Abstract

This study discusses to what extent the inclusion, or not, of the race/color variable in epidemiological analysis of the COVID-19 pandemic can work as an external manifestation of necropolitics and as a producer of health inequities. We conducted a literature review on 09 articles, and on Scientific Electronic Library, PubMed and Virtual Health Library databases. We also conducted a documental analysis on 27 epidemiological reports from all the federal states and the Federal District of Brazil. We did not see much information regarding race/color, which can be interpreted as an intentional omission in order to hide those who the epidemics affects the most. The denial of basic and fundamental rights is the element that characterizes the larger racist structure of Brazil’s COVID-19 policies.

Key words
Racism; Black population; Health equity; Pandemic; COVID-19

Introduction

On March 11, 2020, due to the COVID-19 fast dissemination in many continents, the World Health Organization (WHO) declared it pandemic. Although the disease is considered a global threat it is known that its propagation affects specific social groups in different ways¹1 Noronha K, Guedes G, Turra C, Andrade M, Botega L, Nogueira D, Calazans JA, Carvalho L, Servo L, Ferreira MF. Pandemia por COVID-19 no Brasil: análise da demanda e da oferta de leitos hospitalares e equipamentos de ventilação assistida segundo diferentes cenários. Cad Saúde Pública 2020; 36(6):e00115320.. Baqui et al.²2 Baqui P, Bica I, Marra V, Ercole A, van der Schaar M. Ethnic and regional variations in hospital mortality from COVID-19 in Brazil: a cross-sectional observational study. Lancet Glob Health 2020; 8(8):E1018-E1026. analyzed the Brazilian Influenza Epidemiological Surveillance Information System, and it pointed out that non-white people are at higher risk of dying from COVID-19.

The effectiveness of the preventive measures that the Ministry of Health recommended are unrealistic for low-income Brazilians. These are policies that maximize existing social inequalities. A large portion of the Brazilian population, for example, has neither access to water nor money to buy and use hand sanitizers. Informal economy and “favelas” are also obstacles to implement the WHO recommendations which Brazilian states have adopted and enforced, such as social distancing³3 Bardi G, Bezzera W, Monzeli G, Pan L, Braga I, Macedo M. Pandemia, desigualdade social e necropolítica no Brasil: reflexões a partir da terapia ocupacional social. Rev Interinstitucional Bras Terapia Ocupacional 2020; 4(3):496-508..

According to the Brazilian Institute of Geography and Statistics (IBGE)⁴4 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese de indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2018., non-white people are more affected by social restrictions. An analysis that took into consideration race/color showed that 47,3% of black people in Brazil work in informal economy compared to 34,6% of white people. Moreover, black people’s per capita home income is R$ 934, while white people’s is R$ 1,846⁴4 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese de indicadores sociais: uma análise das condições de vida da população brasileira. Rio de Janeiro: IBGE; 2018..

The pandemic in Brazil exposes and exacerbates historical problems that affect not only Brazil’s public health, but also its economy, general structure, and politics. Brazil is considered a multiethnic country, but its history reveals a racist structure that subjugates and circumscribes black people to the edges of public policies⁵5 Goes E, Ramos D, Ferreira A. Desigualdades raciais em saúde e a pandemia da Covid-19. Trab Educ Saude 2020; 18(3):e00278110.

6 Barata R. Epidemiologia e políticas públicas. Rev Bras Epidemiol 2013; 16(1):3-17.^-77 Revista Consultor Jurídico. Defensorias pedem que coleta de dados da Covid contemple registro de raça e cor [Internet]. 2020 [acessado 2020 Jul 10]. Disponível em: https://www.conjur.com.br/2020-jun-17/defensorias-pedem-dados-covid-contemplem-raca-cor
https://www.conjur.com.br/2020-jun-17/de... . The pandemic enhanced the existing overlap of social and racial inequalities in Brazil⁵5 Goes E, Ramos D, Ferreira A. Desigualdades raciais em saúde e a pandemia da Covid-19. Trab Educ Saude 2020; 18(3):e00278110.^,88 Biato S, Oliveira A. Racismo Institucional na Saúde. Rev Serv Soc UNIGRANRIO 2019; 1(3):118-138.^,99 Araújo D, Santos W. Raça como elemento central da política de morte no Brasil: visitando os ensinamentos de Roberto Esposito e Achille Mbembe. Rev Direito Práx 2019; 10(4):3024-3055..

It is essential to recognize that identifying the morbimortality epidemiological profile, especially during public health emergencies, is fundamental to outline public policies that could mitigate these emergencies⁶6 Barata R. Epidemiologia e políticas públicas. Rev Bras Epidemiol 2013; 16(1):3-17.. However, the COVID-19 data gathered in the country reveals that the shortage of race/color data makes it impossible to verify the impact of the pandemic on this population accurately, and it hinders the development of specific strategies⁷7 Revista Consultor Jurídico. Defensorias pedem que coleta de dados da Covid contemple registro de raça e cor [Internet]. 2020 [acessado 2020 Jul 10]. Disponível em: https://www.conjur.com.br/2020-jun-17/defensorias-pedem-dados-covid-contemplem-raca-cor
https://www.conjur.com.br/2020-jun-17/de... .

