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INTERVIEW

Naomar Monteiro de Almeida Filho: Diseases as complex objects

Epidemiologist warns that the pandemic cannot be described solely through the virus or the infection caused by it

Denise CoutinhoEpidemiologist Naomar de Almeida Filho, from Bahia, used the pandemic to advance his general theory of health, formulated in 2000 to study mental disorders. He believes the COVID-19 pandemic involves continuous interaction between its more visible elements and other environmental and symbolic components. “No isolated analysis can explain all of it,” he states. The most recent version of his theory came out in the August 2020 issue of the scientific journal Estudos Avançados (Advanced Studies).

Almeida Filho was born in Buerarema, in southern Bahia. At 68, he is married and has five children and six grandchildren. He grew up in the nearby town of Itabuna, which he later left to study medicine in Salvador and epidemiology in the United States. He was dean of the Federal University of Bahia (UFBA) from 2002 to 2010, later returning to his hometown from 2013 to 2017 to help establish the Federal University of the South of Bahia (UFSB). To reduce the effects of geographical exclusion, he helped implement university colleges in eight towns, where students could start their programs before going to one of the three main campuses.

In 2019, when he became a visiting professor at the University of São Paulo Institute of Advanced Studies (IEA-USP), he began working in both Salvador and São Paulo. He became, as he calls it, a “soteropaulistano,” a word he invented by fusing the term soteropolitano, or native of Salvador—also called Soterópolis, or Savior’s City in Greek—and paulistano, or native of São Paulo. He is self-isolating on the island of Itaparica, alternating between walking or running on the beach and participating in livestreams on subjects such as the pandemic, universities, and the possibilities of improving education in Brazil.

Age 68
Field of expertise
Epidemiology and Public Health
Institution
Federal University of Bahia (UFBA)
Educational background
Undergraduate degree in medicine (1975) and master’s in community health (1976) from UFBA, PhD in epidemiology and medical anthropology (1981) from the University of North Carolina, United States
Published works
203 scientific articles and authorship or coauthorship of 28 books

What is the general health theory?
This theory may finish my career as an epidemiologist. I called it holopathogenesis because it seeks to understand the origin of diseases within their relationships and effects, not only through their most evident causes. I presented these ideas in two papers in the Revista de Saúde Pública [Journal of Public Health], in 2013 and 2014, and I initially used them to investigate mental health. More recently, I used it in a paper for Estudos Avançados to treat the pandemic as a complex object. The theory stems from the concept of multiplanes and hierarchical interfaces, by the Argentine philosopher Juan Samaja [1941–2007], who was a friend of mine, plus contributions from Latin American thinkers, such as Milton Santos [a geographer from Bahia, 1926–2001] and Néstor García Canclini [Argentine anthropologist], as well as Gilles Bibeau [Canadian anthropologist]. Its foundation is simple. Any given disease will have biological, environmental, social, and cultural impacts, meaning there are simultaneous occurrences on various levels: microstructural, covering molecular and cellular reactions; microsystemic, referring to metabolism and tissues; subindividual, or processes that occur in the organs or systems of the body; individual, represented by the medical expression “clinical cases,” referring to those affected by a disease; epidemiological, covering populations at risk of disease; ecosocial, which examines environmental changes linked to new or old diseases; and symbolic or cultural. The challenge is coordinating levels, dimensions, and interfaces.

What has this approach revealed about the pandemic?
During a pandemic, it cannot be said that one thing causes another, because in complex systems everything is integrated. No isolated analysis can explain all of it. The pandemic cannot be described solely through the virus or the clinical signs of COVID-19. A pandemic is a singular and complex event—not unlike hurricanes, tsunamis, and wars—which changes not only human bodies, but also the social fabric, economic relations, the media, and politics. To understand such a phenomenon, with so many changing interfaces, a more holistic view is needed. The pandemic behaves differently in different places because societies, realities, and institutional reactions differ. All of this should be considered when fighting it. A pandemic is an opportunity to develop new ways of thinking and acting. Because it is a critical event, the pandemic imposes the need for integrative, interdisciplinary, and transdisciplinary thinking. In short, there are no simplified solutions for a complex issue.

How do you view the pandemic in Brazil?
With much concern. Brazil will go down in history as one of the countries that had the worst response to it. There is denial, redundant measures, unnecessary conflict, and corruption. At first—as early as February—an emergency operations center was established. However, this center recruited only biological or clinical research experts. Epidemiologists and public health workers, who know about strategies to fight epidemics, have not been heard or have been only modestly involved in decisions so far. We missed the chance to control the epidemic before it spread. South Korea and Japan have implemented very efficient epidemiological surveillance systems using simple logic: identifying cases early, tracing their contacts, and isolating everyone. Neglecting isolation and quarantine measures is a way of applying the concept of “herd immunity,” which is widely criticized in the epidemiological field for being inhumane. This ends up promoting social selection, achieving collective immunity by sacrificing the elderly, those with pre-existing conditions, the poor, and Black people, who died the most in Brazil. Many of these deaths could have been prevented.

