The Positive Right to Health

21 Dec

As a public health, human rights, and health disparities major, I believe that it is important to address the issue of health and health care as I have studied it within the Brazilian context. The situation of health in Brazil is so unique because in Brazil health is regarded as a universal service that is not prioritized for any one individual or group. Rather, everyone is afforded the same right, and the right must be acknowledged equally. The Brasilian government and minister of health have mandated through the Sistema Único de Saúde (SUS) that health care be provided for everyone, not just Brasilians….ANYONE in the country. Furthermore, if treatment is not available in the area of injury/ailment, then, by law, the person seeking treatment must be transported to a locale in which treatment is available.

While there is some discrepancy as to whether or not this system effectively promotes optimal health for all Brazilians and adequately acknowledges inequities in health care access and community conditions that promote good health—inevitably, no one system is perfect—I believe that the acknowledgement of health as a right in Brazil reinforces the system as a progressive one, worthy of praise.

As an American student, I cannot help but reflect upon the differences between the capitalistic health care system in the United States and the universal system of health that is provided and acknowledged within Brazil. With the recent controversy surrounding the Health Care Reform Act in the United States, much time and many strenuous efforts have been exerted by United States citizens and legislators toward debunking the social, economic, and ethical ramifications of implementing a new system that promotes a “positive right” to health.

Supreme efforts have been made by proponents of the health care bill to argue for the acceptance of the law because of the benefits that it awards those who were once barred from access to adequate health care due to lack of coverage by a health care provider. Alternatively, arguments from the opposing viewpoint acknowledge the partiality of the “pay your way” system, in which those who are deemed capable of affording their own health care are also responsible for funding the new health care system for others as well.

Difference #1:Community Empowerment and Community Mobilization

While I understand the “anti-socialism mentality” of those Americans in opposition to universalized health care, my experiences within Brazil have reinforced my belief that health is a human right, which should be acknowledged equally for all. While, indeed, there remains much room for improvement within the Brazilian health system, I believe the addition of health as a human right to Brazilian law has empowered a community effort and fostered a social cohesion among Brazilians to know, understand, and utilize as well as improve their right to health.

In the United States, this right is non-existent; thus, it cannot be so forcefully demanded. There exists solely a conception of health as a privilege. In this manner, the absence of a formal written law regarding health as a benefit and basic necessity for all serves as barrier among Americans struggling to improve their health. Lack of acknowledgement of health as a human right by United States policy disempowers Americans who lack the health benefits they could otherwise demand from the government under a system similar to the Brazilian health. Their inability to demand their rights keep them disbarred from socio-economic progress and attaining optimal health status.

In general, I have gathered the impression that social cohesion among Brazilians is very powerful. Community mobilization is often utilized and recognized as a key method to inspire and demand change in policy. From just my short time within the country, I have witnessed several “em greve” (on strike) posters on the outside of banks and posts offices. My own host mother participated in a strike with several others from her work place for higher pay from her employer at UFBA (Universidade Federal da Bahia). There is a sense of empowerment among the Brazilian people that is also visible among issues related to health care. I once spoke with a group of public health students from UFBA about their perception of the health care system. They all agreed that the idea was laudable, but they believed more could be done to promote health, particularly throughout the state of Bahia. Coincidentally, they were on their way to a protest demanding improved access to public health materials in health posts in rural areas.

Difference #2: The Definition of Health-Treatment vs. Prevention

Although I believe the United States is progressively realizing health as a human right for all, the shift toward providing universalized insurance coverage is only the first step to acknowledging health as a right. In this manner, I perceive Brazilian health care laws as having proactively surpassed American health care laws in terms of progressively attempting to improve health for all. I believe that unlike the empowered language of Brazilian health laws, the laws which reinforce health within the United States lack both the vernacular and the intent to accept health as right.

In the United States, there is an emphasis on the provision of health care, rather than an overall desire to improve health status for Americans, i.e. an overall focus on the treatment of disease. In Brazil, however, there is an acknowledgement of the all-encompassing factors that affect health and access to health care and a provision made through law to address both pre-existing health conditions as well as to prevent conditions that may arise as a result of socio-economic class and living conditions, deficiencies in education, unequal access to health care resources/underdeveloped health care infrastructure, etc.

