Epidemic/pandemic preparedness in Brazil amongst transnational migrants

This brief aims to provide an analysis of the Brazilian response to the COVID-19 pandemic regarding transnational migrants and to look forward on how to build epi/pandemic preparedness in a way that is considerate of migrants’ rights, cultures and political demands.

Building on Leach et al., the objective of this brief is ‘to rethink preparedness more fundamentally as a dynamic social, cultural and political process’¹ and to shed light on how the country’s response to the pandemic failed to be inclusive.

This brief details key policy and operational considerations for the Brazilian Unified Healthcare System (Sistema Único de Saúde, SUS) policymakers, health managers and public health authorities. It draws on ethnographic research from the main author’s doctoral research on the impact of the COVID-19 on racialised migrant and refugee communities in Brazil,^2,3 on other academic and grey literature on the topic, and on guidelines and proposals for SUS produced in consultation processes organised by civil society.

Key considerations

The key considerations below are based on what can be learnt from the experience of migrant communities in the Brazilian Unified Healthcare System during the COVID-19 pandemic. These points are expanded at the end of this brief.

To enhance inclusiveness in the healthcare system for migrants during epidemics/pandemics:

• The Ministry of Health should create a National Policy for Comprehensive Healthcare of Immigrant, Refugee and Stateless Populations that is considerate of migrants’ sociocultural, ethnic and racial specificities. The policy should be codesigned with migrant communities, and a plural set of disciplines should be engaged in its elaboration and implementation.
• There should be capacity-building opportunities for health professionals, managers and students to improve their ability to deliver inclusive services that enhance healthcare access and outcomes for diverse populations.
• Health surveillance systems and methods of data collection should be improved so they can provide data for the structuring of policies. These systems should build on a wide array of disciplines.
• Access rights, equity and inclusiveness should be assured in the healthcare system to benefit migrants and local communities.

The health system, migrants and COVID-19: an overview

Brazil has one of the largest universal healthcare systems in the world. The SUS was created after a mobilisation process that started in the 1970s and engaged different sectors of Brazilian society. This process culminated, in 1988, in the universalisation of access to healthcare. SUS is commended nationally and internationally for its successful health policies, vaccination programmes, well-structured health surveillance systems and its substantial experience in dealing with pandemics, epidemics and outbreaks.⁴

However, the system struggled to be inclusive and equitable during the COVID-19 pandemic. Racialised transnational migrants – those who are categorised in Brazil, through an intricate racialisation process, as Black, Brown and/or Indigenous – were particularly vulnerable. They often lived in marginal areas of the largest cities and these areas often have few resources and high rates of unemployment. These migrants were often unaware of how the healthcare system worked or what rights they had to access it. These communities were vaccinated at a slower pace than the national population and faced barriers to accessing healthcare.

In Brazil, no data was collected on the nationalities of those infected or killed by COVID-19 or of those vaccinated. The healthcare system focused on ‘one-size-fits-all’ responses rather than more flexible, localised responses.

Indigenous migrants and refugees, such as the Warao people from Venezuela, were not assisted by the country’s Indigenous Health Care Subsystem (SasiSUS). They could not be identified as Indigenous by health professionals in any of the country’s health data collection systems and were not deemed to be a priority group for vaccination. Living in urban areas or moving between villages and cities, a condition shared by 62% of Indigenous people in Brazil, revokes eligibility, as SasiSUS only assists Indigenous people living in officially demarcated Indigenous land. The distinction between villagers and non-villagers also makes the assurance of rights to differentiated care harder; a right that is granted in Law 9.836/99.⁵

The COVID-19 pandemic catalysed the social mobilisation of migrant communities to produce collective proposals and guidelines for SUS, which enabled the discussion of a national health policy for migrant, refugee and stateless populations. The process of mobilisation has produced extensive material – both ethnographic and produced by migrants themselves – on the SUS experiences of migrant populations during COVID-19 and also proposals for strengthening the system by producing equity-oriented policies and actions. The social mobilisation processes were innovative and had a high level of engagement from migrant communities throughout Brazil.

Transnational migrants in Brazil: 2010-2024

Important aspects of recent migration in Brazil

Transnational migrants. The number of transnational migrants in Brazil rose 24% between 2011 and 2020, and the majority of this contingent is constituted by Black and Indigenous populations from Latin-American and African countries.^6,7 The current transnational migrant population totals almost 1.3 million people, who are mainly concentrated in the southeastern states of São Paulo and Rio de Janeiro (38%), in the northern state of Roraima (22%) and in the three southern states of Rio Grande do Sul, Paraná and Santa Catarina (17%).⁷ Of the 20 most numerous nationalities, only seven are from countries in the Global North.

