Social inequities in covid-19 pandemic times: a reflection

Abstract

The impact of the pandemic has put the world on alert not only because of the health crisis, but also because of the economic and political impacts it unleashed. This essay reflects on disadvantaged and marginalized populations, more exposed to covid-19 due to the conditions in which they survive, with reduced access to basic sanitation and, therefore, less likely to adopt the recommended preventive measures. Worldwide, the contingency plan against Sars-CoV-2 required governments to take measures to protect human life and seek health equity. The Brazilian State, however, shirked from prior preparation to face the pandemic and did not establish coordinated strategies. Given that justice and equity in health strengthen cohesion in the search for safeguarding lives, ethics in care should include the implementation of public policies that correct distortions.

Bioethics; Health vulnerability; Socioeconomic factors; Health equity; Coronavirus infections

Resumo

O impacto da pandemia colocou o mundo em estado de alerta não só pela crise sanitária, mas pelos impactos econômicos e políticos desencadeados. Este ensaio reflete sobre populações desfavorecidas e marginalizadas, mais expostas à covid-19 devido às condições em que sobrevivem, com menos acesso a saneamento básico e, portanto, menor possibilidade de adotar as medidas preventivas recomendadas. Em todo o mundo, o plano de contingenciamento contra o Sars-CoV-2 exigiu dos governos medidas de proteção da vida humana e busca de equidade em saúde. O Estado brasileiro, no entanto, furtou-se da preparação prévia para enfrentar a pandemia e não estabeleceu estratégias coordenadas. Considerando que a justiça e a equidade em saúde fortalecem a coesão na busca por salvaguardar vidas, a ética no cuidado deveria passar pela implementação de políticas públicas que corrijam distorções.

Bioética; Vulnerabilidade em saúde; Fatores socioeconômicos; Equidade em saúde; Infecções por coronavirus

Resumen

El impacto de la pandemia ha puesto al mundo en alerta no solo debido a la crisis sanitaria, sino también a los impactos económicos y políticos que ha desencadenado. En este ensayo se reflexiona acerca de las poblaciones desfavorecidas y marginadas, más expuestas a la Covid-19 debido a las condiciones en las que sobreviven, con menos acceso al saneamiento básico y, por lo tanto, menos posibilidad de adoptar las medidas preventivas recomendadas. En todo el mundo, el plan de contingencia contra el Sars-CoV-2 exigió de los gobiernos medidas de protección de la vida humana y búsqueda de equidad en salud. El Estado brasileño, sin embargo, se esquivó de la preparación previa para enfrentarse a la pandemia y no estableció estrategias coordinadas. Teniendo en cuenta que la justicia y la equidad en salud fortalecen la cohesión en busca de salvaguardar vidas, la ética en el cuidado debería implicar la implementación de políticas públicas que corrijan distorsiones.

Bioética; Vulnerabilidad en salud; Factores socioeconómicos; Equidad en salud; Infecciones por coronavirus

This theoretical essay addresses issues of ethics and care for human life in the context of the covid-19 pandemic. The text rests on conceptual bases of bioethics focused on persistent situations of social inequality that affect vulnerable groups. Among them is the homeless population, who face difficulties in accessing resources and have limited opportunities.

The pandemic has put the world on alert not only because of the health crisis, but also because of the economic and political impacts it unleashed. This crisis is therefore all the more reason to pay attention to especially vulnerable groups and examine arguments based on human rights, social injustice and human solidarity. And, given the many difficulties faced by all, the concern for those who are homeless should be stressed. Among the various groups that make up this population, who live unnoticed, are the collectors of reusable and recyclable materials.

In Brasília, DF, the country’s capital, waste pickers usually concentrate on the North Exit of the largest public university in the Midwest region, the University of Brasília. The group, made up of individuals and families, survives under plastic sheeting, surrounded by solid waste and domestic animals, with no water available for the adoption of basic hygiene habits. There is no proper disposal of waste or sanitary facilities at the site, and the sewage runs in the open. Without access to any type of basic sanitation, waste pickers are exposed to risk factors for various diseases¹ .

