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Brazil’s healthcare system unprepared for fast-aging population

. Mar 17, 2019
healthcare retirement pension system

Twenty-seven-year-old Fábio Cruz lost hope in Brazil’s public health system when his mother suffered a stroke. Doctors at a downtown casualty unit sent him home, diagnosing his 60-year old mother with a bout of “stress.” When Mr. Cruz took his mother to Albert Schweizer public hospital in Realengo days later, doctors rushed her to treatment, shocked at her condition.

“There are good people in the public health system,” sighs Mr. Cruz. “But others are completely unprepared.”

At a moment when politicians across Brazil have focused their efforts on reforming the country’s ailing pension system amid rapid demographic changes, the topic of healthcare for Brazil’s senior citizens has received little attention.

</span></p> <p><span style="font-weight: 400;">But just as the Brazilian pension system will require major adaptations to shoulder the burden of an aging population, so too will the country’s public health system, the SUS. For Mr. Cruz and millions of others, the </span><a href="https://brazilian.report/power/2018/07/11/brazil-public-healthcare-system/"><span style="font-weight: 400;">system</span></a><span style="font-weight: 400;"> is inadequate in caring for their elderly family members—75 percent of which rely on the SUS exclusively for their healthcare, according to the Ministry of Health. </span></p> <p><span style="font-weight: 400;">Brazil’s population of senior citizens is set to </span><a href="https://www.who.int/ageing/publications/global_health.pdf"><span style="font-weight: 400;">triple over the next 30 years</span></a><span style="font-weight: 400;">, accounting for nearly a third of the country’s population by 2050. The same demographic change that took France 120 years to achieve between 1860 and 1980, Brazil is set to undertake in 20, making the country home to the </span><a href="http://www.revistahcsm.coc.fiocruz.br/brasil-tera-sexta-maior-populacao-de-idosos-no-mundo-ate-2025/"><span style="font-weight: 400;">sixth-largest</span></a><span style="font-weight: 400;"> elderly population in the world by 2025. </span></p> <hr /> <p><img loading="lazy" class="alignnone size-large wp-image-14814" src="https://brazilian.report/wp-content/uploads/2019/03/export-KM9lY-1024x683.png" alt="healthcare retirement pension system" width="1024" height="683" srcset="https://brazilian.report/wp-content/uploads/2019/03/export-KM9lY-1024x683.png 1024w, https://brazilian.report/wp-content/uploads/2019/03/export-KM9lY-300x200.png 300w, https://brazilian.report/wp-content/uploads/2019/03/export-KM9lY-768x512.png 768w, https://brazilian.report/wp-content/uploads/2019/03/export-KM9lY-610x407.png 610w, https://brazilian.report/wp-content/uploads/2019/03/export-KM9lY.png 1200w" sizes="(max-width: 1024px) 100vw, 1024px" /></p> <hr /> <p><span style="font-weight: 400;">The shift itself is the result of simultaneous drops in fertility rates and increased life expectancy, just as much the fruit of Brazil’s modernizing economy as improvements in healthcare. But as healthcare improved, the country saw a profound epidemiological transition. That is, where infectious and communicable diseases once took a much larger toll on the population, Brazil now sees a more significant share of non-communicable, chronic and degenerative </span><a href="https://brazilian.report/podcast-brazil/2018/07/18/podcast-diseases-return-brazil/"><span style="font-weight: 400;">diseases</span></a><span style="font-weight: 400;">. </span></p> <h2>Demographic shift adds pressure on healthcare system</h2> <p><span style="font-weight: 400;">“The Brazilian healthcare system was structured before the demographic change,” says Dr. Luiz Roberto Ramos, Full Professor of Preventive Medicine at the </span><span style="font-weight: 400;">Federal University of the State of São Paulo.  “Where you once saw hospital waiting rooms full of mothers and children, they are now filled with senior citizens.” </span></p> <p><span style="font-weight: 400;">For the better part of the last century, Brazilian health education successfully focused on early-life and childhood health. These efforts, alongside national economic development, contributed to a leap in life expectancy: whereas Brazilians in 1940 may have hoped to live to their mid-40s, 2017 average life expectancy stood at nearly 80 for men and women.</span></p> <p><span style="font-weight: 400;">Brazilian healthcare, however, failed to adapt. “As I often tell my students,” says Dr. Ramos, “there is a major discrepancy between specialization fields in Brazilian medicine. Pediatricians and gynecologists are the top two chosen specializations. Geriatricians are in the minority.” A </span><a href="http://www.sbgg-sp.com.br/pub/mais-idosos-poucos-geriatras/"><span style="font-weight: 400;">2016 survey</span></a><span style="font-weight: 400;"> by the Federal Health Council and the Brazilian Society for Geriatrics and Gerontology recorded 1405 geriatricians in Brazil, or one for every 24,000 senior citizens. The World Health Organization (WHO) recommends a rate of 1:1,000.</span></p> <p><span style="font-weight: 400;">It isn’t just about geriatricians, Dr. Ramos warns. “What’s missing is interdisciplinary training for healthcare teams.” Elderly patients often present multiple conditions and illnesses, requiring attention from health professionals trained in multi-morbidity as well as physical therapists and psychiatrists.