Beyond Institutional Racism? An analysis of the content of the Black Population Health Policy

The concept of Institutional Racism (IR) gained emphasis in the late 1990s and the 2000s. It became one of the central terms in the discussion on racism and the Black Population Health. In Brazil, this category hegemon-ically influences the understanding of racism in health studies and debates. This qualitative case study paper analyzes the incorporation of the IR concept in Brazil in implementing the National Comprehensive Health Policy for the Black Population. Government documents from the Ministry of Health and the Institute of Applied Economic Research were analyzed. Although the formal inclusion of the discussion about IR in the public policy agenda in the early 21st century is a great achievement, apprehending this fact in isolation disregards the dialectical interaction between individual, institutional, and structural forms in the racialization dehumanizing process. Thus, combating IR depends on facing the reasons that lead institutions to reproduce racism and its consequences on access to housing, work, education, and health services and actions.


Introduction
Institutional Racism (IR) gained emphasis in the late 1990s and the 2000s, thus becoming one of the central terms in the discussion on racism and the Health of the Black Population 1 .In Brazil, the IR category has a hegemonic influence on understanding racism in health studies and debates [1][2][3][4] , reflected in the content of the National Comprehensive Health Policy for the Black Population (PNSIPN).
Conducting a critical analysis of concepts becomes fundamental when understanding that these represent and translate reality and that both are in constant transformation 5 .In the field of public policy analysis, the content is delimited around the problems it intends to modify.Thus, it concerns its programs, projects, actions, objectives, goals, internal and external coherence, and political and social perspectives 6 .
Understanding such importance, the question arises about the ability to apprehend the existing reality in the concepts used to direct Health Policies' content in the Unified Health System (SUS) context.In government texts, in Brazil, IR is understood as the systematic production of ethnic-racial segregation within institutions 7 or, in a more recent version of the PNSIPN, this conception is reiterated and equated with that of Structural Racism, but without deepening between the particularities of this concept and the content expressed in the previous version 8 .
The texts that present the PNSIPN indicate the creation of programs to identify discriminatory practices and sensitize professionals as the main strategies to combat IR 7,8 .
Regarding the milestones that underlie the process of implementing the policy, in 2004, the document "National Health Policy for the Black Population: a Matter of Equity" was endorsed by the signature of a term of commitment by SEPPIR (Special Secretariat for Racial Equality Promotion Policies) and the Ministry of Health, during the First National Seminar on Health of the Black Population.In 2005 and 2006, several seminars and technical meetings culminated in the approval of the "National Policy for the Comprehensive Health of the Black Population" by the National Health Council in 2006.However, the policy was enacted by Ordinance Nº 992, of May  13, 2009, only in 2009 9,10 .
Combating IR is one of the objectives of the PNSIPN.Its hallmark is the recognition of racism, racial inequalities, and IR as social determinants of living conditions and the health-disease process.Furthermore, it is based on the elimination of inequalities and the promotion of equity in health.
During the legitimization of the policy in the sphere of the health system, despite advances, it appears 11 that the proposals made were insufficient to guarantee the Black population the universal right to health equitably: their health condition and illness were not even equated with that of the non-Black population, even after establishing the SUS and a decade after the enactment of the policy.
Data on morbidity and mortality available in the Health Information Systems and reports produced by the Institute of Applied Economic Research (IPEA) point to a non-reduction in racial inequalities in the promising economic period experienced in the country between the first and second decades of the 21 st century [11][12][13] .
When faced with the Black population's situation of life, health, and illness, even after the enactment of a specific health policy for their needs, the question arises about the potential of the content chosen to direct the actions of the policy, more specifically on IR, as a guide for transforming the existing setting.Although it is widely used in Brazilian literature, there is littleor even unpublished -criticism regarding its origin, development, and limitations for eradicating racial inequalities.
This paper aims to analyze the incorporation of the IR concept in Brazil in implementing the PNSIPN.We will briefly provide a historical background of the IR conception and its apprehension in Brazil within the PNSIPN.Then, we will present some criticisms already formulated for the concept.Finally, we will analyze the relationship between the IR particularities and the broader racialization dynamics in the Capitalist Production Mode.

