Abstract

Introduction

The literature dealing with the rise of the Collective Health movement in Brazil¹1. Nunes ED. Saúde Coletiva: história de uma ideia e de um conceito. Saude Soc. 1994; 2(3):5-21.

2. Osmo A, Schraiber LB. O campo da Saúde Coletiva no Brasil: definições e debates em sua constituição. Saude Soc. 2015; 24(1):205-18.^-33. Vieira da Silva LM, Paim JS, Schraiber LB. O que é Saúde Coletiva? In: Paim JS, Almeida Filho N, organizadores. Saúde Coletiva: teoria e prática. Rio de Janeiro: MedBook; 2014. p. 3-12. suggests that its historical roots date back to 1950-60, linked to the USA movements for reforming medical education (comprehensive and preventive medicine) as well as the healthcare reforms oriented to incorporate the poorest population (community medicine). The emergence of this movement was investigated in order to examine this historical process and research its peculiarities in the way it happened in the state of São Paulo. This article frames this historical moment, but deals especially with preventive medicine departments in connection with medical schools. For this end, the period considered depicts a set of new schools that are created in São Paulo based on the preventivist movement, conjugated to the so-called São Paulo developmentalism between 1940 and 1960, along with major reformulations in existing schools.

The methodology adopted encompassed bibliographic research, desk review and oral history. The documents collected and used in this study are institutional records of the medical schools that were the loci of the departments that came to be linked to Collective Health. These schools are listed in Table 1. Through oral history we obtained the testimonies of those who experienced the creation of the Collective Health of São Paulo and its further development. We included in the survey 38 key informants drawn from the institutional base represented in terms of their historical experience: academic institutions participating in Collective Health; State Department for Health of São Paulo, subjects chosen among formulators and scholars of Sao Paulo health policy; and institutions that were a fundamental support to Collective Health. Table 2 shows the interviewees discriminated by institution, scientific subarea mentioned in the interview, sex and type of historical performance in the field: if the interviewee participated before 1980, was labeled as ‘formulator’. Those who had activities later than 1980 were classified as ‘participants’. Using triangulation with documentary data, we analyzed the testimonials that were pertinent to the selected frame of the present study. They were personally identified and presented in the text by their names followed by their respective institutions. This procedure was agreed upon regarding ethical terms at the time of recording the interviews, and it was adopted because they are public figures notoriously recognized as actors-authors of the history of Collective Health. The analytical interpretation of these interviews allowed us to reach what Camargo defined, in relation to oral history, as:

Preventivism and medical schools in Brazil

The medical reform that materialized between the years 1940-50, as a result of the specific science aspects revolving around the structuring of the American medical schools in the previous decades under the impact of the Flexner Report, included several currents of thought regarding matters that were closely related although:

In all of them there was an integrative component due to the specialized fragmentation in the training and the need for a change that was imposed from the outside to the medical practice, as a reflection of the new social needs related to medical care, i.e.:

To fulfill these demands, several meetings were organized aiming to articulate the different visions of those currents of thought. The Pan American Health Organization organized seminars involving Latin American countries inspired by the pioneering conference organized in November 1952 in Colorado Springs, USA by the American Association of Medical Colleges (1953), and funded, inter alia, by the Rockefeller Foundation. Those seminars were interested in promoting on a more general level, actions in the field of public health, as well as individual health care. It was in this context that the preventivist ideology emerged, stemming from three aspects:

