Care in socially vulnerabilized territory and the COVID-19: intersectionality and emic dynamics on care ethics

Abstract

The aim of this study is to understand care, before, during and after the COVID-19 pandemic, in a vulnerabilized territory, considering intersectionality, care ethics and the emic dynamics. The method was qualitative research. The subjects were community leaders, and health professionals of Primary Health Care at the Family Health Unit (USF) of the Brazilian Unified Health System (SUS). Challenges and Potentialities in care were identified. Care went within, against and beyond the State in a decolonial way. Politicization and public policies’ improvement of care are understood as coping with the pandemic.

Care; Intersectionality; Public policies; COVID-19; SUS

Resumo

O objetivo é compreender o cuidado antes, durante e depois da COVID-19 em território vulnerabilizado, considerando a interseccionalidade, a ética do cuidado e a dinâmica êmica. O método foi a pesquisa qualitativa com líderes comunitárias e profissionais de saúde da Atenção Primária na Unidade de Saúde da Família (USF) do Sistema Único de Saúde (SUS). Desafios e potencialidades foram identificados. O cuidado foi com, contra o e para além do Estado, de forma decolonial. A politização e a melhoria de políticas públicas do cuidado, na essência êmico-ético-política, são compreendidas como eficientes no enfrentamento à pandemia.

Cuidado; Interseccionalidade; Políticas públicas; COVID-19; SUS

Placing the study

The study of care in socially vulnerabilized territory¹based on a plurality of racialized²women practices, itineraries, subjectivities, and experiences are the focus of this research. The justification on the current relevance of the theme for feminist studies is that care, as an object, under the triangulation of care ethics³, intersectionality and the emic⁴dynamics of the territory relating to COVID-19, has not been studied yet. Care provided outside the USFs has emic specificities and is usually not paid for, although it is responsible for the reproduction and maintenance of life itself. Paid care is tied to USFs or as maid and/or caregiver. How can we approach care in racialized communities, under state negligence, and precarious life, before, during, and after the pandemic, such as the description below?

During the pandemic, the Association of the Fishermen's Village delivered several food baskets, and vegetables, hygiene material for women, sanitary pads, and books for the children. We made coffee, lunch, and dinner. We got masks and started delivering them. On each pole of the streets, we fixed how to use the masks, alcohol gel. We mixed water and detergent and hung it up on the poles around the Village, for the people who are homeless. (Potira)

Reflecting on community care practices, we need to critically verify the relationship between emic-ethical dynamics that correspond to care realities and rethink care actions and policies. It is essential to indigenize and blacken feminisms (Carneiro, 2001, 2017) and care studies, to expand the relation of care with the sciences, State, Rights Guarantee System (RGS), public policies, especially regarding the pandemic and necropolitics⁵( Mbembe, 2016 ), in the peripheries of capitalism.

The COVID-19 Pandemic brought several restrictions to the existing care practices and itineraries in socially vulnerabilized territories ( Cualhete et al., 2022 ). The Pandemic is described as one of the greatest international public a health crisis of the last decades, having reached the entire planet ( WHO, 2020 ). It increased the challenges in socially vulnerabilized territories, aggravated by the already existing syndemic and neoliberalism, such as the continuous dismantling of social politics, SUS, since December 2016, with the constitutional amendment 95 that froze investment in social areas, the cuts on labor rights (2017), and on Social Security (2019) ( Araújo et al., 2020 ; Dantas, 2020 ).

The objective of this study was to understand care in a vulnerabilized territory called Fishermen's Village, in the city of Cubatão, Metropolitan Region of Baixada Santista, São Paulo State, Brazil. For this end, we critically consider the relationship between the emic dynamics and ethics of care, considering intersectionality and its idiosyncrasies.

We found a lack of care studies developed in socially vulnerabilized territories, that combine “intersectionality” with “care ethics”. This combination may promote critical reflections around gender, race, and class by comprehending the local sense of care under specific social condition. It may potentialize a proper construction of public policy, delineated here as emic-ethical-political care. Ethics and politics of care may be conjugated in such a way that one cannot be thought of without the other ( Pintasilgo, 1998 , Gonzalez, 2020 ). In the case of favelas , the emic may assist to understand actions within, against and beyond the State, contribute to changes on an ethical-political care level and the RGS. The first step is to delimit the methods used and the socio-history.

Methods and historicization of the territory

The method applied was qualitative participatory research⁶, conducted with field and online activities from 2017 to 2023. The 12 participants from the territory were: 3 Community Leaders (women), 8 Community Health Workers women (CHW) and 1 male doctor from the USF. They were engaged through meetings in the USF. Careful listening to the narratives and intense insertion of the researchers in the territory allowed better understanding of the object, the emic, and its transformations ( Schmidt, 2008 ). We completed 9 in-depth interviews, 7 workshops with participant observation and 24 field diaries.

Researching care in socially vulnerabilized territories, means seeing the marks left by colonialism, patriarchalism, racialization, capitalism, and neoliberalism, that deeply sharpened during the COVID-19 pandemic ( Camilo et al., 2021 ). This continued “coloniality,” is a process of dehumanization as a strategy of exploitation, to make the colonized less than human being, forcing subjectivities to resist in the “fractured locus” of colonial difference ( Lugones, 2014: 948). Racialized women resist daily to humanize the lives in the community, a resistance building the favelas’ feminisms ( Jorge, 2023 ).

The social-historical contextualization of this territory requires a focus on Cubatão, one of the nine cities in the Metropolitan Region of Baixada Santista. There are 131,626 inhabitants (Brazil, 2020b) and the political emancipation happened on April 9th, 1949 ( Anhas; Silva, 2017 ). The main economic resource are industries, mainly petrochemical ones, installed in the 1950's, simultaneously with the construction of the Anchieta Highway, in 1947 ( Anhas; Silva, 2017) . The first working class villages from this period were migrant families from Northeast Brazil and they built houses on stilts, on mangroves, facing urbanization and environmental challenges ( Anhas; Silva, 2017) . There is one Family Health Unit (USF) in the Village, with three Family Health teams, outlining the only potent State's presence in this territory. Around 40 thousand families (underrated) live on stilts, without basic sanitation ( Anhas; Silva, 2017) . The USF professionals mentioned the increase in the population is due to the growth in unemployment since 2016 (Brazil, 2019), which rose during the Pandemic, between 2020 and 2022.

