Communication interfaces and challenges in the Brazilian Unified Health System

This article aims to reflect on communication and health projects and strategies involved in the struggle for the right to health, construction and defense of the Unified Health System. Drawing on studies, debates and deliberations that have been ongoing since the 8th National Health Conference and based on contemporary communication configurations, it problematizes tensions, challenges and opportunities related to digital culture, journalistic coverage and public communication in health institutions in Brazil.


Introduction
Within the projects of Brazilian Health Reform and the Unified Health System, SUS, the links between democracy and health were woven to widen and historically contextualize the concept of health as a result of the ways in which each society organizes, produces and distributes its material and symbolic wealth.
In theses agreed during the 8th National Conference on Health, communication, cannot be dissociated from the possibilities of participation and is present in a number of areas including: the right to education and full information, freedom, free expression and organization; the ban on the advertising of medicines and products that are harmful to health; the proposed creation of a national information system, guaranteeing essential access to information necessary for the social control of the services 1 .More broadly, these references have as common ground the understanding that the reformist project would not advance without political struggle and awareness of the universal right to health and the causal links of health-disease processes, especially those involved in its social determination, joined together within the concept of health awareness 2 .
As it has been repeatedly highlighted since then, they transcended the sectoral boundaries and were inserted into the democratic projects of the nation 3 .
Registered in the 1988 Constitution as part of the social security model, the universal right to health preserved the footprints of its formulation and accumulated increasing challenges to its implementation.As in that time Brazil and the world were being engulfed by neoliberal waves, the struggles for the construction of the SUS, in its different frameworks of greater turbulence, resistance or advances that made it seem closer to the ideals of the Reform, were marked by chronic underfunding and became more complex with the changes of the demographic pattern of morbidity and mortality; with the precariousness of public policies in urban areas and in the countryside, with the growth of violence and environmental crimes.And, yet, with the development and incorporation of technology which, especially in health, redefine the work, the relationship of citizens with the professionals and the strategies of (inter)national economic groups in the area of health care, insurance, pharmaceutical laboratories, large industries of equipment and various inputs, making essential to the whole scene the media, market, supply and the demand of health.
Over the last 30 years, health communication interfaces within SUS continue to expand and diversify, consisting today of a sector made up of practices and production of knowledge.Since the early days of redemocratization, criticisms of the traditional conceptions that moved the practices of health education and communication were intensified: vertical, normative, centered on disease and biological aspects, dissociated from living conditions and disinterested in the dialogue with the population.Likewise, the "neoliberal trend of the media, which was so silent about SUDS", was highly criticized, as it conferred great visibility on its problems, "deviations" and positions contrary to the process of reorganization of the public health services" 4 .The advisors acting inside the health institutions were also under scrutiny through their work exclusively with the management and especially the manager, with the marks of personalism, most often linked to political-electoral projects.
This period of intense activity was not only under criticism, but it was also a productive practice and conceptual experimentation, intensified in the early years of the twenty-first century with the vigor and potential of digital networks.Concepts, actors, spaces, demands, projects and communication interfaces were expanded, mainly related to social participation, democratization of the state and public policies [5][6][7] .As well as themes and interests in search of legitimacy in the health sector itself, largely voiced during health conferences and in the congresses of the Brazilian Association of Collective Health (Abrasco: Associação Brasileira de Saúde Coletiva).
Along this route, we have defended a conception of communication 8 beyond the diversified set of services and technologies, with a more visible face, in order to highlight the processes of production, circulation and appropriation of meanings that allow individuals and collectivities to constitute themselves, the world and the society they inhabit.Under this perspective, communication cannot be confused with persuasion or dissemination, nor be restricted to the means that it can be used -although its grammars and the social uses that shape them are always decisive -; nor to the actions and technical products and professional categories that produce them -although these are fundamental for the public visibility of themes and subjects and, therefore for the struggle for plurality and reduction of asymmetries, especially when seen as practices that update or subvert crystallized relations of power.
As an alternative to the transference models and topical and segmented actions, we have proposed a communication itself conceived and carried out in accordance with the principles of SUS and not "just" to make them more visible.The universal right to communication addresses the right to information and the right to speech in public spaces for debate, technologically mediated or not.The Equity in communication recognizes that among the extreme concentration of material and symbolic wealth that characterizes Brazil, the word is one of the most conspicuous items, compromising democracy -which does not exist without plurality, recognition and visibility of political individuals and the effective conquest of citizenship rights, including health.We are talking here about concentration of communication media, but not only that.There are many voices that find very adverse conditions to be heard in institutions and even at health councils and conferences.Integrality, inspired by levels of health care, allows to reinforce the wholeness of the communicative circuit, so important for the primacy that production ("the emitter pole") holds in health practices.The debates and achievements that articulate the many faces of integrity and care also put in the foreground other principles that are so relevant to those who see communication as a dialogical relationship, as recognition of the wholeness and listening to others.Decentralization and participation, cross-cutting principles, are fundamentally linked to the deconcentration of power.As such, its conquest and exercise are achieved not only at councils and conferences, but at the daily actions of services and at other health institutions.
