Black Women’s Health and Primary Health Care: Between the Coloniality of Care, Everyday Struggles, and Confronting RacismAbstract
This essay examines the social position of black women, particularly in primary health care (PHC), and highlights how racism, sexism, and inequalities of class and geography contribute to their vulnerability. Using intersectionality as a theoretical-political tool and a critique of the coloniality of care, the text demonstrates how the universalist logic, based on supposed neutrality and an insufficiently developed approach to racial equity, renders the vulnerabilities of these women invisible, along with the impacts on their living conditions, especially in contexts such as the streets, favelas, and incarceration. It questions the effectiveness of approaches that, by failing to consider the multiple layers of oppression, reinforce stereotypes and contribute to the perpetuation of social disadvantages. The essay emphasizes the leadership of black women in denouncing institutional racism and in creating collective and ancestral care technologies. It underscores the urgency of articulating and mainstreaming public policies, with emphasis on the National Policy for the Comprehensive Health of the Black Population and the National Policy for the Comprehensive Health of Lesbians, Gays, Bisexuals, Transvestites, and Transsexuals, highlighting significant ongoing initiatives. It concludes that equitable care requires confronting racism within PHC practices grounded in black feminist epistemologies and the valorization of re-existence experiences within the territories.
Keywords:
Black Women’s Health; Racism; Intersectionality; Vulnerability Production; Coloniality.
Resumo
Ao analisar o lugar social de mulheres negras, em especial na Atenção Primária à Saúde, esse ensaio evidencia como o racismo, o sexismo e as desigualdades de classe e território operam na produção de vulnerabilidades. Tendo a interseccionalidade e a crítica à colonialidade do cuidado como ferramentas teórico-políticas, problematiza como a lógica universalista, alicerçada numa suposta neutralidade, e a equidade, insuficientemente trabalhada quanto à questão racial e de gênero, invisibilizam as vulnerabilizações dessas mulheres e as repercussões nas condições de vida, especialmente nos contextos de rua, favela e cárcere. Questiona a eficácia de abordagens que não levam em consideração múltiplas camadas de opressão, reforçam estereótipos e contribuem para a manutenção de desvantagens sociais. Destaca o protagonismo de mulheres negras na denúncia do racismo institucional e criação de tecnologias coletivo-ancestrais de cuidado. Aponta a urgência em articular e transversalizar políticas públicas, com destaque à Política Nacional de Saúde Integral da População Negra e Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais, e destaca significativas iniciativas em curso. Conclui-se que um cuidado equânime exige o enfrentamento ao racismo e sexismo nas práticas da APS, fundado em epistemologias feministas negras e na valorização de suas experiências de reexistência.
Palavras-chave:
Saúde de Mulheres Negras; Racismo; Interseccionalidade; Vulnerabilização; Colonialidade.
Presentation
Universality, comprehensiveness, and equity, as well as regionalization, hierarchical organization, and social participation, are the pillars that structure the Brazilian Unified Health System (SUS). Primary Health Care (PHC), the gateway and locus for the organization and management of comprehensive care, is central to the operationalization of these pillars and to guaranteeing health as a constitutional right for the Brazilian population. These important and foundational milestones of the SUS should imply a review and deepening of the conceptions of rights, citizenship, and equity that inform its policies and actions, taking into account the profound disadvantages, historically produced, that define the social place of populations, based on intersections such as class, race, and gender, in the pursuit of reparation. Thus, this essay discusses the maintenance of institutionalized logics and exclusionary and vulnerability-inducing practices, bringing to the debate analytical keys such as coloniality and racial devices (Carneiro, 2023), as they prevent the full right to health for a significant part of the Brazilian population, with a special focus on black women.
The (un)civilizing landmarks of colonialism and modern coloniality define which historically produced groups suffer social disadvantages and inequalities. Racism, white supremacy, and the construction of otherness define the process of occupying places in the world, the recognition of the human condition, and the right to citizenship. In the modern Brazilian colonial scenario, black women constitute a group deprived of the right to be subjects (Gonzalez, 2018).
