MORBIDITY AND MORTALITY IN DISABLED PERSONS OF THE SOCIAL SECURITY IN BRAZIL

The aim of this study is to describe the morbidity and mortality of disabled persons who receive the Benefit of Continued Provision of the Organic Law on Social Assistance of Brazil. Descriptive study documentary with a quantitative approach, performed in the Single System Benefits Information of the Ministry of Social Welfare, involving any benefits that were, in October 2012, active, suspended, or terminated by death or other reasons. The data were obtained using a form. Among the more than two million people with active benefits, the most common disorders were mental (30.2 %), neurological (11.4%) and congenital (5.6%). In people with benefits terminated by death, disease with the highest prevalence were: neoplasms (13.2%), mental disorders (11.2%), diseases of the circulatory system (10.6%). The mortality rate was 141 deaths per thousand disabled people with assistance benefit for maintenance. Mental illnesses and cancers are prevalent in people with active benefits and terminated by death, respectively. The mortality rate among people with disabilities receiving the benefit is 22 times larger than that of the Brazilian population. Palavras-chave: Disabled persons. Social security.Social assistance. Morbidity. Mortality.


INTRODUCTION
Work dignifies the individual, making it productive, enabling their social insertion, affirming interpersonal relationships, provided that their environments and appropriate means the coexistence with the hardships, shortcomings and differences, own of the contemporary world and globalized (1) .
When the person is affected by disability to work, need to resort to grant by the State of financial benefit whose duration is influenced by the gravity of a health problem, age or socioeconomic condition (2) .
One of the causes of incapacity for work include the falls, hit, mva, motor or sensory deficiencies, congenital or acquired, that can lead to permanent disability, in addition to considerable socio-economic cost due to assistance medical and social security benefits (3) .
The WHO estimated that more than a billion people _ 15% of the world's population _ live with some disabilities.About 200 million experience considerable functional difficulties (4) .In Brazil, 45.6 million people _ 23.9% of Brazilians _ reported mental or intellectual disability, motor, visual or hearing (5) .
Thanks to the Decree nº 6.214/07, based on the International Convention on the rights of persons with disabilities, these people so called "disabled person" are now treated with the expression "person with disabilities".These Decree also determined that, at the request of the welfare benefit, the evaluation should be made not only by medical expertise, but also by the social service of the National Social Security Institute (6)(7) .
Recently, the State instituted the Law No. 13.146/15, which considers that disabled person who has long-term impediment physical, mental, intellectual or sensory, so that physical or attitudinal barriers can clog your full participation and effectively in society (8) .
The efficaciousness of the physical or attitudinal barriers faced by people with disabilities, is guaranteed since the Federal Constitution of 1988, when he says, in his Art.194, that social security brasileira ensures the rights relating to health, welfare and social assistance (9) .The article 203 ensures the benefit of Providing continued, regulated by Law 8.742/93 -organic law of Social Assistance.The text ensures a minimum monthly salary to the disabled or elderly person with 65 years or more attesting to monthly household income per capita of less than a quarter of the minimum salary (6) .This benefit, implanted in January 1996, required examination by a doctor of the health system or the National Social Security Institute testifying as to the disability as permanent and disabling.Currently, it is considered disabled person that crippled for life and for work with the evaluation being performed only by medical expertise of the National Social Security Institute (6) , reducing fraud or political use.
In this sense, in February 2012, the Social Security statistical bulletin reported the attendance of 3.999.462Brazilians, of which more than 2 million disabled and more than 1.7 million are elderly above 65 years (10) .Furthermore, although this benefit is operated by the Ministry of Social Welfare, the provision does not depend on previous contributions.Is a health care benefit (6) .
The benefit of Continuing Provision has been the subject of study of many fields of knowledge, which brought contributions to better understanding of the subject in relation to the concepts and criteria adopted by the benefit, and its importance as a mechanism for social protection (11) .
The opinion of the medical expertise to the granting of this benefit if supports on criteria contained in an instrument based on the international classification of functioning, disability and health (ICF) (12) .Medical expertise The National Social Security Institute also continues using the 10th.revision of the international classification of diseases (ICD 10), registering a primary and one secondary diagnosis.
Reflecting on the profile of people with disabilities benefiting from this Brazilian public policy, appeared the following question: which morbidity and mortality found in the population that receives the assistance benefit to the person with a disability?
To answer that question, it was necessary to first while identify the amount of Benefits Continuing provision granted to persons with disabilities who were active, suspended, or terminated by death or other reasons, in 2012.It was selected this year for the study to be the timeline for one of the authors prepare their dissertation.
This study was justified by virtue of insipience of research about the epidemiological profile of people with disabilities who receive this benefit (11) .And why weren't they found publications on Virtual Health Library and the National Library of Medicine of the United States to describe the causes of continuity, or not, of the use of this welfare benefit granted to the disabled person.
In view of the above, in this study, where the benefit of Continued Provision of the organic law of Social Assistance (BPC of LOAS) was named welfare benefit the person with disabilities, the goal was to describe the prevalence of diseases and mortality coefficient found in people with disabilities who receive welfare benefit to the person with disability.