Humanitarian visas. The creation of a special type of humanitarian visa for refugee-like situations, used for the first time in 2012 to facilitate the entrance of Haitians, represented a considerable change in the country’s migration policy. This new visa type increased the migration inflow to the country considerably, especially from Latin American and African countries experiencing humanitarian crises. The humanitarian visa is a faster route to temporary regularisation; however having official migrant status is not necessarily linked to an assurance of rights.² Beyond Haitians, this visa type has also been issued to Syrians, Afghans and Ukrainians. The number of asylum requests has also increased, from 232 in 2011 to 36,945 in 2019, a 159-fold increase.⁸

Racial categories. Migrants move not only through borders but also through different systems of categorisation of ethnic and racial differences. Black (pretos) and Brown (pardos) are the official categories adopted by the Brazilian state to refer to the country’s population of negros. African and Latin American migrants frequently state that ‘they learn they are Black in Brazil’ and pinpoint experiences of racism as pivotal to their understanding of their racial classification in the country.^9,10

‘Black and Brown’ migrants. The substantial growth of the ‘Black’ and ‘Brown’ (as categorised by the Brazilian state) migrant population stands out. In 2011, Black and Brown migrants represented only 13.9% of the migrant workforce in the country; this proportion grew to 62.4% by 2020.⁶ These migrants are usually in informal jobs and are often subject to precarious work conditions.

Feminisation of migration. Between 2010 and 2019, 688,367 women entered the country (through any means)¹¹ and 299,504 were officially admitted between 2011 and 2020.⁸ For comparison, between 2011 and 2020, 499,933 men were admitted. Between 2010 and 2015, female migrants were often originally from Argentina, Uruguay, Paraguay, Chile, USA, Germany, France, Portugal and Spain. From 2016 onwards, there has been an increase in the arrival of Haitians and Venezuelans.

Politicisation of migration. There is an increasing trend of politicians and members of the Brazilian military advocating for migrant rights. Aiding Venezuelan migrants has been associated with the ‘fight against socialism’ and these migrants are seen as ‘victims of socialism’.¹² Former president Jair Bolsonaro had previously referred to refugees as ‘the scum of the Earth’,¹³ yet his administration was responsible for granting refugee status to tens of thousands of Venezuelans, despite there being specific restrictions on the entrance of Venezuelans during the COVID-19 pandemic.

Militarisation of migration policies. Starting in 2018, Brazil responded to the increase in Venezuelan migrants with Operation Welcome (Operação Acolhida) led by the Brazilian military. This militarisation of the reception of Venezuelan migrants was deemed to be a success nationally and internationally.^14,15 This approach to governance of migration represents a perspective based on the notion of security against a foreign threat and produces a form of militarised humanitarianism.¹⁶

Interiorisation programme. Operation Welcome has an interiorisation programme that reportedly aims to alleviate the pressure on public services in Roraima, a low-income northern Brazilian state that borders Venezuela and through which most Venezuelans are entering the country. The programme seeks to send migrants to other states to work in government mediated jobs. Many of these jobs have been reported to be close to slavery. The relocated migrants do not have support networks in the receiving states and/or are not financially able to go elsewhere, both of which increase their vulnerability.¹⁷

Indigenous migrants

Indigenous people from Venezuela have been systematically displaced and expelled from their original territories, as in every country of South America. The Brazil-Venezuela, Brazil-Guyana and Venezuela-Guyana borders are inhabited by Yanomami, Macuxi, Warao, Taurepang, E’ñepá, Pémon, Wayúu and Kariña peoples. It has been reported that for a long time, these populations have unofficially moved across national borders that are within their traditional territories. However, since 2014, these groups have started to migrate more intensely to Brazil’s northern cities and beyond. In 2023, the population of Indigenous migrants in Brazil totalled 9,474. This population comprises Warao (67%), Pémon (28%), E’ñepá (2%), Kariña (2%) and Wayúu (1%).¹⁸

The Warao population, including those in traditional territories in Venezuela, totals around 50,000. Around 6,000 currently live in Brazil; they are originally from the Orinoco River Delta in the Amazon rainforest, Northeast Venezuela, and were largely displaced by a massive government mining project. These migrants started to arrive in some of Brazil’s major northern cities, such as Manaus, in 2014. They later migrated within the country, and some were sent to different municipalities through the government’s interiorisation programme. Warao people are now present in several Brazilian states, some of them thousands of kilometres away from their traditional territories. Many of Warao do not speak Spanish or Portuguese and do not primarily identify themselves as Venezuelans.

