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In 2019, a 26-year-old from São Paulo lost his job. Having a young son to raise, he went to work as a driver for transportation applications. Each month, he rented a different car and spent more than 12 hours a day in it to cover expenses and make a profit. One day he began to cough, then expectorated, but did not have time to go to the doctor or hospital. He ended up dying “a victim of a simple disease, which is treated with a common antibiotic,” reports pathologist Paulo Saldiva, from the Faculty of Medicine of the University of São Paulo (FM-USP), who spoke with the widow.
Differences in income, urban infrastructure, gender, race, and public health organization are critical in determining who gets sick, who succumbs to a particular disease, where the diseases will appear, and who will have the economic consequences. They are the social determinants of health, a concept used by health professionals, epidemiologists, and family doctors to designate both the non-direct biological causes of diseases and well-being.
In the same city, the poor distribution of health funds, different urban conditions and social segregation can also be decisive for the appearance of diseases. With the arrival of Covid-19, the spread of the disease to the peripheries soon became a central concern.
The first cases in Brazil were found in central neighborhoods with the highest purchasing power in São Paulo. According to the Covid-19 Bulletin, published on April 17 by the São Paulo City Council, Morumbi, a high-class district in the southern zone, continues to have the highest number of confirmed cases: 297. But there are already more deaths in districts such as Brasilândia (54), in the north, Sapopemba (51) and Cidade Tiradentes (37), in the east. In Morumbi, there are seven deaths.
“The risk of dying prematurely in the city of São Paulo, today, depends more on the postal code [CEP] than the genetic code, “says Saldiva. Pointing to a map of the incidence of cardiovascular disease in the municipality, the researcher shows that the numbers are worse in the peripheries, with the exception of Brás, a central neighborhood with a high concentration of homes secondary and immigrants living in precarious conditions
“If I know the distance from the center where a person lives, their skin color, gender, socioeconomic level and level of education, I explain 62% of the variability of these diseases,” he says. “In other words, in medical school, I teach only 38% of what is necessary to prevent death.”
Epidemiologist Rita Barradas Barata, from the Faculty of Medical Sciences of Santa Casa de São Paulo (FCM-SCSP), points out that, since the current pandemic coronavirus is a new infectious agent, “the entire population is susceptible and no one has prior immunity. ” That is, in principle, there would be a certain level of risk. On the one hand, the elderly, who have been the most vulnerable group, are proportionally more frequent in the highest income groups. On the other hand, pre-existing diseases are more present among the low-income classes. “All social strata are vulnerable, but living and health conditions are very uneven in the country and this, yes, can be a problem,” he points out.
Barata cites the agglomeration of households, predominantly in the urban peripheries, where the poorest populations live. “This is an element that can greatly facilitate the transmission of any respiratory disease. And, therefore, it must occur in the case of the coronavirus,” he says. “The worst food conditions, a higher prevalence of chronic diseases without adequate control, such as diabetes, hypertension and obesity, can increase the risk for the poorest populations, not to mention the enormous impact of cessation of work activities and sources of income for the vast majority of the poor population is causing “, warns. Even social isolation, recommended to protect against the virus, is more difficult in these neighborhoods than in central areas, where homes are larger and have better infrastructure.
Léo Ramos Chaves Diseases caused by poor housing conditions, such as that observed in some regions of Diadema, in Greater São Paulo, impact the economy Léo Ramos Chaves
Agglomeration and sanitation
Data from other diseases, already present in Brazil, suggest that some neighborhoods in some Brazilian cities have too high an exposure to respiratory diseases. One of the highest incidences of tuberculosis, for example, occurs in the Rocinha favela, in Rio de Janeiro. There are 372 cases per 100,000 inhabitants, while the country’s average is 34 per 100,000. In 2010, some blocks of Rua 4, within the favela, were urbanized, with access to the water and sewerage network, in the context of the Growth Acceleration Program (PAC). In this area, the disease has almost disappeared. Elsewhere on Calle 4, the incidence remains high. This fact explains how the concentration of people in small spaces favors the spread of the disease, which also makes it occur frequently in overcrowded prisons in the country. Income and housing inequality is reflected in the country’s racial inequality data: in 2016, 63.7% of tuberculosis cases were found in the black population, according to data from the Ministry of Health.
The same is true with pneumonia. “Mortality from pneumonia is very high in Brazil. Every year around 80 thousand lives are lost, most of them of advanced age,” says epidemiologist Maria de Fátima Marinho de Souza, consultant to the Ministry of Health in the study “Carga global disease in 2017. ” The survey data, conducted between 2015 and 2017 and based on various public databases, show that the disease has caused more deaths in recent years, even among newborns. “There is no way to expect the data to improve, because poverty continues to increase, social programs have been reduced, the health system has suffered cuts in resources. With the end of the Mais Médicos program, we lost many professionals who worked precisely in the most vulnerable areas. It is the scene in which the new virus begins to circulate, “he warns.
