1. Introduction

The exploitation and enslavement of the black population throughout history have remnants and consequences today, especially in the perpetuation of historical mortality patterns that are often veiled in society. However, the COVID-19 pandemic has exposed data highlighting social, socio-economic, and structural disparities.

An American study calculated the transmission rate of COVID-19, considering any monetary compensation paid to the African-American descendants of enslaved people in Louisiana, United States. This study pointed out that if this payment had been implemented before the pandemic event, its effects on the health of the black population would have been different, including a lower mortality rate, probably due to the opportunities to reduce some factors, such as: better housing conditions; less exposure to risk situations; access to the use of preventive measures. The same study showed a COVID-19 mortality rate up to seven times higher in the black population compared to the white population, considering that the inadequate payment of compensation had an impact on this rate (^{Richardson et al., 2021}).

In Brazil, during the COVID-19 pandemic, a survey identified the profile of patients admitted to the Intensive Care Unit (ICU). It showed that 71.10% of patients were black and that 77.36% of them faced a higher probability of death compared to white patients (^{França et al., 2021}). According to ^{Almeida (2021}), race is a determining factor of vulnerability in our society since the state is built on policies of exclusion and the identification of bodies that are useful and those that are discarded.

Another example of these exclusionary policies, often adopted by several countries, was the failure to identify on the notification form the nationality of the population that became infected with the virus or died from COVID-19. The literature has shown this to be the case in countries with large immigrant populations, such as Canada (^{Choi et al., 2020}), the United States (^{Richardson et al., 2021}) and Brazil (^{Souza et al., 2020}). When it occurred, the expression used for this identification focused on the terms white or black race without considering the specific vulnerabilities related to the immigrant's condition.

Regarding the importance of identifying race in health care records, it should be noted that many chronic diseases are more prevalent in black and brown people than in white people, including Diabetes Mellitus (DM) and Hypertension (HA). These diseases, combined with other factors, have become risks for the worsening of COVID-19 during the pandemic. From this perspective, it is not appropriate to establish a care policy without knowledge of the social determinants of health. Without this knowledge, it is impossible to plan comprehensive care and guarantee the principle of comprehensive health care. Furthermore, disregarding these determinants creates a risk for vulnerable populations, including the black immigrant population (Santos et al., 2020).

In Brazil, access to health services is guaranteed to everyone by the legislation and policies of the Unified Health System (SUS), from primary care services to hospitals.

However, the black immigrant population faces barriers such as xenophobia and racism (^{Moraes, Araújo & Camargo, 2023}) built with historical reflection and appropriated by the culture of their people. It is up to health professionals to identify the vulnerabilities and social determinants that lead individuals to seek health services, using the principles of the SUS, as these indicate that care should be provided in a universal, comprehensive, and equitable manner.

Equity is a principle that must be worked on to promote critical reflection. Social problematization must be built daily among team members, especially among Primary Health Care nurses (PHC). The practice of discussions tends to instigate reflections and the best ways to build unequal care for the unequal. Public policies have been drawn up with this intention, including the National Policy for the Comprehensive Health of the Black Population, which suggests welcoming as an access strategy. However, its applicability depends not only on its existence as a protocol but also on professionals who are aware of its recognition and are interested in breaking paradigms (Maisa et al., 2021).

Considering the context previously discussed, we established this study's research question: How does the perception of health professionals influence the management of actions carried out in PHC for black immigrants during the COVID-19 pandemic? This research aimed to identify how health professionals welcomed and attended to black immigrants who sought health care during the COVID-19 pandemic.

2. Methodology

Exploratory and descriptive qualitative study. This research was based on the theoretical perspective of structural racism, which seeks to understand how aspects of race and racism impact social construction. Considering this theoretical perspective, the aim is to understand how the historical processes of slavery and colonialism still reverberate in social sectors and how they can have an impact on the health of the black population. It is necessary to understand that racism is essentially structural, serving as an organizing element of society's economic and political logic. The maintenance of this structure is configured as a normative expression that underpins inequalities, permeating adjustments to practices of exclusion and violence (^{Almeida, 2021}).