Citing the IPVS⁷( São Paulo, 2010 ), Cubatão had 21.2% of the population in the high vulnerability group, 21.0% in the extremely high vulnerability group. There are 42.2% of its population with low socioeconomic status and heads of households, mostly racialized impoverished women, with non or low formal education. The Fishermen's Village was included in the category of very high vulnerability ( Moraes et al., 2017 ).

Impoverished racialized women compose the intersectionality in the territory

The category Intersectionality⁸, especially race, gender, and class, helps to understand care in the studied territory, where most care workers are racialized impoverished women. Intersectionality is the colonial process that enslaved and socio-politically dehumanized racialized women ( Padovani, 2017 ). In the patriarchal peripheral capitalist societies like Latin America, women, depending on class, race, and other imbrications, are put in different power structures, work conditions, that define lives and deaths ( Teixeira, 2021 ). The Continuous PNAD 2018 showed that black women perform more unpaid care for their own families, neighbors, low paid care work for white bourgeois and middle-class families, institutions, and companies (Brazil, 2019). The same wages (or lack of wages) are applied to racialized, foreign, migrant, and indigenous women (Brazil, 2019).

I don't precisely know the number of people who work in family homes as housekeepers (and care workers), but you see, in the morning, in the middle of the pandemic, women going out to work. Their bosses didn't let them stop working. They had no other income or option. (Potira)

Racialized women in this territory have not had the chance to follow the sanitary protocols to curb the curve of infected by the COVID-19 pandemic. This condition influences all members of the household and the community. Intersectionality determines the life in geopolitics, like the situation of Brazilian migrant women, and the unequal distributions of power ( Piscitelli, 2008 ). The Pandemic has enhanced the importance of racialized and migrant women’s care work for the global economy ( Vergès, 2020 ). The leftovers of precarious jobs, none or low paid caring, cleaning, cooking, prostitution, and others, are left to the racialized impoverished women, with no rights or access to rights. The case of Philippine women, within a vast contractual labor system in the United Arab Emirates known as ‘kafala’ makes this condition explicit, in which they must work exclusively for their employer, obtain their approval to leave the country, highlighting the absence of labor rights ( Parreñas, 2021 ). These analogous-to-slavery life conditions are historically often found in Brazil ( Teixeira, 2021 ). Intersectionality also covers the largest female prison population ( Davis, 2016 ) and not only women of the global south, but also incarcerated women worldwide ( Padovani, 2019 ). If we aim at the color and class of these women in Brazil, we end up with racialized and impoverished women ( Padovani, 2019 ).

This category has helped public policy by highlighting how difference influence policy and how “power devices produce difference” ( Moutinho, 2014: 203). In peripheral capitalism, the impoverished racialized women of favelas have been structurally abandoned for centuries, resisted, and cared for the good of the community all along ( Jorge, 2023 ; Camilo et al., 2021 ). Intersectionality “instrumentalizes antiracist movements, feminists and protective instances of human rights to deal with the agendas of black (and racialized) women” for structural changes ( Akotirene, 2019: 37), emancipation and for the overcoming of the operating system.

These analyses focus on realities in which racialized women have been confined since colonialism, shaping subjectivities under harsh living conditions, violences, hunger, and poverty ( Gonzalez, 1982 , 1984 ; Saffioti; Almeida 1995 ; Padovani, 2017 ; Teixeira, 2021 ; Passos, 2023 ). To combat this, all feminisms should be regarded as “non-essentialist and historically contingent discursive practices” ( Brah, 1996: 358), working together to create antiracist feminists’ theories and practices. Intersectionality does not imply reductionism, but rather constitutive reciprocity, within each category ( McClintock, 1995 ). It exposes inequalities, resistances, and possibilities of policy transformation of the territory.

The impossibility of doing Social Science without an analysis of differentiation categories and their intersectionality is proven in various studies ( Padovani, 2017 ). Intersectionality has become essential in Latin America to analyze care in vulnerabilized territories, where most people who provide and receive care, whether through SUS primary health care or through community leaders and care workers, are racialized impoverished women. To overcome the deleterious capitalist system, it is necessary to understand subjectivities within territorial emic dynamics and its historicity. Society needs to admit that racialized women from the favelas exist, not only as victims, but also as protagonists of strong resistance ( Jorge, 2023 ).

Care, emics and ethics in vulnerabilized territories

Care is found in this territory in many facets. In a dialectical sense, care appears in an emic way, that is, one that makes sense to the specific group and, not always understandable through ethical universality, which is not always applicable in this territory. It appears both with emancipatory characteristics and in challenging situations. The category of care, linked to ethics, goes back to the feminist's movement of the 1970s⁹. The importance of the advances¹⁰for women's lives is irrefutable, however, universal, and ethical do not necessarily relate to the local care aspects. Significant criticism along these lines was made by racialized feminists¹¹. They brought other categories when reflecting on care ethics, such as: class, race (ethnicity), territory, colonial history, culture, politics, rights, and environment. The critics made it possible to point out that unpaid or low paid care is mostly performed by racialized women, while white women are relieved to perform better paid work in the labor hierarchy ( Gonzalez, 1982, 1984, , 1984 , 2020 ; Parreñas, 2001 ; Vergès, 2020 ; Teixeira, 2021 ; Passos, 2023) . So, it would not be fair to impose an ‘ethical’ normative interrelationship of care responsibility if racialized women remain at the bottom of the care work responsibility and are not cared for the same way ( Maia, 2009 ; Araujo, 2018 ; Vergès, 2020 ; Guimarães; Hirata, 2021) .

Domestic workers (Saffioti, 1978; Federici, 2013 ; Teixeira, 2021 ) and Migrant domestic workers ( Parreñas, 2001 ; Piscitelli, 2008 ; Vergès, 2020 ), who leave behind their families to do care work for other families in richer neighborhoods or in countries around the world to serve the global economy ( Parreñas, 2001 , Vergès, 2020 ), could not follow the sanitary protocols ( Vergès, 2020 ; Teixeira, 2021 ; Passos, 2023 ). Domestic work puts women in specific subordinate positions, as a category of inquiry into gender, race, class, and other power relations in the global economic transformations also differs among women ( Piscitelli, 2008 ; Parreñas; Boris, 2010 ; Teixeira, 2021 ).

