"Ensiná-los a viver": a política de saúde pública, da tuberculose à AIDS

 

'To teach them how to live: the politics of public health from tuberculosis to AIDS

 

En les enseignant à vivre: la politique de santé publique de la tuberculose jusqu'au SIDA

 

 

Alan Sears

 

 


RESUMO

A crise da AIDS tem despertado grande interesse na exame crítico da política de saúde pública. Boa parte dessa reflexão tem seguido a perspectiva da "análise cultural" em que se combinam as teorias pós-modernas com a perspectiva política do "pluralismo radical". Essa combinação constitui uma rejeição da teoria marxista do Estado e, além disso, desvia a atenção do Estado como objeto de análise. Este artigo apresenta-se como uma resposta à "análise cultural", utilizando uma investigação histórica sobre a política de saúde pública no Canadá para mostrar como esta tem se concentrado no Estado e para refletir sobre a natureza e os limites da política social.


ABSTRACT

The AIDS crisis has aroused considerable interest in the criticai examina-tion of public health. Much of this work has come from the perspective of cultural analysis combining postmodernist theories with the politics of 'radical pluralism'. This work constitutes a rejection of Marxist state theory, and indeed has directed attention away from the state as an object of inquiry. This article is a response to 'cultural analysis', whiclruses an historical examination of public health in Canada to show the ways in which it has been oriented around the state, reflecting the character and limites of social policy.


RESUME

Le SIDA a attiré Fattention vers Pexamen critique de la politique de santé publique. La plupart de ces études ont suivi la perspective de "Fanalyse culturelle" oü les théories post-modernes se combinent avec la perspective politique du "pluralisme radical". Cette combinaison constitue un rejet de la théorie marxiste de l'État et méprise l'importance de l'État comme objet d'analyse. Cet article se presente comme une réponse à "Fanalyse culturelle" en utilisant une recherche historique sur la politique canadienne de santé publique nettement axé sur 1'État.


 

 

