There is controversy regarding the meaning of the creation, during the 1970s in Brazil, of a social space directed towards health problems on the population level, called collective health. According to several authors, Brazilian collective health is part of the region-specific school of thought called Latin American social medicine (Breilh 2008, Paim 1992, Tajer and Laurell 2003, Waitzkin et al. 2001, Yamada 2003). From another perspective, Latin American social medicine is viewed as one of the historical manifestations of the universal phenomenon corresponding to the search for social justice, which supposedly has characterised international public health since its birth in Europe and the Americas (Krieger 2003). In the latter perspective, it has been viewed as an academic discipline that is present not only in Latin America but also in the Anglo-American world (Porter 2006). Most of these works have not been founded on empirical investigations of national experiences.
To bridge this gap, a historical study of the genesis of collective health in Brazil was carried out. The choice of Brazil as a case study is justified by the fact that collective health in Brazil is an area of knowledge and a specific field of practice that is distinguished from both preventive medicine and traditional public health (Minayo 2010, Nunes 2005, Paim 1992). Although studies of the genesis of collective health in Brazil have been conducted by several authors with different focuses (Luz 2009, Nunes 1994, Paim and Almeida-Filho 1998, Ribeiro 1991,Teixeira 1985), the question of this term's meaning as a social space or a relatively autonomous field in Bourdieu's sense has not been investigated in a manner that exploits the full potential of Bourdieu's theory, particularly with regards to the interactions of individual paths and the conditions of historical possibilities.
In addition, there is general interest in the study of the relationship between doctors and social health movements. Although most studies on health movements focus on social groups of users who are opposed to medical power (Brown and Zavestoski 2004) or analyse doctors' participation in the formulation of specific policies (Pinell 2002b, 2002a) in relation to specific social health movements, such as abortion (Joffe et al. 2004), a Brazilian case study of the emergence of collective health reveals the predominant participation of physicians in creating an interdisciplinary space geared towards the production of knowledge and anti-hegemonic health practices.
The historical study of the genesis of fields and social spaces can provide an understanding of the contemporary meaning of collective health, as such a study reveals conflicts and disputes that existed at the origin of the field and that have since been forgotten. Revelations from historical studies may also explain the arrangements and unconscious contributions of social agents, which can explain the positions adopted in relation to the struggles and issues at stake in today's field study (Bourdieu 2012). In addition, by studying the emergence of a space that attempts, among other things, to take on the project of becoming a field, the present work may also contribute to the analysis of the creation processes of the habitus specific to a certain social universe.
To what extent did this Brazilian invention correspond to a specific socio-historical phenomenon? Is it merely a different name for institutional public health? Conversely, is it a consolidated field with relative autonomy? The objective of the present study is to contribute answers to these questions based on Bourdieu's field theory.
Bourdieu's concept of field corresponds to the idea of a social microcosm, a relatively autonomous network of relationships between agents with a common interest, which he called illusio, and a habitus that corresponds simultaneously to the dispositions that guide agents' practices together with the schemes of perception that guide agents' interpretations of the social world. These dispositions are acquired over the course of a path corresponding to the successive positions occupied in the social space by the agents (Bourdieu 1979, 1992). Bourdieu considered economic, cultural and social capital to be the main forms of power used by social agents in their struggles in a social space (Bourdieu 1980, 1986a). Moreover, Bourdieu specifically examined the scientific, political and bureaucratic forms of capital. He also considered the central role of symbolic capital, which results from the conversion of other forms of capital, as a capital of recognition. Some of the particular species of capital, as scientific, bureaucratic and political, can be considered as specific forms of symbolic capital. Scientific capital is defined by Bourdieu as a set of properties that are the product of acts of cognition and recognition among peers within the field of science by reference to the contributions to knowledge brought by each agent (Bourdieu 2001). Political capital corresponds to acts of cognition and recognition that are related to the agents' capacity to represent and mobilise people (Bourdieu 1986b). Bureaucratic capital is considered to be a kind of informational capital that acts as a meta-capital by exercising power over other forms of capital. It is related to the use of material and symbolic resources and the power of nomination and certification (Bourdieu 2012). Bureaucratic and political capital can exist both in an embodied state as dispositions and in an institutionalised state as positions that are occupied.
