By PAULO CAPEL NARVAI*
“Health systems” have the mission, in addition to indispensable individual assistance, to carry out actions that adequately respond to all social health needs
Have published on the website the earth is round, articles about health, covering everything that, in my opinion, is important on the subject. I often focus on structural and cyclical aspects of our universal health system, the SUS – Sistema Único de Saúde, as it, despite its numerous problems, including chronic underfunding, is recognized as an important achievement of Brazilian society, whose principles and guidelines are embedded in the 1988 Constitution (CF1988), in the chapter “On the Social Order”, which the CF1988 itself states is “based on the primacy of work, and social well-being and justice as its objective”. It was not for nothing that Ulysses Guimarães described the 1988 Federal Constitution as a “Citizen Constitution”.
To SUS, I dedicated a book entitled “SUS: a revolutionary reform – To defend life”, detailing the historical process and political struggles that led to its achievement and analyzing its theoretical foundations, challenges, risks and perspectives.
In the texts published here, and when approaching topics related to health in other contexts, I have referred, in addition to the term “health”, to the expressions “public health” and “collective health”, as I understand them, seeking to differentiate them in a such that they are understandable to my interlocutors. The concepts sometimes come together, sometimes they move away, as they effectively have different meanings, although in some contexts they can be taken as synonyms. The very concept of “health” is not, contrary to what many think, self-explanatory.
For this reason, sometimes a reader asks me to “explain these differences”. As I am a professor of Public Health at USP, it is common for people to ask me the question that came to me, once again at the beginning of March, when the academic year began: “Why is the degree at USP in 'Public Health' and not in 'Collective Health', if all other courses in Brazil are in 'Collective Health'?” I always respond that the topic is complex and that, in the case of USP, a clue to trying to understand this is in the book “One hundred years in Public Health: the academic-institutional trajectory of FSP/USP – 1918-2018”, published in 2019, the digital version of which is available free of charge on the USP open books portal. In the introductory chapter, which I had the pleasure of writing with my colleague Eliseu Waldman, we address the topic of Public Health in the XNUMXth century, in São Paulo and Brazil.
In this article, I reproduce and develop some excerpts from chapter 8 of the book “SUS: a reform…”, to help those interested in this reflection on health, public health and collective health. I'm sure this is nothing more than a brief introduction to these themes, which is why I count on the generosity of more demanding readers.
Health
Different definitions of “disease” have accompanied humanity since time immemorial and based on these various understandings about its meaning, men were, in different historical periods, and according to the material, scientific and technological resources at their disposal, organizing ways of dealing with the disease. illness and its consequences. The ways of understanding diseases were sufficient to try to face and solve the problems of diseases, in individuals and populations, for centuries and centuries (Andrade & Narvai, 2013).
As an expression of something undesirable, negative, threatening and often deadly, “disease has the capacity to draw attention and signal to man that something is not going well with sick individuals or communities and that, therefore, it is I need to do something not only to ward off the threat that the disease poses, but also to understand the intimate nature of that threat” (Lefevre et al., 2004).
But, when the Second World War ended in 1945, it was necessary not only to react to something (the disease), but to affirm something (health), as the United Nations (UN) was willing to create a specific organization to deal with with issues related to health, in countries and, therefore, on a planetary scale.
It was not possible, however, to define “health”, as there were so many focuses and approaches that accumulated over time. But it was possible to construct a concept of “health”. Thus, when the World Health Organization (WHO) was created on April 7, 1948, a date since then dedicated to the celebration of “World Health Day”, health was defined as being “a state of complete physical well-being , mental and social and not just the absence of illness or disease”. Many consider illness and disease to be synonymous.
But they are not, as someone can be sick without the manifestation of the disease occurring to such a degree that there is significant impairment of bodily functions, preventing the exercise of one or more functions and compromising the person's self-care and autonomy. There would therefore be illness, but not illness. When the disease progresses to the impairment of some function, characterizing some degree of functional incapacity, requiring hospitalization or professional care provided by third parties, it is admitted that there is, then, an illness, in addition to the disease. But this distinction between health and illness, based essentially on the possibility of self-care or the need for heterocare (professional, therefore), is arbitrary and can be accepted or not.
