Health Equity in Brazil: Intersections of Gender, Race, and Policy. Kia Lilly Caldwell. Champaign: University of Illinois Press, 2017, 216 pp.
Health Equity in Brazil begins by introducing the readers to Alyne da Silva Pimentel, a 28-year-old Afro-Brazilian woman who died as a result of inadequate medical treatment after delivering a stillborn baby in 2002. Taking an intersectional approach, Caldwell’s work expounds on the shortcomings of Brazil’s public health care system as the cause of her death, exposing the “gross inadequacies and failures in the quality of maternity care and emergency obstetric care provided to poor, African-descendant women in Brazil” (p. 115). Although the book analyzes the structural conditions that shape Afro-descendant peoples’ access to and experiences within Brazil’s public health care system, the on-the-ground work and knowledge produced by local activists take center stage.
By situating Black women’s organizing, writing, and participating in local, regional, and international conferences as key sites for theorizing, Caldwell conceptualizes health equity in a way that acknowledges how “gender, race, class, and other forms of social marginalization shape differential health outcomes for marginalized populations” (p. 12). Her analysis points to the “urgency of intersectionality,” as opposed to universality, at various stages of organizing, making demands, and designing and implementing health equity policies. Caldwell shows that an alternative to a universalist approach to health care and equity is necessary, proposing a grounded theory that underscores why racism, sexism, and classism interlock in ways that have material and often deadly consequences for Afro-Brazilians. Caldwell’s theory of health equity provides a framework for rethinking intersectionality as both transnational and diasporic.
Health Equity in Brazil contributes to recent literature that examines how anti-Blackness functions within, and as a result of, different state institutional apparatuses (see Paschel 2017). The text reveals important tensions that exist within a nation lauded for its advancements in universal public health, even as, on an everyday basis, Afro-descendant women face a stark reality of inadequate access to public health institutions and substandard care. As Caldwell points out, Black women are disproportionately affected by a number of health issues, from forced/coerced sterilization and higher rates of maternal and infant mortality, to daily confrontations with institutional racism, sexism, and heterosexism in public and private health care institutions. While the book provides an in-depth analysis of state–civil society activism and the advancements and challenges that exist, its descriptions of interactions between Black grassroots organizations are sparse. This is not necessarily a weakness of the text but rather a path that leaves open the opportunity for future research agendas to examine the relationship between interlocking oppressions and coalition building.
Caldwell’s theoretical approach is strengthened by her use of qualitative data from collaborative research. She relies heavily on works published by Black women activists and Black women’s organizations, interviews with health activists, and participatory observations at seminars and conferences related to the health of women and Afro-descendants. Each chapter integrates these works as primary sources, providing a holistic understanding of the political processes that underlie both the creation and implementation of local and federal policies and grassroots responses to gendered racial disparities in health.
Chapter 1 provides a genealogy of women’s movements and organizations since the 1970s. Readers are introduced to the types of organizations that emerged to tackle women’s health at the federal level and the types of activism that occurred transnationally during UN conferences and regional encontros (meetings). Caldwell identifies the political shifts that influenced the Brazilian government to move from health policy frameworks aimed at population control to frameworks that viewed health as a human right. Paying close attention to local-level activism, Chapter 2 explains how Black women activists mobilized an intersectional praxis to create holistic health policies and initiatives. While legislators often focus on either race or gender when creating policies and programs to address health equity, Black women activists organized around the fact that race, gender, and class are “mutually constituted and inseparable determinants of Black women’s social identities and social experiences” (p. 50). This approach led Black women activists to create autonomous organizations, activities, and policies that would not only reduce the rates of health-related ailments but also lessen their impacts on impoverished Black communities. Caldwell notes that autonomous Black women’s organizations were instrumental in documenting the role of race in the differential health status between cisgender Black and white women, as well as the role of gender among cisgender Black men and women (cisgender refers to individuals whose gender identity matches the sex that they were assigned at birth). However, there remains a question surrounding how this intersectional approach might provide insights into the needs and experiences of Black trans and gender-nonconforming people.
Chapter 3 and Chapter 4 broaden the conversation on health and health equity by describing federal responses to grassroots activism in Brazil as well as some of the challenges of implementation. Chapter 3 concentrates on the ideological shift from a color-blind, universalist approach to health to one that recognizes race as a contributing factor to health disparities and inequalities. Advocacy around sickle cell anemia was a key starting point for discussing health in Black communities prior to race-conscious policies. This entry point paved a way for activists to articulate race and racism as social determinants of the health and wellbeing of Afro-descendants. Chapter 4 examines the ways in which institutional racism poses a challenge to creating and implementing race-conscious policies and practices. Of particular importance is the quesito cor (race/color data). For decades, the government did not collect information based on race/color because race was not considered to be a salient category that influenced social divisions and discrimination. A myth of racial democracy contributed to the “invisibility of the Black population in the health sector and the denial of their specific needs and experiences” (p. 101).
Chapter 5 brings the reader back to Alyne. Caldwell interrogates the interlocking forms of oppression that shape Alyne’s and other Black women’s experiences with and access to health care. These stories speak to the relationship between gendered anti-Blackness and health through the lens of maternal mortality. In Chapter 6, Caldwell traces the development of HIV policies and initiatives at the federal level as well as HIV-related initiatives created by Black women’s organizations. She argues that early activism around HIV/AIDS led by Black women filled a vacuum created when the state chose to neglect the importance of race in the prevention and treatment of the epidemic. Caldwell ends the book with a note about the hostile right-wing turn in Brazilian politics. As a result of this turn, a number of the advancements that Black social activists have made over the last three decades are at risk of being dismantled, with life-threatening consequences for many Black Brazilians; however, Caldwell concludes by emphasizing that “the battle is far from over” (p. 187).
Caldwell’s work demonstrates both analytical and methodological rigor that contributes to academia, activism, and public policy. This book is vital for anyone interested in health policy, the relationship between national and international political institutions, grassroots organizing, and mobilizing intersectionality (see Perry 2016). The text would make a valuable addition to any introductory course in anthropology, Black studies, Latin American studies, or gender studies, as well as specialized courses in gender and human rights, feminist methods and theory, and Latin American politics.
Paschel, T. 2017. Disaggregating the Racial State: Activists, Diplomats, and the Partial Shift toward Racial Equality in Brazil. In The Many Hands of the State: Theorizing Political Authority and Social Control, edited by K. J. Morgan and A. Shola Orloff, 203–28. New York: Cambridge University Press.
Perry, K. K. Y. 2016. Geographies of Power: Black Women Mobilizing Intersectionality in Brazil. Meridians: Feminism, Race, Transnationalism 14: 94–20.