In addition to respiratory diseases, other diseases persist in Brazil for health reasons. “How many times the diarrhea is not caused by the unhealthy environment? If the water accessible to the population is contaminated, there will be more diarrhea. Doctors can treat it with medicines, but without looking at the social determinant, the problem will not be solved”, he argues. Marine
“Now, extreme poverty has increased again in Brazil and deaths from diarrhea have increased, which also causes a spike in infant mortality. This implies loss of health, because even those who do not die are weakened and may be victims of the next disease, “he observes
Faced with the advance of the Sars-CoV-2 virus, without access to quality hospital services, the population of the periphery and slums has created its own mechanisms of solidarity and dissemination of information. This is the case of the “Favela sem corona” network, established in Rio de Janeiro to strengthen prevention, facilitate food donations and face the consequences of social isolation, such as depression, for example. Entities such as the Central Unica das Favelas (Cufa) and the Movement of Homeless Workers (MTST) organized information campaigns and food collection.
The Association of Residents of Paraisópolis, a community in southern São Paulo, hired a medical team on their own to try to stop the spread of the virus. “Numerous solidarity actions have emerged in recent weeks to serve this population. However, no matter how difficult they are, these networks are limited in scope. Issues such as the mass distribution of masks and hygiene kits, basic baskets, medicines and the installation of field hospitals only the State can guarantee “, observes the sociologist Tiaraju Pablo D’Andrea, coordinator of the Center for Peripheral Studies of the campus east side of the Federal University of São Paulo (CEP-Unifesp).
In late March, CEP-Unifesp published the document. Proposals for urgent measures to contain Covid-19 in the peripheries. The 23 items are varied and reveal the challenges that peripheral areas have faced with the arrival of the pandemic. Ten measures are inexpensive, such as suspension of rent and taxes, and maintenance of school meals. So far, D’Andrea says, the three-month suspension of water and electricity rates in the São Paulo favelas has been the most important government measure to protect these populations.
Similar steps have been taken in several states. “In Brazil, making the necessary decision of physical isolation without observing the marked social, racial and class differences means that the decision is not completely effective. In order for them to move away from activities that earn their living, the most vulnerable need to be supported “he warns.
Other measures refer to access to water, with water trucks in communities without sanitation, the installation of field hospitals and the fight against gender violence. Domestic violence cases have been on the rise since the enactment of social isolation. According to information from the Women’s Ministry, complaints of assault in Ligue 180 increased by 9% between the first and the second week of March. The ministry also reported that complaints of domestic violence in the state of Rio de Janeiro increased by 50% in the period. According to D’Andrea, “in the current scenario, these women are less likely to access the legal means instituted to protect them.” The sociologist reports that, with the publication of the measures, which were presented to the city council and the state government, there were contacts of councilors and state deputies interested in carrying out the proposals.
Favela Valinhos, Rio de Janeiro: agglomeration of homes where the poorest populations live. Photo: Léo Ramos Chaves
Social determinants
The relationship between health and social conditions began to be studied by medicine in the 19th century. “The state of health is indissoluble by the way in which societies are organized and, therefore, by the way of life of individuals and social groups,” says Barata. Little by little, the understanding of the social determinants of health grew.
At first, the research showed only the effect of poverty on the incidence of the disease, “given the abominable conditions in which workers lived at the time of the Industrial Revolution,” says the Santa Casa researcher.
Later, “the researchers discovered that not only poverty caused illnesses, but, in general, the social position of individuals, with their degree of wealth, power and prestige, that is, the relative differences between groups also began to be seen as important to explain health inequalities, “he observes.
“At the end of the 20th century, other social relationships, such as those established between genders, ethnic groups, groups with different identities and sexual orientations, were also included as determinants of health,” he adds.
The Zika fever epidemic, which affected Brazil between 2015 and 2016, with the greatest weight in the northeast region, had a particularly greater weight in women, as shown in the research “Social and economic impacts of virus infection of Zika “, presented in 2018 by the Oswaldo Cruz Foundation (Fiocruz), in association with the Federal University of Pernambuco (UFPE) and the London School of Hygiene and Tropical Medicine, in the United Kingdom.
Having to care for children affected by congenital virus syndrome, popularly known as “microcephaly,” they were forced to give up their jobs and personal projects. Data from the Secretary of State for Social Development of Pernambuco reveal that 70% of the mothers were young people between the ages of 14 and 29 and 77% were black, with 57.3% of the affected children belonging to families supported by the help from Bolsa Família.
