Abstract

Introduction

Izabel dos Santos is a character who cannot be omitted from any discussion about Brazilian public health. Her greatest contribution was in the field of nursing training, especially in terms of technical and professional education, which is an area that, for reasons that will be discussed, can be identified as playing a crucial role in the renovation of policies and guidelines for professional training in health.

Izabel's career followed a long and rich trajectory, which contained experiences, ideas, sanitary practices and political-institutional projects that were at the center of Brazilian public health. Among these experiences, special mention should be made of her training and work within the Serviço Especial de Saúde Pública (SESP- Special Public Health Service) and the Pan American Health Organization (PAHO). We would suggest that Brazilian public health can be understood as a long-term movement, which sometimes opposed and sometimes incorporated trends and tendencies, and which was capable of dialoguing with a long tradition of ideas and practices that had been established for centuries. Thus, collective health has been referred to both as an interdisciplinary field of knowledge - the result of the convergence of three major currents, public health, epidemiology and policy¹1. Paim J, Almeida-Filho N. A crise da Saúde Pública e a utopia da Saúde Coletiva. Salvador: Casa da Qualidade; 2000. – as well as also being seen as a field of articulation and political activism centered on the goals set by health reform²2. Escorel S. Reviravolta na Saúde: origem e articulação do movimento sanitário. Rio de Janeiro: Ed. Fiocruz; 1998..

Izabel's connections with international movements have also been recognized, whether through the circulation of ideas and proposals from Brazilian experiences, or via international organizations such as the PAHO. In this respect she also circulated ideas and proposals through founding national frameworks outside Brazil and through the work of foreign experts in Brazil. A good example of these rich connections - which were never unilateral - is the relationship between the so-called movement of Latin American social medicine, and social thought in Brazilian health³3. Nunes ED. As Ciências Sociais em Saúde: reflexões sobre as origens e a construção de um campo de conhecimento. Saude soc. 1992; 1(1):59-84.,⁴4. Nunes E. As ciências humanas e a saúde: algumas considerações. Rev Brasileira de Educação Médica 2003; 27(1):65-71..

Izabel and the SESP: living and learning about public health

Izabel dos Santos was born in Pirapora, Minas Gerais, Brazil in early March 1927. She graduated in nursing at the Hugo Werneck School of Nursing in Belo Horizonte in 1950 but she truly became a public health nurse after she entered the SESP, which was created in July 1942 in the context of World War II. This agency became feasible thanks to the signing of a bilateral cooperation agreement between the governments of Brazil and the United States. The initial issue that motivated the creation of this “special” health service was a malaria epidemic in the north and northeast of Brazil, which was responsible for serious economic repercussions in relation to the rubber industry, which in turn was important for the allied war effort and for the installation of North American troops who were based in Brazil⁵5. Campos ALV. Políticas internacionais de saúde na era Vargas: o Serviço Especial de Saúde Pública, 1942-1960. Rio de Janeiro: Editora Fiocruz; 2006..

As a newly graduated nurse, the young Izabel was hired to work in the SESP. As a professional working for the SESP she returned to Pirapora, where she worked intensely in the organization of local health services and the training of nursing, laundry, cooking and cleaning staff. Working for the SESP, Izabel experienced the vastness of Brazil from the health point of view; it was an extremely interesting and promising experience within the sphere of Brazilian public health. It is impossible to understand Izabel's legacy without first quickly reviewing the institutional experience that the SESP represented; it was an experience that not only shaped Izabel's future, but also shaped an important and strong tradition within the Brazilian field of public health ⁶6. Castro J, Paranaguá de Santana J, Nogueira R. Izabel dos Santos. A arte e a paixão de aprender fazendo. Natal: Observatório RH NESC/UFRN; 2002..

