This article in essay form is an invitation to reflect upon the emancipatory character of health surveillance, a debate that was interrupted in the 1990s. In these times of grave political and institutional crisis in Brazil and in the year of the first National Conference on Health Surveillance (1ª CNVS, acronym in Portuguese), it is particularly appropriate to revive the critical theoretical and epistemological discussions that have grounded the trajectory of Latin American social medicine and public health over the last 40 years. To this end, I draw on aspects of critical thinking on modernity devised by the Portuguese sociologist Boaventura de Sousa Santos, who postulates three pillars of domination: capitalism, colonialism (or coloniality), and patriarchy. In the current context of a crisis of civilization, rethinking emancipation requires us to refresh our understanding of the meaning of social struggles in terms of their relationship with the knowledges and epistemologies undermined by modern civilization and still present in the Global South, whether in spaces occupied by indigenous peoples and poor farmers or in urban peripheries.
Health Surveillance; Crisis of civilization; Modernity; Coloniality, and epistemologies of the South
Este artigo, na forma de ensaio, é um convite à reflexão sobre o caráter emancipatório da vigilância em/da saúde, um debate interrompido na década de 1990. Em tempos de grave crise política e institucional no Brasil e no ano da 1ª Conferência Nacional de Vigilância em Saúde (1ª CNVS), é estratégico renovar as discussões teóricas e epistemológicas críticas que fundamentaram a trajetória da medicina social latino-americana e da saúde coletiva nos últimos 40 anos. Para isso, baseamo-nos nos pensamentos críticos da modernidade que articulam o capitalismo, o colonialismo (ou a colonialidade) e o patriarcalismo como os três pilares da dominação, segundo o sociólogo português Boaventura de Sousa Santos. Em um contexto de crise civilizatória, repensar a emancipação significa atualizar o significado das lutas sociais em seu relacionamento com o conhecimento e as epistemologias desprezadas pela civilização moderna e ainda presentes no Sul Global, seja nos espaços indígenas e camponeses ou nas periferias urbanas.
Vigilância em Saúde; Crise civilizatória; Modernidade; Colonialidade e epistemologias do sul
Introduction: a reflection upon health surveillance and its emancipatory potential
The reflection proposed by this article in essay form is guided by a key question: to what extent can health surveillance be emancipatory and what are the limitations and challenges it faces in modern times? My attempt to contribute to this debate is based on over 40 years of experience in the field of public health research and policy-making within Brazil’s Unified Health System (SUS, acronym in Portuguese). The main bulk of my work has focused on workers’ health, health and the environment, and health promotion, involving collaborative action research with numerous vulnerable groups from urban and rural areas, including forest peoples.
Throughout the article, I explore four intertwined themes. First, I synthesize the elements underlying the current political and institutional crisis underscored by the guiding document for the first National Conference on Health Surveillance (CNVS, acronym in Portuguese)11. Conselho Nacional de Saúde (CNS). Documento orientador da 1a. Conferência Nacional de Vigilância em Saúde. Brasília: CNS; 2017.. This document outlines critical challenges for health surveillance policy and action in the context of the major backward steps taken by Brazil leading to the rupture of pacts established by the country’s 1988 “citizens’ constitution” and the albeit limited and contradictory advances made by the PT (Workers’ Party), brought to an abrupt end by the impeachment of President Dilma Rousseff.
Secondly, I revive the debate around health surveillance that first arose in the 1980s driven by the field of Latin American social medicine (LASM) and, in Brazil, by the health reform and public health researchers. My intention is to revisit an interrupted debate torn between two poles: a broader emancipatory perspective, which we might call the social determinants approach to health surveillance22. Teixeira CF, Paim JS, Vilasboas AL. SUS, Modelos assistenciais e Vigilância da Saúde. Informe Epidemiológico do Sus 1998; 7(abr-jun):9-27.; and a more restricted, operational and control-oriented conception, which has become the hegemonic approach adopted within the Ministry of Health and SUS. As will be seen below, to this day, the counter-hegemonic concept maintains a flickering spark of vitality within the field of public health research and through practical actions undertaken at local level, albeit in a piecemeal fashion, which navigate between political-institutional spaces of elections and coalitions favorable to their implementation at the fragile threshold between that which institutes and that which is instituted. The discussion of health surveillance has never been revived, not even at federal level during the PT administrations, nor have more solid, systemic and systematic efforts been made to support innovative actions more in line with a social determinants approach to health surveillance.
In the third section of this article, I propose a new framework for understanding the limits and possibilities of health surveillance. This framework goes beyond a critical approach based on political economy, the analysis of the recent development of capitalist forces in Brazil, and on the political makeup of the state and social classes that forge the contradictions, advances, or setbacks of social struggles and achievements of democracy. Without rejecting this interpretation, which marked the history of LASM and underlies the thinking of several intellectuals involved in Brazil’s health care reform and the guiding document for the first CNVS, I present an alternative framework still little explored in the field of public health. I draw on authors that discuss the theme of modernity, coloniality and postcolonialism, specifically the Portuguese sociologist Boaventura de Sousa Santos. For Santos, we need an alternative way of thinking about alternatives33. Santos BS, Araújo S, Baumgarten M. As Epistemologias do Sul num mundo fora do mapa. Sociologias 2016; 18(43):14-23. that allows us to rethink the role of utopias and emancipatory social struggles in these times of expanding global capitalism and escalating crises, such as the crises of democracy, ecological crisis, and the spread of violence.
