Who are they, what do they talk about and who listens to the poor?

Maraiza Alves Freitas Augustus Tadeu Relo de Mattos William Zaccaro Gomes Maria do Carmo Gullaci Guimarães Caccia-Bava About the authors

Resumo

O direito a uma vida digna para todos requer a superação de desafios impostos aos grupos mais vulneráveis, sendo a pobreza um dos fenômenos mais antigos e devastadores. Ouvi-los é essencial para criar possibilidades de superação. O estudo objetiva identificar características dessa escuta, no contexto da promoção da saúde e dos Objetivos de Desenvolvimento Sustentável-ODS, esforço internacional de apoio à superação da pobreza, dentre outros. Por meio de revisão integrativa de literatura, realizada com os termos de busca (Pobreza, Direito à Cidade, Política de Equidade e Identificação da Pobreza) foram analisados 86 estudos que escutavam os grupos vulneráveis: mulheres, crianças, adolescentes, jovens, adultos, idosos, famílias e usuários de drogas, todos pobres e trabalhadores de baixa qualificação. Cada estratégia apresentada foi relacionada a um ou mais ODS. A ampliação da proteção social e dos espaços de escuta aos grupos vulneráveis, e políticas públicas que viabilizam o combate à pobreza, foram as estratégias mais recorrentes nos estudos analisados. A equidade deve ser pensada no bojo de políticas abrangentes e universalizadoras de direitos, superando as políticas fragmentadas e focais que deixam de atacar as causas estruturais da pobreza e da exploração humana.

Palavras-chave
Pobreza; Vulnerabilidade social; Desenvolvimento sustentável; Equidade; Promoção da saúde

Abstract

The right to a dignified life for all requires overcoming the challenges imposed on the most vulnerable groups, and poverty is one of the oldest and most devastating phenomena. Listening to them is essential to create remediating opportunities. This study aims to identify characteristics of this listening in the context of health promotion and the Sustainable Development Goals - SDGs, an international effort to support the fight against poverty, among others. In an integrative review of literature, conducted through the search terms of Poverty, Right to the City, Equity Policy and Identification of Poverty, 86 studies that listened to vulnerable groups, such as women, children, adolescents, adults, the elderly, families and drug users, all poor and low-skilled workers were analyzed. Each strategy shown was related to one or more SDGs. The recurrent strategies in the studies analyzed were increased social protection and spaces to listen to vulnerable groups, as well as public policies that enabled the fight against poverty. Equity must be thought of in the context of comprehensive and universalizing rights policies, overcoming fragmented and focal policies that fail to address the structural causes of poverty and human exploitation.

Key words
Poverty; Social vulnerability; Sustainable development; Equity; Health promotion

Introduction

According to the World Health Organization - WHO11.organização Mundial de Saúde (OMS). Relatório Mundial de envelhecimento e Saúde. [Internet]. 2015 [acessado 2017 maio 02]:[cerca de 28p.]. Disponível em: http://sbgg.org.br/wp-content/uploads/2015/10/OMS-ENVELHECIMENTO-2015-port.pdf.
http://sbgg.org.br/wp-content/uploads/20...
, a long and healthy life for all requires solid investments in the future of societies, providing the freedom to experience lives that previous generations have not imagined. Designing and sustaining life dignity as the right of all and not as the privilege of the few requires overcoming challenges that threaten existence and impose themselves on the most vulnerable groups on the planet.

Eradicating poverty in all its forms and realms is now the greatest global challenge, a condition for sustainable development. “Releasing the human race from the tyranny of poverty and misery and healing and protecting our planet” urgently requires realizing radical and comprehensive actions that will lead the world towards sustainability, resilience and inclusion22.organização das Nações Unidas (ONU). Transformando Nosso Mundo: A Agenda 2030 para o Desenvolvimento Sustentável [Internet]. 2015 [acessado 2017 Maio 07]: [cerca de 49 p.]. Disponível em: https://na-coesunidas.org/wp-content/uploads/2015/10/agenda-2030-pt-br.pdf
https://na-coesunidas.org/wp-content/upl...
.

The poverty found in humanity admits diverse interpretations, emphasizing either economic aspects associated with the incapacity to work or to inequity and injustice33. Magalhães KA, Cotta RMM, Gomes KO, Franceschinni SCC, Batista RS, Soares JB. Entre o conformismo e o sonho: percepções de mulheres em situação de vulnerabilidade social à luz das concepções de Amartya Sen. Physis [periódico na Internet]. 2011 Dec [acessado 2017 Mai 09]; 21(4):[cerca de 21p.]. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttex-t&pid=S010373312011000400017&lng=en.http://dx. doi.org/10.1590/S0103-73312011000400017
http://www.scielo.br/scielo.php?script=s...
. The neoliberal policies of international institutions stem from this economistic understanding as a paradoxical alternative to the exclusion deriving from a shrinking State and the centralization of power in the mercantilist logic44. Ribeiro CRO, Zoboli ELCP. Poverty, bioethics and research. Rev. Latino-Am. Enfermagem [serial on the Internet]. 2007 Oct [cited 2017 May 09]; 15(Spec):[about 6 p.]. Available from: http://www.sci-elo.br/scielo.php?script=sci_arttext&pid=S010411692007000700020&lng=en.http://dx.doi.org/10.1590/S010411692007000700020
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. In the ethical-philosophical perspective based on wage labor, it is pointed out that poverty derives from an unfair distribution of society's riches, which is a form of vulnerability, since people lose dignity and the intrinsic value of human existence and, without any possibility of escaping from exploitation, can lose their lives.