The Brazilian Unified Healthcare System

The Brazilian Unified Health System (SUS) covers more than 80% of the population living in the country.¹⁹ People from neighbouring countries, such as Bolivia, Paraguay and Venezuela, migrate to Brazil to seek health assistance. Access rights to healthcare were universalised in 1988 after a decade and a half of mobilisation by the Brazilian Health Reform Movement.

SUS principles. The stated principles of the SUS are universality, comprehensiveness and equity. Universality refers to the universality of access and care regardless of migration status or documentation. This stated universality of SUS is often used to resist attempts to tailor health services to increase access for marginalised communities, such as racialised migrants.³ Comprehensiveness refers to the comprehensiveness of care, which entails a multiplicity of therapeutic approaches that consider the social, cultural, economic, ethnic-racial and other components that determine health and illness experiences. Equity refers to the equity of health policies and actions; SUS seeks to provide healthcare to each individual, group and territory to the extent of their needs.

Community participation. The participation of the community in the development of health policies is another SUS pillar. The system itself arose from the deliberations of a participatory forum, the 8th National Health Conference. Thus, public health services – through the managing councils of health units – and public health policies – through municipal, state, and national health councils — should be oriented by the participation and supervision of their users. Healthcare users have the legal right to participate in the decision on public health budgets, priority actions and themes, among other relevant issues.

Political changes. President Dilma Rousseff was impeached in 2016 in a politically biased investigation, and, in the same year, a neoliberal agenda began to be implemented. Budgetary cuts harmed the healthcare system’s capacity to operate and even previously successful programmes, such as vaccination campaigns, started to experience difficulties. Vaccination rates for diseases for which immunisations are provided by SUS, such as measles, tuberculosis and polio, dropped to historical lows and below the world average.²⁰

Fears of deportation. The shifts in the Brazilian political context also impacted the willingness of migrants to report their presence to health teams and services. This change was motivated by their fear of being reported by health professionals to law enforcement agents. As an immediate effect of regulations issued during the COVID-19 pandemic, 3,376 migrants were deported in 2020 and 2021,³ sometimes even when they were eligible for refugee status.

The Indigenous Health Care Subsystem

Process of creation. Brazil’s Indigenous Health Care Subsystem (SasiSUS) was created in 1990 and operationalised in 1999 with the objective of enhancing healthcare coverage amongst Indigenous populations. SasiSUS was initially managed by the National Foundation of Health, but in 2010, a special secretariat for Indigenous health was created inside the Ministry of Health after broad consultation with Indigenous people and several rounds of negotiation between community leaders and the federal government.

Territorialisation. SasiSUS is territorialised in 34 Special Sanitation Districts of Indigenous Health and offers primary care within officially demarcated Indigenous land. Cases of medium or high complexity are supported by Indigenous Health Centres (CASAI), which are located in some major cities and host those who have left their territory for specialised care. Indigenous peoples’ participation in control of public health actions are guaranteed through Local and District Councils of Indigenous Health.

Interculturality and co-design of therapeutic plans. Intercultural care is legally assured for Indigenous populations, meaning that health teams must codesign therapeutic plans and treatment with Indigenous healers and plans must be based on healers’ traditional knowledge.²¹ The right to intercultural care is guaranteed at all levels of care, although violations to this right by health teams are commonly observed.²² Indigenous health agents are trained to perform as mediators between health teams and Indigenous communities. These agents work to enhance adherence to intercultural care principles, provide information and help develop intercultural approaches. Health professionals and authorities sometimes see Indigenous health agents as replicators of biomedical knowledge to their communities.²³

Access to SasiSUS for villagers and non-villagers. SasiSUS distinguishes between ‘villagers’ (aldeados) and those living in urban areas (não aldeados, non-villagers). However, there are no formal criteria for the two groups in the country’s legislation and the decision on who is a villager is left to health professionals.²⁴ The distinction is made because SasiSUS does not operate in cities. Indigenous people living in urban areas are assisted by regular SUS primary or specialised care, mainly under the administration of municipalities and states. The existence of SasiSUS does not remove the obligation for states and municipalities to provide access to differentiated care for Indigenous people in urban areas, even though SasiSUS does not operate in these places. Differentiated care for Indigenous people living in urban areas is legally assured in all levels of care.

