CARLOS NETO, Daniel; DENDASCK, Carla; OLIVEIRA, Euzébio de. The historical evolution of public health – Revista Científica Multidisciplinar Núcleo do Conhecimento. Vol. 01, Year 01, Ed. 01, pp. 52-67, March of 2016. ISSN: 2488-0959, Acess Link: https://www.nucleodoconhecimento.com.br/health/historical-evolution
It is found in the earliest historical records, the constant search for man’s pursuit of curing their illnesses. One of the first records about the practice of medicine through the Bible itself, where in addition to mentions of individuals search for cures for their illnesses. Meet the historical evolution of health, especially public health, it is essential for them to understand the phenomena that are part of the contemporary table, looking like that, through this recognition taking lessons that enable administrative strategies and/or Resolutive to what is as “health care crisis”.
KeyWords: Public Health. Evolution of health. History of health.
The concept of health has suffered several interventions over the past 100 years, it was conceptualized from different world views, in a social and historical construction, leaving the simple concept of absence of disease to a broad concept with various dimensions, such as biological, behavioral, social, environmental, political, and economic.
Today, the concept adopted worldwide is the World Health Organization defines as: “a State of complete physical, mental and social, and is not only the absence of disease or infirmity.” (WHO, 1946)
However, it wasn’t always so treated in the course of its historical evolution, because the study here carried out, it was found that the health “from religious through magic design design simplistic absence of disease, until you reach the most comprehensive design adopted by the World Health Organization” (CZERESNIA, 2003).
Therefore, the design of which is health suffered several modifications until the current concept more adopted the World Health Organization and seeks primarily to health promotion which is based on the fundamental human right to allow to increase control over their health and its determinants, and the health of all peoples is essential to achieve peace and security.
Weaving a brief comment about the origin of the term health, this comes from the etymological root salus. In Latin, this term designated the main attribute of the integers, intact, intact, and the Greek term originates salus holos, in the sense of wholeness, root of the terms holism, holistic. In other words, this term refers to all.
Once defined what is health, is of paramount importance to understand its historical development in the world, because as already stated earlier, health suffered religious, social and economic interventions. And to understand the approach of health is at the present time it is necessary to know its history, since what you see today is the report of contemporaneity and which has its roots in were very old. Pointing such importance on the history of health and disease it is noted:
That health and illness are something more than biological phenomena; that around the care, control mechanisms and cures are relevant dimensions of the history of health and disease and that th[…]e health-disease process relates not only to the healthiness or unhealthiness of our countries, but it is revealing, constituent and trainer of crucial aspects of modernity and the social, political, intellectual history and culture. (HOCHMAN; XAVIER; PIRES-ALVES, 2004, p. 45)
Assuming the premise of health as a religious concept, it can be said, then, that the concern about health in a collective way, came with the first epidemics that affected a larger number of people, causing it to think the cause of them. In the Bible, has records of diseases, such as leprosy (Hansen’s disease currently), which affected the lives of many people in the time before Christ, bringing the concern of isolating lepers to avoid contagion from the rest of the population, because they understood that the disease was contagious, as it was seen as a divine punishment. Note:
Leper is that man is filthy; the priest shall declare totally filthy, in your head has the plague.
Also the robes of the leper in whom the plague is, will be torn, and his head will be discovered, and will cover the upper lip, and shall cry: filthy, filthy.
Every day in which the plague there is in it will be unclean; filthy’s, dwell alone; your home will be outside the camp. (LEVITICUS 13:44 -46)
In this conception of religion, still in the middle ages, the Church exerted great influence on politics and consequently with respect to health. Because, following the biblical teaching above referred to, the disease was treated as a divine punishment and patients were isolated. However, this conduct to isolate patients ended up delaying the scientific advances in the field of health, as proved just the lack of treatment of the population, as shown in Sevalho vision (1993, p. 5):
In the middle a[…]ges houses to assist the poor, shelter to travellers and pilgrims, but also instruments of separation and exclusion when served to isolate patients from the rest of the population. One of the basic values that involved the existence of hospitals in the medieval period was the charity, because caring for the sick or contribute financially to the maintenance of these houses meant the salvation of the souls of benefactors.
However, this understanding of divine grace came to be questioned with the appearance of new diseases, causing some scholars to believe that diseases could pass from one person to another and starting the idea that there are ways to prevent disease, as Sevalho points out (1993, p. 5):
In the year 1300, the time of the black death, an Arab doctor reported that the disease could be contracted by contact with patients or through clothes, dishes or earrings (Sournia & Ruffie, 1986). Anyway, in the medieval Christian world view, was the fear that the disease contextualized printed. The feeling that should be kept at a distance, the necessary removal of unknown danger sensed, fear of suffering and death.
After that was the Church’s domain, then the phase of rationalism and scientific breakthrough, it is called the enlightenment. During this period, along with science, the knowledge of the health field had a huge breakthrough, this is because “the human being that accompanied the birth of modern science was Conqueror and owner of nature, no longer your participant and observer harmonious. This paved the way to therapeutic interventionist practices “. (SEVALHO, 1993)
From this more rational vision of the disease, it was possible to think of ways to prevent epidemics of the time. With the release of scientific research during this period, major discoveries were made as the way to prevent some diseases and contain contagion. One of them were vaccines which represented a milestone for the prevention of tuberculosis, tetanus, meningitis, a disease that in remote times were able to decimate populations.
It has been during this period also the discovery of the first microscope.
With the arrival of the Enlightenment, anticipated the emergence of capitalism. Capitalism by starting the factories, generating jobs extremely exhausting.
Consequently, there were urban centers, social inequality and the lack of structure in these centres. As is pointed out:
The serious social problems of the early industrial capitalism, the disastrous conditions of life and work, generated by the formation and growth of urban centres and the growing need to expand the industrial capital, at the expense of the exploitation of the workforce and of poverty. (SEVALHO, 1993, p. 6)
In this manner, surge, from then on, the influence of social context on the health of the population, for the disorderly growth of the cities and of the nuclei of workers not always had the most perfect condition of housing, basic sanitation, proper treatment of water. And with these serious social problems began to worry about the influence of living conditions in the health of the individual.
Then, realizing that social issues influenced health conditions of the population, and for the first time heard the term social medicine, as Sevalho (1993, p. 6):
A penetration of medical knowledge in the field of social environment, applied to the panorama of Germany and France’s mercantilist of 18th century and the incipient capitalism of the 19th century industrial England, gave birth to the social medicine in the interweaving of three movements from Foucault (1979). The police German doctor, a medicine that compulsory measures for disease control, the French urban medicine, remedial of cities while spatial structures that sought a new social identity, and, finally, a medicine of the work force in Britain, where industrial had been faster development of a proletariat. These moves came to social medicine, driven by the revolutionaries of 1848 and their prospects for economic and political reforms, as a speech about living conditions, about the kind of socially organized by capitalist conformed by the Industrial Revolution due.
And social medicine would be duly registered in the middle of the century, as it is said:
Furthermore, only in the mid-19th century, in 1848, the term social medicine would win record. Arose in France and, although the General concomitant took hold of Europe, in the process of fighting for the political and social changes. (NANI, 1998, p. 108)
However, after this period the emergence of capitalism and with the new findings as to the existence of germs, have given rise to new forms of understanding the disease, as the “theory of causation” of Louis Pasteur.
And was the left of these new discoveries and new concepts of social disease that health became focused on biomedical disease and not the individual, as it analyzes Nunes (1998, p. 109):
It was only from the second half of the 19th century, marked by investigations of Pasteur and Koch, that inaugurate the Era of germ, and that would transform dramatically medicine “a people-oriented profession for disease-oriented.”
As Salomon-Bayet (1986, p. 12), the biomedical revolution brought about by the work of Pasteur can be called “lapastorization of lamédicine” that distinguishes it from “lapasteurization of lamédicine”, in the sense that it means, on the other hand, a eórica revolution and, on the other, the medicalization of society, legislating on public health, institutionalizing teaching and acting politically and socially. Without doubt, the discoveries of micro-organisms will be of the utmost importance to public health, especially when, in addition to the individual agent relationship, established an epidemiological model as an interaction between these two elements and the environment.