Although the UN-linked organization's concept (“definition”, according to the WHO) of health is widely disseminated, it has been heavily criticized since it was announced. One of these criticisms maintains that the concept is utopian, as “complete physical, mental and social well-being” is a very difficult, if not impossible, condition to achieve – without going into the merits of what “well-being” means for each person. person, or in each culture. Critics have argued that the term “complete” should be removed from the definition “since health is not an absolute state” (Terris, 1992), even questioning its operational usefulness, since being subjective, the concept would be more of a “declaration of principles and not exactly a definition” (Hanlon, 1955).
The affirmation of health as being something different than simply not having an illness is at odds with common sense. Although in biomedical terms health can be conceptualized as “a set of judgments of an instrumental nature, normatively guided by the notion of technical control of natural and social obstacles to the practical interests of individuals and communities, having as a material basis the knowledge and mastery of causal regularities in the organism (body/mind/environment) and, as a form of validation, a well-defined series of a priori criteria to control uncertainties” (Camargo, 1997), for people, with exceptions, those who are not sick are healthy, and few take care of the topic beyond that. But “talking about health is not equivalent to talking about non-disease and talking about illness is not equivalent to talking about non-health” (Ayres, 2007).
Although a definition of health is, therefore, an open question in the academic world, it is accepted in practical terms and for operational purposes that, at the sub-individual level, “health” is one of the dimensions of a complex of chemical reactions, cellular interactions and physical flows at molecular, tissue and systemic levels. The ability of a cell, tissue or organ to adapt and produce responses resulting from changes in the internal and external environment at different levels of biological development will characterize the emergence, or not, of a pathological state (Narvai & Frazão, 2012).
At the individual level, “health” is one of the dimensions of a process in which varying degrees of dysfunctions or abnormalities and varying degrees of normalities or organic functionalities dynamically alternate, in which the latter predominate over the former. Such dysfunctions and abnormalities occur in individuals who are simultaneously biological organisms and social beings. Thus, any change in health results not only from biological aspects, but also from the general conditions of the existence of individuals, groups and social classes, covering individual and collective dimensions.
On the individual level, the extreme moments would be, on the one hand, the “most perfect well-being” and, on the other, death, with a series of intermediate events. Whatever the disease-producing stimulus and whatever the nature and magnitude of the individual's response, the result is a process, understood as such, a series of concomitant or successive events (Leser et al., 1985).
On a collective level, this process, conceptualized as the “health-disease process”, corresponds to more than the sum of the organic conditions of each individual that makes up a population group. Although the health conditions of a given population are commonly expressed by quantitative indicators, qualitative aspects and dimensions can also be used for this purpose. Demographic and epidemiological measures, indicators relating to deaths, illnesses, health services, risks of becoming ill and dying and living conditions can be used. In this dimension, the compound term “health-disease” is an expression of a broader social process that results from a complex web of factors and relationships, represented by determinants closer to and more distant from the pathological phenomenon, depending on the level of analysis adopted: family , household, community, neighborhood, municipal, national, global.
Thus, only in very specific situations does “health” result from the availability and access to health services which, although essential for, on an individual level, producing comfort, controlling pain and reducing suffering, have, in the collective dimension, a very important role. modest in producing better levels of health. Health “does not refer to given regularities that allow us to define a way of doing something, but concerns the very search for something to do. We are always in movement, in transformation, in becoming, and because we are finite in time and space and do not have the possibility of understanding the totality of our existence, individual or collective, we are always, from each new lived experience, in contact with the unknown and seeking to reconstruct the meaning of our experiences.
