de almeida : builder of bridges between Nursing and Public Health in Brazil

Professor Maria Cecília Puntel de Almeida (1944-2009) built a professional and academic career of which the main feature was her attempt to create and strengthen the interface between Nursing and Public Health in Brazil. From the beginning of her career she recognized this connection and understood the complexity of health problems and peoples’ needs when seeking care. Her commitment took the form of both scientific output and also her contributions to the various fields in which she worked. As well as her contribution to the concept of the work process of nursing, she contributed to thinking on health practices and multi-professional training in the construction of a differentiated body of knowledge, which she approached from the perspective of the struggle for democracy in health and understanding of this as a right of citizenship.


the quest for training in public health
In the professional and academic career of Maria Cecília Puntel de Almeida (1944-2009) we see her activity in two fields: public health, and nursing.She contributed an important leadership, whose effects remain today, since the impacts of her contributions to Brazilian nursing are still present and remain up-to-date.This article, however, highlights the interface in which she operated, and which led to theoretical and conceptual contributions on public health being a strong component of her academic output.
She was affectionately known by all those who knew her as Professor Cecília, and began her activity in health when still very young, starting the nursing course at the Ribeirão Preto Nursing School of São Paulo University (EERP-USP) at the age of 17.
Graduating in 1963, she opted to enter the world of work immediately, by the path of public health.She was hired as a nurse at the Vila Lobato Community Social Medical Center, a health unit linked at the time to the Childcare Departments -pediatrics, gynecology and obstetrics, and preventive medicine -of the Ribeirão Preto Medical Faculty of USP (FMRP-USP) and the Hospital das Clínicas of the Ribeirão Preto Medical Faculty (HCFMRP-USP).The purpose of this unit was to provide maternal and child care and also to work in the community -thus it had different features from the hospital environment, and this seems to have been a factor which set off her desire to continue her training in the field of public health.
Her master's degree, in 1966 and 1967 at the National School of Public Health, of the Oswaldo Cruz Foundation (ENSP/Fiocruz), culminated in her dissertation "Public health nursing in the Health Unit 1 ", given when she was still a public health nurse at HCFMRP-USP.In her Memorandum for the competition for the Professorship of EERP/USP she recorded that "The fact of having done her master's degree at another unit, outside Ribeirão Preto and with other public health professionals [...] enabled me to start professional activity with a more general view of the problems of health and the importance of a multidisciplinary approach for treating these problems" 2,3 .
Certainly the work experience allied to her interaction, while doing her master's degree, with other professionals in a context of strong political mobilization in the country enabled her horizons of activity and comprehension of teamwork to be widened, in a multi-professional and interdisciplinary approach -aspects which are so necessary to the field of health.In a way, this question was a strong feature of her work as a nurse, teacher and researcher, present in her scientific output and in her activity as mentor of professionals in the postgraduate environment.
Her activity in this master's degree course was in a contrary direction to the scientific output relating to Brazilian nursing at the time, which tended to give exaggerated value to internal aspects of the profession, such as techniques applied in care, preparation of care models, evaluation of bio-psychosocial care, etc. 3 .Soon after completion of her master's degree, she entered EERP-USP as a teacher, where she dedicated her full time to teaching, research and extension courses -seeking to put the tripartite model that still characterizes USP today into practice.She was a professor there for four decades, until she retired in 2008, for reasons of health.
She recognized the close interface between public health and nursing from the beginning of her career, which both reflected her comprehension of the complexity of the problems of health and of peoples' needs in seeking healthcare, and also helped expand her understanding of these factors.Both her scientific output and her contributions in the various areas in which she worked show recognition that "health problems go beyond the barriers and frontiers of the professions, and care is involved in a complexity that calls out for a diversity of knowledges and actions" 3 .
In the 1970s, as a professor at EERP-USP, she took part, together with other teachers of EERP-USP, in a seminar of the Pan American Health Organization (PAHO -or Organização Pan-Americana da Saúde: OPAS), in Cali, Colombia, coordinated by Juan Cezar Garcia and Olga Verderese 4 .That seminar sought to develop the plan for establishment of Nursing Research Centers in Latin America, and was planned and held under strong influence of Juan Cesar, a pioneer of the social sciences in health in Latin America, who recognized the limits of positivism in dealing with problems of health and the need to introduce new methodologies and theoretical frameworks that would make it possible to relate the social structures to the social problems, making progress in a historical-dialectic 5 outlook.
