By DC Coitinho, PhD and JA Silvester, PhD
Brazil, along with many other countries in the developing world, faces an epidemiological transition in a scenario characterized by gross fertility rates as low as 2.3 and a continually rising life expectancy to 67 years (63 for men and 71 for women). On the one hand, this is good news; on the other hand, however, it translates into a fast-growing older population which presents society with major social challenges. Foremost among these challenges is to guarantee that older persons have access to adequate food and nutrition - their basic and fundamental human right.
The legislative framework to deal with these challenges is gradually being created. Following the adoption of the principles of the 1966 Covenant on Economic, Social and Cultural Rights into a body of national law in 1992, a first attempt to assure the social rights of older citizens was the establishment, by law, of the National Policy for Elderly Persons in 1994. The purpose of this policy was to promote autonomy, integration and the effective participation of older people in Brazilian society. State obligations were detailed in the areas of work and social security, health, education, housing and urban planning, culture, sports and leisure and social assistance.
Four years later, the Brazilian Human Rights Programme was launched with a specific item devoted to elders. In early 1998, the Ministry of Health launched a public process of health policy formulation which addressed priorities established on epidemiological relevance, social demand and political needs. The principles of partnership, inclusiveness, shared responsibility and decentralization were taken as the basis for the process of policy formulation which encompassed the consultation of all relevant segments of the Brazilian Society. The Food and Nutrition Policy was the first to be considered, recognizing the access to adequate food and nutrition as a fundamental human right and defining a number of guidelines and strategies to deal with food and nutrition problems throughout the lifecycle, especially those specific to the needs of older citizens. Following these same principles and process, the National Policy on the Health of Elderly Persons was recently formulated, defining in greater detail the obligations of the different social actors in promoting the health and living standards of this segment of the population.
Within such a comprehensive body of official policies, what can older adults in Brazil expect from the health system in terms of nutrition and the access to adequate food and nutrition as a basic human right?
As a first step, the health sector should have a full, updated and comprehensive assessment of the nutritional situation of our older population. The only nationally representative household survey that assessed the nutritional situation of elders was carried out in 1989. Anthropometric assessment showed rates of BMI <20 kg/m2 of 26.9% in men and 24.7% in women 65 years of age or older, living in families with monthly incomes of less than US$68 per capita. These percentages decreased with an increase in income, and for those older persons living in families earning more than US$300 per capita; low BMIs were found in 11.3% of the men and 10.5% of the women. In all income groups, however, a steep increase in the percentages of low BMIs for the older population was observed when compared with the group 45-64 years of age- the percentages almost doubled.
More recently, a series of locally based studies and assessments have shown:
à Poor knowledge and professional advice on the best feeding practices in order to maintain a healthy weight and to manage the most prevalent non-communicable diseases;Although these studies give an overview of the situation, more emphasis should be given to such assessments. "Mapping" (cataloguing names and addresses) older persons in need and assessing their needs are essential parts of respecting, protecting, and fulfilling the basic right to adequate food and nutrition -the three obligations of the State in human rights governance. As a first attempt to address the nutritional problems of older persons in Brazil, activities are being planned and implemented with financing from federal funds. The starting point of any nutrition activity is the baseline assessment and continuous surveillance, followed by the dissemination of correct information about food contents, food safety, healthy food habits and lifestyles, the improvement of hospital care in regards to nutrition, and the provision of supplementary foods to those most in need. Given the technical advice of experts, members of the Ministry of Health's Advisory Committee on Nutrition and Ageing ace developing the following strategies:
à High rates of undernutrition and micronutrient malnutrition among hospitalized and institutionalized older persons;
à Increasing rates of undernutrition and micronutrient malnutrition among those 70 years and older - the main causes being poverty, isolation and poor family/community support, dependency, physical and mental disabilities and diseases.
(a) Information, education and communication activities are being planned and implemented at national level to improve the general awareness and knowledge of the Brazilian population on the rights of older people. Examples of such activities include the distribution of a booklet containing appropriate nutritional information to the more than eight million older persons who attended the immunization campaign against influenza in April 1999; 30 second broadcast inserts on commercial television channels; and the creating a comprehensive databank on food and nutrition and ageing within the Ministry of Health's free-of-charge telephone information service (Dial Health).Also fundamental is the understanding that human rights governance is the responsibility of all sectors of society; therefore, social action directed to elders should not be limited to the governmental sector, but equally be the responsibility of all other social actors in society: organized civil society, community leaders and the business sector. The Municipal Health Councils can play an active role to establish and to promote such key partnerships. In addition, the Councils could monitor the extent to which the economic, social and cultural rights of older persons are being respected, protected and fulfilled by reporting to the National Human Rights Commission or to the Ministry of Justice on possible violations. The International Year for older Persons has been celebrated during 1999, and it marks the start of a long road to assure the realization of the right to food as a fundamental human right for all Brazilian citizens - who are all getting older every day!
(b) To act locally through the Incentive to Combat Nutritional Deficiencies. This is a financial incentive provided to municipalities by the Brazilian Federal Government through the Ministry of Health to implement nutrition activities and interventions. To be entitled to these financial resources, a work plan is formulated by the local health officers and submitted to the Municipal Health Council. These local Councils are the main mechanism of social control over public funds spent on health and therefore, include representatives of civil society, community leaders and the local business sector. This incentive is directed primarily to the nutrition rehabilitation of malnourished children, but municipalities decide their own priorities. More than 4,600 of the 5,507 Brazilian municipalities have already enrolled in the programme, and 23% have already decided to assist their older population with a portion of the available funds. This shows how much local level health officers, personnel and community leaders are aware of the nutritional vulnerability of this age group, and that activities to raise public awareness about the problem may be showing some impact. In such municipalities, the work plans should include nutritional assessment, monitoring, and information, education and communication activities. The distribution of food supplements may or may not be part of the local initiative. In those instances in which the municipalities have decided to distribute food for needy older persons, general technical advice from the Ministry of Health is given; the food is, however, produced locally, making it more likely that the food will meet local cultural values.
Dr JA Silvester, Head of Health in Ageing Programme; Dr DC Coitinho, Food & Nutrition Coordinator Secretariat of Health Policies, Ministry of Health, Esplanada dos Ministérios, Bloco G Edificio anexo, Sala 206 B, Brasilia, DF Brazil; tel 55 61315 2244; fax 55 61322 3912; email firstname.lastname@example.org