Requests for help multiply on posters with confusing messages along the road, where children approach cars as soon as they notice any sign of help. The dire situation, due to the timid action of public policies and the lack of protection from the State, shows that the group is the weakest link in the social fabric. Standing at the base of the social pyramid, collectors’ fundamental rights seem unattainable.

The upheavals caused by the pandemic affected this population. Although with greater repercussions on socially vulnerable groups, Sars-CoV-2 affected everyone in some way, without distinction of skin color, class, ethnicity, values, beliefs and customs. Landing at airports and gaining the highways, passing through urban streets until reaching the rural area, the coronavirus triggered physical, mental and emotional illness in individuals, as well as a health, economic, financial, cultural, political and religious crisis in the country.

The pandemic’s fallout led institutions to streamline access to information and correct certain distortions related to the lack of transparency and delays in actions. The contingency plan to combat covid-19 forced the implementation of health protocols that changed daily life, causing people to think about the integrality of life and the relationship with the other² .

Given the magnitude of the problem, the World Health Organization (WHO) recommended that its member States create control mechanisms with health institutions and implement policies capable of addressing priority needs, expanding and improving the public debate on human rights, human dignity, ethics, justice and social equity³ , ⁴ . The turmoil that convulses human affairs today imposes a change in habits and attitudes, leading institutions to rethink the ongoing process and its outcome.

Potter points out that, for the survival of world civilization, nations must find a bridge to the future⁵ not giving in to political oppression, economic exploitation, cultural domination and collective and environmental destruction, which affect human rights and dignity, respect for fundamental freedoms and the environment. Well-being is not only social but must follow the principle of sustainability of planetary life for the maintenance of ours and future generations. Therefore, in a globalized world, ethical reflections must recognize the other, value life, practice justice, cordial, solidary and respectful coexistence, and co-responsibility for everyone’s lives⁶ .

Concrete nature of respect for human rights and dignity

The reality of waste collectors is not the only example of inequity in Brazil’s capital or in its different territories. The lack of reach of social equality and distributive justice policies affects several disadvantaged groups, whose invisibility crosses the frontier of being and having, deteriorating human dignity and violating fundamental rights. However, as Junges⁷ points out, the ethical category of respect for dignity and human rights should precisely emphasize the most vulnerable individuals and groups.

In this sense, Hamel⁸ states that ethics must be comprehensive and pluralist to guarantee democratic rules of popular participation and ensure equalization between human rights and the sovereignty of the people⁸ . To correct social deviations and deprivations, resources and opportunities must be distributed fairly, seeking to establish and guarantee the functioning of institutional structures based on human rationality and solidarity³ , ⁴ . In the legal field, human rights cannot be neglected, as they are the pillars of freedom, equality and participation, capable of guaranteeing respect for human dignity in its various dimensions.

The Brazilian Constitution points out, in its Article 196 that Health is a right of all and a duty of the State and shall be guaranteed by means of social and economic policies aimed at reducing the risk of illness and other hazards and at the universal and equal access to actions and services for its promotion, protection and recovery ⁹ . In the same sense, Article 2 of Law 8080/1990 establishes that health is a fundamental human right, and the State must provide the conditions necessary for its full exercise ¹⁰ .

In practice, however, the Brazilian National Health System (SUS), which aims at universal access and intersectoral care, has been overloaded for years considering that a significant portion of the population depends and has on it their only choice of health care. In this context, the scarcity of material and human resources has deprived population groups from receiving efficient, safe and continuous services. This is also compounded by the lack of sensitivity and social commitment from public bodies and authorities.

Such difficult pandemic times show that it is necessary to fight to strengthen a free and inclusive public health system, as provided for in the Brazilian Constitution¹¹ . SUS has been working to combat covid-19 through care and vaccination of the population, while many developed countries in the Northern hemisphere that do not have a universal public system have been facing a greater impact than expected in the face of the pandemic. This scenario caused the international debate on ensuring access to health care as a fundamental human right to be guaranteed by the State to resurface.