In the pandemic, people who worked for other families (care, housekeepers etc.) or in companies ended up going to work for fear of being fired. There was also a lot of unemployed people. (Potira)

This unequal relationship of who gives, receives, and is paid to care, also includes who has and who doesn't have access to quality care. In countries with a public health system, the “humanization” of care ( Sarti, 2006 ) is discussed in ethical terms ( Palácios, 2019) , opposing the biologisms, the fallacy of objectivity in the biomedical health paradigm and the technological excess, arguing that the “humanization” of care has become a central theme in the field of collective health ( Sarti, 2006) . The “human” in the “humanization” equation does not account for bodies without full citizenship, leaving racialized impoverished bodies out ( Maia, 2009, , Ribeiro, 2018 ; David, 2023 ; Passos, 2023) .

Old bodies are also left out of the care equation (Debert, 2015, 2016). The concern with care, particularly about aging population and the care deficit, the insufficient number of caregivers “to meet a growing amount of dependent elderly” ( Debert; Pulhez, 2019: 5). The racialized women in this territory, solo mothers/grandmothers, who were the family providers for decades, do not have access to care in old age, especially in the pandemic.

We had 4 deaths so far (October 2020). One was a lady who was already sick, had high blood pressure. Three more died of COVID here. There is no one to take care of the elderly because younger people work outside and cannot afford caregivers. (Iracema)

This scenario exposes how inequality in relation to care is present. Intersectionality more than determines care, it also defines who can live and who must die. This illustrates the concept of necropolitics ( Mbembe, 2016 ) and not a matter of option ( Maia, 2009 ). The relationship between care, local and global economy is highlighted in the expansion of professional caregivers and the impacts of care-related public policies as being global phenomena ( Guimarães; Hirata, 2021 ). Care in Latin America has expanded in the last centuries, however “in a context of poorly structured markets, with reliance on domestic workers to provide home care as paid workers in both formal and informal arrangements” ( Guimarães; Hirata, 2021: 241). Care workers are mostly from vulnerabilized territories like this one, still far from having adequate public policies ( Teixeira, 2021 ). The market and global society depend on racialized women, but they have no one to rely on when they get older. Abandonment is an imperative.

Society cannot function without the unpaid (and poorly and informally paid) work of caregivers. Having the data [...] allows public policies to be based on realities rather than on the prejudices, habits, or structural injustices of a previous time about gender roles, class, ethnicity, race, migrant status ( Tronto, 2021: 17).

Although ethics of care and care studies advanced in the last decades, there is a lack of depth in the field of care in vulnerabilized territory. Another deficiency is that studies focus mostly on the fragilities, and not on potent practices. It is also missing a deepening of the primary health care role as one of the few care offerings available, even if precarious. Care produced in this territory, tend to have specific emic dynamic between care practice and tradition, and it may contribute to an effective ethical-political essence, to improve public policies around care provided by SUS, by taking intersectionality and local knowledge as base for structural transformation.

We were there for a long time without a doctor, before and during the beginning of the pandemic. Then only one doctor came. The dentist isn't working because of COVID. (Iracema)

In this condition of state abandonment, women mobilized and cared for the community themselves. The ethical-political care in this study, far from being a normative proposal, suggests the constantly construction, within, against and beyond the State ( Holloway, 2021 ). An “ethical-political issue” is that one cannot speak in the first-person singular of something painfully common to millions of women living in Latin America, like brown, black, and indigenous, “ Amerindian and Amefrican women, subordinated to a Latinity that legitimizes their inferiority” and demands from them constant work, mobilization, and resistance ( Gonzalez, 2020: 140). The emic can enhance ethical-political care.

Taking intersectionality in the reflections of care ethics, is significant to mention that the valuing of care as work and as a universal right, is opposed to the principles of care as a product, promoted by neoliberal ideologies and to the idea that all women are in the same oppression position. In women's lives, especially racialized women in and from Latin America, the moral, financial, and political valuation of care work, removes them from the condition of invisibility, devaluation and towards paid work and real access to rights.

Challenges and fragilities for care

The challenges and fragilities hinder collective ( Merhy, 2006 ; Paim; Almeida-Filho, 2014 ) and humanized ( Sarti, 2006 , Maia, 2009 ) care practices, itineraries, experiences, and subjectivities ( Passos; 2023 ). We observed that several challenges do not relate to a normative ethical care in the territory, aggravated since Constitutional Amendment EC-95 and the revocation of Basic Care Programs, like NASF-AB (Brazil, 2012, 2020c). The cuts from the technical note no. 3/2020-DESF/SAPS/MS, on January 28, 2020, explain how citizens no longer had the right to specialized basic care services, according to the statements of health professionals. Neoliberal- and necropolitics during the COVID-19 worsted the already existing fragilities, since care provided at USFs, daycare, school, community organizations, and churches, had their activities restricted or shut down.

He cut all the budgets (until 2022). Health, education, the areas that need it the most. Why not cut from them (their own paychecks)? (Joênia)

The cuts in social areas during the last neoliberal governments are in the local collective consciousness, on how the situation worsens for the workers, while the governing stratum maintain their privileges. The state negligence appears in this territory in this period (2016-2022), boosting the weakening of care, which slowly changed in 2023 after the political switch and more investment in social areas.

Care in mental health has many challenges. The cases of mental illness increased in the Pandemic. The statements show two types of reaction: the shame of people who suffer violence or mental illness, as well as the hostility of people around the victims.

In my area if you have (depression) it is not openly. [...] Here people are ashamed to say that... It's a lot of people who have it here. (Yara)

This situation evidenced the importance of SUS, CAPS¹²and SUAS¹³capillarity. Most racialized impoverished women here were unemployed during the pandemic peak and overloaded in childcare, since schools were closed, which surcharged their workload and stress. The continuous exposure to stress, several types of violence, absence of effective public policies and lack of prospects, prolonged for years, can culminate in self-extermination ( Passos, 2023 ). There were several cases during the Pandemic and little care action could be done. An aquilombamento ¹⁴in SUS could help prevent it ( David, 2023 ).

