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On-line version ISSN 1678-4782
J. Pediatr. (Rio J.) vol.81 no.1 Porto Alegre Jan./Feb. 2005
Luís R. C. M. Bonilha;I Carlos R. S. F. RivorêdoII
IM.Sc., School of Medicine, Universidade
Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
IIPh.D., School of Medicine, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
OBJECTIVE: To present, in an essay form,
two distinct views on well-child care.
METHODS: Using several different methods of historical analysis, the two most common views on well-child care are presented: the positivist one, whose foundation is essentially based upon historical facts, and that of social criticism, concerned with how historical facts are inserted in society at different levels.
RESULTS: The coexistence of two distinct views on well-child care reveals two conflicting ideologies, but it does not invalidate the two different types of knowledge.
CONCLUSIONS: Even though the understanding of well-child care through a historical approach does not allow for definitive conclusions on what it is or what it will be, it encourages reflections on more practical meanings, namely: the possibility to consider practices that gather an ensemble of positive knowledge without disregarding their limitations, and the formulation of well-child care practices concerned with social care, determined by several aspects, instead of by ideological interest.
Key words: Well-child care, History, Ideology.
Two different ways to look at well-child care?
Traditionally, well-child care is defined as "the set of techniques used to ensure perfect physical and mental development of a child, from the gestational period up to the age of 4 or 5 years, and, by extension, from gestation to puberty."1 This definition is based on the hypothesis that care - biologically, psychologically and socially speaking - can prevent diseases, help full genetic expression, free of environmental interference, helping develop "a healthier and certainly happier adult, with a better quality of life."2
Seen as such, it resembles a comprehensive guide that comprises smaller ones, specific and full of details which, if properly used, accomplish the objective of preventing all sorts of disorders. These guides must be "scientifically-based," that is, they should result from research in different fields, such as nutrition, anthropometry, immunology, psychology and dentistry. This way, they are intended to contrast with the common sense and dictate the most scientifically appropriate way to care for children. This assemblage of different fields of knowledge and activity characterizes well-child care as a technical and social practice, since it is founded upon technical bases, but falls within the ambit of social relations.
A view of well-child care that recognizes all threats to children's health and establishes medical practices to resolve them, and which is essentially scientific and neutral from the political, ideological and economic point of view, can still be found in textbooks,2-4 scientific journals5 and protocols written by authorities in charge of publishing new rules, guidelines and consensus reports.6,7
There is however a different view on well-child care, which is described in a large number of publications issued in the 1960s that criticize its neutral and positive posture. Based on the theoretical references of social sciences, several authors see well-child care as a social practice that is subjected to all sorts of political and economic agents, with reasons, purposes and consequences that go beyond the mere establishment of scientific norms that ensure a child's development. Therefore, under the guise of helping to prevent infant mortality through education, there were other projects that, for instance, aimed at establishing a behavioral and moralizing pattern not only for children, but also for the entire family, based on a behavior that is considered ideal by the dominant classes.8 Thus, well-child care would represent the consolidation of a project implemented in Europe in the 18th century, whose aim was the health preservation of children, who were essential to the big and modern nations, which measured their force by the size of their armies and markets.9
From its origin in the late 19th century to the present time, well-child care incorporated characteristics that are peculiar to each period and place wherein it was practiced, receiving new determinations and influences from hegemonic groups without, however, driving away from its ideological roots, that is, using education to modify situations that would otherwise depend on extensive social reforms.10-15 By reading the criticisms about it, we see the multifaceted nature of well-child care, which is able to adapt to the determinations of historical time without changing the virtually stable core of its practices.
The aim of the present article is to approach these two different, but ideologically compromised, ways of conceiving, investigating and advertising well-child care, which are always in constant conflict and nonconvergent. By resorting to history, we will discuss the possibility of bringing these two distinct views together so that they can complement each other, especially with regard to their practice.
Going through the history of well-child care
The possibility of having two different historical versions for a single issue demonstrates the existence of two different definitions of this issue, and also distinct ways to understand and go through these historical versions. Although this is not the aim of the present study, it is necessary to closely examine the issues as far as historical methods are concerned, or at least, to describe the trends used to analyze the structure of well-child care.