METHODOLOGY
Exploratory, descriptive research, documentary, with a quantitative approach, carried out with data recorded in the Information System of benefits (SUIBE) (13) of the Ministry of Social Welfare, through the internal network computers.The SUIBE is a database of restricted access to the managers of the National Social Security Institute or the persons authorized, formally, by the Executive management of this municipality.In this way, the collection permission in this database was granted because one of the authors to act as medical Supervisor-Expert in this institution.
It was investigated the registration of all persons with disabilities with assistance benefit in maintenance (kept) in October 2012, previously classified in groups by the database Information System of benefits (SUIBE) of the Ministry of Social Security and watched as benefits "kept", "active" and "terminated by death"(13).The study took place from March 2011 to February 2013.So, when the collection of data, the census, defined as "the measurement of specific features of a universe of social and physical objects, scanned in all units or elements that make up such a universe or population" (14) .Although involved secondary data, this study included the Census of all social assistance benefits to the person with disabilities held since 1996, in addition to the active and terminated by death in the second October 2012, in Brazil.The SUIBE is a source of social security data that covers all Brazil sites where there is a social security agency.Is a management information system organized by DATAPREV company and fed with data from other systems, such as: Computerized system of deaths; the national registry of social information; the Administration system of Disability Benefits; the system of evaluation of the disabled person the benefit of Continuing Provision; and, still in its infancy, Benefits System.
There is no grant or denial of benefit, involving the applicant's examination by medical expertise, without the necessary scanning of your complete process of application in the Evaluation System of the person with a disability to provide Continuing benefit.Even in the case of proceedings in which professionals have completed the appraisal report writing it by hand, this report is scanned and placed on a virtual process.However, it is worth remembering that the system of evaluation of the disabled person the benefit of Continued Performance has only been deployed from the year 2009.Before that, only the administrative data and some medical data were scanned in another system, called PRISM.This fact justifies why, in this research, it was found a significant amount of "unclassified" when it was analyzed the variable disease misdiagnosed as the main studied data refer to periods before and after the PRISM systems and system of evaluation of the disabled person the benefit of Continued Performance.
In specific form, described the following variables: a) sex; b); c) geographic region; d) disease misdiagnosed as main, categorized according to the chapters of the ICD 10.In the SUIBE database, the variable age comprised 12 classes, which were recategorized into four tracks (per year): less than 20; 20-39; 40-59; 60 or more.The variable geographical region, categorized as regions, North, Northeast, Midwest, South and Southeast, was obtained based on raw data pertaining to the units of the Federation.
The diseases were classified as each chapter of ICD 10.This way, the SUIBE has identified the numbers of active and terminated benefits for death related to the disease diagnosed as principal.
In this study, were considered benefits terminated by death in October 2012 only the cases described in the SUIBE as: "Ceased p/M. of deaths (Sisobi) "or" Death of the Holder of the Benefit" (13) .Benefits terminated classified otherwise were not considered because they do not allow to establish certainty of occurrence of death, which could distort the result of the calculation of the coefficient of mortality.
The information collected were organized into electronic spreadsheets of the program Microsoft Office Excel.The data were divided into four specific patterns of SUIBE: a)Benefits assets (people with disabilities who are receiving the benefit); b) Benefits terminated by death (admitted as total deaths); c) Benefits terminated or suspended for other reasons; and d) Beneficious held (admitted as population of people with disabilities;refers to all active benefits added to suspended or terminated for various reasons).Are called kept because, in the past, were required by people with disabilities and were granted by the INSS.And, subsequently, continued active or have been terminated or suspended.
On analysis of the data, considering that was done a census rather than a sample of the population of people with disabilities with assistance benefit in maintenance in Brazil, using the descriptive statistics of the type distribution of frequencies, with the use of indicators of morbidity and mortality of type prevalence and mortality coefficient.Thus, most of the results were expressed as absolute and relative frequencies using the constant 100 (percentage).Only in the case of information on mortality was used to 1000 (per thousand).
It was calculated the prevalence of the disease diagnosed in people with active and terminated benefits for death.The mortality coefficient for 1000 persons with disabilities was calculated as the division between number of benefits terminated by death and total benefits.
The survey was conducted within the standards required by the Declaration of Helsinki, registered in the National System of information on ethics in research involving humans (SISNEP).Was approved by the Research Ethics Committee of the State University of Paraíba (CAAE 0380.0.133.000-11) and authorized by the Ethics Committee of the medical expertise of the worker's health section of the Executive management of the National Social Security Institute of João Pessoa, Paraíba.

