Abstract

This paper addresses the popular health movement in Nova Iguaçu-RJ in the 1970s and 1980s. Amidst political repression, residents organized themselves to find solutions to various problems, including health problems. Health demands are enhanced both by the dengue epidemic and linkages with the Brazilian health reform and a struggle for democracy. Using documental historical sources from newspapers, health dissemination papers and documents from the House of Oswaldo Cruz-Fiocruz collection, this paper concludes that the example of Nova Iguaçu reveals both the complexity of the process of political opening at the local level and efforts of conducting a health reform where it was needed the most. Resistance on the part of the medical corporation, private interests in health and the existence of a still incipient popular political organization and culture are some of the elements that account for the hardships in advancing the manifest wishes of policies. The specificities of local arenas also point to possible institutional arrangements, sometimes very peculiar and not reproducible in other settings.

Health services reform; History of public health; Popular movements in health; History of Nova Iguaçu-RJ; Health policy

Introduction

At the end of May 1986, in the Baixada Fluminense, Rio de Janeiro, organized groups from Nova Iguaçu and other municipalities were preparing to obstruct the Presidente Dutra Highway, the country’s main road, in a demonstration for the right to health, in a region of disorderly urban growth, poor infrastructure, where the emerging dengue scourge made hundreds of new victims daily and where clientelism and violence prevailed.

This mobilization for better living conditions in Nova Iguaçu had come a long way, at least since the mid-1970s, when the desire for change once again mobilized the spirits, despite all the fears of life under the civil-military dictatorship. Local stakeholders and authorities of health institutions participated in the demonstration. The then regional superintendent of Social Security’s Medical Care Institute (INAMPS) was there. João Carlos Serra was part of the team of Hésio Cordeiro, who assumed the Presidency of INAMPS a few months earlier. In this executive function, Cordeiro represented a multifaceted movement, which had also been active since the mid-1970s, fighting for changes in health institutions, policies and practices and, at the limit, for structural changes in our society.

This paper revisits that popular movement for health, especially in Nova Iguaçu, its epicenter, between the 1970s and 1980s. Amid the repressive atmosphere, residents have been gathering since the previous decade in search of solutions to problems in areas such as housing, health, transportation and education, in what would eventually become a significant expression of popular neighborhood mobilizations that marked the struggle for democracy.

This militancy turned out to be very successful, including in the field of health. We examined these popular demands and the responses of the public authorities, especially from the INAMPS perspective, when led by Cordeiro and a group of technicians, all from the Brazilian Health Reform, a movement that had succeeded in including some of its guidelines in the government program that started with the unexpected mandate of President José Sarney in March 1985. It is, therefore, a matter of revisiting, from a historical perspective, this meeting between a relevant neighborhood movement and the reformist health policies carried out by one of the most important authorities, namely, INAMPS. This text is also a way, with focus on the management and perspective of Cordeiro, to examine, in practice, the first steps of the transformation of the reform’s doctrinal principles into a policy. All this occurred in the midst of a party reorganization process that, as is almost always the case, imposed more demarcations and distances than common affinities.

The Movement of Nova Iguaçu’s Neighborhoods (MAB) has already been studied in different contexts and approaches¹1. Mainwaring S. Os movimentos populares de base e a luta pela democracia: Nova Iguaçu. In: Stepan A, organizador. Democratizando o Brasil. Rio de Janeiro: Paz e Terra; 1988. p. 275-301.

2. Renou TG. A diocese de Nova Iguaçu e a questão da educação e saúde nos movimentos sociais de 1970-1990 [dissertação]. Niterói: UFF; 1994.

3. Silva PT. Origem e Trajetória do Movimento Amigos de Bairros em Nova Iguaçu (MAB) 1974/1992: Relação vanguarda-base-massa: práxis política e educativa [dissertação]. Rio de Janeiro; Fundação Getúlio Vargas; 1993.-⁴4. Pinheiro Junior JM. A Formação do Pt na Baixada Fluminense: um estudo sobre Nova. Iguaçu e Duque de Caxias [dissertação]. Niterói: UFF; 2007., including collective health, in which its connections with the Health Reform are examined⁵5. Zancan L, Magalhães R, Souza RG. Atores Sociais na formulação do programa especial de saúde da Baixada. Bodstein R, organizador. Serviços Locais de Saúde: construção de atores e políticas. Rio de Janeiro: Relume-Dumará; 1993. p. 41-62.

6. Gerschman S. A Democracia Inconclusa: um estudo da Reforma Sanitária brasileira. Rio de Janeiro: Editora Fiocruz; 2004.

7. Stotz EN. A Educação Popular nos Movimentos Sociais da Saúde: uma análise de experiências nas décadas de 1970 e 1980. Trabalho, Educação e Saúde 2005; 3(1):9-30.-⁸8. Souto L. O Direito à Saúde e a Reforma Democratica do Estado Brasileiro: uma construção social republicana [dissertação]. Rio de Janeiro: UFRJ; 2012.. Much of this literature was written in the 1980s and early 1990s, and some works remained under low circulation in the form of academic dissertations. Thus, this paper is also an invitation to a new reading of these works. In dialogue with this literature, the primary sources mobilized were: (1) articles from daily Rio de Janeiro newspapers; (2) health dissemination papers, notably the publications of the Radis-Fiocruz project; and (3) documents of the Personal Collection of Hésio Cordeiro and interviews that integrate the collection of the House of Oswaldo Cruz-Fiocruz.

Much of today’s debates were already there, in the wake of the Brazilian Health System (SUS), either regarding the organization and financing of public health care, their relationship with the business provision of services, health work regimes, ways of promoting a better distribution of resources in the territory or social participation in management, its possibilities and limitations.

