In this paper, the question of Brazil's insertion today as a country with the characteristics of modern consumer societies is discussed, focusing on the commercialization of the health sector, the segmentation of the health system and the contradictions of the rights to health care in the social context in question. Some research data on these issues broadcast in the National News Bulletins of Globo TV during the year of 2012 are presented, in which the high technology private hospital as a consumer icon, the underfunding of the public health system and the rejection of a poor and deprived Unified Health System are analyzed.
Consumer society; Health; Television; Social rights; Underfinancing of public health
Discute-se aqui a nossa inserção como país, hoje, nas sociedades de consumo características da modernidade, enfocando a mercantilização na área da saúde, a segmentação do sistema de saúde e as contradições do direito à saúde no contexto social em questão. São apresentados dados de pesquisa sobre o tema no Jornal Nacional da Rede Globo de Televisão, durante o ano de 2012, na qual se analisa o hospital privado de alto padrão tecnológico como ícone de consumo, o subfinanciamento do sistema público de saúde e a rejeição de um Sistema Único de Saúde pobre e carente.
Sociedade de consumo; Saúde; Televisão; Direitos sociais; Subfinanciamento da saúde pública
Brazil, a consumer society
When mapping out the possible or necessary desired paths for the future of society, these are conditioned to actions unfolding in the present. It is assumed that society has a given plasticity such that, with adequate intervention and through adequate consciousness, it would be able to take on the format envisioned for this society. However, this plasticity is rarely or almost never verifiable. While social projects are elaborated with the intent of social changes, they do not occur as expected or according to the desired sense of change attributed to them, as Eugênio Vilaça11. Mendes EV. 25 anos do Sistema Único de Saúde: resultados e desafios. Estudos Avançados 2013; 27(78):27-34. claims: throughout the years, the ample constitutional conception of a universal health system has taken on diverse meanings, as expressed in the segmentation of the Brazilian health care system. In this sense, the dream of universalization has been transforming itself into the nightmare of segmentation.
This process is evident in Brazil when we consider projects related to citizen's rights, legally sustained by the Constitution of 1988, among them being the Sanitary Reform Law that created the national public health system known as the Unified Health System or SUS (Sistema Único de Saúde). Among the analyses regarding the factors involved in this process, we have detected a strong presence of consumption and a market of products and services, which by the end of the 20th century has become hegemonic for most countries.
In this specific social context, being someone means being a consumer. Consumption qualifies the individual and identities are produced through consumption. The differences in an individual's access to the market reflect social inequalities. The right of the consumer overlaps and becomes a reference for considerations regarding social rights, as we have seen in the judicialization of cases involving the right to health and demands for state provisions in Brazil.
In a consumer society, the individual is integrated when he/she is a complete or relatively complete consumer or, in other words, when this individual has the financial resources to buy what he/she needs or deems to need for him/her and for his/her dependents. When analyzing consumption as a reference for social insertion, Amélia Cohn22. Cohn A. Estado e sociedade e as reconfigurações do direito à saúde. Cien Saude Colet 2003; 8(1):9-18. highlights that the question of the distinct levels of social insertion tends to then be measured almost exclusively by income levels; hence by the ability of individuals to show if they are or are not apt to provide for their basic social needs in the private sphere.
In such societies, as Bauman33. Bauman Z. O mal estar da pós-modernidade. Rio de Janeiro: Jorge Zahar; 1998. (1998) claims, there are those who have partially entered the consumer market. The State exists for these 'flawed consumers' or consumers who do not have sufficient financial resources to meet their basic needs. Segments of the population who do not have resources to partially or entirely cover their health care needs rely on the State, which, in turn, helps or provides the means for meeting such needs. In a society that privileges market access for fulfilling needs, provisions such as social programs, unemployment benefits and cash-transfer programs like bolsa família are a compensatory and provisional measure.
Given the expansion of a "society of consumers" in Brazil, one can observe that an individual makes use of SUS while he/she does not have enough resources for health care, but as soon as this individual is able to attain social insertion as a consumer, he/she uses the market or makes use of both the state and market health care services. In other words, the individual may buy a determined service in the market and may use the state system for other services.
