Can a grand vision of 4,000 free public gyms overcome inequality and fight Brazil’s health crisis? Catherine de Lange reports.
The Baptist church in Arthur Lundgren district sits perched on a hill overlooking the sprawling metropolis of Recife, north-east Brazil. It is a little after dawn as the crowd starts to gather and the local residents find themselves spots in the cobbled street and on the narrow pavements outside, squeezing in wherever they can. The air feels warm even at this hour – it’s the 13th of January, and the middle of the Brazilian summer. The women hang their handbags on the church railings. When the congregation is ready and everyone has found their spot, they all turn to the front and raise their hands to the sky. Then they bend over to touch their toes.
For almost an hour, the residents of this neighbourhood will stretch, balance, sweat and lunge. It’s hard to spot the instructor through the throng, wedged in as she is between the church wall and a parked mini camper van, her disembodied voice counting down the exercises above and around the crowd. Children, parents, grandparents – most of them in lycra shorts and trainers – have gathered today, as they do five days a week, not to pray but to work out.
This is just one of thousands of classes taking place simultaneously each morning and evening across Brazil. It is part of a bold vision that’s persuaded government officials to invest over a billion US dollars in free, safe access to regular exercise for anyone in almost every city in this, the fifth-largest country in the world.
With obesity one of the world’s biggest public health crises, policy makers around the world are beginning to realise that exercise might well be the best form of medicine. But it’s a treatment that many people are denied.
Pedro Hallal was a shy PhD student from the south of Brazil. Then, one day in 2003, he found himself invited, pretty much by chance, to an unexpectedly high-level meeting in the capital, Brasília.
It was another world for Pedro. “I went into the room and there were all these guys wearing ties. I was 21 or 22. I was really intimidated.”
The delegate list included experts in the fields of nutrition and smoking, and representatives from the ministries of health, education and sports. The topic was physical inactivity, which was just beginning to be recognised as the link between a number of major chronic diseases previously the preserve of wealthier nations – diabetes, heart disease, obesity. The Ministry of Health needed the experts to tell them one thing: how can we get people moving?
In the 1930s, about half of all deaths in Brazil were from infectious diseases, but this dropped to just 10 per cent by 2007. During the same period, the share of all deaths caused by cardiovascular disease tripled to 31 per cent. By 2008 almost half of men in Brazil were overweight.
The health problems that result from being inactive have already gripped much of the developed world. Inactivity has come to be seen as one of the biggest public health problems of the 21st century. A 2012 study published in medical journal the Lancet made headlines worldwide, showing that inactivity is responsible for more deaths each year than smoking, principally through chronic diseases such as heart disease, diabetes and cancer. And another study showed that just 15–30 minutes of brisk walking a day could add three to five years to an inactive person’s life.
For an hour and a half, Pedro sat in the room, silent, as the officials discussed what they thought was the best solution: a TV advertising campaign espousing the benefits of being more active.
But Pedro knew this wasn’t right. He raised his hand. They had it all wrong, he said. Their campaign idea was based on the assumption that people do not realise being inactive is bad for their health. But that wasn’t true.
© Thomas Slater
You would be forgiven for thinking that Brazil is the last place on earth that needs help getting into shape. In many respects, the country famed for body-conscious residents, football stars, string bikinis and beach volleyball lives up to its reputation.
At five in the morning, power walkers pace the beach-front promenades in Recife’s well-to-do districts, and long after dark, football games are played out on floodlit pitches around the country. In Brazil’s big city centres, you are never far from a private gym, which are often open 24 hours a day.
Behind the health-conscious facade, however, you’ll find a sharp dichotomy: the rich will prioritise exercise in their leisure time, but those with little means are active less and less.
More than 10 per cent of Brazilians live on just two US dollars a day, despite the fact that the country ranks fifth in the world for its number of billionaires. The richest 1 per cent of the population has the same amount of wealth as the poorest 50 per cent.
Much has been made of the government’s attempts to tidy the favelas (shanty towns) that surround Rio de Janeiro in preparation for hosting the world’s two biggest sporting events – the 2014 football World Cup and the 2016 Olympic Games – yet inequality persists. The contrast between the opulent neighbourhoods of Rio and its favelas is probably one of the most extreme in the country, but inequality is rife wherever you go.
For many, the 2014 World Cup is a missed opportunity to tackle health problems and inequality.