We speak of ourselves, in the first person plural, as a collective of black women, a historically vulnerable group whose words written here reflect and are anchored in our life trajectories and our academic experience. We are specialists, masters, and doctors in the fields of public health and the human, social, and biomedical sciences.
We will address issues that present themselves as obstacles and challenges for a Primary Health Care system that aims to operationalize the principles of the Brazilian Unified Health System (SUS) and conduct comprehensive health care. Analyses of life and death policies currently in place in Brazil and of social and health indicators, combined with the experience and activism of this collective, underpin our writing. The analysis of these challenges is not anchored in current interpretations regarding management, such as insufficient funding, or the organization of healthcare networks, even though we agree with these assumptions. We analytically turn our gaze to the “path of history” related to our social formation process and current hegemonic interpretations, which continue to be translated into public policies. We question assumptions that forge a Primary Health Care system incapable of recognizing and providing care attentive to the intersection of racism, patriarchalism, cisheterosexism, and other social markers of inequality that found and organize this society.
We discussed social demarcations that affect the health-illness and care process of black women, understood as subjects traversed by oppressions, vis-à-vis the role of Primary Health Care (PHC) as a gateway to the right to health. Understanding black women as integral and plural subjects, we analyzed the expressions and repercussions of these oppressions in their conditions of existence (worldviews) and health, especially women experiencing homelessness; those with experience of incarceration; victims of state violence; and lesbians, transvestites, and transsexuals, who are violated daily and made invisible in health practices.
By mobilizing policies such as the Street Clinic, the Family Health Strategy, and the Women’s Health Care Pathway and actions aimed at the LGBTQIA+ population, we problematize the historical and daily challenges faced by these women and the still-insufficient approach in collective health and public policies. We highlight their exclusion from normative-assistance models, marked by the primacy of biological risk and the medicalization of inequalities. Problematizing the challenges imposed on these women implies breaking with the reproduction of neoliberal necropolitical capitalism in health spaces.
In contrast, we bring the perspective of Latin American black feminism (Gonzalez, 2018) on vulnerabilization, given its centrality to care, to bear on health care for black women from a critical and emancipatory perspective. We employ the intersectional lens (Collins, 2019) as an interpretive framework for the diverse experiences of illness and care faced by black women, shaped by the intersection of various social markers of inequality, without reproducing essentialism, silencing, and oppressions, and capable of proposing pathways toward effective social justice. We propose theoretical, methodological, and analytical epistemes forged within black intellectualism, aiming to confront the institutional racism prevalent in healthcare and advancing toward a truly democratic, comprehensive, equitable, and universal system of care.
Maria Lugones (2019) states that black women are not recognized as women, nor as subjects. Our existence in modern/colonial society is presented in the fractures of coloniality, in subterranean paths that question the imposed colonial order. From these margins, we produce knowledge, confronting the coloniality of knowledge and epistemicide (Quijano, 2005; Carneiro, 2023), which silence and invalidate feminist and black intellectual production. Patricia Hill Collins (2019) refers to us as “outsiders within”-black women who courageously embody the space of scientific knowledge production. As marginal navigators in the fractures of the modern/colonial world, our perspectives bring to the center of the analysis aspects intentionally made invisible by the modern/colonial world system, but essential in guaranteeing health as a constitutional right.
Why problematize the place of racialized and gendered women in binary terms within Primary Health Care (PHC)? Policies, programs, and actions are anchored in frameworks such as health planning, situational analysis, territorially defined priority problems, guidelines, and protocols aligned with the principles and guidelines of the Brazilian Unified Health System (SUS). However, there is an imbalance in the fulfillment and effectiveness of these, due to the insufficient inclusion of racial/genderist considerations within these principles. We problematize the underlying references in the conceptualization and operationalization of these policies/programs.
