‘Hunger would kill us instead of COVID‐19’: Elders' response to the pandemic in Debre Markos Town, Ethiopia

Abstract The COVID‐19 pandemic has posed unpredictable challenges globally. Older adults are among the population groups most vulnerable to COVID‐19. Poor urban elders in Ethiopia struggle to meet their basic needs due to waning traditional familial norms of providing care for elders as a result of urbanisation, poverty and migration. The aim of this study was to give voice to vulnerable elders during the COVID‐19 lockdown in Ethiopia and to reveal their sources of support. Using a qualitative case study design, data were collected from 27 elders aged 60 and above in Debre Markos Town, Ethiopia via in‐depth interviews conducted from March–May 2020. To determine the nature of support provided for destitute elders, data were also gathered from two local officials. Narrative data were analysed using thematic analysis. Four prominent themes were identified: ‘Hunger would kill us instead of COVID‐19,’ ‘Feeling hopeless and begging to die,’ ‘We prefer social support rather than food donations’ and ‘Gratitude.’ Elders considered the practice of social distancing to fight COVID‐19 as an unwelcome luxury for people whose livelihood depends on begging and petty trade. The physical distancing programme put elders in isolation, diminishing their capacity to maintain their livelihood. Due to the increasing disrespectful attitudes towards aged people, elders felt even less valued than usual. Interactions were described as undermining, embarrassing and abusive. A special emergency fund and organised social supports are needed to minimise the effect of the pandemic on vulnerable groups like destitute elders in Ethiopia. Moreover, an institutional welfare response is needed to ensure elders can live a dignified life.


| INTRODUC TI ON
COVID-19 has brought unexpected challenges to human beings globally and its effects varied based on the socio-economic status of particular populations. Elders are particularly affected by  due to preexisting chronic medical health conditions like diabetes and heart disease (Daoust, 2020;WHO, 2020). Elders need special attention during the COVID-19 crisis, and their voices, opinions and concerns must be heard (UNFPA Global Ageing Network, 2020).
Older adults living in long-term care facilities, who live alone, or who are highly care-dependent are especially vulnerable to  infection and may face barriers to obtaining accurate information, food, medication, and other essential supplies during quarantine or social distancing conditions (WHO, 2020).
According to the UNFPA Global Ageing Network (2020), although the proportion of elders in developing countries is lower than in Global North countries, the existing system for geriatric care is elder unfriendly. In general, Global South nations have the fewest health resources, limited experience caring for older patients (including few geriatric specialists), less institutional care for elders, and few public or NGO support structures for outreach, screening and community-based care of elders. The challenge of meeting elders' needs is aggravated due to the decline of traditional familial care systems for elders in Global South countries as a result of urbanisation, poverty, migration and HIV/AIDS (Zelalem et al., 2021).
To a large extent, elders in Africa were struggling to get the necessary care and support before the pandemic.
In Ethiopia, care for elders has traditionally been provided by family, neighbours and church institutions. Increasingly, many elders are left without a caregiver and struggle to survive by engaging themselves in begging, small business activities, and other informal livelihood means (HelpAge International, 2013). In the absence of any public income support, many elders in Ethiopia are facing the challenges of homelessness, financial abuse and neglect (Kotecho et al., 2022). Ethiopia, a country with more than 5 million elders, has not yet implemented a national ageing policy or any specific entitlements for older adults.
Researchers have begun to document issues in relation to older adults and responses to COVID-19. Using data from 27 countries, Daoust (2020) studied older people's responses to the pandemic and found that despite the greater mortality rate among older adults from COVID-19, they were not the most compliant age group to preventive measures. Despite the geographic reach of Daoust's analysis, none of the countries studied were on the African continent.
In an even broader study of the impact of the COVID pandemic on elders with data from 62 nations including three African nations, Kim and Jung (2021) reported that social distancing measures increased the mental distress of elders. While an increasing number of studies have documented the unmet needs of elders in Ethiopia before the pandemic (e.g. Abate et al., 2020;Abdi, 2012;Ayana, 2012;Chane & Adamek, 2015;Hamren et al., 2015;Moges et al., 2014;Zelalem et al., 2021), research on care and support for elders in response to COVID-19 in Ethiopia is lacking. With the goal of shedding light on ways to protect elders from COVID-19 infection and to ensure their basic needs are met, we examined Ethiopian elders' responses and needs in relation to the COVID-19 pandemic. Thus, the aim of this study was to give voice to vulnerable elders during the COVID-19 lockdown in Ethiopia and to reveal their sources of support.
Ababa, the capital city of Ethiopia. Nearly half of the residents of Debre Markos Town have monthly incomes below the federal poverty rate in Ethiopia (Biyena & Beyene, 2019). Among the 7 kebeles or subdistricts (smallest government unit in Ethiopia) of Debre Markos Town, kebele 04 was selected using a purposive sampling technique. Purposive sampling is used in studies where participants are selected based on specific cases of interest (Bernard & Bernard, 2013;Rubin & Babbie, 2014).
The first author was a member of the Debre Markos University's Psycho-social Care and Support Sub-Committee under the university's COVID-19 Prevention and Response Task Force. During that time, the researcher was working as a social worker/resource mobiliser to prevent food insecurity among vulnerable children, women and elders, and as a COVID-19 Prevention Educator in the study area.

