable diseasesrelate to the lack of access to safe drinking water andinadequate sanitation. More than one billion peoplecannot obtain safe drinking water, and more than twobillion people lack access to adequate sanitation.150.Ironically, while malnutrition continues to beendemic in parts of South Asia and Africa, obesity is__________________(A/S-27/19/Rev.1 and corrigenda), annex. Sustain, Malnutrition Overview (Washington, D.C.,2002), available from http://www.sustaintech.org/world.htm. “A world fit for children”, final document of the specialsession on children, in Official Records of the GeneralAssembly, Twenty-seventh Special Session, Supplement(A/S-27/19/Rev.1 and corrigenda), annex. A/58/153/Rev.1ST/ESA/284 Assessing vulnerabilities: malnutrition among children Malnutrition among children, as measured by the proportion ofchildren under the age of 5 who are underweight and underheight, isstartling in many regions.Malnutrition is most prevalent in the regions of sub-Saharan Africa,South Asia and East Asia and the Pacific, where in many countries over40 per cent of the children are underweight or underheight. Source: FAO, State of Food Insecurity in the World, 2002 (Rome, 2002), and WorldWorld Development Indicators, 2003 (Washington, D.C., 2003). becoming a major health problem, not only indeveloped countries but increasingly in manydeveloping countries as well. The number of obesechildren continues to grow, and chances that anoverweight child will suffer lifelong weight problemsare high. According to the World Health Organization(WHO), developing countries are seeing rapidincreases in body mass indexes, a height/weightformula used to measure overweight and obesity,particularly among the young. WHO also estimates thatworldwide some one billion people can be consideredoverweight, with 300 million people clinically obese.The share of young people (children and youth) in thetotals is unknown, but the long-term consequences forpublic health systems can be extensive and structural.In developing countries, there is the likelihood of newdemands and an increased strain on public healthservices, as health-care systems will need to deal withboth tropical and preventable diseases as well as withobesity-related illnesses, such as diabetes andcardiovascular disease, which typically require high-cost treatment.__________________ World Health Organization, World Health Report, 2002:Reducing Risks, Promoting Healthy Life (Geneva, 2002).See also Seth Mydans, “Clustering in cities, Asians arebecoming obese”, New York Times (13 March 2003).151.One disease not clinically related to malnutritionor poor nutrition, but very much related to poverty, isHIV/AIDS. Roughly 16 per cent of all new HIVinfections in 2001 were among children. About800,000 infants were infected with HIV, mainlythrough mother-to-child transmission, in 2002. Largelyas a result of the high infection rates among pregnantwomen in Africa, it appears that children are currentlythe fastest-growing age group among HIV infections:the total of 800,000 infections in 2002 contributed to acurrent total of 3 million infected children (table).Currently, some 1.8 million pregnant women areinfected with HIV/AIDS, 1.5 million of whom are insub-Saharan Africa. Mother-to-child transmission ofthe virus through pregnancy, labour, delivery orbreastfeeding is responsible for over 90 per cent of theHIV infections in infants and children under the age of15. HIV/AIDS has begun to undermine the years ofsteady progress in child survival. In the worst affectedareas, the under-five mortality rate is expected toincrease by over 100 per cent.__________________ Joint United Nations Programme on HIV/AIDS,Epidemic Update (December, 2002); and World HealthOrganization, World Health Report, 2002: ReducingRisks, Promoting Healthy Life (Geneva, 2002). A/58/153/Rev.1ST/ESA/284 TableChildren, youth and HIV/AIDS in 2002(Millions)Have been infectedwith HIV/AIDSCurrently living withHIV/AIDSNewly infected inDied from HIV/AIDSin 2002 Adults6242.05.03.1Youth (15-24)2212.02.41.5Children4-53.00.80.6 Source: UNAIDS, Epidemic Update (December, 2002); and Vivian Lopez, “HIV/AIDS andyoung people — a review of the state of the epidemic and its impact on world youth”, paperpresented at the Expert Group Meeting on Global Priorities for Youth, Helsinki, 6-10October 2002. Figures in italics are estimates.152.A second devastating effect of the HIV/AIDSpandemic on children is the emergence of a new groupof children who are AIDS orphans. More than 11million children currently under 15 have lost one orboth parents to AIDS. That number is forecast to morethan double by 2010. Before the onset of AIDS, about2 per cent of all children in developing countries wereorphans. By the end of 2002, in the 10 worst affectedcountries of Africa, more than 15 per cent of thechildren had become orphans.153.The social and economic impacts of AIDSthreaten the well-being and security of millions ofchildren worldwide. As parents and other familymembers become ill, children take on greaterresponsibility for income generation, food productionand care of family members. They face decreasedaccess to adequate nutrition, basic health care, housingand clothing. Fewer families can afford to send theirchildren to school, with young girls at particular risk ofbeing denied an education first. Isolated fromemotional connections with the family, some turn torisky sexual behaviour. While most of these childrenwere born free of HIV, they become highly vulnerableto infection themselves.154.Health and educatiexperienced during childhood continue to have a strongbearing on adolescent