This alternative way of thinking reflects a broader critique of Eurocentric or Western modernity as a universal civilizing project. Emancipatory social struggle is seen to go beyond class struggle and processes of regulation and emancipation. Instead, it entails the incorporation of other views, experiences, and knowledge stemming from the social struggles waged in the Global South: that is to say, the spaces, peoples and cultures that have been radically excluded and made invisible by centuries of colonial, capitalist and patriarchal domination, and remain so due to the continual emergence of new forms of domination in times of neoliberal globalization.
Finally, based on the above discussions, I reflect upon the question raised at the beginning – to what extent can surveillance be emancipatory? – and conclude by outlining some of the current challenges faced by health surveillance and suggesting possible paths forward.
The first National Conference on Health Surveillance in a context of crisis
The theme of the first CNVS is “Health Surveillance: Rights, Achievements, and Advocacy for a Quality Public Unified Health System”. The guiding document11. Conselho Nacional de Saúde (CNS). Documento orientador da 1a. Conferência Nacional de Vigilância em Saúde. Brasília: CNS; 2017. , approved by the National Health Council, provides an extensive analysis of the current situation in Brazil. The core theme of document is National Health Surveillance Policy and Strengthening the SUS: the Brazilian People’s Right to Health Protection and Promotion. The document then goes on to discuss four strategic themes: (i) the role of health surveillance within the SUS; (ii) government responsibilities; (iii) health surveillance – knowledge, practice, work processes, and technology; (iv) participatory and democratic health surveillance for tackling health inequities.
The guiding document paints a rather negative picture of health surveillance in Brazil and around the world. For example, it states that, paradoxically, following the 2007/2008 global financial crisis, an even more conventional neoliberal movement is underway whose fiscal austerity measures are draining resources from production and redistributive social policies, thus penalizing the middle and lower classes rather than the rich who are getting richer. The impeachment of 2016 ruptured the troubled and fragile social pact developed around the 1988 “citizens’ constitution”. The neoliberal (or ultraliberal) solution imposed by an unelected government addresses the economic crisis by implementing backward measures, undoing albeit limited advances in social inclusion policy and democratic participation made during the 13-year-reign of the Workers’ Party. The currently proposed amendments to the Federal Constitution, such as labor and social security reforms, pose a serious threat to citizenship, democracy, and human rights.
In fact, the move to impeach President Dilma Rousseff constitutes a process of radicalization, stemming from an underlying conservatism that intensified during Dilma Rousseff’s government, particularly from 2014 onwards. This process ended up undermining the very foundations of representative democracy in Brazil and was thus called a coup. Its aim is to destroy the achievements made in areas such as education, the environment, health, social security, land rights, access to decent work, family income, family farming, food and nutrition security, public security, the protection of the rights of vulnerable and discriminated groups, including indigenous peoples, quilombolas, poor farmers, blacks, slum dwellers, women, and LGBT people.
The primary driver for these backward steps is the Brazilian National Congress and bancadas (lobby groups) linked to the interests of agribusiness, mining, construction and civil engineering companies, conservative religious groups, the arms industry, etc. Apart from Congress, various departments within the judiciary and the executive branch itself, with huge support from Brazil’s hegemonic media, have upheld exclusionary and anti-democratic measures that weaken fundamental rights and the protection of public and common goods. Other affected areas include urban issues and basic sanitation: the theme of democratic, sustainable and healthy cities is strategic given the proportion of Brazil’s population living in urban areas. The document highlights that the lack of sanitation in Brazil’s urban periphery – a reflection of the sociospatial inequalities of Brazilian cities – is at the heart of outbreaks of dengue, zika and chikungunya that have reached epidemic proportions. It then goes on to stress other worsening social and environmental problems such as pollution, water shortages and natural/man-made disasters, like the emblematic environmental tragedy/crime caused by the Mining company Samarco in Minas Gerais in November 2015. The document also outlines other major challenges such as food production, the concentration of land ownership driven by agribusiness, agrochemical contamination, and obesity.
The document acknowledges that the country’s structural problems, which exacerbate concentration of income and power, sociospatial inequalities, and environmental degradation, are by no means new. Rather, they are deeply rooted in extractive capitalism, which has spread across Brazil and Latin America as a whole and now stands at a crossroads. The export of agricultural and mineral commodities has produced a primary surplus, thus leading to a reduction in external debt and enabling the implementation of redistributive social policies and the maintenance of the aforementioned fragile social pact. At the same time, however, it has strengthened the political power of conservative groups, intensified the concentration of land ownership, funneled wealth to the rich elite, favored rentism, and aggravated environmental degradation and land conflicts involving indigenous peoples, quilombolas, and poor farmers. As expected, the global financial crisis and China’s growth slowdown has had a major political and economic impact on commodity-exporting countries.
In short, the document paints a somber picture, with little hope of progress towards universal, comprehensive, participatory, and territorial health surveillance. How then does one think the bases of a national health surveillance policy to be discussed at the first CNVS? How can we promote a convergence towards health surveillance that encompasses the full spectrum of society and embodies the struggles for rights, democracy, and health? How do we interpret the context and challenges that the current crisis poses for shaping the future of health surveillance? In short, is it possible to think in terms of emancipatory health surveillance?
