Respiratory failure: In memory of the late Cesaria Evora, the Barefoot Diva


Cesária Évora with the nickname of the “Barefoot Diva”, for always going on the stage barefoot, to me like many other listeners who do not even understand the lyrics of her song, was a very special singer with an incomparable heavenly voice. She is dearly missed for more than 4 years, dying from respiratory failure on December 17, 2011. Cesaria or the “Queen of Morna” or to me “Miss Perfumado”, for her popular album, was born on 27 August 1941 in Mindelo, Sao Vicente, Cape Verde and died in the same place at home surrounded by family and friends. She was popular not for a heavenly voice, or being barefoot on the stage, but smoking on the stage during the intermissions, despite the rules of the concert halls and an ambassador of Cape Verde, the rest of Africa and UN World Food Programme. She was smoking to the last moment of her life, surrounded by family and friends at her home in Cape Verde, with always open doors.

It was June 2002, when in Montreal Jazz festival, while in the morning after the first day of arrival, in a coffee shop, I heard her voice and music. I learnt her name for the first time that morning and saw her for the first time in the festival as she happened to be there. One more time, I was privileged to see her performance in Toronto, where she appeared as usual barefoot and smoked during the intermission, applauded by the audience who mostly like me, perhaps did not understand the lyrics of her songs. That , I guess did not matter as we do not understand the song of a canary or cardinal, or an angel if sings for us! Later on, I learnt her songs were about her love for her little country and Africa, that she would be homesick when she was away for short performances. Also  wishing rain that was rare for her dry homeland that in a few days will change it to a large beautiful garden. Singing for her mama to hear her, and for Africa, the cradle of the world and the fertile continent, to unite and live in peace not wars, and becoming the “United States of Africa” and realizing their capabilities,… 

Cesaria’s father, a part-time musician died, when she was 7 years old,   and at the age of 10 she was placed in an orphanage, as her mother could not raise all her six children. At the age of 16, she was persuaded by a friend to sing in a sailors’ tavern. In the 1960s, she started singing on Portuguese cruise ships stopping at Mindelo as well as on the local radio. It was only in 1985 when at the invitation of Cape Verdean singer Bana, she went to perform in Portugal. In Lisbon she was discovered by the producer José da Silva and invited to record in Paris. Évora’s international success came only in 1988 with the release of her first commercial album “La Diva Aux Pieds Nus” (The barefoot diva), recorded in France. Prior to the release of this album, Cesaria recorded her first LP titled “Cesaria” in 1987, that was later released in 1995.

Her 1992 album “Miss Perfumado”, that included one of her most celebrated songs, “Sodade” sold over 300,000 copies worldwide. Her 1995 album “Cesaria” brought her broader international success and the first Grammy Award nomination. In 1997, she won KORA, All African Music Awards in three categories: “Best Artist of West Africa”, “Best Album” and “Merit of the Jury”. In 2003, her album “Voz d’Amor” was awarded a Grammy in the World music category. In 2010, Cesaria performed a series of concerts, the last of which was in Lisbon on 8 May. Two days later, after a heart attack, she was operated on at a hospital in Paris. On the morning of 11 May 2010 she was taken off artificial pulmonary ventilation, and on 16 May she was discharged from the intensive-care unit and transported to a clinic for further treatment. In late September 2011, Cesaria’s agent announced that she was ending her career due to poor health. On 17 December 2011, at age 70, Cesaria died in Sao Vicente, Cape Verde, from respiratory failure and hypertension, while was still receiving people and smoking, in her home in Mindel, popular for always having its doors open.

Respiratory Failure:

Respiratory failure results from inadequate gas exchange by the respiratory system, so the arterial oxygen, carbon dioxide or both cannot be kept at normal levels. Respiratory failure is classified as either Type I (only with low blood oxygen level or hypoxemia) or Type II (with both hypoxemia and increased CO2 level or hypercapnia). The type I is caused is mostly acute and caused by low ambient oxygen such as in high altitudes, or ventilation-perfusion mismatch such as in pulmonary embolism, or diffusion problem like in pneumonia. Type II respiratory failure is mostly chronic, caused over time by increase airways resistance such as due to COPD (Chronic Obstructive Pulmonary Disease) & asthma; or caused by a decrease in the area of the lung available for gas exchange such as in chronic bronchitis.

Since Cesaria Evora’s respiratory failure seems to be a result of COPD due to her incessant smoking and her cardiovascular condition, the emphasis here will be on COPD that in fact is the most common cause of respiratory failure.

COPD (Chronic Obstructive Pulmonary Disease):

COPD is an obstructive lung disease characterized by long-term poor airflow, presenting with symptoms such as shortness of breath, cough and sputum production, worsens over time. COPD is caused by either emphysema or chronic bronchitis or both. Emphysema is a physical damage to the air sacs (alveoli) of the lungs, caused mostly by smoking, losing the inner walls of alveoli that eventually rupture, and creating one larger air space instead of many small ones. This reduces the surface area of the lungs and, in turn, the amount of oxygen that reaches the bloodstream. Chronic bronchitis is prolongation and recurrence of acute bronchitis that is caused by lung infections such as bacteria and viruses, or the inflammation of lung by corrosives such as smoking. A productive cough that is present for at least three months each year for two years, is chronic bronchitis that may have damaged the lungs, have caused emphysema and COPD. (5-6)

