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INTRODUCTION
Global capitalism witnessed in the second half of the 20th century one of the most significant energy crises in fossil fuel production, particularly in oil production and exploration. This situation prompted national governments to seek sustainability alternatives and overcome supply vulnerabilities from this energy matrix. In this setting, international market interests in agrofuels propelled the resurgence of a neodevelopmentalist plan in Brazil, marked by the expanded agricultural frontiers in the sugar and ethanol sector1.
The foreignization of Brazilian lands primarily occurs in regions the financial capital deems as ‘demographic voids’, forming ‘sacrifice zones’2 in favor of economic development. These territories experience social inequality, lack of equitable public policies, weak environmental and labor laws, and ineffective State oversight3.
Despite expanding agricultural frontiers into new territories, such as the Brazilian Cerrado4, sugarcane monoculture has persisted for over five centuries in the national biomes, especially in the Northeast5. Even with a slight 0.5% reduction in the Brazilian area dedicated to sugarcane monoculture, the estimated productivity for the 2022/2023 harvest is 3.9% higher than the previous season6. In 2020, Brazil became the world’s largest sugarcane producer, and Pernambuco was the third state in the country with an expanded production sector, showing a 22.9% increase in ethanol production against the previous year7. Projections for the 2022/2023 harvest anticipate an expansion of planted areas in Pernambuco due to the reactivation of old bankrupt mills, land leasing, and the acquisition of lands previously used for pasture6.
In Pernambuco, sugarcane monoculture is concentrated in the Zona da Mata, where manual sugarcane harvesting still prevails in 96.5% of production areas6, often leading to strenuous slavery-reminiscent labor conditions8. The sector is characterized by labor force overexploitation and precarious labor9. The production process in the region retains age-old and degrading agricultural practices such as plantation, deforestation, and regular biomass burning. Simultaneously, it incorporated modernizing technologies of the export-oriented industrial agribusiness, including the intensive use of pesticides that contaminate several environmental biome life-supporting matrices such as air, soil, and surface and underground waters, and lead to exposure and harm to human health1,10,11.
This study understands the health/environment/work relationship through the historical eco-social construct. According to Breilh12, critical processes projected over time and space take on protective and healthy facets when constructing, maintaining, and enhancing equity favorable to human life in society. Similarly, they develop destructive facets when they promote inequality, deprivation, and individual and collective health deterioration. Epidemiological processes occur based on real possibilities inscribed in the ways of life of a social formation. They are materialized in lifestyles unique to the experienced realities, in this case, the territories of sugarcane agribusiness. Therefore, this study aims to analyze the protective and destructive critical processes of socio-environmental health in territories subjected to sugarcane production.

METHODS
This study’s theoretical and methodological framework is grounded in the Latin American critical epidemiology of the social determination of health and the Matrix of Critical Processes proposed by Breilh12. This cross-sectional study was conducted through participatory research13 with exploratory analysis and a qualitative approach.
The study area encompassed the five Pernambuco municipalities with the most significant areas of land devoted to sugarcane monoculture, considered priorities in health surveillance of populations exposed to pesticides in the state14: Água Preta and Sirinhaém in the Zona da Mata Sul, and Goiana, Aliança, and Itambé in the Zona da Mata Norte. The five communities participating in this investigation were identified with the support of the Landless Rural Workers Movement (MST) and Municipal Health Secretariats, considering the geographical proximity to sugarcane plantations and the intense exposure to the production processes associated with this monoculture. These communities are linked to territories of occupation or agrarian reform settlements that claim or already hold land ownership.
Data were collected from January to August 2022 through the construction of the Participatory Rural Diagnosis (PRD), which aimed to facilitate dialogical, critical, individual, and collective reflection on the shared reality in the research territories, fostering the strengthening of community organization to address concrete problems15.
Articulation meetings were followed by ten community workshops for PRD construction – two in each municipality. Participants included family farmers, residents, and rural workers exposed daily to the multiple sugarcane production ecosystem harm on their land or surrounding areas of their residence. Thirty-four women and thirty men over 18 participated in the workshops, totaling 64 individuals. The entire PRD process was photographed and recorded with the participant’s consent, and the workshops were later transcribed.
The workshops were operationalized using pedagogical tools suggested by Verdejo16: a) a community organization matrix for characterizing strengths, weaknesses, opportunities, and threats shared among community residents; b) a work flowchart to identify activities performed at each stage of individual work in sugarcane fields, and perceptions of risks and harm attaching to human and environmental health. Both tools were adapted per the objectives of this investigation, and the issues diagnosed by the communities were organized into dialogue-conducive matrices and socio-environmental diagrams.
Fig1
In the data analysis phase, the discourses were initially systematized through meaning condensation17, guiding the identification of central themes related to the research objective: a) The productive model of the sugarcane industry and its modernizing technologies; b) Socio-environmental deregulation; c) Preservation of social inequalities; d) Contaminating ecological relationships in the sugarcane production process; e) Labor exploitation patterns; f) Violence in rural areas; g) Pesticide poisoning related to unhealthy daily practices; h) Respiratory disorders related to seasonal burnings; i) Physical exhaustion and occupational accidents; j) Land social function and popular agrarian reform; l) Public policies for the protection of family farming and other essential rights for health equity; m) Bonds of solidarity, community organizational forms, and resources; n) Family farming ecologization; o) Individual and family self-care practices.
Subsequently, the central themes were organized in a matrix of critical processes12 within global, community, and individual hierarchical dimensions, classified as either health-protective or destructive processes in the ecosystem health of the sugarcane territories under consideration. The analysis was guided by the “dialectical movement between unity and hierarchy that intertwines the dimensions of collective health determination”12:42.
This study received approval from the Research Ethics Committee. Consequently, all participants in this research signed the Informed Consent Form (ICF) and the authorization to use sound and images. The primary database was shared in the repository (https://data.scielo.org/) to contribute to the Brazilian open science initiative.

