ABSTRACT

This assessment aimed to evaluate the putative spatial relationship between sanitation indicators (access to water and sewage) considering the Rio de Janeiro State Water and Sewage Company (CEDAE) parameters and the COVID-19 incidence among districts with and without slum areas. The data of confirmed COVID-19 cases analyzed were obtained from the Rio de Janeiro Health Panel. We considered the division of the municipality into four regional blocks. The mean COVID-19 incidence was 9.78 cases/1,000 inhabitants in the 163 city districts. The lowest COVID-19 incidence rate was most reported in slum regions, with lower per capita income and sanitation coverage, suggesting a significant gap in testing and case underreporting. Reducing inequality and structural racism should be a priority. The COVID-19 syndemic strongly contributed to significant socioeconomic and public health losses. Our commitment to the Sustainable Development Goals of the 2030 agenda of the United Nations is pivotal in a backdrop of reconstruction.

KEYWORDS
Incidence rate; COVID-19; Water supply; Sewage coverage; Poverty areas

Introduction

Amid the recent backdrop of the enactment of Federal Law nº 14.026/2020¹1 Brasil. Lei Federal nº 14.026, de 16 de julho de 2020. Atualiza o marco legal do saneamento básico e altera a Lei 9.984/2020, atribuindo a Agência Nacional de Águas – ANA competência para regulação dos serviços públicos de Saneamento Básico. Diário Oficial da União. 16 Jul 2020. [acesso em 2020 jun 26]. Disponível em: https://www2.camara.leg.br/legin/fed/lei/2020/lei-14026-15-julho-2020-790419-publicacaooriginal-161096-pl.html.
https://www2.camara.leg.br/legin/fed/lei... , which changed the Sanitation Regulatory Framework (Law nº 11.445/2007)²2 Brasil. Lei Federal nº 11.445, de 5 de janeiro de 2007. Estabelece as diretrizes nacionais para o saneamento básico e para a política federal de saneamento básico. Diário Oficial da União. 8 Jan 2007. [acesso em 2020 jun 26]. Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2007-2010/2007/lei/l11445.htm.
http://www.planalto.gov.br/ccivil_03/_at... , pro-market and favoring the entry of private companies in the sector, the debates and the history of the construction that gave rise to it, and the national and international examples pointing out the risks of the concession of services to the private sector – mainly for the less profitable municipalities³3 Pinto JR, Noronha S. “Quem são os proprietários do saneamento no país?”. Instituto Mais Democracia Fundação Boll Brasil. 2017. [acesso em 2020 jun 26]. Disponível em: https://br.boell.org/pt-br/2018/04/16/quem-sao-os-proprietarios-do-saneamento-no-brasil.
https://br.boell.org/pt-br/2018/04/16/qu... , were disregarded. As a result, with a privatization agenda, Brazil went against the global trend of cities and countries that have regained control of water management and sanitation⁴4 Morosini L. Mais caros, menos eficientes. Revista Radis. 2018 [acesso em 2020 jun 26]; (189). Disponível em: https://radis.ensp.fiocruz.br/phocadownload/revista/Radis184_web.pdf.
https://radis.ensp.fiocruz.br/phocadownl... .

The privatization/concession of the State Water and Sewerage Company of Rio de Janeiro (CEDAE) was linked to the renegotiation of the state’s debt with the Federal Government, initiating the concession process of water and sewage services⁵5 Rio de Janeiro. Consulta Pública sobre Concessão da CEDAE. [acesso em 2020 maio 30]. Disponível em: http://rj.gov.br/consultapublica/Documentos.aspx.
http://rj.gov.br/consultapublica/Documen... . The concession project was developed by the National Bank for Economic and Social Development (BNDES), in which Rio de Janeiro (MRJ) was the only one with its territory fractionally included in the project, with its districts divided into four blocks. The consultation stages for receiving proposals and public hearings were held remotely during the COVID-19 pandemic when a large part of the population was demobilized, as was the scientific community, absorbed in the issues and demands imposed by the most significant challenge in contemporary public health. For this reason, different stakeholders opposed the consultation during a global public calamity setting. Considering that the public hearing is a social participation instrument – crucial to the democratic and decision-making process of approving the object under public consultation –, and aiming at the public interest, the constitutional principles of legality, freedom, equality, full defense, isonomy, audi alteram partem, symmetry, law proportionality, and the popular will should have been ensured sovereignly⁶6 Dal Bosco MG. Audiência pública como direito de participação. OAB - Mato Grosso do Sul. 2013. [acesso em 2020 jun 26]. Disponível em: https://oab-ms.jusbrasil.com.br/noticias/1645537/audienciapublica-como-direito-de-participacao.
https://oab-ms.jusbrasil.com.br/noticias... .

