In the 1960s and 1970s, the state of São Paulo reshaped its public health policies in tune with new models of management and scientific production that came to define the field of collective health in Brazil and influenced the creation of the Unified Health System (SUS) under Brazil’s 1988 Constitution. This is the conclusion of the study “The history of collective health in the state of São Paulo: the emergence and development of a field of knowledge and practice,” which is now receiving the final touches by historian André Mota, professor at the University of São Paulo School of Medicine (FMUSP) and coordinator of the institution’s Historical Museum. Based on methodology from oral history, dozens of interviews were conducted with agents from the field of collective health at medical schools and associations in São Paulo and with public policy makers from different regions. These were supplemented by reference to institutional documents.
“The various medical schools that were set up in the state in the 1950s and 1960s under the influence of preventive medicine opened the way for the emergence of a public agenda that wove ties between medicine, health, and society in the following years,” argues Mota. Until the late 1950s, the state had only three medical schools: the University of São Paulo, in the capital (1913); the Paulista School of Medicine (1933), which gave birth to the Federal University of São Paulo (Unifesp); and one in Ribeirão Preto, which is a branch of USP in rural São Paulo. The following years saw the opening of three more medical schools: in Botucatu in 1962 (now part of São Paulo State University-Unesp, founded in 1976); in Campinas in 1963 (the first unit of the University of Campinas-Unicamp, founded in 1966); and the School of Medical Sciences of the Santa Casa of São Paulo in 1963, located in the capital.
It was at the school in Ribeirão Preto that preventive medicine came to the fore and claimed institutional space. “The establishment of the medical residency program in 1962 was a milestone in the training of providers who are focused on preventive health action,” says Professor Carlos Henrique Assunção Paiva, coordinator of the History and Health Observatory at the Oswaldo Cruz Foundation (Fiocruz), citing a study by researcher Everardo Nunes, professor at the Unicamp Department of Preventive and Social Medicine.
To a greater or lesser extent, all the other schools of medicine mentioned above likewise built their curriculums around the precepts of preventive medicine. “Up until then, the prevailing idea was that a good doctor was a specialist in diseases and therefore had the knowledge to act on the patient’s body,” says Mota. “Later, in the 1960s and 1970s, the expectation was that providers would engage in social intervention to prevent the outbreak of diseases.”
The brand of medicine practiced in São Paulo from the 1930s on was heavily influenced by the Flexner model, developed by U.S. educator Abraham Flexner (1866-1959). In 1908, Flexner published a report on the courses of study at all 155 schools of medicine in the United States and Canada, triggering a reformulation of medical education in both countries. The new model was characterized by standardization, apprenticeship, and scientific training, with teaching hospitals serving as laboratories for the training of new physicians. This was the approach upheld by the Rockefeller Foundation commission that came to Brazil in 1916 to evaluate its study of medicine and offer scholarships for Brazilians to attend medical school in the United States. In 1918, through Arnaldo Vieira de Carvalho (1867-1920), director of the São Paulo School of Medicine and Surgery (now FMUSP), the government of São Paulo signed agreements with the U.S. foundation and allocated $1 million of the associated funds to FMUSP. The Hygiene Institute (today the USP School of Public Health) was founded that same year as a part of the School of Medicine and Surgery.
“Until then, doctors worked at the patient’s bedside; because of the new concepts in the realm of medicine, new graduates now had to have laboratory knowledge,” reports Mota, in an allusion to the Flexner reform. Brazil already had public health doctors, who responded to the need for prevention initiatives, including Oswaldo Cruz and Vital Brazil in Rio de Janeiro. “Sanitary services were set up in major cities to address epidemiological outbreaks and foster a climate that would not discourage immigrant labor from coming here,” says Tânia de Luca, professor at the Department of History, School of Sciences and Letters/Unesp, Assis Campus, and scholar of early 20th-century medicine in São Paulo.
With a mushrooming population and therefore an increased threat of contagious disease, the city of São Paulo founded the Butantan Institute in 1901 and the Pasteur Institute in 1903. The city also equipped its municipal health system with laboratories and libraries. But it was more than a decade before professorships were established in medical specialties. FMUSP only took this step in the 1930s.
The picture changed after World War II, when the idea of the welfare state came on the scene worldwide. This was the phase of preventive medicine. Health services began charting needy and vulnerable urban areas and casting greater light on the relationship between poverty and disease. “Although much emphasis was put on prevention, this doesn’t mean the approach necessarily advanced democracy,” Mota points out. “Public initiatives were essentially interventionist, without citizen engagement. Cultural and lifestyle differences weren’t recognized. Knowledge was still divided into normal versus pathological.”