Having this scenery as reference, there would be many ways to discuss the relationship between communication and health, but we chose to problematize the media production and communication at health institutions.The choice of media, far from understanding it as the exclusive object of study or taking it as the ultimate representative of communication, recognizes its overflow to all spheres and social domains.Therefore, we start discussing how this communication setting has affected the relations and social practices, whether they are technologically mediated or not.Subsequently, we explore the studies focused on the analysis of media production on health, privileging the press coverage on SUS.The third part is dedicated to public communication at health institutions from a pioneering experience on the SUS pathway, the so-called Programa Radis, conducted by Fundação Oswaldo Cruz.

Communication and health in times of communication rearrangement
One of the most remarkable milestone of our times is the advent and impressive expansion of the internet and other digital media at the most varied spheres of human activity.This phenomenon has mobilized a heterogeneous group of thinkers from the most diverse areas of knowledge, who point out their organic connections with globalization and the consolidation of neoliberalism and financial capital, by making possible the planetary flows of information, along with new forms of social organization, conflicts and the perceptive structures they engender.
The sharp expansion of the technological possibilities of production, distribution and consumption of contemporary media culture marks the distance of societies characterized by the presence of the mass media.Among scholars of communication, the idea that the new configuration points to the mediatization of the social sphere, which extrapolates boundaries and previous forms of relations, has been gaining ground.It stresses a particular form of institutionalization, increasingly autonomous, in which the media and their logics are predominating in ascending degrees, going beyond its own means, but in its own non-mediatic social institutions 9 , and interpersonal daily relations producing practices and communicative, cultural and social changes 10 .
Increasingly driven by the acceleration of digital technologies and digital networks, terms such as logic and media culture take on broad meanings to encompass the institutional, aesthetic, norms and informal rules with which the media distributes resources and symbolic materials.Thus, these terms expand its meanings to all types of text-images, sounds, shows-with which individuals and groups shape opinions, behaviors, identities and expectations.Similarly, their grammars and ways of doing also become part of the "overall texture of experience" 11 .This omnipresence of media culture, expressed in the metaphors of overflowing and flooding, requires not only the study of changes experienced in one or more media in this new scenario, but other ways of understanding the relations between communication and society.
Among us, some formulations emphasize the mediatization phenomenon as an ongoing process.Braga 12 , characterizing the moment as a transition, locates the mediatization as an "interactional processuality of reference" to highlight that its logic and devices begin to encompass and give the tone without denying, however, other types of interaction.Making an analogy with written culture, he emphasizes that media turns out to drive the processes of social construction of reality.According to Verón 13 and Fausto Neto 14 , in societies where mediatization is in the process of being implemented, it is not enough to just refer to media as a field or central actor, as its logical and protocols impose themselves and become constituents of the operating mode itself of non-media institutions, processes and interactions between them and the social actors.Sodré's 15 statements go beyond this and claim the existence of a new way of life, the bios media, marked by increasing virtualization and tele-realization of human relationships.This technoculture results from the articulation that hybridizes social and media institutions, under the imperative of capital and market, transforming past forms of mediatization, perception and socialization, but does not cover social totality.
In these and other perspectives, there are relevant issues to health, as long as we have in mind Rubim's 16 advice that "the assertion of this new social and communication circumstances surely cannot arise preconceived and fixed behaviors involving the predominance of the power of communication about other social fields".From this point of view, the current scenario cannot be reduced once again to the issues of media, now that it is digitalized.Now we have to recognize the role of communicative technomediation culture, within the growing distrust of the political framework, and how its links to the market and social institutions is reconfiguring the ways of producing senses, subjects, sociability and power relations 17 .
Understood as such, there are many manifestations of this scenario in the health sector.Teixeira et al. 18 , in their article about SUS and a humanized network, offer a synthesis: Computational and communicative resources invaded not just the 'hard technologies' of health (Merhy 2002) but also its field of relations and knowledge production: e-mails, electronic medical records, computerized systems of finance and job scheduling, monitoring and evaluation of health programs, teleconferences, e-learning courses and communities of practices, are some of the examples of how the internet, computing and its possibilities are here to stay and are making a space increasingly expressive at SUS, particularly, with the arrival of new generations of professionals already familiar with life in cyberspace.