I do not propose to answer such complex questions. Instead, I suggest ways of thinking about them based on frames of references as yet little explored by the field of public health research based on some of the ideas of postcolonialism and decolonial thinking and the proposals of Boaventura de Sousa Santos. In this way, I aim to help develop new ways of understanding and moving towards an emancipatory approach within the field of public health and, more specifically, in the debate surrounding health surveillance.
However, before exploring the bases of this alternative way of thinking, the following section provides a brief overview of the emergence and development of the field of health surveillance, demonstrating the enduring tensions and impasses within the field of public health and SUS.
Conventional health surveillance or the social determinants approach: an interrupted debate
It is curious to note that, despite being such an important component of public health, up until now health surveillance has received little academic and political attention in this field, at least in relation to other areas. This is particularly striking, given that, historically, health surveillance is the area of public health that deals directly with the social and environmental determinants of health and the development model discussed in the guiding document. Approximately three decades after the end of the military government, the 1988 citizens’ constitution, and the beginnings of the SUS, despite various operational advances, the field of health surveillance continues to lack a clear definitions and policy, particularly at local level.
According to Ministerial Order 3.252 of 2009 of the Ministry of Health, health surveillance encompasses a number of subareas and sectors, ranging from traditional disease and health surveillance to workers’ health, environmental health, health promotion, and health status assessment, reflecting both the development of a Nova Saúde Pública44. Paim JS, Almeida Filho ND. Saúde coletiva: uma “nova saúde pública” ou campo aberto a novos paradigmas. Rev Saude Publica 1998; 32(4):299-316. (a new public health) and innovation in the SUS. The above are core areas, for they address the risks and vulnerabilities associated with the model of economic development adopted by the country. According to Sabroza55. Sabroza PC. Estudos epidemiológicos na perspectiva do aumento da vulnerabilidade dos sistemas sócio-ambientais brasileiros. Epidemiologia e Serviços de Saúde 2007; 16(4):229-232., this model is responsible for social inequalities and regional disparities, resulting in an epidemiological transition with disease patterns that differ substantially to those experienced by core countries. As a result, inequality is a major theme of Latin American epidemiology, thus otherwise known as social epidemiology.
In the 1980s and 90s, a number of studies were conducted within the field of LASM assessing health services and systems planning and organization. One of the main authors was the Argentine scholar Pedro Luiz Castellanos66. Castellanos PL. Epidemiologia y organización de los servicios. In: Organización Panamericana de la Salud (OPS), Organización Mundial de la Salud (OMS). La formación en epidemiologia para el desarrollo de los servicios de salud. Washington: OPS, OMS; 1987. p.30-40. Série Desarrolllo de Recursos Humanos, n° 88, who emphasized the importance of analyzing health-disease processes and living conditions for tackling social inequalities.
This discussion flourished in Brazil at the beginning of the 1990s in consonance with the debates surrounding the health reform and the development of the SUS77. Paim JS, Teixeira MG. Reorganização do sistema de vigilância epidemiológica na perspectiva do Sistema Único de Saúde (SUS). Seminário Nacional de Vigilância Epidemiológica, Anais. Ministério da Saúde, Fundação Nacional de Saúde- CENEPI, 1992. p. 93-144., for which SUS, modelos assistenciais e vigilância da saúde (SUS – care models and health surveillance) by Carmem Teixeira, Jairnilson Paim, and Ana Luiza, was a milestone text22. Teixeira CF, Paim JS, Vilasboas AL. SUS, Modelos assistenciais e Vigilância da Saúde. Informe Epidemiológico do Sus 1998; 7(abr-jun):9-27.. The work systematizes the main differences between the two hegemonic models – the médico-assistencialista model, characterized by a somewhat paternalistic approach to healthcare and its delivery, and sanitarista (sanitarist model) – and the emerging proposal for health surveillance that was to be developed through the SUS. The latter was centered around health effects, risks and needs, living and working conditions, and incorporating communication-based work processes into local health planning and programming, situational analysis, and medical and health technologies. The organizational structure of the proposed model envisaged intersectoral action, healthy public policy, and health care operations oriented towards specific health problems and groups. In short, it was a proposal in line with the spirit of public health, despite limitations such as the acritical coexistence between specialist biomedical knowledge and popular knowledge and social struggles for the definition of health needs and priorities.
The proposal reflected an ongoing dispute during the congresses of epidemiology at the time involving two different facets of health surveillance55. Sabroza PC. Estudos epidemiológicos na perspectiva do aumento da vulnerabilidade dos sistemas sócio-ambientais brasileiros. Epidemiologia e Serviços de Saúde 2007; 16(4):229-232.,77. Paim JS, Teixeira MG. Reorganização do sistema de vigilância epidemiológica na perspectiva do Sistema Único de Saúde (SUS). Seminário Nacional de Vigilância Epidemiológica, Anais. Ministério da Saúde, Fundação Nacional de Saúde- CENEPI, 1992. p. 93-144..
