UNIVERSITY OF CALIFORNIA, SAN DIEGO

Health in Black and White:

Debates on Racial and Ethnic Health Disparities in Brazil

A dissertation submitted in partial satisfaction of the

requirements for the degree Doctor of Philosophy

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in

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Anthropology
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by

Anna Pagano
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Committee in Charge:

Professor James Holston, Chair

Professor Nancy Postero, Co-Chair
Professor Thomas Csordas
Professor Gerald Doppelt
Professor Ivan Evans

2011
 UMI Number: 3458492

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University of California, San Diego

2011

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 TABLE OF CONTENTS

Signature Page .................................................................................................................... iii

Table of Contents ............................................................................................................... iv
List of Figures .................................................................................................................... vi
List of Tables ..................................................................................................................... vii
Acknowledgements .......................................................................................................... viii
Vita .................................................................................................................................... xii
Abstract of the Dissertation .............................................................................................. xiii
PART I: RACE, MEDICINE, AND BIOPOLITICS IN BRAZIL ..................................... 1
Chapter 1: Introduction ....................................................................................................... 1

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Race and Ethnicity ................................................................................................ 13
Biologization and the Re-Biologization of Race................................................... 15
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Medicalization ....................................................................................................... 23
Medicalization of Race.......................................................................................... 25
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Biopower and Biopolitics ...................................................................................... 28
Applying a Biopolitical Framework to the Medicalization of Race ..................... 29
Race and National Identity in Brazil ..................................................................... 33
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Black Movement Activism.................................................................................... 45

Public Health in Brazil .......................................................................................... 47
Ethnographic Field Sites ....................................................................................... 50
Chapter 2: Everyday Narratives on Race, Racism, and Health ......................................... 58
Patients’ Narratives on Race and Health ............................................................... 64
Health Care Professionals’ Narratives on Race and Health .................................. 76
Patients and Providers: A Counter-Biopolitics ..................................................... 88
PART II: THE BLACK HEALTH AGENDA .................................................................. 91
Chapter 3: The Birth of the Black Health Agenda in Brazil ............................................. 91
Black Health Activism in Brazil ........................................................................... 92
The Black Health Agenda in São Paulo .............................................................. 102
The Black Health Agenda in São Luís ................................................................ 108

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Chapter 4: The Black Health Epistemic Community in Brazil ....................................... 118
The Politics of Categorization ............................................................................. 122
The Imperative of Self-Declaration..................................................................... 134
Etiological Claims ............................................................................................... 141
Medicalizing Racism ........................................................................................... 154
Discourses of Difference ..................................................................................... 156
Implications for Citizenship ................................................................................ 161
Conclusion........................................................................................................... 171
Part III: AFRO-BRAZILIAN RELIGIONS AND HEALTH ......................................... 174
Chapter 5: Health and Healing in Afro-Brazilian Religions ........................................... 174
Afro-Brazilian Religions: A Brief Background .................................................. 176

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Mãe Letícia .......................................................................................................... 179
Pai Cesar.............................................................................................................. 184
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Healing in Afro-Brazilian Religions ................................................................... 189
Chapter 6: Afro-Brazilian Religions and the State.......................................................... 207
Partnerships between Terreiros and SUS: Rehabilitating History ...................... 208
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Razor Blades and Comic Strips........................................................................... 215
Other Sources of Conflict.................................................................................... 220
Cultural Competence and the Terreiro ................................................................ 231
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De-Sacralizing the Terreiro ................................................................................. 236

Conclusion........................................................................................................... 243
Chapter 7: Afro-Brazilian Religions and Ethnic Identity Politics in the Brazilian
Public Health Arena ........................................................................................................ 244
Terreiro Health Activists’ Identity Politics ......................................................... 247
Conclusion........................................................................................................... 269
Chapter 8: Health in Black and White ............................................................................ 272
Bibliography .................................................................................................................... 281

