According to the World Bank, the United States ranked 8th position and Brazil 77th in the Gross Domestic Product (GDP) per capita in 2019 (World Bank Group). Succinctly, the GDP per capita measures an economy’s size, and although scholars contest whether the GDP is a welfare indicator, it remains one of the most common economic indexes – corroborating the assumption we are analyzing (more money = more development) (Bergh, 2009). Similarly, the 2020 Human Development Report ranked the United States in the 17th position and Brazil 84th (UNDP). However, according to the Global Access to Healthcare Index, Cuba ranks 7th position among the top-performing countries in healthcare access, and the United States 10th, closely followed by Brazil 12th. Concerning accessibility domain and access to child and maternal-health services, while Brazil ranks 9th and 5th, respectively, the United States is not even mentioned (The Economist, 2017).

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These data, whose outcomes seem somewhat counter-intuitive, are related to healthcare system design choices. They shed light on the topic’s complexity, as healthcare efficiency clearly demands more than wealth, especially for minorities and marginalized groups. Different healthcare systems reveal different political decisions and underlying priorities. Therefore, “(…) it is a question of how we shape the world in which we want to live” (Freedman, 2005). 

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For instance, the Brazilian constitution (1988) assures health as a universal right and an obligation of the state (Art. 196, Constitution of Brazil, 1988). Hence, it was a political decision that resulted in the Brazilian Unified Health System (SUS, or Sistema Único de Saúde, in Portuguese), which has massively increased its coverage over the 30 years of its existence and currently grants “nearly universal access to health-care services for the population" (Castro et al. 2019).  However, despite its impressive achievements, Brazil is not a healthcare paradise, much less a gender equity one.

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The interesting point here is that, despite the cultural, economic, and political differences between the United States and Brazil, the countries are similar in terms of a structural gender healthcare gap, each in their own way. That is to say that there are other variables beyond available resources and broader public policy design when it comes to gender. Structural sexism is a bottleneck preventing women and girls from fully guaranteeing their right to healthcare, and it intervenes in direct access and assurance of rights. Spoiler alert: the situation gets even worse when considering race, sexual orientation, gender identity, as well as social and economic vulnerabilities (Homan, 2019). 

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Brazil and the United States share two core difficulties, which represent challenges widely faced across North and Latin America: (1) access to healthcare and (2) assurance of sexual and reproductive health and rights (SRHR).

 

First, let us focus on access to healthcare. In Brazil, even though there is a mixed system, allowing private and public health insurance, SUS is a public alternative that assures equal and universal access to healthcare. However, despite the exceptional design and striking accomplishments, the system still lacks proper funding due to an inadequate allocation of often not enough public resources and failures to coordinate governance structures (Dias et al. 2013). Moreover, regional, class, and gender inequalities cut across the system’s performance and expose a significant portion of the population to deplorable conditions, such as lifelong waiting queues and the scarcity of appropriate materials and health professionals (WHO, 2008).

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A healthcare system does not survive exclusively on good intentions, and insufficient resources may kill.

 

Josilene dos Santos, who died of cardiac arrest after waiting for heart surgery for over seven years, is only one of the victims of the system’s inefficiency (TV São Francisco, 2018). The situation tends to worsen all over the country because, since 2016, fiscal austerity measures have frozen investments in the public health system, among other areas, threatening SUS’s continuity and its democratic achievements (Paim, 2018).

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By its turn, while investing around 17% of its GDP on the health budget, the United States healthcare system still privileges private or employers provided insurance, while the public options are limited and insufficient to cover the demographic demands. After losing her job and consequently her health insurance, Susan Finley avoided going to the doctor, even not feeling well, because she feared the medical bill, and died in 2016 (Sainato, 2020). The COVID-19 pandemic worsened the situation: Janet Mendez survived the Coronavirus and received an inadequate $4000,000 medical bill from the hospital and is still struggling with billing processes (Goldstein, 2020). Deborah Gatewood, a black woman health care worker, died of COVID-19 after an extremely late diagnosis – another avoidable victim of the US healthcare system (Griffith, 2020).

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Now, let us focus on the assurance of sexual and reproductive health and rights (SRHR). In Brazil, abortion is a matter of criminal law instead of autonomy and primary healthcare ("Clandestinas"). It is not considered a crime only when resulting from rape, the pregnant woman’s life is demonstrably in danger, or cases of fetal anencephaly (Art. 124-128, Brazilian Criminal Code, 1940). As expected, the illegality does not stop women from aborting, driving them towards unsafe methods and, ultimately, death when they cannot afford the exorbitant bills of illegal clinics (Cardoso, 2020). Between 2008 and 2015, Brazil registered about 200,000 hospitalizations per year due to abortion-related procedures. Unfortunately, more in-depth information is not available, as official abortion data in Brazil is limited and does not even include illegal abortion (Cardoso, 2020). 

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Those who have died have names: Ingriane Barbosa Carvalho was a black woman in her thirties, worked as a babysitter, and had three children (Peterson, 2020). In 2018, after performing an unsafe abortion by inserting a plant stalk into her vagina, she was hospitalized because of a generalized infection and died (Rickly and Soares, 2018). 

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In the United States, preventable pregnancy-related deaths are more likely to happen to Black, Indigenous American, or Alaska Native (AI/AN) women. Healthcare access, quality, implicit racial bias, and the lack of accurate data are among the principal factors contributing to the disparity. These women have historically lived in the shadow of official data and the system, severely affecting their life quality and perspective. For the first time in history (but only now), the United States had a standardized data collection for maternal mortality, and black women died 2,5 more than white women (Chuck, 2020). The emergence of a wave of conservative politicians and judges has aggravated this problematic scenario, threatening reproductive rights in several states (Williams, 2019). After all, we are once again reminded that achieved right and guaranteed right are not synonyms.