“If you look at the news you see, ‘Oh Brazil is the best place in the world’ – it is not,” says Pedro. “Brazil continues to face problems that are less marked and less visible than before. You still have poverty and you still have violence.”
Both of those are barriers to exercise. Research in the USA has also shown that income is a considerable obstacle to physical activity: 49 per cent of children in households with incomes under $40,000 were active in sports, compared with 73 per cent of those in households with incomes over $80,000.
Unlike those who can afford expensive memberships of sports clubs and gyms, poor people have neither the time nor the money. Pedro’s own research has found that lack of money and feeling tired were the main reasons people gave for their lack of physical activity. They often have to commute long distances for work, and by the time they do get home, exercising outside in their neighbourhoods isn’t an option – in Brazil, many streets are badly lit and unsafe. Most of the poorer neighbourhoods aren’t even properly paved, which has also proved a barrier to even simple exercise like walking.
“When you look at total energy expenditure [the poor] do more, but it’s not their choice, it’s not voluntary,” says Pedro. Sometimes people need to walk to work because there is no other way, or their work may be physically demanding. On the other hand, he says, “rich people are exercising because they want to or they think it’s important”.
These patterns are shifting. In the last decade, the country’s booming economy and the Bolsa Família, a welfare system which gives subsidies to poor families, has helped pull 50 million Brazilians out of poverty. With new economic opportunities, those who can are moving out of physical labour into more sedentary professions. They are also commuting less actively. “When poor people get some money, the first thing they do is to get a motorcycle or a car,” says Pedro.
The effect on health is beginning to show. A little extra cash brings a lot more health problems, says Braulio Cesar, a researcher at the Faculdade Estácio de Alagoas in Maceio, south of Recife, who has been working on initiatives to encourage poorer Brazilians to do more exercise. Those families that rely on the Bolsa Família subsidies are becoming more obese, he says. With more money, people have better access to food, cars and technology like computers, and they do less physical activity, he says. It’s also cheaper to eat badly because processed foods that are high in fats and sugars are often cheaper than fresh produce. When you consider the fact that Brazilian diets are commonly high in fat – meat is often eaten for all three meals of the day – it’s no surprise that hypertension, diabetes, cancer, obesity and cardiovascular disease are on the rise.
© Thomas Slater
Pedro’s academia da saúde (‘health gym’) movement began officially in 2011. But its roots go back to the early 1980s and another Pedro, physical education teacher Pedro Ivo Silveira, in Recife.
Silveira’s idea was to bring physical instructors to the streets at times when people are free to do leisure activities – before and after work. Until then, the word ‘academias’ (‘gyms’) was associated with the very rich, who could afford memberships of private fitness centres. But Silveira’s idea would come to be known as the ‘academia da cidade’ – the gym of the city, of the people.
In 1983, Silveira’s initiative led to four sites in Recife. Trained physical education professionals would turn up to run free workouts and give health advice for members of the community. “It was an immediate hit with the population,” says Eduardo Simoes of the University of Missouri, USA, who evaluated the academias for the US Centers for Disease Control and Prevention (CDC).
Although the idea was popular with the community, the initiative was a small-scale affair and a lack of political support meant it all but fizzled out completely – in two of the neighbourhoods locals decided to keep the programme running by paying the instructors themselves.
Pedro Hallal was just a baby back then. Born to a physician father and a social worker mother specialising in the care of children with Down syndrome, working in healthcare would have been an obvious career choice for him – even his two sisters are doctors. Yet young Pedro held other ambitions. Growing up in Pelotas, a city in the southern corner of Brazil bordering Uruguay, his dream was to be a footballer. And indeed it looked promising: Pedro made it to state level, playing against two-time FIFA World Footballer of the Year Ronaldinho. “We have videos of us playing,” reminisces Pedro, who’s still known today as “Pedrinho” to his friends, family and colleagues. He excelled at tennis too, also reaching state level. “I was a sportsperson all my life,” he says.
But when it came to formal trials at Flamengo, one of Rio’s leading football clubs, Pedro didn’t make the grade. The vague plan B was to study physical education and become a football coach. So, like the majority of Brazilian students, Pedro stayed at home and went to the local university – the Federal University of Pelotas. But after conducting small studies on exercise physiology and the history of sport, research piqued his interest and he stayed on to do a PhD in epidemiology. “And the one topic that connects physical education and epidemiology is physical activity and health,” he says, which led to that fateful meeting in Brasília.