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 LIST OF FIGURES
Figure 1. Household Income, 2000 ................................................................................... 54
Figure 2. Distribution of Race/Color (Pretos and Pardos), 2000 ...................................... 55
Figure 3. Public Health Facilities and Distribution of Population by Color
in São Paulo, 2000........................................................................................................... 169
Figure 4. Population Density of São Paulo, 2000 ........................................................... 170

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 LIST OF TABLES
Table 1. Characteristics of Sample Population ................................................................. 65
Table 2. Self-Identified Race or Color .............................................................................. 69
Table 3. Beliefs Regarding Health Outcomes between Blacks and Whites...................... 69

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 ACKNOWLEDGEMENTS

First and foremost, I would like to thank my chair and mentor, Professor James

Holston, for investing in my development as a scholar and for holding me to such high

academic standards. Professor Holston’s influential scholarship on citizenship and the

anthropology of Brazil has served as an indispensable model for my own work. Over the

past seven years, I have been deeply inspired by his insistence upon maintaining

excellence in anthropological inquiry; the elegance with which he presents his arguments;

and his commitment to making anthropology relevant to the problems of modern society.

Professor Holston’s example of careful scholarship combined with intellectual fervor will

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always remain with me.
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I owe an enormous debt of gratitude to my co-chair, Professor Nancy Postero,

who has been a fantastic mentor throughout the conception and execution of my doctoral
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project. Professor Postero’s expertise in Latin American and political anthropology has

marked my work in important ways. Her dedication to theoretical rigor and the public
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relevance of anthropology are complemented by her unique gift for mentoring junior

scholars. Professor Postero has been a steadfast source of encouragement and a powerful

role model along the way.

Professor Thomas Csordas has supported and influenced my scholarship in

numerous ways. Most importantly, having the opportunity to work with him led me to

pursue medical anthropology. Professor Csordas expressed interest in my research from

the beginning, and he gave me the fortuitous opportunity to participate in a U.S.-Brazil

Consortium focused on health, cultural diversity, and social inequality. My involvement

in the Consortium broadened my academic horizons and helped pave the way for the

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realization of my doctoral project. I am grateful for his kind guidance and support

throughout my doctoral program.

I am grateful to have an eminent sociologist of race like Professor Evans on my

doctoral committee. I was initially drawn to his work on apartheid in South Africa

because part of my family has lived there in exile for decades. When I first presented my

research proposal to him several years ago, Professor Evans reassured me of its relevance

and contribution to the social study of race. Since then, he has received my updates with

constant kindness and encouragement. His collaboration has been a tremendous boon.

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Professor Gerald Doppelt graciously agreed to join my committee toward the end

of the project, and he has been an excellent addition. His detailed, elegant work in
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political philosophy, and particularly his scholarship on multiculturalism and liberalism,

has helped me to think through challenging and often contradictory terrain. I particularly
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appreciate his critical feedback on the theoretical foundations of my project.

This project would never have left the paper, had it not been for the exceptional
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generosity of numerous Brazilians who extended their expertise, time, and friendship to

an endlessly curious and stubbornly persistent anthropologist-in-training. I can only

imagine how odd it must be to have a stranger arrive in one’s life out of nowhere, and ask

to shadow him or her while relentlessly posing odd questions. Thus, I was humbled by

the willingness of people in the field to share their lives with me. The “fieldwork”

experience went far beyond academic exploration and taught me a great deal about

human kindness and solidarity.

My research was generously funded by a Fulbright-Hays Doctoral Dissertation

Research Abroad fellowship, and by a National Science Foundation Doctoral Dissertation

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Improvement Grant. Pre-doctoral fieldwork was made possible by grants from the UCSD

Center for Iberian and Latin American Studies, the UCSD Institute for International and

Comparative Area Studies, and the FIPSE-CAPES U.S.-Brazil Consortium project

directed by Professor Thomas Csordas. The UCSD Department of Anthropology

provided me with fellowships and teaching assistantships, as well as office space, during

my program. During my two years of write-up at UC Berkeley, I was fortunate to receive

office space from the Department of Anthropology, and to participate in Professor

Stanley Brandes’ dissertation writing workshop. I am deeply grateful for all of this

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assistance.

