Abstract

Our work discusses the effects of Covid-19 on older adults’ health, which is considered the leading risk group in this pandemic. We start with a brief ag(e)ing demographic discussion in Brazil and then address how this period has produced and reinforced discourses that show ag(e)ing stereotypes. These discourses are related to the difficulties in facing the social distancing effects and its possibilities in the context of residential care and in long-term institutions in the state of Bahia, Brazil, where we centralize this discussion. To conclude, we emphasize the urgency of organized and coordinated actions that understand the ag(e)ing process complexity to face both the prejudiced discourses about older adults and the effects of isolation. We also point to the need to recognize and involve ourselves in the other generations of which we are a part, whether in memory or projection.

Keywords:
Aging; Pandemics; Ageism; Health of the Institutionalized Elderly

Introduction

In January 2020, the World Health Organization (WHO) declared a pandemic due to Covid-19, a disease caused by the Sars-CoV-2 virus, after characterizing it as a Public Health Emergency of International Concern. Considering the Epidemiological Report #27, which covers week 33 (August 8^th to 15^th), we see that 104,065 people died from Covid-19 in Brazil. In this picture, the percentage of deaths of older adults in Brazil is 72.6% (75,588) - an alarming number that could be much higher given the underreporting²2The number of cases varies, primarily because of uncertainty about the total number of infected, due to the lack of tests to confirm infection, producing significant discrepancies. See analysis available at: <https://bit.ly/3ekvJbk>. of cases and the plateau we had in August (Brazil, 2020aBRASIL. Boletim Epidemiológico Especial 27. Brasília, DF: Ministério da Saúde, 2020a.).

From a populational standpoint, older groups are generally automatically considered more susceptible to complications of Covid-19 than younger ones. Despite this, while the South region, for example, is more populated and twice as old than the North region, it is the latter that has the highest Covid-19 incidence and mortality rates, according to the aforementioned Epidemiological Report. From such divergence, we can see that the country’s comprehensive scenario of inequality directly impacts the experiences of ag(e)ing³3We use ag(e)ing as a neologism meant to simultaneously index notions of age, aging, and aged (Mazuchelli, 2019)., which must, thus, be considered in any reflection on the subject. The pandemic, in this sense, focuses on scenarios that already existed previously, making inequalities more prominent and profound.

Therefore, it is necessary to have clarity and lucidity to reflect on the complexity of the relationship between ag(e)ing and the pandemic in Brazil. Today, the country has more than 28 million older adults (13.4% of the population) and presents different ag(e)ing patterns. In the Bahia state, for example, the percentage of older adults is lower than the country’s average (12.6%). However, the demographic ag(e)ing process should be more intense in the state. The estimate is that between 2018 and 2060, the percentage of older adults will more than double (+156.5%), while one in three Bahia-born will be older adults by 2060. In this scenario, the ag(e)ing index of the population of Bahia, which today is the 11^th highest among the 27 Brazilian states, would reach, in 2060, the 3^rd highest in the country (IBGE, 2018IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Projeções da População do Brasil e Unidades da Federação por sexo e idade: 2010-2060. Rio de Janeiro: 2018.).

It is essential to remember, thus, that ag(e)ing is a multidimensional phenomenon, varying according to socioeconomic, cultural, racial, gender, and territorial issues. Therefore, in the current Brazilian context, we cannot fail to look at ag(e)ing as a historical process sewn to economic, racial, and gender inequalities. There are older adults who care and are cared for, who provide financial support, who need resources for their survival, and who live on the streets. It also leads us to think, especially in the midst of this pandemic, about the place reserved for older adults within a neoliberal logic that privileges the workforce to the detriment of the heterogeneity of roles that could come from the valorization of social and cultural knowledge belonging to older adults, including work environments. It is in this context that this reflection lies and seeks to present options that encompass such imperative issues.

In the next section, we discuss how the discourses that circulate about older adults help us understand this place reserved for them in our society. Next, we address the challenges of responsible, multidimensional distancing, also based on the removal of the social-affective network, which can worsen situations of psychological suffering. In this discussion, we bring important data about the most vulnerable part of the population - those in long-term institutions. Therefore, we articulate discourses about older adults in times of pandemic with the challenges imposed by the dynamics of physical distancing as a way to cope with Covid-19. Finally, we point to the necessity to listen to older adults in their heterogeneity; that is, we seek ways to understand the experience lived by them, reflecting on the need to discuss the intergenerational responsibility in health promotion, so crucial at this time.

