Compare and contrast Brazil and the United States. What do you already know about Brazil? What do you think is similar between the US and Brazil? What do you find differ

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Alan Osmo Universidade de São Paulo. Faculdade de Medicina. Departamento de Medicina Preventiva. São Paulo, SP, Brasil. E-mail: [email protected]

Lilia Blima Schraiber Universidade de São Paulo. Faculdade de Medicina. Departamento de Medicina Preventiva. São Paulo, SP, Brasil. E-mail: [email protected]

The field of Collective Health: definitions and debates on its constitution1

O campo da Saúde Coletiva: definições e debates em sua constituição

Correspondence Lilia Blima Schraiber Universidade de São Paulo. Faculdade de Medicina. Departamento de Medicina Preventiva. Av. dr. Arnaldo, 455, 2ºandar. São Paulo, SP, Brasil. CEP:01246-903.

DOI 10.1590/S0104-12902015S01018

1 This paper was written based on the oral presentation in the VI Brazillian Congress of Social and Human Sciences in the Health Field, in 2013.

Abstract At first sight, Collective Health might seem to be multiple and fragmented. Aiming to understand better what defines it as knowledge and activity in society, we made a theoretical review of historical and epistemological considerations developed by researchers who dedicated themselves to character- izing it as a scientific and social field. First, based on this literature, we provide a brief panorama of the emergence of Collective Health in Brazil. It is important to notice that its origins date back to the end of the 1970s, in a context in which Brazil was experiencing a military dictatorship. Collective Health emerges, at that moment, connected with the struggle for democracy and with the Health Reform movement. We show the influences of preventive medicine and social medicine in its constitution. Then, we explore different attempts to delimit it as field of knowledge and practice. We sought to present Collective Health not through one single definition, but taking into account the multiplicity of constructions about it that we found. This allows us to point to an identity of difficult development and that is still under construction. Keywords: Collective Health; Public Health; Social Medicine; Scientific Domains; Knowledge.

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Resumo A Saúde Coletiva pode, em um primeiro contato, parecer bastante múltipla e fragmentada. Buscando compreender melhor o que a define como conhe- cimento e atuação na sociedade, realizou-se uma recuperação de natureza teórica das considerações históricas e epistemológicas desenvolvidas por pesquisadores dedicados a caracterizá-la como campo científico e social. Primeiro, com base nessa produção bibliográfica, foi feita uma breve caracte- rização da emergência da Saúde Coletiva no Brasil. É de se destacar que suas origens situam-se no final da década de 1970, em um contexto no qual o Brasil estava vivendo uma ditadura militar. A Saúde Coletiva nasce, nesse período, vinculada à luta pela democracia e ao movimento da Reforma Sanitária. Apontam-se as influências do preventivismo e da medicina social em sua constituição. Ao longo deste estudo, foram exploradas distintas tentativas de sua delimitação como campo de saberes e de práticas. Buscou-se apresentar a Saúde Coletiva não com uma definição única, mas considerando a multiplicidade de construções encontradas, o que permite apontar para uma identidade de difícil elaboração e ainda em desenvolvimento. Palavras-chave: Saúde Coletiva; Medicina Social; Domínios Científicos; Conhecimento.

Introduction What instigated the choice of the theme for this study was the perception that, at first sight, Collec- tive Health seems to be multiple and fragmented, both from the theoretical and from the practical points of view. Therefore, aiming to understand it better, a study was carried out, based on the produc- tion in Collective Health in Brazil, in an attempt to answer the following questions: What characterizes and defines Collective Health? What distinguishes it from other fields of knowledge and intervention?

In this preliminary reflection on such issues, we decided to revisit studies that viewed it as a specific field and that were conducted by authors who are considered references in Collective Health, as they participated in the development and implementa- tion of the proposal for a Collective Health in Brazil at the end of the 1970s. These authors are research- ers in the areas of Epidemiology, Human and Social Sciences in Health, and Health Policy, Planning and Management, and have studied the constitution of Collective Health from these distinct fields.