While I was in Brazil, several respected anthropologists helped to mentor me.

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These include Professors Sérgio and Mundicarmo Ferretti, who graciously invited me to

participate in their research group and even shared ethnographic forays with me. I greatly
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appreciated the opportunity to discuss my research with these renowned scholars of Afro-

Brazilian religion in Maranhão and their bright, creative students. In São Paulo,
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Professors Carlos Eugênio Moura, Vagner Gonçalves da Silva, and José Guilherme

Magnani also extended kind and helpful guidance. Professor Esther Hamburger, a

colleague of my chair Professor Holston, provided crucial support with logistical matters

of fieldwork.

During the past several years, I have been fortunate to have the steadfast support

of friends in the U.S. and Brazil. In particular, I want to thank my dissertation-writing

partner at UC Berkeley, James Battle, for helping me stay the course; my dear friends

Lotta Rao and Mana Barari for providing much-needed emotional support and laughter;

and my roommate-turned-friend Angela Arthur for giving me a safe haven during the

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final stretch. I am also grateful to my wonderful colleagues at the UCSD Department of

Anthropology, and in particular to Paula Saravia and Jorge Montesinos for their kind

hospitality and support during my defense. In Berkeley, I am also indebted to my

supervisor from the Ford Foundation’s Difficult Dialogues Initiative, Dr. Hilda

Hernández-Gravelle, for her tremendous and consistent kindness, patience, and

compassion. In Brazil, I am grateful to Viviane Barbosa for easing my stay in São Luís;

Luana Negrelly for being a great roommate, fellow animal lover and friend in São Paulo;

and Kathy Knight Depintor for her gringa companionship in São Paulo.

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Though they are thousands of miles away, my family has been my rock

throughout this process. They have supported me through my unconventional life

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choices, endured my stress-induced histrionics, and above all reassured me that I could

reach my goals. My mother, Lynn DeMarcus Pagano, has encouraged me through thick
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and thin. To say how much I admire and appreciate her strength and humor would not be

enough. Quite simply, I owe everything to her. My brother, Matthew Pagano, has
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provided big-brotherly guidance and has often taken late-night calls “for the team”

despite the time difference. He has helped me to laugh at my own follies and has brought

me joy during difficult times. The newest addition to our family, Jim Soll, has often lent

an ear and given me helpful advice. I admire his kindness and gentle approach to life, and

I aspire to become more like him. Finally, during the writing of this dissertation I have

thought frequently of my father, Dr. Roberto Pagano. He is responsible in large part for

my academic pursuits and for much of who I am. I would have loved for him to see this

day.

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 VITA

1998 Bachelor of Arts, University of Florida

2002 Master of Arts, University of Florida

2005-2006 Teaching Assistant, Department of Anthropology

University of California, San Diego

2007 Research Assistant

California Department of Health Services/UC San Diego

2009-2011 Research Associate

Ford Foundation, Difficult Dialogues Initiative
Berkeley and Oakland, CA

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2011 Doctor of Philosophy, University of California, San Diego

PUBLICATIONS
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Pagano, Anna. 2006. The “Americanization” of Racial Identity in Brazil: Recent
Experiments with Affirmative Action. Journal of International Policy Solutions 5:9-25.
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Pagano, Anna. 2002. “Religion and the Politics of Racial Identity in Salvador’s
Movimento Negro.” Master’s Thesis, University of Florida.
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FIELD OF STUDY

Major Field: Sociocultural Anthropology

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 ABSTRACT OF THE DISSERTATION

Health in Black and White:

Debates on Racial and Ethnic Health Disparities in Brazil

by

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Anna Pagano
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Doctor of Philosophy in Anthropology
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University of California, San Diego

Professor James Holston, Chair

Professor Nancy Postero, Co-Chair
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In 2006, the Brazilian Health Council approved a National Health Policy for the

