The contribution of Paulo Freire’s thought to Popular Health Surveillance

Paulo Freire considered Popular Education (PE) as an emancipatory process, through debate and critical action, as a dimension of human existence. This text aims to conduct a narrative literature review on the articulations of Paulo Freire’s ideas with Popular Health Surveillance (PHS) actions based on his contributions to Education and Health. The text presents how the contributions of Paulo Freire and Popular Health Education inspired the construction of Popular Health Surveillance, which seeks to promote the transformation of local reality in the face of rights violations and advocate for life. Thus, experiences from vulnerable territories and populations often use Popular Education pedagogical strategies to establish PHS practices. Popular Health Education becomes crucial in the territory to stimulate the transformation of individual perception and discuss their reality. Promoting a praxis about the “critical situation” in the daily lives of social stakeholders allows diagnosing reality based on scientific information in dialogue with culture and popular organization as a possibility of building the “viable unprecedented”.


Introduction
Popular Health Surveillance (PHS) actions conducted by grassroots movements in the face of deterritorialization, rights violations, and illnesses, generally caused by the socioenvironmental degradation mode of imperialist colonial capitalism practiced in Brazil, have in Paulo Freire's ideas a political path of resistance to the established in order to understand better the possibilities of transforming reality in a perspective of struggle in defense of cultural values and healthy, supportive, and sustainable lifestyles.
Freirean Popular Education contributes to Collective Health through "co-labor-active" networks between social and popular movements with the Unified Health System (SUS) and with education and research institutions (schools and universities).Popular Health Education (PHE) movements have contributed to Health based on the Freirean thought's reflections and constructions, which have been expressed in a Pedagogy and a conception of the world centered on dialogue, debate, and joint action between professionals and the population 1 .
The praxis of Freire's Popular Education occurred as a place of resistance in a period of advancing neoliberal policies associated with establishing authoritarian governments through a military-corporate dictatorship in Brazil in the 1960s and 1970s.Paulo Freire considered Popular Education an emancipatory process through debate, critical reflection, and action as dimensions of human existence.Popular Education thus unleashes processes in which, through paths guided by lovingness, affection, and joy, the knowledge-of-experience-of-subjects-and-collectives is made, grounded on cultural diversity, with a critical-reflective emphasis and an emancipatory intent 2 .
Popular Education emerged from adult literacy experiences and was appropriated by several societal sectors, highlighting the health sector through the work of professionals and activists in the fight for the right to health.These professionals and activists develop reflections and theoretical productions grounded on Popular Education conceptions by placing themselves in the position of apprentices with popular authors and activists.In this context of developing an educational concept systematized by Paulo Freire in the second half of the 20 th century, many health professionals, dissatisfied with the commercialized, verticalized, and biomedical practices of health services, engaged in this process.In the void of the State's neglect of social problems and demands, initiatives, and actions began to take shape and sought solutions through dialogue and articulation between popular and academic knowledge 3 .
In the field of health, to some extent similar to Popular Health Education, Popular Surveillance surfaces as a concept and movement of re-existence based on the social need that emerges from the criticism of formal and institutional health surveillance models 4 , the limitations of their effectiveness, and the consolidation as a public State policy, including setbacks in the face of the dismantling of labor and environmental legislation, with the destructive advance of neoliberalism, the agro-mineral-hydro-fossil-business model and life's commodification, especially in the last decade.Nevertheless, the National Health Surveillance Policy 5 was established only in 2018.
Considering the history and premises of the meeting of Paulo Freire's ideas and Health, particularly Health Surveillance, this text is a narrative literature review that aims to articulate Paulo Freire's ideas with Popular Health Surveillance (PHS) actions.We propose a re-signification of the collective challenges that emerge from the observations of experiences that mobilize PHS in a dialogical approach with the human needs of social reproduction and their vital journeys, sharing a guiding inspiration: the postulates of Paulo Freire's Popular Education.
