Rodolfo dos Santos Mascarenhas: a pioneer of health history

Abstracts

Studies on the work of Mascarenhas analyze his contribution to the history of health in Sao Paulo and the aspects of his work which place him in what is entitled the second generation of health workers of São Paulo state - being the first generation the one led by Emílio Ribas. This article recaptures these points and highlights his last works on preventive and community medicine. We argue that the conception of public health consolidated during his education was essential for his interest in the new model of medicine that was starting to spread in the country.

History of health; Health centers; Sanitary administration; Preventive medicine

Os estudos que comentam a obra de Mascarenhas analisam sua contribuição à história da saúde em São Paulo e os aspectos de seu trabalho que o enquadram no que se convencionou chamar de segunda geração de sanitaristas paulistas - a primeira seria liderada por Emílio Ribas. Esse artigo retoma esses pontos e destaca seus trabalhos mais recentes, relacionados à medicina preventiva e comunitária. Argumentamos que a concepção de saúde pública consolidada em sua formação foi central para seu interesse no novo modelo de medicina que começava a se difundir no país.

História da saúde; Centros de saúde; Administração sanitária; Medicina preventiva

Introduction

The work of Rodolfo Mascarenhas is characterized by its pioneering in the construction of the history of health in Sao Paulo State and in the discussion of themes related to the hygiene transformation process in collective health. Always tuned with the international literature in the public health sector and extremely interested in aspects associated with the development of preventive medicine, Mascarenhas was a link between health conceptions, spread by the generation that preceded him in the Institute of Hygiene, and the new concepts and practices of medicine developed from the middle of the same century.

His academic career is similar to what was previously followed by health workers such as Geraldo Horácio Paula Souza and João de Barros Barreto who, in charge of the Sanitary Service of Sao Paulo in different moments implemented important structural modernization reforms. Both men were granted scholarships by the Rockefeller Foundation to study at Johns Hopkins University where they had contact with new precepts of the sanitary idea, spread by the Rockefeller Foundation in several parts of the world from the beginning of the twentieth century¹. This model of thought framed the way our author conceived public health structures and practices, providing him with tools for constant updates.

Academic degree and professional experience

Rodolfo dos Santos Mascarenhas was born on July 6th 1909, in São José dos Campos (SP Brazil). He graduated from the Faculty of Medicine of Rio de Janeiro (RJ Brazil) in 1932 where he specialized in phthisiology. Back to his hometown, he started to work as a physician and became interested in local politics. Between 1933 and 1935 he was the mayor of São José dos Campos².

In 1936 he joined the Sanitary Service of Sao Paulo State as a physician. In the following year he returned to university to take a specialization course in hygiene and public health in the Institute of Hygiene at the Sao Paulo Medical School. According to the physician himself, his contact with the Institute of Hygiene was crucial for his degree in public health. The beneficial professional interaction with the health worker Paula Souza also resulted from that period³.

At the time when Mascarenhas attended the specialization course the Institute of Hygiene was directed by Paula Souza, who was a central character in the modernization of the health services in Sao Paulo. Paula Souza had obtained his degree at the Johns Hopkins University, where he was in touch with new public health conceptions, which saw the sanitary education and the construction of health centers (local units directed to primary activities of horizontal character) as the heart of a new sanitary organization model. In 1922, Paula Souza took up the position of director of Sanitary Service and led a great reform on the public health services in the state by creating the first health centers in the city of São Paulo⁴. Mascarenhas showed great respect for Paula Souza, considering him a friend and mentor.

In 1940 Mascarenhas joined the Free School of Sociology and Politics, where he taught Political Science and Public Administration, later becoming a full professor of both chairs. In 1943 he received a fellowship for the Hygiene and Public Health Course at Yale University, where he earned his PhD. After finishing his PhD, in 1945, he stayed in the USA for nine more months aiming on understanding the organization of the public health services in that country².

The return of Mascarenhas from the USA coincided with the transformation of the Institute of Hygiene in to School of Hygiene and Public Health of the University of Sao Paulo. At that point he was invited by Paula Souza for the position of adjunct professor in that institution, taking up the "public health technique" chair, so far directed by Paula Souza. In 1949 Mascarenhas took a public exam for the position of associate professor at the School of Hygiene and Public Health, which was at that time linked to the University of Sao Paulo. The thesis he prepared for that exam is nowadays an obligatory reference for studies on public health history in São Paulo state¹.