When Izabel joined the SESP, strategic and military reasons were no longer sufficient, on their own, to sustain the agency. Surprisingly, given this new scenario, the SESP was not wound up but was actually expanded and by the late 1960s it covered the whole of Brazil, a move that marked its strong, national character and vocation. This process of expansion, which was negotiated periodically so that one cannot consider it as a wholly linear movement, also marked the construction of a standard of public health administration that was quite influenced by what could be called the North American school. Izabel was undoubtedly influenced by that tradition.

The SESP model preached the message of political and administrative decentralization, as well as the need for health services to consider the lifestyles and cultures of its users and the commitment of its staff to scientific research⁷7. Castro Santos LA, Faria LR. A reforma sanitária no Brasil: ecos da Primeira República. Bragança Paulista: EDUSF; 2003.. However, it should not be assumed that these organizational guidelines regarding public health were understood as ready and finished. On the contrary, the bilateral cooperation between the USA and Brazil was monitored and adjusted in different circumstances. An example of this occurred in November 1952 when, at the request of the Division of Health Education of the SESP, Mayhew Derryberry and Mary Jo Kraft (the latter being the Point IV Regional Consultant of Health Education) made a technical visit to Brazil and issued a report on the conditions of the program as well as recommendations to improve it⁸8. Serviço Especial de Saúde Pública (SESP). Visitam o Brasil dois técnicos norte-americanos. Boletim do SESP 1952; 28:4-5..

Among these recommendations were support for the availability of health education assistants, on a trial basis; health centers of varying sizes; and greater community participation in the planning and implementation of health programs⁸8. Serviço Especial de Saúde Pública (SESP). Visitam o Brasil dois técnicos norte-americanos. Boletim do SESP 1952; 28:4-5..

There were various criticisms of the SESP that were related to the political and administrative autonomy of the organization, which was formally responsible to the Ministry of Education and Health - and thus was outside the administrative structure of the Departamento Nacional de Saúde (DNS - National Department of Health) - and which had its own budget, from both the Brazilian government and the United States government, in addition to sources from its own agreements⁹9. Bastos NCB. SESP/FSESP: 1942 – evolução histórica – 1991. 2° ed. Brasília: Fundação Nacional de Saúde; 1996.. Another aspect that was widely criticized was its model of medical coverage, which was considered to be restrictive and against the idea of health coverage for all, an idea which had been systematically supported by international organizations from the 1970s, especially on the part of PAHO and the World Health Organization (WHO)¹⁰10. Organización Panamericana de Salud (OPAS). Reunión de Ministros de Salud (grupo de estudio). Washington: Oficina Sanitária Panamericana; 1963.–¹²12. Organización Panamericana de Salud (OPAS). Informe sobre la III Reunión Especial de Ministros de Salud y medidas necesarias para dar cumplimiento a las decisiones adoptadas. Washington: OPAS; 1972..

The fact is that the SESP's “special” status endowed it with an extraordinary capacity for articulation and administrative flexibility, given that the organization was unburdened with the tasks imposed by the administration and bureaucracy of the DNS. This in turn meant that the SESP quickly spread throughout the country, even in remote regions where historically there had been no medical service available, because it was able to function as a kind of laboratory of organizational and institutional innovations.

For example, in the field of health education the SESP was not only innovative in the development of teaching methods and persuasion strategies, but also in the development of staff training programs, which were initially performed in the United States through the distribution of scholarships. According to a study by Oshiro, in 1944 the SESP was funding forty technicians in North American universities through scholarships, although over the years the SESP gradually chose to train personnel in Brazil (in the Department of Public Health in São Paulo), which was a result of both the high cost of training abroad and also the greater institutionalization of training health workers within Brazil itself¹³13. Oshiro JH. Educação para a Saúde nas instituições de Saúde Pública [dissertação]. São Paulo: PUC; 1988..

In the early days, the structure of the services provided by the SESP was based on organization into health districts and health facilities (health centers and clinics), which operated with basic teams composed of a doctor, microscopist, laboratory technician, and a security guard. The creation of health centers resulted in an expansion of the teams. The actions of these centers always unfolded on two main fronts: on the one hand, curative medical care; on the other, more focused action to prevent diseases. It was in this latter area that health education and staff training were important tools in strategies devised by the SESP¹⁴14. Serviço Especial de Saúde Pública (SESP). Programa de Higiene Pré-natal e da Criança. Boletim do SESP 1944; 7(1):1..