RESULTS AND DISCUSSION
The central themes of the analyzed statements condense the meanings attributed to critical processes regarding the socio-environmental determination of health in sugarcane-producing territories, as described in Table 1.
Global critical health processes
The economic monopoly of the sugar and ethanol sector over the territories of this study abides by the private interests of large corporations in the international agribusiness of rural commodities18, which define the type of crops local workers should plant and the technological work methods they should adopt.
This guy’s land here is suitable for cassava, but he’s planting sugarcane [...] The bank pressured the settler who was here and said, “The project will only get the ‘go ahead’ if it’s to plant sugarcane” [...] On top of that, the second part of the project will only come out if we have the poison report [...] We depend on the poison. (Água Preta, PE).

The statement above elucidates how banks address the requirements that shape public policies for offering credit to rural workers, intervening directly and concretely in ecosystem and social health. According to Capellesso et al.19, credit programs promote the conservative modernization of Brazilian agriculture, encouraging the so-called ‘technological packages’, whose predatory nature encompasses the socio-environmental consequences of the production and consumption of pesticides and transgenic seeds developed and patented by large transnational companies that dominate the crop market of widely traded exportable products. The State’s neoliberal economic stance vis-à-vis the agribusiness modus operandi is reflected in the territories studied here, where residents affirm that:
…they are in charge. They say they meet environmental standards. However, every time they come, they take out a strip. They gradually degrade [...] And the plant plants sugarcane there in the river. Where is IBAMA? (Itambé, PE).

In the middle of the street, any city and chubby boy sells [pesticides]. Isn’t that right, guys? If I have money, I’ll go there and come back with loads of poison (Aliança, PE).
Notably, the statements converge on the direct consequences of production, environmental, and health deregulation, especially from 2018 to 2022, which made labor and environmental legislation more flexible, dismantled inspection bodies and social control, and provided an unprecedented trade/consumption of pesticides20.
We should highlight the persistent social inequality due to issues of land, race, gender, education, employment, income distribution, and access to essential services, along with the centuries-old invisibility of general and specific needs regarding the quality of life and health of populations dwelling in rural areas of the national territory21,22. The Participatory Rural Diagnosis (DRP) identified weaknesses and equivalent threats related to the precarious public services offered in these municipalities, such as basic sanitation, access and quality of health services, education, transport, public security, leisure and cultural spaces, and opportunities for better jobs. However, the communities debated the historical sugar and ethanol sector land use and occupation process, and the concentration of land, power, and income have been the main responsible for preserving social inequalities and favorable conditions for the territory’s socio-environmental exploitation. Despite this, the defense of the social function of land and the right to popular agrarian reform emerged as central themes of the units of analysis:
Can we live in a more just and dignified way? We can. How? We know the occupation is fair [...] When we arrived here, the land was without social functions and needed to produce how it was supposed to. It did not pay social security contributions, which persists (Itambé, PE).