From that moment there was a decline of public health, concern with the social context and the living conditions of the population.
However, over time the alternative health and holistic (whole) health again defended by many health professionals. To do so, treat health as a positive concept and not just as a concept of absence of disease, as the more classical definition of public health in the year of 1920, see:
Public health is the science and art of preventing disease and disability, prolong life and develop physical and mental health, through organized community efforts for environmental sanitation, control of infections in the community, the education of individuals nosprincípios personal hygiene and the organisation of medical services eparamédicos for the early diagnosis and early treatment dedoenças and the máquinasocial improvement that will ensure cadaindivíduo within the community, a standard of living adequate for health àmanutenção. (WINSLOW, apud ROUQUAYROL 1920; ALMEIDAFILHO, 2003 p. 29)
And finally, in the year 1946, the current concept of health proposed by the World Health Organization, as had been exposed.
From the who concept, in the 70, in Latin America, raised the importance of the social sciences in health approach. Reason were organized conferences, like the one in Alma-Ata and the Ottawa Conference, to think about strategies to improve health worldwide promotion and reach the full physical, mental and social.
Among what was agreed in the Declaration of Alma-Ata (1978) is mainly:
- The achievement of the highest degree of health requires the intervention of many other social and economic sectors, in addition to the health sector
III. The promotion and protection of the health of the population is essential for sustained economic and social development and contribute to improving the quality of life and achieve world peace;
- The population has the right and duty to participate individually and collectively in the planning and implementation of health actions;
VII-1. Primary health care is both a reflection and a consequence of economic conditions and the socio-cultural and political characteristics of the country and its communities;
But the need to organize the conferences mentioned did not come out of the blue. They came, mainly, from the 60s marked worldwide by changes in political scenarios and by calls for “sex, drug addiction and rockn’roll”. Motivated by libertarian thoughts, it was also at that time that the discussions and mobilizations that deeply marked the history of Public Health in the World began, bold thoughts and with nationalist experiences allowed the elaboration of the Alma-Ata Declaration, and thus, the expansion of the understanding of the complexity of guaranteeing this fundamental right to human beings: health, and the alteration of strategies originated the thought of health promotion, being a fundamental axis to achieve the utopia of “Health for all by the year 2000” (MENICUCCI, 2007, p. 158)
In the face of so much mobilization, a series of discussions and international conferences began, aiming at improving concepts and systematizing and ideas on how to achieve success in the goals established in the Alma-Ata Declaration and the Ottawa Charter, which to this day they remain symbols of transformation and the way of thinking about health in the world.
Among other goals, the Alma-Ata Declaration (1978) also established:
VII-3. It comprises at least the following areas: education on the main health problems and the corresponding methods of prevention and control; promoting the provision of food and appropriate nutrition; an adequate supply of drinking water and basic sanitation; maternal and child care, including family planning, immunization against major infectious diseases; the prevention and fight against local endemic diseases; the appropriate treatment of common illnesses and injuries; and the availability of essential drugs;
VII-4. It includes the participation, in addition to the health sector, of all sectors and related fields of activity of national and community development, in particular agriculture, food, industry, education, housing, public works, communications and others, demanding the coordinated efforts of all these sectors;
VII-5. It demands and encourages, to a maximum extent, self-responsibility and the participation of the community and the individual in the planning, organization, functioning and control of primary health care. In fact, the text of the Alma-Ata Declaration, by expanding the vision of health care.
Having said the above quotes, it is possible to confirm the inseparability of social, economic and cultural factors to achieve quality public health and equity. Thus involving all sectors of society, including civil society.
However, the concern with health promotion did not stop there, because in 2005, the Bangokok Charter – the result of the Sixth Global Conference on Health Promotion in Bangokok, Thailand – came up with the scope of identifying actions, commitments and promises needed to address the determinants of health in a globalized world through health promotion. In the aforementioned Charter, health promotion was recognized:
The United Nations recognizes that achieving the highest level of health is one of the fundamental rights of any human being, regardless of race, color, sex or socio-economic status.
