Racism and the Production of Care in the Brazilian Unified Health System (SUS): Challenges for Primary Health CareAbstract
The struggle of the organized black movement led to the approval of the National Policy for the Comprehensive Health of the Black Population (PNSIPN—acronym in Portuguese) in 2009, a milestone in the recognition of institutional racism within the Unified Health System (SUS—acronym in Portuguese). This article aims to analyze the production of care for the black population within the context of Primary Health Care (PHC) in the Greater ABC region, considering challenges to the principle of equity and to the implementation of the PNSIPN. This is a qualitative study involving twenty-four semi-structured interviews with managers, social actors, health professionals, and users of the Brazilian SUS. The narratives revealed political and institutional barriers to implementing the PNSIPN, including professionals’ lack of awareness, the absence of race/color data in health information systems, and resistance to recognizing racism as a structuring element of the health-disease process. In light of Sueli Carneiro’s work, it is argued that the mechanism of raciality selectively invokes biopower, determining who has access to “keeping alive” and who is subjected to “letting die.” Achieving racial equity within SUS requires recognizing institutional racism as a determinant of inequities and incorporating antiracist practices in health services. The right to health remains denied to the black population.
Keywords:
Institutional Racism; Primary Health Care; PNSIPN; Black Population Health; Equity
Resumo
A luta do movimento negro articulado levou à aprovação da Política Nacional de Saúde Integral da População Negra (PNSIPN), em 2009, um marco no reconhecimento do racismo institucional no âmbito do SUS. Este artigo tem o objetivo de analisar a produção do cuidado à população negra no âmbito da Atenção Primária em Saúde (APS), na região do Grande ABC, considerando o princípio da equidade e a implementação da PNSIPN. Tratase de estudo qualitativo com a realização de 24 entrevistas semiestruturadas com gestores, atores sociais, profissionais de saúde e usuários do SUS. As narrativas revelaram barreiras políticas e institucionais à efetivação da PNSIPN, expressas no desconhecimento da política e da importância do quesito raça/cor; e na resistência em reconhecer o racismo como elemento estruturante do processo saúde-doença. À luz de Sueli Carneiro discute-se que o dispositivo de racialidade aciona o biopoder de forma seletiva, determinando quem tem acesso ao “fazer viver” e quem é exposto ao “deixar morrer”. Conclui-se que a efetivação da equidade racial no SUS exige o reconhecimento do racismo institucional como determinação das iniquidades e a incorporação de práticas antirracistas nos serviços de saúde. O direito à saúde segue sendo negado à população negra brasileira.
Palavras-chave:
Racismo Institucional; Atenção Primária à Saúde; PNSIPN; Saúde da População Negra; Equidade
Resumo
A luta do movimento negro articulado levou à aprovação da Política Nacional de Saúde Integral da População Negra (PNSIPN), em 2009, um marco no reconhecimento do racismo institucional no âmbito do SUS. Este artigo tem o objetivo de analisar a produção do cuidado à população negra no âmbito da Atenção Primária em Saúde (APS), na região do Grande ABC, considerando o princípio da equidade e a implementação da PNSIPN. Tratase de estudo qualitativo com a realização de 24 entrevistas semiestruturadas com gestores, atores sociais, profissionais de saúde e usuários do SUS. As narrativas revelaram barreiras políticas e institucionais à efetivação da PNSIPN, expressas no desconhecimento da política e da importância do quesito raça/cor; e na resistência em reconhecer o racismo como elemento estruturante do processo saúde-doença. À luz de Sueli Carneiro discute-se que o dispositivo de racialidade aciona o biopoder de forma seletiva, determinando quem tem acesso ao “fazer viver” e quem é exposto ao “deixar morrer”. Conclui-se que a efetivação da equidade racial no SUS exige o reconhecimento do racismo institucional como determinação das iniquidades e a incorporação de práticas antirracistas nos serviços de saúde. O direito à saúde segue sendo negado à população negra brasileira.
