By PAULO CAPEL NARVAI*

The extreme right wing in the federal government seriously injured the SUS

“It's a good thing that the Lula government has Nísia Trindade in health and in charge of the SUS.” The praise for the minister came from a friend, doctor and former municipal health secretary of a city in São Paulo, after the program “Conversation with the President”, on December 12, 2023, which also had the participation of the Minister of Health. Upon completing the first year of his third term, President Lula has been taking stock and reporting to society.

It's good. It is an effort to overcome the difficulties of his government's social communication and, above all, to confront the misinformation and deliberate misinformation disseminated intensively against him and his ministers. But some of Lula3's difficulties go beyond misinformation and fake news, so harmful to democracy and social life. Some difficulties originate from the President of the Republic himself.

Lula proposes simplistic solutions to complex issues, and that is a problem. But these “solutions” originate from Lula’s widely recognized sensitivity to capturing, understanding and trying to solve the difficulties faced daily by most people. “Lula gets the diagnosis right, but he gets the therapy wrong,” said the doctor friend who manages the SUS.

Lula gets the diagnosis right when he feels that the population needs the SUS, wants to maintain and develop our universal health system, public, controlled by the State and “by the community”, as guaranteed by article 198 of the 1988 Constitution, but wants more and better services. Lula knows that the people defend the SUS, but they want a better SUS than the one we have today. Recognizes that the focus placed this year on intensifying the effort to recover enormous losses in vaccination coverage, reducing queues “for everything” as a result of the disruption of municipal services imposed by the pandemic and the cuts in resources made under the previous administration is correct. .

You also know that “the destruction” of the Ministry of Health is not just a rhetorical expression, typical of political discourse. Nísia Trindade and the first echelon of Health, which brings together a handful of stars, have been working their hearts out to remake the teams and management processes that, having taken many years to establish, were brutally dismantled during almost seven years of terrible federal administration of the SUS.

This context began to be produced shortly after the 2016 coup, by the team put in place by Michel Temer to take care of the SUS, and was dramatically aggravated by the neo-fascist misgovernment between 2019 and 2022. In Brazilian federalism, organizing public health programs and projects takes time, requires lots of competence and resources. The extreme right in the federal government seriously injured the SUS.

Lula knows, therefore, that the detailed and competent work that Nísia Trindade has been carrying out with her team in reorganizing her ministry, in rearticulating and restructuring the federative entities that make up the SUS, re-establishing and strengthening inter-federative relations, and, when necessary, carrying out direct interventions, as in the case of indigenous health. Therefore, the president shielded Nísia Trindade. He curbed greed for his position, took his appointment upon himself and strengthens it whenever he can, as he did in closing of the 17th National Health Conference, on July 5, 2023, and on the program “Conversation with the President”, when he pointed to the scenario he wants for health “at the end of my government”, clearly indicating that Nísia Trindade will remain on the team of ministers.

The tone of voice, the rigor with data, the support on scientific evidence and the “half-light” style of Nísia Trindade contrast with the search for spotlights, the half-words, the grandiloquence and stridency of some ministers, current and of past governments. Some, including in the president's party, consider her fragile and hesitant, but that is just appearance. The set of actions that mark the work carried out by the Ministry of Health in Year-1 of Lula3 shows the opposite.

There was a recovery in SUS funding, contrary to the expectation that in 2023 the SUS budget would be reduced by around R$22,7 billion compared to 2022. The opposite happened. There was, according to Nísia Trindade, “an increase of R$34,4 billion”. Even though the SUS has had many budget losses in recent years, and the chronic underfunding scenario has not been overcome, the budget has increased substantially. The Annual Budget Law (LOA) for 2024 foresees reaching R$218,5 billion, which corresponds to an increase of 46% compared to 2023.

This increase in the SUS budget translated, in 2023, into an additional 28 thousand places in the “Mais Médicos” program, benefiting 96 million people. The “Farmácia Popular” program expanded free access to more than 40 medicines for 55 million people. For surgeries, R$600 million was invested in the “Queue Reduction” program. The SAMU program began renewing the ambulance fleet with the acquisition of almost 2 thousand new vehicles and received an investment of R$1,7 billion. In the “Brasil Sorridente” program, 4,3 thousand new oral health teams were accredited and 360 mobile units were delivered to municipalities.

