The importance of the historical perspective for social thinking in health : the contributions of Madel Luz and

This article examines the work of two authors who represent academic production on collective health from 1970 to 1980: Madel Luz and Emerson Merhy. Their theoretical production was based on Marxist studies and Michel Foucault, and centered on history. The object of this analysis was this particular aspect, which became important to the field of collective health, since the authors broke with previous positivist and evolutionist thinking on health. Although Luz and Merhy reiterated the ideas and methodological approaches of their predecessors, they were part of the group that launched a critical historiography in the field of health. Studying works like these builds understanding on the relevance of historicity in the relationship between collective health, politics, learning, and practice.

T his article questions the use of historical perspective in the field of collective health in Brazil.It is founded on certain studies that currently comprise what can be called social thinking on health in Brazil, and is part of the results of a project entitled "Reflexões sobre o pensamento social em saúde, um estudo teórico acerca da produção da saúde coletiva" ("Reflections on social thinking in health, a theoretical study on the production of collective health"), 1 which focused on original theoretical production in the field of collective health during the 1970s and 1980s 2 and contains approaches involving sociological, social-historical, and political-economic matrices.
The research project focused on the theoretical and methodological approaches of authors and works considered to be representative of the field, because they address scientific production which is interested in a new way of thinking about public health; in other words, they highlight perspectives of the analyses on Brazilian social formation and also investigate new theoretical, analytical, and interpretative models.Based on these assumptions, these studies were considered "classic" 3 or foundational in the field of collective health.
According to Minayo (2010, p.79), during the 1960s and 1970s the phenomenological model was extremely important as a counterpoint to the positivist analyses which had dominated studies in the field until that time.The 1970s also saw the growth of Marxist studies, in which medicine and public health are depicted from the viewpoint of class struggle, relations and domination, and labor.Within these studies, history becomes a cornerstone of analysis.
Without a doubt, the 1970s excel in all areas when we look back at the areas of preventive and social medicine and public health.Clearly, there were many reasons for attention to turn back to health.Issues related to health and medical attention had not been addressed (and had even deteriorated), while the theoretical models which had prevailed in the past no longer could be counted on to explain this reality.There was said to be a crisis in both generation of knowledge as well as in a particular practice (Nunes, 1996, p.59). 4   Mello (2010), in a doctoral thesis addressing thinking on health in Brazil, refers to the 1970s as a transition to what he defined as radical thinking in Brazilian public health.He states, "the moment was much more than deconstructing the past and seeking new theoretical instruments, noteworthy of which were dialectical and historical materialism and Gramsci's analytical categories, which permeated much of the bibliographic production over the next decade " (p.223).
This period was a rupture which revealed important social aspects related to supply and demand for health care services, highlighting economic and political issues as well as class differences.This rupture was in line with the political context in the West (May 1968 in Europe, and the civil rights movement in the US) and with the struggle against the military dictatorship in Brazil, which took shape not only in the political sphere but also in the social realm, with regard to class inequalities that were reflected (and continue to be reflected) in the field of health.It is therefore understood that the paradigm shift theory was linked to the new discussions which came from social movements, a phenomenon that was also seen in studies on health in Latin America (Nunes, 1996;Hochman, Santos, Pires-Alves, 2004).These studies reflected not only that moment in time, but also the new theoretical framework used by the authors, which was mostly based on Marxist scholars and Michel Foucault, who saw history as the main explanatory element.Along these lines, in this study we maintain that when faced with the challenge of the new, referring back to historical explanation becomes crucial.
For Amélia Cohn, themes and issues that are current and transverse must be recollocated, and the current production of knowledge in collective health must be questioned: Cohn (2012, p.25) warns of the need to return to the origins of the field, in the sense of recovering the politicization of health in the context of producing and practicing knowledge; in other words, "recovering the social dimensions of health." It is from this perspective, and among growing concerns about the current challenges and discord around defending the right to health and the principle of universality in Brazil's Unified Health System (Sistema Único de Saúde, SUS), that a return to the texts which founded a field of knowledge based on health as social and historical production is both necessary and current.Theoretical production in the field of collective health and sanitary reform, which permitted the SUS to be constructed as a socio-political project in Brazil, has been called upon to support new interpretation and theoretical approaches to social thinking, in a critical way and without "lessons from the past" from the perspective of theoretical repositioning in the face of current turbulence with regard to health.Paim (1981), Nunes (1996), and Escorel (2012) have named Sergio Arouca and Cecília Donnangelo as the intellectual shapers of the field of collective health in Brazil, who helped construct new analytical tools to understand reality.These tools were important in the sanitary reform movement.

