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The place of WhatsApp in the ecology of care – by Marilia Duque

LauraHaapio-Kirk26 August 2018

Author: Marilia Duque

Dr. Gusso uses WhatsApp Business at Amparo Health Clinic (Photo: Marilia Duque)

In 2015 a PwC research report suggested that the Brazilian m-health market would reach $ 46.6 million while a GSMA report forecasted that 45.7 million Brazilians would benefit from mobile health projects (see here). In 2017 the scenario was even more optimistic. According to Statista, Brazil was expected to become the largest m-health market in Latin America with revenues of around $ 0.7 billion. These numbers explain the impressive amount of m-Heath startups and startup Incubators I’ve seen in Sao Paulo (see Eretz.bio, for example). But they don’t explain why after 7 months of fieldwork I still couldn’t find the people who are actually using these m-health apps. Instead, I found an intensive use of WhatsApp among my informants, filling the gaps in communication and making a huge impact on the ecology of care which we address in this project.

For example, every day early in the morning, Ms. M (54) sends a good morning message through WhatsApp to four lady-friends older than her. “It is like volunteer work because I know they are lonely and that message will make them happy and socially connected”, she explained. Ms. D (66) also starts her day sending a WhatsApp message. But in her case, the message is sent to her only daughter who lives in France, as a sign that she spent the night well. She is supposed to send this message every day before 10am otherwise her daughter will call a friend to check on her. “Some people say my daughter abandoned me, but the truth is that she is closer than many of my friends’ children who just live nearby”.

That is the same in the case of Dr. J., a physician who works in Sao Paulo and uses WhatsApp to take care of his 93 year-old father. After having a stroke, his father moved to Dr. J. brother’s house located two hours away.  Dr. J. created a WhatsApp group to talk to his brother and to his father’s caregiver. He gives her all the instructions she needs, and she updates him with information such as what his father ate, how he slept, how much water he drank, how much he exercised and how he was feeling. After a few months, he could tell how improved his father was and he explained how WhatsApp helped him and his family to feel safe and engaged.

Dr. K. also uses WhatsApp to provide care at distance. He works in my field site as a generalist providing ambulatory care to old people. WhatsApp allows him to give orientation about what to do when patients don’t feel well, and he can also ask them to go to his office if necessary. In many cases, he said, he can solve problems providing only care at distance. Dr. K. believes that the simple fact that the patients know they can use WhatsApp to contact him makes them feel safe and comfortable.

WhatsApp is also helping clinics to manage people’s health. Amparo Health, for example, is a clinic that uses WhatsApp Business to connect patients to doctors. The patient pays a monthly fee to have access to low-cost exams and to specialists like ophthalmologists, gynecologists, dermatologists, nutritionists and psychologists. What is new here is that all procedures and exams are coordinated by a generalist, who is available on WhatsApp. Dr. Gusso, the head physician at Amparo Health, explains that because the clinic business model is based on membership, they have no interest in demanding unnecessary exams or appointments. Doctors are paid by the hour and not by performance and that includes time to answer WhatsApp messages during the morning and afternoon. At the end of the day, he said, they are using WhatsApp to provide care at a distance, helping people to stay healthy, to feel safe and to save money. Prevent Senior, a health insurance company, also uses WhatsApp to make patients’ lives easier. In cases where treatments require on-going medication, patients can use WhatsApp to ask for new prescriptions. They can receive their prescriptions at home or they can go to the doctor office to get them, but with no need to schedule an appointment.

WhatsApp is the primary method of communication for 96% of Brazilians with access to smartphones. And among my informants older than 60 years old, that is also the app they use the most. Now imagine what can be achieved if WhatsApp features are explored to make the communication between health insurance companies, doctors, patients, caregivers, family and friends healthier too.

