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Portraits of nightfall

In their majority of rural origins, the elderly of São Paulo were manual laborers and have little schooling

Born 87 years ago in Pedreira, a town in the interior of São Paulo, Matilde Lazzari Zanardi never went to school. Her elder sister died young, and was still a girl when she had to help her mother to take care of her nine younger brothers and sisters. While they were studying, she had to take care of the house. Besides being busy with household tasks, she worked on the fields. In 1940, after having lived for a brief period in the industrial suburbs of the city of São Paulo, she went back to Pedreira, and it was there she married Hugo Antonio Zanardi, with whom she was to have two children, Osvaldo and Maria Ivone. On the day after the marriage, the couple moved to São Paulo city for good.

In the capital, they both worked in the textile sector. He as a printer, she as a weaver. At around the age of 50, Matilde, who had learnt to read and write on her own and in spite of not having been to school, retired. But to earn some extra cash and to remain busy, this descendent of Italians started to sell jewelry. “She would visit the customers in their homes and sell objects made of gold and silver”, recalls 40-year old architect Liamara Milhan, Matilde’s granddaughter.

Life followed its normal course for the Zanardi clan, who all (parents, children and even grandchildren) lived close to each other, in houses in São Paulo’s Eastern Region. Until, in 1984, Matilde’s husband died of a heart attack at the age of 70. Even with her loss, the pensioner (with a pension of one minimum salary) soldiered on. In October 98, an aneurysm in the brain, followed by a stroke, almost brought her down. In spite of her old age, today she is recovering from the blow at home, with the help of her family and medicines.

The path followed by this former weaver serves, in great measure, as witness to the life story of a significant part of the elderly who live in the capital city of São Paulo. Being a woman, for having studied little, coming from a rural background, for having retired earning little, having done manual work, living with her family and depending on medicines – in short, for all this -, Matilde shows all the main characteristics of the contingent of almost 1 million elderly who live in the largest and most prosperous Brazilian metropolis.

This can be said after coming across the main results of a survey carried out by researchers for the School of Public Health of the University of São Paulo (USP), in partnership with the Pan-American Health Organization (PAHO), and with support from FAPESP. Formally denominated SABE , the acronym in Portuguese for Health, Well-being and Aging, the work outlined a portrait of who are and what the state of health is of the people aged 60 or more who lived in the municipality of São Paulo in 2000 The inhabitants in this age group account for 9.3% of the population of the capital city of São Paulo, according to data from the Brazilian Institute of Geography and Statistics (IBGE in the Portuguese acronym).

Here are a few figures provided by the study, which recorded an average age of 69 amongst the elderly of São Paulo. Forming a majority in the total population of the metropolis, women are even more strongly represented in the third age, accounting for 60% of this age bracket. One out of five elderly people never went to school, and 60% studied for less than seven years. Before moving to São Paulo, almost two thirds of them lived in the countryside until the age of 15, for a period of not less than 60 months.

In their professional life, a little more than 75% of the old people were engaged in occupations that demanded mostly physical efforts. Medicines are a companion for all the hours and of almost everyone: 87% use some kind. Two thirds of the people who have reached the third age have earnings of between one and five minimum salaries, coming essentially from old age pensions, as 80% of them do not work any more. Finally, 86% of the senior citizens live in company, along with someone from the family (spouse, children or relatives). Can you see a bit of Matilde in São Paulo’s elderly people?

These figures and percentages are just a sample of the hundreds of items of information that are starting to emerge from Sabe (for other data, see the table on page 36). To fulfill the objective of the project, the researchers had to interview 2,143 elderly people who lived in São Paulo, visit their domiciles, and take their measurements (weight, height, skin flap to see the layer of fat, etc.). The people who made statements for the study were statistically selected to form a representative set of the oldest group of the population of the city.