Health Promotion is based on this fundamental human right and offers a positive and inclusive concept of health as a determinant of quality of life, including mental and spiritual well-being.
Health Promotion is the process that allows people to increase control over their health and its determinants, mobilizing themselves (individually and collectively) to improve their health. It is a central function of Public Health and contributes to the work of tackling communicable diseases then communicable, in addition to other health threats. (CARTA DEBANGOKOK, 2005).
Even after the definition of the concept of health by the World Health Organization, the curative idea of health is still very strong, since even today, there is an understanding that health promotion is the treatment of a disease. (BERRIDGE, 2000 )
Therefore, the days of prosperous public health between the two world wars, the unfolding of the public health empire in the hospital-based one, was a mistake for public health, moving away from the path of health needed by the population.
Thus, the necessary value for public health is often not given, forgetting the holistic view of health promotion, as Virginia Berridge (2000, p. 11) warns:
The tension between the relationship with medical services and the role of the community remained exemplified in the 1960s, by community medicine and the epidemiology of chronic diseases, and has not yet been resolved. The duality of the role of public health has been a permanent theme, on the one hand between prevention and promotion (or development), and on the other, between the planning and administration of health services.
In addition, public health still faces a gap between practice and theory, as “the dilemma between instrumentality and apoliticality, academic knowledge and militant knowledge, remains important points for the current public health debate” (NUNES , 1998, p. 110)
In this brief historical exhibition, we conclude that the history of public health in the world is directly linked to the political and economic situations that outlined the trajectory of health, its needs for reformulation and the establishment of bold goals to guarantee this as a fundamental right to human beings .
It can be seen that the challenge of building efficient public health is still a challenge in almost the whole world, as well as overcoming other violations of human rights, as Bernardo adds (2012, p. 5):
The globalization that brings together the continents and favors a discussion on the health condition, which allows thinking of strategies to work health policies for all; it is the same globalization based on neoliberal principles, which does not allow the public to be efficient and which has the minimum state as its fundamental guideline. Making it difficult to implement quality public health, with equity and universality.
Evidently, all the achievements in the transformation of thinking around health are events that marked and allowed history to take place in this way, however, it is concluded that there is still much to go on, as each day there is more need for elaboration public policies to improve the deficiencies that exist in the current precarious medical care.
THE STANDARDS ESTABLISHED IN BRAZILIAN LEGAL ORDERING IN THE HEALTH AREA
The norms are fundamental to regulate any thematic that concerns the collectivity and among these norms we cannot fail to observe the fundamental laws that are those of Constitutional order and in this particular Brazil that in its legal history has seven constitutions without the current Constitution of 1988, which best standardized the health issue.
However, health care was not recognized in the Brazilian legal system until 1923, but the growing needs of the population around the problems inherent to health and the pressures exerted by certain social groups led governments to focus their attention on the health. (RODRIGUEZ NETO, 2003).
The great historical milestone of the recognition of health in the Brazilian legal system occurred through legislative decree nº 4.682, of January 24, 1923, known as Lei Eloi Chaves, as assures Santana (2010, p. 51):
Legislative Decree Nº. 4,682, of January 24, 1923, known as Lei Eloi Chaves, author of the respective project, ensured, among us, the initial milestone in the constitution of the Health System, within the Social Security System, established there.
Therefore, it is noted that this law was considered as one of the first interventions by the Brazilian State in order to ensure some type of security or social security in Brazil.
It happens that this guarantee of health care was linked only to the social security sector, that is, it was only intended for taxpayer workers, as stated by Santana (2010, p. 51): Health here was thought and structured as medical care linked to the world of work and, therefore, to Social Security.
It did not have the necessary systemic vision, that is, health was thought apart from the collective actions that are its own. Therefore, one can even refer to a defect of origin.