Thus, at the outset, health education was not simply about health practices; it also incorporated programs directed at the training and improvement of professionals who joined the SESP. It was in this environment that Izabel entered the SESP and subsequently graduated as a health worker. In her own words:

… I didn't just organize one hospital, I organized several hospitals, many services, several health facilities … So I started to be a reference for those functions as an employee of the SESP foundation⁶6. Castro J, Paranaguá de Santana J, Nogueira R. Izabel dos Santos. A arte e a paixão de aprender fazendo. Natal: Observatório RH NESC/UFRN; 2002..

At the start of the 1950s, the recognition of Izabel's work meant that she was promoted to be the Regional supervisor of the SESP. She subsequently began busily working to organize services within the cities of São Francisco, São Romão and Januária in the state of Minas Gerais, as well as other cities located within the scope of the Plano Salte (Jump Plan) of the Dutra Government (1946-1951).

As part of these changes the Division of Health Education was transformed into the Division of Education and Training in 1953, which more clearly expressed the activities that had already been part of the scope of the department from the outset. The old functions of health education passed to the Technical Guidance Division, which became exclusively responsible for professional staff training, project management and the implementation of courses. Coordinated by Nilo Chaves de Brito Bastos, the division began to organize training courses targeted at students from all over the country, from state health departments and the SESP's own programs; these courses were intensive and lasted six months⁹9. Bastos NCB. SESP/FSESP: 1942 – evolução histórica – 1991. 2° ed. Brasília: Fundação Nacional de Saúde; 1996..

From that period on, with the crucial participation of Izabel dos Santos, the SESP began to excel in preparing nurses to work in the hospital environment and also in public health facilities¹⁵15. Bastos NCB. SESP/FSESP: 1942 – evolução histórica – 1991. 2° ed. Brasília: Fundação Nacional de Saúde; 1996.,¹⁶16. Campos ALV. Cooperação internacional em saúde: o serviço especial de saúde pública e seu programa de enfermagem. Cien Saude Colet 2008; 13(3):879-888.. Through scholarships, which were funded by the Institute of Inter-American Affairs (IIAA), the Rockefeller Foundation and the Kellogg Foundation, Brazilian youngsters studied in North American universities. In both the hospital environment and the field of public health, nurses would play an important role in health education strategies ¹⁷17. Renovato RD, Bagnato MHS. As contribuições do Serviço Especial de Saúde Pública para a formação pro-fissional da Enfermagem no Brasil (1942-1960). Rev Brasileira de Enfermagem 2008; 61(6):909-915..

With regards to staff training, the idea of inserting social sciences into the area of health by means of health education served to shape the projects to reformulate the training activities of the SESP. The SESP developed integration and in-service training strategies, anticipating a discussion that would take off in the 1970s. The premise of this discussion was that once professionals were trained in the actual conditions of the health service (i.e. training that was capable of reproducing the health and working conditions of the services) they would be able to perform their activities with greater technical capacity¹⁸18. Serviço Especial de Saúde Pública (SESP). Enfermeiras para o Brasil. Boletim do SESP 1953; 33:5.–²⁰20. Serviço Especial de Saúde Pública (SESP). Preparação de técnicos e auxiliares de Educação Sanitária. Rev Serviço Especial de Saúde Pública 1954; 6(2):497..

As part of the in-service training module, health professionals were sent to one of the SESP health facilities near the city of Belém, where they were able to practice their professional activities under the supervision of more experienced colleagues. This internship enabled health professionals to also acquire greater knowledge about the local epidemiological problems and the political and administrative set up of the SESP. SESP employees also received a grant, which funded a year studying in the United States. With the support of the Rockefeller Foundation and the Kellogg Foundation, nurses received grants for three years⁹9. Bastos NCB. SESP/FSESP: 1942 – evolução histórica – 1991. 2° ed. Brasília: Fundação Nacional de Saúde; 1996..