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1 Alguns trabalhos importantes que se ajustam mais ou menos ao esquema da "análise cultural" incluem os de Adam [ADAM B., "The State, Public Policy and AIDS Discourse". Contemporary Crises 13, 1989], Mort [MORT F., Dangerous Sexualities: Medico-Moral Politics in England since 1830. Londres, Routledge and Keagan Paul, 1987], Patton [PATTON C., Sex and Germs: The Politics of AIDS. Montreal, Black Rose, 1986], Padgug [PADGUG R., "Gay Villain, Gay Hero: Homosexuality and the Social Construction of AIDS", in K. Peiss e C. Simmons com R. Padgug, Passion and Power: Sexuality in History. Filadélfia, Temple University Press.], Tesh [TESH S., Hidden Arguments: Political Ideology and Disease Preveníion Policy. New Brunswick, Rutgers University Press, 1988.], Watney [WATNEY S., "Taking Liberties: An Introduction", in E. Carter e S. Watney (eds.) Taking Liberties: AIDS and Cultural Politics. Londres, Serpent's Tail, 1989] e Weeks [WEEKS J., Sexuality andItsDiscontents. Londres, Routledge, 1985].
2 TESH S., Hidden Arguments: Political Ideology and Disease Prevention Policy. New Brunswick, Rutgers University Press, 1988.         
3 Veja-se Fee e Fox [FEE E. e FOX D. (eds.) AIDS: The Burdens of History. Berkeley, University of Califórnia Press, 1988], uma excelente coletânea de artigos que examinam criticamente a história da saúde pública à luz da AIDS.
4 FOUCAULT M., The History of Sexuality, v. 1, Nova York, Vintage Books. (Tradução brasileira, História da sexualidade), 1980, p. 93.         
5 FOUCAULT M., The Birth of the Clinic. Nova York, Pantheon. (Tradução brasileira, O nascimento da clínica. Rio de Janeiro, Forense Universitária, 1977, pp. xiv, 163, 196-99).         
6 FOUCAULT M., The History of Sexuality, op. cit., 1980, p. 98.         
7 FOUCAULT M., "On Governmentality". Ideology and Consciousness, ne6,1979, p. 20.         
8 WEEKS J., Sexuality and Its Discontents. op. cit.
9 WEEKS J., op. cit, p. 6-7.
10 WEEKS J., "AIDS: The Intellectual Agenda", in P. Aggleton, G. Hart e P. Davies (eds), AIDS: Social Representations, SocialPractices. Londres, The Falmer Press, 1989, p. 10.         
11 WATNEY S., "The Spectacleof AIDS", in D. Crimo (ed)A1DS: CulturalAnalysis, CulturalActivism. Cambridge, MIT Press, 1988, p. 75.         
12 WATNEY S., "The Spectacle of AIDS", op. cit.
13 MORT F., Dangerous Sexualities: Medico-Moral Politics in England since 1830, op. cit., 1987, p. 219; WEEKS J., Sexuality andlts Discontents, op. cit, 1985, pp. 242-5, 253-5.
14 FOUCAULT M., The History of Sexuality, op. cit., 1980, p. 96.         
15 CALLINICOS A., AgainstPostmodernism: A marxist Critique. Nova York, St. Martin's Press, 1990.         
16 MORTF., Dangerous Sexualities: Medico-Moral Politics in England since 1830. op. cit., 1987, p. 6.         
17 WATNEY S., PolicingDesire. Mineápolis, University of Minnesota Press, 1987, p. 64.         
18 WEEKS J., Sexuality andlts Discontents. op. cit., 1985, pp. 253-5.         
19 WATNEY S., "Taking Liberties: An Introduction", in E. Carter e S. Watney (eds.) TakingLiberties: AIDS and Cultural Politics, Londres, Serpenfs Tail, 1989a, p. 51.         
20 PALMER B., "The Fx:lipse of Materialism: Marxism and the Writing of Social History in the 1980s". SocialistRegister 1990.1990, p. 131.         
21 MORT F., Dangerous Sexualities: Medico-Moral Politics inEngland since 1830. Londres, Routledge and Keagn Paul, 1987, p. 126.         
22 MORT F., op. cit., p. 209.
23 LILLIENFELD A. e LILLIENFELD D., "Epidemiology and the Public Health Movement: A Histo-rical Perspective". Journal of Public Health Policy 3(2), 1982, p. 145.         
24 BEAUCHAMP D.E., "Community: The Neglected Tradition of Public Health". Hastings Center Report 15(6), 1985.         