development. Equally important__________________ United States Agency for International Development,UNICEF and UNAIDS, “Impacts on children, families,and communities”, in Children on the Brink, 2002: AJoint Report on Orphan Estimates and ProgramStrategies (Washington, D.C., TvT Associates/TheSynergy Project, 2002) available fromhttp://www.unicef.org/publications/pub_children_ the_ brink_ is the fact that those vulnerabilities may also haveimplications for adolescents in terms of both theirbehaviour, particularly risk-taking and antisocialception of social reality.Youth drug abuse and juvenile155.Two significant sources and manifestations ofsocial vulnerability and risk for youth are drug abuseand juvenile delinquency. Drug abuse is a source ofvulnerability, in that it can lead to undesirable andnegative consequences, such as early termination ofeducation, unemployment or even HIV/AIDS from theuse of unsterilized needles. However, it also is aconsequence of vulnerability. Youth with emotionallyunsupportive or troubled and unstable families or whofeel unhappy and without hope as a result of theirsocio-economic status or perceived futures may turn todrugs to relieve stress and escape their currentsituation. Similarly, juvenile delinquency is a source ofvulnerability and risk, particularly when it is related tothe possibility of continuing on to serious criminalactivity in adulthood, as well as a consequence ofyoung people taking action as a response to otheremotional and/or socio-economic vulnerabilities.156.No comprehensive international comparative dataare available on drug use by young people. Youth druguse in developing countries remains particularlyelusive. However, according to the data that areavailable, alcohol, tobacco and cannabis are thesubstances most commonly used by young people A/58/153/Rev.1ST/ESA/284 The first drugs used are usuallytobacco and alcohol and, in some communities,inhalants. The greatest use of substances is generallyfound in the last two years of high school, continuinginto early adulthood in most countries. In almost allregions, boys are more likely to use all substances thangirls and are more likely to use them in risky ways.Rates of alcohol and tobacco use by students in Europeappear to be the highest in the world, while students inNorth America and Australia appear to have the highest157.Urban youth tend to use substances to a greaterextent than those in rural areas. Similarly, countries insocial and political transition, such as those in Centraland Eastern Europe, may have an environment thatcontributes to increased use of substances by youngpeople. Tobacco and alcohol consumption has alsobeen promoted through aggressive marketingcampaigns reaching ever-increasing numbers of peopleworldwide despite efforts in some countries, includingharsh health warnings, to curb marketing aimed atyounger populations.158.Young people use substances for many of thesame reasons adults do, such as to relieve stress andheighten enjoyment, yet there are other reasons that arespecifically related to adolescent development. Youngpeople are at a stage in life where they desire and needto demonstrate independence from parental and societalauthority, and take risks and satisfy their curiosityabout new experiences while often being exposed tonegative peer pressure. Many experiment with drugs;some go further and adopt risk-taking behaviours, suchas drug and alcohol abuse, habitual use of tobacco ordelinquency.159.Although substance-use decisions also involveperceptions of risk by the individual, it has long beenestablished that young people tend to ignore the long-term risks associated with substance use. Young peoplealso tend to minimize the risks posed by their ownsubstance use, with young men tending to do so morethan young women. Young people almost everywheregenerally tend to use substances to a greater extent andin riskier ways than older people.__________________ Unless otherwise indicated, data presented on drug useare from Gary Roberts, “Youth and drugs”, paperpresented at the Expert Group Meeting on GlobalPriorities for Youth, Helsinki, October 2002.160.Social vulnerability and exclusion have a directinfluence on the risks of youth using and abusingdrugs. Recent studies examining substance use patternsdistinguish between mainstream youth and youth livingin difficult circumstances with fewer opportunities andless support, including young people living indeveloping countries as well as those living out of themainstream and experiencing social exclusion indeveloped countries. Substance use by those youngpeople, often referred to as the “especially vulnerable”,tends to be aimed more at relieving difficultcircumstances, including physical or emotional pain,and at coping with such things as neglect, violence,physical or sexual abuse, homelessness and war, orwith difficult economic circumstances, such as longerworking hours and unemployment. In contrast,mainstream youth are more likely to use substances toenhance pleasure and as part of their leisure activitiesand culture. While there may be some overlap betweenthe two, the issues and challenges can be quitedifferent. Substance use and abuse by young peopleliving in difficult circumstances strongly illustrateshow drug abuse is also a consequence of socialvulnerability.161.Juvenile delinquency is another source andconsequence of youth social vulnerability and risk andis often highly correlated with drugs and drug abuse.Juvenile delinquency encompasses a multitude ofdifferent violations of legal and social norms, rangingfrom minor offences to severe crimes committed byminors. Some types of