I believe that the environment makes people go into depression! The person doesn't have a nice house, doesn't have the support of the parents (nor from the public power), is looking for a job and can't get it, has a kid, and doesn't receive any pension, I think this makes the person sick! (Janaina)

The victims feel they have no way out. There is no freedom of choice, or it is not even a matter of effort and merit, but a socio-political imperative ( Maia, 2009 ; Tamanini et al., 2018 ; Passos; 2023 ). The arrival of COVID-19 exacerbated the existing problems in the pre-Pandemic ( Portela et al., 2020 ). The restrictions in the peak, made it difficult to fight several sufferings.

The heart hurts. We are devastated. Imagine, if Katarina helps everyone who needs food. Once we went to a woman's house. The house had no door. The girl is alone. They steal her things, and she says: “I can only do cleaning work, or we eat or”... it hurts, and we can't do anything. We don't have the support of the City Hall to solve this problem! (Tainara)

Hunger seems deployed in the interest of subordination to maintain the hierarchy of class, race, and gender in the social spectrum and exploitation through non or low wages of racialized impoverished women. Racialized women and their families in this territory are condemned to generations of poverty and subjected to aggravated conditions of violence, humiliation, suffering, sickness, and death. Care, in the fight against hunger during the pandemic, was reduced to assistencialism through basic food hamper acquisition, soup kitchens and donations, with absence of public power. Collective mobilization, “because every black woman is a quilombo ” solved some challenges ( Dealdina, 2021: 20).

During the Pandemic the situation of unemployment among women increased and so did illnesses ( Marques et al., 2020 ). Illness is directly linked to living conditions far under the standards established as human basic rights, demonstrating once again the governance necropolitics. It was impossible to follow sanitary protocols due to this living situation. The restricted resolvability that care has under certain conditions, challenging the ethical-political core, is shown below.

For a while people tried to stay at home, but it's bad when you have no space, no window, no space to breathe […]. A lot of mosquitoes […]. Not everyone has access to the internet even with a cell phone. People go in front of the Salvation Army for the wi-fi and crowd together. (Potira).

Everything interferes with health, life conditions. The person who lives there, on the stilts, the tide fills the shack where people live (…), the rats go into the house. (Ana)

The greatest challenges for ethical-political care in this territory are the different types of violence, arising from slavery and patriarchal inheritance, in the intersectionality avenues of Coloniality, regarding gender, race, and class ( Akotirene, 2019 ; Gonzalez, 2020 ,1984; Davis, 2016 ; Padovani, 2017 ; Passos, 2023 ). Although criminalized by Law 7.716/1989 (Brazil, 1989), including the 2010 and 2012 amendments, racial violence persists in the territory affecting daily life. One form of structural violence present is against black children and youth, committed by public security agents and militias. In one year, 35,783 youths were murdered in Brazil, a record rate in the last ten years (Brazil, 2023). At this very moment, Operation Shield ( Hailer, 2023 ) is taking place in this region, which has cost the lives of dozens of young, racialized people and one security agent.

The problem is when the police come, okay? The police came and shot them. The kids ran like crazy. (Iracema)

Structural violent racism affects the women here, mothers of the chased or killed victims, leaving them torn apart, as May Mothers¹⁵: mothers who lost their children to State violence, like the mothers from Plaza de Mayo in Argentina ( Hailer, 2023 ). The subjectivation of racialized women from vulnerabilized territories is traversed by violence as a strategy of coloniality ( Passos, 2023 ). Strategies of aquilombamento ( David, 2023 ), with attentive care ( Passos, 2023 ) towards may mothers and families of victims, that understand the historicity, the intersectionality and the emic dynamic of the territory might strengthen subjectivities. Uniform cameras and anti-racist education of security officers may reduce this practice. The decriminalization of cannabis commerce and the youth emancipatory education may transform the violence-incarceration-death-cycle.

The cases of domestic violence have suddenly increased in the Pandemic (Marques et al ., 2020; Passos, 2023 ), corroborating the United Nations data ( ONU Mulheres, 2020 ). In this territory care became ineffective in situations described by leaders and CHWs.

Some cases of domestic violence last for many years and cause such unbearable suffering that they lead women, including mothers, to self-extermination. Women get tired of getting hit, some take medicine, and we say, “we know why you took medicine to kill yourself because of your husband.” We had an employee. She was getting beaten up with a belt. He told her to take her clothes off and she took them off. She never told us. She washed the dishes and cried. (Iracema)

Victims of domestic violence, in abusive relationships, are silenced and economically depended. This process makes interventions difficult, also aggravated with religious patriarchal morality of women’s subordinated role. Victims feel ashamed and blamed.

And we say, “Mom, why didn't you ask for help?”, “Oh, aunt, I'm ashamed, I didn't want to expose myself”. So, there are many, many cases here. (Iracema)

Ethical-political care requires specialized attention from various state agencies, in an intersectoral way ( Paim; Almeida-Filho, 2014 ), which this territory doesn’t have, especially during the restrictions and overload in the COVID-19 peak. USF prioritized COVID-19 patients and pregnant women. There is no women’s police station or shelter home. Violence against children, and pedophilia was a major challenge. The closing of schools in the pandemic, left children permanently with their aggressors. Leaders and CHWs felt powerless.

There is a lot of pedophilias in this neighborhood! I see several that I can't even imagine. Then I think: I won't get involved? But I can't do anything!" (Yara)

One place that opened was a community-based organization that received children, so the mothers could work, and the children could be far from their step/fathers/aggressors.

I went to teach children (in the pandemic), because the mothers, perhaps because they did not feel prepared to help with school activities, were taking it out in a violent way […]. (Potira)

The boy arrived here with bruises on his body [...]. One day he came here purple because he was playing with his little sister, and then he stepped on her foot, and then his stepfather beat him up. Then I said “Oh my God in heaven, I can't let you...” But at the same time, I told the boy that I wouldn't tell anyone. (Iracema)

Feminicide and homicide here are part of the patriarchal culture, based in parallel justice of drug trade. The practice “in a quarrel between husband and wife, I will put the spoon in before death do them part”¹⁶( Rufino, 2019: 205) does not always work. Care struggles with impotence in the face of feminicide and experiencing the murder of women and adolescent girls is very painful.