The exclusionary nature of the economic and productive model affects the populations of the Brazilian countryside differently, making it urgent to implement agrarian reform and distributive land interventions to ensure the land’s social function. This condition is essential since rural people and communities are those whose ways of life, production, and social reproduction are predominantly land-related23.
We identified in this study that the guarantee of the right to agrarian reform transformed the living and working conditions of farming families and acted protectively in the subsumption of community ways of life and family lifestyles:
We lived on what belonged to others. Not now. It’s good because everyone here has a little piece of land to work on and fight to survive (Água Preta, PE).

These findings align with the Land Statute24 provisions. They are grounded on the understanding that the full performance of the land’s social function promotes equity, social justice, workers’ well-being, environmental preservation, and economic productivity.
Public policies to protect family farming and other essential rights for health equity also emerged as a central theme of the statements. They were categorized as a critical protective process that favors global health. Carvalho and Marin25 argue that family farming promotes community food and nutritional security since the advancement of agricultural frontiers and increased areas planted with sugarcane replace the diversity of food crops.

Community health critical processes
The spillage of juice produced by the plants into the beds of rivers, streams, and dams26 and the use of pesticides were identified as determining causes of water contamination in the territories studied:
This river is contaminated. People throw pesticides around (Água Preta, PE).
When our mothers went to wash clothes, we drank water there. Not anymore. It’s undoubtedly death if you drink that water. It\'s no longer suitable for washing clothes (Goiana, PE).
Guedes et al.10 investigated the same municipalities as in the present study. They revealed water contamination in surface and underground waters, where all identified pesticides are authorized for use in sugarcane crops. Another study identified water matrices as a common destination for pesticides in the agricultural sector. It explained how these contaminating substances are transported to surface and underground waters through intentional spraying, runoff, atmospheric volatilization/dispersion, and soil leaching27. The aerial spraying of pesticides every six months by the plants close to harvest time was cited in the five municipalities as an ecosystem contamination pivot, and this type of application drastically increases the drift of pesticides into the environment28.
It [the plane] will only reach 3% of the target. The remaining 97% drops hard on us. [...] It is flying around atop the houses here and releasing [the poison]. It arrives and sprays over the goats. Another thing is that almost everyone’s trees here burned and were lost (Itambé, PE).
Furthermore, the regular burning of sugarcane biomass was described as the work stage that precedes workers’ manual cutting in the middle of the extensive sugarcane fields. The centuries-old preservation of this destructive practice favors productivity in regions with rugged topography that hampers harvesting mechanization and depend on human labor29. Despite the destructive and unhealthy nature of regular fires, rural workers consider them necessary since the sugarcane fiber dried by the heat requires fewer machete blows to cut and helps to achieve the productivity target imposed by the plants. This condition is one of the labor alienation and over-exploitation mechanisms, considering that the accelerated work pace and exposure to burning sugarcane increases the potential risk of workers becoming ill30.
The worst thing is smoke and black dust. When it catches fire, you don’t stay inside the house; there’s nowhere to go. Your house is dark, and you are not breathing (Aliança, PE).
Regarding work exploitation patterns, all communities describe the plundering of workers with imposed abusive targets, unfair and per-production payments, exhausting working hours and rhythms, substandard working conditions, and physical, chemical, biological, ergonomic, and psychological exposure under threats of dismissal or not being hired in the following harvest, which endorses previous studies on the topic9,31.
Many employees here don’t want to work at the Plant. The work there is very demanding [...] If they complain, they don’t work [...] A worker is no longer called if he isn’t producing anything [...] Not everyone can meet three goals a day (Sirinhaém, PE).

When I put the scythe in here, it would split open. The guys would say, "Hey, come here." the group pressed the sugarcane, and I had to finish my rhythm in 10 minutes. I couldn\'t stop (Itambé, PE).