The text methodology is a qualitative narrative review that aims to dissect the contribution of Freire's thought in the construction of PHS through the practical-theoretical experiences of the authors.Narrative review articles are broad and appropriate for describing and discussing the development of a particular subject 6 .Therefore, we opted to identify Paulo Freire's works that most contribute to implementing PHS practices, contextualizing them with Collective Health until they materialize in the subjects' practices in their territories.
This text is structured in three sections, discussing how Freirean ideas have come closer to PHS practices.The first section, "Freirean Dialogues with Public Health", presents the synergy and historical development between Freirean ideas and Public Health.The second section, "Freirean Approaches to Popular Health Surveillance", addresses the PHS emancipatory perspective based on Popular Education to strengthen territories in the face of socioenvironmental injustice.Finally, in the third section, "The Freirean Legacy for Popular Health Surveillance", we present Paulo Freire's legacy in PHS experiences and how these ideas are materialized in popular practices.

Freirean dialogues with Public Health
Freire's dialogic pedagogy was consolidated with his book Pedagogy of the Oppressed 7 , produced during his exile in Chile and published for the first time in Spanish in 1968.In this book, he pointed out that, in order to achieve a critical education based on a debating conception, it was necessary to confront the "banking" conception, in which oppressive education becomes an act of deposit (as in banks), in which "knowledge" is a gift from those who think they are wise to those who supposedly know nothing.This verticalized teaching-learning method reinforces the status of capitalist exploitation and oppression and its social inequalities 7 .In this work, the author points out the theory of anti-dialogical action, which proposes domination through fragmentation by excluding people's leadership, to propose a theory of dialogical action through the shared construction of thought, where there is no hierarchy of knowledge between learners and educators.In this sense, individuals are the subjects of their historical process to understand their reality and, as a result, find possibilities for its transformation.
The contribution of Freire's ideas transcends the educational bases of institutionalized training, driving dialogues and reflections, and is incorporated into the foundations of health practices, especially those territorialized and reproduced by grassroots movements, such as Popular Surveillance, which draws on this Freirean historicity.In this sense, when approaching institutionalized health, with its contradictions and vertical orientations marked by inequalities, we should consider actions to denounce the status quo (critical act) while transformations can be mobilized 8 .This process is possible through Popular Education as a political and pedagogical practice of training with people, contextualized by their social demands and based on transforming reality as an emancipatory process for a democratic and popular society.
The emergence of Popular Health Education occurred primarily from the 1970s onwards, in the context of the working classes' lack of access to substandard health services, the impossibility of entering the labor market, which excluded workers from social security benefits (social security, social assistance, and health), and poor in-come, housing, and food conditions.This period witnesses the escalated establishment of Preventive and Social Medicine Departments at Brazilian universities, along with postgraduate training projects in Family and Community Medicine, besides creating and strengthening Public Health and experimenting with university extension projects adhering to the Community Health and Medicine Movement 9 .As part of this process, health professionals began to engage more intensively and constantly with grassroots groups and began to outline attempts to integrate health actions into local social dynamics.The experience of the Popular Health Movement (MOPS) in the East Zone of São Paulo is the best known, but many similar movements are still active today.Calling for an understanding of the social dynamics of populations in situations of vulnerability for health work, Victor Valla states that "the interpretation crisis is ours".He exemplifies that, in the work that health professionals do with dwellers, especially the vulnerable, they need to understand the several dimensions of life, which involve cultural roots, housing, the environment, and work 10 : Every proposal put forward by hygienists presupposes "prediction" as the primary category since the idea of prevention implies looking to the future.However, we could hypothesize that these population sectors lead their lives with the primary category of "provision", meaning that the memory of hunger and the difficulties of survival faced in the past makes them look to the past and worry about providing for today.Thus, an idea of "accumulation".In this sense, the proposal of "prediction" would be in direct conflict with that of "provision" 10 (p.41) (emphasis in original).