The monetarist interpretation establishes income shortage as an indicator of poverty, a view that persists in the lack of other realms that are an alternative to monetary indicators55. Comim F, Bagolin IP. Aspectos qualitativos da pobreza no Rio Grande do Sul. Ensaios FEE [periódico na Internet]. 2002 Dec [acessado 2017 Maio 07]; 23(1):[cerca de 23 p.]. Disponível em: https://www.econbiz.de/Re-cord/aspectos-qualitativos-da-pobreza-no-rio-grande-do-sul-comim-flavio/10001788685
https://www.econbiz.de/Re-cord/aspectos-...
.

Soares66. Soares SSD. Metodologias para estabelecer a linha da pobreza: Objetivas, subjetivas, relativas, multidimensional. Texto para Discussão, Instituto de Pesquisa Econômica Aplicada (IPEA) [Internet]. 2009 [acessado 2017 Maio 07]; 1381(1):[cerca de 54 p.]. Disponível em: http://hdl.handle.net/10419/91156
http://hdl.handle.net/10419/91156...
affirms that poverty as a lack of resources can be classified as (a) absolute poverty - used from the capacity of consumption in relation to income, with the UN parameter77.organização das Nações Unidades (ONU). “Pobreza com base na renda é apenas um dos elementos que constitui o bem-estar e desempenha um papel instrumental para determinar o exercício de outros elementos que o constituem” [Internet]. 2005 [acessado 2017 Mai 07]. Disponível em: www.scielo.br/scielo.php?s-cript=sci_nlinks&ref=9367138&pid=S1806
www.scielo.br/scielo.php?s-cript=sci_nli...
of US$ 2.00 per day; (b) relative poverty, based on the average consumption of a local society, where the poor are below this standard; (c) administrative poverty, a parameter for access to government programs, such as the Bolsa Família (Family Grant) Program; (d) subjective poverty, coming from people themselves from their context and history66. Soares SSD. Metodologias para estabelecer a linha da pobreza: Objetivas, subjetivas, relativas, multidimensional. Texto para Discussão, Instituto de Pesquisa Econômica Aplicada (IPEA) [Internet]. 2009 [acessado 2017 Maio 07]; 1381(1):[cerca de 54 p.]. Disponível em: http://hdl.handle.net/10419/91156
http://hdl.handle.net/10419/91156...
,88. Picolotto VC. Pobreza e desenvolvimento sob os paradigmas da renda e das capacitações: Uma aplicação para a Grande Porto Alegre através dos indicadores fuzzy [dissertação]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2006..

Giffin99. Giffin K. Pobreza, desigualdade e eqüidade em saúde: considerações a partir de uma perspectiva de gênero transversal. Cad Saude Publica [periódico na Internet]. 2002 [acessado 2017 Jan 26]; 18(Supl.):[cerca de 9 p.]. Disponível em: http://www.scielo.br/pdf/csp/v18s0/13797.pdf
http://www.scielo.br/pdf/csp/v18s0/13797...
criticizes the argument that reducing poverty in peripheral countries relies on birth control because, while international programs in 1990 prevented 412 million births, changes in the pattern of sexual distribution of labor did not allow women to overcome it.

In most societies, the current capitalist process of production and consumption of goods and services threatens life. Sustainability involves an articulation between health, environment and economy that requires a more solidary economic and social organization, a transformative agenda and mechanisms of governance capable of implementing this agenda at the local level1010. Gallo E, Setti AFF, Magalhães DP, Machado JMH, Buss DF, Franco Netto FA, Buss PM. Saúde e economia verde: desafios para o desenvolvimento sustentável e erradicação da pobreza. Cien Saude Publica [periódico na Internet]. 2012 Jun [acessado 2017 Maio 09]; 17(6):1457-1468. Disponível em: http://dx.doi.org/10.1590/S1413-81232012000600010
http://dx.doi.org/10.1590/S1413-81232012...
.

WHO11.organização Mundial de Saúde (OMS). Relatório Mundial de envelhecimento e Saúde. [Internet]. 2015 [acessado 2017 maio 02]:[cerca de 28p.]. Disponível em: http://sbgg.org.br/wp-content/uploads/2015/10/OMS-ENVELHECIMENTO-2015-port.pdf.
http://sbgg.org.br/wp-content/uploads/20...
is concerned about growing international inequalities, disparities in opportunities, wealth and power; unemployment, especially among young people; ethnic, political and religious conflicts; extremism and terrorism and with the depletion of natural resources, environmental degradation, desertification and land degradation, freshwater shortage, loss of biodiversity, climate change and its impacts on countries and peoples. It concludes on the risk to the survival of many societies and the biological systems of the planet.

