COVID-19 and Neglected Diseases in the face of inequalities in Brazil: a matter of sustainable development

The COVID-19 pandemic has led underdeveloped countries, such as Brazil, to face not only new challenges, but the exacerbation of so many others that have not even been solved. The countless problems resulting from the pandemic affect the population in an unequal way, both with regard to access to care treatment and measures to mitigate contamination. This article starts from the hypothesis that the deep social inequalities in health, associated with political and economic factors that permeate Brazilian society, integrate conditions that could lead to COVID-19 becoming part of the group of Neglected Diseases. Through a non-systematic literature review, it raises the main characteristics related to the clinical aspects and the demands of the Brazilian social protection system, analyzing the points of contact between them, based on the common matrix of social inequalities. It is believed that the possible ways for this hypothesis not to be confirmed will be to invest in the elaboration of public policies with an emphasis on solidarity, human rights, the strengthening of global governance and the ethical action of each person towards sustainable development for the entire planet.


Introduction
The COVID-19 pandemic has had several impacts both on society and in the health area, in particular, highlighting a health crisis that involves environmental, economic, social, cultural and political processes and their inextricable interdependencies.It has been generating important transformations and questions in the context of the organization of people's lives, families and different social groups, pointing out imperative needs to change consumption habits and to rethink the sustainability of the planet 1 .
Data collected in the Data Favela/ Instituto Locomotiva 2 survey, carried out in 262 communities in all states of the federation and released at the beginning of the pandemic, revealed the concern of residents with the impact on family income due to the interruption of economic activity in this part of society that have no savings or resources to maintain their standard of living if they are unable to work, nor are they able to comply with the scientific community's recommendations for social distancing.Corroborating these concerns, the map on socio-territorial inequalities in the city of São Paulo, published by Rede Nossa São Paulo 3 at the end of the first half of 2020, pointed out that in districts with better living conditions, deaths from COVID-19 grow little, while in the districts "where people live for a shorter time, there are also worse living conditions" 3 , in which mortality from this cause has been increasing considerably since the beginning of the pandemic.
Another no less important point are the sequelae, which are currently being defined as 'long COVID' 4 , which also occur in patients who do not develop COVID-19 in the most severe forms.As it is a disease that causes multisystemic changes, it affects not only the lungs, but can also generate sequelae in various organs of different types and often overlapping, causing changes in the heart and kidneys, lack of muscle strength, predisposition to thrombosis, cognitive dysfunction, among others.
These two major problems -socio-territorial inequalities and the sequelae -associated with the present pandemic generate many questions, among them the one raised by Hotez et al. 5 in their paper, written still in the beginning of the COVID-19, when this still had only about 1% of confirmed cases in Southern Hemisphere countries.In the title with which they open the manuscript, the authors asked whether COVID-19, given its rapid tendency to spread, could become the next neglected tropical disease.At that time, low testing and difficulties in accessing diagnosis were already pointed out as one of the many components of the problems of health systems in poor countries and/or with great social inequalities in Africa, Asia and Latin America.
In a later article, already in 2021 6 , Hotez et al. signal the deep global economic downturn due to the advance of the pandemic and its harmful effects (direct and indirect) in poor countries.Such facts, as has been exhaustively pointed out in the media, also extend to peripheral countries, such as Brazil.However, even so, one can ask what would lead COVID-19 to become a Neglected Disease (ND), since, unlike these, it has great visibility and the complex system of innovation in global health is looking for scientific approaches to its control?Some clues to this discussion can be pointed out: one, related to the patients' sequelae, generating or aggravating chronic health conditions; and another, more profound, linked to poverty and social inequalities in health, in which the problems of access to diagnosis and treatment in a timely manner, the difficulties in prevention and hygienic measures, in the lack and/or precariousness of housing, in the impossibility of social distancing and to follow the recommended 'stay at home' (the population's confinement strategy adopted at the beginning of the pandemic, to prevent the spread of the virus 7 ) -among other difficulties and inequities -, end up generating, in a vicious cycle, a greater probability of contamination, the development of sequelae, which deepen the immense structural inequalities, especially in poor and peripheral countries.