Discourses on ag(e)ing in times of pandemic: between childishness and stubbornness

It is no breaking news to think that the pandemic has brought to light the problems of inequality that plague Brazil. From education to health, we see that we are not only dealing with the challenges posed by a virus whose transmission is frighteningly fast and whose effects on our organism are diverse and, although better understood today, still quite mysterious.⁴4Consider, for example, the fact that the virus is being associated with ischemic stroke in young patients (Beyrouti et al., 2020), while we thought at the beginning of the pandemic that its main focus was the respiratory tract. There are also reports of heart problems associated with the infection, and many researchers are still investigating possible lasting effects resulting from the disease in children and young people.

The challenges posed are thus many. However, when we look closer at our context, we realize that older adults, who should have greater protection from society, not only are left unassisted by the State but suffer from the discrimination that puts them in the place of not knowing. That means they do not know how to take care of themselves nor understand how complex the country’s situation is. It is what we can see, for example, in memes⁵5Memes can be understood as “units of cultural transmission, or imitation” (Dawkins, 1976). In the context of social media, memes refer to shared messages that may be accompanied by an image or video and that carry an ironic and jocular tone (Torres, 2016). circulating in social media since the beginning of the pandemic; interesting discursive creations for observing the circulation of meanings about ag(e)ing.⁶6Although it is not within the scope of this article to discuss the concept of discourse, we can understand it, in general, as the utterance or text (oral and written) produced in a given situation and determined by historical and social conditions.

This discussion about how discrimination circulates is crucial for understanding its effects on the lives of older adults and fighting it. In the first example we bring to ground this reflection, older adults are compared to “children over 60” who should stay home because there is a “black car in the neighborhood picking up old people to make soap.” The jocular tone of the meme resumes childhood narratives often used as inhibitors of undesirable behavior. In this case, it takes up the popular narrative of dangers outside the home to ensure that children and, in this case, older adults understand the necessity of staying at home given external threats. The strategy would be justified in the belief that only with this resource, older adults could understand the seriousness of the situation and the risk of exposing themselves to the streets and the virus.

This discursive strategy of returning to childhood to dialogue with ag(e)ing and older adults is no novelty. Hockey and James (1993HOCKEY, J.; JAMES, A. Growing up and Growing old: age and dependency in the life course. London: SAGE, 1993.) show that the association of the old with the young, employed recurrently in advertisements, for example, is a sign of how this relationship metaphorically structures the experiences of ag(e)ing. According to the authors, “the conceptual pairing of the very young with the very old in language use reflects a particular framing of aging in Western cultures” (Hockey; James, 1993HOCKEY, J.; JAMES, A. Growing up and Growing old: age and dependency in the life course. London: SAGE, 1993., p. 18). Childhood and youth thus function as a compass for the possibilities, qualities, and demands of older adults, and thus constitute our universe of understanding about ag(e)ing. This is how we often come to think of old age in childlike terms, say the authors: older adults think like children, have qualities associated with childhood stages of development (such as tantrums and stubbornness), and need to be cared for like children.

A paradox also supports this way of thinking and treating the ag(e)ing process. In order to age well, it is necessary to maintain youthful characteristics, while such characteristics are also seen as problematic when associated with this group. In this regard, Py and Scharfstein (2001PY, L.; SCHARFSTEIN, E. A. Caminhos da Maturidade: representações do corpo, vivências dos afetos e consciência da finitude. In: NERI, A. (Org.). Maturidade e velhice: trajetórias individuais e socioculturais. Campinas: Papirus, 2001., p. 123-124) state that our culture

