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LETTERS TO THE EDITOR

ON THE BRAZILIAN ELDERLY AMERINDIANHERITAGE AND THE VERY OLD ITALIAN-BRAZILIAN LONGITUDINAL STUDY ON AGING

To the Editor: In a recent article entitled Geriatrics inBrazil: A Big Country with Big Opportunities, Garcez-Leme et al. point out that the ethnic distribution in Brazilincludes 53.8% whites, 6.2% blacks, 39.1% mulattos, . . .and 0.2% Indians.1 These data are based on the Braziliancensus, which takes individuals own subjective impressionsabout their skin color, do not represent reality, andclearly underestimate the Brazilian elderly Amerindian her-itage. Indeed, most Brazilians (including older people) aregenetically mestizo, either white/black (mulattos), white/Indian (Caboclo), orFmore commonlyFa mosaic of thethree (Brazilian mestizo par excellence). The proportion ofcontribution of each of those three ethnicities to

the makeup of the typical Brazilian elderly genetic pool iscuriously racially democratic: approximately one-third ofeach group.2

Even what Garcez-Leme is considering to be a whiteperson is on average a tri-hybrid mestizo with 39% Europe-an, 33% Amerindian, and 28% African genetic background.2

This is an important phenomenon not just for genetics butalso to understand the typical Brazilian elderly cultural iden-tity as being part of a new and universal civilization, insteadof just being Europeans transplanted to the Americas. More-over, Amerindians used to hold their older people in highesteem, and this influence can still be seen not just in Braziliansociety, but in all of Latin America.3,4

Garcez-Leme et al. cited the Bambu Aging Studybut failed to refer to the Very-old Italian-Brazilian Lon-gitudinal Study on Aging (Veranopo lis Project), which wasthe first longitudinal study on aging in Brazil.This study was implemented originally by the WHO Col-laborating Research Center for Prevention of Chronic-Degenerative Diseases Associated with Aging, locatedat the Department of Geriatrics of the Catholic Universityof Porto Alegre. It consists of a very old cohort (!80)of Italian Brazilians living in Verano polisFin southernBrazilFand it was conceptualized by Dr. Elisabete Mi-chelon, who noted that this population had the longest lifeexpectancy in Brazil: greater than 80. Of the possible fac-tors associated with longevity in this population is the al-

most universal moderate intake of red wine by itsinhabitants, especially older people.

This study has been contributing important knowl-edge to the field of the oldest-old in geriatrics, es-pecially in the topics of cardiogeriatrics57 and geriatricpsychiatry.810

Idiane Rosset, GNPDepartment of Geriatrics

Kyoto UniversityKyoto, Japan

Departments of Geriatrics and Gerontological NursingUniversidade de Sao Paulo

Sao Paulo, Brazil

Matheus Roriz-Cruz, MDDepartment of Geriatrics

Kyoto UniversityKyoto, Japan

Institute of GeriatricsUniversidade Catolica do Rio Grande do Sul

Rio Grande do Sul, Brazil

Jarbas S. Roriz-Filho, MDRosalina Partezani-Rodrigues, GNP, PhD

Departments of Geriatrics and Gerontological Nursing

Universidade de Sao PauloSao Paulo, Brazil

Antonio C. De Souza, MD, PhDInstitute of Geriatrics

Universidade Catolica do Rio Grande do SulRio Grande do Sul, Brazil

WHO Collaborating Research Center for the Prevention ofChronic-Degenerative Diseases Associated with Aging

ACKNOWLEDGMENTS

Financial Disclosure: We declare that we have no financial

conflicts of interest.Authors Contributions: Idiane Rosset conceived and

wrote the manuscript together with Matheus Roriz-Cruz.Rosalina Partezani-Rodrigues and Jarbas S. Roriz-Filhohelped with the literature review and suggested the inclu-sion of the Veranopo lis project. Antonio C. De Souza par-ticipated in the Veranopolis project and reviewed themanuscript.

Sponsors Role: None.

REFERENCES

1. Garcez-Leme L, Leme MD, Espino MD. Geriatrics in Brazil: A big country

with big opportunities. J Am Geriatr Soc 2005;53:20182022.

2. Pena SD. Brazilian Molecular Picture [Portuguese]. Ribeirao Preto: FUDEC-RP, 2 002.

3. Minayo MSS, Coimbra-Junior CE. Anthropology, Health and Ageing [Portu-

guese]. Rio de Janeiro: Fiocruz, 2002.

4. ScliarM, Csillag C. Ageingand Brazilianliterature.Lancet 1999;354(Suppl3):

1819.

5. Schwanke CH, Da Cruz IB, Leal NF et al. Analysis of the association between

apolipoprotein E polymorphism and cardiovascular risk factors in an elderlypopulation with longevity. Arq Bras Cardiol 2002;78:561579.

6. Da Cruz IB, Almeida BS, Schwank CH et al. Obesity prevalence among the

oldest old and its association with risk factors and cardiovascular morbidity[Portuguese]. Rev Assoc Med Bras 2004;50:172177.

JAGS 54:856875, 2006

r 2006, Copyright the AuthorsJournal compilationr 2006, The American Geriatrics Society 0002-8614/06/$15.00

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7. Marafon LP, Da Cruz IB, Schwanke CH et al. Cardiovascular mortality pre-

dictors in the oldest-old. Cad Saude Publica 2003;19:799807.8. Xavier FM. Bereavement-related cognitive impairment in an oldest-old com-

munity-dwelling Brazilian sample. J Clin Exp Neuropsychol 2002;24:294301.