The genesis of collective health in Brazil was analysed from this perspective as the product of a struggle to redefine the sub-fields of preventive medicine and public health.1 The founders of collective health were opposed to the dominant conceptions of preventive medicine, public health and hygiene. This hypothesis led us to examine the following: (i) the positions of the sub-fields of preventive medicine and public health in relation to the field of power (here the political and bureaucratic fields); (ii) the structure of relationships between the various positions held by the competing founders in this sub-field; (iii) these agents' habitus, that is, the dispositions that they acquired during their careers before entering this sub-field and later within the sub-field, to objectify the differences between the founders and the doctors that dominated the aforementioned social space. Thus, the analysis that was developed, as supported by the paths of the founders and the conditions of historical possibilities, has showed that this social space originated from a meeting of agents with different social backgrounds but who interconnected, creating a structure that was independent of each agent considered individually.
The composition and origins of social space
The construction of a social space is a complex and contradictory process. It is not derived from a direct determination of social structures or from a rational action planned by a group of social agents who guided their paths in that direction (Bourdieu 1992). As analysed by Elias, isolated plans and actions are connected so that ‘From this interdependence of individuals emerges a sui generis structure, a more irresistible and stronger structure than the will and reasoning of the people forming it’ (Elias 1994 : 194). Such is the case of the genesis of the collective health space in Brazil. The conditions of possibility for its creation may be related to concomitant occurrences, such as financing from American foundations, the political and institutional action of the Pan American Health Organization (PAHO), funding from Research and Projects Financing (a public organisation linked to the Brazilian Ministry of Science and Technology), the national political crisis and the state of the intellectual field in the 1960s and 1970s. However, the space that was then made possible resulted in a place for critical knowledge and the formulation of anti-hegemonic projects in reference to the objectives formally detailed by financial institutions. The explanation for this apparent paradox arises from the specific characteristics related to the genesis of this space, which are analysed in the present article.
The introduction of preventive medicine in Brazil occurred as part of the initiatives directed towards the modernisation of medicine. It was promoted by the PAHO in the 1950s with financing from the Milbank and Kellogg Foundations (PAHO 1976), which provided educational scholarships to recently graduated doctors from Brazil and other Latin American countries to complete graduate courses in public health in the USA. The work of Juan César Garcia (1932–1984), an Argentinian doctor and sociologist, with the PAHO, is noteworthy. Garcia not only formulated the general lines of research for a programme of studies and action but also developed the role of political leadership through the mobilisation of institutional resources to support the emerging programmes of preventive medicine and to introduce to the field of health the teaching of social sciences from a Marxist perspective (Garcia 1985, Nunes 1994).
Most of the founders of collective health played an active role in the struggles for the democratisation of the country and contributed to the construction of a movement with wide social participation, the Brazilian health reform movement (Paim et al. 2011). Moreover, although the country was still under military dictatorship under the government of General Geisel (1974–1979), the period was characterised by political distension and the establishment of the 2nd National Plan for Development that included financing for social research, which permitted the organisation of some of the centres of the emerging collective health project (Escorel 1999, Ribeiro 1991).
Discussions related to the formation of the sanitary reform project occurred in clandestine spaces such as the Brazilian Communist Party or the so-called Andromeda project, as well as in university spaces, such as the preventive medicine departments, or legal associations such as CEBES and ABRASCO. The Andromeda project was a clandestine meeting of 15 to 20 people, composed mainly of doctors who had held positions in international organisations or in federal public institutions as well as some members of the Brazilian Communist Party (F8) (Franco Netto and Abreu 2009). The health movement organised by these associations involved student, medical and union leaders and culminated in 1986 with the 8th National Health Conference, where guidelines and principles for health reform and for the subsequent organisation of the unified health system were discussed (Paim et al. 2011).
When the first ABRASCO board of directors was established it displayed the whole political spectrum necessary to legally establish an entity, even in the authoritarian period. Frederico Simões Barbosa, named president at the establishment of the entity, and Benedictus Philadelpho de Siqueira, president of the first elected board of directors, had national recognition, the former as a researcher and the latter as the head of an important preventive medicine department. However, they did not necessarily share the project of establishing a new field. This union involved the participation of Carlyle Guerra de Macedo, the then coordinator of the human resources programme of the PAHO in Brazil, who coordinated one of the meetings that resulted in the creation of ABRASCO.