juvenile delinquency areconsidered to be part of the process of maturation andgrowth and disappear as young people make thetransition to adulthood. Many socially responsibleadults committed some kind of petty offence duringtheir adolescence. Arrests rates, mainly for pettyoffences, are typically highest among 15 to 19 year- However, at the other extreme, other juvenilescreate stable criminal groups with a correspondingsubculture and begin to engage in the same activities asadult criminal groups.162.The available data show that delinquency andcrime are gender-specific, with males being more__________________ Michael L. Benson, Crime and the Life Course: AnIntroduction (Los Angeles, California, RoxburyPublishing Company, 2002). A/58/153/Rev.1ST/ESA/284 vulnerable and at risk than females. The crime ratesof male juvenile and male young adult offendersrecorded by the police are more than double those offemales. Young males are convicted six or seven timesmore often than young females. The number of malejuvenile suspects per 100,000 per age group is morethan six times the number of females, and in the case ofyoung offenders it is even 12.5 times as many. Manypossible reasons for those differences exist, includingless social tolerance of behavioural deviations by girlsthan by boys, stronger family control over girls thanover boys, and social and historical differencesbetween the sexes with respect to violence, such thatyoung men may use violence as a means to constructgender identity.163.Juvenile crime has become a worldwide problem.During the 1990s, a majority of the regions of theworld suffered from a rise in youth crime. Countries intransition have been particularly affected; since 1995,juvenile crime in a number of countries in transitionhas increased by more than 30 per cent. Juvenile crimelevels in developed countries remain high, both byhistorical standards and in comparison to othercountries. Delinquency is also a problem in developingcountries, where juvenile delinquency and extremejuvenile problems occur at levels higher than in othercountries, particularly in relation to street children,who have ruptured ties with their families and engagein various survival activities on the street.164.Data from many countries also show thatdelinquency is largely a group phenomenon, for twothirds to three fourths of all juvenile offences arecommitted in groups. Group delinquency, in which theyoung people belonging to a particular group form andshare a joint assumed identity, exhibits thecharacteristics of a subcultural group. The mostextreme examples of this, and the most likelyparticipants in group delinquent activities, areterritorial gangs. According to statistical evidence,juvenile gangs commit three times more crimes thanyoung people who are not gang members. Studiesreveal that the most frequent offences committed by thegangs are fighting, street extortion and school violence;however, the appearance of juvenile street gangs isalmost always also accompanied by drug trafficking.__________________ Unless otherwise indicated, data on juvenile delinquencyare from Alexander Salagaev, “Juvenile delinquency”,paper presented at the Expert Group Meeting on GlobalPriorities for Youth, Helsinki, October 2002.Children and adolescents are more likely to be victimsof juvenile crimes than other social groups: in general,the victims of juvenile crimes usually belong to thesame age group as the perpetrators.165.While economic factors, including highunemployment and poverty, may strongly influenceyouth delinquency, they are not always pivotal, andother social factors, such as cultural norms and values,family cohesion, peer-group influence and a supportivesocial environment also play a role. For example, inwestern societies, disinvestment of social capital inpoor urban neighbourhoods may very well explain theincreased occurrence of crimes by young people.Urbanization may also play a role — urbanizedsocieties have higher registered juvenile crime rates incomparison with countries with a strong rural lifestyle.One explanation is that urbanized societies may haveless social control and social cohesion, whereassocieties that are more rural are able to rely to a greaterextent on family and community control to deal withantisocial behaviour.166.The role of families and family life is clearlyimportant: young people living in so-calleddysfunctional families, characterized by conflict,inadequate parental control, weak ties with othermembers of the extended family and community, andpremature autonomy, are closely associated withdelinquency. As with drug use, children and youngpeople in disadvantaged families with feweropportunities for legitimate employment and who faceeither the risks or reality of social exclusion areoverrepresented among juvenile offenders. If, inaddition to living in a dysfunctional and disadvantagedfamily, a youth is also of an ethnic minority or from amigrant family, the level of vulnerability todelinquency can be even higher.167.Other factors that can have an influence are themedia, such as television violence and itspopularization of violent heroes, low educationalattainment, social exclusion, peer group pressure, theadoption of delinquent images and a delinquent identityby adolescents, and also the prospect of financialaward from delinquent behaviour. For example, sellingdrugs is associated with financial reward, particularlyin communities where there are few other, or otherwise__________________ See, for example, Benson, op. cit., chap. III, for anoverview of John Hagan’s theory of criminal capital anddisinvestment. A/58/153/Rev.1ST/ESA/284 low-paying, economic