Addressing the COVID-19 pandemic has intensified the debate about the possibilities and limits of surveillance actions and practices in the field of health. In this sense, the World Health Organization (WHO) and other international organizations have been discussing the need to structure policies and actions to address health crises, suggesting that surveillance should be treated using a comprehensive approach and as part of prospective risk management, rather than sectoral approaches and management in reaction to harm and consequences.¹1. Freitas CM, Cunha RV. A vigilância em saúde diante da Covid-19 - desafios e lições para o enfrentamento de emergências em saúde futuras. In: Santos AO, Lopes LT, organizadoras. Reflexões e futuro [Internet]. Brasília: CONASS; 2021 [citado 2021 Out 20]. (Coleção Covid-19; vol. 6). p. 152-69. Disponível em: https://www.conass.org.br/biblioteca/volume-6-reflexoes-e-futuro/
https://www.conass.org.br/biblioteca/vol...

In Brazil, the debate on strategies to address the pandemic has not only reactivated a conceptual reflection on the notion of health surveillance, present ever since the Brazilian National Health System (Sistema Único de Saúde - SUS) began to be built; it has also stimulated the formulation of proposals by the Collective Health (Saúde Coletiva) academic community, such as the Front for Life Plan (Plano da Frente pela Vida),²2. Frente pela Vida. Plano nacional de enfrentamento à pandemia da Covid-19. Versão 3. [São Paulo]: Frente pela Vida; 2020 [citado 2020 Dez 01]. Disponível em: https://frentepelavida.org.br/uploads/documentos/PEP-COVID-19_v3_01_12_20.pdf
https://frentepelavida.org.br/uploads/do... and has reactivated a discussion led by the National Health Council in 2018, during the 1^st National Health Surveillance Conference,³3. Conselho Nacional de Saúde. 1ª Conferência Nacional de Vigilância em saúde: Relatório Final. Brasília: Conselho Nacional de Saúde; 2018a [citado 2021 Fev 11]. Disponível em: https://drive.google.com/file/d/1dI4F1e03LKCsLRF7h0OXzxC8VCVkRZkc/view.
https://drive.google.com/file/d/1dI4F1e0... which was a landmark in preparing the National Policy on Health Surveillance.⁴4. Conselho Nacional de Saúde. Resolução nº 588, de 12 de julho de 2018. Institui a Política Nacional de Vigilância em Saúde. Brasília: Conselho Nacional de Saúde. 2018b [citado 2018 Jul 18]. Disponível em: https://conselho.saude.gov.br/resolucoes/2018/Reso588.pdf
https://conselho.saude.gov.br/resolucoes...

Analysis of the conceptual development of health surveillance shows that this notion is linked to the distinct forms of “health surveillance” - epidemiological, environmental, occupational health, etc. - denominating institutional practices that delimit objects, methods and technologies of intervention in health problems and population groups exposed to specific risks. However, the same notion, whether as surveillance for, from or in health, has also contributed to the debate on the change of the care model, as

The process of institutionalizing health surveillance, in turn, has taken place under the auspices of a fragmented view of health surveillance, showing uneven development in recent decades, both with regard to the definition of legislation, which underlies and regulates surveillance actions, and also in the political-institutional sphere, due to the directional nature given to health policy and to the process of building the SUS.⁶6. Teixeira CF, Vilasbôas ALQ. Modelos de atenção à saúde no SUS: transformação, mudança ou conservação? In: Paim JS, Almeida-Filho N, organizadores. Saúde Coletiva: teoria e prática. Rio de Janeiro: Medbook; 2014. p 287-301. As such, national management of health surveillance has become divided between the Ministry of Health and the National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária - ANVISA), while implementation of the different forms of "health surveillance" at the state and municipal levels of the SUS has been marked by tensions and conflicts over funding and forms of organization and the division of management of health surveillance actions between the State and Municipal Health Departments.⁷7. Seta MH, Dain S. Construção do Sistema Brasileiro de Vigilância Sanitária: argumentos para debate. Cien Saúde Colet. 2010;15(Suppl 3):3307-17. doi: 10.1590/S1413-81232010000900002
https://doi.org/10.1590/S1413-8123201000...

Nevertheless, it is worth highlighting the efforts to articulate primary care and health surveillance activities, the management of which is institutionally separate, in both the Ministry of Health and the State Health Departments’ organization charts. Despite this, during the period in which the Family Health Strategy was expanded, the proposal was made to go beyond care based on spontaneous demand, which predominates in primary healthcare centers, by training health teams to plan and program actions based on the analysis and prioritization of the health problems of the population in the territories covered by health centers. This therefore sought to articulate practices related to health promotion, risk prevention and care for prioritized population groups,⁸8. Campos CEA. O desafio da integralidade segundo as perspectivas da vigilância da saúde e da saúde da família. Cien Saúde Colet. 2003;8(2):569-84. doi: 10.1590/S1413-81232003000200018
https://doi.org/10.1590/S1413-8123200300... ^,99. Teixeira CF. Saúde da família, promoção e vigilância da saúde: construindo a integralidade da atenção à saúde no SUS. Rev Bras Saúde Fam. 2004;5(7):10-23. so as to get closer to the comprehensive conception of health surveillance, which seeks to articulate the control of determinants, risks and harm to the health of the population in the different territories.⁵5. Teixeira CF, Paim JS, Vilasbôas AL. SUS, modelos assistenciais e vigilância da saúde. Inf Epidemiol Sus. 1998;7(2):7-28. doi: 10.5123/S0104-16731998000200002
https://doi.org/10.5123/S0104-1673199800...

In recent years, much of this has been lost, not only because of the difficulties that the SUS has suffered over the course of its history, but above all as a result of the changes made by the federal government with effect from 2015, as well as the accelerated process of dismantling health policies and programs.¹⁰10. Teixeira CFS, Paim JS. A crise mundial de 2008 e o golpe do capital na política de saúde no Brasil. Saúde Debate. 2018;42(Esp 2):11-21. doi: 10.1590/0103-11042018S201
https://doi.org/10.1590/0103-11042018S20... Indeed, underfunding, privatization, precarization of work and the drastic reduction in investments in infrastructure, science and technology, personnel training and qualification and, specifically, the political decisions regarding primary care funding and organization,¹¹11. Melo EA, Almeida PF, Lima LD, Giovanella L. Reflexões sobre as mudanças no modelo de financiamento federal da atenção básica à saúde no Brasil. Saúde Debate. 2019;43(Esp 5):137-44. doi: 10.1590/0103-11042019S512
https://doi.org/10.1590/0103-11042019S51... have intensified the structural problems faced by the SUS, which, added to the outbreak of the COVID-19 pandemic, has called into question the viability of maintaining the health system as proposed in the 1988 Federal Constitution.¹²12. Paim JS. A Covid-19, a atualidade da Reforma Sanitária e as possibilidades do SUS. In: Santos AO, Lopes LT, organizadoras. Reflexões e futuro [Internet]. Brasília: CONASS; 2021 [citado 2021 Out 20]. (Coleção covid-19; vol. 6). p. 310-24. Disponível em: https://www.conass.org.br/biblioteca/volume-6-reflexoes-e-futuro
https://www.conass.org.br/biblioteca/vol... ^,1313. Ocké-Reis CO. O SUS sobreviverá aos tempos de pandemia? Saúde Debate. 2020;44 (Esp 4):261-6. doi: 10.1590/0103-11042020E417
https://doi.org/10.1590/0103-11042020E41... Over the course of the pandemic, despite the countless problems that characterized federal management of the crisis, state governors and city mayors implemented measures for prevention, transmission control and care for severe cases by expanding the number of beds, hiring personnel and purchasing equipment, rallying laboratories and research centers, adopting mobility restriction measures and providing economic support to a significant part of the population facing unemployment and a drop in their family income.¹⁴14. Damasceno ASB, Santos JS. Análise do processo da reforma sanitária brasileira: implantação e implementação de políticas, programas e ações de saúde em 2020. [Internet]. Salvador: Observatório de Análise Política em Saúde; 2020 [citado 2020 Nov 29]. Disponível em: https://www.analisepoliticaemsaude.org/oaps/matriz/analises/1/
https://www.analisepoliticaemsaude.org/o... In turn, primary care faced serious problems due to lack of knowledge about COVID-19 and precarious health team working conditions, so that in many cases there was a drastic reduction in the number of individuals seen to, with pent-up demand for care for high-incidence chronic diseases.¹1. Freitas CM, Cunha RV. A vigilância em saúde diante da Covid-19 - desafios e lições para o enfrentamento de emergências em saúde futuras. In: Santos AO, Lopes LT, organizadoras. Reflexões e futuro [Internet]. Brasília: CONASS; 2021 [citado 2021 Out 20]. (Coleção Covid-19; vol. 6). p. 152-69. Disponível em: https://www.conass.org.br/biblioteca/volume-6-reflexoes-e-futuro/
https://www.conass.org.br/biblioteca/vol... ^,1515. Mendes EV. O lado oculto de uma pandemia: a terceira onda da COVID-19 ou o paciente invisível [Internet]. Brasília: Publicações CONASS; 2020 [citado 2021 Nov 18]. Disponível em: https://www.conass.org.br/wp-content/uploads/2020/12/Terceira-Onda.pdf
https://www.conass.org.br/wp-content/upl... Notwithstanding, many municipalities took steps to adapt their infrastructure, train and protect health professionals, including a huge effort to implement the vaccination program, when vaccines became available.

