Abstract

Mário Magalhães da Silveira (1905-1986) was the main mentor of the school of thought known as “developmental public health” whose influence peaked at the III National Health Assembly. A critic of the adoption of North American models of public health organization, of the centralism and vertical organization of public health campaigns and the interference of international bodies, the public health doctor held the view that as health is a problem of superstructure, it depends on industrial economic development. He also defended the urgent need to municipalize public health in order to attend to the real needs of the Brazilian population. A pioneer of the intermingling of economic and demographic variables, he may be seen as a predecessor of the health economy discipline. The article describes the professional path of Mário Magalhães as a backdrop to his critical thinking on specific national situations and the health policies adopted.

Key words
Public health; National health policy; Developmental public health; Municipalization; Mário Magalhães da Silveira

Biographical details

Mário Magalhães da Silveira was born in Maceió, (Alagoas), on April 24^th, 1905, to José de Magalhães, journalist, and dona Naná, whose family owned land in the hinterland of the state. He studied at the Diocesan school, with French as his main foreign language, spent some time at the Military School in Ceará and in Bahia, in 1925, would be the first of the four Magalhães da Silveira brothers to obtain a medical degree. At medical school Mário was a classmate of his cousin Nise, whom he would eventually marry.

Soon after graduation, he travelled to Rio de Janeiro where, at Manguinhos, he attended the Specialization in Hygiene and Public Health course, then a three year course – two at Oswaldo Cruz Institute and one at the Medical School. In 1931, he held the position of public health doctor in the National Health Department of the Ministry of Education and Health, occupying a number of posts in the profession “from the most humble, as a traveling doctor for the Rural Prophylaxis Health Center to Director of the Department of Health of the state of Sergipe”¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

Between 1938 and 1940, together with public health doctors Ernani Braga and Valério Konder, he was an aide to dr. Almir Godofredo de Castro, the federal health authority of Region IV (Rio Grande do Norte, Paraíba, Pernambuco and Alagoas). In the early 1940s “he travelled all over Brazil, in his professional performance, from the Amazon down, in the early days of the second rubber saga, when few dared to live there, especially whoever had already tasted the pleasures of Rio”²2. Silveira MM. Meu Tipo Inesquecível. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. Rio de Janeiro: Revan; 2005. p. 17-19..

From 1953 onwards, with the creation of the Ministry of Health, and up until 1964, Mário Magalhães played a decisive role as an advocate of the new health policies being proposed, working directly with health ministers, writing their speeches and even those of the nation's presidents. Mário Magalhães was, for over twenty years, the main mentor of the school of thought known as ‘developmental public health’.

In 1959, when Celso Furtado was Supervisor of SUDENE (Superintendence of the Development of the Northeast Region), Mário was responsible for its public health programs, prioritizing water supply and sewage disposal systems²2. Silveira MM. Meu Tipo Inesquecível. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. Rio de Janeiro: Revan; 2005. p. 17-19., before building hospitals. During the Jânio Quadros administration, when all federal civil servants were required to return to their institutions of origin, he once again worked with the health ministers. Even after being removed from SUDENE, he continued to take part in the Superintendence's Council as a representative of the Ministry of Health.

At the National School of Public Health (ENSP) he created and taught, between 1960 and 1961, the “Socio-economic fundamentals” chair of the Basic Public Health Course for Doctors, as well as writing for Conjuntura Econômica (Economic Conjuncture) of Getúlio Vargas Foundation and Desenvolvimento & Conjuntura (Development & Conjuncture) published by the National Industry Confederation. He also taught at ISEB (Higher Institute of Brazilian Studies) and organized conferences on health and development in a number of courses held by CEPAL.

In 1962 he was elected president of the Brazilian Society of Hygiene and, in 1963, appointed Secretary-General to the III National Health Assembly by the Minister of Health. Besides his duties as Director of the division of the public health organization which received all the papers to be presented at the event, he was also the rapporteur for the technical commission in charge of studying the subject of municipalizing health services.