Historical thinking in studies on collective health
In Brazil, an early and important scholar in the history of medicine and public health was Lycurgo Santos Filho , who published História da medicina no Brasil: do século XVI ao século XIX (History of medicine in Brazil: from the sixteenth to the nineteenth century) in 1947.In 1977, the first volume of his monumental História geral da medicina brasileira (General history of Brazilian medicine) was published, and the second volume appeared in 1991.In this type of work, history appears as a sequence of events in which the knowledge of certain period overcomes the errors and superstitions of the previous period, and brings with it answers considered to be more satisfactory, knowledge which is thought to be superior and more rational.This was a technical-functional (or technicist) analysis, which ignored the cultural and symbolic aspects and the conflict existing in society.
The field of knowledge in collective health rests upon the theoretical and methodological contributions that comprise the principle of the health/disease process and the scale of access to health services as a result of the social and historical production of a certain reality (in this case, in Brazil).As we have mentioned, prior to the 1960s and 1970s, historical knowledge in the field of health was based on an evolutionary, linear, and cumulative understanding of the historical processes.In contrast, studies on collective health sought História, Ciências, Saúde -Manguinhos, Rio de Janeiro to interpret health events and phenomena linked to their context, removing the hermetic and naturalized aspects that the objects of study had previously presented.In other words, previous studies considered science as a laboratory practice and organization of services which prophylaxis required, a sharper observation of both the environment and forms of illness of the body etc., but did not take into account the social, cultural, and political aspects which were thought to hinder scientific development.Examples include the widely cited studies by Lycurgo Santos Filho (1947, 1977, 1991), and Rodolfo Mascarenhas (1949).
The counterpoint adopted by the historical perspective on collective health can be explained with Hobsbawm (1997) as a reference: it brings the "social function of the past" into scale, in the sense of understanding how the transformation of society is translated by the constant tension between present and past.This tension stems not from alleged scientific progress in medicine and epidemiology, but rather by the often-confrontational relationship between scientific knowledge, social intervention, social control, popular culture, class interests, and economic domination.Similarly, the debate on the structural connections which have historically been maintained between public health and its forms of organization and Brazil's political, economic, and social systems permits reflection on the standoffs and contradictions that have marked the construction of our health system.Here we bolster the argument that the theoreticians and their texts fled from neither standoffs nor contradictions.
Analyzing the historiography of public health in Brazil, specifically based on the works of Hochman (1998), Castro Santos (1985), Nunes (1994Nunes ( , 2000)), and Merhy (1992Merhy ( , 2014)), we can describe the discursive arrays which dominated different periods as follows: until the mid-1950s, construction of the sanitarian notion based on "control" as protection, followed by another period beginning in the mid-1970s which legitimates the ideals of health protection as a historic and social product.For many of these authors, the current debate seems to indicate a need to politicize the discourse of knowledge production in health, which is considered the scene of a crisis in social protection systems.
In this sense, production in the field characterizing the 1970s, which is part of the theoretical change from "health as control" to historical and social production, creates a dividing line.The work of Emerson Merhy and Madel Luz, who each generated two texts during this period, can be analyzed from this perspective: on the one hand Luz's 1982 work Medicina e ordem política brasileira: políticas e instituições de saúde  (Medicine and the Brazilian political agenda: health policies and institutions,  and As instituições médicas no Brasil: instituição e estratégia de hegemonia (Medical institutions in Brazil: the institution and strategy of hegemony) (released in 1979), and on the other hand Merhy's Capitalismo e saúde pública: a emergência das práticas sanitárias no estado de São Paulo (Capitalism and public health: the emergence of sanitary practices in the state of São Paulo) (released in 1986) and A saúde pública como política: os movimentos sanitários, São Paulo, 1920Paulo, -1948: : os modelos tecnoassistencialistas e a formação das políticas governamentais (Public health as policy: sanitarist movements, São Paulo, 1920Paulo, -1948: : techno-assistentialist models and the formation of governmental policies) (published in 1992).Although these authors base their work on distinct theoretical references, they share the idea of class conflict and its expression in health care policies and repression of its demands.We therefore propose to discuss in this article what these works represented when they were published and what dialog they proposed with respect to the political and social dimension of relationships between health and the state.We also intend to introduce some contradictions into their arguments.