The origins of collective health in Brazil can be found within various departments of preventive medicine in the schools of medicine.2 Guilherme Rodrigues da Silva (1928–2006), the son of a gold miner from the region of Chapada Diamantina in Bahia, and Hésio de Albuquerque Cordeiro, the son of a Rio de Janeiro doctor, were both recently graduated doctors who had initially directed their careers towards clinical practice. They shifted to preventive medicine after receiving invitations to complete their graduate studies in the USA, with financing from Kellogg and CAPES in the 1950s and 1960s, respectively, in programmes aimed at modernising the teaching of medicine. The third medical leader was Antônio Sérgio da Silva Arouca (1941–2003), who, in contrast to the other two, experienced strong contradictions when choosing medicine. Arouca, who may be considered one of the most important founders, followed a unique path (Franco Netto and Abreu 2009). He was one of the few founders who, years afterwards, abandoned the field he had created to prioritise his professional exercise of politics. He became a federal representative and was one of the national leaders of the Brazilian Communist Party. Thus, his dispositions were mainly political. He choose preventive medicine when he realised that this was an opportunity to reconcile political activity with medicine:
I truly found myself in medicine when I discovered preventive medicine … As I had been involved in this political background since university, I was preoccupied almost unbearably with how to combine the profession with politics. (Arouca, interview with Pasquim, 2002)
For several other doctors who followed varied, but primarily stable, social paths, their political dispositions were referenced as a reason for entering the departments of preventive medicine. Additionally, many of the interviewees began their careers in clinical specialities and then migrated to preventive medicine to perform a different type of medicine that was committed to the interests of the general population – social medicine. Others clearly expressed mental conflicts between choosing the clinic and their preference for research, management or numbers, as illustrated in the following two statements:
Sebastião then … [asked me] if I wasn't interested in some way to do preventive medicine, to do research … both in the laboratory and the field. (F7)
I always had a greater propensity for mathematics … But it was the second year of medicine, on Saturdays, that I started to have statistics lessons … with Professor Guilherme Rodrigues da Silva. I said … there is a reason here for me to stay in medicine.
Preventive medicine was part of the reform of medical teaching. One of the founders of preventive medicine explained that it was based on research, the laboratory and extramural activities. This individual, a doctor who had substantial scientific and bureaucratic capital, had a career that involved a centrist political position and came from a predominantly clinical background:
In the second half of the 1950s, a modernisation movement began in the teaching of medicine throughout Brazil. Gradually, the French influence declined, while the American increased … suggesting the idea that it was absolutely necessary to devise another way of teaching preventive measures, including hygiene.
(Interview, medical doctor graduated in 1949, F1)
These options did not correspond to the development of hygiene or traditional public health but was instead a rupture with these fields. Some of the interviewees clearly expressed their dislike for the discipline of hygiene, which they attended during the medical course:
‘I found hygiene to be the dumbest thing possible’ and even ‘the hygiene chair is really pathetic’.
(Interview, medical doctor graduated in 1971, F15)
However, what did these agents involved in the genesis of collective health consider a rupture? In the meetings carried with teachers from the departments of preventive medicine in São Paulo in the 1970s two concepts regarding the initial project were discussed. The first was related to the critique of preventive medicine as a proposal for changing medical practices and the alternative of a social medicine as a possibility for intervention not only for sick biological bodies but also for society, which also influenced the production of diseases. This critical thinking developed with respect to health would later become a component of a habitus in the form of an illusio, that is, an investment in the creation of this new space. In the theoretical framework for the master's in community health at the UFBa, which served as a basis for the creation of ABRASCO, the concept of what would be a new social medicine, then named as collective health, was spelt out:
The objective of collective health is constructed within the limits of biology and all that is social, and understands the investigation of the determinants of social production of illnesses, and the organisation of health services, as well as the study of the historicity of knowledge and of practice and that ‘The teaching of collective health implies a wide concept of practice, including technical practices, theoretical practices and political practices … In this perspective those practices carried out by students and teachers tend to connect with the wider movements of social forces’. (ABRASCO, 1982)
These concepts varied or were given different emphases depending on the position of the agent. Arouca clearly explains the project of the split from preventive medicine and its transformation into social medicine:
‘That is where there was this idea of how we started to create a field in Brazil that went beyond preventive medicine, and that was transformed into social medicine’ (Arouca, interview with Pasquim 2002).