One of the most challenging and perhaps most difficult aspects for professionals/mediators to understand in their contact with the population is popular culture in its most different and plural presentations.This culture should be thought of as accumulated, systematized, interpretative, and explanatory knowledge and not as a barbarized culture, a fallen form of hegemonic culture, or a mere and poor expression of the particular 11 .
A large part of Popular Health Education experiences today aims to overcome the cultural gap between institutions and the population since one side generally does not understand the logic and attitudes of the other 12 .On the one hand, we have established Public Health based on scientific and hegemonic knowledge, where health services, several State sectors, and supplementa-ry health are found.On the other, the dynamics of illness and healing in the popular world, the resistance and existence practices of the various populations, especially the vulnerable.
In Collective Health, Popular Education is a movement that expresses itself in care practices, the production of shared knowledge, and the establishment and strengthening of popular leadership.Popular Education also enables a rapprochement and dialogue between popular knowledge, scientific knowledge, health professionals, and institutions 13 .
We should note that the paths taken to develop an institutional Popular Education policy have been long and arduous, beginning with the establishment of the National Network for Popular Health Education in 1998 and then the creation of the Popular Education Thematic Group of the Brazilian Association of Collective Health (ABRASCO) in 2000.In 2002, a letter from the National Popular Education movement was sent to then President Luiz Inácio Lula da Silva regarding Popular Education as a necessary practice for comprehensive care, the qualification of social participation, and the necessary changes to the training processes of health professionals 9  The political-pedagogical framework of Popular Health Education based on social constructivism comes with a set of knowledge and practic-es, considering that learning is a complex process that occurs in the daily context lived through the interaction between active and creative social stakeholders who engage in new experiences and are confronted with others already lived, thus developing new mental schemes, expressed in individual and collective knowledge 14 .Added to this is the framework of Critical Pedagogy 15 , which sees education as a practice of freedom that, through a critical understanding of reality, makes it easier for people to recognize/understand the several forms of oppression and mobilizes them to confront them, understanding knowledge as belonging to a more significant act, that of knowing and understanding, and thus constituting the epistemological element of the learning action.
Moreover, Popular Health Education is a strategic tool to support the reduction of regional and social inequalities, the strengthening of cultural pluralities and diversities, and the possibility of being in the world.It enhances social participation and shared management, which are extremely necessary in relationships among managers and between managers and SUS workers and clients in order to strengthen citizenship and build a life-enhancing society 10 .
As a result, Popular Education is the right instrument for dialogicity, strengthening the paths toward social transformation without denying the citizens' interpretation of the world interwoven in their lives and everyday lives.It strengthens people's criticality and boosts autonomy, in the sense that the educational act is a political act that indicates a break with the sense that the educator is the one who knows, thinks, says the word, disciplines, has the authority of knowledge, and the students are the ones who do not know, are the ones who are thought of, the ones who listen docilely, the disciplined, and the ones who must adapt to the determinations of the one who guides, as interpreted in the Pedagogy of the Oppressed 7 .

Freirean approaches to Popular Health Surveillance
The premise of Popular Surveillance is that people play a leading role, recognizing subjects as knowledge holders, bringing new perspectives of analysis that include a collective view of the oppression and injustice endured to overcome them.In this sense, Popular Surveillance dialogues with fundamental inputs from Freire's theory for reflecting on and understanding the world: "critical situation", "critical act", and "viable unprecedent-ed".PHS becomes vital in guiding the dispute over public policies that contribute positively to the socioenvironmental determination of health.
In this case, the issues are covered up by the "critical situations" that present themselves to people as if they were overwhelming historical determinants, to which they have no choice but to adapt.In this way, people do not get to transcend the "critical situations" and discover or see the "viable unprecedented" 16 beyond and regarding them.
Freire 7 affirms that a "critical situation" refers to barriers, obstacles, and extremely oppressive historical problems, which are interpreted by the subjects as impossible to change.He states that overcoming "critical situations" requires complex pedagogical processes that can awaken a reflective and critical view of reality and the construction of a collective project for the future, bringing out what he calls the "viable unprecedented".