The non-inclusion of this variable on daily COVID-19 epidemiological reports corroborates with what several authors¹⁰10 Werneck J. Racismo institucional e saúde da população negra. Saúde Soc 2016; 25(3):535-549.

11 Soares Filho A. O recorte étnico-racial nos Sistemas de Informações em Saúde do Brasil: potencialidades para a tomada de decisão. In: Batista L, Werneck J, Lopes F, organizadores. Saúde da população negra. Brasília: ABPN; 2012. p. 49-69.

12 Romero D, Maia L, Muzy J. Tendência e desigualdade na completude da informação sobre raça/cor dos óbitos de idosos no Sistema de Informações sobre Mortalidade no Brasil, entre 2000 e 2015. Cad Saúde Pública 2019; 35(12):e00223218.^-1313 Kabad J, Bastos J, Santos R. Raça, cor e etnia em estudos epidemiológicos sobre populações brasileiras: revisão sistemática na base PubMed. Physis 2012; 22(3):895-918. say about the lack and/or incompleteness of the race/color variable in the epidemiology, public health, and health social sciences fields. The position adopted by the State during the pandemic denounces the unfair, avoidable, unacceptable, and inhuman character that the public health policies can undertake¹⁴14 Buss P, Pellegrini F. Iniqüidades em saúde no Brasil, nossa mais grave doença: comentários sobre o documento de referência e os trabalhos da Comissão Nacional sobre Determinantes Sociais da Saúde. Cad Saúde Pública 2006; 22(9):2005-2008..

Based on the premises of the social determinants of health, this article focuses on discussing how the inclusion (or not) of these determinants on the COVID-19 pandemic epidemiological analysis manifests and contributes to the necropolitics and increases unjust and avoidable health inequities.

Thus, this article tried to fill this gap without exhausting the topic. It sought to highlight the importance of the racial variable in the epidemiological data analysis of COVID-19 infections in Brazil. We understand that this article’s theme gravitates towards necropolitics and deals with racism (institutional and structural, primarily). In order to provide a better understanding of the object and the intended goal, we decided to make a brief explanation based on selected epistemological references about the aspects below.

“Some will die?” Necropolitics and the choice of who may live and who should die

The Cameroonian philosopher, theorist, and politician, Achille Mbembe, discusses how State’s policies of exclusion are based on the idea of an existing “social enemy.” According to him, the State selects groups who are considered useful or disposable¹⁵15 Mbembe A. Necropolitica: seguido de sobre el governo privado indirecto. Santa Cruz de Tenerife: Melusina; 2011.. Achille Mbembe’s concept of necropolitics can be understood as a paradigm of the division between social segments. It regulates – and regularizes – the State’s power over lives. The State dictates who is allowed to live and who should die to guarantee the operation of the capitalistic war engine¹⁵15 Mbembe A. Necropolitica: seguido de sobre el governo privado indirecto. Santa Cruz de Tenerife: Melusina; 2011.. In this sense, the sentence that relativizes the gravity of the COVID-19 pandemic, said by the president of the Federative Republic of Brazil, Jair Messias Bolsonaro, on March 27, 2020, is loaded with “necro biopower”. It reveals a morbid and intentional¹⁶16 Araújo M. O que necropolítica tem a ver com a pandemia e com falas de Bolsonaro [Internet]. TAB Uol; 2020 [acessado 2020 Jul 10]. Disponivel em: https://tab.uol.com.br/noticias/redacao/2020/04/03/o-que-necropolitica-tem-a-ver-com-a-pandemia-e-com-falas-de-bolsonaro.htm?cmpid=copiaecola
https://tab.uol.com.br/noticias/redacao/... policy implemented and executed by the State.

The necropolitics’ concept confirms the understanding that the State does not deal with different groups in the same way. It also confirms the understanding according to which the constitutional right to live will depend on the group that a person belongs to¹⁷17 Brito MD. Não. Ele não está. Curitiba: Appris Editora; 2018.. The necropolitics’ concept is related to the State’s measures that promote life and death based on characteristics that rank people, stratifying them among those who should be eliminated and those who may live¹⁶16 Araújo M. O que necropolítica tem a ver com a pandemia e com falas de Bolsonaro [Internet]. TAB Uol; 2020 [acessado 2020 Jul 10]. Disponivel em: https://tab.uol.com.br/noticias/redacao/2020/04/03/o-que-necropolitica-tem-a-ver-com-a-pandemia-e-com-falas-de-bolsonaro.htm?cmpid=copiaecola
https://tab.uol.com.br/noticias/redacao/... . In a society founded on racism, which is one of the mechanisms of a domination political system, two complementary ideas define modern “forms of subjugation and death”¹⁸18 Foucault M. Em defesa da sociedade: curso no Collège de France (1975-1976). São Paulo: WMF Martins Fontes; 2010.(p.146): the supposed existence of both “races” and “inferior” human races¹⁸18 Foucault M. Em defesa da sociedade: curso no Collège de France (1975-1976). São Paulo: WMF Martins Fontes; 2010..