</span></p> <p><span style="font-weight: 400;">For Fábio Cruz, this gap in medical training became immediately apparent. He visited a local family clinic in late February to pick up prescribed medications and medical assistance following his mother’s release. Clinicians gave him medication, but asked him to return after the Carnival holiday for medical assistance. “Sure, if I can bring her back dead,” he replied.</span></p> <p><span style="font-weight: 400;">Mr. Cruz considered private healthcare options, but was stymied with </span><a href="https://brazilian.report/money/2018/02/22/inflation-impacts-brazilians-income/"><span style="font-weight: 400;">high costs</span></a><span style="font-weight: 400;"> and long waiting lists. While he possesses private health insurance, his mother does not, and she cannot be claimed as a dependent. This means care options such as at-home nursing are out of the question: Mr. Cruz works days and studies at night, meaning he would need to pay for 12-hour shifts daily.</span></p> <p><span style="font-weight: 400;">Realizing he had run out of options, the 27-year-old took matters into his own hands, purchasing nursing supplies with his own money and taking a week off work to care for his mother. “My office has been generous with me,” he says. </span></p> <p><span style="font-weight: 400;">But the cost of sanitary supplies alone quickly began to stack up. “An adult can go through three to four diapers per day, and each pack contains seven diapers, costing around BRL 20 to 23,” he says. A two-day stock, along with disposable gloves and moistened towelettes, can add up to almost BRL 100.</span></p> <p><span style="font-weight: 400;">Exasperated, Cruz took to social media, tweeting a plea for help. </span></p> <hr /> <p><img loading="lazy" class="aligncenter wp-image-14811 size-medium" src="https://brazilian.report/wp-content/uploads/2019/03/Screen-Shot-2019-03-17-at-09.53.42-300x248.png" alt="Brazil's healthcare system unprepared for fast-aging population" width="300" height="248" srcset="https://brazilian.report/wp-content/uploads/2019/03/Screen-Shot-2019-03-17-at-09.53.42-300x248.png 300w, https://brazilian.report/wp-content/uploads/2019/03/Screen-Shot-2019-03-17-at-09.53.42-768x635.png 768w, https://brazilian.report/wp-content/uploads/2019/03/Screen-Shot-2019-03-17-at-09.53.42-1024x847.png 1024w, https://brazilian.report/wp-content/uploads/2019/03/Screen-Shot-2019-03-17-at-09.53.42-610x505.png 610w, https://brazilian.report/wp-content/uploads/2019/03/Screen-Shot-2019-03-17-at-09.53.42.png 1262w" sizes="(max-width: 300px) 100vw, 300px" /></p> <hr /> <p><span style="font-weight: 400;">Though reluctant at first (“I didn’t want people to think I was running a scam”), a friend convinced him to post his bank account information and to accept monetary donations. When the support came, Mr. Cruz took to posting photos of the supplies he purchased with each donation. </span></p> <h2>Caring for the elderly</h2> <p><span style="font-weight: 400;">He knows that continuing to provide care for his mother will be arduous. The week we met, he had taken his mother to his sister’s house, anxiously returning to work. When asked if years in the future he would consider placing his mother at an assisted living institution, or what is known in Brazil as a long-term care institution for the elderly (ILPI), Mr. Cruz shakes his head. “That question leaves me confused. But right now, at age 27, I can’t see myself doing that.” </span></p> <p><span style="font-weight: 400;">ILPI’s are stigmatized in Brazil, often seen as centers of abandonment or thinly veiled psychiatric wards. Brazil’s 1988 constitution even </span><a href="https://www.senado.leg.br/atividade/const/con1988/CON1988_05.10.1988/art_230_.asp"><span style="font-weight: 400;">names families</span></a><span style="font-weight: 400;"> as primary caretakers (alongside “society and the State”) of senior citizens, and prioritizes care within homes. The 2003 </span><a href="http://www.planalto.gov.br/CCIVil_03/leis/2003/L10.741compilado.htm"><span style="font-weight: 400;">Senior Citizen Act</span></a><span style="font-weight: 400;"> goes even further, prioritizing care for the elderly “by their own families.” ILPI’s are thus underused in Brazil in comparison to international standards. As of </span><a href="http://www.ipea.gov.br/portal/images/stories/PDFs/livros/livro_cuidados.pdf"><span style="font-weight: 400;">2010</span></a><span style="font-weight: 400;">, around one percent of Brazil’s senior citizens are cared for at ILPI’s, whereas European institutions care for an average of five percent.</span></p> <p><span style="font-weight: 400;">Even if ILPI stigma and cultural associations were to disappear, however, such institutions are in no position to receive the growing number of Brazilian senior citizens that suffer from declining functional capacity. A 2010 </span><a href="http://www.ipea.gov.br/portal/images/stories/PDFs/livros/livro_cuidados.pdf"><span style="font-weight: 400;">IPEA study</span></a><span style="font-weight: 400;"> counted just over 3500 ILPIs in all of Brazil, covering only 30 percent of Brazilian municipalities. </span></p> <p><span style="font-weight: 400;">For now, Mr. Cruz remains optimistic. He has joined a Facebook group for the family members of stroke victims, where participants offer tips for recovery and trade healthcare equipment. “I truly believe [my mother] is going to get better. That’s what keeps me from losing hope.” He makes it clear, however, that he won’t be depending on the public health system. “I don’t want to see what happened there repeat itself,” he says.

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Edmund Ruge

Edmund is a freelance journalist based in Rio de Janeiro. He holds a Master's Degree in International Economics and Latin American Studies from the Johns Hopkins School of Advanced International Studies.

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