RESULTS AND DISCUSSION
In October 2012, it was examined whether the registration of 2,737,867 assistance benefits for people with disabilities, of which 2,004,819 were active, 385,348 terminated benefits for death and 347,700 terminated or suspended for other reasons.
For every 100 people who received the assistance benefit in October of 2012, more than 30 had mental illness, more than 11 were with neurological diseases and more than 25 were carriers of congenital malformations, diseases of the circulatory system, eyes, and other external causes poisoning, musculoskeletal system diseases, infectious or ears (table 1).
In Brazil, the concept of person with disabilities is article 1 tax of the Convention on the rights of persons with disabilities, internalized in the form of article 5, paragraph 3, of the Federal Constitution of 1988.In this jurisdiction, the deficiency is characterized as a long-term deterrent, motor, sensory in nature or intellectual, which culminates in drawbacks and/or limitations to full participation and effective of the individual in society on equal terms with other people (15) .
Mental illnesses are most often found in people who receive welfare benefit.However, in the population with benefits terminated by death, the occupy the first Neoplasms as main diagnosis, followed by the mental illness and the circulatory system.
The Brazilian demographic census 2010 reveals that mental deficiency is most commonly related to lower rate of activity or occupation (5) .Such given converges to the fact of having been found this type of disability as the most common among the recipients of the benefit of medical assistance to persons with disabilities.Whereas the 2010 census recorded that 1.4% _ 2.67 million Brazilians _ reported mental deficiency (5) , based on the data of this research (table 1), one can estimate that less than a quarter of these people receive welfare benefit from the National Social Security Institute.
It is understood that the benefit of Continuing Provision is an important measure in the fight to extreme poverty.Base your claim on legal responsibility of medical expert to accept, or reject, the election of the applicant puts over other variables, that are difficult to measure, the example of discrimination and prejudice that hinder the employability, developing the condition of poverty in which the disabled person if find the (11) .
Another explanation for the denial of the benefit comes from the field of Bioethics: as a result of study of 118 medical experts experienced Labor Federation units, 20 Word is in social security medical expertise, the experts made an attempt to comply with the law (16) .
In the current study, we cannot say that the disease diagnosed in people with benefits terminated by death was cause of death of the beneficiary, however, one can infer that disease somehow contributed to the death.According to information of the indicators and Basic Data of the interagency network of information for health, Ministry of health of Brazil, in 2010, the leading causes of death are as follows: diseases of the circulatory system (30.87%);neoplasms (16.93%); external causes (13.55%); diseases of the respiratory system (11.27%),infectious diseases (4.62%); diseases originating in the perinatal period (2.24%); other causes set (13.55%).In the present study the Neoplasms were present in 13.2% of persons with benefits terminated by death, while in the Brazilian population, this illness was cause of 16.93% of deaths.Circulatory diseases already present in 10.6% of disabled people who died and were Cienc Cuid Saude 2016 Abr/Jun; 15(2):242-249 responsible for 30.87% of deaths of the total population of Brazil (17) .Account of the literature that, in relation to social assistance benefits held in the country, 83% are for people with disabilities and 17% for the elderly.And that, in the period of June 2010 to June 2011, one of the 3,553,262 people who obtained their benefit approximately 6% of the beneficiaries only enjoyed that right by virtue of judicial determination (18).The total of benefits held found this study are similar to those of other research in that the granting of the benefit of Continuing Provision was greater in the States Alagoas, Ceará, Paraíba, Pernambuco, Rio Grande do Norte and Sergipe (18) .
In Brazil, the mortality was of 141 deaths for every 1000 persons with disabilities with assistance benefit in maintenance.Mortality was higher in men and residents in the Southeast and Midwest, and lowest in the North.From the group with 20-39 years of age, the rate has doubled in each of the two age groups following (table 2).On the other hand, data from the Ministry of health, reporting that, in total, Brazilian population in the year 2010, the gross mortality rate or mortality went from 6.3 deaths per 1000 inhabitants per year, being the higher rate of 33.42 per 1000 inhabitants in Rio Grande do Norte, with 80 years or older, by year (17) .
The Organic law of Social Assistance considers as unable to provide maintenance of the person with a disability the family whose monthly income per Member is less than a quarter of the minimum wage.At the moment, this means that the disabled son of a couple, with a second normal child, whose father receives real salary per month of 724 and the mother has to take care of their children, not perpetually entitled to welfare benefit.
No one can deny people with disabilities the same rights as the other members of the society have to social protection directed at and vulnerability to poverty (4) .Being a person with disability implies a double vulnerability: this is the condition that needs to be checked by medical experts (19) and social workers of the Social Welfare.
In this sense, in research about what has changed in the lives of people with disabilities to the enjoyment of the benefit of Providing continued, detected that this benefit allowed the consumption of goods, food, health treatments and housing expenses of those persons and their families, besides enabling the increase of social and financial independence in relation to the family, contributing to the expansion of the notions of autonomy and citizenship (20) .*Benefits maintained or in maintenance are all active, suspended and terminated benefits for various reasons.† Coefficient by 1000, assuming benefits terminated by death as number of deaths and total benefits retained as population of people with disabilities.Source: Prepared by the authors based on SUIBE data (13) of the Ministry of Social Welfare.
Finally, it is worth saying that the use of the ICF is already a practical reality disciplinary action of medicine and social service in the constitutional guarantee of the rights of persons with disabilities in social security of Brazil.According to the literature, these nurses must explore the feelings, aspirations, expectations, emotions of this social segment, because this identification enables the humanization of assistance, which helps the person cared for in the confrontation of his condition of disabled person (21) .However, there are case reports in the literature about the possibility of the person with disabilities prefer the benefit of Continued Provision to the detriment of the work due to instability of the formal labour market and the importance of family financial maintenance.And, in that case, take advantage of the benefit, too, provides free time to perform other work activities (22) .