Popular mobilization and health in the Baixada Fluminense

The Baixada Fluminense was the center stage of protest movements since the 1950s, which intensified their presence on the eve of the 1964 coup. It was a reaction to a process of disorderly urban expansion and harsh living conditions. This first cycle of popular mobilization was, however, aborted by the dictatorship. By the mid-1970s, however, the period of retraction of residents’ mobilization came to an end. Its starting point was the establishment, under the leadership of Dom Adriano Hipólito, Bishop of Nova Iguaçu, of Catholic parish groups to discuss community problems. Dom Adriano arrived in the region in 1966 and, in 1968, the diocese adopted the formation of ecclesial communities as its orientation. Gradually, its activity sought a more formative profile of the local leadership and a higher degree of organization. At the outset, the Community Integration Movement was set to undertake the revitalization of the Caritas Diocesana later on, making it a formal entity responsible for social works. In the 1970s, especially in the late 1970s, these groups associated themselves with clandestine organizations opposed to the regime. By that time, local conditions became even more severe, as a disorderly urban growth spread at an alarming speed, as was the case for reduced services and violence¹1. Mainwaring S. Os movimentos populares de base e a luta pela democracia: Nova Iguaçu. In: Stepan A, organizador. Democratizando o Brasil. Rio de Janeiro: Paz e Terra; 1988. p. 275-301.,³3. Silva PT. Origem e Trajetória do Movimento Amigos de Bairros em Nova Iguaçu (MAB) 1974/1992: Relação vanguarda-base-massa: práxis política e educativa [dissertação]. Rio de Janeiro; Fundação Getúlio Vargas; 1993.,⁵5. Zancan L, Magalhães R, Souza RG. Atores Sociais na formulação do programa especial de saúde da Baixada. Bodstein R, organizador. Serviços Locais de Saúde: construção de atores e políticas. Rio de Janeiro: Relume-Dumará; 1993. p. 41-62.,⁸8. Souto L. O Direito à Saúde e a Reforma Democratica do Estado Brasileiro: uma construção social republicana [dissertação]. Rio de Janeiro: UFRJ; 2012..

Health issues were one of the initial focuses of the movement in Nova Iguaçu. In 1974, four hygienist physicians, namely, Antônio Ivo de Carvalho, Anna Leonor de Carvalho, José de Carvalho Noronha and Lúcia Souto began providing care at a health post in Nova Iguaçu. Progressively, a list of demands around living conditions is proposed, serving as a key to a process of organization of the residents. The following year, the Mother and Child Care Community Program was created, and at the end of 1975 the Diocese went on to run eighteen local clinics and began to hold periodic meetings, including the Pastoral of Workers and the few independent movements, laying the foundations of a process of establishment of residents’ associations in several neighborhoods, also approaching clandestine organizations of opposition to the military regime. Setting the Neighborhood Friends Movement (MAB) as an entity of coordination and communication with public institutions was the next step³3. Silva PT. Origem e Trajetória do Movimento Amigos de Bairros em Nova Iguaçu (MAB) 1974/1992: Relação vanguarda-base-massa: práxis política e educativa [dissertação]. Rio de Janeiro; Fundação Getúlio Vargas; 1993.,⁵5. Zancan L, Magalhães R, Souza RG. Atores Sociais na formulação do programa especial de saúde da Baixada. Bodstein R, organizador. Serviços Locais de Saúde: construção de atores e políticas. Rio de Janeiro: Relume-Dumará; 1993. p. 41-62.,⁷7. Stotz EN. A Educação Popular nos Movimentos Sociais da Saúde: uma análise de experiências nas décadas de 1970 e 1980. Trabalho, Educação e Saúde 2005; 3(1):9-30.,⁸8. Souto L. O Direito à Saúde e a Reforma Democratica do Estado Brasileiro: uma construção social republicana [dissertação]. Rio de Janeiro: UFRJ; 2012..

All this movement would draw the attention of local representatives of the intimidating practices of dictatorship times. In September 1976, Dom Adriano was kidnapped, beaten, bathed in red paint and left naked in the wilderness. This attack had national repercussion and ended up giving visibility and, after all, strengthening the movement that the church and resistance groups carried out in the Baixada¹1. Mainwaring S. Os movimentos populares de base e a luta pela democracia: Nova Iguaçu. In: Stepan A, organizador. Democratizando o Brasil. Rio de Janeiro: Paz e Terra; 1988. p. 275-301.,³3. Silva PT. Origem e Trajetória do Movimento Amigos de Bairros em Nova Iguaçu (MAB) 1974/1992: Relação vanguarda-base-massa: práxis política e educativa [dissertação]. Rio de Janeiro; Fundação Getúlio Vargas; 1993..

In an attempt to summarize, up to 1985, approximately, the course of this movement of districts can be described as involving three intertwined processes. The first one concerns the creation of associations of inhabitants integrated to the movement; an unequal process, where communities more permeable to mobilization and those of incipient organization are distinguished. By 1983, more than a hundred associations had formally organized themselves into a federation¹1. Mainwaring S. Os movimentos populares de base e a luta pela democracia: Nova Iguaçu. In: Stepan A, organizador. Democratizando o Brasil. Rio de Janeiro: Paz e Terra; 1988. p. 275-301.,³3. Silva PT. Origem e Trajetória do Movimento Amigos de Bairros em Nova Iguaçu (MAB) 1974/1992: Relação vanguarda-base-massa: práxis política e educativa [dissertação]. Rio de Janeiro; Fundação Getúlio Vargas; 1993..