This guiding compass also appears in the interpretation of decisions made by people in the ag(e)ing process. The refusal of older adults to acquire more modern cell phones, such as smartphones, is understood as a result of the difficulty/incapacity they would have in using it and not as a possible desire to live without this technology. Although both interpretations are possible and the market is adapting itself by creating devices that respond to the demands of older adults, the first seems to be the most recurrent. The wish to live without this technology becomes respected as such only when there is a movement calling for a life without these resources. The “phone-free life” movement, for example, gained space in the media when famous people started advocating for it, such as actor Eddie Redmayne, journalist James Brown, and writer Peter Brown Hoffmeister. All of them, at some point, had to justify this desire to live without technology; however, in none of the cases did their interlocutors question their ability to use technology (Mazuchelli, 2019MAZUCHELLI, L. P. Stereotypes and representations: discourses on and in ag(e)ing. 2019. Tese (Doutorado em Linguística) - Instituto de Estudos da Linguagem, Universidade Estadual de Campinas, Campinas, 2019.). We thus conclude that, while for some this decision can be seen as eccentric or political (if we consider, for example, the recent scandals of private information leaks on social media), for others, it is interpreted as a direct effect of ag(e)ing. That is, refusal is understood as difficulty when ag(e)ing comes into consideration.

The second example we bring is, again, based on the circulation of strategies to restrain this population since the decisions made by them are, in general, disregarded. In the following image, we see a woman inside a cage accompanied by the description “Cage for stubborn older adults for sale. Payment in 10 installments”. The insertion of “for older adults” as a qualifying element of “cage” gives animal-like characteristics to “older adults”, depriving them of human characteristics and, therefore, objectifying them. It is no wonder that Chauí states, in the presentation of the work Memory and Society, by Ecléa Bosi, that “in our society, to be old is to fight to continue being a man” (Chauí, 1994CHAUÍ, M. Apresentação. In: BOSI, E. Memória e sociedade: lembrança de velhos. São Paulo: Companhia das Letras, 1994. p. 17-33., p. 18).

There is, in this meme, another example of the essentialization of the ag(e)ing process, which contributes to the perpetuation of discrimination against this group. Claims that older adults are stubborn are recurrent, although there is no scientific evidence that ag(e)ing means becoming (more) stubborn. What seems to happen is that society interprets possible difficulties in understanding and disagreements as a direct effect of ag(e)ing. Thus, biological, generational, geographic, economic, gender, and racial aspects are disregarded, as are the situational contexts in which these subjects would be stubborn. It is not an exaggeration to think how other adjectives could be used: “persistent”, “insistent”, “capricious”, “obstinate”, “resistant”, and “reluctant”, among several others that could carry a more or less positive aspect. Once again, we observe older adults’ attitudes being interpreted negatively, revealing a pervasive imaginary of negative bias.

The belief, therefore, that older adults leave their houses because they fail to understand the grave situation the country is going through not only strengthens the proliferation of these memes but the very discriminatory view of ag(e)ing.

Questioning these and other statements that recurrently circulate is fundamental for us to reflect on the mechanisms of oppression of ag(e)ing that underlie discriminatory and violent practices, such as judging older adults incapable of taking care of themselves when, at the same time, they are left aside in the decisions to control this pandemic⁷7One example is the return of in-person classes, which generally disregards the domino effect of the reopening of schools, given that the percentage of families with school-age children living with older adults is high. According to IBGE data (2016), among those living with older adults, 13% are up to 17 years old, 41% are adults, and 46% are also older adults. Although it is not the scope of this article, another example that should be followed to ensure health and respect for older adults is Covid-19’s vaccination plans.. Lack of research is noteworthy, at this time of pandemic especially, on who are these older adults who will not stay home and why they do it. It is quite significant to think, for example, that one of the first deaths reported in Brazil because of the virus infection was that of the 63-year-old housekeeper Cleonice Gonçalves. A resident of Miguel Pereira, Cleonice traveled 120 km to work in a residence in an affluent neighborhood in the Rio de Janeiro capital. It was in the house of her employer, who had just returned from a trip to Italy, that Cleonice was infected with the virus and died three days after presenting the first symptoms. She, who had worked since she was 13 years old, like thousands of other older adults, had to leave her house to support her family⁸8An article on Cleonice’s case can be found here: <https://glo.bo/3dwvISt>. Accessed in July 2020.. According to research data from LCA Consultores, about 10 million people depend on retiree income to live (Chiara; Brandão, 2018CHIARA, M.; BRANDÃO, R. O material jornalístico produzido pelo Estadão é protegido por lei. O Estado de São Paulo, São Paulo, 15 jul. 2018.). Cleonice’s case is thus no exception.