Its directives echoed during the debate regarding a new professional training advocated by the Seminars that were held in Viña del Mar, Chile, 1955 and Tehuacan, Mexico in 1956 (Doc 4). The presence of Brazilians, including several coming from São Paulo^d(d)Alagoas: Abelardo Duarte, José L. de Gusmão Lyra; Bahia: Rodrigo Argollo Ferrão, Ruy Santos; Ceará: Francisco Araújo, Jurandir Picanço; Minas Gerais: Josias Vaz de Oliveira, Justino Moraes Sarmento, Leontino da Cunha; Pará: José R. da Silveira Netto; Paraíba: Humberto da Cunha Nóbrega, Newton Lacerda; Paraná: Milton Munhoz; Pernambuco: Álvaro Vieira Mello, Antônio S. dos Santos Figueira, Joaquim Costa Carvalho, Waldemir Miranda; Rio de Janeiro: Almir Castro, Hamilton Lacerda Nogueira, João Barros Barreto, Manoel José Ferreira; Rio Grande do Sul: Luís Guerra Blessmann, Paulo Moreira; São Paulo: Augusto Leopoldo Ayrosa Galvão, João de Aguiar Pupo, Jairo Ramos, José L. Pedreira de Freitas, José Maria Freitas, Raphael de Paula Souza, Walter Pereira Leser, Zeferino Vaz (Doc 4)., reveals the level of interest and impact in medical schools. This also introduced changes in the Faculty of Public Health, when Rodolpho Mascarenhas incorporated that theoretical reference in 1962 and was invited to support the Secretariat for Health of São Paulo state, at the invitation of Secretary Walter Leser⁷7. Mascarenhas RS. História da Saúde Pública no Estado de São Paulo. Rev Saude Publica. 1973; 7:433-46.. It also had repercussions in Nursing Schools, although these repercussions happened in a later stage, already as an influence of medical schools and public health:

Throughout Latin America and especially in Brazil, new medical schools were created, meanwhile the curriculum of the existing ones was experiencing reorganization. In all of them, the preventivist bases acquired relevant space⁸8. Silva GR. As origens da Medicina Preventiva como disciplina do ensino médico. Rev Hosp Clin Fac Med USP 1973; 28:91-6.. Regarding the institutional organizing axis, it was recommended:

The teaching of medicine using this perspective should equip the future doctor with:

For this, the discipline of Preventive Medicine should contemplate a series of topics:

Metropolis interiorization: about the constitution of medical schools in the paulista countryside (1948-1963)

The state of São Paulo was the privileged place in Brazil for the implementation of these new proposals for medical education reform, since it presented itself to the world as the Brazilian state that had appropriate potentialities. According to Arruda, in the 1950s:

For this political project of re-democratization linked to the new developmental needs, São Paulo associated in a single movement the economic recovery, the valorization of the municipalities and the determinations contained in the São Paulo Constitution of 1947, advancing in the professional and scholar training of certain groups and impelling actions of interiorization of educational institutions, among them the universities¹⁰10. Vaidergorn J. As seis irmãs - as Faculdades de Filosofia, Ciências e Letras: institutos isolados de ensino superior no estado de São Paulo – 1957-1964 [tese]. Campinas (SP): Faculdade de Educação da Universidade Estadual de Campinas; 1995.. Whenever the topic was medical education, then considered a subject that “even the most distant and backward people recognized as an advantage, even when they could not share it”¹¹11. Hobsbawm EJ. Era dos extremos: o breve século XX: 1914-1991. São Paulo: Companhia das Letras; 1995. (p. 346), it is shown in the documents that there was an intense game of forces both political and academic, at the local, state and federal levels. In this game preventivism as a medical innovation would make a difference.

It was in this context that a not well-defined group of medical schools was created ranging between what would be state or private, state or federal, resulting in diverse medical training profiles, due to their local specificities. In addition to the lack of seats in the two schools of the capital - the Medical School of the University of São Paulo, created in 1912¹²12. Mota A. Tropeços da Medicina Bandeirante: medicina paulista 1892-1920. São Paulo: EDUSP; 2005. (Doc 3), and the Escola Paulista de Medicina in 1933¹²12. Mota A. Tropeços da Medicina Bandeirante: medicina paulista 1892-1920. São Paulo: EDUSP; 2005. -,the argument for the creation of medical schools was to provide the countryside student with:

Additionally, a whole network of medical professionals under the leadership of professors from medical schools and the Paulista Medical Association, claimed for the need of statutory changes for their professionals, salary equalization, gradually building up a full demonstration of the medical corporate force¹⁴14. Almeida FO. Coesão e interesses da medicina paulista diante do populismo adhemarista: contradições e ambivalências. Soc Cult. 2011; 14(1):131-9..