The evaluation of environmental sanitation policies and integration strategies involving the different management areas of a region can be conducted by analyzing the impacts generated by environmental changes. One of the ways to measure the effectiveness of an environmental sanitation policy is to capture its impact through health indicators or their absence thereof⁷7 United Nations Children’s Fund, World Health Organization (UNICEF/WHO). Water, sanitation, hygiene, and waste management for the COVID-19 virus. [acesso em 2020 maio 30]. Disponível em: https://wash.unhcr.org/download/covid-19-wash-technical-brief/.
https://wash.unhcr.org/download/covid-19... .

In this context, evaluating the COVID-19 cases and their possible correlation with sanitation conditions would be a current and strategic indicator guiding public policies. Also, hand hygiene, household hygiene, food hygiene, mask use, and social distancing are relevant non-pharmacological measures in mitigating the transmission of SARS-CoV-2. Therefore, access to water is central to this pandemic control⁸8 Fundação Nacional de Saúde. FUNASA - Impactos na saúde e no sistema único de saúde decorrentes de agravos relacionados a um saneamento ambiental inadequado. Brasília, DF: Fundação Nacional de Saúde; 2010.. Furthermore, the high vulnerability of part of the population to inadequate or nonexistent sanitation-related diseases has been described. Also, dengue, malaria, and leptospirosis can be aggravated in the current COVID-19 context, given the possibility of community virus transmission through untreated sewage or contaminated water⁹9 Zhang H, Kang Z, Gong H, et al. The digestive system is a potential route of 2019-nCov infection: a bioinformatics 2 analysis based on single-cell transcriptomes. bioRxiv. [Preprint]. [acesso em 2020 maio 30]. Disponível em: https://doi.org/10.1101/2020.01.30.927806.
https://doi.org/10.1101/2020.01.30.92780... .

In this study, we investigate the possible spatial relationship between the COVID-19 incidence rate (cases/inhabitants), economic (per capita income), and sanitation indicators (water access index and sewage collection index) in districts with and without slum areas, considering the regional blocks proposed in CEDAE’s concession model.

Material and methods

This observational, ecological, and analytical study, including the COVID-19 incidence in the MRJ, was based on data from the municipal portal Painel Rio Covid¹⁰10 Rio de Janeiro. Secretaria Municipal de Saúde. Painel Rio Covid-19. [acesso em 2020 jul 8]. Disponível em: http://www.data.rio/datasets/painel-rio-covid-19.
http://www.data.rio/datasets/painel-rio-... searched until July 8, 2020. Statistics on the population of each district were obtained from the Pereira Passos Institute¹¹11 Instituo Pereira Passos. Data. Rio Informações sobre a cidade. [acesso em 2020 jul 8]. Disponível em: http://www.data.rio/.
http://www.data.rio/... , and the two sanitation indices (access to water and sewage collection) were obtained from the National Sanitation Information System (SNIS) for 2018¹²12 Brasil. Ministério do Desenvolvimento Regional, Secretaria Nacional de Saneamento (SNS), Sistema Nacional de Informações sobre Saneamento (SNIS), Programa Web “Série Histórica”. [acesso em 2020 jul 8]. Disponível em: http://www.snis.gov.br/.
http://www.snis.gov.br/... .

The databases were built using a Geographic Information System (GIS), considering as secondary data: confirmed COVID-19 cases; per capita income; Human Development Index (HDI)¹³13 Atlas do Desenvolvimento Humano no Brasil. Como ler o IDHM 2010. [acesso em 2020 jul 20]. Disponível em: http://www.atlasbrasil.org.br/2013/pt/o_atlas/idhm/.
http://www.atlasbrasil.org.br/2013/pt/o_... ; access to water and sewage collection indices in the MRJ, in districts, and Subnormal Clusters (ASN) in the MRJ.