| Sample
The target population for this study was 35 elders who had been screened for nutritional support and COVID-19 prevention supplies such as sanitiser and masks. From this group, 27 participants were selected using the following criteria: (a) willing to take part in the study, (b) living in Debre Markos City, (c) having an active connection with the kebele 04 Women Affairs Office of the city, (d) not having permanent income/ a history of multiple sources of income, and (e) having health problems such as HIV/AIDS or a disability. The head of the Debre Markos City kebele 04 Women Affairs Office assisted with identifying potential study participants. Two experts from the East Gojjam Zone Women Affairs and the Labor and Social Affairs Office were also interviewed to provide context for the study.

| Data collection
Data were collected after obtaining an ethics approval letter from the Office of Research, Addis Ababa University and after securing the permission of the kebele's head. Data were collected using indepth interviews and a document review. The study purpose and procedures were described to research participants as part of the oral consent procedures. The researchers met with the participants face-to-face to conduct individual interviews. Interviews were held in the kebele's office, elders' rented homes or in Saint Michael church. Interviews were held from March-May 2020 and took 30-45 min. Interview guides were prepared in Amharic, the mother tongue of the participants. Both the interviews and the transcriptions were initiated in Amharic and later translated into English.
Several open-ended questions and probes were used to ask study participants about their experiences with maintaining their livelihood since the start of the 2020 pandemic including the impact of social distancing measures such as mask wearing, maintaining physical distance, using hand sanitiser and lock-down orders.
Respondents were asked about their sources of support since their usual means of livelihood were severely eroded due to such measures. Finally, respondents were asked to share their perspective on changes needed to support vulnerable elders.

| Data analysis
Data analysis procedures followed Braun and Clarke's (2006) six steps of thematic data analysis: (a) familiarising oneself with the data, (b) generating initial codes, (c) looking for themes, (d) reviewing themes, (e) defining and naming themes and (f) producing the report.
The issue of credibility in qualitative research concerns the extent to which the data gathered reflects the perspectives and circumstances of the study participants. To enhance the trustworthiness of qualitative data, Anney (2014) recommends approaches such as prolonged engagement in the field, peer debriefing, triangulation, member checking and providing 'thick' descriptions. To establish the credibility of the data, triangulation was used in this study by collecting data from three sources: the older adults themselves, local government officials, and a review of pertinent policy documents. In addition, as the themes were identified from the narrative data, peer debriefing was used to ensure agreement on the identified themes.
Researchers contacted the study participants for member-checking to give them the opportunity to review a first draft of the study's findings.

| Ethical considerations
To ensure the ethical nature of the study, data collection was carried out using voluntary participation, informed consent, and privacy protection with the research participants. The participants were all adults, aged 60 and above. They were each given information about the nature of the research, the potential benefits, risks, and ways to withdraw from the study. Oral consent was obtained from all participants.

| FINDING S
Twenty participants were female and 7 were male. They ranged in age from 60 to 82 with an average age of 72. About half (n = 13) were homeless and lived outside in church courtyards. All were followers of Orthodox Christianity. Most of the participants were divorced.
In terms of health status, all of the participants were suffering from illnesses like HIV/AIDS and various forms of physical disability which exacerbated their vulnerability to COVID-19.
As Table 1 shows, most elders in the study area earned their living from begging and petty trade. The pandemic has been a particular challenge for them since their business activities were interrupted to avoid COVID-19 infection. Wheat flour and teff (grain from an annual grass native to Ethiopia) were distributed to elders according to family size. Accordingly, a household with three or more family members received 21 kilos of teff and 10 kilos of wheat per month.