The myth of racial democracy, as a value of political, economic, and epistemic elites, forges the idea of universality to strategically erase historically and socially produced differences (Nascimento, 2016), erecting the cisheteronormative white attribute as a reference and definer of the “normal body,” thus qualified to receive care. A similar analysis is made of the principle of equity, which, in policy terms, is informed by class inequality, concealing the fact that, in countries like Brazil, class hierarchies correspond to those of race. This argument also applies to the cisheteropatriarchal binary that defines the “normal body.” We are facing two important ‘phenomena’: institutionalized racism and LGBTQ+ phobia.
Gendered racism implies the daily reproduction of racial and gender inequalities in care processes. Here, we criticize the guidelines for the compartmentalization of policies, which separate care recipients, as well as the micropolitics of care. Planning instruments, as well as the women’s care pathway, have not foreseen and do not incorporate into their guidelines health inequalities for black, lesbian, transgender, and transvestite women, despite what the indicators discussed below show.
The National Primary Care Policy (PNAB) defines the Family Health Strategy (ESF) as a priority in the expansion and consolidation of primary health care in Brazil and fundamental in broadening the right to health and dignity (Brazil, 2017). Health promotion and disease prevention, multiprofessional structure, and territorial focus are some of the elements that make PHC in the ESF model powerful in producing health and care for black women. However, the coloniality that governs our society is ingenious in the art of producing and reinforcing colonial care practices by keeping black women deprived of subjectivity and as bodies traversed daily by necropolitics, ignoring the socio-racial determinants of their health conditions (Passos, 2020; Mbembe, 2018).
Discussing PHC in Brazil involves several milestones, such as the organizational proposal anchored in the essential and derived attributes brought by the white American intellectual, Starfield (2002). This work is relevant to the field of PHC; however, it suffers from analytical silences and hegemonic standardizations that sustain the ongoing maintenance of coloniality. Despite the importance of PHC milestones such as the notion of territory, her studies rarely discuss how intracultural systems of oppression and social markers of inequality limit the operationalization of these attributes. Take cultural competence as an example: forged in the coloniality of knowledge-power, it proposes respect for cultural diversity as a path to effective care. This approach does not necessarily rely on a non-exoticized perspective of knowledge outside the standards of Eurocentric Western science, maintaining significant elements of the hegemonic rationality of understanding and imposing care, in colonial terms, on non-hegemonic cultures. As a derivative of this attribute, it can be conceived that caring for black women would involve respecting religions of African origin and understanding the socially imposed images of control, but this does not necessarily mean recognizing the right to subjectivity and dialogue between rationalities of care.
Thus, it is evident that health policies, such as those related to communicable and non-communicable diseases, whose worst indicators refer to black people, as discussed later, are not sufficiently prioritized in government actions. It should also be highlighted that there is an issue of insufficient registration of race/color data in the SUS (Brazilian Unified Health System) information systems, a practice that obscures the disadvantages in the health conditions of the black population, supporting the myth of racial democracy and explanations of inequalities under the banner of class.
Socio-racial and gender disparities did not occur by chance; they are the result of a societal project rooted in coloniality-an ordering arrangement of global racial, economic, gender, and cultural hierarchy (Quijano, 2005; Lugones, 2019). Coloniality reinforces the production and normalization of inequalities based on race/color and gender through structures of power, knowledge, and subjectivity, which organize bodies, subjectivities, and territories while being anchored in legitimized structural violence. In discussing the subaltern position of the black population in monopolistic and industrial capitalism, Lélia Gonzalez (2018) denounces a structure that exploits, subalternizes, and makes precarious primarily black women.
According to Sueli Carneiro (2023), the colonial past remains latent in the Brazilian social imaginary, sustaining racialized gender relations that place black women at the base of the social pyramid, marked by objectification and dehumanization, in contrast to the universalizing discourse of female oppression.