In March 1964, he was a member of the Brazilian delegation to the World Health Assembly presided by minister of health Wilson Fadul. Returning to Brazil, the situation had changed: he was required to submit to interrogations in at least three Military Police Inquiries, was removed from the position of trust he held at the Ministry of Health and no longer allowed to teach at ENSP. He was re-located to the National Service of Tuberculosis, in Rio de Janeiro, directed by Hélio Fraga, who was seen as a conservative and well-liked by the military. “It was almost a professional exile by choice”³3. Gerhard G. Depoimento Germano Gerhardt Filho. In: Depoimentos Orais do projeto Memória da Tuberculose no Brasil, 1990-1992..

After 1964, the public health doctor began to participate as a professor in courses offered by the Medical Association of Guanabara State, an entity that united socialist and communist doctors who were critical of medical practice, focusing on the interests of the common people.

In the 1970s, and for some years, Mário Magalhães served at the Health Secretariat of the then Guanabara state, even at the Health Center of Mangaratiba (West area of Rio de Janeiro city), but, mostly, in the Department of Epidemiology and Statistics, where he organized the mortality files and updated twenty years of statistics. During this time he also worked with a group from IPEA (Institute for Applied Economic Research) recovering the guidelines of the III National Health Assembly in order to orientate the PIASS (Internalization of Health and Sanitation Actions Program).

In 1979, Isnard Teixeira and Celso Arcoverde went to Brasília in his place to receive the medal granted him in 1963 by president Goulart and only then, with the political amnesty, being delivered. Mário refused to go, being averse to honors. When his friends came back with the medal, he threw it in the toilet.⁴4. Escorel S. Saúde Pública utopia de Brasil. Rio de Janeiro: Relume-Dumará; 2000.

In 1983, Mário became very ill with pneumonia. Upon being hospitalized, an aneurysm of the abdominal aorta was found which would cause his death in September 1986.

1920 to 1945: formative years and professional activities

Mário Magalhães began his career as a public health doctor at a medical center for Rural Prophylaxis. The Rural Prophylaxis Service was created in 1918 in response to the clamour of the Pro-Sanitation League of Brazil led by Belizário Penna, demanding health and sanitation services reforms for the outback of Brazil. Ever since the scientific expeditions organized by Manguin-hos’ researchers, the reality of the interior of the country and its diseases were seen as drawbacks to the increase of economic capacities, to a degree that motivated Miguel Pereira, in 1916, in a speech to the National Academy of Medicine, to declare: “Brazil is a big hospital”⁵5. Escorel S, Teixeira LA. História das Políticas de Saúde no Brasil de 1822 a 1963: do Império ao desenvolvimentismo populista. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. 2a ed. Rio de Janeiro: Editora Fiocruz; 2012. p. 279-321..

Since malaria was rampant, the government decided to create a system to distribute quinine, called ‘State quinine’. […] The Rockefeller Foundation's first intervention in Public Health in Brazil also took place in those days: a service was created to fight parasites, mainly in the Northeast. […] This system soon proved to be entirely unproductive, for children continued going barefoot, bathing in the same rivers – it was a continuum¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

In the post World War I framework, a time when Europe's hegemonic axis and worldwide influence shift to the United States, Brazilian doctors began attending Public Health courses at Johns Hopkins University and returned to Brazil “full of enthusiasm for U.S. Public Health. What they learned and saw led them to believe that if an identical health system could be implanted in Brazil, we would have a population as rich and as healthy as that of the U.S.”¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

Mário Magalhães first worked as a public health doctor in an institutional context that bore the imprint of Carlos Chagas’ reform of the National Department of Health, characterized by the centralization of public health administration as well as the coordination and increase of health services⁵5. Escorel S, Teixeira LA. História das Políticas de Saúde no Brasil de 1822 a 1963: do Império ao desenvolvimentismo populista. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. 2a ed. Rio de Janeiro: Editora Fiocruz; 2012. p. 279-321..

This tendency would give rise to a doctrine which, gradually, gained the support of the great majority of health technicians in Brazil. In a conference delivered at the Military Academy of Medicine, Health Minister Aramis Athayde (09/1954 – 11/1955), whose thinking had a lot in common with that of Mário Magalhães – who may, in fact, have written the minister's speech – describes the reform:

The main point was that public health measures should be imposed and, for implementation to be quick and energetic, the authority of those in charge should derive from a higher level than the municipality that lacked sufficient funds to deal with the difficult local health issues⁶6. Silveira MM. Conferência proferida pelo ministro da Saúde na Academia de Medicina Militar, no Rio de Janeiro em 27 de junho de 1955. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. Rio de Janeiro: Revan; 2005. p. 27-41..