In both cases, the commitment to the democratic issue of health can be seen in the different analytical narratives: (1) the right to health considering the unique social formation of Brazil; (2) health and capitalist modes of production in Brazilian history and society; (3) the technical dimension of medical work and its centrality in public health policies; and (4) the central role played by the state in ensuring access to health care.
Gilberto Hochman (2007, p.153), in an article entitled "História e políticas" ("History and policies"), writes "in Brazil, studies on public policies from the historical perspective achieved a broad multidisciplinary reception and a large audience."He adds that until the 1980s, studies in the social sciences and humanities emphasized understanding specific state policies in the national scale.According to Hochman (2007, p.154), this involved understanding the nature of the Brazilian state, its authoritarian and centralizing bias, economic modernization and inequality, and reflecting on the possibilities of building a democratic order.This extensive set of works moved between a narrative organized by theory and historical research, which was often criticized by historians.In this way, historical processes were scenarios and contents of a theoretical and formal argument that organized and interpreted them.
As mentioned, the more critical studies of health protection during this period considered analyses on the formation of Brazilian society and adopted a historical perspective that methodologically and analytically observed the health strategies and policies as phenomena linked to the nuances of the social and historical context in Brazil.Madel Luz and Emerson Merhy, in their works discussed herein, are in line with this perspective because they emphasize the strong relationship between the historical moments in which public health practices were formulated and developed and the more significant processes of modernization in the country.

Madel Therezinha Luz
Madel Luz's academic trajectory has been cosmopolitan and multidisciplinary; she graduated from the Universidade Federal do Rio de Janeiro (UFRJ) in 1962 in philosophy, completed her master's degree in sociology at the Université Catholique de Louvain in 1969, and earned her doctorate in political science at the Universidade de São Paulo (USP) in 1978.The first book examined here, As instituições médicas no Brasil, was produced while Luz was completing her doctoral studies at USP and led a team of researchers at the Instituto de Medicina Social at UFRJ, whom she thanks in the preface as coauthors of the text.Her other book is a collection of texts by various authors which she compiled and edited.
As instituições médicas no Brasil, which was published in 1979 and re-released in 2013, analyzes institutional medical power and its position during 1960-1964 and 1968-1974 in four stages: (1) analysis of health policies; (2) the health of the population; (3) the image of health institutions in the newspapers; and (4) institutional medical practice (production and reproduction of medical knowledge), more specifically, in the university hospital.The hypothesis of this study was that state health institutions possess a technical-scientific discourse and practice this discourse/knowledge through large-scale organized intervention in the lives of various sectors of the population, thus becoming political agencies of containing and controlling public disease.
The author characterizes the periods studied as institutionally imposed by the state through medical discourse (namely private health care).She also points out that the consequence of this hegemonic discourse by the state was the increase in state assistance, hospital structure, and the figure of the salaried physician.As a result of the hegemony of the hospital structure and the payrolled medical sector, medical education then returned to these two dimensions.The medical institutions strengthened, according to the author, as a project of the hegemony of classes in the "clarity of its ambiguity," and thus indicates the goal of her work: "to seize the ambiguities of the process of establishing hegemony as the establishment of power" (Luz, 2013, p.14).
Luz specifies the methodological approach of her work and its theoretical affiliation with strong academic rigor, which doubtless bolstered the fact that this work became a reference in the field of collective health.As the coordinator of the research which led to the thesis, she noted that When analyzing the role of specific institutions in the strategy of hegemony in certain situations, we wish to contrast the traditional models of analyzing institutions with a model of dialectical and historical analysis.This therefore involves developing a specifically political approach to organizations, helping to construct a science of history and political science (Luz, 2013, p.32).
She also indicates that the analytical approach to political institutions is specifically political because it "is intended to discover their specific density as the modes of power in one mode of social production, not reducing them to a reflection of the evolution of productive forces or to reproducing the social relations of production" (Luz, 2013, p.32).
