By HESIUM LAMB, JOSÉ LUÍS FIORI e REINALDO GUIMARÃES

Presentation and full text of the pioneering document of the Brazilian sanitary intelligensia

Presentation by José Luís Fiori

The reconstruction of history is a very difficult task, because the paths of the past are neither simple nor linear, and often involve personal memories and emotions. As in the case of the creation of the Unified Health System, the largest public system of universal medium assistance in the world. It was created by the 1988 Constitution, which recognized “health” as a universal right, and as an obligation of the Brazilian State.

But before 1988, there was a long journey and a great mobilization of forces and social organizations that participated in the fight for the constitutional recognition of this right of the Brazilian people. This struggle had many social, political and intellectual roots and contributions, but it is also possible to identify some important steps that were taken within the State bureaucracy itself, and in particular, within INAMPS, with the creation of the Prompt Action Program (PPA ), in 1975, a first experience of universal and free emergency care, but which did not last long; and also the creation of the Integrated Health Actions (AIS) program in 1984.

In the field of ideas, however, and of the intellectual or ideological struggle itself, the fundamental role that the Institute of Social Medicine of the State University of Rio de Janeiro played in this history should be highlighted. The IMS was created in the early 70s by a small group of progressive doctors and sanitarians who managed to resist and escape the control and political and intellectual repression of the military dictatorship, and create a research and graduate program in the area of ​​Health. Public, encouraged by the Christian humanism of the doctor from Rio de Janeiro Américo Piquet Carneiro, and led by the enthusiasm and strategic intelligence of two younger, idealistic and left-wing doctors, doctors Nina Pereira Nunes and Hésio Cordeiro.

It was thanks to the energy and dedication of this small initial group, and to the support they had from the Pan American Health Organization, that they were able to gather around the graduate program created in 1974, a significant group of equally young and progressive professionals, composed of physicians, epidemiologists, sociologists, psychoanalysts, demographers, political scientists, philosophers and economists. And after that, the founders of the IMS themselves “submitted” themselves to the condition of students in the first experimental class of master's students that graduated in 1976, as was the case of Hésio Cordeiro himself, and of several other physicians, such as Reinaldo Guimarães, José Noronha and João Regazzi, among many others, who later occupied prominent positions in the formulation and management of the national health policy in the following decades.

Over the years, and particularly in the 1980s, the IMS became a center for high-level multidisciplinary and heterodox intellectual reflection, and a true “school of power”, where several ministers and state secretaries of Health were trained. , and several presidents and directors of the Oswaldo Cruz Foundation, and many other national and international centers of excellence. And after that, and during its fifty years of life, the IMS ended up becoming one of the main – if not the main – training center for the Brazilian health intelligentsia. Michel Foucault, Giovani Berlinguer (who inspired the Italian health reform), Ivan Illich, Mario Testa, Cristina Laurel and countless other internationally renowned intellectuals and sanitarians who made a decisive contribution to the maturation of the three major theoretical lines that contributed most for the formation of critical thinking at the IMS: Rudolph Virchow's “German social medicine”; the critique of “medical iatrogenesis”, by the Austrian Ivan Illich; and the “microphysics of power”, by the Frenchman Michel Foucault.

And it was within the Institute of Social Medicine that, in 1975, the first systematic and left-wing intellectual proposal for a universal health system was born, inspired by the National HealthSystem in the 40s, and by the Italian Health Reform of the 70s. The originality of the IMS, at that moment, was to go beyond the pure exercise of criticism of the military regime, to think about what to do concretely in the field of Brazilian health at a time when the progressive forces managed to come to power, as happened, at least in part, in the period of the “New Republic”, between 1986 and 1990.

In order to formulate the first proposal, a small group of professors from the IMS, led by Hésio Cordeiro, carried out, from 1975 onwards, a work of consultation with trade unions and medical associations in Rio de Janeiro, in order to jointly and consensus, a new sanitary project for Brazil. This work of consultation and collective discussion took approximately one year, and it was after these multiple “hearings” with unions and medical and health corporations, that the first version of this text/manifesto that appears below, on “ The democratic question in the area of ​​health", which circulated among a restricted audience, in 1976.

And it was from this initial platform that it began to be disseminated and reproduced by various magazines and institutions, often without the name of its original authors. In 1979, it was published by CEBES Magazine, and ended up becoming a true manifesto of the Brazilian health movement, in the early 80s, until its recognition and formalization as a document and decision of the VIII National Health Conference, in 1986.

Further ahead, this same original text from 1976 became the “compass” of Hésio Cordeiro’s administration at the head of INAMPS, from 1986 onwards, when the SUDS was created, which functioned as an embryo of the Unified Health System, before that it was enshrined by the 1988 Constitution, and long before it was institutionalized, already under the aegis of the Ministry of Health.