This article, therefore, deals with the correlations between COVID-19, the ND and social inequalities in Brazil.In addition, its main objective is to provoke reflections on these possible convergences and their effects on the population, in the pandemic and post-pandemic period.
Thus, its relevance lies in the possibility of promoting a debate on the possible impacts of a deepening of the social inequities of poverty and social exclusion, on the population's health and, especially, establishing a critical analysis from the hypothesis that one of these impacts is expressed in the perspective of COVID-19 becoming a ND.

Paths taken to analyze the problem
In order to obtain a broad and global view of publications on social inequalities, poverty, NDs and public policies in the COVID-19 pandemic, a non-systematic, narrative-type review of the published scientific literature on the topic of inequalities and their impacts on the health of vulnerable populations was carried out, with a special focus on NDs and COVID-19.The electronic search focused on articles in the following databases: SciELO, Google academic and the Virtual Health Library (VHL), using the following descriptors: 'COVID-19', 'poverty', 'social inequalities' and 'neglected diseases'.The period of the bibliographic survey included the enactment of the Law on the Unified Health System (8080/90) 8 , until the month of July of 2020.From the survey, a brief theoretical discussion was carried out on the main descriptors, with the purpose of analyzing the question raised about the possibility of COVID-19 becoming a ND.This study is part of the first stage of research on the subject, whose results will be presented in future publications.
Regarding the social determinants of the health-disease process, a growing tendency was identified to carry out studies that address the relationship between health and historical-social, economic, cultural and environmental factors.The National Commission on Social Determinants of Health (CNDSS) 9(78) defines them as social, cultural, ethnic, racial, psychological and behavioral factors that influence the occurrence of health problems and their risk factors in the population.
Thus, according to the World Health Organization (WHO), they are linked to the conditions in which a particular person lives and/or works.
In recent decades, both in national and international literature, there has been an extraordinary advance in the study of the relationship between the way a given society is organized and developed and the health situation of its population 10 .This advance is particularly remarkable in the study of health inequities, that is, those health inequalities between population groups that, in addition to being systematic and relevant, are also avoidable, unfair and unnecessary 11 .
As the United Nations (UN) 12 report on the pandemic indicates, the process of managing health, humanitarian, economic and social crises can only be successful with institutional transparency and responsibility, in addition to inclusive, participatory and representative responsiveness in all levels.In Brazil, there were problems with the dissemination of epidemiological data, by the Ministry of Health (MS), in 2020.Thus, the constitution of the "Consortium of Communication Vehicles was important and necessary in view of the lack of transparency of the actions of the federal government" 13 (9) , contributing to the dissemination of cases and deaths of COVID-19.However, according to the authors, the way in which these data are presented has limitations that interfere with the proposition of actions to deal with the pandemic in the country 13 .
Finally, stands out the federal government's 'scientific denialism', that is, the "explicit disregard of issues that require scientific recognition and validation" 14(81) propagating "false information" 14(81) .Even if it is a specific action of the current government that can be reconfigured in the future, with more democratic management, the impact of the erosion of public policies, the credibility of institutions and information will possibly last for a few years, intensifying inequities.It is believed, therefore, that these elements contribute to COVID-19 becoming a ND.

Governance and its effects in times of a pandemic
The State is responsible for performing certain functions in society.These functions undergo changes, especially to meet changes in human needs and social relationships.In contemporary times, one of the functions assigned to the State is the eradication of poverty and marginalization, the reduction of social and regional inequalities, as well as the promotion of the good of all, without prejudice of origin, race, sex, color, age and any other forms of discrimination, as can be seen from art. 3, items III and IV, of the 1988's Constitution of the Republic 15 .To achieve these objectives, the State must institute and allocate social policies for various areas, including social protection (work, health, social security and assistance).Remember that public policies can be defined as: [...] the set of decisions and actions that the State designs, implements, monitors and evaluates based on a permanent process of inclusion, deliberation and effective social participation with the objective of protecting, promoting, respecting and guaranteeing the human rights of all individuals, groups and collectivities that make up society, under the principles of equality and non-discrimination, universality, access to justice, responsibility, transparency, transversality and intersectoriality 16 (45) .