The objective of Medicina e ordem política brasileira, the 1982 compilation edited by Luz, is to present the constitution of some medical institutions from the nineteenth century to the 1920s, along with their interventions in society, links with the state, and social pressures for health.In the text, the authors demonstrate their understanding that the state and science are complementary, as follows: Science is therefore part of the state, the historic fruit of the need for its intervention in social life and in the life of populations that had to be organized in accordance with the logic of the new social relations.In capitalism, science is not part of the 'dominant ideas:' 'it is its dominant idea,' its most brilliant idea (Luz, 1982, p.16; emphasis in the original).
The book addresses the Imperial Academy of Medicine (Academia Imperial de Medicina), which was transformed into the National Academy of Medicine during the Republican period, the "Tropicalist School of Bahia" ("Escola Tropicalista Baiana"), the Oswaldo Cruz Institute, and the Brazilian Hygiene Society (Sociedade Brasileira de Higiene).In order to examine these institutions, the authors incorporate works by Michel Foucault and Antonio Gramsci as theoretical benchmarks.They implement Foucault's "The birth of social medicine," a lecture delivered at the Universidade Estadual do Rio de Janeiro in 1974, and Gramsci's concept of the organic intellectual.
Luz criticizes the traditional historiographic milestones of medicine and public health but ultimately upholds them, such as the aforementioned rupture resulting from a tradition inaugurated by the "Tropicalist School of Bahia," which was created a posteriori (in the twentieth century) by traditional historiography as a movement toward innovation and discontinuity, as seen in Edler (2011).The first part begins with an analysis of the labor uprisings of the early twentieth century, and ends with Oswaldo Cruz .The second part returns to the nineteenth century and also finishes with Oswaldo Cruz.Although he is presented as an authoritarian and interventionist character in the history of public health, Cruz appears as a game changer for national history as well as for traditional historiography.
The first part of the book carefully analyzes the 1920s, and presents a new view of history in its innovative analytical vision: the 1920s do not precede the 1930s.There is a tendency to analyze the decade prior to the Vargas Era, the 1930s, considering what would happen next (which is an anachronistic analysis), an error which Luz avoids.Rather than "the decade preceding Vargas," she portrays the 1920s as years of crisis, inflation, problems that still reflect the 1890 boom-and-bust of the Rui Barbosa era which were still felt in Campos Salles's deflationary policy denoted "financial hygiene," along with the "doctor" Joaquim Murtinho, "the minister of finances."In social terms, the text clearly shows the pressure on the working class, from impoverishment as well as beatings by employers, fines, miserable hygiene in factories and homes, and from endemic and epidemic diseases.Initially, the authors outline an important idea that returns and crystallizes only at the end of the book: on the one hand the problem of yellow fever, smallpox, and the plague, and on the other hand tuberculosis.When they return to Oswaldo Cruz at the end of the text, the thesis is explicit: epidemic and urgent health problems received swift, energetic, and authoritative responses from the state, while chronic diseases requiring prevention, attention, and investments did not.
As for the 1920s, they go on to interpret the 1923 Elói Chaves Law (regulating retirement and pension funds, which by 1929 served 140,435 workers), which was established by pressure from the working class but regarded as elitist and paternalistic.Thus, as in the years preceding Vargas, labor policy is interpreted by Luz and her colleagues as conciliatory.
The last chapter of the first section is more closely tied to the second part than the first, since although it concentrates on the late nineteenth century and Oswaldo Cruz, it returns to the late eighteenth century to mention and demarcate the beginning of social medicine, relying on Foucault (1979) and Machado et al. (1978).The authors mention the centralization of the Joanine period with the Protomedicato board and Fisicatura regulamentation, followed by the decentralization advanced by the 1828 Chambers Law until the First Republic, finally reaching the project imposed on the city of Rio de Janeiro.This project is considered authoritative, because (1) it was imposed by the State; (2) it was not consensual; and (3) it represented the interests of minorities (Luz, 1982, p.79).The História, Ciências, Saúde -Manguinhos, Rio de Janeiro interests of these minorities manifested in the character of Oswaldo Cruz, with the need to clean up the capital to continue and boost international trade, ignoring the residents and daily life in the city.Historiographic sources are presented which report the military character of the operations headed by Cruz andFrancisco Pereira Passos (1836-1913), who achieved "success" from their point of view and generated a massive revolt.This creates a space to bring in the thesis of the first part of the book: although the 1981 Constitution establishes a (politically and economically) liberal state, the issue of health reveals a centralist, authoritarian, and oligarchic state.