At the time this text was written, in 1976, none of its authors imagined the importance it would have in the following decade, much less could they imagine the shape that the future would give to their project and their dreams. But looking at it from the perspective of the past, I can say that I am very proud of having participated in this intellectual and institutional adventure, and of having been at the side of Hésio Cordeiro and Reinaldo Guimarães at the time we wrote this manifesto, as militants in the struggle for redemocratization of the country, and as enthusiastic defenders of the universal right to health for all Brazilians.

The Democratic Question in the Health Area

There is practically a consensus among experts on the diagnosis that, from the 60s onwards, the standard of living of the population has gradually deteriorated. Significantly increased infant mortality, endemic diseases, rates of accidents at work, the number of mentally ill, etc. Sanitation conditions, environmental pollution and nutritional levels also deteriorated to the point of worrying the authorities, who are now somewhat pessimistic in relation to what they call “absolute poverty”.

At the same time, popular mobilization against unemployment, low wages and poor living conditions is growing. Also growing, and more specifically, the population's irritation against queues, bureaucracy, corruption and the costs of poor medical care they receive. Finally, union complaints and demands against agreements and contracts with medical companies are on the rise.

Meanwhile, Brazilian medicine is experiencing a profound crisis. Criticisms of its quality are exacerbated. Its effectiveness is increasingly being questioned.

Doctors are accused of negligence and unnatural greed for salary. Hospital owners are threatening to close them because their profits are falling.

It is in this context that most of the material that has been conveyed by the mass media is located. Numerous objective elements support the partial veracity of these accusations. However, what is only recently coming to light, in a still somewhat covert form, are the real causes of the detected distortions. The ultimate roots of the anarchy established in medical care and the population's health insolvency: the commodification of medicine consciously promoted and accelerated by a privatizing, concentrating and anti-popular government policy.

Policy that replaces the voice of the population with the wisdom of technocrats and the pressures of the various business sectors; health policy that follows the general lines of the government's socioeconomic position: privatizing, entrepreneurial and concentrating income, marginalizing around 70% of the population from the material and cultural benefits of economic growth. Health policy, which also reduced public health expenditures to a minimum, favoring curative and highly sophisticated medical-hospital care, even when the country's health situation indicates the enormous importance of the "old" problems: schistosomiasis, Chagas disease, malaria , malnutrition, high infant mortality rates, combined with the emergence of new patterns of urban mortality (cancer, cardiovascular diseases, accidents, violence, etc.). Health policy, in short, that forgets the real needs of the population and is guided exclusively by the interests of the minority constituted and confirmed by the owners of medical companies and managers of the health industry in general.

A recent example of this form of elitist and anti-popular policy is the attempt to create the check-consultation, whose only objective is to satisfy the interests of service producers, offering the population the illusion of better access to health services.

Faced with this essentially anti-democratic policy, the vast majority of health professionals are today placed in the trenches of an inglorious battle, trying to remedy the evils of ineffective planning for a needy and undernourished population, with techniques that are sometimes as or more dangerous than the very diseases you want to eliminate.

On the other hand, the population, marginalized from decisions about health policy in the same way as from most decisions about national life, finances a system that offers little or nothing in return.

Faced with this scenario, it is the duty of the population and health professionals, in the workplace and gathered around their representative entities, to present their diagnosis of the situation. Even more, adding to the climate of debates that characterizes the national political conjuncture today, advance and propose platforms of struggle that seek to unite their aspirations in line with the constitution of a democratic medicine.

It is in this sense that the Brazilian Center for Health Studies presents its contribution to this debate and this fight. (This sentence and this authorship were added to the original version of the text, after 1979)

– The diagnosis presented already indicates the main lines of a proposal, limiting responsibilities and defining the main obstacles that stand in the way today, in Brazil, between the democratic ideals and the possibilities of response and real adequacy of our health system to those ideals.

By an authentically democratic health it is understood:

1 – the recognition of the universal and inalienable right, common to all men, to the active and permanent promotion of conditions that enable the preservation of their health.

2 – recognition of the global socio-economic nature of these conditions: employment, salary, nutrition, sanitation, housing and preservation of acceptable environmental levels.

3 recognition of partial, but non-transferable, responsibility for medical actions themselves, individual and collective, in the active promotion of the population's health.

4 – the recognition, finally, of the social nature of this Law and of the responsibility that rests with the community and the State in its representation, for the effective implementation and protection of the aforementioned conditions.

Therefore, measures are needed that:

1 – hinder the most harmful effects of market laws in the area of ​​health, that is, stop the entrepreneurship of medicine.

2 – transform lucrative medical acts into a free social good available to the entire population.

3 create a Unified Health System.

4 – attribute to the State the total responsibility for the administration of this System.

5 – delegate to the Unified Health System the task of planning and executing a national health policy, which includes: basic research, training of human resources, individual and collective medical care, curative and preventive, environmental control, sanitation and minimal nutrition to the survival of a healthy population.