The blocks proposed by the CEDAE⁵5 Rio de Janeiro. Consulta Pública sobre Concessão da CEDAE. [acesso em 2020 maio 30]. Disponível em: http://rj.gov.br/consultapublica/Documentos.aspx.
http://rj.gov.br/consultapublica/Documen... concession project were considered in the comparison: Block 1 (Botafogo, Catete, Copacabana, Cosme Velho, Flamengo, Gávea, Glória, Humaitá, Ipanema, Jardim Botânico, Lagoa, Laranjeiras, Leblon, Leme, Rocinha, São Conrado, Urca, Vidigal); Block 2 (Anil, Barra da Tijuca, Camorim, Cidade de Deus, Curicica, Freguesia (Jacarepaguá), Gardênia Azul, Grumari, Itanhangá, Jacarepaguá, Joá, Pechincha, Recreio dos Bandeirantes, Tanque, Taquara, Vargem Grande, Vargem Pequena); Block 3 (Bangu, Barra de Guaratiba, Campo dos Afonsos, Campo Grande, Cosmos, Deodoro, Gericinó, Guaratiba, Inhoaíba, Jardim Sulacap, Magalhães Bastos, Paciência, Padre Miguel, Pedra de Guaratiba, Realengo, Santa Cruz, Santíssimo, Senador Camará, Senador Vasconcelos, Sepetiba, Vila Kennedy, Vila Militar); and Block 4 ( Abolição, Acari, Água Santa, Alto da Boa Vista, Anchieta, Andaraí, Bancários, Barros Filho, Benfica, Bento Ribeiro, Bonsucesso, Brás de Pina, Cachambi, Cacuia, Caju, Campinho, Cascadura, Catumbi, Cavalcante, Centro, Cidade Nova, Cidade Universitária, Cocotá, Coelho Neto, Colégio, Complexo do Alemão, Cordovil, Costa Barros, Del Castilho, Encantado, Engenheiro Leal, Engenho da Rainha, Engenho de Dentro, Engenho Novo, Estácio, Freguesia, Galeão, Gamboa, Grajaú, Guadalupe, Higienópolis, Honório Gurgel, Inhaúma, Irajá, Jacarezinho, Jardim América, Jardim Carioca, Jardim Guanabara, Lapa, Lins de Vasconcelos, Madureira, Mangueira, Manguinhos, Maracanã, Maré, Marechal Hermes, Maria da Graça, Méier, Moneró, Olaria, Oswaldo Cruz, Paquetá, Parada de Lucas, Parque Anchieta, Parque Colúmbia, Pavuna, Penha, Penha Circular, Piedade, Pilares, Pitangueiras, Portuguesa, Praça da Bandeira, Praça Seca, Praia da Bandeira, Quintino, Ramos, Ribeira, Ricardo de Albuquerque, Rio Comprido, Rocha, Rocha Miranda, Sampaio, Santa Tereza, Santo Cristo, São Cristóvão, São Francisco Xavier, Saúde, Tauá, Tijuca, Todos os Santos, Tomás Coelho, Turiaçu, Vasco da Gama, Vaz Lobo, Vicente de Carvalho, Vigário Geral, Vila da Penha, Vila Isabel, Vila Kosmos, Vila Valqueire, Vista Alegre, Zumbi).

The thematic maps were built with the geoprocessing program QGIS, version 2.18.13, and TerraView Social Policies, version 4.2.2, using Moran’s spatial statistical analysis¹⁴14 Anselin L. Local Indicators of Spatial Association – LISA. Geog. Analy. 1995 [acesso em 2020 jul 25]; 27(2):93-115. Disponível em: https://doi.org/10.1111/j.1538-4632.1995.tb00338.x.
https://doi.org/10.1111/j.1538-4632.1995... . The relationship between two variables was performed using the Spearman correlation coefficient for the 95% confidence interval (p<0.05), using the BioEstat 5.3.¹⁵15 Pagano M, Gauvreau K. Princípios de bioestatística. São Paulo: Cengage; 2004. program.

Results and discussion

COVID-19 incidence

The mean incidence rate for the 163 districts of the MRJ was 9.8 cases/1,000 inhabitants, the same as for the median. The highest incidence rate was observed in the Bonsucesso district, with 40.7 cases/1,000 inhabitants, and the lowest rate was in Vila Kennedy, with 1.1 case/1,000 inhabitants. There were no confirmed cases in the districts of Gericinó and Grumari until the analyzed date.

