Abstract

Introduction

Giovani Berlinguer’s invaluable contribution to the field of public health in Brazil and throughout Latin America was marked by a rigorous academic output that constantly questioned the relationship between medicine and politics, and a constant dedication to combating unjust inequality. Such disparities are evident in the social determinants of health, the conditions of daily life, labor exploitation, and the absence of national health systems that are capable of reducing inequality by ensuring the universal right to healthcare. The defense of life was the common thread that ran through his research and political struggles in defense of health reform, internationalism in public health, everyday bioethics, and a health system in which all citizens and immigrants are guaranteed a right to health care.

The link between quality research output and a political commitment to the defense of health and life marked the trajectory of this man of his time, socialist, sanitarian, and humanist. Berlinguer’s work transcended his life and times, since it was always orientated towards building a caring society in which life and human dignity are uplifted to the highest value, thus averting the risk of them becoming mere commodities, and science and medicine act as promoters of social welfare. In Berlinguer’s progressive view of health, the fact that disease is regarded as part of nature is no reason to resign ourselves to this eventuality, given that many illnesses are either avoidable, curable, or mitigable, thus confirming his belief in the human capacity to make history: “health should be a continuous and progressive conquest: there is an “historic level of health” that man continually proposes to raise”. The final teachings of one of his books are a good example of the legacy left by a man who viewed science as an engine of progress and social justice:

“We can extract some lines of action from the five symbolic words we use as the titles of our chapters. Suffering? Reduce it with appropriate treatment. Diversity? Avoid considering it a disorder and marginalization. Danger? Distinguish between true and false risks, combat the disease not the patient. Signs? Increase and interpret them. Stimulous? Direct it towards knowledge, solidarity, prevention and transformation”¹1. Berlinguer G. A doença. São Paulo: CEBES-Hucitec; 1988..

This article presents a brief biography, where the enumeration of the facts speak of a life that epitomized, at all times, the most fruitful of relationships between science and politics. It highlights specific aspects of his academic output that deserve special mention, given the impact they had on the field of public health in Brazil. The epistemological principle that praxis is a producer of knowledge and commitment to social transformation runs through all his works. This analysis emphasizes the wide-scale diffusion of his texts published in Portuguese and the critical role that they played in conforming areas of knowledge such as workers’ health, bioethics and health reform.

Brief Biographical Notes on a Generous Life

Giovanni Berlinguer was born in 1924 in Sassari, Sardinia, where he spent his childhood, and lived in Rome up to his death at the age of 90. His simplicity and generosity, love for the sea, which he sailed in search of new horizons, and political commitment to internationalism can be traced to his village upbringing in Sardinia and the influence of his father, Mario Berlinguer, a notable lawyer and defender of human rights who participated in the Italian resistance movement between the two world wars.

His experiences during the world wars marked him deeply, enabling him to elucidate the perverse relationship established between medicine and politics through the creation of biopolitics, which legitimized the domination, exploitation, and even elimination, of human beings in the name of science (eugenics). This falsification of science was used to justify the political domination that flourished in Europe at the beginning of the Twentieth Century and expanded across the continents:

“I am referring to the idea that emerged against the backdrop of colonialism, of absolute superiority of certain human races over others. This idea consisted of an attempt to use the laws of nature to legitimize the excellence of a race and thus the right/duty to exercise dominion over others, and the regressive dream of biologically guiding the perfecting of our species. This tendency had a number of antecedents, even before taking on a scientific guise: I am referring to slavery, genocide of the peoples of Africa and America, and to the denial (up to the 1900s, also here in Brazil) of freedom to Negros. When science was captured by hegemonic calculations”²2. Berlinguer G. Causas sociales y implicancias morales de las enfermedades (conferência de Berlinguer na Fiocruz). [acessado 2015 ago 10]. Disponível em: http://www.agencia.fiocruz.br/causas-sociales-y-implicancias-morales-de-las-enfermedades-confer%C3%AAncia-de-berlinguer-na-fiocruz
http://www.agencia.fiocruz.br/causas-soc... .

