Victims of epidemics, slavery, genocide, and countless other episodes of violence during the colonial enterprise in Brazil, which continues decades into the 21st century in some regions, Indigenous peoples face health inequities resulting from a five-century history of social marginalization and vulnerability. Since the late 1990s, the health and well-being of Indigenous peoples in the country have benefited from progressive legislation that values sociocultural diversity within a public primary healthcare subsystem attending to Indigenous peoples living in federal Indigenous lands. However, these transcultural ideals remain elusive in practice. The Indigenous Healthcare Subsystem continues to suffer from numerous systemic problems, including low quality of local services, lack of health professional training for work in intercultural contexts, and unpreparedness for attending to health emergencies involving Indigenous peoples living in voluntary isolation. Being Indigenous in Brazil in the 2020s implies greater chances of higher infant mortality, lower life expectancy, suffering from undernutrition and anemia during childhood, living with a high burden of infectious and parasitic diseases, being exposed to a swift process of nutritional transition, and experiencing a surge in chronic violence. Community case studies have shown the importance of close patient follow-up over long periods of time, the heavy burden of disease due to nutrition transition since the mid-1980s, the relevance of international reference curves for evaluating Indigenous child undernutrition, and failures of primary healthcare provided to Indigenous populations. Improvements in national health information systems in Brazil beginning in the early 2000s have shown external causes, perinatal diseases, infectious and parasitic diseases, and respiratory diseases to be the leading causes of death among the country’s Indigenous population.
Article
Health of Indigenous Peoples in Brazil: Inequities and the Uneven Trajectory of Public Policies
Ricardo Ventura Santos, James R. Welch, Ana Lucia Pontes, Luiza Garnelo, Andrey Moreira Cardoso, and Carlos E. A Coimbra Jr.
Article
History of Public Health in Latin America
Marcos Cueto and Steven Palmer
From the late 19th to the late 20th century, Latin America was a developing region of the world in which public and private health discourses, practices, and a network of agencies were consolidated. Many organizations appeared as a response to pandemics, such as yellow fever, that attacked the main ports and cities, and they interacted with global agencies such as the Rockefeller Foundation. Frequently, single-disease-focused and technocratic approaches were promoted in a pattern that can be defined as the “culture of survival.” However, some practitioners believed in public health programs as a tool to improve the living conditions of the poor, the most important being comprehensive primary health care, which emerged in the late 1970s. Toward the end of the Cold War (ca. 1980s), neo-liberal reformers supported a restrictive idea of primary care health that overemphasized cost-effectiveness and efficiency.
Article
Brasília’s Experience With Wastewater Treatment Systems: A Case Study
Klaus Dieter Neder
Brasília is one of the few large cities in the developing world that provides full coverage of sanitation services for its population, including the collection of wastewater and adequate wastewater treatment. Caesb, the local water and sanitation utility, has developed a lot of experience in the planning, design, construction, and operation of sanitation systems, with a special emphasis on the need to use appropriate treatment technologies. Today, serving a population of more than three million people, Caesb runs 16 wastewater treatment plants, using technologies from very simple natural treatment processes, such as stabilization ponds and overland flow processes, to very sophisticated units, including tertiary activated sludge plants, with flotation as an effluent-polishing treatment step. During the development of the several different sanitation solutions, Caesb has found that it has been best to use simple, natural, low-cost treatment processes to achieve feasible and sustainable solutions even when, in specific circumstances, more sophisticated processes are required. The desire to increase the sustainability of the treatment plants has also stimulated Caesb to improve the performance of the applied treatment processes, which was achieved by the implementation of several modifications aimed at reducing costs and improving the efficiency of the plants. Today, the treatment of all wastewater produced in the city guarantees the quality of the discharge to the point that water bodies located downstream of wastewater treatment plants are used as resources for water supply for the city.
Article
Evaluating Condominial Sewerage Programs: Technology and Community Engagement
Patrícia Campos Borja, Earthea Nance, and Luiz Roberto Santos Moraes
Condominial sewerage is a socio-technical system used in many parts of the world. It has the potential to expand service coverage due to its low cost and adaptability. However, the results and effectiveness of projects that have been implemented and their evaluation methods have been little studied. The aim of this article is to discuss experiences of evaluation of this technology, which have focused on use, functioning, social participation, and health impacts. Other aims are to propose an evaluation scope and to present a comprehensive framework to support future evaluations.
