Collective Health: Theory and Practice. Innovations From Latin America
Collective Health: Theory and Practice. Innovations From Latin America
- Ligia Maria Vieira-da-SilvaLigia Maria Vieira-da-SilvaUniversidade Federal da Bahia Instituto de Saúde Coletiva
Throughout history, knowledge and practices on the health of populations have had different names: medical police, public health, social medicine, community health, and preventive medicine. To what extent is the Brazilian collective health, established in the 1970s, identified with and differentiated from these diverse movements that preceded it? The analysis of the socio-genesis of a social field allows us to identify the historical conditions that made possible both theoretical formulations and the achievement of technical and social practices. Collective health, a product of transformations within the medical field, constituted a rupture in relation to preventive medicine and public health and hygiene, being part of a social medicine movement in Latin America that, in turn, had identification with European social medicine in the 19th century. Focused on the development of a social theory of health that would support the process of sanitary reform, collective health has been built as a space involving several fields: scientific, bureaucratic, and political. Thus, it brought together health professionals and social scientists from universities, health care services, and social movements. Its scientific subfield has developed, and the sanitary reform project has had several successes related to the organization of a unified health system, which has ensured universal coverage for the population in Brazil. It has incorporated into and dialogued with several reformist movements in international public health, such as health promotion and the pursuit of health equity. Its small relative autonomy stems from subordination to other dominant fields and its dependence on the state and governments. However, its consolidation corresponded to the strengthening of a pole focused on the collective and universal interest, where health is not understood as a commodity, but as a right of citizenship.
- Global Health
Collective health can be considered as a noun designating the health of populations. In this regard, although there have been records of knowledge and actions related to the health of human groups since antiquity, the systematization of knowledge, the formulation of recommendations, as well as the creation of organizational instances aimed at facing sanitary problems at the population level arise only with the development of the modern state (Pinell, 1995; Porter, 1999). In this perspective, Sir William Petty’s political arithmetic in the 17th century in England and the medical police of Johann Peter Frank in the 18th century in Germany could be considered as its precursors (Rosen, 1974). Additionally, the French hygienist movement (La-Berge, 1992) and English public health in the 19th century (Rosen, 1994) took the health of populations as their object, thus shifting their concern from the individual and the disease to the collective and to health.
Throughout the 20th century, various denominations were given to academic disciplines, institutions, and state actions aimed at population health: public health, preventive medicine, social medicine, community medicine, new public health, health of populations, and collective health (Vieira-da-Silva & Pinell, 2014). Some of these denominations have been treated either as synonyms, part of the history of medicine (Ackerknecht, 2016), or as singular events, often related to social movements (Paim, 2006; Pinell, 1995; Rosen, 1974, 1994). In search of a more substantive designation for public health, Porter (2000) considered it more appropriate to name this object as the collective action related to the health of populations.
Studies on the emergence of public health have shown that its origins are in Brazil, in the 1970s, as part of a Latin American movement criticizing preventive medicine and institutionalized public health, and aiming to develop a social medicine (Garcia, 1989b; Paim & Almeida-Filho, 1998; Tajer, 2003; Waitzkin et al., 2001a). In this perspective, collective health has been considered as a field of knowledge and sphere of practices (Donnangelo, 1983; Paim & Almeida-Filho, 1998). There is a reasonable consensus among Brazilian authors on the pertinence of considering it as a field in the sense of Bourdieu (Campos, 2000; Luz, 2009; Nunes, 1994; Ribeiro, 1991), among others.
In a previous work, the historical analysis of the genesis of public health showed that it could be considered as a social space with a project to become a field at the time of its emergence (Vieira-da-Silva & Pinell, 2014). Its subsequent development has brought elements that allow it to be characterized as a field in the process of being consolidated (Vieira-da-Silva, 2018). For Bourdieu, social space and field are related but not equivalent concepts. Although every field is a social space, not every social space is a field. A specific field would be the product of the historical differentiation of different social groups. It would consist of a network of relationships between positions, agents, and institutions, interested in certain issues that are at stake and become the object of disputes (Bourdieu, 1996).
Although there is an extensive Brazilian bibliography analyzing collective health from different angles (Donnangelo, 1983; Garcia, 1989a; Luz, 2009; Nunes, 1994), few studies have been published in English, and the question about national specificities and their articulation with international public health is controversial. For some of the founders of collective health in Brazil, it represents a phenomenon that is distinct from institutionalized public health, while for others it is a synonym. As a contribution to this dialogue, the emergence of Brazilian collective health and its relations with public health and social medicine on the international level will be analyzed.
