1José Gerfeson Alves
2Carolaine da Silva Souza
3Hilderlânia de Freitas Lima
4Leilane Barbosa de Sousa
5Flávia Paula Magalhães Monteiro
6Thiago Moura de Araújo
1Universidade da Integração Internacional da Lusofonia Afro-Brasileira. Redenção, CE. Brasil.
ORCID: https://orcid.org/0000-0003-0364-3151
2Universidade da Integração Internacional da Lusofonia Afro-Brasileira. Redenção, CE. Brasil.
ORCID: https://orcid.org/0000-0002-6369-5749
3Universidade da Integração Internacional da Lusofonia Afro-Brasileira. Redenção, CE. Brasil.
ORCID: https://orcid.org/0000-0003-3755-0340
4Universidade da Integração Internacional da Lusofonia Afro-Brasileira. Redenção, CE. Brasil.
ORCID: https://orcid.org/0000-0003-0266-6255
5Universidade da Integração Internacional da Lusofonia Afro-Brasileira. Redenção, CE. Brasil.
ORCID: https://orcid.org/0000-0001-9401-2376
6Universidade da Integração Internacional da Lusofonia Afro-Brasileira. Redenção, CE. Brasil.
ORCID: https://orcid.org/0000-0002-8410-0337
Corresponding author
José Gerfeson Alves
Rua Josué Castelo Branco, 170, Centro, Redenção-CE, Brasil, CEP 62790000.
E-mail: gerfesondip@gmail.com
Submission: 09-12-2022
Approved: 06-04-2023
ABSTRACT
Objective: reflect on the health of the Brazilian black population in the context of chronic diseases and its relationship with public policies. Method: theoretical-reflective study based on national and international scientific literature, as well as the authors' perception and critical analysis. Results: three categories were presented: social indicators on the chronicity of diseases in the black population; health indicators of the black population in the face of chronic diseases; and public policies for the health of the black population in the chronicity of diseases. Final considerations: raised reflections about the implementation of public policies for this population, as well as pointing out the limitations aimed at the prevention of diseases and injuries and health promotion.
Keywords: Blacks. Health of Ethnic Minorities. Public Policy.
RESUMEN
Objetivo: reflexionar sobre la salud de la población negra brasileña en el contexto de las enfermedades crónicas y su relación con las políticas públicas. Método: estudio teórico-reflexivo basado en la literatura científica nacional e internacional, así como la percepción y análisis crítico de los autores. Resultados: se presentaron tres categorías: indicadores sociales sobre la cronicidad de enfermedades en la población negra; indicadores de salud de la población negra frente a enfermedades crónicas; y políticas públicas para la salud de la población negra en la cronicidad de las enfermedades. Consideraciones finales: planteó reflexiones sobre la implementación de políticas públicas para esta población, además de señalar las limitaciones dirigidas a la prevención de enfermedades y lesiones y promoción de la salud.
Palabras clave: Negros. Salud de las Minorías Étnicas. Política Pública.
RESUMO
Objetivo: refletir sobre a saúde da população negra brasileira no contexto das doenças crônicas e sua relação com as políticas públicas. Método: estudo teórico-reflexivo baseado na literatura científica nacional e internacional, como da percepção e análise crítica dos autores. Resultados: apresentaram-se três categorias: indicadores sociais na cronicidade de doenças na população negra; indicadores de saúde da população negra frente às doenças crônicas; e políticas públicas para a saúde da população negra na cronicidade de doenças. Considerações finais: suscitaram reflexões acerca da implementação de políticas públicas a essa população, bem como apontar as limitações voltadas à prevenção de doenças e agravos e promoção da saúde.
Palavras-chave: Negros. Saúde das Minorias Étnicas. Política Pública.
INTRODUCTION
How the social, economic, political, and cultural contexts influence the health of a population are multiple and differentiated. When it comes to the health of the black population, the environment, which excludes and denies the natural right to belong, determines special conditions of vulnerability. In this sense, this population shares unequal spaces in society, including inequalities in being born, living, getting sick, and dying(1).