Who is Indigenous? The distinction between villagers and non-villagers has been denounced by Indigenous community leaders as an assimilationist approach.²⁵ The distinction also draws attention to the debate on who should be acknowledged as having Indigenous rights, including access rights to SasiSUS, and on the establishment of subjective criteria for defining who is and is not Indigenous. There are reports of health professionals justifying the denial of access to SasiSUS by saying ‘You are not Indigenous anymore and have not been for a long time now’.²⁵ The distinction between Indigenous people living in urban areas and those living in villages in demarcated land disregards the ongoing forced displacement and expulsion of Indigenous populations since colonial times.

Prioritisation for vaccination. During the pandemic, Indigenous people living in demarcated land were deemed a priority for vaccination, while those in the cities were not (see Box 1). Indigenous migrants, such as the Warao and Pémon, whose land cannot be demarcated by the Brazilian government as it is not inside the Brazilian territory, were not among those deemed a priority. Additionally, the federal government only counted infections and deaths of Indigenous people due to COVID-19 in its databases if they were living in villages and disregarded the infections and deaths of those living in cities. This approach led to the underrepresentation of the deaths of Indigenous people, including those in mobility, in the overall data.

Box 1. Priority or not?

Source: Authors’ own.

Transnational migrants and SUS during the COVID-19 pandemic

SUS played a fundamental role during the COVID-19 pandemic and provided health services to a large portion of the population of Brazil. However, the system was put under stress due to a lack of structural and professional resources that could have helped healthcare providers meet the increased demand for services.

Access rights for migrant populations. There are no legal barriers for migrants to access SUS. Access rights are constitutional and are also specifically granted, without any discrimination regarding nationality or migration status, in Law No. 13.445/17, known as the ‘Migration Act’.²⁶ Ministry of Health Ordinances Nos. 2.236/21²⁷ and 940/11²⁸ establish that migrants do not need to present proof of residence, immigration papers or other similar documents to receive healthcare.

Practical barriers to access. Despite the legal right migrants have to access SUS, in practice there are a number of barriers that prevent them from receiving healthcare. These barriers include migrants’ lack of knowledge about how SUS operates, the lack of translated materials that explain SUS, healthcare providers’ illegal requests for residence and migration documents and healthcare providers’ lack of knowledge about migrant access rights. In São Paulo, for example, health units in marginalised neighbourhoods were reported to be refusing to treat or vaccinate migrants who could not present documentation. There were other reports that some health units also refused to assist migrants who did present the relevant documents.³

Targeting Venezuelans. Venezuelans were the only migrant group specifically mentioned in the regulations related to Brazil’s COVID-19 border closures. Ordinance No. 120, issued on 15 March 2020, was the first ordinance related to closing the borders and it specifically closed the border with Venezuela.²⁹ This ordinance and others specifically mentioning Venezuelans were the only ones to justify closing the borders as a way to ‘protect SUS’.^29,30 These ordinances specifically forbid Venezuelans from entering the country even if they had permanent residency. This restriction did not apply to other nationalities.³¹

Nationality data in SUS. The two SUS forms most commonly used during the pandemic to collect data were the Flu Syndrome Form and the Severe Acute Respiratory Syndrome (SARS) Form, neither of which collected nationality data. The original ‘Country of origin’ field of the Flu Syndrome Form was changed to ‘Country/ies travelled to in the last 14 days’ during COVID-19.³ The SARS Form was used in specialised care and did not have a nationality field. This form was the most intensively used for data collection related to aggravated COVID-19 cases.

The Healthcare Network for Immigrants and Refugees ran a campaign to demand that Municipal and State Health Departments added nationality to all their SUS forms, including those related to COVID-19, and were guided on the importance of the collection of nationality data. The Network also demanded that nationality disaggregated COVID-19 mortality and morbidity data were included in the Ministry of Health’s epidemiological bulletins and monitoring panels.