25 FRIEDMAN E., "Your Own Kind: AIDS and the Communitarian Ethic", in J. Griggs (ed.), AIDS: Public Policy Dimensions. Nova York, United Hospital Fund of New York, 1987.         
26 PORTER D. e PORTER R., "The Enforcement of Health: The British Debate", in E. Fee e D. Fox (eds.). AIDS, 1988.         
27 BEVAN A., In PlaceofFear. Londres, Heineman, 1952, p. 73.         
28 Isso foi retratado por Rosen [ROSEN G., A History of Public Health. Nova York, MD Publications, 1958, pp. 209,224-5] como um acidente ligado ao subdesenvolvimento relativo da ciência médica na época. Eu diria, contudo, que a teoria e a prática da saúde pública continuaram a orientar-se para o Estado apesar do crescimento da ciência médica no século XX.
29 FRAZER W.M., A History of English Public Health 1834-1939. Londres, Balliere, Tindall and Cox, 1950, p. 1.         
30 PATTON C., Sex and Germs: The Politics ofAIDS. Montreal, Black Rose, 1986, p. 58-9.         
31 WATNEY S., "AIDS, Language and theThird World", in E. Cater e S. Watney (eds.), TakingLiberties, 1989b, p. 190.         
32 CHADWICK E., The Financial Value of Sanitary Science. Londres, 1887.         
33 ONTÁRIO. Ministry of Health AnnualReport. Toronto, Província de Ontário, 1982, p.46.         
34 KAY G., e MOTT )., Political Order and theLaw ofLabour. Londres, Macmillan, 1982, p. 91.         
35 MARX K., Capital, v. 1. Moscou, Progress, 1954, p. 172.         
36 CORRIGAN P. e SAYER D., The Great Arch: English State Formation as Cultural Revolution. Oxford, Basil Blackwell, 1985.         
37 WATNEY S., "The Spectacleof AIDS", in D. Crimo {td.)AIDS: CulturalAnalysis, CulturalActivism. Cambridge, MIT Press, 1988, p. 73.         
38 CLARKE S., "State, Class Struggle and the Reproduction of Capital". Kapitalistate 10/11. 1982, p. 123.         
39 HASTINGS C., "The Modera Conception of Public Health Administration". Conservation ofLife 3 (3&4), 1917, p. 90.         
40 MARX K. e ENGELS F., The German ldeology. Nova York, International, 1970, p. 107.         
41 ABRAMS P., "Some Notes on the Difficulty of Studying the State". Journal ofHistorical Sociology, 1(1), 1988.         
42 SMITH W.G., "Psychology and Public Health". Public Health Journal 9(3), 1918, p. 107.         
43 BUSHNELL F., "The Appointment of Ministers of Health". Journal ofthe Royal Sanitary Institute 24(3), 1903, p. 297.         
44 CANADÁ, "Report of the Chief Medicai Officer's in Canada. Department of the Interior. Annual Report (Otawa, King's Printer), 1915, p. 56.         
45 ASHTON J. e SEYMOUR H., The New Public Health. Milton Keynes: Open University Press, 1988, p.17.         
46 ONTARIO, Provincial Board of Health AnnualReport. Toronto, L.K. Cameron/A. T. Wilgress, 1912, p.9.         
47 MUSTO D., "Quarantine and the Problem of AIDS", in E. Fee e D. Fox (eds.), AIDS: The Burdens of History. Berkeley, University of Califórnia Press, 1988.         
48 SLACK P., "Responsess to Plagues in Early Modern Europe: The Implications of Public Health". Social Research 55(3), 1988.         
49 HILL H. W., The New Public Health. Nova York, Macmillan, 1920, pp. 191-2.         
50 Essa discussão foi extraída de Sears (1990). Veja também Roberts [ROBERTS, B. From WhenceThey Carne. Otawa, University ofOttawa Press, 1988] e Bator [BATOR, P. Saving Liveson the Wholesale Plan: Public Health Reform in the City of Toronto, 1900-30. Tese de Doutorado, Universidade de Toronto, 1979] para discussões acerca da saúde pública e dos controles da imigração neste período.
51 CLARKE C.K., "Immigration". Public Health Journal 10(10), 1919, p.441.         
52 CANADA, "Report of the Chief Medicai Officer" in Canada. Department of Immigration and Colonization. Annual Report. (Otawa, King's Printer), 1919, p. 28.         