From this perspective, Bento¹⁹19 Bento B. Necrobiopoder: Quem pode habitar o Estado-nação? Cad Pagu 2018; 53:e185305. says that death policies have characterized Brazil’s history. These are systematic techniques planned and enforced by the State against populations that must disappear²⁰20 Ribeiro M, Moura R. Entre a biopolítica e o necropoder: O lucro durante a pandemia [Internet]. Justificando; 2020 [acessado 2020 Jul 10]. Disponível em: https://www.justificando.com/2020/04/09/entre-a-biopolitica-e-o-necropoder-o-lucro-durante-a-pandemia/
https://www.justificando.com/2020/04/09/... (p.4).

The black population’s health and the silence of the notification forms: a brief contextualization

Historically neglected, the interface between racism and the black population’s health has only recently become the object of Collective Health research²¹21 Lopes F. Para além da barreira dos números: desigualdades raciais e saúde. Cad Saúde Pública 2005; 21(5):1595-1601.. Wenerck¹⁰10 Werneck J. Racismo institucional e saúde da população negra. Saúde Soc 2016; 25(3):535-549. considers that the lack of data related to race is a sign of how delicate this topic is both in the research fields and in health policies formulations¹⁰10 Werneck J. Racismo institucional e saúde da população negra. Saúde Soc 2016; 25(3):535-549..

For instance, in epidemiology, race was not part of the discussions for a long time. It was not present in any official papers. It only began to be included in health information systems around the second half of the 20th century, due to black movement’s demands¹⁰10 Werneck J. Racismo institucional e saúde da população negra. Saúde Soc 2016; 25(3):535-549.^,2222 Adorno R, Alvarenga A, Vasconcellos M. Quesito cor no sistema de informação em saúde. Estud Av 2004; 18(50):119-123.^,2323 Brasil S, Trad L. O movimento negro na construção da Política Nacional de Saúde Integral da População Negra e sua relação com o Estado brasileiro. In: Batista L, Werneck J, Lopes F, organizadores. Saúde da população negra. Brasília: ABPN; 2012. p. 70-97..

Although there is a lack of epidemiological analysis on the topic, some studies on child mortality, deaths from external causes, risk of pregnancy and birth complications, and reduced access and accessibility to health services show that the black population’s health conditions have worsened²⁴24 Araújo EM, Costa MCN, Hogan VK, Araújo TM, Dias AB, Oliveira LOA. A utilização da variável raça/cor em Saúde Pública: possibilidades e limites. Interface (Botucatu) 2009; 13(31):383-394.. Meanwhile, the quality of information on death causes of this population is being compromised¹²12 Romero D, Maia L, Muzy J. Tendência e desigualdade na completude da informação sobre raça/cor dos óbitos de idosos no Sistema de Informações sobre Mortalidade no Brasil, entre 2000 e 2015. Cad Saúde Pública 2019; 35(12):e00223218.. Buss and Pellegrini Filho²⁵25 Buss P, Pellegrini Filho A. A saúde e seus determinantes sociais. Physis 2007; 17(1):77-93. recognize that inequities between people and groups of people in Brazil are strong and self-evident. Health inequities in this country, besides being “systematic and relevant”, are, above all, “avoidable, unjust, and unnecessary”²⁵25 Buss P, Pellegrini Filho A. A saúde e seus determinantes sociais. Physis 2007; 17(1):77-93.(p.2).

Among several questions, one is particularly significant: organizations and black movement active participants believe that the applicability of race variables is legitimized because it demystifies the mythology of Brazil being a racial democracy. When we ignore this variable, we jeopardize the investigations of inequities in the Brazilian healthcare system²²22 Adorno R, Alvarenga A, Vasconcellos M. Quesito cor no sistema de informação em saúde. Estud Av 2004; 18(50):119-123.. Although Brazil recognizes the relevance of this information for health policy evaluation, its inclusion in health information systems is new. In order to briefly examine the process that included black people’s well-being in health care programs concerning health policies, laws, guidelines and decrees²²22 Adorno R, Alvarenga A, Vasconcellos M. Quesito cor no sistema de informação em saúde. Estud Av 2004; 18(50):119-123.^,2626 Brasil. Lei nº 12.288, de 20 de julho de 2010. Institui o Estatuto da Igualdade Racial; altera as Leis nos 7.716, de 5 de janeiro de 1989, 9.029, de 13 de abril de 1995, 7.347, de 24 de julho de 1985, e 10.778, de 24 de novembro de 2003. Diário Oficial da União 2010; 21 jul.

27 Brasil. Racismo como determinante social de saúde. Brasília: Secretaria de Políticas de Promoção da Igualdade Racial; 2011.

28 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral da População Negra: uma política para o SUS. Brasília: MS; 2015.^-2929 Brasil. Portaria nº 344, de 1° de fevereiro de 2017. Dispõe sobre o preenchimento do quesito raça/cor nos formulários dos sistemas de informação em saúde. Diário Oficial da União; 2017., we created a timeline (Figure 1) of key milestones achieved due to the insertion of ethnic-racial information in the Brazilian health care system secondary data.