We should go back to and value primary healthcare, which is essential in a pandemic

What should be emphasized?
In an August Le Monde Diplomatique paper, my colleagues Gulnar Azevedo, Claudia Travassos, and I showed that the correct epidemiological view would be the opposite of what is being done. Here, the health care system was involved through an inverted logic, prioritizing extremely complex quaternary care—this is why we keep hearing about ICU beds. Hospitals should be the last resort in terms of care, not the main focus of the fight against the pandemic. We should go back to and value primary health care, which has been dismantled in recent years. In a pandemic, basic health care is essential to monitor symptoms as they crop up in neighborhoods and villages. And, even without any symptoms, suspected cases must be seen as potential spreaders of the virus and isolated, as well as those with whom they had any contact.

Let us talk about your research career. What would you say are the highlights?
I attended UFBA medical school from 1970 to 1975, during a university reform that allowed students to put together their own curriculum. Because I completed many courses early, I had some free time in my third year and joined the choir; I also took courses in German, Spanish, anthropology, archeology, history, and folklore. I became familiar with the departments of Psychiatry and Preventive Medicine. Close to graduation, I broke the national security law for reporting inadequate conditions in psychiatric asylums. I obtained a master’s degree in community health and later got a grant from the Rockefeller Foundation to get a PhD from the University of North Carolina at Chapel Hill, then an important psychosocial epidemiology center in the United States. For my thesis, I studied the effects of migration and unemployment on mental health. When I returned, in 1982, I joined the Department of Preventive Medicine at UFBA as a collaborating professor. We established research groups and, in 1994, we implemented the UFBA Institute of Collective Health with help from colleagues trained abroad and pioneering research approaches.

What were you proposing?
Health inequality was a topic that permeated our research. I was most interested in the social determination of mental health. Based on epidemiological studies, we were one of the first groups in the country to show the effects of gender, class, race, and racism on mental health. Behavioral disorders, aggression, and alcoholism occur more often in men than women, but women are more likely to suffer from depression and anxiety. We found that while marriage tends to protect men, it represents a mental health risk for women, probably due to the sexism that pervades Latin American society. In 2004, we showed that being female, black, and poor means one is nine times more likely to experience depression and anxiety, compared to being male, white, and upper class. There is a complex synergy between sexism and racism.

At UFBA, graduates from interdisciplinary bachelor’s degree programs are more mature, responsible, and self-reliant

How was your experience as dean of UFBA?
In 2001, I was a visiting professor at Harvard. During one of my trips back to Salvador, at a meeting to discuss the election of the next dean at UFBA, my candidacy began. I come from a background of research and teaching, so I quickly taught myself about the history and social mission of the university, with a focus on management and institutional organization. My first term, from 2002 to 2005, was marked by affirmative action aimed at Black, Indigenous, and poor people, boasting the most comprehensive affirmative action regime of the time. We also expanded the university into rural areas. During my second term, we began a deeper institutional transformation at UFBA, with innovations that inspired REUNI [Program to Support the Plans for Restructuring and Expansion of the Federal Universities System in Brazil]. With REUNI, we went from 3,700 undergraduate students at UFBA to 8,000. This growth was based on the proposal to create interdisciplinary bachelor’s degrees, or BIs, to offer general training before specific training. It was a tropicalist, or tropicalized, mix of the most interesting things about both the college system of the Anglo-Saxon university model and the Bologna Process in Europe. I wrote a book about this, Universidade Nova: Textos Críticos e Esperançosos [New University: Critical and Hopeful Essays] [Editora Universidade de Brasília and EDUFBA, 2007]. We implemented the BIs amid huge controversy.

Why were they controversial?
REUNI really did increase the number of students, but not enough, and maintained the professional training model. In the REUNI project for UFBA, the BIs challenged this traditional model. They were seen as an Americanization or Europeanization of the Brazilian university. Those that opposed it argued that funds should be used first to remedy issues and shortcomings before admitting more students—that any expansion would be to the detriment of education. Students occupied the Office of the Dean building for 45 days to prevent the University Council from voting on REUNI. Even with all the outrage, we were able to implement the project and start the first BI class in 2008.

