Abstract

This article aims to understand the view of racial equity and the motivations for approaching the health of the black population in Collective Health, Nursing, and Medicine courses at a Brazilian public university, guided by the black perspective of decoloniality. Considering Institutional Racism, it is necessary to invest in the interfaces between the education and health sectors in the training of professionals for the Unified Health System. This is a qualitative study with an intervention-research approach, affirming a social and political commitment to transforming reality. Workshops were held with representatives of the Structuring Teaching Centers of the selected courses. The theme of the health of the black population has been elaborated in a prompt and decontextualized manner, with no reflection based on structural racism, power relations, and Brazilian socio-historical formation. This creates a distance from the guidelines proposed by the National Policy for Comprehensive Health of the Black Population. At the end of this article, perspectives are identified for the reorientation of health training, aimed at increasing democratic density and racial equity.

Key words:
Health of the black population; Institutional racism; Higher education; Professional training in health

Introduction

To understand how colonialism and racism influenced Brazilian racial formation, Lélia Gonzalez¹1 Gonzalez L. A categoria político-cultural de amefricanidade. Rev Tempo 1998; 92(93):69-82. drew attention to ethnocidal violence, intrinsic to the view of European whiteness and colonial expansion, which continues to this day and generates inequities in the lives of the black population and indigenous peoples. The author affirmed racism as a Brazilian cultural neurosis and focused on the ideological configuration of Latin American racism, characterized by the ideology of whitening and how it has been disseminated in the formulation of scientific knowledge. An idea of a harmonious relationship between races was forged, which would justify the nonexistence of racism in Brazil. Its effects, like those of colonialism and imperialism, are hidden by the notion of racial democracy.

Based on this premise and recognizing the need to include the theme of racism and the health of the black population in the training of health professionals, this article aims to understand the view of racial equity, based on intervention research, and the motivations for approaching the subject in the development of Public Health, Nursing, and Medicine courses at a Brazilian public university in the country’s Midwest region.

The study’s analytical framework is the black perspective of decoloniality. Since, historically, “the coloniality of power, being, and knowledge has helped us think of strategies to transform reality”²2 Maldonado-Torres N. Analítica da colonialidade e da decolonialidade: algumas dimensões básicas. In: Bernardino-Costa J, Maldonado-Torres N, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 27-54. (p.10), decoloniality is understood as an academic, political, and collective project. In this sense, she discussed key categories for understanding the complexity of ethnic-racial relations: the racial issue and racism, Eurocentrism, the epistemic-political uses of colonization, and the epistemicide of black thought in science. This perspective allows approaches to emancipatory practices and projects that influence different fields of knowledge²2 Maldonado-Torres N. Analítica da colonialidade e da decolonialidade: algumas dimensões básicas. In: Bernardino-Costa J, Maldonado-Torres N, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 27-54., making the need for decolonization of curricula and knowledge in Brazil urgent. However, “recognition and political will are not enough to decolonize the mind, politics, culture, curricula, and knowledge”³3 Gomes NL. O Movimento Negro e a intelectualidade negra descolonizando os currículos. In: Bernardino CJ, Maldonado TN, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 223-246. (p.226). To achieve decolonization, it must go beyond the production of knowledge and reach the social structures of power through “an epistemological, political, and social rupture that is also conducted by the black presence in places of power and decision-making, academic structures, culture, and the management of education, health, and justice”³3 Gomes NL. O Movimento Negro e a intelectualidade negra descolonizando os currículos. In: Bernardino CJ, Maldonado TN, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 223-246. (p.226).

Taking the reading of Brazilian particularity as a reference, Gomes³3 Gomes NL. O Movimento Negro e a intelectualidade negra descolonizando os currículos. In: Bernardino CJ, Maldonado TN, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 223-246. presented one of the central questions asked by the black movement from a black and decolonial perspective: the critique of the myth of racial democracy anchored in the belief of “the existence of harmonious relations between the different ethnic-racial groups of our country, the result of the relationship between the Portuguese colonizer and the people he dominated”⁴4 Gomes NL. O movimento negro no Brasil: ausências, emergências e a produção dos saberes. Pol Soc 2011; 10(18):133-154. (p.138). The myth of racial democracy is present in the way racial relations were forged; therefore, racism also manifests itself in the educational³3 Gomes NL. O Movimento Negro e a intelectualidade negra descolonizando os currículos. In: Bernardino CJ, Maldonado TN, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 223-246.^,55 Jardim R, Oliveira Júnior MG, Schott M. Percepção de racismo no ensino superior em saúde na perspectiva docente. Rev Bras Polít Adm Educ 2022; 38(1):e113350.^,66 Mello L, Resende UP. Concursos públicos federais para docentes e ações afirmativas para candidatos negros. Cad Pesq 2020; 50(175):8-28. and healthcare system⁷7 Geraldo RM, Oliveira JC, Alexandre LSC, Aguiar MRA, Vieira AFS, Germani ACCG. Preenchimento do quesito raça/cor na identificação dos pacientes: aspectos da implementação em um hospital universitário. Cien Saude Colet 2022; 27(10):3871-3880.

8 Anunciação D, Pereira LL, Silva HP, Nunes APN, Soares JO. (Des)caminhos na garantia da saúde da população negra e no enfrentamento ao racismo no Brasil. Cien Saude Colet 2022; 27(10):3861-3870.^-99 Batista LE, Santos MPA, Cruz MM, Silva A, Passos SCS, Ribeiro EE, Toma TS, Barreto JOM. Produção científica brasileira sobre saúde da população negra: revisão de escopo rápida. Cien Saude Colet 2022; 27(10):3849-3860..

Taking into account the dimension of Institutional Racism⁹9 Batista LE, Santos MPA, Cruz MM, Silva A, Passos SCS, Ribeiro EE, Toma TS, Barreto JOM. Produção científica brasileira sobre saúde da população negra: revisão de escopo rápida. Cien Saude Colet 2022; 27(10):3849-3860.