Reflecting on the discourses circulating about ag(e)ing shows us the naturalization of thinking on ag(e)ing. In times of pandemic, these stereotypical discourses reveal the contempt that society bears for these subjects by comparing them to animals or depriving them of the ability to reflect on their time. It is worth noting that, although the two memes play with the strategy of creating means to ensure the care of these subjects, the nature of these discourses is violent precisely because it deprives them of their humanity, contributing to the naturalization of the more than 70% of older adults who have died from Covid-19.

Challenges and implications of social distancing

Considering the complexity of the disease and the lack of adequate and safe drugs for its treatment, to date, the main form of coping with Covid-19 is following social distancing measures, which reduce the interactions between uninfected and infected people who have not yet been identified and, therefore, not quarantined. These measures include closing and restricting the operation of workplaces, schools, and shops and canceling activities involving crowded gatherings. Social distancing has been used worldwide as a strategy to contain the advance of the pandemic and, consequently, the collapse of health systems. Another measure, which requires greater investment in the early detection of cases, is the isolation of sick people from those not infected to reduce the risk of disease transmission (Aquino et al., 2020AQUINO, E. M. L. et al. Medidas de distanciamento social no controle da pandemia de Covid-19: potenciais impactos e desafios no Brasil. Ciência e Saúde Coletiva, Rio de Janeiro, v. 25, supl. 1, p. 2423-2446, 2020. DOI: 10.1590/1413-81232020256.1.10502020
https://doi.org/10.1590/1413-81232020256... ).

Although fundamental for those most susceptible to the most severe form of the disease, such measures present challenges since the burden and effect of distancing vary depending on the social situation of the older adult. As stated earlier, the heterogeneous nature of the ag(e)ing process, coupled with social, gender, and racial inequality, makes this situation even more complex, justifying our reflection.

We may affirm that one of the main results of social distancing and isolation as necessary measures against the advance of the disease is its effect on interpersonal relationships and the very health of older adults. As we saw in the previous section, this care has revealed the violent nature of some stereotypical discourses that end up infantilizing older adults or even treating them as dispensable in the process of understanding, preventing, and containing the disease. In this context, we highlight the implications of social distancing at work, in support networks, and ultimately in the increase of violence against older adults.

In general, population data show that 26.3% of Brazilian older adults remain active in the labor world, and 53.8% of those who receive retirement benefits continue working (IBGE, 2016IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Síntese de indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: 2016.). The decision to continue in the labor world after age 60 is justified, for example, by the need to supplement the family income. In times of pandemic, being tied to work implies two situations: (1) the impossibility of physically going to work, either having the option of remote work or not and (2) the continuity of face-to-face work that leads to exposure to social contact, which increases the probability of contracting the disease.

Considering that 30% of Brazilian older adults are illiterate and that 16.6% have less than 3.3 years of schooling (Neri, 2020NERI, M. Onde estão os idosos? Conhecimento contra o COVID 19. Rio de Janeiro: FGV Social, 2020.), the possibility that the most socially vulnerable older adults occupy a position that can be developed remotely through digital technologies is quite small⁹9We must remember that, even before the pandemic, many older adults, especially the poorest, besides losing their jobs due to their ag(e)ing, end up occupying the most precarious positions because of issues such as low education.. The probability that these people are left without full income or without any income at all, in cases of termination, is thus high. In both situations, part of this population will depend on the government’s social security actions to maintain the subsistence of their household, which has been the object of political dispute since the beginning of the pandemic. Another important aspect for understanding this reality is the decrease and precariousness of jobs for older adults, as previously pointed out. Nevertheless, it is necessary to consider that, in contract termination cases during the pandemic, the return to work will probably be more difficult later since older adults will compete against a larger contingent of young people and adults who are also unemployed.

Even though the Older Adult Statute, Law no. 10.741/2003, determines the prohibition of discrimination due to age limit, the reality of the neoliberal world, based on productivity, accentuates the inequality of opportunities, as stated by the president of the Center for Longevity Economy Studies, Jorge Felix:

The risk, therefore, of loss of income, even if partial, and of employment, whether during the pandemic or after it, is a determining factor in understanding the “breakings” in social distancing, as we saw in the previous section, or the stress generated by precarious financial situation and lack of prospect. It is symptomatic to observe that these elements are systematically ignored in disease control process in Brazil and the discussion in the community, increasing the scenario of fragility of these older adults’ physical and mental health and imposing more forceful challenges to them.