This scenario of inequality has allowed the implementation of new public policies in the Unified Health System (SUS), aimed at the black population and other populations in vulnerable situations. Thus, the National Policy for Integral Health of the Black Population (PNSIPN) emerges as an instrument for the promotion of equity within the Brazilian health system(1,2).
Such policy has as a mark the recognition of racism, racial inequalities, and institutional racism as social determinants of health, besides adding epidemiological data from the declaration of color in the declaration of live births(2,3).
The data of the annual report on racial inequalities in Brazil prove that, even after years of the abolition of slavery, the black population suffers from its consequences, with less access to health care, a higher probability of maternal and infant death, vulnerability to violence, and lower quality and life expectancy(3).
It is known that, as of the 2010 census, the black population became the majority of the Brazilian population (54%)(4). Considering the completeness of black and brown populations, it is observed that a significant percentage increase occurred, 27.6%, higher than the population growth of Brazil in the same decade, which was 12.3%, noting even a more relevant variation when comparing blacks (37.6%) and browns (26.0%), i.e., the black population is more than half of the Brazilian population(1,5).
The health of the black population stands out because of its significant increase due to self-declaration on race/color. Self-declaration refers to the perception that each person has about his/her race/color, which implies considering not only physical traits, but also the ethnic-racial origin, sociocultural aspects, and the subjective construction of the subject, considered an important aspect for the construction of public policies, through the consolidation of health indicators that translate the effects of social phenomena and inequalities on different population segments(6).
In the epidemiological context, the prevalence of diseases in Brazil has been changing in recent years. Although a period of a worldwide pandemic of the coronavirus is still being experienced, the picture of infectious and parasitic diseases has been giving way to another scenario: chronic-degenerative diseases and preventable diseases are gaining ground, as they are more prevalent in black people, such as hypertension, diabetes mellitus, sickle-cell disease, HIV/AIDS, gestational syphilis, viral hepatitis, and tuberculosis(6).
On the other hand, the health of the black population is also more susceptible to some genetic and hereditary diseases, such as sickle-cell anemia. Due to the recurrence of this type of anemia, the National Policy for Sickle Cell Disease Care was published in 2005, which contemplates and supports those diagnosed with the disease. Besides sickle cell anemia, glucose-6-phosphate dehydrogenase deficiency has a relatively high frequency in black Americans and Mediterranean populations, such as in Italy and the Middle East. In addition, breast cancer also shows a high mortality rate among black women and hypertension, which is more predisposing to blacks(2,6).
In the literature, studies in the health area that used the variable race/color showed high rates of illnesses and deaths of the black population due to chronic diseases. Therefore, the study proposal is justified by the need to reflect on this scenario, to weave evidence of persistent inequalities rooted in policies, practices, and racist cultural beliefs that permeate this population and thus raise future directions for the planning and creation of public policies based on health indicators.
Thus, the study aims to reflect on the health of the black Brazilian population in the context of chronic diseases and their relationship to public policies.
METHODS
This is a theoretical-reflexive study carried out from August to October 2022 during the discipline of health and nursing in the scenario of Lusophone countries, of the graduate nursing program of the University of International Integration of Afro-Brazilian Lusophony (PPGENF/UNILAB), based on national and international scientific literature, as of the authors' perception and critical analysis.
To obtain the data, a literature review was developed in the U. S. National Library of Medicine (PubMed), Latin American and Caribbean Literature on Health Sciences (LILACS), and the Scientific Electronic Library Online (SciELO).
The selection of descriptors was made by consulting the Health Sciences Descriptors (DeCS), which were: Health of Ethnic Minorities, Chronic Disease and Public Policy, and the alternative term Health of the Black Population.