While the State provides qualified health services, mainly those related to high complexity issues, the access is restricted and even disputed by private health care plans that make use of public health care services, which then make distinctions between SUS users and private health care clients when using public services. Although there are exceptions, state health services do not adequately meet the needs of the majority of the poor population. After a quarter of a century of efforts and negotiations to implement SUS, the public health system is considered inferior to private health care plans. Even when private health system services are of poor quality, SUS is still evaluated as worse, even if this is not the actual case.
There is a complex combination of factors that conditions the State to have an undervalued provision: the underfinancing of the system, the association of SUS with lower classes and poor places, the reduction of SUS to an assistance system, the decreased value given to Primary Health Care, to its professionals and users, the lack of humanization in health care, job insecurity, the lack of knowledge about SUS among professionals and society, the association of public health to specific campaigns and programs44. Santos NR. SUS, política pública de Estado: seu desenvolvimento instituído e instituinte e a busca de saídas. Cien Saude Colet 2013; 18(1):273-280.. Each of these factors can be understood as the result of the relation between SUS and a society that privileges both the consumption and the private provision of health care services and products. In light of this situation, the State can never directly provide services for all of the population that would be considered equal or superior to that which is provided by the best private health care services. This is why the SUS project, as designed by the Brazilian Sanitary Reform, is incompatible with the private provision of health care in a growing market of health care products and services. In order for this market to exist, SUS needs to be worse. The hypothesis of two competing, parallel systems of the same value and quality, a private and public system, cannot sustain itself. In addition, it is worth highlighting how clientelistic and patrimonial practices, embedded in traditional and conventional Brazilian political culture, also devalue SUS.
As Paim55. Paim J. O futuro do SUS. Cad Saude Publica 2012; 28(4):612-613. states: The future of SUS depends on what is being done today. The underfinancing of the public system and the incentives given to private health plans, including the expansion of the market with the inclusion of public servants and the so-called "C" class, point to the reproduction of SUS as an inferior [system] for the poor and as a compliment to the private sector, particularly in cases with costly procedures. The rationalizing policies that have been implemented, while relevant, have not been enough to renew the hopes for a dignified, democratic and quality health system for all Brazilians.
Hence, we legally have a public Unified Health System (SUS) and a private Supplementary Health System, being that the public system is not the only system given that there is also the private system. In addition, the private system is not entirely complementary since it competes with the public system, acts as force that devalues SUS in both politics and the media, and drains public resources for private sources66. Bahia L. O sistema de saúde brasileiro entre normas e fatos: universalização mitigada e estratificação subsidiada. Cien Saude Colet 2009; 14(3):753-762.. As a result of the segmentation of the health system in Brazil and according to Eugênio Vilaça11. Mendes EV. 25 anos do Sistema Único de Saúde: resultados e desafios. Estudos Avançados 2013; 27(78):27-34., SUS, as a system of universal coverage, has consolidated itself as a public health sub-system, which exists along with a private sub-system of supplementary health care and another private sub-system that is directly paid for by clients.
Consumer society, health and TV
When considering how notions and needs regarding health are created in Brazil nowadays, it is worth reflecting on how these issues are presented in the media and more specifically on television.
In fact, a defining characteristic of consumer societies is increased media consumption in all social spaces, a phenomenon that has implications on the social production of health and diseases.
There is no other medium that is more present or influential in the daily life of Brazilians than the television, which has become the main cultural reference in the country. In 2011, 97% of the households had a television; even the residences without a refrigerator or basic infrastructure had a television (PNAD-IBGE 2011). In Brazil, a television spectator spends an average of four hours a day with his/her eyes glued to the television.
This permanent and massive consumption of TV in Brazil occurs in light of a global context of the development of consumer societies. In contemporary global societies, communication has emerged as a prominent area of business or the apex of technological development with influences on all other economic areas. It has therefore become a public space of global and cultural standardization, as well as an education medium with great reach in the entire world. According to Marshall McLuhan, in the second half of the 20th century, the expansion of television transmissions via satellite transformed the planet into a "global village". Ulrich Beck77. Beck U. Sociedade de Risco: Rumo a uma outra modernidade. São Paulo: Editora 34; 2010. claims the following: We could say people meet every evening at the village green of television and consume news [...] They are part of a globally standardized media network [...] institutional and national boundaries are in a certain sense no longer valid.
