Socioeconomic inequalities in Health: Reflections on the academic production from Brazil

Since colonial times, Brazilian society has been characterized by a perverse concentration of wealth in the hands of a small elite. Ethnic group inequities were superimposed upon the concentration of wealth, with the near extermination of the native population and the massive slave trade. On top of socioeconomic and ethnic disparities, gender inequities also play an important role in Brazilian society. Since international rankings of income concentration became available (http://www.tradingeconomics.com/brazil/ gini-index-wb-data.html), Brazil has been consistently placed among the 10 most unequal countries in the world, and has often occupied the first position. Our Gini index showed significant declines in the past two decades, and such a reduction in inequality, jointly with the implementation of the Sistema Único de Saúde (National Health System), is deemed to have been one of the major drivers of the improved health status of the Brazilian population [1]. The massive economic inequality has had an impact on our academic production. For anyone working in the area of Public Health in Brazil, the role of social determinants, and in particular the magnitude of the health gap among the rich and the poor, are too evident to be ignored. As a result, Brazilian academics have produced a rich literature on the area of social determinants and health inequalities [2, 3]. In this commentary, I provide a brief personal view of the evolution of the study of health inequalities in our country, and discuss how the contents of the present journal supplement reflect our academic production. Up to 1980, the quantification of socioeconomic position at individual or household level was uncommon. I recall two landmark articles from the 1970’s: an ecological study by Jairnilson Paim correlating indicators of poverty to health outcomes with States as the units of analysis, [4] and Carlos Monteiro’s survey on child nutrition according to land ownership in rural São Paulo State [5]. Both of these articles inspired my PhD thesis, which used multiple linear regression—a state-of-the-art approach at that time—to relate child health and nutrition to land tenure patterns in my home state of Rio Grande do Sul [6]. At that time, the dominance of academics with social sciences background in Public Health led to a great degree of mistrust regarding the use of quantitative methods for assessing inequalities. I remember that when presenting my PhD thesis at a national conference in the 1980’s, I was accused of being a “positivist”. Over time, quantitative studies gained wider acceptance, but were still strongly influenced by Marxist literature, as for example by attempting to adapt the concept of social class in our analyses [7–9]. These classifications resulted in several categories (e.g. underproletariat, typical proletariat, small bourgeoisie, etc.) and required combining information on occupation, qualifications, employment status and other variables. Because most of the information was based on open questions, classification of individuals had to be done manually and the process was very time consuming. Over time, these classifications were abandoned, even though several analyses showed that they were strongly associated with health outcomes. Over time, more and more Brazilian studies relied on classifications of “social class” adopted in market research, particularly the one proposed by the Associação Brasileira de Empresas de Pequisa or ABEP (http:// www.abep.org/criterio-brasil). Earlier versions of the scale classified families into classes from A to E, whereas the present scale has seven strata, from E1 to E7, [10]. The scale is based on an additive index that combines the number of several household assets (television, car, freezer, etc... including also the presence of full-time housekeepers), educational level of the head of household and characteristics of the neighborhood (paved streets, piped water). Each component of the index is Correspondence: [email protected] International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil