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Conteúdo (article):

History, Science, and Collective Health

Gilberto Hochman
Casa de Oswaldo Cruz-Fiocruz
e-mail gilberto.hochman@fiocruz.br
Orcid 0000-0001-7834-336X

Abstract:

The article analyzes the presence of the history of health in the journal Ciência e saúde coletiva from 1996 to 2020, exploring relations between the disciplinary field of history and the multidisciplinary field of public health and examining their tensions, commonalities, and potential synergies. It shows how the history of health has featured in the journal’s articles and issues over the course of the journal’s twenty-five years and describes the main initiatives, results, and topics addressed in this realm. The article then offers a critical evaluation and discusses pathways for boosting the presence of history in articles and thematic issues of Ciência e saúde coletiva.

Keywords: History; public health; scientific periodicals; human sciences, health policies.


Introduction


History has been part of Brazil’s field of public health since the latter emerged during the final quarter of the twentieth century, as part of the movement in the human and social sciences in health. Since the beginning of this century historians have displayed a more distinct disciplinary identity as the result of various processes of institutionalization, not only the longer-term process through which history was institutionalized but also the more recent institutionalization of public health, or collective health, as it has been known in Brazil since the 1970s. From an intellectual and political point of view, this relationship has been a positive one, but it is well worth examining the roads it has traveled. Collective health has interacted with history and incorporated it in many different ways, and one approach to gaining at least a partial appreciation of the dynamics of this interface is to look at the articles published since 1996 by Ciência e saúde coletiva, a journal of the Brazilian Collective Health Association (Associação Brasileira de Saúde Coletiva, or Abrasco).

As a multidisciplinary field, collective health requires an understanding of the space/time of its processes and to this end calls on history to legitimate the present, help celebrate victories, strengthen professional identities, remember events, and scrutinize milestones with the intent of lending meaning to narratives of the present and advancing proposals for the future.1 In many cases, public health seeks “history lessons,” especially at times of political and public health crises like epidemics. The intellectual and political reconstruction of the various filiations and progressive origins of Brazil’s public health, or sanitary, reform and of its Unified Health System (Sistema Único de Saúde, or SUS) was one of the most fruitful endeavors in the writing of Brazil’s history of public health. For many, history affords the reconstruction of a political and intellectual lineage while it is likewise a learning territory that can inform choices and actions in the public health arena.2

Scholars who feel that public policy is always history3 and, consequently, that public health is thus history have urged that the past be “put back in” as an element in the analysis of health policies and actions, moving beyond the field’s role in professional training. In the view of the U.S. historian Charles Rosenberg, history can make its greatest contribution to health policies through its fundamental sense of the contingencies and complexities of individual and social experience with health and illness. Rosenberg thoughtfully calls attention to how historians’ interactions with public health keeps them from producing depoliticized texts.3 History, according to Rosenberg, is at once knowledge and political action.

A portion of professional historians have responded positively to this urging, but with the opposite goal, that is, of transforming the present into history. Part of the field has striven to address contemporary issues by having historians serve as witnesses and analysts, using their own specific methodological resources. History is thus authorized to speak about the present as well, suggesting a scenario that might spark more competition with the public health field than dialogue.

Yet these “uses of history” are not uncontentious. This disciplinary field tends to reject the idea of lessons drawn from the past, or of a “master history of life,” or of history as a school of the present, even if the intricate relation between present and past is recognized. Writing about the “place of history in public life,” the British historian Quentin Skinner allows that history can serve a public purpose, but he still hopes historians will not make this their main goal.4 As pointed out by Rosenberg, historians feel uncomfortable making prognoses, which is precisely one of the main inputs policymakers expect from them.3 However, as a growing number of historians have become attuned to the theoretical debate over presentism, over the specificity of contexts and of the past, and over the hazards of historical analogies and distortions traceable to a certain “public history,” they have begun reaffirming that history matters not only as an academic discipline but also in the realm of public debate and for policymakers, decision makers, and policy enforcers.5 This tension is relevant to understanding relations between history as a disciplinary and professional field, and public health, which is genetically multiprofessional and pluridisciplinary.

It was against this backdrop of concerns and expectations that the historical perspective on the phenomena of health and illness became the field of the history of health in Brazil. This perspective is not monopolistic and finds expression in many areas, associations, institutions, and scientific periodicals. In Brazil, the field has benefitted from not having imported the European and U.S. debate over how to define “history of medicine,” “medical history,” “history of health,” “history of public health,” and “history of disease,” how to determine their nebulous boundaries, or even whether the field belongs to social and cultural history.6 Given the field’s conceptual and political elasticity, we can approach it through myriad facets in our efforts to understand it, from its origins through its consolidation, while at the same time the very nature of public health invites this dialogue.