Regarding the process of social hierarchization, Carneiro (2023) names epistemicide as a mechanism of erasure and appropriation of black culture, technology, and knowledge production. Abdias Nascimento (2016) deepens this analysis by situating epistemicide as a genocide that is not limited to physical elimination but operates in symbolic and spiritual destruction by prohibiting worldviews, silencing narratives, and discontinuing memories that sustain the complexity of black lives.
It is crucial to recognize that, even under the persistent attack of an epistemicidal project (Carneiro, 2023; Nascimento, 2016), black women continue to create and cultivate forms of existence founded on other rationalities, modes of care, cosmoperceptions, and pedagogies of freedom, which resist/re-exist the colonial order. This knowledge neither derives from nor diverges from what is called Western scientific knowledge; it exists on its own, with its own ontological legitimacy and profound connection to lived experience. It is embodied, collective, and trans-/intergenerational knowledge, forged at the crossroads between the body, territory, and memory, sustaining networks of affection, healing, and political mobilization, historically rendered invisible, though never fully silenced.
Although the text points to the presence of institutional racism in health policies and practices, it also highlights a significant shift, represented by recent initiatives from the federal government of the SUS (Brazilian Unified Health System), aimed at prioritizing equity policies, with a focus on the health of the black population.
The Diversity of Womanhood Includes Lesbians, Transvestites, and Transsexuals, Who Are Often Made Invisible in Healthcare Practices
Maria Lugones (2019) points out that gender coloniality has imposed biological dimorphism, the hierarchical male/female dichotomy, heterosexuality, and patriarchy as the norm and standard of social organization on modern Western societies. Cisheteronormative patriarchy, taken as the rule in our society, is the result of a violent process of colonial imposition that, according to the author, renders invisible other models of social gender organization that do not fit this pattern. The author also argues that, in relation to black women, because racism deprives us of the condition of subjects, we are objectified females produced according to the needs of the modern/colonial society in which we are embedded.
Thus, an intersectional perspective is essential to understanding the life-illness-death process of black LGBTQIAPN+ people in Brazil. Without an intersectional lens, we universalize these experiences from a white cishegemonic perspective. And when black people question the patriarchal cisheteronormative framework, the response is harsh, violent, and relentless; it is necessary to invisibilize, discard, and turn folkloric these experiences to maintain the modern/colonial order intact. Brazil is one of the most violent countries in the world for trans and transvestite people, with a significant gender and race bias. According to the 2025 annual report of the National Association of Transvestites and Transsexuals of Brazil (ANTRA), in 2024, only 86 of the 122 murder cases could have the race/color of the victims identified. Of that total, approximately 78% were black: black women/trans and transvestites are the group most susceptible to lethal violence in the country (Benevides, 2025).
For black transmasculine people, passing as cisgender exacerbates the violence. Being recognized as a black man is to be perceived as a social enemy, exposed to modern/colonial extermination. They live under constant fear of rape, imprisonment, or death. Although the focus of this essay is on black women, silencing this violence would be complicit in its social reproduction.
Black lesbian, bisexual, trans, and transvestite women need to fight to reclaim their existence. When we dare to break with the colonial imposition of heterosexuality, we reject the meager humanity that the modern/colonial gender system offers us by objectifying and hypersexualizing our bodies and affections. These women are diverse and have distinct experiences; therefore, reducing their experiences to a single standard would serve as a mechanism for essentializing and dehumanizing them. The intersectional lens allows this entire group to be recognized in its specificities and to receive healthcare in a truly comprehensive and equitable manner. It is a debate about the health and social inclusion of the LGBTQIAPN+ population, in which racialization and socio-historical contextualization are necessary, producing knowledge about gender and sexuality from other perspectives so that the institution of health does not operate as a tool of the modern/colonial imposition of gender.
