Living and Dying in São Paulo: Immigrants, Health, and the Built Environment in Brazil

Book Title: Living and Dying in São Paulo: Immigrants, Health, and the Built Environment in Brazil

Author: Jeffrey Lesser

Publication Details: Duke University Press, 2025, 320 pp., $29.95 paperback

Even though the Brazilian Family Health Strategy (FHS), the country’s distinctive model of primary care, has achieved success in numerous ways, its high degree of territorialization remains particularly controversial among family physicians. In contrast to most countries, where family doctors are responsible for lists of individual patients, FHS teams are assigned lists of addresses. This means that moving even a block or two can result in a patient being reassigned to a different care team. The rationale behind this policy is rooted in the idea that health care should be community-based rather than individualistic.

Jeffrey Lesser’s Living and Dying in São Paulo does not explicitly enter this debate, but its richly detailed account of health-related issues in one particular São Paulo center neighborhood—Bom Retiro (Good Retreat)—nonetheless prompted me to reconsider how territory and primary care are interconnected.

Lesser, a professor at Emory University and scholar of Brazilian immigration, draws on a broad range of research methods—ethnography, oral history, archival work, cartography, and more—to produce a multifaceted portrait of the neighborhood. As a family physician, I am not equipped to assess the methodological rigor of these approaches, but I can attest to the readability and depth that results from their synthesis. The book skillfully weaves together historical vignettes, contemporary observations, anecdotes, and data, moving fluidly between past and present.

Lesser and his team accompanied a local FHS team in Bom Retiro, known as Team Green (FHS teams are commonly referred to by colors). He also observed a health surveillance team—professionals who do not provide direct care but instead focus on public health measures such as inspecting areas for potential mosquito breeding grounds. Historically, Brazilian health policy has been oriented toward infectious disease control, with the transition to more patient-centered care both recent and uneven. Lesser’s observations capture how these distinct paradigms coexist:

The book also illuminates the persistent tendency of Brazilian public policy to leave health professionals to cope with the fallout of broader systemic failures. In the 19th century, rapid urbanization led to overcrowded housing and poor sanitation, facilitating the spread of disease. Lacking the political will or capacity to intervene in urban planning, the state deployed a kind of health police to enforce sanitary measures. Today, social and housing inequalities continue to drive outbreaks of dengue and the persistence of tuberculosis. While the view of the health worker as police has largely faded, the underlying pattern remains: policies often avoid structural determinants and focus narrowly on diagnosis and treatment.

These tensions are further explored in Lesser’s comparison between the 1918 flu and COVID-19 pandemic. He writes,

Caught between mitigating structural inequalities and inadvertently reinforcing them, FHS teams often face ethical dilemmas. One remarkable example described in the book is how Team Green sets up a pop-up health clinic inside a garment workshop to tend to the workers, especially pregnant ones. Whereas basic infrastructure and privacy are lacking, the justification is that these individuals will not seek care because it means less of an already precarious earning and that the pop-up clinic is the least-worst option.

While the state often fails to act sufficiently on social determinants of health, Lesser argues that the residents of Bom Retiro are acutely aware of them: “I cannot emphasize enough that for the historical and contemporary residents of Bom Retiro, health, crime, and violence were part of a single equation” (p. 85). That description stands in contrast to what I observe in my own practice on the city’s outskirts. My patients are often reluctant to link their fatigue to long working hours, violence, or lack of leisure time—preferring instead to attribute it to vitamin deficiencies. I wonder whether this difference, too, reflects the historical particularities of Bom Retiro.

Although Living and Dying in São Paulo has not changed my position on the debate between patient lists and address-based assignments, it has deepened and complicated my understanding of it. This book will be of particular interest to readers concerned with the intersections of urban geography, immigration, and public health in Brazil.