Social Medicine and the Brazilian Collective Health
The origins of social medicine have many interpretations. The first was by the historian Georges Rosen, who associated the emergence of this conception, in France, with the ideas arising out of the French Revolution, mainly the acts of the Convention of 1793 and 1794 that established a system of social assistance including medical care (Rosen, 1974, 1994). According to this author, the use of the adjective social for medical issues was not new when Jules Guérin, editor of the Gazette Médicale of Paris, formulated the term “Social Medicine” in 1848 (Rosen & Nunes, 1983).
Another strand of analysis of the French events in the early 19th century emphasizes the establishment of a hygienist movement that had as reference the journal Annales d’Hygiène Public et de Médecine Légale, whose editorial board included the physicians Parent-Duchatelet and Villermé. This group was characterized as being composed of social and medical researchers, and as a hygiene party (Coleman, 1982; Porter, 1999). Although formed by activists from the medical elite, the group was not composed exclusively of medical doctors; it also included pharmacists, veterinarians, and administrators, recruited from the bourgeoisie and with a predominantly liberal ideology (Coleman, 1982; Ramsey, 1994), or even as experts of the state (Murard & Zylberman, 1985).
The character of the hygienist movement for some, or of social medicine for others, oscillates between the revolutionary, the reformist, and the essentially moral. For some historians, the causes of diseases were attributed, by hygienists in the early 19th century, to improvidence, dissipation, and debauchery, and the return to health implied a reconversion to the virtues of order (Faure, 1994). Considering hygiene more as a discourse on well-being than as a positive science, Leonard (1981, p. 150) identified, in the thinking of the Annales authors, economic and geographical arguments to support the “sinister trilogy of poverty-ignorance-disease” in relation to which they proposed the “happy triptych of abundance-education-health.” The relationship established between poverty and disease not only raised humanitarian feelings on the part of hygienists, but also led to concern about the risk that this situation brought to the elites.
For Michel Foucault, in contrast, all modern medicine would be social in the sense of taking the social body as its object. According to this author, capitalism has socialized the body as a labor force, and, thus, society’s control over the individual would take place not only through ideology, but also through the body. He considers the body as a biopolitical reality and medicine as a biopolitical strategy (Foucault, 1979).
Controversies also revolve around the universal character of social medicine. In this perspective, it has been understood as a phenomenon that would correspond to the search for social justice, one of the characteristics of international public health (Krieger, 2003), or as an academic discipline, existing all over the world (Porter, 2006). However, it has also been analyzed as a movement that is specific to Latin America, the product of a complex process of social construction (Breilh, 2008; Iriart et al., 2002; Laurell, 2003; Paim, 1992; Tajer, 2003; Waitzkin et al., 2001b).
Brazilian collective health was then established, in the 1970s, as part of this Latin American movement of social medicine, which was characterized by the development of studies aimed at understanding the social determinants of diseases and the social organization of health care services (Donnangelo, 1975, 1976; Garcia, 1972, 1989b; Laurell, 1983). This articulation with other Latin American groups dates back to the 1950s, based on the seminars promoted by the Pan American Health Organization (PAHO), aimed at spreading the teaching of preventive medicine and, in particular, incorporating social sciences into medical education (PAHO, 1976). It corresponded to a real break in relation to preventive medicine and institutionalized public health. Although it had some similarities to Rosen’s interpretation of European social medicine, it incorporated some elements of Foucault’s analysis.
The Social Spaces Where Brazilian Collective Health Emerged
In Brazil, the movement, initially called social medicine, has been a product of the intertwining of the paths of several agents: medical doctors, sociologists, and professionals from various backgrounds, both in health and in the social sciences.1 It has developed mainly in three social spaces: (a) in the departments of preventive medicine at the medical schools; (b) in government institutions (municipal and state health departments), and (c) in social movements. That is, in the scientific, bureaucratic, and political fields and at the intersections between these fields.
Preventive medicine emerged in the first half of the 20th century in the United States and the United Kingdom as part of the modernization of medicine, as a component of the reorganization of the practice that sought to instill into physicians a new, preventive attitude and thus to face the expansion of public health (Arouca, 2003). It spread to Latin America through initiatives taken by the Pan American Health Organization and was supported by funding from North American foundations, such as Milbank, Rockefeller, and Kellogg (Vieira-da-Silva, 2018).