9. Xavier FM, Ferraza MP, Argimon I et al. The DMS IV minor depression

disorder in the oldest-old: Prevalence rate, sleep patterns, memory function

and quality of life in elderly people of Italian descent in southern Brazil. Int J

Geriatr Psychiatry 2002;17:107116.

10. Xavier FM, Ferraza MP, Trenti CM et al. Generalized anxiety disorder in a

population aged 80 years and older [Portuguese]. Rev Saude Publica 2001;

35:294302.

REASONS FOR THE HIGH COMPETITIVENESS INENTERING A GERIATRICS FELLOWSHIP IN BRAZIL:SOME COMPARISONS WITH THE UNITED STATES

To the Editor: In a recent article entitled Geriatrics inBrazil: A Big Country with Big Opportunities, Garcez-Leme et al. affirm that competition between internal med-icine (IM) residents to enter geriatric medicine (GM) fel-lowships is keen, with more than 20 candidates per trainingslot, but the authors do not explain the possible reasonsassociated with this phenomenon in Brazil.1

In fact, Brazilian GM has surpassed most of its moretraditional IM subspecialties in attractiveness, and in manyprograms it has become the single most competitive sub-specialty within IM. This has been the case at the CatholicUniversity of Brazil, Porto Alegre, as well, which was thefirst to offer GM training in Brazil, nearly 30 years ago.1

The above affirmation may trouble the attentive Amer-ican reader, because it contrasts acutely with the Americanreality.2

The reasons for this phenomenon seem to be mainlyrelated to the peculiar development of this specialty in Bra-zil and its relationship with the development of IM, familymedicine (FM), and the unified national healthcare system.

Indeed, one of the most important reasons for thesuccess of GM in Brazil has been a clear institutionalseparation between GM, IM, and FM, which providesthe geriatrician with a status equal to the other IM sub-specialties.

In Brazil, unlike in the United States, the IM and FMmovements did not become important beforeFbut insteadcoincided withFthe geriatrics movement in the 1980s.3 Itfollows that, in Brazil, the GM movement did not find animportant barrier imposed by the IM and FM establish-ment, as is the case in the United States.4

To become a geriatrician in Brazil, one must complete a2-year residency program in IM before applying to a fel-

lowship in geriatrics, which takes 2 more years. It is notpossible for family doctors to become geriatricians.The Brazilian Unified Health System was established

based on the family doctor, with a clear space for GM at thesecondary level.3,5 Recent legal measures issued by the Bra-zilian Ministries of Health and Education require everymajor public hospital to include geriatricians in its cadreand encourage each faculty of medicine to have or develop adepartment of geriatrics.5

On the contrary, according to Professor Hazzard, theAmerican healthcare system is not well designed to addressolder peoples needs, because it is fragmented and poorlycoordinated, costly and economically skewed and discour-

ages the coordination of care of older people.

6

It is not without struggle that Brazilian geriatrics isthriving in such a favorable environment. In fact, pioneer-ing Brazilian geriatricians tried to establish their specialtyagainst strong interests, especially those imposed by thetraditionally established IM subspecialties. The specialty isnotoriously indebted to the names of such mavericks asprofessors Yukio Moriguchi, Mario Sayeg, Eurico Car-valho-Filho, Mateus Papaleo-Neto, Wilson Jacob-Filho,

and Renato Maia-Guimaraes (currently president of theInternational Association of Gerontology), to cite but a few.We fully agree with Becker when he poses that the

fundamental problem with American GM is related to threebasic interrelated phenomena.4 First, the decision to classifyand certify GM as a combined subdivision of IM and FM,which created a weak discipline with poor prestige. Second,this decision led to GM being certified not as an actualspecialty but as an added qualification (certificate ofadded qualification, CAQ) to an internist title. Third, ger-iatricians who complete the 2-year geriatric fellowship arecertified with the same CAQ as (non)geriatricians who per-form the 1-year course. Consequently, the CAQ does notprovide any real specialty status to GM.4

The further development of American GM will dependon its recognition as an independent subspecialty and on therealization of the American dream of a universal nationalhealth system7 in which GM can be considered a specialty tobe referred to at the level of secondary care. AlternativelyFasin the United KingdomFvery old patients (!80 or 85) couldalso have the possibility of direct access to the specialty.8

Independent status for GM, a minimal fellowship of 2years, and the creation of departments of geriatrics hascontributed to establish the specialty in the United Kingdomand has been working for the rest of Europe,9 Canada,10

and Brazil.1 Japan has already 25% of its medical schoolswith departments of GM.4

Meanwhile, although fully recognizing that Americangeriatrics is de facto (but not de jure) at a further stage ofdevelopment, Brazilian geriatricians continue teaching theirjunior fellows about the ideal models of American re-search, British practice.

Matheus Roriz-Cruz, MDDepartment of Geriatrics

Kyoto UniversityKyoto, Japan

Institute of GeriatricsUniversidade Catolica do Rio Grande do Sul

Rio Grande do Sul, Brazil

Idiane Rosset, GNPDepartment of Geriatrics

Kyoto UniversityKyoto, Japan

Ana C. Cury, MDDivision of Aging

Massachusetts General HospitalHarvard University

Boston, MA

Jarbas S. Roriz-Filho, MD

Department of Geriatrics

LETTERS TO THE EDITOR 857 JAGS MAY 2006VOL. 54, NO. 5

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