As shown in Figure 1, both Decree 992, May 13, 2009 (which establishes the National Health Integrity of Black Population Policy, or PNSIPN) and Decree 344, February 1, 2017, recognize the importance of inserting race/color data in health forms. This information is vital to monitor and evaluate actions established in the Brazilian Statute of Racial Equality, assuring the Brazilian black population equal access to health care system²⁶26 Brasil. Lei nº 12.288, de 20 de julho de 2010. Institui o Estatuto da Igualdade Racial; altera as Leis nos 7.716, de 5 de janeiro de 1989, 9.029, de 13 de abril de 1995, 7.347, de 24 de julho de 1985, e 10.778, de 24 de novembro de 2003. Diário Oficial da União 2010; 21 jul.

27 Brasil. Racismo como determinante social de saúde. Brasília: Secretaria de Políticas de Promoção da Igualdade Racial; 2011.

28 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral da População Negra: uma política para o SUS. Brasília: MS; 2015.^-2929 Brasil. Portaria nº 344, de 1° de fevereiro de 2017. Dispõe sobre o preenchimento do quesito raça/cor nos formulários dos sistemas de informação em saúde. Diário Oficial da União; 2017..

According to the Brazilian Decree 344/2017, filling in the race/color field is mandatory. However, recent studies have shown that most of the health information system forms lack information about race/color¹²12 Romero D, Maia L, Muzy J. Tendência e desigualdade na completude da informação sobre raça/cor dos óbitos de idosos no Sistema de Informações sobre Mortalidade no Brasil, entre 2000 e 2015. Cad Saúde Pública 2019; 35(12):e00223218.^,3030 Santos J, Dias F, Carvalho M, Pedrosa G, Caetano S, Souza E. Avaliação de completude da variável raça/cor nas notificações de violência, 2009 a 2017, Rio de Janeiro. Rev Saúde Foco 2020; 5(1):49-57.^,3131 Lino R, Fonseca S, Kale P, Flores P, Pinheiro R, Coeli C. Tendência da incompletude das estatísticas vitais no período neonatal, estado do Rio de Janeiro, 1999-2014. Epidemiol Serv Saúde. 2019; 28(2):e2018131.. During the COVID-19 pandemic, epidemiologic vigilance has become one of the foundations of public health policies. It turns data into action³²32 Temporao J. O enfrentamento do Brasil diante do risco de uma pandemia de influenza pelo vírus A (H1N1). Epidemiol Serv Saúde 2009; 18(3):201-204. which makes such information not neutral (neither is its omission). Therefore, every data informed via official organisms may be only an interpretation made with individual intentions. Also, it is important to say that any research as this one that investigates official data and clarifies intentions, is essential for understanding this structure

As a consequence, it becomes clear that this research is nothing less than necessary.

Methodology

This article is a literature review based on document and scientific literature analysis. Our research question is: considering Brazil’s situation during the coronavirus pandemic, how does the absence of the social health determinant, race/color, in epidemiologic analysis highlight the necropolitical mechanism of racism as a producer of health inequities?

We analyzed June 17, 2020, monitoring panels and epidemiologic bulletins from all Brazilian federal states and the Federal District. These are official information available on the state’s Health Departments websites and on their virtual platforms created to monitor the pandemic. The analysis aimed at finding race/color determinants in these panels and bulletins.

We searched for epidemiologic bulletins in all Brazilian local government websites and the Federal District. We found twenty-seven epidemiologic bulletins until June 17, 2020. We read all the available documents, and we systematized the data we collected. We tried to identify which states used the social determinants related to race/color on at least one of the following analysis categories: confirmed COVID-19 cases; SARS victims hospitalized and later confirmed as COVID-19 cases; and COVID-19 as the cause of death.

To better understand the implications of this health social determinant during the COVID-19 pandemic in Brazil, we conducted a literature review on the Virtual Health Library (BVS), the Scientific Electronic Library Online (SciELO), and PubMed databases. Our search strategy used Health Science Descriptors (DeCs) associated with the boolean operators: “black people AND COVID-19”, “racism AND COVID-19”, “racism AND coronavirus infections.”

We looked for national and international studies (in Portuguese, English, and Spanish) that connected COVID-19 cases and the black population. We excluded replicated studies and studies that did not include the research object. Initially, we found a total of 102 publications. After applying the inclusion and exclusion criteria, we selected nine documents, Figure 2, and after the analysis, we built a summary table. We collected the data between May and July 2020.

Since the data we used was anonymous and available for the general public, according to Ordinance 466/2012 from the National Health Council, the research did not need approval from the Human Research Ethics Committee.

Results and discussion

We analyzed twenty-seven epidemiologic bulletins and monitoring panels on June 17, 2020. Only five (19%) of the twenty-six Brazilian states, and the Federal District, had the race/color variable in at least one of the analyzed categories (confirmed COVID-19 cases; SARS patients who were hospitalized and later confirmed as having COVID-19, and deaths from COVID-19). The five states were: Alagoas, Amapá, Paraná, Rio Grande do Norte, and Rio Grande do Sul (Figure 3). We also analyzed nine articles (Chart 1) that helped us understand the information we gathered from the epidemiologic bulletins.