This position was also present in the discourse of Garcia, for whom:
‘social medicine seminars could not ignore these influences… distinguishing social medicine and public health and separating preventive medicine’
(Garcia 1985: 26).
Moreover, the founding doctors established relationships with a university social science group. The principal leader of this group was Maria Cecília Ferro Donnangelo (1940–1983), whose doctoral and teaching dissertations, ‘Medicine and society’ (Donnangelo, 1975) and ‘Health and society’ (Donnangelo 1976), were two of the first critical works. These, along with the essay by Garcia (1972), contained the elements necessary for the theoretical rupture that would later be consolidated with the thesis of Arouca, defended in 1975, The Preventivist Dilemma (Arouca 2003). In this work Arouca takes a radical stand in his criticism of preventive medicine and develops an analysis of the relationship between medicine and capitalism. Both works led to academic productions that followed the perspective of the creation of a social theory of medicine for some authors and of health for others.
The issues at dispute were correlated with the trajectories and the positions of agents in this social space. The motive of some of the sociologists, as symbolised by the path of Donnangelo, to develop an area, initially health sociology (that later became social sciences in health), converged with and complemented but was distinct from the motives of the group of doctors. According to Luiz Pereira (1933–1985),3 Donnangelo's doctorate advisor, she sought ‘the construction of the object of the field of studies that academically would be called health sociology’ (Pereira, 1976: 97). Another sociologist, who earned her PhD at Paris X Nanterre University, in 1973, and was supervised by Alain Touraine and later by Bourdieu, explained her choice to work at the Institute of Social Medicine of Rio de Janeiro as a
challenge [that] was … helping to form a new discipline and a new way of thinking. And I … had seen that health was a very good field in which to think about society.
However, there were differences within the group of social scientists, related to their path, which included the recognition of practical intervention by the health system as a component of the collective health subject. Another founder, a philosophy graduate with a 1969 master's degree in sociology from Louvain, Belgium and a doctorate in political science, indicated the following:
The paradigm in collective health is not identical to the paradigm in the social sciences … they seek … to understand and interpret the linked social and cultural phenomena, including health … [while] collective health … also has a paradigm of intervention … of the production of truths and the efficiency of transformation through action.
(Interview, philosophy graduated in 1962 and sociologist graduated in 1969, F19).
Despite the convergence between the groups on several issues, these initial differences became the object of disputes and conflicts between the disciplines and paradigms, primarily within preventative medicine departments but also in ABRASCO, as shown by questions on the identity of the space. It is worth remembering the possible influences of the development of medical sociology, which began in the 1950s and 1960s in both departments of sociology and departments of medicine (Hollingshead 1973). At that time there were two approaches to the relationship between sociology and medicine: one was called the sociology of medicine and the other was known as sociology in medicine (Syme 2000). It was mainly the perspective of sociology in medicine that was involved in the incorporation of the social sciences into Brazilian collective health.
Both groups had, at the time of the genesis of the space, different capitals. The principal leaders possessed high scientific, bureaucratic or political capital, mainly differentiated by their political position, their university bureaucratic capital and their generation. Some of the doctors participated in organised political parties, such as the Brazilian Communist Party or other leftist parties, such as the Communist Party of Brazil or Popular Action, which was a leftist organisation with a religious influence. There was also a group of leftist doctors who were not organised into political parties. The political positions of the generation that graduated in the 1950s ranged from centre right and centre left to Catholic left. The social scientists either were not politically militant or were militant leftists and were not organised into parties. The objectives of the core scientific work, including dissertations and theses, varied by the diversity of the paths: from pure sociology to the sociology of medicine and social epidemiology and from epidemiology or infectious disease epidemiology to clinical research and management.
Other oppositions were established between science and technique practice and between technique and politics. The former also arose in other academic departments in Latin America and included differences between the perspectives of old sanitarians and sociologists on scientific issues:
The relationships between sanitarians, especially those between the old school and the young anthropologists and sociologists, have been strained since the beginning due to differences in the type of problems that were discussed, in world views and in the methodology employed. The sanitarians were interested in solving concrete problems in their communities for which they needed, for example, surveys of descriptive data. The anthropologists and sociologists, in contrast, formulated problems of a higher level of abstraction related to the power structure of the population. This confrontation occurs within the hierarchical structure of the academic unit, where the social scientist occupied the lower level.