Television feeds into consumption and values the consumer, who constitutes its public. In contemporary societies where both the social production of identities and social insertion occur through consumption, TV becomes the privileged mass space to stay up to date. In other words, it is how one can become attuned to market and fashion tendencies: TV or what is being said or seen on it, is a necessary common denominator for anyone who belongs to this society. The TV permanently updates social practices, drives values, judgments, inspirations, objects of desire and rejection, and also produces collective facts which, are acombination of information with a collective aspect that is destined to guide citizens in society, according to Lefévre88. Lefèvre F. A Saúde Como Fato Coletivo. Saúde e Sociedade 1999; 8(2):83-91.
This is the context where the idea of "collective health" is created as one of the current representations in this space of standardization. Through this prism, collective health can be seen as a set of information or facts on health and diseases that are 'publicized' in the media in a given social conjuncture or in a given historical moment. In summary, we can say that collective health is also the notion of health that appears in the media 88. Lefèvre F. A Saúde Como Fato Coletivo. Saúde e Sociedade 1999; 8(2):83-91..
Here it worth going beyond the classic, unidirectional notion of communication processes, which understand that a message is formulated by the emitter and arrives at the receptor through one channel. This simplified scheme distorts the process of the social production of media discourses, as if the messages could be produced by an autonomous emitter that is detached from society, the audience, market tendencies, news on the internet, and the variety of causes and conflicts of opinions present in social environment. In another model, which considers communication in a network, the formulation of a message is created in an interlocution network. Emitters and receptors are not autonomous, but are part of a multipolar, communicative network. Here the notion of communication is less concerned with the transference of meanings and more concerned with the web of meanings, forming a "symbolic market" in which symbolic goods are produced, circulated and appropriated by people99. Araújo I. Cartografia da Comunicação. In: Lefèvre F, Lefèvre AMC, Ignarra R, organizadores. O Conhecimento de Intersecção. São Paulo: IPDSC; 2007. . This model of communication is becoming more present given the growth of mass media on the internet parallel to conventional channels.
Health on the nightly news - Jornal Nacional
In order to investigate the themes on health in this complex context, we chose the nightly news Jornal Nacional as our object of analysis during 2012. Jornal Nacional is one of the most important sources of communication in this network, making it both influential and strongly subjected to the influences of multiple connections in the "symbolic market", where it is a highly recognized spokesperson. In 2012, Jornal Nacional had an average audience of 25 million spectators on a daily basis, 56% of the televisions in the country tuned into it, and a total of 33 points in the National Television Panel ratings - PNT-Ibope1010. Feltrin R. Ibope do Jornal Nacional no país cresce com Patrícia Poeta. Folha de São Paulo - UOL - F5 [periódico na internet]. [acessado 2012 maio 9]. Disponível em: http://f5.folha.uol.com.br/colunistas/ricardofeltrin /1087708-ibope-do-jornal-nacional-no-pais-cresce-com-patricia-poeta.shtml
http://f5.folha.uol.com.br/colunistas/ri... , which represents more than six million people and 300 thousand residences in the 14 main metropolitan regions of the country. This audience fluctuates and in 2012 there was an increase of about 5% given a number of factors such as telenovela audiences, the performance of a tv presenter, and even the small variations in the time the nightly news was going to air, which indicates a permanent search for a public that reflects 70% to 75% of the A, B and C consumer classes1111. Globo.com [Portal na Internet]. [acessado 2012 maio 9]. Disponível em: http://comercial.redeglobo.com.br/programacao_jornalismo/Jornal Nacionalac5_intro.php
In the current study conducted at the Public Health College of the University of São Paulo, 246 stories presented on the nightly news broadcast of the Jornal Nacional, for the entire period of 2012, were analyzed. These stories add up to 7 hours and 15 minutes of video available at the following site http://g1.globo.com/jornal-nacional/videos and can be accessed by using the keyword HEALTH. These 246 stories were presented in 158 editions of the news, which signals that health emerges in half of all the nightly news editions of that year, given that in 60% of these editions health appears only once, in 30% of the editions health appears twice and in 10% of the editions health appears 3 to 6 times in one single edition of the news. Throughout 2012, health was the opening story for nine editions of the nightly news.
