abstract: 'Background COVID-19 spread rapidly in Brazil despite the country''s well

  established health and social protection systems. Understanding the

  relationships between health-system preparedness, responses to COVID-19,

  and the pattern of spread of the epidemic is particularly important in a

  country marked by wide inequalities in socioeconomic characteristics

  (eg, housing and employment status) and other health risks (age

  structure and burden of chronic disease).

  Methods From several publicly available sources in Brazil, we obtained

  data on health risk factors for severe COVID-19 (proportion of the

  population with chronic disease and proportion aged >= 60 years),

  socioeconomic vulnerability (proportions of the population with housing

  vulnerability or without formal work), health-system capacity (numbers

  of intensive care unit beds and physicians), coverage of health and

  social assistance, deaths from COVID-19, and state-level responses of

  government in terms of physical distancing policies. We also obtained

  data on the proportion of the population staying at home, based on

  locational data, as a measure of physical distancing adherence. We

  developed a socioeconomic vulnerability index (SVI) based on household

  characteristics and the Human Development Index. Data were analysed at

  the state and municipal levels. Descriptive statistics and correlations

  between state-level indicators were used to characterise the

  relationship between the availability of health-care resources and

  socioeconomic characteristics and the spread of the epidemic and the

  response of governments and populations in terms of new investments,

  legislation, and physical distancing. We used linear regressions on a

  municipality-by-month dataset from February to October, 2020, to

  characterise the dynamics of COVID-19 deaths and response to the

  epidemic across municipalities.

  Findings The initial spread of COVID-19 was mostly affected by patterns

  of socioeconomic vulnerability as measured by the SVI rather than

  population age structure and prevalence of health risk factors. The

  states with a high (greater than median) SVI were able to expand

  hospital capacity, to enact stringent COVID-19-related legislation, and

  to increase physical distancing adherence in the population, although

  not sufficiently to prevent higher COVID-19 mortality during the initial

  phase of the epidemic compared with states with a low SVI. Death rates

  accelerated until June, 2020, particularly in municipalities with the

  highest socioeconomic vulnerability. Throughout the following months,

  however, differences in policy response converged in municipalities with

  lower and higher SVIs, while physical distancing remained relatively

  higher and death rates became relatively lower in the municipalities

  with the highest SVIs compared with those with lower SVIs.

  Interpretation In Brazil, existing socioeconomic inequalities, rather

  than age, health status, and other risk factors for COVID-19, have

  affected the course of the epidemic, with a disproportionate adverse

  burden on states and municipalities with high socioeconomic

  vulnerability. Local government responses and population behaviour in

  the states and municipalities with higher socioeconomic vulnerability

  have helped to contain the effects of the epidemic. Targeted policies

  and actions are needed to protect those with the greatest socioeconomic

  vulnerability. This experience could be relevant in other low-income and

  middle-income countries where socioeconomic vulnerability varies

  greatly.Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.'
affiliation: 'Atun, R (Corresponding Author), Harvard TH Chan Sch Publ Hlth, Dept
  Global Hlth \& Populat, Boston, MA 02115 USA.

  Rocha, Rudi; Massuda, Adriano, Fundacao Getulio Vargas, Sao Paulo Sch Business Adm,
  Sao Paulo, Brazil.

  Rocha, Rudi; Rache, Beatriz; Nunes, Leticia, Inst Estudos Polit Saude, Sao Paulo,
  Brazil.

  Atun, Rifat; Castro, Marcia C., Harvard TH Chan Sch Publ Hlth, Dept Global Hlth
  \& Populat, Boston, MA 02115 USA.

  Spinola, Paula, UCL, Ctr Global Hlth Econ, London, England.

  Lago, Miguel, Inst Estudos Polit Saude, Rio De Janeiro, Brazil.'
author: Rocha, Rudi and Atun, Rifat and Massuda, Adriano and Rache, Beatriz and Spinola,
  Paula and Nunes, Leticia and Lago, Miguel and Castro, Marcia C.
author-email: ratun@hsph.harvard.edu
author_list:
- family: Rocha
  given: Rudi
- family: Atun
  given: Rifat
- family: Massuda
  given: Adriano
- family: Rache
  given: Beatriz
- family: Spinola
  given: Paula
- family: Nunes
  given: Leticia
- family: Lago
  given: Miguel
- family: Castro
  given: Marcia C.
da: '2023-09-28'
doi: 10.1016/S2214-109X(21)00081-4
earlyaccessdate: MAY 2021
esi-highly-cited-paper: Y
esi-hot-paper: N
files: []
issn: 2214-109X
journal: LANCET GLOBAL HEALTH
keywords-plus: COMMUNICATION
language: English
month: JUN
number: '6'
number-of-cited-references: '38'
orcid-numbers: 'Spinola, Paula/0000-0002-4554-4250

  Castro, Marcia/0000-0003-4606-2795'
pages: E782-E792
papis_id: 226fc75d3a4c55779118d4e972112da8
ref: Rocha2021effectsocioeconomic
researcherid-numbers: 'Spinola, Paula/HKW-4879-2023

  Castro, Marcia/S-2681-2019'
times-cited: '131'
title: 'Effect of socioeconomic inequalities and vulnerabilities on health-system
  preparedness and response to COVID-19 in Brazil: a comprehensive analysis'
type: article
unique-id: WOS:000652845500025
usage-count-last-180-days: '5'
usage-count-since-2013: '35'
volume: '9'
web-of-science-categories: Public, Environmental \& Occupational Health
year: '2021'