It was with this motto that, in 1947, the physician-politician Adhemar de Barros toured the countryside in his electoral campaign to the state government, with the promise of building the “University of the Interior”. After winning the election and with enormous pressure from interior cities, that same year Bill no. 10 of the Legislative Assembly was halted by an Opinion from the Commission of Teaching and Regiment of the University of São Paulo on such an attempt. Signed by Zeferino Vaz, the project was assessed as imperfect and unenforceable. Specifically, it was modified stopping the creation of a university, instead proposing higher education schools subordinated to the University of São Paulo (USP). As a result, on August 20, 1948, legislation was passed approving the emergence of three higher schools under the administration of USP: the Ribeirão Preto Medical School, the Pharmacy and Dentistry School of Bauru and the Escola de Engenharia de São Carlos¹⁴14. Almeida FO. Coesão e interesses da medicina paulista diante do populismo adhemarista: contradições e ambivalências. Soc Cult. 2011; 14(1):131-9..

This action allowed two core centers of higher education to emerge in the Sao Paulo state: one that concentrated more socially prestigious careers, with courses planned by the State, and another formed by mainly private, isolated schools. Beginning in the 1950s, the core of state schools grew in a controlled manner, followed by the first six Faculties of Philosophy, Sciences and Letters, which in 1976 became the State University of São Paulo (UNESP). However, the core of private schools grew more and more disorderly throughout the municipalities in the interior, and not all of them achieving long life¹⁵15. Nosella P, Buffa E. Educação superior e desenvolvimento no estado de São Paulo. Cad Hist Educ. 2005; 4:167-82..

The first experience in the country initiated as a municipal political project for the creation of an “interior” medical school was in Sorocaba. At the end of the 1940s, the local forces of the Catholic Church, in the figure of Father André Pieroni, and of the city hall, in the figure of the doctor and mayor Gualberto Moreira converged, the former with the intention of creating a faculty of philosophy while the latter aimed for a medical school (Doc 1).

The operation of the faculty resulted from the Federal Decree n. 28.003, dated April 14, 1950 and signed by the president Eurico Gaspar Dutra which, in its article 1, designates the Sorocaba Foundation of the State of São Paulo^f(f)In the 70's there was an economic downturn that closed the Foundation that managed the School, and the medical school was fully incorporated into the Sao Paulo Pontificial Catholic University in order to keep it running. as its manager agency. Its faculty, almost all made up of USP professors - Antonio Dacio Franco do Amaral, Carlos da Silva Lacaz, Charles Edward Colbertt, Ernesto de Souza Campos, Odorico Machado de Souza and Samuel Pessoa, among others -, developed a medical school following the Flexnerian line, but with a low complexity laboratory base. A Public Health Laboratory was also built, following the hygienist tradition, not being part of the ongoing preventive movement. The newly founded Santa Lucia Hospital, equipped by the Votorantin Industries, at that time considered a modern hospital, changed its original maternity character gaining the status of a general hospital in order to host the medical school that was being formed¹⁶16. Rossini LL. As origens da educação superior em Sorocaba: a Faculdade de Medicina e a Faculdade de Filosofia, Ciências e Letras [dissertação]. Sorocaba (SP): Universidade de Sorocaba; 2015..

