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Reply: The SUS exists!

The SUS exists.

That is a concrete fact.

Critical thinking will enable us to focus on this phenomenon and to construct concrete analyses of this concrete fact: the SUS exists11. Paim JS. Reforma Sanitária Brasileira. Rio de Janeiro: Editora Fiocruz; 2008..

However, as André Dantas has pointed out, it is important to note that the SUS is “neither fully implemented, nor totally public”.

Yet Maria Lúcia underlines the fact that the SUS has persisted, albeit “in times of ultra-liberalism”

Well, these facts lead me to doubt the argument, which has been increasingly aired (perhaps due to the difficulties of the current situation in Brazil) which states that: “The SUS does not fit into the current dynamics of international capitalism and it does not fit in Brazil”.

What leads me to doubt this categorical statement about the future?

I will now make some observations about this issue.

Throughout history, the “dynamics of capitalism” have never been able to prevent class struggle. Neither have they succeeded in overcoming the effects and outcomes of libertarian and emancipatory political struggles, even when they have been partially institutionalized. Groups such as workers, women, and black and indigenous people have all all rowed against the capitalist tide, influencing political life, social and civil rights, customs, relational practices, etc. It is also true that in the last thirty years capitalist forces have imposed defeats and setbacks in relation to these movements. These are dark times of ultra-neoliberalism.

Thinking about these experiences of reforms, one could argue that life proceeds in “slices”. Even when our pretensions, strategies and tactics lead us to aim for the abstract figure of “totality,” whether in the name of revolution, or the absolute, or any other denomination, in practice there will be partial changes, “slices”, if you will. An important part of the old power relations will always be part of the new arrangements, whether they are referred to as reformists or revolutionaries.

In this sense, the SUS represents one of the “slices” of well-being and rights that the anti-capitalist movement (even when its participants do not classify themselves in this way) manages to highlight within the “totality” of “ultraliberalism”.

Numerous factors and elements interact within the dynamics of the SUS. Political groups were established in favor of changes in relation to health; a political project was insituted that that was included in the Brazilian Constitution; and there were changes in the institutionality of the health sector. All this has ocurred, despite the fact that the many sectors of this movement have had diverging levels of influence on the health reform project. There has also been the specific contributions of health workers, popular groups in favor of access, some governing managers, researchers, teachers and students, among others. It should be stressed that the general ethos of the SUS was opposed to the growing hegemony of neoliberalism in Brazil and worldwide. The SUS has always been rowing against the tide.

I would like to highlight what I would refer to as “institutional activism” as an important factor in the resistance to the “dynamics of capitalism” and also as a significant factor in the construction and sustainability of the SUS (both of which are precarious).

Yes, institutional activism or militancy. I am not referring to entryism within the state apparatus or the hope that management can act for change. I refer to the integral, institutional and social struggle of workers, in varying degrees, with popular sectors struggling for both the implementation of the SUS, the introduction of democratic management models, and the reform of health know-how and practices. I believe that this type of spirit has been largely lacking in the construction of true socialism. It has been discouraged and even repressed. In Brazil, there have been, and still are, movements in support of mental health, popular education, humanization, environmental health, the fight against AIDS, in defense of the rights and health of indigenous populations, black people and the LGBT community. Political, scientific, cultural and ethical activism. This is worth gold; it is worth more than gold, it is the belief that we represent hope. “Our revolution” – referring to the movement led by the US politician Bernie Sanders - with similar strategies.

It is worth remembering that there also exists, at the same time, patrimonialism, corporate actions, cooptation and coercion by the government designed so that workers and social movements act according to the interest of the market and the political power of the State.

In addition to these obstacles, as Maria Lúcia has pointed out, the relationship between health activism and the exploited majority of the population has never been solid and, in recent years, it has been shrinking further. Nevertheless, there are thousands of activists who make up organizations such as Abrasco and CEBES, who conduct the anti-asylum struggle, the resistance to violence, against medicalization, the degradation of cities and the environment, and various other social expressions of resistance to capitalism.

I like to use the idea of what has been referred to as “the eleventh house of the architect”. I use this image to counter-balance the increasingly common view that political theory should be restricted to demonstrable evidence. Using the methodological procedure that I adopted in my article about the SUS, architects, whether individually or collectively, utilize history, experience and data to develop projects, models and new programs to reflect political, social and ethical values. It is important to make the connection between technique and politics; the old notion of “praxis”. However, nothing and nobody will be able to make assurances that the knowledge constructed from these connections can be taken as the absolute truth or used as concrete guidance to achieve social welfare and democracy.

From my own personal theoretical, practical and ethical perspectives, end results and utopias must always be in close harmony with the means. Even the ends, the goals themselves, should always be in question; in perpetual movement, constituting and re-constituting. If space is to be secured for critical reflection about the ends, then the means need to be continually revised from the point of view of diversity of interests, values, harmful effects, and so on.

I owe much of my ability to research policies, and to perform clinical and public health, to Antonio Gramsci; however, I do not agree with his phrase: “whoever wants the ends should want the means.” I do not agree with those words because there are several ways to achieve similar goals, and also because this phrase authorizes the sacrilization of the means; it stimulates strategies and tactics aimed at supposed ends such as manuals of conduct, hiding bureaucratic traps, power struggles, etc. Judging people or movements as enemies or opponents based on differences in relation to methods and approaches has resulted in injustices and threats to freedom and democracy.

I see no way to socially or scientifically separate the means from the ends. I do not bet, nor believe; I have the testimony of history on my side, through the evidence of anti-democratic ends, to build a future democracy. Social justice and solidarity need to be practiced, as far as possible, in every space of dual power or governability that is constructed by the emancipatory movements. Nothing justifies acrimony, the concentration of power, or disrespect for diversity and dialogue in collectives, groups, institutions or movements.

Finally, Professor Ronaldo Teodoro rightly concludes that in recent years there has been an “oligarchization of power that directly denies the democratic tradition ... in which the SUS was born.” In fact, the succession of political and economic events over the last decade have been unfavorable to the development and sustainability of the SUS. However, Professor Teodoro also admits that despite the “anti-health lobby” in the media, according to opinion polls “direct service users of the SUS have a positive perception of it”, unlike the sector of the middle class that does not use SUS services.

So, to sum up, despite the current difficulties hope still exists and the creation of a broad movement to defend the SUS is a concrete possibility

This is the spirit of institutional activism created by the Health Reform Movement.

I would like to thank André Dantas, Maria Lúcia and Ronaldo for the care and generosity with which they read and commented on my article concerning actions required to defend the SUS.


  • 1
    Paim JS. Reforma Sanitária Brasileira Rio de Janeiro: Editora Fiocruz; 2008.

Publication Dates

  • Publication in this collection
    June 2018
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