Racial equity and education of ethnic-racial relations in Health Care courses

Rebecca Alethéia Ribeiro Santana Marco Akerman Deivison Mendes Faustino Ana Lucia Spiassi Iara Coelho Zito Guerriero About the authors

Abstracts

Este artigo discute a prática da implantação da Política Nacional de Saúde Integral para a População Negra por parte dos gestores da educação dos profissionais de Saúde, problematizando a presença da temática “equidade racial em Saúde” no cotidiano das instituições de ensino superior (IESs). Esta pesquisa, composta por entrevistas em profundidade com 12 coordenadores de cursos da área da Saúde de três universidades do Estado de São Paulo, identificou que o novo marco normativo teve efeito positivo no que tange à recepção do tema nas grades curriculares observadas, mas que os coordenadores, no entanto, ainda demonstram desconhecimento ou discordância em relação à sua necessidade.

Saúde de minorias; Educação; Pessoal de saúde; Racismo; Saúde da população negra


Este artículo discute la práctica de la implantación de la Política Nacional de Salud Integral para la Población Negra por parte de los gestores de la educación de los profesionales de Salud, problematizando la presencia del tema “equidad racial en Salud” en el cotidiano de las instituciones de enseñanza superior (IESs). Esta investigación, compuesta por entrevistas en profundidad con 12 coordinadores de cursos del área de la Salud de tres universidades del Estado de São Paulo, Brasil, identificó que el nuevo marco normativo tuvo efecto positivo en lo que se refiere a la recepción del tema en los cuadros curriculares observados, pero que los coordinadores, no obstante, todavía demuestran desconocimiento o discordancia en relación a su necesidad.

Salud de minorías; Educación; Personal de salud; Racismo; Salud de la población negra


This article discusses the current implementation of the National Policy of Comprehensive Health for the Black Population, by the managers of health professionals' education, with the aim of proposing enhanced presence of the subject "racial equity in Health" in the day to day of higher education institutions (HEI). This research work contains in-depth interviews with 12 different coordinators of Healthcare courses from three universities in the State of São Paulo, Brazil and it has identified that the aforementioned normative frameworks have positively influenced the inclusion of such matters in the observed syllabuses. Nonetheless, those coordinators, in turn, still seem to show lack of knowledge or even disagreement with the mentioned policy.

Minority health; Education; Health personnel; Racism; The black population health


Introduction

Since a few decades ago, studiesave drawn attention to the existence of acute racial inequitiesin health(f f For the definition of health, we follow the concept enshrined in the Brazilian Federal Constitution of 1988, article 196: “Health is the right of everyone and the duty of the State, guaranteed by social and economic policHEI aimed at reducing the risk of disease and and universal and equal access to actions and services for their promotion, protection and recovery.” )in Brazil 11. Ministério da Saúde (BR). Pró-Saúde: Programa Nacional de Reorientação da Formação Profissional em Saúde [Internet]. Brasília: Ministério da Saúde; 2005. [citado 8 Out 2016]. Disponível em: http://www.prosaude.org/
http://www.prosaude.org/...

2. Santana RAR. A ótica dos coordenadores de cursos de graduação de profissões de saúde sobre saúde da população negra: raça/cor e currículo [dissertação]. Santo André: Faculdade de Medicina do ABC; 2016.

3. Santana RAR. Abordagem da saúde da população negra nos cursos de graduação da Faculdade de Medicina do ABC [monografia]. Santo André: Faculdade de Medicina do ABC; 2008.

4. Benevides MAS. Perspectiva da equidade no pacto nacional pela redução da mortalidade materna e neonatal: atenção à saúde das mulheres negras. Brasília: Ministério da Saúde; 2005 [citado 10 Nov 2015]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/perspectiva_equidade_pacto_nacional.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...

5. Lopes F. Experiências desiguais ao nascer, viver, adoecer e morrer: tópicos em saúde da população negra no Brasil. In: Ministério da Saúde. Secretaria Especial de Políticas de Promoção da Igualdade Racial. Caderno de textos básicos do Seminário Nacional de Saúde da População Negra. Brasília; 2004. p. 39-100.

6. Batista EA, Escuder MML, Pereira JCR. Cor da morte: causas de óbito segundo características de raça no Estado de São Paulo, 1999 a 2001. Rev Saude Publica [Internet]. 2004 [citado 10 Nov 2015]; 38(5):630-6. Disponível em: http://www.scielo.br/pdf/rsp/v38n5/21749.pdf
http://www.scielo.br/pdf/rsp/v38n5/21749...