Methods
The present qualitative case study paper is nested in a master's dissertation 14 .The Comprehensive Policy Analysis model 6,15 was adopted to construct this work and research on the PNSIPN.This analysis model aimed to investigate public policies and focuses on the content, context, process, and stakeholders involved in policy implementation.
Historical and Dialectical Materialism was employed as a method for the research and analysis of the results.Although it derives from a structured study based on the Comprehensive Policy Analysis Model 6,15 , this paper will concentrate on the content category, essentially the IR concept in PNSIPN-related documents and studies.
The research project was also submitted for analysis and approved by the Research Ethics Committee of the Research Center Aggeu Magalhães/Fiocruz Pernambuco, under Opinion Nº 3.559.717.

The PNSIPN content: emphasizing the fight against institutional racism
In the Comprehensive Policy Analysis Model 6 , analyzing the content of a policy concerns its initial situation, programs, projects, actions, objectives, goals, desired situation, resources, and, finally, its internal and external coherence and political and social perspectives.
Formulated as a policy that aims to promote the comprehensive health of the Black population by curbing ethnic-racial inequalities and fighting against racism and discrimination in institutions, the PNSIPN's first management strategy 7 is confronting IR.IR is found in most documents and planning instruments that address the PNSIPN.
The origins of the "IR" term refer to the book Black Power: the politics of Liberation in America, written by Kwame Ture -formerly called Stokely Carmichael -and Charles Hamilton 16 .At the heart of the fight against racial segregation in the United States of America, the Black Power movement denounces the use of institutions in segregating, persecuting, and murdering the North American Black population in the materialization of this book.The authors argue that IR differs from individual racism by operationalizing, in a less obvious way, the oppression of white American elites through State institutions, which doom Black people to living conditions similar to those of subjugated people in colonized countries.
From its origins in the antiracist struggle in the U.S., IR was also widely debated in England in arenas such as universities, the judiciary, and the press, especially in events involving arbitrary police action against the diasporic population from Africa, South Asia, and the Caribbean 17,18 .
An emblematic fact influenced the understanding of racism in developing Brazilian public policies.Judge William Macpherson used the concept of IR to support the legal report presented in 1999 in the case of the murder of Stephen Lawrence, who, together with another young black man, Duwayne Brooks, was attacked by five young white men in 1993 [17][18][19] .
In this report, the concept of IR no longer had the same semantics applied in the North American context of the 1960s.In the cited example, the term incorporates the accountability of institutions, permeated by racism but apparently alien to its relationship with the State and the actions of individuals.
Accordingly, Sampaio 19 reports that although the term has been developed in England since the 1960s, from 1993 onwards, this conception has been understood by institutions that confront racism as "a collective failure of an organization" -as enunciated by the Commission for Racial Equality (CRE).
According to Stuart Hall 18 , despite the advances -including in understanding the everyday racism perpetuated in England -given its generalization, the IR term in the judicial inquiry generates in critics of the reports a feeling of impunity towards individuals who engage in racist or discriminatory actions.
During the transition from the 20 th to the 21 st century, the IR concept gained space in health studies as an interpretive possibility for the effects of racism.This conceptual application is largely inspired by attempts to confront racism in institutions in the USA 20 , Canada 21 , Australia 22 , and England 23 .
In Brazil, during the 1980s, 1990s, and 2000s, the action of Black movements vis-à-vis the State acquired new contours.Besides the direct claim, an institutional action occurred through some of its members' occupation of government secretariats and councils at municipal, state, and federal levels 24,25 .
In the sphere of health policies, preceding the construction and formulation of the PNSIPN, we should underscore the Black Women Movement's 26 leading role during the Brazilian Health Reform, the fight for reproductive rights, and the creation of the SUS 27 .
