What is the agenda for combating discrimination in the Brazilian Unified National Health System?
Claudia TravassosI; Ligia BahiaII
IInstituto de Comunicação e Informação Científica e Tecnológica em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. email@example.com
IIFaculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil. firstname.lastname@example.org
We rarely discuss or investigate discrimination in health services, although the material and symbolic repercussions are a central issue for improving effectiveness and equity in the Unified National Health System (SUS). The theme emerges occasionally as racial discrimination, generally based on statistical evidence dissociated from either conceptual formulations on race or the reality of discrimination processes.
On this basis, a normative apparatus has been constructed in relation to racial equality in Brazil, expressed formally as affirmative policies which, in thesis, represent a contradiction with the egalitarian and universalist principle of the SUS. The chasm is thereby reopened between the democratic and liberal traditions, expressed in the subtle semantic distinction between the formulations "we are all equal despite our differences" and "we are all different despite our similarities".
Fraser (In: Souza J. Democracia Hoje: Novos Desafios para a Teoria Democrática Contemporânea. Editora UnB; 2001. p. 245-82) discusses the dilemma between strategies to reduce social inequalities based on affirmative as compared to transformative approaches. The former create or reaffirm the identity of subgroups (racial, gender-based, and others), increasing the differentiation between them (dominant multiculturalism), while the latter involve restructuring the framework that produces them, i.e., destabilizing group identities and differentiations. Thus, the affirmative approach fails to alter the structure that generates disadvantages, while the transformative approach reduces inequalities. By dissolving the stigmatization of groups that are the object of disadvantages, the transformative perspective mobilizes solidarity and reciprocity.
In Brazil, racial equality policies emphasize institutional racism, a notion incorporated into the official documents, disconnected from its most current international formulation. The failure to distinguish between racial discrimination attributed to everyday institutional norms and procedures and that generated by interpersonal relations means disclaiming the explanation for the real processes of discrimination that occur in health services. There is no plausibility to the accusation of institutional racism in the SUS. Discrimination in public and private health services results fundamentally from the relations between health professionals and patients. The non-centrality of interpersonal discrimination may be one of the obstacles to obtaining a more solid empirical basis to dynamize the debate on the racial issue in the SUS. The fragile abstractions obtained by applying linear causal models decontextualize the real suffering of those that experience discrimination in health services, whether on grounds of gender, age, social condition, skin color, sexual option, or disease, among others.
The pillars sustaining the racial equality policy fail to inspire effective actions. Even the affirmative intention in the pursuit of racial equality in health cannot be realized, due to the absence of biological validity in the notion of racial diversity. In this vacuum, the National Health Plan for 2008/2009-2011 devotes only a few lines to health policy for Brazil's Black population in the item Populations in Situations of Vulnerability and Inequality, although more than 50% of the Brazilian population consists of individuals that classify themselves as Black or Brown. On the practical level, once again the majority is reduced to a minority, and new enclaves are created in Brazil's state bureaucracy.
What persists is the absence of a policy to combat the discrimination and privileges lying at the base of the social inequalities still permeating the SUS. May the creation of such a policy be oriented by an inclusive agenda, avoiding the creation of new stigmas, since the ones we have already suffice.