The continuous and inexorable contact with the new continually unsettles and re-settles us in the way we understand ourselves, our world and our relationships. It is to this process that the relatively large openness of the meaning of the expression health is related, which we find collectively, in different times and social groups, and among different individuals in a given time and place” (Ayres, 2007).
A Constitution of 1988 states that health actions are of “public relevance”. This stems from the recognition that “health” is a 'pure public good' as it presents, among other aspects, some characteristics that distinguish it from other types of goods and services, including its universality, immateriality, indivisibility and inappropriability (Narvai & Frazão, 2012).
'Universality', arising from the fact that it is essential that everyone, without exception, enjoy it. It was not “only” for humanitarian and social justice reasons, but also for epidemiological reasons: even if injuries or cases or special conditions are located in bodies (individual, therefore), such bodies carry something that interests and, sometimes, threatens everyone in society, because this something they carry represents a risk for everyone and not just an individual risk. Thus, far from being “a personal problem”, health and illness, admittedly, concerns and interests everyone, even when the private dimension of the event is recognized and respected.
'Immateriality', because health has no material existence outside people. You can even donate organs to third parties, but “health”, no.
'Indivisibility' results from the fact that, as it does not have an external material existence, it is not possible to decompose health into components, as is done with certain goods. However, even in its internal material manifestation (the health or pathological impairment of one or more organs) there is, individually, a unique condition that cannot be considered separately. For this reason, as we know, expressions such as “oral health”, “mental health” or equivalents, have merely didactic or operational purposes.
The 'inappropriability' of health is a consequence of it not being possible, due to its inherent characteristics, to transform “health” into a commodity. It is not possible for someone to appropriate someone else's health. It is possible to treat goods and services related to health-illness as commodities: medicines, hospitality in hospitals, provision of professional assistance services, prosthetics, orthoses, etc. And therefore sell them as commodities. But this should not be confused with “selling health” – which, in fact, is simply not possible.
It should be noted, by the way, that people, in their wisdom, tend to simplify things. Just remember our satisfaction when someone we care about is “selling health” – in this case, with the opposite meaning to the “selling health” mentioned, which has a commercial meaning. Joy results only from the understanding, shared by everyone in all social classes and educational levels, that in fact “health is priceless”.
Public health in crisis
The classic definition of public health formulated by Winslow (1877-1957) is well known and can be found in most good manuals on the subject: “Public health is the science and art of preventing disease, prolonging life, and promoting physical and mental health, and efficiency, through organized community efforts, aimed at environmental sanitation, control of community infections, education of the individual in the principles of personal hygiene, organization of medical and nursing services for diagnosis early warning and treatment of disease and the development of social mechanisms that will ensure that each person in the community has an adequate standard of living to maintain health” (Winslow, 1920).
Since the end of the Middle Ages, and benefiting from the possibilities generated by the Renaissance and the Enlightenment, public health has consolidated itself as a field of knowledge and practices in the context of bourgeois revolutions in Europe, in the 17th and 18th centuries, when different visions centered on in man and his living environment begin to nourish explanations for health and disease. Studies on the human body, banned in the medieval period, prosper. In a certain way, but on another level, it revisits the man-nature relations of the Greco-Roman period.
The evolution and diffusion of science are creating the foundations of knowledge that, especially after the Industrial Revolution, would radically and profoundly transform public health – certainly in line with the equally radical and profound transformations that industrialization and modern life would bring. . But they would persist for a long time, and are still very much alive today in populations around the world, explanations based on divine sentences, miasmas and magical-religious factors (Scliar, 2007).
With the emergence of several national states that declared themselves socialist republics, such as the Soviet Union and China, but also other countries in Africa, Asia and Latin America, and especially after the creation of the WHO, public health experienced a paradigmatic crisis. important in the 20th century. The health tradition from the center of power recognized in each society, whether in primitive communities, or in the city-states of Ancient Greece such as Thebes, Athens, Sparta and Troy, or medieval cities such as Genoa, Florence and Venice or, above all, from the constitution and consolidation of national States in the period that goes from the end of the Middle Ages to the 19th century, carry out social control for purely economic purposes, acting in a focused way on people and population groups that present risks, actual or potential, that threaten the communities as a whole, was called into question.
