Aging in the Americas (Winter 2019)

picPhoto by Paz Errazuriz

Editor's Letter



There is no smell of pungent printers ink permeating my office. My interns—Sylvie, Isaac and Marc—are not scrambling to find FedEx boxes to send out ReVista issues to authors and photographers all over the world. I cannot feel the silken touch of the printed page, gaze at the cover—always the cover—we have chosen with our creative designer, Jane Simon. I look for the boxes and feel an emptiness.


This issue of ReVista, the Harvard Review of Latin America is entirely online.


We're trying in this transition. Marc made a wonderful video of our Visiting Scholar Flavia Piovesan who wrote an article about the human rights of senior citizens. We're adding sections on travel (please contribute!) and student perspectives (please contribute also!), as well as a multimedia section. And we’ll have more “room” for book reviews.


And yet as an editor, a journalist and an older person, I can't help but feel that universities have an obligation to the printed word, to the archives, to the permanence of thought. I can't help but think that the printed word must be preserved—particularly in academia.


You, our readers and contributors, will be receiving a survey (if not, here's the link here: Please let us know what you will help decide ReVista's transition.


I ask myself if my attitude is one of aging—the theme of this issue. No one laments the loss of typewriters except as a somewhat artistic object to put on display in the study. But then again, records are coming back, and I know millenials (and younger) who have invested in vintage record players and records. Is print like the typewriter or the record player? We have no way of knowing without the wisdom of the future.


Traditionally a continent of young people, Latin America and the Caribbean face new challenges as people live longer. In this issue on aging, we look at senior citizens as human beings in transition—just like ReVista.


June Carolyn Erlick


There is no smell of pungent printers ink permeating my office. My interns

Sylvie, Isaac and


are not scrambling to find FedEx boxes to send out


issues to authors and

photographers all over the world. I cannot feel the silken touch of the printed page, gaze at the


always the cover

we have chosen with our creative designer, Jane Simon. I look for the

boxes and feel an emptiness

There is no smell of pungent printers ink permeating my office. My interns

Sylvie, Isaac and


are not scrambling to find FedEx boxes to send out


issues to authors and

photographers all over the world. I cannot feel the silken touch of the printed page, gaze at the


always the cover

we have chosen with our creative designer, Jane Simon. I look for the

boxes and feel an emptiness


Table of Contents by Author




First Take: Protection of the Rights of the Elderly: The Impact of the Inter-American System


By Flávia Piovesan

Photos by Paz Errazuriz


I arrived in Bogotá in February 2018, not quite knowing what to expect. I’d recently been elected to the Inter-American Commission on Human Rights, and this was my first period of working sessions. Towards the end of our working session in Colombia (167th session), the Inter-American Court of Human Rights pronounced its first sentence guaranteeing the rights of the elderly. In a decision handed down on March 8, 2018, in the Poblete Vilches y Otros case against the State of Chile, the Inter-American Court consolidated relevant inter-American standards regarding the right of the elderly to healthcare, with emphasis on the right to informed consent. For the Court, it is essential to give visibility to the elderly as subjects of rights that deserve special protection, and the state must respect, protect, and implement these rights


This decision stirred memories of the vigor, commitment and courage of the elderly women, members of civil society organizations who were demanding justice, rights, respect, dignity and protection of the rights of the elderly in Mexico. During the public hearing before the State of Mexico, their voices, full of so much indignation, resilience, and hope, represented, for me, the greatest source of inspiration to develop the recently created Unit on the Rights of the Elderly, which I have the honor and challenge of leading within the Inter-American Commission on Human Rights.




It is not only in war-torn states or societies in conflict that the Commission plays a role. In a changing society in Latin America and the Caribbean, in which the percentage of people over 60 years old is expected to double between 2010 and 2050, the Commission plays an important role in upholding the Inter-American Convention on the Protection of the Human Rights of Older Persons. This Convention is the first and only international treaty on the subject, adopting all necessary measures involving normative frameworks and public policies adequate for the protection of the rights of the elderly.


As a mediator, the Commission encourages an open, direct, transparent, and constructive dialogue between civil society organizations and state agents, based on active listening, to ensure the protection of human rights by complying with the inter-American standards, in accordance with the mandate of defense and protection of rights enshrined in the American Convention on Human Rights.

In Mexico, the elderly women spoke loud and clear, making a powerful appeal for the State of Mexico to ratify the Inter-American Convention on the Protection of the Human Rights of Older Persons. To date, six countries have ratified the Convention: Argentina, Bolivia, Chile, Costa Rica, El Salvador, and Uruguay. Now with the Unit on the Rights of the Elderly, I and my team will take the Convention as its major framework of action, together with the "Inter-American corpus juris" and the development of Inter-American standards on the obligations of states to ensure the right to equality and non-discrimination, as well as the right to a life free from violence. We will also disseminating the Inter-American Convention, encouraging its ratification and full implementation by the states in the region as one of the priorities of this new unit.




During the October 2018 169th session of the Inter-American Commision, civil society organizations that work to protect the rights of the elderly also vehemently demanded the ratification of this Convention. A public audience against the State of Venezuela held during this session held at the University of California, took up the issue of serious violations of the right to healthcare, work, and social security of the elderly in the country.


I believe that focusing on the process of aging from a human rights approach is the greatest innovation of the Inter-American Convention on Protecting the Human Rights of Older Persons, adopted by the OAS on June 15, 2015. Views concerning aging are shifting from the traditional perspective of aging as a passive action in which the elderly are seen only as the beneficiaries of pension plans. Now there is an increased sense of aging as a process of active participation in the community which sees the elderly as agents in its development, consequently strengthening their right to autonomy, independence, and protagonism. This paradigm shift demands cultural transformations to foster new attitudes, policies and practices. It also requires the incorporation of a gender perspective into all policies and programs aimed at realizing the rights of the elderly, with a focus on combating all forms of discrimination and violence against the elderly in all spheres.




For the Convention, the elderly person is someone 60 years or older, unless domestic legislation determines a lower or higher base age, never exceeding 65 years. It defines aging as a gradual process that develops throughout life and involves biological, physiological, psychosocial, and functional changes of various consequences, associated through dynamic and permanent interactions between the subject and his environment. Aging is seen as a process marked by a myriad of changes and consequences, always stemming from the interaction between the individual and his or her environment.


Among the principles embodied within the Convention, the following ones stand out: the principle of dignity, independence, protagonism, and autonomy of the elderly; equality and non-discrimination; participation, integration and full and effective inclusion in society; well-being and care; self-realization; equity and gender equality; solidarity; preferential attention; respect for and appreciation of cultural diversity, and effective judicial protection.



Flavia Piovesan and her colleagues at the IACHR sessions. Photos courtesy of Flavia Piovesan.


Member states must adopt measures to prevent, sanction and eradicate the violation of the rights of the elderly. They must also adopt and implement affirmative measures to carry out the rights set forth in the Convention. It is also the duty of member States to adopt and strengthen legislative, administrative, judicial, budgetary and other measures in order to ensure differential and preferential treatment of the elderly in all areas. as well as the creation and promotion of public institutions specialized in the protection and promotion of the rights of the elderly and their integral development. In addition, member States should promote the broader participation of civil society, especially the participation of the elderly, in the design, implementation, and control of public policies and legislation to be adopted in order to implement the Convention.




As for the protected rights, the Convention establishes the right to equality and non-discrimination on the grounds of age; the right to life and dignity; the right to independence and autonomy; the right to participation and community integration; the right to safety and a life free from violence; the right not to be subjected to torture; the right to free and informed consent in the realm of healthcare; the right to caregiving services; the right to personal liberty; the right to privacy and intimacy; the right to social security; the right to work; the right to physical and mental health; the right to education; the right to culture; the right to accessibility and to personal mobility; among others. Emphasis is placed on the right to independence and autonomy, protected under the Inter-American Convention, which establishes the right of the elderly to make decisions about their life project in order to develop an autonomous and independent life in equal condition, according to their traditions and beliefs, and to have mechanisms in place to be able to exercise their rights.


The Inter-American Convention also determines that every elderly person has the inalienable right to express his free and informed consent in the realm of healthcare, and denial of this right is a violation of the human rights of the elderly. Thus, the member State must guarantee the right of all elderly individuals to express their informed consent in a previous, voluntary, free and explicit way, as well as to exercise the right to modify or revoke that consent, in relation to any decision, treatment, intervention or research concerning healthcare.




The Convention innovates by including a definition of palliative care, that includes providing active, comprehensive and interdisciplinary care for patients whose illness does not respond to curative treatment or patients who suffer from preventable pain. In order to improve their quality of life until passing, special attentions is paid to pain control, as well as the social, psychological and spiritual problems of the elderly, in an effort to comfort the patient, his or her surroundings and his or her family, considering death as a natural process that should not be accelerated nor delayed.


I see the Inter-American Convention as an essential instrument that establishes minimum regional standards for the protection of the rights of the elderly, with strong potential to encourage States to adopt new public policies and legislative frameworks. This is true especially in light of new paradigms capable of understanding aging within the human rights framework, providing an environment of equality, without discrimination, prejudices, stigmatizations and stereotypes, that may hinder the full exercise of these rights. It is the duty of States to foster a new culture that incorporates the "human rights approach" to aging, from the reinvention of institutional practices to the establishment of public policies and normative frameworks.




Gradually, the protection of the rights of the elderly in the inter-American system are being strengthened due to measures such as ensuring greater visibility of the issue in public hearings; the important innovations of the Inter-American Convention on Protecting the Human Rights of Older Persons; the relevant recommendations and decisions adopted by the Inter-American Commission and Court in the system of petitions and cases involving violations of the rights of the elderly, and also due to a newly created institution, the Unit on the Rights of the Elderly. At our next working session (170th session) in December, at the OAS headquarters in Washington, special emphasis will be placed on the protection of the rights of the elderly, in a public hearing requested by various civil society organizations on the diagnosis of the protection of the rights of the elderly in the region and its major challenges and prospects, considering the Inter-American Convention on Protecting the Human Rights of Older Persons and follow-up mechanisms.


Population aging is one of the most significant demographic changes of the 21st century, as well as a triumph of development, as the United Nations Population Fund (UNFPA) states in "Aging in the 21st Century: Celebration and Challenge." According to this Report, life expectancy at birth is now higher than 80 years in 33 countries - just five years ago, only 19 of them had reached this level. Today, only Japan has an elderly population of over 30%, but by 2050, there will be 64 countries in which the elderly population will make up more than 30% of the total. For the first time in history, there will be fewer children than older people in the world. There are about 700 million people in the world over 60 years old (corresponding to approximately 10% of the world's population) - by the end of the decade that number will reach 1 billion. It is estimated that in 2050 the overall percentage of elderly individuals will comprise 20% of the world's population, or approximately 2 billion people. Although all regions show this population growth, two-thirds of the world's elderly live in developing countries, and this number may reach 80% by 2050. It is estimated that in Latin America and the Caribbean, the proportion of people over 60 years old will more than double between 2010 and 2050, from 10% to 25%, reaching 188 million people in our region, according to the Report of the United Nations High Commissioner for Human Rights (E/2012/51).




Despite this demographic trend, the challenge of advancing the protection of the human rights of the elderly in international and national norms and policies still stands.


In this context, the greatest contribution of the Inter-American system to the defense and protection of the rights of the elderly is to spread its transformative impact in the region, strengthening the emergence of a new emancipatory paradigm that takes into account aging from a human rights approach (active, safe and healthy aging), with continued emphasis on the incorporation of a gender perspective, thereby ensuring dignity, independence, protagonism, autonomy and full inclusion for the elderly.


Flávia Piovesan is a member of the Inter-American Commission on Human Rights, Professor of Law at the Pontifical Catholic University of São Paulo and 2018 Lemann Visiting Scholar at the David Rockefeller Center for Latin American Studies.





Video Interview with the Author



Flavia Piovesan is a member of the Inter-American Commission on Human Rights, Professor of Law at the Pontifical Catholic University of São Paulo and 2018 Lemann Visiting Scholar at the David Rockefeller Center for Latin American Studies. In this interview, she discusses human rights for elderly populations in Latin America

Part I: Pensions and Safety Nets

Aging and Pension Reforms: A Look at Latin America


By Carmelo Mesa-Lago


Latin America is growing older. Since the 1950s, the number of people 60 years and older is increasing in the region as longevity is expanding. For many decades, the largest portion of the population was younger than 14, but with the aging process, the size of that group has been declining. On the other hand, those in the middle—15 to 59 years, the “productive” segment of the population that finance those who are younger and those who are older—eventually will shrink hence making more difficult to sustain the other two groups.


In Latin America, aging has been much faster than in developed countries. In 2050, the elderly are expected to be one out of every four people (26%), about the same as in Europe. Such fast growth means that there is less margin for error to plan ahead for the needed adjustments, and the state should play an important role to prevent or alleviate adverse consequences.


There’s a great deal of difference among the region’s countries, however. Already, one out of every five people (20%) in Cuba and Uruguay is 60 years old or more—the oldest countries in the region—, according to the Economic Commission for Latin America (ECLAC). Chile, Argentina, Costa Rica and Brazil are experiencing what ECLAC calls “accelerated aging,” in which the percentage of people 60 years old and above ranges from 13% to 16%. Colombia, El Salvador, Panama, Peru, Mexico, Ecuador, Venezuela and the Dominican Republic make up a group ECLA identifies as “moderate aging,” with 9 to 12% of its citizens 60 or older. The countries that have been the slowest to experience this aging trend, identified by ECLAC as “incipient,” are Paraguay, Bolivia, Nicaragua Haiti, Honduras and Guatemala, from 7% to 9%. This aging trend reflects both a decrease in the birth rate and an increase in life expectancy. The most socio-economic developed countries are the oldest and the least developed are the youngest.


Photo by Jonathan Moller


The fact people live longer is a good thing for human beings, but it creates financial problems. As life expectancy increases, pensioners live and collect their pensions for more years, increasing system costs. Moreover, with fewer people in the middle group, a drop in the number of those working and making contributions makes it difficult to finance pensions: in a young population, the ratio of active workers per pensioner may be nine to one, but in an older population, the ration may shrink to two to one.


Pension systems and types of reforms


In general, pension systems are of two types. There’s the “public” pension, characterized by a “defined benefit” (the law sets the pension amount), “non-defined contribution (it tends to increase through time), pay-as-you-go financing (usually there is a partial collective reserve that helps extend the long-run balance), and administration by social insurance or the state. The second type, the “private” pension usually has “defined contribution” (percentage fees paid upon wages should not change through time), non-defined benefits (the pension amount depends on the contributions paid and the investment yields), fully-funded financing (capitalization based on individual accounts owned by the insured), and private administration (by competing, profit-seeking companies).


Let’s give an example. José Pérez is insured in a public pension system. He pays a monthly contribution based on his salary (the employer usually contributes too), which often increases with the aging of the population and the program itself. These contributions go into a pot, collectively owned by all those covered by the pension. The pension calculation is regulated in detail by law (often setting a minimum and maximum figure). Conversely, María González is insured in a private pension system. She pays a contribution based on her salary (her employer may or may not contribute). These contributions go into an individually-owned account that is invested by the private corporation (AFP) that manages the fund. At the time of retirement, she receives a pension based on the amount in the account. Many in Latin America experience a mix of the two systems.


With the increase in older Latin Americans, there’s much talk of pension reform. These reforms could be “parametric,with some changes in the public system such as raising the retirement age to prolong the life of the pension plan. The reforms could also be structural ones that do not preserve a public system but change it, totally or partially, into a private system. Re-reforms change a privatized system either improving it or turning it back to public.