opportunities. However, thedrug “business” is also associated with increases in therate of violent and aggravated crimes, including byyoung people, thus leading to a perverse relationship inwhich drug abuse and juvenile delinquency aremutually reinforcing.Health-related vulnerability of olderpersons’ health168.A major source of vulnerability for older personsis a lack of access to appropriate health care. Over thepast two decades, changes in economic thinking andapproaches have brought about a restructuring of socialwelfare policies, particularly in health care. In manycountries, economic reforms have resulted in thediffusion of responsibility for the provision of health-care services and in the removal of health subsidies,which has increased the demands on householdincome. Many of the changes have had a wide impacton older persons in terms of affordability and access,particularly if discriminatory health-care rationingbased on age is instituted. Whereas medical advanceshave extended lives and reduced disability, inequalitiesin longevity and health disparities within and betweencountries have widened. For a vast majority of people,including older persons, ill health is related to poverty,and health-care improvement in a country is related toits political economy and overall strategies ofdevelopment.169.Many factors affect the health of individuals asthey get older and become exposed to increasing risk ofillness and disability. Lifetime exposure to povertymeans that many people reach old age already inchronic ill health, showing signs of poverty and diseasebefore their sixtieth birthday. Chronic illnesses,including heart disease, cancer and mental disorders,are fast becoming the world’s leading causes of deathand disability. Non-communicable diseases nowaccount for 59 per cent of all deaths globally, whichmeans that developing countries have a double burdenof disease: rapid growth of non-communicable diseasesat the same time that they are struggling withmalnutrition and infectious diseases such asHIV/AIDS, malaria and tuberculosis. Chronic diseases,which increase dramatically at the older ages, aresignificant and costly causes of disability. It isespecially true for older women who, because ofgreater longevity, have higher incidences ofimpairment and disability, but whose vulnerability todisability is also generated by gender inequalities overthe life course and a lack of understanding of theirphysical, mental-health and post-menopausal needs.170.Older ethnic minorities tend to suffer greaterdiscrimination and disadvantage at every level,including health. Whereas the health profile of thosegroups is comparable to the majority older populationat the lowest socio-economic strata, their constantexistence on the margins points to greater and moreacute vulnerability. Further, in spite of having a poorerhealth profile, older minorities are frequently found tobe isolated from mainstream health and social careservices. A number of reasons can be cited for theirsituation: lack of awareness of services, resulting inpart from ineffective dissemination of information andoutreach by mainstream organizations; languagebarriers, including illiteracy; user fees and issues oftransport; and problems of perception and mistrustbetween service providers and the older persons. Theissue of perception is of particular importance and canimpact all the other issues. Older minorities feel thatproviders do not allocate culturally appropriate carethat may address dietary, religious and linguisticdifferences. In addition, when outreach attempts aremade, they are often based on stereotypicalassumptions about the minority group.171.Until recently the prevalence of HIV/AIDSamong and its effects on older persons had been largelyignored owing to the unavailability of data, whichexcludes the effect of the pandemic on the olderpopulation in many parts of the world, including sub-Saharan Africa, where the decimation of the populationfrom AIDS is most severe. In Western Europe, nearly10 per cent of the new infections declared betweenJanuary 1997 and June 2000 were among persons over50. In the United States of America, 10 per cent of allreported cases occur among people over 50, and overhalf are of African-American and Hispanic origin,indicating greater risks among minority groups. Manyof the older infected persons may have had the virusfor years before being tested, at which time theinfection may be in its most advanced stages. Further,__________________ “Minority ethnic elder care: a synopsis of countryprofiles” (Leeds, United Kingdom, Policy ResearchInstitute on Ageing and Ethnicity [PRIAE], 2002),prepared under the three-year Minority Ethnic-ElderCare research programme, a European Commission FifthFramework Programme. A/58/153/Rev.1ST/ESA/284 age accelerates the progress of HIV to AIDS, and age-related conditions, such as osteoporosis, increase therisk of severe complications.172.The consequences of HIV/AIDS extend farbeyond the disease itself. As mentioned above, AIDShas resulted in growing numbers of orphans around theworld. Older persons, mostly women, are not onlytaking on the care of children who have been orphanedby the disease, but are also suffering the magnitude andcomplexity of the consequences: orphaned children aremore likely to have poorer nutrition, be underweight,drop out of school, and face depression andpsychological problems. If they do not have agrandparent to care for them, they are more likely tolive on the streets, be exploited because they are forcedto work or sell their bodies as their only asset. Theburden of caring for the children is