Lack of data. Nationality fields were never added to the SARS Form, the form most used by health teams. This means there is no reliable data on how many migrants were infected with SARS-CoV-2, how many died as a consequence of the virus, or who were the most affected communities. The nationality of the immunised was also not collected, so there is no available data on COVID-19 vaccination coverage among migrants. This lack of data highlights a lack of health surveillance preparedness. The Municipality of Sao Paulo affirmed that nationality data was “useless” for the structuring of its COVID-19 response. It also stated that it would only collect nationality data after the end of community transmission of the SARS-CoV-2. This means it saw this kind of data was only useful to protect residents from foreign threats.³

Migrants framed as disease vectors. As part of the “nationality in SUS campaign”, the National Public Defender’s Office filed a lawsuit demanding the Sao Paulo municipal administration and the Ministry of Health collect nationality data in COVID-19 forms. The Sao Paulo Municipal Administration expressed that the collection of nationality data was important only as a way to map contagion, that is, when foreigners represented an epidemiological risk. The Ministry of Health responded that it was exclusively collecting data on the country of residence of those living outside Brazil, even if they were Brazilians, as a way to identify chains of infection. In both cases, the collection of data of non-nationals was not oriented by the need to provide equitable responses for migrants in SUS.

Racism and its impacts during the COVID-19 pandemic

Racism impacts the reception of Black, Brown and Indigenous migrants.¹⁰ These groups often face police violence, discrimination in the job market, territorial segregation and ghettoisation, racialised xenophobia and being in a lower social position than in their home country.³²

COVID-19 and racialised populations in Brazil. During COVID-19, investigations in Brazil suggested higher infection and mortality rates among racial and ethnic minorities^33,34 and demonstrated the disproportionate allocation of COVID-19 vaccines to White populations.^35–37 These were both reflected in the access of racial and ethnic minorities to COVID-19 vaccines, with reports of denial of vaccination of racialised migrants in health units located in marginal neighbourhoods.³ There is no official data on how many migrants were infected or killed by COVID-19, nor is there official data on which communities were most affected.

Qualitative research and territorial approach to vaccination. Territorialisation in major Brazilian cities is racialised, with distinctive territorial segregation of Black and Brown populations. Low-income districts and neighbourhoods of cities like Sao Paulo have a higher proportion of non-White populations. Building on that, Faustino et al. (2021)³⁵ and Klintowitz et al. (2021)³⁶ suggested that identifying areas in which there was more circulation of the virus – that is, territories where people were more exposed, mainly for work reasons – and prioritising these for vaccination could lead to more equity in the COVID-19 immunisation campaign and reduce the disproportionate numbers of vaccines going to White populations. Identifying specific narratives linked to experiences of racism amongst immigrants and refugees through qualitative research has the potential to help structure equity-oriented vaccination actions.

Reluctance to seek vaccination. Migrants were reluctant to seek health services, including vaccination, during the pandemic. This reluctance came from migrants’ fear of deportation, increased hostility towards them, and their lack of awareness about their SUS access rights.^2,3 There is only scarce qualitative information available on vaccine hesitancy among different migrant communities.

Specific narratives and strategies. Different migrant communities had different narratives regarding vaccination. For example, within African migrant communities there was a fear that there were two different vaccines – one for White people and another for Black people (see Box 2). Some members of the Haitian community stated that COVID-19 was a White illness and that Haitians were immune to it. The Haitian community largely refused to be vaccinated. Some members of the Angolan community expressed concerns regarding the booster doses, which they refused to take.

Box 2. ‘Vaccines for White people and vaccines for Black people’: impacts of racism on racialised migrants’ assumptions about vaccinations³⁸

Source: Sources cited.

Beyond COVID-19: Co-designing health policies and community participation

Community participation. Community participation in SUS occurs through three main mechanisms: managing councils of health units; municipal, state and national health councils; and National Health Conferences.

National Health Conferences (NHCs). These take place every four years and are attended by thousands of representatives of different groups from every part of the country. NHCs are used to periodically assess and discuss health policies, guidelines and proposals from across all the country’s administrative levels. NHC delegates deliberate and approve the directives that will orientate healthcare implementation during the four-year period between NHCs.

Free National Health Conferences are also part of community participation and are commonly organised by networks of civil society organisations to debate specific topics or to represent specific segments of society. In 2023, for the first time, these conferences could elect delegates to attend NHCs.

Learning from the 1st National Plenary, the 1st National Free Conference on the Health of Migrants and the 17th National Conference of Health

The mobilisation of migrant communities during COVID-19 in Brazil drew on the experience of other organisations and events, such as the Social Forum for Migration in the Americas. The mobilisation efforts were innovative and had an unprecedented level of engagement from migrant communities across Brazil. In total, the 1st National Plenary in 2021 and 1st National Free Conference on the Health of Migrants in 2023 had 1,259 participants.