Structural reforms and re-reforms


Eleven Latin American countries. beginning with Chile, implemented structural reforms from 1980-2005. There are three diverse models. Chile, Bolivia, Mexico, El Salvador and Dominican Republic, in that chronological order, adopted a substitutive system in which the public system was replaced entirely by a private system. Peru and Colombia adopted a parallel system in which the public system continued and a new private system was created, allowing both to compete. Uruguay, Costa Rica and Panama developed a mixed model, in which the public system was converted into the principal mainstay with the establishment of a private system as a secondary backup.


Structural reforms improved some key aspects of public systems, but the negative effects outweighed the advantages and were contrary to many of the reformers’ promises (for details, see C. Mesa-Lago, Reassembling Social Security: A Survey of Pension and Health Care Reforms in Latin America, 2014).


Between 2008 and 2010 three countries rolled back their private pension systems. Chile kept the private system but with substantial modifications that addressed some of the problems. Argentina closed the private system, transferring all its clients and funds to the public system. Bolivia nationalized the private system, but guaranteed the existing individual accounts. In 2017, El Salvador joined the group but its re-reform focused on reducing the fiscal deficit, leaving other key aspects untouched. The Dominican Republic, Panama and Peru have unsuccessfully tried to pass re-reforms.


Photo by Andy Goldstein.


The structural reforms increased retirement ages in Argentina, Bolivia, Chile, Peru and Uruguay (for women); in Colombia, the age was raised in the public system but not in the private one. Costa Rica, Dominican Republic, El Salvador, Mexico and Panama left retirement ages unchanged. The Bolivian structural reform increased retirement ages 10 years for men and 15 years for women, to 65 for both, very high in view of the quite low life expectancy; the re-reform reduced ages to 58 for both sexes. Years of contribution were also expanded in six countries. Re-reforms in Argentina and Chile left ages unchanged.


Countries that have not raised the age for retirement and those with a very young retirement age face a financial and actuarial imbalance because projected revenue will be lower than projected expenditures. Chile has taken measures to avoid this situation. Argentina did not conduct actuarial valuations either before or after the re-reform. Bolivia allegedly took stock of this imbalance, but never revealed the results. The little data that exist from both countries indicate a serious actuarial disequilibrium (in 2018, Argentina increased, voluntarily, retirement ages by five and three years for men and women respectively). Costa Rica had a dispute about the actuarial equilibrium of the public system and, in 2018, increased contributions by one percentage point and began a discussion about raising the retirement age. In Uruguay, expenditures rose because of benefits expansion, aggravated by the second most aged population in the region. A 2020-2065 projection forecasts a decline in fiscal transfers in the mid-term but rising thereafter with the deficit peaking at 24% of Gross Domestic Product (GDP). El Salvador re-reform and Peru’s proposal were not based on actuarial valuations. Panama latest actuarial study has not been released.


In 2015, a presidential commission in Chile approved 58 recommendations, including raising women’s retirement age to 65 on parity with that of men, and the introduction of an employer contribution of 4% of the wage bill. Regrettably, the recommendations were in limbo for one year and a million Chileans demonstrated in the street against the proposals, demanding better pensions, but opposing the age increase (in November 2018, Chile’s new president announced the increase in the contribution).


Photo by Andy Goldstein.


How pensions are calculated


The system administrator calculates the pension. In a public system, those eligible for benefits must meet both the legal retirement age and the required years of contribution. An average of the years of contribution (either the entire working life or a fixed period, such as 20 years) is calculated. Upon that average, a percentage is applied (“replacement rate”), resulting in the amount of the pension. In a private system, those who receive benefits usually don’t have to reach the retirement age or have completed years of contribution if the sum in the individual account is sufficient to finance a minimum pension. The pension is estimated based on the fund accumulated in the account and mortality tables that determines the pensioner’s estimated life span.


Policies to deal with benefits for the aging vary according to the pension system. A public system requires a reform that is financially balanced (annual revenue should be higher than annual expenditure) and in actuarial equilibrium in the long run (projected revenue should match projected expenditures). As expenditures rise, revenue must be increased also; otherwise there will be no funds to pay pensions. To reduce expenditures, retirement ages should be raised or contributions increased or benefits cut or a combination of all these measures. Theoretically, private systems have “defined contribution” but, in practice, they are also affected by aging: as life expectancy increases, the sum accumulated in the individual account becomes insufficient to finance the additional years in the life span, thus requiring similar measures than in public systems. Policies to cope with benefits for the aging are very difficult to implement politically because they have a short-term negative impact on those covered even if the reforms help them to pay their pensions in the long run.


Photo by Valentina Montoya Robledo.


Retirement age and pensions


Generally, retirement ages should be adjusted to the degree of aging: the oldest countries should have the highest ages and the youngest countries the lowest ages, but the table shows otherwise: Cuba (the oldest) and Honduras (the youngest) have the same years of retirement. The type of system could make a difference because, as noted, structural reforms increased retirement ages in several countries. Currently, Costa Rica, Mexico and Peru (all private) have the highest ages; nevertheless Brazil (public) have the same ages as Chile (private). Many countries still need to adjust their retirement ages.

Ranking of counties by aging and retirement ages, 2017



Degree of



Type of system

Cohort 60 years and over (%)

Retirement age



























Costa Rica




















El Salvador














Dominican R.






















































Gender and pensions


In half of the countries, the retirement age for women is lower than that of men, five years in most cases. Women generally outlive men by ten years or longer, but their contribution period is five years shorter, a disparity that significantly increases financial-actuarial costs. The effects on women are diverse depending on the type of pension system. Public ones often have social solidarity (transfers among generations, genders and income groups) so the lower female pension is somewhat increased by such transfers (although women’s pension are still lower than that of men).


Private systems lack solidarity because the individual account is owned by the insured person and there are no transfers of funds. In addition, women are normally paid lower salaries than men for the same task and thus contribute less. Moreover, women often leave their jobs to raise children, reducing even more their contributions and individual accounts. Finally, the pension is calculated based on the amount in such account and mortality rates differentiated by sex. As a result, female pensions in private systems are considerably lower than that of men.


The difference in gender retirement ages is frequently justified as a compensation for unremunerated services by women at home. However, such inequality in sharing domestic tasks should not be corrected by the pension system but by a change in men’s behavior. Another way to tackle this problem is by the state to grant the women some remuneration for the work they do. For instance, Chile’s pension re-reform granted women a voucher for every child born alive. The voucher is deposited in the individual account, earns interest and is collected at the time of retirement. A parametric reform in Uruguay provided a year of contribution to women for each child born alive.


Reforms of public systems


Currently, eleven Latin American countries have public systems. Unfortunately, because they lack an international association (like all private systems) that annually publishes changes in legislation and comparable statistics, less information is available. The International Labor Organization reports on those systems but with not with much frequency.


Brazil modified the parameters of its pension systems for private-sector workers and for civil servants in 1999 and 2003, respectively. Another Brazilian reform in 2015 gradually increased the pension formula that combines years of age and contributions, from 85 for women and 90 for men in 2018 to 90 and 100 respectively in 2026. The actuarial deficit has been reduced but not eliminated.


Cuba has the most aged population in Latin America. In 2011, the number of people in the labor force began to decline. For many years now, the system has endured a significant and growing financial deficit (that peaked at 40% in 2008) financed by the state. That year a parametric reform was passed that increased ages of retirement by five years for both sexes (now 60 for women, 65 for men), raised employer’s contributions by two percentage points and introduced workers’ contributions. These policies have alleviated the financial deficit in the short run but changes have not been sufficient and the actuarial disequilibrium will grow.


In Ecuador, a parametric reform in 2015 left the retirement ages untouched; contributions in the three major insured groups were standardized but left unchanged in the separate schemes.


Photo by Jonathan Moller.


Venezuela’s economic crisis has resulted in a GDP decline of 50% and hyperinflation in 2018 was one million percent, hence pension reserves have practically disappeared and the value of pensions plunged dramatically. Ages of retirement are among the lowest in the region and the country is in the moderate-aging group, but life expectancy is estimated to have decreased in the last three years.


In Guatemala, Haiti, Honduras, Nicaragua and Paraguay, retirement ages are very low (55 to 62 men and women, with the exception of the Honduran retirement age of 65 for men). However, aging is incipient and financial-actuarial imbalances are looming.


Nicaragua has the fastest growing aging in the group, with a retirement age of 60 for both sexes, the lowest retirement age in the region with the exception of Haiti. In the last five years, the financial deficit has steadily grown and the reserve is projected to be exhausted in 2019. To extend the life of the system, a 2018 law increased contributions by seven percentage points (becoming the highest in Latin America) and reduced pensions by 5%. These measures provoked massive demonstrations requesting the annulment of the law; the president eventually conceded but too late, as the protests had become a national movement against him.


Age increase vis-à-vis system bankruptcy


Many countries in the world have been increasing retirement ages in tandem with the aging process, among them United States, United Kingdom, Germany, France, Italy, Belgium, Denmark, Netherland, Finland, Australia, South Korea, Spain, Slovakia, Hungary, Portugal, Iceland, Lithuania, Latvia, Estonia, Croatia, Greece, Bulgaria, Morocco, Madagascar, Curacao, St. Maarten, Kazakhstan and Belarus. The large majority of these are the most developed and aged countries, but five are developing countries, in the accelerated, moderate and incipient aging groups.


In most cases, the age of retirement has been increased gradually or in two stages; it generally goes up between two and five years. Because women frequently have a lower retirement age, the increase is higher for women and frequently in two stages. For instance, 31% of the reforms increased only the retirement age for women, mostly from five to eight years. In some countries, after the retirement age has been raised, it then has been tied to subsequent increases in life expectancy. A few countries limit the age increase to new entrants in the labor force or to those born in the future. The number of countries who are raising retirement ages is growing: 38% of the reforms since 1995 started in 2017-2018. In several countries, the change in age has been difficult due to strong political opposition, as we have seen recently in Greece.


Photo by Jonathan Moller.


Most Latin American countries need to raise retirement ages, particularly for women, as I’ve demonstrated here. If this is not done, actuarial deficits will worsen and some countries will face financial imbalances (the latter is already happening in a couple of countries), the system will go bankrupt and won’t be able to pay pensions.


The state must do the task to avoid huge fiscal deficits and system bankruptcy. The following are suggestions that need to be confirmed by actuarial studies: in the oldest group, Cuba should increase ages, particularly of women, whereas Uruguay should augment the minimum retirement age; in the accelerated group, Chile and Argentina (probably Brazil) should equalize the retirement ages for women and men; in the moderate group, the Dominican Republic and Venezuela should do the same thing, and in the incipient group, Bolivia and Nicaragua should raise ages by at least two years for both sexes.


Education of the insured and the population as well as a wide social dialogue among all relevant sectors are essential to overcome short-sighted political resistance.


Carmelo Mesa-Lago is Distinguished Service Professor Emeritus of Economics and Latin American Studies, University of Pittsburgh, the author of 94 books/monographs and 318 academic articles/book chapters; he was awarded the ILO International Prize on Decent Work shared with Nelson Mandela.









A Shaky Social Protection System Spells Vulnerability: Growing Older in 21st-Century Peru

By María Amparo Cruz-Saco

Photos by María Fernanda García Múnera


Calendaria Noya migrated when she was twenty years old from a small town of farmers and weavers in Cajamarca to the bustling metropolis of Lima. When I interviewed her in 2005 for my project on financial security in old age (Apuntes, vol 33, 2006), Noya told me how she had found employment as a live-in domestic worker in the upscale Miraflores neighborhood.


Noya worked mostly as a nanny, moving from household to household when her young charges grew up. When she turned 63, she completed retirement paperwork, and one year later, she began receiving the minimum public pension of $120 per month. When Noya was approaching seventy years of age, she quit her job as a domestic worker and moved in with her extended family in Lima´s northern cone of districts. She felt that she was too old and too sick to continue caring for new babies (at this stage in her life, the children of the children she helped raised initially).


At first glance, Noya´s story is not distinctive. Several hundreds of thousands of migrants moved from their rural homes into the city in hopes of a better life in the 1950s and 1960s. Their background was in subsistence farming; they had few years of formal education if any, and for the most part they worked in unskilled (or low-skill) jobs once they arrived. Most worked in diverse informal activities such as construction, commerce, repairs, transportation, domestic and other personal services. They often occupied land outside urban centers that slowly grew from precarious and haphazard villages to more developed settlements.


Throughout Latin America, an older population has governments thinking about pension systems.


Over the next few decades, Peru and other Latin American countries followed import substitution strategies that promoted industrialization through protectionist and redistributive policies as well as large government bureaucracies. With the support of public investment, foreign debt and state-owned enterprises, policy makers—often populists— formulated development from within” agendas.


In 1971, the Peruvian dictator General Velasco Alvarado, without any attention to financial sustainability considerations, expanded social security coverage to farmers, peasants, domestic workers and other low-income groups, along with their families. During her active career, Noya´s employers tapped into this opportunity and enrolled her in the now defunct Peruvian Social Security Institute (IPSS). Payroll contribution rates for domestic workers were very low and thus affordable.


A few years later, IPSS was actuarially broke. As a recent Ph.D. graduate in the mid 1980s, I assessed its finances and prospects with Carmelo Mesa Lago, a professor at the University of Pittsburgh (see his article in this issue). Our findings showed that several factors contributed to the severe institutional crisis in the IPSS and to a sharp increase in the public pension debt. Among the causes, we found, were the expansion of coverage at unsustainably low payroll contribution rates (these types of payroll taxes targeted precisely those in Noya´s situation) and the generous benefits granted to special groups of workers (for example, “cédula viva” which gave pensions equal to salaries to government officials), in addition to administrative and financial mismanagement. Social security reform was unavoidable.


In the early 1990s, social security reform efforts were part of a sweeping structural transformation recommended by international financial institutions and executed by another dictator, Alberto Fujimori. The institutional changes promoted greater reliance on the market through trade and financial deregulation, small government, foreign direct investment and safety nets for the poor. The latter were targeted through provision of food, health care and educational assistance, often in remote locations where public services and public assistance were scarce or absent.




IPSS was shut down. A new social security health care institution, EsSalud, now provides services to insured employees and their families, with payroll contributions paid by employers. In lieu of the old pension program, the Office of Pension Normalization (ONP) was created. It enrolls employees and pays benefits to former IPSS pensioners such as Noya. ONP continues as a pay-as-you-go (PAYG), funded with payroll contributions from employees and public transfers.


With ONP now streamlined, the government created and encouraged affiliation to a new private pension system. The system was a copy of the Chilean public pension system, except that the Chilean plan was closed to new affiliates while ONP is open to new affiliation. Private pension fund managers (AFP) administer the retirement savings of affiliated employees. A simplified version of the U.S. 401(k) retirement plans, it excludes, however, tax credits and is only funded with employee contributions. In contrast to ONP, a minimum pension guarantee does not exist—another difference with Chile—, and there are no solidarity transfers among affiliated employees. At retirement age of 65 (for both systems), AFP affiliates can purchase an annuity from insurance companies or make withdrawals until they exhaust their pension balance. Since 2017, AFP affiliates can cash in 95.5 percent of their total pension balance when they turn 65. If they don´t own a home, they can also withdraw, at any time, one quarter of their pension balance to help defray a home purchase.


Employees with registered labor contracts are mandated to make payroll contributions to ONP or AFP. In the public PAYG pillar, eligibility requires twenty years of contributions, and there are minimum and maximum caps for pensions. AFP pensions are determined by the employee´s pension balance. ONP is good for low-income earners, while AFP is suitable for medium- and high-income earners.


The Peruvian labor force is around 16 million people. Employees slightly outnumber self-employed workers who are often unregistered or informal. But only half of the total number of employees contribute to a pension system. This translates into one of the lowest labor force coverage rates in Latin America (Cruz Saco et. al, La desestructuración del sistema peruano de pensiones, Universidad del Pacífico, 2018). The flexibility of entry and exit from formal dependent jobs to unregistered self-employment, the large size of unregistered employment, excessive transaction costs—particularly in AFPand low remunerations explain high evasion rates despite several attempts to make retirement savings more accessible. Some analysts add that most people prefer not to think about old age, and when the probability of detection is low, people have an incentive to evade to have more money to spend immediately.


