# Abstract

The growing flow of Venezuelan immigration has provoked discussions about the insertion of this community in Brazilian territory. Currently, the health system of Roraima has the challenge of effecting the universalization of access to the immigrant population. Therefore, this study aims to understand the repercussions of this phenomenon from the perspective of health professionals. As such, this is a qualitative study with an exploratory approach that analyzed the perception of nursing technicians of the largest hospital in Roraima about the effects of immigration on health services and quality of care. The analysis of semi-structured interviews was based on the content evaluation technique, and categories were listed. Through the categorical analysis of obstacles in health care, we observed structural problems, such as frailties in infrastructure and lack of technical professionals, resulting in work overload, as well as ethnocultural problems, such as the language barrier, which represents a limiting factor for performing quality health care, in addition to the greater frailty in the health condition of immigrants. The findings of this study may help the state of Roraima to reflect critically on the correct use of investments in health, to ensure efficacy, dignity and humanity to immigrants, as well as Brazilians.

Keywords:
Health and Migration; Health Access; Health Systems; Health and Citizenship; Hospital Technical Services

# Introduction

Venezuela is currently experiencing the biggest crisis in its history, resulting in a mass exodus of Venezuelans fleeing this serious political and socioeconomic crisis and lack of health care. In this sense, migration occurs mainly to Spanish-speaking Latin American countries. However, Brazil has received thousands of Venezuelan refugees who, for the most part, enter the national territory through the border with the state of Roraima in search of better living conditions or even to escape hunger (García; Aburto, 2019GARCÍA, J.; ABURTO, J. M. The impact of violence on Venezuelan life expectancy and lifespan inequality. International Journal of Epidemiology, Oxford, v. 48, n. 5, p. 1593-1601, 2019.; Lima, 2018LIMA, J. F. Regimes totalitários e a imigração: uma análise do caso de imigração dos venezuelanos para o Brasil à luz do direito natural. Fibra Lex, Belém, v. 1, n. 4, p. 1-12, 2018.).

Thus, this growing flow of immigration has provoked great discussions about the insertion of this community in Brazilian territory. Most immigrants want temporary jobs and others urgently seek medical care because of the collapse of Venezuela’s health care system. All this leads to overload in Roraima’s public health system. Although migration does not necessarily lead to health threats, it can increase the vulnerability of subjects. Nevertheless, the overload in the system cannot be the reason for automatic restrictions on the care of immigrants, as this represents a serious violation of human rights (Ayres et al., 2003AYRES, J. R. C. M. et al. O conceito de vulnerabilidade e as práticas de saúde: novas perspectivas e desafios. In: CZERESNIA, D.; FREITAS, C. M. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: Fiocruz, 2003. p. 117-139.; War; Ventura, 2017; Lima 2018LIMA, J. F. Regimes totalitários e a imigração: uma análise do caso de imigração dos venezuelanos para o Brasil à luz do direito natural. Fibra Lex, Belém, v. 1, n. 4, p. 1-12, 2018.; Roa, 2018ROA, A. C. Sistema de salud en Venezuela: ¿un paciente sin remedio? Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 3, p. e00058517, 2018.).

In this context, it can be concluded that Roraima is facing one of the greatest challenges in its history: to accommodate and integrate part of the thousands of immigrants from the great Venezuelan diaspora, fugitives from the socio-economic and humanitarian chaos faced in the country. Consequently, Boa Vista, the state capital, seeks to build strategies to welcome and improve the conditions of the Venezuelan immigrant population, which largely inhabits public spaces and streets, impacting health determinants and further weakening the health situation of this group, contributing to the decrease in their quality of life and to the disorganization of the local geographic space, which impacts city dynamics.

In line with this thinking and in view of the important budgetary reflexes generated by Venezuelan immigration in Roraima, especially in the health sector, the state government decreed a public health emergency in the municipalities of Pacaraima and Boa Vista (Roraima, 2019RORAIMA. Decreto nº 26.577-E, de 24 de fevereiro de 2019. Decreta estado de calamidade na Saúde Pública do Estado de Roraima, em face da crise humanitária e violência na Venezuela impactando o serviço de saúde nos hospitais do Estado localizados nos municípios de Pacaraima e Boa Vista. Diário Oficial do Estado de Roraima, Boa Vista, ed. 3425, p. 2, 25 fev. 2019.). Within this scenario, it can be perceived in loco the overburdening of health services throughout the capital; most of these patients are Venezuelan immigrants, that use services from primary care as well as services of greater complexity such as large hospitals.

The scientific literature already recognizes that the phenomenon of immigration has represented an important challenge in the area of public health, with an impact on the level of service dynamics in host countries (Dias et al., 2010DIAS, S. et al. Procura de cuidados e acesso aos serviços de saúde em comunidades imigrantes: um estudo com imigrantes e profissionais de saúde. Arquivos de Medicina, Porto, v. 24, n. 6, p. 253-259, 2010.) and, in this context, one of the places with the greatest increase in demand was the General Hospital of Roraima (HGR), the largest hospital in the state, a reference for all its municipalities and border countries, mainly Guyana and Venezuela.

Thus, the local health system faces the challenge of universalizing the access to quality health services for immigrants and impacting as little as possible on the conditions of access and efficiency of services already received by Brazilians. Amidst this challenge are health professionals, who had work routines profoundly altered due to the intense migratory process.