In this global context, UN member states waive their flags out to end hunger and misery, which is one of the 17 Sustainable Development Goals (SDGs) of the 2030 Agenda.

This work addresses the topic of poverty and seeks to identify the expression of people and social groups that live in this situation and to give visibility to this phenomenon. It asks what groups these are, what do they talk about, who speaks for them, what are their experiences, how they are expressed, where and how they occur, who listens to these groups and how. The objectives of this study are:

  1. General: To identify strategies adopted to allow the vocalization of different vulnerable groups in the context of health promotion and sustainable development.

  2. Specific:

    1. To identify the main databases that address the issue of poverty, as well as the international distribution of this production over time;

    2. To point out the identified vulnerable groups;

    3. To describe what the specific topics studied by the different authors deal with;

    4. To identify how vocalization occurs in these groups: direct or indirect listening of the subjects;

    5. To recognize who speaks for the vulnerable;

    6. To identify the methodological tools used to facilitate expressions;

    7. To identify which strategies addressing poverty are proposed and to which SDGs they align.

Material and methodology

This is a literature review, carried out in successive stages, as established by integrative review scholars1111. Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein [periódico na Internet]. 2010 Mar [acessado 2017 Maio 10]; 8(1):[cerca de 5 p.]. Disponível em: http://www.scie-lo.br/scielo.php?script=sci_arttext&pid=S1679-45082010000100102&lng=en. http://dx.doi.org/10.1590/s1679-45082010rw1134
http://www.scie-lo.br/scielo.php?script=...
,1212. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv. Nurs [serial on the Internet]. 2005 Dec [cited 2017 May 09]; 52(5):[about 7 p.]. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.13652648.2005.03621.x/abstract;jses-sionid=2C990B235A236C2C784CBFB3AB057B57.f03t04
http://onlinelibrary.wiley.com/doi/10.11...
, with the theme of different forms of listening to the voice of the vulnerable, from the perspective of the SDGs established by the UN, in order to contribute to human development and fight against poverty.

The sample was selected by searching the Virtual Health Library Brazil (BVS), with papers indexed by LILACS (Latin American and Caribbean Literature in Health Sciences), MEDLINE (Medical Literature Analysis and Retrieval System Online), VetIndex Express, SciVerse Scopus and the Index Psicologia database.

Papers published between 1985 and 2016 were included, a period defined as one year after the Ottawa Conference, an international milestone for Health Promotion; papers in Portuguese, English and Spanish and those with online public access. Books, theses, dissertations or monographs and online papers with paid access were excluded.

Search was carried out in January 2017, with terms “Poverty”, “Right to the City”, “Equity Policy” and “Identification of Poverty”, combined with the Boolean expressions “or” and “and”.

  1. The combination “Poverty” and “Right to the City” resulted in 31 studies and, after filtering, eight studies were obtained and established Group 1.

  2. The search sentence “Poverty” and “Equity Policy” resulted in 74 papers, of which 25 were selected, establishing Group 2.

  3. The sentence “Identification of Poverty” resulted in 134 studies, of which 53 were included, establishing Group 3.

It is noteworthy that prior to full-text paper reading, the variables to be collected for all groups were defined as follows: society and location analyzed, the paper's theme, the vulnerable group addressed, the type of listening used (whether direct or indirect) to give visibility to the vulnerable group, instruments used in the study (interviews, questionnaires and documentary analysis), recommended strategies for overcoming poverty and vulnerability of that group, as well as the final considerations. A spreadsheet with Microsoft Excel features was created to organize data.

Results

The 86 papers from the searches make up the Search Table (ST), Chart 1.

Chart 1
Search table (ST) constructed from the papers selected for integrative review. Ribeirão Preto, 2017.

Profile of selected studies

The main database of articles were Lilacs, with 64 articles, followed by Medline with 18. PubMed, SciVerse Scopus, VetIndex Express and Index Psicologia returned 1 paper each. For the three groups, papers were found starting in 1996, with increasing quantity as of 2005, as shown in Table 1.

Table 1
Number of papers selected, by search groups and year of publication. Ribeirão Preto, January 2017.

The Portuguese language predominated in 61% of the total works.

The journals that published the eight articles on “Poverty and the Right to the City” (G1) were Revista Gerencia y Políticas de Salud (ST1); American Journal of Public Health (ST2); Mil- bank Quarterly (ST3); Revista de Nutrição (ST4); Asia-Pacific Journal of Public Health (ST5); Family Practice (ST6); Estudos e Pesquisas em Psicologia (ST7); Psicologia, Ciência e Profissão (ST8), totaling eight magazines.