The second situation presented, in which the older adult continues to develop their work in person, ensuring the maintenance of the job, generates another type of consequence: the daily exposure increases the risk of infection, illness, and death, in addition to the possibility of transmitting the virus to their family members. The daily tightrope between the fear of getting sick and the maintenance of work activities, the fear of being the disease vector to their families, and the fear of death substantially increase the stress of these older adults. Although these situations are not restricted to them, since they affect the life of every worker, the consequences can be harsher in the lives of older adults if we consider the greater likelihood of total exclusion from the world of work that threatens the family subsistence, in addition to the greater risk of death. The scenario of complexity in which older workers find themselves thus sheds light on the lack of assistance from the State and the inefficiency of the Older Adult Statute and the protection policies for this population.

Added to the fear for the work situation, distancing also disrupts the lives of older adults by restricting mobility and social interaction, whether with family members with whom they do not live or with the environment with which they relate. In the case of autonomous older adults who live alone, the performance of routine activities becomes a new challenge since distancing demands greater independence. This situation can constitute significant distress, leading to lack of motivation, appetite, will to live, and decreased self-care, bringing consequences to their physical and mental health. Afonso (2015AFONSO, C. V. C. A integração do idoso na sociedade: o papel das redes sociais. 2015. Dissertação (Mestrado em Educação Social) - Instituto Politécnico de Bragança, Escola Superior de Educação, Bragança, 2015.) considers that the feeling of worthlessness can play a significant negative role in this stage of life since the affective ties, constituted within the social network inside and outside the home, play a key role in the will to live.

It is worth remembering that, in many realities, it is outside the home that the most significant social relationships and affective bonds are established since it is not always the family that represents the greatest support for the older adult. According to the Human Rights Hotline bulletin for 2019, reports of violence against older adults represent the second-highest number of records, accounting for 30% of the reports, totaling 50,118 (Brazil, 2019BRASIL. Disque Direitos Humanos: relatório 2019. Brasília, DF: Ministério da Mulher, da Família e dos Direitos Humanos, 2019.). Of the total number of records, 41% are for negligence, 24% for psychological violence, 12% for physical violence, and 2% for institutional violence. The vast majority of reports indicate that the violence is carried out inside the victim’s home, and, in 81% of the reports, violence is committed by someone close to the victim or the victim’s family. Women are more prone (66%) to violence than men, and 67% of the people who suffered violence have a low level of education (illiterate or unfinished elementary school). It means that older adults are not safe within their own homes, which are supposed to be their place of protection, even during the pandemic.

Furthermore, dysfunctional family relationships and social inequality exacerbate violent behavior, intolerance, alcohol, and other substance abuse, whereas women, children, and older adults are the most vulnerable in this context. In a moment of deep social crisis, with uncertainties of all kinds, domestic violence tends to increase. Therefore, it is not unusual for older adults to be in a position of greater risk, often targets of domestic violence (Moraes et al., 2020MORAES, E. N. et al. COVID-19 nas instituições de longa permanência para idosos: estratégias de rastreamento. Ciência e Saúde Coletiva, Rio de Janeiro, v. 25, n. 9, p. 3445-3458, 2020. DOI: 10.1590/1413-81232020259.20382020
https://doi.org/10.1590/1413-81232020259... ).

In this sense, it may be even more difficult for older adults to keep distancing. It is necessary to keep in view, therefore, the complexity of the experience of the pandemic by older adults and to deal with the contradictions of possible transgressions responsibly, before considering them as direct effects of incomprehension and stubbornness, as we observed in the discourses circulating in society addressed in the previous section.

Besides the complexity we already pointed out, relationships become even more complex as older adults’ physical or mental dependence increases, as we often observe in the ag(e)ing process. Those with a dependency status may already be more accustomed to home confinement, which does not mean that social distancing does not affect them since the social support networks outside the family and care are interrupted, representing possible significant suffering. On the other hand, the suspension of caregivers, for example, as a result of how the pandemic crisis affects family members, can generate a notable change in routine. In the medium and long term, the weight of these new arrangements can compromise family ties, home harmony, and the health of those involved. It is thus crucial that all these elements be considered in assessing the direct and indirect impacts of Covid-19 and the resulting social distancing on the lives of older adults.

