During Fatima Marinho’s medical residency, a pregnant woman came to see her for prenatal care.
The 20-year-old woman had moved to São Paulo from a region in the north where Fatima’s family had once come from.
The woman had her first baby and her second baby under Fatima’s care. Then, she was pregnant again, her third time in three years. Fatima thought something was amiss with this woman, but she hadn’t figured out what.
“I realized that she was hiding something. She said she had an emotional condition. She said she could not swallow. She said it was something in her stomach, that she felt suffocated,” Fatima said. “None of these symptoms were common during pregnancy.”
Fatima thought about this woman frequently, and she asked more questions. Eventually, she learned that the woman was living in a slum in a violent marriage, where she was frightened of her husband and where her husband drank and beat her. The woman had no one else to rely on without family nearby.
Fatima reached out to friends who worked for nonprofit organizations, and they mobilized resources to help the woman move with her three children back to the north to be with her family, as she wanted.
From this woman, and the many more who had similar stories, Fatima realized that domestic violence was likely more pervasive than anyone understood, that it was frequently accepted in Brazil, and that it was not possible for one doctor to address domestic abuse.
“There would have to be a policy,” she said. “We need referral services for women, safe houses for those at risk. We had to convince public prosecutors that we need this, and that we need to connect health and justice and police.”
After five years of practice in primary care and emergency departments, Fatima got her master’s degree in public health, moved to work in public health at the City Hall in São Paulo and then later at the Ministry of Health in Brazil.
In roles across her career, it became her professional mission and personal passion to expose the prevalence of domestic violence in Brazil, especially domestic killings.
She first found the data to back up what she had seen as a doctor, when her team was working to improve the quality of cause of death data in the country’s mortality information system.
“We started to investigate cases when the cause of death was unknown. We hired a consultant for states so that they could start investigations. In these investigations, we realized that many of these deaths were due to gender-based violence. We found many women killed by their husbands. The city knows and everyone knows that the husband killed her. And the police know and are giving cover,” she said. “They say things like, she wasn’t a nice lady, she didn’t obey him. In rural areas, it is common that the man beats the woman, if the wife didn’t cook the meal or if she’s late or she complained too much. It is enough of a reason. Everyone was talking about the same situation. It was acceptable, socially acceptable.”
Homicide is now the leading cause of death for Black girls (ages 10-19) in Brazil, and Fatima and her colleagues began publicly asking and investigating why.
There were the families that sold off their young girls to older men, a common form of sexual slavery. There was the case of an 11-year-old girl who was prostituted by her father at a truck stop. Police were paid off to ignore it, and when Fatima’s office alerted prosecutors, the girl disappeared and was later found dead, having been tortured.
Fatima worked to unpack the reasons behind these homicides, from the complacency of police and doctors to the prevalence of harmful alcohol consumption and the lack of economic opportunity for both men and women.
While progress has been slow, Fatima’s work has contributed to the establishment of systems and laws that mandate the reporting of domestic violence, from the health system to police. There are now stricter laws on the definition of rape and mandated arrests to prevent bribery. She has also worked to mobilize doctors and prosecutors to investigate and offer care, when, for example, 12- or 13-year-old girls seek care for pregnancy.
“No one wants to protect girls,” she said. “No one is thinking, it is our commitment as the health sector, but it needs to be.”
Fatima believes that her upbringing has led her to want to better understand the context and root of problems.
“I was raised in a poor family and saw the difficulties of people, real life difficulties, and saw people getting sick without any care. It is from those experiences that I learned that a person is not just a disease or an organ, but has the determinants,” she said. “As a doctor, I learned to that to treat well you need to understand the problem and the environment and determinants or you will not be successful in the treatment. When something is wrong you have to ask why.”
Fatima has applied this lens to work across issues, from encouraging incentives to primary care providers to report domestic violence to helping cities coordinate an approach to diabetes.
In the Brazilian Ministry of Health, she had the lengthy title of director of noncommunicable diseases for health promotion and information and health analysis. In this position, she oversaw 70 staff, as well as many more consultants at the state level.
Fatima first worked with The Union and then Vital Strategies in 2015, as the representative of the Ministry of Health to the Data for Health program in Brazil.
Fatima’s position in government ended in March 2019, and she joined Vital Strategies as a Senior Technical Advisor. Fatima is grateful for Vital Strategies’ global perspective and platform to expand work that she has been doing in Brazil. She has been amazed by how similar the problems and mistakes are in different countries’ systems.
“I would like to see the countries in Africa and Asia that we have been working with really improve the information they have and the way they use the information and make interventions for health promotion,” Fatima said. “With some advocacy we can bring together disease prevention, health promotion and violence prevention.”
At Vital Strategies, Fatima works across programs, including the Global Grants program and Data for Health as Senior Technical Advisor, estimating COVID-19 deaths, analyzing COVID-19’s impact and racial disparities in Brazil, and advising health officials at the municipal and state level in Brazil on COVID-19 surveillance. Vital Strategies and the Faculty of Medicine of Minas Gerais have organized a dashboard of excess mortality with the Consortium of State’s Health Departments (CONASS) in Brazil, which has been used as a source by The New York Times, The Financial Times and The Economist.
She is also a part of the Global Burden of Disease-Brazil network, and the Global Burden of Disease Independent Advisor Committee, working to publish papers and conduct public health research. The global network has been working on a social vulnerability index for municipalities. The network has developed a vulnerability index for the Municipality of Belo Horizonte that will be used to prioritize areas for COVID-19 vaccination. Fatima is also a regular source for journalists in Brazil on a range of issues because of her prior role in the Ministry of Health.
Fatima views data as a treasure map to addressing a problem, if people only want to take action.
“From the data, I can sometimes easily see the problem below the tip of the iceberg,” Fatima said. “The problem is not where you see it, it’s usually behind it. If you work with information, you can show the problem and you can do something about it.”