(i)A more restricted, operational, and control-oriented conception incorporating modern public health practices that would become the hegemonic perspective of health surveillance within the Ministry of Health and SUS. Although this approach incorporates a number of conceptual and methodological advances stemming from innovative experiences, a thorough reshaping of health services has failed to materialize, especially at local level.
(ii) A broader perspective anchored in the social determinants approach to health surveillance and drawing from the principles of public health and health reform, which views the health sector as a promoter of strategic policies to drive social transformation and tackle social inequalities. This approach prioritize and address problems within specific territories and among specific groups, drawing on knowledge from the fields of epidemiology and social health sciences. Its emphasizes intersectoral and sectoral actions for health promotion, risk and disease prevention, and the reshaping of outpatient care and hospital care in line with health needs. It also encompasses occupational and environmental health surveillance and health promotion, a privileged locus of experimentation.
The dispute between the restricted (hegemonic) and broader perspective of health surveillance continues, often in the form of paradox, contradictions and silences in the negotiations that defined health surveillance(s) and its(their) actors or, if we prefer, specialist “bunkers”. Gaps remain not only between the promises to tackle the social and environmental determinants of health, but also in management and autonomy at territorial and local level, which is key to bringing about a shift in the SUS toward a model that overcomes the paternalistic and sanitarist approaches. The territorial issue at local level encompasses a number of questions vital for tackling social inequalities that go beyond the technobureaucratic efficiency of regulatory and supervisory agencies, such as social/community participation and the democracy in which people commit their body and soul to live and work body and soul.
In general terms, it could be said that broader conceptions of health surveillance continue to have a certain amount of force, especially in the academic arena, with some peripheral and piecemeal actions in propitious local and regional settings, as is the case with more progressive governments and engaged professionals. These contra-hegemonic experiences, which are peripheral to the organizational structure of Brazil’s public health system, have existed since the beginnings of the SUS, constituting social practices that yield important conceptual and methodological advances that seek to cross the boundaries between that which institutes and that which is instituted. A number of themes, concepts and methods are incorporated into this process, among which the following: territory and territorialization, including geoprocessing tools for sociospatial analysis of health problems88. Monken M, Barcellos C. Vigilância em saúde e território utilizado: possibilidades teóricas e metodológicas. Cad Saude Publica 2005; 21(3):898-906.; complexity and vulnerability, which help think in terms of different spatial and temporal scales for understanding and modeling problems99. Castellanos PL. O ecológico na epidemiologia. In: Almeida Filho N, Barreto ML, Veras RP, Barata RB, organizadores. Teoria epidemiológica hoje: fundamentos, interfaces e tendências. Rio de Janeiro: Abrasco, Editora Fiocruz; 1998. p. 129-147.
10. Samaja J. Fundamentos epistemológicos de las ciencias de la salud [tese]. Rio de Janeiro: Fiocruz; 1997.-1111. Ayres JRCM, França Júnior I, Calazans GJ, Saletti Filho HC. O conceito de vulnerabilidade e as práticas de saúde: novas perspectivas e desafios. In: Czeresnia D, Freitas CM, organizadores. Promoção da Saúde: conceitos, reflexões, tendências. Rio de Janeiro: Ed. Fiocruz; 2003. p. 117-139. ; interfaces between the environmental and risk sciences and, more recently, political ecology in socio-environmental contexts of greater vulnerability and injustice1212. Porto MF. Uma ecologia política de riscos. Rio de Janeiro: Editora Fiocruz; 2007.; and the ecosystem approach to health as a transdisciplinary, theoretical, and methodological alternative for community interventions1313. Gómez CM, Minayo MCS. Enfoque ecossistêmico de saúde: uma estratégia transdisciplinar. InterfacEHS 2006; 1(1):1-19..
Innovative experiences at local level are frequently the result of cooperation and coordination involving academic groups, the SUS and civil society, including social movements, and the efforts of engaged health professionals. Local health surveillance actions tend to dilute fragmenting borders between the classical and sanitarist approaches to health surveillance and the workers’ and environmental health approach, which in turn helps to integrate, enhance, and limit actions. However, despite specific contributions, a broader theoretical reflection on these experiences was never undertaken, nor were these actions ever consolidated within the SUS at the federal level, and thus the social determinants approach to health surveillance never really came to fruition22. Teixeira CF, Paim JS, Vilasboas AL. SUS, Modelos assistenciais e Vigilância da Saúde. Informe Epidemiológico do Sus 1998; 7(abr-jun):9-27..
For example, between 2009 and 2011, the National School of Public Health (ENSP/Fiocruz, acronym in Portuguese) developed a health surveillance and promotion project in specific territories. Funded by the Ministry of Health, the project was the result of a teacher training program organized by the Network of Schools of Public Health (Rede de Escolas de Saúde Pública) and conducted by the ENSP/Fiocruz. The project revived the debate about health surveillance in these territories and brought it up to date. Its core theme was living conditions and the social and environmental determinants of health and integrated health promotion and prevention. Actions had a strong focus on participation and community engagement and included the development of an agenda defining priority health problems1414. Sabroza P, Porto MF. Uma proposta de capacitação em vigilância das condições de vida e saúde para o SUS de base local e territorial: Oportunidades e Desafios. Rio de Janeiro: ENSP/Fiocruz; 2010. mimeo.. Negotiated at the end of the second Lula administration, the project was discontinued in Dilma Rousseff’s administration. At the same time, a new concept of health surveillance gained strength within the federal government, stemming from Brazil’s inclusion into the global health surveillance network and growing concerns over health security in the face of the emergence of new diseases, risk of pandemics and natural catastrophes, and the threat of bioterrorism1414. Sabroza P, Porto MF. Uma proposta de capacitação em vigilância das condições de vida e saúde para o SUS de base local e territorial: Oportunidades e Desafios. Rio de Janeiro: ENSP/Fiocruz; 2010. mimeo..