53 HILLH. W., The New Public Health. Nova York, Macmillan, 1920, pp. 191-2.         
54 HILL H. W., op. cit., 1920.
55 HILLH.W., op. cit., 1920.
56 DEHLI K., Women and Class: The Social Organization of Mother's Relationsto Schools in Toronto, 1915 to 1940. Tese de Doutorado. University of Toronto, 1988.         
57 DEHLI K.., "Creating a Dense and Intelligent Community: Local State Formation in Early 19th. Century Upper Canada". Journal ofHistorical Sociology 3(2), 1990.         
58 DYKE E., "Tuberculosis in Toronto". Public Health Journal 4(7), 1913, p. 403.         
59 ADAMI J.G., "The Policy of the Ostrich". Canadian Medicai Association, 1919, p. 289.         
60 CONSERVATION OF LIFE. "Canada's Need". Conservation ofLife 5(2), 1919, p. 25.         
61 PLUMPTRE H.P., "The National Council of Women and Conservation". Commission of Conservation AnnualMeeting, 1914, p. 28.         
62 SUTHERLAND N., Children inEnglish Canadian Society. Toronto, Toronto University Press, 1979.         
63 DEHLI K., Women and Class: The Social Organizationof Mother's Relations to Schools in Toronto, 1915 to 1940. Tese de Doutorado. University of Toronto, 1988;          DEHLI, K. "Creating a Dense and Intelligent Community: Local State Formation in Early 19th. Century Upper Canada". Journal of HistoricalSociology 3(2), 1990.         
64 ONTARIO, ProvincialBoard of Health AnnualReport, op. cit, 1904, p. 84.         
65 Análises históricas críticas a respeito do desenvolvimento da regulação sexual nesse período encontram-se em Cassei 1 [CASSEL J., TheSecret Plague: Venerai Disease in Canada 1838-1929. Toronto, University of Toronto Press, 1987], sobre o Canadá; Brandt [BRANDT A., No Magic Bullet. Nova York, Oxford University Press (edição revista), 1987] sobre os Estados Unidos e Mort [MORT F., DangerousSexualities.Medico-MoralPoliticsinlinglandsince 1830.Londres, RoutledgeandKeagan Paul, 1987] sobre a Grã-Bretanha.
66 HASTING C., "The Consequences of Prostitution and Suggested Remedies", in Social Service Congress, Report ofAddresses andProceedings, Toronto, Social Service Council of Canada, 1914, p. 213.
67 STRUTHERS L.R., TheSchoolNurse. Nova York, G.P. Putnam's Sons, 1917, p. 124.         
68 HASTING G., "Democracy and Public Health Administration". Public Health Journal 10(3), 1919, p. 111.         
69 ONTÁRIO, op. cit, 1920, p. 38.
70 CHADWICK E., Report on the Sanitary Condition of the Labouring Population ofGreat Britain, op. cit., 1965, p. p. 75.         
71 FRAZER W.M., op. cit., 1950, p. 90.
72 NEWSHOLME A., TheMinistry of Health. Londres, Putnam, 1925, p. 1.         
73 HASTINGS C., "The Valueof the Public Health Nurse in Public Health and Welfare Administration". American Journal of Public Health 9(8), 1921, p. 713.         
74 HASTINGS C., "The Modern Conception of Public Health Administration". Conservation ofLife 3 (3/4), 1917, p. 88.         
75 REINO UNIDO, 1909, pp. 233-4, sublinhado pelo autor.
76 BRYCE P. H., "Tuberculosis: A Disease of Insanitary Living". Conservation ofLife 4(1), 1918, pp. 15-6.         
77 ONTARIO, op. cit., 1918, p. 25.
78 HAMILTON L.A., "TheSubcommiteeon Women's Activities". Public Health Journal9(2), 1918, p. 58.         
79 WARWICK I., AGGLETON P. e HOMANS H., "Young People's Health Beliefs and AIDS", in P. Aggleton e H. Homans (eds.), Social Aspects ofAlDS, Londres, The Falmer Press, 1988.         
80 CORRIGAN P., State Formation and Moral Regulation in Nineteenth Century Britain: Sociological Investigations. Tese de Doutorado. Durham University, 1977, pp. i-iii.         
81 BATOR P., "The Health Reformers versus the Common Canadian: The Controversy Over Compulsory Vaccination Against Samllpox In Toronto and Ontário 1900-20". OntárioHistory, 75(4), 1983.         
82 PORTER D. e PORTER R., "The Enforcement of Health: The British Debate", in E. Fee e D. Fox (eds.) AIDS, 1988.         