Analyzing the opening stories, due to the attention they receive, reveals the themes, ideas and central images that guide the way in which health and, in particular public health, is regarded in 2012 in Brazil. Seventy-five percent of all of the content on health on Jornal Nacional can be broken down into four thematic categories:
5 opening stories (April 12th, April 17th, May 2nd, June 25th, October 11th) dealt with Hospital Assistance, which adds up to 76 stories throughout the year or 31% of the reports on health.
2 opening stories (April 19th, June 4th) dealt with Science and Technology, a theme present in 51 stories throughout the year or 21% of the reports.
2 opening stories (June 25th, September 14th) on the Consumption of Health Products and Services, which adds up to 28 stories or 11.4% of the stories.
1 opening story (September 28th) on Habits and Behaviors, which appears in 11.8% stories throughout the year.
When analyzing these 246 reports, we noticed that hospitals are the main stage for discussions on health, adding up to 1 hour and 47 minutes of reporting or 25% of the time allotted for health on Jornal Nacional in 2012. In the reports on Jornal Nacional, there is no other reference to health care assistance other than the hospital. There are no other places to deal with health matters. According to the general ideas of the reports, it seems as if diseases are threatening and hospital interventions are the decisive factor for saving the people in emergency situations. Hence, hospitals are the only resource for those who do not wish to die.
Arthur had acute hepatitis and urgently needed a transplant. His disease is rare and extremely serious, and his life expectancy would be very grim, he practically wouldn't have any chance of surviving. Arthur, who was only 2 months old at the time, joined the waiting list as he faced a challenge: he would be Brazil's youngest patient to undergo a liver transplant. (July 3rd, 2012)
At the hospital we found two different representations: on the one hand, the hospital is a "dream of consumption", a super-modern hospital, equipped with sophisticated technology, mobile intensive care units even in aircrafts, and highly specialized doctors. This symbol of consumption is present in 23 stories that particularly highlighted the hospitalization and treatment of celebrities, the elites of society, famous artists and the country's high-ranking government officials.
Reinaldo Gianecchini (a TV's star of Rede Globo) has been at the hospital since yesterday and has had a PET scan: an exam that evaluates the conditions of the patient's organs and tissues. The PET scan showed that the illness responded to the treatment, or in other words, he has the conditions for going through the marrow stem cell transplant. (January 5th, 2012)
The tumor in former president Lula's larynx has disappeared. More than desired, this was the result expected by the doctors: today, a magnetic resonance imaging and laryngoscopy revealed that, in fact, the throat cancer that was 3 centimeters has disappeared. (March 28th, 2012)
On the other hand, hospitals can be one of the most repulsive places when they are associated with SUS. The Unified Public Health System (SUS) portrayed in the reports highlights the inequalities present in society and characterizes that which is public as poor and underfunded. Of the 42 reports in this category, which reflects 17% of all of the annual programming, 24% refer to the lack of infrastructure, 19% to the lack of hospital beds, 15% lack of doctors, 14% to negligence issues and serious mistakes, 12% to strikes and 12% to crime or police incidents.
Patients that seek patient care in two of the biggest public hospital in Natal have encountered overcrowded and very dirty corridors [...]there are unused equipments, mold due to leaks, rust and mosquitoes near the patients (May 1st, 2012)
In the month of June, the hospital registered the death of 16 newborn babies [...] normally the average number of deaths is 3 or up to the maximum of 6 deaths in a period. Ideally, there should be one doctor for every 10 children, today we have one doctor for 40 patients (July 2nd, 2012)
While many reports praise the work done in hospitals, including the reports on public hospitals or those hospitals accredited by SUS, such as Hospital das Clínicas in São Paulo, Santa Casa in Porto Alegre, Instituto de Cardiologia in Brasília, Instituto Nacional do Câncer among others, these are not identified as public hospitals. In other words, their ties to SUS are omitted. Instead, when the reports are negatively describing public hospitals, there is an explicit association of the hospital with the "Unified Public Health System" or "SUS".