| Themes
The narrative data from the in-depth interviews with the 27 elders revealed four prominent themes relating to hunger, hopelessness, lack of social support and gratitude.

| 'Hunger would kill us instead of COVID-19 pandemic'
According to the study participants, the COVID-19 pandemic was not the real challenge by itself for elders. For those with no permanent source of income and no supportive social network, their biggest challenge was getting adequate food to survive and for those who were housed, money to pay for rent. Their source of livelihood was highly endangered by the country's lockdown and stay-at-home measures during the pandemic state of emergency.

| We prefer social support rather than food donations
Some elders were concerned about the impact of pandemic-related Existing evidence confirms the absence of an independent policy that specifically addresses elder care and support in Ethiopia.

| Gratitude for occasional support as a life-saving scheme
Despite the challenges they face, most participants were grateful for the support they were provided. Accordingly, Ebsete, aged 80, expressed her gratitude: I think you reach out to us in the right time. We are facing starvation due to our inability to feed ourselves. While the elders in this study needed emergency food donations, they would have preferred an approach that empowers them rather than one that depicts them as welfare recipients and a burden on society. Institutional welfare systems provide support for all those who are eligible irrespective of race, gender, disability and other identity indicators. The researchers strongly support a welfare scheme that respects the dignity and worth of each human being. Hence, a longterm institutional response from the central government is needed in the study area and throughout the nation. A community that values the contribution of its older citizens is highly needed and thus an entitlement system should be in place to ensure elders' well-being.
In addition to food distribution, a special emergency fund should be introduced to minimise the effect of the pandemic on vulnerable groups like destitute elders in Ethiopia.

| Study strengths and limitations
This qualitative inquiry was able to give voice to vulnerable elders living in Debre Markos Town, Ethiopia, revealing their struggles with food insecurity as a bigger concern than the COVID-19 pandemic. Although grateful for handouts of food and other necessities, the study participants shared their perspectives about the inadequacy of supports for older adults. Essentially, the COVID-19 pandemic exposed the prevalence of an ageist culture in Ethiopia that blocks the development of meaningful social protection for older adults, leaving them in extreme financial strain--pandemic or no pandemic. life is needed rather than the current approach that represents elders as unproductive and as a societal burden. Unlike Global North countries, many Global South nations lack a policy framework that obliges states to provide various care and support mechanisms for older adults. This can be a useful lesson for Ethiopia, a country whose policy framework largely ignores the issue of elders.
Education and training for policy makers and government officials on alternative models of support for elders is crucial and timely.
The haphazard nature of food distribution to elders during the pandemic highlighted the weaknesses of a residual policy. Hence, policy advocacy is needed to support a functional ageing policy in Ethiopia that views support for elders as a state obligation. As Carrieri et al.
(2020) argue, the public sphere must be shaped 'in ways that allow [us] to recognise both the vulnerabilities and potentialities of all generations. One way to do so is to respect the individual person, going beyond categories such as age or age groups, and to promote intergenerational equity and solidarity by fostering connectedness across different generations' (p. 3).

| CON CLUS ION
Professionals in social work, public health, nursing and other helping professions need to be mobilised to provide care and support for vulnerable elders. Though writing about the U.S., Cox' (2020) statement rings true worldwide, 'Social work interventions to reduce the systemic disparities impacting older adults in the midst of the Covid-19 pandemic are essential' (p. 620). In Global North countries helping professionals with geriatric training are available to provide psychosocial care and support to elders at risk of physical or mental distress. As social work educators, we recommend the establishment of a geriatric health service system including mental health services for vulnerable segments of the Ethiopian population including elders. We strongly advocate for the establishment of community-based elder care centres and various income-generating mechanisms to help elders remain self-reliant and live dignified lives.

ACK N OWLED G EM ENTS
The authors thank the 27 Ethiopian older adults who agreed to share their perspectives of the impact of the COVID-19 pandemic.

CO N FLI C T O F I NTE R E S T
The authors declare that there is no conflict of interest to disclose.

AUTH O R CO NTR I B UTI O N
AT and MK conceptualised the study design. AT and MK contributed to data collection and analyses as well as the original drafting of the manuscript. MK provided supervision of data collection and analyses. MA contributed to the literature review, presentation of findings and final drafts of the paper. All authors critically revised the manuscript and accepted its final form.

DATA AVA I L A B I L I T Y S TAT E M E N T
The complete set of narrative data for this study is being stored by the first author, AT.