Palavras-chave:
Racismo Institucional; Atenção Primária à Saúde; PNSIPN; Saúde da População Negra; Equidade
Introduction
The 1988 Federal Constitution enshrined the universal right to health, making possible the creation of the Unified Health System (SUS), guided by the principles of universality, comprehensiveness, and equity (Brazil, 1988; 1990). However, despite this legal framework, the formal universalization of the right to health has not eliminated the structural inequalities that permeate access, quality of care, and health outcomes, especially when considering the black population. In this sense, the specialized literature corroborates that race, territory, and socioeconomic position continue to operate as markers of differentiation within the health system, producing persistent patterns of inequity (Werneck, 2016; Batista et al., 2013).
The struggle of the articulated black movement led to the approval of the National Policy for the Comprehensive Health of the Black Population (PNSIPN) in 2009, a landmark in the recognition of institutional racism within the Brazilian Unified Health System (SUS) (BRASIL, 2017). However, the legal recognition of the policy did not guarantee its full execution, since its effective implementation remains a challenge (Matos; Tourinho, 2018; Silva et al., 2022). The literature indicates that the presence of the policy at the normative level does not automatically translate into changes in work processes, in the organization of care, and in professional practices, especially in Primary Health Care (PHC), the main entry point to the system. There is a lack of indicators, gaps in professional training, and, crucially, resistance to recognizing racism as a social determinant of the health-disease-death process of the black population (Faustino, 2017).
The very construction of the Brazilian Unified Health System (SUS), influenced by the Brazilian Sanitary Reform Movement (MRSB) and Collective Health (SC), aimed at a broader concept of health, recognizing living conditions as determinants (Vieira-da-Silva et al., 2014). However, this ideal was strained by the advancement of neoliberal policies, which led to underfunding and the consolidation of a biomedical model (Souza, 2020). In this context, there is a progressive emptying of the critical perspective of the social determinants of health and the consolidation of more functionalist approaches, centered on risk factors, performance, and productivity of services (Borde, 2014; Vieirada-Silva et al., 2014). To overcome this limited logic, it becomes imperative to rescue critical Latin American epidemiology, operating with the social determinants of health (SDH), which, according to Breilh (2011), highlights the “historical processes that generate collective health problems,” situating inequities in contexts of exploitation and oppression. In contrast, the current care model in the Brazilian Unified Health System (SUS), by limiting itself to “risk factors,” neglects the structures of oppression that condition the illness of vulnerable populations (Werneck, 2016). This theoretical inflection directly impacts the production of care, favoring decontextualized readings of social suffering and hindering the incorporation of the racial dimension as a structuring axis of health practices.
Inequality manifests itself geographically: a study by the Institute for Applied Economic Research (IPEA) (2020) revealed that, although black and poor people have access to primary health care in the peripheries, complex procedures and better-structured services are concentrated in central, white, and wealthy areas. This territorialized pattern of supply expresses how racism operates structurally in the organization of health systems, producing symbolic, organizational, and territorial barriers to care.
The racism that operates within the system is institutional racism, an organizational mode that affects collectivities through “neglect and delegitimization of the needs of black people” (Werneck, 2013; 2016). To understand its complexity, Sueli Carneiro (2023) uses the concept of the “raciality device.” According to the author, this device “configures raciality as a domain that produces powers, knowledge, and subjectivities through the negation and prohibition of powers, knowledge, and subjectivities.” The author highlights that racism fragments the biological field over which biopower exerts control, determining who should live and who should die. This analytical key allows us to understand how seemingly neutral practices within institutions reproduce racial hierarchies and inequalities in access to life.
The management of life, which should be universal, becomes selective, as it promotes ‘making life’ for some, while, through action or inaction, it ‘causes death’ or ‘allows death’ for those living in precarious areas (Carneiro, 2023). The State’s omissions (institutional racism) materialize in high infant and maternal mortality rates and premature deaths in the black population (Batista et al., 2013; Ferreira et al., 2020). In the field of Primary Health Care (PHC), this selectivity is expressed both in the organization of care flows and in biomedical interpretations that disregard the social determinants of illness. This selective management of survival allows Foucault’s biopolitics to be transformed in the context of peripheries and racialized bodies into necropolitics (Mbembe, 2016), where the State operates through omission and abandonment.