The working methodology of the history of well-child care observed in the studies that regard it as neutral and scientific,4,16-19 is similar to the so-called "positivist history", which relegates it to the mere systematic and hierarchical organization of ideas and facts, being unable to explain and interpret human phenomena based on its concrete origin.20 It is a type of history that gives privilege to historical facts, represented by acclaimed names (renowned pediatricians associated with scientific discoveries or with highly regarded institutions) and by great events (implementation of practices regarded as appropriate at different times and in different cultures, according to current scientific knowledge). This essentially descriptive history reduces the analysis of causes to the presentation of historical facts, giving the impression of being a simple and natural sequence of events, characterized by a sense of positive natural evolution of society throughout the times.
The state of the art undergoes a sort of update, in which deficiencies are seen only as reflections of a still poor stage of development of Medicine and society. Gesteira18 summarizes these ideas in the following manner: "And little by little, alongside the progress of civilization and the development of Christianity, the interest in and care for children grew stronger, consisting of legislative measures in support of mothers and children, in different works about moral, material, medical and judicial assistance to mothers and to needy children, which today puts together an anthology of a true science that is extremely vast and complex, adequately defined by the term "well-child care" which, in 1865, thrust Caron into the limelight." Written by the author in 1943, this way to look at the historical evolution of well-child care remains up-to-date, as outlined by Blank:5 "Until the mid-19th century, it was nothing but a set of notions and techniques concerned with hygiene, nutrition and discipline of young children, passed down from mother to daughter generation after generation; and therefore, full of myths and taboos. Then it was embraced by pediatrics, which gradually turned it into a true science, with much broader applications and a more comprehensive age range."
The studies that criticize the original model of well-child care employ other ways to analyze history, seeking to elucidate its development in different political, economic and cultural contexts. Although these new methods are rooted in previous periods, they gained momentum around the 1930s through the Annales d'histoire économique et sociale. Initially referred to as social history, it showed interest in the stratum of society subdued by the dominant power instead of expressing interest in the top echelons of society, represented by kings, statesmen or even by their main opponents, in great events that affected them (wars, revolutions), or in the political, economic and religious organizations under their domain. Such interest was a refusal to accept a history merely based on facts, which gave privilege to economic factors related to great events. The historical fact itself was criticized due to its inaccuracy, since when we are confronted with an event, we see the final outcome of a series of processes that wind up unknown.21
The introduction of these new concepts broadened the historians' field of action, bringing their look towards other sciences, such as psychology, anthropology and arts.22 With this broader view, the history of well-child care was no longer portrayed as being detached from other changes in society. It now went side by side with the history of children, women, families and Medicine, as well as with the history of great political, economic and cultural changes.23
A positivist history
For many authors, the history of well-child care mingles with that of child rearing, dating back to ancient times.4,16-18 Similarly, other authors depict the history of well-child care in primitive societies, from the Stone Age to indigenous peoples, both old and modern.16,17,19
The first works related to well-child care appeared in the Renaissance period. Even though they represented a new appreciation of children, which aroused the interests of researchers, they ended up being just a reaction to the powerlessness of man before infant mortality and diseases, due to the lack of sufficient knowledge to achieve the proposed goals.24
In the 18th century, marked by the Enlightenment, public awareness of the problems that afflicted children was raised. In 1762, Jean-Jacques Rousseau published "Emile, or on Education," in which he propounded that man is born pure, but is then corrupted by society. By advocating a "natural" education, inspired in other animals where the role of the mother is crucial, he introduced the mother-child dyad. Love is the force that brings them together. Once this dyad was established, he introduced another important concept: "Do you wish, then, that he keep his original form? Watch over him from the moment he comes into the world. As soon as he is born take possession of him and do not leave him till he is a man."25
In the 19th century, scientific breakthroughs took the belief in the power of science and progress to its most extreme. Numerous discoveries were made, but one was especially important to well-child care: the Pasteurian Revolution. In 1864, vaccine preparation became consolidated due to the microbial theory of disease. Another important discovery was that microorganisms contaminated water and milk and consequently caused diarrhea, and that these microorganisms could be avoided by boiling the water and milk. For children, this had a great impact, since the death toll from diarrheal diseases used to be heavy, because many of these children were fed raw cow's milk.
