Ricardo Bruno: history, social processes and health practices

Abstracts

This essay has the objective of revisiting the intellectual output of Ricardo Bruno Mendes-Gonçalves (1946-1996), Professor of the Department of Preventive Medicine of the Faculty of Medicine of the University of São Paulo and one of the theoreticians who participated in the construction of the field of Brazilian Collective Health during the years 1970-1990. On the basis of brief biographical and bibliographical information, as well as relevant aspects regarding the historical context in which his output is located, I examine the principal works of the author, their effects on the lines of investigation of investigation of his students and his legacy of contributions and challenges for Collective Health. I highlight the genesis and development of his Theory of the Health Work Process and its impact on the understanding and empirical investigation of the socio-historical dimensions of health practices and on the reconstruction of knowledge and technologies in the context of the Brazilian Health Sector Reform. In particular, I highlight his concern with the ethical perspective of academic praxis and in this sense, with hope as a human value which is historically objectified and intersubjectively constructed.

Collective health; Social medicine; Medicine/History; Health sciences; Attention to health

Este ensaio tem como objetivo revisitar a produção intelectual de Ricardo Bruno Mendes-Gonçalves (1946-1996), professor do Departamento de Medicina Preventiva da Faculdade de Medicina da Universidade de São Paulo e um dos teóricos que participou da construção do campo da Saúde Coletiva brasileira nos anos 1970-1990. Partindo de breves informações biográficas e bibliográficas, assim como de aspectos relevantes acerca do contexto histórico no qual se situa sua produção, examina-se os principais trabalhos do autor, seus desdobramentos nas linhas de investigação de seus alunos e seu legado de contribuições e desafios para a Saúde Coletiva. Destaca-se a gênese e o desenvolvimento de sua Teoria do Processo de Trabalho em Saúde e seus aportes para a compreensão e a investigação empírica das dimensões sócio-históricas das práticas de saúde e para a reconstrução de saberes e tecnologias no âmbito da Reforma Sanitária Brasileira. Ressalta-se, ainda, sua preocupação com a perspectiva ética da práxis acadêmica e, nesse sentido, com a esperança como valor humano historicamente objetivado e intersubjetivamente construído.

Saúde coletiva; Medicina social; Medicina/história; Ciências da saúde; Atenção à saúde

Angelus Novus

When Paul Klee (1879-1940) created his Angelus Novus, in 1920, he certainly could not have imagined that this image would become world famous as a symbol of history. This identity, which would immortalize the drawing as the "Angel of History", derived from the fascination that the work inspired in Walter Benjamin (1892-1940) and from the interpretation which the German philosopher and writer would give to it in his "Theses on the Concept of History", edited 20 years later¹. This deep thinker read in the wide-open eyes, in the dilated mouth and in the open and immobilized wings of the Angel the horror of incessant and implacable progress, which, like a strong wind blowing from the past, pushed it with its back to the future, forcing it to witness the accumulating barbarism and preventing it from saving those who succumb to its destruction.

I cannot help referring to this strong image by Klee and its inspiring interpretation by Benjamin when I revisit the work of Ricardo Bruno Mendes Gonçalves and his contribution to the construction of Brazilian Collective Health. This association derives less from the conceptual ballast of Benjamin's intellectual tradition in the output of Ricardo Bruno than from an aesthetic and ethical link.

In contemplating the image of the Angel, contrary to what one might initially suppose, one experiences a feeling which is not one of static horror in the face of the vision of barbarism, far less of indifference, in the inevitable distancing caused by the course of events. The fact that it is an angel who reveals history to us is no mere detail. The Angel incarnates history, making it visible to us. While its wings are paralyzed by the force of the wind, they are like this because they offer resistance to the wind; the Angel does not allow itself to be swept away by turning its back on the past. The Angel walks towards the future to the same extent as it experiences the force of the past wings. As an angel, it is a messenger, it incarnates the message. And one cannot avoid seeing in the almost puerile features of Klee's/Benjamin's Angel a freshness of renovation, a hope of overcoming barbarism, without turning one's back on history, or specifically because one does not turn one's back on history.