The Federal Public Prosecutor's Office is investigating if SUS doctors are misusing federal hospitals in Rio de Janeiro as specialized clinics in aesthetic medicine [...] In addition to breast implants, facial surgeries with local anesthesia, liposuction of the neck, back and abdomen, all of these services are paid by the Ministry of Health, or in other words, by all of us, the taxpayers. (June 15th, 2012)
The doctor, who was not present during his Christmas shift at the Hospital Municipal do Rio de Janeiro, was heard today. Given his absence at the hospital, a girl, who was shot in the head, had to wait 8 hours before being operated on. A.C.G. was wrongful with the emergency division of the Hospital Municipal Salgado Filho, in the northern part of Rio de Janeiro, when a 10 year old girl, A.S, needed a neurosurgeon (December 28th, 2012)
This kind of focus on hospital care, both positive for rich and private hospitals and negative for public hospitals, is sustained by extensive medical-scientific information gathered in 1 hour and 33 minutes of stories that report on research conducted by well-known institutions in the world such as Columbia University, Johns Hopkins, Harvard, Cambridge and even the Nobel winner in medicine and chemistry. This scientific arsenal feeds into the expectation of being able to access new drugs and procedures elaborated in highly sophisticated laboratories. It is a showcase of the most promising innovations, thus stimulating both the desire and interest of the consumer in having these procedures available at hospital and pharmaceuticals market.
Lastly, 28 stories deal with problems consumers faced in the market. The reports sustain the need for protecting the consumer through the State. This would be the case of providing women with surgeries, paid by SUS, for replacements of inappropriate breast implants, which were acquired by women for aesthetic or health reasons in private clinics or through SUS. This may also be the case of defending clients of health insurance plans who are frustrated with the long wait for certain procedures. This consumer is Jornal Nacional's public: even though private health plans are advertised, given that they sponsor the network, this does not prevent the nightly news from defending the consumers. As we will observe, this defense is not grounded on the social and economic right to health.
Health as a right and a market
The fact that the health market is strongly growing in Brazil is what brings to light the discussion of the health status as a right. This is an extremely complex issue full of contradictions with regard to the growth of consumers looking for private health insurance plans, the role of the State as a buyer in the market for private services and products, and the growth of the market for private service institutions that provide public health services. These matters have led to a questioning of the growth of judicial interference based on the guarantee of the right to health, the citizenship that sustains this right, and the historical conditions that have established this kind of citizenship in Brazil. This discussion also refers to the social transformations in contemporary society, leading towards a modernity crisis that has, among other symptoms, placed the role of the State in check when related to guaranteeing social protection and the second generation of human rights, which are the social and economic rights of citizens, including the right to health.
The right to health is a historical construction, associated with liberal thought that developed in Europe during the 17th and 18th centuries and served as the juridical foundations of modernity in the form of citizens' rights. These ideas were based on the conception of an autonomous subject that asserts priority over the collective and is the bearer of a subjective right calling into question the power of the State1212. Lochak D. Les droits de l'homme. Paris: Éditions La Découverte; 2005.. As Danièle Lochak1212. Lochak D. Les droits de l'homme. Paris: Éditions La Découverte; 2005. analyzes, this is an inherent contradiction of the right to health: on the one hand, there is its liberal origin as a "right of man" and, on the other hand, its economic and collective aspect, which is dependent on the State. Contrary to its liberal foundation, economic rights require the State's active intervention, the mobilization of material resources and the establishment of public services. A welfare state, which provides positive services, has to increase taxes that, in turn, restrict both individual autonomy and the liberty of this individual to choose how he/she wants to spend his/her income1212. Lochak D. Les droits de l'homme. Paris: Éditions La Découverte; 2005..