7. Oliveira F. Saúde da população negra: Brasil ano 2001. Brasília: Organização Pan-Americana da Saúde; 2003.
-88. Batista LE. A epidemiologia e as relações raciais: o estudo da mortalidade. In: Livros de Resumos do 2º Congresso Brasileiro de Pesquisadores Negros; 2002; São Carlos. São Carlos: UFSCar; 2002. p. 49. . The recognition of this framework led to an intense debate that resulted, not without the resistance and protests from various sectors 99. Maio MC, Monteiro S. Tempos de racialização: o caso da ‘saúde da população negra’ no Brasil. Hist Cienc Saude - Manguinhos [Internet]. 2005 [citado 20 Fev 2017]. 12(2):419-46. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-59702005000200010&lng=pt&tlng=pt
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, in the formulation of the National Policy of Comprehensive Health of the Black Population - PNSIPN. The PNSIPN - under debate since 2001, but would only be approved in Tripartite 2008 and published by Portaria 992, of May 13, 2009 - reaffirmed the principles of the Brazilian National Health System (SUS) and in particular, the principle of equity, which presupposes the prioritization of health care “due to risk situations and conditions of life and health of certain individuals and population groups” 1010. Chehuen Neto JA, Fonseca GM, Brum IV, Santos JLCT, Rodrigues TCGF, Paulino KR, et al. Política Nacional de Saúde Integral da População Negra: implementação, conhecimento e aspectos socioeconômicos sob a perspectiva desse segmento populacional. Cienc Saude Colet [Internet]. 2015 [citado 7 Nov 2016]; 20(6):1909-16. Disponível em: http://dx.doi.org/10.1590/1413-81232015206.17212014
http://dx.doi.org/10.1590/1413-812320152...
-1111. Ministério da Saúde (BR). Portaria MS/GM nº 992, de 13 de maio de 2009. Institui a Política Nacional de Saúde Integral da População Negra. Diário Oficial [da] República Federativa do Brasil. 14 Maio 2009. .

Another principle highlighted in the PNSIPN is the one regarding transversality, “characterized by the complementarity, confluence and reciprocal reinforcement of different health policiesI”. According to the text of the PNSIPN, this perspective contemplates a set of strategiesthat encompass a comprehensive view of the subject, considering their participation in the process of construction of the answers to their needs, as well as presents underpinnings in the various phases of the life cycle, the demands of gender and issues related to sexual orientation, life with pathology and the carrying of temporary or permanent disability 1111. Ministério da Saúde (BR). Portaria MS/GM nº 992, de 13 de maio de 2009. Institui a Política Nacional de Saúde Integral da População Negra. Diário Oficial [da] República Federativa do Brasil. 14 Maio 2009. .

The same document highlights as the first item of its general guidelines the “inclusion of the themes Racism and Health of the Black Population in the processes of training and permanent education of health workers and in the exercise of social control in health,” and in the third item highlights the “incentive to the production of scientific and technological knowledge in the health of the Black population”. The document also presents, in its third specific objective, the inclusion of the theme “Combating Gender Discrimination and Sexual Orientation, with emphasis on the intersections with the health of the Black population, in the processes of training and permanent education of health workers and in the exercise of social control”. Later in the twelfth specific objective, it can be read: “encourage carrying out of studies and research on racism and health of the Black population” 1111. Ministério da Saúde (BR). Portaria MS/GM nº 992, de 13 de maio de 2009. Institui a Política Nacional de Saúde Integral da População Negra. Diário Oficial [da] República Federativa do Brasil. 14 Maio 2009. .

The transversal characteristic of the PNSIPN also defines the competence of the different levels of management of the Unified Health System (SUS) to develop permanent interaction strategieswith other policiesof the Ministry of Health related to health promotion, disease control and care and care in health. This normative, in its technical, political and philosophical precepts, was synergic with a movement already underway in the SUS, which is the revision of the Curricular Guidelines of the Health Graduation Courses in its pedagogical model evaluated as technical and specialized. It was recognized in the health context that the pedagogical model up to then - fragmented, expository and centered on the teacher - would not train professionals with the profile, skills and abilitHEI necessary for the changes proposed in the sector 1212. Schmidt LA. Os cursos de fisioterapia no Paraná frente aos conceitos contemporâneos de saúde [dissertação]. Londrina: Universidade Estadual de Londrina; 2002. .

This criticism resulted, as of 2001, in an articulated effort between the Ministry of Education and the Ministry of Health for the consolidation of new curricular guidelines aimed at the training of health professionals 33. Santana RAR. Abordagem da saúde da população negra nos cursos de graduação da Faculdade de Medicina do ABC [monografia]. Santo André: Faculdade de Medicina do ABC; 2008.,1313. Ministério da Saúde (BR). Promed-Programa de Incentivo às Mudanças Curriculares para as Escolas Médicas. Brasília: Ministério da Saúde; 2002.