Thus, governments need to institute and allocate social policies to obtain results in several areas, including promoting the wellbeing of members of society.However, one of the harmful effects of the shrinkage of the State is the attack on social policies, including health policies 10 , an aspect that becomes even more evident in this moment of pandemic.
Since the beginning of the pandemic, the federal government has criticized the need for social isolation on the grounds that it would harm the economy, however, "it can be said that the problem between saving lives or the economy is a false dilemma" 7 (2) .Furthermore, supported by this 'false dilemma', the federal government has been defending that Miraculous treatments are being used as hope for a cure, while at the same time serving as a justification for not closing commercial establishments and other sectors of the economy 14(91) .
It is necessary to "give financial support primarily to those most in need" 7 (2) .Thus, to minimize the impact of the economic crisis on socially vulnerable groups, the Emergency Aid (E.A.) was created in 2020.According to Marins et al. 7 , the E.A. was created against the will of the government and under pressure from civil society, whose obstacles to its implementation were: lack of public transparency about the approvals, disapprovals and analysis of registrations, the delays in carrying out the evaluations and the difficulty in making the benefit reach families 17 .This highlighted the enormous challenge of "attending to, with the necessary urgency and without agglomerations, a significant number of the population" 17(684) .In short, these are very fragile public policies to deal with this enormous health catastrophe.
According to Caponi 18(217) , [...] the epidemic puts us before the weakness of this neoliberal logic centered on meritocracy and success, on the construction of human capital and health-capital (Bihr, 2020), where everyone has to create their own health insurance and take their own risks without owing anything to the State.
Thus, an emphasis has been observed on political decisions that privilege the economy to the detriment of the interests and needs of the whole community, emptying intersectoral public policy projects that could face the pandemic.

COVID-19 and its consequences in Brazil
Contrary to the claim that COVID-19 would be a 'democratic disease' because it affects rich countries in the Northern Hemisphere as well as other developing countries in the Southern Hemisphere, its prevalence is higher among the poor population, majority blacks and residents of favelas and peripheral communities, generating and perpetuating inequalities in Brazil, a country with marked socio-territorial inequalities.Rita Barata 19(12) indicates that, when talking about social inequality, it refers to situations that imply some degree of injustice, in which groups are placed "at a disadvantage in relation to the opportunity to be and remain healthy".And adds: [...] Each and every disease and its population distribution are products of social organization, therefore, it makes no sense to talk about social and non-social diseases 19 (20) .
In general, it is understood that the healthdisease process is intrinsically historical, that is, "determined by the structural and conjunctural conditions in which human populations live" 19 (20) .Economic, social, cultural and political relationships affect the way people live, as well as the ecological context, shaping disease distribution patterns.
Individuals infected with the SARS-CoV-2 virus, the etiological agent of COVID-19, may have an asymptomatic or mild to severe symptomatic course.Symptomatic subjects initially present symptoms similar to those of viral flu, such as fever, cough, headache, dyspnea, diarrhea, myalgia and fatigue.In addition to these symptoms, the patient may have anosmia and/or ageusia 20 .Most evolve with a good prognosis, however some patients may have mild viral pneumonia and/or progress to Acute Respiratory Distress Syndrome (ARDS) with hypoxia, sepsis and septic [20][21][22] .Studies have shown that elderly patients and/or patients with cardiac comorbidity, chronic kidney disease and diabetes have a higher rate of morbidity and lethality 22, 23 .In addition to respiratory symptoms, severe neurological symptoms such as seizures and ischemic stroke have been described 24 .Extrapulmonary involvement is mainly associated with cardiac changes and kidney damage 25 .
A study based on the follow-up of COVID-19 survivors showed that 49.6% had one or more residual symptoms of the disease.Nearly 50% of survivors manifested general symptoms such as fatigue or physical debilitation, sweating, chills, dizziness, arthralgia, myalgia, and limb edema.However, 39% had respiratory symptoms such as polypnea, chest discomfort, cough, excessive sputum and sore throat.However, 13% developed cardiovascular symptoms, such as high blood pressure, flushing, and increased infarction rate.Just under 20% reported sleep disturbances and 4.3% had depression.Alopecia was a frequent symptom in women, considering that 48.5% had this symptom.Interestingly, it was observed that COVID-19 survivors are more likely to develop clinical sequelae after three months of hospital discharge, indicating that these symptoms can be compromised after the acute phase of the infection 26 .
