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Aging and inequalities: social protection policies for older adults resulting from the Covid-19 pandemic in Brazil

Alexandre Kalache Alexandre da Silva Karla Cristina Giacomin Kenio Costa de Lima Luiz Roberto Ramos Marilia Louvison Renato Veras About the authors

The Covid-19 pandemic represents a challenge for the entire world, particularly low and middle income countries, given the fragility of their public policies. An Imperial College, London study11 Walker GT, Whittaker C, Watson O, Baguelin Mark, Ainslie KEC, Bhatia S, et al. The Global impact of COVID-19 and strategies for mitigation and suppression [Internet]. London: Imperial College London; 2020 [acesso em 26 mar. 2020]. Disponível em:
highlighted the global nature of the crisis. Firm and coordinated action by governments, centered on social isolation for the entire population, could save millions of lives worldwide. While not disregarding the socioeconomic impact, emergency decisions must primarily consider the lives of everyone, despite the immediate economic interests.

In Brazil, more than 80% of older adults depend exclusively on the National Health Service (or SUS) for their healthcare. This percentage is even higher among Afro-Brazilians22 Werneck J. Racismo institucional e saúde da população negra. Saúde Soc [Internet]. 2016 [acesso em 20 mar. 2020];25(3):535-49. Disponível em:
and the poor. The SUS has suffered severe budget cuts for years, and even before the pandemic, much of its equipment was already on the verge of collapse due to excess demand. The inequality is striking - as journalist Flavia de Oliveira has said, “The Covid-19 crisis did not create the country’s ills. It exposed them”33 Oliveira F. Vocês que lutem! O Globo (Rio de Janeiro). 24 abr. 2020: Opinião..

There is an urgent need to reverse policies that have led to the dismantling of the SUS, especially in Primary Care. The predictable increase in mortality from other causes due to overcrowding and the need to prioritize hospital services for patients with Covid-19 is also a worry; as is the lack of testing, resulting in an underestimating of the problem; and the shortage of respirators and personal protective equipments (PPE’s), putting the infrastructure and workforce at risk in order to support the growing need for services.

The profile of the Covid 19 pandemic in Brazil differs from that of other countries:

  • it is younger, as long before the age of 60, adults suffer comorbidities that place them in the high-risk group;

  • it is much “darker”, as among the poorest of the poor are Afro-Brazilians. Questions of race and ethnicity are imperative - including indigenous populations, immigrants and nomadic peoples. Without this information, hitherto absent from epidemiological bulletins, strategies to tackle the crisis cannot be properly targeted;

  • it affects women more, through the greater risks faced by the most exposed health professionals, the prevalence of informal work amongst women, their role as providers of food and care for their families, and increased domestic violence;

  • it is even more age based, as economic choices determine the exclusion of older people from health services;

  • it is elitist, as the poorest Brazilians are deprived of access to diagnosis and treatment, wherever they live;

  • it brings more suffering, given the complete lack of palliative care in the public network.

People grow old badly and early in Brazil. Thus, deaths by Covid-19 do not only reflect the age composition of the country, but above all the fact that there have never been policies for active and healthy aging, centered on the promotion of health, lifelong learning, citizen participation and the protection of the most vulnerable44 Kalache A. Envelhecimento ativo: um marco político em resposta à revolução da longevidade. Rio de Janeiro: Centro Internacional de Longevidade Brasil; 2015..

Therefore, the current crisis demands intergenerational and interdisciplinary solidarity from everyone. Like other countries, Brazil’s response to the pandemic was “too little, too late”55 The Lancet. COVID-19: too little, too late? Lancet [Internet]. 2020 [acesso em 06 mar. 2020];395(10226):1-2. PubMed; PMID: 32145772. Disponível em:
. Millions of Brazilians have failed to follow the preventive guidelines, not because they do not want to, but because they cannot: social exclusion and structural discrimination deny them full access to their rights. Constitutional Amendment 95 further reduced resources, from health promotion to prevention, from primary care to hospital services; from sanitation conditions to care for the most dependent - all of which have been affected by severe cuts to the social policies budget.

What responses are being offered to protect older adults living in long-term care facilities for the elderly (LTCFs)? How are the professionals working in these facilities being cared for and protected? How can organizational flows to referral services be guaranteed? What urgent measures can be adopted to prevent the foreseeable deaths in these institutions?

It is vital that we recognize the existence of these problems, and understand that deficiencies in gerontological knowledge make them worse66 Lloyd-Sherlock PR, Ebrahim S, Geffen L, Mckee M. Bearing the brunt of covid-19: older people in low and middle income countries. Br Med J. 2020;368:1-2.. Policies to combat the pandemic must consider the evidence accumulated by those who study aging in order to develop guidelines aimed at the needs of institutionalized older adults and the most vulnerable, considering the limitations of the formal services infrastructure and the absence of integrated care.

That is why the ABRASCO (or Brazilian Association of Collective Health) Thematic Group (TG) on Aging and Public Health55 The Lancet. COVID-19: too little, too late? Lancet [Internet]. 2020 [acesso em 06 mar. 2020];395(10226):1-2. PubMed; PMID: 32145772. Disponível em:
has been working on reflections and proposals that can broaden our response to the serious health and political crisis that Brazil is facing. The absolute priority is the protection of the population as a whole, and in particular older adults, through social isolation aimed at flattening the epidemic curve and thus preventing the collapse of public and private health systems.

We call for the urgent strengthening of primary health care policies, the creation of remote monitoring strategies, the guarantee of survival and protective equipment, the offering of concrete guidance and support for LTCFs, care for homeless older adults, support for older adults who care for other older people or who still depend on casual labor for their livelihood, as well as the assurance of a humanitarian approach and palliative care, when necessary.

Public policies need to be created with people, not for people. Our older adults’ rights councils have been severely weakened over the past year, in particular the National Council, which has little dialogue with civil society77 Associação Brasileira de Saúde Coletiva. Pandemia da Covid-19 e um Brasil de desigualdades: populações vulneráveis e o risco de um genocídio relacionado à idade [Internet]. Rio de Janeiro: ABRASCO; 2020 [acesso em 01 abr. 2020]. Disponível em:

Once again, this TG warns: failure to consider the scientific evidence and WHO recommendations for the adoption of horizontal isolation will lead to an abject, inhuman, indefensible gerontocide.

As part of the understanding that public policies are created with people and not for people, the Revista Brasileira de Geriatria e Gerontologia (the Brazilian Journal of Geriatrics and Gerontology), in its thematic issue on public policies constructed with older adults, invites submissions of scientific articles focusing on the public protection of the lives of older people.


Publication Dates

  • Publication in this collection
    01 June 2020
  • Date of issue
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