The training of technical and auxiliary staff began in 1943. The preparation of health visitors included a course of six to eight months duration, usually living within an institution. To that end, schools to train health visitors were created in the cities of Santarém, Itacoatiara and Palmares. Because of the great demand for health visitors within Brazil and the high costs of training groups it was decided early on in the strategy to opt for in-service training.

Installing laboratories in SESP health units also increased the demand for auxiliary labor. In 1943, in the central SESP laboratory at the Evandro Chagas Institute, the training began of assistant laboratory staff using the in-service training method. The course lasted five months and covered concepts related to chemistry, physics, biology, hematology, parasitology etc., in an attempt to give special attention to the problem of parasitic diseases in Brazil.

The sanitary guards, who were later re-named sanitary assistants, began to be trained in 1944 in a course that only lasted two months. In addition to theoretical subjects, the course also included a practical part that was especially focused on aspects related to community hygiene, such as building private toilets, topography, and sanitary inspection of toilets and wells. These and other activities were listed in the Sanitary Guard's Manual, a document that was produced by the sanitary engineers of the SESP.

From 1953, the SESP also began carrying out the training of health education technicians and assistants. The former were of university level (regardless of subject) and were to work in teams at a regional level; the latter were of secondary school education and were to work in district teams. Both of these posts were intended to expand health education within SESP work programs. In addition, the SESP also promoted the training of midwives, called “curious” in all health units, with results that were considered “quite encouraging”⁹9. Bastos NCB. SESP/FSESP: 1942 – evolução histórica – 1991. 2° ed. Brasília: Fundação Nacional de Saúde; 1996..

SESP's legacy was not only restricted to staff training, particularly in terms of nursing and technical staff; the organization also made an important contribution to the planning of school courses and curricula. For example, the SESP conducted short courses, which lasted about a month, for primary teachers. These courses covered issues such as communicable diseases, first aid, horticulture etc. As an extension of this initiative, in 1950, in a partnership with the Department of Health of the state of Minas Gerais, the SESP organized a hygiene course for hygiene teachers at state schools. This course had the following objectives: to improve the hygiene curriculum, health education, and assistance to children in ordinary schools; to prepare health educators to be used by health and education departments; and also to serve as a model for training health staff in other Brazilian states. Although this initiative did not produce the desired results, due to a lack of integration between the agencies relating to education and health policies, the SESP still contributed to the improvement of regular courses in some cities in the state of Rio Grande do Sul, as well as providing financial support and staff in medicine and nursing faculties around Brazil.

In 1955, the Education and Training Division was abolished and training activities were moved to the Health Education Section of the Technical Guidance Division in order to more or less return to the old structure that had united health education and staff training. This new structure only commenced in 1960, when staff training activities were more centralized from the point of view of coordination and implementation, under the responsibility of the Education and Training Sector, which was directly connected to the director of the Technical Guidance Division.

At this stage, Izabel was working in Mato Grosso and Pernambuco as a SESP employee. In Pernambuco, during the period of the military dictatorship when the SESP was no longer connected with the United States, Izabel developed teaching activities in the Recife School of Nursing. Within this school, and directly linked to staff training activities, Izabel begin to develop a laboratory of ideas that would later result in a kind of matrix for her activities: educating citizens, and by association, good professionals. In Izabel's own words:

My goal was to get them [the nursing students] to leave the small world in which they lived. I used to say, “You are citizens, you have to know what's going on in life and the newspaper tells you things that are happening”. They didn't read anything; they didn't go to the library, or anywhere. It was awful! It was everyone with this terrible little notepads and taking notes about all our sighs […] It was important for them to know what were the issues that were being discussed in society, they needed to analyze and reflect about things⁶6. Castro J, Paranaguá de Santana J, Nogueira R. Izabel dos Santos. A arte e a paixão de aprender fazendo. Natal: Observatório RH NESC/UFRN; 2002..