14. Presidência da República (BR). Lei n. 10.639, de 9 de janeiro de 2003. Altera a Lei n. 9.394, de 20 de dezembro de 1996, que estabelece as diretrizes e bases da educação nacional, para incluir no currículo oficial da Rede de Ensino a obrigatoriedade da temática “História e Cultura Afro-Brasileira”, e dá outras providências. Diário Oficial da União. 10 Jan. 2003.
-1515. Ministério da Educação (BR). Resolução CNE/CP nº1, de 17 de junho de 2004. Diretrizes Curriculares Nacionais para a Educação das Relações Étnico-Raciais e para o Ensino de História e Cultura Afro-Brasileira e Africana. Diário Oficial [da] República Federativa do Brasil. 22 Jun 2004. . Several documents such as the National Curricular Guidelines for Health Care Courses (2001); the Program of Incentive to Curricular Changes in the Courses of Medicine - Promed (2002); the VER-SUS (2002) a strategy of experiences in the SUS for students of health courses; the Health Work Internalization Program - PITS (2002); the Permanent Education Poles of the SUS; the National Policy of Permanent Education in Health (2004) and the National Program of Reorientation of Vocational Training in Health - Pro-Health (2005); among others, offered new parameters for professional training in health 1616. Oliveira NA, Meirelles RMS, Cury GC, Alves LA. Mudanças curriculares no ensino médico brasileiro: um debate crucial no contexto do Promed. Rev Bras Educ Med [Internet]. 2008 [citado 23 Out 2016]. 32(3):333-46. Disponível em: http://www.scielo.br/pdf/rbem/v32n3/v32n3a08.pdf.
http://www.scielo.br/pdf/rbem/v32n3/v32n...
. In those documents there are spoecifications related to the PNSIPN (2009) that should be followed mainly in their call for transversality, integrality and equity of health policies.

In this spirit - but especially through strong advocacy of the Black movement - the 12th National Health Conference (CNS) in 2003 1717. Ministério da Saúde (BR). Conselho Nacional de Saúde. Conferência Sérgio Arouca: relatório final [Internet]. Brasília; 2004 [citado 7 Nov 2016]. 232 p. Disponível em: http://conselho.saude.gov.br/biblioteca/Relatorios/relatorio_12.pdf
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, in its “Work in Health Axis”, incorporates the racial question among actions related to Health Education Management:

Item 81: Modify the training model of health professionals, nowadays focused on the attention to the disease, reformulating the curriculum of the courses of the health professionals, considering the theoretical and practical themes related to the promotion, the surveillance and the comprehensive care to health, the social control and the multiprofessional and interdisciplinary character of health practices. Include disciplinary contents in information and social communication about the ethnic, cultural and racial diversity of the Brazilian people, aspects of subjectivity related to health care and education, harm reduction, basic care and the organization and functioning of SUS.

The demand for the theme of Afro-descendant citizenship in education is urgent, reflected in the enactment of Resolution CNE/CP 01/2003, instituting the National Curricular Guidelines for the Education of Ethnic-Racial Relations and for the Teaching of Afro-Brazilian History and Culture and Africana - DCN ERER. These resolutions regulate and expand articles 26A and 79B of the Law on the Guidelines and Bases of National Education, Law 9394/96, which were included in 2001 by Law 10.639/03 and later supplemented by Law 11645/08 1818. Monteiro RB, organizador. Orientações e experiências para a implementação da Política Nacional de Saúde Integral da População Negra no âmbito da formação e Educação Permanente em Saúde. São Paulo: Editora Câmara Brasileira do Livro; 2010. p. 119-37 [citado 16 Jul 2017]. Disponível em: http://www.saude.sp.gov.br/resources/ses/perfil/profissional-da-saude/grupo-tecnico-de-acoes-estrategicas-gtae/saude-da-populacao-negra/plano-estadual-de-saude/orientacoes_e_experiencias_para_a_implementacao_da_politica_nacional_de_saude_integral_da_populacao_negra_no_ambito_da_formacao_e_educacao_permanente_em_saude.pdf?attach=true
http://www.saude.sp.gov.br/resources/ses...
.

From the formal point of view, there was a favorable scenario for the consolidation of new curricular frameworks that allowed the inclusion, in the debate, of immense social problems, mainly from the point of view of health.

