Contributions from research on the Health Economic-Industrial Complex to the teaching project in Public Health

After 16 years working away from Brazil, I attempted to update my knowledge on research production in Health Policy, Planning, and Administration, urged by recent analyses 1,2,3,4, especially Schraiber’s seminal work 5. I revisited the pioneering research methodology on the theme from 1974 to 2000 6 and reviewed the articles published from 2001 to 2018 in the journals Cadernos de Saúde Pública, Ciência & Saúde Coletiva, Revista de Saúde Pública, and Saúde em Debate, as well as books, anthologies, and theses, selected intuitively. There has been a major reduction in this production on the themes of the national State and its role in guaranteeing universal social protection, as well as in macro policies in Social Security and the Brazilian Unified National Health System (SUS) 2,3,4,5,7, steadily replaced by case studies, reports of local experiences, program evaluations 2,4, and exaltations of identity particularisms, in addition to a virtually total abandonment of the theoretical and methodological approach of Political Economy 8. Intellectual interaction between professors, researchers, and students with different academic and professional backgrounds, whether Marxist structuralists or post-structuralists, post-Modernists or neo-Institutionalists, has been present since the pioneering writings in Public Health 6,9,10. This plurality has not been limited to the organic linkage between original research production and policy, services, and the development of capacities for understanding, interpretation, and transformative intervention in the sector’s reality, based on the “ideology-knowledge-practice triad” 11. This organic linkage was established over the course of the 1970s, oriented by a shared understanding in the “field” concerning the Brazilian health sector: a “Grand Narrative” on the population’s living and health conditions; the evolution of health and corporate-social security policies; the social organization of medical work and the “hospital-centered” healthcare model vis-à-vis the capitalist mode of production; segmented access to medical and hospital care; the “commodification” of health and the power relations spearheaded by the medical profession and the nascent entrepreneurial class, all under the influence of Historical Materialism and Political Economy 3,8,10, which was “The” reference in the subsequent decades for the politically engaged and innovative production of the field’s objects, methods, and products 6,7,12.

Cad. Saúde Pública 2022; 38 Sup 2:e00224720 The foundations for the theoretical and methodological density and complexity of this research output were the seminars held by the Pan American Health Organization (PAHO) from 1969 to 1978, the teachings of Juan Cezar Garcia 13 , with Marxist structuralist orientation, reinforced in the case of various authors by their activism in the Brazilian Communist Party (PCB) 12,14 , and Latin American critical thinking.
"There is an immeasurable wealth of academic production that has come to light in the recently inaugurated field of Collective Health, in which studies have been developed taking the issue of the State, democracy, and social policies as the line for updating the Marxist debate (...), exposing the forms of commodification of health, the dynamics of capitalist accumulation in the sector, and the different organizational configurations and linkages between the public and private sectors" 3 (p. . "In the late 1980s, with the new liberal hegemony, critical thinking had clearly lost its vitality, while many Marxist structuralists had adhered to the liberal-conservative project in one way or another" 15 (p. 33). The 1990s witnessed a profound change in the political and ideological references, accompanying the impacts on the Socialist movements from the electoral defeats of the Social Democratic parties and the dissolution of the USSR, aggravated in Brazil by the self-dissolution of the PCB, the exhaustion of Keynesian and ECLAC (Economic Commission for Latin America)-inspired developmentalism, and intellectuals' increasing disinterest in studying the Brazilian State, thereby favoring the hegemony of utilitarian views of the State and the narrow limits of public policies.
The Public Health field in Brazil initially resisted this change 2,4,6,7 , but since the transition into the 21st century we have lost our reference to the Grand Narrative and thus the depth, complexity, intelligence, and relevance of our production 4,7,12 , which "is becoming increasingly fragmented and fragmentary" 3 (p. 22). We are collectively responsible for the abandonment of Marxism's central methodological category, namely Dialetical Totality, a tendency which adds to the growing depoliticization and "theoretical rarefaction of our production" 5 (p. 36) and has resulted in the impoverishment of critical reflection in articles, books, and theses, now peopled by an inductive empiricism with limited explanatory power, constituting the reason for frustration for many of us. "Pragmaticism, opportunism, and post-Modernism serve as a pretext to block reflection on projects and the future" 11 (p. 302).
Notwithstanding its disciplinary and epistemological diversity, our original research production expressed the authors' reflections on their political, professional, and institutional praxis 3 , and even having concentrated the output on academic studies 2,6 , the field kept a critical eye on the dynamics of the State, the market, society, and politics 4,6,7 .
In the 21st century, our production has swayed increasingly away from praxis 3 , thus leading to an important theoretical-empirical dissociation, expressed in the incapacity to construct a dialogue between the theoretical elements and the research results 5 , which leads to the risk of contributing to the dissemination of speculations, alternative facts, and post-truths. This process is aggravated by the multiplication of research groups that are the "property" of a few researchers and expressions of their personal interests (or disinterests), backed by a "laissez-faire" understanding of department-chair freedom, by "a certain eclecticism in the definition of approaches and methods" 16 (p. 116), and by the growing transformation of our courses/debates into spaces for collective training in manifestations of selfaffirmation of identity groups, in which "places of speech" override reflections on praxis.
The results of this production largely fail to expand or update knowledge, nor do they promote an understanding of reality. They do not contribute to critical reflection and rarely propose innovative research agendas or recommend transformative interventions. They are mostly limited to the description of sociopolitical/health processes. It is never too much to recall Marx's warning: "All science would be superfluous if the outward appearance and the essence of things directly coincided" 17 (p. 939).