In order to implement the reforms, Carlos Chagas invited public health doctors who had studied in the U.S. The “young Turks” as they were called by other public health doctors, “wanted Brazil to adopt the same North American public health system, believing they would thus solve all our problems”¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

The expression ‘young Turks’ was used by their opponents to belittle them. It alluded to the military coup in Turkey, directed by general Ataturke, which led a group of young officers to power. The allusion attempted to characterize the speed with which those young public health doctors climbed to power or held sway over it. Besides this, […] they were extremely authoritarian in their work methods and attempted to force all the other doctors to adhere to their disciplinary regime – which they imagined to be ideal, including exclusive dedication that generated great resistance⁷7. Lima Sobrinho V. A política de saúde pública e o movimento sanitário brasileiro (1920-1950) [dissertação]. Rio de Janeiro: UERJ; 1981..

The 1930 revolution, with the creation of the Ministry of Education and Health, the reforms of 1934 and 1937, and even 1945, would merely enhance the dominance of the “young Turks” appointed to direct the health services in the different states.

It was therefore not by chance that the structuring and consolidation of the public health medical career took place hand in hand with the reforms that sought to define and expand nation-wide governmental actions in the public health field. As priorities for public health were defined, the requirements for the establishment of a regulated medical specialty were also reaffirmed. Meanwhile, this was the same generation that was actively intervening, contributing to build this institutional apparatus, defining priorities and accumulating experiences through day to day work throughout the far reaches of the country, both drawing up political proposals for the sector and implementing policies. Thus, it is quite difficult to separate the process of public health institutionalization, developed from the 1930s onwards, from the personal and professional trajectories of the generation that established itself during this period⁸8. Fonseca CMO. Trabalhando em saúde pública pelo interior do Brasil: lembranças de uma geração de sanitaristas (1930-1970). Cien Saude Colet 2000; 5(1):393411.. Some members of this generation of public health doctors came to occupy the main posts in the Ministry of Education and Health and, after 1953, of the Ministry of Health⁹9. Hochman G. Reformas, instituições e políticas de saúde no Brasil (1930-1945). Educar em Revista 2005; 25:127-141..

With the Estado Novo (1937-1945) the authoritarian centralization of public health policies would only increase. And Mário Magalhães, as well as other public health doctors, was transferred to the North and Northeast in order to develop activities established by the National Health Department. “(…) the public health doctors went to the different states and acted like satraps, imposing public health regulations absolutely unfit for the needs of Brazil. Saying this does not constitute an attack on anyone, because I was one of them”¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

Further centralization took place with the Capanema reform of the Ministry of Education and Health, that sought to end municipal health activities, directing those services to state level governments now in the hands of “interventors”, chosen by the federal government⁹9. Hochman G. Reformas, instituições e políticas de saúde no Brasil (1930-1945). Educar em Revista 2005; 25:127-141.. Besides the eight Federal Health Units and the National Health Conferences, the reform also created services destined to operate on a national level and directed towards specific diseases, following a campaign logic: each service had its own team in each state, as well as specific norms and guidelines, and they all fought over the distribution of financial resources; each nucleus constituted a level of bureaucratic power in permanent disagreement with the others.

As we had been trained for that job, we followed in detail the results of our work. We had rules, we had conditions, we made efforts, it was a tremendous battle, public health doctors, nurses etc. Interested as we were in results, we followed the data – infant mortality, this and that. Nothing changed. It all remained as before. Year after year, some got fed up. I was one of the first to tire. It was not possible¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

At first there were no formal disagreements as to the philosophical ideas regarding public health doctrine. Systematic opposition to the ideas of the “young Turks” would only become formally manifest in the 1940s, led by public health doctor Mário Magalhães⁷7. Lima Sobrinho V. A política de saúde pública e o movimento sanitário brasileiro (1920-1950) [dissertação]. Rio de Janeiro: UERJ; 1981.. One of the main aspects of Mário Magalhães’ criticisms, emphasized with time, was the presence of North American institutions and technicians in health services in Brazil, basically in the Malaria of the Northeast, the Yellow Fever and the Special Public Health (SESP) Services. The public health doctor considered that North American models and methods were being applied with no regard for Brazilian reality, at a great cost due to their sophisticated structure and the high qualification of their personnel, their action having limited impact.

