Abstract

This article traces significant moments in the history of the magazine Saúde em Debate – sourcing references and information from documents, historical studies, editions of the magazine, academic work and interviews with physicians and writers who contributed to its creation. In its 39 years of existence, although there may have been variations in the magazine's editorial policy, its role as a means for exchange of ideas and debate on critical health thinking, and making a contribution by in some way intervening in the Brazilian political process, has not changed. The magazine established itself with a firm reputation as a vehicle of scientific communication especially in the areas of health policy and management, expanding the scope of subjects over time. Among the challenges it has faced, as well as that of financial sustenance, has been its role as an instrument for dissemination of Latin American thinking in the field of health.

Key words
Public health; Unified Health System; Knowledge bases; Scientific publications

Introduction

In the 1970s the military regime was beginning to show its first signs of exhaustion, with the end of the so-called ‘Brazilian miracle’, and the consequences of the 1973 oil crisis, which raised inflation to very high levels compared to the previous period: from 2.4 in the 1960s to 7.1% in the years from 1970.

Economic dissatisfaction, and the hangover from the ‘years of lead’ (a phrase applied to the peak of the dictatorship) – which victimized people in almost all sectors of society – formed the substrate for the emergence of movements of contestation and counter-culture in the arts and in science. It was into this broth, in 1976, that the magazine Saúde em Debate (Health in Debate), was born. It was intended as a vehicle for critical thought on the history and institutional framework of healthcare, and for interpretation of the tight relationship between health, the social logic of power, and the resistance movements – and to be a democratic space for publishing new ideas about healthcare¹1 Editorial. Saúde debate 1976; (1):3. originating from this emerging thought in Brazil and Latin America.

The moment of launch of the idea of the magazine was at the 28^th Annual Meeting of the Brazilian Society for the Progress of Science (Sociedade Brasileira para o Progresso da Ciência – SBPC), in June 1976. At this meeting the scientific community, which was already strongly criticizing the military regime, began to demand the return of exiled professors and researchers – who had been victims of the regime – to their research institutions and the universities.

The expectation of the magazine's creators can be seen in the testimony by Rosa Maria Barros dos Santos as she remembers the moment – in the small hours of a day in October 1976 – when she and David Capistrano da Costa Filho, leader and a founder of the São Paulo public health workers' group, went, on foot, to the printers where the first issue of the magazine was being printed. With the copy of the magazine in his hands, deeply moved, David said: “Rosa, you know what this means, you know why I had to come now [before dawn]. This magazine is our first victory, it will cause great transformations”²2 Paula SHB, Santos RMB, Bonfim JRA, Moraes MLS. A criação de Saúde em Debate, revista do CEBES: narrando a própria história. Saúde debate 2009; 33(81):148- 155..

To be distributed, the magazine needed a legal entity to give it legal status. Thus was born the Brazilian Health Studies Center (Centro Brasileiro de Estudos de Saúde – CEBES), a collective entity which, since then, has been responsible for its political and intellectual direction. This is perhaps a one-off: a case where it was not an entity that gave rise to a publication, but a magazine that gave rise to a social movement. In reality, although this is how several of the actors tell it in their testimony, in practice there was no real distinction was seen between the magazine and the CEBES – rather, a complementarity of strategies and aims.

Since then, in 39 years, Saúde em Debate has published 104 regular editions and five special editions, not without undergoing significant difficulties of situation and context. These moments were overcome by the commitment of the militants of the public health doctors' movement, who spared no efforts to keep this means of debate of critical thought about health in existence – recognized as it was by many as an important and decisive instrument of political mobilization in this field, and in the construction, indeed of the Brazilian Unified Health System (Sistema Único de Saúde – SUS).

This article aims to trace some of the history of thinking of the movement that emerged with the magazine, an provide an insight on the meaning of Saúde em Debate for the Brazilian Public Health Reform, the context, and the motivations that led certain actors to create this respected medium of publication – and also to give some present-day data that show its distinguished role in the publication of scientific knowledge.