The publications that addressed “Poverty and Equity Policies” (G2) included 25 papers and 11 journals were Cadernos de Saúde Pública (ST84; ST9); Ciência Rural (ST10; ST11); Ciência e Saúde Coletiva (ST85; ST12; ST13; ST14; ST15; ST16 E ST17); Physis (ST86); Revista Brasileira de Promoção de Saúde (ST18); Revista Brasileira de Estudos de População (ST19); Revista Colombiana de Bioética (ST20); Revista de Saúde de Pública (ST21); Revista Latinoamericana de Enfermagem (ST11;ST22;ST23); Saúde e Sociedade(ST24; ST25; ST26; ST27; ST28); Revista Panamericana de Salud Pública (ST 29).

The publications related to the “Identification of Poverty” included 53 papers in 39 different journals: Cadernos de Saúde Pública (ST30 to ST36); Revista de Saúde Pública (ST37 to ST41); with two publications are: Ciência e Saúde Coletiva (ST42 and 43); Journal of Urban Health (ST44 and 45); São Paulo Medical Journal (ST 46 and 47); Saúde e Sociedade (ST48 and 49); Revista Baiana de Saúde Pública (ST50 and ST51). The following journals had one paper published on the subject: Ciencia y Enfermeria XX (ST52); Einstein SP (ST53); Estudos de Psicologia (Campinas) (ST54); Global Health Action (ST55); Globalization and Health (ST56); International Journal of Drug Policy (ST57); International Journal of Social Psychiatry (ST58); Journal of Development Studies (ST59); Journal of Health Psychology (ST 60); Journal of Human Growth and Development (ST 61); Journal of Primary Prevention (ST62); Journal of Youth and Adolescence (ST63); Jornal Brasileiro de Pneumologia (ST64); Matrizes-Revista USP (ST65); New Directions for Youth Development (ST66); Patient, Educations and Counseling (ST67); Psicologia e Sociedade (ST68); Psicologia em Estudo (ST69); Revista de Nutrição (ST70); Revista Brasileira de Estudos de População (ST71); Revista Brasileira de Farmacognosia (ST72); Revista Brasileira de Saúde Materno Infantil (ST73); Revista Panamericana de Salud Publica (ST74); Revista Brasileira de Enfermagem (ST75); Revista Brasileira de História (ST76); Revista da Sociedade de Psicoterapias Analíticas Grupais do Estado de São Paulo (ST77); Revista do Instituto de Medicina Tropical de São Paulo (ST 78); Revista Hospital de Clínicas de Porto Alegre (ST 79); São Paulo em Perspectiva (ST80); Temas em Psicologia (ST81); Texto & Contexto Enfermagem (ST82); Biomed Central Public Health (ST83).

Publications’ country of origin

The Brazilian production stands out with 72.4% of the papers, followed by North America (USA), with 15.4% of the papers. The United Kingdom (3.4%), Sweden and Colombia (2.3%) and Indonesia, Greece, Chile and Switzerland had the lowest frequencies (1.1% each).

Societies or locations analyzed by papers, according to each group

G1: In Brazil: Brasília (ST4), Rio Grande do Sul (ST8) and Rio de Janeiro - Favela da Rocinha (ST7).

In the Americas: Medellin-Colombia (ST1); and USA: New York (ST2), two California counties (ST3) and Champaign County, in Illinois (ST6).

In Southeast Asia: Province of Aceh, Indonesia (ST5).

For the G2, dealing with Poverty and Equity Policies, studies that have reanalyzed Brazilian regions were one study involving all 27 Brazilian capitals (ST29); six works covering the whole country (ST84, ST12, ST13, ST17, ST24, ST25, ST27); one on Rio Grande do Sul (ST16); two on Rio Grande do Norte, one of them being, specifically, in rural settlements (ST10); one in the State of Ceará (ST18); one in São Paulo capital (ST26); one study involving two municipalities of Rio de Janeiro (ST14). With focus on the State of Minas Gerais, one study was developed on each of the following locations: Paula Cândido (ST86); Municipality of the metropolitan region of Belo Horizonte (ST23) and Diamantina (ST15).

There were two studies focusing on all of Latin America (ST20 and ST22), and with the frequency of one study, the following were analyzed: Developing Countries (ST9); a set of 27 countries (ST28); Portugal (ST21); East and Southeast Asia (ST19), the whole world (ST85).

In the G3, studies geared to the identification of poverty focused: Brazil: Brazil - whole country (ST49 and ST50); São Paulo (SP) (ST41; ST53; ST71; ST73; ST75; ST76; ST77); Porto Alegre (RS) (ST30; ST37; ST79); Salvador (BA) (ST31; ST38; ST40), Paranaguá (PR) (ST32; ST42); State of Pernambuco (ST34; ST69); State of São Paulo (ST80); Natal (RN) (ST68); Pelotas (RS) (ST36); Niterói (RJ) (ST39); Recife (PE) (ST47); Uberaba (MG) (ST54); Jaboatão dos Guararapes (PE) (ST50); Osasco (SP) (ST65); Belém (PA) (ST61); North and Northeast of Brazil (ST35); State of Pará (ST72); Camboriú (SC) (ST82); Araras (SP) (ST78); São José do Rio Preto (SP) (ST64); Embu (SP) (ST46).