With the fall of Getúlio in 1945, things went from bad to worse. The states proclaimed “independence or death.” The local public health doctors no longer accepted being bossed by federal imbeciles. It practically ended… We, the Federal Government doctors, who had been there, began to return to get our lives going. We tried to convince our elders, who were our friends, that we, as public health doctors, held a responsibility towards the people; that it was not possible to continue to enforce a system that yielded no results. They refused to accept this¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

The end of WWII and the fall of the “Estado Novo” marked the beginning of a new state of affairs in which the health policy crisis “made the time ripe for a debate on the forms of public health medical attention⁷7. Lima Sobrinho V. A política de saúde pública e o movimento sanitário brasileiro (1920-1950) [dissertação]. Rio de Janeiro: UERJ; 1981.“. It is in this context that the ideas of Mário Magalhães start to spread – his critique of the North American model of organizing public health assistance, of the international bodies, of centralization, of the campaigns. This new school of thought that peaked in the early 1960s would be named ‘developmental public health’.

Developmental public health was born in the context of the struggles for the democratization of the country during the Estado Novo and in the heart of the industrialization and urbanization processes that began to be launched […]. The criticism was directed at thecentralizing and authoritarian campaign oriented public health, that, born of the Carlos Chagas reform of 1920-1921, had reached its climax in 1938-1945 when Barros Barreto, director of the National Health Department, with political backing by minister Gustavo Capanema, raised that organism to a central command in charge of putting into practice national public health policies by means of multiple vertical centralized programs, emptying, in the same stroke, both the role of the states in the regional divisions and that of the municipalities in attending to local priorities¹⁰10. Labra ME. Sanitarismo Desenvolvimentista. In: Teixeira SMF, organizador. Antecedentes da Reforma Sanitária. Rio de Janeiro: PEC, ENSP; 1988. Textos de Apoio. p. 15-25..

In a text probably written in 1946, Mário Magalhães offers the following diagnosis: “In Brazil, people die from tuberculosis, but also from parasites, malaria; from lack of medical assistance, from ignorance, and, mainly, from extreme poverty and hunger due to the immense backwardness of the national economy”¹¹11. Silveira MM. Aspectos Econômicos da Luta contra a Tuberculose. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 45-61..

1946 – 1963: the years of influence

In a conjuncture characterized by the Cold War and anti-communism on the foreign front and, internally, by governments that were populist although authoritarian and repressive, Brazil underwent deep economic, social, political and cultural transformations whose ‘cement’ would be ideological battles that included the defense of industrialism, nationalism and developmental interventionism, constituting the “ideology of development” that reached its highest moment at the end of the Kubitschek administration¹⁰10. Labra ME. Sanitarismo Desenvolvimentista. In: Teixeira SMF, organizador. Antecedentes da Reforma Sanitária. Rio de Janeiro: PEC, ENSP; 1988. Textos de Apoio. p. 15-25..

During the Dutra administration, Mário Magalhães was a severe critic of the Salte plan (‘it was a nest of stupidity”) and, due to this, was accused of being a communist.

‘Whoever defends the idea that Public Health is not supplied by doctors, but by economic development, is a communist’, they said. This label was not easy, in Dutra's time! Despite having been a legal government, it was extremely reactionary¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

Also at that time, Mário published an article that accused the National Campaign for the Control of Tuberculosis (CNCtb) of being costly and inefficient. He criticized minister Ernesto de Souza Campos for choosing as priorities the control of tuberculosis, the reduction of infant mortality and malaria control, all problems eminently social and dependent of the economic structure, that public health ‘technique’ on its own would be unable to solve, stating that “tuberculosis, as, in fact, all preventive medicine, is a social problem”¹¹11. Silveira MM. Aspectos Econômicos da Luta contra a Tuberculose. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 45-61..