Among these professionals, we highlight nursing technicians who make up the frontlines of health care, even though they have less autonomy; this is due to, among other factors, the practical difficulty in delimiting the roles among nurses, technicians and nursing assistants that accentuates this aspect (Ferreira; Lucca, 2015FERREIRA, N. N.; LUCCA, S. R. Síndrome de burnout em técnicos de enfermagem de um hospital público do Estado de São Paulo. Revista Brasileira de Epidemiologia, São Paulo, v. 18, n. 1, p. 68-79, 2015.). Therefore, it is hypothesized that these would be the health professionals most vulnerable to the greatest impacts on their work and care routines, due to the increased demand in this reference hospital.

Therefore, this study aims to know the repercussions of Venezuelan migration from the perspective of nursing technicians from the aforementioned hospital. It should be emphasized that this phenomenon of population displacement has affected public health throughout the North region and, above all, in Roraima. However, the literature still lacks in-depth scientific data on the impact of Venezuelan immigration on the local health services of Roraima (Barreto et al., 2018BARRETO, T. M. A. C. et al. O impacto nos serviços de saúde decorrentes da migração venezuelana em Roraima: ensaio reflexivo. In: BAENINGER, R.; JAROCHINSKI-SILVA, J. C. (Org.). Migrações venezuelanas. Campinas: Nepo/Unicamp , 2018. p. 369-373.).

Therefore, the absence of studies aimed at measuring and/or understanding how this immigrant population has impacted health services is emphasized. Thus, these results will be the first in the scientific literature and may serve as a basis for the development of public policies aimed at this population and for the improvement of health services in Roraima and throughout the northernmost region of Brazil.

# Methodology

This study presents a qualitative design with an exploratory approach. Qualitative studies are characterized by focusing fundamentally on human experiences, allowing for the acquaintance of their subjectivity in the multiple actors of society (Benjumea, 2015BENJUMEA, C. La calidad de la investigación cualitativa: de evaluarla a lograrla. Texto & Contexto Enfermagem, Florianópolis, v. 24, n. 3, p. 883-890, 2015.). The exploratory character aims to provide more information about the subject that is intended to be investigated, enabling its definition and design, which allows for the analyses of the theme from various angles and aspects - among them, those that involve interviews with people who had practical experiences with the problem in question (Prodanov, 2013PRODANOV, C. C. Metodologia do trabalho científico: métodos e técnicas da pesquisa e do trabalho acadêmico. 2. ed. Novo Hamburgo: Feevale, 2013.).

The research was based on the HGR, in Boa Vista, and the universe of research was composed of nursing technicians working there. Fifteen technicians who met the following inclusion criteria participated in this study: working in the hospital for more than three years (which was the time frame of when immigration began to intensify), and being an effective employee. Exclusion criteria were: having higher education or being a foreigner.

For the selection of interviewees who met the above criteria, the initial contact was made with nurses from the sectors where the technicians work, namely: emergency care, great trauma and two intensive care units (ICU). The nurses were explained the objectives of the research and its methodology. They then gathered the technicians and passed on the information about the study. Soon after, volunteers were invited to participate in the interviews; the first to accept were elected for the interviews, provided that met the criteria.

Of the total number of interviewees, four worked in the great trauma section, four in the emergency room, four in ICU 01 and three in ICU 02. Within each sector, we sought to interview one technician per work team (there are usually four teams per sector), in order to have greater amplitude of experiences and less interference of the experiences collectively experienced by a given nursing team.

The sample limit was based on the data saturation technique (Saunders et al., 2018SAUNDERS, B. et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Quality & Quantity, [S.l.], v. 52, n. 4, p. 1893-1907, 2018.). Additionally, a semi-structured interview was used, elaborated and recorded by the authors, questioning the impacts of immigration on health services and the quality of care. There was internal validation of the script with two interviews, which were not included in the sample. It is noteworthy that, when the script is appropriate, the saturation point is usually reached at a maximum of 15 interviews (Rhiry-Cherques, 2009 apud Nascimento et al., 2018NASCIMENTO, L. C. N. et al. Theoretical saturation in qualitative research: an experience report in interview with schoolchildren. Revista Brasileira de Enfermagem, Brasília, DF, v. 71, n. 1, p. 228-233, 2018.). The average duration of the interviews was 18 minutes and they took place in June 2019.

In agreement with Streubert and Carpenter (2013STREUBERT, H. J.; CARPENTER, D. R. Investigação qualitativa em enfermagem: avançando o imperativo humanista. 5. ed. Tradução P. S. S. Espada. Loures: Lusociência, 2013.), it is considered that the use of multiple methods of data collection is important, as it increases the credibility of the results. In this sense, in order to strengthen the interpretation of the data captured by the interview script, we also opted for the technique of participant observation.

Currently, it is possible to affirm, in a synthetic way, that the technique is characterized by the promotion of interactivity between the researcher, the observed subjects and the context in which they live, with the immersion of the researcher in the reality of the researched. For this, it assumes conviviality and exchange of experiences primarily through the senses: sight, speech, feeling and experimentation. (Fernandes; Moreira, 2013FERNANDES, F. M. B.; MOREIRA, M. R. Considerações metodológicas sobre as possibilidades de aplicação da técnica de observação participante na Saúde Coletiva. Physis, Rio de Janeiro, v. 23, n. 2, p. 511-529, 2013.).