A second process concerns the election of collective claims that can produce results and provide a leap in the mobilization process. In a more or less chronological sequence, they included: (1) the formalization of regular meetings with the municipal Executive, including for the follow-up of decisions; (2) advocacy of the right to housing of more than one thousand BNH housing group borrowers, then in default and exposed to collective eviction processes; (3) the end of illegal and widespread collection of fees in public schools; and (4) the fight against abusive increases in public transport fares. Health, a topic that has been present since the first hour, has tended to take the shape of a struggle for improvements in the infrastructure of sanitation, preventive services and medical care. In 1986, an inaugural epidemic of dengue would push health to the forefront of claims³3. Silva PT. Origem e Trajetória do Movimento Amigos de Bairros em Nova Iguaçu (MAB) 1974/1992: Relação vanguarda-base-massa: práxis política e educativa [dissertação]. Rio de Janeiro; Fundação Getúlio Vargas; 1993.. Regarding this point, it is worth mentioning that the presence of popular organizations, access to militant doctors, among them, besides those already mentioned, Nelson Nahon, a member of the community council, and respect for the residents’ life experience allowed a relatively quick alarm about the presence of the disease⁹9. Surto foi detectado por piloto de avião. Jornal do Brasil 1986 abr 29; s.p. A Hemeroteca do Radis – acessível em http://www6.ensp.fiocruz.br/radis - que reúne recortes de jornais, não fornece indicação de página. As fontes jornalísticas sem indicação de página são dessa coleção.
http://www6.ensp.fiocruz.br/radis... , in an event close to what is now called popular health surveillance.

A third process to be considered, of a necessarily complex nature, refers to the implications for the MAB of the return to democratic life. The reorganization of civil society led to its association with processes such as the constitution of the Federation of Associations of Residents of the State of Rio de Janeiro (FAMERJ), and on a national scale, of the Movement against Famine, which increased the political weight of the movement against the local and state political context. Gradually, the internal differentiation of the movement around ideological and doctrinal tendencies present in oppositions to leftists in Brazilian politics became more evident³3. Silva PT. Origem e Trajetória do Movimento Amigos de Bairros em Nova Iguaçu (MAB) 1974/1992: Relação vanguarda-base-massa: práxis política e educativa [dissertação]. Rio de Janeiro; Fundação Getúlio Vargas; 1993.,⁸8. Souto L. O Direito à Saúde e a Reforma Democratica do Estado Brasileiro: uma construção social republicana [dissertação]. Rio de Janeiro: UFRJ; 2012..

Even with the end of bipartisanship in 1979, many imagined that Rio de Janeiro politics would remain for some time limited to the traditional competition between the partisan groups of Chagas Freitas and Amaral Peixoto, now accommodated in the PMDB and the PDS. On the one hand, the field of popular movements would be demarcated by those in favor of alignment with what they considered a democratic field, which included the PMDB, the PCB, PCdoB, and leftist organizations such as the MR8. On the other hand, there were groups interested in the construction of alternatives that were intended to be more autonomous vis-à-vis traditional politics, anchored in the trade union and popular movements. This field gathered a large part of the militancy of the Catholic communities, the newly created Workers’ Party and the left-wing groups that joined it.

In the context of the state of Rio de Janeiro, this situation would be radically affected when the campaign for the 1982 state elections was held. Leonel Brizola would become an electoral phenomenon, it would compel popular sectors and would frustrate, in the case of Nova Iguaçu, the electoral expectations of some of the leadership close to the PMDB that participated in the neighborhood movement¹⁰10. Amaral F. Francisco Amaral (depoimento, 1999). Rio de Janeiro: CPDOC/ALERJ; 2001.. This had also become an arena of contention among the forces existing in this new setting.

In 1986, the correlation of forces at the state level would change with the election of Moreira Franco, by the PMDB, which constituted a team favorable to the theses of health reform, including about Nova Iguaçu. In Welfare and Land Affairs was Deputy Governor Francisco Amaral, a Nova Iguaçu politician, close to the movement of neighborhoods and the PCB¹⁰10. Amaral F. Francisco Amaral (depoimento, 1999). Rio de Janeiro: CPDOC/ALERJ; 2001.. In the state health department was Sérgio Arouca, from the PCB and the health movement, which brought to his team, among others, Antônio Ivo de Carvalho, a hygienist working in Nova Iguaçu. At the federal level, Hésio Cordeiro, president of INAMPS, was a staunch ally. His team included José Noronha, also active in the MAB, and other young hygienists⁶6. Gerschman S. A Democracia Inconclusa: um estudo da Reforma Sanitária brasileira. Rio de Janeiro: Editora Fiocruz; 2004..

MAB’s blockade of the Via Dutra in May 1986 coincided with Leonel Brizola’s last year of state government. Party choices and electoral possibilities were decisively there. At the time, mayor of Nova Iguaçu, Paulo Leone, accused of embezzlement, was under pressure from neighborhood movements and opposition politicians. In April, more than 2,000 people marched to the city center, urging his resignation and demanding improved services, including health, now under the impact of the dengue epidemic¹¹11. Passeata em Nova Iguaçu pede mudança de prefeito. Jornal do Brasil 1986 abr 25; p. 4..

Hésio Cordeiro and INAMPs policies

Hésio Cordeiro graduated in Medical School in 1965 at the Faculty of Medical Sciences, former Guanabara State University (now UERJ), after an academic course in which he lived with figures such as Juan Cesar Garcia, Piquet Carneiro, Nina Pereira Nunes and Moisés Szklo. He was one of the founders of the Institute of Social Medicine (IMS) of the then Guanabara State University (UEG), which soon became one of the primary centers for the renewed critical thinking in Social Medicine¹²12. Bezerra Júnior B, Sayd J. Um mestrado certo para um momento preciso: as dissertações de mestrado em medicina social 1978-1990 – uma crônica. Rio de Janeiro: Uerj/IMS; 1993.. As a teacher of this institution, Cordeiro developed fundamental studies for the understanding of medical care in the field of social security¹³13. Cordeiro H. As Empresas Médicas. Rio de Janeiro: Graal; 1984. and drug policy¹⁴14. Cordeiro H. A Indústria da Saúde no Brasil. Rio de Janeiro: Graal; 1980., which included his doctorate at the University of São Paulo (USP) in 1981¹⁵15. Buss P. Medicina social no Brasil: esboço do perfil de um pioneiro. Cad Saude Publica 1988; 4(3):342-348.. About two years later, he would assume the current Brazilian Association of Collective Health (Abrasco). From this position of academic and political recognition among his peers, Hésio would pave the way that would culminate in his nomination for the Presidency of INAMPS.

