Health Inequalities in Brazil: Race Matters Desigualdades Em Saúde No Brasil

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Health Inequalities in Brazil: Race Matters Desigualdades Em Saúde No Brasil 1272 PERSPECTIVAS PERSPECTIVES Desigualdades em saúde no Brasil: é preciso ter raça Health inequalities in Brazil: race matters Desigualdades en salud en Brasil: la raza importa Dóra Chor 1 1 Escola Nacional de Saúde “...111 presos indefesos, mas presos são quase to- dade prioritária, e até mesmo de reuniões cien- Pública Sergio Arouca, dos pretos/Ou quase pretos, ou quase brancos qua- tíficas dedicadas aos Determinantes Sociais de Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. se pretos de tão pobres/E pobres são como podres Saúde. e todos sabem como se tratam os pretos” (Haiti, Apesar do interesse de pesquisadores estran- Correspondência D. Chor Caetano Veloso). geiros sobre as desigualdades raciais em saúde no Departamento de Brasil, não foi possível incorporar investigações Epidemiologia e Métodos No Brasil, o tema “raça e saúde” é controverso. Es- empíricas suficientes a esse respeito no abran- Quantitativos em Saúde, Escola Nacional de Saúde tou convencida de sua importância em função da gente painel sobre o país, publicado em 2011, no Pública Sergio Arouca, escassez de estudos empíricos que investiguem a The Lancet. As exceções apontaram consistente- Fundação Oswaldo Cruz. magnitude e influência das desigualdades raciais mente para a desvantagem dos mesmos grupos Rua Leopoldo Bulhões 1480, Rio de Janeiro, RJ no adoecimento. Não se trata de discutir a hie- raciais – alarmante mortalidade por violência que 21041-210, Brasil. rarquia dos condicionantes das desigualdades atinge jovens pretos e pardos 5, maior mortalida- [email protected] em saúde no Brasil. Penso ser consenso que a de de crianças pretas e pardas até 5 anos de ida- origem é social. No entanto, em um mundo em de 6, dificuldades e insatisfação mais frequentes que o pensamento conservador avança, é preciso no atendimento de gestantes pretas, e a ocorrên- conjugar o universal e o particular incluindo evi- cia de doenças crônicas entre indígenas 7. dências empíricas sobre discriminação, racismo, Na contramão dessa tendência, setores da im- raça e saúde no Brasil. prensa abordam casos de racismo como o do me- Já fui questionada, por colegas e alunos, so- nino negro quase expulso de uma concessionária bre os motivos pelos quais alguns pesquisado- de automóveis no Rio de Janeiro, onde os pais res brasileiros são contrários a estudos de saúde adotivos brancos se encontravam. Nessa maté- com recorte racial. Nunca consegui responder ria, Zuenir Ventura 8 questiona se “o que muitos a essa pergunta de forma direta. A discussão foi chamam de racismo cordial, não seria o contrário, acalorada nos anos 2000, o tema foi apresentado velado, camuflado, que quando flagrado se disfar- em mesa redonda no VI Congresso Brasileiro de ça, alegando engano ou má interpretação”. Como Epidemiologia (2004) e suas palestras publica- curiosidade, Zuenir finaliza a matéria informan- das em Cadernos de Saúde Pública (ver Fórum: do que a mortalidade por doenças infecciosas Raça, Racismo e Saúde no Brasil 1,2,3,4) em 2005. é 43% maior entre crianças negras do que entre Recentemente, desapareceu dos congressos de brancas. Quais são as consequências, na saúde, Epidemiologia e de Saúde Pública como ativi- do tratamento que aquele e outros meninos re- Cad. Saúde Pública, Rio de Janeiro, 29(7):1272-1275, jul, 2013 DESIGUALDADES EM SAÚDE NO BRASIL 1273 cebem? Como saber se a assistência à saúde não nas ciências sociais brasileiras. Na educação, as é permeada pela discriminação? iniquidades raciais foram diagnosticadas como A imprensa noticiou a existência do “SPP” “fortes”, merecendo ação imediata 13. O que po- (se parar parou). É a triagem na fila de espera demos afirmar no campo da saúde? Penso que de serviços de saúde. Será que sendo todos po- não temos evidências suficientes para descar- bres, os pretos ficam no final? Como saber sem tar a raça como um dos determinantes distais pesquisar? E já que o assunto é delicado, difícil de doenças e agravos, uma vez que influencia as de ser mensurado, vamos transformá-lo em ta- “causas das causas”: oportunidade de frequen- bu no que tange a pesquisas empíricas? Não, o tar boas escolas, a “escolha” da profissão (tam- SUS não é racista, como apontam os autores 9. bém condicionada pela avaliação de ingressar Ao contrário, seu ideário é o da universalidade, naquelas mais disputadas) e a renda decorrente igualdade entre todos os brasileiros. No entanto, do trabalho. não podemos achar que em função desse ideário, Considerando raça como um construto so- tratamentos racistas ocorrem somente em outras cial que reúne diversas dimensões da história de instituições. vida de indivíduos e gerações, os estudos de raça Há resultados de investigações brasileiras e saúde realizados em outros contextos não são que fornecem evidências de iniquidades (porque suficientes para dar conta da nossa realidade. injustas e evitáveis) raciais em saúde. Em Pelotas A ausência de segregação legal em toda a nossa (Rio Grande do Sul), a taxa de mortalidade in- história, a miscigenação, e o denominado “pre- fantil de filhos de mães brancas em 1982 (30 por conceito de ter preconceito” configuram quadro 1.000 nascidos vivos) só foi alcançada por filhos único no mundo, diferente do norte-americano de pretas e pardas em 2004! Nesse ano, a taxa de e do sul-africano. No campo das pesquisas sobre mortalidade infantil dos filhos de mães brancas discriminação, instrumentos de medida adequa- já estava no patamar de países de alta renda (13,9 dos ao nosso contexto são necessários e podem por 1.000 nascidos vivos) 10. Investigando a rea- fornecer resultados mais próximos da realidade lização de mamografia na Pesquisa Nacional por brasileira 14. Amostra de Domicílios (PNAD 2008), constata-se As limitações metodológicas são citadas co- que a prevalência do rastreamento era maior pa- mo obstáculos para os estudos epidemiológicos ra mulheres brancas, de maior renda, de maior de raça e saúde. Por exemplo, nas taxas de morta- escolaridade ou que moravam em regiões metro- lidade específicas por grupos de doença segundo politanas de melhor padrão socioeconômico 11. raça, o fato do numerador (número de óbitos) e A literatura internacional sobre desigualda- do denominador (população sob risco em cada des sociais em saúde é volumosa, não descarta a estrato de raça) serem provenientes de fontes de influência da raça e a relaciona com as condições dados diferentes – Sistema de Informações sobre socioeconômicas, apontando a complexidade Mortalidade (SIM; Ministério da Saúde) e Censo e desafios desse entrecruzamento. É necessário Demográfico (Instituto Brasileiro de Geografia e aprofundar esse esforço no campo da Saúde Pú- Estatística), respectivamente, limita a acurácia blica brasileira. dos resultados. No entanto, problemas ainda Os resultados dos estudos nacionais, assim mais importantes, como a cobertura do SIM, não como a comparação com a literatura internacio- nos impediram de estudar a mortalidade bra- nal, reforçam a hipótese de que também no Bra- sileira nos anos 80. Na realidade, esses e outros sil o eixo da desigualdade racial, além do socio- problemas foram evidenciados na medida em econômico e o de gênero, merece investigação que os dados foram analisados e suas limitações na área da saúde. Esses três eixos podem atuar apontadas. Esse processo auxiliou no aperfeiçoa- juntos, criando grupos especialmente expostos a mento do sistema e trouxe informações de gran- riscos. Em muitos casos, a adversidade econômi- de relevância sobre mortalidade no país. ca será a explicação mais importante. Em outros, Outro problema apontado refere-se à varia- esse eixo não será suficiente e a compreensão do bilidade com que as pessoas se autoclassificam. papel da raça e do gênero será indispensável para Como em outros países, também no Brasil a explicar o desfecho e contribuir para a elabora- identidade racial não é fixa nem imutável e sua ção de políticas públicas. validade e confiabilidade são limitadas. Embora Citando Edward Telles 12 (p. 38), “compartilho seja plausível imaginar que as pessoas não alte- da preocupação de que o uso do termo raça forta- rem sua autoclassificação racial em um estudo lece distinções sociais que não possuem qualquer epidemiológico da mesma forma como podem valor biológico, mas a raça continua a ser imen- se sentir constrangidas a fazer em uma candida- samente importante nas interações sociológicas tura a emprego, essa é uma limitação frequente e, portanto, deve ser levada em conta nas análises para os epidemiologistas interessados nos efeitos sociológicas”. Estudos sobre raça têm tradição de exposições psicossociais. Nesse caso, não há Cad. Saúde Pública, Rio de Janeiro, 29(7):1272-1275, jul, 2013 1274 Chor D padrão-ouro e a mensuração não pode ser fei- com magnitudes diversas a depender da pergunta ta por meio de aparelhos, material biológico ou que se deseja responder. O estudo de exposições exames de imagem. Mesmo assim há fortes evi- que se encontram mais próximas do desfecho na dências de seus efeitos sobre a saúde. cadeia de causalidade não é incompatível com a Recentemente, em uma banca de qualifica- investigação de fatores distais, entre os quais se ção, perguntei ao aluno por que iria ajustar o mo- encontra a raça. Não é prudente criar barreiras a delo estatístico de sua tese por raça uma vez que, essa linha de pesquisa sem investigações empíri- do meu ponto de vista, não fazia muito sentido. cas suficientes. O aparente consenso (não expli- Ele respondeu que essas análises eram apresen- citado) de que estudar as desigualdades raciais tadas em outros artigos... mas se deu conta de em saúde cria divisões sociais no Brasil ao invés que eram todos norte-americanos. A escassez de de expô-las, pode reforçar o determinismo bioló- investigações brasileiras bem fundamentadas do gico, distorce a abrangência de outros aspectos ponto de vista conceitual e metodológico assim da discriminação ou não ajuda a compreender como de discussões consistentes de seus resul- as origens das desigualdades sociais em nosso tados, pode levar jovens pesquisadores a imitar país parece ser tão polarizado quanto restringir raciocínios pertinentes a outras configurações a discussão à criação de programas de saúde es- sociais.
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