The term well-child care appeared in 1762, in an inconsequential treaty written by Jacques Ballexserd.4 In 1865, French physician Caron reinforced the use of the term in his work entitled La puériculture ou la science d'élever hygieniquement et phisiologiquement les enfants. Well-child care was then consolidated by the creation of outpatient clinics for healthy infants by Budin, Variot and Doufours. By encouraging breastfeeding and the use of sterilized cow's milk for infants of working mothers who could not breastfeed, these services had a very positive influence on the local infant mortality rates.26 In the subsequent decades, well-child care expanded beyond scientific lectures, outpatient clinics for infants and research studies on physiology and infant nutrition. It was taught at girls' schools,8 and it also influenced public policies concerned with infant and child protection.27
In Brazil, in the late 18th century, there was a gradual increase in the provision of medical care specifically for children, registered in the first treaties about physical education in the Portuguese language, child hygiene guides especially designed for mothers, university theses on childbirth and newborns, and studies about infant mortality.10,13
Well-child care, including the improvements of the microbial theory, was introduced in Brazil in 1890, soon after it became widespread in Europe, brought from France by Moncorvo Filho, who founded the Institute for the Protection and Care of Children of Rio de Janeiro, in 1899, a philanthropic organization whose aim was to care for and protect needy children. Besides providing services that fitted into the patterns of the "Goutte de Lait" in France, the Institute helped advertise well-child care in newspapers, and by making the members of the elite moved, especially the ladies, it also helped publicize hygiene recommendations.10
Between 1910 and 1930, well-child care became institutionalized, was written into the laws, included in the proposals of public health and in pediatric practice. At that time, under North-American influence, health education was strengthened, and began to be directly provided to the population at health centers. New well-child care guidelines were established and began to be developed together with preschool and school-aged children.10 This period was also marked by the implementation of a course for community health agents at the Instituto de Higiene de São Paulo, who also helped to advertise well-child care.14 In the 1930s, the importance of well-child care was heightened, as it was viewed as fundamental for the construction of a great nation. At this time, the Motherhood and Childhood Protection Board was created, as well as the first chair of well-child care at the Brazilian National School of Medicine in 1937, headed by professor Martagão Gesteira. In 1940, the Brazilian National Children's Department was created, and several well-child care centers, maternity wards and prenatal care services were inaugurated.10,13,26
The political advancement of well-child care went hand in hand with scientific improvement, due to the fact that its concept became widespread, not being solely concerned with the prevention of diseases and infant mortality anymore, but also providing a healthy development in every sense, including the psychological one. Probably the major contribution to this new concept of children's health was the one made by Pedro de Alcântara, who was concerned with the prevention of different forms of pressures from the environment. These pressures, for instance, could result from neglect or overstimulation by the family, from an inadequate diet, or from social factors.10
From the 1950s, well-child care began to lose its status to a more curative care based on medical subspecialties. In the 1960s, new strategies for well-child care were adopted, influenced by U.S. movements, such as preventive and community medicine.26,28,29 More recently, especially in the last decade, well-child care became the center of attention and object of study once again in the United States, the United Kingdom and Canada, seeking to build its fundamentals only upon controlled trials and systematic reviews.5
A social history
With regard to the development of well-child care, this method of historical analysis shows an important conceptual difference from what was previously described. Here, well-child care is regarded as a practice that is specific to the modern western society, instead of a designation of different types of care children were provided with in different civilizations during the course of time. Thus, well-child care does not apply to any child, but to the modern child model. Therefore, the social history of well-child care is based on the origin of the modern child.
In the Middle Ages, there was no separation between the worlds of children and adults. As soon as an infant was weaned and able to feed, walk and talk by himself, he could take part in adult activities.30 Body awareness was quite different from ours. The body did not belong to each individual, but to a large natural communal trunk, formed in a constant movement, in which dead ancestors were reborn as one of their descendants. The major concern was therefore to perpetuate their genes. This way, learning during childhood aimed at enabling individuals for such purpose. Given its function, this education could not cease to be collective, with no room for intimacy in the household, as the feeling of being in a large family was strengthened all the time, because the maintenance of a family depended on everyone, adults and children, in an equal degree.31
In the Renaissance, wealth began to accumulate, urban centers developed and the behavior of man changed, as did the emerging bourgeoisie and new employment relationships. The emerging bourgeoisie needed to be recognized according to their wealth, and for this reason, it was necessary to break up with the medieval school of thought. It was then that movements such as individualism, humanism, anthropocentrism, rationalism and universalism flourished. At that time, a new image of life and time began to form, in which an important aspect gradually took shape, but only amidst the wealthy: the willingness to preserve children's lives and spare them from diseases.31 From this time onwards, lineage is no longer important, but the individuals who perpetuate themselves through the children, through their consanguineous children. Children now had a new social status. In this context in which society established a new value and new objectives for humanity, the first acclaimed works on pediatric issues were conducted, among other signs that children also acquired new values.