When considering the blocks by CEDAE’s classification, in block 1 – composed of the neighborhoods of the South Zone –, the mean was 16.6 cases/1,000 inhabitants, in which Gávea and Rocinha had the highest (39.5 cases/1,000 inhabitants) and the lowest (4.1 cases/1,000 inhabitants) incidence rate, respectively. In block 2, the mean cumulative incidence was 11.5 cases/1,000 inhabitants, in which Camorim had the highest rate (32.4 cases/1,000 inhabitants), and Cidade de Deus, the lowest (6.2 cases/1,000 inhabitants). In block 3, consisting of the other Zona Oeste districts, the mean COVID-19 incidence was 6.0 cases/1,000 inhabitants, in which the extremes were represented by Jardim Sulacap (13.1 cases/1,000 inhabitants) and Vila Kennedy (1.1 case/1,000 inhabitants). There were no confirmed cases in the Gericinó district at the time of the analysis. In the Zona Norte districts, which are part of block 4, the mean incidence rate was 8.9 cases/1,000 inhabitants, led by Bonsucesso (40.7 cases/1,000 inhabitants). In Complexo do Alemão, one of the most significant subnormal clusters in the municipality, surprisingly, the mean COVID-19 incidence was 0.2 case/1,000 inhabitants.

Based on official data, blocks 1 (Zona Sul) and 2 (Jacarepaguá and Anil, Barra da Tijuca, Camorim, Gardênia, Grumari, Itanhangá, Joá, Recreio dos Bandeirantes, Vargem Grande, Vargem Pequena) showed the highest COVID-19 incidence rates (figure 1). In contrast, the lowest incidences were reported in districts with a predominance of subnormal clusters (ASN/favelas), evidencing relevant gaps in access to COVID-19 testing in these territories – as reported in the Epidemiological Bulletin of the Sergio Arouca National School of Public Health (ENSP)¹⁶16 Cannabrava MC. Favelas do Rio registram 11 novos casos de COVID-19 nesta quinta-feira(23). [acesso em 2020 jul 25]. Disponível em: https://www.vozdascomunidades.com.br/COVID19nasfavelas/favelas-do-rio-registram-11-novos-casos-de-COVID-19-nesta-quinta-feira-23/.
https://www.vozdascomunidades.com.br/COV... , with consequent underreporting.

According to data from the Brazilian Institute of Geography and Statistics (IBGE) – 2010 Census – the MRJ has the most significant number of ASNs in the state (57.3%, 763/1,332 ASN), comprising 69% of households and 68.8% of Rio de Janeiro dwellers¹⁷17 Instituto Brasileiro de Geografa e Estatística. Sidra Banco de Tabelas Estatísticas. [acesso em 2020 nov 24]. Disponível em: https://sidra.ibge.gov.br/.
https://sidra.ibge.gov.br/... ,¹⁸18 Sotero-Martins A, Salles MJ, Carvajal E, et al. Spatial Analysis of the Municipalities of the State of Rio de Janeiro in Regional Sets for Concession to Privatization of the Main Sanitation Company. 2020. Preprints Scielo. [acesso em 2020 novembro 25]. Disponível em: https://preprints.scielo.org/index.php/scielo/preprint/view/1041.
https://preprints.scielo.org/index.php/s... . During the COVID-19 pandemic, the organization Voz das Comunidades produced data from official information from the Municipal Health Secretariat, family health clinics, and the organized communities, which were recorded in the Coronavirus Update Panel in Rio de Janeiro Favelas¹⁶16 Cannabrava MC. Favelas do Rio registram 11 novos casos de COVID-19 nesta quinta-feira(23). [acesso em 2020 jul 25]. Disponível em: https://www.vozdascomunidades.com.br/COVID19nasfavelas/favelas-do-rio-registram-11-novos-casos-de-COVID-19-nesta-quinta-feira-23/.
https://www.vozdascomunidades.com.br/COV... . Data from 24 ASNs described by the organization Voz das Comunidades were spatially analyzed, considering the estimated population for each of them¹⁷17 Instituto Brasileiro de Geografa e Estatística. Sidra Banco de Tabelas Estatísticas. [acesso em 2020 nov 24]. Disponível em: https://sidra.ibge.gov.br/.
https://sidra.ibge.gov.br/... .

Based on the cumulative incidence rates, mortality rate, and recovery rate for COVID-19, we observed that the ASNs in the districts of Gardênia Azul and Cidade de Deus, both in block 2, had the highest COVID-19 incidence rates. The ASNs located in the districts of Jacaré, Penha, Maré, Caju, Manguinhos, Complexo do Alemão, Tijuca, and Jacarezinho, in the block 4 region, also showed significant values for the incidence rate.