The PNSIPN acknowledges the relevance of the educational processes proposed by the DCN ERER in order to implementing effectively this policy within the SUS as well as remarks the need to ensure the quality of the professional training activities. It also states that this quality needs to be discussed in its political sense, regarding the choices that weigh on the organization of curricula, programs and similar matters. The absence and negligence of certain knowledge and practices in training processes, from the perspective of training and permanent education in health, lead to serious failures in the comprehensive care of the health of all, and especially of vulnerable populations such as the Black population 1919. Monteiro RB. Educação permanente em saúde e as diretrizes curriculares nacionais para educação das relações étnico-raciais e para ensino de História e Cultura Afro-Brasileira e Africana. Saude Soc [Internet]. 2016 [citado 24 Jul 2017]; 25(3):524-34. Disponível em: http://dx.doi.org/10.1590/s0104-1290201612600
http://dx.doi.org/10.1590/s0104-12902016...
.

It is known that the Permanent Education in Health, in its curricular quadrilateral, also includes the Initial Education of Professionals, “when it presents itself largely porous to the multiplicitHEI of the reality of professional experiences and places itself in an alliance of integrated projects between the sector/world of work and the sector/world of education” 2020. Ceccim RB. Educação permanente em saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-77. . Concomitantly, an important literature has been produced around the disparitHEI in access to health of whites and blacks in Brazil 66. Batista EA, Escuder MML, Pereira JCR. Cor da morte: causas de óbito segundo características de raça no Estado de São Paulo, 1999 a 2001. Rev Saude Publica [Internet]. 2004 [citado 10 Nov 2015]; 38(5):630-6. Disponível em: http://www.scielo.br/pdf/rsp/v38n5/21749.pdf
http://www.scielo.br/pdf/rsp/v38n5/21749...
,2121. Ministério da Saúde (BR). Boletim Epidemiológico HIV/Aids – 2014 [Internet]. Brasília: Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais; 2014 [citado 15 Set 2016]. Disponível em: http://www.aids.gov.br/pt-br/node/73
http://www.aids.gov.br/pt-br/node/73...
,2222. Ministério da Saúde (BR). Secretaria de Gestão Estratégica e Participativa. Departamento de Articulação Interfederativa. Temático saúde da população negra [Internet]. Brasília: Ministério da Saúde; 2016. 82 p. (Painel de Indicadores do SUS; v. 7, n. 10) [citado 23 Mar 2018]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/tematico_saude_populacao_negra_v._7.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
and much of it attributes to the health sector participation not only in the active production of these disparitHEI but also in their invisibility. The question that arises in the scope of this work is: what is the effective porosity of the formative processes regarding the important literature that has been produced in relation to racial iniquetiesin health?

The scope of this study is to investigate the extent to which educational institutions geared to the initial training of health workers respond to the prerogatives existing in the aforementioned normative frameworks. Especially, with regard to the offer of contents, practices and reflections that allow future professionals to identify and develop strategiesfor coping with racial inequitiesin health. The data collection was not extended to Permanent Education in general, but to one of its aspects, namely, Teaching Learning, represented by the initial training of health professionals.

Method

This qualitative and cross-sectional study analyzed the practice of implementing the National Policy for Integral Health for the Black Population by health professionals’ education managers, discussing the presence of the theme of “racial equity in health” in the daily life of Higher Education Institutions (HEIs). To that end, the research interviewed coordinators of eight professional health training courses, namely: Physical Education, Nursing, Pharmacy, Physiotherapy, Medicine, Nutrition, Public Health and Occupational Therapy, encompassing the School of Medicine of ABC (FMABC), Public Health School of USP (FSP-USP), and the Federal University of São Paulo - Baixada Santista Campus (UNIFESP-BS).

No coordinators of the courses of Biology, Veterinary Medicine and Dentistry and of Psychology and Nutrition of UNIFESP were interviewed for not being part of the list of selected HEIs courses, or their respective coordinators did not respond to the invitation.

The FMABC, HEI of origin of this research, is an important campus of health education in the region of the ABC of São Paulo housing eight courses in the health area: Medicine, Nursing, Pharmaceutical Sciences, Physiotherapy, Occupational Therapy, Nutrition, Management in Environmental Health and Management Hospital. The FSP-USP was chosen to be able to explore two courses, one of them new: the undergraduate course in Public Health and the Nutrition course. The first classes of public health officers in Brazil at undergraduate level graduated starting in 2012 2323. Lorena AG, Santos L, Rocha CF, Lima MSS, Pino MR, Akerman M. Graduação em saúde coletiva no Brasil: onde estão atuando os egressos dessa formação? Saude Soc [Internet]. 2016 [citado 1 Ago 2017]; 25(2):369-80. Disponível em: http://www.scielo.br/pdf/sausoc/v25n2/1984-0470-sausoc-25-02-00369.pdf.
http://www.scielo.br/pdf/sausoc/v25n2/19...
. The UNIFESP Campus Baixada Santista was selected for having a curriculum focused on interprofessional training with emphasis on integral care(g g “The interdisciplinarity is characterized by the intensity of the exchanges between the specialists and by the degree of real interaction of the disciplines within the same research project” (p. 74). )2424. Japiassú H. Interdisciplinaridade e patologia do saber. Rio de Janeiro: Imago; 1976. .