I consider the most unique and important aspect of Brazil’s right to health to be the definition of “health” that has been adopted into the Brazilian constitution:

A saúde tem como fatores determinantes e condicionantes, entre outros, a alimentação, a moradia, o saneamento básico, o meio ambiente, o trabalho, a renda, a educação, o transporte, o lazer e o acesso aos bens e serviços essenciais; os níveis de saúde da população expressam a organização social e econômica do País.

“Health has determining factors and conditions, among, food, housing, sanitation, environment, labor, income, education, transport, leisure, and access to essential goods and services; levels of the population express the social and economic organization of the country” (LEI Nº 8.080, Article 3º, Lei Organica de Saude).

In today’s society there is a demonstrated need for acknowledgement of one’s rights within the realm of overall health beyond simple access to care. I believe that ensuring equal opportunity for individuals to gain access to a decent minimum of health care does not ultimately affect the social gradient in mortality, implying that guaranteeing access to universal health services alone does not improve health overall. Health care is only one socially controllable factor that significantly contributes to overall health; there are other factors affecting health care, i.e. biology and social determinants of health (e.g. environment, availability of resources, socioeconomic status etc.) which play a defining role in the determining the overall health of an individual.

Because access to health care comprises only a single social determinant of health, the overall quality of health of an individual cannot reach its potential unless all social determinants of health are addressed. Defining a right to health through a universal health care law, as it is defined within the United States, is, therefore, an incomplete approach to promoting a decent standard of health because it neglects many of the biological and societal factors involved in determining the health of an individual.

In addition to universalized health care, SUS also mandates that everyone should have their right to health acknowledged equally. This element of equality cannot be effectively acknowledged simply by guaranteeing free health services as the health care legislature in the United States promotes. One must also consider the structural inequities and social factors which deter or prevent individuals from seeking and receiving access to health care resources and facilities, exacerbating pre-existing disparities in health.

Despite guaranteed free access to care, many still encounter financial and socio-cultural barriers that may lead to discrimination in who actually receives care. For example, even with an extension of health care insurance coverage, there are still issues related to an individual’s ability to exercise to his right to see a health care provider. Lack of transportation to a health care provider, pharmacy, clinic, etc. is a considerable obstacle for many without personal vehicles. Even public transportation can be a burden for many who are pressed for time between working long, tiresome jobs, or are disabled.

Lack of transportation is one particular determinant of health that I noticed was accounted for by the  Brazilian health care system, even within rural communities. Through the Programa Saúde da Família (PSF), a national public health program afforded as a right through SUS, individuals can receive preventative care and treatment or recommendation to see a specialist at their local health care post. During a visit that I made to Cachoeira, a city in the interior of Bahia, I observed a PSF nurse make several visits to the homes of patients who were physically disabled or bed-ridden for a check-up and to ensure that they were being cared for regularly, taking their necessary medications, and adhering to their daily regimens. I was also able to make a grocery delivery to the home of a bed-ridden tuberculosis patient in Santo Antônio de Jesus, another city within the interior of Bahi. Within the United States, no such national program exists; the concept of a “home visit” is outdated and generally frowned upon. I was surprised to see such efforts being made by nurses and physicians to attend to the needs of their patients, as I had never witnessed any similar program within the United States.

Overall, I believe that “health” as defined by Brazilian law adequately capitalizes upon the manner in which health status is dependent upon a wide array of social and behavioral factors. This acknowledgment of health as a multi-dimensional issue is something which I perceive is lacking in American policies and in the discussion of health-related policies. Because the United States has not adopted a right to health like Brazil, there remains a lack of discourse over the social determinants of health and the fundamental causes of disease. I believe that before within American health care policy, a paradigm shift from an access to treatment model to the Brazilian model, affording health as general well-being and way of life will be necessary to effectively address health care disparities.