“We have a lot of material, with the most varied data about old people”, comments researcher Maria Lúcia Lebrão, from the School of Public Health at USP, one of the coordinators of Sabe. “There are not enough people to analyze all the information.” PAHO has sponsored projects identical to the one carried out in São Paulo in the capital cities of another seven countries from Latin America and the Caribbean (Cuba, Costa Rica, Uruguay, Argentina, Mexico, Chile and Barbados). For the moment, only a small part of this data, collected with the same methodology used in the capital of São Paulo, is available for comparison.

By the standards defined by Sabe, 96% of São Paulo’s elderly live in residences that are of a good quality. Their dwellings – in 78% of the cases, owned by them or by someone who gives them the space at no charge – have piped water, sewage systems and a bathroom and have a room for cooking. This good news, though, hides a perverse fact on the geographical location of the old people in the city. The immense majority is concentrated in the more central districts, far from the shantytowns and the outskirts, an indication that growing old is still a privileged of the better-off classes. Although only 13% of the elderly live on their own, seven out of each ten individuals of the age of 60 or more said that they do not rely on anyone to help them in their daily activities.

What kind of help would they like to have? Possibly, a hand in carrying out the once humdrum tasks that have become little torments: 18% have difficulty in dressing themselves, 12% in going to bed and getting up, 10% in having a shower, 7% in going to the toilet, and 6% in eating.Chronic diseases are a shadow that hovers over the elderly, according to the Sabe project. A little over half the old people who reside in São Paulo have high blood pressure. One third reported suffering from arthritis, rheumatism or arthrosis. One fifth claimed they had some heart problem. Those who declared they were diabetic amounted to 18%, four percentage points more than the victims of osteoporosis, a progressive decalcification of the bones that affects women in particular.

Other frequently mentioned ailments were problems with the lungs (12%), embolism/stroke (7%) and cancer (3%). At first glance, the state of health of a person of a ripe old age seems to be inversely proportionate to the number of diseases: more ailments means lower quality of life. However, this is not always true. “Sometimes, an old person with four or five chronic diseases, but all under control, can live better and runs less risk of ending up in a wheelchair than another with one or two health problems that are not being treated in a proper manner”, ponders gerontologist Luiz R. Ramos, from the Center for Studies on Aging of the Federal University of São Paulo (Unifesp).

Recipe for aging well
In the second half of the last decade, Ramos coordinated a project that followed up, over two years, the health of 1,667 old people who lived in Vila Clementino, a district in the city of São Paulo where Unifesp is. Its core goals were to survey risk factors that increased the chances of dying in the third age and to try to understand why some people aged well and others did not. One of the main conclusions of the study was that the focus for attending to this range of the population should not be diseases, purely and simply, but rather the impacts that these ailments had on the cognitive and motor functions of the patient. “The most important thing is that treatment should aim at preserving, or if possible at increasing, the degree of independence (mental and for locomotion) of the elderly person, compared with other people”, Ramos explains.

When looks at the mountain of figures from Sabe, there is one point that stands out: the level of schooling of the aged seems to act like a pointer to their general condition of health, above all in its cognitive aspects. Apparently, the higher the level of the formal education of the interviewee, the lower the physical and mental discomfort. How is this relationship evidenced? It begins to take the shape of reality when roughly 65% of the individuals without any schooling classified their health as poor or bad, ten percentage points above the general results of the survey.

If the subject is mental health, this relationship becomes quite explicit. Regardless of the level of education of the aged, the occurrence of such cognitive problems as loss of memory, logical thinking, and other brain functions, affects 11% of the whole of Sabe’s sample, with a frequency one quarter higher among women than in men. Amongst people aged 60 or more who have never been to school, the incidence of this kind of problem is 17%.