The very genesis of the SUS (Brazilian Unified Health System) was a stage for tension between the MRSB (focused on class) and the Black Movement (MN), which demanded recognition of racial specificities. The struggle of “women dissatisfied with the premature deaths affecting black mothers and children” gave rise to the field of black population health (Werneck, 2013). The PNSIPN (National Policy for the Comprehensive Health of the Black Population) was designed to “entangle” itself within the structure of the SUS, making the fight against racism an inseparable element of the system’s praxis (Faustino, 2017). However, the gap between the normative design of the policy and its daily operationalization remains one of the main challenges for the effective achievement of racial equity.
Given this scenario, this study focuses on research questions that seek to understand how the implementation of the PNSIPN (National Policy for the Comprehensive Health of the Black Population) is being carried out in the territories to organize healthcare for the black population. And how do social determinants and racial constructs relate to barriers in access to and care for the black population?
This study aims to analyze the provision of care to the black population within the scope of Primary Health Care (PHC) in two municipalities in the Greater ABC region, considering the principle of equity in the Brazilian Unified Health System (SUS) and the implementation of the National Policy for Comprehensive Health of the Black Population (PNSIPN).
Methods
This article is a qualitative, exploratory-analytical study that collected data through semi-structured interviews with strategic actors from two municipalities in the Greater ABC Region of Greater São Paulo, which indicated that they carry out the greatest number of strategies of the PNSIPN (National Policy for the Integral Health of the Population), here called “Luanda” and “Benin.” The choice of a qualitative approach is justified by its potential to capture meanings, perceptions, practices, and social experiences, which are particularly relevant for the analysis of institutional processes, power relations, and the production of care in the field of public health.
Thus, four groups of participants were interviewed, identified by categories (Table 2): (i) primary health care managers and their assistants—(G and AG); (ii) policy mobilizers (AMP)—(C); (iii) professionals from the Family Health Strategy (ESF)—(P); and (iv) SUS users—(U). Users were indicated by the reference professionals of the units. The selection criteria for users were being a self-declared black or brown adult, having a continuous link with the Basic Health Unit, and needing referral to other levels of care. In total, 24 interviews were conducted among the four groups listed, as presented in Table 1. The interviewed AMPs were members of councils for the promotion of racial equality (COMPIR) in Benin and the Coordinator of the Strategic Populations Health Committee of Luanda.
Regarding the operationalization of data collection, the interviews were conducted using a semi-structured script, planned to ensure the necessary depth for the study’s objectives. In this sense, the interviews lasted an average of 60 minutes and were recorded with consent, conducted either in person or remotely, according to participants’ availability. Interviews with users took place in their homes. After the completion of the fieldwork phase, the collected data were fully transcribed and subjected to interpretive qualitative analysis, guided by the identification of core meanings and the construction of analytical categories. The procedure involved a preliminary reading of the empirical material, thematic coding, grouping by convergences and divergences, and interpretation in light of the research’s theoretical framework (Gomes, 2009; Minayo, 2014). It is worth highlighting that, in the interviews with the users, a biographical approach was adopted, focused on the construction of life stories, which allow us to recognize the unique experience narrated by an individual, seeking to understand how subjects construct meanings about their health, illness, and care processes throughout their life trajectories (Cecílio et al., 2014).
Regarding ethical principles in research involving human subjects, this study was approved by the Research Ethics Committee of the Faculty of Public Health at the University of São Paulo, CEPFSP/USP (opinion number 6.573.118), as well as the Regional Inter-Management Commission (CIR) of Greater ABC. All participants signed the Informed Consent Form, ensuring anonymity, confidentiality of information, and the right to withdraw at any time.
Results
The diverse professional trajectories and social experiences of the interviewees (Table 2) allowed us to understand multiple perspectives on the implementation of the PNSIPN and on the production of care in primary health care.
Therefore, the interviews with managers, AMPs, and health professionals were organized into three categories of analysis: invisibility of institutional racism and naturalization of inequality, institutional weaknesses in the implementation of the PNSIPN, and care experiences, barriers to access, and the production of vulnerabilities. A combined reading of these categories reveals the fragility of the PNSIPN’s institutional framework, anchored in institutional racism that permeates the management and performance of teams in primary health care, thus contributing to the maintenance of racial inequities.