The LGBT Policy (Brazil, 2013) proposes addressing health with equity and comprehensiveness for LGBTQIAPN+ people. It represents a relevant victory and advancement for organized social movements in civil society in the fight for the right to health, enabling an agenda of essential demands for those who deviate from cisheteronormativity. Notably, the policy fails to apply an intersectional lens in its elaboration and operationalization, ignoring the vulnerability of black people. Failing to recognize the intersection of racism, patriarchy, and cisheterosexism positions the white LGBTIAPN+ experience as the norm, ignores the effects of racial violence, and limits equitable access to health. Assisted reproduction, such as safe abortion, remains inaccessible to a large part of the population. Lesbian women and black people with uteruses are the most affected, resorting to home insemination and facing a higher risk of death from unsafe abortion (Vallandro et al., 2025).
The National Policy for Comprehensive LGBTQIAPN+ Health (Brazil, 2013) represents a significant advance in guaranteeing rights; however, both in its conception and implementation, it has failed to apply an intersectional perspective to its actions, favoring the non-recognition of racism as a fundamental aspect in the experience of a significant part of this population.
Existential Territory and Gendered Racism in the Context of Health, Policy, and Care for Black Women
Social and epidemiological indicators by race/color reveal the underrepresentation of the black population in access to work, housing, and income, and their overrepresentation in maternal and infant morbidity and mortality, reinforcing the urgency of government action against socio-racial disparities. Black women represent 52.5% of the Brazilian female population (sum of those who self-identify as black or mixed-race). From a socioeconomic perspective, black women have a lower average per capita income (R$ 1,764 vs. R$ 2,836) and a higher rate of informality (45.4% vs. 32%), highlighting the structural precarization of work (Brazilian Institute of Geography and Statistics [IBGE], 2023). Living conditions directly impact health outcomes. According to the 2019 National Health Survey, only 78.5% of pregnant black women had seven or more prenatal appointments, compared to 88.9% among non-black women (IBGE, 2020).
According to the 2024 Violence Atlas, 66.4% of femicides in 2022 victimized black women, and 33.6% victimized non-black women. The femicide rate was 4.3 per 100,000 black women and 2.2 per 100,000 non-black women, inequities that highlight racialized gender violence.
Despite primary health care coverage in Brazil exceeding 70%, black women continue to face greater barriers to access, lower resolution rates, and less continuity of care, especially in peripheral and vulnerable areas (Cobo, Cruz, & Dick, 2021). Inequalities do not stem from biological determinism but from the historical production of vulnerabilities forged by cisheteropatriarchal racism and sexism, reinforcing the urgency of an intersectional approach in public health.
This unequal health landscape, generally described by disembodied indicators, the “statistical nobodies,” materializes daily in the concrete lives of black women.
It becomes real in historically vulnerable social spaces, in existential territories (Guattari, 1992) shaped by the struggle to exist, despite deleterious material conditions, in a daily process of life-making, amalgamating social, political, and intersubjective relations marked by precariousness. Thus, we speak fundamentally of black trans women, transvestites, cis women, lesbians, and heterosexuals in favelas, streets, prisons, and healthcare spaces-all existential territories. It is on these that we focus, study, and raise our voices and writings in defense of rights, in unison with women from these diverse spaces. We problematize not only the historical conditions that forge inequalities, but also the policies and practices of care, their organizational and relational bases.
Paths to Exclusion: the Narrative of Black Women Experiencing Homelessness
Black women experiencing homelessness live at the intersection of historical exclusions, institutional oppressions, and everyday erasures, marked by colonial dehumanization and the denial of humanity imposed by gender coloniality (Lugones, 2019). Dissident and racialized “bodies” identified as black remain marginalized and exposed to multiple forms of violence, with their health affected by policies and practices of silencing, stigmatization, and abandonment.
Living on the streets, where their status as human beings is denied, diminishes their existence and makes them targets of successive expropriations, including home, rights, affections, and even their own subjectivity, with the state historically violating human rights through action or omission (Bravo da Silva; Oliveira; Albuquerque, 2025). They face sexual and physical violence, hunger, neglected diseases, and chronic psychological suffering, generally rendered invisible by biomedical approaches.