In such a context, an auxiliary instrument was used in the participant observation process, as recommended by Malinowski (1984MALINOWSKI, B. Os argonautas do pacífico ocidental. São Paulo: Abril Cultural, 1984.); that is, a field script with the guidelines for the observation, including aspects that should be observed according to research concerns. Such guidelines were designed to be followed without the concern of absolute rigidity, leaving room for “imponderables,” unexpected situations and perceptions of the observer (Fernandes; Moreira, 2013FERNANDES, F. M. B.; MOREIRA, M. R. Considerações metodológicas sobre as possibilidades de aplicação da técnica de observação participante na Saúde Coletiva. Physis, Rio de Janeiro, v. 23, n. 2, p. 511-529, 2013.).

Participant observation, according to the abovementioned methodological framing, was performed during one week by all authors, individually, in different shifts and in all sectors of the hospital.

For analysis and treatment of the data of the interviews, content analysis was used (Bardin, 2008BARDIN, L. Análise de conteúdo. Lisboa: Edições 70, 2008.), based on relevant literature. The data obtained from participant observation supported the analysis of the interviews. The statements were separated into content units, with subsequent grouping into categories.

Regarding ethical criteria, we respected the Declaration of Helsinki and resolution no. 466/2012, which deals with research with human beings. This study was approved by the Research Ethics Committee of the Universidade Estadual de Roraima, under opinion no. 3.357.346 and CAAE 12031518.5.0000.5621. All participants signed the informed consent form. Statements were coded with the letter “E,” which represents the interview in question, and an Arabic numeral, representing the number given to the said interview.

# Results and discussion

This study had the participation of 15 nursing technicians, eight women and seven men. The time of experience in the HGR ranged from three to 15 years. Two categories were constructed to synthesize the results: obstacles in health care and the health conditions of immigrants.

## Category 1: obstacles in health care

The main challenges and difficulties in health care in the hospital and for nursing care are addressed here as a result of intense immigration. The category was subdivided into two: structural barriers and ethnocultural difficulties.

### Structural barriers

This category was composed of dialogues that explain the lack of technical professionals, infrastructure developments contribution of inputs, which are deficiencies occurring prior to immigration, configuring themselves as obstacles to quality health care:

This hospital is a reference for the state, Guyana and Venezuela, but not for this number of people, then the situation that was already complicated, became critical. Of ten beds, seven are occupied by Venezuelans. (E8)

The number of beds has not changed and is always busy. Of 10 beds, three or four are Venezuelans. But there was no increase in staff and no infrastructure improvements to accommodate foreigners. (E1)

We serve more Venezuelans than Brazilians. Almost 70% of the people on food queue are Venezuelan patients and their companions. (E10)

We already had a significant lack of material; with the arrival of Venezuelans it grew even bigger. Now for every ten calls, five or six are from Venezuelan patients. And now resources for the Brazilian people are missing. They were already missing. Then it got much worse! (E15)

If there isn’t a bed, I get a chair; in the absence of the specific catheter, you can use a Gelco instead. When there’s no stopcock, we administer the medication directly and ask the patient to hold the bag. We’re always working on some way to make it work here. (E2)

All interviewees reported no changes in hospital infrastructure, also describing improvisational strategies to overcome structural and material deficiencies for nursing care. Many of these improvisations were confirmed by the participant observation.