In the 20th century, the public health that many countries began to aspire to focused on universalizing access to health care, through what was conventionally called “universal health systems”, funded with fiscal resources collected in each country, so that universal access also corresponded to free services provided.
The old public health was called into question. He would need to continue with his classic quarantine and isolation strategies to face epidemics, but he would need to incorporate immunizations and medicines into this arsenal. And even more: given the advances in knowledge regarding disease prophylaxis and the prevention of risks and injuries to motherhood and childhood, for example, public health should greatly expand the range of its interventions in the health of populations. “Appropriate” technologies should be developed to make this possible and for service systems to be economically sustainable, even in resource-poor countries such as Africa, Asia and Latin America. The universal healthcare systems of Western Europe, Canada and Japan showed that this was possible. And it seemed fair to everyone that all people wanted to enjoy this type of health protection.
But to achieve this, it was also necessary to transform the entire theory that supported the old public health. In 1977, the World Health Assembly announced “Health for All in the Year 2000”, as a slogan from which all possible efforts should be made by countries to achieve an extension of coverage of basic health services, developing “simplified health care systems”. The theme would be revisited a year later, in Alma Ata, at the International Conference on Primary Health Care, promoted by the WHO.
The Alma-Ata Declaration, the final document of the event, reaffirms health as a human right, under the political responsibility of governments, and recognizes that its production results from intersectoral actions, and that it is not enough to simply produce good health services. There was a firm conviction, at least among experts, that it is a mistake – and one that could cost countries very dearly – to reduce “health” to the provision of tests, procedures and medicines, even while recognizing the importance of these aspects on an individual level. Health is also, and in many cases above all, a social production, and it is essential to take into account the social aspects that determine it (Buss & Pellegrini-Filho, 2007).
Little by little, a movement was consolidated which, at the international level, would gain the name “New Public Health” and which would be characterized by the affirmation that the public health necessary for countries should be concerned with the prevention of both infectious and non-infectious diseases. , promoting health, and expanding and improving the quality of medical care, including the possibilities of rehabilitation, which scientific development made possible. To this end, the “New Public Health” should “seek answers based on the scientific bases of biological, social and behavioral sciences, having as areas of application populations, problems and programs, according to the framework of universal access” (Paim & Almeida-Filho, 1998).
Therefore, anyone who talks about public health thinks about diseases that affect many people and even entire populations and always has as a reference not only issues related to restoring the health of populations, but the actions that power must take to maintain it. or recover it, for everyone and in everyone's interests. For this reason, those who talk about “public health” look at power and, if there is a State, seek to know what it does, how it acts, based on what type of knowledge, legitimizing how its actions. It also seeks to know how the State obtains resources to finance actions and programs and how it executes these actions and evaluates their results. For “public health” the power lies with the State and this is the subject who is the protagonist, as he is the one at the center of the actions.
Public health
With “collective health” the perspective is different, as the subject of the processes that must produce everyone's health is the population itself, its communities, groups and social classes and their interactions, including the set of institutions and, as I could not leave it alone of being, also the State itself. The center of concern, however, more than disease in populations, is health and the way each society achieves, recovers and maintains it. It is in this sense that collective health rejects the concept of health as being just the “other pole” of the disease.
It states, on the contrary, that health corresponds to something that goes far beyond “non-disease” and that, therefore, actions that only have disease, even if they are epidemics, as a reference for their execution are not enough. Therefore, for collective health, non-sick people in a population matter as much as sick people and epidemics, as what happens to non-sick people is essential for understanding what happens to sick people and individuals vulnerable to epidemics.