With the death of Paula Souza in 1951, Mascarenhas became director of the Public Health chair. His wide professional experience and his position as an heir of Paula Souza led him to become the director of the University for two mandates between 1966 and 1972². During his last year as a head of the institution he worked actively on the creation of the Sao Paulo Association of Public Health, which was also directed by him for two consecutive mandates. In 1975 he was invited by the Sao Paulo state secretary of health, Walter Leser, to direct the Community Health Coordination of the State Department of Health, which institution that coordinated the whole network of health centers in the state. Unfortunately, a few months after taking office, he had a cerebrovascular accident which impaired him to continue working⁵. Mascarenhas died in 1979 due to the disease that affected him.

A pioneer of the history of health in Sao Paulo

The first studies on Brazilian public health appeared in the beginning of the twentieth century, carried out by physicians and health managers interested in documenting the deep changes occurred in the public health sector in that period. These studies discussed the development of the legislation and also of the health institutions. Therefore these studies were characterized as extremely important tools for researchers who subsequently studied public health applying the methodological perspective of history. However, these studies were mostly limited to the city of Rio de Janeiro, owing to its position as the political and cultural center of the Republic, as well as of first capital city to undergo a radical process of urban renovation.

In Sao Paulo, the first noteworthy studies on the trajectory of health services were carried out by Mascarenhas. Still in 1948, he published a long article systematizing the development of the state financing public health in Sao Paulo during the republican period⁶. This inventory was the starting point for his habilitation thesis, defended the following year. Under the title of "Contribution to the study of state sanitary administration in Sao Paulo"³, the extensive study also presents a detailed inventory of public health in Sao Paulo state, discussing the main changes in its structure. In addition, it analyzes the state sanitary organization and delineates a reorganization proposal to the health services.

Only in the 1970's, with the studies of the American researcher John Allen Blount, the history of public health in Sao Paulo became the purpose of a new significant historical analysis⁷. Based on Mascarenhas' data, Blount concluded that, in the beginning of the twentieth century, the success of the Sao Paulo state public health in containing diseases' outbreaks had an important role in the maintenance of the immigration policy and broadly in defining a more general the path for state development.

Emerson Merhy published new studies on the trajectory of the sanitary organization of Sao Paulo in 1985 and 1991^{8 , 9}. In his first study, he tensely addressed Mascarenhas' ideas when stating that he considered sanitary practices and the notions about health and disease as non-historical elements⁸. Although his criticism is correct, the period in which the study was performed must be taken into account, considering that the approaches on the historicity of health conceptions and practices were in the process of development at the time.

In the early 1990's the sanitary organization in Sao Paulo state was the purpose of the studies carried out by Castro-Santos who, similarly to Blount, attributed the improvement on the population's health conditions to the sanitary reform in Sao Paulo state. In addition, Castro-Santos showed how this process was motivated by the construction of nationality ideology and how it was inserted in a context of expansion of the state intervention in the country^{10 , 11}. In the same period, returning to the discussions of Mascarenhas, Ribeiro published a detailed study making an inventory of the public health services in Sao Paulo¹², and Telarolli Junior analyzed the relation between the development of these services and the appearance of great diseases' outbreaks in the state¹³. In the end of the same decade, Hochman's book¹⁴ resumed the route initiated by Castro-Santos. His study analyzed public health policies as an element of construction and expansion of the state and showed the importance of Sao Paulo in the construction of the national policy for the sector.

In a different line of analysis, one of the most expensive topics for Mascarenhas was reconsidered by Faria and Castro-Santos, who studied the health model within the Institute of Hygiene in the 1920's and the professional qualification in this area^{4 ,15.} The authors recreated the trajectory of public health conception, based on the local centers and the horizontal care models, showing that the initiative in Sao Paulo state was the base for the consolidation of a model that, had an important role in the organization of health services in different states despite its non-prevalence.

The abovementioned studies, which today are considered as classics in the historiography of Brazilian public health, were inspired by the pioneer work of Mascarenhas. He analyzed a geographical and temporal context that had been so far neglected in the face of Oswaldo Cruz's actions in the sanitation of the city of Rio de Janeiro. They also brought to light the importance of Sao Paulo state in the acknowledgment of the national public health plan and in the creation of a specific services organization model. Mascarenhas prepared the ground for these results. In addition to systematizing a set of information of extreme usefulness for the studies that followed, his studies addressed aspects of great centrality in the health sector, showing important contribution for subsequent discussions.