In April 2016, I visited Noya to check on her and to gather additional insights for a co-authored book on aging (Cruz Saco et. al, El porvenir de la vejez. Demografía, empleo y ahorro, Universidad del Pacífico, 2018). She had just turned 91 and was living with her niece and family. Noya stayed busy, visiting friends and relatives, watching soap operas and following Peruvian politics. She told me that she never missed a monthly medical appointment at EsSalud where she collected her medication for hypertension and cardiovascular disease.


Noya is one of 2.2 million older persons (65 and older) representing seven percent of Peru´s total population. However, a sharp decline in fertility rates and continuous increase in life expectancy is expected to lead to a rapid increase in that percentage. The low pension coverage, however, means that only 40 percent of this population earns a pension28 percent public and 12 percent private (Situación de la población adulta mayor, INEI, 2018). Alarmingly, the proportion of older persons with a pension is projected to decrease. First, the cashing out as a lump sum pension at the moment of retirement may lead to personal decisions that will not produce a rent or pension in old age. Second, the steady increase in informality reduces coverage rates. And finally, not wanting to think about old age dissuades retirement savings and encourages evasion.


In 2011, the Peruvian government introduced a non-contributive or social pension. In contrast to the stated goals of neo-liberal policy makers, Carolina Trivelli, minister of development and social inclusion (MIDIS), created Pensión 65 to protect older persons who lacked basic resources. Pensión 65 is a bimonthly transfer of $72 to older persons who qualify as extremely poor. As of December 2018, with Pensión 65, the pension coverage of older persons increased from 40 to 66 percent. This social pension represents only a fraction of the average monthly pension of the other two pillars: the average ONP pension is $194, AFP pension, $311 and Pensión 65, $36 (El Comercio, July 31, 2018).


Macroconsult, a Peruvian consulting firm, conducted an impact assessment of Pensión 65 (June 2016). It found that more than half of the beneficiaries lacked any formal education and more than one third had not completed their primary education. For nearly half (45 percent) Quechua was their mother tongue, followed by Spanish with 40 percent, and 11 percent, Aymara. The proportion of Quechua and Aymara beneficiaries is much larger than its overall population participation (12 percent and 1.3 percent respectively). The study encountered that on average two persons lived with the beneficiary, and that 90 percent were insured by the public non-contributive health system (SIS). Most beneficiaries knew the eligibility conditions for the social pension and regarded the service as satisfactory, the study reported. It found that beneficiaries received their pension at an urban center with a Banco de la Nación or in a designated site where a payment truck would park (although payment sites were often a considerable distance from their residence). Almost all of the pension was spent in food that was shared with the family, and the well-being of the beneficiary had improved thanks to the benefit, the study concluded.




Innovations for Poverty Action (IPA), a U.S. based consulting firm headed by Dean Karlan of Northwestern University, conducted another assessment of the impact of Pensión 65 on the well-being of beneficiaries (August 2016). It found a nine percent reduction in the incidence of mental health outcomes (basically depression), a four percent reduction in remunerated jobs thanks to the transfer and a forty percent increase in household consumption. Elderly people did not have to resort to low-paid jobs or peddling water on the streets—a positive benefit for the older population. At the same time, the monetary subsidy was shared within the household whose consumption expenses increased. However, the study found that despite access to non-contributive public health insurance, beneficiaries´ access to health care services and health situations did not improve compared to the control group.


How does this affect Noya’s story moving forward?


First, Noya was indeed fortunate to have been employed in households that paid attention to the importance of insurance to cover health care and old-age. She is probably eligible for Pensión 65 because she is vulnerable, extremely poor, and lacks basic means to sustain herself. In addition, she is single and does not own any real estate or financial assets. Noya also fits the cultural characteristics of the average Pensión 65 beneficiary. Her background is indigenous, she is the daughter of farmers in the northeast Andean valleys, and she did not complete her primary education. At the end of the day, however, Noya did better than Pensión 65 because she earns the minimum public pension which is 3.3 times the social pension (and she also receives two additional payments for Independence Day in July and for Christmas).


Second, Noya´s health is satisfactorily cared for at EsSalud. Waiting time can be long but health providers are kind and listen to her, she says, and she has made her routine medical visits an opportunity to share time with other older persons. She has been operated on twice—a benign brain tumor when she was in her seventies and a hip replacement in her eighties—and in both cases, she recovered well and kept on with her active life. In this sense, her experience seems to differ from the IPA report.


Third, in Peru—as well as in other societies with similar shaky social protection systems for vulnerable peoplethe extended family, the community of friends and charitable organizationswill continue to provide meaningful informal support during old age. Noya would not be as happy or active if it weren´t because of her niece, her nieces family and her large extended family that pays attention to her well-being.


But Noya’s story is different. Not everybody has the level of support that she has.


Pensions are clearly important although even in Noyas case, totally insufficient to pay expenses. Thus, older persons income usually need to be supplemented or supported by family, relatives and friends. Growing old brings with it a variety of difficulties including mobility, chronic diseases such as Alzheimers, cardiovascular issues, diabetes, hypertension and Parkinson’s. Often, additional resources are needed for caregiving. The sad truth is that not every one´s family is supportive. In a poor country like Peru, that is growing older and not getting any richer, these issues will have to be resolved one way or the other.


Maria Amparo Cruz-Saco is the Joanne Toor Cummings '50 Professor of Economics at Connecticut College and Visiting Professor of Economics at Universidad del Pacifico in Lima (Peru). She is co-author of El Porvenir de la Vejez: Demografía, Empleo y Ahorro (2018) and La Desestructuración del Sistema Peruano de Pensiones (2018), and has published extensively on social protection, aging and remittance behavior--among Hispanics in the United States--and on macroeconomic theory and practice. Contact information: and 



Domestic Workers and Retirement: Perpetuating Vulnerability, Uncertainty, and Inequality



By Gigi Arcila-Visbal


That day everyone was either crying or trying to hold back the tears. In the kitchen, Anita Tobon was crying too. Yet, Anita was crying very quietly as if her pain were insignificant or irrelevant. She was crying for the death of her employer of 30 years. Don Enrique Arcila was the closest thing to a father she had. Above all, he was a protector. Now, he was gone and she did not feel “like part of the family, but as only the domestic worker. In Colombia, Anita is not alone in her dependence on the benevolence of an employer. Domestic work employs the second largest number of women in the countryright after peddling of goods such as lottery tickets and newspapers. In Latin America, according to the International Labour Organization, one out of every four women is employed as a domestic worker.


The sense of safety that Anita experienced, while working for Don Enrique, vanished. Anitalike many other domestic workerssays that she felt insecurity as well as anguish, all of which in her case were intensified by a feeling of guilt. After all, Don Enrique had bought a house for her. In Don Enrique’s eyes that was the best thing he could do to guarantee dignity for Anita in her later years.


Despite this gesture by her employer, Anita had never been formalized by Don Enrique as a domestic worker. In other words, she was always paid in cash and never made contributions to a pension plan. Don Enrique, himself, never made contributions to a pension plan. His retirement plan was composed on the assets that he gathered during a life time of saving. Don Enrique, who lived through a number of violent episodes of Colombia’s bloody conflict, had an inherited mistrust in the government and private institutions, one shared by much of Colombia’s working population.


Even though in Colombia there are two pension plansone public and one private regimethe country has relatively few workers affiliated to a pension plan. Both pension regimes are based on monthly contributions set according to level of income. Access to benefits depend on the number of weeks worked (1,300 weeks in the public fund and 1,150 in the private fund), plus reaching the age of retirement; 62 years of age for men and 57 years of age for women.


The pension system is full of complexities and exemptions which might contribute to the low levels of affiliation. For example, the public fund has generated concerns since it is sustained by the working population which does not make enough contributions to make the system self-sufficient. Thus, part of the pensions are paid by the government. Only 2.8 million workers out of the total labor force (12.8 million) are contributing to a pension plan. As a result, 25% of the people in retirement age have a pension, and only 5% are women. In this scenario, the commonality is to have individualsif they have the meansmaking their own provisions for the later years, instead of affiliating to a pension plan. For those who do not have the means to plan for their later years, like the majority of domestic workers, extreme poverty is a likely scenario.


Despite having a house, Anitaat 55, two years away from the official retirement age for women in Colombiahad no savings and no pension. She will have to work for as long as she can to provide not only for herself, but also for her two unemployed sons and two grandsons. The only governmental benefit that Anita, and other domestic workers- are eligible to get upon reaching retirement age is under Colombia Mayor. Colombia Mayor distributes $75,000 pesos (around US$24) every two months to elders who are living in extreme poverty and do not have a pension plan.


“No to Intervention in Central America” showing USA helicopters dropping bombs on Nicaraguan villages.


Even without a pension, Anita’s situation is an exception to the general situation of domestic workers in Colombia and beyond who experience exploitative working conditions both because she owns her home and because her employment conditions were relatively good. The last report by the International Labor Organization asserts that, globally, domestic workers remained as one of the most vulnerable segments of the labor force. Indeed, domestic work is associated more with slavery than to a formal profession that produces value, which gives rise to benefits and a monetary compensation. In fact, many employers are said to see paying domestic workers as an act of generosity and not as a right. Since domestic workers are, in general, invisible in the eyes of the law the propensity for abusing domestic workers is endemic in the profession.


Domestic workers are expected to work longer hours than other workers do. Yet, they are among the workers that earn the lowest wages. In addition, having benefits such as health insurance, maternity leave, overtime payment and pension plans are rarities. It is common to find domestic workers with salaries way below the stipulated minimum wage of a country, and even find that part of their salary is pay in kind. Wage reductions justified based on lodging, food, clothing and even personal favors are common. The matter is that, worldwide, it is frequent to find domestic work as part of the “shadow economy” of a country, than to find domestic work fully protected and regulated by the legislation. In other words, a commonality for domestic workers worldwide is their invisibility in the eyes of the law, rendering them extremely vulnerable.


This problematic exacerbates when taking into account that domestic work not only remains as one of the main professions for women around the world, but it is also increasing. In 1995, there were about 33.2 million domestic workers worldwide. By 2010, this number had risen to a hundred million. In countries like Spain, and Italy the number of domestic workers has doubled. Latin America is not the exception to this trend. In the case of Colombia, according to the official national data gathered by DANE (National Statistics Department) women represent 42 percent of the working population of 21,584,420. In other words, 9,014,698 of women are considered wage laborers. Out of those 9,014,698 working women; 987,525 are domestic workers.


Most of these women will reach retirement age without a pension plan. In essence, in the case of Colombia, having a pension is understood as primarily an individual responsibility with individual consequences, that is, social rights are only available for those individuals that can afford them. When it comes to domestic workers, as well as other workers in the informal economy, it is almost utopic for the government to expect them to constantly contribute to a pension plan when, usually, their salaries are usually below official minimum wages and when the need to cover immediate needs overcomes any expectations to plan for future well-being.




Between 2010 and 2013 only 5.95% of the informal labor force made contributions to a pension plan. It is reasonable to assume that domestic workers were virtually absent from those low contributions. Another fact that adds to the pressing conditions of domestic workers in their later years is the fact that the majority of these women are household heads. In other words, entire families rely on their income. Thus, usually, they do not have financial help from husbands or partners. Additionally, as females, they experienced what the literature calls “the second shift.” Aside from the emotional and physical labor in the house of their employers, domestic workers are also in charge of the physical and emotional labor of their own households. In the absence of a retirement plan, domestic workers are faced with the need to keep working as long as their bodies allow it. In case of sickness, they face situations of instability, vulnerability and eventually the overall deterioration of their living conditions.


Some contend that domestic work is on the decrease, using arguments such as “It has become more expensive to hire a domestic worker; new apartment complexes and houses are designed with no space for a live-in domestic worker; families do not need them anymore, or you do not see as many as before.” Statistics show otherwise, although these common views do indicate changes in the dynamics around domestic work. The number of live-in domestic workers has indeed decreased, but the number of partial (live-out) domestic workers in on the rise. Many middle-class women are entering the labor force, transferring their household responsibilities to women domestic workers. Additionally, the participation of males in household chores has not increased to the point of replacing or equalizing the pivotal role of females in the household, and public caregiving programs are decreasing, making reliance on domestic workers more necessary.


Immigration from neighboring Venezuela is also increasing the supply of domestic workers since this occupation offers the easiest way to enter the labor market in a new society. Becoming a domestic worker does not require formal schooling and the abilities needed are assumed to be intrinsic to be a woman. As Colombia, and Latin America, approach a demographic change in which the elderly population is increasing, the number of women domestic workers reaching the retirement age will also increase. The current system perpetuates the vulnerability, inequality, and uncertainty in the majority of the female labor force – including domestic workers like Anita, who have been relatively well treated. Domestic workers deserve dignity and the right to enjoy peace, stability, and dignity in their elderly years.


Gigi Visbal has a research fellowship from the government of Quebec, Canada. She is currently studying domestic workers and other vulnerable populations in the labor market. She is also a recent graduate from the Master in Special Studies at the Harvard School of Education where she took a multidisciplinary approach to study education and vulnerable populations.







Part II: Facing the Challenges

Life through Medications: Dementia Care in Brazil

By Annette Leibing, Cíntia Engel and Elisângela Carrijo

Photos courtesy of Annette Leibing. 

It is another morning at the geriatric outpatient clinic of the local university hospital. I accompany one of the residents who guides an old woman in a wheelchair and three of her seven adult children into the examination room. The room is so small that there's only space for a writing desk with three chairs and an examination couch. The resident starts asking one of the daughters about her mother’s medications—an endless stream of questions that illustrates the way the older woman is being acknowledged as the outcome of an abstract and complicated management of symptoms and biochemical agents.


Dr. C.: How much are you giving?

Daughter: As you wrote it down: at 4 pm give one [pill].

Dr. C.: Of 25 [mg].

Daughter: Of 25; and at night one of 100, around 9 pm and…

Dr. C. (surprised): Ah, you are giving a whole of 100 or…?

Daughter: Yes, a whole one. With that she sleeps all night.

Dr. C.: Who is giving the medications? She lives with your family?

Daughter: No, we live in the same building; she lives with G. [the son who is sitting beside me]. He recently went to the Public Defender, but it is so complicated…

The daughter explains that G. is trying to get his mother’s custody, so that he can have access to her bank account with her small pension, but one of his brothers is trying to impede that.

Dr. C.: So you are having difficulty with buying the meds?

Daughter: Not really, because I insist that each sibling pays a part. I insist!

The conversation continues with a discussion about the elderly woman’s bowel movements, the safety of the bathroom, and how to avoid falls. The daughter tells us the horror she felt when she found her mother playing with her excrement, her hands and hair full with feces. “She who was always so vain!”

Dr. C.: So, her feces are solid, right? You give Quetiapina 25 in the afternoon, and 100 at night and Citalopram 20 mg, right?

Daughter: Right.

Dr. C.: And the Selozoc.

Daughter: That’s the one for the heart, right?

Dr. C.: It’s the Metropolol.

Daughter: That’s it.

Daughter: Last Friday you gave us the prescription so I can get it at the posto [public outpatient clinic]. (…) I couldn’t get it – the only med I got at the posto [for free] was the AAS.

Dr. C.: And then I wrote [she looks into her notes] I changed the Amiloride with Hidrocloro, (...), right?

Daughter: Yes, that’s it.

Dr. C.: And the Rozucor I changed for the Sinavastatina, you have to pay for it.


Dr. C.: But The Metropolol you get at the posto.