Black Population. The Policy is striking because it promotes the image of a biologically

and culturally discrete black population in a nation where racial classification has

historically been relatively fluid and ambiguous. It transforms established patterns of

racialization by collapsing “brown” (pardo) and “black” (preto) Brazilian Census

categories into a single “black population” (população negra) to be considered a special-

needs group by the public health apparatus. This construction resembles the United

States’ dominant mode of racialization based on hypodescent and represents a significant

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departure from hegemonic portrayals of Brazil as a racially mixed nation. Furthermore,

the Policy challenges national ideologies of racial and cultural unity by affirming the

existence of an essential black body with specific health concerns, as well as an essential

Afro-Brazilian culture that materializes in recommendations for culturally competent

health care. As such, the Policy constitutes an important site for new negotiations of

racial and cultural identity in Brazil.

In this dissertation, I explore the political and social implications of treating racial

and ethnic groups differently within Brazilian health care. I examine how the re-

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definition and medicalization of racial and cultural identities unfolds in public clinics,

temples of Afro-Brazilian religion, and social movements based in São Luís and São
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Paulo, Brazil. Through an analysis of ethnographic data that I collected over twenty-four

months, I assess the impact of recent developments in race-conscious health policy on

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Brazilians’ lived experiences of race, ethnicity, and health disparities.

I argue that the new Policy, and its associated health programs, signals the
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emergence of a new biopolitical paradigm in which the Brazilian state formalizes

citizens’ racial and ethnic differences in order to address inequalities among them. I also

show that many aspects of these programs, which incorporate global discourses and

concepts related to health equity, fail to resonate with Brazilian citizens’ notions about

race and health. Consequently, patients and healthcare providers often resist the new

measures. The result is a disjuncture between policy and practice that ultimately hinders

Brazil’s efforts to reduce health inequalities among its citizens.

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 PART I: RACE, MEDICINE, AND BIOPOLITICS IN BRAZIL

Chapter 1: Introduction

Recently, in response to over two decades of mobilization by black movement

activists and health professionals, the Brazilian government implemented a National

Health Policy for the Black Population. This health initiative is striking because it

promotes the image of a biologically and culturally discrete black population in a nation

where racial classification has historically been relatively fluid and ambiguous.1 In so

doing, it transforms established patterns of racialization by collapsing “brown” (pardo)

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and “black” (preto) Brazilian Census categories into a single “black population”

(população negra) to be treated as a special-needs group by the public health apparatus.

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This construction resembles the United States’ dominant mode of racialization based on

hypodescent and represents a significant departure from hegemonic portrayals of Brazil

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as a racially mixed nation.2

The new Policy, and its associated race-conscious health programs, signals the
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emergence of a new biopolitical paradigm in Brazil. Under this new paradigm, the state

formalizes citizens’ racial and ethnic differences in order to address inequalities among

them. Other examples include race-based affirmative action programs in higher education

and employment, which Brazil implemented in 2001. Although these biopolitical

maneuvers have raised awareness about the extent of inequalities by skin color, they have

also contributed to increased racial essentialism in the public sphere. More than ever

before, Brazilians are making citizenship claims based on supposed biological and

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E.g., Harris (1974).
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See Davis (1999), Silva (1998), Schwarcz (1993), and Skidmore (1993a) on political and intellectual
discourses of race mixing and nationhood, particularly during the Vargas regime (1930-1945).

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cultural differences among them. This is especially the case in the arenas of health policy,

health activism, and medical research. In “fixing” the black population numerically and

politically, the state reinforces the image of an essential black body with unique health

concerns, as well as an essential Afro-Brazilian culture that emerges in “culturally

competent” health care programs directed toward black citizens.