The 1995-2022 slave labor profile set by the Labor Public Prosecutor’s Office in partnership with the International Labor Organization32 identified 57,772 workers living in contemporary slavery conditions. Livestock activity was recorded as the most frequent occupation among the cases, and the sugar and ethanol sector was the second most responsible, with 14% of cases. In Pernambuco, studies discuss the relevance of slave labor in the state’s sugarcane fields in the 21st century and expose the human degradation to which these workers are subjected8,33. Also, violence in the rural region emerged in discourses about critical processes destroying community life. The historic territorial land dispute, use, and occupation in rural areas of the country are marked by intense conflicts involving land ownership, environmental exploitation, and subordination of local communities34, as the account points out:
There was a strong wave of hitmen murders here. People ordered professional killers to kill, burn, and bury alive [...] (Aliança, PE)

The widespread context of violence in the territories studied can be explained by profound social inequality. According to the Atlas of Rural Violence in Brazil, the municipalities with the highest rural violence also have the worst socioeconomic indicators35.
On the other hand, the fabric of community interactive networks in the territories studied builds senses of cohesion and community unity that provide shelter for the coexistence of belonging and cooperation, and comforting and supportive affections between people36. Therefore, the vitality of solidarity ties, community organizational forms, and resources was a central theme revealed through the territorial strengths that fostered local health production.
We have a collective unity […] Even when it comes to solving a problem. The logic is collective work so that one can help the other (Aliança, PE).
Included in the spectrum of the community dimension of health protection critical processes, the effort towards agroecological-based agriculture, recognized by Brandenburg37 as a greening family farming process, was another central theme identified. Agroecological prospects and practices provide political, ideological, and technical-scientific-ancestral support to build local income generation and community self-management projects38. Highlighting those whose leading role is powerfully played by rural women:
We came here to plant subsistence crops and not sugarcane [...] It was a group of women who created a collective garden. They planted corn, made sweets, coconut sweets, tamales, and hominy. They were drained into the PAA and taken to hospitals and schools. It\'s such a beautiful work. They did everything together, and the money was split between them (Água Preta, PE).

Political and community articulations, based on actions promoted by the MST and other social movements in the rural area and the involvement of workers with small rural farmers’ unions, local associations, and community groups, were prominent elements in the narratives about community strengths.
The following stand out among the territorial results of this conjunction of critical protective processes for health: the exchange and trade of local family production, the revival of ancestral environmental knowledge, dialogue with scientific-technical knowledge, nature preservation, the diversification of pesticide-free production for self-consumption and food and nutritional security in communities:
Reforestation…the trees that are recovering and turning it into a forest, bringing back life to where it was dead […] The animals are back. So, it’s possums, foxes, ferrets, raccoons, and snakes. There was even water down there (Itambé, PE).

Those who live in the community know much more about what they need to produce. They know the timing of their production and the most viable crop to plant and harvest tomorrow (Aliança, PE).

Environmental preservation and the recovery of agroecological practices, especially in the community of Itambé, align with the promotion of ecosystem health, and environmental regeneration and transformation of landscapes are the most concrete expressions of relative community autonomy in the face of the socio-environmental impositions of the sugar and ethanol industry in the region.

Critical individual and family health processes
Participants narrated their daily actions in the living and working space and identified threats to individual and family health through collective critical reflection. Pesticide poisoning is a critical destructive process, whose residents’ exposure context includes using and managing poisons in the work routine on sugarcane plantations and through the contamination of the environment and food consumed in everyday life.
The statements condense reports of acute signs and symptoms such as itching, headaches, dizziness, shortness of breath, nausea, vomiting, diarrhea, stomach pain, tachycardia, bradycardia, sweating, fainting, and convulsions, corroborating former studies39, 40.
If someone sweats or smells it, it gives him/her a sinus infection [...] Just uncapping it gives a little pain (Itambé, PE).

The poison causes shortness of breath, diarrhea, stomach pain [...] Sometimes it doesn’t affect people immediately. However, it will affect them if they live in the city because it accumulates every year (Goiana, PE).

Regarding the perception of chronic harm to health associated with the use of pesticides, we identified problems such as cancer, congenital malformations, perinatal diseases, and liver and blood metabolic diseases, as shown by other authors41,42. However, in a study on chronic poisoning, Murakami et al.42 warn of essential gaps in the production of knowledge about the harm caused by the combined exposure of several cumulative active ingredients. Equally expressive were the narratives whose central theme emphasized the critical processes related to the region’s respiratory problems related to seasonal fires.
She has asthma; she was born with this problem, but it gets worse in this season. The fire affects all, even those living far away (Goiana, PE).
There were frequent reports of increased acute or chronic respiratory symptoms during fires, especially in children and older adults. In a recent ecological study, Domingues et al.43 observed a statistically significant difference between the rates of hospital admissions for pneumonia, asthma, bronchitis, and acute bronchiolitis in children and older adults, with higher rates in the five municipalities in this study against a group from another 15 municipalities that do not produce sugar cane in Pernambuco. Ramos et al.44 found that the concentration of air pollutants increased due to sugarcane burning and a significant difference in the rate of hospital admissions due to respiratory problems compared to the non-burning period in the off-season.
The degrading pattern of work imposed by the productive model on community ways of life subsumes individual and family health, with destructive expressions embodied through the physical exhaustion of workers and accidents suffered during toil on sugar cane fields.