Public health was built by a multiplicity of individuals, groups, and institutions representing various areas of knowledge and professional practice, both in Brazil and abroad. The process was historically polyphonic and polysemic and for this very reason deterred the formation of monopolies, whether interpretive, methodological, institutional, or political. In terms of comprehending historical processes, the field’s dialogue with history has helped complexify our understanding of two salient views of the place and role of physicians and health professionals as advanced by the public health field in its inaugural works from a historical perspective, from the late 1970s to mid-1980s: on one hand, a more heroic, reformist view of social medicine, grounded in the work of George Rosen and Henry Sigerist, and, on the other, a more critical interpretation of social medicine and the fabric of biopower, drawn from Michel Foucault.7

History has been making a place for itself within public health and in Ciência e saúde coletiva for more than two decades, a period when the field was also institutionalized as part of the so-called social and human sciences in health. This work was marked by the democratization of Brazil and was also deeply engaged with discussions both of the sanitary reform in its early years and, later, during the impasses encountered in establishing SUS, of the place of the humanities in public health and the formation of health professionals in Brazil. We find indications of this institutionalization process in the growth of literature reviews published since the 1990s, especially on the history of public health and on the place of history and the social sciences in health.8-11 The professional field of history saw fewer of these reviews, except for papers discussing production in the institutional history of science, which intersects with public health and its institutions and professions.12 In another realm, there have been analyses about what we can call a historiographic interpretation of Brazil’s health reform.13-14 More recent Brazilian scholarship has been referenced in articles and books that review the literature on the topics of the histories of health, disease, and medicine in Latin America and the Caribbean.15-20 Part of this academic production has been featured in the pages of Ciência e saúde coletiva.

The history of history in Ciência e saúde coletiva

From 1996 to 2020, 2% of all Ciência e saúde coletiva articles adopted a historical perspective, that is, 104 out of 5,033. These articles were identified by first applying search terms and descriptors (title, abstract, keywords, complete text) and by then reading the selections to ascertain their actual relevance and discard as appropriate. Significant intersections were found with other disciplinary fields, such as the social sciences, education, nutrition, nursing, psychiatry, and philosophy, as well as with other methodological perspectives, such as life history and oral history, public policy analysis, and comparative analysis. The reading enabled a more accurate identification of these 104 papers that present a clear-cut historical perspective.

The history of collective health has gradually expanded its contributions to Ciência e saúde coletiva over the course of the journal’s twenty-five years. Articles have been written by historians but also by social scientists, physicians, biologists, public health professionals, and medical providers whose arguments incorporate a historical outlook. About 60% appeared in thematic issues or special sections, and more than 95% came out after 2000. Prior to that year, only four articles had been written from a historical perspective. As the journal began publishing more issues per year—moving from quarterly in 2002 to bimonthly in 2007 and then to monthly as of 2011—more space became available for articles and thematic issues from many areas, among them the history of public health.

In 2000, which marked 500 years since the discovery (or invasion) of Brazil—or the meeting of civilizations—Ciência e saúde coletiva published its first issue centered on a historical topic, with Everardo Duarte Nunes as guest editor. The issue also marked the first decade of SUS (then very much a work in progress) and the first century of Brazilian public health. During the journal’s first years, Nunes was by far the top producer of articles from a historical perspective. Under the title “100 years of public health” (vol. 5, no. 2), the journal clearly opened more space for the historical perspective in general and for historians in particular. In his guest editor’s note, Nunes proposed an interdisciplinary dialogue with the field of collective health in the twenty-first century:
…during this century, health will be the object of endless, but necessary, discussions. It is not an easy task to address the complex web of relations entailed in understanding the aspects of the health issue that interest us, that is, its social, collective, and public aspects. Accordingly, an interdisciplinary perspective is indispensable given the intersection of historical, sociological, anthropological, political, biological, demographic, statistical, and ecological knowledge. We will only be able to recover what has been entailed in the construction of Brazilian public health—even if only incompletely—with the participation of a group of specialists.21 (p. 216)