In addition to coping with the pandemic, another major challenge will be monitoring post-acute infection outcomes in survivors, given that little is known about medium and long-term symptoms.It is necessary to investigate all possible symptoms manifested after COVID-19 in order to monitor and treat these patients, in addition to collecting data to better define the global impact of the disease, verify the specific clinical needs and design a comprehensive and individualized care plan 27 .A study of long-term post-CO-VID-19 respiratory complications suggests pragmatic and comprehensive primary care to identify lung lesions and complex symptoms, as well as to refer patients to secondary care 27, 28 .A work prepared by an Italian study group, called 'Gemelli against COVID-19 Post-Acute Care Study Group', expresses the need for a multidisciplinary approach due to post-infection systemic clinical manifestations 29 .In view of the above, it is urgently necessary to implement permanent post-COVID-19 health strategies in health services.
The MS, in turn, prioritized actions aimed at "individual care for severe cases through the creation of beds in Intensive Care Units (ICU), field hospitals [...]" 30(162) .However, these authors emphasize the importance of associating this individual care with community and territorial care, through Primary Health Care (PHC).PHC, especially the Family Health Strategy (ESF), carries out screening, testing, monitoring, active search, etc., presenting a "decisive role in the care assistance network, in the control of the epidemic and in the continuity of care" 30(162) .
Furthermore, the effects of the pandemic on mental health are numerous.The fear of illness and death in the face of the pandemic can cause: depression, anxiety, post-traumatic stress syndrome, suicidal ideation, etc. Special attention is needed with health professionals who work directly with infected patients because they are at greater risk of developing psychological problems and suffering 31 .These impacts on mental health are intertwined in markers of gender, race and social class 32 , which need to be considered in the elaboration of strategies for the promotion and prevention of mental health.
It is understood that the increase in the poor distribution of wealth combined with the increase in the number of people experiencing hunger, unemployment and other forms of social suffering as a result of the pandemic, should not be seen as sequelae, which implies permanence and inevitability.The COVID-19 pandemic should be seen as a mobilization imperative to address the Social Determinants of Health (SDH), in order to prevent this disease from reaching the status of neglected, an effort that will also allow for a more successful management of other NDs.

Neglected Diseases and COVID-19
Until the 2000s, NDs were called 'tropical diseases', a term that indicated a conception inherited from colonialism, of a geographical determinism of disease causality 33 .From that decade onwards, the WHO and Doctors Without Borders proposed new terms: 'global diseases' -as is the case with COVID-19; NDs -17 in number, including tuberculosis, rabies and leprosy -and the 'extremely neglected' -among them, visceral leishmaniasis, starting to contemplate the contexts of political, economic and social development.Valverde 34 defines NDs as those caused by infectious agents or parasites and considered endemic in low-income populations.These diseases also present unacceptable indicators and reduced investments in research, drug production and their control.
Negligence, as indicated by Rodrigues When used in healthcare, it demonstrates that it is not a matter of lack of financial resources or lack of available treatments, but the NDs mean that they are ignored by those who should fight them -government, the health system and the pharmaceutical industry.However, neglect also concerns the neglect of populations correlated with poverty, developing a vicious circle that chains at least one billion people across the planet, according to WHO data 35(46) .
With the current pandemic, there is great concern that even NDs that have made progress in recent decades, such as leprosy, will regress with the loss of financial and human resources allocated to the fight against COVID-19 36 .This is a significant premise to be considered and why not, sharing its variables with the coronavirus, since leprosy, while ND, in Brazil, belongs to the incidence statistics with a performance similar to COVID-19, both massively reach people from communities and outskirts of high population density and lacking basic sanitation, as well as other health conditions 37 .Therefore, it is questioned how Brazilian society has been taking care of the subjects that integrate it, emphasizing that citizenship rights -civil, political and social -demand the enjoyment of all other human rights.

