By PAULO CAPEL NARVAI*

Sin it our immense difficulties in ensuring the exercise of the right to health would be even greater.

With about 15 million officially confirmed cases and more than half a million deaths from covid-19 in the short-term epidemiological horizon, the SUS turns 33 on May 17, 2021. Some are embarrassed when it comes to celebrating this anniversary in such a macabre scenario, under a government that spreads pain, suffering and death throughout the country. But those who rely only on the SUS have no doubts in celebrating the existence of the system, because without it our immense difficulties in ensuring that everyone enjoys the right to health would be even greater. In many municipalities, the SUS is practically the only national institution available to the population. It is not little, although it is not enough.

There are many criticisms of the SUS, and fair ones, such as, among others, those who denounce the queues, the poor quality of care, the disregard for people, the precariousness of health professionals (who still do not have a Career-SUS, multidisciplinary and interfederative), the bureaucratization of management and the barriers to effective popular control of health services, provided for in the 1988 Constitution. Although it is neither correct nor appropriate to generalize, it is a matter of concern that these problems still persist in most municipalities today. But we must not lose sight of the fact that it was precisely against situations like these that the SUS was created in 1988. Since then, the commitment and struggle of thousands of citizens and health workers in every corner of the country has not ceased for a single day. , to build, consolidate and strengthen our universal health system.

However, since the SUS was created, the main protagonists of the political process that gave rise to it have been gradually removed from their governing bodies, at all levels, under the slavish complacency of the National Congress, which does nothing to create the Career -SUS, nor prevent public management and advisory positions from continuing to be held by people without professional qualifications, just to cater to all kinds of nepotism and clientelism. On the contrary, most deputies and senators benefit from the legislative loophole, taking advantage of it to nominate underlings to the mayors of their electoral base. Nevertheless, the social construction of the SUS moved forward, such was the strength of the creative energy that was at its origin (the 'Diretas Já' campaign and the municipalist and Sanitary Reform movements) and which prevented the withering away of the system. Until now, at least.

The performance of SUS in the covid-19 pandemic, mitigating the administrative negligence of the Union and of most states and municipalities, made the majority of the population reassess what they think of this public institution. In the capital of São Paulo, for example, for the first time in recent years, the SUS was considered, in April 2021, the best public service in the city, alongside the Metro, a multi-champion in the eyes of São Paulo. According to Datafolha, SUS obtained 2% of the votes in 2015, 6% in 2020 and 13% this year⁽¹⁾. Approval results from a feeling of attachment to the system and the perception that it is a public service in defense of citizenship, as has been demonstrated in the face of the pandemic.

But the 2016 coup and, above all, the election of Bolsonaro, accelerated unprecedentedly the attacks on the SUS, which, at 33 years of age, is under fierce attack. It is true that in the early years, the system made a Herculean effort to resist the violence inflicted on it by the Fernando Collor government (1990-92). Suffice it to mention that Collor did his best not to hold, in 1990, the 9th. National Health Conference, which would boost the process of municipalization, having been partially successful, as that conference took place only two years later, in August 1992. Then, with Collor out of government, the decentralization of the SUS was accelerated, finally establishing a new institutional scenario in Brazilian public health.

In the present historical context, in the midst of the slogan “Bolsonaro out!”, the SUS is faced with a double and gigantic effort: on the one hand, facing and winning the covid-19 pandemic; on the other hand, resisting the disorganization of the Ministry of Health, which commands it at the national level and which, weakened, is very vulnerable to the privatist rage that has Minister Paulo Guedes as its main mentor in Bolsonaro’s ministry.

On the day the Federal Senate installed (27/4/2021) a Parliamentary Commission of Inquiry (CPI) to investigate actions and omissions by the federal government in controlling the covid-19 pandemic in Brazil, Guedes attended a meeting of the Council of Supplementary Health. At the meeting, he reiterated childishness about the genesis of SARS-CoV-2 (“the Chinese invented the Covid virus”) and the demographic transition (“everyone wants to live 100 years, 120, 130 years”) and explained, in an equally childish way , because it is so important for the Bolsonaro government to attack and, if possible, destroy the SUS: Brazil would spend “too much” with the SUS and the government it represents is not capable of facing corruption, nor of managing public money well.