The growth and institutionalization of the field of the history of health in Brazil was accompanied by increased demand for the historical perspective within public health and within the journal.18 In 2008, Ciência e saúde coletiva released a thematic issue entitled “The history of health workers as public policy” (vol. 13, no. 3), bolstering the presence of the historical perspective in its pages and fostering the dialogue between history and the health professions and health workers that was promoted by the World Health Report 2006, “Working together for health.”22 An important aspect of this issue was its reinforcement of contributions portraying experiences from other countries, including the United States, Mexico, Argentina, and India, published in both English and Spanish—evincing one of the field’s traits: intrinsic internationalization. In their introduction, the guest editors lay out the journal’s agenda in the realm of the history of collective health:
History as an instrument of knowledge and critical reflection has been present in the field of public health since its very beginnings. Today this presence is strengthened by the international agenda. Historians, specialists from other areas, and managers have called for a more active meeting between history and health, aimed at a present and future understanding of health system reforms. By analyzing processes in space and time, by placing health and disease into the context of society and culture, historians can tell us about practices of the past, shed light on options, and facilitate comparisons.23 (p. 816)

Another thematic issue came out in 2011, this time linking global health and history on the occasion of the thirtieth anniversary of the eradication of smallpox—announced in May 1980—under a campaign led by the World Health Organization (WHO). Entitled “Immunization, vaccines: past and future” (vol. 16, no. 2), the issue featured articles capturing various historical experiences in vaccination and immunization from the nineteenth century on, especially the post-World War II eradication experience. The call for papers yielded responses from authors representing institutions in a number of countries, who submitted in English, Spanish, and Portuguese. This issue reinforced the international dimension both of the history of health in the journal and of Ciência e saúde coletiva itself. The critical nature of historical reflection in the field of health was also driven home; according to the guest editors, the field should be “heretical and bothersome,” even when it commemorates a global health victory:
Historical analysis produces knowledge and critical reflection in many ways. It can allow us to open the “black boxes” of national and global public health successes. Such scholarship can also reveal the social and cultural issues and conflicts involved in immunization activities, by investigating networks of political and economic interests and detecting diversities and asymmetries within countries, institutions, and teams of workers. The greatest contribution of history to public health is its fundamental sense of time, space, contingency, and complexity,24 (p. 372)

These editorial initiatives and the agendas laid out by the editors of thematic issues were part of the process of institutionalizing the history of health as a field in Brazil at many research and teaching institutions, scientific societies, and professional organizations and in journals from various fields of knowledge. Ciência e saúde coletiva has contributed actively by opening increasing space for contributions from the field of history. Conversely, these contributions have had an impact on the journal by enriching reflections in the field of collective health itself. Signaling this two-way relationship, the journal introduced a new department in 2014, called History and Health, which sets it apart from other public health periodicals in Brazil and even abroad. While major journals like The Lancet and Journal of Epidemiology and Community Health publish papers on the history of health, they do so only occasionally. The introduction of this department places Abrasco’s journal among periodicals like the American Journal of Public Health (AJPH), Argentina’s Salud Colectiva, and Colombia’s Revista de Ciencias de la Salud, which have encouraged and published articles on history and by historians, some with special departments.

In 2015, on its twentieth anniversary, Ciência e saúde coletiva launched the series “Collective health builders,” edited by myself and Everardo Nunes Duarte. This was a unique undertaking with few counterparts in Brazil or abroad; perhaps the only similar initiative is the AJPH department “Voices from the Past.” That year, Ciência e saúde coletiva released twelve articles focused on actors deemed fundamental to the intellectual design and practice of collective health since the post-World War II period. The selection was not limited to Brazilian figures but also included Latin Americans and Europeans whose thinking and actions had an intellectual and institutional influence on Brazilian collective health. The guest editors had this to tell readers about the department:
This is not a case of ratifying or creating a pantheon. On the contrary, we must indeed celebrate our builders, albeit while locating them critically in their time, in history. We also intend to highlight individuals who are less visible, some effectively forgotten, in the more established narratives on health reform and on the creation of Brazil’s Unified National Health System (SUS).25 (p. 137)
The critical historical perspective found support yet again:
The Collective Health Builders were men and women who, in different ways, thought, wrote, spoke, acted, organized, administered and essentially desired and imagined in-stitutions, associations, policies and health systems which would be more public, na-tional, inclusive and egalitarian. These imagined ideas and practices were beset by contradictions, conflicts, and profound differences regarding the paths to be followed, at different times and in different places. The very terminologies which identified the field form a part of this process: hygiene, public health, preventive medicine, social medicine, collective health. These were legacies and choices located in space and time.26 (p. 137)