By recognizing that in any human grouping power is distributed among individuals, groups and social classes, collective health focuses on these relationships and interactions and seeks to unveil the interfaces of different areas and types of knowledge that underlie individual and collective actions, referred to as to the social production of health-illness-care, understood as complex processes and not just, therefore, the absence of illnesses. While public health focuses on disease and, above all, epidemics, collective health focuses its actions on health and the need for its universalization as a human right that must be guaranteed to everyone, without exception.
It is also for this reason that collective health considers that, in contemporary societies, the State is a central institution to ensure everyone's right to health, through public policies, especially in social formations marked by marked inequalities and the lack of recognition of rights. This recognition places, in these societies, the State as a decisive entity for the health of populations, whether through the initiatives it takes for this purpose or through its omissions which result in the deepening of inequalities and, therefore, the social production of disease.
This conception derives from concerns about the direction of democracy in each country and the world, the possibilities of social participation in health, the recognition and expansion of rights, among other political aspects that have been at the center of collective health since its inception. The State is decisive because its actions result in consequences that impact, positively or negatively, the health levels of populations.
Collective health is, therefore, a theoretical and political movement, related to the field of public health, which was originally constituted in Brazil, in the middle of the second half of the 20th century, based on the questioning of old public health and the way it was materializing in Brazil. There are varied understandings regarding the meaning of the expression “collective health”, but it can be said that there is a convergence in understanding it as a field of knowledge that seeks to epistemologically overcome public health, with which it maintains permanent theoretical and political tension.
As a field of knowledge, collective health deals with the health-disease phenomenon in populations as a social process; investigates the production and distribution of diseases in society as processes of social production and reproduction; analyzes health practices (work process) in their articulation with other social practices; and seeks to understand, finally, the ways in which society identifies its needs and health problems, seeks their explanation and organizes itself to face them (Paim & Almeida-Filho, 1998).
The historical context in which the collective health movement emerged was characterized by the crisis in public health and health systems in Latin America, the insufficiency of the responses that research and training in health were giving to this crisis and, in the specific case of Brazil, due to the financial crisis of social security and the so-called “social security medicine” that corresponded to it, which deepened restrictions on access to health services, strictly understood as just a “social security benefit”.
What is conventionally called the “collective health project”, with the strategic objective of producing an epistemological overcoming of public health, as a field of knowledge and practices, through its dialectical negation, gained expression in several dimensions derived from these crises, and which can, of course, simply and briefly, be expressed as having three main dimensions. In an activity promoted by the Institute of Public Health (ISC), at the Federal University of Bahia, in September 2021, I identified these three dimensions as being affected by the areas of: (a) knowledge production; (b) reorientation of professional and researcher training, in undergraduate and postgraduate programs; and, (c) construction in the country of a public health system, along the lines of the English National Health Service (the NHS, as it is better known, in its English acronym) and the Cuban health system.
But collective health intended – and intends – to do all this with a very important innovation: ensuring that, in all these dimensions, everything is done with “popular participation” and, therefore, under the political control of organized society, which should, more than that “complement” the institutional administrative mechanisms of the Brazilian State, also politically control these administrative control bodies.
Almost half a century after its emergence as a theoretical and political movement, collective health remains powerful, in the middle of the first half of the 21st century, and decisively influencing the direction of health in Brazil. It records undeniable successes and many difficulties, taking as a reference the project that constituted it. The country has a universal health system, the SUS, which has provided remarkable services to the health of the population, especially to segments with the worst socioeconomic conditions, although the principles of universalization and equity remain a dream, an ideal to be permanently pursued. .
Despite there being many problems of representation, sometimes compromised by practices of nepotism and party clientelism, “popular” participation is exercised, within the limits of Brazil's fragile democracy, by health councils and conferences, which have regular activity and perform the functions for which they were designed and created. A few dozen specific undergraduate courses in public health have been created, and the “collective health project” has been exerting a relevant influence on public health teaching in various degrees in the health area, including medical training courses.
