With 96 administrative districts, 1,521 square kilometers of area, and 12.3 million inhabitants, the city of São Paulo encompasses a series of distinct realities. Considering this is an election year for mayors and city councilors, candidates need to give due importance to the issue of public health in their campaigns. With that in mind, Umane, a civil society organization that invests on public health initiatives, joined forces with Insper to produce a spatial-temporal reading of public health data.
The result of said partnership is the research “Health in the city of São Paulo.” Over the course of a semester, five researchers from the fields of medicine, geography, health sciences, and engineering worked on a document that is to indicate priority areas for interventions in relation to the following conditions: maternal mortality (including fetal mortality), premature cardiovascular mortality (subdivided into cerebrovascular, ischemic heart disease, and aortic aneurysm), and premature mortality due to diabetes mellitus.
The study, launched on August 7, marked the beginning of a partnership between Umane and Insper — and brought alarming conclusions regarding the impacts of inequality on the population's health.
The risk maps, set according to the area of the city and age group, were drawn based on data from the 10-year period between 2010 and 2019 — with the pandemic, records became more dispersed and are still being organized at the municipal level. Data available for public access was used, such as cartographic databases, population data, epidemiological data, socioeconomic data, and health resource data – the latter made available by the Court of Auditors of the Municipality of São Paulo.
This information was filtered in order to understand the circumstances of mortality in the selected scenarios, considering gender and age group over these 10 years as well as their spatial distribution by administrative district, which allowed the identification of the profiles that presented the highest and lowest risks.
Concerning cerebrovascular diseases, the study indicates that the highest relative risk of premature mortality, estimated in 2019, was in Parelheiros, and the lowest one was in Jardim Paulista. For men, the highest risk was in Perus and the lowest, in Moema. When it comes to ischemic heart disease, among men, the highest risk was found in São Miguel and, for women, in Brasilândia.
“We assumed that having a database is not enough. It needs to be interpreted by people who work on the subject and know where the bottlenecks and what the implementation difficulties are,” says Paulo Saldiva, a pathologist, coordinator of the Urban Health Observatory at the Center for City Studies – Arq.Futuro Laboratory at Insper, and coordinator of the research.
The set of outcomes was not chosen at random, points out Evelyn Santos, manager of partnerships and new projects at Umane. “They represent a large part of premature and preventable mortality in our health system, and are just the tip of the iceberg: the difficulty of promoting healthier lives in urban spaces,” she says.
“We have more vulnerable areas that would benefit from targeted interventions to develop health equity, which is a principle of SUS (from the original, Sistema Unificado de Saúde),” she continues. “In addition to the benefit to the health of the population, analyzing and addressing the causes of these inequalities in the territories also benefits management, which can allocate scarce resources more efficiently in the health system.”
To her, among the main findings of the research, one can highlight that:
• 38% of the variability in the risk of premature mortality among people aged 30 to 69 due to type 2 diabetes in women was explained by socioeconomic conditions;
• A large inequality was found in the standardized mortality rates for type 2 diabetes in women, ranging from 0.21 in Moema to 2.02 in Jardim Helena;
• There is an ongoing average annual growth of 6.7% among women, and 2.0% among men, in the risk of mortality from type 2 diabetes among people aged 30 to 39.
Furthermore, from 2010 to 2019, there were a total of 845 maternal deaths in the municipality. By counting these deaths for every 100,000 live births, we arrive at maternal mortality. “Even though we are aware of how difficult it is to analyze that indicator in each district — since it can be greatly impacted even by a few deaths, since it is a rare event compared to its denominator —, we cannot fail to notice the existing inequality when the number varied from zero deaths for every 100,000 live births in Alto de Pinheiros to 102 in the Sé district,” says Santos.
Health is a multifaceted issue, Saldiva points out. “Traffic accidents are a topic for health agents, as is violence against children. It is an issue that crosses different aspects of life in cities.” When it comes to chronic diseases, in some cases, it is difficult to establish a quick and accurate diagnosis, even if there are professionals qualified to do the job.
“Often, an agent will visit the community, but not test a person for diabetes because they hadn’t been informed of the time and were not fasting. The increase in diabetes in the age group from 30 to 40 means that the population is already suffering the effects of increased obesity cases. With diabetes, people age faster. If the number of cases of the disease decreases, the incidence of maternal mortality also tends to decrease,” observes the doctor.
“The districts of São Paulo are incredibly heterogeneous. People who live in the outskirts of the city and spend more time commuting do not have access to public health services, and the opening hours do not match those of the Basic Health Units (from the original, Unidades Básicas de Saúde - UBS),” points out Paulo Afonso de André, deputy coordinator of the Urban Health Observatory at the Center for City Studies – Arq.Futuro Laboratory at Insper, who also participated in the study. “We are trying to identify solutions. For example: considering the number of people who leave home very early and return late due to transportation, why not bring diagnostic services to train and subway stations?” he explains.
“We want to propose a scientific approach for implementing preventive actions in São Paulo through partnerships among the government, academia, and the third sector – in this case, represented by Umane, an entity that helps maintain hospitals and is well positioned to implement cross-cutting health programs,” reinforces Saldiva. “The mayor can do a lot, if he wants to. That is why it is important that this document reaches the candidates, the debates, the interviews.”
Umane is an independent, non-profit civil association that supports public health initiatives that impact SUS through three programs: comprehensive, full-time care for chronic conditions; actions for the strengthening of primary health care; and the Health Program for Women, Children, and Adolescents. In 2023, the institution supported 19 projects, which were carried out collaboratively with 53 partners, including various sectors of health, civil society, and government.
“Insper has extensive experience in the area of Urban Health and, given its partnership with USP’s School of Medicine, it was possible for the group to develop an innovative methodology that enabled the analysis of indicators in each district of the city. This approach is challenging and made a major difference, since traditional databases usually provide only aggregated numbers for the entire city, making it impossible to analyze municipal inequalities,” says Evelyn Santos.
The study suggests that the following concrete measures be taken:
• The creation of a study center capable of fomenting innovation in health technologies based on the transversality, complexity, and interdependence of the determinants of Human Health, in partnership with public agents from different areas of the municipality;
• Collaboration in the evaluation of areas in the city of São Paulo where the diagnosis of neoplasias should be improved;
• Definition of areas where care for chronically bedridden people should be improved;
• Collaboration in the characterization of spatial variation, along with quality and control of diabetes mellitus;
• Collaboration in the identification of critical areas of maternal and fetal mortality in the city of São Paulo;
• Collaboration in the creation of a school for continuous training for stakeholders in the municipal system on health and climate change issues;
• Collaboration in the implementation of UBS at strategic points in the passenger transport system – “Putting health on the line”
• Collaboration in the use of telemedicine systems (diagnosis, care, and training) in the areas identified as priorities.