83 HASTINGS C., "Democracy and Public Health Administration". Public Health Journal 10(3), 1919, p. 99, ênfase do autor.         
84 LEWIS J., What Price Community Medicine? Brighton, Wheatsheaf, 1986, pp. 2-6.         
85 Foge ao escopo deste artigo discutir as razões desse declínio. Lewis [LEWIS J., What PriceCommunity Medicine? Brighton, Wheatsheaf, 1986, pp. 3,11] explica o declínio em termos de uma falha filosófica dentro da saúde pública, um fracasso na construção de uma abordagem ampla da saúde comunitária. Gostaria de ir mais adiante, ressaltando o lugar da saúde pública entre as mudanças nas prioridades da política social.
86 TURSHEN M., "The Political Ecology of Disease". The Review of Radical Political Economics (9)1, 1977.         
87 FARLOW D.M., "Achieving Health for Aü". HealthSharing 8(3), 1987.         
88 LALONDE M., A new Perspective onThe Health of Canadians. Otawa, Government of Canada, 1974, pp. 17-32.         
89 BAYER R., "AIDS, Power and Reason". TheMilbankQuarterly 64 (suplemento II), 1986, pp. 175-7.         
90 MACKINNON M., CATTRELLE K, KREVER H., "Legal and Social Aspects of AIDS in Canada", in Royal Society of Canada, AIDS: Perspectives for Canadians: Background Papers. Otawa, Royal Society of canada, 1988, p. 9.         
91 FRASER R., COATES R., DUCKETT M., FANNING M., REMIS R., "Public Health Imperatives of HIV Infection and AIDS in Canada" in Royal Society of Canada. AIDS: Perspectives for Canadians: Background Papers. Otawa, Royal Society of Canada, 1988, p. 140.         
92 CONNOR S., "AIDS: Social, Legal and Ethical Issues of the 'Third Epidemic" in Pan-American Health Organization,A/£>5.- Profile of an Epidemic. Washington, Pan-American Health Organization, 1989, pp. 14,157.         
93 CONNOR S., op. cit., pp. 155-7.
94 ALLEN G., "AIDS and Civil Rights". MacLean's 101 (41), 1988, p. 50.          Em 1989, três casos canadenses famosos em Halifax, Otawa e Calgary, levaram a penas de reclusão pela transmissão de infecção pelo HIV. Cada um desses casos recebeu extensa publicidade (por exemplo, no Toronto Star de 15 de agosto de 1989 e no editorial do Globe and Mail de 18 de agosto do mesmo ano).
95 GOSTIN L., "Traditional Public Health Strategies", in H. Dalton et ai. (eds.), AIDS and the Law. New Haven, Yale University Press, 1987, p. 61.         
96 BAYER R., "AIDS, Power and Reason", TheMilbankQuarterly 64 (suplemento II), 1986, pp. 177-8.         
97 SULLIVAN KM. e FIELD M.A., "AIDS and the Coercive Power of the State", Harvard Civil Rights and Civil Liberties Review 23(1), 1988, p. 197.         
98 GROVER J., "Keywords", in D. Crimp (ed,),AIDS; CulturalAnalysis, CulturalActivism. Cambridge, MIT Press, 1988, p. 27.         
99 KULLER L. e KINSLEY L., "The Epidemic of AIDS; A Failure of Public Health Policy". TheMilbank Quarterly 64 (suplemento I), 1986, p. 64.         
100 ADAM B., "The State, Public Policy and AIDS Discourse". Contemporary Crises 13, 1989, pp. 3-9.         
101 WALTERS D., "Needle Exchanges Needed Now". The New Facts ofLife 2(2), 1988, p. 3.         
102 SABATIER R., Blaming Others; Prejudice, Race and Worldwide AIDS, Londres, Panos, 1988.         
103 JOHNSTON R.C., "AIDS and Otherness", in J. Griggs (ed.), AIDS: Public Policy Dimensions, Nova York, United Hospital Fund of New York, 1987.         
104 NELKIN D. e GILMAN S., "Placing Blame for Devastating Disease". Social Research 55(3), 1988.         
105 MOLINERT H. et al., "Prevalence of Infection with Human Immunodeficiency Virus in Cuba", in Pan-American Health Organizations, AIDS: Profile of an Epidemic. Washington, Pan-American Health Organization, 1989, p. 94.         