Highlighting the contradictory nature of the right to health is important for understanding its fallibility given the effects of a consumer society, which among other effects tends to intensify the processes of individualization. The cases of the judicialization of the right to health in Brazil are a reflection of this tendency. Due to the problems related to this collective right and how it is not permanently guaranteed through the exercise of citizenship, the judiciary has been a path for individuals who seek to be heard on matters concerning health issues and affirm their individual right against the State.
Another relevant aspect regarding the genealogy of the right to health refers to the fact society has produced a disadvantaged population that needs assistance in order to survive. While the Declaration of the Rights of Man and Citizen of 1793 mentioned the protection of "destitute" citizens, it was only in 1848 that the idea of a society responsible for its members was constitutionally formalized given the poverty of the working class. From this moment onwards, the right to work, the right to sick leave, unemployment, and aging, and the right to decent housing emerged1212. Lochak D. Les droits de l'homme. Paris: Éditions La Découverte; 2005.. As such, this genealogy points to the emergence of economic rights as a palliative for the poorer population's survival. The right to health emerges in a compensatory context that needs to handle the effects of poverty created by society.
While the right to public provisions has its origin in the social protection of "disadvantaged citizens" and is a palliative measure, the construction of the citizen and the exercise of rights as a social practice are factors that promote dignity and protection of the universality and quality of public services, which occurred in first world countries where economic and social rights have reached a higher degree of development. Nevertheless, when observing both the provision of public services destined to protect the disadvantaged parts of the population, as well as to guarantee the exercise of citizenship in Brazil, one confronts adverse conditions here. The government, which is responsible for the "impoverished SUS", has to inadequately finance this system once it is a system present in a society that privileges access to the private health care system, even when the majority of the population needs state protection.
In the research being conducted on the representations of health in the nightly news reports in 2012, the tension between the deficit of state provisions and the market search for services is an issue present in these stories. The opening story of the September 14th edition of the nightly news called attention to the increase in consumer health spending:
Good night! Brazilian families are spending more with transportation and health and spending less on food.
The pressure on family budgets as a result of spending on transportation and health foreshadows the discontent that emerged in the June 2013 manifestations, which began with the increase in the bus fare, but soon incorporated other questions, including health care problems. In the story presented on January 18th, 2012, data from the Brazilian Institute of Geography and Statistics (IBGE - is responsible for producing statistical information on Brazil, among other research; it is also responsible for carrying out the census) showed that State spending on health adds up to only 44% of the total of public expenditures:
According to research by IBGE released today, Brazilian families are spending more on health than the government did in 2009. Private spending amounts to R$ 835 reais per person, while public spending reached R$645 reais per person.
In addition to the accusation of SUS' underfinancing in the 26 stories on public hospitals on Jornal Nacional that deal with the lack of infrastructure (10 reports), lack of beds (8 reports) and lack of doctors (8 reports), the underfinancing of the health care system is also present in the reports concerning the government's budget. On the February 22nd edition of the news, the National Conference of Brazilian Bishops (Conferência Nacional de Bispos do Brasil - CNBB) criticized the "cut of more than 5 billion of reais from the Ministry of Health's budget." In addition, on the January 16th edition, the president vetoed articles of the Annual Budget Law:
The president vetoed 15 articles of the Law, including those that obliged the federal government to put aside more money for health in case of the review of the gross domestic product.
According to Eugênio Vilaça11. Mendes EV. 25 anos do Sistema Único de Saúde: resultados e desafios. Estudos Avançados 2013; 27(78):27-34., International evidence shows that all the countries that have universal health systems, either Beveridgean or Bismarckian, present a financing structure where public spending on health represents at least 70% of the total spending designated for health. [...] With the present structure of public spending on health, it is impossible to consolidate SUS as a right of all citizens and the responsibility of the State. [...] by specializing in a single system for the poor, given the social disorganization of these excluded groups and their lack of political voice, this system tends to be underfinanced.