10 Almeida SAL. Racismo Estrutural. São Paulo: Pólen; 2019.^-1111 Werneck J. Racismo institucional e saúde da população negra. Saude Soc 2016; 25(3):535-549., its manifestation in health services and Higher Education Institutions (HEIs) is recognized, as well as its consequences in the training of professionals for the Brazilian Unified Health System (SUS), as Racism reproduces health inequities¹¹11 Werneck J. Racismo institucional e saúde da população negra. Saude Soc 2016; 25(3):535-549.. Institutional Racism needs to be analyzed based on the “dimension of power as a constitutive element of racial relations”¹⁰10 Almeida SAL. Racismo Estrutural. São Paulo: Pólen; 2019. (p.31) and how it is exercised by one group over another, considering a social structure. As Almeida stated, “institutions are racist because society is racist”¹⁰10 Almeida SAL. Racismo Estrutural. São Paulo: Pólen; 2019. (p.31), and this is the most neglected side of racism.

It is necessary to recognize other co-determinants that act simultaneously in determining living and health conditions¹¹11 Werneck J. Racismo institucional e saúde da população negra. Saude Soc 2016; 25(3):535-549., which is why intersectionality⁸8 Anunciação D, Pereira LL, Silva HP, Nunes APN, Soares JO. (Des)caminhos na garantia da saúde da população negra e no enfrentamento ao racismo no Brasil. Cien Saude Colet 2022; 27(10):3861-3870.^,1212 Jones CP. Confronting institutionalized racism. Phylon 2022; 50(1):7-22.

13 Pereira BCJ. Sobre usos e possibilidades da interseccionalidade. Civitas 2021; 21(3):445-454.^-1414 Crenshaw K. Documento para o encontro de especialistas em aspectos da discriminação racial relativos ao gênero. Rev Estud Fem 2002; 10(1):171-188. can significantly contribute to the understanding and interrelationship of domination systems¹¹11 Werneck J. Racismo institucional e saúde da população negra. Saude Soc 2016; 25(3):535-549.. Therefore, some public policies, such as the National Policy for Comprehensive Health of the Black Population (Política Nacional de Saúde Integral da População Negra - PNSIPN), assume management strategies and the implementation of actions to combat institutional racism and reduce racial inequities¹⁵15 Brasil. Resolução nº 3, de 30 de março de 2017. Dispõe sobre o III Plano Operativo (2017-2019) da Política Nacional de Saúde Integral da População Negra (PNSIPN) no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2017..

The PNSIPN understands racial equity as a movement to “recognize racism, ethnic-racial inequalities, and institutional racism as social determinants of health conditions to promote equity in health”¹⁵15 Brasil. Resolução nº 3, de 30 de março de 2017. Dispõe sobre o III Plano Operativo (2017-2019) da Política Nacional de Saúde Integral da População Negra (PNSIPN) no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2017. (p.24). Therefore, the ethnic-racial dimension must be part of a national public policy agenda¹⁶16 Monteiro MCS. Desafios da inclusão da temática étnico-racial na educação permanente em saúde. In: Batista LE, Wernek J, Lopes F. Saúde da População Negra. 2ª ed. São Paulo: Associação Brasileira de Pesquisadores Negros; 2012. p. 146-159.. The PNSIPN guidelines enabled the development of strategies towards racial equity, as they proposed the inclusion of the theme of racism and the health of the black population in the training of health professionals, encouragement of knowledge production, recognition of popular beliefs, and the monitoring and evaluation of actions to combat racism¹⁷17 Trad L, Mota C, Catellanos M, Farias VN, Brasil SA. Percepção sobre a Política de Saúde da População Negra: perspectivas polifônicas. In: Batista LE, Wernek J, Lopes F. Saúde da População Negra. 2ª ed. São Paulo: Associação Brasileira de Pesquisadores Negros; 2012. p. 182-203..

Despite some advances that paved the way for the implementation of affirmative action policies, the Brazilian situation experienced setbacks and attacks on democracy, advances towards conservatism, encouragement of various forms of violence against the so-called “minorities”, and the intensification of inequalities, as well as social and health inequities. Another project of the Brazilian cis-heteronormative white elite encouraged the construction of projects such as the Escola Sem Partido Program. In this sense, Gomes³3 Gomes NL. O Movimento Negro e a intelectualidade negra descolonizando os currículos. In: Bernardino CJ, Maldonado TN, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 223-246. discussed the decolonization of curricula and encouraged reflection on the disputes posed through “colonial resistance to a decolonial curriculum”³3 Gomes NL. O Movimento Negro e a intelectualidade negra descolonizando os currículos. In: Bernardino CJ, Maldonado TN, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 223-246. (p.229). The inclusion of the ethnic-racial theme in the HEIs’ curricular components in health training has been emerging, while these institutions have not contributed to the implementation of the PNSIPN⁷7 Geraldo RM, Oliveira JC, Alexandre LSC, Aguiar MRA, Vieira AFS, Germani ACCG. Preenchimento do quesito raça/cor na identificação dos pacientes: aspectos da implementação em um hospital universitário. Cien Saude Colet 2022; 27(10):3871-3880..

However, black movements have been demanding the publication of research on the social conditions of the black population as one of the strategies to promote policies towards racial equity and denounce Institutional Racism⁹9 Batista LE, Santos MPA, Cruz MM, Silva A, Passos SCS, Ribeiro EE, Toma TS, Barreto JOM. Produção científica brasileira sobre saúde da população negra: revisão de escopo rápida. Cien Saude Colet 2022; 27(10):3849-3860.. Education as a right for the black population is also an agenda that instigates change and questions the school curriculum about the discussion of teaching material, the “inclusion of racial themes in teacher training” through the current inclusion of the history of Africa and Afro-Brazilian culture in school curricula, and affirmative action policies in their wide range of forms”⁴4 Gomes NL. O movimento negro no Brasil: ausências, emergências e a produção dos saberes. Pol Soc 2011; 10(18):133-154. (p.137).

