Antonio Gramsci¹1. Coutinho CN. O leitor de Gramsci. Rio de Janeiro: Civilização Brasileira; 2011 asserts “whoever wants an end should also want the means”. Although this observation may appear at first glance rather obvious, it may nonetheless be warranted given the long history of political gambles followed by defeats of the working class.

If health is democracy, then to discuss Brazil’s Unified Health System (Sistema Único de Saúde – SUS) is to discuss politics. It is to think about and act on the present moment, while at the same time understanding how we ended up in the current morass. The daily political struggle should be coupled with the task of “‘knowing thyself’ as a product of the historical process developed up to the present time”²2. Gramsci A. Cadernos do cárcere. vol. 1. Rio de Janeiro: Civilização Brasileira; 2004.. And the flags historically waved by the health movement cannot dispense with this inventory³3. Dantas AV. Do socialismo à democracia – tática e estratégia na Reforma Sanitária Brasileira. Rio de Janeiro: Ed. Fiocruz; 2017.. We aim here to open up the discussion about what to do and how to do it, where the SUS and the necessary struggle to defend it is understood as part of a whole that cannot be broken down into parts. For us, therefore, the adoption (or rejection) of the totality viewpoint⁴4. Lukács G. História e consciência de classe. São Paulo: Martins Fontes; 2003.is decisive in political struggle, including the fight to defend the SUS.

Such a perspective poses some rather awkward, urgent questions: do we still believe that it is possible to preserve or strengthen the SUS (as a universal, public healthcare system) through a struggle that is exhausting itself? Do we want the same democracy that we demanded in the struggle against the dictatorship, because with it the rules of the game that enable institutions to tame capital and control the state would be guaranteed? Is it appropriate to continue the fight to defend the SUS without reevaluating the losses arising from the gamble taken by the health movement on coexistence between public and private in name of a “national Project”?⁵5. Arouca S. Democracia é Saúde. In: Anais da 8ª Conferência Nacional de Saúde; 1987; Brasília. p. 35-44. Can the gamble on the “convergence between the health reform movement and the majority of Brazilian society” dispense with Gramscian/Marxist understanding of civil society as a space of class conflict rather than consensus?

We believe that it is necessary to recognize the limits of this way of doing politics. The first limit concerns method: it is a mistake to bet all your chips on institutional politics, on top-down arrangements that dispense with or relegate grassroots struggles to the background and reveal, in truth, a certain fetish for the state as a place of colorless, tasteless and odorless power, supposedly freely available for the use of the winners of elections. This criticism has already been raised by the health movement; yet, despite the pedagogical reality we are currently experiencing, the modus operandi apparently shows no signs of change.

The second limit is programmatic. It needs to be said that there is no room for consequential political gambles in the construction of a welfare state in Brazil, nor will there be any conquests (not even partial conquests within this order), unless the struggle against capitalism stems from subaltern classes. Given the structural crisis, the capital system cannot stand more “saddle for horse” concessions, both in core capitalist countries and dependent social formations such as our own.

The third limit is practical and in keeping with the previous two: the heavy global offensive waged by the bourgeois on public funds. Once again, it needs to be said that it was not only the underfunding of the SUS that took the wind out of the sails of the health movement, but also our defeat in the class struggle in the field of health. Lack of resources cannot be tackled solely with the formation of parliamentary caucuses, formulation of laws and regulations and the occupation of key posts in the machinery of government. Much more than a constraint, underfunding screams what nobody wants to hear: the SUS (despite not being fully operational or totally public) does not fit within the current dynamics of international capitalism, which manifests itself in a very striking manner in Brazil. Based on the above, we can make the following assertions: 1. It is our role as health workers and activists to understand in a strict sense and radically tackle this defeat; 2. If we ignore this concreteness, insisting on gambles and methods that do not threaten the status quo, we will be doomed to defeat from the outset.

It is true that an architect’s house will always be different from the ten he built before his own. Nonetheless, it is important to reveal the motivation that guided him in his endeavor: the previous houses did not serve or no longer serve present needs. It is essential to identify not only the flaws in the construction process, but also possible flaws in the plan itself do determine what to do and how - renovate or rebuild on new foundations?

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