Difference #3: Cultural Willingness to Advance Health—A Community Support System

One aspect of SUS that I believe is very important to address is the manner in which I believe the idea that the system promotes, universal and equally accessible health for all, adequately reflects the cultural mentalities of the Brazilian people. I noted that in the United States, no such right to health exists. However, I believe this is because the cultural perception of Americans will not allow this to be so. I have noticed in Brazil a valiant effort made by other, e.g. people, doctors, nurses, teachers, passerbys, etc., to help other people. Even the Brazilian government acknowledges the rights of Brazilians and strives to protect these rights. One distinct and powerful example of this that made a significant impression on me is the refusal of the Brazilian government to accept $40 million from U.S. AID grants in May 2005 because they did not agree to the terms of acceptance, which demanded the exclusion of sex workers, transvestites, and homosexuals from benefiting from the money.

Currently, there still remains a stigmatization and unwillingness to declare health and human right within the United States. Much of this unwillingness stems from a cultural uneasiness to fund free services for others; however, there is a slow movement toward the internalization of health as a right for all and this realization will require some sacrifice.  I believe that this strong sense of community care and support is unique to Brazilian culture and that the United States is progressively realizing these same values.

Perceived Issues with the Universalized Health Care System-SUS

While the concept of SUS represents an idealist response to eliminating injustices in health, the system maintains its flaws. From my conversations with my host family and neighbors, public health students, and medical students, I have gathered that, in general, Brazilians agree that SUS is “um process em construção” ( a process in construction). My host mom, along with many others, mentioned to me that they would never seek treatment for an emergency at a SUS hospital, only a private hospital. This is because, through the SUS system, the time that one must wait to be attended to is often very slow. Hospitals remain over-crowded and there is not a sufficient number of doctors to attend to all the patients around the clock.

This was observed during an organized visit to Hopsital Central Roberto Santos (the largest public hospital in Bahia). The emergency room was so crowded that patients were being attended to by family members in the hallway, only being check on occasionally by the nurses and physicians. Despite the efforts of Programa Internação Domiciliar, which prepares patients to live at home under the care of another family member who is competent in assisting them with taking their medications, many patients remain in the hospital. Having taken advantage of the universalized health care system in Brazil (SUS), I found that it was fairly easy to receive treatment. Granted, I arrived at the the hospital at 3 A.M. when there was rarely anyone there.

Another issue associated SUS is the failure of the system to fully account for disparities associated with marginalized groups in society. Not all individuals are equally exposed to the same level of health care, education, and home lifestyles, etc. that would guarantee him the ability to make “healthy” life decisions and maintain his health. For example, if someone is raised in a neighborhood plagued by poverty and rampant drug use, his predisposition to unhealthy behaviors may affect his ability to personally care for himself.

In his Pathologies of Power, Dr. Paul Farmer, a physician and medical anthropologist (as well as a Duke grad!), discusses the manner in which historically rooted social processes within societies (e.g. racism, gender discrimination, poverty, etc.) pose significant barriers toward attaining a decent standard level of health. These structural disparities which Farmer terms examples of “structural violence” plague societies beyond access to health care.  In Brazil, particularly within in Bahia where the population is primarily comprised of Afro-Brazilians, structural violence plays a key role in the health of the population.

The relegation of Afro-Brazilians to an inferior status is a historically rooted process that began when slaves from Africa were brought to Brazil. As slaves, they represented the lowest rung of the socio-economic ladder and regarded as the bottom class. In this manner, their rights were neglected and they were afforded a substandard agree of care and resources. This social construction within Brazilian history placed Afro-Brazilians at a social disadvantage since their arrival in the country.In this manner and from my experiences visiting health posts and observing health issues that plague populations, there is a connection between one’s place in society and one’s health status.

While I agree that the system in Brazil is far superior in construction and implementation to the system currently utilized within the United States, I believe more social policies should be adopted which consider the situations of marginalized populations, such as Afro-Brazilians. These social policies should incorporate a positive shift toward catering to the social determinants of health which put marginalized populations at a disadvantage for attaining optimal health status.


2 Responses to “The Positive Right to Health”


  1. On Brazilian Time « brasilian banter - November 25, 2012

    […] perspective. Brasil has a model HIV/AIDS system, in addition to a universalized health care system (long post about this). While organized prostitution (brothels, the management of prostitutes through a pimp) is illegal […]

  2. On Brazilian Time | blue devil banter - June 18, 2013

    […] perspective. Brasil has a model HIV/AIDS system, in addition to a universalized health care system (long post about this). While organized prostitution (brothels, the management of prostitutes through a pimp) is illegal […]

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