Berlinguer graduated in medicine and surgery in 1952. He began his academic career at the University of Sassari, where he lectured social medicine up to 1974, when he took up the chair of Occupational Health at theUniversitá La Sapienza in Rome. He remained there until he retired at the age of 75, when he received the honorary title of Professor Emeritus. He authored around 50 publications that have been translated into various languages.

He was a member of the Italian Communist Party, alongside his brother Enrico Berlinguer, leader of the party, and a member of the party’s Central Committee for over 20 years. As a student, he was president of the International Students’ Union, and came to Brazil for the first time in 1951 to participate in an international congress held by the organization. Despite being accused of being a Russian spy by Carlos Lacerda, he returned to Brazil during the military dictatorship as deputy of the Italian Communist Party on the invitation of David Capistrano and José Rubens to launch his book “Medicine and Politics”, translated and published in 1978 by the Brazilian Centre for Health Studies (Centro Brasileiro de Estudos de Saúde – CEBES) in partnership with the publisher HUCITEC. The audacity shown by Berlinguer and the young militants of the Brazilian Health Movement paid off. To the publisher’s surprise, the first edition sold an impressive 7,000 copies and influenced a generation of sanitarians. A second edition followed, together with other publications such as A Saúde nas Fábricas (1983), Reforma Sanitária – Brasil e Itália, in partnership with Sonia Fleury Teixeira and Gastão Wagner, A Doença (1988), Minhas Pulgas (1991), Questões de vida – ética, ciência e saúde (1991), Ética da Saúde (1995), andMercado Humano, in partnership with Volnei Garrafa (1996 and 2001).

He played an active part in the Brazilian Health Reform, following developments on the numerous occasions that he visited Brazil to launch his books, and participating as a speaker in various seminars and congresses including the Seminar on Health Reform held at the Politico-social Studies Unit at the National School of Public Health (Seminário sobre Reforma Sanitária no Núcleo de Estudos Político-Sociais da Escola Nacional de Saúde Pública -NUPES), Congresses held by the Brazilian Association of Public Health (Associação Brasileira de Saúde Coletiva –ABRASCO), the World Public Health Congress held by the Latin American Association of Social Medicine (Asociación Latinoamericana de Medicina Social-ALAMES) and the International Association of Public Health (IAPH), and the 4th World Congress of the International Association of Bioethics (IAB). He also participated in national health conferences and represented the Italian General Confederation of Labor at the inauguration of President Lula and returned once again to Brazil to receive the title of Doctor Honoris Causa from the University of Brasília and Oswaldo Cruz Foundation.

His extensive academic output was always associated with political struggle, beginning with an investigation into factory health conditions and health inequalities in Rome. He was responsible for the first National Health Plan adopted by the Italian parliament in 1968, and presided over the drafting of the law that legalized abortion; an unprecedented event for a Roman Catholic country. He was a member of the National Health Council (1994-1996) and UNESCO’s International Bioethics Committee (2001-2007)³3. Have H, Jean M, editors. The UNESCO universal declaration on bioethics and the humam rights – background, principals and application. Paris: UNESCO; 2009., president of the National Bioethics Commission, and rapporteur of the first document that gave rise to the Universal Declaration on Bioethics and Human Rights (2005), which contains the following fundamental articles addressing the defense of human dignity and health:

Article 10 – Equality, Justice and equity - The fundamental equality of all human beings in dignity and rights is to be respected so that they are treated justly and equitably.

Article 11 Nondiscrimination and nonstigmatization - No individual or group should be discriminated against or stigmatized on any grounds, in violation of human dignity, human rights and fundamental freedoms.