In 1985, the main articulators of the health reform movement, at least in its academic realm, strictly espoused the same commitments of the campaign in the late 1970s. Themes such as democracy, universalization, social participation and decentralization were included in the agenda of debates and political intentions. About the nationalization of services, several evaluations flocked in at the turn of the decade¹⁶16. Dowbor M. A arte da institucionalização: estratégias de mobilização dos sanitaristas (1974-2006) [tese]. São Paulo: Universidade de São Paulo; 2012..To a large extent, the fiasco of initiatives such as the National Program of Basic Health Services (PrevSaúde) revealed, at least for some stakeholders, that there were no institutional and political conditions to anchor the confiscation of the vast hospital network that already had organized representatives advocating their interests¹⁷17. Menicucci TA. Público e privado na política de assistência à saúde no Brasil: atores, processos e trajetória. Rio de Janeiro: Ed. Fiocruz; 2007. Thus, the early years of the 1980s witnesses varying viewpoints regarding nationalization of health services. Part of the reformists argued that nationalization could not be achieved immediately, but treated as a process that, as such, would require time and political struggle.

On the other hand, Cordeiro’s management begins as an unfolding of ongoing transformations breaking with the “nodes of authoritarianism”¹⁸18. Paim J. Ações integradas de saúde (AIS): por que não dois passos atrás. Cad Saude Publica 1986; 2(2):167-183.. In 1982, the Social Welfare’s Healthcare Reorientation Plan, namely, the “CONASP Plan” began. In practice, it involved the implementation of several initiatives, among which the Integrated Health Actions Program (PAIS) and the provision of medical care, regardless of the existence of a link with social security¹⁹19. Cordeiro H. Sistema Único de Saúde. Rio de Janeiro: Ayuri Editorial; 1991. (Coleção Saúde, 1),²⁰20. Escorel S. História da política de saúde no Brasil: 1964 a 1990: do golpe militar à reforma sanitária. In: Giovanella L, et al., organizadores. Políticas e sistema de saúde no Brasil. Rio de Janeiro: Fiocruz/Cebes; 2008. p. 385-434.. The old health financing structure then began to suffer significant changes so that the per service unit payment model, commonly referred to as a major source of corruption, was replaced by the financing blocs model¹⁹19. Cordeiro H. Sistema Único de Saúde. Rio de Janeiro: Ayuri Editorial; 1991. (Coleção Saúde, 1). In 1984, the AIS was transformed into a strategy, focusing on interagency integration under the direction of the public sector; definition of actions based on the epidemiological profile; regionalization and hierarchization of services, including private ones; and decentralization of the planning and administration process, among other orientations²⁰20. Escorel S. História da política de saúde no Brasil: 1964 a 1990: do golpe militar à reforma sanitária. In: Giovanella L, et al., organizadores. Políticas e sistema de saúde no Brasil. Rio de Janeiro: Fiocruz/Cebes; 2008. p. 385-434..

Hésio Cordeiro achieved INAMPS Presidency thanks to the agreements that facilitated the victory of the Tancredo Neves/José Sarney coalition, led by the PMDB/PFL alliance, and especially because Sarney decided to maintain the same ministerial composition engendered by Tancredo²¹21. Fausto B. História do Brasil. São Paulo: Edusp; 2003, which meant Waldir Pires assuming the Ministry of Social Security and Welfare (MPAS). In the formation of the second echelon of the government, more leftist forces of the governing coalition obtained essential spaces, and the appointment of Cordeiro as President of the INAMPS, linked to the MPAS, is part of this arrangement¹⁹19. Cordeiro H. Sistema Único de Saúde. Rio de Janeiro: Ayuri Editorial; 1991. (Coleção Saúde, 1),²²22. Cordeiro H. O Instituto de Medicina Social e a luta pela reforma sanitária: contribuição à História do SUS. Physis 2004; 14(2):343-362.. Of course, he was not alone. In strategic positions at the Institute were José Noronha, José Gomes Temporão, Eduardo Levcovitz and José Paranaguá de Santana among other collaborators¹⁵15. Buss P. Medicina social no Brasil: esboço do perfil de um pioneiro. Cad Saude Publica 1988; 4(3):342-348..

In assuming the direction of INAMPS, Hésio sought to advance the strategies of the previous cycle with decentralized planning and administration at the state, regional and municipal levels. The idea was to give new status to political negotiation. The AIS, which under the management of Aloisio Sales reached fifteen units of the federation, is entirely nationalized¹⁸18. Paim J. Ações integradas de saúde (AIS): por que não dois passos atrás. Cad Saude Publica 1986; 2(2):167-183.,²³23. Cordeiro H. Entrevista à Casa de Oswaldo Cruz. Rio de Janeiro: Casa de Oswaldo Cruz; 2004..

In 1987, however, the debate elicited the transfer of INAMPS to the Ministry of Health. Some stances argued that the AIS was a “rationalizing” and technocratic initiative, incapable of producing changes with the desired level of radicality. In an interview published in June 1988, Cordeiro stated that one of the greatest legacies of his administration would have been the “decentralization within the INAMPS”, holding federative units accountable for their programs and their commitments with the municipalities²⁴24. Centro Brasileiro De Estudos De Saúde (CEBES). Inamps: dois passos adiante e um para trás. Saúde em debate 1988 jun 21; p.36-38..