In this context, in the discourse and practice of health institutions, the coexistence of a restricted conception of surveillance can be seen, limited to disclosure of information about the number of cases, deaths and occupancy rates of general ward beds and intensive care unit beds, along with recommendations for "social distancing", "quarantine", care protocols for people with COVID-19 and, finally, vaccination, while the discourses of specialists and scientific entities in the area of Collective Health point to an expanded conception of health surveillance, recognizing the need for articulation between the different surveillance services - cross-cutting the various SUS levels of care - and health promotion actions and primary care at the territorial level, promoting, furthermore, social support measures for vulnerable groups, besides combating fake news.

The debate around the COVID-19 pandemic has reproduced the different theoretical and ideological stances that cross the field of Collective Health, with the appearance of discourses and practices that show the permanence of the "old" view of public health, subordinated to the medical-hegemonic model. Moreover, this model has been strengthened by the expansion of hospital care characterized by private management of public services, compared to "new" public health proposals, based on evidence that guides the definition of strategies and actions focused on specific groups.¹⁶16. Paim JS. Movimentos no campo social da saúde. In: Paim JS. Desafios para a saúde coletiva no século XXI. Salvador: EDUFBA; 2006. p. 117-138.

Meanwhile, the critical side of the scientific community in the area, also represented in the group that prepared the Front for Life Plan, has pointed out the complexity of the pandemic,¹⁷17. Almeida-Filho N. Modelagem da pandemia Covid-19 como objeto complexo (notas samajianas). Estud. Av. (Online). 2020;34(99):97-118. doi: 10.1590/s0103-4014.2020.3499.007
https://doi.org/10.1590/s0103-4014.2020.... highlighting the context of great economic and social inequality that favored its spread in Brazil. They have insisted on the need for comprehensive action, based on the concept of "social determinants of health",¹⁸18. Breilh J. La categoría determinación social como herramienta emancipadora: los pecados de la ‘experticia’, a propósito del sesgo epistemológico de Minayo. Cad Saúde Publica. 2021;37(12):e00237621. doi: 10.1590/0102-311X00237621
https://doi.org/10.1590/0102-311X0023762... ^,1919. Almeida-Filho N. Mais além da determinação social: sobredeterminação, sim! Cad Saúde Publica. 2021;37(12):e00237521. doi: 10.1590/0102-311X00237521
https://doi.org/10.1590/0102-311X0023752... articulating intersectoral policies on health promotion and improvement of the quality of life of the population, with specific proposals aimed at priority social groups, due to their greater social vulnerability, as well as the defense of an integrated, free and universal health system, guaranteed by the Constitution, and widespread diffusion of communication and health education actions, aiming at raising the population’s health awareness, based on the understanding that this is a necessary condition for addressing the current and future epidemics.

As I pointed out elsewhere,²⁰20. Teixeira CF. A ciência no emaranhado dos jogos de poder: reflexões sobre o lugar da saúde coletiva no contexto da pandemia da covid-19 [Internet]. Salvador: Observatório de Análise Política em Saúde; 2021 [atualizado 2021 Abr 07; citado 2022 Abr 20]. Disponível em: https://cee.fiocruz.br/?q=node/1348
https://cee.fiocruz.br/?q=node/1348... the COVID-19 pandemic has made evident the paradigmatic tensions present in the field of health and in the field of Collective Health in particular, intensifying the theoretical and political conflicts between i) the biomedical, clinical and hospital-centric perspective, ii) the epidemiological perspective, which underlies the practices of the "old" and the "new" public health and iii) the radically critical Collective Health perspective, based on the conception of the pandemic as a "hyper-complex" phenomenon, demanding interdisciplinary studies capable of dealing with its multiple dimensions - determinants, characteristics and effects on the population’s health and living conditions. At the same time, the emergence of COVID-19 proposes the implementation of policies and action plans that focus on the various dimensions of a pandemic.

Therefore, the production of knowledge and the development of technologies are challenges for the area, as is the improvement of health surveillance policies and practices based on the integral, intersectoral and participatory conception, as focused by researchers, health service managers and political leaders committed to the Brazilian Health Reform. This requires the unleashing of processes of change, in a context of uncertainty about the country’s economic and political situation in the coming years. However, one can think of health surveillance as a proposal for action capable of inspiring and guiding decision-making about "what to do" in each concrete reality, with a view to resuming the process of building the SUS.

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