Africa: South Africa (ST55; ST56); Ethiopia (ST58).

Latin America (ST63, ST74).

USA: Nashville (ST62); Boston, Chicago and San Antonio (ST45); Miltown - Pennsylvania (ST66); Texas (ST67).

Asia: Pakistan (ST83); India (ST59); Indonesia (ST57).

Middle East: Beirut-Lebanon (ST44).

Global approach (ST33, ST48, ST51, ST52, ST81).

No set location (ST43; ST60).

The papers evidenced the following themes according to the research groups

G1: Socio-environmental vulnerability (ST4), Depression in low-income women (ST6); Rights of children and adolescents (ST8); Health insurance coverage for low-income children (ST3); Right to land use (ST7); Right to health (ST1); Equity, health and land use (ST2); Mother health and use of services (ST5).

G2: Social Determinants of Health and Oral Health (ST29); Agrarian reform and socio-environmental quality (ST10); Social protection; Income transfer, public policies (ST14, ST28); Health, economy, sustainable development and poverty (ST85); Equality, equity, health promotion, political culture, empowerment, popular education (ST27); Fertility and equity (ST19); Human development, poverty and social inequality (ST86); Gender equity (ST84); Poverty and barriers to access to health (ST23); Tuberculosis and iniquities (ST22); homeless population and vulnerability (ST26); Social vulnerability, health conditions and health financing (ST16); Equity, access (ST9); Reproductive health, social perception, equity, gender and health (ST21); Ethnic minorities and social exclusion (ST12); Intersectoriality (ST25); Urbanization, poverty and pollution (ST24); Obesity and poverty (ST15); Relations between state, society, civility and social participation in health policies (ST13); Poverty and ethics (ST11); Justice, bioethics and inequity (ST20); Mortality due to diarrhea and social determinants (ST17); Health promotion and people with disabilities (ST18).

G3: child health, accidents and socioeconomic factors (ST35, ST37, ST38, ST46, ST47, ST53, ST61, ST79); Adolescence, health, family structure and social vulnerability (ST68, ST54, ST66); Community health workers and bioethics (ST49); Prevalence of anemia in different settings (ST70); Favelas and cluster surveys (ST41); Health assessment (ST73); Well-being, youth and urban environment (ST36; ST76); Search for health care and poverty (ST32; ST34); Cancer, family and poverty (ST69; ST67); Young women and sexual life (ST56; ST83); Concept of health-diseases (ST75); Low-income families and ethnographic analysis (ST31); Gender, media and AIDS (ST30, ST55); Indigenous populations and vulnerability (ST72); Poverty, food and social practices (ST42, ST62, ST82); Tuberculosis and socioeconomic conditions (ST51, ST52, ST64); Poverty, exclusion and social vulnerability (ST48, ST59, ST63, ST77, ST80); Women, culture and poverty (ST44); Health promotion and education (ST65); Access to health (ST33); Socio-environmental indicators (ST39, ST50, ST74, ST62); Poverty, migration and mental health (ST45, ST58, ST81); Urban space and socio-environmental vulnerability (ST71); Elderly, vulnerability and social representations (ST60); Protective factors and drug use (ST57); Landless workers and parasitoses (ST78); Ethics in qualitative research (ST43).

Studies focused more on population groups, women and on poor families, as detailed in Chart 2.

Chart 2
Number of articles published, by identified vulnerable groups. Ribeirão Preto, 2017.

Type of listening

Authors considered two types of listening. Direct listening refers to the vocalizations made by members of the groups themselves to researchers, both through quantitative and qualitative or qualitative-quantitative studies. On the other hand, indirect listening was considered as such when the visibility given to vulnerable groups was based on literature data, through review work or by free theoretical essays on the subject. The result of this classification showed the predominance of direct vocalization of vulnerable groups for the works of identification of poverty included in the third group (G3), while indirect listening prevailed for Groups 1 and 2, with the following frequency:

Thirty-nine papers were found in direct listening, of which three for Group 1 (ST4; ST7; ST8); six for Group 2 (ST86; ST14; ST15; ST21; ST23; ST26) and thirty for Group 3 (ST30 to ST32; ST34 to ST36; ST38; ST 40; ST44; ST47; ST53; ST55 to ST58; ST60; ST61; ST63; ST65 to ST69; ST72; ST 75; ST77 to ST79; ST82; ST83).

Forty-one papers were identified in indirect listening, of which five from Group 1 (ST1; ST2; ST3; ST5; ST6); 19 from Group 2 (ST11; ST84; ST85; ST9 to ST13; ST16 to ST20; ST22; ST24; ST25; ST27; ST28; ST29) and 17 from Group 3 (ST37; ST39; ST41; ST43; ST48 to ST52; ST59; ST64; ST70; ST71; ST74; ST76; ST80; ST81). There were also six direct and indirect listening papers, all belonging to Group 3 (ST42; ST45; ST46; ST54; ST62; ST73).

Instruments used

In the three search groups, studies used documentary analysis, semi-structured and structured interviews, participant observation, focus groups and questionnaires. G2 also used selection of indicators, literature review and theoretical essays.