Daughter: The ‘Metro’ I bought… They didn’t have it at the posto, so I bought it.

Dr. C.: But the AAS, the Hidrocloro.

Daughter: The Hidrocloro is for the stomach, right?

Dr. C.: The Hidrocloro is a diuretic, before it was the Moduretic. (…) That’s because the Moduretic was a combination of amiloride with hidrocloro, so I changed it, because now she is only using the Hidrocloro.

The resident turns to me and explains that the diagnosis is a probable Alzheimer’s diseaseprobable because of the many other diseases, comorbidities. It is “the cowardly disease,” says the daughter, because “she was so vain, so beautiful, always so very well dressed, nails, pedicure – even at home. And now this.”

The son G., who was sitting beside me, speaks for the first time.

Son G.: She is sleeping all the time.

Dr. C.: That was after we readjusted the medications?

Son G.: Yes. There are days she lays down, doesn’t even take the meds at night, so I try… ahm…But when she is a little more awake, I put a little bit of perfume on her, so she feels good about herself.

The old woman: screams [and says something unintelligible.

A couple leaving the geriatric unit. One of them has Alzheimer's.


As in the case of this elderly woman and her relatives, growing old in Brazil cannot be understood without taking into consideration the important role medications play in clinical and everyday life. Walking through the streets of any city in Brazil, one is struck by the high number of pharmacies (farmácias). While the World Health Organization recommends one pharmacy per 8,000 individuals, Porto Alegre, for example, the capital of one of Brazil's richer states, Rio Grande do Sul, has one for every 2,100 citizens (Pereira 2017). Some researchers speak about a “culture of medications” (cultura do remédio) in Brazil—an extreme willingness and desire to consume pills and other therapeutic products. Some researchers link this trend to the growing middle class, a higher life expectancy and the extremely rapid aging of the Brazilian population.

However, they also point to the underregulated influence of the pharmaceutical industry for the creation of the "culture of medications" (Pereira 2017). Even the current profound financial crises did not result in a decline in the consumption of medications: “In 2015, at the height of the economic crisis, the pharmaceutical market was the fastest growing industrial sector of the Brazilian economy, growing 8.3 percent while all other sectors were largely declining,” observes Patrick Burton in 2018 in the online journal Pharma Boardroom.



The conversation between the resident and the older woman’s children is predominantly about the family’s compliance with prescriptions, and it reflects the dependence on drugs as a solution. The family and the doctor mostly discuss, evaluate, and adjust an absent-minded body. They change the medications, and that, first of all, they measure against the older woman’s behavior—signs that the family interprets, and based on their accounts, the resident then analyzes. The reading of signs results in a constant alteration of medications and dosages, testing dosages in line with the progression of the disease and the effect of multiple, interacting medication—two kinds of signs that often cannot be separated from each other.

A family’s income further shapes fine-tuning in important ways. All health professionals we interviewed for our study were aware of the limited choices of available medicines for low-income familiesand the prescribing doctor carefully chooses among medications that are either free or available at lower costs through the government program Farmácia popular, steering clear when possible of expensive drugs. Some geriatricians we interviewed said that in the end, the effects of the cheaper medications are the same. However, some lamented that poor people do not get the best medications but the cheapest options—often drugs with more severe side effects than the more expensive ones.



A second point that immediately calls attention in the account about the old woman with Alzheimer’s is the large number of drugs prescribed in an unsettling flow of consecutive and abstract drug names. One can feel that the daughter gets confused sometimes (D: “The Hidrocloro is for the stomach, right?”; Dr. C.: “The Hidrocloro is a diuretic...”). It was astonishing for us the way in which family caregivers were actually able to follow the language of the resident’s questioning. Widespread pharma-literacy is a quite common phenomenon in Brazil. And although the knowledge does not always match the knowledge of a doctor, many Brazilians know a lot about medications. Constant media coverage, public health campaigns, and the prevalence of medications as an everyday topic of conversation fuels their knowledge.


The Pharmaceutical Self

The story about the older lady also points to what we want to call the “pharmaceutical self.” This concept describes the way in which others relate to the person with dementia and how she or he relates to the world through the use and the effects of medications. And although medications are not the only vectors, they play an important role in defining how others relate to who the elderly woman is and has been. At different points in the account of the elderly woman’s dementia, her social life quite easily is reduced to physiological and biochemical events. For instance, when the daughter explains her brother’s difficulty in getting his mother’s pension for his expenses (he is unemployed and lives with his mother), the resident answers: “So you are having difficulty buying the meds?”

Another example is when the daughter tells the resident about the challenge she faces in accepting the untidy, dirty parts of the life of someone with dementia. The daughter exclaims: “she who was always so vain!” and the resident answers: “So, her feces are solid, right? You give Quetiapina 25 in the afternoon, and 100 at night …” The horror of the situation described transforms into a clinical concern of possibly unhealthy bowel movements and which medications to take, even though that specific resident could be described as a caring, sensitive individual.

The tiny examination rooms. Usually doors are left open and residents and more senior geriatricians join ongoing examinations in semi-privateness.


While this clinical gaze risks reducing the old woman to merely a body in decline, other pharmacological practices more strongly seem to connect her to society. For instance, through the act of prescribing the contested specific dementia medications, the resident relates to the effect of the drugs that are supposedly connecting the old woman more to her surroundings. That effect is now measured in activities of daily living, after cognition has been abandoned as a primary therapeutic goal by the pharmaceutical industry. During the time we made our observations, these expensive dementia medications were distributed for free but only after a complex bureaucratic process, and only when the diagnosis was Alzheimer’s disease, rather than vascular or mixed dementia.


The consultation with the elderly woman and her family continued in a dramatic way. The unemployed son who was caring for his mother, but was not able to get hold of her pension, finally started to speak up, in an increasingly agitated way. He complained about the lack of recognition he received for his work, because some of his siblings and, especially one brother, were accusing him of having an easy life and of merely wanting his mother’s money. He described in detail the difficult, and sometimes disgusting, work he had to do—traditionally female work—that went unacknowledged by his family. He continued to scream, while other residents and one of the senior geriatricians came into the tiny room to try to calm the man down. The man started to cry. He had had to scream and interrupt the ritualized protocol to break out of the medication-centered consultation and make people hear his suffering. In this situation, the idea of a pharmaceutical self is not only deeply relational but life-sustaining. The lack of state interventions in Brazil, for which, increasingly, medications are used as a substitute further aggravates the dramatic situation. After this episode, the son was prescribed an anti-depressant.

Poster outside of a pharmacy, announcing the government program for free medications.


The elderly woman would not survive without the family members who care for her, since there is little available space in public assisted-living institutions. The structure of many of those facilities undermines individual ways of living, often with the help of heavy administration of medication. Other institutions like day-centers or homecare exist, but often lack funding. Private solutions like maids (empregadas) or the growing number of caregivers trained in senior citizen programs can help families deal with daily care, but this is an increasingly expensive option. Ultimately, the medicated family is both the central caregiver and patient.


Annette Leibing is a medical anthropologist and full professor at University of Montreal. Her research focuses mostly on issues related to aging, by studyingas an anthropologist Alzheimer’s and Parkinson’s in different contexts, prevention of dementia, aging and psychiatry, pharmaceuticals, elder care and, stem cells for the body in decline, among others.

Cíntia Engel is a doctoral student at the Department of Anthropology at University of Brasília (UnB). She studies dementia, medications, and caregiving in Brazil. She is currently doing a doctoral exchange program at University of Montreal.

Elisângela Carrijo is a doctoral student at the Social Work Department at Pontifical Catholic University of São Paulo (PUC). She is studying aging-related health care and social policies in Brazil. She is currently doing a doctoral exchange program at University of Montreal.


Challenges of Aging in Brazil: Getting Old Before Getting Rich


By Donald Sawyer



The elderly men without pensions or savings were trying to eke out a living selling water and juice in the streets of São Paulo. This recent image on Brazilian television drew attention to the precarious fate of the elderly. Shifting demographics create a challenge for all except the very rich. Among the middle class, everyday personal experience and conversations with colleagues in their 60’s and 70’s make clear that they are spending considerable amounts of time and money to visit and care for their elderly parents and mothers- and fathers-in-law. Great-grandparents and great-great-grandparents, rare in the past, are now becoming common. Only a minority is well-off. For the majority, getting old before getting rich is giving rise to unprecedented new challenges for families and communities, as well as government. The growing number of senior citizens can also have impacts on the economic growth and social welfare of Brazil.


While smaller families and longer lifespans are undoubtedly positive in many respects, the demographic process of changing age structure has its downsides in countries in which poverty is widespread and welfare is limited. Brazil shares many of the challenges due to aging with other countries, but there are also many problems that are specific to Brazil. There are no easy solutions in sight.


In demographic terms, the age pyramid that used to have a wide base and narrow tip is becoming heavy at the top and narrow at the bottom. By 2050, all age brackets under 60 will be smaller than the older bracket. This transformation of age structure, almost turning the pyramid upside down, is due to both lower fertility and higher longevity.


The proportion of Brazilians over age 60 has risen from 5% in 1970 to 15% in 2018 and is projected to be above 25% in 2050. That is, by 2050, one out of every four Brazilians will be over 60. Fertility was nearly 6.0 children per woman in the 1970s, but fell to only 1.8 in 2018, below the replacement rate of 2.2. At the same time, average life expectancy at birth rose from 60 years in the 1970s to 76 years 2018. Population projections show that in the higher age brackets, there will be many more women than men. Income distribution in Brazil is notoriously unequal. Both fertility and mortality are higher among the lower-income brackets.




Because of lower fertility since the 1970s at all income levels, fewer sons and daughters are now available to provide care for their aging parents, who often live into their 80s and 90s. Furthermore, younger generations have often moved to other locations in Brazil or abroad. Because of migration and mobility, many grown children living in other cities or states only see their parents on special occasions. Those left to provide support and care for their parents can be overloaded with responsibilities and costs.


The responsibilities and costs of raising one’s own children have also risen. Rather than contributing to production on family farms, as in the rural past, children now cost money for their schooling and their consumption. There are also many indirect costs. For example, because of growing concerns about security on the streets and in public transportation, many parents drive their children to school and then pick them up.


The fact that many elderly parents are widows or widowers or are now separated or divorced means that they often require more care from their children or other caretakers, rather than relying on a spouse. Some relief may be provided by the middle-age men and women who go back to live with their elderly parents after their own separation or divorce, but this is more common among the generations in their 20s and 30s, whose parents are not yet over 60. The youngsters often have children of their own, i.e. grandchildren for their parents. There is also a gender difference. Although some women can live off their former husbands’ savings or pensions, they generally live longer than men and have lower income, savings and retirement pay.


The social security system in Brazil is already under strong pressure from the increase in the ratio of dependents to active workers who make monthly contributions. People are allowed to retire at young ages, even in their 50’s, if they started working young. The situation is made worse by high rates of unemployment, now at the highest levels ever, as well as underemployment and discouragement to seek any job at all. There are too many beneficiaries for too few contributors. Because of the high political cost, previous administrations have not been able to reform the social security system. The conservative administration that took office in January 2019 puts high priority on this reform, which will probably make retirement more difficult.


Better medical attention, involving more office visits, check-ups, treatments and medicinessometimes including complex surgeryextends lifespans. However, many of these people are living longer without being healthy, especially those over age 70. The bodies of the elderly, especially of those who have lived through serious diseases or accidents, require more assistance, sometimes daily around the clock. Even so, their bodies often age better than their brains, which are increasingly vulnerable to diseases like Alzheimer’s and dementia, making them mentally unable to take care of themselves.


Photo by Jennifer Burtner.


In spite of official government policy since the health reform of the 1980s, Brazil’s state-run socialized medical system (Sistema Único de Saúde - SUS) is not able to provide sufficient health care to all citizens. There are long lines and few doctors and beds. Health care provided by official programs overloads government budgets, reducing investment and expenditures in other areas, like education, infrastructure and security. Private health plans are extremely expensive, especially for the elderly, and new plans can no longer be individual, but only for groups. They are difficult for most people to afford, making them even more expensive for the minority that pays.


The costs of private medical care, including doctors, hospitals and medicines, are very high and keep rising, while most retired people have fixed income. While labor is relatively cheap in Brazil, personal home care is expensive, especially now that it is subject to labor legislation and requirements to pay for 30-day vacations, a 13th month’s wage, social security, severance pay and other benefits. The official internet system called “e-social is too complicated for most old folks to handle. Because of limitations on hours worked, weekends and holidays, some elderly people require three or more caretakers, who in turn require professional management. Many old folks stay living alone in their family homes. Rest homes, called asilos (asylums), are very costly and culturally not well accepted.

At the same time, on the positive side, although the elderly are the most unemployed, caring for the elderly means that there are new employment opportunities for younger people who are unemployed or who have less education or marketable skills. This provides some relief now that many unskilled jobs are being eliminated by technical progress in the form of machines, computers and robots, while only a few new jobs are being created.


In many cases, lifetime savings or property, assets that used to constitute inheritance for children, grandchildren and great-grandchildren and were intended as reserves for their education, are now being spent on doctors, medicines and caretakers. That use of funds is a negative consequence for the younger generations.


Photo by Jennifer Burtner.


Because the velocity of change in information technology leads to a generation gap, many elderly people are not able to use digital equipment and social media that are increasingly required to deal with the banks, business and government bureaucracy or even to interact with family and friends. The fact that they need help with new technology means they may lose the respect of younger generations, who start playing with smartphones as soon as they learn to talk.


The disappointments about economic and political progress at the present time, which are constantly hammered in by television and the media, discourage older people who experienced what they thought to be constant progress during the decades of the late 20th century and the beginning of the 21st century. Disillusion is not good for anyone in terms of health or resilience.



In urban areas, the elderly who increasingly live in apartments instead of houses with yards and gardens often feel lack of contact with nature: trees, flowers, fruit, water and scenery. The risks of theft and violence in the streets make them stay home more than they used to.


Dona Josefa
Photo by Jennifer Burtner.


Some elderly women take up arts and crafts such as knitting, embroidery or painting, while elderly men may take up hobbies such as photography, woodworking or fishing. Increasingly, both men and women find company interacting with pets like dogs or cats, which also require care and therefore limit their mobility. There are few old folks’ communities or social activities for them to participate in activities with others of the same age.


In rural areas, the elderly are often left to care for grandchildren whose parents have moved to cities. Although there are now many more cities and towns in the interior, the rural poor may be left isolated on their empty farms or in small villages, especially when they do not have cars or motorcycles or cannot drive. There is practically no public transportation in rural areas.


Many of the elderly in the countryside can no longer perform physical farm labor on their own land or work for others. Nor can they afford to purchase labor-saving machinery like small tractors called tratoritos. Animal traction is now rare because it is slow and the horses and donkeys require constant care of their own. Lower physical capacity may make old folks feel useless, but at any rate it sets limits on their potential earnings.


What can be done to mitigate the negative effects of aging? There are various possibilities. There could be promotion of volunteer work both for and by the elderly free from the complications of labor legislation designed for male breadwinners. Their knowledge and experience could be made available to society through specific labor legislation that establishes appropriate rules for sporadic work as opposed to regular employment. They could take more care of each other. Community housing could provide collective oversight and attention without being fully institutional. While the elderly in Brazil already have legal rights to priority in lines in banks, stores and airports as well as some free transportation, there could be discounts for their health care and medicines. At the aggregate level, it would be important for more young people to get jobs, pay taxes and contribute to social security. In cultural terms, there could be more recognition of past achievements and current contributions of people born before 1950. There is no magic bullet, but there are many innovations that would go a long way to making better lives for all.


Photo by Rainer Schultz.


Now that many people are living more than 100 years, even in developing or emerging countries like Brazil, no one should bet on not being alive for decades after retirement. Nor should they count on family or government to take care of them as long as they live. This means that we all need to start to get ready for getting old during middle age or even before, whether we are rich or not.