Young, she was 16 years old. And then he passed, pulling her hair, and he would tell her to "stop shouting" and she would say "don't kill me, let me raise my daughter". They took her. When it was night, he came to the family house and said, "it's over". He killed her, killed the other guy, and buried them both together. And this girl's body that we asked for? No, he won't deliver her body. And the daughter doesn't know until today. He raised the girl. She is 10 years old and doesn't know who killed her mother. What was said to her is that the mother is disappeared. [...] It was the father. [...] Just yesterday, that I was going to school, she was coming, "Hi, aunt". And then I talk to God, "God, she will find out someday, because they will tell her what happened". Because she idolizes this father... Father's Day here and she said: "Aunt, I want to make a special present to take to my father". Oh there, that hurt. And we must make a present for her to give to that father that we knew what he had done with her mother. And we have her picture there. (Iracema)

This elimination of girls and women, already subjected to living conditions that have been conferred on them since colonialism, demonstrates topographies of cruel patriarchalism, racism and capitalism in this territory. Raping and killing appear as naturalized, taking the lives of impoverished racialized girls at such an early age. Life seems to have very little value, certainly linked to historical violent practices ( Saffioti; Almeida, 1995 ) and state neglect ( Holloway, 2021 ). The control of the territory by parallel power happens due to the absence of public equipment and the better life opportunities.

Since the beginning of the Pandemic and the increase in violence against women, elderly, children, people with disabilities, LGBTQIAP+, government institutions approved Law 14,022 on July 8, 2020¹⁷(Brazil, 2020a). It can be seen as ethical-political care measures: the registration of domestic violence occurrences, done electronically or through a phone number, the procedural deadlines, the examination of matters, the service to the parties, and the granting of protective measures. In sexual crimes cases, if there is the adoption of measures by the public authorities that restrict the movement of people, the security agencies must establish mobile teams for the corpus delicti exam in the location where the victim is. Due to emic dynamics, the law of silence imposed by drug leaders, who are afraid of State violence themselves, it’s not allowed for victims to reach or be reached public security equipment. In some cases, the young people themselves are the 'drug court' and judge the 'crimes', deciding the 'penalty' to be carried out, which can vary: a 'warning' (threat), physical torture or the death of the alleged 'offender'.

Caring for teenage pregnancies is another challenge. Abortion, done in a precarious manner, represents a serious problem for public health, with greater incidence in countries of the southern cone, being one of the main causes of maternal mortality ( Coelho, 2019 ). Impoverished racialized girls/women are the main victims of maternal mortality and femicide, since they can’t afford private clinics or find any public shelter ( Ribeiro, 2018 ).

It's in these events you get pregnant a lot. And there are those that do abortions. The teenagers who should be active are the ones who are doing so much more foolishness (Jacira)

Due to the criminalization of abortion, girls either abort at home with tools such as knitting needles, self-medication or are forced to complete their pregnancy, becoming mothers at an early age, and are still children themselves. Care, in these cases, need to reach a bigger spectrum than the USF and be approached in schools, with sexual and preventive education. Decriminalization of abortion is a measure to protect the lives of impoverished girls. There’s a high frequency of these occurrences.

Trafficking includes very advanced sexuality. If you enter a party (funk) you see girls having sex openly. [...] Syphilis... [...] Inês got pregnant at 13. [...] Inara at 13. (Iracema)

Community leaders and SUS health professionals find it difficult to deal with violence, advanced sexualization, diseases, rapes, early pregnancies, and feminicide. In Brazil occurs 164 rapes per day, over 500,000 per year (under-reported); 13 feminicides per day, 4,936 in one year, by which black impoverished women are most affected (Brazil, 2023). There was a complete abandonment of the youth and their mothers with the restrictions or absence of public during the pandemic in this territory. The study showed there’s a need of a wide politization for the improvement in all fronts of care: public health, social assistance, education, housing, sanitation, leisure, security, and built together with the social control, community, and councils. COVID-19 has highlighted the importance of the public service in caring for the historically and socially vulnerabilized population. Reparations should centralize in a full spectrum of care as emic-ethical-political.

Potentialities in care and emic-ethical-political relations

Ethical-political care presupposes rights of the people to potentialize public, effective, humanized care ( Sarti, 2006 ), which transforms unequal structures and meets what is recommended by SUS principles and the Constitution of 1988 ( Paim; Almeida-Filho, 2014 ). Intersectionality and emic dynamics must be taken in account in these territories, because racialized women resist State neglect and create efficient forms of care. The potentialities observed here are strong bonds, intersubjectivity, collective articulations and actions against, within, and beyond the State, public policies, and efforts to overcome social vulnerabilization. With the sanitary crisis arrival, the social situation aggravated severely. Yet the access to truthful scientific information about collective health, brought fast adaptations and protection.

We felt the vigilance of the community itself. People ask: 'where's your mask?' […] Especially those who have had or lost a friend because of COVID-19. People no longer look strangely at those with a mask. Some don't wear it because of discomfort or ignorance. People repeat Bolsonaro’s rumors: “oh I already had it, so I don't need to wear a mask anymore” (the supposed herd immunity). Public agencies should educate that even those who have already had it, must continue wearing a mask. But there is the problem of how are you going to comply with health security then, with this misgovernment that gives us so many untruths? (Potira)

Community leaders highlighted the importance of making the population aware of the risks to which they are exposed (not only COVID-19, but also), due to the presence of heavy metal waste disposal dumps by companies, that degrade the environment, affecting life. (Field diary).

[...] to know about our rights as well, [...] mainly in health and education [...] which is what a community needs most. (Jacira)

COVID-19 updates the discussion of power strategies by disseminating narratives of scientific negationism and post-truth (fake news), contributing to the spread of the disease and increase in deaths throughout Brazil ( Lima et al., 2020 ). For collective healthcare, truthful information based on science provides effective tools, as the above-mentioned situation and vaccination campaigns, which potentiates care ( Teixeira et al., 2022 ).

You're getting vaccinated, because there was a group of people who got sick, passed through that hospital, that made a survey, that took to the health ministry, that provided it. (Jacira)

Not only negationism but also the emergency income aid, the lack of health campaigns by the federal, state, and municipal government (2019-2022) in the COVID-19 Pandemic peak and the delay in purchasing vaccines contributed to the fast spreading of the disease and increase in deaths in this territory, as necropolitical actions ( Mbembe, 2016 ). Despite the challenges in relation to care provided by health professionals and the neoliberal dismantling of public health between 2016 and 2022, there is the recognition of SUS' importance, both by community leaders and health professionals, corroborating the notion of ethical-political care ( Maia, 2009 ; Palácios, 2019 ; Gonzalez, 2020) . It reinforces the pedagogical relevance of the family health and the need for continuing education ( Paim; Almeida-Filho, 2014 ; Teixeira et al., 2022) . The universal care must reach people in their specificities, diversities, different ages, considering intersectionality and the emic dynamic.

