Peter Gabriel Delgado
The last four years in Brazil have been one of humanitarian devastation. Hospitalization for cases of child malnutrition has recurred in the poorest regions of the country. Vaccination coverage for common childhood diseases has dropped dramatically. It is in this context of scorched earth that the new government will have to act.
Public health workers in Brazil use the slogan “Health is everyone’s right and a duty of the state” as a constant reference in their practice. These words are, in fact, written in the “Citizen’s Constitution” of 1988, the proclamation of which meant the redemocratization of the country, after 22 years of military dictatorship. As a duty of the democratic state, the universal right to health was introduced starting from the System Unified Health Service, the SUS, created in 1990. The construction and consolidation of the SUS was the arduous struggle of the Brazilian population, health professionals, researchers, doctors, nurses and “invisible workers” (who ensure maintenance , transport, cleaning and safety of the thousand places where care is provided).This gigantic healthcare system has always suffered from a chronic underfunding problem which has been faced in the daily struggle of its policies and its management and has managed to develop in a sustainable way, even if often on the verge of precariousness.
The SUS has achieved indisputable results in terms of: increased health coverage, drastic reduction in infant mortality, control of numerous communicable diseases, implementation of an effective mass vaccination programme, creation of 42,000 family health teams (primary health care coverage has reached 73% of the population), expansion of access to free medicines in primary pharmacies and provision of doctors in the riverine regions of the Amazon and in small villages in the semi-arid region of the northeast. Furthermore, the SUS has developed a psychiatric reform through the deinstitutionalisation of large asylums and the creation of 2,800 community mental health centres.
These and other advances have been built albeit with limited funding and in an adverse social context, of great inequalities and social vulnerability, with high levels of poverty, urban violence, and dramatic concentration of income (Brazil is one of the most unequal countries of the world).Public health has been associated with other policies to tackle social inequalitysuch as raising the minimum wage, creating new jobs, developing social housing programs, making monthly benefits available to poor families, and increasing access to education and daycare.
This scenario of active development of the SUS radically changed in 2016, with the interruption of the democratic process and the dismissal of the elected president, Dilma Roussef, and with the presence of a government that has taken neoliberal policies to the extreme. In 2016, the new right-wing government imposed an amendment to the Constitution that froze spending on social policies for 20 years, in the name of fiscal consolidation. In addition to this measure, which has drastically aggravated the underfunding of the SUS, other government actions have weakened some public health programs, such as the National Basic Care Policy (ie primary care) and mental health policy. The general political scenario has worsened through measures of restriction of the activity of political parties and judicial persecutions of popular political leaders, in order to strengthen the far right, through anti-politics and incitement to hatred towards the left, as well as the massive use of social networks, similar to what happened in other countries of the world. Bolsonaro has implemented an extensive program for limit spending on social policies, and to deregulate all regulations in the health system, education system and job protection. Investments in health, education and social assistance have been brutally cut, the purchase of arms has been liberalized and spread. All this has caused a dramatic increase in unemployment, flattening wages and a worsening of poverty indicators.
With the Covid-19 pandemic, the process of dismantling the SUS has accelerated, with a series of denialist, anti-vax and incompetent health ministers. As a result, Brazil tragically mourned 690,000 deaths from Covid, becoming the fourth country in the world with the highest rate of deaths per 100,000 population [1].
The last four years in Brazil have been one of humanitarian devastation.
The country has re-existed in the big world hunger map: The 2021 National Food Security Survey found that there are 33.1 million people who are “severely food insecure,” the technical name for hunger. And this following the social effects of the pandemic and the revocation of rights and the absence of social policies [2]. Hospitalization for cases of child malnutrition, an event that had disappeared for more than 20 years, has reappeared in the poorest regions of the country. Vaccination coverage for common childhood diseases has dropped dramatically. The Bolsonaro government’s Ministry of Health has implemented a real data blackout, in all sectors, including those relating to stocks of medicines and vaccines. It is in this context of scorched earth that the new government will have to act.
The victory of Luiz Ignácio Lula da Silva, elected on October 30, in a heated dispute with the current president, brings an immense sense of relief and great hope for the country and for public health. Lula previously governed Brazil, from 2003 to 2010, and had developed consistent and regular programs to increase labor income, create jobs and social housing, increase access to public lighting in poorer regions, to promote universal access to primary education, and finally to create an additional income for poor families (the famous and fundamental “Bolsa Família” ). During Lula’s previous presidency, Brazil experienced a social transformation unprecedented in its history. It is estimated that 30 million people have risen out of poverty to move up to middle-low income social strata, creating a phenomenon of considerable upward social mobility. All this ensured the president, when he left the government in 2010, popular approval ratings above 85%, and thus also ensured the election as candidate of his party, the Workers’ Party, for the presidency of the country. In public health, successive governments of Lula and Dilma Rousseff expanded primary health care, created programs for access to basic medicines including antiretroviral drugs, and increased the availability of health personnel in the most remote areas of the country . The psychiatric reform process has been consolidating through the creation of the “De Volta para Casa” program for patients discharged from psychiatric hospitals and the implementation of a large network of community mental health services [3]. The strengthening of social participation in health was also significant, with a large participation of users, professionals and service providers.
With this extraordinary history of commitment to public health, expectations in the field of public health must reflect the hope expressed in the motto “health is everyone’s right and a duty of the state”.
However, the challenges facing Brazil will be very difficult. Brazilian legislation provides for the official establishment of a Government Transition Team, which is carrying out a diagnosis of the situation and preparing the first action strategies of the new government. There is already an investigation into the dramatic situation of underfunding in the health sector (no longer chronic underfunding, but a deliberate withdrawal of resources from the federal health budget). Now it will be a parliamentary battle for the approval of an amendment to the 2023 Finance Law, to fill the dramatic gaps in social policies. The government defeated in the elections has proposed (and the parliament, with a conservative majority, has approved) a 2023 budget that further increases the withdrawal of resources from the SUS and other social policies, thus radicalizing neoliberal policies In these years of devastation there has been a process of job insecurity in the health sector, exacerbated by changes in labor legislation, and even seen the extinction of some health services. Public universities have been subjected to a deliberate policy of financial blockages, which has had an impact on the curtailment of SUS curricula.
The science and technology area has been hit hard, requiring a long-term strategy to resume investment in the healthcare industry (equipment, medicines and vaccines).
Ignàcio Lula’s victory makes it possible to resume the effort to build a universal health system, and other welfare policies, in a divided country, and still under the impact of the pedagogy of hatred and violence exercised by the state in the last 4 years. The public health field has stoically weathered the onslaughts and setbacks of this sad period and is working hard to rebuild the interrupted trajectory. In a context of great political tension, hope shows us the way.
Pedro Gabriel Delgado, professor at the Federal University of Rio de Janeiro
Bibliography
1. Johns Hopkins Mortality Data. (2022). https://coronavirus.jhu.edu/data/mortality
2. Oxfam Brazil/PENSAM network https://pesquisassan.net.br/olheparaafome/
3. Delgado PG., «Mental health reform in Brazil: changing hospital-centered paradigm to ensure access to care», in Souqonline, November 2013