A companion of mine went to cut sugarcane. He suffered a cramp and was stunted entirely. They took him to the hospital because he was having cramps in his head, neck, and whole body. It is a tremendous physical exhaustion (Itambé, PE).

I know a guy who went to cut sugarcane at night. When he struck the sugarcane, the snake fell and bit his arm [...] Another threat: the tractor overturned with 30 other people inside a cart behind it. Five people died (Sirinhaém, PE).

“Lambaeiros” are field night workers. They gather the reeds the machine cannot pick up. Many die in the straw. They fall asleep and are run over by the machines (Itambé, PE).
In a systematic review of the repercussions of working conditions on the health of sugarcane farmers, Silva et al.45 observed repetitive movements, causing musculoskeletal injuries in different body parts and convulsions; sun exposure, causing thermal overload, irritability, mental confusion, water-electrolyte disorders, severe generalized cramps; work accidents occurring during the journey, cuts, falls, burns, and bites from venomous animals; and exposure to pesticides and particulate materials, as already discussed in this article in previous paragraphs.
Despite this, the development of productive backyards was a family self-care practice led by rural women, which was observed in the territories analyzed. They promote health and healthy lifestyles by cultivating medicinal herbs and vegetables for family self-consumption46.
Everyone plants here. One has pumpkin or potatoes; another has yams, cassava, and bananas. All of this is food, a real strength for us [...] It’s because we distribute what we plant. It’s like gratitude [...] We don’t use chemical fertilizers and poisons. We do it naturally (Itambé, PE).
The relevance of productive backyards in the reproduction of family life is well-known, as they provide opportunities for the albeit partial consumption of healthy foods and food and nutritional security. Meanings were observed around the maintenance of these spaces with activities promoting well-being, leisure, care autonomy, community sharing, and nature preservation45.
The communities highlighted other self-care practices, and statements showed that contaminated work clothes are washed separately from others to mitigate exposure of other family members living in the same household. However, the Pessoa et al. study47 revealed that 48% of poison applicators registered in Pernambuco reported that there was no exclusive place for washing contaminated clothes, which was carried out in places with other purposes.
Reproducing critical structural destructive processes limits the relative autonomy of individual action in the face of territorial threats. It highlights their fragility and insufficiency in guaranteeing complete protection, exposing the necessary construction of public policies that promote socio-environmental health.

FINAL CONSIDERATIONS
The theoretical and methodological coherence of Latin American critical epidemiology supported the analysis of the fundamental contradiction of critical processes that protect health in dialectical opposition to destructive processes, which occur in the general societal reproduction dimension in the particular dimension of community groups and the singular dimension of everyday individual and family life.
The diagnosis underscored the State’s absence in all dimensions of the matrix of critical processes of the socio-environmental determination of health, especially in the lowest hierarchies burdened by the destructive subsumptions of the global order, but which, despite this, exercise relative autonomy in generating community, family and individual protective processes. Such findings point to the need to create, expand, and direct public health and social protection policies for rural populations and strengthen this population’s surveillance, care, and health promotion.
Health praxis demands the expansion and strengthening of protective processes and the necessary confrontation to overcome destructive processes in all the dimensions of the socio-environmental determination of health. It is urgent to mobilize and engage populations made vulnerable by the sugar and ethanol sector around the construction of a socio-environmental agenda that requires ethical, equitable, and protective conduct from the State as an active agent in defense of the rights of nature and human life.

FUNDING
The financial resources used in the research were contributed through public calls from the National Council for Scientific and Technological Development (CNPq) – 2018 Universal Notice; from the Science and Technology Support Foundation of the State of Pernambuco (FACEPE), through the Research Program for the SUS: Shared Health Management (PPSUS)/DECIT/SCTIE/MS; and grants from the Coordination for the Improvement of Higher Education Personnel – Brazil (CAPES) – Financing Code 001, the Pernambuco State Health Department and the Oswaldo Cruz Foundation (Fiocruz).

Data repository Scielo Data: https://doi.org/10.48331/scielodata.NJ7OML

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