Therefore, this is not separate technologies, but immersion into a technological constella-tion, which we not only use, but which also have a force of modeling and expressive character, so more naturalized and daily intertwined in affective relations, work and leisure.Thus, their appropriation, in the sense of being oriented toward our ethical and political projects, requires more than a change in the ideological sense of the "content they convey".The article from which we extracted the above quote is a good example to address the various dimensions of collective work and collective structure involved, the option for the collaborative design of the platform, through editing, curating and articulation with other social networks.
The profusion of practices and arrangements for the optimization of body and mind is another strong repercussion of the mediatization processes in the field of health.There are applications that monitor and quantify almost every daily activity, bodily functions, such as heartbeat, the amount and composition of ingested liquids, changes in mood, sleep quality, and so on.Software that relate a multitude of individual data move specific segments of digital technology companies and expand the supply of apparatus for individual risk management, fault correction and improvement of performances 19 .
Health crises, especially the epidemics, make some of the most experienced characteristics of today even more acute.The recent zika epidemic and its association with congenital malformations have highlighted the hybridization of discursive relations and practices among scientific, public health, and media fields.The crisis has put in the forefront the changes related to online communication acceleration and to the multiple voices in different spaces throughout internet.The demands and expectations for explanations have become as fast and relevant as the circulation of the virus, in fierce debates often moved by rumors 20 , the unauthorized versions.According to Araújo and Aguiar 21 , in addition to intensifying exponentially the practices of health and research institutions' media advisory services, which already rely on devices of the media field itself -releases, individual and collective interviews, etc. -the event stressed the mediatization of production and scientific communication, when the logic of the press release replaced, at least provisionally, the canon of peers' review for the publication of articles on the subject in specialized journals.
Finally, the processes of mediatization affect the media field itself hitting the set of practices involved in the production, circulation and reception processes.Perhaps the most relevant milestone is the dilution of the frontiers of this circuit, which before were desired to be so well marked, especially the exacerbation of the circulation embedded in the digital culture.It is within this dimension that the disturbances brought about by the meeting of voices, authorized or not, on the most diverse subjects are manifested: initiatives that amplify the emancipatory power of collective action, but also those of the programmed robots and "fake news".
The so-called traditional media are not immune, they do not either remain traditional, as they have to compete in radically different conditions, not only by developing products for the Internet and by taking advantage of the resources of increasing technological convergence, but also by bringing into their own formats those which no longer fit in the reception 15 .This is especially observed in journalism, either on inserting lines and images recorded with cell phones, either by opening the newsroom backstage scenes or the deepening of narrative shapes increasingly informal.Fairclough 22 calls this type of operation, which is not exclusive of the media, "simulated democracy" because it makes us believe that this is a horizontal relationship by erasing the brands that make explicit the hierarchical positions.These narratives are addressed below.

The health in media and the media health
Discussions and studies devoted to press coverage have pointed out the systematic association of SUS to failures, absences and risk, creating and maintaining the perception of the SUS-problem 23 .Deviation of funds, mismanagement, batches of drugs, sophisticated equipment that are damaged before they are used, and especially the lines of people, make up the body of images and information, largely related to the health care component and "almost always from an alleged inefficiency of the State, incompetence of authorities or professionals in the sector, leading to the construction of a symbolic order little reflective about the field of health policy represented by SUS." 24 Such positioning tends to be maintained even in favorable moments, as Machado' 25 analysis highlights on the positive perception of those who use SUS and the poor visibility of these results, or its transformation, on the pages of O Globo newspaper.
Cavalcante 26 provides concrete evidence of the magnitude of the health care component and the silencing operations: for a six-month analy-sis of the coverage of Diário do Nordeste (CE) in 2013, it had to restrict the SUS universe to the health care services component reaching 943 texts.In a second movement of restriction, the criterion was the appointment of SUS and that universe was reduced to 132 articles, a result in itself eloquent.Out of these texts, 25 had a special call or headline on the cover-page, which as we know is the space reserved for the articles that any newspaper qualifies as greater importance and which draws the attention of the reader.On this "window", SUS was clearly mentioned in just eight articles, most of them involving negative coverage, according to the author.
In the articles, there is a large predominance of national and international official speeches, followed by the presence of specialists in the subject, generally linked to public universities, professional councils and medical scientific societies.The presence of the health professional, the citizen who uses SUS, patients, families, disease associations and social movements is quite variable; more stable is the invisibility of the health advice and advisers.