Progress was hampered even in areas that benefitted, theoretically, from well-defined policies, as was the case with the National Health Promotion Policy (Política Nacional de Promoção da Saúde), which came into force in 2006. A number of authors1515. Traverso-Yépez MA. Dilemas na promoção da saúde no Brasil: reflexões em torno da política nacional. Interface (Botucatu) 2007; 11(22):223-238.,1616. Silva PFA, Baptista TWF. Os sentidos e disputas na construção da Política Nacional de Promoção da Saúde. Physis 2014; 24(2):441-465. have identified a huge gap between the stated intentions of this policy and hierarchical and centralized institutional practices undertaken within contexts of extreme sociospatial inequalities. Criticism suggests that there is a systematic failure to listen to the needs and interests of people and communities, particularly the most vulnerable groups whose fundamental rights are made invisible. Despite advances in primary care, the assessment highlights the inherent limitations of a productivist biomedical model characterized by vertical and nondialogical health systems, making innovative advances in public participation, exercising citizenship, and networking impossible.
How should we reflect upon the gaps in policy, knowledge, and practices and contradictions and paradoxes that endure after 40 years of the Brazilian Public Health Association (ABRASCO, acronym in Portuguese) and 30 years of the SUS? How do we revive the meaning of emancipation in the present day and move towards a model of health surveillance that embodies the most pressing social struggles and transformations of our time?
Alternative thinking for thinking about alternatives: postcolonialism, coloniality, and epistemologies of the South
To reflect on the questions raised above, we draw on works involving Asia, Africa, and Latin America produced in recent decades by intellectuals and political activists. These scholars’ understanding of hegemonic economic globalization draws upon a critique of capitalism and processes of colonialism and patriarchy, which, over the centuries, have always been present in economic and social and epistemological and cultural chasms.
In actual fact, these works comprise a vast intellectual production involving numerous authors and strands of thought1717. Escobar A. Worlds and knowledges otherwise 1: The Latin American modernity/coloniality research program. Cultural studies 2007; 21(2-3):179-210.,1818. Miglievich-Ribeiro A. Por uma razão decolonial: Desafios ético-político-epistemológicos à cosmovisão moderna. Civitas-Revista de Ciências Sociais 2014; 14(1):66-80.. In Asia and Africa, works include postcolonial and subaltern studies from the fields of philosophy, literature, and culture, with names like the Palestinian intellectual Edward Said, the Indian philosopher Homi Bhabha, and Frantz Fanon, who was born in Martinique, but played an active part in the independence of Algeria and influenced the Brazilian educator and philosopher, Paulo Freire. More recently, more specifically at the turn of twenty-first century, and closer to home in Latin America, the modernity/coloniality research program brought together authors such as the Venezuelan, Edgardo Lander, Aníbal Quijano from Peru, Walter Mignolo from Argentina, Arturo Escobar from Colombia, and Enrique Dussel, originally from Argentina and exiled to Mexico. This group have their origins in key authors from the school of Latin America critical thinking linked to theology and the philosophy of liberation, who seek an autonomous and anti-imperialist social science, as well as dependency theorists, such as Orlando Fals-Borda, Rodolfo Kutsch, Pablo González Casanova, Paulo Freire, and Darcy Ribeiro.
For Arturo Escobar1717. Escobar A. Worlds and knowledges otherwise 1: The Latin American modernity/coloniality research program. Cultural studies 2007; 21(2-3):179-210., certain elements sum up the position of those authors who adopt a non-Eurocentric perspective for rethinking the world and its emancipatory possibilities. The following paragraphs outline some of the main features33. Santos BS, Araújo S, Baumgarten M. As Epistemologias do Sul num mundo fora do mapa. Sociologias 2016; 18(43):14-23.,1717. Escobar A. Worlds and knowledges otherwise 1: The Latin American modernity/coloniality research program. Cultural studies 2007; 21(2-3):179-210.
18. Miglievich-Ribeiro A. Por uma razão decolonial: Desafios ético-político-epistemológicos à cosmovisão moderna. Civitas-Revista de Ciências Sociais 2014; 14(1):66-80.
19. Santos BS. A crítica da razão indolente: contra o desperdício da experiência. São Paulo: Cortez; 2002.
20. Santos BS. A gramática do tempo. Para uma nova cultura política. São Paulo: Cortez; 2006.-2121. Santos BS, Meneses MP. Epistemologias do Sul. 2ª ed. Coimbra: Aledina, CES; 2014..
A critical view of modernity and globalization as an historical, sociological, cultural, philosophical-universal, and totalizing phenomenon. The Modern Project is seen as being Eurocentric, holding a particular view of the world in which conceptions of society, nature, and progress negate, disqualify and “invisibilize” other views. Nonmodern subjects are regarded as “subhumans” to be “subalternized”, exploited and subordinated to the capitalist and colonial core. In this context the key task, therefore, is to “deconstruct” and “decolonize” such assumptions and reconstruct new rationalities and imaginaries based on the presence of excluded subjects, peoples, and cultures.