As mentioned, the second part returns to the nineteenth century.But the main focus in this case is to make a distinction between the Imperial Academy of Medicine and the "Tropicalist School of Bahia."In the historiography, everything indicates that Coni (1952) was the first to maintain that a group in Bahia composed of the physicians Otto Wücherer (1820-1874), José Francisco da Silva Lima (1826-1910), John L. Paterson (1820-1882), and Antônio Pacifico Pereira (1846Pereira ( -1922) ) had erected the stronghold of the "school" and defended the progressive parasitological discoveries of medicine from the backsliding represented by the Imperial Academy of Medicine in Rio de Janeiro.Luz followed the same reasoning.Subsequently, the "Tropicalist School of Bahia" was studied more expansively by Peard (1990).According to Luz, the Academy and the "Bahia School" could be divided as follows: Source: Created by the authors, using data from Luz (1982).
The book ends with another bibliographic text on Oswaldo Cruz to clarify the idea of the oligarchic and authoritarian state, which had been presented at the end of the first section through its public health policy; as mentioned earlier, there was a key, self-interested use of "organic intellectuals of health" by the State.For example, in emergencies like epidemics, all efforts were made to preserve the labor force (including complete repression, if necessary); on the other hand, expensive investments in prevention, like those required to reduce or eradicate diseases such as tuberculosis, were not made.
The main point to be highlighted as problematic in Luz's argument is specifically related to this alleged dichotomy, which Edler (2011) indicates as mistaken, between the "Tropicalist School of Bahia" -a myth created after the fact by the historical narrative of the victor (parasitology) -and the Imperial Academy of Medicine.
Edler's argument can be summarized as follows: the doctors of the 1866 Gazeta Médica Baiana were not a "school," the idea that became established in the twentieth century.The idea that the group formed by Otto Wücherer was a cohesive whole, protecting parasitology against the Imperial Academy of Medicine (which represented the pinnacle of scientific backwardness) originated with Coni in 1952, in his search for "precursors" and "heroes" of Brazilian medicine.In this way, both Madel Luz and Julyan Peard position the Bahian doctors as deniers of the old models of interpretation, rebelling against the Academy.*** Madel Luz's strategy was to use history to criticize previous interpretations of thinking on public health; in other words, public health as a means/power of control.She emphasizes the central role of an authoritarian state in each period -"The State is always the main interlocutor" (Luz, 1982, p.10) -which fears sedition, seeks hierarchical order, regardless of how adverse the living and working conditions were for slaves or workers that could cause popular unrest.Luz's work became an intellectual instrument in the struggle for the democratization of health and the training of health workers engaged in the democratic struggle of the country at that time.

Emerson Elias Merhy
The first of Merhy's books we will address, Capitalismo e a saúde pública (Capitalism and public health), is his master's dissertation, which he defended in 1983 at the Universidade de São Paulo School of Medicine.His advisor in this project was originally Maria Cecília Donnangelo , who died before its completion, and Merhy was then advised by Eurivaldo Sampaio de Almeida of the School of Public Health at the Universidade de São Paulo.
Along with other works of the period, it began a line of historiographical research on the field of public health and its practice.The book used Marxist references and brought discussions of the shaping of the field of public health closer to the construction of the modern state.The text is centered around the institution of health practices in order to develop São Paulo as a capitalist power, in accordance with its exceptional nature.The author reissued the text in 2014 through Rede Unida, and in his foreword to the current edition emphasizes the context in which this work was positioned, namely the sanitary reform movement, and stresses what he calls the "theoretical supply of the Marxist field" for this endeavor, citing authors such as Nicos Poulantzas and Antonio Gramsci as well as Franco Basaglia and Giovanni Berlinguer.