Chart 1 shows the distribution of the courses in which the coordinators were interviewed sub-divided among the three Higher Education Institutions.

Chart 1
Distribution of the number of hours and approach of the subject of health of the black population in the courses participating in the research.

As a methodology, we chose Content Analysis (CA), which includes a set of methodological tools that are constantly improved and applied to diverse discourses 2525. Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011. , mainly in the area of social sciences. This methodology identified structuring elements of the thinking common to the academic environment in relation to the theme, revealing beliefs and values through the discourses of course coordinators, reflecting their daily life.

Each coordinator responded to an in-depth interview guided by a script of semi-structured issues, aiming to produce a “finality oriented conversation” 2626. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec; 1992. in which the interviewee discusses subjects relevant to the study in question. The interviews were analyzed based on the content analysis in order to identify the importance attributed by the coordinators to the health theme of the Black population and, specifically, what is the way to make reality this theme in the curriculum of the courses. The curriculum grades of the academic years of 2015 and 2016 were also analyzed through documents provided by the HEI and/or available on the institution’s website, as directed by the academic secretariat and/or coordinators. Data collection was done through documentary analysis, being divided into two categories: compulsory and elective subjects.

The methodology used in the curriculum analysis of the courses was based on that proposed by Calais and Pacheco 2727. Calais SL, Pacheco EMC. Formação de psicólogos: análise curricular. Psicol Esc Educ [Internet]. 2001 [citado 14 Set 2016]; 5(1):11-8. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-85572001000100002&lng=pt&tlng=pt
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in the evaluation of the training curriculum of psychologists, having as one of the types of analysis the verification of the existence or absence of relation of content in the disciplines. The curriculum was obtained through teachers and/or students through shortcuts to access the digital platform on the institutions’ website.

Based on the collected data, the results were described in Table 1 , divided by compulsory and/or elective discipline, multiprofessional or traditional disciplinary approach, discipline name and workload.

The study was submitted and approved by the Ethics Committee of ABC Medical School under the number CAAE 4677815.5.0000.0082. This research has also the approval of the directors/deans for the participation of the institution in the same. A research addendum was sent to the ethics committee with the consent term of the co-participant of the School of Public Health. All interviews were conducted by the first author of this article and all the coordinators signed a Free and Informed Consent Term.

The dialogue with the coordinators of the health courses

Of the total of the interviewees, 10 were women and 2 were men, which shows the “feminization” of health courses 2828. Haddad AE, Morita MC, Pierantoni CR, Brenelli SL, Passarella T, Campos FE. Formação de profissionais de saúde no Brasil: uma análise no período de 1991 a 2008. Rev Saude Publica [Internet]. 2010 [citado 23 Out 2016]; 44(3):383-93. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102010000300001&lng=pt&tlng=pt
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. Regarding racial self-identification, 75% (9) declared themselves to be white, 17% (2) did not respond and 8% (1) declared themselves to be brown. In a Black majority country, such as Brazil, it would be pertinent to carry out future ethnographic studies that investigated the influence of this profile on the treatment of ethnic-racial issues within the university curriculum, especially with regard to what is conventionally called “Hidden curriculum”(h h The term “hidden-curriculum” can be defined as “a set of traditions, values, norms, rules, routines that are not written in any school document but transmitted consciously or unconsciously between teachers and students and between students and students and can generate both a virtuous cycle and a vicious cycle of attitudes and actions that can mark the body and soul of students during the school period or for the rest of the life outside of school” (p. 9). )2929. Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students’ perceptions of teaching. BMJ [Internet]. 2004 [citado 23 Out 2016]; 329:770-3. Disponível em: https://www.bmj.com/content/329/7469/770
https://www.bmj.com/content/329/7469/770...
,3030. Akerman M. “Currículo oculto”: há que se evidenciar ainda mais a sua associação com preconceitos, abusos, humilhações, e violências nas escolas médicas. Cartilha da DENEM. São Paulo: Faculdade de Saúde Pública; 2015. p. 9-11. . In theory, the ethno-racial profile of the coordinators would be irrelevant, since existing regulatory frameworks make institutions responsible for dealing with these issues. However, the set of answers offered by the course coordinators offers a revealing panorama that is analyzed below.