Indigenous health is having its resources doubled: from R$1,6 billion in 2023 to R$2,5 billion in 2024. Heavy investment was also made in the development of digital health, modernizing the network of SUS units across the country , notably in remote regions, with emphasis on the application and electronic medical records Connect. The program was created Health with Science to value science, defend vaccines and confront misinformation and misinformation.

The set of actions carried out in 2023 by the SUS, with around 1,5 billion procedures, including operations as varied as births and transplants (one of which Faustão's heart), dental treatments and vaccine applications, in addition to health promotion and health surveillance actions, mentioned by Nísia Trindade in the program “Conversing with the President”, indicate that there is no fragility or hesitation, but strength and determination.

It's a good thing that the Lula government has Nísia in health and in command of the SUS, because, to the anger of those who want to do everything on the basis of parliamentary amendments, the minister has been defending respect for planning and republican relations with states and municipalities .

But the President of the Republic and his Minister of Health also know that thousands of people die or have illnesses made worse by the delay in carrying out tests and getting appointments with specialists. Anyone who has cancer, for example, cannot wait to be seen a year after being diagnosed. Everything is very urgent.

One of Lula's mistakes in “therapy” for SUS problems is to assume that they can all be resolved directly by the Ministry of Health, whether through its own services or through private services. Take, for example, the case of the poorly named “therapeutic communities”, in which it gives individuals without qualifications the competence to work in a very complex area, such as mental health. This area is one of Lula3's main problems in Year-1 of health.

The simplism of supposed solutions does not withstand more critical analysis. For the president, there would be no reason why therapeutic itineraries for routine health problems should not include examinations and consultations in clinics close to the patients' homes. “There are private clinics there, on the street where the person lives”, as they say. But it's not like that. The SUS, and this is something Lula finds difficult to accept, is not a “large, unitary, nationwide health service”, in which the minister decides what should be done in each city, in each neighborhood.

Lula knows this, understands this, but, because he is sincerely sensitive to the people's pain and suffering, he seems unwilling to accept that this is not how the SUS works. The operational base of the SUS is made up of municipalities, and each municipality has the autonomy to decide what it wants and does not want to do in the SUS under its command. This is an obstacle to implementing simplistic solutions. But this is an achievement for citizenship and the SUS, which can make decisions about health at the local level.

Lula's mind on health continues to be the head of the union president, who wants to offer a great medical and dental outpatient clinic, but also wants to “wrest from the bosses” a good “health plan”. He firmly believes that “health plans” are the best solution and if the rich and the middle class have plans, then he wants “plans” to be accessible to everyone. It is a mistake. But Lula doesn't seem to know this, as he doesn't seem to realize that this is an option that wastes resources, enriches companies, but does not produce collective health. About that, just look at healthcare in the US.

Until the Covid-19 pandemic, Lula declared support for the SUS, but he was no longer enthusiastic about our universal healthcare system. Since his time as a union at ABC in São Paulo, he saw the SUS as just a kind of big “health plan”, controlled by the State. This perception changed radically when Brazil had to face Covid-19. The country then had, at the head of the Presidency of the Republic, a crude anti-SUS mystic who refused vaccines and asked for prayers against the virus, and in command of the SUS a succession of ministers in which, due to his notable incompetence, general of Army Eduardo Pazuello, and, for being an ardent anti-vaccinist, doctor Marcelo Queiroga.

Eduardo Pazuello, the “logistics specialist”, as we know, managed to send vaccines to Amapá (AP) that should have gone to Amazonas (AM). Marcelo Queiroga, a cardiologist and knowledgeable about the safety and effectiveness of vaccines, made himself pass as an anti-vaccinist just to please the then president and his acolytes and the nefarious “hate office”.

During the pandemic, Lula realized the importance of the SUS for all people, and not just for poor people, “the most humble”, as he often says. His understanding of the importance of the SUS beyond assistance to sick people deepened. In her inauguration speech she stated that “the SUS is probably the most democratic of the institutions created by the 1988 Constitution”. But his unionist heart continues to beat for “health plans” for everyone.

Lula recognizes the importance of vaccines and prevention in general, but his focus is always on individual assistance and care. It is missing, or feels the need to disregard, that any health system, in any country, needs to balance preventive actions and assistance care, as an imperative for its economic sustainability. If this balance is broken by the emphasis on assistance care, as “health plans” do, the system loses sustainability, as the needs on this side of the balance are practically infinite and their costs are increasing.