The PNAB (2017) provides for healthcare for homeless people, conducted by Street Clinic (CnR) teams, a component of the Psychosocial Care Network, based on mental health demands. However, there is no reference to care guided by practices to combat gendered racism, even though the population is predominantly black: 68% of homeless people in Brazil (Bravo da Silva; Oliveira; Albuquerque, 2025).
The alignment with the guidelines of the National Policy for Comprehensive Health of the Black Population (PNSIPN) is incipient, revealing the institutional erasure of racism as a social determinant of health (Brazil, 2009; Werneck, 2016).
Primary Health Care (PHC) can break down exclusions and barriers to access for black women experiencing homelessness by adopting anti-racist and decolonial practices. As a government strategy, it is essential to coordinate PHC-including the CnR-with the PNSIPN, particularly in areas related to: a) critical training of professionals who recognize race/gender in the social determination of the health-disease process; b) intersectoral actions: health with social assistance, housing, education, culture, and work; c) building bonds and listening as strategies for welcoming and caring.
As a collective of black women researchers developing studies on the repercussions of gendered racism on the health of black women experiencing homelessness, we dedicate ourselves to dialogical care practices with qualified listening and attentive reading of the intersection of social markers of difference (Gonzalez, 2018). As an example, we present the experience of the project “Elas em Cena” (Women on Stage), also known as “Quartas Delas” (Women’s Wednesdays), developed at “Espaço Normal” (Normal Space), of the social organization “Redes da Maré” (Maré Networks). The space is structured around listening and welcoming, promoted by harm reduction workers acting on the singularity of women experiencing homelessness, understanding the collective dimension of blackness. This listening allows for the monitoring of emerging demands-from guaranteeing the right to food, documentation, and health to strengthening the right to life.
Women in favelas, violence, and colonial care
The experiences of black women living in favelas point to dimensions that relate both to the production of life and to the prohibitions produced by domestic and institutional violence, both of which have a colonial origin (Passos, 2020).
In this sense, the struggle of activists from the favelas of Rio de Janeiro is marked by the denial of basic social rights such as health, food, housing, and public safety. Added to this picture is the systematic exposure to armed confrontations that end the lives of family members and loved ones (Willadino et al., 2024). These stories are characterized by unacknowledged grief and a sense of living death.
Institutional violence, as an expression of colonial care in the fields of health, social assistance, and justice, promotes violations through the punishment and extermination of black bodies and behaviors under the guise of protecting vulnerable individuals. From this perspective, black women experience the loss of their children, receiving only impunity and permanent trauma as responses. However, problematizing care as an ontological need of the social being requires questioning bourgeois sociability, grounded in racism, patriarchy, and class inequalities (Passos, 2020). In turn, the normalization of racial hierarchies (Quijano, 2005) creates the context in which black women from marginalized communities systematically experience institutional violence.
Passos (2020) lists three forms of manifestation of this phenomenon: as a zone of non-being, as killable bodies, and as a stereotyped object. An example of this stereotyping is the racist and sexist discourse about the pregnancy and motherhood of black women, according to which they possess a greater capacity to endure the pain of childbirth and a lower need for care. The author argues that institutions, by denying the body, motherhood, and love, act in a project to contain the civic existence of black women.
In ten years of expansion into vulnerable territories in the city of Rio de Janeiro, PHC has reduced preventable deaths among the black population. Yet, it has not included guidelines to combat racial inequity in access to care. Despite the recognition of racism in the social determinants of health/illness, a gap persists between norm and practice, especially for those most affected by intersectional oppressions (Brazil, 2009).
Women with Experience of Incarceration and the Right to Health
Studies involving incarcerated women highlight the urgent need to discuss mass incarceration and its effects on the right to health of black women. Collaboration with social movements and analysis of strategic documents help us understand the increase in the prison population in the country, the vulnerabilities, and the demands of women with experience of incarceration.
The panorama of incarceration in Brazil places us third in the global ranking of prison populations, where most inmates are young, black, and have low socioeconomic status and low levels of education. According to the National Secretariat of Penal Policies, there are 888,272 people deprived of liberty in the country (June 2024), of which 94.3% (837,626) are men and 5.7% (50,646) are women, in a simplified binary gender logic (Brazil, 2025).