The solution, according to Guedes, would be to hand over everything to the private sector, making the business viable through vouchers for consultations, procedures, surgeries, medicines and other health services, which "the government" would distribute to the population for " health care in the private network”. He closed the reasoning in a terse way, with the summary sentence of the Bolsonaro government's incompetence to coordinate, in a shared way with the federative entities represented by states and municipalities, a universal health system in a complex federative republic like the Brazilian one: “You are poor , you're sick, here's you 'voucher'. Go to [Albert hospital] Einstein if you want. Go wherever you want, here's the 'voucher'. If you want, you can go to SUS”.⁽²⁾

Not a child, however, believes that someone, having a voucher in hand, will be treated at the hospital in the example. Not a single teenager believes that a system with these operational and financial characteristics has economic sustainability in an epidemiological context like the Brazilian one, marked by iniquities and whose health needs are not subject to adequate, integral confrontation, through vouchers for procedures. The serious thing, however, is that Guedes is Bolsonaro's Minister of Economy and his decisions involve the lives of millions of children and adolescents across the country. The only truth in all of this is that, strictly speaking, not even Guedes believes in the nonsense he utters. He says what he says to deceive the unwary and please those he serves – who rub their hands, eager to put them even more into the SUS coffers.

From the very important municipal base of the SUS,⁽³⁾ The fight against the pandemic continues throughout Brazil, in fits and starts, and without national coordination, as I denounced more than a year ago, in March 2020⁽⁴⁾. In this regard, economist Francisco Funcia, adviser to the National Health Council, drew attention to the fact that, significantly, the National Health Plan approved for the 2020-23 period has not yet set annual targets for the coping with the covid-19 pandemic. Therefore, Bolsonaro’s initial bet of “letting die” and, paralyzed, waiting for nature, with collective immunity, to do its part, is ongoing. His belated, ashamed and cynical adherence to vaccines is exactly what it seems: cynicism, with purely electoral purposes. His zero-empathy and insensitivity to the pain and suffering of others gave rise, as someone wrote on a social network, to a kind of nesciopolitics, a Bolsonarist variant of necropolitics driven from the Planalto Palace.

In addition, the fact that the Ministry of Health has been transformed into a target of institutional destruction since the 2016 coup, contributes significantly to disrupting operations to contain the pandemic. Under the presidency of Michel Temer, and led by Ricardo Barros, his Minister of Health, attacks on the SUS and the sectoral policies that the Ministry of Health coordinates at the federal level have intensified. Barros, it is worth mentioning, was the first holder of the Health portfolio who, since 1988, openly and blatantly declared himself as an anti-SUS minister. Others were, but never took it on. Barros, no. He always made a point of stating that he was “Minister of Health, not Minister of SUS”. Denying the value of our universal system, Barros dedicated himself to its destruction and the apology of health plans, which he wanted “popular”, and whose operators he became a true poster boy.

Bolsonaro, in turn, dedicated himself, from his first day at the head of the Presidency of the Republic, to humiliating, publicly disavowing them, the successive Ministers of Health who served him. What matters, however, are the internal consequences for the Ministry of Health and the SUS, of the Bolsonaro way of governing. The daily disqualification of the work carried out by the technical areas of the Health portfolio is part of an administrative tactic set in motion with the aim of destroying the SUS, silently killing it from above, either by politically weakening the Ministry of Health, or by strangling it. or financially.

The main legislative resource for this destructive goal is Constitutional Amendment 95 (EC-95), approved in 2016, immediately after Dilma Rousseff was removed from office. The EC-95 froze for twenty years the resources that fund public policies, including health. According to economists linked to the Brazilian Association of Health Economics (ABrES), since 2018 the SUS has lost BRL 22,5 billion, according to values ​​contained in the 2020 Annual Budget Law. definancing⁽⁵⁾. The consequences are equally disastrous. If SUS financing currently involves an investment of R$ 3,79/person/day, the forecast is that the effects of EC-95 for 2036 will reduce this investment to R$ 1,10/person/day, in 2021 values. If today it is almost a miracle that the SUS boasts the positive numbers it registers,⁽⁶⁾ being an efficient system, quite contrary to what Minister Guedes claims, not a miracle will be able to maintain this performance under the effects of EC-95. It is urgent to revoke this EC of 2016, as its destructive effects on the SUS are increasing day by day.