Subsequently, this movement joined forces with SEPPIR, the Health Councils, and the Ministry of Health, which was decisive for the emergence of the PNSIPN, quoting examples such as Luiza Barros -who became the SEPPIR Minister -, Jurema Werneck, Maria Inês Barbosa, Fernanda Lopes -the last two holders of doctoral theses of great importance for the subject -, among others 28 .
Thus, the institutional fight against racism gained materiality in enacting affirmative policies during the 2000s 29 .At the onset of this decade, the fight against IR became a great initiative to direct the fight against racism.Its use was powerful in the debate on affirmative policies in general and specifically in health policy 1,19,30 , namely, in some articles, the possibility of criticizing regulations, laws, and institutions 19 , and the possibility of working this perspective in a sectoral way in health 31 are celebrated as assets.
Besides directing actions towards the sector itself -largely materialized in training, conversation circles, and qualifications aimed at health professionals -a complementary point for a critical analysis around the centrality of the IR concept in formulating antiracist policies in Brazil is its limitation on understanding the State's conduct in preserving and fighting against racism: the chosen initiative would be made within the institutions, or more specifically in an attempt to adjust or improve the State's functioning.
By the way, shifting the IR concept between "the use of the State by a part of society to oppress another part" to "an institutional deviation" can be illustrated when several writings attribute to the book Black Power 16 the idea that the IR would represent an organization's "collective failure" to "provide an appropriate and professional service" 2,[31][32][33][34][35] .Certainly, this definition focused on organizational action is found in the "Macpherson Report", conducted during the inquiry into the murder of Stephen Lawrence 36 .
While IR is understood as the oppressive action of the American white elites and is even understood similarly to colonialism 16 in the book Black Power, written in the middle of the 20 th century, such a concept no longer denounced the intentionality of its use for oppression -now understood as something caused by a State functioning failure and not as one of its intentions, in the Macpherson report 36 , written in the late 20 th century.
Thus, the understanding of the IR concept limited to the State's failure is quite questionable: although it contributes to the necessary discussion about the deleterious effects of racism, prejudice, and racial discrimination in health institutions associated with this, investment in sectoral actions does not highlight the existing historical and contextual contradictions in the Brazilian State -tensioned between social demands for the transformation of structural inequalities and the preservation of the necessary inequality in capitalism.
Furthermore, another point that deserves to be highlighted in the elaboration of the IR in our country is the influence of the experience of the English institutions in the face of racism, with the British Department for International Development and Poverty Reduction (DFID) financing and contribution in the elaboration, and the United Nations Development Program (UNDP) in the preparation of the Program to Combat Institutional Racism and for developing the PNSIPN 1,37,38 .
Although several articles 1,37,38 mention the participation of UN agencies and the British government in financing and formulating policies and programs to combat racism, none question or view such action from a critical perspective.
The UNDP-DFID cooperation in elaborating programs to combat racism in Brazil can hardly be understood in an unscathed way, given that the geopolitical interest of the United Kingdom, through DFID, in racial conflicts in countries like Brazil cannot be separated from the ambivalent discourse adopted by this department in other settings, when they attempted to confront poverty and promote development policies in so-called backward countries 39 .
Criticism of the understanding of IR as a guiding concept in constructing public policies against racism has been developed by authors from different countries.It contributes to a deeper understanding of this conception.Some of them will be described below.

criticism to IR
In the international context, different authors have criticized the use of IR.According to the Dictionary of Ethnic and Racial Relations 40 , in its institutional sense, racism can refer to anonymous operations of discrimination in organizations, professions, or even entire societies.This concept would point excessively to racism as something omnipresent that permeates the entire society at the individual and institutional levels, openly and subliminally.Later, some authors attempted to restrict the concept, applying it to specific institutional norms and acts.
According to Philips 17 , sociologist David Mason warned in the 1980s that IR would be doomed to a political slogan lacking analysis and rigor.The argument referred to its rootedness in established conventions in American society, lacking empirical proof.