In the pioneer study of medical education in Latin America (1972), Juan Cesar "adopted a theoretical approach that made it possible to analyze medical education not only as an isolated pro-cess, but as a historical process, subordinated to the predominantly economic structure in society where it develops 6 .The same focus was adopted, in 1974, in the study that the author made in partnership with Olga Verderese, on nursing in Latin America, with a focus on the prestige of the profession and its relationships with structural factors.
On returning from the Seminar in Cali, Cecília organized a study group on the theoretical and methodological approaches of the social sciences and their application to the field of health and nursing, continuing the frame of reference with which she had had contact.She invited the sociologist Graciete Borges Silva, with whom she had worked in a long partnership at EERP-USP, to give support to the group's studies.This would later be the origin of the movement to constitute nursing research groups, in Brazil, such as NUPESCO -the Public health Research and Study Center (Núcleo de Pesquisa e Estudos em Saúde Coletiva) of EERP-USP, which for a long time had the benefit of the work of Ricardo Bruno Mendes Gonçalves.This movement also influenced the constitution of the CEPEn -the Nursing Research Center (Centro de Pesquisa em Enfermagem), connected to the Brazilian Nursing Association (Associação Brasileira de Enfermagem -ABEn), and indirectly the conception and creation of the Nursing Research Development Support Center of PAHO/WHO, headquartered at EERP-USP 5 .
In Washington, at the end of the 1970s, another seminar of the PAHO was held with the aim of moving forward with studies on research surveys in nursing, which included presentation of the work "Introduction to analysis of the transformations in the practice of nursing in Brazil from 1920 to 1978", of which the authors were Cecília, Graciete Borges Silva, Márcia Caron-Ruffino, and Dayse Steagall Gomes 4 . This study had a very strong influence in turning around the dominant thinking in Brazilian nursing at the time, introducing the structural historic reference-frame, with a Marxist origin, in approaching nursing practice.
The doctorate, also at the National Public health School (ENSP/Fiocruz), made possible the meetings with -among others -Maria Cecília Ferro Donnangelo and Ricardo Bruno Mendes Gonçalves, who also influenced Cecília's academic output, and with whom she established a partnership.

debate on the process of work and the production of knowledge
In 1984, Cecília presented her thesis entitled "Study of the knowledge of nursing and its practical dimension" (Estudo do saber de enfermagem e sua dimensão prática) 7 , published as a book in 1986 and republished in 1989 8 .This production was a landmark for Brazilian nursing, both in relation to the theoretical and methodological situation, and also in the possibility that it brought with it of recognition of a group of complex questions that characterize the area.The study adopted a Marxist frame of reference, thus enabling an approach to nursing as a social practice consisting of the process of division of labor in health and in a manner articulated to the other practices and to the method of organization of capitalist society.
By studying Brazilian nursing as work, Cecília centered, as principle of focus of investigation, on its instruments, especially knowledge in nursing, which led her to explore the training of nurses in the country, from the early part of the 20 th century -what contents were transmitted in professional training, in relation to insertion into the labor market in health 8 .
In this study Cecília analyzes that the constitution of the knowledge of nursing takes place based on the techniques of nursing, incremented in the period around the 1950s with a knowledge of their scientific fundamentals, followed by a movement that sought construction of theories of nursing, especially of the process of nursing, which breaks down into what is currently called systematization of nursing care.This analysis makes it possible to identify a group of contradictions of the process of work in nursing, such as the centrality of the execution of techniques, in a practice which states itself to be characterized by care, and the predominance of the role of the management, in the nurse's work, which reproduces the division of "internal" work and nursing -reproducing a division of work oriented by tasks and not by patients' and families' needs for care 9 .
Cecília broadened the analysis of nursing in Brazil as a social practice, in that she took this approach to the forums of discussion of the Brazilian Nursing Association (ABEn).She participat-ed actively in the organization of various national Nursing Research Seminars (SENPE), and she was part of the Subjects Committee in the Brazilian Nursing Congress (CBEn) for numerous different years, especially in the 1980s and 1990s.To the CBEn congresses, she brought the theoretical focus of the process of work as a foundation for understanding of the professional training, insertion into the labor market and the social and political determinants of the activity of nursing workers in the health services network.
In her Habilitation Thesis, entitled "The job of nursing and its articulation with the process of work in public health", defended in 1991, in the department of maternal and infant nursing and public health of EERP-USP 10 , Cecília continued to study the practice of nursing in primary healthcare units, now supported on the concept of "technological organization of work" introduced by Ricardo Bruno Mendes Gonçalves in his Doctorate 11 .This analytical category, allied to the "process of work", made it possible to make in-depth study of the organization of the work of nursing and of health in the interior of the services and of the health care network, dealing with the logic or rationality that is the foundation for the actions of care and of management, and the lacunas arising from its fragmentation.