The tensions among the scientific, technical and political struggles emerged from disagreements over the character that ABRASCO should have: should it be an association of graduate studies and research or a political entity focused on the design of health reform and the democratisation of the country? One of the medical doctors, a professor in the Department of Preventive Medicine at the UFBa who contributed to the formulation of Brazilian health reform proposals, said:
Confrontations occurred because many argued, like myself, that ABRASCO was a graduate research entity in public health, and others wanted to transform ABRASCO into an association of public health, which presented … the risk of becoming a corporate association rather than one that could lead the discussion on public policy.
(Interview, medical doctor graduated in 1972, F7)
In relation to some agents in the institutional area of international organisations, such as the PAHO, there was a perception that ABRASCO's project was changing the organisation of health services:
Perhaps not by that name [health reform], but … how to change the organisation of services [was discussed] … the state's responsibility with respect to health was a principle that we all accepted … ABRASCO was created to give life to it.
Another nuance among these perspectives is that, for the founders whose paths started with clinical practice and who came from medical teaching modernisation projects, such as Hésio Cordeiro and Guilherme, this change marked the creation of a social medicine that would correspond to a clinical practice that not only incorporated social considerations but also expanded its objectives towards health services. This change did not mean creating an independent field of medicine but the creation of a medical field with specific standards regarding its object and the practice. In this way, Hesio and Guilherme were the inheritors who rejected their inheritance and contributed to the creation of the conditions for the subversion of the previous order.
While attending residencies in internal medicine in two of the most important universities in the country with a clinical leadership, they accepted the challenge of developing a new discipline. In doing so, although they were oriented by political dispositions and the network of established relationships, they contributed effectively to this change. Finally, there was still another point of view related to the institutional space of health services, which considered the new initiatives as modernising changes of the traditional public health and which saw collective health as a synonym of public health (interview, medical doctor, F15), (1971)
These several points of view are expressed in the variety of orientations given for the human resources formation programmes during that period (Garcia 1985). Later, with the consolidation of the three areas: epidemiology, health policy and social science and health, the oppositions present in the genesis of collective health began to express themselves as conflicts between disciplines and methodologies (qualitative versus quantitative) or theories (positivism versus Marxism), especially in the scientific field (Hortale et al. 2010). The technical versus political and technical versus scientific oppositions appeared to be the dominant trajectory for agents in the bureaucratic and political fields. A doctor whose career was primarily in public health administration but who was also affiliated to a university described the beginning of her career in the following way: ‘I'm down there, I'm a technician’ (interview, medical doctor (1968), F28). In the political space of social scientists in the ABRASCO commission there was a distinction between people who were involved with the commission and those who were more concerned with ‘political things … the movement that was to become CEBES' (Interview, sociologist graduated in 1973, F17).
The Brazilian collective health space emerges as the product of a meeting of agents with different social backgrounds and different positions and paths within the scientific, bureaucratic and political fields. The intersection of their paths created a structure that was independent of each agent considered individually: a network of relationships and specific representative institutions such as ABRASCO; political institutions such as CEBES; academic institutions, such as graduate programmes and centres of collective health and departments of preventive and social medicine.
The collective health space emerged from within the medical field as a criticism of preventive medicine and an ambivalent rejection of institutionalised public health, affirming itself as a project for a social medicine with a political identity similar to that of the 19th century European social medicine (Nunes 1994). The relationship with the medical field lies in the origins of preventive medicine and, in all subsequent developments, in the field of collective health. The creation of the principal departments of preventive medicine occurred as a reform of medical clinical practice, not of hygiene. The tensions, which are present in many testimonies, between the departments of preventive medicine and the schools of medicine marked the genesis of a collective health space. These tensions are expressed in the resistance of medical students first towards hygiene and later towards the teaching of preventive medicine.