It has been a challenge in the healthcare sector to include “racism” and “health of the black population” in the training of health professionals⁵5 Jardim R, Oliveira Júnior MG, Schott M. Percepção de racismo no ensino superior em saúde na perspectiva docente. Rev Bras Polít Adm Educ 2022; 38(1):e113350.^,1818 Rocha DG, Souza DH, Cavadinha E. Equidade nos cursos de graduação em Saúde: marco legal, desafios políticos e metodológicos. Interface (Botucatu) 2019; 232(1):e180017.

19 Conceição CC, Riscado LS, Vilela RQ. Relações étnico-raciais na perspectiva da saúde da população negra no curso de medicina: análise curricular. Rev Bras Ens Sup 2018; 4(3):34-56.^-2020 Valderama WCP, Varanao AEC. Social justice is a dream: Tensions and contradictions in nursing education. Publix Health Nurs 2019; 36(5):735-743., even though the National Curricular Guidelines (Diretrizes Curriculares Nacionais - DCN) and the Political-pedagogical Projects of the Courses (Projetos Político-pedagógicos dos Cursos - PPC) of Public Health, Nursing, and Medicine signal that education in ethnic-racial relations must be included in their training. Another challenge²¹21 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 2016; 25(3):524-534. is the implementation of the DCN for the Education of Ethnic-Racial Relations and for the Teaching of Afro-Brazilian and African History and Culture (Diretrizes Curriculares Nacionais para a Educação das Relações Étnico-Raciais e para o Ensino da História e Cultura Afro-brasileira e Africana - DCNERER) in the training of SUS professionals, linked to the PNSIPN and the National Policy for Permanent Education.

Based on these initial reflections, this article asks: How do the dimensions of racism and its slavery heritage affect health training in Brazilian public universities? How can the inclusion of the health of the black population in higher education expand perspectives toward racial equity in health?

Method

This qualitative, research-intervention study²²22 O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Acad Med 2014; 89(9):1245. is an attempt to answer these questions. This approach is meant to understand that research “inevitably causes transformations and mobilizes forces in the investigated field, including the researcher him/herself”²³23 Paulon SM, Romagnoli RC. Pesquisa-intervenção e cartografia: melindres e meandros metodológicos. Est Pesq Psicol 2010; 10(1):85-102. (p.143). Intervention research has a participatory character and requires social and political commitment to the reality with which it is working, resulting in a co-production/transformation of those who are proposing to better understand the reality and that which is known²³23 Paulon SM, Romagnoli RC. Pesquisa-intervenção e cartografia: melindres e meandros metodológicos. Est Pesq Psicol 2010; 10(1):85-102..

Data production²⁴24 Mendes R, Pezzato LM, Sacardo DP. Pesquisa-intervenção em promoção da saúde: desafios metodológicos de pesquisar "com". Cien Saude Colet 2016; 21(6):1737-1745. occurred through workshops²⁵25 Spink MJ, Menegon VM, Medrado B. Oficinas como estratégia de pesquisa: articulações teórico-metodológicas e aplicações ético-políticas. Psicol Soc 2014; 26(1):32-43. with the Structuring Teaching Centers (Núcleos Docentes Estruturantes - NDE) of the undergraduate courses in Public Health, Nursing, and Medicine at the selected university. Workshops were adopted because they enable dialogic relationships between participants, taking into account the complexity of racism in Brazil, as well as the need to exchange knowledge and produce meaning²⁶26 Pey MO. Oficina como modalidade educativa. Perspectiva 1997; 15(27):35-63..

The NDE was selected for the study because, according to the Ministry of Education, it constitutes “a group of teachers with academic monitoring duties, active in the conception, consolidation, and continuous updating of the course’s pedagogical project”²⁷27 Brasil. Comissão Nacional de Avaliação da Educação Superior (CONAES). Resolução nº 1, de 17 de junho de 2010. Normatiza o Núcleo Docente Estruturante e dá outras providências. Brasília: Ministério da Educação; 2010. (p.1). Furthermore, the NDE may also include university students and educational affairs technicians.

The NDE has space on the course agenda within the College of Health Sciences and School of Medicine of this university with an ordinary monthly meeting. Questions aimed at the NDE of each course were made by sending an email to the coordinators of the centers, explaining the purpose of the research and identifying the availability to address them in person at ordinary meetings. It was necessary to present the study in person to the Medical School’s management and the course coordinator.

The workshops were held between September 2019 and March 2020. The inclusion criterion for participants was that they should be members of the NDE. Of the sixteen participants, nine declared themselves to be white, five brown; one black, and one made no declaration. In total, there were ten female participants and six male participants. One student and one education technician represented the medical course. The workshops were recorded in audio, using a tablet. At a later moment, the recordings were transcribed and categorized using a text editor. A field diary was also used to record observations, dialogues, emotions, tensions, and conflicts that arose during the workshops.

Workshops were held in the three selected undergraduate courses, which aimed to identify the NDE’s view of racial equity and the reasons for approaching the health of the black population in student training. Furthermore, an action plan was prepared to implement the theme of racism and the health of the black population in professional health training after evaluating the data collected during the meetings.

The categorization met the quality criteria for qualitative research²²22 O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Acad Med 2014; 89(9):1245., using thematic content analysis²⁸28 Oliveira DC. Análise de Conteúdo Temático-Categorial: uma proposta de sistematização. Rer Enferm 2008; 16(4):569-576.. From the understanding of the ethical-political direction of equity and how it is applied in health training, the results of this article will be organized by the categories “view of racial equity” of the NDE and “reasons for teaching health to the black population”. The ethical aspects of research with human beings were met, having been approved by the Research Ethics Committee (CEP/CONEP) of the university, according to opinion number 3,387,638, dated June 12, 2019.

Results and discussion

NDE’s view of racial equity

An understanding of the view of racial equity emerged in the first stage of the workshop through the proposed warm-up, aimed at getting to know the participants, based on the experiences of the NDE members and the collective analysis provided by the group.

