André Costa* (CCS)
Repeated discontinuities, tendencies to think in the short term to contain emergencies only, a sometimes tense and sometimes complementary relationship between different cultures, and in the midst of it, a series of practices and efforts to create an inclusive and egalitarian health: these are the four main characteristics of the history of health in Latin America, according to one of its greatest experts, Peruvian historian Marcos Cueto, professor of the Postgraduate Program in History of Sciences and Health from Casa de Oswaldo Cruz (COC/Fiocruz).
In April, Cueto and Steven Palmer, from the University of Windsor (Canada), won the award for the best book on health, science and technology from the Latin American Studies Association (Lasa) for their work Medicine and Public Health in Latin America: A History (Cambridge University Press).
In this interview, the historian presents the main ideas of the book, and argues that the development of medicine in the region was not a mere copy of what was done elsewhere, but that local players played an autonomous role that led to health practices specific to the continent. Cueto also posits the importance of the memory of health: "for some matters, sometimes military, sometimes financial, money is always available. But others that have to do directly with the population, such as health and education, lack resources, because they do not involve immediate profit. That is precisely why it is important to keep alive the memory of history and collective social struggle for health".
Q: What are the main recurrences and permanence that we find in the history of health in Latin America?
Marcos Cueto: We mainly identified four characteristics that cross the history of health in the continent. First, medicine and health practices here derive from a mix of many different cultures. This is a particularity of the continent when compared to other regions in the world. Here, European medicine has mixed with indigenous medicine and also with practices from other regions, such as African and Chinese medicine. These hybrid and mixed-race understandings of health are a hallmark of Latin America. Second, in Latin America, it is recurrent that public health, official health, is born as a patch for emergencies. Health is not traditionally thought by the authorities on the long-term. We define this pattern as a culture of survival. It is not meant to plan, but rather to control epidemics, for example. On the other hand, a third pattern we find is a group of sanitarians who wanted to make health more popular, more collective, for example Sérgio Arouca here in Fiocruz and Brazil. Each country has a similar character that sought a more collective health. We define these efforts as health in adversity. Lastly, in general, hybrid medicine or survival culture failed to have a long-term project. Thus, discontinuity is a recurring factor in the history of health in Latin America. Not finishing the projects is not a fault of us, but this sometimes seems like a vocation, not finishing things. I think these are the main patterns we have found.
Q: Could you better explain what that vocation for discontinuity would be?
Marcos Cueto: Let me give you some examples. In the 1950s, the priority in the health agenda was the eradication of malaria. In 1955, it was believed that malaria would be eradicated in five or eight years. When this date arrived and malaria was not eradicated, the subject changed and the focus was no longer on that. This pattern occurs in all Latin American countries - as well as in many of the world. In 1978, the World Health Organization (WHO) decided at an international conference that its target was "health for all by the year 2000". By 1999, it was already clear that this goal would not be achieved. But reports immediately began to appear saying "Health for all in the 21st Century."
And in recent years, for example, when antiretroviral drugs first appeared for AIDS, there was a proposal of three million antiretroviral drugs for the entire population of the world in 2005. And that goal was not reached. And then we moved on to a new program. But why do we do that? It has to do with a very strong weight of politics in technical health decisions, and also because we get used to this circular behavior of not finishing the project, of thinking that it is all right not to complete an initiative; when we are about to reach a deadline, we do not take a look at what happened, and we immediately appear with another project.
Q: And how about medical pluralism - what is the history of the development of practices from multiple cultures? Which tensions marked its pathway? Is medical pluralism still verified today?
Marcos Cueto: Yes, medical pluralism still exists today - although in some countries, such as Bolivia, Peru, Ecuador and Guatemala, more than in others. These countries have a stronger indigenous population. In Brazil, this influence is less present, but there is still something. For a long time, there were two positions regarding indigenous medicine: first, an official position of persecution. In many countries, near the end of the 20th century, it was illegal to practice indigenous medicine or other kind of medicine such as homeopathy. Only official medicine was allowed. On the other hand, official medical schools did not produce as many doctors as the countries needed, so in practice an agreement was reached between practitioners of Western European medicine and medical practitioners of unofficial health such as indigenous physicians.
Thus, there was a relation of conflicts of tolerance and persecution at the same time. In recent years there has been an attempt, in some countries more than in others, to do what is beginning to be called intercultural health. The concept defines health practices that respect other ideas about the human body and disease, and that respect the practices of healers. For example in Bolivia, the deputy minister of Health is an indigenous physician. And hospitals there allow both Western and indigenous physicians to work at the same time. It is often thought that traditional indigenous medicine serves only to discover the active ingredient of medicinal plants. It is known, however, that knowledge often goes much further; there is knowledge about the method of using plants, for example, and also the psychological treatment that traditional physicians perform with their patients, which is very important and gets lost in Western medicine. The relationship between Western medicine and indigenous medicine remains tense and complementary, contradictory and conflicting.