FINAL CONSIDERATIONS
Mental illnesses are most often found in people who receive welfare benefit, however, in population with benefits terminated by death, the occupy the first Neoplasms as main diagnosis.
Less than a quarter of 2.67 million Brazilians with mental disabilities receive assistance benefit from social security.The other three quarters of people who plead with mental disabilities do not require this benefit, or required, but not but not fall into the income criteria and socio medical eligibility.Facing the possibility of as people don't have access to the application for assistance, the question remains: does active search is necessary for people with mental disabilities eligible for assistance?
For every 1000 people with welfare benefit to the person with disability in maintenance, 141 the benefit ceased by death _ mortality coefficient 22 times higher than found in the Brazilian population.This much higher mortality coefficient can be explained by the own characteristics of vulnerability that feature: are very poor families and with diseases that disable to work and for the acts of daily life.Is configured that, although the population of persons with disabilities receive a financial benefit, feature non-assisted properly by morbidities.
Respect to the vulnerability of the person with disabilities is presented as a question of human dignity and social justice.

Table 1
Prevalence of disease in individuals with social assistance benefits for people with disabilities and terminated by death.Brazil, October 2012.Prepared by the authors based on SUIBE data (13) of the Ministry of Social Welfare(2013)

Table 2
Total social assistance benefits for people with disabilities held and terminated by death, and mortality coefficients, according to sex, age and region.Brazil, October 2012.