extraordinary,especially when it is put in the context of localenvironments that are already ravaged by conflict,famine, displacement and conditions of extremepoverty. Furthermore, many older persons who take onsuch new responsibilities are already in mourning anddeprived of the support from their adult children thatthey had expected in their old age. Their own resourcesare seriously depleted at the same time that they arecalled on to help others possibly worse off than they.173.In a recent case study on the effect of HIV/AIDSon older persons, findings suggested that the loss ofremittances and other economic support, the lack offood and clothing, the high cost of medical fees duringillness, and the inability to pay school fees for orphansaffected the ability of older persons to provide care.Older persons were under serious physical andemotional stress, and cases of physical violence, stigmaand abuse resulting from witchcraft accusations wereprevalent. Moreover, older persons infected with thedisease experienced limited access to health servicesowing to the high cost of care, transport difficulties, thestigma of the disease and the attitudes of health__________________ UNAIDS and World Health Organization, “HIV/AIDSand older people”, in Building a Society for All Ages,Second World Assembly on Ageing, Madrid, Spain, 8-12 (DPI/2264), available fromhttp://www.un.org/ageing/prkit/hivaids.htm. Alan Whiteside, “Future imperfect: the AIDS epidemicin the twenty-first century”, inaugural lecture, Universityof Natal, Durban, South Africa, 5 December 2002. World Health Organization, Impact of AIDS on Older174.At a wider level, AIDS is causing life expectancyto decline. In Southern Africa alone it has fallen fromover 60 years to under 50, and it is expected to fallfurther. Moreover, the movement of HIV/AIDSeastward into Asia, combined with the rapid growth ofdeath rates from tuberculosis and malaria, will result ina continued reduction of life expectancy and anincrease in the vulnerability of and burden on olderpersons, with far-reaching health, economic andpsychosocial impacts.Migrant health and social protection175.Three elements can be identified as the source ofhealth-related vulnerability among migrants. First,there is evidence that their health risks are compoundedby discrimination and restricted access to healthinformation, health promotion, health services andhealth insurance. Second, migrants as a groupdisproportionally suffer from high exposure tooccupational and environmental hazards. Third,migrants are at greater risk because some of theirspecific health needs are ignored or not wellunderstood and therefore are not adequately addressed.176.Migrant health is an area of intense debate.Concerns with pre-existing and untreated conditionssuch as infectious and communicable diseases havelong been a priority for health authorities, sincemigrants pose potential sanitary threats to hostpopulations. A few years ago, considerable public andmedia attention was devoted to the association betweenmigrants and HIV/AIDS. The focus has now switchedto the health threat posed by undocumented migrants.There is also speculation on whether a significantnumber of migrants may be motivated by the health-care entitlements in host countries that provide themwith treatment not available or affordable in theircountry of origin. It is argued that the provision ofhealth care to migrants puts additional financial stresson already overstretched and underperforming publichealth systems. In addition, the use of a healthcondition in court as a ground to challenge expulsionorders in several countries has caused furtheruneasiness on the part of public authorities. It has alsoundermined the case for a legally binding recognitionof health as a human right. So far, although migrants__________________People in Africa: Zimbabwe Case Study(WHO/NMH/NPH/ALC/02.12). A/58/153/Rev.1ST/ESA/284 have argued that expulsion should not be enforcedwhen there are serious, including life-threatening,health conditions and a need for medical treatmentsthat might not be available in the migrant’s country oforigin, all courts have rebutted their claims.177.Migrant health poses a triple challenge by raisingfundamental questions of social equity, public healthand human rights. Unfortunately, the currentcontroversial context makes it difficult to reduce theirhealth-related vulnerability despite ample evidence oftheir plight. For example, in Europe, occupationalaccident rates are, on average, twice as high formigrant workers than for native workers. In bothdeveloped and developing countries, many migrantagricultural workers display pathologies related toexposure to toxic pesticides. The large majority ofthose migrants do not have medical coverage or access178.Work carried out by the World HealthOrganization and the World Bank on mental health hasfound that immigrants and refugees are among thegroups that are disproportionately affected. Althoughknowledge of the mental health of migrant populationsremains fairly limited, there is enough evidence tosuggest that severe psychological stress due touprooting, disruption of family life and a hostile socialenvironment is common. Unfortunately, a large numberof migrants have no or little access to mental healthcare, either because they are excluded from existingservice arrangements or because there is no provisionfor mental health care, a situation that prevails in morethan 40 per cent of countries.179.Trafficking and smuggling expose migrants toadditional health hazards, including dangerous travelconditions, violence and abuse, and unsafe workingenvironments. Those who are