Article 14 Social responsibility and health - 1. The promotion of health and social development for their people is a central purpose of governments that all sectors of society share. 2. Taking into account that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition, progress in science and technology should advance: (a) access to quality health care and essential medicines, especially for the health of women and children, because health is essential to life itself and must be considered to be a social and human good; (b) access to adequate nutrition and water; (c) improvement of living conditions and the environment; (d) elimination of marginalization

He was a member of the World Health Organization’s Commission on Social Determinants of Health (2005-2008), coherently defending his position as the following extract shows:

“The central idea is that medicine and health care are only one of the factors that influence the health of a population. In reality, the principal causes consist of a wide spectrum of social and economic conditions in which people live: poverty and its various manifestations, injustice, the education deficit, food insecurity, social exclusion and discrimination, insufficient child protection, gender discrimination, unhealthy housing, urban degradation, lack of drinking water, widespread violence, and the absence or poor quality of health services”⁴4. Berlinguer G. Causas sociales y implicâncias morales de las enfermedades (conferência de Berlinguer na Fiocruz). [acessado 2015 ago 10]. Disponível em: http://www.agencia.fiocruz.br/causas-sociales-y-implicancias-morales-de-las-enfermedades-confer%C3%AAncia-de-berlinguer-na-fiocruz
http://www.agencia.fiocruz.br/causas-soc... .

He was elected to the Chamber of Deputies representing the Italian Communist Party in 1972, 1976, and 1979, and to the Senate in 1983and 1987. He was member and president of the European Parliament between 2004 and 2009, representing his new party the Democratic Left, allied to the Party of European Socialists.

One of the underlying principles that guided Berlinguer’s academic and political trajectory is that the human right to health, dignity and nondiscrimination can only be guaranteed through universal health protection⁵5. Berlinguer G. Storia della salute – da privilegio a diritto. Firenze-Milano: Giunti; 2011.. This is patently clear in his last book entitled Storia de la salute. Da privilegio a diritto, published in 2011, and his position in the European Parliament in 2006, together with other parliament members, in favor of the declaration demanding the expansion of primary health services to all European residents, including those who do not meet the entry and residence requirements.

As an academic and member of parliament, he sought to avoid the tragedy that was turning the Mediterranean–which he loved so much and viewed as a bridge uniting different peoples –into a giant cemetery, result of a greater evil than the Black Death during the Middle Ages, namely the discrimination in today’s Europe that generates lack of solidarity and corrodes sociability.

Berlinguerand Public Health in Brazil

The importance of Giovanni Berlinguer’s works and his presence in Brazil was notable in areas such as the politics of health, workers’ health, social epidemiology, health reform and, more recently, everyday bioethics.

Within the theme of medicine and politics, he introduced the concept of health awareness, which was widely adsorbed by the national literature on the health reform process. He defines the concept as follows: “health, as article 32 of the [Italian] Constitution affirms, is a person’s right and a collective interest. But, since this right is suffocated and this interest is neglected, health awareness is the individual and collective action to meet this objective”⁶6. Berlinguer G. Medicina e política. São Paulo: CEBES/Hucitec; 1978..

The contradiction between profiting from health and public health is expressed in social inequality and the deformation of human relationships and our relationship with the environment. The formation and diffusion of the concept of health awareness allowed a greater understanding of the forces that impeded health reform in Italy⁷7. Berlinguer G, Teixeira SF, Campos GWS. Reforma Sanitária: Brasil e Itália. São Paulo: CEBES-Hucitec; 1988.. This change was most evident in workers’ awareness and the attitude of unions to the health problem⁷7. Berlinguer G, Teixeira SF, Campos GWS. Reforma Sanitária: Brasil e Itália. São Paulo: CEBES-Hucitec; 1988..

By regarding health reform as a social struggle, Berlinguer shows a wider conception of the process, whereby the desired change towards health protection takes on a cultural, institutional, professional and administrative meaning. Adopting health in the factories as his object, the author maintained that in these settings everything is more intense and more violent⁸8. Berlinguer G. A saúde nas fábricas. São Paulo: CEBES/Hucitec/Oboré; 1983.; however “the true ‘noxious agent’ in modern factories is capital, exploitation, and the division of labor”⁸8. Berlinguer G. A saúde nas fábricas. São Paulo: CEBES/Hucitec/Oboré; 1983.. Nevertheless, these single conditions cannot be detached from political and structural determinants. Occupational diseases tend to become social problems, infecting the whole population and vice-versa, as external environmental conditions (education, transport, housing, and pollution) have a noticeable influence on workers’ health. Thus, Berlinguer called on all political actors and institutions to fulfill their duty to put an end to the psychophysical demolition of those who create the country’s riches and are subjected to the worst form of exploitation.