In the block 1 region, the ASN located in the Catete, Leme, Copacabana, and Vidigal districts stood out with the highest rates (figure 2). Data were not available for the ASNs in the block 3 region districts. These findings suggest that a significant part of Covid-19 cases in the population residing in ASNs was not included in the official statistics, corroborating the underreporting of cases in these areas. Thus, incorporating other agents in epidemiological surveillance in these territories is strategic – notably, from the organized community – reducing notification bias and providing an epidemiological setting closer to the local reality.

Socioeconomic and sanitation indicators

Socioeconomic indicators (HDI and mean per capita income) were significantly correlated with access to water in all blocks of neighborhoods classified by CEDAE. Comparable results were observed regarding sewage collection, except for blocks 3 and 4, in which no significant associations were found between these and socioeconomic indicators (table 1).

In Rio de Janeiro, the highest concentration of income was observed in the Zona Sul districts, except for Barra da Tijuca (Zona Oeste). Ipanema and Lagoa led the statistic, followed by Barra da Tijuca and Leblon and, finally, by the other five neighborhoods in block 1: Botafogo, Copacabana, Flamengo, Humaitá e Leme. The districts with fourth-highest income in the city were divided between the Zona Sul (Gávea, Jardim Botânico, and Laranjeiras), Zona Norte (Grajaú, Jardim Guanabara, Maracanã e Tijuca) and Zona Oeste, represented by Recreio dos Bandeirantes. The districts with the city’s fifth-highest income – Andaraí, Cachambi, Lins de Vasconcelos, Méier, Rio Comprido, Todos os Santos, Vila da Penha, Vila Isabel, São Conrado, Vidigal, Centro, Santa Teresa, Freguesia (Jacarepaguá), Itanhangá, Pechincha and Vila Valqueire – were distributed among the different blocks. Thirty-three of the 160 districts in the municipality had a per capita income between 2 and 14 minimum wages, so that income was concentrated in less than 21% of the population – significantly residing in the Zona Sul and Barra da Tijuca. In the other 127 city districts, the per capita income ranged from zero to two minimum wages. These results unequivocally portray social inequality in the municipality and highlight the importance of the debate on social tariffs in the sanitation concession process, considering that more than 79% of the population is made up of low-income individuals.

In the municipal and state ASNs, the mean HDI was around 0.71, a high index according to the ranges adopted by the Atlas of Human Development in Brazil¹¹11 Instituo Pereira Passos. Data. Rio Informações sobre a cidade. [acesso em 2020 jul 8]. Disponível em: http://www.data.rio/.
http://www.data.rio/... . However, the per capita income in the ASNs was R$ 728.81 in 2010 (i.e., below the amount of two minimum wages at the time). According to the Pereira Passos Institute⁹9 Zhang H, Kang Z, Gong H, et al. The digestive system is a potential route of 2019-nCov infection: a bioinformatics 2 analysis based on single-cell transcriptomes. bioRxiv. [Preprint]. [acesso em 2020 maio 30]. Disponível em: https://doi.org/10.1101/2020.01.30.927806.
https://doi.org/10.1101/2020.01.30.92780... , the mean monthly per capita income of households in reais in the municipal favelas was around 1.5 minimum wages.

From a spatial perspective, the Moran index was 0.436 (p-value 0.01) for the per capita income indicator, showing a spatial association between the districts (figure 3). The Box Map pointed out 76 districts with positive Q1-type spatial association; and 20 of these districts showed statistically significant spatial dependence on the Moran Map (figure 3). Coincidentally, part of them stood out for the high COVID-19 incidence, shown in figure 1.

Concession in sanitation: quo vadis?

About 75% of the city’s dwellings access water through the distribution network. Rio de Janeiro is also in the group of four municipalities where 50% to 75% have access to sanitary sewage collection¹⁸18 Sotero-Martins A, Salles MJ, Carvajal E, et al. Spatial Analysis of the Municipalities of the State of Rio de Janeiro in Regional Sets for Concession to Privatization of the Main Sanitation Company. 2020. Preprints Scielo. [acesso em 2020 novembro 25]. Disponível em: https://preprints.scielo.org/index.php/scielo/preprint/view/1041.
https://preprints.scielo.org/index.php/s... . In other words, the city has relatively adequate basic sanitation conditions. However, 8.9% of the ASNs lack access to water, which means that around 209,386 people do not use the official supply network. This shortcoming is even more expressive in sewage collection, impacting around 21.7% of these territories and 510,077 people.

