Looking to escape winter’s chill? Read this travelogue from Jessica Jerome, assistant professor of health sciences in the College of Science and Health, who received a Fulbright U.S. Scholar Award to study health care councils in Fortaleza, Brazil, last summer. The councils are one component of the country’s universal health care system, and they’re intended to give citizens a voice in health care decisions, priorities and resources. Jerome’s travel diary below offers an inside look at the opportunities and challenges facing health care councils and the citizens they serve.
Arrived in Fortaleza, Brazil. Fortaleza, a city of 2.5 million in the northeastern state of Ceará, is a particularly exciting place to study the health care councils because Ceará was one of the first states in the region to implement the universal health care system. The region’s impoverished rural and urban populations are the system’s target beneficiaries, and the city itself has been the testing ground for several new programs.
Today I attended a daylong State Health Care Council meeting at the Secretaria de Estado de Saúde (pictured below) for representatives from across Ceará. Many of the representatives voiced their displeasure about the lack of medications at various health clinics and an absence of funding for doctors’ salaries during the last two months. Tension was also high due to growing fears that Brazil’s president and high-level National Congress members had absconded with billions of dollars of taxpayer money that should have been earmarked for the health care system.
As the day wore on, the tone of the meeting grew angrier, ultimately culminating in cries to take the council members’ concerns to the Secretary of Health himself. After heated discussion, council members stormed out of the room and headed to the Secretary of Health’s office to confront him. As an American, it was quite striking to see this expression of political passion coupled with direct action!
This week I began visiting local health posts, which are unlike any clinics I know of in Chicago. The local health posts are federally mandated preventive health care units embedded in residential neighborhoods. Their services include vaccinations, prenatal visits, annual checkups, dental care and emergent health issues. A posto staff will typically include three to five general practitioners, two pediatricians, five dentists, several mental health specialists and 20 or more community health workers. The community health workers, often local residents, are each assigned their own micro area in the posto’s purview, and they make daily house calls to inquire after residents’ health care needs and provide information about upcoming services.
Health posts can be found in each and every municipality throughout the state of Ceará, and today, on the way to one of Ceará’s many beaches, I happened to catch sight of this tiny town’s health post (pictured below). The banners advertise free HIV testing and dengue fever information and screening. Explicit promotion of public health is common in Brazil and is not typically perceived as an intrusion of the state into private affairs.
This week I attended a series of local health council meetings in the low-income communities along Fortaleza’s eastern coastline. I first lived and worked in this area in 1999 and 2000, when I was conducting dissertation research on rural-urban migration and traditional medicinal plant usage. I have visited many times since then, and the changes have been extraordinary to witness. Well-paved, bustling roads have replaced cobblestone streets and dirt paths. An extensive public bus system now connects residents to the city center, and a growing middle class supports commercial and educational ventures in the area.
Changes to the community have not been uniform, however, as the photo above illustrates. On the left is a more traditional, family-owned lanches (small restaurant), with handmade advertising, operating according to the informal rules of its local owners. On the right is a new academia (gym), one of the first of its kind in the neighborhood. As residents have become wealthier and better educated, their health care expectations and needs have grown as well.
At the local health council meeting I attended today, an older woman expressed her indignation at having to wait a month and a half to secure a dentist appointment for her husband, who had a bad toothache. She asked the health council president, “What are we supposed to do? Make the appointments when we’re healthy, just in case we get sick?” The president assured her that he would bring everyone’s concerns to the next municipal meeting, where he would attempt to secure funds for an additional dentist at the post. Incidents like this one somewhat tempered the exuberance I had felt upon my initial visits to the local health posts, which seemed extraordinarily well-equipped for being small clinics in impoverished areas of the city. That said, the resident’s indignation can also be understood as an embodied manifestation of the ideal expressed by the Brazilian constitution that citizens are deserving of health care and that it is the responsibility of the state to provide it.
Already time to leave! I feel lucky to have been able to come back to Brazil. I’m already looking forward to next summer, when I hope to conduct follow-up research to find out whether and how the different councils were able to realize their priorities for the year.