Donald Sawyer holds a Harvard A.B. 1969 in Social Relations and Ph.D. 1979 in Sociology. He is former professor of Demography, Federal University of Minas Gerais (UFMG), and Sustainable Development, University of Brasília (UnB). He is a partner and founder of the Institute for Society, Population and Nature (ISPN),



LGBT Older Adults in Latin America: An Emerging Movement

A personal reflection on life course and leadership

By Michael Adams

Movements for social change take place in response to structural conditions that call out for action. The presence and nature of leadership is one factor that determines whether movements get started and how they fare. This article, which shines a spotlight on a budding movement with and on behalf of Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) older adults in Latin America, will focus both on the social conditions that make change necessary as well as early progress to transform the landscape. But the article will start with a brief personal reflection.

Twice over the last year I’ve found myself immersed in scenarios that would have been inconceivable to me just a few years. In October 2017, I joined a team of LGBTI activists from Bolivia, Costa Rica and El Salvador as we formed a delegation to testify before the first-ever public hearing of the Inter-American Commission on Human Rights focused on LGBTI elders. The night before the hearing our unlikely team met in the lobby of our hotel to craft our opening remarks, which would provide an overview and shared perspective of the challenges confronting LGBTI older adults in the Americas. As we sat there hammering out our approach, I couldn’t help but be struck by the significance of the moment—that this small, intergenerational band of activists (at 57, I was the oldest; my youngest colleague was in her mid-20s) was about to engineer an important leap forward in terms of the visibility of LGBTI elder issues in human rights discussions in the region.

Fast forward to August 2018 and members of this same band of activists found ourselves together in Toronto at the 14th Global Conference of the International Federation on Ageing. We watched mesmerized as Bolivian elder Sassa Almendro Zavallos defied the gender binary while performing a traditional Andean dance to open the conference’s first town hall meeting focused on LGBTI aging. In the days that followed we heard riveting remarks not only from Sassa but also from elders from Costa Rica and Brazil. It was now our elders who had taken their rightful place in the forefront of this budding movement by and for LGBTI elders in Latin America. In Toronto I could not help but marvel at how far this incipient movement had come in just a year.


Photo by Michael Adams.

LGBTI Aging Experiences

Work on behalf of LGBTI older adults, emerging in the United States and several other global north countries in the 1970s, sought to cope with social isolation and thin support networks, which had been identified as defining characteristics of LGBTI aging experiences. In the United States, LGBTI elders are often disconnected from their families of origin, are much less likely (than older people in general) to have children, and are more likely to grow old single and living alone. This global north paradigm also includes significant health disparities (including high rates of depression and other mental health issues across the full LGBTI spectrum and high rates of HIV/AIDS among gay men and transgender women), as well as disproportionately high levels of poverty that reflect the accumulated impact of lifetimes of discrimination.

These challenges combine to create a greater need for professionalized services and care. Yet, LGBTI elders in the global north often have encountered discrimination in the delivery of services and care, as well as disregard in governmental policies that structure and regulate those services. This disregard reflects the general invisibility of LGBTI older adults in the global north, even within the very LGBTI communities that elder pioneers created. Invisibility further exacerbates social isolation. While social acceptance of LGBTI people in the global north has grown markedly in recent years, this opening has been of only limited benefit to LGBTI older adults because their very existence often has gone unrecognized.

In working with leaders in the budding movement with and on behalf of LGBTI elders in Latin America, I have learned that there are both similarities and differences in the aging experiences they navigate in their countries. Among the significant similarities are social attitudes about LGBTI people and issues. Given that the life experiences of LGBTI older adults are shaped substantially by their age peers, we look to social attitudes among older adults in Latin America for perspective. In 2018, SAGE joined RIWI and ILGA (International Lesbian, Gay, Bisexual, Trans and Intersex Association) in releasing Public Attitudes Toward Aging Sexual and Gender Minorities Around the World—a 75-country survey report. The report found that while there are a multitude of regional, national and population-based variations across Latin America, on the whole social attitudes that shape LGBTI aging experiences are similar to those found in the global north. For example, support for equal rights for LGBTI people among those 55 and older ranged from a low of 59% (Peru and Ecuador) to a high of 70% (Colombia). This compares to 73% support for LGBTI equality among those 55 and older in the United States.

The limited data on LGBTI older adults from the field similarly indicates that the broad themes associated with LGBTI aging experiences in the global north also manifest in Latin America, but with significant permutations. For example, according to a series of interviews of LGBTI older adults across Bolivia conducted in 2014 by the LGBTI organization Mano Diversa, social isolation and discrimination are key issues. In that Andean country, 58% of interviewees reported living alone, with only 17% reporting stable partner relationships. Instead of living in traditional family stractures, many found housing with friends or informally “adopted” younger people. In Bolivia, 60% reported being thrown out of their homes at some point by their traditional families; 43% reported continued discrimination by their families of origin because of the interviewees’ sexual orientation and/or gender identity. Family-based discrimination is exacerbated by discrimination in the larger society. More than half of interviewees reported being subjected to workplace discrimination because of either their sexual orientation or gender identity. In a stark indication of how discrimination works at the same time against different sectors of the society, 34% reported age discrimination in the workplace, while 4% reported being discriminated against because they are from indigenous communities.

LGBTI older people in Bolivia are often quite poor because of these factors. The vast majority of interviewees in the Mano Diversa study report working in the informal economy without access to social benefits. While the life expectancy among Bolivian men (89% of Mano Diversa’s interviewees identified as men) is 69, a full 71% of the interviewees reported that they continued to work well into their 60s in order to survive financially. In 2017, the Bolivian minimum wage was $3,841 annually, and 40% report working for less than that. Health issues pose another serious threat to LGBTI older adults in Bolivia. with 29% of Mano Diversa’s interviewees saying they were HIV-positive. Similarly, less than 30% reported having access to regular health care. Access to elder services was even more scarce. Only 11% said they went to elder centers. Although nearly a quarter of the respondents —23%—said they accessed services from LGBT community centers, many said that those centers did not provide services to older adults.


Jane Barratt, Secretary General of IFA, leading Call to Action signing ceremony.


A similar 2015 study of LGBTI older adults in Costa Rica, conducted by CIPAC (Centro de Investigación y Promoción Para America Central de Derechos Humanos) found results comparable to those in Bolivia. The majority of LGBTI elders surveyed lacked family support and expressed worries about their aging future due to both discrimination and lack of awareness of the existence and needs of LGBTI elders. The majority also expressed concerns about their lack of housing options and the resultant need to rely on centers for elder care, where LGBTI elders fear discrimination. Based on a survey of elder care staff in Costa Rica conducted by CIPAC, elders’ fears of discrimination are well-founded. More than half—57%—of elder care staff surveyed by CIPAC do not believe that LGBTI older adults exist. More than one out of every four elder care staff workers—26%—consider homosexuality to be a mental illness. And 35% report that their centers would not accept an older LGBTI person.

Elders who are not LGBTI in the care centers share similar unwelcoming attitudes, according to data from the Public Attitudes survey report released by SAGE et al. For example, the Public Attitudes report found that only 34% of Latin American survey respondents 55 and older were comfortable socializing with people from sexual orientation minorities (the term used in the Public Attitudes survey to describe gay, lesbian and bisexual people). Interestingly, Latin American survey respondents indicated a slightly higher level of comfort socializing with gender identity minorities (the term used in Public Attitudes to describe transgender and gender fluid people).

While LGBTI aging experiences in Latin America share some attributes with the global north, there are also notable differences. The role of gender, for example, is quite distinct in different cultures. Just as one example, the work of Mano Diversa in Bolivia has focused on both bisexuality and older adults. Both emphases are relatively rare for LGBTI organizations; both coincide with gender experiences particular to the rural Andean region, including an historical tradition of acceptance of gender fluidity in pre-colonial indigenous cultures and a tradition of public and ritual-based cross-dressing in both rural and urban Bolivia that survives to the present. Many of Mano Diversa’s older constituents have been active, and in some cases well-known, participants in this public cross-dressing culture, including through the personage of La China Morena in Bolivian folkloric dance, as documented in Mexican artist Pablo Vargas’ Memoria 2012-2014.

Breaking Down the Invisibility of LGBTI Older Latin Americans

In recent years, important steps have been taken to begin building a movement with and on behalf of LGBTI older adults in Latin America, thanks in part to the pioneering work of national LGBTI organizations like CIPAC and Mano Diversa. That work has been complemented by a successful effort by a band of Latin American and U.S. activists to incorporate explicit sexual orientation and gender identity protections into the Inter-American Convention on Protecting the Human Rights of Older Persons, which was adopted in 2015 (see the article by Flavia Piovesan in this issue).

Recognizing the expanding opportunities for advocacy and progress, in 2017 CIPAC, Mano Diversa and other Latin American LGBTI organizations formed an alliance with SAGE to catalyze an LGBTI aging movement in Latin America. One of the early actions of the alliance was to apply to the IACHR for the Commission’s first-ever hearing on LGBTI older adults in the Americas. That hearing took place in Montevideo in October 2017 with representatives from SAGE, CIPAC, Mano Diversa and ESMULES (El Salvador) participating. The IACHR hearing helped build momentum for the alliance’s work, resulting in the crafting of a Call To Action on behalf of LGBTI older adults that is based on the Inter-American Convention; the Call was announced and launched last summer at the International Federation on Ageing’s (IFA) 14th Global Conference on Ageing in Toronto. Representatives from alliance organizations joined with LGBTI elders from Bolivia and Costa Rica to form a major presence at the IFA conference, dramatically increasing the visibility of Latin America’s budding LGBTI aging movement.


Sassa Almendro Zaballos (second from right) and fellow Bolivians.


One of the aspects of this early movement work that is worth noting is the intergenerational nature of its leadership. As was vividly displayed at the IFA conference, LGBTI elders themselves are playing a prominent role in informing and leading the work. Elder leadership has given the budding movement both integrity and rich texture. For example, the visible participation of elder leaders like Sassa Almendro Zaballos from Bolivia and Soraya Santiago from Puerto Rico have put the role of gender fluidity in Latin American cultures front and center. At the same time, young activists from CIPAC, Mano Diversa and ESMULES also have played a prominent role both in promoting LGBTI older adults as a priority for their organizations and in pushing international bodies like the IACHR and IFA to pay attention to this long invisible part of LGBTI communities.

My own experience of working in close partnership with younger activists in this movement has reminded me of the tremendous opportunities for movement-building and social change when we combine the accumulated knowledge that comes from generations of experience with the creativity, innovation and technological savvy of younger activists. The success of the alliance’s efforts at the IACHR hearing in Montevideo, for example, was the result of a multi-generational leadership effort that brought all these strengths to bear.

One major obstacle to this budding movement has been lack of resources to support the work and the inequitable distribution of the few resources that are available. For the most part, funders in the LGBTI global space have replicated the invisibility and marginalization of LGBTI older adults by failing to prioritize and support this work. As a result, organizations like CIPAC and Mano Diversa—which operate on very limited budgets—have been trying to advance an LGBTI aging agenda in their countries with very few resources.

The IACHR hearing on LGBTI older adults provided a stark illustration of the problem. While the hearing application was submitted on behalf of Bolivia, Costa Rica, El Salvador and the United States, only the U.S. organization (SAGE) had the requisite resources to pay for a representative to travel to Montevideo to present testimony. With the hearing notice issuing just three weeks prior to the hearing date, SAGE scrambled to leverage a relationship with an LGBTI global funder to secure travel funding for its sister organizations. This last-minute scramble is illustrative of the precariousness of resources available to this young movement; that only SAGE was positioned to secure the travel funds underlines the inequitable allocation of limited resources and concentration of same in the global north.

Thinking Ahead

The movement to shine a spotlight on the needs of LGBTI older adults in Latin America, while promising, is still emerging with its future depending on progress on multiple fronts. Continuing to support, develop and promote elder leadership is essential. At the same time, engagement of younger leaders also is important—a movement with and on behalf of elders who have been isolated from the rest of their community cannot succeed without breaking that isolation. Moreover, cross-regional partnering will be important in this developmental phase of the movement. Global north partners like SAGE bring important assets to the table in terms of experience and infrastructure as well as access to relationships and philanthropic resources.

Making LGBTI older adults a priority in regional and international aging discussions is essential, underlining the importance of efforts like the Call To Action. That prioritization must translate into resources—government and philanthropy must invest in LGBTI elder generations, who are responsible for so much of the progress we have made toward LGBTI equality and equity. Investment of this sort is essential if leaders of all generations are to continue building and advancing this nascent movement with and on behalf of LGBTI elders in Latin America. Together we can build a world where all LGBTI elders age with the dignity, respect and support they deserve.

Michael Adams is the CEO of SAGE, the world’s oldest and largest organization focused exclusively on LGBTI older adults. SAGE works in partnership with organizations across Latin America. Adams holds an AB from Harvard, a JD from Stanford Law School, and a Masters in Latin American Studies from Stanford University.




Long-term Care in Chile

The Faces of Dependency

By Pablo Villalobos

For Spanish, click here.

Chile is experiencing a process of accelerated population aging. This sentence is heard again and again in courses, seminars and speeches. Despite this, it does not always seem clear why aging is a problem.

Probably the dominant view so far has been the economic one. From this perspective, the problem lies in the increase of "dependency" in Chile, a term usually understood as the ratio between the inactive population (over 65 years and under 15 years) and the working population. Using this point of view, the increase in "dependency" poses a problem, since a smaller fraction of the population must pay for the "unproductive" members of society. The problem, then, is stated as one of "productivity loss" and "excessive spending;" as a result, the discussion is restricted to financing pensions and cost containment strategies in healthcare.

From a different perspective, the "other dependency"—or care dependency—addresses these same issues, understanding care as part of a broader discussion about social security. The "other dependency" refers to a condition in which a person has lost her functional capacity to a point where she cannot carry out the activities of daily living. In other words, dependents require help from another person to live their lives.

This other definition of dependency is also related to aging, although both terms are not synonymous; there are dependents who are not elderly and, at the same time, there are many elderly people who are autonomous (without dependency). However, in the current context of demographic transition, population aging is expected to be the main driver in increasing dependency, and the consequent increase in long-term care needs.

Long-term care is defined as actions taken to help people with dependency to live their everyday life. Today, there are many countries that have implemented long-term care systems in response to the growing needs of care of the population. However, in other countries—such as Chile—, the policy response to address the issue has been reactive and scarce, both in coverage and alternatives: the main strategy so far has been financing nursing homes, which currently offer services to a small fraction of the population. The bulk of the burden has been assumed by families, who have taken care of their dependents inside their homes, with little or no support from society.

Poster offering care services for the elderly in Santiago.

This article delves into this problem, emphasizing the need that the country has today to look for ways to face the challenges of aging in a systemic and sustainable way. The country has responded in a fragmented manner to a problem that, to date, seemed exceptional; today we require new solutions for these changes.


Is There Any Poetry in Aging?

Chile is a land of poetry and poets. The only two Chilean Nobel prizes the country are in laureates in Literature, both poets. Gabriela Mistral was awarded in 1945; 27 years later, in 1971, Pablo Neruda received the same distinction. Other widely recognized poets are Vicente Huidobro, Pablo de Rokha, Nicanor Parra, Enrique Lihn, Jorge Tellier, Gonzalo Rojas and Raul Zurita.

Raúl González Figueroa, born in 1931, came to swell the army of writers and poets in the country like others before and after him. Between the 50s and the beginning of the 2000s, he wrote six poetry books and a book of short stories. He received the Municipal Poetry Prize in 1972 for his work Angelica and the Butterflies.

González Figueroa could have been part of the list of illustrious poets of the country, recognized for their works. However, the reason for his recent recognition is different.