Based on the interviewees-centered statements portraying the absence of investments and improvements in the HGR that would be necessary to accommodate the increased demand and improve care for all users, it is reasonable to discuss if the application of the extra resources received was inefficient or invested in other spaces - because, in view of the reported problems, it seems that there was no mitigation of the health crisis in the state. The state of Roraima received, after the intensification of Venezuelan immigration, almost R$200,000 destined for health care, to strengthen and expand hospital care and primary care, as well as assist Venezuelan immigrants (Governo..., 2019GOVERNO destina R$ 14 milhões para assistência a imigrantes venezuelanos. Governo do Brasil, Brasília, DF, 15 fev. 2019. Disponível em: <Disponível em: https://bit.ly/2UGE3Iw >. Acesso em: 24 jun. 2019.
https://bit.ly/2UGE3Iw...
; Roraima..., 2018RORAIMA ganha reforço de R187 milhões em resposta à imigração. Ministério da Saúde, Brasília, DF, 15 maio 2018. Disponível em: <Disponível em: https://bit.ly/2WU4PQx >. Acesso em: 24 jun. 2019. https://bit.ly/2WU4PQx... ). However, it is also noteworthy that the locus of this study, although it is the main hospital in the state, is not the only one to assist this group. Participants heavily emphasized that work overload is based on two main causes. First, there is the huge increase in demand, subjectively quantified by interviewees as 50-70% being of services directed to Venezuelan patients. This opens space for ideas of future quantitative studies that can focus on this approach, since the authors of this study, as health professionals working in Roraima (and through participant observation), believe that there was an overestimation of the percentage of services to Venezuelans in the reports - it is estimated that this number is around 20% to 25%. Nevertheless, even with the authors’ hypothesis of overestimated demand increase, it is still a considerable growth, mainly because it is abrupt, with many real reflexes and deleterious potentials in health care and the quality of services. As a second cause, there is the absence of new professionals from this category of nursing, because even if there were hirings proportional to the increase in the demand of users for the health service, there would be no fundamental changes to the status quo stablished before the problem discussed here. In this sense, it can be stated that the maintenance of the number of professionals for a greater and increasing number of patients necessarily contributes to the weakening of care and to the reduction of the quality of nursing and the health service as a whole. Participant observation also brought a strong perception that there is work overload upon the nursing team, but one cannot make a direct relationship of this overload only with the migratory process. Two participants mentioned that the challenges faced by the hospital sector are even less dramatic than in primary care, where demand is higher, as can be read in the following statements: Here [in HGR] the demand has increased, but in primary care it grew so much more. The amount of patients have increased a lot, specially for me, working in vaccination; everyone comes without a card. So there’s always someone starting [treatments]. (E3) Colleagues working in the [Family Health Program] PSF say that the demand is much higher. (E9) Based on these findings, we believe that part of the increase in care and the flow of immigrants seeking high complexity services is due to the overload of primary care services in the municipalities of Roraima, especially in the capital - or, hypothetically, by their inability to solve problems sensitive to primary health care, or by some failure in the health care network system and its reference and counter-reference systems. In a reflection, Holz et al. (2016HOLZ, C. B. et al. O hospital na rede de atenção a saúde: uma reflexão teórica. Revista Espaço Ciência & Saúde, Cruz Alta, v. 4, n. 1, p. 101-115, 2016.) state that the main demands of the hospital come from non-urgent cases, the resolution of which is the responsibility of primary care. These demands noted in the aforementioned study may contribute to the overload of the hospital service, in the case of Roraima. There are also reports in the literature about the insufficiency of basic health units in fulfilling their demands related to immigration (Dias, 2019DIAS, R. S. As implicações da imigração venezuelana sobre o trabalho dos agentes comunitários de saúde do município de Pacaraima. 2019. Dissertação (Mestrado em Educação Profissional em Saúde) - Escola Politécnica de Saúde “Joaquim Venâncio”, Fundação Oswaldo Cruz, Rio de Janeiro, 2019.), which may contribute to the burden of the tertiary sector noted here. Nevertheless, studies show that the reference and counter-reference system, when well executed through primary care, decreases the demand for hospital services. (Almeida; Santos, 2016SANTOS, F. V. The inclusion of international migrants in Brazilian healthcare system policies: the case of Haitians in the state of Amazonas. História, Ciências, Saúde-Manguinhos, Rio de Janeiro, v. 23, n. 2, p. 477-494, 2016.). Therefore, studies that also address this theme are necessary, since the inclusion of immigrants in primary care services is a complex process due to prejudice, often present in the care of immigrants, and the difficulty of follow-up (Martin; Mr. Goldberg; Silveira, 2018MARTIN, D.; GOLDBERG, A.; SILVEIRA, C. Imigração, refúgio e saúde: perspectivas de análise sociocultural. Saúde e Sociedade, São Paulo, v. 27, n. 1, p. 26-36, 2018.), mainly because of the accelerated dynamics in migration processes, difficulties in the establishment of a fixed residence or, in the case of Boa Vista, the number of people living in shelters, public spaces or in the streets. This reality is described in a study by Baeninger and Silva (2018BAENINGER, R.; SILVA, J. C. J. (Org.). Migrações venezuelanas. Campinas: Nepo/Unicamp, 2018. v. 1. Disponível em: <Disponível em: https://bit.ly/2ULmffG >. Acesso em: 14 nov. 2019. https://bit.ly/2ULmffG... ), whose