In addition to the systematic dismantling of several national programs (such as Immunizations, Mais Médicos, Mental Health, Popular Pharmacy), the disorganization of technical teams and the establishment of a work environment hostile to the SUS in the Ministry of Health, which began with Temer, the Bolsonaro government has been destabilizing inter-federal relations with states and municipalities that had been meticulously built over the last three decades.

Making use of party-political attacks to try to hide its own administrative incompetence, Bolsonarism seeks to reverse responsibilities, placing the consequences of their actions and omissions on governors and mayors.⁽⁷⁾ He does not hesitate, in these processes, to destroy federative institutional constructions in whose processes he did not participate, and to which he never contributed anything significant. It merely appropriates the arduous, meticulous and difficult work of others and, thirsting for power, begins to destroy the SUS with remarkable ideological fury, motivated by purely political-electoral purposes. It finds, however, opponents who recognize in the SUS one of the main achievements of citizenship enshrined in the 1988 Constitution.

The motivation of the anti-SUS ideological rage serves, however, the ultraliberal purpose of privatizing even more. It matters little, for ideology-intoxicated privatists, whether the object involved is a social right, such as health, or any other company. Privatization, according to this logic of destruction of public property, does not allow for exceptions. Privatization is only for the ideological delight of some, and pockets full of money for others – which, sometimes, are the same.

On 26/4/2021, the eve of the installation of the 'CPI of the Pandemic', the Minister of Health went to the National Congress to talk about the vaccination schedule. Following the boss’s guidance, Marcelo Queiroga repeated the Bolsonarist mantra: the delay in vaccination would be the responsibility of governors and mayors, who do not do what they should, creating “controversies” for political reasons. While the game of accountability between the authorities continues, SUS professionals, scalded, distrust the CPI, its directions and outcome.

They fear that it will not result in the strengthening of the SUS and that, in the end, whatever its effects on political party and electoral processes, the SUS and health workers will be held responsible for the carelessness and irresponsibility of leaders of the executive branch. Signaling in this regard was clearly given by Minister Queiroga at an event at the Federation of Industries of the State of São Paulo (FIESP), on 3/5/2021, when he stated that “we cannot accept that out of every 10 patients who are intubated, eight die. This is why we have so many deaths, because health care does not provide the response we expect from it”.⁽⁸⁾ “Health care” is, for Queiroga, the SUS and its professionals.

SUS professionals therefore have plenty of reasons to distrust the CPI, because if its installation was motivated by the need to investigate actions and omissions of the federal government in facing the covid-19 pandemic, this objective was redirected to other targets, the request and under pressure from the Planalto Palace. The so-called “new policy” is fiction to deceive distracted voters. But the CPI's first days of operation, its lenience with Pazuello, accepting the conditions it imposed to testify before senators, and the way in which it listened to former Ministers of Health were enough to dampen the spirits of many people who saw in that parliamentary commission the beginning of the end of the Bolsonaro government.⁽⁹⁾

At 33 years old, SUS is in the government's crosshairs. Especially in metropolitan regions, the network of Basic Health Units (UBS) and Emergency Care Units (UPA) remain under public management and constitute a niche for health plan operators, eager to seize their resources. The immediate target, however, are the federal hospitals in Rio de Janeiro (Andaraí, Bonsucesso, Cardoso Fontes, Ipanema, Lagoa and the Federal Hospital of State Servers). Incompetent to run these federal hospitals,⁽¹⁰⁾ who continue with dozens of closed beds while the state of Rio de Janeiro hastily sets up field hospitals, and fearing reactions to the transfer of their management to the State or Municipality,⁽¹¹⁾ as the units were scrapped and lost hundreds of professionals in recent years, Bolsonaro wants, ignoring health advice and decisions of health conferences, to solve management problems “handing everything over to the private sector”, according to the orthodoxy of the neoliberal model.