Cordeiro organized his management around five points: (1) strengthening collegiate and decentralized management mechanisms at the state level; (2) developing integrated and decentralized programming; (3) reviving services, with more significant investment and quality in the expenditure; (4) improving service delivery; (5) deconcentrating resources allocated then to the South and Southeast regions. The following were assumed as cross-cutting (a) universalization of access to health services and (b) support for Integrated Health Actions, to be conducted by INAMPS, the Ministry of Health and the state secretariats. It was the way to begin the implementation of a new health system¹⁹19. Cordeiro H. Sistema Único de Saúde. Rio de Janeiro: Ayuri Editorial; 1991. (Coleção Saúde, 1),²⁵25. Instituto Nacional de Assistência Médica da Previdência Social (INAMPS). Relatório de Atividades. Rio de Janeiro: INAMPS; 1985..

With significant success and public visibility in facing a long tradition of corruption and promiscuous relationships between private initiative and social security¹⁹19. Cordeiro H. Sistema Único de Saúde. Rio de Janeiro: Ayuri Editorial; 1991. (Coleção Saúde, 1), INAMPS was one of the institutional foundations that enabled the staging of the Eighth National Health Conference in March 1986. This event could contribute to the establishment of an agenda that would unify the positions of both those who supported and participated in the inaugural government of the New Republic and those who remained in the opposition²⁰20. Escorel S. História da política de saúde no Brasil: 1964 a 1990: do golpe militar à reforma sanitária. In: Giovanella L, et al., organizadores. Políticas e sistema de saúde no Brasil. Rio de Janeiro: Fiocruz/Cebes; 2008. p. 385-434.. The so-called “bridging strategy” for the implementation of the SUS begins, with the transfer of hospitals and clinics to the states. To this end, since 1987, the AIS were replaced by the Decentralized and Unified Health Systems (SUDS) and, along this course, progress was made in establishing agreements with the state health secretariats and these, in turn, with the municipal secretariats, which for some was an expression of an INAMPS hegemony in the health sector¹⁹19. Cordeiro H. Sistema Único de Saúde. Rio de Janeiro: Ayuri Editorial; 1991. (Coleção Saúde, 1),²⁶26. Instituto Nacional de Assistência Médica da Previdência Social (INAMPS). Relatório de Atividades 1986-1987. Rio de Janeiro: INAMPS; 1988..

In operational terms, the SUDS directed the transfer of INAMPS care units to the states, the Federal District and territories, and even to the municipalities; it granted real estate and equipment; transferred financial resources to decentralized services; and deployed staff. Even after the exoneration of Raphael de Almeida Magalhães and under the auspices of the new minister, Renato Archer, in October 1987, the process maintained the same direction¹⁹19. Cordeiro H. Sistema Único de Saúde. Rio de Janeiro: Ayuri Editorial; 1991. (Coleção Saúde, 1).

However, the political and economic situation deteriorated rapidly. Following the enthusiasm surrounding the Cruzado Plan, the country faced a massive financial and social crisis. In July 1986, the government announced a package of measures that imposed severe cutbacks on consumption, which were unable to cope with the crisis. In February 1987, the government declared a moratorium on foreign debt²¹21. Fausto B. História do Brasil. São Paulo: Edusp; 2003.

The restoration of partisan support of the Sarney government around a physiological center-right-wing had as one of the central themes the extension of the president’s mandate and would culminate in the removal of non-adherents to the proposal from the government. In the changes in the ministry, Magalhães would leave the MPAS. Furthermore, the President was not very pleased with the implantation of SUDS in the state of Maranhão, his state of origin, when contrary to his interests²³23. Cordeiro H. Entrevista à Casa de Oswaldo Cruz. Rio de Janeiro: Casa de Oswaldo Cruz; 2004.. In March 1988, now under the management of Renato Archer, Cordeiro left the command of INAMPS, a widely repudiated decision¹⁵15. Buss P. Medicina social no Brasil: esboço do perfil de um pioneiro. Cad Saude Publica 1988; 4(3):342-348..

Much of the orientation and changes promoted by the management of Cordeiro were institutionalized in the new health system regulated in 1990. They bequeathed us strengths and weaknesses that would be perpetuated over time. In Rio de Janeiro, the institute concentrated around half of its operational resources and the Baixada Fluminense, faced with a state of a health crisis, would be one of the fronts relevant to health in the process of reform.

Health crisis, popular demand and public response

The inauguration of the Posse Hospital was perhaps the first MAB struggle around the health infrastructure. The construction of the hospital was a private initiative, through public funding, and was subsequently subject to federal expropriation in May 1980. In September, MAB already complained about the delay in its inauguration. The hospital would start operations on the eve of the 1982 elections, and a competition was organized for staffing purposes. Its functioning, however, would be problematic and criticized³3. Silva PT. Origem e Trajetória do Movimento Amigos de Bairros em Nova Iguaçu (MAB) 1974/1992: Relação vanguarda-base-massa: práxis política e educativa [dissertação]. Rio de Janeiro; Fundação Getúlio Vargas; 1993.,⁵5. Zancan L, Magalhães R, Souza RG. Atores Sociais na formulação do programa especial de saúde da Baixada. Bodstein R, organizador. Serviços Locais de Saúde: construção de atores e políticas. Rio de Janeiro: Relume-Dumará; 1993. p. 41-62..

Thus, the emphasis on service delivery in the Baixada obeyed a pattern: essentially healing, low supply and quality of public services and practically an induction to care by a plethora of equally problematic clinics and hospitals accredited by INAMPS⁵5. Zancan L, Magalhães R, Souza RG. Atores Sociais na formulação do programa especial de saúde da Baixada. Bodstein R, organizador. Serviços Locais de Saúde: construção de atores e políticas. Rio de Janeiro: Relume-Dumará; 1993. p. 41-62.,²⁷27. População da baixada, mal de saúde, fechará a Dutra. Jornal do Brasil 1986 mai 18; s.p..