Understanding that the strategies for overcoming poverty shown in the 87 studies analyzed would be in line with the SDGs, these were identified and it was possible to relate them by search groups to one or more SDGs. Chart 3 shows the strategies proposed in the works of Group 1 and 2 and the respective relationships with the SDGs.

Chart 3
Strategies proposed by authors and SDGs related to the studies of Groups 1 and 2. Ribeirão Preto, 2017.

The proposed strategies for fighting against poverty and listening to vulnerable identified in G3 are listed in Chart 4.

Chart 4
Proposed strategies and related SDGs in the studies of Group 3. Ribeirão Preto, 2017.

Discussion

The complex poverty phenomenon requires that multiple aspects underlying the production of life, such as access to land, health services, water, decent work, inclusive education, overcoming social inequities, gender, ethnic minorities and religious groups be considered.

It is imperative that these social groups that experience processes of exclusion vocalize their life experiences, express their needs and mobilize segments of society through strategies to face and overcome their vulnerable and degrading conditions.

Authors’ concerns are revealed in the several dozens of papers surveyed. They are from different regions of Brazil and the world and address general and unique themes that bring us back to the realities of diverse populations carrying the common mark of poverty.

One of the concerns identified is environment. It was recognized that these urban settings became unhealthy through pollution, violence and poverty, affecting mainly the poorest. At a time when, in the world, discussions turn to the right to the city, the critical look at exploration and environmental depletion and its sustainability is justified by the challenge of transforming it to fulfill the historical function of embracing the various social groups that have a right to it, overcoming social exclusion and promoting equity.

Ethnic and racial minorities face situations of poverty, exclusion, marginalization, discrimination and vulnerability, ratified by their current morbimortality coefficients that are among the highest, with hunger and malnutrition and systematic occupational risks and social violence. There will be no equity without confronting and overcoming these conditions.

Regarding gender, the feminization of poverty and the economic model stand out in the logic of exclusion. While there was a hard fought battle for the right not to give birth, the analysis of highly differentiated concrete conditions for motherhood among social groups was relegated in the background99. Giffin K. Pobreza, desigualdade e eqüidade em saúde: considerações a partir de uma perspectiva de gênero transversal. Cad Saude Publica [periódico na Internet]. 2002 [acessado 2017 Jan 26]; 18(Supl.):[cerca de 9 p.]. Disponível em: http://www.scielo.br/pdf/csp/v18s0/13797.pdf
http://www.scielo.br/pdf/csp/v18s0/13797...
. Thus, the fallacy of arguments that reduced poverty in peripheral countries was linked to birth control, against the millions of births avoided without the reduction of poverty falls apart99. Giffin K. Pobreza, desigualdade e eqüidade em saúde: considerações a partir de uma perspectiva de gênero transversal. Cad Saude Publica [periódico na Internet]. 2002 [acessado 2017 Jan 26]; 18(Supl.):[cerca de 9 p.]. Disponível em: http://www.scielo.br/pdf/csp/v18s0/13797.pdf
http://www.scielo.br/pdf/csp/v18s0/13797...
.

There is also a critical view on the so-called urban disposable, the “human waste” to be removed as common urban waste, rescuing the complexity of the existence of a homeless population and the challenges to health policies and other social policies.

Also inevitable is the recognition of a growing poverty and the accelerated concentration of income in the hands of the few. According to ECLAC1313.organizacion de Las Naciones Unidas. Comisión Económica para América Latina y el Caribe (CEPAL). Panorama social de América Latina, 2000-2001 [Internet]. 2001 [acceso 2017 May 09]; S01(G141):[alrededor 267 p.]. Disponible en: http://repositorio.cepal.org/bit-stream/handle/11362/1211/S015427_es.pdf;jsession-id=2E4A2BED4DDC011B610F1AB237D40680?se-quence=1
http://repositorio.cepal.org/bit-stream/...
, the number of poor has increased by 50%, from 136 million in 1980 to 200 million in 1990. The proportion of the poor in the population also increased from 40.5% to 48%1414. Giovanella L. Los sistemas de salud de Argentina, Brasil y Uruguay en perspectiva comparada. Observatório Mercosur de Sistemas de Salud [Internet]. 2013 [accesado 2017 Maio 09]. [alrededor 52 p.]. Disponible en: http://cebes.org.br/site/wp-content/uploads/2015/07/RSD_105.pdf
http://cebes.org.br/site/wp-content/uplo...
. The concentration has reached levels of the end of the 19th century, since the wealth of 1% of the world's population surpassed that of the remaining 99%, and that only 62 individuals concentrate as much income as 3.6 billion people. In 2010, there were 388, which confirms the increasing financial concentration1515. Piketty T. O Capital no Século XX. 2ª ed. Cambrige: Harvard University Press; 2014..