Methodology

This is a documentary study, using as sources: the editions of the magazine itself; books; theses; recorded testimony; and academic work relating to the magazine as a platform of socialization of knowledge and of political action of the Brazilian public health movement. This material served to constitute the body of the work, and its results are presented in three parts. In the first, the context and the motivations for creation of Saúde em Debate are described; the second section presents the results of academic works that have studied the magazine; and in the third sector some present day data and challenges for the future are expressed.

The context and the motivations for creation of the magazine: its importance and impact in the push for re-democratization of Brazil

In the 1970s, with the authoritarian regime showing signs of weakening, Brazilian society began in turn to make more open signs of resistance, with various initiatives and mobilizations.

As Paim³3 Paim JS. Saúde política e reforma sanitária. Salvador: CEPS-ISC; 2002. states it, the creation of the CEBES in 1976, and the launch of the magazine Saúde em Debate in the same year, made it possible for the Public Health Reform to be linked not only to the reform of services – the administrative reorganization of the sector – but also the expansion of the concept of healthcare with the notion of healthcare as a right, as a participation, and as democracy. In the opinion of Fleury et al.⁴4 Fleury S, Bahia L, Amarante PDC, organizadores. Saúde em Debate: fundamentos da Reforma Sanitária. Rio de Janeiro: Editora CEBES; 2007. the early editions of the magazine, especially the first 20, contain an ‘inestimable treasure’: the fundaments of the Public Health Reform.

Precisely because it did not set out to be only a scientific periodical, Saúde em Debate made it possible to build and establish inter-disciplinary coordination and articulation in the field of collective health: not only political and economic, but also in terms of coordination of society, and ideology.

The same year as the magazine and CEBES were created, there were other historic events that were emblematic signs of the time: The beating of Bishop Dom Adriano Hipólito, who was linked to the progressive sectors of the Catholic Church; the death of the factory worker Manuel Fiel Filho in the government's ‘Information Operations Department – Domestic Defense Operations Center’ (‘DOI-CODI’); the imprisonment of the leaders of the Brazilian Communist Party in São Paulo; the passing of the Falcão Law; and the bomb explosions at the head offices of the Brazilian Press Association (ABI) and the Brazilian Bar Association (OAB).

The young health professionals who formulated the idea of the magazine were activists of the struggle against the dictatorship: they were thinking of an instrument of debate and reflection, and construction of an original line of thinking about health, that would question the national policy of ‘liberal neo-developmentalism’, which was specific to the military elite. It was not a question only of challenging health policy, since, in the last analysis, the field of health was understood to be one of the most significant indicators of the way in which the State deals with peoples' individual lives. It was the State authoritarian bureaucratic model that was in question.

As a consequence of this type of State, Brazil's healthcare operated on the disease-based model: that is to say, assistentialist, specialist-based, hospital-centric and based on cure-based. These characteristics were accentuated by the distortions arising from the regime, fundamentally as a result of the privatization of the pension plan system and of the healthcare model that had been instituted. The regime made itself very strongly present in the context of health policies, with an unprecedented process of privatization, particularly after the use of the resources of the Social Health Fund (Fundo de Apoio Social – FAS-CEF) for the subsidized construction of private hospitals to be associated, through health insurance plans, with the Social Security Service, and of the First Aid Action Plan (Plano de Pronta Ação – PPA) of the then Minister Leonel Miranda, as was denounced in the early numbers of the magazine – to the whole of Brazilian society – by Dr. Carlos Gentile de Mello accused⁵5 Mello CG. O Sistema Nacional de Saúde - proposições e perspectiva. Saúde debate 1976; (1):24-26.,⁶6 Mello CG. A irracionalidade da privatização da medicina previdenciária. Saúde debate 1977; (3):8-15..

A clear example of this model can be seen in the field of psychiatry, where what existed was basically asylum institutions, which had the staggering high number of 80,000 beds, absorbing some 97% of all the financial resources allocated to this area. The denunciation of the situation by the Mental Health Commission of CEBES in 1980⁷7 Comissão de Saúde Mental. A psiquiatria no âmbito da previdência social. Saúde debate 1980; (10):45-48. quoted official documents that acknowledged that the system was full of distortions arising from payments for services that were either not rendered or were unnecessary.

