Beyond Bad Food, Malnutrition Plagues Brazilian Hospitals

In the kitchen at Hospital Geral de Camaçari
In the kitchen at Hospital Geral de Camaçari
Phillippe Watanabe

PORTO ALEGRE â€" Sitting on the bed in her white hospital gown, Jéssica Almeida was devouring a hamburger. But the scene is deceiving. In total, the 17-year-old spent a month in the hospital and lost 10 kilograms (22 pounds).

Such weight loss, which might indicate malnutrition, is common among hospital patients in Brazil, and it increases the risk of complications. Malnutrition affects 40% to 60% of patients in hospitals across Latin America, a study published in June in the specialized journal Clinical Nutrition showed.

"When a patient is admitted to a hospital, he's being treated for his sickness but, unfortunately, concern with the patient's state of nutrition is very rarely part of the diagnosis," says Maria Isabel Correia, a doctor specialized in nutrition at the Federal University of Minas Gerais, who led the study.

This is exactly what happened to Jéssica when she entered a hospital in Porto Alegre with a rheumatic fever. "Nobody asked me anything about food."

There are different ways of checking whether a patient is malnourished. Involuntary weight loss is one of them, but alterations in eating habits can also indicate the patient is at risk, according to Correia.

Brazil's Ministry of Health has released a manual of nutritional therapy that advises specialized support staff at hospitals to give patients their full attention. Nutritional therapy includes screening, assessment of the patients at risk, evaluation of their nutritional needs, therapeutic indications and monitoring. For a patient at risk or already affected by malnutrition, there's either tube or intravenous feeding.

Hospital Suburbio â€" Photo: Govba

Losing a little weight while in hospital might seem completely unimportant, but a few kilos lost usually means that the condition is worsening, that the treatment is not working and therefore, that the patient will stay longer in hospital. It also significantly increases chances of dying. The study shows that a person with a high level of malnutrition is three times more likely to die (12.8%, but just 4.1% for mid-level malnutrition).

The research also reveals a lack of attention from hospital staff regarding patients' diet, showing a correlation between the number of days spent in hospital and malnutrition. The data shows that the longer a patient stays, the more chances he has of ending up being malnourished, from 40.2% on the first day to 55.2% after seven days, that percentage reaching 64.4% after 14 days.

Maria Isabel Correia says that the international consensus is that 50% of hospital patients are malnourished. "That's why we call it the most widespread disease in hospitals."

Jéssica first received the visit of a nutritionist four days after her admission. The next one came in the second week, after she was seen eating the hamburger. The young girl was losing weight and not eating properly.

Of course, malnutrition can have various causes, including the disease itself or the effects of certain medical procedures. Or, it can simply have to do with the patient's dislike of hospital food.

Hospital haute cuisine

To try and remedy the taste question, some hospitals, like the São Paulo Faculty of Medicine's Clinics Hospital (HC) are trying out new solutions inspired by cooking competitions like Masterchef: making plates more colorful, improve the food's texture and its presentation.

Hospital meal time in Sao Paulo â€" Photo: Mark Hillary

Beyond illness and long fasting periods to which patients are submitted, the lack of appetite regarding what they're served also plays an important part in malnutrition. "Everybody complains about hospital food," says Maria Carolina Gonçalves Dias, head nutritionist at the HC.

Many patients also need restrictive diets as part of their treatments. But being away from home is also an aggravating factor. "Hospital food is never exactly what you're used to at home," she says. The solution, therefore, is to make hospital food more appealing. And according to the nutritionist, the results are encouraging.

For Gonçalves Dias, the most important factor responsible for malnutrition in hospitals is the lack of a protocol, of knowledge about nutrition therapy. The nutritionist says the problem is not so complicated to solve, and that the fact that it persists is absurd, especially in a place like a hospital. "The patient shouldn't have to say more than just, "I'm undernourished, you need to treat me.""

Keep up with the world. Break out of the bubble.
Sign up to our expressly international daily newsletter!

Where Lockdowns For LGBTQ Meant Moving Back In With Homophobic Relatives

The confinement experience could turn brutal for those forced to live with relatives who would not tolerate a member of the family living their sexual orientation openly as a young adult. Here are stories from urban and rural India.

At a Rainbow pride walk in Kolkata, India

Sreemanti Sengupta

Abhijith had been working as a radio jockey in the southern Indian city of Thiruvananthapuram when the COVID-19 pandemic hit in March, 2020. When the government imposed a nationwide lockdown, Abhijith returned to the rural Pathanamthitta district , where his parents live with an extended family, including uncles, cousins and grandparents.

Eighteen months later, he recalled that the experience was "unbearable" because he had to live with homophobic relatives. "Apart from the frequent reference to my sexual 'abnormality', they took me to a guruji to 'cure' me," Abhijith recalled. "He gave me something to eat, which made me throw up. The guru assured me that I was throwing up whatever 'demon' was possessing me and 'making' me gay."

Early in 2021, Abhijith travelled back to Thiruvananthapuram, where he found support from the members of the queer collective.

Inspired by their work, he also decided to work towards uplifting the queer community. "I wish no one else goes through the mental trauma I have endured," said Abhijit.

Abhijith's story of mental distress arising from family abuse turns out to be all too common among members of India's LGBTQ+ community, many of whom were trapped in their homes and removed from peer support groups during the pandemic.

Oppressive home situations

As India continues to reel from a pandemic that has claimed more lives (235,524) in three months of the second wave (April-June 2021) than in the one year before that (162,960 deaths in March 2020-March 2021), the LGBTQ community has faced myriad problems. Sexual minorities have historically suffered from mainstream prejudice and the pandemic has aggravated socio-economic inequalities, instigated family and institutionalized abuse, apart from limiting access to essential care. This has resulted in acute mental distress which has overwhelmed queer support infrastructure across the country.