It should be noted, however, that the principle of universality in the Brazilian health system has not prevented groups made invisible by social exclusion from being exposed to a high risk of contracting covid-19. Basic rights of these individuals, essential to guarantee respect for dignity, remain neglected.

In this context, institutions should take the “path of reason,” defending human rights as elements endowed with universal validity. An effective engagement of people – not only in complying with the law, but in transforming society – should be encouraged in order to make them more solidary and aware of unacceptable exclusions and injustices³ . In this sense, debates on justice need to go beyond the limits of hegemonic theories and incorporate a moral assessment linked to the promotion of freedoms established by human rights ¹² .

When it comes to health, poverty must be considered, as the lack of access to economic, social, educational, cultural and informational means excludes people from the health production process. Perspectives that do not consider these factors perpetuate a configuration of the right to health as a consumer good, ignoring several determinants and the fundamental character of social justice, which must be promoted by the State and its institutions.

Just institutions and human rights

Rights need to be updated according to the historical context, and this need for updating is even more pressing in critical times such as the pandemic one. It is therefore necessary to review the social, economic, cultural rights of the second and future generations based on a civil ethics¹³ . The awareness that the dignity of the human person is multidimensional, involving the individual’s physical and psychological integrity, moral plenitude, freedom and material welfare conditions, must grow in institutions. From this perspective, it is essential to design legal mechanisms and mediations that correct negligence and inequities, denouncing violations or crimes against dignity and protecting society¹⁴ , ¹⁵ .

The human being should never be seen as a means to reach other ends, and it is this dignity that inspires the greatest ethical rule: respect for the other ¹⁶ . Based on this principle, fair institutions, as structuring cores that support the ethical argument, must ensure that each individual has his rights preserved and guaranteed as a human being who takes care of himself, recognize himself in the other and manages to make his actions a commitment with life and its nature¹⁷ .

The Brazilian Constitution, in its article 5, provides that all persons are equal before the law, without any distinction whatsoever, Brazilians and foreigners residing in the country being ensured of inviolability of the right to life, to liberty, to equality, to security and to property ¹⁸ . In the same sense, article 14 of the Universal Declaration on Bioethics and Human Rights considers that ensuring the promotion of health and social development for their people is a central purpose of governments that all sectors of society share , and that enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief ¹⁹ .

Confronting social problems presupposes cooperation between institutions and civil society, with a dynamic that combines technical and human skills. Creating a culture of collaboration between State and society requires a qualitative leap in human relationships, achieved from an organic movement capable of identifying the inseparability of this relationship. Such a movement would generate a committed, active, politicized and solidary participation²⁰ .

The pandemic has forced people and institutions to help those most in need, even if belatedly. The very Federal Government, with some delay, issued decrees with exceptional social protection measures to be adopted during the period of confronting the public health emergency of international importance resulting from the coronavirus to reduce the effects of the economic crisis aggravated by the pandemic²¹ . One of these measures was the provision of financial assistance to poorer classes.

Society seems to have realized that solidarity is crucial to mitigate the consequences of the disease and reduce the number of deaths. However, as soon as the pandemic passes, it will be necessary to see whether this feeling of solidarity will continue. For this to happen, social movements, private institutions and businesses must maintain donations of financial and material resources, alleviating the inequality that affects the most vulnerable groups.

Actions by government and civil institutions show efforts towards providing universal, equitable and comprehensive assistance to citizens, regardless of gender, race, color, occupation and other social or personal characteristics. However, despite the increase in solidarity, inequality continues to undermine social cohesion, leading to the unfair distribution of opportunities and denying access to health care²² .

The inequalities that persist among the invisible population of large cities, subjected to deprivation since the beginning of their lives, result from poorly solidary governance arrangements, incapable of promoting equity and valuing the dignity of human life. Not being equal, people have different needs and, therefore, should be treated unequally, in the sense that attention falls mainly on those whose needs are greater.