Based on Cecília's output, and her influence in the Nursing Postgraduate Programs of Brazil, innumerable other studies have been produced based on her theoretical framework -studies on: the practices of nursing in public health, in the area of mental health, and in the movement for de-institutionalization; clinical nursing in the hospital space; care for the hospitalized child; care in neonatal units; the practices of local management of basic health services; welcoming and acceptance of users; the network of established relations in team health work; and various other subjects 12 .
In the reflection on the peculiarities of the work of nursing and of health, Cecília and Semiramis Melani Melo Rocha, another colleague of EERP-USP with whom she built a close partnership, analyzed the teamwork and inter-disciplinarity as significant aspects of care.According to Rocha & Almeida, the instrumental logic that provides sustenance to work in health and nursing, anchored on physiopathology for diagnosis and treatment, obtains relative success, but is insufficient because it does not consider the experience being lived by the subjects of care, which requires a more active stance of interrelation and interdisciplinary dialog 13 .Thus, according to the authors, "The knowledge that is capable of providing the grounds for nursing care should be constructed at the intersection between philosophy, which deals with the great existential question of man, science and technology, having formal logic as the agency responsible for structuring rules, and ethics, that is to say an epistemological approach that is in practice committed to human emancipation" 13 .
Beyond the comprehension of the work process of nursing, Cecília also contributed to thinking on practices in health, and was linked to various different forums of discussion that were seeking alternatives for the training of health professionals and their insertion into the world of work.
Ricardo Ayres, in the video in homage to Cecília, states that by creating the conceptual frame of reference for thinking about practice in nursing, she contributed to rethinking of the practice in health in Brazil, and today it is impossible to talk about practices in health without entering into a dialog with her work as an author 5 .
The approach to the work and the work process, brought to the field of Public health by Cecília Donnangelo and Ricardo Bruno, and to the field of Nursing by Cecília Puntel, made possible an innovative approach to the questions related to human resources policies, in particular in relation to the training of health professionals and the management of the work.
Cecília's activity was very important for the comprehension, in her field of action at EERP-USP, and in the field of Public Health, that multi-professional training could contribute not only to the joint circulation of different professionals, but that this circulation would be extremely important for the construction of differentiated spheres of knowledge: knowledge of how to live with other workers in the construction of work in health; knowledge of how to carry out articulated health practices; and knowledge of how to learn from professionals of other fields of training for healthcare.
In this sense, her activity as an educator of people for research and for health services is evidenced by the orientation of a group of 18 master's degree candidates and 22 doctorate students with a range of different trainings, including nurses, doctors, social assistants, and dentists.
In the field of Nursing, she made a marked contribution to the constitution of postgraduate programs in Public health, both in her own school, EERP-USP, and in others.She inspired collaboration in the construction of the Depart-ment of Nursing in Public health at the São Paulo University School of Nursing (EEUSP), and in the related postgraduate program, and also in the constitution of the Doctorate Course of the Ana Nery Nursing School, of Rio de Janeiro Federal University.In both programs Cecília taught disciplines about the theoretical foundations of the process of work in health and nursing, and on nursing in the context of health practices and the health policies of the country.
This activity had a very strong influence on the formation of other programs, since the professionals that she trained when they returned to their home states, especially in the northeast of Brazil, were able to constitute new courses to train workers in nursing with a focus on public health.
Cecília had a wide understanding of health and engaged in the process of construction of Brazil's Unified Health System (SUS), both in local and regional activities in Ribeirão Preto, São Paulo State, and also in the national scenario in relationship with the Health Ministry, especially in projects to train health and nursing professionals.
Thinking once more about Cecília's career, one perceives her concern and significant contribution in the articulation of the actions in training and research into care and management of care and in nursing.In the scenario of the SUS and from the point of view of citizenship, Cecília sought to understand and share the profound connection between the manner of living, work and health of individuals, social groups and the Brazilian population, having as a point of view the quest for democracy and health and the comprehension of health as a right of citizenship.

Collaborations
MJ Scochi, SM Mishima and M Peduzzi participated equally in all stages of preparation of the article.
She invited Donnangelo to collaborate in the first National Nursing Research Seminar (SENPE) held in Ribeirão Preto, São Paulo State, in 1979, and Ricardo Bruno to collaborate in NUPESCO, a group that she coordinated until she retired.