There is little question that significant health disparities exist in Brazil between

racialized groups. This fact is demonstrated by a spate of epidemiological studies

produced by Brazilian researchers in recent years. These studies have only begun to

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appear in the last few years because prior to the late 1990s, the Brazilian public health

system did not record patients’ race data. Since the Ministry of Health mandated the
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collection of these data, researchers have been able to demonstrate that black Brazilians

die in greater numbers than whites (brancos) from HIV/AIDS, homicide, alcoholism and
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mental illness, stroke, diabetes, and tuberculosis (e.g., Araújo et al. 2009, Batista 2005,

Batista et al. 2004, Santos et al. 2007). They have also shown that blacks experience
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higher rates of maternal and infant mortality in comparison to whites (e.g., Martins

2006). In fact, black women’s (pretas) maternal mortality rates were seven times those of

whites in 2001 (Chor & Lima 2005). As of 2000, black Brazilians’ (pretos and pardos)

life expectancy was 5.3 years less than that of whites (Cunha 2008). This scenario

represents a serious public health problem for Brazil, particularly given that just over half

of the Brazilian population now identifies as either preto or pardo (IBGE 2009).

As in the United States, Brazilian epidemiologists have not yet reached a

consensus about the etiology of these disparities. Are they caused principally by

widespread socioeconomic inequality? Racial discrimination in health care? Genetic or

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lifestyle characteristics? At first glance, socioeconomic status would seem to be the most

likely cause based on the unrelenting correlation between skin color and life chances in

Brazil (Lovell & Wood 1998). Blacks (pardos and pretos) represent nearly three-fourths

of the poorest ten percent of Brazilians. Meanwhile, whites account for nearly 83 percent

of the richest one percent (IBGE 2009). Furthermore, the illiteracy rate for pretos and

pardos in 2008 reached a total of twenty-seven percent (13.3 and 13.7 percent,

respectively), whereas for whites it was only 6.2 percent (ibid).

Many Brazilian epidemiological studies attribute health disparities to poverty,

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arguing that residing in poorly served areas interferes with treatment access and

adherence (e.g., Batista 2005). Others, however, show that racial health disparities persist
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even after controlling for factors such as income and education (e.g., Barata et al. 2007).

Meanwhile, explicitly racialist studies are becoming increasingly commonplace in Brazil;

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more and more researchers assume that medically significant differences exist a priori

between “blacks” and “whites,” and thus set out to test hypotheses based on that
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assumption (e.g., Jaime et al. 2006, Ribeiro et al. 2009, Vale et al. 2003).

Complicating the picture further is a pervasive problem of statistical ambiguity.

Many recent epidemiological studies do not separate “preto” and “pardo” into separate

categories, but instead lump them together to form the epidemiological category of

“negro.” This practice is endorsed by social demographers of Brazil such as Lovell &

Wood (1998) and Silva (1988), who argue that individuals switch more frequently

between these self-declared categories than between either “preto” or “pardo” and

“branco” (white). These demographers also claim that similarities between pretos’ and

pardos’ life chances (i.e., educational attainment, income, life expectancy) justify
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consolidating the two categories within statistical analyses (Wood & Carvalho 1988,

Silva 1985).

When it comes to health data, however, the consolidation approach obscures

internal variations between pretos’ and pardos’ epidemiological profiles. For instance,

recent epidemiological studies show that pardos’ morbidity and mortality patterns are

either similar to those of whites (Chor & Lima 2005, Cardoso et al. 2005) or are

intermediate between those of blacks and whites (Lotufo et al. 2007, Fonseca et al. 2007,

Lessa et al. 2006). In spite of these findings, the Brazilian government has opted to

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institute a black health initiative that combines blacks and browns into a single

epidemiological category, and treats them as a homogenous population within Brazilian

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public health care. In this dissertation, I will examine the sociopolitical origins and

consequences of that decision.

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In addition to examining the implications of this new biopolitical paradigm for

Brazilian ideologies of race and citizenship, my analysis engages a broader debate

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concerning racial profiling in medicine. While some scholars argue that race should be

purged from medical research altogether (e.g., Fullilove 1998), others maintain that race

impacts health in real and measurable ways and should therefore be preserved as a

scientific variable (e.g., Risch et al. 2002). My own position approximates Troy Duster’s

(2003b) argument that, since social stratification among racialized groups produces

health disparities over time, race-conscious research and policy can be important tools for

addressing the health effects of racism. However, if these tools describe and

operationalize race in an uncritical manner, they may also contribute to the reification of
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racial differences (Duster 2005).3 Indeed, race-specific health policies can easily become

critical sites for the production of re-biologized discourses of race because they often

(re)inscribe differing biological phenomena between racialized groups. Even when policy

rationales attribute health disparities to both biological and social factors, the process of

defining a racialized body according to health criteria has a race-naturalizing effect.