Health centers as the sanitary organization axis

As previously mentioned the public health vision of Mascarenhas was a result of his proximity to Paula Souza and to the general context of expansion of the health conception developed in some medical education centers of the United States and spread by the Rockefeller Foundation. Such conception emphasized the sanitary education, the multi-professional frame of the health services, the activities of the health visitors, the full-time action of professionals associated with research and health teaching, and expansion of community health centers (HC). The importance of the HC for the health system was one of the most addressed topics in Mascarenhas' studies. Besides his habilitation thesis, several of his articles mention these units which, in his point of view, should act based on principles close to what today we call comprehensiveness, an important ally of health in the sanitary education sector^{15 - 18}.

The centrality attributed to the HCs is part of a great increase in the appraisal of sanitary education. For Mascarenhas, "education of people on hygiene principles is the basic purpose of health services"¹⁹ and the basic purpose of the HCs is to diffuse the knowledge of this discipline. In articles published in 1955^{16 , 17}, he defined the HCs as units focused on serving the population of a district, which should work coordinately. They should have as their main attributions a wide set of activities, which today would include several aspects of what we call primary health care, and when possible they should develop different activities, including medical aid and rehabilitation activities. Similarly to what nowadays regards the Family Health Strategy, Mascarenhas proposed that these centers had the families as their intervention object and that they incorporated home visits as a way of potentiating the education actions in the health sector. He also advocated that every local health action should be performed by the HC.

Mascarenhas also advocated that these units should work connected, in a network, coordinately and in hierarchy. In his early health planning conceptions, Mascarenhas reiterated the idea of integration, mainly between hospitals and the HCs. Moreover, under the perspective of saving material and human resources, he recommended planning the location of the different health units and the state incentive for their coordination. In his point of view "the state government, through technical organs, should study and plan a better coordination between preventive and curative medicine activities at a local extent, connecting public health organs to general hospital institutions"¹⁶.

The attribution of state's responsibility to the coordination of local health activities leads to another very present aspect in Mascarenhas' work: the strong criticism to administrative centralization of health services. For the author, the centralization was a tradition in the Brazilian sanitary administration at its several levels, resulting in lack of service agility and efficiency²⁰. Despite the criticism to centralization, his position on the issue was far from the idea of municipalization. Based on data analysis, which demonstrated the incompetence of municipalities in dealing with quality services, he advocated greater action of the states in financing and managing health services²¹.

In the 1960's the discussions on this issue increased, culminating in the 3rd National Health Conference (1963), when municipalization proposals was the central debate and had the government support²². In the previous year, Mascarenhas presented a new study at the XV Brazilian Conference of Hygiene (Recife, PE Brazil), reaffirming his position on the subject. In this study, he pointed a current aspect of the discussion: the problem of municipal policy distortion. "Other reasons advise against the transfer of health units to municipal government. There is a cultural barrier still obstructing us: the ominous influence of municipal politicking on technical activities of local governments"²³. Ten years later, when the discussions on the decentralization of the health system had been concealed by the authoritarian regime, Mascarenhas reaffirmed, in a new study, his position on the need for decentralization, emphasizing that multilateral agencies such as the PAHO and WHO recommended the same²⁰.

Mascarenhas and preventive medicine

The expansion of complexity and the consequent elevation of medical care costs in the 1940's favored the appearance of a medical model strongly focused on prevention. The so-called preventive medicine appeared in the USA and had among its main imperatives, the medical education directed to preventive actions, the importance of multi-professional practices, and the use of knowledge from social sciences disciplines and from epidemiological analyses. In line with this medicine, community medicine also appeared in the USA two decades later. Result of the development of social movements for the improvement of life and health conditions, community-based health programs had local coordination and participation of communities for the development of actions aiming mainly at the expansion of coverage of primary health care actions. These new medicine models created a strong criticism against healthcare fragmentation, super-specialization of medical knowledge and the biologizing model which favored the search of technical solutions centered in the etiological specificity of specific diseases, without taking into account the social conditions involved²⁴.

The affiliation of Mascarenhas to the public health model disseminated by the Rockefeller Foundation favored his prompt commitment to the new way of thinking which appeared with the preventive medicine. As previously mentioned, it can be observed that the proposal of a sanitary organization based on health centers pointed to the importance of primary care and horizontal actions for disease control. Other concepts, addressed by Mascarenhas in articles published in the 1960's showed his commitment to public health principles originated with the preventive medicine.