In the forward to the original edition of the book, the author announced he had chosen an analysis of this field of activities that went beyond bureaucratic-administrative organizational aspects or technical-scientific characteristics in general.His text therefore targeted reflection on the field of public health as an organic component of all social relations combined.At a time when sanitary reform presented itself as a national project to consider health and the social production of health, as well as the role of the state in guaranteeing rights including the right to health, Emerson Merhy's book emerged as an important cognitive tool in the political dispute.
Social practice, explained as a line of reference in the work of the author during this period, was conceptualized by Cecília Donnangelo and cited in Merhy's (2014, p.18) text as "a specific mode of production, a set of social practices, within capitalist societies, which envision the production and reproduction of the relations between economic exploitation of class and political and particular ideological domination -capital and labor -the bourgeoisie over the proletariat."With this premise, the author focused on health practices in São Paulo during the First Republic, a period considered "significant" by the historiography of health for creating a health intervention apparatus within the social body, in line with the plan to build the State.
Merhy approached the topic in two stages: (a) the specific characteristics of the subject and how it has been approached in different contexts, in order to situate it within the context of capitalist relations, and (b) investigate how health practices emerged and were implemented as social practices in the emerging society of São Paulo in the early twentieth century.Merhy examined public health in São Paulo through its models of technical assistance, identifying its structure at different times and its relations with the dynamics of social processes.He followed this work with another text, his doctoral thesis, which broadened the analysis up to the late 1940s.
His thesis, Saúde pública como política: São Paulo de 1920 a 1948 (Public health as policy: São Paulo from 1920 to 1948), completed in 1990 and defended at the Universidade Estadual de Campinas (Unicamp), emphasizes the sanitary movement, technical assistance models, and the formation of governmental policies.The author analyzes policies according to models as broad formulations, not only as mere articulation of technical knowledge.He considers government policy to be a condensation of technical assistance models which constituted projects by social forces.For Merhy, "model" refers to the technological chain of thought in the field of health action combined with the broader political dimension, taken in a specific field as an arena where disputes are resolved and the social significance of actions are defined.The period examined, 1920-1940, features a society of great complexity, especially in São Paulo (the focus of the study), where industrialization produced a new pattern of relationship between society and the state.
Merhy distinguishes the specificities of health within the broad policies of the authoritarian state of the Vargas Era between 1937 to 1945, a period with poor information available for public health.In his concept of the "model," the author argues that when policy formulators create technical assistance projects, they produce a project which is political and not just related to technological knowledge, even it is founded on technical concepts.The model therefore reveals a form of political power and should express a given conformation of the state.The hypothesis of the study is based on the evidence that the sanitary movement of the 1920s attempted to implement the "model" of the medical-sanitary chain that was foiled after 1930.The author characterizes the formation of the public health apparatus in the clash of political forces within a joint project that was able to combine trends which had previously been separated, as a permanently and specialized vertical model that lasted throughout Vargas's administration from 1930 to 1948.
The importance of Merly's work which is highlighted herein mainly lies in the methodological discussion on technical assistance models and their appropriations for the analysis of health.Later, Merhy (2014, p.15) would move away from these theoretical references.The author explains that this theoretical and methodological break with the Marxist reference is because for him, unlike a linear construction which should be intended to clash with the classist state (the representative of class), the field of health practices is a constant dispute between different plans from countless types of social actors.
First, Merly can be said to fit into and even help inaugurate an analytical tradition within the historiography of Brazilian public health, which is solidified in subsequent studies and believes that the Brazilian health agenda began during the First Republic.This tradition considers the period up to 1930 to be fundamental for the understanding of the relationship between the state, capital, and health intervention in São Paulo as a state action.A number of authors fit into this tradition, although they employ different theoretical and methodological perspectives: Blount, III (1971), Castro Santos (1980, 1985, 1993), Gambeta (1988), Ribeiro (1993, 2004), Telarolli Júnior (1996), Benchimol (1990), Hochman (1998), Benchimol et al. (2003), Löwy (2006), Ponte, Lima, Kropf (2010), Silva (2007, 2011, 2014), among others.

Do the texts meet the challenges they propose?