Contribution of research on the Health Economic-Industrial Complex to the explanation/understanding/interpretation of the Brazilian health sector in the 21st century
Studies on the consolidation/expansion of the Health Economic-Industrial Complex (CEIS, in Portuguese), acknowledging it as the productive base of health and simultaneously as the space for capital accumulation and innovation, competition, and financialization, are critical for reconstructing the Grand Narrative. A prime example is the study on the Health Economic-Industrial Complex, Innovation, and Capitalist Dynamic: Structural Challenges for Building the Universal System in Brazil, led by the Research and Documentation Group in Health Entrepreneurship, Institute for Studies in Collective Health, Federal University of Rio de Janeiro (GPDES/IESC/UFRJ). The group has moved beyond theoretical reflections 8 to study the health market's current reality and its impacts on social protection policies, adopting the Political Economy approach to explain/understand/interpret Brazilian capitalism from a theoretical and historical perspective, analyzing companies that develop direct activities in the provision of individual care or indirectly in training human resources, marketing of health plans/insurance, or production/marketing of materials, equipment, and medicines, further assessing the activity in political-institutional spaces.
In my view, it is in Marxist Political Economy that we find the theoretical and methodological basis for a renewed teaching project in Public Health in Brazil, since it approaches the reality simultaneously from a historical, economic, political, and ideological perspective.
The analysis of the evolution and challenges posed by the Health Industrial Complex necessitate the introduction of a dynamic economic focus in the health field, concentrating on the processes of development, capital accumulation, and innovations, reclaiming approaches from Political Economy 18 .
In addition to analyzing "the contradictory dynamic of capital, whose essence is given by the processes of accumulation, distribution [and] innovation" 19 (p. 107) and relations of power and ownership, Marxist Political Economy establishes "a highly complex link between the process of knowledge and the process of political organization of social forces" 20 , by moving towards transformative praxis, as proposed by Marx in the 11th Thesis on Feuerbach.
This approach also induces the recovery of the political engagement at the origins of Public Health and the methodological orientation from the category of Dialectical Totality, understood as "the perception of social reality as an organic, structured whole in which one cannot understand an element, an aspect, a dimension without losing its relationship to the totality" 21 (p. 23-4), rejecting both causal linearity in the explanation of complex phenomena and positivist pseudo-neutrality in the interpretation of such phenomena, so much in vogue in the age of evidenced-based and value-free policies. The approach understands such phenomena as permeated by social worldviews, as "structured sets of values, representations, ideas, and cognitive orientations" 21 (p. 21).
Based on Marxist Political Economy, the renewal of the teaching project in Brazil's Public Health field will require rebuilding the reflection on the Brazilian State and its irreplaceable role in strategic leadership in the development, reduction of inequalities, and universalization of social protection. For this to happen, our debates and intellectual efforts should be oriented by a collective set (agreed upon with solidarity) of political, institutional, and academic challenges and objectives: (1) Priority for cooperative research and collective production of knowledge based on theoreticalconceptual density in reclaiming the complexity, reconstructing the theoretical-empirical dialogue, critical reflection, technical and scientific innovation, and ethical and political engagement; (2) Shared construction of a Grand Narrative on the Brazilian health sector in the 21st century, based on reflections on the State, market, social classes, distributive conflict, policy, development projects, and expansion of the CEIS; (3) Sharing of knowledge and analyses, based on the ideology-knowledge-practice triad; (4) Formation of a new generation of professors, researchers, administrators, and technicians with capacity for description/explanation -understanding/interpretation -and technical-political-institutional intervention/transformative action in the State, economy, society, and health policy.