From smartphones to target phones – By Marilia Duque

LauraHaapio-Kirk26 April 2018

Author: Marilia Duque

Photo (CC BY) Marilia Duque

Helen, a 67-year-old woman, was frustrated when she couldn’t show me all the pictures of her grandchildren that she keeps on her smartphone. “I came here with nothing. It is not safe”, she said. We were talking at a large square where people come to walk and exercise every day. Curiously, the place is also one of the 200 points with free WI-FI provided by the City Hall in São Paulo. Like Helen, many people who I’ve been talking to mentioned that they don’t feel comfortable using their smartphones in public spaces. Most of them agreed it is not safe to make and receive calls or to text on the streets. And they have good reason to be scared.

The number of robberies involving mobile phones represented 65.1 % of all robberies registered by the police in São Paulo in February of this year (percentage over total robberies involving documents, money, and mobile phones). According to the journal “O Estado de S. Paulo”, half of the streets of São Paulo had at least one mobile phone robbery reported from 2016 to 2017. I talked to 60 people in my fieldsite during this month and the numbers are also impressive. More than half of the informants had a smartphone stolen at least once or have someone in their family who experienced this. Because of that, people are creating different strategies to protect themselves and their smartphones in public spaces. For example, Lucy (65) said she would never answer a call on the street: “I just let it ring”. Lilly (67) makes some exceptions: “I take a quick look inside my bag. If it is one of my children who is calling I just go inside one of the stores on the street, so I can answer the call”. Jonas (56) doesn’t have children but accepts emergency calls only after he gets inside some safe space, like a coffee shop or mall. I have found more people who choose to leave their smartphones at home as a strategy to avoid violence: “I won’t risk my life”, one of the informants told me.

Photo (CC BY) Pixabay

People who have never had a mobile phone stolen or who don’t have a relative who did, feel lucky or blessed. Some of them also believe they haven’t been stolen because their devices are too old (they don’t have a smartphone), like one of my informants said: “Nobody wants that. They would probably say to me to throw it away as garbage”. That is not the case of Marcus (60). He already has a smartphone, a two-year-old one. But when I asked him when he was planning to buy a new one, he answered: “The next time someone steals mine”.

When I started my fieldwork, I thought the cost of service and the high rate of illiteracy (24% of the population older than 60 years) could be the two main barriers for the development of m-health initiatives for elderly people in Brazil. But security has became one of the key issue I will need to be aware of from now on. The strategy to leave the smartphone at home, for example, can invalidate two potential functionalities m-health apps can provide. The first is reminding elderly people to take their medicines correctly. According to Silva, (Schimidt and Silva, 2012), 40% to 75% of old people don’t take medicines at the right time or in the right dosage. The second is to contact relatives in case of a fall: one functionality provided by the apps Elderly Help or Mobil-SOS Be Safe, for example (Souza and Silva, 2016). All these advantages can be lost if elderly people just don’t feel safe enough to take their smartphones wherever they go. As one of my informants told me “if you have white hair, you are already a target”.

References:

Silva, R; Schimidt, O.; Silva, S. (2012). Polifarmácia em Geriatria. Revista AMRIGS 56 (2): p. 164-174.

Souza, C.; Silva, M. (2016). Aplicativos para smartphones e sua colaboração na capacidade funcional de idosos. Revista Saúde Digital, Tecnologia e Educação 1 (1): p. 06-19

Looking to the Future – by Marilia Duque

LauraHaapio-Kirk3 March 2018

Author: Marilia Duque

By the year 2050, the Brazilian population over 60 years old is expected to grow from 24 million to 66 million[1]. Fortunately, my first impression of the District of Vila Mariana, in São Paulo city, where I have been conducting ethnography since January, is that there are already innumerable initiatives for the elderly, both public and private.