Q: And what would be the culture of survival? In the book, it is said that this culture is not characterized by a policy to integrate poor sectors into society, but rather to contain emergencies. Could you explain a little better what this culture is?
Marcos Cueto: One of the problems of medicine and public health is that they always need some political idea to be legitimized. In principle, the common idea is that medicine and public health will provide the physical and mental well-being of the population. But in practice it is not just like that: for governments, health must always be something else. That is, public health is often used as a tool for economic growth, or it is required that public health will not mean big expenses in the budget of states, or public health is used only to control social emergencies such as epidemics. This culture of survival may mean, for example, spending as little as possible on the area of health, or spending more on treatment than on prevention. Or, it is often simpler to think with what health historians like to call magic bullets - that is, the idea that a drug can solve a problem by itself, such as the silver bullets that killed werewolves.
So it is often thought that the solution to AIDS is antiretroviral drugs, or that the solution to malaria is insecticides, or that the solution to tuberculosis is the supervised use of drugs. And all this is important, no doubt, but to face each one of these three diseases, which are considered the main diseases today in Latin America and worldwide, many more actions are needed. For example, alongside retroviral drugs there must be a fight for sex education, a fight against homophobia, a fight for prevention, participation of partners and sick people etc. That is, a broad social sense of collectivity and prevention in public health is neglected in this culture of survival. And we see that today, when try to reduce the budget for health, or when they try to reduce health care, promoting instead some treatments like magic formulas.
Q: Do you understand the current conjuncture of threats to Unified Health System (SUS) as another return of this pattern?
Marcos Cueto: Yes, but in my opinion as a foreigner, SUS was an excellent idea that should be respected and defended. SUS arises with the idea that health – in all its aspects, including prevention, treatment, rehabilitation – is a social and citizens’ right. And now this is being forgotten to turn the system into something very limited, like a package of treatments for sick or very poor people. SUS has many problems, but, like other health systems, it came up with the idea that the rights of citizens are not limited to voting, but also to have a good education and good health service. This idea needs to be regained.
Q: And would you answer critics who say that the budget is not enough to fulfill that right?
Marcos Cueto: This has to do with a general discussion of society. What are the priorities of state spending? Military expenditures? Expenses to pay for economic emergencies? Or spending on things that the population needs? I think if the priorities were reversed, there would be money to do that. I will give a more international example that has to do with Latin America. A few years ago, a very important commission in the WHO, called the Commission on Social Determinants of Health, sought to find the social origins of diseases. And the members of this commission, where many Brazilians participated, thought that the problem of diarrheal diseases, common in favelas [slums], would be solved with 1 billion dollars. They made that proposal in the year 2007, and the answer from the bank and many official agencies was that it was an inaccessible amount for the health system. In the following year, 2008, came the crisis of banks, when the banks of the United States broke; in a few weeks, the US federal government got 700 billion dollars to save them. And then this discrepancy was much discussed. This was a demonstration that for some issues, sometimes military, sometimes financial, money is always available. But others that have to do directly with the population, such as health and education, lack resources, because they do not involve immediate profit. That is precisely why it is important to keep alive the memory of history and collective social struggle for health.
Q: Finally, I would be grateful if you could comment on the fourth concept you mentioned in the beginning: health in diversity.
Marcos Cueto: The culture of survival is not something hegemonic: there are always resistances and alternatives. And that is the health in adversity. There have always been people, groups, universities, magazines, NGOs, and patients who are fighting for a more comprehensive health, at different historical moments. In Brazil, the 8th National Health Conference, in the middle of the 1980s, followed the whole process of democratization and gave rise to SUS, putting in the Constitution that health was a right of citizens. The group also created this term of Collective Health, which does not exist in the rest of Latin America; the idea that health is a community struggle, not just what the state provides to the person. Another example is the case of AIDS, where there was intense participation of NGOs, patients and partners. When antiretroviral drugs appeared, they were very costly. Brazil was the first country that decided in 1996 to provide free antiretroviral drugs to all citizens who needed it. At the time, everyone was saying that this was impossible for a developing country. And the country made that decision by challenging the pharmaceutical companies, which felt that this would break their patent. After a few years, the whole world began to celebrate Brazil, but for a time, from 1996 to 2001, many of these pharmaceutical companies criticized Brazil as if the country was challenging the economic order of health. I think this was another example to show that, when there is interest for the population, it is possible to do different, and change the rules of the game.
*With the participation of Mathes Carvalho.