The two events are described below so their methodologies can be replicated in the design of other SUS policies for migrant communities. If policymakers can understand the broad grassroots engagement that led to the approval of guidelines and proposals by migrants to provide equity-oriented care in SUS, this will help them continue to improve inclusivity in SUS.

The 1st National Plenary. The 1st National Plenary ‘Health and Migration in Times of COVID-19’ took place virtually between June and August 2021. It had five regional stages – one for each of the country’s regions (North, Northeast, Central-West, Southeast and South) – and one national stage. At each regional stage participants proposed sessions on subjects that were meaningful to their local communities and contexts while still in line with eight thematic axes. Participants were encouraged to prioritise subjects linked to their experiences with the heterogeneity of SUS and Brazil’s health policies. At the end of each session, participants drafted three proposals that were voted on in the region’s final session. The national stage then discussed and voted on the approved proposals from the regional stages.

Engagement and results. In total, 383 people from 19 different countries participated across 36 sessions. Overall, the event approved 172 proposals – 148 from the five regional stages and 24 from the national stage. The National Plenary led to the creation of the National Front for Migrant Health (Frente Nacional pela Saúde de Migrantes, FENAMI) and the Observatory on Migration and Health (Observatório Saúde e Migração). FENAMI was formed by the actors involved in the organisation of the Plenary and is responsible for advocating for the implementation of the approved proposals. The Observatory is a partnership between FENAMI and the Laboratory of Migration Studies at the Federal University of São Carlos (LEM-UFSCar) with the objective of producing interdisciplinary qualitative research on the topics raised by the National Plenary.

1st National Free Conference on the Health of Migrants. As Free National Health Conferences could send proposals and delegates to NHC for the first time in 2023, FENAMI organised the 1st National Free Conference on the Health of Migrants (NFCHM) on May 20, 2023. The date, a Saturday, was chosen to make it easier for migrants to participate, as many of them worked during the week. Thirteen regional committees organised 27 in-person ‘access points’ to the online NFCHM. These access points were distributed across 20 cities in 14 Brazilian states and were made possible through a broad collaboration network of organisations and collectives. With 876 participants, the NFCHM was the eleventh largest conference out of the 99 free conferences organised in 2023.

Throughout the NFCHM, contributions from migrants were prioritised; the Conference’s protocols specified that the ratio of migrants to Brazilians speaking should be 5 to 1. As a result, most contributions came from migrants. The participants approved four draft guidelines and 20 proposals, which were sent to be debated at the 17th NHC later in the year. The NFCHM also elected the first migrant delegation to participate in an NHC.

Resolutions. All the NFCHM’s proposals and guidelines were approved at the 17th NHC. After the Conference, the National Council of Health published Resolution No. 719, on 17 August 2023, to make public all the guidelines and proposals approved at the 17th NHC. Within the resolution there were 51 mentions of migrant populations.

SUS guidelines proposed by migrants and refugees

The four guidelines drafted by the NFCHM and approved at the 17th NHC were:

• SUS should apply the critical consideration of migration as a social determinant of health – that is, a consideration that is not ahistorical, static, hierarchised and compartmentalised.³⁹ The design of the National Policy for the Comprehensive Healthcare of Immigrant, Refugee and Stateless Populations should be considerate of sociocultural, economic and ethno-racial aspects.
• SUS should stimulate migrant community participation in social controlling and designing of health policies, ensure migrant participation in municipal, state and national health councils and guarantee the consultation of communities in policy design.
• SUS should guarantee the observation of linguistic, social, cultural, economic, gender and ethno-racial equity in the provision of health services and assistance. The Ministry of Health should provide easy access to information on SUS in other languages, including those not related to the colonial expansion of Europe, such as Warao, Haitian Créole, Aymará and Quéchua.
• SUS should ensure a healthcare system that values Indigenous, local and ​​traditional knowledge and that engages in a meaningful way with knowledge bases beyond biomedicine. SUS should establish intercultural practices in primary care inspired by what is done in SasiSUS.^40,41

National Policy for Comprehensive Healthcare of Immigrant, Refugee and Stateless Populations

The Ministry of Health began production of a proposal for a National Policy for Comprehensive Healthcare of Immigrant, Refugee and Stateless Populations (NPCHIRSP) in 2022. Production was suspended but then resumed during the Lula administration. At the end of June 2023, the Ministry of Health published Ordinance No. 763 that established a one-year working group responsible for formulating the policy proposal. This ordinance did not give civil society representatives an equal footing with their government counterparts and made the Environmental Health and Surveillance Secretariat responsible for coordinating the working group. This decision favoured the association between migration and epidemiological risk, a commonly observed trend in these contexts.^3,42,43 This association was also seen in the country’s response to the COVID-19 pandemic.