The recognition of the fact that the end of the colonies in the global geopolitical landscape, starting with the Americas and apparently coming to an end in the postwar twentieth century, was not actually the end of colonialism. The latter persists not only in the form of capitalist domination of core over periphery in the world-system, but also as domination that denies and invisibilizes existences, subjects, and knowledges. It therefore entails a coloniality of knowledge and power that reproduces forms of domination that are blind to the alternatives proffered by other worlds; “an epistemology of blindness”. The proposal to decolonize ways of thinking and feeling are part of a theoretical, ethical and political movement that calls into question the universalizing pretensions of modernity, its assumedly epistemologically and morally superior ontologies and scientific knowledge, while at the same time seeking to rewrite alternatives drawing from the systematically scorned knowledges, cultures and ontologies of the Global South.
Although these authors recognize the emancipatory nature of Marxism, this form of analysis is viewed as being part of an intrinsically Eurocentric modernity, mirroring liberal ideology, with a universalizing and totalizing ideal embedded in evolutionist ideas such as progress and social determinism, and therefore should be rethought from different perspectives. For example, Dussel’s idea of a post-colonial transmodernity implies that ethics of liberation should be applied not only to workers, but all the oppressed, through the solidarity of all subalternized groups, whose existence and identity have been ontologically denied. Hence the importance of emancipatory social struggles on various fronts, including anti-racism and feminist movements, and the leading role taken by groups undermined by Marxism, such as poor farmers, indigenous peoples, black people, women, slum dwellers, and LGBT people.
Finally, the centrality of the epistemological dispute in social struggles in search of a new decolonial/postcolonial reason. It is assumed that modern Western science plays a central role in processes of domination and exclusion of alternative worlds and knowledge. Social struggles have become struggles for the recognition of multiple ways of knowing that transcend modern-traditional, advanced-primitive, and scientific-ignorant dichotomies, leading to the emergence of new ideas such as hybrid knowledge, border thinking, epistemologies of the South, and the ecology of knowledges.
The Portuguese sociologist and main Portuguese language author in the field of colonial studies, Boaventura de Sousa Santos, holds great importance for Brazil, not only because of the language, but also because he moves between different continents, particularly Africa and Latin America, promoting an interface between the ideas of English, Spanish, and Portuguese-speaking intellectuals and activists. In view of his vast work, including various books1919. Santos BS. A crítica da razão indolente: contra o desperdício da experiência. São Paulo: Cortez; 2002.
20. Santos BS. A gramática do tempo. Para uma nova cultura política. São Paulo: Cortez; 2006.-2121. Santos BS, Meneses MP. Epistemologias do Sul. 2ª ed. Coimbra: Aledina, CES; 2014. and articles33. Santos BS, Araújo S, Baumgarten M. As Epistemologias do Sul num mundo fora do mapa. Sociologias 2016; 18(43):14-23.,2222. Santos BS. Para além do pensamento abissal: das linhas globais a uma ecologia de saberes. Novos estudos-CEBRAP 2007; 79:71-94. published in Portuguese, Boaventura’s ideas provide a useful framework for reflecting upon the questions raised by this article.
One of Boaventura’s most original ideas is that of ‘abyssal thinking”, a central element to his concept of epistemologies of the South33. Santos BS, Araújo S, Baumgarten M. As Epistemologias do Sul num mundo fora do mapa. Sociologias 2016; 18(43):14-23.,2121. Santos BS, Meneses MP. Epistemologias do Sul. 2ª ed. Coimbra: Aledina, CES; 2014.,2222. Santos BS. Para além do pensamento abissal: das linhas globais a uma ecologia de saberes. Novos estudos-CEBRAP 2007; 79:71-94.. The abyssal line forms part of Boaventura’s epistemological and political proposal, which helps understand how modernity, under the triple domination of capitalism, colonialism, and patriarchy, excludes people from the condition of being human, holding rights, and possessing knowledge. The abyssal line is at the same time radical, invisible and “invisibilizing”, and behind phenomena such as racism, xenophobia and other forms of violence against, among others, indigenous peoples, slum dwellers, women, and homosexuals. It is a line that prevents the copresence of the world “on this side of the line” with the world “on the other side of the line”. On the other side are not the excluded, but rather the subhuman beings who are not candidates for social inclusion. This negation of humanity is an essential constitutive element of modernity, since this condition is necessary to ensure that the other side can affirm its universality. Thus, practices that do not fit into the theories do not challenge these theories and inhumane practices do not call into question the principles of humanity33. Santos BS, Araújo S, Baumgarten M. As Epistemologias do Sul num mundo fora do mapa. Sociologias 2016; 18(43):14-23..
