Ribeirão Preto is a medium-sized city located in São Paulo state, Brazil, a four-hour car ride inland of the state capital. It is home to one of the oldest samba schools in Brazil, the third-largest opera house, one of the oldest and most important symphony orchestras, and one of its most beautiful university campuses. Around 700,000 people enjoy living in this vibrant town with its thriving economy and lively bar culture – the result of warm tropical evenings tempting people out of doors.
Ribeirão Preto is also Brazil’s first and until recently its only Angels City, a distinction it gained on World Stroke Day 2023 when it was officially named a safe city for stroke. There are now two Angels Cities in Brazil and by the time you read this, there’ll be three or perhaps more, as Angels team leader Kamila Fachola rolls out the strategy that will some day be part of her legacy.
The concept for Angels Cities arose out of the realisation that the stroke patient’s journey begins and ends in the community, not in the ambulance or in the emergency ward. For stroke patients to have the best outcomes, their city or region has to optimise delivery at every stage of the journey. This means: an informed public able to recognise the symptoms of stroke, emergency transport to the right hospital, acute treatment that meets the highest standard, and finally, a discharge system that supports the patient’s reintegration into the community.
Such an end-to-end transformation would require a tailormade strategy, Kamila realised. “We’d been working with hospitals to improve their stroke care, talking to the EMS, talking to teachers about the FAST Heroes awareness campaign . . . But we did all these things separately; they didn’t work together. So in one region you might have an awareness campaign but an underperforming hospital – or an amazing hospital but the EMS wasn’t good. It didn’t make sense to approach them as separate projects. We needed to implement all our projects simultaneously and transform the entire pathway to really change the reality for the population.”
Choose the right city
If you were to ask Kamila for pointers on how to build an Angels City, she would give you three pieces of advice, the first of which would be to choose the right city. “Start with the good cities,” she says. Working with a city that already meets at least some of the criteria to become an Angels City, “shrinks the change” – a tactic borrowed from the Switch theory of change that motivates people to take action by showing them the finish line is closer than they thought.
That is the reason she chose Ribeirão Preto for her pilot project – a city whose stroke referral hospital, Hospital das Clínicas de Ribeirão Preto, already had two gold awards and would reach platinum in the next two quarters. Its EMS service, Samu Ribeirão Preto, was also very good, although to meet Kamila’s minimum criteria for Angels Cities, they would have to pick up an EMS Angels gold award. Awareness would be measured by the rate of implementation of FAST Heroes in the city’s elementary schools. Progress in respect of rehabilitation would be harder to quantify, but Ribeirão Preto already had a large facility where stroke survivors could access therapeutic services, so Kamila ticked that box.
Mobilise the politicians
Ribeirão Preto was the right city for another reason – it had a mayor who understood both the challenges and the opportunities and who was excited about becoming the political head of an Angels City. When he heard that stroke and not heart disease was the biggest killer in the region, he agreed that change was necessary and urgent.
“There has to be a political force to make this happen,” is Kamila’s second piece of advice. Elected politicians are easily persuaded by the prospect of leaving a legacy; and achieving recognition ahead of other cities and regions is a winning look that plays well during municipal elections.
Aided by a well-connected neurologist at Hospital das Clínicas de Ribeirão Preto, a meeting was arranged with stakeholders including the directors of hospitals and the EMS, where the importance of having an integrated system – and being recognised for it – was agreed.
Start the clock
Besides getting Samu Ribeirão Preto to gold status in the EMS Angels Awards, Angels Cities criteria required the implementation of FAST Heroes awareness campaign throughout the city’s public school system. The mayor again rose to the occasion – he didn’t just make FAST Heroes implementation mandatory in public elementary schools, but signed an order that would bind his political successors to this commitment.
Ribeirão Preto had set itself an ambitious goal: to reach Angels City status within four months. Fixing a deadline is Kamila’s third piece of advice, and the city had chosen an auspicious one – the ceremony marking them as a safe city for stroke would take place on World Stroke Day, 29 October. Before then the EMS would have to collate and report their Q3 stroke patient data, and the FAST Heroes campaign had to be rolled out to 4,000 children in 41 schools.
It meant a tight schedule for everyone including Kamila who had pledged her support at every step of the way and now found herself traveling to Ribeirão Preto every week.
A safe city for stroke
No-one was surprised when October brought the news that Samu Ribeirão Preto had won not a gold but a diamond award.
The celebration on World Stroke Day was a big one, bringing honour to everyone who had helped Ribeirão Preto become an Angels City. But the real meaning of being a safe city for stroke revealed itself one week later, when a small child dialed 192.
“I am here with my grandma,” the little girl told the operator. “I think a clot is attacking my grandma.”
Thanks to her little FAST hero, the patient was quickly transported to the hospital where she was immediately attended by the very same neurologist who had played such a key role in the Angels Cities project. After treatment with thrombolysis and mechanical thrombectomy, grandma was good as new, ready to be discharged into a community that was prepared to support her recovery.
All for one
The power of the Angels Cities project is that it sets one goal to be achieved by everyone, Kamila says. “If one doesn’t do it, then no-one can do it.”
The second city in Brazil to officially become Angels City was Sapucaia do Sul, a small city in the state of Rio Grande do Sul with just 200,000 inhabitants and a single hospital that already ticked every box. Next on Kamila’s list was Curitiba, capital of Paraná state in southern Brazil, where two out of five stroke referral hospitals already held gold status.
Curituba has been recognised for sustainable urban development; it has a low crime rate, is a drawcard for investors, and has been named (by Reader’s Digest) as the best “Brazilian Big City” in which to live. Once it becomes an Angels City, its 2 million inhabitants will have even more to be proud of.
Kamila is already thinking about how to convert an even bigger city like São Paulo which, with over 12 million inhabitants, is the most populous city outside Asia.
“It must be possible to change big cities,” Kamila muses. One city at a time – that’s how you create a safe planet for stroke.