Inclusion criteria were: articles available in full, in Portuguese, English, and Spanish, published in the last five years that responded to the theme of the study. Considering these criteria, six publications were identified, and five from the gray literature and four ministerial documents were also included.
After reading the abstracts and compiling the materials, the selected documents were read in full, followed by the analysis and identification of the convergent elements for reflection. The literature identified allowed the construction of three thematic categories, discussed according to the main Brazilian public policies.
RESULTS AND DISCUSSION
The results will be presented descriptively in three categories, namely: social indicators in the chronicity of diseases in the black population; health indicators of the black population facing chronic diseases; and public policies for the health of the black population in the chronicity of diseases.
Social Indicators in the Chronicity of Diseases in the black population
Chronic diseases occur at any time of life and are characterized by their long permanence, caused by multiple factors. In Brazil, this group of diseases represents the greatest burden of morbidity and mortality, constituting a public health problem, considering the high death rates, as well as the negative impacts on the quality of life of those affected(7).
The black population is the most affected by chronic diseases and is at the base of the social pyramid, presenting the worst socioeconomic indicators, with compromised clinical evolution and prognosis(8). Thus, the knowledge of the health situation of this population is the first step to planning actions and programs that reduce the occurrence and severity of chronic diseases(9).
Therefore, it is necessary to monitor these inequalities with public health policies, prioritizing actions to promote health and prevent diseases, besides expanding and improving the capacity of access and supply to health services for diagnosis and treatment(9).
Thus, the black population has genetic and cultural particularities that may suffer more significant health consequences(10). Social factors such as racial discrimination, poor working conditions, low education, poverty, and restrictions on access to health services stand out as risk factors for the development and/or worsening of chronic diseases. Historically, the black population is affected by these social factors(7).
The Ministry of Health advocates that the social determinants, social inequalities, differences in access to goods and services, low education, and inequalities in access to information, in addition to modifiable risk factors, such as smoking, alcohol consumption, physical inactivity, and poor diet have a direct association with chronic diseases. Thus, it is clear that chronic diseases strongly affect the poorest layers of the population and vulnerable groups, such as the black population(11).
The health inequities experienced by the black population in Brazil are derived from a historical and social process produced by a sum of deprivations in living conditions, which is structured based on racism, differences in the stratification of power status, and privileges in access to goods and services. In this sense, it is considered essential to discuss these inequities, the factors that condition or determine social differences in health conditions, such as the unequal distribution of wealth in our society, gender, and race/color differences(11).
Health disparities are associated with high morbidity and mortality rates of chronic diseases in the black population. This result indicates that low socioeconomic conditions culminate in poor living standards and diets, less access to health services, exposure to pollutants and environmental stressors, decreased literacy levels, and increased likelihood of unhealthy behaviors such as smoking, alcohol consumption, and low physical activity(12).
Studies have pointed out that the social indicators in health have a direct relationship with the development of chronic diseases, such as their comorbidities and higher mortality rates, so these should be considered, especially in the black population which has the worst indicators(13,14).
Is valid the need to improve the provision of health services to this population through the development of actions aimed at health promotion and prevention of diseases, as advocated by the PNSIPN, which proposes to ensure the realization of the human right to health, should include actions of care, attention, health promotion, and disease prevention, as well as participatory management, popular participation, and social control, production of knowledge, training, and continuing education for health workers, aiming to promote equity in the health of the black population(2).
Reflecting on the compromised access of the black population to health services is necessary, given the impact of this situation on the quality of life of these subjects and the ability to participate in preventive actions for diseases and health problems(5).
Given the above, it can be observed that social indicators contribute in some way to the monitoring and guidance of the formulation of public policies related to this population, according to the indicators mentioned in this article. Thus, providing important information for better comprehensive health offered to the black population with access to health services.
Health Indicators of the black population about chronic diseases
Health indicators are the quantitative incidence of diseases, injuries, and deaths, allowing the confrontation of health data between regions and distinct populations(15). Thus, the absence of registration or the lack of any classification criteria on color/race, or ethnicity, goes beyond the relative lack of knowledge about health indicators in the black population. The political relevance of knowledge about the health circumstances of this important segment of the population is conditioned to the existence of information and how it is recorded and collected(16).
