Chronic Kidney Disease and Social Determinants of Health: a critical reading based on Latin American epidemiology.

Abstract

Chronic noncommunicable diseases (CNCDs) are one of the main concerns in contemporary public health, with profound impacts on people's quality of life and high costs for health systems (Aguiar et al., 2020); (Andrade et al., 2024). Data from the World Health Organization (WHO) indicate that 10% of the world's population suffers from this condition, Brazil (2024).In this scenario, Chronic Kidney Disease (CKD) occupies a prominent position by emblematically expressing the antinomy "biological versus social" (Laurell, 1983). CKD is a direct or indirect result of the social conditions in which a society develops, reflecting the particularities of certain social classes in a capitalist context marked by structural inequalities, job insecurity, and the predominance of neoliberal rationality. This study is an excerpt from a broader research project, developed from a critical perspective and committed to the interests of the working class. Based on historical-dialectical materialism, the study seeks challenges and perspectives related to the insertion and permanence in the world of work faced by people affected by Chronic Renal Failure (CRF) in the municipality of Natal, RN. As Almeida-Filho (2004) points out, the articulation of the three fundamental dialectical circuits is essential for understanding the health-illness process in concrete societies: work, social reproduction, and way of life. Far from representing a deterministic option, an apology for economism or historical determinism, the dialectic to which we refer does not recognize any linear progress or development of society and its health, nor does it uphold the absolute primacy of the economic over the cultural-political or of the social over the biological-natural. Health-illness is a social process, requiring comprehensive and intersectoral approaches (Laurell, 1983). Thus, we analyze the health-illness process of Chronic Kidney Disease (CKD) and the processes that constitute it, based on the contrast between traditional clinical epidemiology and comprehensive critical Latin American epidemiology. While the former is guided by a logic centered on the individual, risk factors, and clinical outcomes, the latter proposes a broader and socially determined reading of the health-disease process, considering living conditions, work, social relations, and structural inequalities that permeate the production and reproduction of social classes. In the field of health sciences, linear functional thinking corresponds to a reductionist rationality that, according to (Breilh, 2006; 2024), derives from the positivist paradigm and structural-functionalist logic, centered on the fragmentation of social reality. In this model, health is objectified into statistical and decontextualized risk factors, treated as isolated probabilistic entities that can be technically controlled. The concept of the subject is diluted into a passive condition, insofar as practices are guided by the application of one-dimensional interventions aimed at controlling empirical variables. As Breilh points out, this form of understanding is restricted to the “tip of the iceberg” of phenomena, focused on statistical and fragmented risk factors that cause disease in a factorial reality, obscuring the deeper determinants of the health-disease process. From this point of view, CKD is based on a unidisciplinary and monocultural biomedical view, as a progressive disease associated with adverse renal and cardiovascular outcomes. The clinical approach involves identifying the etiology and interventions to reduce progression and complications. Currently, it is guided by the recommendations of Kidney Disease: Improving Global Outcomes (KDIGO, 2024). Based on this clinical literature, CKD is conceptually defined, in a pedagogical manner, as the presence of abnormalities in renal function or structure lasting at least three months, in which the diagnosis must simultaneously consider three dimensions:

the cause of kidney injury (C), the glomerular filtration rate (G), and the degree of albuminuria (A), synthesized in the "CGA" system (Bastos apud KDIGO, 2024). This paradigm, focused on immediate and measurable causes, ignores the broader forces that structure living conditions and, consequently, patterns of health and disease, the dynamics of power, exclusion, and inequality that permeate society (Breilh, 2024).In contrast, critical complex thinking—formulated from Latin American critical epistemology and widely defended by Breilh (2006; 2024)—clarifies that epidemiological processes take shape in each social class through elements that are relevant to the field of health and involve the “reproductive profile,” “health-illness profile,” and the health-disease process. Thus, the categories of production/work/environment and health are interrelated, assuming health as a historical, multidimensional, and contradictory process, inscribed in the fabric of social life (Breilh; Granda, 1989); (Testa Tambellini et al., 2009). Thus, for Breilh (2024), our socioepidemiological reality is transformed according to the dynamic interrelated movement of three different dimensions: The General dimension (G): of society, which involves social reproduction, with its logic of production and accumulation; power relations, with their civilizing mode; and the corresponding environmental metabolic relations. T h e dimension of particular collectives (P): corresponds to socially determined groups, with their own special ways of living subject to specific social metabolic relations (of social class, gender, and ethnocultural), for the author, with their characteristic ways of living that condition particular patterns of exposure and epidemiological vulnerability, which become an expression of the conditioning of power and metabolic relations); and the Individual dimension (I) of individuals/families with their specific personal lifestyles and mental and physical embodiments (phenotypic, genotypic, and psychological). In this context, it is essential to challenge the limits of the hegemonic clinical model and advocate for the centrality of a critical, transdisciplinary, and intercultural perspective in the production of health knowledge. As proposed by Breilh (2024), it is necessary to overcome the reductionist and fragmented logic of the positivist paradigm, making room for a metacritical dialectical thinking capable of articulating the complexity of social determinations and their expressions in bodies and territories. Thus, understanding DRC in this way is not only a theoretical exercise, but a political and ethical choice: recognizing the affected subjects as historical protagonists, whose experiences embody the contradictions of the current mode of production. Health, in this context, is no longer treated as a simple technical object of intervention and is now conceived as a collective right and common good, requiring intersectoral, territorialized policies committed to social justice and equity.