Theme 23 of 43

Epidemiology, Infectious Diseases & Health Surveillance

In 2021, COVID-19 alone killed more than all external causes combined, and Indigenous people still live 11 years less than White people.

The Mortality Information System (SIM) records the cause of every death in Brazil along with race, age and location; Sinasc does the same for births, capturing birth weight, mother's education and weeks of gestation; and CNES maps the health infrastructure available in every municipality. Cross-referenced, these three administrative registries show how geography and race continue to determine who gets sick, who dies and who has access to care — more than a century after the country's first public health system was created.

Leading causes of death in Brazil (2021)

COVID-19 was, by far, the leading recorded cause of death in 2021, with 424,461 deaths — more than double the second-ranked cause, acute myocardial infarction, with 93,348 deaths. Chronic diseases such as hypertension and diabetes, historically among the country's leading causes of death, landed in positions far behind COVID that year, showing the scale of the pandemic's impact on the national mortality profile.

COVID-19 was the leading cause of death in Brazil in 2021, far surpassing chronic diseases and violent causes combined.

COVID vs. all external causes combined

Adding up all external causes of death recorded in 2021 — accidents, homicides, suicides — the total reaches 156,470 deaths. COVID-19 alone killed 2.7 times more than that entire sum. It's a comparison that puts the scale of the pandemic's health impact in perspective against a set of causes that normally already dominates the country's public debate on safety and violence.

COVID-19 killed 2.7 times more than all external causes of death combined in 2021 — accidents, homicides and suicides together don't come close.

Total records in SIM (2020)

Of the total 1,556,824 deaths recorded by SIM that year, 424,461 had COVID-19 as the cause — 27.3% of everything that died in Brazil. More than one in every four deaths in the country had the pandemic as a direct cause, a level that repositions COVID as the deadliest public-health event in the country's recent history.

More than one in four Brazilians who died that year died of COVID-19 — a quarter of all national mortality concentrated in a single cause.

Mortality by race: COVID exposed the inequality

Mixed-race (parda) people recorded 103,525 COVID-19 deaths, more than the 81,572 deaths among White people in the largest-volume category — even though the mixed-race population is, proportionally, younger than the White population. This excess of deaths reflects the combination of greater occupational exposure (more mixed-race people in essential services, who couldn't stop working during the pandemic) and unequal access to diagnosis and quality hospital care.

Mixed-race people died more from COVID-19 than White people — a direct reflection of greater occupational exposure and unequal access to healthcare.

Chronic diseases: the mortality profile

Heart attack, hypertension, stroke and diabetes together systematically kill more Brazilians per year than violence does — but receive a fraction of the media and political attention dedicated to external causes. Stroke shows up more frequently in the North and Northeast, and diabetes has 70% of its deaths considered preventable with early diagnosis and treatment, which points directly to failures in primary care.

Chronic diseases kill more Brazilians than violence does, but remain far less visible in public debate.

SINAN: communicable diseases by region

Malaria in the North reaches 150 cases per 100,000 population, against 0.1 in the Southeast — a ratio of 1,500 times. Tuberculosis and leprosy, diseases historically associated with poverty and precarious sanitation, are also disproportionately concentrated in the North. These are the so-called neglected tropical diseases: neglected precisely because they mostly affect populations that already have less political voice.

Neglected tropical diseases concentrate in the North of the country — a sanitary inequality that is, in practice, endemic.

Infant mortality: components

Prematurity accounts for 35% of deaths among children under one year old, and infections for another 25% — together, 60% of all recorded infant mortality has a cause preventable with adequate prenatal care, assisted delivery and quality neonatal care. Congenital anomalies, syndromes and external causes round out the picture, but it's the prematurity-infections pair that concentrates the largest share of deaths that could be prevented.

Sixty percent of infant deaths are preventable — prematurity and infections keep killing babies that adequate prenatal care could have saved.

Life expectancy: racial inequality

White people live, on average, 76.2 years; Indigenous people, just 65 — a difference of 11.2 years between the two extremes of Brazil's racial life-expectancy distribution. Mixed-race and Black people fall in an intermediate position, but still far from the level of the White population. The difference isn't biological: it's the accumulation of decades of unequal access to sanitation, preventive healthcare and living conditions.

Indigenous people live 11 years less than White people in Brazil — a direct reflection of centuries of colonization and sanitary abandonment.

SIA/SIH: outpatient and hospital procedures

Eighty percent of specialized exams performed in the country are concentrated in state capitals, even though much of the population lives in the interior. Of the 500 million annual medical visits, 70% occur in primary care — which is positive — but when care requires a specialized exam or a more complex hospitalization, the interior patient often has to travel to a major urban center.

Eighty percent of specialized exams are concentrated in state capitals — anyone living in the interior faces a desert of specialized access.

Cancer: mortality by type and access

Cervical cancer kills twice as many in the North and Northeast as in the rest of the country, mainly due to lack of regular access to the Pap smear — a simple, cheap, and widely available procedure in the more developed regions of the country. Lung, breast and prostate cancer also show high mortality, associated with smoking, late diagnosis and low screening rates, respectively.

Cervical cancer kills twice as many in the North and Northeast due to lack of access to the Pap smear — a death preventable in most cases.

Explanatory hypotheses

Social inequality largely determines differential exposure to COVID-19: mixed-race and Black people worked more in essential services during the pandemic, without the option to isolate. Social-determination-of-health theory explains why chronic diseases, neglected tropical diseases and preventable infant mortality concentrate in the same populations — they reflect living conditions, not biological predisposition. The historical fragility of SUS funding helps explain why the system struggled to handle the pandemic's extraordinary demand. And the concentration of tropical diseases in the North reflects long-standing sanitary abandonment, a direct legacy of the colonial model of territorial occupation.

Policy implications

Adequately funding SUS, in a sustained rather than emergency way, is a precondition for reducing mortality from preventable causes nationwide. Real-time epidemiological surveillance allows outbreaks to be detected and acted on before they spread. Cash-transfer programs reduce occupational exposure to disease by giving families more option to isolate in risk situations. Expanding cancer screening — mammograms, Pap smears — in regions currently uncovered would reduce preventable deaths. And targeted action against neglected tropical diseases, with specific investment in tuberculosis and leprosy in the North, could eliminate one of the country's oldest regional health gaps.