Therefore, the benefit was intended only for workers with formal ties in the labor market, since only those who contributed to Social Security are those who had the right to medical care and medication, which is a determining factor for the deprivation of access to assistance. majority of the population, who had to resort to assistance provided by philanthropic entities. (RODRIGUEZ NETO, 2003)
It is worth mentioning that this decree was published during the 1891 Constitution, but shortly before the 1934 Constitution. It should be noted that the only constitutions that really had significant changes in the right to health were those of 1934 and 1988 , which is why only these will be explained.
The period from 1930 to 1945 and 1951 to 1954 is known as the Vargas Era, being part of the industrialization process in Brazil. However, with the emergence of so many industries, it was necessary to create labor laws to regulate workers’ rights and among these rights the right to health.
The 1934 Constitution was strongly influenced by the Constitution of the German Republic of Weimar for incorporating social, economic, cultural, labor, union and social security rights into its legal system, as stated:
The Weimar Republic inaugurated an unprecedented phase of constitutional structuring of the German State, with a more active role in social development, in the construction of a society with social justice through the fulfillment of the Social Rights formalized in the Weimar Constitution of 11 August 1919 – the sozialstaat or Social Rule of Law. The economic and social order created by the nascent German Republic served as a model for some states in the period immediately after the First World War. In Brazil, for example, the debate over Weimar’s social and constitutional conquests was intense, with the 1934 magna Carta being strongly influenced by the newly created German social model […] This Brazilian constitution practically assimilated the idealized advances of the new German social order , but only in its legal-formal aspect. (GUEDES, 1998, p. 82)
Therefore, this constitution brought a huge advance in Brazilian constitutionalism, with the establishment of bases for social development, mainly in labor issues, such as minimum wage, eight-hour working day, vacation, paid weekly rest, social security, compensation in case of unfair dismissal, maternity leave, etc.
The main feature of this Constitution was:
Its democratic character, with a certain social color, reflected in the effort, which turned out to be unsuccessful, to reconcile liberal democracy with socialism, in the economic-social domain; federalism with unitarianism, in the political sphere (MENDES; COELHO; BRANCO, 2007, p. 158).
Regarding the right to health, Decree-Law 4682 of 1923 was accepted in this constitution, but it did not bring any advance in the guarantees of the citizen who needed health care, as the idea remained that only workers are guaranteed such right.
This situation shows “a protectionism in relation to these to the detriment of the unemployed, informal employees and those who worked in the rural area of the country”, (GONÇALVES, 2012, p. 35)
The big problem hung over the inhabitants of rural areas, who received medical assistance from charities or official services, since these, because they are not formal workers, did not contribute with social insurance. Therefore, those who received the highest quality services were the taxpayer workers and the unemployed and informal workers were offered considerably inferior services, which were under the responsibility of the Ministry of Education and Public Health. (SOUZA, 2011)
Despite this bringing advances towards the establishment of bases for social development, it is clear that such advances were not extended to the entire population, since the right to health was seen as a guarantee of the worker and not of every citizen. (BERTOLLINI FILHO, 2001, p. 34)
In this period, the application of a biopolitical model is present along the lines described by Foucault, in which the State controlled health to increase the productive force, appearing not to care about those who were not formally inserted in the labor market.
In this way, the Old Republic is marked by the principle of worker health, at the beginning of the Vargas Era and, through Decree nº 19.402 / 1930, there was the centralization of public health policies, which took place through the creation of the Ministries of Education and Public Health Affairs.
However, this was the shortest constitution, given that it only lasted for three years because it was abolished by the 1937 coup.
Although historically there have been several milestones for public health in Brazil, such as the creation of the First Health Council in 1948, the construction of public hospitals, the creation of the Ministry of Health in 1953, these changes were not instituted in the 1937 constitutions to the Amendment Constitutional Act of 1969, as the State remained for a long time providing relative health care to taxpayer workers as already mentioned, a fact that really only changed after the sanitary movement in 1978 and above all with the advent of the current Federative Constitution of Brazil of 1988. (GONÇALVES, 2012)
After so many social mobilizations in the 70s and 80s with the disregard for the health of the entire population, which until then was only provided to formal workers, it was necessary to redefine health policies in Brazil, as stated by Menicucci (2007, p. 186):
After the overthrow of the authoritarian regime, with the rise of the first president of the civil republic after twenty years in the military, at a time when a new social pact was being formed in the country, the articulations around the redefinition of health policy grew, which, among all social policies, had a substantially more articulated political proposal. The reform decision-making process was preceded by the creation or convocation of several collective forums, in which the proposal for the transformation of health policy was formally and politically implemented.