The narrative strategies used are rather heterogenic.They depend not only on the type of article, the type and seriousness of the article, but also the frame and vehicle type.There are two regularities observed: the convergence of the speeches with the adopted point of view and, when it comes to denunciation of poor care, overcrowding, critical situations, such as epidemics, the tendency is to accentuate the dramatic tones, images of fear, suffering and indignation.
These strategies in times of health emergency accentuate other features highlighted in studies of journalistic studies on health: the bombastic headlines, the supremacy of numbers, in general in absolute terms, decontextualized and often placed on timescales that accentuate the gravity of the situation (increasing the growth of cases and number of deaths) or the lack of preparation and negligence of the services to deal with the situation (mentioning the waiting time for care) 26,27 .
Several explanations are listed in these and other works, as well as at discussion forums, including those who reject the existence of a partial coverage and credit these characteristics to the factual records -after all, the problems effectively exist and it is the basic duty of the press to show and report them.The prevalence of the SUS-problem, however, is recognized among those who believe or presuppose the credentials of journalism -objectivity (faithful narrative), impartiality (there is no preference for either side involved) and neutrality (commitment to facts, not to those who can benefit or harm with their disclosure) -as well as by the most skeptical ones about these credentials and practice guided by their own criteria of relevance.
The studies based on critical perspectives of speech 24,[26][27][28] have highlighted not only what was said, but fundamentally the ways of saying, work that necessarily implies privileging certain categories, classifications -the concept of disease or health, but also what goes in the editorial of politics or science, with which illustration -that make up certain explanatory schemes, the truer the more naturalized are their tools of production of the real.Such references discharge any possibility to understand media as a space or tool at the service of society.Thus, the forms acquire relevance, such as media, and the journalism especially translates consensus, conflicts and unequal social relations in certain cultural settings.They emphasize that the media analysis cannot exist out the forces that moves society, which presses either for expansion of its spaces and visibility by the change in the rules in the game and either for its maintenance.

Ups and downs of public health communication
The debate, still open, on the concept of public communication also had as a mobilizing factor the redemocratization of the country and the Constitution of 1988 29 .In this text, public communication is one in which the greatest possible diversity of voices has the opportunity to interact providing a space for sharing and trading of the most different interests and senses, privileging the human right to communicate beyond the simple access to information, a process necessarily dialogic and participative.This concept presupposes autonomy of citizens and collectivities in an arena in which both the processes related to the State and to society are present.
Brazil does not have this tradition within the scope of the State, whose authoritarian and patrimonialist bias directs initiatives and communicational processes to the interests of governments or political parties in power.Nor does it occur within society, because of the oligopolistic nature of commercial communication, which subjects public concessions to the interests of a few families, politicalparties and religious groups.As we have seen, the assumption of autonomy and plurality also finds no space in a communication system fundamentally oriented to protect and reproduce its own interests, those of the market and of capital.
The democratic principles of public communication have similarities with the principles of SUS, but communicational processes in the health field that value plurality still face innumerable obstacles to its constitution and sustainability.The examination of experiences that seek to be driven by the exercise of the right to communicate helps us to understand the ups and downs of communication faced by SUS.
Created in 1982, at Sergio Arouca National Public Health School of Oswaldo Cruz Foundation (Fiocruz), the so-called Radis Project had a daily presence in collective health over the last decades, covering the main moments and discussions of the sector and the construction of SUS, since the troubled voting of the 1988 Constitution and the Health Organic Law, in the National Congress, promising experiences of regionalization and pre-SUS municipalization, countless debates, congresses, and health conferences, to the most recent approaches of sustainability and the expansion of rights.
In 2002, at the launch of the Radis magazine, the Program underwent significant changes in its editorial style.Maintaining the expanded concept of health and the social determination of health and disease processes as references, the press coverage incorporated new themes and struggles, which were not associated with the traditional repertoire of the health movement.Voices and perspectives of movements related to other human rights led the discussion beyond the arena of public health.
Another movement of expansion followed the path of its own debates on communication, often left aside in the sector of collective health, due to the predominance of instrumental vision.A bigger and constant space also in the defense of issues related to the democratization of communication in the country.