The 1951 message of Getúlio Vargas, this time constitutionally elected, translates Mário Magalhães’ precise thinking: health is an issue of superstructure and health only improves when muscular strength is substituted by fuel produced energy¹⁰10. Labra ME. Sanitarismo Desenvolvimentista. In: Teixeira SMF, organizador. Antecedentes da Reforma Sanitária. Rio de Janeiro: PEC, ENSP; 1988. Textos de Apoio. p. 15-25.. However, “Getúlio accepted our thesis in his speech, but the forces of inertia were more powerful and everything remained as before, and would remain so until 1964”¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

Although unable to alter the organization of public health, the group of public health doctors led by Mário Magalhães spent the 1950s opposing “formally, the USA biased ideas of the ‘young Turks’, the conceptions of the Sespian public health administration, the vertical structure of SESP (Special Public Health Service) and other public health services” and developing the thesis of the need and viability of municipalization of health services⁷7. Lima Sobrinho V. A política de saúde pública e o movimento sanitário brasileiro (1920-1950) [dissertação]. Rio de Janeiro: UERJ; 1981..

During the JK administration, when “problems in terms of development began to receive more respect”, the ideas of Mário Magalhães were refuted in view of the reduction of malaria and other diseases transmitted by insects, as well as tuberculosis, due to the use of residual insecticides and also of antibiotics and bacteriostatics.

[…] They claimed it was not in fact true, because antibiotics and insecticides had greatly improved health conditions without development taking place. […] Actually, what improved, often, was not exactly health. Health continued more or less the same. […] what improved was the health status but the people's health remains the same, because they continue not having access to food, sleeping poorly etc. So, it is not the same thing¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

Mário Magalhães’ thinking also influenced sociologist Guerreiro Ramos, who dedicated his 1954 book Cartilha brasileira do aprendiz de sociólogo (The Brazilian apprentice sociologist handbook) to the public health doctor¹²12. Maio MC, Lopes TC. Da Escola de Chicago ao Nacional-desenvolvimentismo: Saúde e Nação no pensamento de Alberto Guerreiro Ramos (1940-1950). Sociologias 2012; 14(30):290-329.. The diagnosis made by Guerreiro Ramos, regarding infant mortality, was a critique of measures recommended by child welfare specialists tied to the State, such as the massive building of maternity hospitals and child welfare centers throughout the country. In a criticism very similar to the one Mário Magalhães directed against the CNCTb¹¹11. Silveira MM. Aspectos Econômicos da Luta contra a Tuberculose. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 45-61., “Guerreiro proposed reducing philanthropic enterprises to a minimum, in order to prioritize public investment in more broad policies aimed at transforming food, housing, education and employment conditions”¹²12. Maio MC, Lopes TC. Da Escola de Chicago ao Nacional-desenvolvimentismo: Saúde e Nação no pensamento de Alberto Guerreiro Ramos (1940-1950). Sociologias 2012; 14(30):290-329..

Being members of the Higher Institute of Brazilian Studies (ISEB), created within the Ministry of Education in 1955, Mário Magalhães and Guerreiro Ramos tried to invert the order of the terms in the relationship health-development, present in the notion of the vicious circle adopted by SESP¹²12. Maio MC, Lopes TC. Da Escola de Chicago ao Nacional-desenvolvimentismo: Saúde e Nação no pensamento de Alberto Guerreiro Ramos (1940-1950). Sociologias 2012; 14(30):290-329.. In opposition to Gunnar Myrdall's thesis of the vicious circle of poverty, the new school of public health doctors declared extreme poverty to be the cause of illness and, therefore, the one to be tackled, “in favor of an increase in the average national income and labour productivity, by means of techniques that spare human muscular fatigue”.

The intellectual affinities between Guerreiro Ramos and Mário Magalhães, initiated in the last years of the 1940s, would continue along the next decade. They are basically expressed in the common focus on the socio-economic conditions required to improve the health situation of the people and in their criticism of the use of North American models of public health actions lacking due consideration for the national context. Besides taking part in the II Latin American Congress of Sociology, as rapporteur of the commission presided by Guerreiro, Magalhães was invited to teach classes, in the mid 1950s, in courses offered by ISEB¹²12. Maio MC, Lopes TC. Da Escola de Chicago ao Nacional-desenvolvimentismo: Saúde e Nação no pensamento de Alberto Guerreiro Ramos (1940-1950). Sociologias 2012; 14(30):290-329..

