Note from BW of Brazil: The questions of health and health care (along with income and education) are but two of the areas in which quality of life can be measured in any country throughout the world. BW of Brazil has featured a number of articles discussing this issue in terms of racial inequalities and today’s post digs a little deeper into the topic by analyzing statistics of health and health treatment of women in Brazil along the lines of color/race. As in many other areas of Brazilian life, Afro-Brazilian women (pretas/black and pardos/brown) lag behind white women in various areas of health care according to this study. The bottom line in Brazil’s health system is similar to that of its education system: If one has access to the private sector, health care is a little better, but all told, the health system needs to make drastic improvements and this is even more so when color and/or race is taken into account.
Racial inequality in Brazil: A look at health (Desigualdade racial no Brasil: um olhar para a saúde (title of original article))
by Alexandre Marinho, Simone Cardoso e Vívian Almeida
The year 2011 was established by the United Nations as the International Year for People of African Descent. The goal was to assist in combating racism and reduce, or even eliminate, the economic, social and racial inequalities suffered by people of African descent. To seek ways to reduce the difficulties in access to basic services such as health and education which intensify the discriminatory process. In Brazil, the absence of the variable color, largely of health information systems, complicates the assessment of health status and health services for African descendants.
The Ministério da Saúde (MS or the Ministry of Health), in 2009, in the publication Política Nacional de Atenção Integral à Saúde da Mulher, Princípios e Diretrizes (National Policy for Integral Attention to Women’s Health, Principles and Guidelines) states that “The racial/ethnic category is fundamental to the analysis of health indicators and for planning actions.”
The Organização Mundial da Saúde (OMS or World Health Organization – WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease.” Health is a fundamental component of the level of social welfare and human development. In the Brazilian Federal Constitution of 1988 the right to health of all citizens, as well as the obligation of the State to provide health services indifferently to all Brazilians is explicit.
We see a simplified overview of the health conditions of the population in Brazil from a racial perspective. In the Synthesis of Social Indicators of IBGE (Instituto Brasileiro de Geografia e Estatística or Brazilian Institute of Geography and Statistics), of the year 2009, we noticed that 48.4% of the population is branca (white), 6.8% are preta (black), 43.8% is pardo (brown or mulatto) and 0.9 % is indígena (indigenous). These figures indicate that more than 50% of the population is currently composed of non-whites.
As graph 1 shows, below, pretos and pardos, and then indígenas, are those with the highest infant mortality rates.
In graph 2, below, we see that pretos and pardos have a life expectancy at birth quite less than brancos.
PRIMARY CARE The epidemiological profile of the Brazilian, with unfavorable racial inclination to African descendants (pretos and pardos), is simultaneously the cause and effect of the conformation of the Brazilian health system, with its virtues and contradictions. Notably, it is the result of imbalances of primary care offered by SUS (1).
With regard to the health of women of African descent, the picture is very disturbing. The document of Ministry of Health, Política Nacional de Atenção Integral à Saúde da Mulher – Princípios e Diretrizes (National Policy for Integral Attention to Women’s Health – Principles and Guidelines), of 2009, reports results that should be unacceptable in a country that intends to have a universal, comprehensive public health system, publicly funded and therefore equitable. Among other inequalities, it was found that 5.1% of white women did not receive anesthesia in childbirth. In black women (pretas and pardas) it occurred twice as often (11.1%). SUS pays for this procedure with the aim of reducing the fear of labor pain, to try to reduce the frequency of cesarean sections. We see in the document that 77.7 % of brancas (white women) were oriented towards the importance of breastfeeding and that only 62.5% of black women have this orientation. While 46.2% of white women had companions in childbirth, only 27.0 % of black women exercised this right.
Such perceptions are reinforced in the study entitled “Desigualdades raciais, sociodemográficas e na assistência ao pré-natal e ao parto, 1999-2001 (Racial inequalities, sociodemographics and in assistance to prenatal care and childbirth, 1999-2001)” by Maria do Carmo Leal, Silvana G. N. da Gama and Cynthia B. da Cunha, published in the Revista de Saúde Pública da USP (Journal of Public Health of USP) in 2005. It was found that approximately 80% of preta and parda women made their deliveries through the SUS system. However, 43.7 % of white women had their children at private hospitals.
Dependent on SUS, preta and parda women and those with lower education had less access and poorer prenatal care. Moreover, at the moment of childbirth, for not being accepted in the first maternity they sought (the ill-fated search from one place to another), they were more penalized and received less anesthesia. The inequalities were striking, even when women of different ethnic groups were compared in the same income brackets and education. A simple exercise that we managed to obtain processing data of this research is revealing. Completing high school education (or more) may reduce the risk of poor service quality, as evaluated by mothers, by approximately 70% in brancas, in more or less 50% in pardas and a maximum of around 30% in pretas. Education, ceteris paribus (other things being equal), protects women of African descent less.
The MS in the cited Relatório 2009, shows that, among the leading causes of cancer death in women in Brazil are breast cancer (approximately 15%) and cancer of the cervix (around 7 %). The text points out that cancer of the cervix is twice as common in black women than in white women. However, we verified from PNAD/2008 data, as shown in table 1, that access to basic preventive gynecological examinations is uneven in Brazil.
Another visible element which highlights inequalities in primary care is the provision of oral health services. The PNAD/2008 reveals that 44.8% of brancos have been to the dentist in the last twelve months. This percentage drops to 35.0% among pretos and 35.8 % among pardos.
ORGAN TRANSPLANTS, OTHER FACE OF INEQUALITY
The provision of high complexity services can, with some care, represent inequalities in the trajectory of Brazilians of different colors when they seek attention at different levels of care in SUS. Disparities in Primary Care are carried to levels of bigger complexity and flow into high complexity. This reinforces the picture of inequities in SUS. This seems to be the phenomenon that occurs in the SUS National System of Transplants, one of the largest in the world, and that invested 1 billion reais in 2010 (worth about US$546 million in 2010).
Despite displaying similar transplant needs, access to the transplant system of pretos and pardos is much lower than the white population. This fact, as shown in Graph 2, goes contrary to expectations, in the case of kidney transplants, in the measure that whites are not the majority in the population and even among patients with chronic renal failure, according to PNAD/2008.
In Figure 3, obtained in the Brazilian Registry of Transplants – 10 years. Quantitative Analysis of ABTO, we see that 69% of kidney transplants performed between the years 1995 and 2004 were allocated to the white population. Also there was a disadvantage to women in general, they receive only 39% of kidney transplants, although being a slight majority of the population. So black women, because they are women and because they are black, have a double disadvantage in transplants. According to our study “Desigualdades de transplantes de órgãos no Brasil: análise do perfil dos receptores por sexo e raça ou cor (Inequalities of organ transplants in Brazil: analysis of the profile of the receptors by sex and race or color (Texto para Discussão or Discussion Paper 1629, IPEA, 2011), this situation of inequality between ethnic groups and between genders is not much different for other solid organs.
1. The Sistema Único de Saúde or Unified Health System), better known by the acronym SUS, is Brazil’s publicly funded health care system. SUS was created after the Brazilian Constitution of 1988, which assured that health care is a “right of all and an obligation of the State”. Prior to that, only people who contributed with the social security were able to receive health care. The creation of SUS was important in the sense that more than 80% of the Brazilian population depend on it to receive medical treatment. Brazil provides two-tier health care, but almost 25% of the population pay for private insurance. Source