Structural inequalities in Brazil linked to higher COVID-19-related mortality in low-income areas

Brazil is one of the hardest-hit countries by the coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

A team of researchers aimed to determine the differential health effects of COVID-19 on disadvantaged population groups. They found that low-income and Black and Pardo communities in the country are more likely to die from COVID-19.

Brazil and COVID-19 pandemic

Brazil reported its first COVID-19 case on February 25, two months after it first emerged in Wuhan City, China. The virus had spread to every state in Brazil by March 21. A month after, the country reported its first one-millionth case and about 49,000 deaths.

The virus continued to spread, making Brazil one of the worst affected countries in the world. To date, the global toll of cases has reached 72.87 million and more than 1.62 million deaths have been reported. In Brazil, there are at least 6.92 million cases and over 181,000 deaths.

The coronavirus pandemic has amplified the effects of social inequalities on exposure and death in low socioeconomic groups, not least in Brazil. A few studies have tackled the uneven impact of the pandemic by socioeconomic status and race, particularly in low- and middle-income countries.

The study

The study, published in the pre-print journal medRxiv*, aimed to characterize the differential risk of hospitalization and death in São Paulo state, Brazil. They also wanted to show how vulnerability to COVID-19 is influenced by socioeconomic inequalities.

To arrive at the study findings, the researchers conducted a cross-sectional study using hospitalized severe acute respiratory infections (SARI) reported between March and August 2020 in the Sistema de Monitoramento Inteligente de Sao Paulo (SIMI-SP) database.

Further, the team assessed the risk of hospitalization and death by race and socioeconomic status using multiple datasets for individual-level analyses.

Study findings

The state of São Paulo reported the highest number of SARI hospitalizations per 100,000 population compared to all states in Brazil between March and August 2020.

During this period, 232,540 patients were included in the SIMI-SP database, wherein 230,794 were diagnosed with COVID-19. From these, 223,455 or 98.4 percent were hospitalized, while about 1 percent died without hospitalization.

The study findings showed that social and racial inequalities shape the risk of SARI hospitalization and death. Specifically, Black or Pardo Brazilians living in low-income areas were more likely to be hospitalized and die due to SARI compared to White people.

Also, the team’s assessment of SARS-CoV-2 antibodies in blood donors demonstrated that Black Brazilians and those with lower socioeconomic status are disproportionately exposed to COVID-19. The team also found that patients admitted to public hospitals were at a higher risk of dying than those in private health facilities.

The researchers cited potential factors that influence inequality, which include:

  • Higher comorbidities among poor Black patients
  • Lower access to private care among low-income people

Regarding income, the study revealed that there is a higher risk of hospitalization due to SARI in municipalities with low income per capita and high population density than the rest of the state.

Relative risk of SARI hospitalisation for the RMSP (A). Seven-day moving average of daily median levels in social distancing by race (B) and income (C). Difference in daily social isolation by race (D) and income (E) after the introduction of NPIs. In panels (B) and (C), solid lines show population-weighted median isolation levels and shaded areas show population-weighted interquartile range (25% - 75%). Dashed vertical lines indicate the dates of NPIs that enabled school closure (March 13 was the state NPI) and non-essential activities (March 18 and 22, municipal and state NPIs, respectively).
Relative risk of SARI hospitalisation for the RMSP (A). Seven-day moving average of daily median levels in social distancing by race (B) and income (C). Difference in daily social isolation by race (D) and income (E) after the introduction of NPIs. In panels (B) and (C), solid lines show population-weighted median isolation levels and shaded areas show population-weighted interquartile range (25% - 75%). Dashed vertical lines indicate the dates of NPIs that enabled school closure (March 13 was the state NPI) and non-essential activities (March 18 and 22, municipal and state NPIs, respectively).

All these can be explained by different responses to infection control measures and social distancing guidelines. For instance, in wealthier and predominantly White communities, people were able to isolate faster and maintain isolation for long periods.

Meanwhile, in lower-income areas, people had no choice but to go out and work. These individuals were mostly dependent on day-to-day income, limiting their ability to reduce the risk of getting sick.

Moreover, people in the state have a large difference in accessing healthcare. Only 25 percent of Brazilians have access to private healthcare through health insurance. This means that 75 percent of the population relies on a chronically underfunded public healthcare system.

“Strengthening healthcare access and its capacity will be critical for reducing health inequities during this and forthcoming public health emergencies,” the researchers wrote in the paper.

“Our study highlights the need for additional research to comprehend the effects of social and health inequalities during pandemics,” they added.

*Important Notice

medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Source:
Journal reference:
Angela Betsaida B. Laguipo

Written by

Angela Betsaida B. Laguipo

Angela is a nurse by profession and a writer by heart. She graduated with honors (Cum Laude) for her Bachelor of Nursing degree at the University of Baguio, Philippines. She is currently completing her Master's Degree where she specialized in Maternal and Child Nursing and worked as a clinical instructor and educator in the School of Nursing at the University of Baguio.

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