Indifferent to authorial glories, as Eduardo Kertész¹³13. Silveira MM. Prefácio. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 21-24. would say, Mário Magalhães was the ghost writer for presidential messages and speeches and conferences of the Health Ministers during the entire period that goes from 1951 to 1964. “The influence of the new school of thought is undeniable […]. From Getúlio Vargas (second term) to João Goulart, the same line of thought and data are brought up to underline the belief that the degree of the population's health is the natural consequence of its economic progress”¹⁰10. Labra ME. Sanitarismo Desenvolvimentista. In: Teixeira SMF, organizador. Antecedentes da Reforma Sanitária. Rio de Janeiro: PEC, ENSP; 1988. Textos de Apoio. p. 15-25..

In that decade (1950s), criticism was directed less towards the “campaign model’ as a form of organization [vertical and centralizing] and more towards the perspective that disconnected the medical-public health system's interventions from socio-economic development. […] The main role, at the time, was not played by ‘developmental public health’ nor its ideologues. They would only gain the spotlight in the public health agenda in the early 1960s¹⁴14. Hochman G. O Brasil não é só doença. História, Ciências, Saúde – Manguinhos 2009; 16(Supl. 1):313-331..

Despite all the official speechmaking and the recognition granted to the developmental public health doctors, during the 1954-1961 period no substantial changes were made to the juridical forms. Instead, the State's omission of its duty towards all citizens was consolidated […]¹⁰10. Labra ME. Sanitarismo Desenvolvimentista. In: Teixeira SMF, organizador. Antecedentes da Reforma Sanitária. Rio de Janeiro: PEC, ENSP; 1988. Textos de Apoio. p. 15-25..

The criticism directed to the international bodies, dating from the Rockefeller Foundation's campaign to fight parasites, and whose main focus was (F)SESP's health care model, would be further strengthened by the Morwin Bohan Mission that, within the scope of the Alliance for Progress, proposed a program to end illiteracy in the Northeast, building schools and health centers and distributing “enormous amounts” of powdered milk. Instead, believed Mário, “they should substitute those for good quality milk cattle, so the situation could be resolved once and for all, since Brazil would have available, in the near future, a source of production of basic foodstuffs within its own borders”¹⁵15. Silveira MM. Desenvolvimento Econômico e Saúde. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde -população. 3a ed. Rio de Janeiro: Revan; 2005. p. 63-76..

Mário Magalhães denounced, in 1962, the mission for “wanting to prepare the people of the Northeast for work in other regions of the country […] not having the progress of the region in view but its depopulation […] the public health measures proposed by the Mission intend to fatten the people and lead the country to misspend its resources”¹⁵15. Silveira MM. Desenvolvimento Econômico e Saúde. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde -população. 3a ed. Rio de Janeiro: Revan; 2005. p. 63-76.. And, in 1979, he would once again state “They wanted to diminish the population (…) and also to avoid any more energy being produced in the Northeast”¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

He referred to the 1961 meeting of the Pan-American Health Organization in Punta del Este as “the reign of folly”. “They would have to be too ignorant to imagine it would be possible, in the space of 10 years, and in completely different countries – […] – to obtain the same results”¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

The main danger and what caused a great deal of damage to the development of public health in South America and, as a result, to its economic development, was the malignant interference of international organizations that always proposed plans and programs to lead these countries to spend, uselessly, their funds¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

The influence of Mário Magalhães and of the views of ‘developmental public health’ reached its climax during the João Goulart administration. The public health doctor took active part in developing the National Health Policy presented by Minister Souto-Maior at the end of 1961, that attempted to integrate it with the National Development Plan set up by Celso Furtado, in order to “make Public Health an effective tool to assist economic development”¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

The National Public Health Policy proposed by Souto-Maior and Mário Magalhães is nothing more than an attempt to redefine or give the Ministry of Health an identity of its own, ten years after inconsistent activity, and align it with the progress achieved in the socio-economic sphere […]. In effect, however, the Ministry of Health will be seen as an organism that renders assistance to economic development and never as a means to formulate and implement a social policy¹⁰10. Labra ME. Sanitarismo Desenvolvimentista. In: Teixeira SMF, organizador. Antecedentes da Reforma Sanitária. Rio de Janeiro: PEC, ENSP; 1988. Textos de Apoio. p. 15-25..