Public health and COVID-19: a sustainable development issue
A pandemic also requires a global response, in addition to regional, national and local ones, especially considering its impacts, including those for the future, are also global, drawing attention to the fact that health has no disciplinary boundaries or of knowledge.Furthermore, because it is transdimensional, for its effectiveness it is necessary to take actions in the most varied areas of knowledge.The coronavirus also has no borders, and affects mainly the less favored classes, as mentioned earlier.
One of the possible global responses to the pandemic, which could prevent COVID-19 from becoming a ND, is in the objectives and goals of the UN 2030 Agenda for Sustainable Development, making it imperative to accelerate its fulfillment, highlighting that today we are experiencing a historic moment of depletion of natural resources and a climate and environmental emergency in which capitalism shows its most predatory or destructive face, in addition to setbacks in the fields of democracy and civil rights, as well as distrust and rejection of political systems, not forgetting the enormous social differences.
The 2030 Agenda is an action plan to be implemented by States, aimed at protecting people and the planet, ending poverty and hunger everywhere, combating inequalities within and between countries, building peaceful societies that are just and inclusive, protect human rights and promote gender equality and the empowerment of women and girls, and ensure the lasting protection of the planet and its natural resources.The 2030 Agenda also aims to create conditions for sustainable, inclusive and economically sustained growth, shared prosperity and decent work for all 38 .
It should be noted that the right to sustainable development is multidimensional, insofar as it demands developments in social (exclusive development is not allowed), economic (balance between efficiency and equity, that is, balance of benefits and direct and indirect costs), environmental (right of current generations, without prejudice of future generations to an ecologically balanced environment), ethical (material and immaterial, individual and social well-being) and legal-political (concerning the protection of the right to the future) areas, aiming to ensure the conditions favorable to the well-being of present and future generations 39 .
Coping with COVID-19 is not just a biomedical issue.The solution to the COVID-19 pandemic mainly involves the ethical issue that requires the realization of human rights -especially for poor people -in order to incorporateequity, solidarity, responsibility and transparency in public and private actions.This means that poor people cannot bear the effects of the pandemic alone, even in the form of disinformation generated by fake news, which requires responsible action by public and private authorities, including to create opportunities to improve responses to face emergencies that have arisen during and after this period.
It also requires giving the maximum possible effectiveness to human rights, which must be adopted as a code of ethical conduct to guide relations between States, between States and human beings who are in their territory and between individuals, remembering, including, that human rights -political, civil, economic, social, cultural and environmental -form an indivisible, interdependent and interrelated unit which, if realized, could remove the determinants of health and, consequently, enable all people , including the poor, to have health in the terms defended in this scientific work.In the midst of a pandemic, human rights are even more essential for all people, with no legal support for their suspension at this time.
Respect, protection and promotion of the dignity of the human person, translated into human rights, constitute limits and tasks of the State and individuals.Limits of State activity, because dignity cannot be denied or disregarded.Dignity as a task of the State concerns the requirement to direct its actions in order to preserve it and create conditions that allow its full exercise.
Extreme poverty was defined by the UN Human Rights Council as "the combination of poverty of resources, poverty of human development and social exclusion" 38 (5) , highlighting that, under the scope of human rights, poverty is itself a cause and a consequence of violations of these rights and a condition that makes possible the occurrence of other violations of human rights.
In addition to the issue of human rights, ethics requires that all relevant information about the COVID-19 pandemic be shared with its stakeholders, including to support democratic decision-making that involves the life and health of all people.Thus, everyone should be informed about the saturation of the health system or when it is about to become saturated, about access to respirators, anesthetics, hospital beds and vaccines and the scope that immunization provides, for example.
One cannot forget, still, the importance of surveillance, as a mechanism to reduce the uncertainties that characterize the pandemic, which also requires transparency about the "arguments for prioritization decisions, improves public confidence, increases its acceptability and promotes the compliance with health recommendations" 40 (2) .The public health system to combat COVID-19 demands, in addition to the medical part, a commitment to ethics in several aspects, including governance programs for sustainable democratic development, which are important measures to "face the possible dystopian hopelessness that it is generating in the most vulnerable" 41(76) .