Data was collected between October 2020 and January 2021 through semi-structured interviews using a script developed by the researchers. Twenty-one professionals from the multi-professional health team of ten Basic Health Units (UBS) in a municipality in southern Brazil took part. These professionals were recruited by contacting the managers of each selected BHU, and from there, the available professionals were approached. The scenarios were defined based on a previous survey by the researchers on which territories received the most black immigrants in the municipality under investigation.

The interviewees were identified according to their work category: three community agents (AC 01, AC 02, AC 03), two nursing assistants (AE 01, AE 02), two oral health assistants/technicians (AS 01, AS 02), three nursing technicians (TE 01, TE 02, TE 03), two dentists (DE 01, DE 02), five nurses (EN 01, EN 02, EN 03, EN 04, EN 05), and four doctors (ME 01, ME 02, ME 03, ME 04).

The inclusion criteria were defined as professionals working in PHC in the UBS of the municipality of Curitiba, serving the black immigrant population. The exclusion criteria were professionals on vacation or leave during the data collection period. The testimonies were audio-recorded and fully transcribed.

For the analysis, we adopted Content Analysis. This technique aims to identify the main points of meaning present in the research and is composed of the steps: 1) pré-analysis; 2)

exploration of the material, categorization or coding; 3) processing of results, inferences, and interpretation. This type of analysis is intrinsically linked to the topic in question, giving rise to units of meaning of varying length, according to the rule for cutting out meaning in line with the specific interests of the analysis (^{BARDIN, 2016}).

MaxQDA software® supported data analysis. This software was chosen because it lends credibility to the research approach. We explored the empirical material with MaxQDA® support in the first coding cycle. In the second coding cycle, we refined the codes and added new codes. The integration of the analysis process took place through the Question-Themes-Theories (QTT) resource, which made the empirical categories emerge.

The interviews were carried out after approval by the ethics committee and complied with Resolution 466/2012 of the National Health Council of Brazil. In 2020, the research was approved by the Research Ethics Committee of the Health Sciences Sector of the Federal University of Paraná (UFPR), under number 4.216.553, and by the Municipal Health Department (SMS), under number 4.251.498.

3. Results

The professional category with the most extended service period in the current Basic Health Unit (BHU) was community agent, with an average of 17 years and five months, followed by a dentist, with an average of 14 years and nine months. The category with the shortest service period was doctor, with six years and one month, followed by nurse, with six years and five months.

It should be noted that although the research took place during the COVID-19 pandemic, PHC services were organized so that rapid testing and referral of the population to hospital services could be carried out. However, elective care was temporarily withheld due to the disease's high transmissibility, and the first vaccine dose had not yet been administered to the population. Even with this reorganization of PHC, it was possible to identify in the interviewees' reports other health demands presented by black immigrant users before the pandemic.

After organizing the categories with the support of the MAXQDA software® and based on the typology of content analysis, two empirical categories were highlighted: veiled structural racism in the discourse of health professionals and structural racism as a social determinant and its impact on the health of the black immigrant population.

4. Discussion

When discussing the issue of the reception and care of the black immigrant population in PHC services from the perspective of structural racism, it is imperative to recognize that the impacts of the years of colonization continue to feed the machinery of social exclusion daily, segregating spaces of belonging based purely on the identification of the black body. Individuals are constantly identified by the bodies they inhabit, as is the case with the differentiation between female and male bodies and between white and black bodies.

In this way, bodies carry with them marks that are discernible through the historical processes that have shaped behavior in the realm of the social subjective.

The normalization of "equals" was presented in the interviewees' discourse. Although it carries a sense of equity in health care, it makes identity and the historicity of the representation of the black body invisible. This common practice in society's discourse is proof of the direct relationship between the ability of institutions to assimilate or normalize the influence of structural racism on all individuals, as discussed by Almeida (2020). Within this context, bodily identities are not uniform and carry significant classification marks. Therefore, the discourse that suggests universality in equal care, as expressed by the participants, suggests a perspective that neglects the existence of the black body. However, identifying a person as black will always remain present, bringing with it all its symbolic charge (^{Alves-Brito et al., 2020}).

It is noteworthy that the racial issue is still not adequately recognized in various health and social sectors, which impacts on not having it as a social determinant and, consequently, on topics related to health in a nation like Brazil, with a history in which it was the last country to abolish slavery almost five centuries ago.

