Inequalities in socially excluded areas – a frame analysis of Bolsonaro’s COVID-19 politics in Brazilian favelas

In the ongoing Covid-19-pandemic, favelas have become a tragic symbol of years of failures, mismanagement, and Brazil’s underfunded public healthcare system. External shocks and crises may be expected to burden this system even more. However, how resilient or weak is the public health system, the Sistema Único de Saúde (SUS), really? Which impact did the policymaking of the Bolsonaro government have on health inequalities in favelas? And why are favelas in particular jeopardized by becoming spaces of marginalization and inequality in times of health crisis? The paper looks at a highly contested yet underexplored area of public health research, focusing on informal urban settlements (inter alia favelas) to introduce a geo-health driven approach on inequality studies. Combining inequality theory with the concept of imagined geography, it is argued that favelas are socio-spatial determinants of health in themselves, which are often overlooked in national health policymaking and therefore characterised by a below-average life expectancy and a reliance on alternative (local) health initiatives in service provision – supplementary to the SUS. The paper traces the frame evolution of public health discourses on favelas in the Bolsonaro government before and during the beginning of the COVID-19 pandemic (2020 to mid-2021), using nine semi-structured interviews with public health representatives (activists, doctors, and scholars) and a qualitative systematic review of five medicine-sociological and public health databases. The collected data is analysed based on Walt’s and Gibson’s (1994) health policy triangle framework, allowing to identify networks and power structures between actors, ‘ideological’ positions, and policies. Findings suggest that health services provided by SUS, inter alia access to hospitals and vaccines, have been substandard – compared to other urban spaces within Brazilian cities – even before Bolsonaro’s tenure. However, with the rising COVID-19 mortality of poor people and people living in informal settlements, inequalities in the Brazilian healthcare sector have become more evident and salient in the wider public debate, causing a growing policy contestation and polarization between COVID-19 deniers – with Bolsonaro as the main representative – and people advocating stricter policies and measures in times of crisis, especially for excluded and marginalised populations like favelados. Although health inequalities have worsened, it is not unequivocal if it can be merely traced back to the policymaking of the Bolsonaro government. Instead, it can be observed that current policymaking in the field of health policy is ostensibly limited to selective measures that are typical of a (neo)liberal state. Thereby, it resembles widely the Brazilian welfare state of the 1990s, which was typified by a constant struggle between two paradigms: the (neo)liberal minimum state and the universality claim of the SUS. Brazil is a diverse country, also in terms of its epidemiological profile. Recognizing those differences is an opportunity to find new directions for public health policymaking in fighting health inequalities. This also includes that certain groups are not perceived as being less worthy of receiving care and thus of living, which has been the case with favelados in the Bolsonaro government.