The first few issues of the magazine confirmed the aspirations and expectations of their founders. Among the names that signed the articles in the magazine's first edition are some of the principal activists and authors that were protagonists of the process of Brazilian public health reform, and the creation of the SUS. We mention a few. Sergio Arouca, who published the first work arising from his doctoral thesis⁸8 Arouca ASS. O Dilema Preventivista: contribuições para a compreensão e crítica da medicina preventiva. Rio de Janeiro: Editora Fiocruz; 2007., known as ‘the Preventionist Dilemma’, with a critical analysis of the Natural History of Disease Model of Leavell & Clark⁹9 Arouca ASS. História natural das doenças, Saúde debate 1976; (1):15-19., co-authored with Ana Tambelini a critical essay on the Community Medicine model¹⁰10 Arouca ASS, Arouca AT. Medicina comunitária: implicações de uma teoria. Saúde debate 1976; (1):20-23., a subject that was also covered by Jairnilson Paim¹¹11 Paim JS. Medicina comunitária: introdução a uma análise crítica. Saúde debate 1976; (1):9-11. and Sebastião Loureiro¹²12 Loureiro S. Saúde comunitária. Saúde debate 1976; (1):38-40.. Carlos Gentile de Mello published the article⁶6 Mello CG. A irracionalidade da privatização da medicina previdenciária. Saúde debate 1977; (3):8-15. that would become one of the principal bibliographical sources for critical analysis of the Brazilian National Health System. Mario Testa¹³13 Testa M. Modelos de salud: las condiciones para su desarrollo. Saúde debate 1976; (1):32-37., a Latin American beacon in the field of health planning, published his first article in Brazil, dealing with the health models, and the conditions for their development. And the sociologist Luiz Eduardo Soares¹⁴14 Soares LE. Vendendo saúde: o INPS e a seguridade social no Brasil. Saúde debate 1976; (1):59-63. made an analysis of Brazil's health system and social security system. Many other articles and authors also stand out in this first and innovative issue of the magazine, and in the subsequent issues.

In talking of the magazine's first decade, it is important to highlight its role in disseminating the concept of health as a right, and of construction of proposals for a new health system in Brazil, Indeed Issue 17, which had the cover headline ‘In Favor of a Democratic Health Policy’, was re-issued as an insert for the landmark Eighth National Health Conference in 1986. This edition also published various texts making suggestions for the health sector of the country that was in transition to democracy.

Saúde em Debate magazine as a field of study

The importance of the magazine can also be seen from the references made to it in works that deal with the Public Health Reform Movement¹⁵15 Escorel S. Reviravolta na Saúde: origem e articulação do movimento sanitário. Rio de Janeiro: Editora Fiocruz; 1998.,¹⁶16 Paim JS. Reforma Sanitária brasileira: contribuição para a compreensão e crítica [tese]. Salvador: Universidade Federal da Bahia; 2007., and from the fact that the magazine established itself as a field of study for academic works²2 Paula SHB, Santos RMB, Bonfim JRA, Moraes MLS. A criação de Saúde em Debate, revista do CEBES: narrando a própria história. Saúde debate 2009; 33(81):148- 155.,¹⁷17 Sophia DC. O CEBES e o movimento de reforma sanitária: história, política e saúde pública (Rio de Janeiro, 1970-1980). R. Bras. Hist. Cien. 2012; 5(2):406-408. .

The article by Paula, Santos, Bonfim and Moraes²2 Paula SHB, Santos RMB, Bonfim JRA, Moraes MLS. A criação de Saúde em Debate, revista do CEBES: narrando a própria história. Saúde debate 2009; 33(81):148- 155. entitled The creation of Saúde em Debate, journal of CEBES: telling its own story deals with the memory of the creation of the magazine in the context of the origins of the Public Health Reform and, according to the authors, the purpose was “to show details of the mobilization that gave birth to CEBES, and the participation of São Paulo public health doctors in this process”²2 Paula SHB, Santos RMB, Bonfim JRA, Moraes MLS. A criação de Saúde em Debate, revista do CEBES: narrando a própria história. Saúde debate 2009; 33(81):148- 155.. This work, making use of the oral history, describes the discussions prior to the creation of the magazine from the point of view of two public health doctors who took part in this dynamic. From their testimony, one sees the maturation of Brazilian thinking on public health in the interior of the collective health departments of the public universities, in the specialization courses in public health and in the health services that absorbed the people who came out of these courses.