Books published by Raúl González Figueroa.

In June 2016, some of the poet's work began to circulate in the media. In particular, a fragment of his book The Mirror of the Days published in 1978, was reproduced in local newspapers:

"To remember is to find again / our forgotten body / our body / that tomorrow / will also be a memory / floating in the memory"

This beautiful verse of one of his poems was not reproduced in the newspapers’ cultural pages, but in the crime section. His name, along with the names of two other elderly men, came to light as a result of a police investigation.

On April 28, 2016, three elderly men were reported dead in a nursing home in southern Santiago. The investigations to clarify the causes of these deaths showed that, in all cases, there were signs of malnutrition and lack of care. The information published in the media revealed that Raúl González Figueroa had gone nine days without consuming any food prior to his death. He had not received the medications that were supposed to be administered. González Figueroa, who was suffering from Alzheimer’s, had been living in this residence for several months. He needed help to perform even the most basic activities of daily life, including eating.

His death reignited the alarms regarding the reality of many people, mostly older people, who have lost their autonomy and need help to live their lives, especially those who live in institutions.

Poor living conditions of institutionalized older people in Chile did not begin with the death of González Figueroa. Unfortunately, they did not end there either. From time to time, the national press publishes news related to the issue: clandestine establishments, homes in poor conditions, abuse and deaths due to neglect.

All these cases should encourage society to reflect on how the country will face an increase in long-term care needs in the coming years. This reflection should include strategies on how to ensure the quality of care institutions—homes like the one where González Figueroa died. However, it is also to think about the magnitude of this demographic change and the need to implement different ways of offering long-term care services to people with dependency beyond institutionalization. Our country must provide opportunities to people who require care, especially considering the rapid aging of the population, so they can live high-quality lives. Aging with poetry.


Who Cares for the Caregivers?

Although institutionalization has been traditionally seen as the public policy answer (in some cases only) to deal with long-term care, all countries—and Chile is not the exception—have a scheme that constitutes the backbone of long-term care: informal caregivers.

Informal caregivers are a fundamental pillar of the long-term care structure: in Chile, nine out of ten people who provide care services are informal caregivers, usually a relative who lives in the same house with the person who receives these services. The story of Ana (a fictional character) helps to illustrate what it means to be an informal caregiver in the country.

Ana, 55, has been taking care of her mother for the last eight years. At first, Ana thought that her mother's health problems were not that serious. She decided to continue working full-time and pay more attention to her mother’s routine who, for several years, lived alone without complications. Over time, her mother's condition worsened and her need for care became increasingly evident. Finally, Ana and her brothers decided that their mother could no longer live on her own.

The brothers discussed the possibilities; they all had families and jobs. They think of themselves as middle-class families: they lived a decent life, although constantly dealing with the economic situation and increasing debts. One possibility was to send her mother to a private nursing home— so-called senior suites. However, Ana and one of her brothers did not think their mother should end her days in a nursing home and they ruled out this option both on emotional and economic grounds. A government-run nursing home was out of the question; they had heard too many news about their bad conditions and problems. In addition, since many of these establishments use economic need in their selection, they probably would not be eligible either. In this situation, the only feasible alternative was that one of them would take care of their mother. The situation caused a rift between Ana and her brothers. Ana ended up taking responsibility for the care of her mother.

The bond within the caregiver-dependent pair

She stopped working, having an immediate impact on her household finances. Although her brothers help her economically, her mother's condition generates more and more expenses. One salary doesn’t go far enough with two children. Ana spends an average of 16 hours a day on activities related to her mother's care, splitting her time between preparing meals and feeding, cleaning the house, keeping her company, giving medicines, dressing and undressing, and taking her to the bathroom.

Ana says she would like to work again, but for now, that’s not a possibility. Since she started taking care of her mother, she has not taken vacations. The one time she decided to go out with her husband and children, she worried the whole time because she did not want to leave her mother alone and feared that something would happen in her absence. This situation, plus as well as the fact her mother now lives with them, has worsened their relationship with her husband.

Ana has begun to resent this lifestyle for at least two years now. She complains about feeling tired and sick, but she doesn’t have time to see a doctor; her patience is always taxed. But she feels bad about her resentment because she truly loves her mother. She thinks constantly about her mother’s death. Ana is depressed. Everything she does and doesn’t do takes her deeper into that state. She feels that every day she looks more like her mother.

Ana's story is real, even if she is a composite character. Ana is, statistically speaking, the country's average informal caregiver. Her story, although fictional, reflects the current situation of informal caregivers in Chile. The data shows a reality that today remains invisible to the eyes of society and policymakers. Long-term care is considered a private issue. a situation that occurs within the family bubble. Consequently, there is little information about informal caregivers. Without statistics, the problem is difficult to access and the solutions are difficult to design.


Towards an Integrated Response

The stories of Raúl and Ana show a face of aging that is known but we refuse to accept. Both cases reflect the way in which, until today, the country has approached the situation of people who require long-term care, making people choose between institutionalization and informality.

These cases can be seen as isolated cases, extreme situations. However, we know that, due to the accelerated process of population aging in Chile, these situations will change from being the exception to becoming an increasingly common reality.

Up until now, our society has struggled— with persistence and love—with the issue of caring for people with dependency. The rapid increase in the aging and dependent population forces us to think today about more effective, efficient and sustainable solutions. We must move towards the implementation of a national system of long-term care, which allows us to coordinate the several initiatives that have emerged over time. Additionally, this system should allow the expansion of the current supply of services, ending today’s dilemma between institutionalization and informality, and moving towards a system that provides a "continuum of care" and options.

Training activities for caregivers

It is not only a matter of providing better coverage of long-term care services in Chile but of offering both dependents and caregivers alternatives that allow them to choose what best suits their needs, in order to live their lives with dignity. Persistence and love will remain present; a long-term care system doesn’t intend to replace personal affections, but to recognize an issue that, whether we see it or not, affects us all.



Pablo Villalobos Dintrans works as international consultant working on public policy and public health. He has a background in economics, and holds a doctoral degree from Harvard School of Public Health ’18. His current research focuses on health systems and long-term care policies.

Part III: Focus on Central America

The Challenges of an Aging Society: The Case of El Salvador


By Carolina Avalos

Art by Mauro Arias


I remember vividly my trip at the beginning of the century to Morazán, the mountainous region in northern El Salvador that suffered greatly in the 12- year civil war that ended in 1992. As executive director of the government’s Conditional Cash Transfer Program (CCT), I was accompanying a group of experts sent there to collect the basic information about people who could benefit from the first social transfer program targeting families with young children and pregnant women living in villages ranked as some of the poorest in the country.


I was particularly struck by the precarious conditions of an elderly couple who lived in a one-room shack with a ramshackle tin roof. Their only bed was a hammock. The couple did not qualify for the CCT program because they did not have young children. Yet they would benefit from the planned introduction of basic social services such as drinking water. At the time of my visit, they had to drink water from a nearby polluted stream. As a result of this visit and others, I began to look into what social programs were aimed at this very vulnerable population group—the aging.


As I had feared, these programs were very few or even non-existent in rural areas. This led to the idea and later the design of the Pensión Básica Universal (Non-Conditional Social Pension) intended to benefit the highly vulnerable adult population over 70 years old living in serious poverty. To achieve this goal, we used the program of Comunidades Solidarias to help establish the foundations of the Social Protection System in El Salvador in 2009.


El Salvador, like other Latin American and Caribbean (LAC) countries, faces significant challenges in the face of its fast growing aging population. The population over 60 years of age will represent 17 percent of the total in 2030, and 20 percent of the total population in the region by 2050. We need to identify the challenges so we can develop adequate public policies based on solid evidence to prevent further social exclusion and acute poverty on this fast-growing population group.


Ortensia Palma, 74, was a street peddler when she was 15, but five years later managed to get a stall in the market where she specialized in flowers.


Life expectancy in El Salvador is estimated to double in a 100-year period (1950-2050), reaching 80 years in 2050. The steady increase in life expectancy paints a clear idea of the challenge that we already face as a society. More Salvadorans will be over 60 years (from 11.5 % in 2015 up to 24.1% in 2050), and population projections estimate that the number of elderly will double or even triple during the period 2015-2050. The aging index is estimated to jump from 42.4 in 2015 to 182.2 in 2050; the number of very elderly (above 80 years of age) is indexed to increase from 29.9 in 2015 to 38.3 in 2050, and long-term care from 3.9 in 2015 to 9.3 in 2050 (IDB, 2018).


Social and economic protections for people in the worst conditions of poverty and vulnerability help protect and promote the exercise of the human rights of these groups and to increase social and human capital. At the same time, their access to quality social services such as education, health and drinking water must be improved— measures that impact directly in the human and economic development of a country.


Cash transfer programs implemented in the LAC countries for the last two decades help establish the basis of several Social Protection Systems around the region, including in El Salvador. The design and implementation of these social protection policies is evolving and improving in areas such as institutional coordination of programs, the development of information systems, the targeting and selection of participants, monitoring and evaluation of programs, grievance systems, accountability, and above all, effectiveness.


However, social protection expenditure has not been enough to significantly reduce poverty and inequality. For instance, social safety net spending, as part of social protection, is less than one percent of the Gross Domestic Product (GDP) in El Salvador, compared to other countries like Colombia and Chile that attain percentages of 3 and 3.5 of their GDP respectively (World Bank, 2018). Almost a decade since the Pension Básica Universal (non-contributive) was established in El Salvador, only four out of every hundred persons older than 60 years of age are covered (BID 2017), representing a paltry 0.01% of GDP (World Bank, 2018).


The challenge of population aging in El Salvador is further complicated by social gaps and rifts that have not been bridged since the end of the civil war, 26 years ago. At the same time the country’s population is aging, both internal and international migration has shaped a new model of families and cities that has many implications in terms of social security and pension, health and long-term care. Young people at the height of their productive years migrate for better jobs and, in many cases, to escape violence, leaving some towns filled with elderly and children. The social security and pension services must reflect these new models. We cannot stress enough the importance of an integral reform of the social security and pension system; a system that we can qualify today as fragmented in which multiple systems co-exist and are unsustainable, with a significant tax burden and low coverage (28 % of the economically active population) in a country in which the informal sector nears 70 % of the economically active population. (Avalos, 2017)


El Salvador’s health system must also be reformed to take into account the challenges of the elderly. Many different health schemes co-exist, and the levels of inefficiency and inequity are high. The importance of an integrated concept of the health system is paramount. Its modernization through technology and information systems and sustainability requires a public-private strategic approach and partnerships among private and public sectors, civil society and communities. This is the key to improve and innovate our health system, mostly at the community level, and particularly as our response to the challenges of an aging population, in which chronic and infectious diseases, as well as long-term care, make increased economic and social demands .


Weighing the coffee beans.


The issue of long term care (LTC) becomes critical in this context. In the LAC region about eight million people (11 % of the population over 60 years of age) are dependent, using the definition of the World Health Organization in which a person is not able to carry on at least one basic task of his or her daily life. In El Salvador this percentage applies to 1.7% of the population (or 28, 000 Salvadorians) The LTC becomes a central issue in the design of integrated and comprehensive public policies that recognize the characteristics and needs of this age group, as well as an evaluation of existing informal care, both in regards to its impact and capabilities on the level of families and community.


In El Salvador, only a small percentage of the elderly benefit from a formal pension (9%), and only 4 % benefit from a universal basic pension (coverage of 4%) Around three out of 10 people over 60 live in conditions of poverty, either extreme poverty—subsisting on less than three dollars a day—or moderate poverty, getting by with three to five dollars a day. About 12% of Salvadorans over 60 live by themselves (BID, 2018).


The efforts to improve social protection and care policies for the aging are still very timid in El Salvador. However, it is important to highlight the importance of initiatives such as the creation of the Inter-American Development Bank’s Observatory on Aging and Care , which will provide relevant information for the design of policies based on empirical evidence.


This generally bleak outlook is not due to the lack of reforms, policy designs and the approval of laws to try and resolve these fundamental problems that we face as a country. The reason for the current situation is that all of the above has been carried out in a very complex social, economical and political context. On top of the ongoing process of strengthening democracy, Salvadoran society has been confronted with serious corruption problems, increasing political polarization, weak governance and institutions as well as unprecedented social violence. All these factors have contributed to slow down and even revert some of the few social advances achieved in the last twenty-five years.


To find and provide the right answers to population aging and quality of life for the elderly in the 21st century, one must study the experiences of some smart cities that have introduced innovation and used new information technologies (as well as big data) to shed more light on how to find the right answers. We have to remember that our population will be a more urban one in the coming years. According to the United Nations, more than 80 per cent of the LAC population will live in cities by 2050. This is an emerging issue in the region and some of its major cities are taking it seriously.


The June 2018 McKinsey Global Institute Report on Smart Cities: Digital Solutions for a more Livable Future reveals that the LAC region lags behind compared to other regions of the world in the implementation of digital solutions, all of which will eventually impact the quality of life for the aging . However, in the region, those cities that deploy more digital solutions and applications have made significant progress in mobility, security, health, public services, economic development, housing and community. Santiago, São Paulo, Mexico City, Bogotá, among others, lead these efforts. The Barcelona winner of the Mayor Challenge Grand Prize, Bloomberg Philanthropies, with the Vincles project is a good example. The “Vincles” project (Social Ties) is based on a collaborative approach to care, based on the use of tablets and smart phones, combining both the informal care provided by families and communities and the formal care provided by the health and social services organizations and their experts.


From this perspective, the reform of the pension system and an integrated health system, as well as the introduction of innovation and information technologies, are necessary step towards a quality leap in the care and attention, as well as prevention and long-term care for the elderly. These reforms need to integrate the mechanisms and means to assure the effective enjoyment of human rights, and a dignified life for this increasing segment of the population as well as an integral response to the future challenges that will arise.


This comprehensive and human rights approach will contribute to an effective and coherent response to such a complex issue and assure its sustainability in the long term. The foundation is there with the United Nations international instrument for the protection of the “older population and other human rights protection agreements,” as well as the Sustainable Development Goals (SDG) contained in Agenda 2030, like “No One Will Be Left Behind.In short, architecture of public policies in the framework of the implementation of the SDG, strengthening the political commitment to an inclusive approach. This new architecture, in this new context, offers us a new opportunity to achieve a turning point in sustainable human development in El Salvador.


However, if we do not resolve long-standing structural weaknesses, we cannot respond adequately to current and future problems that may emerge as a result of globalization and demographic transition. The challenges that have emerged in the 21st century could very well increase and widen social and economic inequalities. We need to give 21st-century answers to 21st-century challenges without forgetting the unresolved issues that we have inherited from the 20th century.


Carolina Avalos is an economist and international social policy advisor and former President of the Social Investment Fund in El Salvador. She was a 2015-16 Central American Visiting Scholar at the David Rockefeller Center for Latin American Studies.




The Elderly and the Revolution

Sparking a Crisis in Nicaragua

by Mateo Cayetano Jarquín Chamorro

After the Sandinista revolutionary government was voted out of power in 1990, Nicaragua mostly flew under the international radar. On the infrequent occasions that foreign media spotlighted the small Central American country, writers gushed about its potential as an up-and-coming tourist destination or the next big development success story.