All eyes turned to the young man with his hand up. Pedro picked his words carefully, building his argument on evidence.
His research team had just conducted a study, he said. When asked if exercise is good for your health, 99 per cent of respondents said yes. Ninety per cent were aware that inactivity can increase the risk of high blood pressure and over 75 per cent knew that it can cause diabetes. “These findings suggested that knowledge is definitely not the main barrier against people exercising.”
Rather than telling people they should be exercising, Pedro believes that any successful public health campaign will have to make it fun, enjoyable and convenient. “We don’t want something to be right or to tell people what they ought to do,” he says. Instead, exercise needs to be a choice that anyone can make. And it starts with giving people access.
© Thomas Slater
It is dusk when we pull up at the square in the Buriti district of Recife, and the exercise class is already in full swing. The square itself is situated by the side of a dual carriageway, the pumping dance music competing with sirens as police cars whizz through the rush-hour traffic. Two instructors lead the class and orchestrate a complex circuit – a quarter of the participants are doing a step aerobics class, a quarter doing squats and lunges using a broomstick to balance. The rest are either jogging around the square or working out using hand weights made from sand in a bottle.
Despite the mix of ages in the class, the pace and the intensity are super high. More than anything, it looks like fun.
For over 30 years, Brazil has hosted one of the largest studies of a population since birth.
Like many of the academias this one is built in an open square – they are covered if necessary, depending on the local climate. In the centre is a cemented area large enough for these exercise classes to take place, with anywhere between 20 and 60 people attending each class. Classes run twice in the morning and twice in the evening, to let people attend around work hours and to avoid the worst of the summer heat. Many of the participants I met had first got involved when they walked past a class and just decided to join in.
Around the edge is an array of simple gym equipment – abdominal benches slanting to different degrees, chin-up bars and the like – all fixed in the ground and made of concrete and metal. By making the gyms into a permanent structure, rather than simply organised classes in the street, the hope is that the surrounding equipment, which remains outside of class hours, will encourage other residents – people who don’t usually attend the classes – to take part.
This equipment always seems to be in use, mostly by men. Yet the classes I visit are predominantly made up of women. That’s a good thing, says Pedro – the most frequent users of the service are women of low economic status of an older age, “exactly those who need it most”. Official figures show that those who normally do the most exercise are young, rich and male. Kids, often the children of the women in the class, play around the periphery or mimic their parents. Teenagers circle the activity on bikes. The atmosphere in the floodlit square is charged.
This is a contrast to two years ago, says local resident Maria De Penha. “You couldn’t come here to walk because there was a risk of being assaulted.” She comes five days a week and would be there on the weekend too if only the classes ran. But she wouldn’t have contemplated coming to this place before the academia arrived.
“When the city gyms were installed, people started to use the facility and the drug dealers were intimidated and left,” says Pedro. In Recife, there are several examples of this community reclamation. In some dangerous areas, the police have agreed to work with the organisers of the academias and make themselves present in particularly shady areas during gym hours, offering an additional boost to safety.
For the academias, safety is paramount. “If we assume that a large proportion of the population works in the morning and the afternoon, then they would need to exercise in their neighbourhood in the evening,” says Pedro, “and that’s where safety does matter.” This remains a major issue for Brazil. According to figures from the OECD, 8 per cent of people in Brazil report falling victim to assault over the past year – nearly twice the global average.
The programme still has its problems with violence and crime – people trying to break into the equipment rooms, vandalism. In some poorer neighbourhoods gym sessions are still restricted by the dangers of the night. “After nine, good people stay at home,” I am told. After this time, the gym areas might still be taken over by drug dealers and people drinking.
Yet the academia members and staff I meet seem very at ease. Rildo de Souza Júnior Wanderley, a PhD student administering the academias in Recife, used to work as an instructor at one of the academias in a particularly violent area. He says the fact that the instructors are university-trained and recognised as health professionals means they command a surprising level of respect. “People would never rob a health professional,” he says. He made sure to always wear a university branded T-shirt.
I note a few teenagers lurking suspiciously in the shadows around the outskirts of the gym. I needn’t have worried – they were waiting for the class to finish. The next hour was theirs.
In 2010, when the new Health Secretary was elected in Aracaju, a city a few hours along the coast from Recife, he declared he would close all of the region’s academias and allocate the funding elsewhere. Within 48 hours there had been so many complaints through the local radio and media that he was forced to reverse the decision.