In individual register sheets of hospitalized SARS cases and in all death certificates issued by the Ministry of Health, the race field is present. In recent years the filling and analysis of this variable have been encouraged in order to provide information that could be used to develop more equitable public policies³²32 Temporao J. O enfrentamento do Brasil diante do risco de uma pandemia de influenza pelo vírus A (H1N1). Epidemiol Serv Saúde 2009; 18(3):201-204. against the COVID-19 and other diseases. However, there is still a lack of data related to race/color⁷7 Revista Consultor Jurídico. Defensorias pedem que coleta de dados da Covid contemple registro de raça e cor [Internet]. 2020 [acessado 2020 Jul 10]. Disponível em: https://www.conjur.com.br/2020-jun-17/defensorias-pedem-dados-covid-contemplem-raca-cor
https://www.conjur.com.br/2020-jun-17/de... ^,3333 Subbaraman N. How to address the coronavirus's outsized toll on people of colour. Nature 2020; 581:366-367.^,3434 Del Pino S, Camacho A. Consideraciones relativas a los pueblos indígenas, afrodescendientes y otros grupos étnicos durante la pandemia de la COVID-19 [Internet]. Organización Panamericana de la Salud; 2020 [acessado 2020 Jul 10]. Disponível em: http://docs.bvsalud.org/biblioref/2020/06/1099445/consideraciones-pueblos-indigenas-covid-19.pdf
http://docs.bvsalud.org/biblioref/2020/0... .

The Indicator Panel of the Brazilian Unified Health System (SUS), released in 2016, recognizes the need to fill the race/color field in registration forms and health information systems. These data are important to develop indicators³⁵35 Brasil. Ministério da Saúde (MS). Secretaria da Gestão Estratégica e Participativa. Painel dos Indicadores de Saúde nº 10. Temático Saúde da População Negra. Brasília: MS; 2016.. Nevertheless, some researchers³⁰30 Santos J, Dias F, Carvalho M, Pedrosa G, Caetano S, Souza E. Avaliação de completude da variável raça/cor nas notificações de violência, 2009 a 2017, Rio de Janeiro. Rev Saúde Foco 2020; 5(1):49-57.^,3131 Lino R, Fonseca S, Kale P, Flores P, Pinheiro R, Coeli C. Tendência da incompletude das estatísticas vitais no período neonatal, estado do Rio de Janeiro, 1999-2014. Epidemiol Serv Saúde. 2019; 28(2):e2018131.^,3636 Braz R, Oliveira P, Reis A, Machado N. Avaliação da completude da variável raça/cor nos sistemas nacionais de informação em saúde para aferição da equidade étnico-racial em indicadores usados pelo Índice de Desempenho do Sistema Único de Saúde. Saúde De-bate 2013; 37(99):554-562. have pointed out that in several health information systems in Brazil, this field has not been filled in.

Concerning COVID-19, the data collected in Brazil revealed that only five states disclosed information on race/color variables. These five states, however, did not disclose information on the three categories we chose to analyze. Goes et al.⁵5 Goes E, Ramos D, Ferreira A. Desigualdades raciais em saúde e a pandemia da Covid-19. Trab Educ Saude 2020; 18(3):e00278110. studies reported a similar situation in the USA. Only two of the United States fifty states (Kansas and Illinois) released race-related data.

In Brazil, the Technical Committee of Black People’s Health (CTSPN)³⁵35 Brasil. Ministério da Saúde (MS). Secretaria da Gestão Estratégica e Participativa. Painel dos Indicadores de Saúde nº 10. Temático Saúde da População Negra. Brasília: MS; 2016., created by the Statute of Racial Equality and by Ordinance 2,629/2014, wanted to include discussions regarding black people’s well-being in health surveys. However, the CTSPN distribution map shows that only eleven states, and the Federal District, have such a mechanism. Of the five states that disclosed race/color data, all had such a Committee, except for the state of Alagoas.

The data analyzed from the five Brazilian states showed that the COVID-19 transmission rate among black people is higher in four of them. The exception was the state of Rio Grande do Sul, where 83,2% of its population is self-declared white/caucasian³⁷37 Governo do Estado do Rio Grande do Sul. Secretária da Saúde do Rio Grande do Sul. Boletim Epidemiológico Covid-19, Semana Epidemiológica 24 de 2020 [Internet]. 2020 [acessado 2020 Jul 10]. Disponível em: https://coronavirus-admin.rs.gov.br/upload/arquivos /202006/18134431-be-covid-19-coers-se-24-160620.pdf
https://coronavirus-admin.rs.gov.br/uplo... . Regarding mild COVID-19 cases, in the state of Pernambuco, 60,5% of patients were black (non-white) while in the state of Rio Grande do Norte, 39% of patients were black (non-white).

Alagoas and Pernambuco informed that 66,5% and 77,7%, respectively, of all confirmed SARS (from COVID-19) patients were black. In the state of Alagoas, 68% of the patients who died from COVID-19 were black, in Paraná, 66%, in Rio Grande do Norte, 37%, and in Rio Grande do Sul, 5% (Rio Grande do Sul is the only state where most deaths were among white/caucasian people).