During that period Izabel was against the notion of “training”, according to which health workers were understood to be blank slates to be filled with technical, and supposedly apolitical, content. The relationship between citizenship and professional training with a clear political content, which was so dear to Izabel dos Santos and the public health field, thus originated through the dedicated and decisive work of a nurse working in the SESP.

This suggests the existence of a rich, complex and lasting relationship with respect to the formation of social thinking regarding health in Brazil. It was a relationship which, before it suffered a marked and clear temporal break due to the health reforms of the 1970s, could be considered as a dialogue, and the incorporation of perspectives and practices that had been established since at least the 1940s.

It was in Recife, as a teacher in School of Nursing, that Izabel faced difficulties imposed by the military dictatorship. Although she never belonged to the Communist Party she participated in demonstrations in support of political prisoners, and from then on she faced intimidation and constant surveillance by the political police.

Her move from Recife to Brasília was coordinated by João Yunes, who was then the coordinator of the maternal and child area of the Ministry of Health. At that time, the PAHO-Brazil group was set up for the training of human resources in health, which in 1976 became the Programa de Preparação Estratégica de Pessoal de Saúde (PPREPS - Strategic Development Program of Health Personnel). Izabel already belonged to the staff of the Federal University of Pernambuco and she began her most celebrated phase as national consultant for the Pan American Health Organization (PAHO/WHO).

Her participation in this organization was related to her recognized expertise in initiatives that came to be called “teaching-health care integration.” According to Izabel:

I checked the following: first, that the teaching process has a generating force of energy, enthusiasm, affection for people, which are very important for a process of change; second, that several other actors would be participating in the teaching process, for example, the director of the health unit, the head nurse, nursing attendants and other components of the team all participated. The important thing was that at the end of the course it was not sufficient just to have a systematic, organized and standardized production process, with routines and clearly defined protocols and duties; the most significant thing was the participation and acceptance of the director and the other managers of the health unit in the reorganization of the service. In that way, everybody learned⁶6. Castro J, Paranaguá de Santana J, Nogueira R. Izabel dos Santos. A arte e a paixão de aprender fazendo. Natal: Observatório RH NESC/UFRN; 2002..

Izabel in the PAHO: her legacy

The Pan American Sanitary Bureau (now the Pan American Health Organization) was founded in 1902. Although this organization played an important role in shaping international health at a continental level right from the outset, until the end of World War II it remained exclusively an agency of the U.S. Department of State. Beginning with the administration of the North American Fred Soper in 1947, and especially under the administration of the Chilean Abraham Horwitz, from 1958, the organization began to gradually gain greater programming and administrative autonomy²¹21. Cueto M. O valor da saúde: história da Organização Pan -Americana da Saúde. Rio de Janeiro: Ed. Fiocruz; 2007.,²²22. Lima NT. O Brasil e a Organização Pan-americana de Saúde: uma história de três dimensões. In: Finkelman J, organizador. Caminhos da Saúde Pública no Brasil. Rio de Janeiro: Editora Fiocruz; 2002. p. 23-106..

This period coincided with one of the most vigorous phases of the organization. For example, a strategic agenda of public policies for the training of health workers in Brazil and Latin America began to take shape when, in the wake of continental initiatives such as the Charter of Punta del Este (1961) and meetings of the health ministers of the Americas (Buenos Aires, 1963; Washington, 1968; and Santiago, 1972) – which were supported by the Alliance for Progress and the Organization of American States (OAS), the training of health workers began to take center stage, not only within the PAHO but also within the Brazilian government²²22. Lima NT. O Brasil e a Organização Pan-americana de Saúde: uma história de três dimensões. In: Finkelman J, organizador. Caminhos da Saúde Pública no Brasil. Rio de Janeiro: Editora Fiocruz; 2002. p. 23-106.,²³23. Paiva CHA, Pires-Alves F, Hochman G. A coopera-ção técnica OPAS-Brasil na formação de trabalhado-res para a saúde (1973-1983). Cien Saude Colet 2008; 13(3): 929-939..