In 1983, the state government and the ministries of health and welfare signed a basic agreement for the implementation of the Integrated Health Actions Program, which established the Greater Rio region as one of the priority areas²⁸28. Convênio unifica o atendimento médico no estado. Jornal do Brasil 1983 out 19; p. 5.. In the following year, contractswere signed with local municipalities, including Nova Iguaçu. The MAB then began to press for the creation and actual functioning of the community councils provided for in those tools. In May 1985, a MAB debriefing document revealed the municipality’s complete detachment in the operations of these instances, as well as a minimal capacity to implement the resources already transferred by the federal government³3. Silva PT. Origem e Trajetória do Movimento Amigos de Bairros em Nova Iguaçu (MAB) 1974/1992: Relação vanguarda-base-massa: práxis política e educativa [dissertação]. Rio de Janeiro; Fundação Getúlio Vargas; 1993..

In this same month, Hésio Cordeiro’s management began at INAMPS. Despite the task of advancing a new systemic approach to health, one of the immediate problems was to operate and expand its network of hospitals and clinics in an institutional environment marked by all types of corruption. Another challenge was to manage the workers and the demands repressed by salary readjustments and by adequate work conditions in a situation of spiraling inflation inherited from the military governments. In Rio de Janeiro, these issues have become acuter.

After a first year marked by the fight against fraud and by facing a national strike, the second year of management would be impacted by the emergence of dengue as a relevant epidemiological phenomenon. One of the first affected areas was Baixada Fluminense and Nova Iguaçu in particular.

In the region, the proper functioning of the Posse Hospital was still a promise. To make the hospital operational, INAMPS management would have to face an already chronic problem. In early 1986, it announced its intention to assess the availability of doctors in hospitals in the central regions and to study their relocation in the most disadvantaged areas. About the Posse Hospital, in particular, it was intended to re-evaluate the movement of recently recruited medical personnel using a competition. Such removals had been made on request and involved an exodus of nearly half of the professionals²⁹29. Liminar dá garantia a médicos. Jornal do Brasil 1986 mai 13; s.p..

This type of practice was common throughout Brazil. In an extreme, but real, example, doctors were running to work in Amazon and within a few months were crowded in Rio de Janeiro, using political favors to facilitate moves. The INAMPS management considered this practice illegal. The competition for Nova Iguaçu was expressly directed to allocation in the municipality or priority areas. The Rio de Janeiro Doctors’ Union, the regional council and several medical associations went out in defense of the doctors, and a battle of ordinances and warrants began.

Meanwhile, some hospital directors refused to submit a list of possibly surplus staff, a controversy that even split the medical trade union movement itself, receiving opposition from those who criticized a remarkably corporatist category defense and put residents’ associations on opposite sides. In a compromise solution formulated two months after the onset of the crisis, the temporary and emergency reallocation of one hundred and eleven medical professionals was agreed. On the first day of the agreement, four physicians re-appeared at the hospital²⁹29. Liminar dá garantia a médicos. Jornal do Brasil 1986 mai 13; s.p.. Even in the inaugural times of the New Republic and the Health Reform, of a broad consensus on the need for change, it would not be a simple task to move the medical corporation from its positions, even if it were twenty five miles.

It was in the midst of the dengue crisis, the Posse Hospital crisis and an acute political struggle in the municipality that residents interrupted the traffic on the Presidente Dutra Highway, claiming the declaration of a state of emergency and broad service reform. With the microphone, residents and servants of the Posse hospital, on the one hand, and medical trade unionists, on the other, manifested themselves in conflicting positions. INAMPS, under the triple pressure of the epidemic of dengue, the movement of neighborhoods and the proximity of the election in the state sphere, finalized the preparation of a specific program: Programa SOS Baixada. In Nova Iguaçu, the local political framework made it impossible to include the municipality in the institutional architecture to conduct the program. With MAB’s intervention, the Caritas Diocesana was mobilized as an alternative local body and implementing agency. In the early moments, the State Health Secretariat was also far from the process of formulating the program and managing the new units to be built⁵5. Zancan L, Magalhães R, Souza RG. Atores Sociais na formulação do programa especial de saúde da Baixada. Bodstein R, organizador. Serviços Locais de Saúde: construção de atores e políticas. Rio de Janeiro: Relume-Dumará; 1993. p. 41-62., reflecting the political-electoral tensions of the occasion. The signing of the agreement on the eve of the election and the transformation of the solemnity into campaigning of the coalition led by the PMDB came to be publicly criticized by leaders of the MAB³3. Silva PT. Origem e Trajetória do Movimento Amigos de Bairros em Nova Iguaçu (MAB) 1974/1992: Relação vanguarda-base-massa: práxis política e educativa [dissertação]. Rio de Janeiro; Fundação Getúlio Vargas; 1993. itself. It is noteworthy that within the framework of a reform that was intended to promote a decentralization process, according to the proposals of the health reform movement, the program for Nova Iguaçu was initially formulated without a more significant presence of the state and municipal spheres.