In 1962, by means of intense confabulation, Mário Magalhães was elected president of the conservative Brazilian Hygiene Society (SBH) and organized the XV Brazilian Hygiene Congress in order to discuss three issues: Economic Development and Health; Public Health Program for Economic Development; and Planning and Programming of Medical Health Activities. The Congress set the stage for Minister Wilson Fadul to convene the III National Health Assembly, which took place in 1963, and whose reports, only to be published in 1991, reflect the ideas of the developmental public health doctors.

In 1963, we spoke to minister Wilson Fadul, in order that a National Health Assembly be convened. We had already obtained support for those theses from 800 public health doctors who would take part in the Assembly. We believed there should be no imposition. There should be a consensus among the doctors working in the field¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

During this Assembly the thesis defending municipalization as the model for organizing health services, absent from Souto-Maior's policy, makes an appearance.

They do not go so far as to define the expression [municipalization of health services] or the role the Ministry of Health would play […] generic considerations […] critiques of federal centralization, the weakening of the executive role of municipalities, the dispersion, superimposition and multiplicity of organisms, the high cost/benefit of organizations such as SESP, the low coverage etc.¹⁰10. Labra ME. Sanitarismo Desenvolvimentista. In: Teixeira SMF, organizador. Antecedentes da Reforma Sanitária. Rio de Janeiro: PEC, ENSP; 1988. Textos de Apoio. p. 15-25..

The municipalization philosophy was introduced in the Triennial Plan for Economic and Social Development (1963-1965) proposed by president João Goulart's Planning minister, Celso Furtado, but just as all the proposals of developmental public health, it was suppressed by the civilian-military dictatorship that came to power on April 1^st, 1964. “It is as if the drowning guy swims, swims and dies on the beach. We soon saw that the situation had changed and that here was no more chance”¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

Before the coup, however, Mário Magalhães wins one more victory: the thesis that development determines health and not the opposite – as defended by the rich nations and even by the director-general of the World Health Organization, the also Brazilian Marcolino Candau – was adopted at the meeting of the World Health Assembly in March of 1964¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

The legacy

Mário Magalhães da Silveira was the main leader of the developmental public health school of thought. However, in 1979, he reported his trajectory as having been that of a group of people: “We had a commitment, we were Public Health doctors. We had no other activity (I refer to that group of public health doctors who shared this view)”. “We are not politicians, neither I nor my friends. We have always been professionals interested in our profession.” “As regards to Public Health, I am a man from this field of activity; I have never done anything else in my life. That's 54 years of work”¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

He was said to be a ‘staunch Marxist’¹³13. Silveira MM. Prefácio. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 21-24., but there are no facts that allow us to conclude that he was a member of the Communist Party. He could have been a Party “sympathizer”. His brother Fausto reported¹⁶16. Silveira FM. Depoimento Fausto Magalhães da Silveira In: Depoimentos Orais do projeto Memória da saúde pública no Brasil, 1993-1999. that Mário was well respected, “even by the highly considered communists, as a part of the Party, but I could not say if he was a member because he never told me he had joined. […] But Mário disagreed with the Party; he did not defend their agrarian reform thesis and considered their thesis about the bourgeoisie ridiculous”⁵5. Escorel S, Teixeira LA. História das Políticas de Saúde no Brasil de 1822 a 1963: do Império ao desenvolvimentismo populista. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. 2a ed. Rio de Janeiro: Editora Fiocruz; 2012. p. 279-321..

During the Military Police Enquiry (IPM) of Health he was accused of “planning to cause an epidemic and disorganize everything so the Communist Party could take power”. He replied to the accusation: “(…) But coronel, bear with me. That doctor is a complete ignoramus, if not, he wouldn't write such a thing”¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98.. According to Francisco de Oliveira, he replied: “my commitment is to the people, and when I graduated I swore to use my knowledge in favor of humanity and not against it, so you cannot accuse me of absolutely anything”⁵5. Escorel S, Teixeira LA. História das Políticas de Saúde no Brasil de 1822 a 1963: do Império ao desenvolvimentismo populista. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. 2a ed. Rio de Janeiro: Editora Fiocruz; 2012. p. 279-321.,¹⁷17. Oliveira F. Entrevista concedida à autora. 2000..