In turn, Dhume 41 argues that the notion of IR has power by denoting the responsibility of institutions in preserving unequal racial social relationships.However, in parallel, the concept has limits, making the role of institutions imprecise and redundant by not articulating IR to individual racism and, simultaneously, making its causes and main beneficiaries invisible.The author says one cannot ignore the State's role in structuring racism and forming identities.
Likewise, Dunezat and Gourdeau 42 run across different applications for this concept and point to the indispensable articulation of the different scales of racism and the peculiar roles individuals and institutions play.
Dunezat and Gourdeau 42 affirm there is centrality in the disputes existing in the antiracist field for elaborating counter-hegemonic concepts that can expose racism in their most systemic and structural ways.Thus, regarding the French setting, they consider a substantial production of a counter-hegemonic definition that allows to deconstruct the republican narrative and reveal the inextricably racist and colonial/imperialist/ slave character of the French state, which leads to a form of assimilation of IR to State racism.
Wieviorka 43 considers the IR's strength in the possibility of evidencing racism in societies where the discourse of scientific racism is declining or even where laws criminalize it.He believes this practice is perpetuated if no actions exist to fight against institutional functioning.The paradox of exempting the guilt of the beneficiaries of racism and overseeing the role of institutions in the process would be a weakness that generalizes the responsibility of this event.
In addressing the subject, Silvio de Almeida 44 faces structural racism in IR.He indicates that the relationships at the heart of institutions would be in reproducing social life, so they would not create racism but would reproduce it.This understanding highlights the binding between racism and social structure, so institutions are racist because they are part of a racist society.
Although there is a risk of understanding structural racism 44,45 also falling into abstract elucubration, this term can contribute to the apprehending that the functioning of institutions is concatenated with the capitalist production mode (CPM) and the ways of organizing the social production and reproduction of life.
Thus, in her elucidation, Coretta Philips 17 deems it crucial to understand the role of racialization also in the micro and macrostructural spheres since the conceptualization of IR would be insufficient to explain racial inequalities.Thus, she highlights as counterpoints the roles of interpersonal, cultural, and family relationships at the micro level and the economic production mode, its configuration in neoliberalism, and transna-tional policies as the pillars of racism at the macro level.
Initiatives to confront racism cannot fail to consider the State's performance in having the Black population's worst living and health conditions as a strategy to reproduce the CPM.

Racism as an integral part of capitalism
Racism, as we experience it today, is not a constant in human history 46 .It is a historically constructed oppression initiated, above all, in the genesis of capitalism.Without it, this production mode would not materialize 47 , and with it, it is possible to resign most of a country's population to deplorable circumstances of life and existence 48 .
Fanon 46 affirms racism is a dialectical gangrene.Its confrontation would require the tireless demand for its repercussions on all levels of sociability.In an articulated way, racism would affect not only the lives of individuals but also their interpersonal relationships and the social organization as a whole.
Understanding the inequalities undertaken by the IR requires analyzing the performance of institutions in the lives of individuals and the broader social dynamics.At this point, the initial elaboration of Ture and Hamilton 16 is of great value.Although it is necessary to pay attention to the risk of incurring an anachronistic transposition of the meaning of IR in the U.S. reality in the late 1960s, we should understand the meaning existing in the genesis of this concept and the differentiation as to how that occurs in the PNSIPN content.
In the book Black Power, IR appears as a specific type of racism.Unlike direct and noticeable individual racism, IR would be subtle and veiled and keep Black communities in poverty and discrimination, besides mutilating and destroying thousands of people physically, intellectually, and emotionally.IR would be implemented through neglect or even State direct repressive actions through anti-Black practices 16 .
Given the disparity in the living conditions between black people and white people, Kwame Ture and Charles Hamilton understand that the former lived in a situation similar to that of the colonized countries.The IR term is synonymous with colonialism, operating politically, economically, and socially.
Although existing in very distinct political and geographical spaces, there are similarities between the authors' elaboration with the colonial overview of Algeria outlined by Frantz Fanon in the book The Wretched of the Earth 49 , nominally cited in the work.In the American context, besides affecting physically and emotionally people, IR would also spatially divide cities by segregating the Black community in ghettos, as described regarding those colonized in the Martinican author's book.Thus, in the original formulation of the IR concept, the relationship between racism-based domination and exploitation is explained in its equalization with colonialism.