This topic is timely because in the last few decades, race has regained vigor as a

primary site of action and investigation within the domains of epidemiology, public

health, pharmacology, and genomics in societies across the globe. The contemporary

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medicalization of race represents a revival of similar practices in various locales during

the eighteenth, nineteenth, and early twentieth centuries (e.g., Epstein 2004, Laguardia
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2005). Despite its promised health benefits, however, the re-introduction of race as a

central variable in medical research and practice remains controversial. Many scholars
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have issued warnings about the possible consequences of affirming race as a biological

reality, such as increased racism, eugenics, and genocide in extreme cases (e.g., Stepan
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1991). With this in mind, I argue that even ostensibly antiracist initiatives and discourses,

like the ones I analyze here, must be alert to race-naturalizing elements.

In addition to raising concerns about the medicalization of race, the case of race-

conscious health care in Brazil invokes the problem of reconciling citizenship equality

with special recognition and/or rights for certain kinds of citizens. As Holston (2008) has

argued, the doling out of special treatment to subgroups of citizens is a fundamental

feature of Brazilian citizenship. In Brazil, women are permitted to retire five years earlier

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I assume that biological human “races” do not exist. Rather, I use the term “race” to signify a shifting
social construct that can nevertheless impact health due to social stratification and exclusion. So as not to
compromise readability, I have avoided placing the word “race” in quotes throughout the body of the text.
 6

than men; college-educated prisoners have the right to a private cell; and senior citizens

are allowed to go to the front of the line in all public spaces, including public clinics and

hospitals. These examples of “differentiated citizenship,” as Holston calls them, have

never generated substantial controversy among Brazilians—perhaps because, as Holston

points out, group-differentiated rights have historically benefitted elites.

Race-based affirmative action, by contrast, maintains the regime of differentiated

citizenship but favors those with less power. Affirmative action has therefore met with

significant resistance since its inception in 2001, when the Brazilian government began to

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implement quotas for black (preto) and brown (pardo) citizens in some sectors of federal

employment and several public universities. In some cases, quotas are also set aside for
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indigenous citizens and/or for former students of Brazil’s beleaguered public school

system. Citizens have responded to the quotas with public outrage and lawsuits; many
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Brazilians believe affirmative action amounts to state-sponsored racism (e.g., Veja 2006).

Prior to the advent of affirmative action, Brazil had never formalized citizens’ racial
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differences—at least, not since slavery ended in 1888. Even in times of slavery, the

crown made legal distinctions based on individuals’ status as slave, freed (liberto), or

free, as opposed to their race per se (Holston 2008). The new race-based affirmative

action policies in education and health, therefore, represent a striking reversal of the

Brazilian state’s historical reticence on race within the realm of policy.

Affirmative action in health care, however, is distinct from affirmative action in

education because Brazil’s new initiative does not mandate health care quotas for black

citizens, give them special priority in the clinics, or afford them the right to special

treatment. Rather, it makes the moral claim that citizens who self-identify as black
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(negro/a) should be recognized as physically and culturally different from the rest of the

population, at least in regard to health care. Brazil’s National Health Policy for the Black

Population, then, embeds both a politics of recognition and a politics of difference, but

not a substantial politics of redistribution. The limited redistribution that occurs lies in the

state’s reallocation of public funds to promote scientific research on the health

specificities of the black population, in addition to financing public forums and

educational materials on black health issues. These measures carry significant symbolic

weight but, I argue, are negligible in terms of ameliorating health disparities or changing

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public health practice on a grand scale.