In addition to public health units, there is the AME-IDOSO for example, a centre dedicated exclusively to the care of people over 60, taking referrals from other health units in the city of São Paulo. It provides examinations, medical appointments and treatments, as well as activities such as dance classes. Just a few blocks away, you can find the Elderly Coexistence Centre (NCI), also subsidised by São Paulo City Hall. If you are 60+ and live in the Vila Mariana District you can join a large number of activities such as knitting and crocheting, fitness, circular dancing, senior dance, manual work, pilates, painting on canvas, chanting, memory games and rhythm dancing. I went there the week before the carnival. When I arrived, it was snack time. While one group were doing a dance class in the lounge integrated into a beautiful garden, another group were chatting and eating, all dressed up in traditional carnival ornaments. The worker told me that the menu takes into account the food restrictions and needs of the participants.

(CC BY) Marilia Duque

During this first month, I have already mapped five squares in the neighbourhood, all of them with gymnastics equipment, in another São Paulo City Hall initiative for people over 60 called “Longevity Playground: Happiness is Ageless”.

(CC BY) Marilia Duque

But if you keep walking you will also see many gyms offering activities for the elderly with special prices, not to mention Aqui Fitness, which has a program of physical activities developed by a geriatrician. And just a few minutes away, you can also exercise your mind and improve yourself; the Nossa Senhora da Saúde Parish offers an adult literacy course (20.4% of the population of Brazil over 60 is illiterate[2]), language classes and a Whatsapp course, especially for people over 60.

(CC BY) Marilia Duque

One of my ethnographic challenges is to investigate how the ageing population in the neighbourhood perceives these initiatives. Do they really work? Do they work for everyone? Could appearances be deceptive? This is an important point because Vila Mariana District is far from being a utopia. You can choose to see just the modern buildings that are rising everywhere among the two storey houses. But you will have some difficulty ignoring the Mario Cardin Community, a favela where more than 500 families live in precarious conditions, or the homeless people living on the streets.

(CC BY) Marilia Duque

But for the moment let us take this apparent wealth of amenities at face value. Actually, this raises a rather different question. Do Brazilian people have to get old before they experience something approaching the support and solidarity of an egalitarian state?

 

 

[1] http://www2.camara.leg.br/a-camara/estruturaadm/altosestudos/pdf/brasil-2050-os-desafios-de-uma-nacao-que-envelhece/view

[2] https://agenciadenoticias.ibge.gov.br/agencia-noticias/2013-agencia-de-noticias/releases/18992-pnad-continua-2016-51-da-populacao-com-25-anos-ou-mais-do-brasil-possuiam-apenas-o-ensino-fundamental-completo.html

What If I Choose You To Be Legally Responsible For Me? – By Marilia Duque

ShireenWalton8 January 2018

In 2002, Brazil adopted the World Health Organization guidelines for ageing societies, which protects people over 60 from violence and discrimination, addressing key issues as health, food, education, culture, sports, leisure, work and citizenship. Indeed, the Brazilian Public Health System (SUS) is accessible to everyone. But outside the state health service, the law enshrined in the National Policy for the Elderly sees elderly welfare as a responsibility of “the family, the community, the society and the state”. In other words, the family is also viewed as the primary institution legally responsible for people over 60.

For example, people over 60 are supposed to live with their families, and the state will only intervene when relatives provide evidences that they cannot afford this responsibility. The same applies to nourishment. But the National Policy for the Elderly goes even further. By law, people over 60 can sue their grown-up children to enforce this legal responsibility. If they have more than one child, they can also decide which of them will take on the onus of care. If you are selected, you can sue your brothers or sisters to try to enforce their share in this responsiblity. In most cases however, it will be a lost cause.

My grandmother and me

The National Policy for the Elderly understands that people over 60 can nominate who will become responsible for paying for this support, and it includes choosing just one of their children. If their children don’t have sufficient incomes or are deceased, grandchildren,brothers and even nephews can be nominated, too. Kinship has traditionally been a core topic within anthropology. But in this case, Brazilian law gives it a quite unique dimension – which I will explore during my ethnography of middle-age.

– Marilia Duque