trafficked for work in thesex industry face increased risks of sexuallytransmitted diseases. At the same time, the fear ofdeportation and the absence of medical insurance makethem unlikely to seek medical care.180.Migrants who live in societies that have extensivesocial protections systems do benefit from them.However, owing to existing institutional arrangementsand piecemeal adaptation to the changing nature ofmigration flows, the social protection of migrants andtheir access to social programmes are fragmented,partial and inadequate. The inadequacy of coveragealso reflects a lack of concern for the social needs ofmigrants. Nevertheless, the availability of welfarebenefits to migrants has given rise to a heated debatebetween those who support the right of migrants tocomprehensive social benefits and those for whom thedebate on immigration policy centres on the trade-offbetween the economic benefits of immigration andsocial redistribution.181.At a basic level, migrants’ entitlement to socialprotection depends on whether they live in a countrywhere welfare benefits are provided primarily as aresult of being employed and having contributed to thesocial insurance system — such as in the labour-importing countries of Western Europe — or in acountry where benefits are granted on the basis ofresidence — such as the traditional countries ofimmigration (Australia, Canada, New Zealand and theUnited States), the Scandinavian countries or theUnited Kingdom of Great Britain and Northern Ireland.In labour-importing countries, social benefits dependlargely on the migrant’s specific status — for example,primary visa holder, dependant or refugee — and timerequirements. As welfare provisions are oftencontained in bilateral treaties, the migrant’s country oforigin also matters.182.In most cases, migrants do not qualify for welfarebenefits — beside health care — during their first yearof residence. However, in a few countries, denial ofsocial benefits may last longer, up to several years.Claiming social benefits may jeopardize a migrant’srights and that of his or her family to remain in the hostcountry if he or she does not meet time requirements.Most importantly, residency requirements deny manymigrants social benefits when joined by their families,namely at a time of great need.183.In many countries, in particular in federal States,responsibility for social assistance programmes hasbeen devolved to subnational authorities, increasing thecomplexity and the diversity of situations faced bymigrants. Such differences make the availability ofsocial provisions to migrants unequal both within andbetween host countries.184.While health care is available to all migrants,including undocumented migrants on an emergencybasis, the scope and quality of health services to whichthey have access vary greatly. However, there isevidence that migrants may sometimes be reluctant toassert their rights and do not avail themselves of thehealth services they are entitled to, for reasons ranging A/58/153/Rev.1ST/ESA/284 from a lack of information to cultural gaps and variousforms of discrimination. For unemployment benefits,social assistance and public housing, eligibility criteriaare much more restrictive and often apply only to long-term residents. In a significant number of countries,non-nationals are excluded from certain benefits.185.The non-portability of retirement benefits isincreasingly attracting attention as an issue of equity.Despite many signed bilateral agreements, a largenumber of migrants, in particular from developingcountries, fall outside those agreements and cannotreceive pension benefits if they decide to leave the hostcountry. The issue of the non-portability of benefits hasgained additional momentum following the surge in theinternational recruitment and mobility of skilled186.The social protection of migrants is a questionthat lies at the core of the migration debate. It has beencontended that the open welfare state offers a strongmotivation for people with a low level of human capitalto migrate. Whether there is an economic case or not,the controversy over the social protection of migrantsis one of the issues that feeds anti-immigrant feelings.Inadequate accessibility: a disability187.Every child is unique and has a fundamental rightto education. However, in developing countries only asmall minority of disabled children are in school,falling below 10 per cent in Asia and the Pacific.When denied the basic right of education, disabledpeople become severely restricted in terms of theireconomic, social and political opportunities as well asthe prospects for their personal development. Withoutan education it is more difficult to secure a job,particularly one that pays a decent wage, participateactively and fully in the community and have ameaningful voice in policy making, especially withregard to issues that directly concern the affected188.Children and youth with disabilities face a host ofbarriers to education, starting with an inaccessibleschool environment. In most cases, the lack of proper__________________ United Nations, Economic and Social Commission forAsia and the Pacific, Asian and Pacific Decade ofDisabled Persons, 1993-2002, available fromhttp://www.unescap.org/Decade.teacher training and appropriate teaching materials andmethods makes it unlikely that their special needs willbe addressed in a timely fashion. Negative attitudesand exclusionary policies and practices towardschildren with disabilities as well as a lack of supportsystems for teachers further undermine the schoolingoptions of children with disabilities. The problem isparticularly severe in