However, he advises that awakening workers’ awareness of health does not immediately lead to a struggle against exploitative working conditions. Union organizations in Italy initially followed a different path:‘employers’ tendency to monetize risk, transforming dangerous conditions into compensation, and fuel a spiral in which workers, instead of demanding better working conditions, are remunerated for the lack of preventative measures: amounts that are usually necessary to guarantee the minimum wage, but that compromise the protection of their own life⁸8. Berlinguer G. A saúde nas fábricas. São Paulo: CEBES/Hucitec/Oboré; 1983..

The Italian Communist Party’s proposal to create a national health system was seen by Berlinguer as a step forward in the struggle to reform Italy’s health system. However, he believed that the changes should not stop at organizational transformation and expanding health services. The struggle should include pathology, growing awareness about the relationship between work and health, “a modern awareness of health and an autonomous view of the relationship between science, production and the environment”⁸8. Berlinguer G. A saúde nas fábricas. São Paulo: CEBES/Hucitec/Oboré; 1983..

Thus, the concept of health awareness became indelibly linked to the health reform process as a social struggle that involves the formation of political subjects and the transformation of health awareness from a false awareness to a scientific and political understanding of the production and reproduction of health and disease. Furthermore, it implies recognizing the heterogeneity of these subjects, regardless of their class, and their ideological and political limitations in constructing alliances and defining tactics and strategies to promote the emancipation of workers.

Major achievements made throughout this period, such as the shift from the monetization of risk to collective agreements that achieved better working conditions and the National Health Service, were regarded as progress, albeit limited, towards a deeper awareness of the relationship between work-exploitation-health ultimately reflected in the attainment of employee representational rights and the universal right to health.

What is the relationship between building a national health system, the universal right to health and health reform? What is the connection between the progress made towards the expansion of health awareness and the social struggle to emancipate workers through the construction of socialism?

Berlinguer taught us that the approval of the Law Nº. 833 in 1978, after 20 years of struggle by the labor movement, health professionals and political parties, did not mean the end of the health reform process, but rather only the beginning. The reasons for this statement stemmed from the gaps and imperfections of the law and an increasingly consistent political articulation by the opposition that he predicted would “impute the care shortages and operational problems that would inevitably arise, not on the dark legacy of a drawn-out process, but rather on the reform law or the actual idea that public health is liable to reform”⁷7. Berlinguer G, Teixeira SF, Campos GWS. Reforma Sanitária: Brasil e Itália. São Paulo: CEBES-Hucitec; 1988..

This prophecy, which was fulfilled well in the case of Brazil, was followed by other considerations about the shortcomings of the Italian health reform that, as a public policy, depended on government effort, demanding tenacity, a will to renew and political coherence, which he failed to see in the governments that were to implement the health reform. This analysis led Berlinguer to emphasize the nature of the reform process, whose main aspect is public participation.

“(...) health reform is not just made of procedural rules, decrees, and institutional change. It should be a process that ensures public participation in health promotion, that involves millions of citizens; it should impose social, environmental and behavioral changes that lead to a more healthy existence; it should mobilize tens of thousands of counselors from regions, provinces, municipalities, parishes, members of union, women’s and youth movements and cooperatives and thousands of mayoral advisors; it should transform the daily tasks of doctors, technicians and nurses”⁷7. Berlinguer G, Teixeira SF, Campos GWS. Reforma Sanitária: Brasil e Itália. São Paulo: CEBES-Hucitec; 1988..

This process of institutional change, intense public participation, and mobilization of actors involved in the promotion of social, environmental and behavioral changes and in the daily tasks of health professionals, requires phenomenal effort, which cannot prevail without determination and when the whims of political parties and particularism of professions and groups predominate.