The situation suddenly changed last year, when an unprecedented wave of popular protests rocked the country’s decade-old authoritarian government. President Daniel Ortega’s decision to respond with police and paramilitary violence, and his refusal to consider a democratic transition which would threaten his family’s grip on power, have mired the country in a prolonged crisis which, according to United Nation reports, has left at least 300 dead and more than 2,000 injured. Now, rather than seeing it as “the next Costa Rica,” Latin America watchers fear that Nicaragua will plunge further into chaos and threaten the rest of the region’s stability in the process. But what do the elderly have to do with it?

woman in nicaragua
Photo by Jonathan Moller

Ortega, a 72-year old former Marxist revolutionary with the Sandinista National Liberation Front (FSLN), returned to power through elections in 2006. For the following decade, most Nicaraguans—especially the country’s traditional capitalist class—apathetically condoned his family’s co-opting of state institutions, harassment of dissenters, and conspicuous efforts to create a cult of personality around the dynastic political project he shares with his wife, Rosario Murillo. Popular protests were surprisingly far and few between. Nonetheless, subsequent events proved that deep resentments were lurking just below the surface. It would only take a single spark to light the prairie fire.

It came, unexpectedly, in the form of pension cuts. On April 18, the government announced a reform to the National Social Security Institute (known by its Spanish acronym, INSS) which would reduce pension payments to retirees while increasing the amount that workers and employers must contribute to the social security fund. Unlike Ortega’s myriad violations of the country’s constitution and democratic norms, which Nicaraguans’ indifferently accepted so long as the country was stable and growing, these changes struck directly at their wallets.

The next day, Nicaraguans took to the streets in numbers unusual in the Ortega era, and protested cybernetically with the hashtag #SOSINSS to demand the reform’s abrogation. The government responded in typical fashion, attempting to smother the outbreak by sending shock troops to attack the protests and censoring media coverage of the events. This approach had worked in the past, but this time it only fanned the flames. The rest is now history: the claiming of pension rights morphed into wider political demands for a democratic transition as the Ortega regime began responding with lethal force, thrusting the country into an endless less loop of repression, protests, and further repression.

The politically costly decision to cut pensions was the result of three main factors, each of which tells us something different about the regime’s underpinnings. First, the social security fund was going bankrupt. Independent investigations suggested that the government had arbitrarily withdrawn money from the social security fund and invested it in failed state-owned businesses and development projects, including some run by Ortega’s children. During sunnier economic days, such misuse of public resources could have been papered over. But generous aid from oil-rich Venezuela—which may have totaled as much as half a billion U.S. dollars at its peak—ended in 2014 when global commodity prices dropped and the South American country fell into a severe crisis. The pension reform, along with cuts to social programs and other reductions in government spending, was also an indirect response to this external shock. Third and finally, the International Monetary Fund had advised in favor of the measure. The 21st century FSLN, having abandoned socialist economics in favor of free market policies much more to the liking of the country’s traditional elite, has closely followed the recommendations of multilateral lending institutions in implementing its growth and poverty-reduction strategies. Such organizations have tended to prioritize a balanced budget, for which they believed this austerity measure was indispensable, as a pre-condition for major loans.

Though a popular reaction was not entirely surprising, the depth of the anger and the identity of the street demonstrators raises questions. Indeed, as one of Ortega’s top advisors noted in a Univision interview given in the midst of the protests, it wasn’t senior or middle-aged citizens—those most obviously affected by changes to retirement schemes—that hit the streets. Far from it. The protests first broke out in Managua’s universities, organized by young people several decades away from retirement age. Why did students take up the cause of the elderly, and what does this phenomenon tell us about the role of aging in driving political change in    Latin America?

In developing countries where the social safety is particularly weak, even small adjustments to state pension programs can reverberate across several generations. In fact, not so many Nicaraguans actually rely on these payments; at a peak in early 2018, only 900,000 workers (one out of every four) were employed in the formal sector and therefore were registered in the INSS. Still, this significant cut in spending—which is, in effect, a tax on both workers and businesses to keep a government fund solvent—would, as private sector analysts warned, depress job creation as firms found it costlier to hire workers. Formal sector retirees are more likely to have children and grandchildren who, as members of the middle class, fill up the university halls where the protests began. Young people have good reason to be angry; when the state absconds its responsibility to care for the elderly, it falls on their progeny to eventually support them.

The material impact of pension cuts does not fully explain, however, why this tax protest evolved into something greater. The shell-shocked government actually backtracked on the reform within days, but the protests only grew in size, frequency and belligerence. While the #SOSINSS hashtag proliferated for a time, protestors began demanding the resignation of the police commissioner and the president. Clearly, the pension cuts were symbolic of larger grievances accumulated over the previous decade. To a citizen fed up with corruption and lack of transparency, the government’s self-interested use of pension funds to invest in other projects— effectively mortgaging the elderly’s future—struck a nerve. Those who bemoaned the need to affiliate with the ruling party to access certain state programs such as university scholarships or agricultural credits asked if such submission was even worthwhile. Sectors of society which had quietly looked away as Ortega consolidated a Sultanistic ruling style, such as the private sector associations, were furious that, as with most matters of public policy, nobody—not the legislature, civil society nor the elderly themselves—had any input on this decision. President Daniel Ortega and his inner circle had made the decision without consultation.

Most importantly, the governmental response showed Nicaraguans the extent to which dissent and protest had been criminalized under Ortega. Protests against the social security cuts were not motivated by opposition political parties, many of whom were perceived to be tacit allies of the ruling FSLN. But as the death toll mounted, university students—many of whom first encountered police repression when protesting the state’s inability to stop a forest fire at the Indio Maíz biological reserve—realized that they now were simply defending basic civil liberties. Demands for Ortega’s removal from power were driven by indignation over the repression, not the original policy. Those demands, predictably, engendered an even more ferocious state response. By the end of the summer, the UN human rights office reported that government repression and persecution had created a “climate of widespread terror.”

 woman in nicaragua

In other words, the episode demonstrated that the underlying problem was the closing of democratic spaces. In most societies, governments implement similar—or often more severe— austerity measures without hurling their countries into a months-long chaos. The difference is that in those countries, protests and other forms of participation are a normal feature of public life, even in less-than-democratic political systems. The pension cuts episode shows how, when you circumscribe democratic spaces to an extreme, closing off any escape valves for societal resentment, any minor injustice can degenerate into a situation of great political instability.

Perceived affronts against older citizens, at least in Nicaragua, seem to have a special ability to do so. In 2013, a smaller protest movement called #OCUPAINSS—also brutally, though not lethally, repressed—broke out when the government announced restrictions in who was eligible to receive the minimum state pension.

More than income, the relation between the elderly and political change might be summed up with one word: dignity. Like in many countries, grandparents and older workers embody familial leadership and responsibility, and therefore are viewed with special deference. They are also important vessels of historical memory, in the Nicaraguan case, one imbued with many past heroisms and hardships. Those who overthrew the Somoza dictatorship forty years ago are now retirement age. When ex-FSLN combatants and military veterans are detained or otherwise harassed by the regime, anti-Ortega citizens who identified with the Sandinista revolution are particularly incensed. As the recuperation and repurposing of revolutionary imagery and symbols against Ortega has demonstrated, young rebels are inspired by their living legends. Behind every teenager and 20-something in the barricades there was a strong anciano.  


Mateo Cayetano Jarquín Chamorro is a Ph.D. candidate in Harvard’s Department of History. He is writing his thesis on the Sandinista Revolution.

Video Interview with the Author


Mateo Jarquin is a Ph.D. candidate in Harvard’s Department of History. He is writing his thesis on the Sandinista Revolution. In this interview, he discusses how pension reform sparked protest in Nicaragua, which he uses as an insight into the politics of Nicaragua and surrounding regions. 

Crisis and Caregiving

An Intergenerational Perspective on Aging and Migration

By Kristin Elizabeth Yarris

In December 2017, I visited Managua, Nicaragua, to give a public talk at the Universidad Centroamericana (UCA) about my recently published book, Care Across Generations: Solidarity and Sacrifice in Transnational Families. Managua is a sprawling capital city where directions are still given in relation to streets and other sites damaged by a major earthquake in 1972. The city was aptly called a “ciudad chaotic” by Dennis Rodgers (in a 2008 working paper entitled An Illness called Managua).

For the week of my visit, the city seemed memorably familiar—the UCA was in session; students walked to the nearby Metrocentro mall to hang out in the welcome air conditioning; taxis and buses swarmed to pick up waiting pedestrians, and everyday life seemed to have its typical, albeit somewhat chaotic, Managua rhythm. If there was tension in the air, I might have been oblivious to it, excited as I was to reconnect with several of the families who had participated in my research study about transnational migration and intergenerational care.

One of the families I spent time with during my 2017 visit was that of Norma, one of the 24 families in my original research study, the fieldwork for which I conducted in 2009-10. Norma’s daughter, María José, migrated to New York in the early 2000s with her sister Karla, leaving her son, Jeremy, in Norma’s care. Norma lives in Cuidad Sandino, on the outskirts of Managua, in a household compound shared by her older son, Michael, and his wife and two children. Norma’s younger son, Norman, also lives nearby with his wife and two children. Now in his early 40s, is a professional driver who drives for many non-governmental organizations (NGOs) and businesses operating in Nicaragua. I came to know him in 2004, while studying for my Masters in Public Health at UCLA, as he provided transportation for the health NGO I interned with; ever since then, Norman has provided my transportation when I visit Managua.

Student protestors in front of the UCA. Courtesy of Inti Ocon/AFP/Getty

During my December 2017 visit, Norman took me to and from the UCA, family homes and other Managua locations.  He described feeling that the city was on edge, with recent public protests by students and gay rights (LGBTQIA) organizations facing strong-armed police tactics. Civil society, including foreign NGOs, was expressing growing discontent about what they viewed as repressive government interference. Norman even reflected on what he would do if things got worse, wondering how he would make a living, and where he might go in order to support his wife and two young children. He did not mention the option of his own migration, even though his two sisters have lived and worked in the United States for nearly two decades.

Perhaps because I was focused on my book talk and excited to reconnect with families from my research study, I was distracted and didn’t see how tense things were in Managua. I certainly did not foresee that, just a few months later, Nicaragua would be plunged into another cycle of political chaos, nor that Norman would be pushed to make the difficult decision to leave Nicaragua.

In my work, I seek to understand people’s experiences of migration and of aging within intergenerational and lifecourse perspectives. For me, this means considering the cumulative impacts of migration across generations on extended families and individual family members at any one point in time or historical moment. I also approach migration’s impacts on families through the lens of care, tracing how family members reconfigure care relations in response to migration and how intergenerational caregiving can sustain transnational families. Such an approach situates Norman’s decision to migrate in response to Nicaragua’s recent political turmoil both in the context of historical legacies of political violence and outmigration in the country and of his family’s experiences with migration across generations.

This intergenerational approach views migration more widely than the decisions of individuals, offering insights into the complicated emotional and interpersonal terrain navigated by members of transnational families over time. Further, an intergenerational approach reveals how people experience growing old in countries marked by high rates of outmigration like Nicaragua, where aging is associated with shifting relations of care, solidarity and sacrifice within transnational family relationships.

In Nicaragua, then, people’s responses to the current political crisis are refracted through memories and experiences of previous generations of political violence and conflict-induced migration. In other words, past historical events, such as the Somoza dictatorship and the Contra War, have a significant impact on family relations of solidarity and sacrifice, pushing families apart as some members emigrate, and yet also fostering new relations of care among those who stay in Nicaragua. 

In this way, we can conceive of the influence of generations as cohorts (following Karl Mannheim’s 1972 “The Problem of Generations” in Essays on the Sociology of Knowledge, Routledge), who share collective experiences of socio-historical events and whose encounters with contemporary challenges are refracted through memories of these past experiences. Generations can also be considered in relation to social regeneration, revealing how childbearing and childrearing organize family relations of care and membership in and across generations (child/parent/grandparent) within networks of extended kin (see Jennifer Cole and Deborah Durham, Generations and Globalization: Youth, Age, and Family in the New World Economy, Indiana University Press,  2007).

In Care Across Generations, I examine the caregiving roles of Nicaraguan grandmothers who assume primary responsibility for raising children after mothers (usually, the grandmothers’ daughters) have migrated—mostly to Costa Rica, Panama, Spain and the United States. Although the concept of “the third age” has been critiqued in cross-cultural studies of aging (for example, see Jessica Greenberg and Andrea Muehlebach, “The Old World and its New Economy, 2007 in the previously mentioned Cole-Durham volume), the idea of “la tercera edad” as signifying membership in a grandparent generation (e.g. the “third generation,” defined in relation to the earlier life stages of childhood and parenthood) is nonetheless analytically useful and corresponds with how Nicaraguan grandmothers see themselves. Thus, my intergenerational analysis of transnational family life reveals migration’s impacts on families in the present, as relations of care are reconfigured across generational lines, from migrant mother to grandmother caregiver, and as family members’ responses to migration are infused with memories and meanings from the migratory experiences of past generations.

These women approach grandmothering as a practical enactment of their solidarity with their migrant daughters as a way for them to share in the sacrifice of transnational family life. In this intergenerational framing, mothers migrate, sacrificing physical presence with their children and families for the opportunity to work abroad and send money as remittances back to Nicaragua. Children of migrant mothers also share in the sacrifice of transnational family life, taking advantage of the educational opportunities afforded by remittances to study hard and do well in school. Grandmothers, for their part, sacrifice their desire for family co-presence, assuming primary caregiving for their grandchildren, thus enabling mothers to migrate but also sharing in the intergenerational sacrifice of migration.

It is through such a perspective that I am currently following several families from my research study, staying in touch primarily through the phone application WhatsApp, attempting to understand the intergenerational dynamics of migration and care as they play out over time and in the face of current crises. One of these families is that of Norma and Norman.

When I first met Norma in 2009, she was vibrant and full of life, thriving in her role as a primary caregiver for her grandson, Jeremy, whose mother María José had emigrated to the United States with her sister Karla about a decade prior. While her daughters’ departures had led Norma into an episode of what she described as depression, she had bounced back within a few months, recuperating her job as a legal assistant for the city of Managua and buoying her mood with the busy-ness of everyday caregiving for Jeremy (aged 10 at the time). Norma found pleasure and purpose in caring for Jeremy, assuming the role of his “mamá Norma,” mothering again for another generation.

Migrants waiting to enter Costa Rica at the Penas Blancas crossing in August, 2018. Photo by El Caribe

In interviews with me in 2009-10, Norma reflected on her daughters’ migrations through the prism of her former husband’s migration a generation prior. Miguel, the father of Norma’s children, had been aligned with the Somoza regime. When the Sandinista revolutionary government seized power in 1979, Miguel fled, along with thousands of other Somocistas, for the United States. While his departure was difficult for Norma, who had to assume care for their four young children on her own, she still felt it was inevitable, a result of a shifting political climate.  However, within one year of his departure, Miguel lost touch with Norma and their children, his remittances dropping off and his communication becoming infrequent. When María José and Karla left Nicaragua a generation later, largely in response to the economic insecurity of the neoliberal period in Nicaragua (from 1990-2006), Norma feared their migration would result in a similar abandonment of their family back home. This did not come to pass, however, as Norma’s daughters established themselves in the United States, gained steady employment and obtained legal residency, which enabled them to regularly send remittances to, and maintain contact with, Norma, even now, after nearly two decades of transnational family life.

In 2009, Norma and Jeremy were also anticipating his reunification with María José in New York. So ready were they for this eventuality, in fact, that Norma had secured all the necessary paperwork for Jeremy’s visa application, and they had even managed to find winter coats and boots for Jeremy in one of Managua’s many public mercados (markets). Although a 2010 interview at the U.S. Embassy in Managua failed to grant Jeremy’s visa, due to problems with the application on María José’s end; by 2012, Jeremy’s visa was authorized and he left Nicaragua to join his “mamá María” in the United States.

In December of that year, on a return visit to Managua, I found Norma visibly affected by Jeremy’s departure. Where she had once seemed vibrant, now her 60 years of life showed in the weariness of her expression and the solemnness of her voice. She missed Jeremy, she told me, but she had to sacrifice her own desire to be with her grandson for the sake of his reunification with María José. Mindful not to repeat the parent-child ruptures that her former husband’s migration had precipitated, Norma viewed her care for Jeremy as encompassing the ethos of sacrifice and solidarity that would sustain her transnational family across future generations.