In the 17th century, a new sense of childhood was molded by clergymen, lawmakers, moralists and educators, characterized by the psychological and moral interest in children, which required an education that could turn them into rational and Christian citizens.30 This process is consolidated in the 18th century through the Enlightenment, a period that is central to the development of scientific interest in children, as well as to a new concept of Medicine, which begins to show concern for society.
In the 16th century, England, France and Austria began to calculate the active force of their populations.32 The extremely high rates of mortality observed in societies where the number of inhabitants used to be their greatest wealth, because all other societies depended on it, showed the necessity to devise strategies for the improvement of the population's health status. The fear of decimation that gripped the great nations, which depended on their populations to raise their armies, their colonies, their workforce and their markets, among other things, gave rise to State Medicine. Three of its major examples were the Medical Police in Germany, Social Medicine in France and Medicine of the Poor in England. Although different, what they had in common was the establishment of a link between Medicine and the government for the strengthening of nations.32 Through distinct mechanisms, they sought to improve the health of the poor without having to redistribute wealth.
In this process in which Medicine gathered together with different nations due to the concern with their populations, took shape what Foucault32 denominated "the privilege of childhood and the medicalization of the family." Privilege of childhood means the concern with birth and mortality, and also with the correct "management" of this period of life. Therefore, the government and Medicine showed concern with the "survival of children into adulthood, with the physical and economic conditions for such survival, and also with necessary and sufficient investments so that the period of development can be useful."32 On the other hand, medicalization of the family is the process whereby new rules for the parent-child relationship were established. As a result, a series of obligations were imposed on parents and on children: hygiene care, breastfeeding, healthy garments and physical education. Michel Foucault stressed the existence of another process as important as this private process of change in family relationships: life should abide by medical recommendations. From this moment on, bodies and life are medically established.32
By analyzing the birth of philanthropy, Donzelot9 intelligently discussed the preservation of children's health in the 18th and 19th centuries. His analysis followed two parallel strands: the first concentrated on the large number of works that advertised child rearing, in which there was a concern with the preservation of elite children's health, whose care, until then, were marked by the traditions that preceded the rise of bourgeoisie, which, according to modern moral principles, led to the misuse of the body due to lust and vanity. The second one dealt with the strategies for the preservation of poor children's healthy growth, which required the reformulation of the roles of each family member, resulting in the modern nuclear family, whose main objective is to raise and protect their children. The idea of motherly love and the emphasis on breastfeeding were characteristics of this model. According to this model, what was socially constructed became a psychological constant due to social pressure.33
Such processes could be authenticated with the advent of the Pasteurian Revolution and of the Positivist Doctrine in the mid-19th century, through which science acquired the necessary authority to assert something that had been longed for since the Renaissance: the capacity to establish rules that could reduce infant mortality and the incidence of most diseases, forming a new society comprised by healthy adults. For Boltanski,8 the management of private life, of families, within the home, is the major objective of well-child care. This way, it is the extension of State Medicine and Preservation of Children's Health. Its unfoldings such as outpatient clinics for healthy infants, the encouragement of breastfeeding and sterilization of cow's milk were the inputs for philanthropy, understood by Donzelot as measures for the poor, with the aim of guiding their lives, reducing their social cost and increasing the number of workers.9
The diffusion of well-child care in Brazil was different from that which took place in industrialized countries, once more revealing its social determination. Although it was imported from France soon after its emergence, it was only institutionalized in the 1920s, when industrialization became a reality and there was a growing need for labor force and a necessity of response to workers' movements that claimed better living conditions. In the 1930s, during the Estado Novo dictatorship, its proposal for a renewed society matched that of nationalists and eugenists, which contributed to its consolidation and great political power.10
The history of well-child care in Brazil also shows the transfer of the western world's hegemony from Europe to the United States, after World War I, characterized by the importation of health centers and health education. After World War II, the process was intensified with the importation of prevention models, integral medicine and community medicine, all of which originated in the United States, in an attempt to implement a health reform without impacting the politically and economically powerful private medicine.28 The great deal of money invested by the United States in all these projects raised some doubts as to the mere intention of protecting children, suggesting an attempt to reproduce in Brazil the necessary conditions for the opening of new markets. As part of a project for the integration of world capitalism, the World Health Organization used well-child care as a strategy to improve the living conditions of impoverished populations, employing education to change bad habits, which were responsible for social ills, and to submit the populations to the system of rules.13