Speaking to queer collective representatives across India, I learned that the heightened levels of distress in the community was due to longstanding factors that were triggered under lockdown conditions. Family members who are intolerant of marginalized sexual identities, often tagging their orientation as a "disorder" or "just a phase", have always featured among the main perpetrators of subtle and overt forms of violence towards queer, trans and homosexual people.

Calls from lesbians and trans men to prevent forced marriages during lockdowns.

Sappho For Equality, a Kolkata-based feminist organization that works for the rights of sexually marginalized women and trans men, recorded a similar trend. Early in the first wave, the organization realized that the existing helpline number was getting overwhelmed with distress calls. It added a second helpline number. The comparative figures indicate a 13-fold jump in numbers: from 290 calls in April 2019-March 20 to 3,940 calls in April 2020-May 2021.

"Most of the calls we have been getting from lesbians and trans men are urgent appeals to prevent forced marriages during lockdowns," said Shreosi, a Sappho member and peer support provider. "If they happen to resist, they are either evicted or forced to flee home. But where to house them? There aren't so many shelters, and ours is at full capacity."

Shreosi says that the nature of distress calls has also changed. "Earlier people would call in for long-term help, such as professional mental health support. But during the pandemic, it has changed to immediate requests to rescue from oppressive home situations. Often, they will speak in whispers so that the parents can't hear."

Lack of spaces

Like many of his fellow queer community members, life for Sumit P., a 30-year-old gay man from Mumbai, has taken a turn for the worse. The lockdown has led to the loss of safe spaces and prolonged residence at home.

"It has been a really difficult time since the beginning of the lockdown. I am suffering from a lot of mental stress since I cannot freely express myself at home. Even while making a call, I have to check my surroundings to see if anybody is there. If I try to go out, my family demands an explanation. I feel suffocated," he said.

The pandemic has forced some queer people to come out

Sumit is also dealing with a risk that has hit the community harder than others – unemployment and income shortage. He's opened a cafe with two other queer friends, which is now running into losses. For others, pandemic-induced job losses have forced queer persons from all over the country to return to their home states and move in with their families who've turned abusive during this long period of confinement.

Lockdowns force coming out

According to Kolkata-based physician, filmmaker and gay rights activist Tirthankar Guha Thakurata, the pandemic has forced some queer people to come out, succumbing to rising discomfort and pressure exerted by homophobic families.

"In most cases, family relations sour when a person reveals their identity. But many do not flee home. They find a breathing space or 'space out' in their workspaces. In the absence of these spaces, mental problems rose significantly," he said.

Not being able to express themselves freely in front of parents who are hostile, intolerant and often address transgender persons by their deadname or misgender them has created situations of severe distress, suicidal thoughts and self-harm.

Psychiatrist and queer feminist activist Ranjita Biswas (she/they) cites an incident. A gender-nonconforming person died under suspicious circumstances just days after leaving their peer group and going home to their birth parents. The final rites were performed with them dressed in bangles and a saree.

"When a member of our community asked their mother why she chose a saree for someone who had worn androgynous clothes all their life, she plainly said it was natural because after all, the deceased 'was her daughter,'" Biswas recalls.

The Indian queer mental health support infrastructure, already compromised with historical prejudice, is now struggling

David Talukdar/ZUMA

"Correctional" therapy

In India, queer people's access to professional mental healthcare has been "very limited," according to community members such as Ankan Biswas, India's first transgender lawyer who has been working with the Human Rights Law Network in West Bengal.

"A large majority of the psychiatrists still consider homosexuality as a disorder and practice 'correctional therapy'. It's only around the big cities that some queer-friendly psychiatrists can be found," Biswas said. "The pandemic has further widened the inequalities in access to mental health support for India's LGBTQ community."

Biswas is spending anxious days fielding an overwhelming amount of calls and rescue requests from queer members trapped in their homes, undergoing mental, verbal and even physical torture. "We don't have the space, I just tell them to wait and bear it a little longer," he said.

Medical care is dismal

Anuradha Krishnan's story, though not involving birth family, outlines how the lack of physical support spaces have affected India's queer population. Abandoned by her birth family when she came out to them as a trans woman in 2017, Anuradha Krishnan (she/they), founder of Queerythm in Kerala who is studying dentistry, had to move into an accommodation with four other persons.

Isolation triggered my depression

"I am used to talking and hanging around with friends. Isolation triggered my depression and I had to seek psychiatric help." Living in cramped quarters did not help with quarantine requirements and all of them tested positive during the first wave.

What is deeply worrying is that the Indian queer mental health support infrastructure, already compromised with historical prejudice, is now struggling, placing more and more pressure on queer collectives and peer support groups whose resources are wearing thin.

During the 10 months of the first wave of the pandemic in India in 2020, Y'all, a queer collective based in Manipur, received about 1,000 distress calls on their helpline number from LGBTQ+ individuals. In May 2021 alone, they received 450 such calls (including texts and WhatsApp messages) indicating a telling escalation in the number of queer people seeking help during the second wave.

As India's queer-friendly mental health support infrastructure continues to be tested, Y'all founder, Sadam Hanjabam, a gay man, says, "Honestly, we are struggling to handle such a large number of calls, it is so overwhelming. We are also dealing with our own anxieties. We are burning out."

Sreemanti Sengupta is a freelance writer, poet, and media studies lecturer based in Kolkata.

Keep up with the world. Break out of the bubble.
Sign up to our expressly international daily newsletter!