Primary Care and the Reproduction of Health Inequity in a Central São Paulo Neighborhood Open Access

Pingel, Emily (Spring 2021)

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This dissertation bridges public health scholarship on health disparities with a medical sociology focus on culture and history, investigating relationships within a neighborhood primary care clinic in São Paulo, Brazil. I argue that the health of neighborhood residents is contingent upon the material configurations of the neighborhood and the cultural imaginaries at hand among neighborhood residents and health professionals. Relying upon fifteen months of ethnographic fieldwork, including 450 hours of participant observation and 58 in-depth interviews, I seek to expand a body of work theorizing race, racism, and health within spatial context. I offer three innovative contributions in service of this goal: 1) I center my analysis on multi-professional health service teams, moving the sociology of health professions beyond examining the role of a singular group (i.e., physicians), and 2) I reinvigorate the sociological perspective on culture and community health and 3) I incorporate digital communications into the study of patient-provider interactions.

Table of Contents

Table of Contents

Chapter 1: Introduction. 1

Health Equity in Brazil 2

The Neighborhood of Bom Retiro and the Bom Retiro Public Health Clinic (BRPHC). 4

Research Questions. 5

Theoretical Background. 6

Inequalities and Health. 6

The Social Determinants of Health. 15

Racial and Socioeconomic Inequalities in Brazil 20

Racial Health Disparities in Brazil 26

Chapter 2: Immigrants, Migrants, and Paulistanos: Racialized Geographies of Labor and Health in São Paulo, Brazil 30

Introduction. 30

Race, (Im)migration and Housing in São Paulo. 31

Space, Place, and Racialization. 34

The Bom Retiro Public Health Clinic 36

Methods. 39

Results. 42

Racialized Geographies in Bom Retiro. 42

Racialized Geographies and the Utilization of Primary Care Services 50

Racialization through the Lens of Class and Gender. 57

Conclusions. 62

Chapter 3: Seeing Inside: How Stigma and Recognition Shape Community Health Worker Home Visits in São Paulo, Brazil 65

Introduction. 65

Home Visits in Bom Retiro. 67

Recognition and Stigmatization. 69

Cultural Schemas of “the Other”. 71

Methods. 74

Participant Observation. 74

In-Depth Interviews 76

Data Analysis 78

Results. 79

Home Visits and the Roles of Community Health Workers. 79

“Open Arms”: Visiting Older Adult Patients 82

“It’s complicated”: CHWs Interactions with Immigrant Patients 84

Attending Patients with Stigmatized Identities 91

Implications and Conclusion. 96

Chapter 4: Virtual Aspirations: How Women in São Paulo, Brazil use WhatsApp to Communicate their Desires for Safety and Stability 102

Introduction. 102

Women’s Experiences of Uncertainty and Loss 102

The Integrative Practices and Nutrition Group (ING) 106

Affective Desires 110

Methods. 112

Results. 115

Convivência through the ING.. 116

Threats of Precarity. 118

Messages of Fear 119

“Light and Enjoyable”. 123

Conclusion.. 128

Chapter 5: Conclusion. 130

Race, Racism, Immigration and Health. 130

Culture, Affect, and Space in the Context of Health. 133

Public Health Implications. 135

Future Research.. 137

Concluding Remarks. 141

References. 143

Appendix I: Patient Interview Guide. 160

Appendix II: Health Professional Interview Guide. 164


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