Inspired by discussions about human capital, which had started in the 1950s, experts pointed to the importance of capital contained within humans, especially in terms of health and education. In general, this capital was seen as both an explanatory component and a decisive promoter for economic and social development.

In this respect, as always, Izabel dos Santos was in the right place at the right time. During her time at the SESP, from the early 1950s onwards, she strove in practical terms for the development of staff training initiatives; the decentralization of health actions; and discussion about the participation of communities in the planning and development of sectoral policies. These ideas and practices conformed, through institutions such as PAHO, to part of a field that came to be known as Latin American social medicine³3. Nunes ED. As Ciências Sociais em Saúde: reflexões sobre as origens e a construção de um campo de conhecimento. Saude soc. 1992; 1(1):59-84..

At that time, the context of health personnel in Brazil was far from stable. Although the situation was less severe with regard to the supply of qualified personnel, such as doctors and dentists, there was a deficit with respect to the nursing staff that continued until the 1980s. The question that needed to be addressed was precisely the training and distribution of professionals within Brazil, which was an issue that was strongly taken up by the Ten Year Health Plan for the Americas of the 1960s. Coupled with the challenge posed by the deficit of health professionals was the challenge of over-specialization, which removed professionals from basic health care. In Bastos's words, “there was an urgent need for doctors able to provide initial contact for primary health care and assistance”⁹9. Bastos NCB. SESP/FSESP: 1942 – evolução histórica – 1991. 2° ed. Brasília: Fundação Nacional de Saúde; 1996..

In this context, Izabel, together with Carlyle Guerra de Macedo, José Paranaguá de Santana, Danilo Garcia, Stela Winge, Cesar Vieira, Regina Coeli Nogueira, Francisco Lopes and Alberto Pellegrini Filho, became a member of the initial team of the Programa de Preparação Estratégica de Pessoal de Saúde (PPREPS - Strategic Development Program of Health Personnel). In the words of the group's coordinator, Carlyle Macedo:

It wasn't very difficult to form the group because freedom was relatively restricted. First, we had to have people from the three ministries. Let's say that I represented the PAHO, so there was no pressure to have specific people from the PAHO, but the ministries had to have people. So we had to accept who the ministries recommended. And they usually did not recommend the best people. No, I don't want to criticize; we got along fine with the people who came. But one person came from each ministry. And we had to recruit about four or five more people, which was not difficult, one of our greatest successes, for example, was finding Izabel Santos. She was a pillar of that group, she was fantastic²⁴24. Macedo CG. Depoimento a Carlos H. A. Paiva, Fernando Pires-Alves, Gilberto Hochman e Janete Castro. (Brasília, 1-2 de março de 2005). Transcrito por An-nabella Blyth. Conferência de fidelidade por Alex dos Santos da Silveira. 5 horas. (Fita 1, Lado B)..

Together with Regina Coeli, Izabel developed activities that led to the formation of the so-called Large Scale Project a few years later. José Paranaguá describes the early years of the PPREPS in the following words:

Apart from the more specific training activities that were carried out in the country [Brazil] much more intensively, there was also training in technical education, and training of technical staff and health assistants, which was the area of Izabel Santos. Early in the 1980s, about 1980 or 1981, the Large Scale Project began, which was intended to conduct training for technical teams to work with curriculum design. Through the Large Scale Project, over 2,000 people were trained; male and female nurses. This proposal was referred to as methodological training for the development of integrated curriculum training and the training of health assistants²⁵25. Santana JFP. Depoimento a Carlos H. A. Paiva, Fernando Pires-Alves, Gilberto Hochman e Janete Castro. (Rio de Janeiro, 21-22 de fevereiro de 2005). Transcrito por Andréa Ribeiro. Conferência de Fidelidade por Alex dos Santos da Silveira. 5 horas (Fita 4, lado A)..