In the elderly who have studied for less than seven years, this rate falls to 5%. And for those that have clocked up over seven years on the school benches, it is a mere 1%. “A person able to study usually reaches a better socioeconomic condition in his lifetime, and is better informed health issues”, says Ruy Laurenti, also from USP’s School of Public Health and another coordinator of Sabe. “He or she gets prepared and has better conditions for aging well.”The worrying indices of cognitive deterioration in the aged, also found in the other Latin American countries mapped by Sabe, are an indication that a series of problems are likely appear in the near future, in particular, dementias like Alzheimer’s disease, and the loss of autonomy for carrying out daily tasks.

In other words, this elderly person, if the mental deterioration advances, will have to be permanently assisted by someone. For psychologist Ana Teresa de Abreu Ramos Cerqueira, from the School of Medicine of the São Paulo State University (Unesp) at Botucatu, who is also taking part in the analysis of the data from Sabe, the relationship between schooling and cognitive disturbances really does exist. It is a real problem, but it needs to be put into perspective a bit.

“The results vary a lot according to the methodology we use to discover this kind of information”, Ana Teresa ponders. “There often happens what we call a false positive for problems of cognition or dementia, especially in diagnosing the situation of less educated people.” The old people who have not studied have greater difficulty in answering the researchers’ questionnaires than people with more schooling. The result: many people with little or no schooling end up being labeled, wrongly, as demented or a sufferer of mental problems.

Older and without money
PAHO’s concern in studying old age in this part of the planet has a clear reason: in the next 20 years, the number of persons aged 60 or more in Latin America and the Caribbean is practically going to double, leaping from 42 million individuals in 2000 to an estimated 82 million after 2020. In this same period, in proportional terms, the increase will be a bit smaller, but still very considerable. The elderly will go up from 8.1% to 12.4% of the total population of these countries. In this picture of rapid aging in the Latin American societies, Brazil is no exception.

In 1940, only 4% of its population was 60 years old or more. According to the census, the elderly in 2000 now added up to 8.6% of all Brazilians – a contingent of 14.5 million individuals, 55% of which women. In the next 20 years, the aged population of Brazil may exceed 30 million persons and account for almost 13% of its inhabitants. “It may not even seem such a lot of folks in proportional terms, above all when one looks at the figures for the European countries, where over 15% of the population is elderly”, comments Ruy Laurenti. “But the absolute number of old people in Brazil is very large and will continue to grow”.

The consequences of the considerable increase in the quantity of people in the so-called third age on the health and social security systems are evident and are already being felt nowadays. Suffice it to mention the heated national debate on the maximum ceiling for old age pensions and the minimum age for applying for the benefit. Besides this, there is the impact of aging on family relationships. Who has never taken part in one of those family meetings to discuss, in low and somewhat embarrassed voices, where granny is going to live now that grandpa has gone? Strictly speaking, thebiggest problem is not even the aging of the population of Latin America (in Asia and Africa as well), but, rather, growing old without health and quality of life.

This issue is even more dramatic in the universe of the poor and developing nations, like Brazil and its neighboring Latin countries, where a good part of the aged have little formal education, money is short and the public services precarious. “First, the developed countries got rich, and then, old”, explains Maria Lúcia Lebrão. “We are getting old before getting rich.” The data from the Sabe project in the São Paulo capital city illustrates this maxim.

Paying for health insurance is a luxury that only four out of every ten old people living in São Paulo manage to keep up. Matilde is one of those enjoying this benefit. As the plan is an old one and only gives her the right to being attended to in a hospital in the region, the amount of the monthly fee, about R$ 150, is regarded as low for her age.The aging of the population and the increase in the average life expectation at birth – in 1980, it was 62.7 years for the Brazilians, and now it is almost 69 years – are national phenomena. But according to data from the IBGE’s census, the presence of the aged in the 27 units of the federation varies – and it varies a lot.

At the base, there is a group of states in which the oldest part of the population represents between 4% and less than 7% of their inhabitants. This is the case of the whole of the northern region. In an intermediate situation, there is a large group of states where the proportion of old people varies from 7% to 9% of their inhabitants. In São Paulo, for example, people 60 years old or more account for 9% of the population.