The view of racial equity predominated in the Public Health course associated with the intentionality of policies, as, according to the participants, they can modify the degree of social inequalities. This understanding also predominated based on the unfolding of the concept of equity, present in the principles of SUS, aimed at social justice. In Brazil’s circumstance, as one of the teachers pointed out, the racial issue is related to a historical debt present in the country. Three views on racial equity predominated in the Medicine course: that it exists when there is no difference between people; that it would be a way to promote social justice and, finally, the notion of equity was related to the idea that everyone is equal. Although historical debt and social justice were considered, the effects of a colonial, slaveholding heritage were not deeply explored, while the racial debate continued to be secondary.

One of the views in the Nursing course associated racial equity with equality, citing the Federal Constitution of 1988²⁹29 Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out., which establishes the treatment of everyone without distinction of race, and racial equity would mean having black students enrolled in the course. One of the teachers explained that it would be important to understand the Brazilian context since the country has a historical debt of at least five hundred years. Two other teachers highlighted the importance of ensuring opportunities for those students who need them most and that this issue needs to be considered from a racial perspective.

The view of equity related to the degree of intentionality of public policies and the capacity to modify social inequalities stands out, as mentioned in the Public Health course. There are aspects of an unfair and unnecessary nature¹⁸18 Rocha DG, Souza DH, Cavadinha E. Equidade nos cursos de graduação em Saúde: marco legal, desafios políticos e metodológicos. Interface (Botucatu) 2019; 232(1):e180017. that will influence how certain ethnic-racial groups have access to social policies. Analyzing them requires understanding how social structures and political processes without the dimension of equity are perverse and, thus, create inequalities³⁰30 Almeida Filho N. A problemática teórica da determinação social da saúde. In: Roberto PN, organizador. Determinação social da saúde e reforma sanitária. Rio de Janeiro: Cebes; 2010. p. 13-36. that intersect in an intersectional way and can be related to income, education, race/ethnicity, and social class³¹31 Heard E, Fitzgerald L, Wigginton B, Mutch A. Applying intersectionality theory in health promotion research and practice. Health Promot Int 2020; 35(4):866-876.. The black perspective of decoloniality could guide work in this direction as it contributes to the analyses of social and political structures²2 Maldonado-Torres N. Analítica da colonialidade e da decolonialidade: algumas dimensões básicas. In: Bernardino-Costa J, Maldonado-Torres N, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 27-54..

Racial equity was also mentioned in the Medicine and Public Health courses as a way to promote social justice³²32 Braveman P. What is Health Equity: And How Does a Life-Course Approach Take Us Further Toward It? Matern Child Health J 2014; 18(2):366-372.. Striving to achieve health equity means reducing disparities between groups characterized by racial/ethnic belonging, taking into account the discrimination they experience in society³²32 Braveman P. What is Health Equity: And How Does a Life-Course Approach Take Us Further Toward It? Matern Child Health J 2014; 18(2):366-372..

Racial equity was mentioned in the three courses as being related to Brazil’s historical debt and the social determination of the black population. This view converges with the study by Rinehart³³33 Rinehart D. Política Nacional de Saúde Integral da População Negra: discursos da gestão municipal do SUS [tese]. Brasília: Universidade de Brasília; 2013., which understood the Brazilian historical context and institutional racism as hindering access to health actions and services and the implementation of the PNSIPN. The author identified a critical factor regarding the semantic hijacking of the word equity, as it is used without its theoretical and political understanding³³33 Rinehart D. Política Nacional de Saúde Integral da População Negra: discursos da gestão municipal do SUS [tese]. Brasília: Universidade de Brasília; 2013.. Some subjects in the medicine workshop approached equity conceptually, but the health of the black population was mentioned superficially, without deeply reflecting on race and racism, which demonstrated the challenge of transforming the institutional political culture of historically white, elitist universities with colonized curricula and structured by the coloniality of power, being, and knowledge²2 Maldonado-Torres N. Analítica da colonialidade e da decolonialidade: algumas dimensões básicas. In: Bernardino-Costa J, Maldonado-Torres N, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 27-54..

Racial equity was mentioned in the Nursing course as being related to ensuring opportunities for those who need it the most, including access to health services and education. Equality of opportunities is mentioned as an affirmative action goal³⁴34 Mattos WR. Ubuntu: por uma outra interpretação de ações afirmativas na universidade. In: Bernardino CJ, Maldonado TN, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. and equity is a path to be taken to achieve equality¹⁸18 Rocha DG, Souza DH, Cavadinha E. Equidade nos cursos de graduação em Saúde: marco legal, desafios políticos e metodológicos. Interface (Botucatu) 2019; 232(1):e180017.. Rinehart³³33 Rinehart D. Política Nacional de Saúde Integral da População Negra: discursos da gestão municipal do SUS [tese]. Brasília: Universidade de Brasília; 2013. discussed the problem in Brazil of denying opportunities, goods, and services to the black population, despite clear evidence of discrimination this group continues to experience⁷7 Geraldo RM, Oliveira JC, Alexandre LSC, Aguiar MRA, Vieira AFS, Germani ACCG. Preenchimento do quesito raça/cor na identificação dos pacientes: aspectos da implementação em um hospital universitário. Cien Saude Colet 2022; 27(10):3871-3880.

8 Anunciação D, Pereira LL, Silva HP, Nunes APN, Soares JO. (Des)caminhos na garantia da saúde da população negra e no enfrentamento ao racismo no Brasil. Cien Saude Colet 2022; 27(10):3861-3870.^-99 Batista LE, Santos MPA, Cruz MM, Silva A, Passos SCS, Ribeiro EE, Toma TS, Barreto JOM. Produção científica brasileira sobre saúde da população negra: revisão de escopo rápida. Cien Saude Colet 2022; 27(10):3849-3860..