Racial injustice, because of the process of slavery and sometimes manifested through exclusion, leads to a social disparity of inequality, creating a fallacious perspective of homogenization that prevents society from realizing the persistence of racism. The ruling class in Brazil, although numerically inferior, has established norms and standards that naturalize and sometimes color the historical process, promoting a consensus on the nature of domination and other forms of racial supremacy (Almeida, 2020).

Regarding the comments that praised the hygiene of black immigrants, ^{Kilomba (2020}) says that the construction of the social imaginary of black people is directed towards places of racial isolation, segregated in conditions that are not only social but also spatial, as marginal places within the territories of the city, as places recognized as vulnerable. The aesthetics of these territories are seen as dirty, so the identification that this population maintains adequate hygiene standards is something to be admired.

A study conducted by the American Heart Association and presented by ^{Churchwell (2020}) identifies that, from the conditions resulting from the social organization of structural racism, the black population is exposed to various events such as childhood trauma, discrimination, health disparities, and inequities, prejudice, racial trauma, social determinants of health and economic position. These elements contribute to the onset of heart disease. Therefore, when discussing what health professionals can help to provide for their population, the impact of the social life of the black body within a society that produces racism always cannot be ignored.

The research highlights that black immigrant women seek out health services for prenatal care and, in the process, discover associated or existing pathologies that are naturally screened out in this condition.

It is worth noting that access barriers can have an impact on many women starting prenatal care late, and although black immigrant women seek out health services more than black immigrant men, the approach and care provided by professionals can have an impact on their decline and, consequently, on the maternal and child health of this population. Although Brazil already has policies to guarantee rights and access, there is still a structural and cultural barrier to overcome (^{Vieira et al., 2022}).

^{Dias et al. (2023}) points out that inequalities in access to health services, associated with socioeconomic barriers, result in significant disparities in the detection, treatment, and prevention of Sexually Transmitted Infections (STIs). The stigma related to STIs compels as food within racial stereotypes, leading to difficult access to information and health services. In contrast, racial discrimination in health systems compromises the quality of care.

Barriers can be overcome differently, but responsibility for action is shared. Everyone’s individual, cultural, and specific values, and in this research, the focus on black immigrants, are barriers linked to history yet to be broken and not always mediated by professionals prepared to do so. It is necessary to implement sectoral and intersectoral actions linked to policies as support tools for understanding and establishing person-based care (^{Tafner et al., 2023}).

The methodological limitation of this study is that the setting investigated was chosen because it is home to significant communities of black immigrants in the municipality participating in the study. Although, this may have brought the participants closer to issues related to structural racism. However, this limitation does not detract from the novelty of this research since it is an approach that has yet to be investigated in the context of the COVID-19 pandemic around the world. It also sheds light on a veiled practice that can compromise the reception and care of this population in PHC services. Throughout this study, it is relevant to note that no conflicts of interest or substantial disagreements were identified between the researchers.

5. Final considerations

The existence of structural racism in society, with its naturalized inference, impacts the provision of health services to the black immigrant population since the absence of this debate in professional training and society reflects discriminatory practices.

The homogenizing approach of equality in health care, while seeking equity, often makes the identity and history of the black population invisible, which determines the health and disease process of this population. This situation highlights the need to recognize and combat structural racism. The impacts on the health of the black immigrant population go beyond the physical aspects; they are perceived in the social segments, for example, in the spatial segregation they face in the city they live in and the psychological ones resulting from traumatic events of discrimination. These findings point to the importance of considering the social dimension of the existence of structural racism as a determinant of the health of the black immigrant population.

Intersectoral movements and actions are needed to promote efficient, effective, and individual-centered care, especially for black immigrants.

The study highlights the importance of recognizing racism as part of the social structure and seeking to overcome it with anti-racist practices. Historical inequalities persist, highlighting the need for anti-racist policies and education to promote fair and equal coexistence between black and white populations to build a more equitable future.

This research underscores the critical role of health rights knowledge among the population. For the participants, the absence of this knowledge significantly hampers their access to services and the quality of care they receive from professionals.

It is noteworthy that the use of the MaxQDA® software presented a rapid separation of information during data processing, which allowed the researcher more time for analysis. Scientific rigor also generated the promotion of quality knowledge and social impact and required qualitative research.