While the massive manifestations in 2013 demanded State responsibilities with regards to social rights, which the Executive responded to with great concern and miniscule measures, the slogans and claims of the posters spontaneously shown to the world in the manifestations do not question or change the lack of support for and social mobilization in defense of SUS. According to Vilaça11. Mendes EV. 25 anos do Sistema Único de Saúde: resultados e desafios. Estudos Avançados 2013; 27(78):27-34., It is estimated that it would be necessary to double the Ministry of Health's budget so that there can be a process capable of universalizing health care. Hence, there is no way we can be hopeful for finding a solution to this problem in this decade, and as a result, public spending will remain close to 50% of the total spending on health, thus maintaining the segmentation of the health care system. Therefore, the social mobilization necessary for making the public and unified health system viable needs to greatly restrict the private subsystem and double public spending. In reality, the manifestations attacked SUS and did not criticize the private health plans, even though these have been the targets of frequent complaints at the Consumer Protection Agency (PROCON) and have led to the suspension of more than 300 private health plans from 38 providers who were registered for poor health care services in 2012. One of the common posters seen during the manifestations read the following: "STUFF THE 20 CENTS IN SUS", as a parody of a popular depreciatory saying used to signal the rejection of someone or something. By rejecting SUS and the State this SUS belongs to, the saying reveals the lack of health financing. In response to what public spending should focus on, another common poster seen read the following: "FIFA STANDARD HOSPITALS", indicating the consumer society's own aspiration with regard to health care. As we have previously seen, the tendencies expressed in the manifestations, whether they are related to the rejection of a poor and underfinanced SUS or to one of consumption's main goal of having a hospital with high technology standards, are also largely represented in the media and do not present any support for a public and universal health care system.
Another aspect of this problem is related to the late development of citizenship in Brazil, as an inheritance from a colonial and slave history, which paradoxically found the country entering modernity with a largely illiterate population, a large landowning and monoculture economy and an absolutist State. We are still influenced by the repercussions of this inheritance given an economic, political and social reality that violates, cheats or ignores the laws of this country and where a confluence of factors either creates obstacles or decreases the chances for exercising one's rights. One of these factors is that Brazil was never capable of exercising its national sovereignty given its historic submission to Portugal, then to England and later on to the United State and the IMF. In addition, the process of citizenship building, stimulated by post World War II, was barbarically violated for two decades of military regime. From the 80s onward with the redemocratization process, the nation-state was weakened, as occurred throughout much of the planet during this globalization era that is at the mercy of supranational forces. At the end of the 20th century, Hobsbawm1313. Hobsbawm E. Era dos Extremos O breve Século XX 1914-1991. São Paulo: Cia das Letras; 1995. observed that the territorial, sovereign and independent nation-states, including the older and more stable ones, saw themselves weakened by the forces of a supranational or transnational economy. This process of diminishing the power of the States, as José Murilo de Carvalho 1414. Carvalho JM. Cidadania no Brasil O Longo Caminho. São Paulo: Civilização Brasileira; 2010. points out, produces a change in the existing national identities, affecting the nature of older rights and reducing the relevance of the right to participate. In this context, the modern citizen and active participant in the processes of building a democratic nation, which were advocated by the guidelines that founded SUS, are theoretical inferences that have faced the deconstruction of this model in the past 25 years.
The lack of mobilization in defense of SUS also reflects another characteristic of contemporary societies. The abandonment of the agora of the nation-state occurs in a generalized context of the weakening of institutional ties, such as those of the family, social class and political parties, resulting from the very ruptures of modernity1515. Giddens A. As Consequências da Modernidade. São Paulo: Editora Unesp; 1991.. Parallel to the weakening of institutional ties, the social production of an identity based on consumption and the market begins to configure an individualized society. According to Bauman1616. Bauman Z. A Sociedade Individualizada Vidas Contadas e Histórias Vividas. Rio de Janeiro: Jorge Zahar; 2009. , the public sphere has been stealthily yet steadily colonized by private concerns trimmed, pealed and cleaned by their public connections and ready for (private) consumption but hardly for the production of (social) bonds... "In this individualized society", the more thorough is the surrender of the state's sovereignty over the consumer commodity markets and the more redoubtable and intractable the sovereignty of the markets becomes 1717. Bauman Z. Vida Para Consumo A Transformação das Pessoas em Mercadoria. Rio de Janeiro: Jorge Zahar; 2008. . Lastly, one can analyze this as the fact individualization means market dependency in all dimensions of living 77. Beck U. Sociedade de Risco: Rumo a uma outra modernidade. São Paulo: Editora 34; 2010. . As a result, part of the responsibilities that were once attributed to social institutions are transferred to the individual, as the institutions become weaker. Increasingly we see how an individual has to deal with the weight of his/her decisions and initiatives regarding his/her role as a consumer in the market.