Some of the views of equity shared in the Medicine and Nursing courses were those of no difference between people and the term would be a synonym for the equality provided for in the Federal Constitution of 1988. Almeida Filho³⁰30 Almeida Filho N. A problemática teórica da determinação social da saúde. In: Roberto PN, organizador. Determinação social da saúde e reforma sanitária. Rio de Janeiro: Cebes; 2010. p. 13-36. helped explain some of the concepts that emerged during the workshops. The first is diversity, which is expressed in the variation in characteristics of a population as “natural or genetic variation, expressed in individual differences, arising from the interaction of social and biological processes, produces diversity in collective social spaces and inequalities in human populations”³⁰30 Almeida Filho N. A problemática teórica da determinação social da saúde. In: Roberto PN, organizador. Determinação social da saúde e reforma sanitária. Rio de Janeiro: Cebes; 2010. p. 13-36. (p.30). The second is differences, which emerge individually through the effects of diversity or inequalities in subjects and “manifest themselves through complex relationships between social and biological processes in individual subjects”³⁰30 Almeida Filho N. A problemática teórica da determinação social da saúde. In: Roberto PN, organizador. Determinação social da saúde e reforma sanitária. Rio de Janeiro: Cebes; 2010. p. 13-36. (p.30). Equity is not synonymous with difference and is related to social structures and political processes. When these lack equity, they create inequality, which “can be expressed by demographic or epidemiological indicators (in the health field), as empirical evidence of differences”³⁰30 Almeida Filho N. A problemática teórica da determinação social da saúde. In: Roberto PN, organizador. Determinação social da saúde e reforma sanitária. Rio de Janeiro: Cebes; 2010. p. 13-36. (p.30).

Regarding the widespread idea that everyone is equal¹1 Gonzalez L. A categoria político-cultural de amefricanidade. Rev Tempo 1998; 92(93):69-82., Barros and Sousa³⁵35 Barros CPF, Sousa MF. Equidade: seus conceitos, significações e implicações para o SUS. Rev Saude Soc 2016; 25(1):9-18. theorized the principle of equality as a guide for citizenship and, consequently, for civil, political, and social rights, related to the state of social welfare and described in the Federal Constitution²⁹29 Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out.. Gonzalez¹1 Gonzalez L. A categoria político-cultural de amefricanidade. Rev Tempo 1998; 92(93):69-82. warned that the affirmation of equality before the law is merely formalistic, given the ideological sophistication of racism. Barros and Sousa³⁵35 Barros CPF, Sousa MF. Equidade: seus conceitos, significações e implicações para o SUS. Rev Saude Soc 2016; 25(1):9-18. stressed that, while equality has a logic of “homogeneous distribution: to each person the same amount of goods or services”³⁵35 Barros CPF, Sousa MF. Equidade: seus conceitos, significações e implicações para o SUS. Rev Saude Soc 2016; 25(1):9-18., equity considers that “people are different and have different needs”³⁵35 Barros CPF, Sousa MF. Equidade: seus conceitos, significações e implicações para o SUS. Rev Saude Soc 2016; 25(1):9-18. (p. 13), requiring equitable public policies.

Thinking about reorienting health training, Gouveia et al.³⁶36 Gouveia EAH, Silva RO, Pessoa BHS. Competência Cultural: uma Resposta Necessária para Superar as Barreiras de Acesso à Saúde para Populações Minorizadas. Rev Bras Educ Med 2019; 43(1):82-90. contextualized a scenario in which stereotypes, privileges, and racism were perceived in the relationship between providers and users of healthcare services. According to the authors, the learning path was complex and healthcare providers denied the power relations and reproduction of racism¹1 Gonzalez L. A categoria político-cultural de amefricanidade. Rev Tempo 1998; 92(93):69-82. that exist in their practices. The urgent reorientation of health training¹⁹19 Conceição CC, Riscado LS, Vilela RQ. Relações étnico-raciais na perspectiva da saúde da população negra no curso de medicina: análise curricular. Rev Bras Ens Sup 2018; 4(3):34-56.^,3737 Rizzo TPR, Fonseca ABC. Concepções e práticas de educação e saúde da população negra: uma revisão integrativa da literatura brasileira. Reciis 2019; 13(4):896-910.

38 Freitas Junior RAO, Santos CAD, Lisboa LL, Freitas AKMSO, Garcia VL, Azevedo GD. Incorporando a Competência Cultural para Atenção à Saúde Materna em População Quilombola na Educação das Profissões da Saúde. Rev Bras Edu Med 2018; 42(2):100-109.^-3939 Figueiredo GO, Orrillo YA. Currículo, política e ideologia: estudos críticos na educação superior em saúde. Trab Educ Saude 2020; 18(11):1-29. requires a process of “teaching-service-learning in the real world [...] through the learner’s interaction with ethnically and culturally diverse populations”³⁸38 Freitas Junior RAO, Santos CAD, Lisboa LL, Freitas AKMSO, Garcia VL, Azevedo GD. Incorporando a Competência Cultural para Atenção à Saúde Materna em População Quilombola na Educação das Profissões da Saúde. Rev Bras Edu Med 2018; 42(2):100-109. (p.106), which enables decolonial movements.

Motives for approaching the health of the black population in health training

Some motives were described in the Public Health course supporting the inclusion of the health of the black population in health training. One of them was the importance of analyzing social indicators of violence¹1 Gonzalez L. A categoria político-cultural de amefricanidade. Rev Tempo 1998; 92(93):69-82. and how they reveal the relationship between racism and health. One of the workshop participants commented on the situation of domestic workers and the issue of black women, signaling that the contemporary scenario had been one of modern slavery¹1 Gonzalez L. A categoria político-cultural de amefricanidade. Rev Tempo 1998; 92(93):69-82.^,4040 Ribeiro D. Quem tem medo do feminismo negro? São Paulo: Companhia das Letras; 2018.. The history of teachers participating in social movements and being involved in the theoretical approaches to the issue of gender and race during teacher training was also mentioned as a reason for incorporating these topics in undergraduate health courses.