Roberto Nogueira (a medical doctor) joined the group in the early 1980s and he, José Paranaguá, Francisco Lopes and Izabel would go on to be the longest-serving members of the PPREPS. With the help of Nogueira, Izabel developed the Large Scale Project in the early years of the 1980s.

At first, this project consisted of a direct initiative to train auxiliary staff for basic health services. In 1981, amid a climate of great expectation surrounding the proposed implementation of the PREV-SAÚDE (PREV-HEALTH), the Large Scale Project provided direct assistance to the PREV- HEALTH by supplying qualified staff. It was for this purpose that the Program for the Development of In-Service Training Systems for Health Assistants was created, which would soon be referred to as the Large Scale Project²³23. Paiva CHA, Pires-Alves F, Hochman G. A coopera-ção técnica OPAS-Brasil na formação de trabalhado-res para a saúde (1973-1983). Cien Saude Colet 2008; 13(3): 929-939..

The fact that the PREV- HEALTH was never implemented resulted in the fact that the Large Scale Project had an impact in other areas. The forcefulness and innovative approach of the Large Scale Project influenced methodological and political-pedagogical aspects within the health field, in the sense that a deliberate choice was made to comprehensively train health staff, as opposed to merely training them for skills that were “useful”.

The Large Scale Project's impact and legacy were described by José Paranaguá thus:

Izabel dos Santos developed training for health assistants, which we used in other areas. There was training for a specialization course in management, which lasted for about ten years at the Federal University of Minas Gerais, but which was originally intended to be a project developed in seven universities²⁵25. Santana JFP. Depoimento a Carlos H. A. Paiva, Fernando Pires-Alves, Gilberto Hochman e Janete Castro. (Rio de Janeiro, 21-22 de fevereiro de 2005). Transcrito por Andréa Ribeiro. Conferência de Fidelidade por Alex dos Santos da Silveira. 5 horas (Fita 4, lado A)..

Roberto Nogueira considers that the greatest legacy of the PPREPS was the work of Izabel dos Santos. In his words:

Izabel [dos Santos] gave great emphasis to the Large Scale Project. I have the impression that, apart from Carlyle [Guerra de Macedo], Izabel was the great leader of the program. Even today, everyone who was involved with that project still respects and praises her. When he was the director of the PAHO in Washington, Carlyle used to phone her to ask her advice; Izabel's force was very impressive²⁶26. Nogueira R P. Depoimento a CHA Paiva e J Castro. (Rio de Janeiro, 26 de julho de 2005). Transcrito por Andrea Ribeiro. Conferência de fidelidade por Alex dos Santos da Silveira. 4 horas (Fita 1, lado B)..

The work that was developed by initiatives such as the PPREPS undoubtedly expressed the formation of a set of Brazilian proposals, not only regarding the issue of training and management of health personnel, but more particularly, for a reorientation and renewal of the health system in Brazil. Although Izabel's contribution was not explicitly theoretical, it went beyond the scope of the merely practical. Izabel played an important role in the formation of a theoretical archive concerning the training of technical health workers. On a more general level, she was also a leading figure in creating a view that health workers – whatever their level and training – were perceived as individuals, with intentions, passions and interests.

There could only be one matrix for the training of health workers: that of citizenship. Izabel considered that without a perspective that contained elements of politics, ethics and citizenship it was impossible to deliver health work that was in tune with people's needs. Convictions such as this made up the core of Brazilian sanitary and public health reforms and they were a key ingredient in binding together the work of many people.

Final Considerations

Izabel dos Santos was a person to whom the Brazilian Public Health owes much. She qualified as a public health nurse through the auspices of the SESP in the 1950s and worked for about 20 years for that organization. Izabel also worked for the Federal University of Pernambuco and the PAHO, where she remained as a consultant until 1997. She is celebrated as one of the most important people in terms of vocational education policies in Brazil. Her career is an example of the wealth of experience, and of the technical and regulatory positions, that exist in the public health field in Brazil - a wealth whose taxation is represented by public health.