The reference that Collective Health configures a “field” is registered in almost all the publications. In this text, we will maintain this reference following Paim and Almeida Filho (1999, 2000). In their reflec- tions on Collective Health, these authors character- ize it as a “field of knowledge and an specific sphere for practice”: “Collective Health can be considered an interdisciplinary field of knowledge whose ba- sic disciplines are epidemiology, health planning/ management and social sciences in health” (Paim; Almeida Filho, 2000, p. 63).

However, in a recent publication that focuses on Collective Health, this qualification of “field”, which, since the beginning, has been grounded in the con- cept coined by Pierre Bourdieu (1993), is relativized, in view of the fact that Collective Health, sometimes called “area”, sometimes “social space”, has, in its development, a tendency to consolidate as a field (Vieira da Silva; Paim; Schraiber, 2014).

In light of this open question, as a future or consolidated field, what most instigated us was the delimitation of a scientific and practical identity based on its knowledge contents and intervention scopes. Thus, in the above-mentioned revisit to pub-

Saúde Soc. São Paulo, v.24, supl.1, p.201-214, 2015 203

lications about the construction of Collective Health

in Brazil, we aimed to reveal which areas of expertise

have been mentioned since its origins. Less than a

bibliographic review, therefore, this study aims to

present a rereading of important discussions on the

identity of Collective Health.

This is an effort to clarify what constitutes

the “whole” of Collective Health, in an attempt

to overcome a possible fragmentary view that

has been produced by the diverse disciplines

that compose it, in order to provide a better un-

derstanding of the construction of its identity.

According to Everardo Nunes (2005), this effort

seems to be an important concern in the history

of Collective Health:

Recovering the history and unveiling its internal

composition (epistemé) has been one of the con-

cerns of many studies and analyses that have been

following the very construction of Collective Health

in Brazil. This effort has been present since the

1980s and continues to the present day, with the

aim of providing the elements that configure our

identity and reveal who we are, where we are, what

we do, and the products of our practices (p. 14).

The present paper is divided into two parts. The

first briefly approaches the constitution of Collec-

tive Health in Brazil as presented by authors in the

field. In this part, we emphasize schools of thought

about health-disease processes in collectives as

ways of thinking that are different from that of the

traditional public health and from that based on the

view coined by modern medicine. The way in which

questions of medicine and of public health are ar-

ticulated is the reference to understand the issues

that surround the disciplinary content that the Col-

lective Health proposal has embraced. The second

part explores contrasts among distinct attempts to

define Collective Health. These contrasts are also

present in texts written by authors in the field, who

present different perspectives on the delimitation

of Collective Health, and indicate the existence of a

large multiplicity of schools of thought concerning

its definitions as a field.

The constitution of the field of Collective Health in Brazil Nunes (1994) situates the origin of the field of Col- lective Health in the 1950s. Vieira-da-Silva, Paim and Schraiber (2014) consider that it dates back to the end of the 1970s, as the benchmark they utilize is the emergence of the term Collective Health in Brazil, and the creation of the civil association that would represent the field: the Associação Brasileira de Pós- Graduação em Saúde Coletiva (Abrasco – Brazilian Association of Postgraduate Programs in Collective Health). However, the authors do not deny the roots that Nunes has pointed in previous periods. Thus, Collective Health consolidated with this name and with its specificities in Brazil. Although the name has not been adopted in other countries, many authors see Collective Health as part of a broader movement in Latin America, as Nunes himself has argued (1994).