According to José Rubens Bonfim, one of the interviewees, David Capistrano was alleged to have taken his inspiration from the German magazine Die medicinische Reform (Medical Reform), founded in 1948 by Rudolf Virchow, to create the magazine Saúde em Debate with the aim of publicizing and disseminating new ideas about health. Another interviewee, Rosa Maria Barros dos Santos, provides the complement that among the motivations was “the idea of creating a magazine that would discuss the subject of Health and Democracy, setting out ways forward for new social achievements […]”²2 Paula SHB, Santos RMB, Bonfim JRA, Moraes MLS. A criação de Saúde em Debate, revista do CEBES: narrando a própria história. Saúde debate 2009; 33(81):148- 155.. Further, the article describes how the magazine was circulated - mainly at events, where there would be discussion of subjects that were important for the political moment at that point in time in various states. The testimonies of Bonfim recognize that the actual output of the magazine “does not reflect the very large number of people who were involved in the project”²2 Paula SHB, Santos RMB, Bonfim JRA, Moraes MLS. A criação de Saúde em Debate, revista do CEBES: narrando a própria história. Saúde debate 2009; 33(81):148- 155..

Sophia's doctoral thesis, entitled CEBES and the public health reform movement: history, policy and public health (1970-1980), took CEBES as its subject, dedicating three of its four chapters to studying the content and the authors of Saúde em Debate magazine in its first decade, with the aim of “presenting a more wide-ranging vision of Saúde em Debate: the profile of the writers of its articles; the most frequent subjects; the subjects that were given priority; and the authors that published most in that decade”¹⁷17 Sophia DC. O CEBES e o movimento de reforma sanitária: história, política e saúde pública (Rio de Janeiro, 1970-1980). R. Bras. Hist. Cien. 2012; 5(2):406-408.. She aimed to demonstrate the importance of the publication in the process of the Public Health Reform. The author justifies the choice of the magazine for the study as being “due to the importance that it had in the area over the whole of the 10 years of its publication up to the acceptance of the Unified Health System (SUS) at the Eighth National Health Conference”¹⁷17 Sophia DC. O CEBES e o movimento de reforma sanitária: história, política e saúde pública (Rio de Janeiro, 1970-1980). R. Bras. Hist. Cien. 2012; 5(2):406-408..

It showed that “more than just a means of publication, Saúde em Debate became a point for convergence of multiple interests and an important means for formation and shaping of the Unified Health System”¹⁷17 Sophia DC. O CEBES e o movimento de reforma sanitária: história, política e saúde pública (Rio de Janeiro, 1970-1980). R. Bras. Hist. Cien. 2012; 5(2):406-408.. Further, according to the author, “it is a vehicle which, since its origins, had as a main distinguishing feature examination of the institutional framework and the management of health policies”¹⁷17 Sophia DC. O CEBES e o movimento de reforma sanitária: história, política e saúde pública (Rio de Janeiro, 1970-1980). R. Bras. Hist. Cien. 2012; 5(2):406-408..

Sophia divided the first decade of the magazine (1976 to 1986) into three phases. In the first (1976-1980), the most frequent area discussed in the articles, according to the author, were: (1) planning of healthcare (this item included the texts that deal with subjects relating to health policy, systems, services, and practices at the various levels of the system); (2) human resources in healthcare; (3) preventive medicine; and (4) community medicine. In the second phase (1980-1982) the most frequent subjects in the magazine were: (1) community participation and mobilization in healthcare; (2) workers' healthcare; (3) planning in healthcare; (4) human resources in healthcare; (5) the social security system; and (6) the Prevsaúde system. In the third phase (1984-1986) the main themes dealt with were: (1) planning in healthcare; (2) reform of the health services; (3) family planning; (4) collective health, and reform of the healthcare sector¹⁷17 Sophia DC. O CEBES e o movimento de reforma sanitária: história, política e saúde pública (Rio de Janeiro, 1970-1980). R. Bras. Hist. Cien. 2012; 5(2):406-408..