When the interviewees were asked if they identified any relationship between Race/Color and Health, the group was divided between those who perceived some relationship and those who did not. It is worth to say that the majority of those that glimpsed some relation, attributed the causal nexus to the biological differences, and a smaller part to the historical factors. As can read in the testimonial below: "“I think genetic issues I believe exist, as there are even I think among ... among whites, among Blacks, but I think ... and Asians, ..., like hypertension in the black race and more predisposition to osteoporosis"(coordinator 8).

Among those who did not identify the relationship between race/color and health, it is the idea of the primacy (or exclusivity) of socioeconomic inequalities that is a causal link between health inequalities, and there is no room for racism as a possible determinant, as one can read in the following statement:

“Yes, I believe. The campus here has a broader discussion of the concept of health, we have the understanding in the formation of our student that there is a relationship of living conditions, work, housing, leisure, education, access to health service as the production of care and its determinants with the subject’s health. In this sense, people understand that in Brazil the most disadvantaged classes have a large concentration of people of a color of a race that curiously or not curiously, coincidentally or not Brazil has a history in relation to this, much of this population group is related with the black color.” (coordinator 1).

In this approach, reality “race” could figure at most as a consequence of economic inequalities, but not a Social Determinant of Health:

“...the race would have some influence for the epidemiological occurrence of one ... of a particular disease more than another, but what we have perceived today is that the socio-environmental conditions end up being the great determinant. So the people who end up living in the condition of greater vulnerability ... are ... they end up being more susceptible to certain health/disease processes ... of course this is not ... it is not a rule for everyone, right?!” (Coordinator 4)

We point out the contradiction between the implications of this testimony and the existence of a significant bibliography produced within the scope of the social and human sciences in health pointing to the existence of diverse intersections between race, class, gender and other markers of difference 3131. Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social determinants of health discussion paper 2 (policy and practice). Genebra: OMS; 2010. p. 9-63.

32. Crenshaw K. Cruzamento: raça e gênero. Brasília: Unifem; 2004.

33. Crenshaw K. A intersecionalidade da discriminação de raça e gênero [Internet]. 2012 [citado 23 Jun 2013]. Disponível em: http://www.acaoeducativa.org.br/fdh/wp-content/uploads/2012/09/Kimberle-Crenshaw.pdf
http://www.acaoeducativa.org.br/fdh/wp-c...
-3434. Taquette SR. Interseccionalidade de gênero, classe e raça e vulnerabilidade de adolescentes negras às DST/AIDS. Saude Soc [Internet]. 2010 [citado 23 Jun 2016]; 19 Supl 2:51-62. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-12902010000600006&lng=pt&tlng=pt
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. On the contrary, what is perceived is that in this space, the argument used to explain Brazilian race relations is the same as that found in common sense 3535. Bernardino J. Ação afirmativa e a rediscussão do mito da democracia racial no Brasil. Estud Afro-asiát [Internet]. 2002 [citado 23 Out 2016]; 24(2):247-73. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0101-546X2002000200002&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s...
,3636. Spiassi AL, Faustino DM, Viso ATR, Cavalheiro LO, Vichessi DF, Sant’Anna V, et al. O movimento negro do ABC Paulista: diálogos sobre a prevenção das DST/Aids. Saude Soc. 2010; 19(2):121-33. , as can be seen in the following statements: “I think so, maybe there is ... but I think it is difficult to measure in our country ... our population is miscegenated “(coordinator 7) or yet “Well in my opinion, there is no relationship between health and, race, color. They are the same and should be treated in the same way” (coordinator 5).

When asked the opinion of the coordinators of the courses regarding the inclusion of the race/color question in the SUS medical records, it was observed that the group is divided among those who believe that the procedure can help to better understand the possible relations between race and health, and those who believe that the question could threaten the principle of universality. There is also a third group that expressed doubts about the validity of the collection, since it had never thought about the subject.

In relation to the first group, composed of coordinators favorable to the collection, we found: “I think the color, it is a given because also you, again, see the issue of inequality, right?” (Coordinator 2). Another coordinator argues:

“We know that the Black person, of course, has specific health issues... that needs to be considered, right? So, I guess that’s why. And, and even in terms of statistics, who are the ones demand for the health service, how are we going to give dimension to that health service, right?” (Coordinator 9)

Among those who expressed opposition to the collection of this data in the service, the following arguments were recorded: "Because it is about the health of the population, I understand it like that, the health of population is the health of population. It does not matter if this population is Black, White, Asian, whatever. Right?" (coordinator 8)

Another interviewee stated: "I believe that yes and no, I believe it is important, but thinking, in research ... But at the same time, if we think about the idea of SUS, of universality, equality, ‘health for all’ , then it may not matter so much" (coordinator 10).