Smoking is the most common cause of COPD, while other factors such as constant air pollution superimposed on genetically sensitive lungs may play smaller roles. Poorly vented heating and air-conditioning, or smoking from frying oil cooking could also in long-term irritate the lungs, causing inflammation or susceptible to infections, then bronchitis, emphysema and finally COPD. Most cases of COPD can be prevented by reducing exposure to the risk factors, such as stopping smoking, otherwise there is no specific treatments, and respiratory failure and death will soon ensue. As of 2013 COPD affects 329 million people or nearly 5 percent of the global population, and alone in 2013, it resulted in 2.9 million deaths, with more than 90% of these deaths occur in the developing world. Therefore smoking is more an epidemic cause of COPD and respiratory failure than the cause of lung cancer as already documented elsewhere on this site. (7-8)

The complications of COPD:

COPD due to the obstruction of the airways, creates enormous resistance on the air, oxygen to get into the lungs and CO2 to get out of the lungs. This in turn exerts high pressure on the heart to pump oxygenated blood to the lungs that their blood vessels have been narrowed over time. Therefore over time, the affected blood vessels in the lungs become stiffer and thicker, causing fibrosis that further increases the blood pressure within the lungs and impairs their blood flow, causing “Pulmonary Hypertension”. In turn the increased workload of the heart causes its hypertrophy, specially of the right ventricle, making the heart less able to pump blood through the lungs, ultimately causing right heart failure. As the blood flowing through the lungs decreases, the left side of the heart receives less blood, hence less oxygen, therefore it becomes harder and harder for the left side of the heart to pump to supply sufficient oxygen to the rest of the body, especially during physical activity. Cardiovascular disease is an important comorbidity in patients with COPD, and there is good evidence that COPD is associated with increased risk of Myocardial Infarction (MI) or heart attack, with smoking multiplying such risk. At the end if the person does not die from heart attack, he or she will die from pulmonary failure as a result of pulmonary edema and pleural effusions over time. (9-11)


Cesária Évora loved to smoke to the last day of her life. She has apparently had hypertension as well, that with smoking over time added to the risk of her developing COPD, having heart attack and finally succumbing to death with respiratory failure if she was saved from her heart attack. While smoking is the major risk factor in developing COPD, 30% of individuals with COPD had never smoked. (12) So here other causes, mainly infections of the lung, e.g. bronchitis, specially when becomes recurrent and chronic, are contributing. Also only 20% of smokers will develop COPD, so making smoking not the cause but risk factor. Most recently “ciliopahty” or the pathology of cilia in the epithelial cells of the lung’s airways have been linked to the development of COPD. Cilia are important cells to maintain a healthy lung, and vital in transporting mucus and any inhaled pathogens like bacteria, up the airway and out of the lungs to prevent infection. Ciliopathy is a cellular dysfunction within the airway epithelial cells, which leads to mucus accumulation, shortened cilia cells, and impaired defenses against infection. (13) Therefore the Barefoot Diva who like to smoke, could live longer if her lung infections were controlled, so her voice would still fill our ears in delight, as she is deeply missed.

Dr.Mostafa Showraki, MD, FRCPC                                                                  Lecturer, School of Medicine, University of Toronto,Author: “ADHD:Revisited” Book/ “”/””


  1. Werb, Jessica (24 March 2006). “The Barefoot Diva on her best behaviour”. The Globe and Mail. Retrieved 21 March 2015.
  2. Cesura Evora: Cape Verde’s soulful “barefoot diva”.  The Independent. Retrieved 23 October 2014.
  3. “Grammy-winning singer ever dies at age 70″.  The Washingtion Times. Retrieved 23 October 2014.
  4. Burt, Christiana C.; Arrowsmith, Joseph E. (1 November 2009). “Respiratory failure”. Surgery (Oxford). 27 (11): 475–479.
  5. Reilly, John J.; Silverman, Edwin K.; Shapiro, Steven D. (2011). “Chronic Obstructive Pulmonary Disease”. In Longo, Dan; Fauci, Anthony; Kasper, Dennis; Hauser, Stephen; Jameson, J.; Loscalzo, Joseph. Harrison’s Principles of Internal Medicine (18th ed.). McGraw Hill. pp. 2151–9.
  6. Decramer M, Janssens W, Miravitlles M (April 2012). “Chronic obstructive pulmonary disease”. Lancet. 379 (9823): 1341–51.
  7. Vestbo, Jørgen (2013). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Global Initiative for Chronic Obstructive Lung Disease.
  8. Showraki, M. Lung cancer: Not all about smoking.
  9. Tuder, Rubin M.; Marecki, John C.; Richter, Amy; Fijalkowska, Iwona; Flores, Sonia (2007-03-01). Pathology of pulmonary hypertension. Clinics in chest medicine. 28 (1): 23–vii.
  10. Fein DG, Zaidi AN, Sulica R. Pulmonary Hypertension Due to Common Respiratory Conditions: Classification, Evaluation and Management Strategies. J Clin Med. 2016 Aug 26;5(9).
  11. Rothnie KJ, Yan R, Smeeth L, Quint JK. Risk of myocardial infarction (MI) and death following MI in people with chronic obstructive pulmonary disease (COPD): a systematic review and meta-analysis. BMJ Open. 2015 Sep 11;5(9):e007824.
  12. Eisner MD, Anthonisen N, Coultas D, Kuenzli N, Perez-Pad. Committee on nonsmoking COPD, environmental and occupational health assembly. An official American Thoracic Society public policy statement: novel risk factors and the global burden of chronic obstructive pulmonary disease. Am. J. Respir. Crit. Care Med., 2011.
  13. Shaykhiev R, Crystal RG. Early events in the pathogenesis of chronic obstructive pulmonary disease. Smoking-induced reprogramming of airway epithelial basal progenitor cells. Ann Am Thorac Soc. 2014 Dec;11 Suppl 5:S252-8.



Welcome to a new Medicine site