Flash-forward to June 2018, as Nicaragua plunged into political chaos, Norman made the difficult decision to emigrate, like his sisters had two decades before. Managua was turning increasingly unsafe, with the frequent tranques, (human barricades of protestors) and curfews complicating mobility in the city and with increased violence at the hands of parastate actors known as turbas. Even the UCA had become a seat of political unrest, with student-faculty protests in April 2018 leading police to fire mortars directly onto campus. (A detailed account of the factors precipitating the current crisis can be found in the 2018 report of the Comisión Interamericana de Derechos Humanos.)

 As the protests spread, economic activity ground to a halt and Norman could no longer find work as a driver. Many foreign companies have closed up and left Nicaragua—among them, the Costa Rican construction firm that had been among Norman’s key clients. One such client told Norman that, should he decide to leave, he would help him get settled in Costa Rica. Norman pondered that offer for weeks as his business dried up and it became increasingly difficult to support his family. Ultimately, with the help of María José (who sent money for airfare), Norman left Nicaragua with his wife and their two young children.  In doing so, Norman joined the more than 40,000 Nicaraguans who have fled to Costa Rica since the current crisis began, most crossing by land and lacking legal residency status in Costa Rica. (While Norman and other Nicaraguans are technically eligible to apply for asylum status on the grounds of political persecution, the cost of legal resources for the process make it outside the reach of the majority of migrants from the neighboring country.)

In a recent conversation via WhatsApp, I asked Norman about his experience in Costa Rica. He recounted the difficulties he had obtaining work, finding housing and supporting his family.  Frustrated by the impossibility of obtaining a drivers license as an undocumented migrant, Norman couldn’t work as a driver and instead drew on his personal connections with the former employer to find temporary work on a construction project. (I found it hard to imagine Norman, who would drive around Managua and environs in cleanly-pressed slacks and collared shirts, engaged in hard labor on a construction site.) Norman worked long, hard hours, returning at the end of the day exhausted to his wife, Azucena, and their children, but barely bringing home enough money to cover rent and food. To make matters worse, Norman’s six-year-old daughter was experiencing frequent bullying at her preschool and among peers on the basis of her nationality. Azucena became increasingly impatient with their situation and longed to return to her extended family in Managua. Norman wouldn’t even consider allowing her to do so without him, memories of his own father’s abandonment making family separation seem an impossible choice. Ultimately, the pressure was intolerable and, after six months in Costa Rica, Norman and his family returned to their home on the outskirts of Managua.

When I talked with Norman about his time in Costa Rica, I was curious how his mother had reacted to his migration experience. He told me that Norma reacted in her typical perfunctory manner, viewing his migration as a necessary response to political and economic insecurity—as she had similarly responded to her daughters’ and her husband’s migrations in the past. For his part, Norman considered his own troubled experience as an example of Nicaraguans’ historically complicated relationship with Costa Rica. On the one hand, Costa Rica offers a site of exile for Nicaraguans fleeing political violence now, just as it did during the 1980s, when tens of thousands of Nicaraguans sought shelter from the violence of the Contra War. At the same time, Nicaragüenses in Costa Rica face rampant discrimination, limiting their social and economic opportunities in the neighboring country. As he considers the ways in which political and familial histories repeat across generations, Norman is uncertain about his country’s and his family’a future, saying “no sé que va a pasar, no lo puedo saber” (I don’t know what’s going to happen, I can’t know.)

In thinking about Norman, Norma, and their transnational family, an intergenerational perspective reveals how migration experiences in the present refract past migratory episodes. In this sense, Norman’s trepidation about migrating reflects his fear of repeating a painful pattern of paternal abandonment that he experienced as a child after his father left for the United States. Norman tells me as much, emphasizing that “mi prioridad es mi familia, es ser padre para mis hijos” (“my priority is my family, is being a father for my children.”)  At this stage of his life, as a parent/father, Norman considers the possibility of migration in relation to this primary goal of being a caregiver and economic provider for his family.

 Of course, his considerations remain complicated as life remains hard (to use Roger Lancaster’s classic phrase about life in Nicaragua) and as Norman and other migrants and potential migrants must balance the need to economically provide for their families with their desires for physical copresence—an impossible balance, which constrains all migratory decisions. While I can not foresee the future for Norman and his family, just as I can not foresee Nicaragua’s political future, I do know that family relationships and responses to contemporary crises will continue to be understood through the prism of past experiences, for this is what an intergenerational perspective on migration and aging reveals.

All names of research participants herein are changed to protect individuals’ anonymity


Kristin Elizabeth Yarris is an Associate Professor in the Department of International Studies at the University of Oregon, where she also Co-Directs the Center for Global Health and serves on the Dreamers Working Group. Her first book, Care Across Generations: Solidarity and Sacrifice in Transnational Families, was published in 2017 by Stanford University Press. Her research and teaching focus on transnational migration and global mental health.

Aging in the Diaspora: Salvadoran Women Who Made Italy Their Home

By Donna DeCesare


Milan, Italy: Silvia Tobal prepares paper flower decorations at the Casa de la Cultura Salvadoreña in Milan, for the upcoming Flower Festival beauty pageant. Copyright © Donna De Cesare, 2018


La Deliciosa restaurant, just outside Concepcion Quetzaltepeque, El Salvador, tempts travelers with homemade gelato and pasta, as well as pupusas, tamales and other local favorites. Rosie Galdamez, the gregarious 34-year-old proprietress, spent almost eight years as a domestic worker in Milan before deciding to return to raise her Italian-born Salvadoran son near his grandparents in the village of her birth. Many, like Rosie, decide to come back to tend to seniors, but many Salvadoran seniors are choosing to age in the relative safety of the Italian diaspora.


“I have a sister in Italy who was supportive but the life there just wasn’t for me;” she says. “I suffered with so much nostalgia and work left little room for life. Here, you have family, friends and acquaintances close, not dispersed. And they have time for you. If you are sick they notice and they are generous. And I have my aging parents who need looking after as well.”


Uphill from Rosie’s restaurant, the road continues to climb overlooking cow pastures and fields of corn. Rows of traditional single-story adobe dwellings with terracotta-tiled roofs abut opulent edifices rising two and three stories. They seem incongruous, but I am reminded of Rosie’s nostalgia for home while she lived in Milan. These “villas” are emblems of diaspora success. They are also a peculiar embodiment of a common émigré desire—to return home to live an idyllic retirement in pastoral comfort with space for an abundance of guests, children and grandchildren.


Yet strangely, these casonas loom in empty silence, achingly forlorn, weathering as if aging before their time. A fleeting glance at newspaper headlines on any given day is sufficient reminder that tranquility in even the safest-seeming hamlet is fragile in El Salvador. The tentacles of roving gangs and other violent actors reach far and wide. They have made El Salvador once again a country that people flee for their lives—as many in Rosie’s village can attest.




Emigres seek safety in places where they are likely to find a familiar face and helping hand. Salvadoran migration to the United States dates back to the 1980s and El Salvador’s brutal civil war. That the elderly folks in Rosie Galdamez’s town have children in Los Angeles or Houston or Washington DC is unremarkable. What surprised me is how many also had family members in northern Italian cities and towns. I wondered just how long this Italian migration has been going on.


A year ago in Milan I began to find some answers. I interviewed three senior women, all community leaders who were pioneers from that first generation of Salvadorans who emigrated to Italy beginning more than a decade before the outbreak of the civil war. Silvia Tobal and Deidamia Moran knew each other slightly in El Salvador. They emigrated within a few years of one another in the early 1970s. Celia Landaverde (whom I was fortunate to meet before her passing on August 1, 2018), didn’t know either Tobal or Moran in El Salvador. They learned of one another by reputation and through the community work each did in Italy.


Milan, Italy: Silvia Tobal with Deidamia Moran on Mother's Day at the Oscar Romero Community celebration at the Shuster Center in Milan Copyright © Donna De Cesare, 2018


None of the women had worked in domestic service in El Salvador. None had travelled extensively in her own country before traversing 6,000 miles from San Salvador to Milan alone, each on her own maiden journey by plane. Perhaps most consequentially, none of them spoke a word of Italian. Given the exacting scrutiny they would face as live-in housekeepers, this may have been a partial blessing. Unfamiliar with the cuisine and its preparation, they were also unprepared for the expectation that chores conform meticulously to enigmatic criteria deemed a matter of common sense by their well-to-do northern Italian employers.


Finding other Salvadorans in their limited hours of weekly respite became essential to lower stress and animate their survival. For all three women this necessity became a protector of identity and an impetus to get involved in community service and to fulfil their human potential.


Landaverde began to focus on migrant labor rights as a volunteer with the Italian National Association Beyond Borders (ANOLF), later working in an official capacity as a rights educator under its alliance with the Italian Confederation of Labor Unions (CISL). Tobal focused on building community through social and popular cultural events, founding the Casa de la Cultura Salvadoreña, to promote Salvadoran popular heritage including folkloric dance, marching bands, food and language. Moran, recognizing spiritual life as a cornerstone of Salvadoran identity, forged the Oscar Romero Community at the Shuster Center. This project both engaged diaspora immigrants in support for newcomers, but sought to maintain their connection and assistance to the communities they left behind in El Salvador, even as they themselves became more established in Italy. The Catholic Shuster center campus in the northeastern Lambrate district of Milan, afforded sports fields and space for celebratory events as well a modern chapel in which to worship Salvadoran style. In addition to Spanish language, the Sunday Mass and religious observances incorporated cultural practices, rituals and hymns familiar to Salvadoran Catholics.


The stories of how Celia Landaverde, Silvia Tobal and Deidamia Moran came to be recruited for work and built lives in Italy are individually impressive, but these women were also part of a significant trend. Salvadoran migration to Italy began as a female migration occurring at a time when women from other parts of the world were also arriving to fill a niche labor demand. The northern Italian industrial boom of the mid 20th century created new wealth and social mobility for the Italian middle class as well as for the established well-to-do families.


It also meant that women from Italy’s impoverished south who traditionally migrated north for work as live-in domestic service for the first time enjoyed expanding labor options. Many preferred factory work with its greater personal freedom and the superior pay, benefits and workers’ rights protections that resulted from unionized collective bargaining. As the supply of  Italian women seeking domestic work declined, the growing demand for “family collaborators” (the official designation for domestic service in the Italian labor code), opened the market to migrant women.


Some employers began to see a financial advantage in hiring non-Italian labor. Although by law, foreign workers are entitled to the same rights and working conditions as their Italian counterparts, in reality women without language skills and knowledge of the law could be persuaded into arrangements of non-regulated informal employment. Without contractual protection and dependent on employers for lodging, an emerging class of unregulated clandestine workers were in the short term ripe for wage theft and/or abusive work schedules. In the long term, such clandestine arrangements would leave older workers without the safety net of social security. As those pioneering women of the early migration found, education, autonomy and self-care were indispensable for the paths they forged.


Celia Landaverde: Community Leadership and Immigrant Rights


Of the three Salvadoran Italian women profiled, Celia Landaverde arrived first in Italy. Born in 1948, she emigrated to the city of Milan in the late 1960s. “It was not for adventure or to look for opportunities, it was simply to survive,” Landaverde told me. As a child she was an avid student and attended a Catholic boarding school on scholarship. Just as she started 9th grade, however, her 37-year-old mother died. The impact was immediate. Celia Landaverde lost both the mother she loved and the education she craved. At age 14 she went to work assuming responsibility for her four much younger siblings. As the years passed her meager wages barely sustained them. She despaired of ever being able to honor her mother’s dying wish that all her children be educated.


“I confided in Don Juan Masaya, one of the priests at the Calvary Church which was near the store where I worked and he promised to help,” Landaverde, recalled. The well-known church in San Salvador was run by the Somascans, an Italian missionary order. Through these priests, Landaverde made contact with the Italian family who hired her and arranged her travel. “We Salvadorans didn’t need a visa for Italy so I arrived as a tourist, on a plane ticket bought by the family that employed me. They met me at the airport and took me to live and work at their home,” she told me.


Landaverde toiled for her first three years in Italy without a legal work contract. Finally, she persuaded her employers to normalize her status in 1971. She continued caring for the family’s three children for the next two years, sending what she saved by living with them to El Salvador to support her siblings and their schooling. But she found that the hours and demands of “live-in service,even if compensated to full requirements of Italian law, still frustrated her desire to attend night school. She continued to do domestic work, but sought to work an eight-hour daily schedule. Some nuns helped her find a private room to rent. Landaverde began taking classes and spending her weekends as a volunteer with Catholic Charities setting a course that led to decades of work as a union activist focused on immigrant integration and labor rights.


At first when people suggested I work with the unions I was afraid and in my ignorance tried to steer clear of them. I carried memories from El Salvador where everyone feared association with unions, because of the repression,” she explained. “But I learned that I was wrong. I started seeing how people were being abused by the clandestine labor system here. I complained to the police, but nothing happened. I couldn’t just close my eyes. It took time but finally my work with ANOLF as a volunteer led to my salaried work as an educator for the union.” Her work brought Celia Landaverde into contact with the diverse ethnicities and faith backgrounds of Italy’s immigrants. She worked equally for all, she told me. However, in the eyes of the Salvadoran community she remained their own pioneer and a trusted advisor.


The last time I spoke with Celia Landaverde was at the end of May 2018, two months before she passed away. She was at a life skills workshop for immigrants promoting social integration and civic awareness. Despite her declining health, in retirement she continued to counsel immigrants on residency requirements and regularly attended training events organized by the International Women’s Group (GDI) an ANOLF affiliate which she founded and presided over as president for 40 years.


Milan, Italy: Celia Landaverde (center) attending a workshop training of the International Women's Group (GDI) which she founded and presided over as president for 40 years. The banner behind Celia Landaverde is the emblem of the National Association of All Ages for Solidarity (ANTEAS) which is an affiliate of the retired workers of Italian Confederation of Labor Unions CISL. ANTEAS provides space in their offices for other organizations to hold meetings and workshops. Celia's group has been meeting here since her official retirement from CISL. Copyright © Donna De Cesare, 2018


It wasn’t long before a queue had formed. Well-wishers embraced her and shouted greetings; others solicited advice. With a professorial flourish she batted the compliments away as if swatting flies, but clearly relished her role and the display of regard. She huddled with an anxious man who feared being stranded in France if he travelled there with his employer and his expired resident permit. He was visibly relieved as Landaverde proffered a solution. “But you must act quickly, she said smiling while shaking her finger. Toward the end of the evening a tearful young woman, a former prosecutor who had received death threats in El Salvador, approached with a bouquet of flowers. As they embraced the woman exclaimed: “Doña Celia you saved my life. I want everyone to know that today because of your advice and support I learned that my asylum request has been granted.”


Silvia Tobal: Preserving identity for the next generation


When Silvia Tobal left San Salvador for Italy on September 7, 1972, she was 24 years old. “Looking back I think how completely unprepared I was,” she said. “The only thing I knew was that I would be caring for an elderly Italian woman.The job offer had come through Silvia’s friend Christina Rosales who was working for a family in Italy. Christina’s employer had passed Silvia’s name to a family friend who wanted someone reliable willing to commit to a three-year contract. Three years seemed a lifetime to Tobal, but Christiana begged her to come and the pay was many times what her job at the Armed Forces Cooperative in El Salvador paid. Tobal was helping to support her younger sisters so she agreed. Then almost as soon as she arrived in Italy, Christina, who was the only person Tobal knew there, decided to go back to El Salvador.


Living completely enclosed in someone else’s world, on call except when sleeping and without language to communicate or the comfort of familiar food was devastating. I never have felt so alone. I cried every day and I hardly ate,” Tobal recalls. “It was years before I ever