The "viable unprecedented" is a process of forming critical knowledge vis-à-vis realities and experiences and producing collective strategies to overcome oppressive situations, which Paulo Freire calls "critical acts", moving toward the construction of other concrete and viable realities, the so-called "viable unprecedented" 7 (p.18).
The emergence of the "viable unprecedented" results from a pedagogical process that necessarily involves critical reflection on reality by the subjects involved, moving toward constructing alternative projects for the future built collectively.Reflections and denunciations of unjust and oppressive realities must be followed by announced possibilities for change and the construction of projects to overcome them 8 .
The pedagogical process occurs through the codification and de-codification of concrete reality.This work is based on themes that make sense to the population, and from these themes, it would be possible to develop a critical analysis of reality to decode it.The generating themes generally involve "critical situations" in people's daily lives, which cannot continue as they are and need to be overcome.The perception of and reflection on "critical situations" awakens individuals' intentionality to act and collectively discover the "viable unprecedented" 8 .In this sense, Popular Surveillance dialogues with the Freirean theory when it aims to be: [...] a pedagogical exercise in constructing citizenship for all those involved in work, health, and their territory, favoring the discovery of collective actions that bring potential contributions to detecting and preventing diseases and illnesses, promoting life, and constructing a Good Living 17 .
The issues, health problems, and deterritorialization, which deteriorate living and working conditions, generate social mobilization in Popular Surveillance, calling on residents, researchers, and health professionals to rebel against rights violations.The struggle to produce and reproduce life can be a pedagogical process involving health research and fieldwork dimensions.In this sense, Popular Surveillance can be considered a process favoring the construction of "viable unprecedented" since it is an exercise in recognizing/knowing the reality of the territories, with popular protagonism, which stimulates reflection on historical "critical situations" 17 .
The "critical situation" is a category that allows us to look at the concrete and historical dimension of reality in order to transform it.A critical author who analyzed Brazilian reality in the 20 th century, when Freire produced his work, is the geographer and physician Josué de Castro.This author captures the Brazilian reality through malnutrition and its regional differences, making a significant contribution to understanding Brazilian capitalism and its effects on the social determination of health 18 .Hunger, according to him, is produced by social inequalities and structural problems, such as the need for agrarian reform, and materializes in the precarious conditions of human existence, always associated with the production of disease and death.His work, dated 1946, provides information to understand how we reached the current phase of economic development in the country, without solving the problem of hunger and poverty.
Ruy Moreira 19 argues that Brazilian spatial formation is marked by the expansion of urban-industrial capitalism in a geoeconomic rearrangement of geobotanical bands, creating, cycle by cycle and over time, a regional division that formed the basis for the territorial division of labor and the exchanges necessary for industrial development.This territorial formation created oppressive mechanisms throughout the country and has accompanied the development of Brazilian capitalism to this day.
Understanding the circuits of capital in the production of disease is broader than identifying them in territories since their determinations can exceed the area in question.We should familiarize ourselves with the driving forces behind the political economy of human and natural exploitation.In many cases, the origins of the diseases (hotspots) are in the so-called developed countries that continue to expropriate the natural wealth of African and Latin American countries 20 through neocolonial extractivism, justified by developmentalist discourses, such as the expansion of agricultural and energy commodities.
Based on an understanding of the production chains of large agribusiness corporations, mining, hydro-business, and other neoextractivist processes, Popular Health Surveillance begins to exercise Development Surveillance, transcending the institutionalized and operational limitations of Health Surveillance as a civilizational challenge 21 .
The general determinations of capitalist society are observed in experiences with a power-capitalized stakeholder and capital that seeks accumulation by plundering environmental resources.As a result, social resistance through popular organization emerges as forms of re-existence, questioning, and opposing the current neoliberal capital model.Studies and research in Collective Health are fundamental to understanding the "critical situations", from the perspective of living and health conditions in which people are subjected to the effects of neoliberal development in their territories, such as the spraying of pesticides, the release of pollutants into the atmosphere and soil, the contamination of water sources, deforestation, and the loss of biodiversity.