Another interviewee emphasized that the collection of the race data would only be justified in the case geared to the finding of biologically determined diseases:

"Only in relation to ... perhaps the incidence of certain diseases to help in the diagnosis ... for you to help in the treatment, of course, in the genetic point of view those that have more incidence could have some importance. Otherwise you do not. I am of the opinion that no." (coordinator 3)

Finally, one of the people interviewed stated that they had not thought about the subject before: "I confess that I had never specifically thought about this ... in that respect right?! But so, if you ask me what is done with this information I ... I confess that I never stopped to think right? ... It is information that really is important or not, right?!..." (coordinator 4).

One of the issues of the in-depth interview referred to the coordinator’s opinion on the need for the health issue of the Black population in health curricula. Despite the aforementioned statements, the interviewees were unanimous in affirming the importance of ethnic-racial themes in the training of health professionals:

“I think so, right. Even to bring the discussions, in relation to the history, to the culture, of the Black population, which is important because it, well, it is inserted in the Brazilian population, it is part ... I believe that the students have to know , and you must have, that knowledge, in your studies, during your studies.” (coordinator 10)

In spite of the unanimity, some interviewees showed that they are betting on the theme of equality, and not on the recognition of differences, as the driver of racial debate in health courses, as we read: “Well in my opinion, there is no relationship between health and, race, color. The equals (sic) and should be treated in the same way.” (coordinator 5).

Another question sought to investigate the existence or absence of the health issue of the Black population in the planning or evaluation of the curriculum under the coordination of the interviewees. The answers showed that the subject is addressed in elective subjects (Gender, Race and Ethnicity, and History and Afro-Brazilian Culture) and in basic subjects (Anthropology, Epidemiology, Collective Health/Public Health, Work and Health and Politics) and integrating activities such as university extension and supervised internship, carrying out this topic.

Only one course chose not to approach the subject because it understood that equality must be preserved in teaching and that there is no differentiation in the way patients are treated.

The set of responses allowed to create the Figure 1 .

Figure 1
The Black Population Health Approach in the Coordinated Course

Attention was drawn to the approach taken regarding mentioning the compulsory nature of the Ministry of Education as a great stimulator to introduce the topic in courses. What varied, substantially, can be expressed in the following question: what meanings do the coordinators attribute to the normative obligation? As you can read in the following testimony: “Actually, there is a law, from the Ministry of Education, right, that requests that the curricula have this discipline inserted in the formation. So we put it as an option” (coordinator 10). Another interviewee stated that she did not see any problems in the regulations, or in offering the topic, but indicated that the course dealt with the subject in an optional manner: “Yes, we do, we have, today... well, now it’s been a while since we have included, as a subject, optional, in the curriculum of the course, and then we have ‘Afro-Brazilian history and culture ‘...” (coordinator 2)

In other courses, the health theme of the Black population is diluted in more general disciplines of collective health, without a direct focus, as in the following statements:

“The health that we discuss in the course is in the field of collective health debate ... We prepare for the field of Social Policies, for Health, for Social Security, for Social Assistance, Education, Environment... ” (coordinator 11)

“Then, also in the Policy discipline has a whole discussion, then they have to pick up some specific criticism to study. Not only looking directly at the Black population.” (coordinator 13)

Another coordinator expressed concern about the need to mainstream the issue, but revealed that the issue is still under discussion in the course:

“...A plastic Surgeon does not argue whether black skin differs a little in surgery, that is not an issue addressed, surgery, the clinical part that is not approached transversally as a matter during the whole course. And there is a discussion about this need to put this gradually in each discipline. That is to say, this information is addressed throughout the course, not only in the mandatory part, that you do in each discipline a little of the discussion of subjects in general, that is, that would be one of those that are needed throughout the course, we have discussed this in this new model of pedagogical project of how we will approach this throughout the course.” (coordinator 6)

There are also the courses in which the coordinators informed to approach the subject from the perspective of extension projects. However, an explicit mention was not made of the health issue of the Black population in any of the mentioned projects, only the possibility of the student facing this reality:

“...by a determined Health Service that identifies stories of subjects that this student will know through home visits and meetings, all accompanied, oriented, so that the student can dialogue with the subjects and understand Health in the history of that individual, ..., it will depend very much on the teacher who is guiding the student, to have this training and awareness that there he is faced with a particularity.” (coordinator11)