Although required, healthcare professionals, in many cases, did not fill in the race/color field (22% in the states of Rio Grande do Norte and Alagoas; 28% in Rio Grande do Sul; and 62,2% in Pernambuco). We observed the same in data regarding deaths, which corroborates with what Laurencin and McClinton’s³⁸38 Laurencin C, McClinton A. The COVID-19 Pandemic: a Call to Action to Identify and Address Racial and Ethnic Disparities. J Racial Ethnic Health Disparities 2020; 7:398-402. found in the state of Connecticut, USA, where the race/color field was not filled in 55% of the confirmed cases.

The production of statistical data that consider the race/color variable has been mandatory in Brazil for some time, and the challenges to collect these data, regarding race/color, are explicit. Milanezi³⁹39 Milanezi J. "Eu não vou parar por causa de uma raça": a coleta da raça/cor no SUS [Internet]. Blog DADOS; 2020 [acessado 2020 Jul 10]. Disponível em: http://dados.iesp.uerj.br/coleta-da-raca-cor-no-sus/
http://dados.iesp.uerj.br/coleta-da-raca... points out that despite the existence of the item race/color in SUS forms and information systems, we still have to deal with the lack of data and the inefficiency of data crossing.

It is important to say that the high percentage of omissions regarding the race/color variable may jeopardize COVID-19 general analysis, especially in the state of Pernambuco, where omissions exceeded 60% of the total. Melo and Valongueiro⁴⁰40 Melo GBT, Valongueiro S. Incompletude dos registros de óbitos por causas externas no Sistema de Informações sobre Mortalidade em Pernambuco, Brasil, 2000-2002 e 2008-2010. Epidemiol Serv Saúde 2015; 24(4):651-660. highlight that these omissions may mask or distort important information, compromising the understanding of the disease’s real magnitude. They also hinder any planning of actions aimed at monitoring and preventing the disease.

According to Milanezi³⁹39 Milanezi J. "Eu não vou parar por causa de uma raça": a coleta da raça/cor no SUS [Internet]. Blog DADOS; 2020 [acessado 2020 Jul 10]. Disponível em: http://dados.iesp.uerj.br/coleta-da-raca-cor-no-sus/
http://dados.iesp.uerj.br/coleta-da-raca... , some professionals consciously refuse to fill in the race/color field even after they were told to do so in their training. They even discourage their co-workers to follow local protocols stating that this information is not relevant compared to others. According to these professionals, this is an inconvenient topic to discuss with a patient.

During this study, we observed that the Brazilian Ministry of Health, through the Center for Emergency Operations in Public Health, in the Special Epidemiological Bulletin No. 09 on COVID-19 in Brazil, presented information on the distribution of hospitalizations due to SARS and deaths from the new coronavirus infection by race/color⁴¹41 Millett GA, Jones AT, Benkeser D, Baral S, Mercer L, Beyrer C, Honermann B, Lankiewicz E, Mena L, Crowley JS, Sherwood J, Sullivan PS. Assessing Differential Impacts of COVID-19 on Black Communities. Ann Epidemiol 2020; 47:37-44.. The omission of the social determinant, race/color, in the epidemiological health analysis may reveal an intention to make invisible those who are most affected by the epidemic. It reflects how the Brazilian government strategies to fight COVID-19 show total disregard for human life.

Thus, not only public policies that are directly related to healthcare have an impact on the protection of people’s lives. Other government actions also end up being responsible for “those who live and those who die.” In this sense, genocide – understood here as deliberate extermination – can take different forms. In Brazil, the conditions that subjugate black people create and reproduce a historical framework structured in “unjust social, cultural, and economic processes”²⁸28 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral da População Negra: uma política para o SUS. Brasília: MS; 2015.(p.5). Racism is at the center of these structures, widening the gap of vulnerabilities and allowing non-white people to experience unequal health realities⁴²42 Jesus V. Racializando o olhar (sociológico) sobre a saúde ambiental em saneamento da população negra: um contínuo colonial chamado racismo ambiental. Saude Soc 2020; 29(2):e180519..

In order to promote healthcare equity, PNSIPN²⁸28 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral da População Negra: uma política para o SUS. Brasília: MS; 2015. recognizes the existence “of racism, ethnic-racial inequalities and institutional racism as social health determinants”²⁸28 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde Integral da População Negra: uma política para o SUS. Brasília: MS; 2015.(p.18), Werneck¹⁰10 Werneck J. Racismo institucional e saúde da população negra. Saúde Soc 2016; 25(3):535-549. highlights, though, that the PNSIPN policies have not been adequately implemented. When analyzing COVID-19 in the USA, Millet et al.⁴¹41 Millett GA, Jones AT, Benkeser D, Baral S, Mercer L, Beyrer C, Honermann B, Lankiewicz E, Mena L, Crowley JS, Sherwood J, Sullivan PS. Assessing Differential Impacts of COVID-19 on Black Communities. Ann Epidemiol 2020; 47:37-44. highlight that in order to have a complete notion of the impact of this disease on black populations, a greater number of states must decide to disclose race/color data.