In this way, in the Angel of History there is a commitment to Good, albeit a good which is not an abstract idea or even an individual experience, but a construction counterfactual to the evil which is materialized in the suffering of the other, in the ailing of flesh and bone individuals affected by the violence and negligence of concrete actions accumulated in and by history. What unites us, with the mediation of the Angel, in our concern to save these individuals from the destruction of barbarism, is nothing other than the community of origin and destination, which links us to them as human beings, which identifies us as the human race and is the source of hope for overcoming evil.

These are the affinities with the contribution of Ricardo Bruno to the construction of the field of Collective Health within Brazil, on the one hand, through his attempt to bring history, in its radical materiality, into social thinking on health and on the other, in his determination to do this without ever losing sight of the ethical sense of this historical salvage and of scientific praxis in general. Historicity, materialism, health as a concrete value for the concrete human value, hope as a virtue to be pursued in the scientific praxis of Collective Health: These are the ideas which seem to me to characterize most strongly Ricardo Bruno's legacy to the "school"² which he helped to build in Collective Health.

While, due to the nature of this essay, it is mandatory to provide the reader with some biographical data and information on the whole of his work, I do not intend here to cover the whole of his output and to exhaust his multiple contributions. The reader will perceive that emphasis is placed on a number of works considered as the most characteristic and on certain theoretical constructs disseminated in them. I hope that these choices do not excessively bias a reading of his work, impoverishing an understanding of their general sense, but on the contrary, encourage new readings and re-readings to impress a renewed potency on the dialogue to which the powerful intellectual construction of this late master is incessantly inviting us.

Brief biographical

and bibliographical notes

Ricardo Bruno was born on August 2, 1946 in the city of São Paulo. An outstanding pupil at every stage of his education, he entered the Faculdade de Medicina da Universidade de São Paulo [Medical School of the University of São Paulo] (FMUSP) as one of the top students, a position which he maintained throughout his studies. He graduated in Medicine in 1971 and during the years from 1972 to 1974, he held the Medical Residence in Preventive and Social Medicine at the Departamento de Medicina Preventiva [Department of Preventive Medicine] (DMP). As part of his studies, he also took the Specialization Course in Public Health, administered by the Faculty of Public Health of USP.

In this same year of 1974, he began a teaching career at the DMP, working with significant lecturers in this Department and figures of great importance for the academic construction of Brazilian Collective Health, such as Professor Guilherme Rodrigues da Silva (1928-2006) and Professor Maria Cecília Ferro Donnangelo (1940-1983)³.

Donnangelo was undoubtedly the main interlocutor in his academic career, not only for his status as her intellectual closest collaborator, but especially due to the long lasting theoretical dialogue he established with the theme of her main work⁴: the investigation of the techno-social consubstantiality of health practices and the search for apprehension and management of this consubstantiality in knowledge applied to technical and political actions aimed at Collective Health.

Ricardo Bruno defended his master's thesis in 1979⁵, published as a book several years later⁶ and in 1986 his doctorate⁷, also published subsequently⁸.

Throughout his teaching career, he was active in various forums for the academic and political construction of the field of Collective Health, with the Associação Brasileira de Saúde Coletiva [Brazilian Collective Health Association] (Abrasco). He regularly conducted study groups with the Nursing School of Ribeirão Preto and also developed significant interchanges with the Federal University of Bahia and the Escola Nacional de Saúde Pública [National School of Public Health]. He made a significant contribution to the training of staff, both within the University or as an extension activity. Particularly relevant, from this perspective, were his activities with the CADRHU (Curso de Aperfeiçoamento e Desenvolvimento de Recursos Humanos - Course for Further Study and Development of Human Resources), devised in 1987 on the basis of the partnership between the Pan-American Health Organization, the Ministry of Health and various academic institutions, and the CEFOR (Centro de Formação de Recursos Humanos da Secretaria Municipal de Saúde de São Paulo - Centre for Staff Training of the Municipal Health Secretariat of São Paulo), during the administration of Luiza Erundina as Mayor of São Paulo (1989-1993).