In a study published in 1961, Mascarenhas and Pacheco discussed the fragmentation of scientific knowledge and its consequences for health, showing that this process had led to technicism and to an incomplete vision of the human being and his needs. The reversion of this situation occurred through the integration of knowledge, which resulted from the introduction of teaching social sciences and notions of history and philosophy of knowledge in medical and public health schools. The importance of the social sciences in medical education is an aspect frequently observed in the author's works. Mascarenha's interest in this topic, besides the relation to his sociology teaching experience, fits in the general movement of integration of social sciences to medical education, which was part of the preventive medicine scope.

The approximation of Mascarenhas to the principles of preventive medicine led him to acknowledge a new way of conceiving the health-disease process. In his first papers this process had the lifestyles of different groups as a central aspect. Accordingly, the sanitary education, as a fundamental element of change of the ways these groups associate with disease-causing factors, would be an important tool for public health. His last studies altered the factors of this equation, giving emphasis to the living conditions. By approaching the ways of thinking the social health determinants, he affirmed that the health-disease process has its foundations in the socioeconomic conditions and the possibility of overcoming it is by changing these conditions.

[...] of primordial interest for this activity is the population's standard of living [...] In groups with a low living standard, any sanitary action does not produce but scanty results, once their components do not dispose of enough resources or discernment to appropriately acquire the necessary minimum needs to a normal life: food, housing, clothing, transportation, etc. It turns out that the increase of the standard of living of certain social groups has to be imposed so they can enjoy complete physical, mental and social well-being ¹⁹.

Still in the context of his commitment to preventive medicine, Mascarenhas reflected on the role of the state regarding health. His ideas on this aspect, written in 1961, revealed the context of the search for reforms in the health sector, which preceded the coup d'etat of 1964¹⁸. His text, according to his early convictions, now also shared by several health workers, reinforced the importance of the integration of health activities and services and, in an extremely current approach, suggested strong state action in the coordination of the sector. Regarding the organization of the system, Mascarenhas affirmed that people's health was government responsibility, and that federal and state bodies should maintain primary care institutions. Regarding other healthcare levels, he proposed that state-owned institutions should be responsible for the planning, the coordination and the supplementation of activities not covered by private or philanthropic sectors¹⁸.

Final considerations

In the early 1970's, ideas of change in the healthcare sector based on preventive medicine conceptions simmered in the heads of many health workers in Sao Paulo. In this context, Mascarenhas, surrounded by other health workers, undertook in 1973 the process of creation of the Sao Paulo Association of Public Health (APSP). His purpose was to create an institution that promoted the debate on health issues and stimulated the improvement of field education⁵.

Heading the institution, Mascarenhas created meetings with this purpose. In 1975 he promoted the Study Week on Medical Aid in Brazil, where over two hundred professionals from several states of the country discussed the structuring of the health worker career. In the following year, the institution formulated the project for the First Sao Paulo Conference of Public Health. This conference was held in 1977, along with the XIX Brazilian Conference of Hygiene. At that moment, Mascarenhas had already interrupted his professional activities due to health problems.

The APSP in its first years had an important role in the discussion of professional issues, such as incentivizing the creation of the health worker career⁴. Although it did not claim for transformations in the health field, spread by entities such as Cebes and Abrasco, APSP´s first focus was on the organization of professionals who, subsequently, joined in the fight for deep changes in our health system.

The authors who analyzed the development of the recent sanitary view in Brazil emphasized the importance of criticism to the limits of preventive medicine in the creation of a social health concept, which opened way for the Brazilian sanitary reform²⁴. Mascarenhas' professional performance in the field of preventive medicine leads us to reversely consider the legacy of concepts and practices of this medicine for the history of Brazilian health and its relation with the medical conceptions that began to develop in the country in the 1920's. Belonging to a group of health workers with a wide and non-biologizing view of health, Mascarenhas consolidated his professional education with the knowledge conceived under the scope of preventive medicine. Based on these two thinking styles, his conceptions and practices helped to cement the foundations to new collective health practices.

Aknowledgments

I'm grateful to researcher Luiza Teixeira-Costa for completing the research on Rodolfo Mascarenhas' texts in health the libraries of the University of São Paulo.

References

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Publication Dates

• Publication in this collection
  Apr 2015

History

• Received
  13 Oct 2014
• Accepted
  23 Nov 2014