6 – Establish effective mechanisms for financing the system, which are not based on new tax burdens on the majority of the population, nor new specific taxes on health. The financing of the Single System should be based on a greater proportional participation of the health sector in the federal, state and municipal budgets, as well as on the increase in collection resulting from a fundamental change in the current regressive nature of the tax system.

7 – organize this system in a decentralized manner, articulating its organization with the political-administrative structure of the country at its federal, state and municipal levels, establishing basic units, coinciding or not with the municipalities, constituted by population agglomerations that would eventually gather more than a municipality or unfold others with greater population density. This decentralization is intended to enable an authentic democratic participation of the population at the different levels and instances of the system, proposing and controlling the planned actions of their organizations and political parties represented in governments, and assemblies and instances of the Unified Health System.

8 – This decentralization aims, on the one hand, at greater efficiency, allowing greater visualization, planning and allocation of resources according to local needs. But it aims, above all, at expanding and streamlining authentic popular participation at all levels and stages in health policy.

This, perhaps the fundamental point of this proposal, denies a merely administrative or “statist” solution. It is a question of channeling the claims and propositions of the beneficiaries, transforming them into voice and vote in all instances.

This also avoids a centralizing type of participation so dear to the corporatist spirit and so apt for the co-optive manipulations of a strongly centralized and authoritarian State as the Brazilian State has traditionally been.

9 – establish a statute of coexistence between salaried practice linked to the Unified Health System and the authentic practice of private practices that has a tradition in Brazilian medicine.

10 – define a specific control strategy over the production and distribution of medicines, as well as the production and/or importation of consumption of medical equipment. That this strategy bears in mind the real, majority and regionalized needs of the population, reducing expenses and unnecessary sophistication to a minimum.

These political options lead to a proposal for profound transformation in the current health system whose initial measures are:

I – Create the Unified Health System (SUS).

II – Grant to the Ministry of Health the management of the SUS, with the task of planning and implementing, together with the state and municipal governments, the National Health Policy. The body must have normative and executive power, including over the private and business sector, being permanently controlled by the population through its representative organizations, via clearly established and institutionalized mechanisms.

III – Define the Medical Assistance Policy, currently carried out by Inamps, already framed and disciplined by the governing body of the SUS, through the immediate suspension of agreements and payment contracts for service units for the purchase of medical acts from the private business sector , replacing them with global grants; establish effective control mechanisms for these contracted units that prevent harmful consequences such as lowering the salaries of professionals and reducing the quality of care; control to be exercised jointly by a representative of the Unified Health System with a permanent seat in the direction of these units.

IV – Create immediately, albeit progressively, with the resources previously spent on health insurance and others, a national network, duly regionalised, of outpatient clinics and health posts, aimed at applying preventive measures, articulated with primary medical care, of cases emergencies and accidents at work. For the operation of these posts, doctors working in the Single System and, above all, auxiliary staff, whose training should be strongly encouraged, should be used.

V – Definition of a policy for the rural area suited to the real needs of its population, de-conditioning the provision of medical assistance from satisfying the electoral interests of party groups.

VI – Redefine the current FAS policy so that the expansion of the basic health services network starts to work.

VII – Prioritize environmental control measures, particularly those aimed at reducing endemic diseases such as Chagas disease, schistosomiasis, malaria, etc.

VIII – Plan the training and distribution of health professionals, defining priorities for the training of non-specialized and specialized personnel.

IX – Define a policy for the production and distribution of medicines and medical equipment guided by simplification and technological efficiency and aimed at reducing dependence on foreign capital through:

• Greater state participation in research, training of researchers and development of national technology aimed at the production of fundamental raw materials for the industrialization of essential medicines; similarly to what was originally proposed by the project itself or Central de Medicamentos;

• control of profit remittances abroad;

• effective control of the quality and quantity of marketed drugs;

• import only those equipment and drugs that have had their effectiveness proven through use for a minimum period of five years.

The set of these demands constitutes a first stage in the formulation of a platform for the fight in favor of an authentic democratization of Brazilian Medicine and Health. It is not intended to be executive or to cover administrative implementation details. It's not your goal. It only defines the main lines that should guide, in our opinion, fundamental political decisions.

From this moment on, a democratic debate is opened, as broad and fertile as possible, with all entities and institutions interested in solving the current crisis in Brazilian Medicine. Debate that deepens these indicated points, leading to the most complete formulation of a platform that groups and mobilizes doctors and non-doctors in the fight against the current government policy for health and in favor of a Democratic Medicine.

*Hesium Lamb, was professor at the Faculty of Medical Sciences at UFRJ and received the title of Doctor Honoris Causa from Fiocruz.

* Jose Luis Fiori Professor at the Graduate Program in International Political Economy at UFRJ. Author, among other books, of Brazil in space (Voices).

*Reinaldo Guimaraes  is a doctor and was a professor at the Faculty of Medicine of UERJ.