The "colonialism" category -also elaborated differently by several authors, but here aligned with the elaboration of Fanon 49 , Ture, and Hamilton 16 -allows understanding of the disparities imposed on the dynamics of racialization within a country and in the broad international context.We should emphasize that not only currently but historically, the process of racialization and division of humanity into different races, justified and enabled colonization 50 , which, in turn, through pillage, enslavement, and extermination, paved the way for the dawning of the age of capitalist production 51 .
The particularity of the debate about IR's impact on society has differences that are not that subtle when compared to the meaning formulated in the U.S., England, and Brazil.While IR would be at the service of the dynamics of segregation and exploitation imposed on blacks within the largest capitalist power in the book Black Power, in the later examples, it would mean the failure of the State to provide proper operational conditions of its institutions, either in a central country of capitalism with an extensive history as a colonizer or in its incorporation into a country on the outskirts of capitalism with a secular colonization history.
The denunciation of the discriminatory action of the institutions, among them, the SUS, made through the analysis of IR emerges as a substantial strategy.However, seizing this fact alone disregards the dialectical interaction between individual, institutional, and structural forms in racialization's dehumanizing process.As in interpersonal racism, IR is a manifestation of racism as something necessary for the historical preservation of inequalities in Brazilian society.
The fight against IR depends on the ability to meet the reasons that lead institutions to reproduce racism and the consequences in accessing housing, work, education, and consequently, health services and actions.

Final considerations
Choosing a specific theoretical conception to substantiate a policy does not necessarily ensure that actions will be determined from this perspective.However, the theoretical perspective adopted has strongly influenced the PNSIPN's case.
Assimilating the IR conception in Brazil, emphasizing the performance within the restricted sphere of organizations, is similar to what occurred in other countries, particularly in England, where racist police performance was attributed to some professionals or institutions without proper correlation with the structure of the social and the State's performance.
The objectives proposed in elaborating the policy are extremely relevant in promoting BPH, reducing racial inequalities, and facing racism and discrimination in the SUS.The formal inclusion of the discussion about IR in the public policy agenda in the early 21 st century is a great achievement, given the recognition of the role of organizations in reproducing racism.
These notes arouse the need to run other studies that evidence the conceptual debate and the effective proposal for planning and implementing health actions and services for the Black population; deepen the contrast between the objectives, the conceptual basis, and the implementation of the policy; investigate the work of different authors such as international organizations, researchers, SUS clients, organized social movements, managers, and workers in implementing the PNSIPN.
Despite the progress represented in the inclusion of content in the State agenda, it is clear that realizing the proposals contained as the objectives of the policy and transforming unfavorable health conditions experienced by the Black population require overcoming the conception and action focused on the institutional nature of racism, considering the individual and social repercussions of the racialization process.
Even in the face of the relevant limitations, acting within the State under the aegis of the CPM, confronting the deleterious effects of racism on people's daily lives requires incorporating nodal points of its reproduction.It is essential to consider racism as a strategy of subjugating people and preserving this reality, which is crucial in the particular dynamics of the Black population and universally in the Brazilian social conforma-tion, whose reproduction compels a State where racialization is not a failure, but a systematic logic.
Far from the pretense of elaborating a new category to replace the IR concept, realizing this proposal and, consequently, the SUS itself imposes on us the task of grasping the main determinations regarding the health of the Black population, understanding and contributing to the transformation of the Black population's role in Brazilian society -its place in the universe of work, and its situation of income, education, and housing.
The feasible fight against racism through the SUS must continue pointing to the deleterious consequences of people's health inequalities, identifying and confronting the manifestation immediately, but should not forget the transformation of their founding causes.collaborations DFL Silva, TM Lyra, JB Rosas, and DM Faustino worked equally on the research's conception, methods, and final drafting.