rural areas, as special educationschools are located mainly in urban areas.189.Given the dynamics of disability and health,access to adequate health-care services is essential forthe promotion of independent living for the disabled.Health services play a critical role in the prevention,diagnosis and treatment of illnesses and conditions thatcan cause physical, psychological and intellectualimpairments. However, for the majority of persons withdisabilities living in developing countries, as well asfor a significant minority living in industrializedcountries, poverty precludes access to those vitalservices, either because health-care facilities andpractitioners are not sufficiently available or becausethere are not enough funds to purchase neededmedications and devices. Not only are there too feworthopaedic surgeons, the number of medicalrehabilitation centres to help people adapt to disablingconditions is insufficient to meet the demand, andmany more appliances such as orthotics, prostheses,hearing aids and wheelchairs are needed to improvedaily functioning.190.Independent living implies integrating thedisabled into the general community, rather thanplacing them in exclusionary institutions or relegatingthem into “colonies” of disabled. Community-basedrehabilitation programmes, which are in the process ofbecoming fairly well established in industrializedcountries but remain rare in developing countries, tendto be part and parcel of independent living strategies.The intention of the programmes is to lower the costsand increase the effectiveness of disability services byreplacing more costly, segregated, medically basedinstitutional approaches with more cost-effective andresponsive approaches intended to empower andsupport disabled persons and their families.__________________ Robert L. Metts, “Disability issues, trends andrecommendations for the World Bank”, Social ProtectionDiscussion Paper No. 0007 (Washington, D.C., WorldBank, 2000). A/58/153/Rev.1ST/ESA/284 191.The potential for enhancing the possibility ofpersons with disabilities to carry on independent liveswithin the community rests on the adoption ofinclusive technologies and universal design inbuildings, public facilities, communications systemsand housing. Inclusive technical devices, such aswheelchairs, crutches, sign language translation,Braille machines, adaptive keyboards, and audiocassettes can significantly improve mobility andcommunication for the disabled. Likewise, adopting theprinciples of universal design can greatly facilitate thephysical accessibility of schools, training centres,workshops, offices, public buildings and residences.If those accommodations are made, disabled peoplewill have greater ease of access to education,employment and social, political and culturalopportunities, all of which can improve their well-being and that of the communities in which they live.Threats to the well-being of indigenouspeoples192.The overall well-being of indigenous peoples isthreatened in a number of different ways. One majorsource of vulnerability is the risk of disintegration ofthe social structure that is crucial to their survival.Other sources of vulnerability, many of which aredirectly related to their social structure, include healthproblems; a lack of education and a lack of access toeducation; migration; armed conflict; loss of lands; andviolence, exploitation and abuse.193.The health of indigenous peoples is closelyrelated to their lands. The appropriation of ancestrallands, environmental degradation and dwindlingnatural resources compromise agricultural livelihoods,the supply of food specific to their diets and thesources of their traditional medicines. Furthermore,indigenous peoples have been exposed to diseases thatwere once those of “outsiders”; the incidence of suchillnesses as AIDS and cancer from radioactivepollutants, against which traditional medicine is not__________________ See “Disability and poverty reduction strategies: how toensure that access of persons with disabilities to decentand productive work is part of the PRSP process”,discussion paper, InFocus Programme on Skills,Knowledge and Employability (Geneva, InternationalLabour Organization, Disability Programme, 2002),para. 36.effective, has been on the rise among indigenous194.In the area of education, indigenous peoples facediscrimination in two spheres. First, they often lackaccess to educational facilities. Second, educationalcurricula seldom take into account the specialcharacteristics of indigenous peoples. Thus, indigenouschildren often drop out of school, while those that docontinue often face discrimination in gaining access toinstitutions of higher education. Furthermore,compared to boys, indigenous girls are less likely toattend school, and fewer indigenous children attendschool as compared with other children. As a result, thelowest literacy rates are often observed among195.The opening of indigenous territories has led tothe migration of indigenous youth to urban centres,leaving older members of the community in traditionalsettlements or at relocation sites. Urban migrationerodes the intergenerational support that has sustainedindigenous peoples over many years and severs ties totraditional territories. Older indigenous peoples, left ontheir own in less desirable physical environments,become victims of abuse and maltreatment, hunger and The departure of the younger membersresults in higher dependency ratios within indigenouscommunities and, unless reversed, eventually leads tothe extinction of those communities. Thereoutmigration of indigenous women seeking work inother countries as domestic