Kia Lilly Caldwell’s book fills a gap in the scholarship on health policies and social justice in Brazil. The extensive literature on how class, gender, and race affect access to health care and health outcomes contrasts with the paucity of research on the experience of those at the underprivileged end of all these categories; namely, poor black women. Caldwell focuses on this group, and she justifies her intersectional approach by explaining that their unique experience cannot be fully captured by analyses that consider race, gender, or class separately.
Apart from addressing an important and underresearched topic, this book also presents the perspective of activists in women’s and black women’s movements on issues related to racial discrimination, human rights, and health. Health Equity in Brazil is thus a relevant contribution for substantive and methodological reasons.
The book starts with three observations. First, there is a significant disparity in health outcomes between white and African-descendant Brazilians, despite the existence of a universal public health system. Second, women are denied several reproductive rights, which has an impact on their health, and this problem is more severe for black women. Third, the myth that Brazil is a “racial democracy,” although contradicted by the facts, is a persistent obstacle for advancing affirmative policies aimed at redressing race inequalities. These observations set the scene for the analysis of the role activists have played in drawing attention to the racial disparity in health and in advocating policies to improve the health status of the Afro-Brazilian population, and of black women in particular.
Chapter 1 focuses on the role of feminist activists in placing issues of gender and race in the debates about health policies. Caldwell describes how these activists have challenged policies seen as detrimental to the health of women and have advocated measures to protect women’s reproductive rights. Chapter 2 explains the book’s intersectional approach and presents evidence that black women are more harshly affected by the insufficient protection of women´s reproductive rights. It also discusses how black women’s organizations have drawn attention to race inequalities in health.
Chapters 3 and 4 analyze the black activists’ fight to affirm the importance of considering race and racism when discussing health inequality. These chapters argue that “institutional racism” exists in the Brazilian public health system, as shown by the worse health outcomes of black people when compared to the white population and by the insufficient diagnosis and treatment of sickle cell anemia, a disease with higher prevalence among African-descendants. Chapter 5 discusses the case of Alyne Pimentel, a pregnant poor black woman, who died due to medical negligence and to the lack of adequate maternal and obstetric care. This case is used to illustrate the intersectional relationship between gender, race, and class that shapes the experience of black poor women in Brazil.
In chapter 6, Caldwell recognizes the success of the policy for HIV/AIDS in Brazil but criticizes the fact that it focused on socioeconomic disadvantage only and failed to address issues of race, despite the evidence that Afro-Brazilians are more vulnerable to the HIV/AIDS epidemic. The conclusion of the book is that universal policies and policies focused on the poor are insufficient to redress health inequalities in a context of institutional racism. Therefore, “race-conscious” health policies, including affirmative actions, are necessary.
This is a thought-provoking conclusion. Equality may demand unequal treatment in favor of the disadvantaged, but any form of favorable treatment must be justified. In a context of scarce resources, priority setting needs to follow reasonable principles of distributive justice (Govind Persad et al., “Principles for Allocation of Scarce Medical Interventions,” The Lancet, 2009). One such principle is to give priority to the worse off, according to health-related measures, such as health needs, access to health care, individual disease burden over lifetime, or health outcomes. It has also been suggested that health systems should focus on low-income groups and rural populations, who tend to be disadvantaged in terms of health and health care (World Health Organization, “Making Fair Choices on the Path to Universal Health Coverage,” 2014). Caldwell innovates in suggesting that race should also inform health policy decisions in Brazil because, due to institutional racism, Afro-Brazilians have special disadvantages that cannot be redressed via the expansion and improvement of universal policies or policies focused on low-income people.
This idea of “race-conscious” actions in health should not be too quickly dismissed, but it needs to be backed by more evidence and analysis, as Caldwell herself acknowledges when she calls for more research that takes race into account (117, 156). Although the book shows cases of racism (stigma, stereotyping, and symbolic and physical violence), affirming that there is institutional racism in the health system is a larger step, and the evidence presented in the book to substantiate this point allows different interpretations. Caldwell mentions the disparities in health outcomes and in access to healthcare to prove that institutional racism exists; however, these disparities may be caused by background inequalities that are external to the health service.
The statistical association between race and health needs to be controlled by class and location. Mentioning the case of Alyne Pimentel, Caldwell argues that “[i]nstitutional discrimination against women, particularly Afro-Brazilian women, in the health system was a major factor shaping the quality of services offered in the region in which Alyne lived, as well as the deplorable level of care she received” (142–43). Alyne’s gender and race are emphasized to explain the level of care she received, but one could think that poverty is the central issue here. Brazil has a gravely underfunded public health service, and a deplorable level of care is not found only in maternal and obstetric care. We do not know if Alyne would have been saved if she were white, if she needed a different type of care, or if she lived in an equally poor area with a lower proportion of Afro-Brazilians, but her treatment would probably have been different if she lived in a more affluent area of if she could afford private care. The case of Alyne is a striking example of how the health of poor black women can be affected by inadequate care, but it does not show that the experience of men or white women is better when controlled by class and location.
It also needs to be recognized that in a context of limited resources, race-conscious policies will have opportunity costs, and they may come at the expense of the expansion or improvement of universal policies or of policies focused on the poor. In the case of Brazil, race-conscious policies would require further justification, considering the success of universal and focalized policies (e.g., Bolsa Família and Mais Médicos) in improving the health and welfare of the poor (Davide Rasella et al., “Effect of a Conditional Cash Transfer Programme on Childhood Mortality: A Nationwide Analysis of Brazilian Municipalities,” The Lancet, 2013) and of the Afro-Brazilian population in particular (Tereza Campello, ed., Faces da desigualdade no Brasil: um olhar para os que ficaram para trás, 2017).
It is therefore disappointing how Caldwell responds to academics who criticize the idea of racially specific health policies. Instead of responding to the critics’ arguments, she focuses on their personal characteristics to explain their position. Caldwell emphasizes that many of these critics, like most scholars in Brazil, are white. She also mentions the critics’ background in anthropology, which, she argues, has a “racialist and racist history . . . [and] played a role in the development of scientific racism, as well as in providing scholarly justifications for European imperialism” (172).
The analysis of feminist and black women’s activism in health offers a fascinating contribution to understanding changes in policy, but one could wonder if there are instances in which the book overstates the impact of these activists. For example, Caldwell claims that the Brazilian Supreme Court ruling in 2012 allowing the abortion of anencephalic fetuses “resulted from the pressure placed on the Brazilian judicial system by feminist health activists” (32). This claim is far from evident. The case was filed by a trade union of health workers represented by a prominent lawyer and legal scholar, Luís Roberto Barroso, who later became a Supreme Court justice. The feminist group Rede Nacional Feminista de Saúde, Direitos Sexuais e Direitos Reprodutivos spoke in a public hearing at the court, but other groups, especially medical associations, also actively participated in the proceedings. Therefore, the claim that the decriminalization of the abortion of anencephalic fetuses was the result of pressure from feminist groups requires evidence that the court made its decision moved by external pressure (rather than the judges’ personal convictions or sound legal arguments) and that this pressure came exclusively or mainly from feminists (rather than other groups, such as health professionals).
Health Equity in Brazil is a thought-provoking book that offers an original perspective on health equity in Brazil. Not all readers will agree with its conclusions, but it raises questions that deserve further investigation.