Ana, presented the axis and highlighted the importance of making the population aware of the Family Health service, emphasizing the health education factor and the groups that participate in the service. Equity in service, each case is a case. (Workshop DiverSUS)

The consciousness of ethical-political care raises awareness both among community leaders and SUS professionals, about the relevance of the emic dynamic and the intersectionality of class, race, and gender towards a decolonial emancipation, based on Paulo Freire, Frantz Fanon, and the local knowledge ( Walsh, 2017 ). The political and structural transformation in the territory that permeates care, should be implemented in full spectrum: education, psychology, social assistance, housing, sanitation, leisure, environment, thru policies that overcome all inequities. Community leaders and CHWs demonstrate awareness of the emic-ethical-political care process and present concrete proposals.

This is not a simple “plim!” thing. Legislation, law, rule, what we must [...] talk to the city hall. Let's make [...] a leisure area in front of the community, there's a bike path, it can be a sport side [...], let's legalize a point there with signs on the highway saying: look, you crab [...] people will stop, buy, see the green area, and ask: "can you bring another one? We can do fishing program, sightseeing, and other activities. (Jacira)

To carry out care actions in everyday life, the mobilization of racialized women who have historically resisted is attentive to daily events. Black women efforts explained by Gonzalez (2020) go back to our ancestors, where quilombola ¹⁸women participated in the fight against military expeditions aimed at their destruction, never failing to educate our children in the anti-slavery, anti-colonialism, and anti-racist spirit.

Yesterday I was talking to a woman from our street, we are forming a commission to go to the drug leaders to talk to them about the funk dance that they are doing here. (Iracema)

Sexuality, early pregnancies, spreading of diseases and violence are challenges observed in the funk dances held even during the Pandemic peak. Young black impoverished girls were among the majority affected by it. During the Pandemic, the women in the territory created a network, thru WhatsApp group, to exchange information, such as assistance centers, guardianship councils or women's police stations, emergency financial aid and numbers, encouraging each other to use the law/State. Awareness of their rights and how to access public equipment, helps the efficiency of ethical-political care, for themselves and their children under violence. The nuances are not always covered by the law, so they act beyond it and within the state, according to the emic demand in given circumstances.

Nilce called and said that her father is mistreating her, in private incarceration. We activated the Guardianship Council, which was Sofia. Sofia went to the house, took the girl, put her in the shelter, now the mother contacted us "see if the major can pick her up and take her to the airport to go to Fortaleza". But the major is not here. At this point we pass to the girls (public equipment) to see what they can do. (Iracema)

The collective articulation strengthens the care, also by combating gender and race-based violence. Although the community organization was used during the Pandemic, more public equipment for children is necessary, such as day and night care centers, school all day long, and spaces for leisure. Violent situations, aggravated during the Pandemic. Community leaders and CHWs, by living in the territory, getting to know women, their stories, can provide better care. There is a need for anti-patriarchal, anti-violence, and sexual education in all caregiving routes, for all generations, so boys' and men's awareness can coexist in respectful and non-violent ways. Expansion in the care offered by CAPS and CAPSi, assistance by SUAS, women’s police stations and shelter homes should help the process. These actions may enable women emancipation from this life condition.

Then we went and made sure she denounced. She reported it, he was taken out of the house by the police... Today she's fine, working here with us. (Iracema)

From the perspective of housing, the racialized impoverished women’s articulation in the past began the occupation of the territory, and local urbanization, in an emic-ethical-political care essence. They mobilized the mayor's participation and used political paths, strengthening the awareness of their rights. As a quilombola inheritance, black women motivated their communities “to revolt, flee and form quilombos ” ( Gonzalez, 2020: 198), the process of aquilombamento ( David, 2023) .

She said that when she came here everything [...] was an area of invasion, everything was bush! [...] A group of women got together and closed the old track [...] and the mayor of the time began to supply cars with landfills and made the urbanization. (Iracema)

The potentiality of the women's interventions for structural changes is multisectoral. The interaction researcher-collaborator drives transformations with Latin and decolonial roots. Decoloniality aims to expand the sciences centered only on Northern knowledge (Europe and the USA) ( Quijano, 2007 ). The university exchanges valuable knowledge with the community, learning the local dynamics ( Walsh, 2017) and mediating critically within, against and beyond the state ( Holloway, 2021) .

Oh, I liked it because we can express our point of view too, [...] we weren't understood and we can talk and this helps our performance at work, so it was good, very interesting [...]. Thing is that a psychologist here at the university can come, we bring the people and yourselves, develop this activity [...] we end up using you, as support that we should receive from the city. (Tainara)

From a decolonial point of view, knowledge can coexist ( Walsh, 2017 ; Gomes, 2017 ). The USF, in this territory, despite difficulties, configures a propelling space of politicized care, towards an emic-ethical-political core:

And we thank God because, even with so much difficulty, we have a USF in here. (Iracema)

Health professionals value deeply the importance of capillarity and teamwork, performed by all Primary Care professionals, in the search for care integrality. By considering the knowledge and practices of the territory, the understanding of care is broadened and approaches structural improvements to strengthen its emic-ethical-political essence. Care, built collectively with the population, awakens consciousness of the still present patterns of colonial power and the way everyone is involved ( Santos, 1997 ; Walsh, 2017 ; Padovani, 2017 ; Akotirene, 2019 ). Primary care must build a horizontal dialog with the population ( Teixeira et al., 2022 ).

The family physician […] reinforced the idea that it is necessary to remove the medical-centered vision, valuing other professionals, because only in this way will it be possible to provide an integral service to the population. (Workshop DiverSUS2)

In Care Ethics, neoliberal capitalism could be seen as a machine of irresponsibility that drives and reproduces privilege for white rich men, with its hegemonic discourse ( Tronto, 2013 ). This study showed that responsibility for care falls on racialized impoverished women, faced with a public apparatus, that neglected the territories during the pandemic. The understanding of care ethics emerged from this study goes beyond the ‘responsibility’ and move towards a functioning emic and ethical political construction of care, built with the racialized women from these territories, based on paid work and real access to rights.