“We already suspected it was important to people but from that day on we knew it wasn’t going to close again,” says Braulio Cesar, who spent seven years at the Federal University of Sergipe in Aracaju setting up and evaluating the city’s academia programme.
In Recife, the first Brazilian city to allow citizens to vote on local government spending, the programme was picked as the top priority for three years in a row. “That was amazing,” says Eduardo Simoes, “A health promotion programme being ranked in the top three alongside emergency medical care and education – I’d never heard that before. So the programme hit a chord with the population.”
What really convinces politicians and funders is evidence. That’s why an international team, including Simoes at the CDC and Pedro working with the Brazilian Ministry of Health, has been evaluating the programmes under the umbrella organisation project GUIA (Guide for Useful Interventions for Physical Activity in Brazil and Latin America). Their initial evaluations of the first cities to adopt the academias consistently demonstrate how wide-reaching the programme’s effects on the population were. Thus far, three studies conducted in Recife have all reported positively. Phone surveys show that between 2009 and 2011 the proportion of adults who said they did no physical activity went down from 16 to 14 per cent.
Another evaluation in Aracaju found that those who were currently participating in an academia were 13 times more likely to be reaching the recommended level of activity than those who’d never taken part, showing that the scheme gets people moving who aren’t physically active otherwise. According to the study’s findings, just hearing about the academias, never mind actually taking part, seems to increase a person’s likelihood of meeting recommended levels of physical activity by 60 per cent. Perhaps most surprisingly of all, the effect is contagious – even if they’d never heard of the academias, people in an academia’s locale were twice as likely to be physically active as people who weren’t.
The most compelling findings come from the latest evaluations conducted by GUIA, which has compared not just neighbourhoods within the same city, but cities that have an academia system up and running and similar cities that don’t. The results are just being written up for publication, but they back up the previous findings. “The more the community is exposed to the programme the more activity they do – not just the users themselves but those who are involved tangentially,” says Simoes. People who see the programme in action, or hear about it from their relatives and neighbours, end up doing more physical activity than they would have done if it didn’t exist, even if they don’t themselves take part.
The gyms also connect to local healthcare facilities, offering people a free fitness assessment when they sign up and a re-evaluation every three months. Those who are flagged as having hypertension or being overweight are given a fast-tracked appointment at the health clinic, making the programmes even more popular, Simoes says, because healthcare is so limited for those who rely on the public health service in Brazil.
Researchers at the university in Aracaju also note that those in the programme use less prescribed medication, while also enjoying more obvious health benefits such as weight loss. Even when there are no physical health benefits recorded, the nature of exercise, especially outdoors and in the community, means participants often feel a huge sense of improvement in their mental wellbeing, and in their perception of health – how good they feel. Jessica-Juliana, who attends the Alto de Capitao academia in Recife, tells me that although she joined initially to improve her fitness, she’s also benefited from a huge boost in her self-esteem. Another big draw for her, and many of the other participants, is the variety of classes, which include martial arts, aerobics and dance, changing from one session to the next.
Jessica-Juliana has been attending the academia for three months. On average, people keep going to the academias for two years, although some people come and go with the seasons. Yet even those who drop out of the formal exercise classes are significantly more likely to continue exercising afterwards. That’s one of the biggest challenges, says I-Min Lee, professor of epidemiology at the Harvard School of Public Health. “I think the issue is that we have to sustain the interest. We know human beings are notoriously fickle – you are interested in something and if it doesn’t stay fresh we tend not to engage in it. These classes change so that stays fresh.”
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Yet the real success of the academias stems from the fact that once people join, they make friends and gain support from them. Jessica says she thinks of herself as a shy person, but the classes have given her the chance to meet others – and the confidence to get to know them. Studies in Brazil have found that people who have social support – whether it’s family or friends and neighbours – do more exercise. This matches research conducted in the USA, which found people who walked more often for exercise were more likely to have good social support than those who walked less or not at all.
It’s not a coincidence that a community element is a key part of the initiative, says Pedro. “What makes some people exercise and not others? We know that the social environment matters a lot. Family and friends who support you and invite you to do things with them; if you have a good social network you will be more active. We also know that some features of the physical environment are conducive to exercise.” He says that green areas and interconnected streets mean that people move more.