Nevertheless, Berlinguer proposed an inversion of reasoning to understand the revolutionary potential of health, by understanding that health reform involved a set of changes within state bodies, the health field, going beyond the doctor-therapist to include preventive and environmental aspects, and the political system, comprising a tendentiously unifying, albeit decentralized, national process. He thus highlights the positive side of health reform as a fertile ground for action and cultural and political transformation, whereby health takes precedence over the disease. The challenge lies in the fact that this transformation requires a deep revolution that involves all parties, and which traverses our everyday existence. This stems from the dual nature of the health/disease phenomenon since, although health is a private fact, “maybe being the most intimate phenomenon of the individual sphere”, disease requires a collective response in terms of prevention and treatment, rehabilitation and integration⁷7. Berlinguer G, Teixeira SF, Campos GWS. Reforma Sanitária: Brasil e Itália. São Paulo: CEBES-Hucitec; 1988..

Criticized for having “a linear conception of history, which corresponds to an expansionist conception of democracy, where Marxism is presented in the form of rationalist enlightenment ideology”⁷7. Berlinguer G, Teixeira SF, Campos GWS. Reforma Sanitária: Brasil e Itália. São Paulo: CEBES-Hucitec; 1988., Berlinguer leaves it to the reader to decide whether this criticism applies to the health reform movement. However, a tone of contradiction will always be present in his analyses; for example, when he affirms that the health reform introduces shortfalls, imbalance and distortions that cannot be attributed solely to the legacy, such as lack of expenditure control, expansion of private activities that parasitize the public system, and the sharpening of regional disparities, conservatism of the actors represented on the councils⁷7. Berlinguer G, Teixeira SF, Campos GWS. Reforma Sanitária: Brasil e Itália. São Paulo: CEBES-Hucitec; 1988.. However, he clearly states that the Welfare State should be criticized more for its distortions than for its excesses⁷7. Berlinguer G, Teixeira SF, Campos GWS. Reforma Sanitária: Brasil e Itália. São Paulo: CEBES-Hucitec; 1988..

The defense of health reform as a social democratic reformist project did not hide however a fundamental contradiction. His revolutionary character was incompatible with a capitalism that commoditizes the body and health: “a reform based upon socialist principles, albeit expressed in contradictory norms, and a society that maintains the essential characteristics of capitalism...”⁷7. Berlinguer G, Teixeira SF, Campos GWS. Reforma Sanitária: Brasil e Itália. São Paulo: CEBES-Hucitec; 1988..

Finally, the decommoditization of care and the struggle against all types of exploitation and commoditization of life – and of the human body in the form of slavery, prostitution, and the organ trade – is the strategic underlying principle of the political struggle to develop universal public health systems as part of a health system reform based on everyday bioethics⁹9. Berlinguer G, Garrafa V. Mercado humano: estudo bioético da compra e venda de partes do corpo. Brasília: Editora UnB; 1996..

The common thread to Berlinguer’s work was his deep humanism in rejecting the domination and exploitation of human beings, which brings him close to the Christian humanists and the natural law tradition. On the other hand, his trademark was his deep conviction that health, life, and bodies must not be treated as commodities; which places him among the field of class struggle posited by Marxism.

His transit between humanist values and the insurgent values of class struggle made him an original scientist and a transnational militant in search of democracy who left an indelible mark on public health in Latin America. He taught us to treat health awareness as a scientific field connected to the struggle for hegemony, which allowed him to see the monetization of health defended by the unions in Italy as an obstacle to be overcome and never an enemy to the political struggle for the universal right to health. He also taught us that the struggle for health is part and parcel of the struggle for democracy, which can only be achieved through the universalization of human rights and development of national public health systems.

At a time in which international cooperation agencies bow down to mercantile interests, replacing the defense of the universal right to health with a corrupted version called universal health coverage, nothing more current than Berlinguer’s works. It is evident that this proposal is nothing more than an updated version of the struggle to preserve the hegemony of the capitalist face of the health service, which has turned the achievements made towards a universal system into a proposal to “enthrone” inequality, whereby individuals are offered “universal” coverage in accordance with their health commodity purchasing power.

The idea that it is impossible to turn life into a commodity and reduce health to a mere care demand, disregarding the social determinants of health, will always be revolutionary, because it establishes a contradiction that permits the formation of political subjects, a deepening of health awareness, and collective organized action in defense of universal health care systems.

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