Postgraduate studies have taken important steps to incorporate public health, going beyond the traditional framework of public health, although much of the production originating in master's and doctoral courses continues to take place under this influence, which is almost always conservative. But, despite its importance, popular participation is very far from exerting any relevant influence, both on the different levels of health training and on the directions and agendas of scientific research in this area. Notable exceptions only confirm this predominant characteristic.
It is undeniable, however, that in the half century since its creation, the Brazilian collective health movement has consolidated a new paradigm in the field of public health, refusing the hegemony of biologicalism that still prevails, affirming the need to think of health-disease-care as a triad indissoluble, advocating participatory management as a corollary of a health system under the control of users, reaffirming the production of knowledge aligned with the health needs of the population and, unequivocally, linking health to democracy as a condition 'sine qua non' for its social production.
Many attribute to the public health doctor Sérgio Arouca a founding role in the collective health movement, mentioning “The preventive dilemma: contribution to the understanding and critique of preventive medicine”, his most relevant academic work, as a landmark. However, if his doctoral thesis, defended in 1975 at Unicamp, is recognized as a classic in the field, curiously the expression “collective health” appears only once in the text, in a quote from the book “Treaty of elementary hygiene”, by Becquerel, published in 1883. The mention occurs right at the beginning of the introduction section of the thesis, when Sérgio Arouca presents the reader with the object to be problematized: preventive medicine. Even considering “collective” as an isolated term, it only occurs eight times throughout the thesis and always as a qualifying adjective, never as a noun. The expression “public health”, in turn, is mentioned 47 times.
But Sérgio Arouca spoke and, more than talking, acted, a lot and in an insistent, persistent, recurring way about health reform. For this reason, among so many decisive social actors, he was the protagonist of this process, marking it so deeply and significantly that it is not possible to talk about the Brazilian health reform without mentioning him.
Collective health and the Health Reform movement derived from it bequeathed the Unified Health System to Brazil. After the “long gestation” of the 1970s and 1980s, politically “fertilized” by the mass struggles of the campaign for 'Direct now' and with the memorable landmark represented by the 8th National Health Conference (1986), the SUS had its “birth” on the day 17 May 1988, at the 267th Session of the National Constituent Assembly, which established it as the universal health system of the Brazilian State. Thus, the SUS, as an institution, is a state system – even though the provision of assistance services is carried out not only by state-owned services, but shared by privately owned services. Such services, known as “privates” are, however, “complementary” and regulated by institutional governance processes carried out by federative entities, within the competence of the SUS.
For this reason, the actions and services maintained by the SUS are always of universal public access, as the private law organizations that participate in the SUS, through contracts and agreements, do not have private access to specific people or social groups. Brazilian legislation prevents access to “SUS services” from being mediated or conditioned by any non-health criteria. It is often said, in this regard, that the SUS is 100% public, even though the health services that comprise it are not 100% state-owned.
There is a myth that there would be in Brazil two systems health system, one public, the other private. This belief is based on the fact that as the CF1988 assured (art.199) that “health care is free to the private sector”, this would characterize the scenario of two health systems.
The main problem with this interpretation of the 1988 Federal Constitution is that “health”, as I mentioned, cannot be reduced to mere care procedures. In this sense, there may be a health care “service system” that, transforming care into goods, responds to the needs of individuals, according to market rationality, and whose purpose is, therefore, to produce profits to be appropriated by shareholders and owners. But this does not correspond to a “health system”, whose actions focus, as is the case of the SUS, on acting on all determinants of health-disease in populations and not just on biological processes. “Health systems”, it is worth reiterating, have the mission, in addition to the indispensable individual assistance, to carry out actions that adequately respond to all social health needs.
For this reason, the SUS is, effectively, the only health system in Brazil. And the difficulties we faced during the Covid-19 pandemic indicated that for all Brazilians, without exception, the SUS is more necessary than ever (Bousquat et al., 2021).
*Paulo Capel Narvai is senior professor of Public Health at USP. Author, among other books, of SUS: a revolutionary reform (authentic). [https://amzn.to/46jNCjR]
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