In the next section, we discuss the impact of social distancing in long-term care institutions, the context of greatest vulnerability, emphasizing the challenges faced by those who live there.

Institutionalized older adults and Covid-19

In addition to the issues highlighted in the previous section about the effects of social distancing on the lives of older adults who are isolated in their homes, the pandemic draws attention to the great vulnerability of those residing in Long-term Care Facilities (LTCF) (Comas-Herrera et al., 2020COMAS-HERRERA, A. et al. Mortality associated with COVID-19 outbreaks in care homes: early international evidence. London: International Long-term Care Policy Network, 2021.). With the suspension of visits, for example, because of the social distancing measures, older adults were deprived of the already reduced contact they had with family members and friends who visited them. Contact with the outside world became mediated by electronic devices, until then unusual for most and inaccessible for many.

The need for controlling access to LTCFs is unquestionable, either because the transmissibility rate may be higher than 60% after virus introduction in these settings (Arons et al., 2020ARONS, M. M. et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. The New England Journal of Medicine, Waltham, v. 382, n. 22, p. 2081-2090, 2020. DOI: 10.1056/NEJMoa2008457
https://doi.org/10.1056/NEJMoa2008457... ; Moraes et al, 2020MORAES, E. N. et al. COVID-19 nas instituições de longa permanência para idosos: estratégias de rastreamento. Ciência e Saúde Coletiva, Rio de Janeiro, v. 25, n. 9, p. 3445-3458, 2020. DOI: 10.1590/1413-81232020259.20382020
https://doi.org/10.1590/1413-81232020259... ) ¹⁰10The speed of spread is influenced by the fact that the infection has diverse clinical presentations. While older adults, hypertensive, diabetic, with heart disease, and immunosuppressed individuals have high mortality, many infected individuals have mild and moderate symptoms or remain asymptomatic (Dowd et al., 2020; Wu; McGoogan, 2020). or due to other factors associated with LTCFs in Brazil, such as the higher incidence of individuals institutionalized for physical frailty and lack of social and family support - many may present cognitive impairment, are physically inactive, have no partner, children or family members, or are 80 years old or older (Del Duca et al., 2012DEL DUCA, G. F. et al. Indicadores da institucionalização de idosos: estudo de casos e controles. Revista de Saúde Pública, São Paulo, v. 46, n. 1, p. 147-153, 2012. DOI: 10.1590/S0034-89102012000100018
https://doi.org/10.1590/S0034-8910201200... ; Lini; Portella; Doring, 2016LINI, E. V.; PORTELLA, M. R.; DORING, M. Factors associated with the institutionalization of the elderly: a case-control study. Revista Brasileira de Geriatria e Gerontologia, Rio de Janeiro, v. 19, n. 6, p. 1004-1014, 2016. DOI: 10.1590/1981-22562016019.160043
https://doi.org/10.1590/1981-22562016019... ). However, the profile of the institutionalized older adults also differs according to the funding of the LTCF. In non-profit institutions, there are a higher proportion of illiterate individuals, without companions, Black and Brown, not retired, without health insurance, without children, and who, in general, did not use to receive visitors before the pandemic. In private LTCFs, however, the main reason associated with institutionalization is the severity of the disease (Pinheiro et al., 2016PINHEIRO, N. C. G. et al. Desigualdade no perfil dos idosos institucionalizados na cidade de Natal, Brasil. Ciência & Saúde Coletiva, Rio de Janeiro, v. 21, n. 11, p. 3399-3405, 2016. DOI: 10.1590/1413-812320152111.19472015
https://doi.org/10.1590/1413-81232015211... ).

We thus observe that grouping frail older adults who present multimorbidities and reduced functional reserve in collective residences increases the likelihood of developing more severe outcomes of Covid-19. Besides the profile of the residents, another fundamental factor in understanding the vulnerability of the LTCF is the concentration of employees who circulate in other risk environments, such as public transportation, other care and assistance institutions, outpatient clinics, and hospitals.