According to Juan Samaja 22 , epidemiology, and public health were born out of the positivist movement, and their categories were individuals and their places of residence, seen as isolated and homogeneous.The focus is sometimes on the lifestyle of individuals rather than the structural conditions that determine the groups' living conditions, thus blaming people for their illness 23 .Jaime Breilh 23 affirms that this theoretical model -traditional epidemiology -does not explain the event, as it only describes and calculates the probability of it happening.As such, it is a theory that is functional to established power since it cannot show how the social, economic, and political structure determines the outcome.
Samaja 22 states it is necessary to understand the social determination of the health of populations beyond the centrality of counting cases (incidence and prevalence rates) and the morbimortality profile, giving way to the contexts, environments, and mechanisms through which the life processes of the population are constantly produced and reproduced.In this sense, the determination of the health-disease process thus becomes the expression of sociohistorical nexuses, which exacerbate inequalities traversed by intersectional class, gender, and race markers expressed in multiple and intersecting inequalities, generating and reproducing different ways of being in the world from their life territories.The challenge that needs to be faced is to understand the relationship between health-environment-production-work, considering society's formation and organization historical process under neoliberal capitalism, which, by advancing with the commodification of life and reduction of labor and environmental rights, promotes the reaction of population groups, especially populations exposed to vulnerabilities, and enables the establishment of collective projects that enhance resistance and counter-conduct actions.
Besides discussing the importance of the social determination of health, we should understand the territory where the interactions, conflicts, resources, health needs, and problems of a given population are expressed, along with resistance potentialities and strategies.The territory is a privileged place to observe the processes that interfere with the health of populations and their relationships, resulting from certain sociohistorical conditions and mediated by the sociopolitical contexts expressed there 24 .Popular Health Education in the territory becomes fundamental for stimulating the transformation of individuals' perceptions and debating their reality.Promoting a praxis about the "critical situation" in the daily lives of social stakeholders allows for diagnosing reality based on scientific information in dialogue with culture and popular organization.The PHS is a possible path toward driving the construction of "viable unprecedented", as it seeks to articulate territorial experiences with the possibility of enhancing strategies that strengthen and promote life.

The Freirean Legacy for Popular Health Surveillance
Jorge Machado et al. 25 argue that Popular Health Surveillance is an action strategy that starts from a continuous process, from identifying the dynamics, problems, and potentialities in the territories, dialoguing with the actual health needs of the population to preserve life, especially in vulnerable populations.
Research points to the diversity of actions and nomenclatures that cover what we understand as Popular Health Surveillance.The converging conceptual element is the appropriation of Health Surveillance concepts such as information, communication, and investigation for action, but in PHS organized by populations and popular movements, in which they associate technical-scientific knowledge with popular knowledge in the face of violations of the right to life, especially socioenvironmental rights 17,26,27 .
The work of educator Victor Vincent Valla in the favelas of the northern zone of Rio de Janeiro is a milestone in the dialogue between Popular Education and Health Surveillance.Civil Health Surveillance was a construction of the 1990s which, based on Paulo Freire's Popular Education, added the shared construction of knowledge and the collective ombudsman, presenting an aspect of Health Surveillance that included popular participation and contributed to social transformation, complementing traditional Epidemiological Surveillance 28 .
Analyzing Popular Health Surveillance experience in implementing uranium and phosphate mining in Ceará, Alves 29 believes that risk and situations of vulnerability can be highlighted through Popular Education that enhances community participation in participatory monitoring based on an understanding of reality.The author points out that disseminating knowledge is a strategy for mobilizing and organizing communities to identify allies, networks, and forces, both external and internal to the territory, in order to monitor companies, the State, and infrastructure projects 29 .The "critical situation" of a community where mining activities are expanding is an example of the importance of developing critical awareness through education as an opportunity for the collective organization of PHS actions.