Among the objectives was the transformation of Nova Iguaçu into the “first Brazilian health district” established in the health reform process³⁰30. Baixada terá distrito sanitário. Jornal do Brasil 1986 out 03; p. 5.. A reorganization of the service network was proposed, providing services at all levels of complexity. Nova Iguaçu then had, with problematic functioning, a hospital, four INAMPS emergency care units, twenty municipal health posts and a state health center. The program would include four new INAMPS posts and the accreditation of thirty-five popular clinics, reinforcing the diocesan network.The administration of the clinics would be incumbent upon the Caritas Diocesana, using the transfer of INAMPS funds already allocated and not used by the municipality. The Community Health Committee would validate the doctors to be accredited in the clinics, according to a criterion that would sequentially privilege volunteer doctors working in the philanthropic network, doctors residing in Nova Iguaçu, linked or not to the institute, and those that were connected and but not residents who wished to be allocated in the municipality, receiving financial compensation³⁰30. Baixada terá distrito sanitário. Jornal do Brasil 1986 out 03; p. 5.,³¹31. Instituto Nacional de Assistência Médica da Previdência Social (INAMPS). Distritos de Saúde. Rio de Janeiro: INAMPS; 1986..The initial conception of the program provided for the accreditation of physicians, with registered clients, who would receive by clientele and not by consultation, similar to the UK’s National Institute for Health model. This proposal received direct criticism from the portion of the health movement that advocated an orientation for the provision of services by the State³²32. A hora e a vez do médico de família. Jornal do Brasil 1986 nov 13; s.p.,³³33. Pagamento por captação não se coaduna com a Reforma Sanitária. Súmula 1987, abr; p. 2..

The expanded cooperation with Caritas Diocesana began at the end of 1986, with encouraging results. In July 1987, newspaper Jornal do Brasil published an extensive and complimentary report on an initiative that was “revolutionizing care”, with lengthy consultations, home visits and educational lectures in an atmosphere of rapprochement with the community³⁴34. Inamps revoluciona atendimento na Baixada. Jornal do Brasil 1987 jul 12; s.p..

The victory of Moreira Franco and the arrival of the coalition led by the PMDB to the state government opened the possibility of a greater articulation with the state sphere in the program’s format. Sergio Arouca was the new State Secretary. His immediate advisors included Antonio Ivo de Carvalho. Lucia Souto, also from the militant group in Nova Iguaçu, former secretary of the MAB, would coordinate the actions in the Baixada. When Sérgio Arouca leaves the office, forced to choose between this position and that of Fiocruz president, the health portfolio is taken over by José Noronha, another hygienist who worked in the municipality⁵5. Zancan L, Magalhães R, Souza RG. Atores Sociais na formulação do programa especial de saúde da Baixada. Bodstein R, organizador. Serviços Locais de Saúde: construção de atores e políticas. Rio de Janeiro: Relume-Dumará; 1993. p. 41-62.,⁸8. Souto L. O Direito à Saúde e a Reforma Democratica do Estado Brasileiro: uma construção social republicana [dissertação]. Rio de Janeiro: UFRJ; 2012..

With a more significant presence at the state level, the initiative was renamed the Special Health Program of the Baixada (PESB), assuming a scope intended for the installation of fourteen mixed units, as well as the construction of two general hospitals and ten outpatient clinics designed for working from the concept of assigned demand, and the patient is served preferably by the same multi-professional team. The mixed units would consist of five medical clinics and one dental clinic, laboratory, radiology services, emergency, vaccination and a user service pharmacy. They would have a board of directors, with seats for representatives of officials and residents. The latter would also have an active voice in the process of choosing the locations where facilities would be installed. Conceived for the development of integral actions, a low referral to units of greater complexity was foreseen. These units began to operate in October 1988, working in collaboration with the twenty-eight posts under the care of Caritas Diocesana³⁵35. Noronha JC, Pereira TRC, Levcovitz E. Estratégias para a Construção de Sistemas Locais de Saúde no Estado do Rio de Janeiro. Boletin de la Oficina Sanitaria Panamericana 1990; 109:5-9..

In March 1988, this favorable conjunction of political and institutional circumstances, which kept aligned with INAMPS and the State Health Secretariat, would be broken with the replacement of Hésio Cordeiro in the Institute’s presidency. If, on the one hand, the Constitutional Congress was able to ensure a vote on a text that affirmed, at least in part, the principles that guided the health reform movement, on the other, at the federal executive level, the type of party arrangement which would give a conservative support to the last years of the Sarney government implied in more obstacles than possibilities for the advance of the SUDS.

By the end of 1988, the political setting would change in Nova Iguaçu. The accusations of corruption culminated with an intervention in the municipal Executive. Deputy Governor Francisco Amaral was appointed intervener. At this point, Lucia Souto took over the municipal health portfolio. Within a few months, the municipal and state governments signed an agreement for the municipalization of state-run activities³⁶36. Sem acerto de contas. Tribuna da imprensa 1989 fev 22; s.p..

The implementation of the SUDS and its replacement, the SUS, would face difficulties of several orders in the municipality. According to Zancan et al.⁵5. Zancan L, Magalhães R, Souza RG. Atores Sociais na formulação do programa especial de saúde da Baixada. Bodstein R, organizador. Serviços Locais de Saúde: construção de atores e políticas. Rio de Janeiro: Relume-Dumará; 1993. p. 41-62., the transformation of the original SOS Baixada proposal into a program with an vital state component would imply essential changes in its format, giving greater centrality to the operation of the state network of mixed units, which would have resulted in a reinforcement of the emergency care function, with low integration into a referral network, and would have replicated the care model and unsuccessfully competed with the system of private clinics and their local influence.

The implantation of the mixed units was also criticized, either for the delay in its implementation or because first units were inaugurated hastily and on the eve of municipal elections. At that time, the political environment was dominated by electoral competition and conflicts that also divided the neighborhood movement. At this juncture at the end of 1988 in particular, for example, MAB and FAMERJ were led by competing leaders³3. Silva PT. Origem e Trajetória do Movimento Amigos de Bairros em Nova Iguaçu (MAB) 1974/1992: Relação vanguarda-base-massa: práxis política e educativa [dissertação]. Rio de Janeiro; Fundação Getúlio Vargas; 1993.,⁶6. Gerschman S. A Democracia Inconclusa: um estudo da Reforma Sanitária brasileira. Rio de Janeiro: Editora Fiocruz; 2004..