The efforts for the construction of a Faculty of Medicine in Ribeirão Preto were a joint endeavor of the state political plan and the local elites. The unquestionable economic importance of the municipality in the production of sugar and alcohol also defined the strength of its representatives in the Legislative Assembly in order to have the approval for a medical school. At the municipal level, “everyone worked hard. The Medical Center, the hospitals, the directors of the Faculty of Dentistry and Pharmacy, the colleges, the press, the Municipal Chamber, the City Hall”¹³13. Araújo MJ. A Faculdade de Medicina de Ribeirão Preto 1948-1975 [tese]. São Carlos (SP): Centro de Educação e Ciências Humanas da Universidade Federal de São Carlos; 2007. (p. 76). However, it was not until 1951 that a Memorandum was sent to state Governor Lucas Nogueira Garcez, pointing out the infrastructural and academic conditions for the project¹³13. Araújo MJ. A Faculdade de Medicina de Ribeirão Preto 1948-1975 [tese]. São Carlos (SP): Centro de Educação e Ciências Humanas da Universidade Federal de São Carlos; 2007..

Influenced by the Pan American Congress of Medical Education held in Peru, the teaching regime was written and presented to the University Council, being approved with Law n. 1,467, dated December 26, 1951. Once this law was passed in 1952 and having as first director Zeferino Vaz, the basic disciplines began in the first year of medical education (Doc 5). As a contributing force, the presence and interest of the Rockefeller Foundation influenced and invested in the construction of classrooms and laboratories as well as subsidizing the training of teachers in the USA. In ten years, the Foundation invested one million dollars in all these projects¹³13. Araújo MJ. A Faculdade de Medicina de Ribeirão Preto 1948-1975 [tese]. São Carlos (SP): Centro de Educação e Ciências Humanas da Universidade Federal de São Carlos; 2007.. The results were considered innovative and in a short time the institution would become a national reference.

To do this, it swiftly introduced the preventive precepts, concomitantly with its institutional organization. In this process and as early as 1954, the professor of Hygiene Pedreira de Freitas was responsible for organizing and founding a new area of teaching and research, Hygiene and Preventive Medicine, inspired by his trips as a fellow of the Rockefeller Foundation to the USA and Puerto Rico. Also was influential his connection with the Samuel Pessoa^g(g)Samuel Barnley Pessoa was an important parasitologist, highly concerned with isuues related to poverty and social backwardness in the country group and his prestige as an official participant in the First Seminar on Preventive Medicine Teaching, held in Viña del Mar, Chile (Doc 5).

Among the initiatives, it is worth mentioning two core groups:

In Campinas, the reflections of this interiorization were soon apparent. The local efforts were directed towards a medical school, meanwhile USP, which would be responsible for the new school, proposed a Law School. There was an intense clash in the City Chamber and a strong opposition from the leading group of USP, including the Faculty of Medicine, whose budget was decreased because of the school of Ribeirão Preto, and saw in this project another threat to their interests. However, under the intense political pressure that gained momentum in the State Assembly in 1953, Law no. 2,154 was replaced, with the triumph of the proposal to create a medical school in Campinas (Doc 6).

However, little was done to make it reality (Briani, 2003), and in 1958, the topic returned to the fore, when other cities presented interest in a medical school:

Botucatu, Catanduva and São José do Rio Preto. Feeling the danger of seeing its project to fail, the Campinas elite re-grouped forces and pressed in every way the state government, in the so-called Pro-Faculty Movement:

As a way to end this impasse it was presented a memorial describing the infrastructural, corporate and geographic conditions of Campinas, even with the addition of an underlying ultimatum, consisting in a proposal of then president Juscelino Kubitschek aiming for the foundation of a federal medical school in the city. In a Report of Analysis, bearing the names of Zeferino Vaz, Cantídio de Moura Campos, Isaías Raw and Paulo Vanzolini and the final signature of Ulhôa Cintra, it was decided in 1963 favorable to the creation of two state medical schools without the direction of the USP: one in Botucatu and another in Campinas. Curiously, the latter was assumed by Zeferino Vaz himself (Doc 6). In fact, many teachers from Ribeirão Preto contributed to the formation of the Campinas medical school, as well as the creation, in 1965, of its department of Preventive Medicine. Ribeirão Preto was the origin of the teachers Miguel Inacio Tobar Acosta, founder of this department, Manildo Fávero, Ana Maria Tambelini Arouca and Antonio Sérgio Arouca, author of the book The Preventivist Dilemma (2003), a doctorate thesis defended in 1976, now a classic of Collective Health:

The curriculum of the Faculty of Medical Sciences of Unicamp was also influenced by the discussions of the meetings and congresses on preventive medicine and medical training proposed a decade earlier, including, therefore, preventivism. According to Everardo Nunes, the course in Campinas would have been initially theoretical-conceptual:

From the 1970s, preventive and social medicine was established as a field, with hygiene and sanitation as its founding references:

It was also under the Carvalho Pinto government (1959-63) that the creation of the Botucatu Medical School was presented to the Legislative Assembly of São Paulo, also the result of many disputes over the interiorization of higher education in the state. In that heated debate, there is a record as early as 1957, when Congressman Francisco Franco resumes the discussion of the need to train young interns of that region in a medical university course, presenting Botucatu's qualifications to receive such a school (Doc 7).

The first group of the Faculty of Medicine of Botucatu began in 1963, when there was still no teaching linked to the preventivist movement. It was only in 1969, following the initiative of Professor Cecilia Magaldi, that this department emerged, albeit not by that name:

The Department was called Medicine in Public Health and Legal Medicine. Years later and already with the term Collective Health in the public debate, the Department decided to simply be called “Public Health” and not “Collective Health” […] and this is the name it has until today (Antonio PP Cyrino, FCM UNESP).

This fact already indicates the influence of sanitarianism in this process, due to the kind of training Professor Magaldi had as well as others of the work team:

The last medical school founded in this period was the Faculty of Medical Sciences of the Santa Casa de Misericórdia de São Paulo in 1963. Fruit of the centenary experience of Santa Casa de Misericórdia in the medical-hospital field and having been the school hospital of the Faculty of Medicine of USP until the mid-1950s, this treasure of clinical and technological experiences was gathered in the creation of a medical school. Under the direction of Emílio Athié, several international trips were made to define the best curricular devices, creating nine departments, among them Social Medicine, as well as special courses such as General Culture, History of Medicine, Mathematics, Legal Medicine, Hospital Administration and Practical Nursing (Doc 2).

It should be remembered that the Ministry of Education and Culture accepted the creation of this school by enrolling it in the same frameworks of preventivism as the other schools of the time:

In this case, there was also influence of the thought originated in the Faculty of Public Health of USP:

In fact, we have already been born with this perspective of public health, because it was Airosa who came here to set up the [Social Medicine] department. He was coming from public health, but it could have been completely different. (Rita Barradas Barata, FCM Santa Casa).

The Department of Social Medicine began its activities in 1966, and three physicians were invited to be part of it:

[…] Professor Diogo Pupo Nogueira, Professor Italo Martirani and Professor Bernardo Berlicó […],they invited Professor Airosa Galvão, who was an entomologist, and José da Silva Guedes, who had graduated in Medicine from USP having also a social vision (Regina Giffoni Marsiglia, FCM Santa Casa).

The proposal, in this case, was to integrate the basic areas to the knowledge of social medicine and also to make them encompass all the training from the first to the sixth year of graduation.

Considering now the first two medical schools of the municipality of São Paulo, namely the School of Medicine of the University of São Paulo (1912) and the Paulista School of Medicine (1933), they stayed until the 1960s under the framework of the Flexner Report, using teaching linked to the rigorous training of techniques, based on individual experimental knowledge, from research in biomedical sciences, reinforcing the split between individual and collective, private and public, biological and social, curative and preventive¹⁹19. Almeida Filho N, Paim JS. A crise da saúde pública e o movimento de saúde coletiva na America Latina. Brasília: Organização Pan-Americana de Saúde; 1995..