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A Case Study of Brasília and the Federal District: Community Participation and Sanitary and Environmental Education in Condominial Sewerage Systems at CAESB
César Augusto Rissoli and Maria Martinele Feitosa Martins
Adding a social component to sanitation work has traditionally been done as a separate, “decorative element,” which can be seen as dispensable. By this logic, a direct relationship is not forged between the objective of the project and the interest of its beneficiaries, and so the sanitation intervention is rendered ineffective.
The Federal District Environmental Sanitation Company (Companhia de Saneamento Ambiental do Distrito Federal) (CAESB) has used the Condominial Sewerage System for over 30 years with a great deal of success. It has become a reference point for this type of sanitary sewage modal, where the community mobilization social component, which involves community participation and environmental education, demonstrates that these areas are key to achieving success and effectiveness in a sanitation intervention, which is a fundamental element in the current context of chronic service deficits of this type of infrastructure as well as of insufficient resources.
This article seeks to describe the defining aspects of the Condominial Sewerage System in the Federal District and provide an overview of the key features of the methodology as used by CAESB and its experience in developing the social components of community participation and environmental education which are used in implementing this type of sanitary sewerage system. At CAESB, this social component is absolutely inseparable from the technical component, which is why it is called “technical-social mobilization.” It is a set of actions, always transversally linked with the technical procedures, establishing the common objective of universalization of sewerage system service. Operating in this way for more than 30 years has established a strong relationship between the company and the community, based on a sense of civic duty. This has optimized resource use and allowed every family to connect to the system, with more than 350,000 sewage connections, serving more than 1,500,000 inhabitants throughout the Federal District.
Article
Health Workforce: Situations and Challenges in Latin America, the Caribbean, and Brazil
Maria Helena Machado, Renato Penha de Oliveira Santos, Pedro Miguel dos Santos Neto, Vanessa Gabrielle Diniz Santana, and Francisco Eduardo de Campos
The greatest challenge in the development of universal health systems worldwide is to increase organization, training, and regulation of the health workforce (HWF). To accomplish this, the World Health Organization (WHO) has pointed out several strategies utilized since the beginning of the 2000s.
One of the world regions with the greatest internal HWF disparities is the Americas, more specifically Latin America and the Caribbean. Brazil is another of the countries in this region that presents great inequities in its HWF distribution, although its Unified Health System (Sistema Único de Saúde, or SUS), created after 1988, is one of the largest universal health systems in the world. It is worth noting that Latin America, the Caribbean, and Brazil historically have high levels of social inequality and have recently become regions severely affected by the COVID-19 pandemic.
Despite some advances in the formation and distribution of HWF in Latin America and the Caribbean in the last 10 years, structural problems persist in the health systems of several countries in this region, such as Brazil. The COVID-19 pandemic aggravated some problems such as the distribution of specialized health workers in intensive care units and the precarious working conditions in several public health services that were organized to face the pandemic.
Article
Health for All and Primary Health Care, 1978–2018: A Historical Perspective on Policies and Programs Over 40 Years
Susan B. Rifkin
In 1978, at an international conference in Kazakhstan, the World Health Organization (WHO) and the United Nations Children’s Fund put forward a policy proposal entitled “Primary Health Care” (PHC). Adopted by all the World Health Organization member states, the proposal catalyzed ideas and experiences by which governments and people began to change their views about how good health was obtained and sustained. The Declaration of Alma-Ata (as it is known, after the city in which the conference was held) committed member states to take action to achieve the WHO definition of health as “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Arguing that good health was not merely the result of biomedical advances, health-services provision, and professional care, the declaration stated that health was a human right, that the inequality of health status among the world’s populations was unacceptable, and that people had a right and duty to become involved in the planning and implementation of their own healthcare. It proposed that this policy be supported through collaboration with other government sectors to ensure that health was recognized as a key to development planning.
Under the banner call “Health for All by the Year 2000,” WHO and the United Nations Children’s Fund set out to turn their vision for improving health into practice. They confronted a number of critical challenges. These included defining PHC and translating PHC into practice, developing frameworks to translate equity into action, experiencing both the potential and the limitations of community participation in helping to achieve the WHO definition of health, and seeking the necessary financing to support the transformation of health systems. These challenges were taken up by global, national, and nongovernmental organization programs in efforts to balance the PHC vision with the realities of health-service delivery. The implementation of these programs had varying degrees of success and failure. In the future, PHC will need to address to critical concerns, the first of which is how to address the pressing health issues of the early 21st century, including climate change, control of noncommunicable diseases, global health emergencies, and the cost and effectiveness of humanitarian aid in the light of increasing violent disturbances and issues around global governance. The second is how PHC will influence policies emerging from the increasing understanding that health interventions should be implemented in the context of complexity rather than as linear, predictable solutions.