The harmony between the subjects dealt with in the articles published by the magazine and the related political system is demonstrated by the magazine's dealing with the subject of family planning at just the same time when there was a strong movement for adoption of population control policies in the country¹⁸18 Costa AM. Politica de Saúde Integral da Mulher e Direitos Sexuais e Reprodutivos. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Politicas e Sistema de Saúde no Brasil. 2a ed. Rio de Janeiro: Editora Fiocruz; 2012. p. 979-1010..

Sophia analyzed 161 articles published in the 15 first issues of the magazine. She notes that “a marked characteristic of the articles published in Saúde em Debate in the period was the space devoted in 1985 and 1986 to defending the movement's idea of holding the Eighth Health Conference”¹⁷17 Sophia DC. O CEBES e o movimento de reforma sanitária: história, política e saúde pública (Rio de Janeiro, 1970-1980). R. Bras. Hist. Cien. 2012; 5(2):406-408. – thus providing clear evidence and example of the magazine's political role.

The value given to this conference, in the magazine, was, she said, associated with the stance of criticism of the health system as it was at that time, and the convergent ideas and proposals for changes. “Saúde em Debate allied strong calls for holding the Eighth Conference with a stance strongly and openly in favor of a National Health Policy, and outlining of a unified and democratic National Health System”¹⁷17 Sophia DC. O CEBES e o movimento de reforma sanitária: história, política e saúde pública (Rio de Janeiro, 1970-1980). R. Bras. Hist. Cien. 2012; 5(2):406-408..

She concludes that the magazine stood out among publications dealing with the construction of a new system based on the principles of universalization, equity and integration of health, “progressively occupying a space in the public scenario, defining the points of reference for those that were politically militant in the area”¹⁷17 Sophia DC. O CEBES e o movimento de reforma sanitária: história, política e saúde pública (Rio de Janeiro, 1970-1980). R. Bras. Hist. Cien. 2012; 5(2):406-408.. Further, she says, it was “a magazine that brought together scientific and political knowledge in an alliance applied to management of health policies, through the medium of a critical and alternative vision of the health system in existence at the time”¹⁷17 Sophia DC. O CEBES e o movimento de reforma sanitária: história, política e saúde pública (Rio de Janeiro, 1970-1980). R. Bras. Hist. Cien. 2012; 5(2):406-408..

Saúde em Debate in numbers – and the challenges for the future

In these 39 years the magazine published 104 regular issues, and five special issues. Occasionally more than one numbered edition was published at the same time in a single print run to regularize the frequency, which resulted in 101 magazines actually published. Since 2008, it has regularly produced four issues per year, one each quarter, as well as special editions, the most recent being: (i) Saúde em Debate in the presidential elections: memories and outlook (2010); (ii) Health, development and sustainability: challenges of Rio+20 (2012); (iii) Mental health (2013); and (iv) Evaluation of Basic Healthcare (2014). A special issue on policy, planning and management in healthcare is currently being prepared for publication soon.

Since 2008, when the magazine began to have its own website for control and flow of submissions, 1,916 original articles have been received. Of these, 385 (20.09%) have been published; 63 (3.28%) have been approved and are awaiting publication; 270 (14.09%) were refused due to not being about the relevant area, or not being in accordance with the magazine's editorial policy; and 1,123 (58.61%) were refused after peer review. Of the total, 75 articles (3.91%) are in the process of evaluation. Now tech-updated, the magazine uses web tools for the whole of its process of submission, evaluation and publication.