As Marmot points out, social inequalities are killing on a large scale and no less important is considering that all lives matter²³ . For this, solidarity must be part of an ethical civilizing process that promotes the exercise of democracy for the equal conquest of civil rights.

Care of human nature: solidarity and ethics

If all forms of life matter, it is necessary to promote dialogues with the different possibilities of being in the world in a healthy way, in a cycle of care that starts with oneself and reaches out to the other. “Being healthy” refers to care interactions and interconnections that go far beyond the organic and concrete, as they result in the construction of health models endowed with philosophical, political, economic and cultural richness. Biological aspects are one of the elements of this great plot that goes from the individual to the collective, composing the symphony of life and good living.

Within these interactions, health is understood as the maintenance of alliances with different forms of knowledge and flows, in a relationship of interdependence with everything that exists. The good life expands this coexistence through respect for all beings. The principles of this way of life are the fight against injustices, privileges and inequalities and the bond of “one with all”²⁴ , ²⁵ .

Today, models of thought and health care exclude projects and people in whose experiences other ways of being in the world are recognized. In this sense, the traditional Brazilian communities – indigenous, quilombolas , riverside dwellers, etc. – remain excluded from State actions for health access and protection, even in the face of a crisis such as the pandemic one²⁶ , ²⁷ . These communities are subject to the same logic of invisibility described here in relation to the group of waste collectors – the invisibility of those who are exposed to all kinds of adversities and face the pandemic in the most vulnerable way possible.

In this context, a bioethics framework constructed from the Brazilian and Latin American reality must bring the persistent contrasts and needs of vulnerable populations to the center of the discussion. This perspective incorporates debates about asymmetries in the meeting of the self with the other and about the situation of public policies that deal with social inequalities, discrimination, vulnerabilities and inequities²⁸ , ²⁹ .

The ethics of care in human relationships involves the understanding that no one falls ill alone. The democratization process — through disease prevention, education and sanitary inclusion — must consider the social determinants of health. Thus, it is up to us to fight for public policies that correct distortions and for justice and equity in health to be strengthened amid the superhuman strength to save lives.

Final considerations

The covid-19 pandemic showed the world new ways to achieve the right to health. WHO, in particular, has shown that the lack of access to health care is determined by the disrespect for economic, social, educational and cultural rights essential to the dignity of life. The scientific community, academic institutions, surveillance and health care systems and non-governmental bodies were also present, creating a task force to achieve effective vaccines and try to discover medicines that would save lives.

In view of the population falling ill, SUS did not shirk its responsibility for the principles of universality, equity and integrality, which ended up strengthening a system that had been scrapped and devalued in recent years. The brilliance of research and the assistance of public institutions of higher education to SUS professionals show that it is possible to think about health under a different logic, different from the one that has prevailed around the world.

Covid-19 posed major challenges to the global governance system. The frenzy of individual accumulation, the exorbitant profit of large companies and the omissions and lack of protection on the part of the State, with denial and anti-humanist actions, remind us of what is the daily agenda, to whom this society reveres, to whom we are submitted and who holds the power. Therefore, social protection measures must be triggered by international organizations to favor global equity, implementing public policies that correct distortions and strengthen social cohesion in the search for safeguarding lives.

On the other hand, the humanitarian crisis has also brought out the best in human nature: solidarity. Perspectives that open up for the post-pandemic point to social justice movements, as this global crisis cannot be faced without considering that the time has come to transform human relations. Such transformation must aim at creating governance systems committed to equity, human rights, dignity of life, respect for diversity, social responsibility and the protection of current and future generations.

Nature’s antibody against destructive human action was present at this moment of pandemic. This moment can be seen as what the composer and philosopher Tiganá Santana³⁰ calls “open hour”, which refers to the various transits where anything can happen. In this collective moment, the time has come to take care of oneself, the other, the family, work, the earth, nature, the planet and the universe, in order to better serve our humanity.

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Publication Dates

• Publication in this collection
  18 Oct 2021
• Date of issue
  Jul-Sep 2021

History

• Received
  16 Oct 2020
• Reviewed
  19 July 2021
• Accepted
  29 July 2021