For several reasons, it is difficult to situate this case vis-à-vis the vast body of
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literature on reconciling group rights and individual rights within liberal democracies

(e.g., Taylor 1994, Kymlicka 1995, Benhabib 2002, Young 1990). First, Brazil is not a
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liberal democracy in the classic sense. It is closer to a social democracy due to the state’s

strong emphasis on social rights. Second, as stated above, race-conscious health policy in
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Brazil does not extend special rights to black citizens, at least not in the sense of

obligating health care providers to treat self-identified black patients differently. The

literature cited above, by contrast, addresses legislated group rights within such spheres

as political representation and legal pluralism, as opposed to recognition in and of itself.

Nevertheless, a few concepts from the literature on multicultural citizenship are

useful for understanding the cultural politics of race-conscious health care in Brazil. One

is what Taylor refers to as “cultural survival” and Kymlicka calls “polyethnic rights.”

Polyethnic rights include legal protection and/or government funding for certain cultural

practices of minority groups, with the goal of helping these groups to integrate more
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effectively into the wider society (Kymlicka 1995: 30-31). “Cultural survival” implies

state protection for the maintenance of minority groups’ cultural traditions (Taylor 1994:

61). There is an element of state protection for cultural survival when, under the new

black health initiative, the Brazilian state funds conferences on Afro-Brazilian religious

healing, as well as cultural competence training for public health employees on Afro-

Brazilian religious practices. Furthermore, by funding cultural competence training, the

state indirectly attempts to protect the right of Afro-Brazilian religious practitioners to

non-discrimination within public health care on the basis of creed. In affiliation with the

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new black health initiative, members of Afro-Brazilian religions have launched a

movement against religious intolerance within public health care facilities. I discuss this

movement in detail in Part III.

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Taylor’s (1994) theorization of multiculturalism and the politics of recognition
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also helps to elucidate the case I analyze here. Taylor frames his discussion in terms of

the tension between the politics of universalism, or equal recognition, and the politics of
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difference. The politics of equal recognition arises from a “difference-blind” liberal

tradition that upholds human dignity as a universal value. Universalism implies identical

rights for all citizens, while the politics of difference entails differentiated citizenship

claims by specific individuals or groups. Despite the apparent opposition between the two

orientations, Taylor argues that the politics of difference is actually informed by a

presupposition of universal and equal human potential, which he interprets as the equal

right of all members of society to assert their own identity and to have it recognized by

others. The paradoxical result is that “the universal demand powers an acknowledgement
 9

of specificity” (39). As I show in Parts II and III, advocates of the new health initiative

for black Brazilians make the same argument.

This tension between universalism and the politics of difference emerges in the

case at hand because the Brazilian health care system is based on a strong universalist

philosophy that proclaims the value of equal treatment for all citizens. Although the

National Health Policy for the Black Population does not currently mandate differentiated

treatment according to race, the emergence in Brazil of a special area of medicine

devoted to black patients’ particular needs has sparked protest from Brazilian

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intellectuals, scientists, and health care professionals who interpret the Policy as racist

(e.g., Fry et al. 2007). Furthermore, the idea that practitioners of Afro-Brazilian religions
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should be allowed to wear their religious ornaments during certain kinds of medical

examinations, while other patients must remove all ornamentation, constitutes a claim for
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differentiated treatment. Thus far, though, I have heard only anecdotal evidence that

some public health providers have refused to accommodate these patients’ religious-
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based needs. In contrast to affirmative action quotas in higher education, opposition to

the black health initiative has not yet escalated to the level of litigation.

Although Brazil’s new black health initiative does not currently entail legally

enforceable special rights for black patients, I argue that it has important implications for

biopolitical citizenship. Biopolitical citizenship can be defined as the relationship of

citizens to the nation-state in matters of not only biological life and health, but also

“political representation and inclusion in the polity and society” as enacted through these

realms (Epstein 2007:13). As Epstein notes in his study of U.S. minority activism for

inclusion in clinical research, “biomedical inclusion was not just a matter of counting up