Democracy, power, knowledge, and health: questions for the future of social medicine

This essay aims to explore possibilities and challenges for the future of Social Medicine.[1] It is inspired by empirical ethnographic research, as part of a PhD in Collective Health, in a Brazilian public maternity hospital, which does not escape the contradictions of being part of a universal health system immersed in a context of deep racial, gender, social, and economic inequalities. To understand how the contradictions generated by social inequalities shape health services, relationships, subjectivities, and bodies, I analysed the hospital as an englobing technology in the care of abortion complications in Brazil. One of the key arguments is that stratification shapes practices and uses of biomedical technologies in health care [1]. Based on this experience analysing clinical encounters, in this essay, I briefly turn to the history of Brazilian Collective Health, along with theoretical and methodological inspirations from the field, to reflect on challenges for the future of social medicine [2,3,4]. To deepen the understanding of the dynamics of social relations established in the hospital, it was necessary to further the understanding of how the Brazilian health system is organized. My ethnographic research reveals that this specific organization is expressed in the ways of caring for women who seek the maternity ward to treat their health problems, for example.

Brazilian Collective Health,[2] since the end of the 1970s, has been consolidated as a field of knowledge production and a practical field of health care, which, concomitantly with the sanitary reform movement (Reforma Sanitária) and the country’s democratization, led to the creation of the Unified Health System (Sistema Único de Saúde, SUS). Health democratization was at the centre of the debate on health that gave rise to the SUS, as well as the inclusion of health as a right in the Brazilian Constitution in 1988, both important milestones for the country [4,10,11].

Inspired by European Social Medicine, researchers and activists for sanitary reform in Brazil (sanitaristas), when conceiving the term ‘Collective Health’ (Saúde Coletiva), sought distance from the traditional notion of Public Health and to incorporate the consideration of social determinants in health as one of the pillars to understand and act on the health of collectivities [12,13]. The Brazilian health reform project also had as a horizon the need for societal transformation as a whole, including the reorganization of power relations, based on the values of social justice and human rights [10,11,14,15].  

While the foundations of Collective Health in Brazil are advanced and complex, its project has not been completely incorporated into Brazilian society. This means that there is scientific knowledge that has been produced that can be refined and deepened. However, beyond the production of knowledge, I argue that Social Medicine should be concerned with understanding how knowledge is related to power, in order to understand which knowledge assumes a hegemonic position and which unfolds in broader health policies and beyond. Health policies may incorporate the assumption that health is a process that goes beyond the health sector exclusively, unfolding in systems and services that place users’ well-being at their centre. Thus, researchers in Collective Health, or Latin American Social Medicine [16], have made efforts to learn from the limitations encountered in the practical implementation of their assumptions and utopias. In this essay, I intend to systematize some lessons from this field that can inspire the development of a Social Medicine for the future.

‘Long live the SUS (SUS – Sistema Único de Saúde – Brazilian Unified Health System) / Always in defense of the right to health’. Billboard displayed at the Hospital das Clínicas of the Federal University of Bahia, Brazil. Designed by the Observatory of Political Analysis in Health research group. Photo credit: Mariana Lima

Recent research has pointed to directions that can be further explored. First, I propose that the Social Medicine of the future should be concerned with complexifying and refining the concept of health itself [20,21]. This would entail – based on empirical research using methodologies that privilege the point of view of different actors in relation and in practice, such as those proposed by STS studies [22] – studying what specific agents understand about health. Doing so would engender what Berlinguer [23], an author who inspired the sanitary reform movement in Brazil, called ‘political health consciousness’ or ‘health consciousness’. Berlinguer proposes this concept as part of his claim that ‘health […] is a right of the person and a collective interest. But as this right is stifled and this interest is neglected, health consciousness is the individual and collective action to achieve this goal’ (p. 3558). In other words, it is crucial to understand how actors incorporate the notion of health as a citizenship right.

My interviews with women in a Brazilian public maternity hospital show that, although health is a Constitutional right, it is still far from being understood as such by users of health services. In a highly stratified society, health is often understood as a commodity – that is, there is a symbolic value associated with the power to consume health products, which often translates into the valuation of advanced or ’boutique’ technologies [24], associated with a devaluation of what is public. I argue that Social Medicine should be concerned with understanding the complex relationship between developing ‘health consciousness’ and the values associated with consuming health services, particularly in contexts where the power of consumption defines and hierarchically produces bodies and subjectivities. In order to achieve this, a central question for social medicine is the analysis of power relations.

Another subject that requires further investigation into how health becomes a commodity is the power relations in societies, in order to analyse the complex networks among states, national and international health markets, and neoliberalism [25]. Related to this is the need to analyse health inequalities at local and global levels, so that we may reflect on ways to democratize health. It is well known that in Brazil, although there exists a universal and public system, health markets profit by receiving public resources, the result of a complex relationship between philanthropic and private companies providing services that receive public resources to manage and provide services for SUS [12,25,26]. A critical Social Medicine should be concerned with understanding these complex relationships, which result in allocating funds that could be invested in the public system, sustaining a lucrative market in health. For example, the health manufacturing industry has benefited from public resources by producing goods for the sector. Studying these relationships would improve understanding of the new forms of privatization of the public and universal system, and allow action towards deprivatization, assuming that privatization is in part responsible for deepening stratification and discrimination in health [26]; this is a topic that was little explored in my ethnography, which deserves further exploration. Another central question for social medicine is the deeper understanding of economic relations and health.