The criteria for distributing companies responsible for covering sanitation in socio-environmentally vulnerable areas are not mentioned in the concession process public notice. Only 28 of the 42 municipalities in the state that house ASNs are part of the blocks described in CEDAE’s concession project. In this context, it is worth noting that the MRJ – which subsidized 77% of CEDAE’s collection¹⁸18 Sotero-Martins A, Salles MJ, Carvajal E, et al. Spatial Analysis of the Municipalities of the State of Rio de Janeiro in Regional Sets for Concession to Privatization of the Main Sanitation Company. 2020. Preprints Scielo. [acesso em 2020 novembro 25]. Disponível em: https://preprints.scielo.org/index.php/scielo/preprint/view/1041.
https://preprints.scielo.org/index.php/s... and was unequally divided into the four blocks – holds the highest percentage of ASNs in the entire state (57.3%). Sanitation coverage is not clearly defined for part of the territories with ASNs. Thus, a sizable portion of the population may remain uncovered by adopting the current project model – which would characterize a structural racism modality, with considerable persistent uncertainties in assisting favelas.

The proposal presented by the BNDES does not contain guarantees for the application of the social tariff, nor does it show details on the universalization goals in the areas of subnormal clusters, not even whether the investments described by blocks will be sufficient to achieve the universalization of sanitation in irregular areas in each concession block. The eventual non-adherence of any municipality will give rise to the change in the percentages of the allocated grant provided for in the contract. Furthermore, the MRJ cannot be forced to join the project fractionally to guarantee the feasibility of the concession transfer process to the state. Finally, no legal and economic support can sustain the public service provided in the vein of the cross-subsidy to allow for its viability since a poor service cannot be remunerated.

Final considerations

The difficulty of universalizing health and public services is closely related to social inequalities. Favelas have been considered problematic territories since their inception due to the disorderly urban space occupation, high population density, low per capita income, growing violence¹⁹19 Motta E. Resistência aos números: a favela como realidade (in)quantificável. MANA. 2019 [acesso em 2020 julho 25]; 25(1): 072-094. Disponível em: http://dx.doi.org/10.1590/1678-49442019v25n1p072.
http://dx.doi.org/10.1590/1678-49442019v... ,²⁰20 Ezzati M, Pearson-Stuttard J, Bennett JE, et al. Acting on non-communicable diseases in low- and middle-income tropical countries. Nature. 2018 [acesso em 2020 jul 8]; 559(7715):507-516. Disponível em: http://10.1038/s41586-018-0306-9.
http://10.1038/s41586-018-0306-9... , poor or absent access to drinking water and sewage, the high frequency of inadequate environmental sanitation-related diseases, poverty⁹9 Zhang H, Kang Z, Gong H, et al. The digestive system is a potential route of 2019-nCov infection: a bioinformatics 2 analysis based on single-cell transcriptomes. bioRxiv. [Preprint]. [acesso em 2020 maio 30]. Disponível em: https://doi.org/10.1101/2020.01.30.927806.
https://doi.org/10.1101/2020.01.30.92780... and, more recently, COVID-19²¹21 Gray DM, Anyane-Yeboa A, Balzora S, et al. COVID-19 and the other pandemic: populations made vulnerable by systemic inequity. Nat Rev Gastroenterol Hepatol. 2020 [acesso em 2020 jul 8]; 17(9):520-522. Disponível em: http://10.1038/s41575-020-0330-8.
http://10.1038/s41575-020-0330-8... ,²²22 Byrareddy SN. Impact of Social Determinants of Health on the Emerging COVID-19 Pandemic in the United States. Front Public Health. 2020 [acesso em 2020 ago 25]; (8):406. Disponível em: http://10.3389/fpubh.2020.00406.
http://10.3389/fpubh.2020.00406... . Thus, this study contributes to better unraveling the COVID-19 backdrop in Rio’s favelas to subsidize the design and adequacy of health actions geared to this population, particularly vulnerable in the municipality.

Reducing inequality, inequity, and structural racism, marked by differentiated access between residents of subnormal clusters and formalized places, should be prioritized, whether from a socioeconomic or public health viewpoint. The COVID-19 syndemic contributed heavily to significant losses in both contexts. In a reconstruction setting, it is essential to resume the commitment to the Sustainable Development Goals of the United Nations 2030 Agenda²³23 Mejia R, Hotez P, Bottazzi ME. Global COVID-19 Efforts as the Platform to Achieving the Sustainable Development Goals. Curr Trop Med Rep. 2020 [acesso em 2020 ago 25]; (20):1-5. Disponível em: http://10.1007/s40475-020-00209-y.
http://10.1007/s40475-020-00209-y... .

References

Publication Dates

History