At the top, with a rate of elderly that reaches two figures, three states appear: Paraíba (10.2%), Rio Grande do Sul (10.5%) and Rio de Janeiro (10.7%). Not by chance, the municipalities of Porto Alegre (capital of the state of Rio Grande do Sul and Rio de Janeiro city are also the cities with most elderly people (11.8% and 12.8%, respectively, of their inhabitants).The association of one of the most traditional districts of the Southern Region of the city of Rio de Janeiro with the image of nice old folks – relatively prosperous compared with the bulk of Brazilian pensioners – walking on the beach or doing exercises on the sand has now become a classic.

“Twenty seven per cent of the dwellers in Copacabana are elderly”, say physician Renato Veras, a director of the Open University for the Third Age (Unati), a project run by the State University of Rio de Janeiro (UERJ) which each semester lays on 125 courses for 2,200 elderly people. A specialist in health in the third age, Veras says that the public health sector is still not ready to attend to the growing demand for services specially aimed at the more aged portion of the population. “Even with this enormous presence of old people, do you think you will find a gerontologist at a health center in Copacabana?”, the doctor asks.

Nursery for the old
Taking care of the elderly is different from dealing with children or adults. That is why many specialists defend the implementation of differentiated services for this age group. Veras is in favor of stepping up home visits for this portion of the population. “At home, the elderly get less hospital infections and are in an environment that they know”, says Unati’s director. Implanting a system for home visits demands complex logistics in order to efficiently and rationally manage the movement of medical teams. According to Veras, though, if it is well managed, this service even reduces the costs of assistance, to the extent that it acts more preventively and prevents unnecessary admissions to hospital.

Indeed, leaving home and getting to a hospital or a doctor’s surgery offices can be an impossible task to be fulfilled by many old folks. In São Paulo, according to Sabe’s results, the lack of (good) public transport has gone so far as to be the cause most cited by interviewees for missing appointments with doctors. Another possibility of a differentiated service for the elderly, which does not exclude the proposal above, is to stimulate the creation of companionship centers for this segment of the population, places that works like day nurseries for the third age.

At these places, people who have already past 60 can spend the day carrying out physical and intellectual activities, always under the supervision of someone from with a medical background, at least a nurse. At night, the old folks go back home. “This way, they do not lose the bond with the family and they keep active”, says Maria Lúcia Lebrão, from USP’s School of Public Health, who advocates this idea.Some of the so-called universities for the third age carry out, in a fashion, the role of the companionship center for the elderly.

It is true that the number of places offered on their courses and activities is usually too small for the demand. But those who manage to get a place are pleased. This is the case of the 65-year-old housewife Guiomar Genaro Hachel, who for four years has attended activities for the aged at the Pontifical Catholic University of São Paulo (PUC/ SP) and, for three years, has been taking part in the Open University for the Third Age (Uati) maintained by Unifesp.

Not accompanied by her husband, Guiomar has now attended the whole cycle of talks and is now doing “extracurricular lessons” of theater, ballroom dancing and tai chi chuan. “At the university, I become more informed and make friendships”, says this grandmother of six. The presence of men is lower in the courses for the third age, but not nonexistent. A widower and a pensioner, former marketing professional Celso Pavarin, aged 73, started to attend Uati this year. Besides the regular talks laid on by the universities, takes lessons in theater, ballroom dancing and information technology. “More than knowledge, what most impresses me in Uati is how kind people are”, explains Pavarin, who for 21 years has been carrying around a coronary bypass in his chest. “Here, it’s good to be old. More people ought to have this opportunity.”

The Project
The Conditions of Health in Latin America and the Caribbean (99/05125-7); Modality: Regular line of grants for research; Coordinators: Ruy Laurenti and Maria Lúcia Lebrão – USP’s Faculty of Public Health; Investment: R$ 236,295.00