Inequalities in marginalised urban areas – An analysis of Bolsonaro’s COVID-19 politics in Brazilian favelas

Introduction: During the COVID-19 pandemic, Brazil’s favelas have become emblematic of longstanding systemic failures, chronic underfunding, and mismanagement within the country’s public health infrastructure. These informal urban settlements have been particularly vulnerable to the compounded effects of external effects. This paper examines the resilience of Brazil’s public health system, the Sistema Único de Saúde (SUS), in the face of the pandemic, with a specific focus on how the Bolsonaro administration's policy responses have influenced health inequalities in favelas. It hereby interrogates the socio-political and spatial dynamics that render these communities disproportionately affected during health crises. Methods: Drawing on inequality theory and the concept of imagined geographies, this study conceptualises favelas as socio-spatial determinants of health that have been systematically disregarded in national health policymaking. It hereby employs Walt and Gibson’s (1994) health policy triangle framework to analyse qualitative data derived from semi-structured interviews with public health professionals (including activists, physicians, and scholars), as well as a systematic review of literature from five public health and medical sociology databases. This framework enables a critical examination of actor networks, power dynamics, ideological orientations, and policy developments during the early phase of the pandemic (2020--2021). Results: The findingsreveal that access to public health services in favelas, such as hospital care and vaccinations,was already substandard relative to other urban areas prior to Bolsonaro’s presidency. However, the pandemic further exacerbated these inequalities, increasing their focus onpublic discourse. The resulting policy contestation was marked by polarisation between proponents of stringent public health measures and COVID-19 denialists, with Bolsonaro as a central figure. While health disparities intensified during his tenure, evidence suggests that these outcomes cannot be attributed solely to his administration’s policies. Rather, the analysis indicates a continuity with previous decades, highlighting a broader tension between two paradigms within Brazilian health policy: the (neo)liberal minimum state and the universality claim of SUS. Conclusions: Thisresearch provides essential insights into the management of a health crisis in marginalised urban spaces in the example of Brazilian favelas. It highlights how space is an important determinant of health that is undermined in policy-making.