While the World Bank recommends health systems equity policies, developments of the macroeconomic policy with external debt financing and public indebtedness compromise resources for health, reducing broad and universal policies to targeted programs and extension projects of coverage1616. Senna MC M. Eqüidade e política de saúde: algumas reflexões sobre o Programa Saúde da Família. Cad Saude Publica [periódico na Internet]. 2012 [acessado 2017 Maio 09]; 18(Supl.):S203-S211. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pi-d=S0102-311X2002000700020&lng=en.
http://www.scielo.br/scielo.php?script=s...
.

Thus, agreeing with scholars in this area, there is an understanding that equity must be thought within the policies governed by the principle of universality. Taken in isolation, it can impose the “replacement of solidarity and equal opportunities values with radical utilitarian individualism values”1717. Mateucci N. Liberalismo. In: Bobbio N, Mateucci N, Pasquino G. Dicionário de política. 5a ed. Brasília: Universidade de Brasília; 1993.apud1818. Almeida C. Eqüidade e reforma setorial na América Latina: um debate necessário. Cad Saude Publica [periódico na Internet]. 2012 [acessado 2017 Maio 08]; 18(Supl.):S26-S36. Disponível em: http://www.scielo.br/pdf/csp/v18s0/13790
http://www.scielo.br/pdf/csp/v18s0/13790...
. Thus, even the implementation of the Bolsa Família (Family Grant) Program has questioned the potency of its conditionalities to actually strengthen families’ autonomy1919. Pawson R. Evidence-based policy: the promise of “realist synthesis”. Evaluation [serial on the Internet]. 2002 [cited 2017 May 09]; 8(3):[about 18 p.]. Available from: http://journals.sagepub.com/doi/abs/10.1177/135638902401462448
http://journals.sagepub.com/doi/abs/10.1...
.

The theme of differentiated access to health services, which can be defined by their availability, accessibility, economic feasibility and acceptability, which is marked by conceptual differences between access and use, but in common identify that the poor use less effective interventions2020. Alves CF, Siqueira AC. Os direitos da criança e do adolescente na percepção de adolescentes dos contextos urbano e rural. Psicol. ciênc. prof [periódico na Internet]. 2013; [acessado 2017 Maio 10]; 33(2):[cerca de 13 p.]. Disponível em: http://www.scielo.br/scielo.php?s-cript=sci_arttext&pid=S141498932013000200015&ln-g=en&nrm=iso&tlng=pt
http://www.scielo.br/scielo.php?s-cript=...
.

In this setting, the role of international conferences2121. O’Donnell O. Access to health care in developing countries: breaking down demand side barriers. Cad Saude Publica [serial on the Internet]. 2007 Dec [cited 2017 May 08]; 23(12):2028-2034. Available from: http://http://dx.doi.org/10.1590/S0102-311X2007001200003
http://dx.doi.org/10.1590/S0102-311X2007...
is highlighted, since WHO policies have been consolidated in these spaces. The best known are those of Alma Ata2222.organização Mundial de Saúde (OMS). Declaração de Alma-Ata. [Internet]. 1978 [acessado 2017 Jan 02]: [cerca de 60p.]. Disponível em: http://apps.who.int/iris/bitstream/10665/39228/5/9241800011_por.pdf
http://apps.who.int/iris/bitstream/10665...
, due to the emphasis placed on Primary Health Care, and Ottawa2323. World Health Organization (WHO). The Ottawa charter for health promotion. [Internet]. 1986 [cited 2017 May 09]: [about 6 p]. Disponível em: https://www.dgs.pt/paginas-de-sistema/saude-de-a-a-z/carta-de-ota-wa-1986.aspx
https://www.dgs.pt/paginas-de-sistema/sa...
, which gave great visibility to health promotion. Brazil participated in the first event, but not in Ottawa, which counted more on developed countries and with few peripheral countries, unlike Alma Ata. Peripheral countries also met in Jakarta, Port-of-Spain (Caribbean) and Bogotá (Colombia) in 1992, and were signatories in the latter.

In Alma Ata, the concept of health was “the most complete state of physical, psychic and social well-being”2222.organização Mundial de Saúde (OMS). Declaração de Alma-Ata. [Internet]. 1978 [acessado 2017 Jan 02]: [cerca de 60p.]. Disponível em: http://apps.who.int/iris/bitstream/10665/39228/5/9241800011_por.pdf
http://apps.who.int/iris/bitstream/10665...
, idealized and not so operational, which used the programmatic actions to curb differences in the health status of the population. According to the WHO2424.organização Mundial de Saúde (OMS). Declaração de Santafé de Bogotá. [Internet]. 1992 Nov [acessado 2017 Jan 02]: [cerca de 50p.]. Disponível em: http://www.opas.org.br/coletiva/uploadArq/Santafe.pdf
http://www.opas.org.br/coletiva/uploadAr...
, health ceases to be a “state” and becomes a “project”2525. Sabroza PC. Concepções sobre saúde e doença. Curso de aperfeiçoamento de gestão em saúde. Educação a distância. [Internet]. 2006 [acessado 2017 Maio 07]. Disponível em: http://www.abrasco.org.br/UserFiles/File/13%20CNS/SABROZA%20P%20ConcepcoesSau-deDoenca.pdf.
http://www.abrasco.org.br/UserFiles/File...
, one for each nation or social group, according to its economic, technical, political and cultural possibility2424.organização Mundial de Saúde (OMS). Declaração de Santafé de Bogotá. [Internet]. 1992 Nov [acessado 2017 Jan 02]: [cerca de 50p.]. Disponível em: http://www.opas.org.br/coletiva/uploadArq/Santafe.pdf
http://www.opas.org.br/coletiva/uploadAr...
.