Ricardo died of AIDS in 1996, in the same year in which combined anti-retroviral therapy, the so-called cocktail, arrived in Brazil, unfortunately, not in time for him to benefit from it. By an irony of destiny, the inventor of the Theory of the Health Work Process left us exactly on May 1, the day on which we celebrate Labor Day in Brazil.

The body of written works which Ricardo Bruno left behind is not very voluminous and some material is hard to access, with a compilation of this output provided in the attached list (Chart 1). His influence was nevertheless very significant and is still felt even today, with his works still being cited almost 20 years after his death. Starting from the techno-social consubstantiality of health practices, Ricardo developed his Theory of the Health Work Process, a theoretical framework which, starting from premises of historical materialism and genetic structuralism, provided consistent and useful bases for a broad range of studies in the field of health.

Chart 1.
Bibliography of Ricardo Bruno Mendes-Gonçalves (1979-1996).

Theory of the Health Work Process

In order to achieve a better understanding of Ricardo Bruno's intellectual output, the context in which it was produced should be recalled, especially among new generations of readers. Like the Brazilian Health Sector Reform (RSB) movement itself, Ricardo began his academic development during the military dictatorship, joining the group of intellectuals and healthcare professionals who criticized the situation of exceptional measures, the curtailment of democratic freedoms and the political persecution and repercussions of the situation on the health framework of the country, characterized by profound inequalities and difficulties. In this context, it is not surprising that the discursive tradition of Social Medicine⁹, which originated in the revolutionary Europe of the start of the 19^th century, became a strong influence on Brazilian public health. From this movement of ideas, updated for Brazil by the theoretical developments deriving from the Marxism and structuralism of the first half of the 20^th century, by the local experience of poverty and social inequality and by the political resistance to the military regime, a strong perception was retained of the relations between the health conditions of the population and the organization of social life (political, economic, cultural) and the conviction that it was not possible to alter the former without transforming the latter.

In this sense, Medicine and its technosciences had to be stripped of their aura of neutrality and the action of doctors (and of other healthcare professionals) of its almost "priestly" character, to be understood as the social practices which they were. They had to be understood as elements historically structured within the context of the interests of actual subjects, localized temporally and geographically, which constructed them in accordance with possibilities which were materially and ideologically demarcated. Only this critical appropriation could bring to light its political biases and practical limits, creating conditions for its reconstruction in a form consubstantiated with the reconstruction of social life in a more general form.

The works of Sérgio Arouca¹⁰ and Cecília Donnangelo⁴ were paradigmatic for this movement within Brazil and are considered to be canonical for a set of theoretical and applied studies which were developing within the context of the RSB. On the trail of these studies, Ricardo Bruno produced his master's thesis on "Medicine and History" 5, to which we shall henceforth refer with the acronym MH.

Despite the fact that in most cases, a doctorate marks the specific contribution of an author to his field of operation and, in the case of Ricardo Bruno, that his doctorate was perhaps his work which was the most widely disseminated and had the greatest impact, I consider that MH plays a central role in the whole of his work. While relatively little read and cited, without MH there would be no Theory of the Health Work Process and the entire derived range of investigations of its consequences.

This statement may be in conflict with the impression caused by a first reading (or rereading) of this study today. As we read through the pages of MH today, it appears to be a dated study. The Marxian philosophy which supports it closely follows the structuralist reading of the 1970s, still without traces of the metacritical reconstructions which would give it a new shape in the 1980s and 90s, including in the output of the author himself. The relations between infrastructure and superstructure are interpreted in a way which is still rather mechanical, deterministic, and with little sensitivity to other sources of social normativity; paying little attention to dynamic communication processes acting as tensioners of the institutions, particularly facilitated by the rapid and capillary means of communication of the digital age. Lastly, there is a major concern with the definition of the productive (or unproductive) character of health work (the focus of a debate with Arouca) which today appears completely vacuous in view of the transformations, since it spends its social life in late capitalism, in which the progressive and unlimited incorporation of material technology into work processes, the extensive institutional mediation of the relations of production and the commodification of the notion of social well-being, among other aspects, make the different moments of material reproduction of contemporary societies increasingly interwoven and interdependent.