The expression “collective health” has been used as to denote the association created in 1979 to bring together the various graduate programs: the Brazilian Association for Graduate Studies in Collective Health (ABRASCO)2. As an apparently neutral noun, the term “collective health” made it possible to bring together the various trends existing within the graduate programs in social medicine, preventive medicine, public health, and community health, and also incorporate nonmedical professors and researchers (Vieira-da-Silva, 2018). In the final report of the first meeting of graduate programs in collective health, where the creation of ABRASCO was discussed for the first time, the object of collective health was described as:
built within the limits of the biological and the social and comprises the investigation of the determinants of the social production of diseases and the organization of health care services, and the study of the historicity of knowledge and practices about them. In this sense, the interdisciplinary character of this object suggests an integration in the sphere of knowledge, and not in the sphere of strategy, of bringing together professionals with multiple backgrounds.(ABRASCO, 1982, Annex, p. 18)
This formulation was the product of theoretical elaboration and meetings between professors from the departments of preventive and social medicine and the first graduate programs. The basic assumptions of the reference framework of the master’s degree in community health, incorporated at the time of the meeting that created ABRASCO, also evidenced a concept of health articulated with its social determinations, health practices as social practices, which implied a dialogical relationship in the teaching process.
Subsequently, collective health became the object of theoretical construction as a field of knowledge (Donnangelo, 1983; Nunes, 1994; Paim & Almeida-Filho, 1998; Schraiber, 2008; Silva et al., 2019), with emphasis on some key concepts, such as the concept of health (Coelho & Almeida Filho, 2002; Scliar, 2007; Silva et al., 2019), transdisciplinarity (Almeida Filho, 1997; Castiel, 1997; Cohn, 2003; Luz, 2009), and vulnerability (Ayres et al., 2003), among many others.
The development of a social theory of health, inaugurated by the pioneering work developed by Garcia (1972), Donnangelo (1975, 1976), and Arouca (2003), was followed by many others, which sought to investigate the social determinants of health and disease through social epidemiology and the social organization of health care services. These works provided the theoretical foundations for the formulation of a project for the Brazilian Sanitary Reform. According to Paim (2008), in addition to the idea and the project, a health movement was established (Escorel, 1999), bringing together different social segments in a long-standing political and institutional process.
Although the country was still in a civil and military dictatorship, it was the years of the so-called distension of the government of General Geisel (1974–1979), a time when social movements were also reorganizing and pressing for freedoms and for the return to democracy. The second National Development Plan then formulated financed research projects through the National Council for Scientific and Technological Development (CNPq) and Finep (Funding Authority for Studies and Projects), among which were the Program for Social and Economic Studies in Health (Peses), Program for Population and Epidemiological Studies and Research (Pepps), and the program to support graduate studies in social medicine of the Institute of Social Medicine (IMS) at Rio de Janeiro State University (UERJ) (Ribeiro, 1991). These three programs contributed greatly to the constitution of collective health at National School of Public Health (ENSP) and UERJ, which were two central institutions at that time, alongside The Federal University of Bahia (UFBA) and USP.
In that context, municipal and state experiences were developed at the same time, where professors from the departments of preventive medicine or alumni of graduate programs in social medicine, preventive medicine, and public health interacted with managers and sanitarians from different generations, seeking to change the health care system. There were even sanitarians linked to the Sanitary Reform project holding positions in the Ministry of Health during the Geisel government (Guedes, 2008). Also, in the State Health Departments (SES), in some states, administrative reforms introduced innovations toward the direction pointed out later by the sanitary movement. An example was the reform implemented in the health department of the State of São Paulo between 1967 and 1970, with the creation of the Multi-Purpose Health Centers (Guedes, 2008) and the career of a sanitary doctor in São Paulo (Mello & Bonfim, 2015). Municipal experiences of local reorganization of health care services were varied, constituting experiments for the subsequent construction of what would become the Unified Health System (SUS). Examples include the “Montes Claros Project” in Minas Gerais, in 1975 (Teixeira, 1995), and the nine case studies deemed to be successful municipal experiences of decentralization of health care, in the 1980s (Almeida, 1989).
There was also an interaction between the experiences of municipalization of health care, the theoretical production from universities, and entities focused on the political debate on the health care situation and proposals for its reform. The Brazilian Center for Health Studies (Cebes), which used to edit the journal Saúde em Debate, published the critical theoretical arguments and, together with the Brazilian Association of Graduate Studies in Public Health, led the formulation of the Sanitary Reform project and contributed to the articulation of different social movements around the struggles for their inclusion in the 1988 Constitution (Escorel, 1999; Paim, 2008).
Institutionalization and Consolidation of the Collective Health Field in Brazil (1979–2019)
The scientific subfield of collective health, understood here as the segment related to the graduate programs and research, has been consolidated over the 40 years following the creation of ABRASCO, in 1979. That year, there were five graduate programs that took part in the inaugural seminars and meetings (Magaldi & Cordeiro, 1983), while in 2020 there were 97 programs recommended by CAPES3 (Coordination for the Improvement of Higher Education Personnel) (Brazil, 2020a). There were also three specialized journals that used to disseminate scientific production. In 1990, this number increased to 12 specific journals and, in 2016, 22 national journals with the name “Collective Health,” “Public Health,” and/or “Epidemiology” had been evaluated by Brazil (2020b).