surveys show a large number of Venezuelan immigrants surviving on the streets with the help of the Boa Vista population. Moreover, in the same study, there are reflections on the Brazilian military operation, carried out jointly with non-governmental organizations and the United Nations, called Operação Acolhida (“Operation Welcome”), which houses a large number of immigrants, refugees or not. ### Ethnocultural difficulties Language is noted as the most important cultural barrier of care, because language is one of the vehicles for practicality, bonding and response of user to therapy. Nevertheless, based on the interviewees’ statements, validated in the participant observation, most of nursing technicians have resistance to the use of Spanish. However, the use, when possible, would be beneficial for the humanization of health care. The language interferes more on their side! They don’t put the slightest effort into learning how to speak Portuguese. We strive to try to pass on the information, many of them think that we have to learn to speak Spanish. I say: “No! You have to learn to speak Portuguese, you are in Brazil. You are the ones that have to learn.” (E10) According to a study conducted by Chubaci and Merighi (2002CHUBACI, R. Y. S.; MERIGHI, M. A. B. A comunicação no processo da hospitalização do imigrante japonês. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 10, n. 6, p. 805-812, 2002.), during hospitalization of Japanese patients, it was noted that language composes a barrier not only to understand the disease and treatment, but also to relate to the health team. Therefore, the lack of proficiency in the language contributes to a feeling of distrust, need for help from family members, suffering and repentance for not speaking Portuguese. Therefore, the possibility that Venezuelan immigrants also experience these feelings that can further weaken their health-disease process is not ruled out, making them even more vulnerable and aggravating their possible feelings of impotence. In a more recent study conducted by Guerra and Ventura (2017GUERRA, K.; VENTURA, M. Bioética, imigração e assistência à saúde: tensões e convergências sobre o direito humano à saúde no Brasil na integração regional dos países. Cadernos Saúde Coletiva, Rio de Janeiro, v. 25, n. 1, p. 123-129, 2017.), it was demonstrated that this cultural barrier is accentuated when the disease is more severe, since high complexity procedures and technical terms become more abundant in these situations. Moreover, to Aguiar and Mota (2014AGUIAR, M. E.; MOTA, A. O Programa Saúde da Família no bairro do Bom Retiro, SP, Brasil: a comunicação entre bolivianos e trabalhadores de saúde. Interface, Botucatu, v. 18, n. 50, p. 493-506, 2014.), both the health professional and the immigrant user report that the other has difficulty understanding their language. This can be observed in this study and was proven by the participant observation, since the nursing technicians consider that Venezuelans are “uninterested” in learning the Portuguese language, showing difficulty in understanding the information. Interviewees also report that immigrants think that health professionals should adapt to the patient’s language. During observation in one of the intensive care units, the mother of a Venezuelan pediatric patient was extremely distressed because she did not understand either the details of the prognosis or the treatment of the serious health situation that her daughter was going through, and the main obstacle was the language barrier. However, it is believed that part of the humanization of nursing care is based on the understanding of the socioeconomic situation and the social vulnerabilities of those who need health care. In this case, it is not reasonable to require that people who go through the unexpected process of forced immigration be penalized, in terms of health care, for not yet mastering the language of the welcoming country. On the contrary, health professionals should redouble their efforts to achieve efficient communication, or even require training from health services in order to deal with this problem. When the health professional refuses or is not inclined to adapt to language barriers in immigrant care, one of the main strategies for health promotion and disease prevention, which is health education, is seriously compromised. This weakens not only nursing care, but overall health care, regardless of the level of complexity of the system. In addition, behavioral differences here, which are registered by the interviewees, but not confirmed during the period of participant observation, indicate that immigrants strongly demand the fulfillment of their needs. However, even if this is the case, this demand is constitutional, since the Brazilian National Health System (SUS) is universal, integral and equitable. [Venezuelans] are very arrogant and demanding, they want priority and care fast, they don’t want to wait, and so I give them the silent treatment and sometimes ignore them (E13) They were used to [Venezuela] with one type of food and we have another. Despite being refugees and despite hunger, they do not eat everything (E5) They are very emotionally unsettled sometimes, require a lot, things that we can not do (E14) We only havetraining [in the field of] nursing, but not to serve foreigners. We even have patients from Lethen, Guyana, and also immigrants from Haiti (E8). It is believed that the interviewees possibly are accustomed to the passivity of Brazilian users in relation to the demand of their rights, even more so that the country has been undergoing a cultural and ideological polarization in recent years, even putting the SUS and its principles at risk (Teixeira; Vilasboas; Paim, 2018TEIXEIRA, C. F.; VILASBOAS, A. L. Q.; PAIM, J. Mais que nunca, é preciso lutar. Saúde Debate, Rio de Janeiro, v. 42, n. 2, p. 5-10, 2018.). Thus, it is perceived in the statements of the technicians that there is a denial, or disagreement, on the acquired rights of users of the SUS, represented by the surprise of the interviewees in the face of the demands of immigrants. The interviewees also lack