Based on a distinction between “project” and “field” of Collective Health, Nunes (1994) proposes that the emergence of this field occurred in three stages: the first, called pre-Collective Health stage, lasted for fifteen years from 1955 onwards, and was marked by the establishment of the preven- tive medicine’s project; the second, which lasted until the end of the 1970s, is called social medicine stage; the third goes from the end of the 1970s to, at least, 1994, when the author wrote the paper Saúde coletiva: história de uma ideia e de um conceito (Collective health: the history of an idea and of a concept). The author considers that the last stage is the period of Collective Health per se. Accord- ing to Nunes (1994, p. 2), “the emergence of these projects reflects, generally speaking, the broader socioeconomic and political-ideological context, as well as the successive crises that are present both in the epistemological level and in the level of health practices and human resources education”.

Paim and Almeida Filho (1999) also point to the importance of context in issues related to field of knowledge. These authors, based on the ideas proposed by Kuhn and Rorty, defend that the con- struction of scientific knowledge is not produced by investigators in an isolated way, in the abstract; rather, it is institutionally organized, within cul-

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ture, and immersed in language. Therefore, science would be socially and historically determined. The authors propose that science should be understood as a social practice that has particular principles, is exercised in a process of dialog and negotiation, is targeted at the production of a localized and dated consensus, and is based on a certain solidarity of those who act in the scientific community.

We believe that an important advantage of this periodization is that it highlights preventive medicine and social medicine as approaches to the health-disease process in collectives that can be recognized as the roots of the Collective Health proposal that was developed in Brazil, and which influenced the institutional implementation of the field.

In the sections below, we will characterize these roots so that it is possible to understand the modal- ity of disciplinary and practical proposition that they constituted.

1) Preventive Medicine

According to Paim and Almeida Filho (1998), in the 1940s, some researchers started to diagnose, in the United States, a crisis of a certain medicine that was extremely specialized and fragmented, which caused an increase in costs related to medical prac- tices. In response to this, proposals for changes in medical teaching emerged and incorporated into it an idea of prevention. These proposals were the basis for a reform of the curricula of medicine programs in many North American universities in the 1950s. International health organs adhered to the new doc- trine, which was called Preventive Medicine. Thus, the proposal was internationalized.

Nunes (1994) explains that the emergence of the “preventive project” in Latin America occurred in the second half of the 1950s, in the seminars that were held in Chile and Mexico, sponsored by the Pan American Health Organization (PAHO). The reforms that were defended in these seminars were associ- ated with a pedagogical plan:

The great balance of the period is the inclusion, in the

medicine undergraduate program, of disciplines and

themes associated with epidemiology, behavioural

sciences, health services management, and biosta-

tistics. Thus, when the biologization of teaching was

criticized, as it was grounded on individual, hospital-

centered practices, the aim was not only to introduce

other types of knowledge, but also to provide a more

complete view of the individual (Nunes, 1994, p. 7).

The fact that teaching was based on specializa- tion made medical education become shattered. As a reaction against this, proposals for changes in teaching were made, so that the future doctor could understand the individual as a whole, as it was believed that this would promote a recom- position of the bio-psycho-social dimension that had been fragmented. The social movement that originated Preventive Medicine as a discipline in the curriculum of medical schools was called Comprehensive Medicine, and aimed to recompose specialized practices (Schraiber, 1989). However, the only result was the inclusion of one discipline in the curriculum, even though it pervaded several moments of the doctor’s education. No integrative projects other than the teaching of prevention were incorporated, neither in doctors’ education, nor in their professional exercise in the health services. Schraiber (1989) has argued that these proposals intended to promote a reform of medical practice, but they assumed that this reform would be performed in the sphere of doctors’ education, as if each doctor in his/her practice was the main resource to transform the way of providing care for the population. This way of thinking about the reform of medical practice was well characterized, as a liberal and individualizing reading of social issues that was typical of the North American cul- ture regarding the State’s role in society, by Arouca (2003), in a publication that is considered, today, a bench mark for Collective Health in Brazil (Vieira da Silva; Paim; Schraiber, 2014).