At the same time, the theoretical rigor and competence with which Ricardo deconstructed the image of the doctor (and with him, of the healthcare worker in general) still impresses today, as someone placed on the sidelines of history, producing and using rational, objective and true knowledge on behalf of a universal and abstract good named health. On the other hand, this rigor and competence maintains its arguments from any pamphleteering or manicheistic sliding, which has to reduce the doctor to a mere "organic intellectual of the bourgeoisie" or Medicine to an ideological construct strictly intended to control the labor force and legitimate its domination (albeit while being this as well).

Perhaps this characteristic cost MH the small popularity which it achieved at the time of its publication, at such a politically polarized time. The fact nevertheless remains, with the historic patience of theoretical work, that the conceptual perspective achieved by Ricardo Bruno contributed to the construction of approximations to the study of health practices within Brazil, in which materialism and history became not merely forms of expressing the adoption of a political stance, of critical negotiation, but positively characterized possibilities for theoretical and applied research of a reconstructive character. Perhaps the influence of authors such as Antonio Gramsci (1891-1937), Lucién Goldmann (1913-1970) and György Lukács (1895-1971) favored his sensitivity to the opening of historical development and to the role of subjects and their interactions in this development, not only permitting an escape from Marxist dogmatisms but also betting on the reconstructive possibilities in the very interior of health practices.

In MH, Ricardo Bruno brilliantly developed the characterization of the dual stance of doctors in capitalist societies. On the one hand, they belong to the intellectual elite which formulates hegemonic social projects, based on the legitimacy and practical part of the medical sciences. On the other hand, they are workers who produce services and as such, are dominated not only by the relations of production which progressively define their work and way of life procedures (through training and employment, remuneration, social status regimes, etc.), but also by the progressive power of technology in determining the value of sciences (of which doctors are supposed to be the masters) and the place of professionals in concretely operated health work processes. However, it was precisely in this contradictory situation that Ricardo Bruno discerned the emancipatory potentialities of a theoretical practice devoted to exploring the way in which technologies relate to the Health Sciences and their subjects. Betting on a scientifically solid and politically aware understanding of these technologies could tension and transform the positions of subjects, power relations and hence collective health and Society projects.

With this, MH ends by leaving open, more than a line, a genuine program of investigations, capable of stimulating and supporting various schools within Brazilian and Latin American Collective Health. In a brief and non-exhaustive inventory of these investigations within his own school, we should highlight, in addition to his own doctorate⁷, the studies by a number number of his colleagues, collaborators and students on medical work¹¹, medical technologies¹², evaluation of primary health care technologies¹³, health planning¹⁴, epistemological and philosophical aspects of health practices^{15 - 18} and the various studies applied to the experimental primary health care service which Ricardo aided to establish and develop, the Centro de Saúde Escola Samuel Barnsley Pessoa [Samuel Barnsley Pessoa Academic Health Centre], or the Centro de Saúde Escola do Butantã [Butantã Academic Health Centre]^{19 , 20}, where experimentation with alternative technological models follows his proposal of collaborating on the construction of inclusive and emancipatory health practices²¹.

In his doctorate⁸, on the technological organization of work in the basic units of the State Government of São Paulo, abbreviated by us as OT, the conceptual framework constructed in his master's thesis was developed to the point of configuring a Theory of the Health Work Process. In addition to the conceptual development, a qualitative empirical study, combining the observation of services with interviews with professionals, sought to grasp the materiality and historicity of health practices within the concrete context of public health in São Paulo. The theoretical framework was then put to the test, most successfully. Ricardo Bruno identified in this study the polarization of knowledge, implemented concretely in the health units around two typical procedures of applied rationality: the clinic and epidemiology. He demonstrated how these abstract poles are related to work processes involving structurally interdependent objects, instruments and objectives, but which are sufficiently different to sanction or hinder different subjective perspectives and techno-political plans which conflict with each other within the organization of Attention to Health, under construction within Brazil.