The magazine, which is distributed to more than 100,000 readers in all of Brazil's municipalities, and is accessible through the internet and social networks, brings together articles and opinions of readers and other sources.The major shift has been the transformation of its role as a "messenger" of collective health to that of a space of public communication increasingly populated by new and different voices, influenced by its own editorial line in the construction of guidelines and process of production and edition of the articles.This has been a dialectical process in which the magazine opens to new interlocutors and, at the same time, sees this opening extended by them, depending on the need and desire to communicate.The more silenced voices in other spaces appropriate the discursive space of the magazine, the more interest the readers manifest, flagging a desire not only to speak, but also to hear other less current voices.The articles try to hear the social movements and the citizens involved with the subjects, as well as researchers and experts.The user, the worker, the manager and the health adviser all talk about SUS.

Hegemonic communication in health
As we already know how unusual this perspective is in most related commercial media vehicles, it may seem trivial and even obvious in communication performed by public institutions committed to SUS.The reality, however, is more complex, and imposes challenges to the daily construction of collective narratives permeated by diversity and contradictory points of view.In large part, such narratives are also among those that explain why the principle of participation and social control, which distinguishes the design of SUS, although imposed by legislation and required as a counterpart of budget transfers among the Federation bodies, never fully took place in most health boards of the three spheres of Government, nor, particularly, in the daily lives of health units and the system management, as evidenced in the discussions occurring at the National Health Conferences.
On one hand, there is a set of difficulties arising out of the authoritarian Brazilian tradition, that translate into a quite specific conception of mentored participation that approaches or confuses the accession to certain viewpoints and predefined schedules.Regardless of value judgments as for the proposals on the screen, the institutional communication vehicles can change the ideological direction, but tend to preserve some brands criticized since the first moments of construction of SUS, such as the personalization of management and its achievements, the absence of dissent, the presence of singular, confirmatory voices.
The hegemonic speeches which daily advocate a private or privatized system, also weaken the constitutional right to health, in so many ways, in the spaces of SUS themselves.It is no different in press consultancies, starting with the increasing outsourcing and high turnover, at the initiative of the managers themselves.Overwhelmed by financial and political crisis, other difficulties or interests, it is not often the interest in training these professionals about SUS itself and its communicational dimensions.The fact is that the reproduction of market strategies and models find much more favorable ground than the more critical, decentralized and in line critiques with SUS principles would require.Despite many initiatives that advance in more dialogic and permanent relations, the emphasis on disclosure ends up prevailing even when working with digital social networks, with greater potential for interaction, or when seeking, in conjunction with health counselors and popular communicators, more room for a positive view of SUS, giving up to consider the practical experience in dialogue with citizens and movements.Likewise, it is reaffirmed that the major problem to be faced -in health promotion or disease prevention strategies -is the ignorance of the population and not the type of knowledge, and the existing social conditions to obtain it or to challenge it.Therefore, there is a political struggle involved.
Over the last 15 years, the militancy for the democratization of communication and awareness of the importance of communication on the part of social movements, health councils, instances of SUS and collective health entities was intensified 30,31 .More meaningful advances will be hardly obtained, however, if such issues are not embraced within the political agenda of SUS and future emancipative movements that will take place in 2018, another major challenge shall arise.

Conclusion
Throughout the three topics of this article we tried to point out elements of the communication sphere involved in the struggle for the right to health, in the construction and defense of SUS.The picture is not complete and our opinions and provocations had the main aim of pointing out the urgency to rethink our practices and agree on a communication policy of SUS as strong as the current challenges.As much as it depends on the best knowledge, art and commitment of its communicators, we shall hardly advance if SUS communication does not exceed and transform technical areas.
Two milestones seem to be decisive.On the one hand, we should radicalize the right to communication, universally and in an equitable manner, in the daily actions of health and citizenship.And by understanding these connections as vi-tal to health and democracy, we should include them among the social determinants of health.On the other hand, we should understand the specificities, but not compartmentalizing spaces and technologies.The creation of channels, websites, pages or spaces in future networks is certainly indispensable and is inevitable.However, these initiatives, when thought of as isolated or even integrated action, under the hegemony of marketing models or organizational communication in the ways touted by the market, seem to us not only insufficient, but also going the opposite direction of SUS and Sanitary Reform projects.Thinking of them under the inspiration of the multiple faces of integrity and care, and facing the challenges of media coverage, it may offer us new ways of doing.
In both cases, the paths that allow participation and re-encounter with social movements, not only those of health, not only in councils and conferences, continue to be transversal and lead us to routes that approach us to the project of democratic society, fairer and more cooperative, that boosts SUS.

Collaborations
JM Cardoso and RL Rocha participated in the design, bibliographical research, review and final approval of the manuscript.RL Rocha contributed towards writing the text related to public communication and JM Cardoso to the other sections.