Several studies indicate that comorbidities such as Diabetes Mellitus, Arterial Hypertension, and other chronic health conditions are risk factors that can worsen Sars-CoV-2 infection. Data from National Health Research (PNS in Portuguese) show, for example, that regarding chronic diseases, there is a predominance of Arterial Hypertension (44,2%) and Diabetes Mellitus (12,7%) in non-white people when compared to white people (22,1% and 6,4% respectively). A prevalence that even exceeds the national numbers (21.4% and 6.2%, respectively)⁴³43 Brasil. Ministério da Saúde (MS). Indicadores de vigilância em saúde descritos segundo a variável raça/cor, Brasil. Boletim Epidemiol 2017; 48(4):1-35.. The same data were also verified by Price-Haywood et al.⁴⁴44 Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and Mortality among Black Patients and White Patients with Covid-19. N Engl J Med 2020; 382(26):2534-2543., in a retrospective cohort with 3,626 patients with COVID-19 in Louisiana, USA.

In addition to the findings that indicate the prevalence of chronic diseases among non-white people, it is important to highlight that other factors contribute to the development of these pathologies. These factors are also more common among the black population, such as inadequate consumption of fruits and vegetables, and alcohol abuse⁴⁵45 Brasil. Ministério da Saúde (MS). Vigitel Brasil 2018 População Negra: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas para população negra nas capitais dos 26 estados brasileiros e no distrito federal em 2018. Brasília: MS; 2019.. These racial differences in the distribution of the diseases and risk factors should not be attributed solely to biological and/or behavioral differences related to race/color. Above all, as Laster Pirtle⁴⁶46 Laster Pirtle WN. Racial Capitalism: A Fundamental Cause of Novel Coronavirus (COVID-19) Pandemic Inequities in the United States. Health Education Behav 2020; 47(4):504-508. reminds us, they are consequences of the systemic racism that structure people’s lives.

It is also important to highlight that Brazilian Public Defender Offices (Federal and locals), together with representative groups, filed different petitions to Court demanding government officials to fill in the race/color field in health forms and publicize them (Figure 4). According to Laurencin e McClinton³⁸38 Laurencin C, McClinton A. The COVID-19 Pandemic: a Call to Action to Identify and Address Racial and Ethnic Disparities. J Racial Ethnic Health Disparities 2020; 7:398-402., representative groups from the USA also filed similar petitions in American courts.

Nidhi Subbaraman³³33 Subbaraman N. How to address the coronavirus's outsized toll on people of colour. Nature 2020; 581:366-367. and Goes et al.⁵5 Goes E, Ramos D, Ferreira A. Desigualdades raciais em saúde e a pandemia da Covid-19. Trab Educ Saude 2020; 18(3):e00278110. say that in the USA, the Center for Disease Control and Prevention (CDC) also hid the number of deaths and people infected by race and ethnicity. These data only began to be released in late April after public protests from legislators, doctors, and civil rights groups.

The omission of race/color information (and other analysis variables such as gender) from epidemiological surveillance system forms endorses the necropolitical structure that makes black people’s deaths invisible. The message is that their lives can be taken at any time without any accountability from the State. In practice, the policies that the Brazilian government creates to face the pandemic ignore the black population. These policies are a necropolitical mechanism of structural and institutionalized racism. In this sense, racism, as Mbembe⁴⁷47 Mbembe A. Necropolítica. São Paulo: n-1 edições; 2018. highlights:

[…] is the engine of the necropolitical principle. It is, above all, a technology that focus on allowing the exercise of biopower, in other words, the right of death. In the economy of biopower, racism works as a regulator of the distribution of death and it also allows the murderous functions of the State⁴⁷47 Mbembe A. Necropolítica. São Paulo: n-1 edições; 2018.(p.18).

This type of omission is a distinctive feature of racism. It only confirms the myths that Brazil is a racial democracy and a country characterized by cordiality. To omit race and color from health forms is an attempt to hide the reality set before society’s eyes: racial inequalities base the decision of who must die. The Criminal System that incarcerates, the police violence that annihilates, the public health system that ignores the deaths of black people, these are all symptoms of widespread institutional racism. The necropolitics found fertile ground in Brazil.

Poteat et al.⁴⁸48 Poteat T, Millett G, Nelson LE, Beyrer C. Understanding COVID-19 Risks and Vulnerabilities among Black Communities in America: The Lethal Force of Syndemics. Ann Epidemiol 2020; 47:1-3. point out that concerning COVID-19, “we are not at the same risk. Like many others, this is a racialized disease”⁴⁸48 Poteat T, Millett G, Nelson LE, Beyrer C. Understanding COVID-19 Risks and Vulnerabilities among Black Communities in America: The Lethal Force of Syndemics. Ann Epidemiol 2020; 47:1-3.(p.3). As in the USA, structural racism in Brazil is located at the beginning of a cycle that culminates in the State’s neglect.