In this sense, OT established itself as a powerful critic, both of the impoverishment of the incorporation of epidemiological rationality into basic care, where it would have a fundamental role to play, and of the lack of attention of public health strategies to the importance of clinical rationality in the construction of practices effectively capable of carrying on a dialogue with populations and their health requirements. In other words, he deconstructed the technical conservativism which empowers and polarizes these two spheres of knowledge and points to clinical-epidemiological integration as a horizon for the overcoming of individualist, naturalizing and technocratic understandings of the technological organization of primary health care.

It is unnecessary to emphasize the openings brought by OT to the field of Collective Health, which extends, as highlighted in the works mentioned above, from the possibilities of a historical-epistemological revisiting of the knowledge of health to the proposal of the new arrangements between knowledge and technology (and their subjects) in the health services. From these openings evidence nevertheless also arose of fragilities, lacunas and inadequacies of the Theory of the Health Work Process. Unfortunately, Ricardo did not live long enough to work on them, but did leave us some indications of the way in which he interpreted them and the ways in which they could be elaborated. We shall examine these in summary fashion, by way of a conclusion.

Of needs and hope

As the Theory of the Health Work Process was applied, criticized and developed, and at the same time, as the social, political and academic context surrounding him was modified, Ricardo Bruno became increasingly interested in what we could call the moment of "consumption" in the relations of capitalist production for thinking about the place of health practices. That is to say, the dimension of health needs and its implications for demand for attention and responses of health services were more and more prevailing over the structural aspects of production processes themselves amongst his theoretical concerns. This movement becomes clear when we compare his first systematic text for the dissemination of the Theory of the Health Work Process²² with its expanded version, re-edited several years later²³.

The most important theoretical influence in this movement was undoubtedly the work by the neo-Marxist philosopher, Agnes Heller²⁴, who was a disciple of Lukács. In the revisiting by the author of Marx's philosophical works, in a search for the meanings found in them for the notion of human needs, Ricardo Bruno identified a productive updating of Marxian ontology, in some way stripping it of the rigidity of structuralist readings. The recovery by Heller of a strong sense of history as a becoming process of??? as development and the opening which it gave to the positive presence of values and its intersubjective construction, sustained by the dialectic between "necessary needs" and "radical needs", appears to have replied to the self-criticism which Ricardo made at the time of what he called the "negative conception of historicity", "grudging functionalism" and "insufficiency of the concept of structure" in the studies of the Theory of the Health Work Process². Understanding the technological organization of health actions by means of health needs, such as those identified by professionals and by their potential beneficiaries, proved to be a fertile way of giving positivity to the inexorable presence of the ethical sense, of the normative value of any scientific construction on the material and historical basis of health practices, always under dispute in the materiality of social relations²⁵.

Ricardo Bruno also came into contact, through the output of his pupils, with other proposals for reconstructing historical materialism, especially the output of the "Frankfurt School" and Habermas' "Theory of Communicative Action", even positioning himself positively with regard to them^{2 , 26}. In these propositions, he saw an effective adoption of a stance with regard to values and at the same time, strong potentials for resisting totalitarian and messianic attitudes in defending normative positions, due to its strong foundation in the dialogical relationship of openness to the other. He did not fail to demonstrate a certain skepticism, however, with regard to the rather abstract character of the regulating idea of an "ideal community of communication" implicit in the concept of communicative reason. He nevertheless formulated this criticism not as a disqualification but as a challenge, or even an invitation to seek the concrete basis for the construction of effective communication processes²⁶.

In the two texts mentioned above, which are commentaries on the works of his pupils, and at the same time, a kind of balance sheet of his own work, what nevertheless remains as his principal legacy is not any type of demand or prescription, but a type of confidence. It is as if, throughout the whole of his trajectory, Ricardo wished to share a special discovery, which he understood as having to accompany the entire theoretical and technical practice of Collective Health: hope. The hope which he saw as a virtue, which he judged as deriving not from an abstract moral precept, like a kind of faith, but as an objective historical value for human beings. It is the hope, I would say, which we read in the Angel of Klee/Benjamin and which arises transparently from Ricardo's words: "Hope is not a dogmatic state of mind from which we depart for life, but a point of arrival in permanent flight... It is the ideal condition in which human beings may have real motivations in approaching other human beings in communicative fashion".

