Brazil's response to COVID-19: commercial determinants of health and regional inequities matter
Authors: Rafael Dall'Alba, Dais Gonçalves Rocha
Journal: The Lancet Global Health (2021)

The study by Rudy Rocha and colleagues in The Lancet Global Health1Rocha R Atun R Massuda A et al.Effect of socioeconomic inequalities and vulnerabilities on health system preparedness and response to COVID-19 in Brazil: a comprehensive analysis.Lancet Glob Health. 2021; (published online April 12.)https://doi.org/10.1016/S2214-109X(21)00081-4Summary Full Text Full Text PDF Scopus (152) Google Scholar provides important evidence of the relationship between inequity and socioeconomic vulnerability in the outcomes of hospital care in the context of COVID-19. However, it is necessary to highlight elements that have previously determined the current health scenario in Brazil. Pre-existing inequities (ie, severely unequal situations that violate social justice) have been amplified by the pandemic, especially with regard to access to health technologies and health care for individuals and communities, as well as for municipalities, states, and countries in situations of vulnerability. In Brazil, the situation has worsened since the political crisis of 2015 that triggered the implementation of austerity policies, which have weakened the state by dismantling public policies, not only for health but also for social security, agriculture, science and technology, and education (especially in universities).2Doniec K Dall'Alba R King L Brazil's health catastrophe in the making.Lancet. 2018; 392: 731-732Summary Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 3Doniec K Dall'Alba R King L Austerity threatens universal health coverage in Brazil.Lancet. 2016; 388: 867-868Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar In expanding the perception of health inequity in the context of the syndemic in Brazil, it is important to be aware of the commercial determinants of health and how the public agenda has been captured by corporate lobbying in favour of private interests.4Kickbusch I Allen L Franz C The commercial determinants of health.Lancet Glob Health. 2016; 4: e895-e896Summary Full Text Full Text PDF PubMed Scopus (338) Google Scholar, 5Barlow P Labonte R McKee M Stuckler D Trade challenges at the World Trade Organization to national noncommunicable disease prevention policies: a thematic document analysis of trade and health policy space.PLoS Med. 2018; 15e1002590Crossref PubMed Scopus (34) Google Scholar Commercial interests have contributed to worsening scientific denialism and technological epistemic inequity, and led to the Brazilian federal government responding hastily with technologies and interventions that lack scientific evidence of therapeutic effectiveness against COVID-19 (such as hydroxychloroquine and ivermectin) but have considerable market value. By contrast, commercial interests have led to marginalisation of proven effective interventions without market value, such as so-called soft technologies (non-pharmaceutical interventions) or social technologies6Merhy EE Health: the cartography of living work. Hucitec, São Paulo2002Google Scholar based on approaches to health promotion, bonding, and co-responsibility for the health process (eg, social isolation, use of masks, proper hygiene, care management, and health-care networks).7Nogueira J Rocha DG Akerman M Políticas públicas adoptadas en la pandemia de la COVID-19 en tres países de América Latina: contribuciones de la Promoción de la Salud para no volver al mundo que existía.Glob Health Promot. 2020; (published online Dec 20.)https://doi.org/10.1177/1757975920977837Crossref Scopus (15) Google Scholar The negative consequences of commercial determinants of health can also affect the performance of primary health care, a recognised locus of practice for these soft technologies. Primary health care has a central role in guiding care in health-care networks, but has been weakening since 2015 and has reduced capacity for coping with COVID-19.8Guadalupe Medina M Giovanella L Bousquat A Magalhães de Mendonça MH Aquino R Primary healthcare in times of COVID-19: what to do?.Cad Saude Publica. 2020; 36e00149720PubMed Google Scholar It is necessary to highlight that the technological care model (as opposed to the hegemonic biomedical model) has been a source of constant dispute,9Fertonani HP de Pires DEP Biff D Scherer MDdA The health care model: concepts and challenges for primary health care in Brazil.Cien Saude Colet. 2015; 20 (in Portuguese).: 1869-1878Crossref PubMed Scopus (78) Google Scholar and commercial interests have the capacity to distort public health demand and draw focus to, for example, hospitals and drugs, which are economically attractive for the market. Consequently, they promote a disproportionate flow in the distribution of resources (which are already limited by underfunding) to make tertiary (hospital) care the centre of health-care networks, mobilising about 60% of investments from the federal budget, whereas primary health care and surveillance are of low value and therefore receive insufficient investment. This dynamic also influences users in the search for health services, often leading to overuse of emergency health-care services and underuse of primary health-care services, including promotion and prevention strategies. Rocha and colleagues' study1Rocha R Atun R Massuda A et al.Effect of socioeconomic inequalities and vulnerabilities on health system preparedness and response to COVID-19 in Brazil: a comprehensive analysis.Lancet Glob Health. 2021; (published online April 12.)https://doi.org/10.1016/S2214-109X(21)00081-4Summary Full Text Full Text PDF Scopus (152) Google Scholar reveals the need to resume the regionalisation of the unified health system (SUS) to reduce the inequities existing between Brazil's federative units. The country's large area and lack of effective regional development policies are key factors in understanding regional inequities. With the current structure of the health system, some of the more socioeconomically vulnerable regions (such as the north and northeast regions) are affected by an unavailability of health professionals, in addition to having fewer universities and less ability to compete for calls for proposals for research funding and technological innovation. This cycle of concentration of research resources and graduate programmes in the southeast and south regions10Pacheco Santos LM Moura EC Barradas Barata RC et al.Fulfillment of the Brazilian agenda of priorities in health research.Health Res Policy Syst. 2011; 9: 35Crossref PubMed Scopus (25) Google Scholar of the country has hampered the visibility of knowledge and technologies produced locally, and the confrontation of inequities reproduced and accentuated by public health services and policies. The incomplete agenda for the decentralisation of management of the SUS and municipalisation promotes the concentration of decision making and financial power in the central ministry of health, making it difficult to respond quickly to emergencies such as COVID-19. Finally, COVID-19 amplifies the detrimental effects—on various levels, from health technologies to the macrostructure of the state—of policies that are already responsible for increasing inequities and deaths. In this scenario of profound political, ethical, and democratic crisis, the scientific evidence of inequity, not only supports a direction for future actions to strengthen the SUS, but also recalls one of the important principles of the founding of the SUS: democracy is health. We declare no competing interests. Effect of socioeconomic inequalities and vulnerabilities on health-system preparedness and response to COVID-19 in Brazil: a comprehensive analysisIn Brazil, existing socioeconomic inequalities, rather than age, health status, and other risk factors for COVID-19, have affected the course of the epidemic, with a disproportionate adverse burden on states and municipalities with high socioeconomic vulnerability. Local government responses and population behaviour in the states and municipalities with higher socioeconomic vulnerability have helped to contain the effects of the epidemic. Targeted policies and actions are needed to protect those with the greatest socioeconomic vulnerability. Full-Text PDF Open Access