The importance of the historical argument in analyses of public health is discussed by several authors.Carvalho and Lima (1992), in a relevant consideration of historical studies undertaken in this area in Brazil, recognize that a specific and transdisciplinary field of study began to form in the 1980s and 1990s and deserves closer analysis in terms of its trends and methodological pathways.Focusing on works which have already been recognized as references in the historiography of Brazilian public health in this period (Machado et al., 1978;Luz, 2013Luz, , 1982;;Carvalho, 1987;Chalhoub, 1986;Sevcenko, 1983Sevcenko, , 1984;;Bahia, 1988;Benchimol, 1990;Costa, 1980;Needel, 1985;Porto, 1985;Costa, 1986;Castro Santos, 1987), these authors emphasize that production on the subject in Brazil progressed in line with the trends of contemporary European historiography.They state that the European historiographic tradition, represented by Michel Foucault (among others) and featuring a causal association between cities and diseases, interventions on the urban world in a disciplinary and social plan, with medical discourse about the body of the worker, is repeated in the major works on the history of Brazilian public health.
We can state that these works involve a version that can be approximated to what we attempt to characterize as the form of a social history related to the absolutization of explanatory concepts, drifting toward the limit, in reifications.Notions such as 'urban life,' 'technology of power,' 'organic intellectual,' and 'medicalization' appear in these texts in a relatively unqualified manner, reproducing the same meanings and the same explanatory value these expressions held in their original theoretical contexts within the context of Brazilian modernization in the late nineteenth and early twentieth century (Carvalho, Lima, 1992, p.130; emphasis in the original).
The works analyzed by Carvalho and Lima are relevant and launched a tradition of historiographic production in collective health in Brazil.We understand that the issues raised by Madel and Merhy were intended to insert the particular characteristics of Brazilian social formation into studies in this field, broadening the historical arguments which permitted a rapprochement with the issues and events of our own reality, even if this perspective has not been fully achieved.After all, the "sparse use of sources, reification of concepts, and even its analytical Manichaeism" (Hochman, Santos, Pires-Alves, 2004, p.44) are important weaknesses to indicate.Merhy (2014, p.30-31) states that There have been various studies on the Old Republic period in São Paulo which identify Emílio Ribas and Geraldo Horácio de Paula Souza as representing two major historical stages of sanitary practices in São Paulo.However, those by Rodolfo Mascarenhas have stood out the most among all the analyses of public health in the state of São Paulo.These studies express the incorporation of the two types of public health analyses mentioned above [studies highlighting grand figures and those focusing on institutional organization, prioritizing scientificity], and also faithfully portray an entire methodological line which still dominates today in all the work that has been produced to understand this field of practice.
Luz, in turn, says that "historical knowledge is confused with historical myth, the tired historical 'myth' that still resists and confuses historical 'thought'...However, history in Brazil continues to be partly mired in the historic mythology, producing and reproducing models of knowledge of such a nature that they involve and deform history itself" (Luz, 1982, p.35; emphasis in the original).The author refers both to the "mythological" interpretations of Brazilian production itself and to the uncritical adherence to the myths and ways of thinking of the cultural metropolis, to which Brazilian history remains tied, in her opinion.

says that
Without establishing new empirical evidence, these revisionist and often iconoclastic works help themselves to the same chronological milestones raised by groundbreaking studies.Instead of refuting the thesis established by classical historiography, they analytically articulate the limiting terms, uncritically reproducing the positivist demarcation they intend to combat.
Both Merhy and Luz make the mistakes they initially intend to avoid: they repeat previous works, with their temporal markers, main characters, and myths that define specific delineations and "geniuses" that revolutionized Brazilian public health for the better.What they have done with iconoclasty is to reverse value judgments and characterize them as authoritarian -which they were.
Theoretically, there was also no great innovation in "decolonization" (as Madel argues in his book) in terms of the results of research and interpretations of the past by the intellectual metropolis: the studies of Michel Foucault become "self-explanatory mirrors."Merhy cites Foucault in the bibliography, but does not mention the differentiation he makes between public health practiced in Germany, France, and England.And Luz uses concepts from Gramsci such as the "intellectual organic" and some from Foucault, but these are restated.For both authors, the Brazilian reality becomes an empirical field to be inserted within Marxist and Foucaultian constructs.