How does the interdisciplinary bachelor’s degree program work?
With BIs, students can pick one of four major areas—sciences and technology, humanities, arts, and life sciences. They are three-year programs and consist of general training. The first year has common curriculum components within the chosen area; from then on, students build their curriculum. If they do not enjoy it at first, which happens often, they can switch because the initial foundation is the same. They then go on to programs for specific professions to complete their training. The idea was for the entire university to adopt this format but, at UFBA, BIs became just another option. The university kept all its traditional programs, added the four new bachelor’s degree programs, and established a new campus for them—a kind of mini-college—the Professor Milton Santos Institute of Humanities, Arts and Sciences.

Personal collection In 2015, from Itabuna, Almeida Filho (plaid shirt) coordinates the digital network of UFSB campusesPersonal collection

Was there any resistance?
Lots of it, from both teachers and students. REUNI was first conceived as a membership program to which universities would submit proposals, but became a fund shared by all universities. The REUNI decree took place on May 2007; a working group was set up, with representatives from MEC [Ministry of Education], ANDIFES [Brazilian Association of Directors of Federal Higher Education Institutions], unions, and students. Several events were held to discuss the REUNI guidelines, but the six original points became disjointed. There was no integration between undergraduate and graduate programs; many institutions were against affirmative action, which at the time was still controversial. A guideline I have always found important was the integration between the university and the education system, to make basic school stronger.

Were the bachelor’s degree programs successful?
Professors now report that students who come from the BIs are more mature, responsible, and self-reliant. But the idea of making this the standard for the university was not accepted. Students continued to have the opportunity to go through other programs directly, with the BIs as another option. We initially admitted 1,600 BI students, of whom at least 20% went on to professional programs. Traditional programs resisted. Only the law and psychology programs established areas of concentration for BIs. Areas of concentration are blocks of specific curriculum components for each program, such as anatomy or parasitology for medicine. This way, students can have some training before their intended profession program. This is how North American and European universities work. The school of medicine still makes BI graduates take all courses in the medical curriculum, because they consider BIs an illegitimate entry into the university, since BI students do not take the entrance exam. This makes no sense; BI students go through a good portion of that training and should not be made to study all nine years of medical school. The law program was more welcoming; they soon saw that BI graduates in humanities were incredibly good and increased their admittance to 30% for the day program and 50% for the night program.

What did you take away from this experience at UFSB?
UFSB was established from scratch through a 2013 bill, in a region that had no access to federal education. In 2012, I coordinated the planning committee and was appointed the first dean. According to the law, the university headquarters would be in Itabuna, with two campuses in Porto Seguro and Teixeira de Freitas. However, geographical exclusion is a serious problem in that region. For example: a young man from Medeiros Neto, a municipality 1,000 kilometers (km) from Salvador and 600 km from Itabuna, may be brilliant, but if he is poor and cannot leave his hometown, he has no chance of attending university. After being immersed in the region for a long time, we designed solutions. In addition to the three campuses, we established university colleges in eight cities, which function as remote university sites. It is an adaptation of the community college models, which employ idle high school spaces. Students are admitted through their ENEM [National High School Exam] grades, but they compete through local practices. All students receive general training during their first year. If they perform well, they go on to one of the main campuses. The health programs are in Teixeira de Freitas; the humanities and arts programs are in Porto Seguro; and the science, engineering, and technology programs are in Itabuna. This model optimizes resources because there is no need for professors to have multiple specialties. To overcome geographical exclusion, we had to prioritize digital connection. The model we call “metapresencial” works very well. I have taught lectures to 300 students, with 30 being physically present in my class and the others in the network of university colleges.

I do not believe that making education more accessible means a loss of quality. Smaller scale is not necessary for excellence

What is the general training like?
Freshmen study Portuguese, geography and society, university and society, computers and mathematical reasoning, English, and an introduction to their chosen field, while encouraged to experiment with other areas. One of the most significant innovations is the sensitivity experience, a sequence of activities that all professors and students go through. At first, professors bring a memento mori—small objects that represent their identity and tell their story. Then, students are invited to bring their own objects—dirt, water, and vegetation samples, sounds, or images—and talk about them; it leads to incredible discoveries. A student from the Coaraci university college took a bottle of polluted water from the Almada River, which supplies Itabuna and Ilhéus. Someone asked him, “Where does this water come from?” “From the river,” he answered. “Where does the river come from?” they asked. They realized they had no idea where the river spring was; they then went up the river to find it. After general training, the curriculum is personal.