The Invisibility of Institutional Racism and the Normalization of Inequality
Institutional racism manifests itself through negligence and a misunderstanding of the principle of equity: “At the primary health care unit we must prioritize everyone... it’s not just one ethnicity or race; otherwise it would be a bit... discriminated against” (G2). This conception reveals the persistence of a universalist logic that ignores historically produced inequalities and tends to neutralize the racial dimension as a determinant of care.
This view of equity as discrimination directly opposes the perception of black actors, such as the counselor of Benin (C1), who reports feeling “powerless” in the face of “negligence” and everyday microaggressions (“do not sit there, sit here”). This view is corroborated by the statement of another manager, who noted that Black people arrive at the clinic “doubting that they have this right. At the reception desk, the difference between black and white people is immediately apparent. Black people have a harder time scheduling an appointment. They feel somewhat more vulnerable” (AG1).
These narratives reveal the coexistence of two regimes of perception: on the one hand, managers and professionals who deny the existence of racial inequalities in the name of a supposed neutrality of care; on the other hand, subjects who experience symbolic and institutional barriers daily. The naturalization of these inequalities contributes to the maintenance of practices that do not recognize racism as a public problem, shifting it to the individual sphere and hindering its incorporation as a structuring axis for the planning and organization of care in PHC.
Institutional Weaknesses in the Implementation of the PNSIPN
The interviews reveal that the implementation of the PNSIPN (National Policy for the Comprehensive Health of the National Population) presents varying degrees of institutionalization in the municipalities studied. In Benin, according to AG1’s report, COMPIR, which was once “very active,” suffered “discontinuity due to political issues,” resulting in “loss of credibility” and weakened agendas. In Luanda, a movement towards greater institutionalization was observed, with the creation of a “Strategic Population Health Committee” by decree, and intersectoral articulation facilitated by its link to the mayor’s office.
Regarding the most prevalent health problems in the black population, it was found that the SUS (Brazilian Public Health System) offers medications recommended for the control of both persistent hypertension and sickle cell anemia; however, these are offered in isolation and do not provide comprehensive care as advocated in the PHC guidelines or in the care pathways for these conditions: “...we have been talking with pharmaceutical assistance about how this issue of offering medications that can better contribute to the care of black people works...” (G1). In the narratives as a whole, a biomedical perspective prevailed, dissociated from racism.
As for the ongoing training of PHC professionals on collecting data on race and skin color and raising awareness about incorporating ethnic and racial issues into continuing education programs, this took place only in Luanda through focus group discussions at health facilities, in addition to analyses of indicators disaggregated by race or skin color to guide health-related projects. Professionals from Benin had difficulty explaining the purpose of collecting race or skin color data: “I would say it is just a registration formality. But I don’t know if there is anything about the treatment itself that would differentiate it. I don’t think so, you know? At least for us here, the treatment is the same” (P8).
These findings highlight barriers to policy implementation and explicit neglect of racial inequities and their influence on the health-disease process. The weakness in the racial education and literacy of managers and workers gains special relevance due to the collective perception of racial equality, coupled with the fear, among the unmobilized base, of assuming their racial identity. The biomedical perspective neglects the intersections that place the black population at the crossroads of illness and premature death.
Care Experiences, Barriers to Access, and the Production of Vulnerabilities
It is noteworthy that the analysis of the interviews with the professionals considered the assumptions of the Family Health Strategy (ESF), especially the recognition of territorial diversity, the bond, and the classification of risks and vulnerabilities as a basis for planning care actions.
In this sense, the interviewed teams demonstrated knowledge of the territory according to the logic of descriptive or conventional epidemiology and identified users according to race and socioeconomic conditions: “We have quite a few black and brown people, and it is a very vulnerable population in financial terms.” “The most prevalent here are cardiovascular diseases, mainly derived from hypertension and diabetes” (P04). This approach, although important for the organization of services, proves to be limited in understanding the structural dimensions that produce specific vulnerabilities for the black population.
Specific actions are taken in vulnerable territories to expand access in the studied cities. In Luanda, the nurse reported that the population is “very needy, so they are completely dependent on the SUS (Brazilian public health system). Here is what they have regarding access to health (...). [This population] is the one that misses the fewest appointments, the one that most adheres to health behavior” (P1).