From the late 1950s and the 1960s, the organizational model proposed by the SESP became inextricably linked with (and even rivalled ideologically, to a greater or lesser extent) other national health standards such as so-called ‘Campanhismo’ (‘campaignerism’) and developmental sanitarism. The SESP left a complex legacy which influenced thinking and practices regarding public health in Brazil to this day.

On the one hand, the SESP model proposed a decentralized political and administrative structure, especially at the state level; on the other hand, the ‘campaigners’ operated a more centralized model (the so-called national departments). On the one hand, those who supported the SESP believed in health education as a process to transform unhealthy behavior and social conditions; on the other hand, the developmentalists supported the need for structural changes in society, changes that even seemed to go beyond the scope of the area of the developmentalists. A rivalry grew up between these various schools of thought based on their different propositions and positions. The circulation of actors and development of public policies, which did not fail to vigorously consider the different perspectives, show not so much a competitive environment, but rather the existence of a space marked by a plurality of routes and a wealth of proposals.

The career of Izabel dos Santos is an example of this. By collaborating decisively in the development of education and training policies for health personnel in Brazil she was simultaneously consistent with the various emerging perspectives and public health doctrines of her time. Far from merely reproducing already established ideas and practices, Izabel was firmly opposed to a “technical” perspective based on the idea of training human resources, and she sought to build and consolidate a more politicized and committed perspective linked with the idea of citizenship.

In the wake of ‘campaignerism’ and developmentalists, Izabel played a key role in the process of the bureaucratization of health services; a strategy that was unanimously embraced by international agencies and “health schools”. If there was disagreement about procedures, i.e. the way in which to use the resources of the administrative machinery, there was also agreement about the objectives of the construction of a state apparatus that was increasingly involved in health issues. Starting with her experiences at the SESP, Izabel made important contributions, especially in the development of state health departments in some Brazilian states.

Furthermore, Izabel dos Santos's career is particularly revealing about changes in the paradigm of epistemological support in the health field; it represents a move away from a point of view that was solidly naturalist and normative, towards a more complex form, in which the social sciences would gradually have greater (although never hegemonic) importance. Although it dates back to earlier periods, the institutionalization of human and social sciences in the area of health advanced radically post-1945 because of a certain accumulation of cultural capital within the social sciences themselves, and also due to a political and ideological context that was favorable, and which provided, among other factors, the financial and human resources that were sufficient to give momentum to this new scenario.

This social science, inserted in the health field, would have a distinctly national function; to be ultimately presented as a primary tool to promote national development via the dissemination of values, as well as ethics related to health, which could be promoted through staff training, and which its employees would put into practice.

Above all, Izabel was the embodiment of the practice of these ideals, which conformed to the matrix of Brazilian public health. This was Izabel dos Santos; a nurse and a creator of initiatives that were considered to be key in the field of education and health work in Brazil. Initiatives such as the Programa de Qualificação de Auxiliares e Técnicos de Enfermagem (PROFAE – the Program for the Qualification of Nursing Assistants and Technicians) and the Large Scale Project, both of which dealt with technical education in health, are examples of the strength of her ideas and the structuring effect of her practices in the formation of a field of policies.

For example, the PROFAE was very productive; it led to the emergence of initiatives such as the Programa de Formação de Profissionais de Nível Médio para a Saúde (PROFAPS – Program for the Training of Middle Level Health Professionals), which was developed from 2009. The PROFAE left a political-institutional legacy via the establishment of a network of technical schools for the Sistema Único de Saúde (SUS – the Brazilian Unified Health System), the RET-SUS, and it was the steady hands of Izabel that were involved in those initiatives.

Izabel left us in December 2010, at the age of 83, but she remains alive through the ideas that she bequeathed, the nurses she helped to train, the network of technical schools that support the SUS, and in the proposals that, even today, shape the field of Brazilian public health.

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