There was a coordinator who preferred not to approach the subject in the courses for not “seeing” differences between blacks and whites:

“It is then... In our course there is no difference, it is all the same. Wow! When it arrives in the fourth year of internship we only work with patients in need. We do not work with a particular patient, it’s SUS. Right? So any place, hospital, clinic is, collective room, all SUS. So I guess our student does not have it. He does not see the patient differently or among themselves students, they don’t see it that way.” (coordinator 5)

Another interviewee was also outraged by the compulsory nature of the topic in the curriculum and stated that the course will only deal with the subject if it is notified by the Ministry of Education:

“... the way it is put it became an obligation of course to have some discussion about health, but I think this was misplaced in the sense that, as a mandatory thing, then what happens, we do a an elective, a class, and from the legal point of view we have already fulfilled our role. So I do a course, then if there’s someone from the Ministry of Education who’s in charge of the college now, whoever gives information to the Ministry of Education will not say anything, they have that function, but that’s not covered transversely, addressed as a subject that is discussed in all disciplines.” (coordinator 6)

The last question was about the participation or not of the coordinators in some project, activity or discussion forum concerning the health of the black population. Only a small part of the interviewees had already participated in some action. Since most of those who participated, did so in a timely manner, except for the testimony that follows:

“This has even been debated because the government launched a project to improve the attention of people of the black race, saying that their healthcare was worse, so this created in the doctors, at least in some forums that I participated, even in the social network, a questioning of this type of approach.” (coordinators 6)

In other cases, participation, when there was, was punctual in activities such as Black Consciousness Week, occasional presence in forums, among others, as seen below:

“Not research... so I participated... so, following some forums there on the campus itself, right?... we ... this year was the third year that ... is ... has been organized an ... activity in the black conscience week...”. (coordinator 4)

“I already attended a seminar and tried to help, I do not know if it helped a lot. In fact, it had an initiative, one of the students that is from the Forum Against the Extermination of Poor, Black and Peripheral Youth.” (coordinator 12)

The other coordinators, who corresponded to the majority of respondents, stated that they had never participated in activities of this nature.

Conclusion

The results presented here suggest that, in spite of the relevant normative framework produced in the last 15 years on the integral health of the Black population, the subject still finds a set of difficulties of consolidation in the curriculum of the training courses of health professionals. Although the research was restricted to nine courses, twelve coordinators and three universities, it could offer important clues related to the field as a whole.

It was noted that the topic is already present in an important part of the investigated institutions, but still incipient in most cases. Nonetheless, the frequent reference to the obligation “imposed” by the Ministry of Education, rather than the recognition of importance, is referenced as a justification for insertion of the subject into the prescribed curriculum of the courses. On the other hand, the prescribed curriculum for health, in its presuppositions aimed at humanistic formation, seemed to find great challenges to its concretization, since a significant part of the anlyzed testimonies show clearer references to the values of universality and abstract equality (principle of isonomy), but ignores or does not understand deeply the references about the recognition of difference. An explanatory hypothesis of his position may be the lack of knowledge of the existing bibliographical production aimed at the analysis of racial equity/inequity relations in health. One nefarious effect, however, of the lack of references on the question posed is the invisibility of racism as a Social Determinant of Health. Another result of this is the waste of valuable opportunity to prepare future health professionals starting from the initial education process in a way that allows them to deal with these issues in their work environment in a humane and not purely technical way.

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  • f
    For the definition of health, we follow the concept enshrined in the Brazilian Federal Constitution of 1988, article 196: “Health is the right of everyone and the duty of the State, guaranteed by social and economic policHEI aimed at reducing the risk of disease and and universal and equal access to actions and services for their promotion, protection and recovery.”
  • g
    “The interdisciplinarity is characterized by the intensity of the exchanges between the specialists and by the degree of real interaction of the disciplines within the same research project” (p. 74).
  • h
    The term “hidden-curriculum” can be defined as “a set of traditions, values, norms, rules, routines that are not written in any school document but transmitted consciously or unconsciously between teachers and students and between students and students and can generate both a virtuous cycle and a vicious cycle of attitudes and actions that can mark the body and soul of students during the school period or for the rest of the life outside of school” (p. 9).

Publication Dates

  • Publication in this collection
    04 Feb 2019
  • Date of issue
    2019

History

  • Received
    22 Feb 2017
  • Accepted
    15 Mar 2018
UNESP Distrito de Rubião Jr, s/nº, 18618-000 Campus da UNESP- Botucatu - SP - Brasil, Caixa Postal 592, Tel.: (55 14) 3880-1927 - Botucatu - SP - Brazil
E-mail: intface@fmb.unesp.br