In the case of the Paulista School of Medicine, Walter Leser tells us that there were already some basic notions of prevention in the 5^th grade course of Hygiene given by teachers Guilherme Arbanz, Otávio Germeck and Hélio Lourenço de Oliveira that were reluctantly accepted by the students. It was with the impact of Viña del Mar that the School distributed “the disciplines of the area of prevention in all the years of the course, promoting its integration with the other components of the curriculum and culminating in the creation of the Department of Preventive Medicine”²⁰20. Leser WSP. Discurso nas novas instalações do Departamento de Medicina Preventiva da Escola Paulista de Medicina em 1980 In: Bonfim JRA, Bastos S, organizadores. Walter Sidney Pereira Leser: das análises clínicas à medicina preventiva e à saúde pública. São Paulo: Hucitec; 2009. p. 344-46. (p. 345). And so it was called, although some of the staff preferred the concept and the name of Social Medicine: But it didn't get traction, because everyone calls you ‘the preventive’, even within the department! I fought, I thought it was a political struggle, an effort to be able to change. I even took the lead for a while, and I changed it! It did not prevail (Paulete Goldemberg, EPM UNIFESP).

At the University of São Paulo Medical School, even though the director, Aguiar Pupo, participated in the Viña del Mar Conference in which the preventive medicine programs in medical schools were discussed, it was only in 1967 that a movement in this direction was consolidated with the creation of the Chair of Hygiene and Preventive Medicine, transformed in 1969 in the Department of Preventive Medicine. This delay was the consequence of the institutional larger interest in the regarding medical technologies and medical specialization²¹21. Silva GR. Da higiene à medicina preventiva: história do departamento de Medicina Preventiva da FMUSP Rev Méd (São Paulo). 2002; 81:24-7..

However, besides the creation of a Department of Preventive Medicine, the preventivist premises were able to flourish through a newly created Experimental Course within this school:

Final considerations

On the one hand, the creation of medical schools had in the developmental period of São Paulo interfaces with the state needs for the formation of literate elite, in which medicine played a central role. However, on the other hand this process was also due to a quite particular moment - the emergence of preventivist proposals in medical education and in the field of public health. However, even if these dimensions could finally result in institutional homogeneity, it is worth highlighting certain particularities involving actors and their proposals.

Preventivist foundations cannot be seen without their applications on the ground, without their group proposals or even without their ability to push for innovations, as it is expressed from the history of each of these medical schools in the period. Only using an analytical bias we may perceive, the participation of these groups and their institutions in the formulation of a social thought in health and Brazilian Collective Health and consider that this thought is composed of several currents.

Discussing the theoretical basis for the concept of natural history of diseases²²22. Leavell H, Clark EG. Medicina preventiva. São Paulo: McGraw-Hill; 1976., Arouca draws attention to the mythic concepts dear to preventivism and community medicine, such as those of population and community, which would be used to neutralize the idea of classes and conflicting interests, depoliticizing the plurality of groups and minorities⁶6. Arouca S. O dilema preventivista: contribuição para a compreensão e crítica da medicina preventiva. São Paulo: Unesp; 2003.. On this subject, Donnangelo and Pereira studied certain constitutive features of community medicine because:

These questions are very important to understand how the influence of preventivism or community medicine has been under institutional, corporate and even theoretical complexity, absorbed in different ways. In this sense, in addition to the creation of the medical schools of this period defined as developmentalist (19401960), plural experiences took place between preventivism and community medicine, giving rise to varied modes of curricular organization and practice in each institution. And it was in this diversity that the proposal of social medicine, originally made by Juan César García acknowledging the presence of the social issues in health, was incorporated²2. Osmo A, Schraiber LB. O campo da Saúde Coletiva no Brasil: definições e debates em sua constituição. Saude Soc. 2015; 24(1):205-18..

It is from such influences that a social thought in medicine and health begins to be elaborated systematically and with an interdisciplinary character, central subject to understand subsequent processes that would eventually lead to the creation of what is called Collective Health.

References

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