On the occasion of publication of its 100^th issue, in 2014, the editorial stated that “in its 38 years of existence, and resistance, Saúde em Debate magazine has been one of the most important vehicles for dissemination of debates about the Brazilian Public Health Reform, the progress, and the difficulties, of the Unified Health System (SUS), and for construction of an area of critical thought about Brazilian and Latin American health”¹⁹19 A revista Saúde em Debate comemora seu 100° número [editorial]. Saúde debate 2014; 38(100):4.. It highlights the undeniable historical role of the magazine in the field of public health, since in the magazine “public health doctors found a space for expressing their opinions and publishing the results of their studies and research, and the professionals of the area found a point of reference for political and healthcare practices” ¹⁹19 A revista Saúde em Debate comemora seu 100° número [editorial]. Saúde debate 2014; 38(100):4.. The editorial also said that the magazine has resisted the adoption of a policy (which many scientific magazines have adopted) of ‘commercializing’ dissemination of knowledge by charging submission fees and/or fees for publication of articles. It believes that this political decision “widens access for authors, and helps to democratize the dissemination of scientific knowledge that is socially important for thinking about the dilemmas and challenges of Brazilian and international healthcare”¹⁹19 A revista Saúde em Debate comemora seu 100° número [editorial]. Saúde debate 2014; 38(100):4.. But the editorial also recognizes the enormous contribution of public institutions that have cooperated with the magazine in making this possible.

More recently Saúde em Debate has received and published articles by authors from various Latin American countries, becoming, also, a point of reference for professionals and managers of those countries. Perhaps one of the challenges for the future could be to expand the volume of publications of academic output from the Spanish-language countries, and, with this, consolidate a position as a vehicle for dissemination of Latin American critical thought.

At present, Saúde em Debate magazine is indexed in the following databases: Literatura Lati no-americana e do Caribe em Ciências da Saúde (Lilacs), História da Saúde Pública na America Latina e Caribe (HISA), Sistema Regional de In- formación en Línea para Revistas Científicas de America Latina, el Caribe, España y Portugal (LA- TINDEX), Base de Datos Bibliográfica de Revistas de Ciencias y Tecnología (PERIÓDICA), and Sumários de Revistas Brasileiras (SUMÁRIOS).

In 2012 it was included in the Scientific Electronic Library Online (SciELO), a web library that includes various Brazilian scientific periodicals; and in 2015 it was invited to be part of the Red de Revistas Científicas de América Latina y el Caribe, España y Portugal (REDALYC).

Final considerations: chronicling and commenting on the new struggles against conservative liberalism

In can be said that over these almost four decades, Saúde em Debate has reaffirmed its position as a vehicle of scientific and political communication for the field of Brazilian collective health, particularly in the area of health policy and management. But we have widened the horizon, both in terms of subject and theory, of the articles published, basically because the complexity of health problems has widened, and also because, to start and sustain a debate in any field of knowledge, confrontation of ideas coming from different lines of thinking is essential. On this aspect, as the editorial of the 100^th edition of the magazine says: “Saúde em Debate is open for theoretical and methodological contributions that deal with the various sciences for understanding of the complex reality that characterizes the field of health – but without abandoning the areas of ideas that we have always argued for, in terms of health as a right, and of systems of public and universal health for all. These prerequisites, too, orient the magazine’s editorial policy.”¹⁹19 A revista Saúde em Debate comemora seu 100° número [editorial]. Saúde debate 2014; 38(100):4..

As can be seen from the numbers presented above, the flow of articles submitted is relatively large, which indicates the robustness of the magazine. However, it is also a challenge for CEBES, which is the magazine’s source of financial support. Some steps have been taken, such as: (i) making review and translation of the articles the financial responsibility of the authors, with the editorial team monitoring these stages and choosing the revisors; and (ii) a request that authors that publish in the magazine should affiliate themselves to CEBES as a way of strengthening the entity, and maintaining the democratic access to this important means of dissemination of knowledge in the field of health.

We conclude by pointing out the limits of this present study – especially in relation to analysis of the content of the magazine. However, the wealth of the magazine itself as a source of investigation is evident, and this could awaken interest for further studies, similar to some of those that have been cited in the text above.

References

Publication Dates

History