When questioned about specific pathways for vulnerable populations, professionals frequently resorted to explanations centered on biological or genetic predisposition, especially in the case of hypertension in black people: “The use of some type of medication that is more indicated is more effective precisely in the black race...” (P4). The reproduction of racial stereotypes in the field of reproductive health is also observed, with cultural interpretations about the higher fertility rates among black women and the individual responsibility placed on families, without recognition of the social conditions that structure such trajectories.
Because we see many cases of single mothers, mostly mixed-race and black... So, yes, we mostly see many cases of pregnant teenagers or teenagers with some sexually transmitted disease... And we can’t always help... (P5).
A doctor from Luanda reveals the barriers that the elderly population faces in accessing medical specialties. The need for long and costly trips outside the municipality due to the scarcity of local specialists makes it impossible to continue treatment, even with the team’s efforts to request internal referrals.
Yes, there are [barriers to access], especially for the elderly. Unfortunately, we have specialties like endocrinologists, rheumatologists, and orthopedists, where appointments are often scheduled outside the municipality, and these are elderly people who need to travel, mainly by bus, and have to take two or three different modes of transport to arrive there. They go to the first appointment and second appointments, but when they need regular appointments, that is when the problems start, and they start missing appointments (P2).
Although the reach of primary health care in these vulnerable territories is crucial to guaranteeing universal access, the results reveal significant distortions between the guidelines of the Family Health Strategy (ESF) and daily care. These inconsistencies are aggravated by the widespread lack of knowledge among professionals regarding the National Policy for the Comprehensive Health of the Black Population (PNSIPN), which is frequently neglected under the argument of ‘non-discriminatory’ care. This view, however, masks institutional racism by ignoring the unique needs of the black population, demonstrating that the physical presence of the service, by itself, does not ensure the realization of equity.
Interviews with users allow for a more profound understanding of these vulnerabilities based on their life trajectories, analyzed through the lens of race. The narratives reveal historical processes of school exclusion, early work, precarious housing, food insecurity, illness, and violence, spanning different generations of the same family.
I come from a poor family; I didn’t even have notebooks to study. I studied with computer paper from school; they stapled it in the middle. I have never had an easy life. I was like the kind of person who went to school and arrived at recess thinking about eating school lunch (U1).
The accounts of mother and daughter (U5 and U6) reveal the imposition of “having to work” to ensure the family’s survival and the perpetuation of school exclusion across three generations: “I studied until I completed elementary school because I stopped after I became a mother” (U6); “I entered the first grade and left the second... Because we were very poor, you know, so we had to work to be able to eat; otherwise we wouldn’t eat” (U5). And regarding U6’s children: “I made them all study, up to the first and second grades. Their university studies depended on them. But they work so well.”
Furthermore, the users’ narratives express the persistence of structural conditions that limit access to social rights and produce prolonged exposure to social and health risks, configuring a cumulative pattern of vulnerability: “There are ten (children). Then five died, one died at age 12 after being run over... three little ones died... all those diseases” (U5).
Simultaneously, the denial of the postpartum period and the devaluation of breastfeeding as “frivolous” (U6) illustrate how slave-like productivity can override the recognition of women’s physical and emotional needs: “I’ve never breastfed, and my mother would give birth in one day, and the next day, she’d already be running her household chores. We had no food. I never drank milk; I ate plain cooked cornmeal, just like that.” (U5). This set of narratives allows us to identify the persistence of historical patterns of devaluation of the body and care of black women: “I didn’t breastfeed my two first children because she (the mother) wouldn’t let me. She said it was fussiness” and “And I couldn’t have postpartum rest either” (U6).
U5’s story also highlights how racism is perpetuated both by the bureaucratic state and by inhumane social practices. Starting to work at age ten and continuing until age 60 did not guarantee her the right to a secure retirement.
I used to make bricks by burning them... I was already about ten years old when I started... When I moved here, I got a job working for a family; I worked in that house for 20 years and in the house across the street for ten years, where I retired (U5).