Socio-environmental determinants and lifestyles are factors that can directly instigate the health conditions of the population. Thus, it is understood that health is the consequence of a diversity of aspects associated with quality of life, including appropriate standards of food, housing, and sanitation, as well as possibilities of education throughout life, adopted lifestyles, and access to health care(17).
Considering the continental conditions and the sociodemographic, economic, and ethnic-racial differences in Brazil, screening activities for the different regions and populations are fundamental for the adequate confrontation of the different epidemiological pictures. Thus, the health indicators, according to ethnic-racial groups, showed the worst situation for black groups, especially the quilombola communities(18).
Authors(8) have highlighted the predominance of cases of the disease among patients living in rural areas and far from cities, a recurrent fact for the black population, a situation that is associated with the worst prognosis, since the territorial distance hinders outpatient follow-up, leading to unsatisfactory adherence to treatment and inadequate management of acute complications.
Tuberculosis disease represents a serious public health problem and is directly related to poverty. Between 2004 and 2013, the incidence rate was higher in the indigenous population, followed by the rate in the black population. As for leprosy, prevalence is observed in black, brown, and indigenous populations compared to other populations(2).
Epidemiological studies conducted in quilombola communities from 2012 to 2014 identified a high rate of chronic diseases in adults. In this research, 87.8% presented chronic problems associated with the digestive system and 48.8% demonstrated some level of prehypertension or hypertension. Another study conducted in the state of Bahia observed that almost half, 45.4% of the evaluated quilombolas showed hypertension and that this condition was associated with high age, low education, and poor economic status(7).
In this context, the prevalence of arterial hypertension in quilombola communities has varied between 38.4% and 45.4%, presenting a percentage rate higher than that of the general population in Brazil. The risk factors for the progression and worsening of this disease are dyslipidemia, abdominal obesity, glucose intolerance, and diabetes mellitus, besides modifiable causes such as socioeconomic determinants and inadequate access to health care. Thus, it can cause permanent damage to individuals through the emergence of cardiovascular, cerebrovascular, and renal diseases(17).
According to the studies, breast cancer is also one of the chronic diseases that affect the black population. On the other hand, most of the cases observed were white patients (46.4%). Thus, the results of the studies analyzed were quite diverse, disagreeing with other studies that show the black race as the main ethnic group associated with breast cancer, besides having the worst prognosis when compared to other racial-ethnic groups. However, because it is a population with few opportunities for health services, the cause of death is greater in this population compared to the white population. Pointing out possible causes of the late diagnosis of the disease, and the more difficult access to screening tests and therapeutic assistance(19).
It is estimated that between 70% and 85% of the population will manifest some symptoms of chronic disease during their lives. However, there are still divergences as to the prevalence and predisposing factors, especially when ethnic-racial characteristics are considered(18).
Furthermore, the proportion of patients who do not constantly undergo routine exams and screening for chronic complications, contrary to the norms proposed by the Ministry of Health for outpatient follow-up and management of disease complications. On the other hand, many people cannot get the exams, due to the lack of access to health services, being the case for the black population. Thus, early detection of abnormality indicates therapeutic measures that reduce the risk of the event by 92%(8).
Still, sickle cell anemia is cited, as the most common hereditary disease in Brazil, originating from an abnormal hemoglobin, called hemoglobin S (HbS), which replaces hemoglobin A (HbA) in individuals affected by infections that may be directly or indirectly linked as cause of death in about 62% of deaths of patients in the first 10 years of life(16).
On the other hand, the Ministry of Health understands that the situation of inequity and vulnerability affects the health of the black population and recognizes that the racism experienced by them harms these indicators, compromising the access to public health services, since the good quality of health generates conditions for the insertion of individuals in different spheres of society(2).