The idea that the same size fits all, in other words, that the adoption of equal measures for an unequal society puts the health of the most vulnerable at-risk (black people, homeless people, LGBTQI+ population, and incarcerated people)⁴⁹49 Devakumar D, Shannon G, Bhopal S, Abubakarcriar I. Racism and discrimination in COVID-19 responses. Lancet 2020; 395(10231):1194.. In this sense, the World Health Organization and the Pan American Health Organization (PAHO) recommend that governments develop social participation environments and build strategic alliances with the most vulnerable ethnic groups, ensuring their participation in the development and elaboration of actions to fight COVID-19³⁴34 Del Pino S, Camacho A. Consideraciones relativas a los pueblos indígenas, afrodescendientes y otros grupos étnicos durante la pandemia de la COVID-19 [Internet]. Organización Panamericana de la Salud; 2020 [acessado 2020 Jul 10]. Disponível em: http://docs.bvsalud.org/biblioref/2020/06/1099445/consideraciones-pueblos-indigenas-covid-19.pdf
http://docs.bvsalud.org/biblioref/2020/0... .

It is important to highlight that this article has some limitations, mainly because of the lack of data related to the pandemic and the health of the black population. The incipient amount of studies²2 Baqui P, Bica I, Marra V, Ercole A, van der Schaar M. Ethnic and regional variations in hospital mortality from COVID-19 in Brazil: a cross-sectional observational study. Lancet Glob Health 2020; 8(8):E1018-E1026. related to the State’s omission regarding such data and necropolitics also limited this study. Furthermore, the time elapsed between the collection of the data and their publication is so long that by the time they are read, they no longer represent reality.

Final considerations

Most of the articles that were part of this review were qualitative studies published in public health journals, predominantly in the year 2020. The surveys that the authors²2 Baqui P, Bica I, Marra V, Ercole A, van der Schaar M. Ethnic and regional variations in hospital mortality from COVID-19 in Brazil: a cross-sectional observational study. Lancet Glob Health 2020; 8(8):E1018-E1026.^,55 Goes E, Ramos D, Ferreira A. Desigualdades raciais em saúde e a pandemia da Covid-19. Trab Educ Saude 2020; 18(3):e00278110. conducted are complementary and converge with the data found in the analysis of epidemiological bulletins that the Brazilian states disclosed. Preliminary analysis of epidemiological bulletins of the states that released race/color data already shows that the highest number of SARS hospitalizations and deaths by COVID-19 are of black people.

It is recognized, as already presented in the discussion of this study, that the conclusions presented are limited due to the lack of data, in the Brazilian context, on race/color in the epidemiological bulletins and the high percentage of incompleteness presented by the states that disaggregate by race/color.

Racism and social inequalities are barriers to equal access to basic services. However, according to Singh et al.⁵⁰50 Singh I, Chand K, Singh A, Kandadi RK. Time for a culture change: understanding and reducing risk, morbidity and mortality from COVID-19 in those of black and minority ethnicity [editorial]. Br J Hospital Med 2020; 81(5):1-4., the actions necessary to mitigate those problems, despite being well known, are not taken. It reveals the necropolitical character of power, which operates through the reversal between life and death⁵¹51 Lima F. Bio-necropolítica: diálogos entre Michel Foucault e Achille Mbembe. Arq Bras Psicol 2018; 70(esp.):20-33..

When the State omits race/color data, it denies basic and fundamental rights. This omission characterizes the racist and obscurantist structure that underpins policies against COVID-19 in Brazil. It also brings the necropolitics discussion to the center of the debate. Meanwhile, the pandemic is spreading, and the number of deaths is growing. These are deaths that have been “silenced, trivialized, naturalized, and that have been happening with consent”⁴²42 Jesus V. Racializando o olhar (sociológico) sobre a saúde ambiental em saneamento da população negra: um contínuo colonial chamado racismo ambiental. Saude Soc 2020; 29(2):e180519.(p.12).

Finally, race/color data is a valuable tool for developing racial inequality indicators during the pandemic. Access to tests has been a privilege (and not a right), and the numbers point to greater morbimortality in the black population²2 Baqui P, Bica I, Marra V, Ercole A, van der Schaar M. Ethnic and regional variations in hospital mortality from COVID-19 in Brazil: a cross-sectional observational study. Lancet Glob Health 2020; 8(8):E1018-E1026.^,55 Goes E, Ramos D, Ferreira A. Desigualdades raciais em saúde e a pandemia da Covid-19. Trab Educ Saude 2020; 18(3):e00278110.. Such data should be made available not only by epidemiological surveillance centers but also by public policymakers. At the same time, it is essential to develop quanti-qualitative studies seeking to deepen such analyses and broaden the understanding of necropolitical mechanisms in racial control, especially during the COVID-19 pandemic, a time of extreme vulnerability.

Acknowledgements

We want to thank Luzimary Vieira Pereira for the sensitive reading of the preliminary version and for understanding the urgency and absence during the production of this work. We also thank Everton Oliveira for his outstanding work in the construction of the images. Translated by members of the Voluntary translation of informative materials related to COVID-19 project, offered by NUPEL/UFBA and supervised by professors M. Daniel Vasconcelos B. Oliveira, Dr. Feibriss Henrique Meneghelli Cassilhas, Dr. Lucielen Porfirio, and Dr. Monique Pfau. To the anonymous reviewers of Ciência & Saúde Coletiva journal for their comments and suggestions.

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