(...) My mom retired at the standard retirement age because she was two years short. They wanted proof that she was 71, but I remember she was 73… She couldn’t obtain that proof… So, instead of retiring with two pensions, she retired with just one (U6).
In an articulated manner, the three analytical categories demonstrate that the production of care in PHC occurs in a context marked by the invisibility of institutional racism, the fragility of the institutionalization of the National Policy for the Comprehensive Health of the Black Population (PNSIPN), and multiple experiences of vulnerability lived by users. The narratives reveal tensions between the formal recognition of universal access and the persistence of symbolic, organizational, and territorial barriers that disproportionately affect the black population. These findings allow us to understand how practices, discourses, and institutional arrangements intertwine in the reproduction of racial inequities in the daily routine of services.
Discussion
Given this empirical scenario, the following discussion seeks to unveil how racism in the Brazilian Unified Health System (SUS) manifests itself in a complex web of denials and resistances, revealing the persistence of a colonial logic that masks the maintenance of social order as a guarantee of security. In this context, the actions of health management, instead of dismantling racism, often perpetuate it, fostering a conformism that becomes a barrier to an effective anti-racist struggle. This dynamic was empirically observed in the incipient implementation of the National Policy for the Comprehensive Health of the Black Population (PNSIPN), with low incorporation of the policy as a structuring axis for the management and organization of care.
As argued by Faustino (2017), the field of black population health not only exists but is essential for the effective realization of the universal right to health in Brazil. According to him, the National Policy for the Comprehensive Health of the Black Population (PNSIPN) recognizes the specificities of the health-disease process of the black population, using the SUS (Brazilian Unified Health System) management tools to confront institutional racism and its consequences. To disregard the relevance of this field would be to ignore the very prerogative of a SUS that, since its origin, has been based on the articulation between specific programs and the guideline of universal rights. Thus, the field of black population health is a fundamental demand to confront racial inequities, promoting a broader notion of social justice that integrates recognition and distribution and ensuring that the right to health is, in fact, universal and equitable for all.
Beyond the organization and practices aligned with the PNSIPN guidelines, the analysis of the interviews reveals that the understanding of local reality is profoundly influenced by theoretical conceptions of health and disease. In this sense, Breilh (2023) offers a new epidemiological conception. He criticizes conventional epidemiology (positivist, linear causality) for focusing on “risk factors” without delving into their social roots. In contrast, critical Latin American epidemiology, anchored in the social determination of health, understands the health-disease process as an expression of historical, social, and political processes. This interpretative key allows us to understand why the predominantly descriptive reading of the territory, observed in the results, proves insufficient to address racially produced vulnerabilities.
This perspective aligns with studies suggesting that the causes for the higher incidence of hypertension in black people may be primarily related to stress caused by racial discrimination and the unfavorable socioeconomic position of this population group; in other words, biological factors alone do not explain the most prevalent diseases in the black population, which would require a specific line of care (Mendes, 2018; Brazilian Institute of Geography and Statistics [IBGE], 2021). From this perspective, the professionals’ statements, by resorting to biologizing explanations, highlight the persistence of this interpretative reduction, which ignores the historical and social marks that shape the health of racialized bodies.
The Expanded Clinical Approach in Primary Care, as a care model, seeks to guarantee shared and interprofessional care and the centrality of individuals in the production of life. Cunha (2010) states that “there is almost never a single path for individuals in complex situations”; that is, “biomedical knowledge is one force among many others in the lives of individuals” (p. 124). However, the findings suggest that this approach has not yet been consistently implemented in the teams’ practices, as it continues to be undermined by a disease-centered care model.
Thus, the teams’ responsibility for producing a comprehensive and individualized clinical approach should be centered on the needs of individuals or on interrupting cycles of poverty, including preventing unnecessary deaths of multiparous women. A study by Soares et al. (2008) has shown a higher risk of maternal death among multiparous women and those from socially disadvantaged backgrounds, associated with healthcare failures. This data aligns with empirical narratives about reproductive health and unequal access to care. In this context, the implementation of a comprehensive clinical approach presupposes the incorporation of intersectionality as an analytical tool. The application of this approach can support strategies that recognize potential and address vulnerabilities (Couto et al., 2019).