Public health, solidarity and public and social policies
Confronting COVID-19 requires re-establishing the bonds of solidarity that link human beings to each other and to non-humans.Solidarity is an operational key piece of paramount importance in public and social policies aimed at protecting health, noting, in this sense, that it is in the field of public health where, perhaps, the social factor of mutual dependence, of human solidarity, is in more evidence 42 .
Health solidarity cannot have borders, demanding, among others, investments in public health; the adoption of public policies to combat COVID-19, the determinants and inequities of health and poverty, and the guarantee of social protection for all human beings, ensuring access to the rights inherent to human work and social security, which consists of a complex of rights, comprising the rights to health, social security and social assistance (articles 6 and 194 to 204 of the Constitution of the Republic of 1988) 15 .And, it is noteworthy that being protected means "the foundation of resources and rights that it provides to the modern individual and that allows him to become a member of society in his own right" 43(189) .
However, Brazil has been experiencing setbacks in this regard, further expanding social inequalities.Just see, for example, that, according to the 2017-2018 Family Budget Survey -'Analysis of Food Security in Brazil' -, published by the Brazilian Institute of Geography and Statistics (IBGE), severe food insecurity, in which people reported reaching to go hungry, reached 4.6% of Brazilian households, equivalent to 3.1 million homes.This percentage means that 10.3 million people live in households in this situation, with 7.7 million living in urban areas and 2.6 million in rural areas, observing that severe food insecurity happens when people have deep food deprivation, and could lead to starvation.In addition, in 2017-2018, of the 68.9 million households in Brazil, 36.7%, the equivalent to 25.3 million households, had some degree of food insecurity: mild (24%, or 16 .4million), moderate (8.1%, or 5.6 million) or severe (4.6%, or 3.1 million) 44 .This picture concerns the years 2017 and 2018 and was certainly seriously affected by the COVID-19 pandemic, and there is no denying its close relationship with the process of deconstruction of the Brazilian social protection system.
It is worth remembering that social protection has a relevant social function: first, because it is a valuable instrument to combat poverty, social inequalities, exclusion and social insecurity, which is even recognized in Recommendation No. 202 of the International Labor Organization (ILO) 45 ; second, because, according to the aforementioned Recommendation, social security represents an investment in people, social security systems act as automatic social and economic stabilizers, helping in the transition to a more sustainable economy, overcoming extreme poverty and reducing inequalities and social differences within and between regions, in transitioning to formal employment and in establishing sustainable, mutually supportive social security systems.
In order to achieve full protection, the State must implement a set of actions, policies, plans and programs to be built with broad participation and cooperation from society, including international ones, involving public and social policies as a mediation between State and society, with the development of social protection structures.

Final considerations
The COVID-19 pandemic exposes many of Brazil's political-institutional contradictions and vulnerabilities: the emptying of democratic instances of social participation; losses in the field of social protection and labor rights at a time when people are most in need of subsistence conditions; the reduction of investments in the health field and setbacks in health policies when the population most needs a robust health system; the denial of science and so on.
Therefore, the hypothesis of this study is that, with the increase in social inequalities, COVID-19 is, in fact, part of the group of NDs.Such consideration is even more alarming when we consider that, possibly, the advent of vaccines will not be enough to contain the spread of the disease throughout the planet, since the human right to health demands the enjoyment of all other human rights, which whether civil, political, economic, social, cultural and environmental, completely eliminating poverty.It is therefore necessary to dissipate the mists that surround NDs in Brazil, exposing their causes and proposing paths that allow those who are affected by them to come out of invisibility.
In this way, it is important to bet on the ability of society to respond in solidarity, based on a greater engagement of all its sectors, especially social movements, in the construction of public and social policies capable of reducing the harmful consequences of the pandemic for the Brazilian population.
Furthermore, it is believed that, in order to face a pandemic of gigantic proportions such as the one we are experiencing, including one that does not respect geo-socio-political-economic boundaries, it will be necessary to strengthen the bodies responsible for global governance.Responses to the pandemic depend a lot on the ethical action of each person, groups of people, public authorities, the international community towards sustainable development for the entire planet and in which no one is left behind.
35(46), has the meaning of carelessness or diligence, oversight or lack of application and lack of attention or disregard in a given context, situation, task or occurrence.