Why did you leave the Office of the Dean before the end of your term?
The university model we designed included broad co-management, not just involving professors, technical and administrative staff, and students; we wanted to include all of society. As such, we tracked down social movements and community organizations in the area, identifying local leaders and masters of knowledge. In 2015, we held a Social Forum for southern Bahia. Each segment established itself—some more easily, such as elementary school teachers, and others with more difficulty, such as shellfish gatherers, popular artists, and quilombola communities [Brazilian maroon settlements]. Each preparatory meeting had around 2,000 participants. Each self-organized segment could elect one delegate for every 100 people. These delegates then elected representatives for the Social Strategic Council of UFSB, who could even participate in the dean elections. We recognized wise leaders of the people in the region as training instructors at the university. The MST’s [Movimento Sem Terra, or Landless Workers’ Movement] Terra à Vista Settlement, in Arataca, grows a type of terroir organic cocoa that is well respected in Belgium. The fishermen of the region are deeply knowledgeable about climate and winds. The Pataxó and Tupinambá indigenous people have a rich oral culture and very sophisticated rhetoric. But opening up the university to a shared governance cannot go unscathed. As careful as we were in selecting teachers, who were also assessed through the university project, they were trained with traditional curriculums and brought with them traditions inherited from other institutions. We were unable to find a common ground. I resigned in October 2017, when I realized most teachers, civil servants, and some of the students had turned against the project. I saw there was no more room for me, so I retired and left.

What did you do after that?
In 2018, I approached the Brazilian Academy of Science and contributed to a document indicating paths of innovation for Brazilian universities. I was asked to join a working group on the future of USP, coordinated by Luiz Bevilacqua—a dear friend of mine and a great mentor at UFABC. In March 2019, I became a visiting professor at the IEA; I went back and forth for a while until I finally moved to São Paulo. The room next to mine was occupied by the Basic Education Chair, funded by Itaú Social. I began sitting in on the activities of the chair, which included very competent and welcoming colleagues. I helped them put together a work plan. The basic idea is that training by discipline has no future; it has been outgrown all over the world. The interdisciplinary teaching degrees implemented in the university colleges of UFSB, in parallel to the BIs, are a possible solution to renew the common curricular base, which organizes secondary school in large areas—although the training of teachers still takes place in segments. This year I was asked to assume the chair.

How do you assess the possibility of change in São Paulo universities?
USP has immense creative energy and has already carried out innovative interdisciplinary experiments. Over the last 27 years, USP has had a fantastic interdisciplinary program: the bachelor’s degree in molecular sciences, based on a very advanced view. In the São Carlos campus, there is an interdisciplinary teaching degree with a rich experience of integration with the basic education network, using museums and unconventional teaching spaces. In line with Anísio Teixeira [1900–1971] and Darcy Ribeiro [1922–1997] from UnB [University of Brasília], UFABC implemented bachelor’s degree programs in science and technology before UFBA. I recently heard the great news that UFABC had implemented interdisciplinary programs. UNESP [São Paulo State University] has an interdisciplinary bachelor’s degree program; UNIFESP [Federal University of São Paulo] has interdisciplinary programs in its Baixada Santista and São José dos Campos campuses. Even UNICAMP has a history full of innovative initiatives. The current dean, Marcelo Knobel, established PROFIS [Higher Interdisciplinary Training Program, implemented at UNICAMP in 2011], an innovative proposal for geographic inclusion whose main issue, in my view, is being too modest—only admitting a hundred gifted students from the public school system each year, when the university can take many more. Many defend the idea that expanding education and making it more accessible means a loss of quality. I am convinced smaller scale is not necessary for excellence. In a country like Brazil, we must expand excellence to reach more people.

Is there anything new in places besides Bahia and São Paulo?
From 2007 to 2011, there have been other initiatives that bring curricular and pedagogical innovation. I would point out the universities with regional or international integration, such as UNILA [Federal University of Latin American Integration, based in Foz do Iguaçu, Paraná] and UNILAB [University of International Integration of Afro-Brazilian Lusophony]—half of whose students are African and half Brazilian—in Redenção, Ceará, the first city to declare the end of slavery in the country. The issue is that Brazil has not yet decided which university model it wants to follow. It currently uses a less-than-virtuous mix of three systems: the French system, with universities established from colleges, such as USP and UFRJ [Federal University of Rio de Janeiro]; the German system, with an emphasis on research; and the North American system, more restricted to graduate studies in certain areas. Interinstitutional relations are lacking; there is no network of innovative institutions capable of significant exchange, starting with the professors themselves. In the United States, England, and even continental Europe, professors usually advise students at several different institutions. Amartya Sen [Indian economist, winner of the 1998 Nobel Prize] worked half the year at Harvard, in the United States, and the other half at Cambridge, in the United Kingdom. This is not yet possible for us.

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