The Medicine course expressed the relevance of the workshop in promoting debates regarding racial equity in the NDE. A member of the technical staff said that, when serving black students enrolled in the course, it was clear that they were occupying the university space. A need for representation of black professors and students in the academic community was also emphasized⁶6 Mello L, Resende UP. Concursos públicos federais para docentes e ações afirmativas para candidatos negros. Cad Pesq 2020; 50(175):8-28.. Another motive raised in the Medicine course was the recognition of the historical debt that exists toward the black population and using affirmative action policies³3 Gomes NL. O Movimento Negro e a intelectualidade negra descolonizando os currículos. In: Bernardino CJ, Maldonado TN, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 223-246.^,66 Mello L, Resende UP. Concursos públicos federais para docentes e ações afirmativas para candidatos negros. Cad Pesq 2020; 50(175):8-28.^,88 Anunciação D, Pereira LL, Silva HP, Nunes APN, Soares JO. (Des)caminhos na garantia da saúde da população negra e no enfrentamento ao racismo no Brasil. Cien Saude Colet 2022; 27(10):3861-3870. to reverse this situation. Studies on the health situation of this segment were also mentioned, again highlighting indicators of violence.

A Nursing course instructor considered it important to approach risk factors, epidemiology, and the prevalence of diseases in a given population, as it would facilitate the crafting of specific policies. The instructor emphasized the need for critical thinking so that it would be reflected in professional practice. The approach to the health of the black population as a social right, the social determination of health, and indicators that reveal inequities, emerged as motives.

Despite the sense of equity appearing in the Medicine and Nursing course workshop associated with the concept of health policies, statements emerged pointing out that the health of the black population did not need to explicitly appear in the course curricula. However, there was evidence that proved the need to address its specificities, such as the prevalence of cervical cancer in black women⁴¹41 Paulista JS, Assunção MPG, Lima FLT. Acessibilidade da População Negra ao Cuidado Oncológico no Brasil: Revisão Integrativa. Rev Bras Cancerol 2019; 65(4):e-06453.. The Academic Center for Medicine representative added that knowledge about racial equity needs to be related to socioeconomic and epidemiological issues, allowing greater visualization of health problems.

The motives for including the health of the black population in health training can also be observed in work aimed at combating social inequalities, highlighting those based on color or race⁴²42 Instituto Brasileiro de Geografia e Estatística (IBGE). Estudos e Pesquisas Informação Demográfica e Socioeconômica Desigualdades Sociais por Cor ou Raça no Brasil. Brasília: IBGE; 2019.. The Brazilian Institute of Geography and Statistics (IBGE) presented indicators that demonstrated ethnic-racial inequalities related to the job market, education, violence, political underrepresentation, and housing conditions, the consequences of which imply greater levels of economic and social vulnerability⁴²42 Instituto Brasileiro de Geografia e Estatística (IBGE). Estudos e Pesquisas Informação Demográfica e Socioeconômica Desigualdades Sociais por Cor ou Raça no Brasil. Brasília: IBGE; 2019.. The challenges of including equity in health training has been discussed in recent literature¹⁸18 Rocha DG, Souza DH, Cavadinha E. Equidade nos cursos de graduação em Saúde: marco legal, desafios políticos e metodológicos. Interface (Botucatu) 2019; 232(1):e180017.

19 Conceição CC, Riscado LS, Vilela RQ. Relações étnico-raciais na perspectiva da saúde da população negra no curso de medicina: análise curricular. Rev Bras Ens Sup 2018; 4(3):34-56.^-2020 Valderama WCP, Varanao AEC. Social justice is a dream: Tensions and contradictions in nursing education. Publix Health Nurs 2019; 36(5):735-743., which highlights the difference in the new profile of healthcare providers and the complexities of everyday life⁷7 Geraldo RM, Oliveira JC, Alexandre LSC, Aguiar MRA, Vieira AFS, Germani ACCG. Preenchimento do quesito raça/cor na identificação dos pacientes: aspectos da implementação em um hospital universitário. Cien Saude Colet 2022; 27(10):3871-3880.

8 Anunciação D, Pereira LL, Silva HP, Nunes APN, Soares JO. (Des)caminhos na garantia da saúde da população negra e no enfrentamento ao racismo no Brasil. Cien Saude Colet 2022; 27(10):3861-3870.^-99 Batista LE, Santos MPA, Cruz MM, Silva A, Passos SCS, Ribeiro EE, Toma TS, Barreto JOM. Produção científica brasileira sobre saúde da população negra: revisão de escopo rápida. Cien Saude Colet 2022; 27(10):3849-3860..

According to Rocha et al.¹⁸18 Rocha DG, Souza DH, Cavadinha E. Equidade nos cursos de graduação em Saúde: marco legal, desafios políticos e metodológicos. Interface (Botucatu) 2019; 232(1):e180017., “recognizing the centrality of the debate on equity constitutes the possibility of changes in teaching-learning as it is currently known”¹⁸18 Rocha DG, Souza DH, Cavadinha E. Equidade nos cursos de graduação em Saúde: marco legal, desafios políticos e metodológicos. Interface (Botucatu) 2019; 232(1):e180017. (p.10) and, for this to be effective, continuous dialogue and the exchange of knowledge with different actors are necessary. When health equity is placed at the center of the debate, issues that demarcate structural boundaries that affect blacks and whites, men, and women¹1 Gonzalez L. A categoria político-cultural de amefricanidade. Rev Tempo 1998; 92(93):69-82., are emphasized, explaining synergistic interactions between social, racial, and gender inequalities⁴³43 Silveiro ACL, Dias NG. Abordagem da saúde da população negra nos cursos da área de saúde. Temas Educ Saude 2019; 15(1):24-37..