Silva et al. (2018) point to the impacts of racism on the health of older black people, including prolonged time spent in the workforce and poorer health conditions. The accounts highlight this process of cumulative vulnerability throughout the life cycle. Following this line of reasoning, the Social Doctrine of the Black Population (SDS) offers theoretical support for understanding how perverse exclusions produce inequities and have consequences for the healthy aging of the black population: the naturalization of racism that manifests itself through systematic rights violations, undignified pensions associated with precarious employment relationships throughout life, or the urgency to secure the minimum necessary for survival.
Consequently, the discussions presented reveal a central paradox in PHC: although services are organized around the universal principles of the Brazilian Unified Health System (SUS)— universality, equity, and comprehensiveness—the limited understanding of local reality, anchored in a descriptive epidemiology devoid of a critical analysis of the social determinants of health, makes the realization of equity impossible, especially for the black population. The narratives of health professionals, while demonstrating access to and provision of services, fail to recognize and address racial inequities, treating them as generalities or, worse, reproducing essentialist and racist views that disregard the historical and structural impacts of racism on health.
According to Carneiro (2023), racial hierarchy, sustained by the racial apparatus, operates through economic exploitation and exclusion of Black people, ensuring capital accumulation via marginalization. In this way, racism ceases to be considered a remnant of the colonial past and is understood as an active mechanism.
Regarding reproductive health, this system operates by denying the postpartum period and devaluing breastfeeding as “frivolous,” illustrating how the productivity inherent in slavery can override the recognition of women’s physical and emotional needs. This evokes reflection on the colonial legacy: the persistence of the same treatment received by enslaved women.
Carneiro (2023) argues that biopolitics intertwines gender and race, resulting in varied impacts on life and death production. National data confirm this inequality, with a higher proportion of maternal deaths among black women (Brazil, 2023). A professional’s comparison between white and black women reveals how these inequalities become ingrained in the daily routine of services.
Sueli Carneiro (2003) has been a tireless voice in denouncing the symbolic and material violence that befalls black women. She emphasizes how the intersection of gender and race produces a particular experience of oppression for black women, in which their lives are constantly permeated by the denial of rights and the exploitation of their labor and bodies. The author reminds us that black women are at the base of the social pyramid, sustaining structures that oppress them.
In line with Carneiro’s studies, the experiences of U5 and U6, marked by a lack of care and the demand for inexhaustible strength, can be understood from the perspective of the instrumentalization of the black woman’s body, historically perceived as a productive resource and not as a being in need of care and protection. The deaths of U5’s children from childhood illnesses and being run over and the alcoholism and violence that widowed her twice are not mere individual misfortunes; they are symptoms of a system that fails to guarantee health, safety, and well-being for the black population. Precarious housing, lack of basic sanitation, and urban violence are factors that, as Werneck (2016) points out, are intrinsically linked to structural racism and state negligence, resulting in profound health inequities for this population.
This state negligence is amplified by Faustino’s analysis (2022), which, in reinterpreting Fanon in the contemporary Brazilian context, suggests that racialization continues to be an essential tool for maintaining structural inequalities in global capitalism. Racialization, in this sense, is not only a matter of physical domination but also psychological and cultural domination, perpetuating the exclusion and exploitation of racialized populations on a global scale.
Reflecting this global dynamic, the institutional distance from the realities studied is expressed in the fragility of the institutionalization of the PNSIPN (National Policy for the Comprehensive Health of the Black Population), which limits its capacity to systematically guide the organization of work processes and the production of care in PHC. Feuerweker (2014) states that the distance between institutional spaces and the subjects in the territories has harmed councils and mechanisms of social participation. The consequence is the weakening of social participation, leading to the risk that policies such as the PNSIPN will become formal and ineffective against racism.
Underlying this participatory fragility, Nunes and Louvison (2020) highlight that the process of biomedicalization has promoted a monoculture of hegemonic conceptions of biomedical knowledge, predominantly defining knowledge and interventions related to health, illness, care, and cure. This model neglects the specific needs of the black population, which faces the socioeconomic impacts of racism, highlighting the urgency of more comprehensive health policies that are sensitive to racial issues. In empirical findings, this monoculture is expressed in the invisibility of institutional racism as a determinant of the health-disease process and in the normalization of barriers to accessing care, even in contexts of formal service provision.
