Print version ISSN 0042-9686
Bull World Health Organ vol.85 n.11 Genebra Nov. 2007
Giovanni Marcos LovisiI, 1; Cleusa Pinheiro FerriII; Karla Christina Ornelas AmadoI; Martin PrinceII
IDepartment of Psychiatry, Federal University of Rio de Janeiro State, Rua Ladeira dos Tabajaras 94/808, Copacabana, Rio de Janeiro, 22031-110 Brazil
IIInstitute of Psychiatry, Kings College London, PO Box 060, De Crespigny Park, London SE5 8AF, England
Brazils rapid development has led to profound social and economic stresses. With a Gini index of 60.7 it is one of the worlds most unequal countries; the poorest 20% share just 2% of the nations income. A third of the population lives in extreme poverty, unemployment is high and a quarter of all jobs are in the informal sector. Ten million people are aged 65 and over in Brazil, comprising 6% of the population.1 Recent governments have sought to improve the lot of older people through progressive non-contributory pension schemes covering both rural and urban populations. Nevertheless, as in many developing countries, older people remain largely dependent upon family support, particularly in the event of the onset of disability.2
There are no reliable estimates of the number of homeless persons in Brazil. The United Nations Centre for Human Settlements has defined homelessness (2000) in broad terms as a condition of detachment from society characterized by the lack of the affiliative bonds that link people into their social structures. Homelessness carries implications of belonging nowhere rather than simply having nowhere to sleep.
Homelessness can thus encompass those living in insecure circumstances as well as hostel dwellers and those forced to sleep without shelter. In Brazil, rural poverty, rural-to-urban migration and income inequality are all likely to contribute to homelessness. The discourse on homelessness in Brazil is currently dominated by the landless rural poor and the plight of street children; the large numbers of urban street-dwellers are given relatively little attention. We investigated pathways into homelessness for older people through a survey of all older residents of public hostels in Rio de Janeiro.
Setting and participants
Rio de Janeiro has two statutory institutions providing board and lodging for homeless people. Most of the elderly are housed by the Fundação Leão XIII funded by the state government. Applications for admission may be made by outreach programmes, directly by individuals or by referral from general hospitals. At the time of this survey, they lodged 802 people (567 men and 235 women), of whom 112 (13.9%) were aged 65 years or over.
Narratives from open-ended interviews revealed that many of these older hostel residents were isolated, and that they had lived on the margins of society for much of their lives. Typically, they had migrated into Rio from the rural areas of the state or from Brazils north many years previously. They had lost contact with their families of origin, and most had failed to establish settled ties in Rio. Few had married, and most who had married were divorced. Many had worked in the years leading up to becoming homeless, but in the informal sector. Loss of employment was critical for many participants: some had accommodation that was tied to their work and when they lost their work they lost their home; others simply could not afford to support themselves when their income was gone. The onset of impairment and disability was an important precipitant of homelessness, both because of the consequent loss of employment and income, and because family support was not forthcoming.
The insecurities experienced by older people living in low- and middle-income countries with limited pension and social welfare provision are well recognized. However, this is to our knowledge the first systematic study of indigent older people from Latin America, and one of the first such studies from any developing country. We sampled all residents of the two main public hostels in Rio and received a good response rate. The experiences and characteristics of those admitted to public hostels may not be representative of homeless older people in general.
Older people seem to be over-represented in Rio de Janeiros public hostels, accounting for 14% of hostel residents but only 10% of Brazils adult population. In marked contrast to the pattern observed for older homeless people in developed countries, most of them had become homeless for the first time late in their lives.3 Disability was an important route into homelessness for those becoming homeless for the first time in late life, and these people were much more likely to have been referred to the hostel directly from hospital. The assessment protocol, particularly the lack of informant histories, did not allow us to make a formal diagnosis of dementia. Nevertheless, the strong association between age at admission and presence of significant cognitive impairment suggests that incipient dementia in those lacking family support may have been a contributory factor for an important subgroup of older people.
Non-contributory (social) pensions provide insurance against the risks faced by older people, including uncertainty over how long they will live, how long they will remain healthy, whether they can count upon the support of others if they need it and how long they can earn an income. Brazil is one of only a handful of low- and middle-income countries to have established a progressive non-contributory pension programme for older people.4 Many, if not most, of the participants in our study should have been eligible, raising the question of why so few (16%) were receiving such a pension. The answer probably lies in rigorous means testing. The older hostel residents were uniformly poorly educated, socially isolated and marginalized; the application and assessment procedures may well have been beyond their abilities without help from others.
Competing interests: None declared.
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3. Stergiopoulos V, Herrmann N. Old and homeless: a review and survey of older adults who use shelters in an urban setting. Can J Psychiatry 2003; 48:374-80.
4. Gorman M. Age and security: how social pensions can deliver effective aid to poor older people and their families. London: Help Age International; 2004.
(Submitted: 23 April 2007 Accepted: 2 May 2007 Published online: 21 September 2007)