At the Bogota Conference, a concept of equity was discussed and was related to the elimination of unnecessary, avoidable and unfair differences that restrict opportunities to achieve the right to well-being2424.organização Mundial de Saúde (OMS). Declaração de Santafé de Bogotá. [Internet]. 1992 Nov [acessado 2017 Jan 02]: [cerca de 50p.]. Disponível em: http://www.opas.org.br/coletiva/uploadArq/Santafe.pdf
http://www.opas.org.br/coletiva/uploadAr...
.

Almeida1818. Almeida C. Eqüidade e reforma setorial na América Latina: um debate necessário. Cad Saude Publica [periódico na Internet]. 2012 [acessado 2017 Maio 08]; 18(Supl.):S26-S36. Disponível em: http://www.scielo.br/pdf/csp/v18s0/13790
http://www.scielo.br/pdf/csp/v18s0/13790...
points out an imprecision between equality and equity and a distinction between difference and diversity, which are the most critical conceptual issues. For health promotion, the WHO incorporates the two concepts. The first one is related to the political change of health determination's general aspects2626. Sigerist H. The University at the Crossroad. Nova York: Henry Schumann Publisher; 1946.. The second is geared to unhealthy behavioral and lifestyle changes, which is one of the fields of public health formulated by Lalonde2727. Lalonde M. A new perspective on the health of Canadians. In: Organización Panamericana de la Salud (OPAS). Promoción de la Salud: Una Antología. Publ. Cient. OPAS [Internet]. 1974 [acessado 2017 Maio 07]: [cerca de 557 p.]. Disponível em: http://www.phac-aspc.gc.ca/ph-sp/pdf/perspect-eng.pdf
http://www.phac-aspc.gc.ca/ph-sp/pdf/per...
.

While the different Health Promotion Conferences may admit conceptual inaccuracies, they all have the highest principle of overcoming poverty and social inequalities, and that all citizens of the world must be embraced, protected and assisted in their main right, which is life. This was the case from the first to the most recent event, which took place in Shanghai in November 2016 and reaffirmed the 2030 Agenda for Sustainable Development.

The famous motto of Alma Ata2222.organização Mundial de Saúde (OMS). Declaração de Alma-Ata. [Internet]. 1978 [acessado 2017 Jan 02]: [cerca de 60p.]. Disponível em: http://apps.who.int/iris/bitstream/10665/39228/5/9241800011_por.pdf
http://apps.who.int/iris/bitstream/10665...
“Health for all in the year 2000” is now reiterated in Shanghai2828.organização Mundial da Saúde (OMS). Líderes globais concordam em promover saúde para alcançar Objetivos do Desenvolvimento Sustentável. Brasília: OPAS/OMS Brasil [Internet]. 2016 Nov [acessado 2017 Maio 07]. Disponível em: http://www.paho.org/bra/index.php?option=com_content&view=article&id=5298:lideres
http://www.paho.org/bra/index.php?option...
by the slogan “Health for all and all for Health”, demanding the involvement and commitment of managers, professionals and citizens in this technical, ethical and political construction. In the world, and especially in Brazil, this challenge is monumental, with successive losses of financial resources for social areas, with Constitutional Amendment 95/17, and the degradation of the poorest strata of the population due to the loss of labor and pensions rights, labor insecurity and progress toward the logic of the interests of the international market. These policies clash head-on with the essential interests and rights necessary for the social production of health, since systematic, unnecessary and unfair differences increase.

Final considerations

In this complex setting that affects the most diverse social groups in the most different regions of the world, focal and disarticulated policies can hinder the achievement of SDGs. International agencies’ concerns about poverty are of great relevance, considering the right of access to land, basic sanitation, water, food, exploitation-free labor, access to health services and, above all, people's conscious and leading participation in their self-determination and in the control of the social determinants of health.

Many of these challenges have been addressed through fragmented and sectoral policies that lose the ability to provide concrete responses to vulnerable social groups around the world as they fail to address the structural causes of poverty and human exploitation, thus perpetuating this condition.

This overcoming involves establishing complex global priorities that are broken down into ethical and political decisions, such as eradicating world hunger and implementing peace policies, versus keeping global hegemony through military power and extermination policies.

Countries affiliated to the international movements and each citizen should above all support the movements for peace, prosperity, social and economic development and the self-sufficiency of developing countries, as well as the pathways of sustainable development to transform life for the better in the whole planet.

References

Publication Dates

  • Publication in this collection
    Dec 2017

History

  • Received
    30 June 2017
  • Reviewed
    04 Sept 2017
  • Accepted
    03 Oct 2017
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