Colonial/abyssal thinking helps us to analyze the presence of two realities that coexist simultaneously: (i) the metropolitan reality, the space of modernity and the Eurocentric Global North, in which global capitalism expresses both its benefits and most evident contradictions. It is oriented by knowledge-regulation grounded in modern-day notions of science, rule of law, and the state, and their respective institutions; and (ii) the reality of the Global South, which does not refer to a geographical location, but rather serves as a metaphor for the human suffering caused by the radical forms of exclusion generated by capitalism, colonialism, and patriarchy. In this space, dominated by forms of exploitation and violence, modern notions of state/rule of law/science do not operate. It is also the space of social struggles, resistance, and alternatives to forms of oppression; struggles which, by definition, point towards post-colonial and post-abyssal societies.
The abyssal thinking allows us to talk about a North within the South, that is to say, metropolitan spaces, principally in peripheral and semi-peripheral countries, with a certain degree of rule of law and that coexist with forms of violence and exploitation2424. Wallerstein I. Globalization or the age of transition? A long-term view of the trajectory of the world-system. International Sociology 2000; 15(2):249-265.. This is the “modern” colonial North within the South that allows us to understand the blindness of the elites and middle classes in the face of the many forms of violence and massacres that occur, often in close proximity, against groups that have been radically excluded by the abyssal line.
For Boaventura, the two great utopias of modernity, restricted to the metropolitan space, act as a mirror within the same Eurocentric civilizing framework. On the one hand, liberalism, transformed over recent decades into neoliberalism, which manifests what Polanyi2323. Polanyi K. A Grande Transformação. Rio de Janeiro: Ed. Campus; 2000. called the “great transformation”: the creation of a market-based society based on private ownership, with powerful economic groups that have radically detached themselves from peoples’ needs and individual and collective dignity. The capitalist market has increasingly undermined economies and markets that interrelate in terms of reciprocity and redistribution and which persist, resist, and reinvent themselves in community spaces and other settings, especially in the Global South. On the other, utopian socialism, marked in the nineteenth century by the works of Marx, who saw capitalism as a social system that would inevitably embark on a dialectical march towards fairer societies and social relations and a fairer distribution of the proceeds of labor: socialist or communist societies. Two mutually critical and diverging strands of utopian socialism therefore developed: social democratic reformism, strengthened by the creation of the welfare state in Western Europe after the Second World War; and revolutionary socialism, which refers mainly to the Russian Revolution of 1917 and revolutionary processes in Latin America, Africa and Asia.
Reflections of the emancipatory potential of public health and health surveillance in times of crisis
Boaventura’s notion of utopias and the glimmer of hope that shines through emancipatory struggles are central to his work, given that we have experienced a profound disillusionment with modern utopias in recent decades. On the one hand, the fall of the Berlin Wall and end of the Soviet Union left the dreams of both reformist and revolutionary socialism shattered, while on the other realizing the dreams of emancipation via the false myth of unlimited economic growth became increasingly unlikely. The neoliberal hegemony inherent in international agencies (IMF, World Bank, and OECD), national institutions, and the media is at the heart of deregulation and the commodification and privatization of life and nature. This process is eloquently depicted by the guiding document for the first CNVS. However, a broader interpretation of contemporary capitalism reveals that it is a global movement, specific not to Brazil or Latin America, but rather to colonial modernity itself, with its deepening social, economic, political, and ecological crises.
This is why we must problematize and move forward, even when this entails “tactically defending” a project for this country. A project that is characterized as national, developmentalist and sovereign, that is inclusive, publicist and universal in terms of rights and their protection thereof, and that promotes sustainable development with redistributive economic growth, among other jargon from the field of so-called progressivism that has marked the intellectual stance adopted within the field of public health. I am not saying that we should not defend this project, especially at this critical moment in which our country is taking a giant step backwards. The question is that it reproduces a view of economic, scientific and technological development that is at the heart of modernity and its colonial project. Without undergoing a profound renewal of ways of thinking and feeling, which some have called a “decolonial turnaround” or corazonar, key fields such as public health are likely to shut themselves away in their own modern institutions – universities, health centers, hospitals, etc. – like cloisters of established truths that are impervious to new emancipatory instituting processes.
While generating perplexities, current crises are viewed superficially by a modernity that is increasingly encastled in the fleeting present. We are living a rocky and superficial present entrenched between the past and future, whose immobilizing alienation lies in the expectation of a future that expands indefinitely along the one-way path of modern rationality, with its objective and universal science. Progress, which is inevitable, is only a matter of time. The crises, however, tell another story.
Since utopias seek to meet the needs and aspirations of a present time with the paradox of being realized in a future time, reinventing utopia is to converge towards the subjects and knowledges radically excluded or undermined by modernity; a utopia in which tolerance and solidarity are reinvented through the struggles and epistemologies of the South.
We are without doubt living in difficult times for such a task: Boaventura suggests that the crisis is increasingly aggravated by globalization, given the fact that nonradical exclusion more protected by the rule of law is shrinking, while nonradical exclusion entailing exploitation and violence is rising. The South is “invading” and “occupying” the North in various ways, strengthening the formation of ghettos and walls within the metropolises. This is one way of talking about the crisis of democracy in various countries around the world, including those in the capitalist core.