In the case of Merhy's study, the sequence of introductory chapters and their references to traditional ideas of health processes in countries such as England should also be noted; these are not included in other parts of the text and do not aid in the understanding of the object of study, whose causal relationship appears belatedly and without demonstration, namely that pressures from worker strikes in the 1920 spurred initial attention by the state to the health of the working class.Therefore, to a certain extent the author contradicts his expressed connection with dialectic historical materialism, since "the past cannot be exclusively or primarily on its own terms" (Hobsbawm, 1997, p.159), it is part of a historical process which permits analysis and understanding of the dynamics of social issues, a historical process which yields to institutional analysis in Merhy's work.
However, even despite the problems mentioned above, these studies should be considered (1) within their contexts, which makes them representative due to the intellectual and political roles they exerted at that moment in history, and also (2) for being linked to the theoretical perspective of the rupture with positivism and the studies that disconnected science from its social, political, and economic aspects, as if the production of knowledge were disinterested.

Final considerations
The texts by Merhy and Luz remain as reference works, 5 establishing questions and continuities that allow them to establish analytical pathways to current issues in the field.This is not to avoid criticizing or repeating them, but instead (after the tradition of social thinking) to find identities, lineages, ruptures, and continuance in what refers to the object of study as well as the theoretical nuances adopted by these authors.
When addressing topics related to health policies in different periods, historical arguments were used by Merhy and Luz, in most cases differently from how they had been used in descriptive or evolutionist studies.However, the historical perspective present in both studies resulted from the theoretical decisions by these authors to present the public health agenda, its institutions and services, health interventions, and collective and individual illness as objects of dialectic analysis.This is the challenge for the use of historical perspective without being subject to descriptive and uplifting narratives (or even those based on real happenings), which have been indicated as uncritical.Berridge (2010), looking for a response to inquiries into the need for historical "evidence" for current-day producers of health policies, points to the trap that can become what is known as "bad history."Citing English historiography, Berridge warns that there is no lack of historical analysis on current public health policies in which the historical evidence is used for a certain type of interpretation that seeks lessons from the past to support or justify contemporary discourses.
Is the historic argument relevant to production in the field of collective health, as it was in the works presented herein?In a society where thinking becomes increasingly technocratic and positivist, the answer tends to be "no."Our point of view is different: yes, the history does indeed matter, a lot, as Hochman stated (2007, p.154).Confronting current health issues with the methodological framework that this "type" of making history permits may allow a reflective agenda that focuses on our political responses to the processes of living and illness in a society that remains uneven and divided.
Collective health has guided the discussion on historical and social issues of health supported in fields of knowledge that conform to its theoretical underpinnings, namely the humanities, social sciences, policy and epidemiology.In the interface between these disciplines, the field faces its "own function" in research, education, and in the social practice, understanding and acting on externalities in health resulting from our social formation.The theoretical break in the 1970s and 1980s discussed in this article attempted to create the same fabric of other changes in political thinking and social praxis in the period.Paim (2008, p.292) states that "Collective health theoretically supported Brazilian sanitary reform from the triad of ideology, knowledge, and practice, because it emerged together with proposal and the plan for sanitary reform."But Paim concludes that sanitary reform in Brazil, which was the substantial fruit of the rupture mentioned above, was transformed from its "revolutionary" essence of a political project to become an "unfinished social reform."The theoretical field which indicated the need for social transformation has been constructed; the Brazilian reality, on the other hand, has not kept pace with the momentum of change which was created in studies on collective health during the period.
The Ministry of Health's 2014 report indicates overwhelming health indicators pertaining to historical and social inequalities in Brazil, for example: (1) homicide is a significant cause of death among young men, Blacks, mixed-race people of African descent, and indigenous people, especially in the north, northeast, and midwest regions of the country; (2) although infant mortality is decreasing, inequality persists in Brazil's poorest areas; (3) race/color continues to be a considerable epistemological variable when analyzing life expectancy and morbidity and mortality (Brasil, 2015).
These data place us face to face with our continuances resulting from socio-historical formation in Brazil, such as inequality, racism, and regional differences.These continuances must gain historicity in collective health, a historicity which keeps the field from abandoning the triad which was fundamental to its own construction: ideology, knowledge, and practice.noTEs 1 Supported by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).
3 According to Gildo Brandão (2005, p.236), it is important to read the classics because their propositions and empirical foundations are a source of problems and theoretical issues for current scientific research since they are witnesses to the times when they emerge.