The basis of the reflection that I bring to this table is the relation between health policy and medicine, addressed under an internationalist approach, as the basis for a final comment, as conclusion.
At the end of World War II flourished a widespread feeling of solidarity, whose expression in international relations was the cooperative ideal enshrined within the United Nations. In practice, it meant the mobilization of subsidies from rich countries to poor or behind the pace countries ‘ development. On the American continent, this meaning has resulted in the proposal that economic development would be an indispensable step to overcoming social deprivation of the majority of the populations, with the acceptance tacitly shared that foreign aid would be up to the United States, holder of greater economic, financial, industrial, technological, scientific and military power. The pan-americanist ideals, that had been remodeling gradually since the beginning of the nineteenth century, renewed more quickly in line with the circumstances of war of World War II and with the paranoic minuet of the cold war that settled then.
The response of the United States to the population explosion triggered in the postwar period, and the consequent expansion of demand for goods and services of all kinds, included, in the area of public health, the creation and expansion of government programs. Institutional capacity to control communicable diseases and coping of chronic diseases was consolidated. This approach was shared across all sectors and dated back to the years of 1930, with the guidance of the Keynesian policy of President Roosevelt, but intensified itself induced by tonic of governmental planning and management during the war effort. In the subsequent phase of peace shaded by the threat of a renewed conflict in the atomic age, this administrative competence has become a prerequisite for economic development, favoring the increase of availability of goods and services to wide ranges of population.
In Latin America this planning and development ideals associated with State intervention in the economy was part of the culture and expectations of government leaders, spreading with the creation of stimuli for import substitution and inductive measures of national industrialization processes. During this period, the most serious dimensions of health in virtually all countries of this region were the high incidence of infectious diseases, high infant mortality and low life expectancy, in a context of growth and urbanisation of the population. Scarcity and discredit of the information available was an important limitation of the management capacity of public services and the private sector. And the concerns emphasized the workforce shortage affecting all kinds of professionals, training centres, libraries and teaching materials, in addition to the traditional educational approach blurred from national realities.
With this picture, the commonly adopted measure was the significant expansion in the training of health workers, seeking to adapt the workforce to growth of demand of healthcare systems. However, unchained initiatives lacked guidelines consistent with national realities, driven by classical models of intervention, primarily geared to the specialized training aimed at individual medical services, while public health continued to deal with communicable diseases and evils arising from social deficiencies, especially the lack of basic sanitation.
The economic crisis of the years 80 and the failure of communism with the collapse of the Soviet Union marked with the fall of the Berlin wall have configured the scenario of reinvigoration of the theses of liberalism, whose principles were established by the Washington consensus. Under the nickname of neoliberalism, somehow this ideology just rescued a version of classical liberalism, aiming at contesting of social and welfare policies and, in terms of international relations, the irrelevance of solidarity as orientation of international development cooperation.
This new international situation was reflected, in the area of health, in the promotion of sectoral reforms, merely complementary or concurrent with economic reforms and processes of public management. In the United Nations system, despite the Declaration of Alma-Ata proposing the slogan of Health for All, the agencies and the development promoters banks adopted contradictory guidance, supporting health sector reforms based on two fundamental points: the limitation, or preferably in the reduction of these sectoral resources; and in the pursuit of efficiency and effectiveness, with emphasis on the transition to management models and private services offering. The incontestable result of those processes was the worsening of inequalities and the deterioration of health conditions.
The Brazil battled the oncoming traffic of these guidelines from 1985, due to the democratization process with emphasis on social rights that succeeded the military regime. The reflections of this process in the field of health were enshrined in the Constitution of 1988, when defining health as ‘ right of all and duty of the State” and establish the Sistema Único de Saúde (Unified Health System). Such advances represent both contributions and results from the wider process of the society as a whole, from the social movement triggered in the previous decade under the slogan ‘ democracy is health ‘, which came to be known as the Brazilian health reform.
The influence of the national health policy has been decisive in the modeling and implementation of the Brazilian education management agenda and the work in this sector, including and sharply in the case of medicine. Furthermore, this influence has taken place in a systematic way and coordinated with the international agendas. Secondary deduction is that the Brazilian experience is redolent of ideology and practical experiences developed in regional and global scenarios.
In the early decades of the second half of the last century, the existing institutional weakness in most Latin American countries did not allow them to develop assessments and intervention proposals concerning human resource deficiencies of their health systems. Situation that caused the emergence of a number of initiatives which, while shared by target countries themselves, were generally deliberated and enforced with strong external interference, by other countries agencies or broadcasted by international bodies.
The predominant objective in this phase was to prepare teachers of medicine and public health, train new professionals and specialists and, when possible, create schools or expand their vacancies, depending on the expansion of health services. Although with reluctance, the low effectiveness of these initiatives was confirmed, because of cultural differences between the countries and chronic deficiencies of the educational institutions. Also, it was soon proved to be an undesirable side effect of these strategies, as the ‘ brain drain ‘ was caused by the retention of professionals after stages or courses abroad, or to there attracted after formed in the countries of origin.
New medical schools were created during this period, relying on external support, creating a process that gradually came to be adopted autonomously by the countries, as were the more expressive cases of Brazil, Mexico and Colombia and, with less intensity, Peru, Ecuador, Bolivia, Chile, and several Central American countries. In some countries, prior to the creation of new schools, the existing ones opted for large-scale expansion of their vacancies. The record occurred at the University of Buenos Aires, which in one entry (1973) made 12 thousand initial enrollments in the courses of the health area.
Although these measures have contributed to reduce the general shortage of doctors in the countries, they did not manage to change the situation of health. One of the reasons more alleged pointed the model of medical training, generally transferred from foreign experience, with no correlation to the health care systems of their own country and, even less, the nosological demands of their populations.