The term "Popular Health and Environment Surveillance" was also used by Carneiro and Pessoa 30 to describe surveillance practices that focus on the role of communities and social movements in the fight to defend life.These authors argue that it can be strengthened if articulated with the SUS and academia as long as they recognize popular stakeholders and knowledge and involve themselves in participatory dialogical processes.
In an integrative literature review, Silva et al. 27 found the influence of Freirean ideas on Popular Health, Environment, and Work Surveillance actions.Therefore, Popular Education is a methodological inspiration and a valuable tool for analyzing the local context through previous knowledge and experiences to understand the determinants of problem situations better and propose solutions and actions.It is a process of materializing popular community leadership, in which participatory means of sharing knowledge are provided to build more effective public poli-cies, and the health of these communities is promoted and protected 27 .
Meneses et al. 17 also point out Paulo Freire's contribution to selected studies on Popular Surveillance practices in a literature scoping review.In the Freirean Popular Education approach, the shared construction of knowledge gathers practical resources for debating and transformative social mobilization.This movement also implies respect for the population's right to choose and decide on their care needs and priorities.It challenges people to a participatory-propositional role, not just an implementing role in health actions 17 .
Considering the knowledge of experience or "realized knowledge of experience", as Paulo Freire 18 used to say, Popular Surveillance preserves in its perspective participatory traditions of building knowledge in defense of life, territories, and the environment and mobilizing new ideas and creative approaches to this debate to strengthen Health Surveillance and its integration with Primary Care.Thus, the experiences of territories, communities, and vulnerable populations often employ the pedagogical strategies of Popular Health Education to become Popular Health Surveillance practices.

Some considerations
Aligned with the understanding that the current socioecological metabolism crisis requires a multi-scalar and multi-dimensional analysis, Popular Health Surveillance deepens the critique and need for Development Surveillance by understanding/perceiving the socioenvironmental determinants of health-disease-care processes.
In the current neoliberal logic, which escalates all processes of exploitation, life, labor, and nature, reaching an intensity that has compromised the very production and reproduction of species, we should reflect to act in ways that promote the maintenance of life on Earth.Hegemonic capital on an international scale is proposing neoliberalism as the way out, in other words, more capital by expanding the commodification of life in all its dimensions and in an increasingly authoritarian way, restricting fundamental democratic rights.
The severe ecological crisis we are experiencing expresses expansionist and tragically uncontrollable capitalism.We need to expand the networks of popular health workers and popular surveillance workers, who are all, in essence, grassroots health educators, to act in future popular surveillance and climate disaster contingency plans.The survivors, as a result of their work, will have to expand their organizational and solidarity capacity in order to face up to today's significant challenges and fight to preserve a world in which all beings can coexist and to announce the "viable unprecedented" with a prospective "hope" that does not wait but engages in defense of life.PHS has this strategy, which involves defending substantive democracy.
We understand that PHS can also be a care practice, dialoguing with the environment, the territory, and social dynamics, as it debates the way of life and its consumption/production relationships in this society, from a collective commitment to building the world in solidarity.PHS is a Pedagogy of Care that can enhance Health Surveillance.PHS can be a crucial pedagogical strategy for states to conduct public, democratic, and dialogical surveillance.Popular Surveillance combines Education as a way of understanding the world.It enhances the pedagogical care process in building a participatory action of Health Surveillance and Popular Health Education with the Unified Health System's principles of universalization and equity.
Based on the Freirean concept, we emphasize that PHS needs to be built on the interaction of the varied popular, ancestral, and territorial knowledge with scientific knowledge based on dialogue, listening, otherness, and respect for the knowledge of populations and territories.In this sense, it facilitates sharing diverse repertoires concerning life defense practices based on the reality experienced by each population, weaving paths that consider the varying dimensions of life, the human dream, the freedom to think, invent, create, and produce life, because they articulate knowledge and promote collectivity.