Various schools of medicine opened their doors in the 1960s when demand was sparked by a new middle class, engendered by a phase of development in São Paulo. The state capital became the definitive financial hub, while the mechanization of agriculture lent impetus to the interior. Mota highlights the role of Walter Leser (1909-2004) during this period. Leser was a professor with the FMUSP Department of Collective Health and served as state secretary of health twice, under governors Roberto de Abreu Sodré (1967-1970) and Paulo Egydio Martins (1975-1979).
During Secretary Leser’s first term of office, he launched what is known as the Leser reform. Health centers were installed throughout the state, forming the “backbone of the public health organization,” and 622 posts were opened for public health doctors, although these were only completely filled during Leser’s second term. He also established courses to train public health physicians at the USP School of Public Health. It was against this backdrop that FMUSP created a Department of Preventive Medicine in 1969, lagging somewhat behind the institutes founded in the early 1960s.
According to Mota, the political activism of the actors involved – who were opposed to the military dictatorship – was vital to shaping the view of “health as a duty of the State,” a motto that was incorporated into the legal framework of the SUS. Another “São Paulo singularity” that had a bearing on Brazil’s national public health system was decentralization. Under Leser, some services, like prenatal and early child health care, were shifted away from hospitals and into health centers, which were also assigned responsibility for implementing preventive medicine measures. Paiva cites another advance that came to inspire federal policy: “an outlook that produced professionals like parasitologist Samuel Pessoa, who was concerned with social problems, and thus framed the idea of rural sanitation as a central issue to be addressed.”
Lina de Faria, professor at the Federal University of Southern Bahia (UFSB), Sosígenes Costa campus, who holds a doctorate in collective health, believes that preventive medicine in Brazil can be traced further back. In her opinion, “when the Hygiene Institute was founded in São Paulo in 1918, major ground was gained by what would later be known as preventive medicine.” Faria also sees continuity between that period and the laws passed in the 1980s. “Universal health care was a grievance of the public health movement in the 1920s,” the researcher says. “The basic assistance model thus has deep roots in the history of public health in São Paulo and Brazil.”
According to Mota, the preventive medicine approach gradually came under fire in the 1970s, when the field of collective health emerged. “The theory was no longer as normative and the role of healthcare providers lost something of its interventionist, normative character and came to involve social interpretation,” the researcher says. As he sees it, a key trait of collective health is that it incorporates professionals from other areas into the field of medical knowledge and even into medical school faculty, like psychologists, sociologists, nurses, anthropologists, and historians. “This has expanded the explanatory power of health,” the researcher says.
In Mota’s opinion, it was a matter of superseding the duality between the ideas of normalcy and pathology, notions that stem from a conservative view of the patient. This polarization, says Mota, promoted the notion of a “body-machine” aimed at social productivity and moralist conceptions of behavior lying “outside the norm.” Some examples of the fresh new concerns introduced by collective health are the perception of how patients talk about their own bodies during medical consultations, the complementarity between the social and the physical, and a focus on specific segments of society, like black women. One emblematic sign of the shift in these conceptions was the 2011 renaming of the Department of Preventive Medicine at the Unicamp School of Medical Sciences to the Department of Collective Health.
The study is limited to São Paulo but Mota does not underestimate how important other states have been in shaping national health policy. In his opinion, technology is a flagship of medicine in São Paulo while Rio de Janeiro has influenced public policy – for one reason, because it was the nation’s capital until 1960. In this regard, the Oswaldo Cruz Institute (IOC/Fiocruz) – born as the Serum Therapy Institute in 1900 – plays a national role. Mota underscores the contributions to the design of the SUS made by Sergio Arouca (1941-2003), public health specialist, two-time federal representative, and president of IOC/Fiocruz from 1995 to 1998. “Modern health initiatives have been undertaken mainly by the government in Rio de Janeiro, while charitable organizations have played a more central role in São Paulo,” Mota says in conclusion. In the opinion of Paiva, “The history of Brazilian public health can be seen as a process that has been cumulative and prolonged but not linear.” “In this sense,” he says, “the ‘São Paulo legacy’ occupies a more predominant position on the timeline of Brazilian collective health.”
The history of public health in the State of São Paulo: the emergence and development of a field of knowledge and practice (nº 2013/12137-0); Grant Mechanism Regular research grant; Principal Investigator André Mota – University of São Paulo School of Medicine; Investment R$151,882.75.