106 É claro que a responsabilidade pela "terceira epidemia" não cabe totalmente aos agentes da saúde pública. Com efeito, muitos deles superaram o uso de uma linguagem explicitamente excludente (Toronto, 1984). Eles continuam, porém, a fundar suas atividades em concepções implícitas excludentes da comunidade e de seus membros.
107 ALBERTA. Comunity and Occupational Health. Education and Caring: Alberta's Program for the Prevention, Management and Control ofAlDS, 1987, p. 1.         
108 Veja a crítica deste slogan em Watney [WATNEY S., "The Spectacle of AIDS", in D. Crimo (ed.) AIDS: Cultural Analysis, Cultural Activism. Cambridge, MIT Press, 1988, pp. 72-2]          Veja também o Ontário Ministry of Health Aids Awareness WeekAd, que afirma: "Alguns dizem que a ignorância é uma bem-aventurança. Quando se trata de sexo, a ignorância está longe de ser uma bem-aventurança. Ela é um evidente perigo."
109 WATNEY S., "The Spectacle of AIDS", in D. Crimo (ed ,)AIDS: Cultural Analysis, Cultural Activism. Cambridge, MIT Press, 1988, p. 77.         
110 BAYER R., "AIDS and the Gay community: Between the Specter and the Promise of Medicine". Social Research, 52(3), 1985, pp. 586-7.         
111 HOMANS H. e AGGLETON P., "Health Education, HIV Infection and AIDS", in P.Aggleton e H. Homans (eds.), Social Aspects ofAIDS. Londres, The Falmer Press, 1988, pp. 160-2.         
112 WATNEY S., "The Spectacle of AIDS", in D. Crimo (ed.)AIDS: CulturalAnalysis, Cultural Activism. Cambridge, M1T Press, 1988, p. 80.         
113 OPPENHEIMER G., "In the Eye of the Storm: The Epidemiological Construction of AIDS", in E. Fee e D. Fox (eds.), AIDS, 1988, p. 278.         
114 LAST J.M., "Ethics, Mores and Values - and AIDS". Canadian Journal of Public Healthl & (2), 1987, p. 75.
115. NELKIN D. e GILMAN S., "Placing Blame for Devastating Disease". Social Research 55(3), 1988.
116. MOLlNERT H. et aI., "Prevalence of Infection with Human Immunodeficiency Virus in Cuba", in Pan-American Health Organizations, AIDS: Profile of an Epidemie. Washington, Pan-American Health Organization, 1989, p. 94.
117. É claro que a responsabilidade pela "terceira epidemia" não cabe totalmente aos agentes da saúde pública. Com efeito, muitos deles superaram o uso de uma linguagem explicitamente excludente (Toronto, 1984). Eles oontinuam, porém, a fundar suas atividades em concepções implícitas excludentes da comunidade e de seus membros.
118. ALBERTA. Comunity and Occupational Health. Education and Caring: Alberta's Program for the Prevention, Management and Control ofAIDS, 1987, p. 1.
119. Veja a crítica deste slogan em Watney [WATNEY S., "The Spectacle of AIDS", in D. Crimo (ed.) AIDS: Cultural Analysis, Cultural Activism. Cambridge, MIT Press, 1988, pp. 72-2) Veja também o Ontario Ministry ofHealth Aids Awareness WeekAd, que afirma: "Alguns dizem que a ignorância é uma bem-aventurança. Quando se trata de sexo, a ignorância está longe de ser uma bem-aventurança. Ela é um evidente perigo."
120. WATNEY S., "The Spectacle ofAIDS", in D. Cri mo (ed.)AIDS: CulturalAnalysis, CulturalActivism. Cam bridge, MIT Press, 1988, p. 77.
121. BAYER R., "AIDS and the Gay community: Between the Specter and the Promise of Medicine". Social Research, 52(3), 1985, pp. 586-7.
122. HOMANS H. e AGGLETON P., "Healtb Education, HIV Infection and A1DS", in P.Aggleton eH. Homans (eds.), Social Aspects ofAlDS. Londres, The Falmer Press, 1988, pp. 160·2.
123. WA TNEY S., "The Spectacleof A1DS", in D. Crimo (ed.) AlDS: CulturalAnalysis, CulturalActivism. Cambridge, MIT Press, 1988, p. 80. 124.
OPPENHEIMER G., "ln the Eye ofthe Storm: The Epidemiological Construction ofAIDS", in E. Fee e D. Fox (eds.), AlDS, 1988, p. 278.
125. LAST J.M., "Ethics, Moresand Values-and AIDS". Canadian Journal of Public Health 78(2), 1987, p.75.

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