In this context, it is important to consider that, as collective residences, LTCFs still lack health professionals for their full operation (Brazil, 2005BRASIL. Ministério da Saúde. Resolução - RDC no 283, de 26 de setembro de 2005. Diário Oficial da União, Brasília, DF, 26 set. 2005. Disponível em: <Disponível em: https://bit.ly/3emWmwv >. Acesso em: 22 abr. 2021.
https://bit.ly/3emWmwv... ). The absence of trained professionals to correctly evaluate symptomatic residents and staff and to identify signs and symptoms of clinical worsening increases the risks of disease spread and adverse outcomes. This particular aspect is crucial, given the fight against the pandemic in LTCFs is even more complex because it includes, in addition to the adoption of social distancing measures, extensive testing for diagnosing older adults, constant surveillance of health actions with caregivers and residents, training and capacity building, availability of PPE, constant cleaning and disinfection of environments, and control of access and circulation in the LTCF (Danis et al., 2020DANIS, K. et al. High impact of COVID-19 in long-term care facilities, suggestion for monitoring in the EU/EEA, May 2020. Euro Surveillance, Stockholm, v. 25, n. 22, 2020. DOI: 10.2807/1560-7917.ES.2020.25.22.2000956
https://doi.org/10.2807/1560-7917.ES.202... ; Yen et al., 2020YEN, M. Y. et al. Recommendations for Protecting Against and Mitigating the COVID-19 Pandemic in Long-Term Care Facilities. Journal of Microbiology, Immunology and Infection, Amsterdam, v. 53, n. 3, p. 447-453, 2020. DOI: 10.1016/j.jmii.2020.04.003
https://doi.org/10.1016/j.jmii.2020.04.0... ). These measures would bring even greater safety with a health professional in the LTFCs, which could decrease the proportion of deaths in these institutions since, when compared to the general population, it has exceeded 50% in countries such as Canada, Norway, and France.¹¹11We must note that comparisons between different countries are not simple, given the differences in public and health policies, type of testing used, criteria for defining whether the death was secondary to Covid-19, and the characteristics of the homes that can be considered LTCF (Comas-Herrera et al., 2020).

Covid-19 has therefore thrown open an issue that has been inflicting for many years. The fact that, in the gap left by the State for the care of those without family economic resources, as determined by the Older Adult Statue (Brazil, 2003BRASIL. Estatuto do Idoso. Brasília, DF: Ministério da Saúde, 2003.), care has become the responsibility, to a large extent, of philanthropy. Without inspection, however, many LTFCs do not meet the minimum criteria for proper functioning, remaining irregular or operating illegally, which, in the context of the pandemic, further increases the vulnerability of older adults living in these institutions. The problem is even worse when we consider that it is not rare for caregivers to lack health training, a problem that could be minimized if the entire national territory were, for example, covered and served by teams of the Family Health Strategy (FHS). The FHS’s prerogative is to conduct home visits, seeking to know and assist the residents of their assigned territory (Brazil, 2017BRASIL. Ministério da Saúde. Portaria no 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, DF, 22 set. 2017.). The coverage of the FHS, however, reaches only 62.79% of Brazil. In the areas covered, these teams often do not know the LTCF of that locality due to the regularization issue (Brazil, 2020bBRASIL. Ministério da Saúde. Nota Técnica no 9/2020-COSAPI/CGCIVI/DAPES/SAPS/MS - Isolamento para idosos institucionalizados: orientações de higiene e cuidados. Diário Oficial da União, Brasília, DF, 2020b. Disponível em: <Disponível em: https://bit.ly/3tGdBiE >. Acesso em: 27 set. 2020.
https://bit.ly/3tGdBiE... ).