We can see the effects of this individualized society in the protests that shook the nation in 2013. A definitive element of these manifestations was the direct attack on political parties, the Congress and other state institutions, including SUS, expressing, therefore, the current gap between these institutions, as results of the redemocratization of the country, and the citizens. The attempts of union organizations to join the manifestations were unsuccessful, further illustrating how resistant these manifestations were to any kind of association to institutions. The variety of posters, sayings and expressions, where each individual brought his/her own vindication, orchestrated the polyphony of singularities present in the multitude, creating an extremely representative mosaic of this modernity in contemporary societies.
A free of charge SUS
When considering SUS as free of charge, the social representations of SUS' services are situated in a symbolic field that doubts the quality of these services. Even when you consider state services of good quality, and to top it off free of charge, the reaction is of an unexpected surprise or as an exception to the rule. This was clearly observed in the nightly news edition of March 31st with the testimonies of users regarding the robotic surgeries at the Instituto Nacional do Cancer:
Monica got rid of throat cancer less than a month ago and is cured: I didn't feel any pain. Everything went very smoothly! "And it was all free, right!"
In addition, this was evident on the edition of March 1st, which looked at the evaluation given to hospital care in the city of Vitória for the SUS Performance Index (IDSUS):
The attention given to very complex cases is considered very good by the Ministry. Mrs. Teresa underwent treatment for pancreatic cancer that she discovered last year: "I was very well taken care of! I'm being sincere, from the doctors, to the radiotherapy, to the chemo: I am surprised!"
Hence, by placing SUS in a field of being free of charge, its services are considered a donation or a benefit, paradoxically removing SUS' value as a right to health. This is an issue that refers back to another inheritance from our historical development: the political paternalism that boasts itself as the provider of benefits for the population. Therefore, certain developments, which should be understood as citizen's historically conquering social rights, are in fact benefits given to the people by governments. Political paternalism is an attribute of a receiving population's passive condition in terms of social benefits. The influence of populism, coming from the Estado Novo's (meaning New State, was the dictatorial period from 1937-1945 under the rule of President Getúlio Vargas) dictatorial style of the "father of the poor", extends itself until the present and pervades the political discourses found on all sides of the political spectrum. In this context, one can also analyze SUS' free services as gifts from the governments, given that these governments appropriate themselves of these benefits and declare them as their very own achievements. This also does not take into consideration the political party aspect of the problem, since health care issues serve as a significant bargaining chip during elections with the majority of the population that is dependent on SUS.
Another aspect of this matter is in the use of combining private and public services for a significant part of the clients of health insurance plans. These individuals act as consumers in the market, by checking out prices, analyzing the cost-benefit, and changing health plans according to their needs. In addition to these actions, they also include SUS' free services as one of their options. Specialist consultations, diapers, bandages and dressings, medication, exams and various other free products and services are consumed not by "SUS' poor", as defined by Paim, but by clients that buy in the market. Here SUS is a complementary system individuals rely on as a right in order to save money.
Are we or aren't we a consumer society (in a general manner and more particularly with regard to health), after all? It is possible to state that we are, at least in light of the "Brazilian way" or the way in which we carry strong traces of our historical past, such as slavery and paternalistic/authoritarian tendencies, into the present.
With regard to health more specifically, where are we headed towards?
It is very difficult to risk any kind of forecast. We think a promising path of investigation that seeks to systematically and rigorously study health should currently begin to consider indicators or groups of indicators regarding the future.
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Publication in this collection
04 Oct 2013
01 June 2014
04 June 2014