The people, getting to know our rights, [...] helps a lot. Especially in health, education, which is what a community needs most. (Jacira)

The epistemes, arising from years fighting for this territory, relate to public policies in a challenging and potentiating way. This accumulation of knowledge concerning care, can be an instrument to evaluate and criticize the effectiveness of public policies, especially during and after Pandemic times. Women are aware of the intersectional position to which they are relegated and attentive of their history, resistance, rights, potential, in the search for emancipation, emic-ethical-political care and structural changes. They know the demands and the ways to operationalize it.

It is necessary to invest in popular education and break with the policies of favor (clientelism). [...] The community must know its rights and its duties. (Jasmin)

We must see, legislation, what we must do, for this community. See what is best for us. (Jacira)

The study demonstrates that the broad politicization of care is efficient when it is collective, with critical social participation, social control, councils, community, social movements, organizations, articulated leaders, and state agencies that approach intersectionality and the emic dynamics. Understanding the role of racialized women in this territory is vital to break with the forces that historically places them at the bottom of the social pyramid, in invisible, unpaid, or precariously paid care work relations, and not benefiting from quality public or private care in a full spectrum. This process would improve if there were more public investment in vulnerabilized territories ( Akerman, 2005 ; Merhy, 2006 ; Teixeira et al., 2022 ).

Final considerations at this point

The prism of differentiation highlights that academic production is inescapably woven by intersecting categories ( Padovani, 2016 ). The aim of understanding care, before, during and after the COVID-19 pandemic in a socially vulnerabilized territory, using the analytical categories: intersectionality, ethics of care, and the emic dynamics, was elaborated in this study. The results raised the challenges and potentialities of care, as well as the importance of politicizing care. The challenges expose the inefficiencies due to the lack of investment in public policies and equipment, the reproduction of several violent practices, depletion, and impossibility to fulfill the social isolation, determining life and death. The potentialities highlight effective forms of care beyond, against, within, the State, thru the RSG, emancipating, and provoking structural transformations in the territory, in an emic-ethical-political way.

Especially in the Latin American context, in vulnerable territories, debates in the field of public health must consider not only the dynamics of the territory, but also recognize the protagonism of racialized women in the construction of care. The urgency to face the colonial legacies is perceptible in Brazil, extremely unequal, not only socioeconomically, but racially and in gender issues. Reparation is urgent. Racial privilege is one of the key points to improve the ethic of care, as it highlights how, the white group has been the beneficiary of the exploitation of racial socially excluded groups in the capitalist system, and it was the racialized housemaid who enabled the emancipation of the white employer, the female boss, from the double shift system, since care is essential for the reproduction of life ( Gonzalez, 2020 ; Teixeira, 2021 ; hooks, 2022a; Jorge, 2023 ). It is time for men to take over care for the maintenance of life. We need time, moreover, being overloaded female working class, to “think, write, dream and live beyond race” (hooks, 2022b:302).

Intersectionality linked with care ethics, critically demonstrate a relevant understanding of care modus operandi in socially vulnerabilized territories, considering the plurality, and unveiling that humanized-universal care do not always reach these realities. It opens towards possibilities to approach care, that enables racialized people to survive amid state negligence, and to contribute for the improvement of the RGS and public policies, thru the expansion and politization of care, as an “ethical-political issue”, collectively and locally constructed, potentiating intersubjectivity ( Gonzalez, 2020: 140).

The study shows a difficult relationship with the State, at times violent, other times negligent, and sometimes the only provider of any kind of care assistance, even in need of improvement. It reinforces that the capitalist system is the original cause of crises in society, due to its predatory hurtful feature, perpetuating class, gender, racial oppression, vulnerabilization and violence ( Coelho; Wolff, 2020 ; Gomes, 2017 ). The world was confronted with changes in relation to care in the pandemic. Neoliberal projects of social austerity fell to the ground. Collective health, public care and equipment became explicit essential pillars of society, with necessity of investments in the tripod (social security, assistance, and public health) and in the expansion of public equipment, with efficient articulation and control by the population compromised with transformation, care politicization, permanent education, and the federal university presence. The various instances of care, by rethinking through intersectionality and the emic dynamic may effectively expand public policies, that reach these territories. Structural transformations of care must include a dialectical historicity, which implies a commitment to the emancipation of impoverished racialized subjectivities, the uncompromising defense of human rights, democracy, and full citizenship, in an emic-ethical-related approach.

National and international studies encourage research that enables social transformations based on the concrete reality of people, highlighting participatory methodologies as an important tool for understanding contexts, producing knowledge, and revealing subjects ( Saffioti, 2015 ). The contribution of this study to care ethics, is also to reveal how racialized impoverished women are fundamental for improving the politicization of care, corroborating the leading role and wisdom in the maintenance of the society in all care fronts, including the economical and the reproduction of life. Valuing care work and rights, as workers and users of SUS, must be priority on the agenda of political decisions and racialized women must compose the spaces of knowledge, education, power, and political decision-making.

Another contribution is the expansion in the scope of care ethics to socially vulnerabilized territories. With all the complexity of those contexts, the results may help care scientists understand that the recent relational circumstances of care, propagated in care ethics studies, the inequity in care, through the intersectionality lens. Furthermore, to motivate scientists and society to produce science and policies, by which racialized impoverished women are beneficiaries of quality and ethical-political care, be better paid, receive decent working rights and rights to retirement from care work. Committing to democracy, working women should have a vital interest “in the fight for socialism. […] This strategy calls into question the validity of monopoly capitalism” ( Davis, 2016: 244) and the politization of care work, material and moral as well. Politicization of care is historically essential ( Merhy, 2006 ; Paim; Almeida-Filho, 2014 ).

COVID-19 associated with state negligence, neoliberalism and necropolitics intensified the syndemic, caused an increase in suffering, vulnerabilization, violence, cases of mental illness and deaths (Lole; Stampa; Gomes, 2020; Teixeira et al., 2022 ). Considering this overview, it is essential to rethink the investments on the full spectrum of care, the strengthening of primary health care and the family health strategy, SUS, before, during and after Pandemic experiences. SUS is a revolutionary reform in defense of life ( Narvai, 2022 ). This study contributes to recover and advance strategies about the role of PHC in the society, solidifying its principles, such as universality, equity, social control, integrality, and intersectorality, but also, in a dialectical way, considering the emic dynamic and locally produced wisdom of racialized impoverished women.