The space analysed here emerges as a specific field of knowledge on the relationships between health and society from a Marxist perspective, albeit a critical one that sought out a non-economic Marxism. The space seeks alternative external references, such as Foucault, Althusser and Bourdieu but fails to examine the contradictions between these three authors' thought. Although the term collective health had earlier corresponded to a distinctive strategy, when the new space was created it sought to distinguish itself from public health, hygiene and preventive medicine, given its apparent neutrality, becoming an object of theoretical construction. As a noun, it pleased epidemiologists who wanted to study the abstract population and the social scientists and other health professionals, such as nurses, social workers and physical therapists, who wanted to construct a non-medical space. The project of this new space then had to confront not only the field of preventive medicine but also the well-established habitus of the medical field, institutionalised public health and the field of power.
The relationship between the founders and the field of power was established from the beginning by the very formulation of the health reform project. During this period (1976–1986), the health reform project was an anti-hegemonic project similar to the social movements that attempted to democratise the country. With the victory of the opposition in the national elections, one of the questions that later came into play was who would occupy the directing positions of the unified health system. All these positions, from state ministers to provincial and municipal secretaries, needed intimate partisan and political connections. However, those relationships were also established through a more technical route involving state, national and international ‘experts’ (Murard and Zylberman 1985). In this way, the hierarchy of the space was established similar to that in other fields of cultural production in relation to the grade of autonomy and distance from the demands of the field of power. On one hand, the scientific space of collective health has the greatest autonomy from the demands of the field of power; on the other hand, the bureaucratic space is more dependent on state demands.
This apparent paradox, related to the fact that the criticism of preventive medicine was developed in the spaces created to promote it (Escorel 1999), reveals the error of prioritising external factors in the explanation of social facts. The genesis of the social medicine space, later collective health, derives from the joining of paths of some agents who unconsciously incorporated the collective history of Brazilian intellectuals and certain international groups and ideas from the 1960s; Marxists and disputers, as well as a taste for popular music and Brazilian new film (Marques 2007, interviews). However, the genesis of collective health also suffered from the influence of other agents with centre-right and centre-left political dispositions who participated in the creation of the space with the goal of either the modernisation of medicine or the reform of health services. Yet they also incorporated the collective history of hygiene and institutionalised public health, the then dominant medicine and sociology. These additions, moderated by the individual stories, resulted in the variety of paths that met and constructed a new and diversified space.
This paradox is not only related to the conditions of possibility of the constitution of space itself but also to the specific characteristics that were constructed by the agents who were determined by the structures that represent these conditions of possibility. To create departments of preventive medicine it was not sufficient to have physicians with a preventive perspective. However, this limitation was not only due to the reproductive role of the school using Bourdieu's analysis, nor is it because the social determinants of medicine and its practices are all related to capitalism. Rather, it is because the agents themselves who became interested in, or who were invited to organise the teaching of preventive medicine, brought with them dispositions to develop other theoretical and political practices. Conversely, the relationship between the space and the field of power concerns this origin. Many of the paths of the founders shifted from a university background where there was an accumulation of scientific and symbolic capital into positions in different international organisations or into various high-level positions in the government.
In this way, this space was born from inside the medical field, in which a large part of its agents have kept their identity and roots. The loss of their identity as doctors, when it existed, was received with ambivalent feelings because the new identity varied between places and interviewers. One of the most important founders declared himself a sanitarian, a name given to those previously known as experts in hygiene and institutionalised public health, which was a relationship that the new space aims to sever. Only one of the interviewees declared that he was a health socialist, a name that is more consistent with the original project. The problem of identity was not undertaken by the group of social scientists, who objectively had their own field during the time of the creation of collective health. However, considering that opting for collective health meant leaving their field of origin for another field, this group was the second to organise a periodic scientific conference of its own (Brazilian Congresses of Social Sciences and Humanities in Health), delineating a specific sub-space.
The individuals involved could be described as doctors but not doctors, and instead as sociologists or social scientists bearing the descriptor ‘of health’. Often with an ambivalent political identity – that was too technical for the political field and too political for the scientific field – one of the main issues for this created space is to affirm itself as a field in the sense of a construction of identity and the search for relative autonomy. If the new identity is not completely established, the old identities are ambivalently rejected. To what extent has this space become a field and to what extent does it persist as a space? The study of its genesis did not offer elements by which to characterise it as a field with respect to its relative autonomy and the establishment of a unique identity and a specific habitus. The answer to this question requires complementary studies directed towards a better objectification through the analysis of the evolution and transformations of the space/field of collective health from its earlier period until now.