Some authors also found a relationship between the norms of well-child care and the interests of economically strong sectors. The best example was that of the powdered milk industry, which seemed to have a determinant role in minimizing the strong stance taken in favor of breastfeeding by carrying advertisements in the mass media and among health professionals, in partnership with assistentialist public policies for the distribution of powdered milk, through well-child care programs implemented between the 1940s and the 1980s.11,12,34
The same period was marked by a certain change in the alliance between Medicine and the government, which continued to exist, but now with a different purpose. Since labor force reproduction was no longer important (quite on the contrary, it was harmful due to an uncontrollable population explosion), a new form of health care was established (curative and private care), designed for employed workers. This model favored the government, by maintaining the workers' health conditions, and the dominant groups in the health sector, represented by the pharmaceutical industry, diagnostic technology industry and healthcare companies.11,26,35,36
In the last decades, the failure of this model, in conjunction with the movements of preventive, community and social medicine, helped outline proposals concerning reforms in healthcare services and medical practice, as well as in medical education. In the specific case of children's health, this process gave rise to the so-called social pediatrics, which reconsidered well-child care, making use of social sciences.29 Although it originated alternative projects related to the practice and teaching of well-child care,37-40 it is not possible to attest whether it was capable of changing its ideological stance, which consisted of labor force reproduction.
Two ideologies and some questions
The existence of two views regarding the history and definition of well-child care actually reveals two ideologies. By considering ideology as "a political justification of social positions,"41 we may find, in the positive history of well-child care, a way to conceal its relationship with power. On the other hand, the social history of well-child care, if seen as a battle against ideology, which consisted in denouncing it in order to eliminate it, thus redesigning a new well-child care model that is free from the influence of the dominant classes, turns out to be a new way to determine what is right, constituting therefore a new ideology.
Thus, the main difference between the two views presented herein apparently lies in the role of dominant classes, responsible to a great extent for knowledge development, including well-child care. In the positivist approach, the idea of creating and maintaining well-child care was targeted at the progress of civilization and protection of children, whereas from the social history perspective, it was targeted at wealth, as well as at the consolidation and maintenance of the political and economic power of the elite. However, such difference does not seem to determine an insurmountable antagonism between the definitions of well-child care. In other words, we do not believe that by recognizing well-child care as an ideological practice we will invalidate the fact that its scientific norms may contribute to the physical and psychological development of children. Quite on the contrary, we think that these views complement each other and allow for the improvement of pediatric practice.
Perhaps the first application of this critical view on the history of well-child care is a way to better understand its limitations in every-day practice. Traditionally, the unsuccessful results of well-child visits are attributed to the mother who, out of lack of information or neglect, does not follow the pediatrician's recommendations.10 However, sometimes the blame is placed on pediatricians, who do not know how to convey the necessary information in a proper way. If one understands that well-child care does not comprise "universal and infallible scientific truths," but norms established in different historical moments and with different purposes, it may be possible to mitigate the blame attached to mothers or to pediatricians in the face of apparent failure. Likewise, this understanding may even help pediatricians to find less authoritative and rigid ways of expressing their recommendations, employing, for instance, medical decisions based on the concrete material reality of families.
Even though, in most cases, it is not possible to clearly identify economic interests or any other interests that are not intended to benefit only the children, knowledge about the history of well-child care prevents pediatricians from taking new documents and guidelines as absolute laws, as some of them, such as the new vaccine schedules6 or the new warnings about the consumption of cow's milk in the first year of life,7 are very distant from the reality of most Brazilian families. Ideally, these considerations could be included in the discussions for the development of consensus reports, so that observations can be made about their applications in different services, such as in a private practice or at a unit of the Unified Health System, and in families of different socioeconomic backgrounds.
Our aim here was to analyze issues that enable general pediatricians to take part in discussions on well-child care based on other fields of knowledge (e.g.: history and sociology), since none of this information seems to deny its importance; on the contrary, it encourages further reflections, considering that well-child care is a practice under permanent reconstruction in the course of time.
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Manuscript received Feb 26 2004, accepted for publication May 12 2004.