Additional setbacks. There were other setbacks in the creation of the proposal for the NPCHIRSP. These included the ordinance expiring in June 2024 and not being renewed. This expiry means that although the working group is still operational, it has no responsibility to produce deliverables and could be terminated at any time. Another setback is that the Ministry of Health has stated that it will now produce a National Strategy for Migrant Health rather than a National Policy. A strategy does not entail the same level of commitment by the government in producing practical actions and in engaging communities in the codesign and implementation of those actions. Current community participation methodologies are failing to engage migrant communities and the exchange of information between government and civil society actors has so far been desultory.

Key considerations for policymakers to enhance inclusiveness in SUS for migrants during epidemics/pandemics

These key considerations for policymakers bring together what was learnt from the experience of migrant communities in SUS during the COVID-19 pandemic. The objective of these recommendations is to improve SUS preparedness for epi/pandemic events in a way that is considerate of migrants’ rights and contexts. They develop further the considerations presented at the beginning of this brief.

Create a NPCHIRSP that is considerate of migrants’ sociocultural, ethnic and racial specificities. The policy should be codesigned with migrant communities and a range of disciplines should be involved in its elaboration and implementation.

The Ministry of Health should:

• Create a permanent technical committee for the NPCHIRSP within the Primary Care Secretariat. This committee should be 50% representatives of SUS users (including researchers and scholars), 25% health workers and 25% government representatives. SUS user representatives should come from organisations and collectives led by or who work with migrants and from research groups and academia. The committee should coordinate the process of elaboration, implementation and assessment of the NPCHIRSP and other national guidelines regarding the health of migrant populations.
• Codesign the methodologies for consultation, participation and writing with migrant communities to enhance these communities’ advocacy for the NPCHIRSP, produce more meaningful collaboration and ultimately lead to more policy impact.
• Organise a broad consultation process that engages migrant communities nationwide. The federal government should mobilise governmental agents from the three administrative levels, and civil society organisations and social movements should engage migrant communities.

There should be capacity-building opportunities for health professionals, managers and students to improve their abilities to deliver inclusive services that enhance healthcare access and outcomes for diverse populations.

The Ministry of Health should:

• Offer an introductory training course on Migration and Health for health managers and professionals at the SUS Open University. The course should introduce the important aspects to consider when structuring equity-oriented health policies and interventions for migrant populations. It is important that the course considers a multiplicity of perspectives and provides insight from a wide array of disciplines, including sociology, anthropology and psychology. A similar course is currently in development at the Observatory of the International Migration at the University of Brasília.
• Open a conversation with the Ministry of Education and professional associations on the inclusion of migrant health topics in health science undergraduate courses.

Health surveillance systems and methods of data collection should be improved so they can provide data for the structuring of policies. These systems should build on a wide array of disciplines.

The Ministry of Health should:

• Update all SUS forms to collect nationality data as a way to identify migrant populations in the Ministry’s databases. The Ministry should provide guidance to health managers and other health professionals that stresses the importance of data collection.
• Create specific programmes of funding in the National Council for the Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico), Foundation for the Scientific and Technological Development in Health (Fundação para o Desenvolvimento Científico e Tecnológico em Saúde) and State Foundations for Research Funding for the production of qualitative research on the health of migrants in Brazil that values the multiplicity of epistemological perspectives.
• Provide, through the National School for Public Administration (Escola Nacional de Administração Pública), regular training courses for health surveillance professionals on migrant rights and the sociology and anthropology of health.
• Deepen its engagement of social science researchers and scholars in surveillance policy design and create a pluridisciplinary and equity-oriented environment.

Access rights, equity and inclusiveness should be assured in SUS to benefit migrants and local communities.