permanent education in the scope of care for immigrants. This education, if present, could mitigate part of the problems reported here, because it would be more prudent for the health care and care provider to adapt and understand the needs and limitations of their patients than the other way around. Moreover, for health education, it is assumed that the professional has theoretical and technical bases and, in addition, has a good socioanthropological background, which allows him to deal more easily with cultural clashes, in addition to training to sensitize and humanize health care and care. Similarly, an ethnographic study on Haitian immigration in the Northern region points to cultural differences as barriers to assistance. As an alternative strategy, the Government of Amazonas created Portuguese language classes for Haitians and established a partnership with Médecins Sans Frontières, aiming at training for health professionals in municipalities and the state on Haitian culture, as well as notions of vocabulary and approach to health care, with successful results in the quality of care provided by the SUS in this municipality (Santos, 2016SANTOS, F. V. The inclusion of international migrants in Brazilian healthcare system policies: the case of Haitians in the state of Amazonas. História, Ciências, Saúde-Manguinhos, Rio de Janeiro, v. 23, n. 2, p. 477-494, 2016.). Successful strategies such as these could be encamped by health managers also in the state of Roraima. ## Category 2: health conditions of the immigrants This category focuses on the main health conditions and aspects related to the health-disease process of the immigrant population. We have collective health, and there they didn’t. So many patients - of cancer, HIV - came here. (E9) They have very poor health, more precarious than the people of rural areas, it is even worse. (E13) They are leading in rates of tuberculosis, and also brought yellow fever, malaria, measles that spread throughout Brazil. (E5) They come with the worst diseases you can imagine, the most horrible. (E6) Their [health] standard is pretty horrible, they’re pretty much all injured, there’s a lot of serious patients. They don’t have there [Venezuela] the treatment we have, vaccines up to date, they don’t have the routine of worrying about health. (E12) They brought back measles and it spread throughout Brazil. (E7) There is enormous demand from Venezuelans with some diseases that in Brazil have already been abolished, such as polio, rubella and measles. (E13) From the statements, it is noted that immigrants have greater fragility in health conditions when compared to Brazilians. This is certainly due to the deterioration of social determinants in Venezuela, a result of the economic collapse installed in this country, which has had profound impacts on the Venezuelan health system. In fact, studies show that Venezuela is currently experiencing a deep generalized crisis and lacks medicines, hospital supplies, human resources and basic financing - that is, its health system is in ruins - in addition to unfavorable social determinants for the quality of life and health of the population (Roa, 2018ROA, A. C. Sistema de salud en Venezuela: ¿un paciente sin remedio? Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 3, p. e00058517, 2018.; The colapse..., 2018). Although it is difficult to have reliable reports from Venezuela’s state agencies about the health system and the health conditions of the population, as the Maduro administration openly denies this wide-open crisis, the scientific literature has released studies and reports of experiences that show us the immeasurable chaos in Venezuelan health, with deplorable conditions, lack of medicines, health professionals and inputs in both the public and private system. These problems were intensified in the Maduro administration, generating one of the largest forced migrations of the century (Fraser; Willer, 2016FRASER, B.; WILLER, H. Venezuela: aid needed to ease health crisis. The Lancet, London, v. 388, n. 10048, p. 947-949, 2016.; Lima, 2018LIMA, J. F. Regimes totalitários e a imigração: uma análise do caso de imigração dos venezuelanos para o Brasil à luz do direito natural. Fibra Lex, Belém, v. 1, n. 4, p. 1-12, 2018.; Muci-Mendoza, 2014MUCI-MENDOZA, R. Venezuela: violence, human rights, and health-care realities. The Lancet, London, v. 383, n. 9933, p. 1967-1968, 2014.; Roa, 2018ROA, A. C. Sistema de salud en Venezuela: ¿un paciente sin remedio? Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 3, p. e00058517, 2018.). In forced migration, social determinants in health are influenced by the migratory pattern, the reason for immigration, the existing health system, the social and demographic system and the health needs of forced migrants (Pacheco-Coral, 2018PACHECO-CORAL, A. D. P. Statelessness, exodus, and health: forced internal displacement and health services. Cadernos Saúde Coletiva, Rio de Janeiro, v. 34, n. 4, p. e00027518, 2018.). Nevertheless, the high social vulnerability of most immigrants in the state of Roraima contributes to the decrease in quality of life and to the fragility of health conditions, altering the health-disease process in the direction of the disease. Social exclusion and homelessness, together with malnutrition and restricted access to health care, build favorable conditions for the development of health problems, whether infectious or not. From the participant observation, it was possible to verify that many Venezuelan patients actually arrive at the hospital in more delicate conditions: some even in rags, others with severe health conditions; many arrive seemingly malnourished and apparently suffering. In fact, it is noticeable that there is resurgence of many infectious diseases in Roraima. We have, for example, tuberculosis, which has increased significantly in the state, with an important part of the cases concentrated on Venezuelan immigrants. It is a disease that has a direct relationship with social determinants, such as poverty and malnutrition (Boa..., 2019BOA Vista reforça combate à tuberculose após aumento de 14% nos casos em 2018. G1, Roraima, 