Letter from Brazil: COVID-19 And Older People in Fortaleza, Brazil’s Worst-Hit City

This blog is written by Peter Lloyd-Sherlock. It draws on and develops content from the presentation made by João Bastos for the Global Platform’s 7th weekly webinar, available in Portuguese here.

Fortaleza lies on Brazil’s beautiful northeast coast. This is one of the poorer parts of the country but the local government has made recent strides to promote international tourism. Over the last couple of years, the local airport was upgraded and now receives direct flights from Europe and North America. But what had seemed like a success story of local development also paved the way for Coronavirus’ early arrival. It is no coincidence that the three worst-affected cities in Brazil all have airports with international connections.

Fortaleza airport: the price of global connectivity?

Over the past few years, I’ve been involved in a research project in Fortaleza, looking to develop integrated health and social care services for older people. One of the reasons why we chose to work in Fortaleza was the city’s deserved international status as a pioneer of public health interventions, including community health agents. Also, several leading experts on older people’s health are based there.

João Bastos is one of these experts. As well as former President of the Brazilian Society for Geriatrics and Gerontology, he is the city government’s lead on health services for older people. João himself was one of the first Covid-19 cases in Fortaleza, falling ill in March, but fortunately making a good recovery after a few miserable and worrying days.

As soon as he was back on this feet, João and his colleagues started to prepare for the pandemic. Unlike countries such as the UK, the city health department paid particular attention to the situation in local care homes. Liaising closely with the city’s department for social assistance (which has overall responsibility for care homes), they visited all the city’s old age homes and conducted a quick survey in order to identify those at most risk. The survey (conducted back in mid-April) found that all care homes were facing serious challenges. But a small number were especially vulnerable, lacking any capacity to screen for potential symptoms and struggling to access daily food and medicines. These high-risk care homes were targeted for priority support and the city’s health and social assistance departments continue to work closely with them.

At the same time, the city government rolled out a raft of other sensible public health measures including efforts by the city mayor and state governor to establish a lockdown (directly at odds with the damaging approach taken by national president Bolsonaro).

It would be nice to report that this enlightened approach to preparing for the pandemic, meant that Fortaleza has been spared its worst effects. Sadly, the numbers say otherwise. By 20 May, Fortaleza had a Covid-19 death rate (505/million population) approaching to that of Italy (534), and the rate continues to spiral.

As in all cities, this burden has not been shared equally across the population. To date, 77 per cent of recorded deaths have been among people aged 60 or more. Covid-19 deaths have been heavily concentrated in the poorest parts of the city. This chart from João’s presentation compares neighbourhoods with higher rates of socio-economic deprivation (on the left) with numbers of Covid-19 deaths to date. It tells its own story…

Socioeconomic inequality and Covid-19 deaths in Fortaleza, by mid-May 2020.

Socio-economic disparities in Covid-19 deaths are hardly surprising in a country with such high levels of inequality. As many have observed, Covid-19 mortality is not just associated with age, male sex and other health conditions: it is a socially-determined outcome. There are many ways in which poorer Brazilians are especially exposed to the pandemic. Perhaps the most obvious is the limited scope for social distancing in densely populated neighbourhoods with precarious infrastructure.

Social distancing here???

Inpatient health resources in Fortaleza, especially intensive care, are extremely limited and will not be available to the vast majority of people suffering from severe symptoms. A few days ago, the local press ran a story about a young man who camped for 6 days outside an emergency clinic to pressure staff into providing a bed for his seriously ill father. He eventually succeeded, but this does not change the fundamental shortage of services.

Older man given hospital bed after son camps outside the hospital for six days.

João and his colleagues in Fortaleza are painfully aware of the need to reach out to older people in the city’s poorest neighbourhoods. Immediately after presenting to our webinar, he met local health and social assistance agencies to launch a new initiative to identify and support care-dependent older people in the city’s many favelas.

Fortaleza may be the hardest-hit city in Brazil to date, but it is unlikely to remain so for much longer. Other cities in Brazil and beyond have much to learn from the impressive efforts of its public health and social assistance workers to cope with this catastrophe.