By analyzing the crisis in its broader sense, from a global perspective and in all its complexity, the work of Boaventura recognizes that the crisis is one of modern civilization. It can only be confronted by inverting the logic of time: by expanding the present, which is the task of “sociology of absences”; and contracting the future, the task of “sociology of emergences”. In short, the central aim of sociology of absences is to turn impossible objects (the knowledge and experience of the peoples and cultures of the South undermined by the epistemology of blindness of colonial modernity and its abyssal thinking) into possible ones, and thus turn absences into presences. Hence the fundamental importance of a convergence between this new critical thinking and the struggles of indigenous peoples, blacks, women, workers, slum dwellers, LGBT people, and the imprisoned. The decolonial proposal advocates recognition of the knowledge and expectations of these peoples and communities together with respect for their dignity. Hence the importance of collaborative methodologies engaged in social struggles that promote the active copresence of subjects excluded by the abyssal line, with the encounter between knowledges/ecology of knowledges.
The complementary task of sociology of emergences is to build a future of plural, concrete, and simultaneously utopian and realistic possibilities, based on what emerges in the present in movements that seek to break the monoculture of knowledge and power, enabling the emergence of alternatives that form the bases of a civilization and paradigm shift. Alternative thinking enables us to think about the cross-scalarity of struggles both as micro spaces of daily struggles in pursuit of micro utopias, and more global and national spaces that reflect macro utopias, involving questions such as the role of the state, public policy, peaceful coexistence between peoples and countries; that is to say an alternative globalization. Both the spaces of struggle and utopias are not exclusionary and are able to cooperate and communicate in various, albeit complex and uncertain, ways. This is the “glocal” challenge: think globally and act locally.
Rethinking alternatives is vital in view of the crisis, which, assuming it is a crisis of civilization, is set to continue in the future even with a more or less partial reversal of the coup that is currently underway in Brazil, with the possibility of direct elections and resumption of economic growth. In the context of Brazil and health, various constraints and backward trends existed even before the coup, and everything indicates that the extractive developmentalist model will remain strong even with a more leftwing government. The question here is the level of conflict and degree of liberty that will be available for exercising resistance and developing alternatives in more conservative or progressive scenarios.
All said, it is vital to promote reflection on the role of health surveillance and promotion that transcends restricted visions tied to the conception of the regulatory state, promoter of economic development. The main challenge is to overcome thinking based on positivist science monopolized by specialists who fail to engage with other knowledges and detach themselves from the most pressing social struggles of our times. This is perhaps the greatest challenge of public health: face a still invisible enemy that resides in the epistemologies and paradigms of modern science deeply ingrained in biomedicine, epidemiology, and even the social sciences, who arrogate to themselves the title of specialists and study “subjects”, talk about them and for them, but rarely together and with them.
The conception of science is at the core of the epistemological disputes still disregarded by the large majority of intellectuals from the field of public health, who dogmatically believe in the universal and superior role of science as the basis of progress and solving health problems. Little progress can be made in this area as long as we fail to recognize that the enemy is not next door, but rather within our minds and ideologies, which shape a vision of science that invalidates and are detached from genuine encounters between knowledges inside and outside science present in the context of social struggles.
Having said that, it is also necessary to overcome the idea that state institutions base their approach exclusively on the universal modern rationality underlying knowledge-regulation. This vision means that technicians and bureaucrats in organizations such as the National Health Surveillance Agency (Anvisa, acronym in Portuguese) establish themselves as specialists in communities and decision-making processes, the latter of which are closed to nonspecialists and radically exclude and are detached from the knowledges, practices and struggles of the peoples and groups subalternized by modern rationality. It is this pretension of universality, objectivity and neutrality that allows the family farmer from an agricultural reform settlement involved in important social struggles to be treated by Anvisa in the same way as a transnational food giant.
Overcoming these limitations does not imply, as many might imagine, abandoning the achievements of science and its technology in some kind of return to primitive barbarism, as feared by modern rationality. Decolonizing public health and health surveillance and promotion implies promoting more horizontal dialogues in contexts of social struggle, thus enabling the emergence of emancipatory knowledges and practices that go beyond the universalisms that invisibilize alternative socialibilities, economies, and other ways of knowing, feeling, working, and producing. Such emergences are set to assume an ever-stronger leadership role in the social struggles of our time, a time of civilization and paradigm shifts in which, far from realizing the dreams and promises of modernity, many societies are heading towards dystopia.
Health, whether the intellectuals of the field of public health like it or not, continues to be a privileged locus of social experimentation for the epistemologies of the South and ecology of knowledges. Take, for example, the encounters between knowledges and potentially emancipatory practices in the area of indigenous health, rural health, quilombolas’ health, health in the favelas, and mental health, or the encounters between health and art in the liminal spaces between defined knowledge and in the borders that refuse to bow down to the coloniality of power and knowledge. Themes such as healthy eating, food security and sovereignty, agroecology, sanitation in rural areas and favelas, and the struggle for housing and inclusive and democratic cities. Another theme that drives new practices involves ecological crises and conflicts resulting from pollution, disasters, access to water and water scarcity, or related to the sense of sacredness of rivers, trees and forests that is part of countless cosmovisions. In all these spaces and issues, always marked by emancipatory struggles, the concept of development, health and nature is increasingly called into question and reworked through social struggles that advocate for dignity and the well-being of all people and peoples. Emancipatory health surveillance calls for a permanent shift in ways of thinking which, in the name of the supposed objectivity and superiority of science and the effectiveness of rules and regulations, form the abyssal lines that prevent the encounters and mobilization that are vital for ensuring transformation in times of crisis.
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