Although men still make up the majority in the prison system, the incarceration of women grew by 567.4% between 2000 and 2014, compared to 220.2% among men. From 2016 to 2024, it jumped from 39,751 to 50,646, impacting penal and security policies (BRAZIL, 2025). The occupancy rate of Brazilian prisons exceeds the number of available spaces, highlighting overcrowding that amplifies human rights violations in prison. It is not a matter of demanding more prison spaces, but rather of confronting over-incarceration “as a broader structural problem, linked to a process of criminalizing poverty” (Simas, 2024, p. 26).
Black women of reproductive age are the majority in Brazilian prisons, serving sentences in closed regimes, accused of committing non-violent crimes such as drug trafficking. This overrepresentation in spaces of criminal punishment reproduces centuries of penal selectivity (Simas, 2024), associated with the country’s structural racism. The criminalization of poor women affects them and their families, as they usually provide financial and emotional support. Prison under the pretext of correction operates as a space of distortion, with the argument of the war on drugs legitimizing the mass incarceration of black bodies-with an even greater impact on black women (Borges, 2019).
Racism structures the degrading living conditions in the Brazilian prison system, demanding reflections on necropolitics and penal abolitionism in the face of the racial and social hierarchization that makes black women vulnerable. Carrascosa (2023, p. 7) speaks of the “modernized permanence of the history of slavery in our black lives, in the prison and policing systems that are omnipresently deadly to our bodies,” which will mark our subjectivities as a colonial project legitimizing the State as a historical agent of violence.
Borges (2019) points out that the criminal justice system ignored the category of gender, and only at the beginning of the 20th century did female punishments begin to resemble male punishments, generating “equality” in repression, but not in the recognition of the specificities of incarcerated women. This intensified oppression without addressing their demands. Among the violations are negligence in the care of pregnant and postpartum women and the absence of basic items such as sanitary napkins and toilet paper, highlighting the lack of gender equity in Brazilian prisons (Borges, 2019, p. 64).
National and international documents allow us to discuss important milestones concerning the rights of the incarcerated population, especially women’s health. The National Policy for Comprehensive Healthcare for People Deprived of Liberty in the Prison System (PNAISP, 2014a) integrates prison health into the SUS (Unified Health System) network through coordination between the Ministries of Health and Justice. It recognizes the diversity of the incarcerated population, including the specific needs of women, and defines prison units as entry points and points of healthcare attention. Primary care teams and prison health services are responsible for ensuring comprehensive care within prisons and coordination with the network outside prisons. More than a decade after the PNAISP, challenges persist regarding its implementation and the effectiveness of state and municipal action plans.
The National Policy for Attention to Women in Situations of Deprivation of Liberty and Released from the Prison System (PNAMPE), a joint initiative of the Ministry of Justice (MJ) and the Secretariat of Policies for Women (SPM), emphasizes the recognition of the specificities of women’s social groups and establishes the following guidelines: confronting violence against women deprived of liberty; joint and coordinated work among governmental spheres for the implementation of the policy; participation of civil society in social control; and humanization of the conditions of serving sentences and guaranteeing rights such as health, education, food, and protection of motherhood and childhood (Brazil, 2014b). In 2010, in response to the global increase in the female prison population, the United Nations Rules for the Treatment of Women Prisoners and Non-Custodial Measures for Women Offenders were created within the framework of the UN Economic and Social Council. Brazil is a signatory to the document, which considers gender-specific issues in incarceration, both in the execution of sentences and in prioritizing non-custodial measures to prevent women from entering prison. But what progress has been made in this regard?
Given the issues of race and gender mentioned, the experience of incarceration in Brazil is shaped by intersections that determine the vulnerability of lives deprived of liberty, where incarcerated women suffer double invisibility due to both their imprisonment and their nonconformity to societal expectations of the female body (Borges, 2019).