Gender was also decisive in the Ebola epidemic, which attacked Liberia, Sierra Leone and Guinea, in Africa, between 2013 and 2016. Anthropologist Denise Pimenta, PhD from the Faculty of Philosophy, Letters and Human Sciences at the University of São Paulo (FFLCH- USP) coined the expression “dangerous care” to refer to the death of women in these countries. In fact, in those countries, there were more deaths of women than men during the epidemic, and Pimenta argues that the reason lies in the role reserved for them, as caregivers of the sick. The results were published in the thesis “Dangerous care: plots of affection and risk in Sierra Leone”, defended in 2019.
In the central region of São Paulo, a homeless man wears a mask to prevent contamination by the new coronavirus. Photo: Léo Ramos Chaves
Public politics
“Globally, there is a great problem of articulation of public policies between different spheres of government. Health policies must take into account the place where they will be applied, in order to be able to treat differently differently,” says the pediatrician. and Paulo Buss, the general coordinator of the Fiocruz Center for International Relations.
“In Brazil, for example, the situation of blacks is much worse than that of whites. The racial issue involves employment, health, education, and sanitation policies. The same is true of gender and the difference between the center of cities and rural periphery. Health policies have to respond to these inequalities, “he says. Dengue, in turn, affects more areas with open sewage and lack of access to drinking water.
“Each specific problem has its social determination. Whoever lives in Ipanema, with a good health plan, obviously has more access to hospitals than a family that lives in Duque de Caxias, in Baixada Fluminense,” he summarizes, adding that the elderly incidences Malaria is found on the outskirts of large cities and in isolated populations in the north of the country.
Adjusting public policies to the social determinants of health is not always a trivial task, says Fátima Marinho, citing the case of the Pact for Health, which imposes improvement objectives on various indicators in states and municipalities, under penalty of federal intervention or cut of resources. One of the indicators is that of gender violence, which generated a deadlock among the municipalities with the lowest population.
According to the 2006 Health Pact, municipalities must report the facts to the federal government. However, municipal officials resist, not in principle, but in circumstantial aspects.
“The aggressor feels threatened by the aggressor, since it is an environment in which everyone lives, everyone knows each other. It is not like in big cities,” explains Marinho. “When a pediatrician sees a child who has been abused in a rural area, if there is a complaint, the aggressor knows who reported him, because the doctor comes to that position only once or twice a week.
Municipalities complain that this puts health professionals at risk, “he reports. In Brazil, medical care for victims of sexual violence is regulated by Law 12,845 of 2013. Since 2006, the Ministry of Health has a surveillance system for Violence and Accidents, with the aim of improving the notification of cases.
Beyond social
“When I speak of social determination, I am speaking of politics, economics, the environment and the social itself,” Buss explains. According to him, the economic determinants go in two directions: both economic inequalities that cause effects on the incidence of diseases and illnesses that affect the economy.
The economic paralysis resulting from social isolation, in the case of coronavirus, can be considered an extreme case of economic impact, but deaths and diseases caused by pollution in large cities and diseases caused by poor housing conditions also affect the economy. . In 2012, the USP Air Pollution Laboratory, coordinated by Saldiva, calculated that a 10% reduction in pollution in the municipality of São Paulo would save 114 thousand lives, which would correspond to savings of R $ 10 billion.
The pandemic is now expected to have a strong economic impact, especially among the poorest. In an editorial published by the magazine. The lancet, the last two Nobel Prize winners in economics, economists Faheem Ahmed, Na’eem Ahmed, Christopher Pissarides, and Joseph Stiglitz estimate that each percentage point of decline in world Gross Domestic Product (GDP) caused by the Sars-CoV- 2, will throw 10 million people into poverty.
However, it is not yet known how severe the recession will be, nor how long it will last. The Economic Commission for Latin America and the Caribbean (ECLAC) estimated that Latin American economies are expected to shrink by at least 1.8% this year, but it does not rule out that the drop in the region will reach 4% of GDP. The data is found in the report “Latin America and the Caribbean facing the Covid-19 pandemic: economic and social effects”.
Scientific articles
MARINHO DE SOUZA, María de Fátima et al. Microcephaly in Brazil: prevalence and case characterization of the information system on live births (Sinasc), 2000-2015. Epidemiology and health services: Magazine of the Single System of Health of Brazilv. 25, n. 4, p. 701-12, 2016.
AHMED, Faheem and AHMED, Na’eem et al. Why inequality could spread Covid-19. The Lancet Public Health2020.