Thus, it was in the Federative Constitution of Brazil that the right to health came to be consolidated through the list of social rights, art. 6 of CF / 1988, as provided:
6th. Social rights are education, health, food, work, housing, leisure, security, social security, maternity and childhood protection, assistance to the destitute, in the form of this Constitution. (BRASIL, 1988)
But innovation did not stop there, as health received special attention in the current Constitution in Title VIII – On the social order, Chapter II – On Social Security, Section II – On Health, which goes from art. 196 to art. 200.
The provisions of the Constitution have brought the rights and obligations of both the state and the individual of all to the due health care, as provided in art. 196 of the Constitution:
Art. 196. Health is the right of all and the duty of the State, guaranteed through social and economic policies aimed at reducing the risk of disease and other diseases and universal and equal access to actions and services for their promotion, protection and recovery . (BRASIL, 1988)
Analyzing the constitutional provision, it appears that:
The State must adopt public policies that induce social and economic development, reduce inequality, eliminate factors that negatively affect the health of the population, such as low income, lack of education, poverty, unemployment, hunger, and others determinant and conditioning factors of a poor quality of life that will certainly influence the health conditions of the population, increasing the risk of diseases. (RODRIGUEZ NETO, 2003, p. 97)
Therefore, the current Constitution defined the State’s obligations to provide the entire population with a decent health service, but also the adoption of public policies to reduce the problems that directly and indirectly affect the health of individuals. It is the so-called promotion, protection and recovery mentioned in art. 196 of the CF / 1988.
This Constitution also created the Unified Health System so that public health actions and services are part of a regionalized and hierarchical network, organized according to some guidelines, namely:
Art. 198. (…)
I – decentralization, with a single direction in each sphere of government;
II – comprehensive care, with priority for preventive activities, without prejudice to assistance services;
III – Community participation. (BRASIL, 1988)
Finally, in art. 199 of the Constitution, also ensured that health care is free private initiative favoring the emergence of health plans. (BRASIL, 1988)
Two years after the promulgation of the 1988 Constitution, Law 8,080 of September 19, 1990, known as the SUS Law, was introduced in the Brazilian legal system that provides for the conditions for the promotion, protection and recovery of health, the organization and functioning of the corresponding services and other measures, see:
Art. 1 This law regulates, throughout the national territory, health actions and services, performed alone or jointly, on a permanent or occasional basis, by natural or legal persons under public or private law. (BRAZIL, 1990).
This law also established health as a fundamental human right, and the State must provide the conditions necessary for its full exercise, as provided in art. 2nd of the Law. 8.080 / 90.
As robustly demonstrated, health is currently understood as: promotion, prevention, protection and recovery from diseases. These concepts are mentioned in art. 196 of the Federal Constitution and in art. 2, paragraph 1, of Law 8,080 / 90, as shown below:
Art. 2º (…)
- 1º The State’s duty to guarantee health through the formulation and execution of economic and social policies aimed at reducing the risks of diseases and other diseases and in establishing conditions that ensure universal and equal access to actions and services for their promotion , protection and recovery. (BRAZIL, 1990)
It is clear that Brazil has adhered to the concept of health by the World Health Organization of the search for complete well-being, physical, mental and social, as in art. 3 of Law 8080/90 established that:
Art. 3 The levels of health express the social and economic organization of the country, with health as determinants and conditions, among others, food, housing, basic sanitation, the environment, work, income, education, physical activity, transportation, leisure and access to essential goods and services.
Thus, it can be concluded that the current constitution was crucial for the recognition of the right to health as a social and fundamental right, guaranteed to the entire population, since as it was studied for a long time, health care was provided only to a portion of the population. population.
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