Averse to the spotlight, he had a sharp tongue. He loved going to debates to discuss and criticize. He said, of a colleague who wrote enormous books, that he disliked trees. He termed those who had gone to the Punta del Este meeting “fools”. “He was a Quixote… tall, ascetic, untidy, carelessly dressed, his hair never saw a comb; he had a fantastic capacity to speak, truly impressive, tough but not agressive”¹⁷17. Oliveira F. Entrevista concedida à autora. 2000., reported his long time friend Francisco de Oliveira, who also defined him as “this unforgettable combination of Quixote and Sancho, where the wisdom of madness joins the smartness of simplicity …”²2. Silveira MM. Meu Tipo Inesquecível. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. Rio de Janeiro: Revan; 2005. p. 17-19..

Mário Magalhães was a pioneer in intersecting economic variables with demographic indicators. In his texts, he underlines the relationship between population pyramids and the level of economic development. He disagrees with family planning/birth control programs (centered on individuals and families) considering the solutions to be of a collective and governmental order (policies for development, distribution of wealth, municipalization).

The public health developmental view holds, as its main idea, that the level of a population's health depends, in the first place, on the degree of economic development of a country or region and that, therefore, measures of medical-public health assistance are, in most part, innocuous when they fail to accompany or to integrate this process.

The vast experience and a careful study of the failures did not lead me to be disillusioned or to disbelief in the methods of the public health technique, but led me to the fundamental point of view of this work: preventive medicine and the public health technique hasten the achieving of favorable results, proposing the best that can be done, at a certain time, to quickly surmount stages of public health development; they cannot, however, vanquish the prevailing economic and social conditions […]¹¹11. Silveira MM. Aspectos Econômicos da Luta contra a Tuberculose. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 45-61..

We do not intend to diminish the importance of medicine in preserving life and improving the health conditions of mankind. The fact that we are a doctor is the only guarantee of our devotion to public health medical science. It is, however, necessary to situate the issue correctly. Mankind has needs that are previous to those of a public health medical order, those known as the fundamental needs: food, housing or shelter and clothing¹⁵15. Silveira MM. Desenvolvimento Econômico e Saúde. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde -população. 3a ed. Rio de Janeiro: Revan; 2005. p. 63-76..

Mário Magalhães bequeathed a limited set of texts consolidated by Silva and Morell in “National Public Health Policy. The trinity revealed: economics-health-population”¹⁸18. Silveira MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. in which he reaffirms his main ideas. “The health of a population only improves when it is possible to substitute the muscular strength, human or animal, required for heavy work – needed for community life – by the energy of solid, liquid or gaseous fuel”¹1. Silveira MM. Política de Saúde Pública no Brasil nos últimos 50 anos. Conferência pronunciada no Simpósio sobre Política Nacional de Saúde, Comissão de Saúde da Câmara dos Deputados, Brasília, 1979. In: Silveira, MM. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 77-98..

Health is an issue of superstructure¹¹11. Silveira MM. Aspectos Econômicos da Luta contra a Tuberculose. In: Silva RS, Morell MGG, organizadores. Política Nacional de Saúde Pública. A trindade desvelada: economia-saúde-população. 3a ed. Rio de Janeiro: Revan; 2005. p. 45-61.. Just as a building whose foundations must be built beforehand, it depends on the economic structure. Only industrialization, urbanization and technological progress can produce enough means to provide a surplus and enable part of it to be allotted to providing general welfare and, therefore, health¹⁰10. Labra ME. Sanitarismo Desenvolvimentista. In: Teixeira SMF, organizador. Antecedentes da Reforma Sanitária. Rio de Janeiro: PEC, ENSP; 1988. Textos de Apoio. p. 15-25.. In order to implement these ideas, planning on a demographical basis, and municipalization, appear as strategies.

In the last years of his life, Mário Magalhães was progressively left on the sidelines of events and gradually dwindled, losing heart. At a certain point he said to Chico de Oliveira¹⁷17. Oliveira F. Entrevista concedida à autora. 2000.: “ To live is to exert influence and I no longer influence anything at all”. He was wrong.

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