Health Inequalities in Brazil

Observations from the Field

Public hospital in Cor is a world-renowned heart hospital. Photo by Marina de Moura

As the fifth-largest nation in the world, Brazil is diverse not only in culture but is also clearly marked by social disparities. While the melodic rhythm of the Portuguese language and the generous spirit of the people are enchanting, it is also the Brazilian people’s openness to share their lives that make extremes of wealth and poverty so evident. After only a few rides on the public bus, one is privy to stories of the joys and tragedies of people’s lives. Likewise, no more than a few hours in one of Brazil’s major cities are necessary to observe firsthand the infamous slums beside skyscrapers or beachside resorts.

I first arrived in Brazil as a doctoral student in 1999 to carry out a pilot study for a research project that would eventually become part of my thesis in public health. This led to a number of visits over the course of the next four years to set up the study and oversee fieldwork. My purpose was to examine how the circumstances of caregivers, specifically informal social support and depression in mothers, might be related to child growth. This endeavor brought me to discover not only the world of research but also the vibrant country of Brazil, full of complexity and contrasts.

According to the World Bank, Brazil consistently ranks among the top ten most unequal countries in the world in terms of the income distribution. As I reflect on my experiences and what is particular to Brazil, I hope that my training as a researcher and my distance as a foreigner can provide some perspective. The focus of my research on the role of social conditions on the growth of infants and toddlers brought me to the most impoverished communities in one of the poorest states, located in the most economically depressed region of the country. The study was based in low-income neighborhoods of Teresina, Piauí, in northeast Brazil.

Because there were no direct flights to Teresina, my trips from Boston often extended over thirty hours door to door. Although I did not realize it at the time, many short visits in a short period—from home in Boston, to Southeast Brazil, and then back to Piauí—facilitated comparisons between these settings. If my experiences had been confined to the industrial southeast or southern regions, I certainly would have had a very different impression of Brazil. The research project in Piauí provided an unusual opportunity to enter the homes of a randomly selected sample of mothers over 15-years-old. Our study’s demographic statistics revealed that the average income in these households was approximately US $100 monthly, with 15 percent of the residents making less than $35 monthly. Seventy-seven percent of the mothers had completed less than an eighth grade education. Half of the families lacked a toilet and 46% lived in a house made of mud. Perhaps most surprising to me was that, despite these difficult conditions, hospitality and welcome were almost never lacking.

These hardships also created some challenges for the research team. Since study participants often lived on unnamed streets without addresses, creating maps was often the only way that we could locate and keep records of those we interviewed. Also, since many mothers had low literacy skills and almost no households in these neighborhoods had phones, in-person interviews were necessary to administer the questionnaires. Finally, household surveying was especially tough, given the weather in Teresina. Although there are dry and rainy seasons, it is always hot (often over 90°F). Confronting the heat on a daily basis to reach the houses and conduct the interviews (while carrying the anthropometric measuring devices and scales) was not easy.

What is quickly apparent is that inequalities in Brazil exist by socioeconomic status, ethnicity, and gender, and are also clearly demarcated by geographic region. The Northeast region has lower percentages of literacy, number of years of formal education, and the highest percentage of the population living in extreme poverty. Data from 1998 show that the South and Southeast regions provided 75% of Brazil’s gross national product. However, even without knowledge of the actual figures, one promptly senses this difference, noting that an equivalent meal is approximately double the price in São Paulo than in Teresina. These inequalities can be upsetting. On one of my stopovers on the way back to the US, I realized that the bill from dinner that I shared with several Brazilian researchers in São Paulo was approximately Brazil’s monthly minimum wage (i.e. more than the monthly salary of a family I had visited the day before). I began to wonder how much people think about these disparities and how they come to terms with them..

In terms of public health, there is ample reason to be concerned, since it is well known that poverty is almost always associated with poorer health. So it is not surprising that health statistics in Brazil clearly reflect regional economic differences. Although not the focus of our study, our findings supported the already-existing literature showing that poverty and inadequate sanitation are strong correlates of poor child physical growth. Child growth as a health indicator is extremely important. It reflects child wellbeing and nutrition and is intricately associated with child mortality as well as later physical and cognitive development. A report from the Instituto Brasileiro de Geografia e Estatística(IBGE) using 1990 census data indicated that the infant mortality rate in the northeast was more than double that of the Southeast and Southern regions. Likewise, a study published by Monteiro and collegues in 2002, summarizing data from 1996, showed that the prevalence of stunting in 1-4 year olds was more than ten times higher in the 25% poorest compared to the 25% richest in the Northeast region.

It is possible that regional identities in Brazil are accentuated by these geographical income disparities. Upon hearing my foreign accent when I spoke Portuguese, people often commented on it. To my surprise, this remark was followed by the question ‘Are you from São Paulo?’ Interestingly, it seemed that from the local perspective, the Southeast was as remote and foreign as another country. In one of our study neighborhoods, families urged me to meet the other “foreigner,” a nun living and working in the community. Upon meeting her, it became apparent that she was actually from the state of Rio Grande do Sul (the southernmost state in Brazil). Beyond the cultural and historical regional differences, it may be even harder for individuals to identify with people who differ greatly by lifestyle factors that are moderated by income. Perhaps this is a reason why regional identity is especially strong among the very poor. The poor who do not migrate for work seldom leave the region. For those who do pursue employment opportunities away from home, the identity gulf may be enlarged by the marginalization of low-income nordestinos when they arrive, for example, in the Southeast. Although there are strong historic and cultural differences across Brazil, it is likely that the economic and ethnic inequalities that track these geographic regions also strengthen their separate identities.

There have been many initiatives aimed at reducing regional economic inequalities, especially over the last half century. These include governmental administrative reform at the end of the 1960’s, a series of specific programs during the 1970’s, the World Bank-funded Projeto Nordeste in the 1980’s, and more recent initiatives to attract investment in the region. Some current programs to improve children’s health include Brazil’s national Programa de Saúde da Familia (used as a basis for our pilot studies and targeted as part of our study sample) and the recent hunger reduction program, Fome Zero.

Since my first visit to Brazil almost ten years ago, many formal attempts have been made to improve public health and reduce economic inequalities. Undoubtedly, these programs have made some difference, but there is still a long way to go. I hope that my study, for which more data analysis is now underway, will make a small contribution to improving our understanding factors related to child growth in low-income settings like Piauí.