Preventive actions are essential to contain the increase in health needs and make universal systems, such as the SUS, viable. It is not easy, of course, to reach the balance point. But the SUS needs this balance and, for this reason, the actions it carries out need to reach everyone, and not just the poor and humble, as Lula supposes.

It is with this complexity as a reference that the Ministry of Health and SUS work. Lula senses the relevance of this work and supports it – even if he doesn't understand it very well. As, in fact, most people don't understand either, as the subject is really complex. Everyone rightly wants to avoid pain and suffering, live well, escape death. I heard the other day from a friend that “we didn’t need to burn in pain during this short hiccup that is life”.

Those who defend and fight for the SUS know this, they know this “burning in pain” well. David Capistrano Filho, one of the creators of the SUS, used to say, and even wrote, that “our work is a war against the consequences, in the field of health, of poverty, hunger, ignorance, unhealthy and unsafe work environments, of an entire violent, cruel form of social organization, generating brutal inequalities. In a word, we wage a war in defense of health and life, against the trail of suffering and death with which Brazilian capitalism marks the existence of millions of people.”

But Lula and Nísia Trindade know that the problems of the SUS, such as dissatisfaction with queues and delays for consultations, exams and surgeries can transform, or be opportunistically transformed, into a kind of electoral campaign for the opposition to the government. Of course, Lula is keeping an eye on this possibility and acts to neutralize the political-electoral use of the difficulties of the SUS. This is also a battle on a symbolic level.

Therefore, at the lights out of 2023, it was very well received by SUS defenders, the symbolic green light opened for our universal healthcare system by Bill Gates, the creator of Microsoft. In article on your blog the businessman and philanthropist recognized important achievements of the SUS in controlling infant mortality and financing public health and the articulation of these efforts with social programs such as Bolsa Família. He highlighted that, in 1990, 24% of Brazilians lived with an income of less than 2,15 dollars per day and that, three decades later, this percentage decreased to 6%. For him, the SUS is an example to other countries, which could “learn and imitate”.

It is this understanding, that health means being able to live well, that this must be possible for everyone, and that it is up to the SUS to articulate the actions that are necessary to make living well possible for everyone, that has marked the management of health and the SUS in the Year-1 of Lula3.

It's a good thing that the Lula government has Nísia Trindade in health and in command of the SUS, because if Lula feels the need to give the SUS this direction for a good life for all, his health minister not only feels this need, but implements actions in this direction, as it knows what needs to be done and how to do it. In fact, it has been doing so.

I conclude with another error by Lula, who often cites José Serra and Nísia Trindade as Health Ministers who “aren’t doctors”. It must be due to one of these processes in which our heads refuse to accept something, that Lula “forgets” to include Army General Eduardo Pazuello on this list of non-medical health ministers. I won't dwell on this, but several former health ministers were not doctors.

The long list includes lawyers Antônio Balbino, the first to be appointed Brazil's health minister (1953), Armando Falcão (1961), Vasco Leitão da Cunha (1964) and Gilberto Occhi (2018); Pedro Paulo Penido (1960), dentist; José Goldemberg (1992), physicist; Barjas Negri (2002-03), economist; Agenor Álvares (2006-07), biochemist-sanitarian; and Ricardo Barros (2016-18), engineer. Almost all, it is true, with ephemeral passages through the ministry.

But Ricardo Barros' three years were a real nightmare. Nothing compares, however, to the 10 months of Eduardo Pazuello's administration, marked as one of the biggest disasters in Brazilian health management. His successor, Marcelo Queiroga, even tried to match him in incompetence and discredit, but it must be recognized that he did not even reach the general-minister's feet.

For this reason, the President of the Republic's error is understandable. I want to be wrong with Lula on this, because I would also very much like to forget that, one day, our health, and many lives, were dependent on decisions made by Eduardo Pazuello.

It's a good thing that the Lula government, and Brazil, today has Dr. Nísia Trindade in health care and in charge of the SUS.

*Paulo Capel Narvai is senior professor of Public Health at USP. Author, among other books, of SUS: a revolutionary reform (authentic). [https://amzn.to/45IhkhQ]

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