References

• ¹ Benjamin W. Teses sobre o conceito de história. In: Benjamin, W. Obras escolhidas I. Magia e Técnica, Arte e Política. São Paulo: Brasiliense; 1987. p. 222-232.
• ² Mendes-Gonçalves RB. Prefácio. In: Ayres JRCM, organizador. Epidemiologia e emancipação. São Paulo: Hucitec; 1995. p. 13-20.
• ³ Ayres JRCM, Mota A. Medicina Preventiva. In: Mota A, Marinho MGSMC, organizadores. Departamentos da Universidade de São Paulo. Memórias e Histórias. São Paulo: CD.G Casa de Soluções e Editora; 2012. p. 124-137.
• ⁴ Donnangelo MCF. Saúde e Sociedade. São Paulo: Duas Cidades; 1976.
• ⁵ Mendes-Gonçalves RB. Medicina e história. Raízes sociais do trabalho médico [dissertação]. São Paulo: Universidade de São Paulo; 1979.
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• ⁸ Mendes-Gonçalves, RB. Tecnologia e organização social das práticas de saúde. Características tecnológicas do processo de trabalho em saúde na rede estadual de centros de saúde de São Paulo. São Paulo: Hucitec; 1994.
• ⁹ Nunes ED, organizador. Medicina Social. Aspectos históricos e teóricos. São Paulo: Ed. Global; 1983.
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• ¹¹ Schraiber LB. Medicina Liberal e Incorporação de Tecnologia. As transformações históricas na autonomia profissional dos médicos em São Paulo [tese]. São Paulo: Universidade de São Paulo; 1993.
• ¹² Dalmaso ASW. Estruturação e transformação da prática médica. Estudos de algumas das características do modelo de trabalho na segunda metade do século XIX e início do século XX [dissertação]. São Paulo: Universidade de São Paulo; 1991.
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• ¹⁷ Barison EM. Processo saúde-doença e causalidade. Uma arqueologia das relações entre a clínica e a saúde-pública [tese]. São Paulo: Universidade de São Paulo; 1995.
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• ¹⁹ Schraiber LB, organizadora. Programação em saúde hoje. São Paulo: Hucitec; 1990.
• ²⁰ Schraiber LB, Nemes MIB, Mendes-Gonçalves RB, organizadores. Saúde do adulto. Programas e ações na unidade básica. São Paulo: Hucitec; 1996.
• ²¹ Centro de Saúde-Escola Samuel Barnsley Pessoa - FMUSP-Butantã. [acessado 2015 jan 5]. Disponível em: http://www2.fm.usp.br/cseb/.
  » http://www2.fm.usp.br/cseb/
• ²² Mendes-Gonçalves RB. Processo de trabalho em saúde [mimeo]. São Paulo: Universidade de São Paulo; 1988.
• ²³ Mendes-Gonçalves RB. Práticas de saúde: processos de trabalho e necessidades. São Paulo: CEFOR; 1992. [Cadernos CEFOR - Textos 1].
• ²⁴ Heller A. Teoría de las necesidades en Marx. Barcelona: Península; 1986.
• ²⁵ Schraiber LB, Mendes-Gonçalves RB. Necessidades de saúde e atenção primária. In: Schraiber LB, Nemes MIB, Mendes-Gonçalves RB, organizadores. Saúde do adulto. Programas e ações na unidade básica. São Paulo: Hucitec; 1996. p. 29-47.
• ²⁶ Mendes-Gonçalves RB. Seres humanos e práticas de saúde: comentários sobre "Razão e Planejamento". In: Gallo E, organizador. Razão e planejamento. Reflexões sobre política, estratégia e liberdade. São Paulo: Hucitec; 1995. p. 13-31.

Publication Dates

• Publication in this collection
  Mar 2015

History

• Received
  29 Oct 2014
• Accepted
  24 Nov 2014