For this, he ordered his current Minister of Health to start talks with business groups interested in the business, under the pretext of “contributing to reforming the SUS”. On 22/4/2021, Jorge Moll Filho, founder of the D'Or network of hospitals, was officially received by the Minister of Health. It is not possible to understand exactly how his contribution to reforming the SUS would be, but it is worth mentioning that the businessman would have, “in just over a year”, added about US$ 11 billion to his fortune, estimated at around $2 billion in early 2020.⁽¹²⁾

It has been like this in these 33 years of SUS: its greatest enemies have been put in charge of it. Honorable exceptions only confirm the general rule. Now, there is no shortage of Bolsonarists wanting to “take the SUS for Christ”, blaming the system for the overwhelming Brazilian failure to face the pandemic.⁽¹³⁾ Despite everything, the system resists because its workers resist. For this reason, on the anniversary of SUS, recognition of its priceless value must be given to those who, on a daily basis, give life to our universal health system. These, contrary to what is proclaimed in the media and social networks, and also in the CPI of the Senate, are not heroes, but just professional public servants, in search of recognition, justice, respect and decent work in suitable work environments. It is not much. But all this has been denied them for 33 years.

*Paulo Capel Narvai is Senior Professor of Public Health at USP.

Notes

1. Ferrasoli D. SUS appears for the first time among the best public services in São Paulo. Folha de S.Paulo [Internet]. April 29, 2021; Available in: tinyurl.com/ejhznk86
2. Martello A, Gomes PH. Guedes says that the State “broke” and that it will be “impossible” to meet the growing demand in health. G1 Brasilia [Internet]. April 27, 2021; Available in: tinyurl.com/782f7cv7
3. Biernath A. Covid-19: the Brazilian city that saw cases collapse after “real lockdown”. BBC News Brazil [Internet]. March 11, 2021; Available in: tinyurl.com/2n5bbmza
4. Narvai PC. Epidemiological flat earthism. The Earth is Round [Internet]. March 16, 2020; Available in: https://dpp.cce.myftpupload.com/terraplanismo-epidemiologico/
5. It works FR. Chronicle of four thousand daily deaths announced (with an upward trend): the contribution to this tragedy of the federal (dis)funding of the SUS during a year of COVID-19. Sunday [Internet]. 2021;(10). Available in: tinyurl.com/49aw69f6
6. Narvai PC. SUS, 32 years old: this land has an owner. The Earth is Round [Internet]. 2:1–8. Available in: https://dpp.cce.myftpupload.com/sus-32-anos-esta-terra-tem-dono/
7. Mourao AHM. Limits and Responsibilities. The State of São Paulo [Internet]. May 14, 2020; Available in: tinyurl.com/34baunke
8. Simões E. Queiroga blames failure in health care for the number of deaths from covid. UOL Notícias – Reuters Agency [Internet]. May 3, 2021; Available in: tinyurl.com/6bhunhu8
9. Kertzman R. Either the Covid CPI ends in impeachment or Brazil is gone for good. IstoÉ [Internet]. April 14, 2021; Available in: tinyurl.com/fek8f6sz
10. Brazil CI. Covid-19: Rio negotiates opening of 300 beds in federal hospitals. Agência Brasil [Internet]. March 19, 2021; Available in: tinyurl.com/wwpxwsm9
11. Júnia R. Rio de Janeiro proposes to manage the Federal Hospital of Lagoa. National Agency [Internet]. March 24, 2021; Available in: tinyurl.com/ebux5kfz
12. Couto M. Net worth of the founder of Rede D'Or 'grew' US$ 11 billion in one year. Yahoo Finance [Internet]. February 17, 2021; Available in: tinyurl.com/43dcabry
13. Junior P. Fabio Wajngarten: “There was incompetence and inefficiency”. See [Internet]. 2021; Available in: tinyurl.com/b43y6ykc