However, in the context of Brazilian society²2 Maldonado-Torres N. Analítica da colonialidade e da decolonialidade: algumas dimensões básicas. In: Bernardino-Costa J, Maldonado-Torres N, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 27-54.^,1010 Almeida SAL. Racismo Estrutural. São Paulo: Pólen; 2019., it has been stated that rights are equal, racism is an inhumane and segregationist reality that has repercussions on the daily lives of all social classes and even takes on a genocidal face when it is expressed in the lower economic classes, notably in favelas and the outskirts of urban centers. In the health field, racial bias can be perceived through practices and attitudes alluding to discrimination and prejudice, considered as foundations through which institutional racism is built and consolidated, determining inequalities in access to services, in the provision of care⁴⁴44 Johnson TJ. Racial Bias and Its Impact on Children and Adolescents. Pediatr Clin North Am 2020; 61(2):425-436.

45 Gatewood E, Broholm CC, Herman J, Yingling C. Making the invisible visible: Implementing an implicit bias activity in nursing education. J Prof Nurs 2019; 35(6):447-451.

46 Gonzalez CM, Deno ML, Kintzer E, Marantz PR, Lypson ML, McKee MD. Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development. Patient Educ Couns 2018; 101(9):1669-1675.^-4747 Assis JF. Interseccionalidade, racismo institucional e direitos humanos: compreensões à violência obstétrica. Serv Soc Soc 2018; 133:547-565..

In addition to racial bias being perceived in the access to healthcare services, racism is negatively reflected in the diagnosis and clinical treatment of black patients⁴⁴44 Johnson TJ. Racial Bias and Its Impact on Children and Adolescents. Pediatr Clin North Am 2020; 61(2):425-436.^,4646 Gonzalez CM, Deno ML, Kintzer E, Marantz PR, Lypson ML, McKee MD. Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development. Patient Educ Couns 2018; 101(9):1669-1675.. Expanding the debate and creating effective transformations in these scenarios requires changes in professional training through undergraduate curricula³3 Gomes NL. O Movimento Negro e a intelectualidade negra descolonizando os currículos. In: Bernardino CJ, Maldonado TN, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 223-246.. Yet, in Brazil, the theme found in the DCN and PPC of such courses as Public Health, Nursing, and Medicine, is incipient in scientific production, providing evidence on how it is implemented in undergraduate courses¹⁸18 Rocha DG, Souza DH, Cavadinha E. Equidade nos cursos de graduação em Saúde: marco legal, desafios políticos e metodológicos. Interface (Botucatu) 2019; 232(1):e180017.^,4242 Instituto Brasileiro de Geografia e Estatística (IBGE). Estudos e Pesquisas Informação Demográfica e Socioeconômica Desigualdades Sociais por Cor ou Raça no Brasil. Brasília: IBGE; 2019.. It is worth highlighting the importance of equity in academic training and its ability to mobilize protagonists³3 Gomes NL. O Movimento Negro e a intelectualidade negra descolonizando os currículos. In: Bernardino CJ, Maldonado TN, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 223-246. in upholding the principles of SUS and training healthcare providers who are committed to social justice. However, despite legal advances, the crisis in the university education system remains visible⁴⁸48 Almeida Filho N, Nunes TCM. Inovações curriculares para Formação em Saúde inspiradas na obra de Anísio Teixeira. Trab Educ Saude 2020; 18(1):1-24..

The context for implementing changes in teaching has been a challenge³3 Gomes NL. O Movimento Negro e a intelectualidade negra descolonizando os currículos. In: Bernardino CJ, Maldonado TN, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 223-246., as it is based on an obsolete and fragmented curriculum that is inadequate for tackling inequities⁴⁹49 Rozendo CA, Salas AS, Cameron B. A critical review of social and health inequalities in the nursing curriculum. Nurse Educ Today 2017; 50:62-71.

50 Furlanetto DLC. Políticas indutoras (pró-saúde) e a reorientação da formação de profissionais da área da saúde para o fortalecimento do SUS [tese]. Brasília: Universidade de Brasília; 2015.^-5151 Conterno SFR, Lopes RE. Pressupostos pedagógicos das atuais propostas de formação superior em saúde no Brasil: origens históricas e fundamentos teóricos. Avaliacao 2016; 21(3):993-1016.. Explaining them in health is related to the issue of race/ethnicity and has been documented to illustrate how they contribute to poor results in the health-disease process of these groups as compared to the white population⁴⁹49 Rozendo CA, Salas AS, Cameron B. A critical review of social and health inequalities in the nursing curriculum. Nurse Educ Today 2017; 50:62-71.. This trend, which is also observed in the Brazilian case, requires training that enables the understanding of the PNSIPN, “its reasons and emergence, as well as the specificities, understanding, and a critical anti-racist view regarding the triggering and determining factors of racism in health care”¹⁹19 Conceição CC, Riscado LS, Vilela RQ. Relações étnico-raciais na perspectiva da saúde da população negra no curso de medicina: análise curricular. Rev Bras Ens Sup 2018; 4(3):34-56. (p.47).

The approach to the health of the black population should not be limited to genetic conditions and the prevalence of diseases without contextualizing factors that are associated with these conditions and examining them with a critical, nonracist view¹⁰10 Almeida SAL. Racismo Estrutural. São Paulo: Pólen; 2019.. Conceição et al.¹⁹19 Conceição CC, Riscado LS, Vilela RQ. Relações étnico-raciais na perspectiva da saúde da população negra no curso de medicina: análise curricular. Rev Bras Ens Sup 2018; 4(3):34-56. argued that “approaches that encourage decision-making regarding diagnoses and treatments, in the patients’ clinical evolution, are necessary, avoiding negligence and negative consequences in the quality of care”¹⁹19 Conceição CC, Riscado LS, Vilela RQ. Relações étnico-raciais na perspectiva da saúde da população negra no curso de medicina: análise curricular. Rev Bras Ens Sup 2018; 4(3):34-56. (p.52).