Towards an Anti-Racist and Anti-Sexist Primary Health Care Agenda
As we have discussed, the intersection of oppressions exacerbates violations against black women, who are frequently reduced to submission and servitude. This perverse logic, in addition to racism, imposes the disqualification of their identities and ways of life, legitimizing their invisibility in public policies and social representations (Gonzalez, 2018).
In this essay, we use powerful analytical keys from black feminism. Intersectionality, as an analytical and political tool, highlights how race, gender, class, and territory operate together in the vulnerability of people’s lives. Collins (2019) defines images of control as social constructs that restrict our place in society. Gonzalez (2018) shows that, in Brazil, black women have historically been situated in hypersexualization, subservience, or the mothering of white children. Breaking these roles means living within the fractures of coloniality, confronting daily violence.
Control and invisibility are maintained through institutional mechanisms that preserve privilege and naturalize exclusion, without confronting structural racism. The failure to produce indicators based on race/color and gender identity, the absence of cross-cutting policies, and the erasure of “marginalized voices” in public decisions constitute systematic forms of the racial apparatus (Carneiro, 2023).
Health policies aimed at populations outside the white cisheteronormative matrix often render social struggles invisible. Black women’s movements denounced racism and sexism as part of the determinants of health inequalities, driving the creation of the PNSIPN (Brazil, 2009). Thus, a commitment was made to confronting institutional racism in health and to actions aimed at: a) Intersectional recognition of the specificities of black women in health services; b) full and equitable access to care; c) confronting obstetric violence and maternal mortality; d) combating institutional racism; e) promoting reproductive health, respecting the autonomy of black women; f) training and capacity building of health professionals for anti-racist care.
Sixteen years after its creation, the PNSIPN (National Policy for the Comprehensive Health of the Population) continues to have low implementation within the SUS (Brazilian Unified Health System), and its effectiveness and adherence by states and municipalities still face obstacles (Batista, 2020). The synergy between the policies highlighted here and the mainstreaming of actions that consider population diversity is still insufficient within the SUS, including Primary Health Care.
Nevertheless, there is progress! Recent initiatives stand out, such as the creation of the Alyne Network (Brazil, 2024), a significant federal initiative focused on the health of black women, in light of the serious inequalities and international condemnation of Brazil for the negligent death of Alyne Pimentel, a 28-year-old pregnant black woman, in Belford Roxo, State of Rio de Janeiro. The Alyne Network assigns a strategic role to PHC, providing for transfers to states and municipalities, which must adhere by means of local plans and reduce maternal mortality for black women. The target is 50%, considering that they are the most affected by obstetric racism-expressed in omissions and violence in care, such as fewer prenatal consultations, failures in examination protocols (syphilis and HIV), less presence of companions during childbirth, and less access to analgesia (Criola, 2021). This 2021 report from the Criola NGO reinforces its long-standing denunciations regarding the impact of racist cisheteronormative patriarchy on the living and health conditions of black women.
For these women, discussing health means discussing social justice, historical redress, and the right to life; it is therefore essential that PHC consolidates itself as a space of welcome and renewal, strengthening care through active listening, emotional bonds, and anti-racist, culturally grounded practices, with a view to promoting health equity.
Governmental responses to social pressures, especially in the face of the effects of racism on black women, demonstrate the power of their movements. These achievements result from the historical and collective struggles of black women. Thus, for our academic-political collective, joining forces with the diversity of marginalized women is strategic to amplify their demands and worldviews, recognizing not only their fragilities and vulnerabilities but also the resistance strategies that guide the right to health and the formulation of policies.
Financing:
Acknowledgments:
We appreciate the technical and financial support from the PMA Program, of the Vice-Presidency for Research and Biological Collections - Oswaldo Cruz Foundation (Fiocruz).
We thank the black women participating in our initiatives for their trust, attention, and willingness to engage in dialogue, and exchange knowledge.
Data Availability Statement:
The research data are now available.
References
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