More generally, after the reconfiguration to the right of the parliamentary base of the Sarney government and the departure of Hésio Cordeiro from INAMPS, the health reform process faced additional difficulties. INAMPS’ transfers to the states were drastically reduced, well below the readjustments granted to private providers. At the same time, there was a growing resistance to transferring real power to the state and municipal spheres. The traditional clientelistic bargain of the old INAMPS and the centralized control over hospitalizations and payments to hospitals and clinics³⁵35. Noronha JC, Pereira TRC, Levcovitz E. Estratégias para a Construção de Sistemas Locais de Saúde no Estado do Rio de Janeiro. Boletin de la Oficina Sanitaria Panamericana 1990; 109:5-9.

36. Sem acerto de contas. Tribuna da imprensa 1989 fev 22; s.p.

37. SUDS: retrocesso, não! Súmula 1988 nov; p. 1.-³⁸38. Programa na Baixada combate carências da miséria. Proposta 1989 set; p. 3. was back on track.

In February 1991, in an article in newspaper Jornal do Brasil, Cordeiro states that a perhaps irreversible crisis had affected the projects in the Baixada. Then affiliated to the PDT and in the opposition, he held the state government accountable. Cordeiro lamented the abandonment of a project guided by the ideas of continuity and integrality of care for individuals and families; of response to patients’ demands; of participation and social control in the management processes; and of adequate and stimulating remuneration for workers. He adds that state government, in his last years in office, would have deliberated to reduce the allocated resources. Although it called for more transfers from the central government, it continued to reduce the overall annual percentage of health expenditure. And this became even more serious³⁹39. Cordeiro H. Saúde na Baixada. Jornal do Brasil 1991 mar 2. p. 11. Rio de Janeiro.in the Baixada. If health were underfunded, the Baixada Fluminense would return to abandonment.

Final considerations

In January of 1991, on the eve of a new Leonel Brizola government in the state, Baixada residents again interrupted traffic of a federal highway, now the Washington Luiz. On the agenda, the construction of a general hospital in Duque de Caxias, the fight against dengue that began to manifest itself in the most severe forms, the improvement of sanitation and a protest precisely against the bankruptcy of Baixada’s unique program. Alternative staffing mechanisms had been abandoned, and services, including mini-posts, were again poorly performing⁴⁰40. Moradores denunciam descaso. Súmula 1991 abr; p. 5.. An initiative considered virtuous by residents came to an end.

In the previous decade, while under various constraints, the democratization process had made a crucial breakthrough with the 1988 Constitution. Its inseparable part, the multiple movements for the quality of life, social rights and citizenship, each in its way, walked the road to life under democracy. The MAB was summoned in this text as a significant example of this type of collective experience, in a social context of enormous difficulties, also as a model of the issues of accelerated economic growth when it occurs in the lack of democracy.

In that same decade, a broad national movement for the establishment of the right to health and the universalization of access to care gained importance in Brazilian political life. More than a formal value, democracy was evidenced as the means by which fundamental rights and broad social policies capable of both sweeping the past and paving a decent future for Brazilians would be based. In the specific field of health, policies such as AIS, SUDS and, finally, SUS modeling are examples not only of the alignment of this arena with the national debate but, above all, their leading role in the broader dispute about the part of the state in the construction of citizenship. And in the field of institutional transformations underway, INAMPS, the figure of Hésio Cordeiro and the team that supported him would play a decisive role in shaping the ideas, policies and programs that were crucial for the construction of SUS.

The example of Nova Iguaçu reveals how complex and multifaceted both the process of political opening at the local level and, in particular, the efforts to conduct a health reform where it was most needed were. The resistance on the part of the medical corporation, private interests in the provision of health services, the existence of a still incipient popular political culture and an associativism in progress are some of the elements that explain the difficulties of advancing the manifest wishes and desires at the political level.

However, the specificity of local arenas not only tells us about the more concrete difficulties of implementing health reform but also points to the possibilities of institutional schemes, sometimes very peculiar and not reproducible in other settings. For example, the particular role of the figure of Dom Adriano Hipólito for the establishment of a social movement.

In addition, the local arena was also able to explain, in the wake of the SUS, faced with the outbreak of dengue as a persistent problem, in the outskirts of the metropolis that concentrated most of the operational resources of the largest public health agency, how the health reform faced issues such as difficulties of allocating medical personnel in deprived areas; of hiring and auditing the provision of private service; of financing and coordinating institutional arrangements among the spheres of government; of programmatic continuity in the face of doctrinal conflicts and political-partisan competition; and of feasibility and ways of practicing social control. Thus, the local situation also contributes to the general understanding of political proposals and the conditions to facilitate them.

Two decades later, Minister of Health José Gomes Temporão, when reflecting on the conditions of medical care in the Rio de Janeiro metropolitan area, mobilized the idea of a sphinx to be deciphered: the “Sphinx of Rio”. How is it so that, with so many equipment and means, we continue without equating the conditions of health services? On the agenda are issues very similar and updated from those experienced then in the process of democratic reconstruction and affirmation of rights, even after continued efforts of a whole generation of militants for democracy and health.

Acknowledgments

In memory of Maria José Assunção Paiva. We would like to thank Antônio Ivo de Carvalho, José Noronha and Rivaldo Venâncio da Cunha for the previous reading and their comments, as well as Gabriele Carvalho de Freitas for her support in identifying documentary sources.

The elaboration of this paper was supported by the National Council for Scientific and Technological Development (CNPq), the House of Oswaldo Cruz-Fiocruz and the Carlos Chagas Filho Foundation for Research Support of Rio de Janeiro (FAPERJ).

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