Public policies for the health of the black population in the chronicity of diseases
Public policies are tools for acquiring results, thought, planning, building, and applying effectively and rationally to solve the problems of the population, prioritizing social welfare(20). On the other hand, despite the progress in the implementation of these policies aimed at black populations, scientific evidence shows weaknesses compared to what is recommended in specific policies, such as the PNSIPN and the National Policy for Integral Care of People with Sickle Cell Disease, and the profile of living and health conditions observed(7).
PNSIPN aims to ensure equity in the realization of the human right to health in its aspects of promotion, prevention, care, treatment, and recovery of communicable and non-communicable diseases and disorders, including those of higher prevalence(2). This policy is not being implemented as it should be, considering that the black population is still invisibilized regarding their health rights, so effective actions aimed at changing this reality(20) are necessary.
According to the IBGE, in 2019, 56.1% of Brazilians will declare themselves black or mulatto, thus, the majority of the population needs these policies. Public policies demand to enable social rights constitutionally guaranteed, especially in the area of health, ensuring universal and equal access to health actions and services, and contemplating the specificities of the black population(9).
At present, we observe that no progress has been made regarding public policies aimed at the health of the black population. Although there are laws, ordinances, and normative instruments that guide them, there is a lack of investments to ensure equity and fulfillment of the rights to health of this population in Brazil.
The elimination of racial disparities in health and the production of appropriate responses for the promotion of the health of the black population requires the development of affirmative actions at different levels, implying the establishment of unique measures, based on in-depth diagnoses which should be the basis for the design of processes, protocols, actions, and specific policies according to the needs and particularities of this population(2).
These changes should be able to alter the forms of daily activities as much as the processes of planning, monitoring, and evaluation, and involve actions at three different levels or opportunities, being: access and use; internal institutional processes; results of actions, and public policies(20).
It is necessary to guarantee comprehensive health care for the black population, through policies, programs, and specific actions articulated in the universal health policy, that is, the Unified Health System (SUS). Thus, we defend a conception of universal policy that guarantees everyone the right to health, without losing sight of the differences between individuals who have specific needs regarding the health-disease processes and care(15).
The evidenced results point to the need for healthcare assistance to the black population, and serve as a parameter for Brazilian governments to develop health strategies consistent with the needs of Ethnic and Racial communities(3).
Morbidity and mortality from chronic diseases are predominant and of a socioeconomic pattern in Brazil, and associated with the black population. That being said, interventions to prevent and manage these disparities with actions directed to this population, which is exposed to risk factors and faces greater barriers to access to health(12), are fundamental.
FINAL CONSIDERATIONS
It is known that the history of the black population is guided by social exclusion, resulting from racist practices in our society, which are updated and perpetuated over time. Reflecting on chronic diseases in this population considered vulnerable, both in their living conditions and health, is not an easy task, since there are still several social factors that determine the health status of these subjects, highlighting the inequity of health conditions in the Brazilian scenario.
In this sense, advances have been observed in the development of public policies aimed at this population; however, there are still weaknesses in their implementation. The findings of this study may raise reflections about the services provided to this population, as well as point out the limitations aimed at the prevention of diseases and illnesses and health promotion. In addition, to sensitize health professionals about the marks of institutional racism in Brazilian health services, which still have not effectively broken the barriers of access, not offering health care directed to racial/ethnic groups in their specificities and demands.
As limitations, we highlight the lack of scientific evidence on public policies aimed at the black population. However, the data presented in this reflective study may subsidize subsequent research and contribute to the formulation and management of public policies appropriate to the expressed health needs of the black Brazilian population.
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Support and Acknowledgment: University of International Integration of Afro-Brazilian Lusofonia. There are no thanks.
Scientific Editor: Francisco Mayron Morais Soares. Orcid: https://orcid.org/0000-0001-7316-2519
Rev Enferm Atual
In Derme 2023;97(2):e023052