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• 1
  Socially Vulnerabilized Territories as in the article “Meanings of Neglected Diseases in the Global Health agenda: the place of populations and territories” ( Oliveira, 2018 ).
• 2
  Racialized as explained by Davis in the preface to Ferdinand (2022) .
• 3
  Ethics involves the systematization of moral concepts of right and wrong for humanity, as an attempt to universalize actions and human rights and the needs for a dignified life on a political level, such as health, food, housing, education, work, and access to it ( Maia, 2009 ; Palácios, 2019 ).
• 4
  Emic, are standards of actions, right and wrong, that prescribe what people of a certain group and territory ought to do, that makes sense to the local collectivity ( Santos, 1997 ; Akerman, 2005 ) and its subjectivities, experiences and demands, at micropolitical level ( David, 2023 ; Passos, 2023 ).
• 5
  In Necropolitics “[...] killing or letting life constitute [...], is to exercise control over mortality and to define life as the deployment of power.” ( Mbembe, 2016: 123).
• 6
  The data used is an unfolding of three research developed in the Laboratory of Social Inequalities (LEDS), from 2017 to 2023, approved by the Research Ethics Committee (REC) of UNIFESP, according to the ruling n. 2.047.444 and financed respectively by the National Council for Scientific and Technological Development (CNPq), n. 407836/2016-0, n. 140062/2021-1 and CAPES 8882.430741/2019-01.
• 7
  The Paulista Index of Social Vulnerability (IPVS – Índice Paulista de Vulnerabilidade Social ) is a typology that classifies the census sectors in the municipalities of São Paulo State into social vulnerability groups [ http://www.iprs.seade.gov.br/ipvs2010 – access: July 2023].
• 8
  In the 1970s and 1980s research addressed gender, race, and class in Brazil, even though they did not use the term intersectionality ( Gonzalez, 1982 , 1984 ; Saffioti; Almeida, 1995 ). In the legal erasure of racialized women, the category “intersectionality” was first coined in the USA, enhancing the intersection of the categories, that made it possible to capture the institutional racism structuring the state apparatuses and capitalism itself ( Crenshaw, 1989 ). The root is allocated in black feminism ( Crenshaw, 1989 ; Piscitelli, 2008 ; Collins, 2012 ; Moutinho, 2014 ; Davis, 2016 ; Padovani, 2017 ; Akotirene, 2019 ), as an analytical sensibility, whose experiences were unobserved by both white feminism and the anti-racist movement (black male men) ( Akotirene, 2019 ).
• 9
  Care studies date back at least fifty years in the Anglo-Saxon world ( Gilligan, 1982 ; Moller-Okin, [1989 ] 2008; Tronto, 1993 , 2013 , 2021 ; Noddings, 1986 ; Parreñas, 2001 , 2010, 2021 ; Keller; Kittay, 2017 , among others). Short after, care studies have sparked growing interest in Central and South America with Borgeaud-Garciandia, Guimarães and Hirata (2000), Sarti (2006) , Guimarães, Hirata and Sugita (2011), Arango Gaviria and Molinier (2011) , Hirata and Guimarães (2012) , Federici (2013) , Debert and Oliveira (2015) , Kuhnen (2015) , Debert (2016) , Hirata and Debert (2016) , Araújo (2018) , Debert and Pulhez (2019) , Teixeira (2021) , Guimarães and Hirata (2021) and others.
• 10
  Historically, in a patriarchal context, it was recognized that women have a “different voice” from men, taken as universal moral, so that women have a different way of solving moral dilemmas, based on ethics of care, grounded in unique relational experiences ( Gilligan, 1982 ). So, care agenda proposed the debate on “public” versus “domestic”, the inequalities that affect women and the false dichotomy of care and justice ( Moller-Okin, 1989 ). Later, the unequal sex division of care and its devaluation was studied ( Tronto, 1993 ), then care was a principle of vulnerability, a web that we depend on to exist, placing care on the central political agenda in the Democracy, a Democratic Care ( Tronto, 2013 ). Theorists in the global north, when stating that care is significant for society, questioned the relation between women and men to understand the ethics, the invisible and unpaid work women have been doing for humanity for centuries ( Gilligan, 1982 ; Noddings, 1986 ; Moller-Okin, [1989 ]2008; Tronto, 1993 ; Molinier, 2005 , Paperman, 2005 ).
• 11
  hooks (2000) , Collins (1991) , Parreñas (2001) , Maia, (2009) , Tamanini et al (2018), Araújo (2018) , Debert; Pulhez (2019) , Guimarães; Hirata (2000, 2021), Teixeira (2021) , Passos (2023) and many others.
• 12
  CAPS- Psychosocial Care Centers and CAPSi- Children's Psychosocial Care Centers.
• 13
  SUAS- Unified System of Social Assistance.
• 14
  Collective resistance in institutions, racial literacy, disestablishment of racism and other oppressions, reparation to a dignified life and spaces, where people feel belonging and welcomed, however they are.
• 15
  The May Mothers movement in Brazil is a network of mothers, family members and friends of State violence victims located in São Paulo, especially in the capital and Baixada Santista Metropolitan Region.
• 16
  “Em briga de marido e mulher, eu vou sim meter a colher antes que a morte os separe” ( Rufino, 2019) . It means intervening and separating the conflict before the woman is killed.
• 17
  Law 14,022 of July 8, 2020, amends Law 13,979 of February 6, 2020, provides for measures to confront domestic violence [ http://www.planalto.gov.br/ccivil_03/_ato2019-2022/2020/lei/L14022.htm - access: July 2023].
• 18
  Quilombolas are inhabitants of Quilombos , which are remote territories in the forests, with communities created by conscious people who resisted and ran away from enslavement brutality, both in the Casas Grandes (big houses of the enslaved owners) and in the Senzalas (slave quarters), as well as from forced labor on plantations (monocultures) and other places. After fleeing, they built shelters and cultivated societies for the common good and a more dignified life.

Publication Dates

• Publication in this collection
  15 Jan 2024
• Date of issue
  Sep-Dec 2023

History

• Received
  10 Oct 2022
• Accepted
  03 Oct 2023