Cited by 136COVID-19 epidemiological studiesHealth disparities and outcomesCOVID-19 Clinical Research Studies

Social inequalities and COVID-19 mortality in the city of São Paulo, Brazil

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Ribeiro, Karina Braga, Ribeiro, Ana Freitas, Veras, Maria Amélia de Sousa Mascena, de Castro, Marcia Caldas·2021·International Journal of Epidemiology

Abstract

Background: Heterogeneity in COVID-19 morbidity and mortality is often associated with a country's health-services structure and social inequality. This study aimed to characterize social inequalities in COVID-19 mortality in São Paulo, the most populous city in Brazil and Latin America. Methods: We conducted a population-based study, including COVID-19 deaths among São Paulo residents from March to September 2020. Age-standardized mortality rates and unadjusted rate ratios (RRs) [with corresponding 95% confidence intervals (CIs)] were estimated by race, sex, age group, district of residence, household crowding, educational attainment, income level and percentage of households in subnormal areas in each district. Time trends in mortality were assessed using the Joinpoint model. Results: Males presented an 84% increase in COVID-19 mortality compared with females (RR = 1.84, 95% CI 1.79–1.90). Higher mortality rates were observed for Blacks (RR = 1.77, 95% CI 1.67–1.88) and mixed (RR = 1.42, 95% CI 1.37–1.47) compared with Whites, whereas lower mortality was noted for Asians (RR = 0.63, 95% CI 0.58–0.68). A positive gradient was found for all socio-economic indicators, i.e. increases in disparities denoted by less education, more household crowding, lower income and a higher concentration of subnormal areas were associated with higher mortality rates. A decrease in mortality over time was observed in all racial groups, but it started earlier among Whites and Asians. Conclusion: Our results reveal striking social inequalities in COVID-19 mortality in São Paulo, exposing structural inequities in Brazilian society that were not addressed by the governmental response to COVID-19. Without an equitable response, COVID-19 will further exacerbate current social inequalities in São Paulo.

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  • There is a preponderance of evidence demonstrating that the COVID-19 epidemic has disproportionately affected lower income sub-city units, and the Americas is no exception.

    “There is now a preponderance of evidence demonstrating that the epidemic has disproportionately affected lower income sub-city units, and the Americas is no exception [17–22].”

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  1. [16]16. Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Statist Med 2000;19:335-51.
  2. [40]40. Leite AKF, Ribeiro KB. Older adults with cancer in the city of Sao Paulo: what factors determine the place of death? Rev Sau ´de Pu ´blica 2018;52:66.
  3. [45]45. Miranda M. Classificac¸ão de Rac¸a/Cor e Etnia: conceitos, Terminologia e Me ´todos Utilizados Nas Cie ˆncias da Sau ´de No Brasil. Thesis. Escola Nacional de Sau ´de Pu ´blica, Rio de Janeiro 2010.
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Authors
Ribeiro, K. B., Ribeiro, A. F., Veras, M. A. D. S. M., & de Castro, M. C.
Affiliations
  • Faculdade de Ciências Médicas da Santa Casa de São Paulo (BR)
  • Universidade Municipal de São Caetano do Sul (BR)
  • Harvard TH Chan School of Public Health, Department of Global Health and Population, Boston, United States of America
Corresponding author
Ribeiro, Karina Braga
Venue
International Journal of Epidemiology
Published
2021-02-28
Volume
50
Issue
3
Pages
732-742
ISSN
  • 0300-5771 (ISSN-L)
  • 1464-3685
OpenAlex
W3134855230
Cited by
134
References
41
Citations by year
2026: 7 · 2025: 13 · 2024: 27 · 2023: 23 · 2022: 47 · 2021: 17
FWCI
11.02
Type
journal article
Language
en
Open access
Locations
  • International Journal of Epidemiology (publishedVersion, public-domain)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
Governo Brasil
Topics
  • Physical Sciences › Mathematics › Modeling and Simulation › COVID-19 epidemiological studies
  • Social Sciences › Health › Health disparities and outcomes
  • Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
Keywords
COVID-19 mortality, social inequality, health disparities, racial disparities, sex differences, socioeconomic status, household crowding, educational attainment, income, urban districts, São Paulo, mortality trends, COVID-19 pandemic response
MeSH terms
COVID-19, SARS-CoV-2, Brazil, Cities, Crowding, Family Characteristics, Female, Humans, Male, Mortality, Socioeconomic Factors

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