In addition to Preventive Medicine, Community Medicine arrived at Latin America. It emerged, in the 1960s, also in the United States, in a period of intense popular and intellectual mobilization around social issues. Donnangelo and Pereira (1976) have shown that Community Medicine was a response to the low coverage of medical care for the poors, such as communities of migrants or low- income strata of the North American society, and to the low coverage for the elderly – as they were out of the job market, they had no adequate access

Saúde Soc. São Paulo, v.24, supl.1, p.201-214, 2015 205

to medical services. Diverse intervention models were tested and institutionalized in the form of organized movements in urban communities, aim- ing to reduce social tensions in the ghettos of the main North American cities. In the field of health, there was the implementation of community-based health centers subsidized by the federal govern- ment, which were targeted at performing preven- tive actions and providing primary care to the local population (Paim; Almeida Filho, 1998).

Like in Preventive Medicine, there was, in the Community Medicine proposal, an emphasis on the “behavioural sciences”. In this case, however, knowl- edge of sociocultural and psychosocial processes aimed to “enable the integration of healthcare teams in ‘problematic’ communities, through the identification and cooptation of local social agents and forces for health education programs” (Paim; Almeida Filho, 1998, p. 304).

International organs in the field of health incor- porated, once again, the new ideological movement, community-based and preventive, and translated its doctrine into the needs of different contexts in which it could be applied.

Although Community Medicine and Preventive Medicine emerged in different moments in the United States, they arrived more or less at the same time in Brazil (Donnangelo; Pereira 1976; Schraiber, 1989).

2) Social Medicine

The Social Medicine movement emerged in Latin America at the end of the 1960s and beginning of the 1970s. Its center is the discussion of the appre- ciation of the social dimension as the sphere that determines the emergence of illnesses and health possibilities, in disease prevention and health promotion. Furthermore, the social dimension is the adequate sphere for intervention, beyond and in articulation with medicine as intervention in individual cases (Vieira da Silva; Paim; Schraiber, 2014). Therefore, it is an alternative view to the biomedical reduction in which medical knowledge and practice structured themselves, even though with diverse explorations regarding the meaning of the appreciation of the social sphere. In this sense, the central figure in Latin America, with a strong influence in Brazil, was the Argentinian doctor

and sociologist Juan Cesar Garcia, by means of his work within the PAHO (Garcia, 1985; Nunes, 1983; Vieira da Silva; Paim; Schraiber, 2014). By valuing the presence of the social sphere in health, Garcia, like many Brazilian researchers who participated in the construction of Collective Health, searched for references in a historical-structural approach to the social sphere. Thus, he did not merely assume a segmented presence of the social sphere like the isolated approach to elements of the environment and of the population itself.

On the other hand, many authors refer to Social Medicine based on George Rosen’s studies, and they focus on the movement that emerged in Europe in the middle of the 19th century.

Regarding this, Nunes (1983) says:

This paper written by Rosen has been considered

of fundamental importance to the understanding

of social medicine, and one of the points that it

raises is the question of sanitary problems, which

increase due to the transformations deriving from

the industrialization process (p.19).

Rosen (1983) argues that a central issue in Europe during the 19th century was which political orientation the government should follow in order to increase national power and richness. The industry was considered one of the main means. As a result, work started to be seen by political leaders as an es- sential element to generate national richness. Any loss of productivity caused by illness and death was, at the time, seen as a significant economic problem. This approach implied the idea of a national public intervention in health, which was developed in many directions, depending on the country.

The first place in which the State’s concern for the population’s health problems flourished was in the German states, even before they were unified or underwent the industrialization process, and the idea of medical police emerged for the first time. Ac- cording to Rosen (1983), Polizei, in German (police), derives from the Greek word politeia. The theory and practice of public management came to be known, throughout the 18th century, in the German states, as Polizeiwissenschaft (science of police), and the branch that deals with health management, as Med- izinalpolizei (medical police).