Since the beginning of the period under consideration, based on a series of international conferences promoted by Paho (Colorado Springs, USA, in 1952; Tehuacan region, Mexico, in 1954; and Viña del Mar, Chile, in 1955), it was sought to reshape medical education through inclusion of disciplines and creation of preventive medicine and social departments in colleges. Other later measures, also sponsored by the same organization, included the training of leading teachers, including headmasters of schools in the area of health, focusing on the formulation and management of new analytical tools and new approaches to improve the performance of the educational process.
Among other contributions of Paho it is included the creation of Bireme and the Textbook Program, beyond the support and guidance in the creation of associations of health professions education, such as the Pan American Federation of Schools and College of Medicine. These initiatives included with sponsorship from entities of the United States counterparts and subsidy of private foundations that country, interested in improvements in the training of these workers according to the parameters of the so called ‘ developed world ‘.
New approaches in the development strategies of human resources in health in Latin American countries were introduced from the sixties, reflecting the global trend identified with the ‘ mantra of the planning and management of public policies ‘ which flourished in the post-World War II.
The creation of new medical schools persisted throughout the period, with periodic waves of inhibition of these openings, usually by corporate pressures of medical entities, worried about alleged superabundance of labor markets of their countries, as well as organizational and pedagogical needs of their schools.
The renewal of pedagogical guidance was brought to many places, including proposals for curricular integration between different professional courses through schools or health sciences centers, inclusion of activities on the network of health services and the community itself, in addition to the emphasis on preventive and social medicine content. However, these experiences have not adapted to the pace of the creation of courses and colleges, besides almost always perished because of the lack of harmony between the educational and health systems of the countries.
With regard to the chronic problems of shortage of doctors in the health services, the largest expression strategies included: the rural internship curriculum for medical students (and some other health professions); the medical services required (designated as compulsory social service) in small localities within countries, lasting six months to a year; and the offer of wage incentives to stimulate the establishment of professionals in poor or distant communities.
As for the compulsory social service experiences, the greater mount occurred in Mexico, from 1959, with the temporary distribution of graduates in areas devoid of doctors, where they should act with the supervision of their schools or universities of origin, in an integrated manner with the local health services. These two features were almost always neglected, under the most diverse claims, causing wear and disparagement of the strategy. Other countries have adopted similar policies, with difficulties and results also alike, with participants complaining of their own unpreparedness to act and lack or chronic disability of local resources available to address the problems, apart from the lack of rear of both the academy and the network of services. Another expected effect was the fixing of professionals in the localities or even in the region where they had the mandatory internship, what has been rarely proven.
During this period, the medical expertise spread across Latin America, with the system of residences. Even without absorbing all graduates, it led to the current situation of predominance of labor market specialists in health, contributing to the concentration of doctors in major cities and consequent shortage on inland regions. This is an aspect that represents the central difficulty for the provision of services in vast areas of the national health system, markedly the poorest in the socioeconomic point of view.
The resumption of the educational focus in the scope of the agenda of shared experiences in Latin America, especially those broadcast by Paho, have been restricted in recent decades to the strengthening of the Primary health care strategy (APS). Prevailing guidelines are based on the participation of the ‘ family doctor ‘, along the lines of the Cuban health system, or the ‘ family health team ‘, according to the proposal of SUS in Brazil.
Several aspects were left aside in this brief historical review. Others were just vented, for example the international migration of health personnel that, although relevant issue in many parts of the world, only recently acquired importance in Latin America and particularly in Brazil. They constitute important experiences in the context of the cooperation of some countries in the region with Cuba, aiming at the provision of doctors in their health systems, especially in primary care component, nicknamed in Brazil as ‘ primary care ‘.
This historical summary admits that policies and strategies tested in one country do not always lead to beneficial results, to be adopted uncritically in other national contexts, even though these Nations share historical, political or cultural identities. However, the analysis and the evaluation of these shared experiences would help to illuminate the construction of future relations between medicine and society ‘.
The systematic assessment of this background is therefore the challenge that I present to CFM its Committee of Humanities in Medicine, in the context of the debate in this Congress on medicine in modernity, under the oppression of the flexnerian meaning, taut between science and art.
As a closure to this message I present the meditation that was suggested by a colleague, when reviewing the preliminary notes that I wrote for this presentation:
Flexner is only an actor of a historical drama written by each of the doctors and researchers of the area. According to Heidegger, the technique is the essence of modernity and the technique is not an instrument or a means; it is a way of showing things in a disposal of ‘ requisitability ‘ (order). The establishing the ICU, the hydroelectric power plant and the atomic bomb is “a placement of everything in nature in a way of an availability of items that can be ordered”. ordered for what? To control the disease, productive energy or generate destructive energy. The same way of thinking is in everything and nobody is the leading actor of the drama of modernity. Everyone is in service of the technique. Look at your site, for what you so much do, and see that it also puts it out there at your disposal for the knowledge of the reader or the seeker, with just one click. (Roberto Nogueira).
Roberto Passos Nogueira is a doctor, researcher of the IPEA, scholar of philosophy.
* José Paranaguá Santana is a doctor, master of Tropical Medicine and a PhD in health sciences. Coordinator of the Center for Bioethics and Diplomacy Studies in Health and Advisor of the Center for International Relations at Fiocruz Brasília. Member of the Academy of Medicine of Brasília. He received from the Ministry of Health the Oswaldo Cruz Medal of Merit (Gold category). He was Advisor to CRM/DF and consultant of the Pan American Health Organization.
Presentation on a Roundtable on “The art of making science,” during the IV Brazilian Congress of Humanities in Medicine, sponsored by the Federal Council of Medicine in Recife (PE), in November 6th, 2014.