From this perspective, it becomes imperative to recognize that the mere prevalence of diseases is not sufficient to characterize health inequities, especially when it comes to the black population. The insistence on disregarding the social determinants of the health-disease process, which is intrinsically linked to racism and precarious socioeconomic conditions, results in unfavorable outcomes and the deprivation of the principle of equity in access to care. This perspective directly relates to the results, which highlighted the centrality of a biomedical rationality in the professionals’ narratives, dissociating care from the social, territorial, and racial dimensions that structure the experiences of illness and access to services.
To reverse such outcomes, Silva et al. (2022) argue that the effective implementation of the PNSIPN and the transformation of the unfavorable health conditions of the black population require considering the individual and social repercussions of the racialization process. Racism operates as a strategy of subjugation and maintenance of social hierarchies, requiring the confrontation to go beyond isolated actions and address the structural bases of inequalities.
In summary, in light of the empirical findings, it is observed that the persistence of the invisibility of institutional racism, associated with the fragility of the institutionalization of the National Policy for the Comprehensive Health of the Black Population (PNSIPN) and the centrality of a biomedical rationality in the work processes of PHC, produces concrete effects on the organization of care and the reproduction of racial inequities. The analytical categories reveal that, despite formal access to services, symbolic, organizational, and territorial barriers remain that disproportionately affect the black population, limiting the realization of the principle of equity. The life trajectories of the interviewed users demonstrate how social determinants, influenced by the racial framework, create cumulative vulnerabilities throughout their life cycles. In this sense, strengthening the PNSIPN requires not only the expansion of normative actions but also the transformation of training processes, management practices, and the micropolitics of care to incorporate an anti-racist, intersectional perspective oriented towards the production of life within the Brazilian Unified Health System (SUS).
Final considerations
The findings of this study show that, although the relevance of services is recognized, the racial dimension is not yet incorporated in a cross-cutting and structural way into the work processes of PHC teams. The lack of knowledge about the National Policy for the Comprehensive Health of the Black Population (PNSIPN) and the difficulty in identifying situations of racial discrimination in services indicate institutional weaknesses and gaps in the training and racial literacy of managers and workers that need to be addressed. PHC encounters individuals daily whose lives are marked by historically constructed inequalities; recognizing this dimension is essential to producing qualified care, overcoming strictly biomedical approaches, and strengthening practices committed to equity.
The narratives presented demonstrate that the mechanism of race operates simultaneously on both material and symbolic levels, producing inequalities that accumulate throughout life and impact illness, old age, and access to work, education, and health. The stories also reveal affections, solidarity, and strategies of resistance, showing that, despite rights violations, there is a powerful agency exercised by black families in their territories. These elements are essential to understanding how PHC encounters—and needs to recognize—subjects affected by complex experiences that cannot be explained solely by socioeconomic vulnerabilities but by a historical project of racial dehumanization. Therefore, these trajectories highlight the centrality of racism as an operator of inequalities and as a structuring element of living conditions, illness, and access to health services.
Thus, this study reaffirms the urgent need to strengthen anti-racist practices within PHC, integrating a racial perspective into team training, management tools, and the organization of daily care. The effective implementation of the National Policy for the Comprehensive Health of the Black Population (PNSIPN) depends on recognizing that race is not a secondary variable but a fundamental determinant of health, capable of producing barriers to access, accumulated vulnerabilities, and differentiated patterns of illness and death. Incorporating this understanding is an essential condition for advancing the construction of a Brazilian Unified Health System (SUS) committed to racial justice, the institutionalization of equity, and the unconditional defense of the black population’s lives.
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Financial support:
This study was conducted with support from the Coordination for the Improvement of Higher Education Personnel—Brazil (CAPES)— Funding Code 001.
Data Availability Statement:
The data supporting this study are not publicly available in order to protect the privacy and anonymity of the study participants, but are available upon reasonable request to the corresponding author.
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Edited by
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Editors:
José Miguel OlivarRaquel Souzas