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The development of the theory and practice of public administration was intimately related to the interests of the Absolutist State. Therefore, a sys- tematization of managerial thought and behavior was reached and it attributed wellbeing activities to the absolute State. However, the legislator was responsible for determining the greatest wellbeing, so that the State had the power to intervene in the individuals’ matters aiming at the common good. The development and application of the concept of “medical police” was a pioneering attempt to create a methodical and precise examination of health prob- lems from the social point of view. At the beginning and in the middle of the 19th century, it was in France that this type of study developed theoretically. In France, however, the concept of medical police was not broadly accepted (Rosen, 1983).

In the context of the French Revolution, health and wellbeing problems were addressed by the revo- lutionary governments. There was even an attempt to establish a national social assistance system that included medical care. Although it did not advance, some of the ideas and objectives of the period would deeply influence France in the first half of the 19th century. “Ideas of public service and social utility provided the seed from which new ideas germinated concerning the relation among health, medicine and society” (Rosen, 1983, p. 43).

During the first half of the 19th century, there was, in France, a fruitful encounter between so- cial philosophy and medicine. “As a result, French medicine was permeated, to a considerable degree, by the spirit of social change” (Rosen, 1983, p. 46). The contact with the new living conditions deriving from the industrialization process, such as workers’ conditions and the social reality in which they lived, caused the emergence of new ideas in the field of health in its relations to society. The idea of Social Medicine germinated in this scenario. Jules Guérin was one of the first authors to use this term, in 1848.

Nunes (2007) emphasizes that it was in a revolu- tionary context dating back to the 1840s that many doctors, philosophers and thinkers assumed the social character of medicine and illness. The ideas and proposals that had progressed in France before and during the revolutionary movement of 1848 spread across Germany. Among the main names of

the German movement, which assumed Social Medi- cine instead of Medical Police as its proposal for national intervention, were Neumann and Virchow. Neumann, in 1847 (apud Rosen, 1983, p. 50), states that “medical science is intrinsically and essentially a social science and, as long as this is not recognized in practice, we will not be able to enjoy its benefits and we will have to satisfy ourselves with emptiness and mystification”.

The proponents of the idea of medicine as a social science employed it as a conceptual formulation under which they summarized defined principles:

The first of these principles is that people’s health

is a direct matter of society and society has the

duty of protecting and guaranteeing its members’

health […]. The second, as Neumann noticed, is that

social and economic conditions have an important

and – in many cases – crucial impact on health and

illness and that these relations must be submitted

to scientific investigation […]. The third principle,

which follows the other two logically, is that the

steps taken to promote health and fight against

illness must be both social and medical (Rosen,

1983, p. 51-52).

The influence of this entire formulation on the Brazilian Collective Health can be seen, for example, in the fact that these principles were revisited in Brazil in the VIII Conferência Nacional de Saúde (CNS – 8th National Health Conference), in a reread- ing that was appropriate to the historical context of the 1980s and to the reality of a country in the periphery of the capitalist development. Therefore, these principles, as connections between medicine and the social sphere, will influence the Brazilian Health Reform.

However, the revolutionary process of the 1840s was defeated in Germany and also in France, and due to this, the medical reform movement ended quickly (Rosen, 1983). During the next decades, the broad reform proposal became a limited program. The idea of social medicine reappeared in a meet- ing summoned by the World Health Organization, WHO, in 1952, in Nancy and, later on, in a document released by the PAHO in 1974 (Nunes, 1994).

The end of the 1960s and beginning of the 1970s were extremely fertile years in terms of theoretical

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discussions about health-society relations. There was a great influence of discussions held by authors in the human sciences, and a bench mark was the lecture that Michel Foucault delivered in 1974, in Rio de Janeiro, about the origins of Social Medicine (Nunes, 2005), in which he re-discussed the signifi- cant content of this term. According to Paim (1992), at this moment, there was, in Brazil and in the rest of Latin America, an important theoretical production that recognized the bonds between health practices and the social totality. In this sense, the contribu- tions from the social sciences to the study of health were fundamental so that we could reach the current degree of systematization of knowledge in the field.