Attentive to these issues, the Bahia State Secretary of Health (SESAB in Portuguese), in pioneering conduct, created the Inter-sectoral Commission for Monitoring LTFCs in Bahia, intending to monitor health actions in the institutions through tele-advice, installed in the State Reference Center for Older Adults Health Care (CREASI in Portuguese, Bahia, 2020bBAHIA. Tribunal Regional Eleitoral - BA. Portaria no 133, de 9 de setembro de 2020. Diário da Justiça Eletrônico, Salvador, 23 set. 2020b.).¹²12Structured under CREASI’s management, the commission is formed by six workgroups. Four groups perform telemonitoring of each LTCF within 72 hours intervals. When a resident or employee with symptoms suggesting or confirming Covid-19 is identified, the LTCF starts daily telemonitoring performed by a specialized CREASI team (geriatrics physicians, nursing, and physiotherapy). The technical-operational support team is activated when there is a need for inter-sectoral articulation with municipal and state managers to solve problems identified in contacts with the LTCF, such as care support, testing, transfers, training, and meetings (Brazil, 2020b).

The report released by the commission in early August indicates that 193 LTCFs had been identified in 79 municipalities in the state, encompassing a total of 5,087 institutionalized older adults (Bahia, 2020aBAHIA. Boletim informativo nº 2. Salvador: Comissão Intersetorial de Monitoramento das Instituições de Longa Permanência do Estado da Bahia, 2020a.). Among the institutions mapped, four were closed during the pandemic, whereas 69 remained active in the capital and 120 in other municipalities. Of the total, 54% are located in the Eastern macro-region, with 37.8% in Salvador, the capital. In about four months of the commission’s activities, 796 cases of Covid-19 were confirmed among LTCFs residents. Of these, 532 (67%) were already recovered, and 94 died. The case fatality rate due to Covid-19 in the observed institutions in Bahia was 11.8%, considering 94 deaths among the 796 confirmed cases of older adults in LTCFs. Among the staff, 306 tested positive for Covid-19, with 225 (83%) recovered in the period. There have been no reports of Covid-19 deaths among staff in long-term care facilities in the state.

The work of this commission, the first in Brazil, is fundamental for understanding the situation in which institutionalized older adults find themselves during the pandemic, as for developing concrete actions that guarantee LTFCs functioning, their safety, and the health of their residents and of those who work there. The work done by the commission points to the need for advancing in the improvement of public policies for the care of older adults, already guaranteed by law, yet incipient, especially considering the moment we face. It also contributes to the crucial development of understanding what it means to age in the various Brazilian locations and contexts, which, once again, is fundamental to fight stereotypical discourses that sustain discriminatory and violent practices.

Final considerations

This work, written in the middle of the Covid-19 pandemic, was born from the demand to articulate the effects of discourses that circulate about older adults with the issues imposed by social distancing measures. Due to a complete devaluation of this portion of the population that is often ignored, homogenized, and obliterated, we consider such reflection fundamental to critically understand the complex scenario of ag(e)ing in Brazil. Given the general character of this reflection, there are still many questions that need further development and investigation, especially considering the long-term effects of social distancing measures and the economic and social impacts on the lives of this portion of the population.

Regarding the challenges imposed by the social distancing and isolation measures, either in the residential context or in long-term care facilities, the challenges presented point to the urgency for comprehensive organized and coordinated actions that value the National Health Service (SUS in Portuguese) care logic, primarily the actions in Primary Health Care. Moreover, we consider it essential to integrate such actions with reflections that do not homogenize the ag(e)ing process and do not feed biased discourses, which show us the need to listen to older adults to understand how they are, within diverse realities and knowledge, dealing with the pandemic. We start, thus, by understanding that any successful action of confrontation and care related to older adults must be related to the questioning and deconstruction of stereotypes and the development of actions based on heterogeneity and the singularity of the ag(e)ing experiences.

Considering this work was written in August 2020, more than 120 thousand Brazilian older adults have died from Covid-19. Even without an expressive decrease in daily cases, the issues related to resuming to the new “normal” seem to gain more and more space, without the required critical and humanitarian reflection on older adults’ physical and mental health. In addition to institutional actions, we need to understand that the moment requires another responsibility, of an intergenerational nature, based on the understanding of recognizing and implicating ourselves in the other generations of which we are part, either in memory or in projection (Mazuchelli; Oliveira, 2020MAZUCHELLI, L. P., OLIVEIRA, M. V. B. Morra quem morrer: desprezo aos idosos em meio à pandemia da Covid-19. Medium, [s.l], 4 ago. 2020. Disponível em: <Disponível em: https://bit.ly/3sA3wCs >. Acesso em: 25 ago. 2020.
https://bit.ly/3sA3wCs... ).

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