The movement to develop Social Medicine in Latin America responds to the visible signs of extreme political authoritarianism and the inequalities that are expressed in health disparities, as well as the weakness of the state in guaranteeing basic rights [14]. Brazil, with one of the greatest levels of inequality in the world, reveals that, in addition to poverty, deep racial, gender, and social inequalities have perverse effects on health. One of these effects is the production of a perception of health as distinction, in Bourdieu’s sense [27], a good that confers symbolic power to those who can consume it. Public health, on the other hand, is understood as produced for those who are unable to pay, that is, for the poor [28].

Based on my ethnographic research in the public hospital [1], and on recent debates in the field of Collective Health [4,12,13], I argue that to advance Social Medicine we must focus on two main points: scientific comprehension and proposals to improve the democratization of health [11], and analysing power relations in specific and global contexts, in addition to studies that focus on power, politics, and health.

Democracy and health

Social Medicine should be concerned with deepening the theoretical understanding of health as part of democracy. In order to reflect on the relationship between health and democracy, I argue that one should start from the assumption that all forms of medicine are social, since they address a ‘social body’ [4], and that health practices create social relations [2,3]. If health is a state of life, Social Medicine should seek to develop ways to democratize this vital state.

Social Medicine should thus be concerned with understanding health as a state of life, that is, the different ways people live their daily lives, including their different access to health services, food, education, basic income, and other aspects that can be included in what is called the Social Determination of Health [12,13]. Researchers can look beyond the country level to the whole planet, aiming to develop ways of democratizing the vital state in order for it to not be a privilege of one segment of the population or another. To democratize health would lead to a more reasonable distribution of risk.

Another issue that deserves further study is health as a productive sector, including its complex relations with the industrial health sector, how it interferes in the organization of national and international systems and in relations with the state [25,26], as well as in the training of professionals. Investigating health as an area that produces goods and services would show that what has been built in Brazil is very different to what was planned.

And finally, Social Medicine should examine how to develop systems that ensure the right to health, so that it is not simply a rhetoric. This would entail promoting the democratization of access to health services, based on social justice and human rights [28]. In addition, it would involve further developing a notion of health as a democratic field of knowledge, recognizing the diverse knowledges that shape health practices and the need to decolonize health knowledge.

In my ethnographic study of reproductive health care, I found that Brazilian women’s state of health and their access to health services still need significant advances, despite the existence of a universal health system. The service that receives mainly black women from the lower social classes is frequently underfunded, placing a series of barriers in the way of these women having their constitutional right guaranteed. The Brazilian case thus reveals both an advance in terms of the inclusion of health as a Constitutional right, and also a challenge to transform this right into effectively democratic services. It is therefore necessary to examine the power, political, and market relations that obstruct the implementation of a genuinely universal health system.

Health and power

Although the field of Social Medicine is theoretically advanced, it is necessary to deepen the analysis of power, economic and political relations. The Brazilian experience in Collective Health, and its movement for an egalitarian and democratic health system, shows that it is necessary to study the relations that obstruct this idea from actually resulting in improvements in the vital condition of the population. What makes some knowledge more relevant than others, in terms of health, and how is ignorance in health strategic produced [29]? I argue, therefore, that Social Medicine has the task of investigating both the micro-power relations that operate within health services, in a circumscribed and situated way, and also the macro-power relations that hinder the transformation of rhetoric into concrete services that democratize the health of the population.

[1] The author would like to thank the prize committee, all the readers who collaborated with the edits, revisions, and suggestions, and Professor Ligia Vieira da Silva for the discussions on Social Medicine and Collective Health in Latin America. 

[2] Vieira-da-Silva [5] analyses the genesis of Brazilian Collective Health, from the trajectories of its main founding agents, mainly physicians interested in mitigating the effects of social issues on the health of their patients, and sociologists. It is also worth mentioning the influence of Foucault’s visit to Brazil in 1974 [6], where he gave several lectures, and the participation of social movements, such as black women activists. Vieira-da-Silva defends the position that Collective Health is a field, although a relatively new field, as defined by Bourdieu [7]. It originates as part of a broader movement to modernize medicine and reform health systems in Latin America, even though the term ‘Collective Health’ has only been adopted in Brazil. The field emerges from criticism of traditional institutionalized Public Health, as well as from the Preventive Medicine movement; it was inspired by the European Social Medicine movement but sought to create something new from the Latin American experience; therefore, it has also been called Latin American Social Medicine in Brazil and in other countries of the continent. Its key premises are the democratization of health, which would accompany the broader democratization of the country, which has gone through a period of military dictatorship, with a strong political and practical character, in the transformation in the manner of practicing medicine itself, articulated with a theoretical development that grounded the practice and collective actions, based on Latin American social epidemiology and social determinants of health. See: Osmo and Schraiber [8], Barreto [9].


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