On the proposal of social medicine, Sérgio Arouca states:

Therefore, Social Medicine emerges with two

tendencies; the first […] a movement to modify

medicine connected with the process of change

in society, or […] through its institutional change

[…]; the second is an attempt to redefine the posi-

tion and place of objects inside medicine, to make

conceptual delimitations, to discuss theoretical

frames. In short, it is a movement at the level of

knowledge production that, through a reformu-

lation of the basic questions that enabled the

emergence of Preventive Medicine, tries to define

an object of study in the relations between the

biological and the psychosocial spheres. Social

medicine, by electing these relations as its field of

investigation, tries to establish a science that is

situated on the boundaries of the current sciences

(Arouca, 2003, p. 150).

In the fragment above, Arouca highlights two dimensions of Social Medicine: the formulation of proposals for intervention in social life and in medicine based on the health-society connection, and the proposal for establishing a branch of studies about this specific connection, focusing on illness issues and on issues related to the production of medical assistance and professional practices in the services. In addition to a criticism against a certain kind of medicine – expensive, fragmented and with few results to the population’s health -, there was also a discussion on the amplification of the health service coverage to the population. According to

Nunes (1994), it was the beginning of the crisis of the developmentalist model of public health, which had postulated that one of the effects of economic growth would be the improvement in health condi- tions. This is particularly valid for Brazil at the time. Although the country was undergoing a moment of economic growth, this produced no results to the living conditions of its population.

In the 1970s, there was, in the international scope, an intensification of the discussion about the amplification of health service coverage. The 1977 World Health Assembly launched the slogan “Health for all by the year 2000” (Paim; Almeida Filho, 1998). In Brazil, in a context marked by the strengthening of repressive forces on the part of an authoritarian State, as well as by an increase in social inequalities and a worsening of the living conditions of a large part of the population, a field of knowledge and of innovative practices was gradually built in the area of health.

Nunes (1983), referring to Laurell, argues that critical reflection on medicine and its institutions in Latin American countries at the time can be seen as an answer to four groups of questions: 1) class position explains the distribution of diseases in the population much better than any biological factor; 2) the belief that the population’s health conditions would improve as a result of economic growth proved to be wrong; 3) the development of medical-hospital care did not bring a significant advance in the health indexes of the groups covered by it; and 4) the dis- tribution of health services across different groups and social classes does not depend on technical and scientific considerations, but mainly on political and economic considerations.

3) Collective Health in Brazil

Paim and Almeida Filho (1998) have shown the existence of mutual influences between the devel- opment of a project of field of knowledge called Collective Health and the movements in favor of democratization in Brazil, especially that of health reform. This leads us to emphasize the importance of considering the historical context in which Col- lective Health emerged, which was that of a country living under an authoritarian regime. Thus, it is possible to state that the

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Alliance of Collective Health with democracy and

human and social rights is due to the historical

fact that the field is gestated in a decade marked

by social turbulences and movements claiming for

changes, in the fight against dictatorship in Brazil

and in favor of social reform (Schraiber, 2008, p. 15).

This social reform includes a health reform in the project of Collective Health. In Brazil, two institutions emerged directly connected with this project: Cebes and Abrasco. The Centro Brasileiro de Estudos de Saúde (Cebes – Brazilian Center for Health Studies) was created in 1976 “discussing the issue of democratization of healthcare and being constituted as an organizer of culture capable of reconstructing healthcare thought” (Paim, 2008, p. 78). According to Paim (2008), Cebes is recognized as the first institutionalized protagonist of the Brazilian health movement, and it has played an important role in the socialization of a critical aca- demic production coming from the then-emerging field of Collective Health.

Two important moments in the creation, in 1979, of the Associação Brasileira de Programas de Pós- Graduaç&#xE3

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