helpers has alsoincreased. While their remittances help indigenouscommunities financially, lasting outmigration alsoleads to the further breakdown of families and social196.Increased military actions to combat drug cartelsand armed insurgency, as well as the presence of__________________ Chandra Roy, “Racial discrimination against indigenouspeoples: a global perspective”, Indigenous Affairs, No. 1(2001). “Human rights of indigenous peoples: indigenouspeoples and their relationship to land”, final workingpaper prepared by the Special Rapporteur to theCommission on Human Rights (E/CN.4/Sub.2/2000/25). Victoria Tauli-Corpuz, The Resistance of the IndigenousPeoples of Asia against Racism and RacialDiscrimination (Baguio City, Philippines, IndigenousPeoples’ International Centre for Policy Research andEducation, n.d.), available fromhttp://www.tebtebba.org/tebtebba_files/ipr/racism.htm (accessed 4 November 2002). A/58/153/Rev.1ST/ESA/284 paramilitary forces, have hastened the socialdisintegration of indigenous peoples’ communities andhave forced thousands of them off their lands,converting them into refugees. The problem becomeseven more difficult for indigenous communities locatedalong the borders of several nation States where policeprotection is not effective.197.Other conflicts exist between indigenous peoplesand members of modern society coexisting on adjacentlands, stemming from differences in their concepts ofland rights. Violent means have sometimes been usedto evict indigenous peoples from their lands. Otherhuman rights violations against indigenous peoplesinclude assassinations, forced disappearances,compulsory relocation and destruction of villages andcommunities. Missionary work of followers ofinstitutionalized religions and the subsequentconversions of some members of indigenouscommunities have also led to conflicts within thosecommunities and the rejection by some members oftheir indigenous cultures.198.Another source of vulnerability is exploitationand abuse. Displaced women possessing only farmingskills become easy prey to prostitution rings. In areaswhere land has been expropriated for logging,indigenous women may be forced into prostitution onlyto be left behind when the logging operations arecompleted.199.Oppression and alienation from their owntraditions has had serious sociocultural, psychologicaland emotional effects on indigenous peoples. This ismanifested in a very high incidence of domestic abuseand violence, alcoholism and suicide in indigenouspeoples’ households, particularly in urban settings.“Over-policing” has also resulted in theoverrepresentation of indigenous peoples in custody,with high levels of youth institutionalized and A high incidence of mental health problemshas also been observed among indigenous children__________________ “Briefing notes”, World News, 6 February 2001. “Indigenous issues: human rights and indigenousissues”, report of the Special Rapporteur on the situationof human rights and fundamental freedoms of indigenouspeoples (E/CN.4/2002/97). Aboriginal and Torres Strait Islander Social JusticeCommissioner, Social Justice Report, 1997 (Sydney,Australian Human Rights and Equal OpportunityCommission, 1997), available fromhttp://www.humanrights.gov.au. Path: publications.taken from their families and placed as servants in non-200.The sources of vulnerability and problemsmentioned above are exacerbated by indigenouspeoples’ isolation. They usually live in remote areaswhere access to health, education, housing and refugeeservices is limited. Indigenous peoples often havelimited resources to protect themselves from violenceor to punish perpetrators when formal justice andcriminal justice systems are located in faraway urbanareas.Conclusion201.Traditionally, the public sector provides basicsocial services, including education, health care andsocial assistance and social protection to ensure equalaccess and protect the basic needs of individuals,families and communities. Those services form anintegral part of the capacity to cope with the effect ofsocial risks. Unfortunately, fewer and fewer resourcesare available for such purposes in the currentenvironment of public sector retrenchment in bothdeveloped and developing countries. As a result, thereis a general trend towards reductions in publicprovisions while alternative methods of deliveringbasic services have fallen short of expectations in termsof universal access. The situation has further weakenedcoping capacity, especially among disadvantaged and202.The disintegration of social infrastructure in theareas of education, health care and administration/governance, and the weakening of social institutionshave put large segments of the population at risk fordisease, lawlessness and ignorance, all of whichcontribute to increasing vulnerability.203.Furthermore, the demographic transition bringswith it such social concerns as older persons’ health,which is becoming an issue for more people in morecountries as population ageing occurs. All the while,precious resources are spent fighting expensive (bothin money and human lives) wars instead of addressingsocial ills and the special needs of large segments ofthe population in some of the world’s poorestcountries. For some, they are trapped in a viciouscycle: poverty and unmet social challenges — violentconflict — deepening social division and poverty. A/58/153/Rev.1ST/ESA/284 204.The challenges posed by the social ills analysedin the present chapter are great for both nationalGovernments and the international community.Commitment and cooperation are needed at thenational and international levels to address those