23 mar. 2019. Disponível em: <Disponível em: https://glo.bo/33X8Oxa >. Acesso em: 29 mar. 2020. https://glo.bo/33X8Oxa... ). It can also be mentioned that there was an increase in the number of HIV cases in the state and that this infection, when untreated, also has an impact on the epidemiology of tuberculosis (Rodrigues, 2019RODRIGUES, E. RR registra quase 2 mil casos de AIDS e HIV e maioria são homens. Folha de Boa Vista, Roraima, 26 jun. 2019. Disponível: <Disponível: https://bit.ly/2ylkpuk >. Acesso em: 29 mar. 2020. https://bit.ly/2ylkpuk... ). Moreover, it could be noted that in 2018, in Venezuela, there was a measles outbreak that hit nine of the 23 states and culminated in the reintroduction of measles in Brazil by Roraima, generating an outbreak in other regions (Branco; Morgado, 2019BRANCO, V. G. C.; MORGADO, F. E. F. O surto de sarampo e a situação vacinal no Brasil. Revista de Medicina de Família e Saúde Mental, Teresópolis, v. 1, n. 1, p. 74-88, 2019.; Brasil, 2019BRASIL. Secretaria de Vigilância em Saúde. Situação do sarampo no Brasil - 2018-2019. Informe nº 37. Brasília, 19 mar. 2019. Disponível em: <Disponível em: https://bit.ly/2UOCuIB >. Acesso em: 4 ago. 2019. https://bit.ly/2UOCuIB... ). Thus, the interviewees attribute the reappearance of controlled diseases in Brazil to the immigrant population. In this context, the resurgence of these immunopreventable infectious diseases demonstrates that Venezuela’s vaccination coverage is insufficient, enabling the return of previously controlled diseases such as rubella, polio and measles (UNICEF, 2017UNICEF - UNITED NATIONS CHILDREN’S FUND. WHO and UNICEF estimates of national immunization coverage: 2018 revision. Nova York, 28 jun. 2019. Disponível em: <Disponível em: https://bit.ly/39Bb9zi >. Acesso em: 4 ago. 2019. https://bit.ly/39Bb9zi... ). However, thesediseases, mediated by pathogens once controlled in Brazil, could, in part, have been avoided through adequate vaccination coverage of the population of Roraima. Thus, outbreaks of immunopreventable diseases indicate weaknesses in the fulfillment of immunization goals of all populations involved. It is known that 73.3% of the municipalities did not reach the goal of vaccination coverage for measles in Roraima (Mendes, 2019MENDES, A. Ministro alerta secretários de saúde para ampliar a cobertura vacinal do sarampo. Ministério da Saúde, Brasília, DF, 14 fev. 2019. Disponível em: <Disponível em: https://bit.ly/39wmReq >. Acesso em: 5 ago. 2019. https://bit.ly/39wmReq... ). # Final considerations In view of the above, it is perceived that the state of Roraima lacks effective and intelligent investments in healthcare, despite the transfers made to mitigate the abrupt increase in demand. This is because the infrastructure and input contribution were and still is deficient, and there were no increases in the hiring of nursing technicians. In this sense, with the overload of work of the technicians, it became a challenge for them to provide nursing and health care. Moreover, the most prominent cultural barrier in this study is language. A strong resistance was identified to the use of Spanish by the interviewees, aligned with the lack of investments in the learning of the native language of immigrants. Thus, the offer of language courses, both Portuguese for immigrants and Spanish for health professionals, would be an interesting strategy to improve care. The interviews showed that Venezuelans were more incisive in the demand of their rights and this was not well received by nursing technicians. The health status of these immigrants is remarkably fragile and this, in the interviewees’ view, corroborates as the main factor a picture of outbreaks of diseases previously controlled in Brazil. Part of these findings demonstrates a xenophobic view of the health professionals studied here, since they disregard important social determinants in the health of immigrants and their condition of high social vulnerability, attributing to them this state of calamity and emergency in public health in Roraima, as well as much of the problems of health services. Finally, this work has as theoretical weaknesses the low coverage of the classes of health professionals as well as being based only in the main hospital in the state. Therefore, studies that broaden the debate on the quality of care in the face of forced immigration are necessary to direct the public authorities in their investments, in the identification of social determinants, in raising awareness and training of health professionals. In addition, to broaden the vision already introduced here, it is up to new research to focus on the impact of immigration in the scope of primary care and analyses that quantify the impacts of immigration on the health system. Thus, more information will be gathered for the development of public policies aimed at immigrants in Roraima, in order to promote their social insertion in a dignified and humanized way. # References • AGUIAR, M. E.; MOTA, A. O Programa Saúde da Família no bairro do Bom Retiro, SP, Brasil: a comunicação entre bolivianos e trabalhadores de saúde. Interface, Botucatu, v. 18, n. 50, p. 493-506, 2014. • ALMEIDA, P. F.; SANTOS, A. M. Atenção primária à saúde: coordenadora do cuidado em redes regionalizadas? Revista de Saúde Pública, São Paulo, v. 50, p. 80, 2016. • AYRES, J. R. C. M. et al. O conceito de vulnerabilidade e as práticas de saúde: novas perspectivas e desafios. In: CZERESNIA, D.; FREITAS, C. M. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: Fiocruz, 2003. p. 117-139. • BAENINGER, R.; SILVA, J. C. J. (Org.). Migrações venezuelanas. Campinas: Nepo/Unicamp, 2018. v. 1. Disponível em: <Disponível em: https://bit.ly/2ULmffG >. Acesso em: 14 nov. 2019. » https://bit.ly/2ULmffG • BARDIN, L. Análise de conteúdo. Lisboa: Edições 70, 2008. • BARRETO, T. M. A. C. et al. O impacto nos serviços de saúde decorrentes da migração venezuelana em Roraima: ensaio reflexivo. In: BAENINGER, R.; JAROCHINSKI-SILVA, J. C. (Org.). Migrações venezuelanas. Campinas: Nepo/Unicamp , 2018. p. 369-373. • BENJUMEA, C. La calidad de la investigación cualitativa: de evaluarla a lograrla. Texto & Contexto Enfermagem, Florianópolis, v. 24, n. 3, p. 883-890, 2015. • BOA Vista reforça combate à tuberculose após aumento de 14% nos casos em 2018. G1, Roraima, 23 mar. 2019. Disponível em: <Disponível em: https://glo.bo/33X8Oxa >. Acesso em: 29 mar. 2020. » https://glo.bo/33X8Oxa • BRANCO, V. G. C.; MORGADO, F. E. F. O surto de sarampo e a situação vacinal no Brasil. Revista de Medicina de Família e Saúde Mental, Teresópolis, v. 1, n. 1, p. 74-88, 2019. • BRASIL. Secretaria de Vigilância em Saúde. Situação do sarampo no Brasil - 2018-2019. Informe nº 37. Brasília, 19 mar. 2019. Disponível em: <Disponível em: https://bit.ly/2UOCuIB >. Acesso em: 4 ago. 2019. » https://bit.ly/2UOCuIB • CHUBACI, R. Y. S.; MERIGHI, M. A. B. A comunicação no processo da hospitalização do imigrante japonês. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 10, n. 6, p. 805-812, 2002. • DIAS, R. S. As implicações da imigração venezuelana sobre o trabalho dos agentes comunitários de saúde do município de Pacaraima. 2019. Dissertação (Mestrado em Educação Profissional em Saúde) - Escola Politécnica de Saúde “Joaquim Venâncio”, Fundação Oswaldo Cruz, Rio de Janeiro, 2019. • DIAS, S. et al. Procura de cuidados e acesso aos serviços de saúde em comunidades imigrantes: um estudo com imigrantes e profissionais de saúde. Arquivos de Medicina, Porto, v. 24, n. 6, p. 253-259, 2010. • FERNANDES, F. M. B.; MOREIRA, M. R. Considerações metodológicas sobre as possibilidades de aplicação da técnica de observação participante na Saúde Coletiva. Physis, Rio de Janeiro, v. 23, n. 2, p. 511-529, 2013. • FERREIRA, N. N.; LUCCA, S. R. Síndrome de burnout em técnicos de enfermagem de um hospital público do Estado de São Paulo. Revista Brasileira de Epidemiologia, São Paulo, v. 18, n. 1, p. 68-79, 2015. • FRASER, B.; WILLER, H. Venezuela: aid needed to ease health crisis. The Lancet, London, v. 388, n. 10048, p. 947-949, 2016. • GARCÍA, J.; ABURTO, J. M. The impact of violence on Venezuelan life expectancy and lifespan inequality. International Journal of Epidemiology, Oxford, v. 48, n. 5, p. 1593-1601, 2019. • GOVERNO destina R 14 milhões para assistência a imigrantes venezuelanos. Governo do Brasil, Brasília, DF, 15 fev. 2019. Disponível em: <Disponível em: https://bit.ly/2UGE3Iw >. Acesso em: 24 jun. 2019.
» https://bit.ly/2UGE3Iw
• GUERRA, K.; VENTURA, M. Bioética, imigração e assistência à saúde: tensões e convergências sobre o direito humano à saúde no Brasil na integração regional dos países. Cadernos Saúde Coletiva, Rio de Janeiro, v. 25, n. 1, p. 123-129, 2017.
• HOLZ, C. B. et al. O hospital na rede de atenção a saúde: uma reflexão teórica. Revista Espaço Ciência & Saúde, Cruz Alta, v. 4, n. 1, p. 101-115, 2016.
• LIMA, J. F. Regimes totalitários e a imigração: uma análise do caso de imigração dos venezuelanos para o Brasil à luz do direito natural. Fibra Lex, Belém, v. 1, n. 4, p. 1-12, 2018.
• MALINOWSKI, B. Os argonautas do pacífico ocidental. São Paulo: Abril Cultural, 1984.
• MARTIN, D.; GOLDBERG, A.; SILVEIRA, C. Imigração, refúgio e saúde: perspectivas de análise sociocultural. Saúde e Sociedade, São Paulo, v. 27, n. 1, p. 26-36, 2018.
• MENDES, A. Ministro alerta secretários de saúde para ampliar a cobertura vacinal do sarampo. Ministério da Saúde, Brasília, DF, 14 fev. 2019. Disponível em: <Disponível em: https://bit.ly/39wmReq >. Acesso em: 5 ago. 2019.
» https://bit.ly/39wmReq
• MUCI-MENDOZA, R. Venezuela: violence, human rights, and health-care realities. The Lancet, London, v. 383, n. 9933, p. 1967-1968, 2014.
• NASCIMENTO, L. C. N. et al. Theoretical saturation in qualitative research: an experience report in interview with schoolchildren. Revista Brasileira de Enfermagem, Brasília, DF, v. 71, n. 1, p. 228-233, 2018.
• PACHECO-CORAL, A. D. P. Statelessness, exodus, and health: forced internal displacement and health services. Cadernos Saúde Coletiva, Rio de Janeiro, v. 34, n. 4, p. e00027518, 2018.
• PRODANOV, C. C. Metodologia do trabalho científico: métodos e técnicas da pesquisa e do trabalho acadêmico. 2. ed. Novo Hamburgo: Feevale, 2013.
• ROA, A. C. Sistema de salud en Venezuela: ¿un paciente sin remedio? Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 3, p. e00058517, 2018.
• RODRIGUES, E. RR registra quase 2 mil casos de AIDS e HIV e maioria são homens. Folha de Boa Vista, Roraima, 26 jun. 2019. Disponível: <Disponível: https://bit.ly/2ylkpuk >. Acesso em: 29 mar. 2020.
» https://bit.ly/2ylkpuk
• RORAIMA. Decreto nº 26.577-E, de 24 de fevereiro de 2019. Decreta estado de calamidade na Saúde Pública do Estado de Roraima, em face da crise humanitária e violência na Venezuela impactando o serviço de saúde nos hospitais do Estado localizados nos municípios de Pacaraima e Boa Vista. Diário Oficial do Estado de Roraima, Boa Vista, ed. 3425, p. 2, 25 fev. 2019.
• RORAIMA ganha reforço de R\$ 187 milhões em resposta à imigração. Ministério da Saúde, Brasília, DF, 15 maio 2018. Disponível em: <Disponível em: https://bit.ly/2WU4PQx >. Acesso em: 24 jun. 2019.
» https://bit.ly/2WU4PQx
• SANTOS, F. V. The inclusion of international migrants in Brazilian healthcare system policies: the case of Haitians in the state of Amazonas. História, Ciências, Saúde-Manguinhos, Rio de Janeiro, v. 23, n. 2, p. 477-494, 2016.
• SAUNDERS, B. et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Quality & Quantity, [S.l.], v. 52, n. 4, p. 1893-1907, 2018.
• STREUBERT, H. J.; CARPENTER, D. R. Investigação qualitativa em enfermagem: avançando o imperativo humanista. 5. ed. Tradução P. S. S. Espada. Loures: Lusociência, 2013.
• TEIXEIRA, C. F.; VILASBOAS, A. L. Q.; PAIM, J. Mais que nunca, é preciso lutar. Saúde Debate, Rio de Janeiro, v. 42, n. 2, p. 5-10, 2018.
• THE COLLAPSE of the Venezuelan health system. The Lancet, London, v. 391, n. 10128, p. 1331, 2018.
• UNICEF - UNITED NATIONS CHILDREN’S FUND. WHO and UNICEF estimates of national immunization coverage: 2018 revision. Nova York, 28 jun. 2019. Disponível em: <Disponível em: https://bit.ly/39Bb9zi >. Acesso em: 4 ago. 2019.
» https://bit.ly/39Bb9zi

# Publication Dates

• Publication in this collection
03 June 2020
• Date of issue
2020