Research promotion agencies, such as CAPES and CNPq (National Council for Scientific and Technological Development), have recognized collective health as an independent area of knowledge in medicine, creating permanent committees that are specific for the evaluation of research projects and graduate programs. Expansion and internationalization of scientific production (Viacava, 2010), despite the persistence of a certain national centrality of research (Packer, 2015), were also verified.
If, at first, graduate education and scientific production contributed to the construction of the field, the creation of undergraduate programs in collective health, in the first decade of the 21st century, helped to consolidate its relative autonomy (Bosi & Paim, 2010).
The Sanitary Reform project, even though it had not been implemented as originally conceived, was institutionalized with the organization of the Unified Health System, which extended health care coverage to the entire population and developed several initiatives related to the shift of the health care model and with impact on the population’s health (Castro et al., 2019; Paim et al., 2011). These achievements have been threatened by fiscal and economic policies, implemented since 2016, which have reduced resources for the already underfunded health care system (Paim, 2019).
The Brazilian response to the COVID-19 pandemic, during 2020, has relied on the existence of this health care system, which is public and has universal coverage, structured with an emphasis on primary health care, but it is also prepared for any high-complexity hospital care required, as well as for vaccine production. It has faced the difficulties of the national political situation and the military occupation of the Ministry of Health by agents without health training and who declared they did not know the Unified Health System. The government’s attitude of denying the seriousness of the epidemic also compromised the unity and effectiveness of the measures adopted, jeopardizing the process of communication and adequate information for the population (Henriques et al., 2020).
Brazilian collective health has been consolidated as a relatively autonomous field, the product of the intersection of the diversified trajectories of its founders, under certain historical conditions of possibility. Although it corresponded to several ruptures with the previous experience, namely, with preventive medicine and institutionalized public health, it also represented continuity and overlap with them, in several aspects (Vieira-da-Silva, 2018).
On the international level, it was part of the social medicine movement in Latin America with which it has identification mainly in the effort to articulate the development of a social theory of health with the reform of health care systems. It also incorporated the ideals and principles from various movements of innovation in public health and medicine, such as comprehensive care, the emphasis on primary health care, the incorporation of studies on social determinants of health, and the formulation of intersectoral health promotion policies.
The specificity of this social space, which has been historically constructed, is revealed in the search for a social theory of health and disease; in the establishment of specific institutions, such as institutes of collective health and social medicine; in the organization of a network of graduate programs in collective health; and in the creation of undergraduate programs in collective health. In parallel, and in close articulation with the consolidation of its scientific subfield, a movement toward Sanitary Reform was developed, seeking to ensure health as a right of citizenship. This position, aimed at the public and the universal, was opposed to the market position, oriented to profit.
In the field of collective health, the authority over the diagnosis of population health problems and their solutions translated into health-related policies and programs is at stake. This authority is also in dispute with the medical field, the political field, and the bureaucratic field in which collective health is embedded. As they are socially dominant universes, their logics and hierarchies tend to influence collective health, although refracted and translated based on a logic that is specifically sanitary and internal to the field (Vieira-da-Silva, 2018). For Bourdieu (1996, 2015), the fields, understood as social microcosms, are embedded in each other.
Therefore, the relative autonomy of a field would be greater the greater its resistance to external influences, as well as its capacity to define the specific issues at stake. In this perspective, the relative autonomy of collective health is low and is in constant dispute with such other social fields.
The consolidation of the scientific subfield has contributed to the autonomy of collective health with regard to the production of knowledge. Its dependence on the state, in turn, has historically made it difficult to incorporate products from research into the management of health care systems. It depends on the characteristics of governments and the distribution of power in societies. Understanding these issues not only contributes to the reflexivity needed for research on health care policies and systems, but it can also indicate possible alternatives and limits for their transformation toward public and universal interests.
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1. For more details on the main trajectories of the founders, see Vieira-da-Silva (2018), especially chapters 2 and 3. There were many founders of collective health in these different social spaces. It would be practically impossible to list everyone. A highlight should be given to the trajectories of Guilherme Rodrigues da Silva, who organized the Bahia branch and the USP Department of Preventive Medicine; Hésio de Albuquerque Cordeiro, who created the Social Medicine Institute; and also Antonio Sergio da Silva Arouca and Maria Cecilia Donnangelo, who elaborated the main theoretical contributions at the time.
2. Abrasco is an acronym for the Brazilian Association for Graduate Studies in Collective Health. (In Portuguese is: Associação Brasileira de Pós-Graduação em Saúde Coletiva)
3. Capes is the acronym for the Coordination for the Improvement of Higher Education Personnel (In Portuguese is: Coordenação de Aperfeiçoamento do Pessoal Docente). It is a brazilian government agency under the Ministry of Education.