There is a degree of conceptual confusion in the understanding of equity¹⁸18 Rocha DG, Souza DH, Cavadinha E. Equidade nos cursos de graduação em Saúde: marco legal, desafios políticos e metodológicos. Interface (Botucatu) 2019; 232(1):e180017.^,5252 Santana RAR, Akerman M, Faustino DM, Spiassi AL, Guerriero IACZ. A equidade racial e a educação das relações étnico-raciais nos cursos de Saúde. Interface (Botucatu) 2019; 23:e170039. and, despite the universal and equal access advocated by SUS, persistent inequities are present in Brazilian society. Hence, the relevance of investigating the NDE’s view of racial equity, as there is a strong denial of racism in Brazil¹1 Gonzalez L. A categoria político-cultural de amefricanidade. Rev Tempo 1998; 92(93):69-82., making it difficult to understand and influence the health-disease process⁵5 Jardim R, Oliveira Júnior MG, Schott M. Percepção de racismo no ensino superior em saúde na perspectiva docente. Rev Bras Polít Adm Educ 2022; 38(1):e113350.. As an example, Walderama and Varano²⁰20 Valderama WCP, Varanao AEC. Social justice is a dream: Tensions and contradictions in nursing education. Publix Health Nurs 2019; 36(5):735-743. interviewed Nursing course instructors in the United States and came to the realization that most white instructors equated equity to equality. Therefore, this view may ignore the association of multiple systems of subordination. The authors identified the concepts of equality and individualism as two pillars of white privilege and racism, situating European imperialism that benefited from the perverse, genocidal colonization of indigenous peoples and the enslavement of African peoples and their descendants. These perceptions promote the myth of meritocracy and serve to perpetuate a biomedical model focused on disease and the individual without connection to the social determination of health²⁰20 Valderama WCP, Varanao AEC. Social justice is a dream: Tensions and contradictions in nursing education. Publix Health Nurs 2019; 36(5):735-743.. Therefore, the perspective of decoloniality, when looking at these historical, cultural, and political reflections, also allows them to be reversed²2 Maldonado-Torres N. Analítica da colonialidade e da decolonialidade: algumas dimensões básicas. In: Bernardino-Costa J, Maldonado-Torres N, Grosfoguel R, organizadores. Decolonialidade e pensamento afrodiaspórico. Belo Horizonte: Autêntica; 2018. p. 27-54..

Despite the urgent need to include racial equity in the training, Santana et al.⁵²52 Santana RAR, Akerman M, Faustino DM, Spiassi AL, Guerriero IACZ. A equidade racial e a educação das relações étnico-raciais nos cursos de Saúde. Interface (Botucatu) 2019; 23:e170039. found that the health of the black population is presented in an incipient form in some courses and its inclusion has been made to meet the mandatory legal framework, there must be “recognition of [its] importance, as justification for the inclusion of the topic in the curriculum prescribed in the courses”⁵²52 Santana RAR, Akerman M, Faustino DM, Spiassi AL, Guerriero IACZ. A equidade racial e a educação das relações étnico-raciais nos cursos de Saúde. Interface (Botucatu) 2019; 23:e170039. (p.12). In teaching practice, the authors identified a lack of knowledge of bibliographical production focused on analyzing racial equity/inequity relations, which may contribute to racism’s invisibility as a Social Determinant of Health.

Jardim et al.⁵5 Jardim R, Oliveira Júnior MG, Schott M. Percepção de racismo no ensino superior em saúde na perspectiva docente. Rev Bras Polít Adm Educ 2022; 38(1):e113350. analyzed the instructors’ perception of racism in higher education. What they found was a preponderance of white instructors and a tendency to deny the existence of racism on campus and that “these data are a reflection of the academic universe in which we learned to adopt a meritocratic and universalist discourse, understanding racism and racial discrimination as phenomena that occur outside of the university”⁵5 Jardim R, Oliveira Júnior MG, Schott M. Percepção de racismo no ensino superior em saúde na perspectiva docente. Rev Bras Polít Adm Educ 2022; 38(1):e113350. (p.9). The study further underscored how racism was hidden in universities and that there was an urgent need to implement the DCNERER.

Conclusion

The NDE’s view of racial equity generated important reflections regarding the intentionality of public policies and the promotion of social justice, the existence of a historical debt in Brazil, and the significance of understanding the social determination of the black population. However, the debate that everyone in Brazil is equal before the law was emerging, a discourse that was widespread through a false idea of racial democracy and the exaltation of miscegenation.

The fundamental reasons for approaching the health of the black population in undergraduate health training courses were: knowledge of studies and indicators related to racism and health; the need for studies that denounce institutional violence and its reproduction in the health system, the relevance of the teachers’ training path and approaches to the issue of race and gender, the recognition of the historical debt in Brazil and the need to reverse this situation through affirmative action policies, the approach to the topic as a social right, and, finally, the educational institutions’ ethical-political commitment to critical thinking in training.

Despite the reasons for approaching the topic, the health of the black population, when mentioned, has been worked on in a specific and decontextualized manner, without reflecting on structural racism, power relations, and Brazilian socio-historical formation. In view of this, the need for investigations into the whiteness of the faculty in the health area is highlighted, considering Brazil’s cultural neurosis and the concealment of racism in academic training institutions.

The relevance of intervention research and the black perspective of decoloniality is emphasized, considering the refusal of scientific neutrality and the need for epistemic justice. The unveiling of the coloniality of power, knowledge, and being, expressed in the Brazilian racial issue and in the health and education systems, is recognized.

The reorientation of health training requires professionals who mobilize and demand changes in favor of equity and democracy, entailing the study of the PNSIPN and the effective implementation of the DCNERER. Finally, this study highlights the potential of strengthening institutions; dialogic, community, and extramural construction; and demonstrations to affirm this debate in universities through the inclusion of different segments of the black movement; SUS users and professionals; undergraduate health forums; the thematic group on racism and health of the Brazilian Association of Public Health; student representation of black students, such as “Negrex”; the Brazilian Association of Black Researchers; and Afro-Brazilian Studies Centers.

Acknowledgments

This study was conducted with financial support from the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) through the payment of a master’s scholarship to one of the authors.

References

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