The Ministry of Health should:

• Translate information about SUS into Spanish, English, French, Arabic, Haitian Créole, Quíchua, Aymará, Warao, Lingala and Swahili and also provide feedback channels within the SUS ouvidoria (ombudsman) in those languages. Providing information and communication channels in a range of languages helps assure access rights and enhances user trust. The Ministry should provide guidance for municipal and state health secretaries and departments on how to make translated materials available, including displaying them in health units.
• Establish cultural brokerage and mediation programmes, raising awareness of the different approaches available. There should be debates on the orientation of those programmes, engaging professionals, researchers and scholars from knowledge fields related to cultural brokerage and mediation, such as anthropology and psychology. Additionally, the Ministry should clarify and establish the formation processes of professionals engaged in cultural mediation and brokerage. Cultural mediation professionals should be included in healthcare and psychosocial care teams.
• Enable SasiSUS to provide supervision and courses for primary and specialised healthcare teams on how to assure Indigenous migrants and refugees the right to interculturality and how to codesign therapeutic approaches with them.
• Engage the SasiSUS in the provision of care for Indigenous people living in urban areas, such as the Warao. The previous successful engagement in some states (for example Pernambuco) of the local Special Sanitation District of Indigenous Health with the ‘SUS in the Street’ programme during the pandemic could be a model for the implementation of similar approaches.
• Extend eligibility for health actions (such as vaccination prioritisation) for Indigenous people to include Indigenous people living in urban areas.
• Create national guidelines for intercultural approaches in mental health, psychosocial support and healthcare, including on how to incorporate culturally competent care into the daily practices of healthcare services.
• Produce guidance for health teams that explains migrants’ access to SUS and healthcare, including that the presentation of valid Brazilian documents is not needed for SUS registration or for access to care.
• Adopt territorial criteria for vaccination planning, especially during outbreaks, and immunise the populations of territories in which there are higher rates of over mortality. COVID-19 has shown that the racial and economic segregation in Brazil impacts access to vaccination. Adopting territorial criteria has the potential to produce more equity-oriented immunisation campaigns.
• Engage migrant communities in managing councils of health units and municipal, state and national health councils, and grant migrant populations the right to participate in the design of health actions and policies. As part of this engagement, produce informative materials about social participation in different languages and organise workshops and seminars on relevant topics. The Ministry could partner with Municipal and State Councils of Health, Managing Councils of Health Units and civil society organisations to provide annual training for migrant communities on popular participation and social control in SUS.

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Authors: Alexandre Branco-Pereira (National Front for Migrant Health and Health and Migration Observatory, [email protected]) and Gabriela Carvalho Teixeira (National Front for Migrant Health, [email protected]).

Acknowledgements: We wish to acknowledge expert input from others who contributed their insights to this brief: Dr Fabiane Vinente, Migration and Health Specialist (Fiocruz) and Dr Juliana Corrêa, Post-Doctoral Researcher and Public Health Specialist (Getúlio Vargas Foundation). Additional acknowledgements are also extended to Santiago Ripoll and Catherine Grant (IDS). This brief was reviewed by Tabitha Hrynick (IDS), Annie Wilkinson (IDS), Dr. Fabiane Vinente, and Dr. Juliana Corrêa. Editorial support provided by Nicola Ball. This brief is the responsibility of SSHAP.

Suggested citation: Branco-Pereira, A. and Teixeira, G. (2024). Epidemic/pandemic preparedness in Brazil amongst transnational migrants, Social Science in Humanitarian Action (SSHAP). www.doi.org/10.19088/SSHAP.2024.046

Published by the Institute of Development Studies: October 2024.

Copyright: © Institute of Development Studies 2024. This is an Open Access paper distributed under the terms of the Creative Commons Attribution 4.0 International licence (CC BY 4.0). Except where otherwise stated, this permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and source are credited and any modifications or adaptations are indicated.

Contact: If you have a direct request concerning the brief, tools, additional technical expertise or remote analysis, or should you like to be considered for the network of advisers, please contact the Social Science in Humanitarian Action Platform by emailing Annie Lowden ([email protected]) or Juliet Bedford ([email protected]).

About SSHAP: The Social Science in Humanitarian Action (SSHAP) is a partnership between the Institute of Development Studies, Anthrologica , CRCF Senegal, Gulu University, Le Groupe d’Etudes sur les Conflits et la Sécurité Humaine (GEC-SH), the London School of Hygiene and Tropical Medicine, the Sierra Leone Urban Research Centre, University of Ibadan, and the University of Juba. This work was supported by the UK Foreign, Commonwealth & Development Office (FCDO) and Wellcome 225449/Z/22/Z. The views expressed are those of the authors and do not necessarily reflect those of the funders, or the views or policies of the project partners.

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