Starting in 2016, the series became a permanent department within the history section and since then has received a steady influx of submissions, with nineteen articles published or approved through 2020. By lending continuity to the series, the goal has been to stimulate the collective health field to contemplate its history through a critical analysis of the pathways journeyed by its main architects, making the presence of history more enduring and attractive to the broad spectrum of researchers and professionals in collective health. With its continuance, the series has published articles not only on members of the collective health “pantheon” or on physicians but also on the forgotten and the bothersome, as well as on women and Blacks, who are underrepresented in more classic narratives. As part of this educational effort, the series has also expanded the notion of the history of collective health, incorporating thoughts and ideas about actors and processes that predate the institutionalization of the field, whose landmarks were the establishment of Abrasco in 1979 and of the Brazilian Center for Health Studies (Centro Brasileiro de Estudos de Saúde, or Cebes) in 1976. Primarily, the series incorporates the architects and intellectuals of collective health as “interpreters of Brazil,” currently relegated to the field of studies of Brazilian social thought.26

These one hundred some articles, which came largely in response to calls for submissions to thematic issues or the Health and History department, addressed such topics as: public health campaigns; medical and public health education; care and healing professions, institutions, and practices; global health; health policies and systems; psychiatry; health reform; epidemics and endemic diseases; techniques and technologies; and the history of disease and of medical and scientific disciplines. Articles from a historical perspective have also figured in issues dedicated to reflective commemoration of such milestones as the establishment of SUS, the primary health care movement, psychiatric reform, and public health reform. Special note must also be made of Everardo Duarte Nunes, who, over the course of the journal’s twenty-five years, has been its most prolific author and has worked to foster interdisciplinarity and promote the history of the collective health field and of the social sciences in health.

Final considerations

History began taking firmer root at Ciência e saúde coletiva in the year 2000, along two avenues: first, through the growth of the field of the human and social sciences in health, with the journal as its lead spokesperson, and second, through the institutionalization of the history of health within collective health and also within the field of history itself, expressed in the appearance of numerous departments of history at universities and research institutes, research groups and lines of research, and museums and in the availability of greater space in periodicals and at conferences. The twenty-first century has introduced two new elements: first, a dialogue between health on the one hand and methods and theories on the other and, second, a thoroughgoing commitment to documents and sources, a demand attributable to the professionalization of the history of health. This complexifies the still-developing relations between history and collective health, given expectations (sometimes divergent, as we have seen) about the role history can play for each discipline and professional field.

The history of health still has only a somewhat timid presence in Ciência e saúde coletiva for various reasons (some already mentioned), stemming from the editorial process itself or from existing differences between epistemic and professional communities that are in perpetual growth and transformation. Further growth in the coming years demands that we understand these factors and respond to them through editorial action. From a more general editorial viewpoint, a periodical in the human and social sciences in health competes with history periodicals when it comes to drawing papers written from a historical perspective. The latter periodicals have the advantage of applying citation, note, and bibliographical style rules friendlier to texts by historians, who generally use primary sources of diverse origins that are harder to reference with the Vancouver style. Article length is another issue, since scholarly history journals accept submissions of 10,000 to 12,000 words, a number more appealing when a paper presents empirical data derived from historical research. Lastly, the Brazilian evaluation system for academic journals, called Qualis, effectively discourages historians from publishing history of health papers in public health journals, since it ranks journals within disciplinary categories, and public health journals of course score lower within the history category. As mentioned earlier, the multidisciplinary nature of the history of public health continues to generate misunderstandings, which sometimes affects the evaluation of originals submitted to the History and Health department. Peer reviewers from disparate backgrounds often have quite distinct expectations and demands regarding submitted articles, which means the editorial department must play a more active role in consolidating review and re-submission requirements.

The challenge of making time and space more permanent constituent elements of public health debates, processes, ideas, practices, policies, agents, and agencies has been met. Yet more must still be done to give the history of health greater substantive space in the pages of Ciência e saúde coletiva. This extends to encouraging greater integration among associate editors, holding debates, offering thematic issues from a historical perspective, and more aggressively disseminating published articles and history topics through social media and other forms of public communication on the part of Abrasco and the journal.

In dramatic, tragic times, like these of the Covid-19 pandemic, the human and social sciences, of which history is part, play a vital role in helping us understand the events around us and informing public and social responses to the public health emergency. The vocabulary of the pandemic is that of the humanities and of history: distancing, contagion, crisis, care, inequality, discrimination, dystopia, disease, gender, insecurity, interaction, isolation, cleansing, masks, fear, death, coverup, policies, practices, drugs, resistance, resilience, risk, rupture, health, system, and violence, to list just a few of these words. History will continue to be part of this endeavor in the pages of Ciência e saúde coletiva.

[Translator’s note: Where available, quotations from Ciência e saúde coletiva were sourced from their English translations on the journal website. However, minor adjustments were in some cases deemed necessary.]

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