Simoes and Pedro are leading a much larger assessment, which has thus far collected data from over 10,000 people, comparing their health status, physical activity levels, diabetes, hypertension and other factors. Although there is still more analysis to do, they say they have evidence that not only does the intervention improve the health of those who take part, the effects even spread to those who live in a different neighbourhood.
“The findings suggest that creating a gym in a given city will increase physical activity levels of those exposed to it in the first place, and then, after some time, increase the level of physical activity of the entire population of that city,” says Pedro. Why? “Because the launch of a gym creates a physical-activity-friendly environment that makes people think more about exercise, makes them more motivated, and so on. People who see the activities get motivated by seeing it and then decide to join, or even to exercise in another place. Finally, people talk to each other, particularly in small cities. Therefore, the news gets quickly to lots of people.”
© Thomas Slater
Boa Viagem is one of the wealthiest districts in Recife, if not all of Brazil. A main road runs between the skyrise hotels and the white sand beach. Just shy of the sand is an academia, one of the original sites designated by Silveira back in the 1980s. It’s 7am and a few hundred metres away, in an area that used to be one of the poorest slums in the city, another academia is also in full swing. After a workout on the beach, the participants strip down to their swimwear and head into the sea for an aqua aerobics session. The natural water pools formed by a rocky reef along this stretch of the beach offer protection not just from the waves, but from the danger of shark attacks, which threaten the wealthier areas further up the road. As one of the PhD students showing me around points out, these people may be poor but they have other resources.
Could the academias concept work elsewhere? Perhaps. Political, social and cultural norms have a tremendous influence, says Simoes, and a big part of the programme’s success is due to its location. Brazilians, especially in the north-east of the country, are outdoor people with a focus on local community, he says. Recife is a city where there is no chance of rain for most of the year – the natural way of socialising in the north of Brazil is being outside.
“In the USA you dream of building the best house in the world. In Recife, people dream of living in the best neighbourhood in the world, of carnival and beach soccer.”
That said, the academia programme has already been exported to San Diego in the USA, where it is being run in economically disadvantaged, largely Hispanic communities. It took more than two years to adapt and set up the Californian version, which is currently being evaluated.
Regardless of social norms, we still see the same patterns in who is most likely to lead an inactive life, says Simoes. Whether in Europe, Africa or anywhere else, the people most active in their leisure tend to be relatively well-off young men. The academias are full of older, lower-income women. This programme is a marker for change, he says.
Yet the future of the academias remains uncertain. Politically, the initiative has moved jurisdiction from the Secretariat of Health Surveillance to the Department of Primary Health Care, which means Pedro and others who have been on the project for years are no longer key advisers. “They have separated the intervention from those who were responsible for making it happen,” says Pedro. “I am extremely concerned. They are taking lots of decisions that I would say are in the wrong direction.”
One is a shift in focus from physical activity to a broader use of the space – cooking classes, sports groups for teens. Although these still benefit the local communities, Pedro worries that broadening the programme reduces the likelihood of investment from politicians who won’t really understand what they are paying for, let alone how to judge its success.
Moreover, the programme itself has stalled – almost 500 of the gyms that have been funded are open, but over 1,350 have been funded but are caught up in bureaucracy and not yet built, with another 1,122 currently half-built (see map).
Pedro and his team have visited 80 of the 180 cities where the gyms were given the go-ahead in the state of Pernambuco. Flipping through photographs on his laptop, he shows me picture of all the cities where academias were promised but not delivered. Some of the sites are just wasteland or half-built. One looks like a bog. In another city, they took the gym funding and built a school on the site instead. In another, the gym has already disintegrated and been covered in graffiti.
Pedro is still confident in the model of physical activity classes in a community setting. “I think it works. But the way the model is being implemented is completely wrong,” he says. “That’s important to differentiate. In science, sometimes when something doesn’t work people immediately say ‘let’s give up and try something else’. In this case I don’t think it’s try something else, it’s try to make the original plan work – and the original plan was focused on physical activity.”
This could yet change, with an upcoming general election in October. It will be down to the new government to decide what happens to the gyms. “I think the idea of the academia da saúde is so institutionalised now that it would be weird for a new government to completely forget about it,” says Pedro. “But I would love to have a government that would make more of it. The challenge here is not to create something new, it’s to make the idea really happen.”
Pedro Hallal receives funding from the Wellcome Trust, the publisher of Mosaic.