The acute crisis that plagues Brazil today causes the perplexity of the unexpected in the academic community. Especially after the experiences of democratic consolidation represented, although differently, by the governments of Fernando Henrique Cardoso, Lula, and Dilma. This historical setback was not in the scientific imaginary. The constant and recurrent aggressions to the development of the Brazilian National Health System (SUS) and the consolidation of constitutional precepts, in permanent construction since 1988.

The social sciences were fundamental for consolidating the field of Collective Health, although always requested in a way that I will call “dependent” here. Together with the Policy, Planning, and Management sub-area, they were considered as the pillars of the field. The reason for calling it “dependent” remains to be clarified: in the paper cited below, by reconstituting the history of field formation, the authors showed that the leading doctors in emergencies-basic training doctors-approach social scientists and even incorporate those with intellectual and political interest in the field of knowledge of social sciences and health in the university’s staff (Vieira-da-Silva, 2018VIEIRA-DA-SILVA, L. M. O Campo da Saúde Coletiva: gênese, transformações e articulações com a Reforma Sanitária Brasileira. Rio de Janeiro: Fiocruz; Salvador: EDUFBA, 2018., p. 63). From then on, and we are talking about the end of the 1960s and the 1970s, the social sciences are being gradually incorporated into the production of knowledge of Collective Health but having their study object defined by the Brazilian Sanitary Reform’s agenda, thus losing the autonomy of a more specific view of health as an object of the social sciences.

The very evolution of the field of Collective Health, internally marked by the struggle to guarantee health as a right and the construction of the institutional and organizational framework of health that would give it concreteness, eventually generated some characteristics of the lines of analysis and content the social sciences adopted in the area.

I already pointed out one of them in a 1989 paper (Cohn, 1989COHN, A. Caminhos da Reforma Sanitária. Lua Nova, São Paulo, n. 19, p. 123-140, 1989. DOI: 10.1590/S0102-64451989000400009
https://doi.org/10.1590/S0102-6445198900... ): the need for the field to provide reasons for the proposal of sanitary reform, as well as the institutional organization to be built and/or under construction, and of the political strategy adopted-the reform within the State. Therefore, early political science gains prominence among the social sciences in scientific production, starting from the mid-1970s- a founding moment in Collective Health.

Marxist studies and analyses prevail in scientific production to face the “traditional knowledge” of public health: hygienist and positivist. Thus, they are opposed to the then prevailing analyses, which focused on health from the anthropological (cultural and behavioral) and sociological (types of social relations between social subjects, division of labor, among others) perspectives. Numerous classical studies were made during this time. It is worth remembering here one of the pioneers (Ferreira-Santos, 1973FERREIRA-SANTOS, C. A. A enfermagem como profissão. São Paulo: Editora Pioneira, 1973.) in the social sciences area, though all of them are consistent and well-founded, who effectively contributed to understanding the relation between health and society, but did not encompass the social and political struggle of the time, which consisted in combating health privatization, the hospital-centered model of medical care, and proposing a new model of comprehensive, equitable, and universal health care, promoted by a public health system, in the context of fighting for the re-democratization of society.

Although anthropology, and later sociology and other human sciences, have roughly preceded political science in the study of health/disease, in the Brazilian case they end up losing prominence in analyses and political studies that most directly responded (and respond) to the Brazilian Sanitary Reform’s needs and priorities; and initially Marxist analyses, since Collective Health is built from its opposition to the previously dominant positivist knowledge. Gramsci is one of the most invited authors in the analyses and continues to be on behalf of several classical authors and historians of the SUS and its achievements and setbacks. There are among them many texts, interviews, and conferences of Jairnilson Silva Paim.

Thus, we can see a complex movement in the production of social sciences and health, as Everardo Duarte Nunes (2015NUNES, E. D. A revista Ciência & Saúde Coletiva e o processo de institucionalização de um campo de conhecimentos e práticas. Ciência & Saúde Coletiva, Rio de Janeiro, v. 20, p. 1975-1982, 2015.) points out, but also in several other papers, in which on the one hand there is the expansion of knowledge frontiers in the area of humanities focused on health, and on the other the prominence of political analyses within Collective Health, and that more closely interacts with the other areas of this field of knowledge, creating, in the most recent period, a diaspora between the most global and the most individualizing analyses and theories, focused on the dimensions of identity, reception, and humanization of health care.

This is not about hierarchizing by importance and weight these distinct analysis and theoretical productions line, but we should note the remaining difficulty in the social sciences of facing the articulation between the biological and the social (Asa Cristina Laurell), the micro and the macro, and the construction of horizontal articulations among their many sub-areas. All this is clarified by these areas’ different degrees of proximity and even “dependence” with the dynamics of the Brazilian Sanitary Reform’s political process, either in its offensive moments or in its defensive moments, as of currently.

The need for a project for refoundation of the Brazilian Sanitary Reform is a consensus, pointing to the need to build a nation and society project with appropriate health proposals as a right. Another consensus is that the reduction of health financing is an extreme blow against the SUS, with the PEC (Proposed Amendment to the Constitution) of the ceiling of public spending, although it has never counted on the State’s financial generosity, since it has already been constituted in times of the priority of the precepts of adjustments to fiscal balance. During the pandemic, it is worth noting that this radicalization of the budgetary constraint consists in cutting oxygen from the SUS. But along with it comes the almost consensus that the SUS suffers from a sharp management deficit.

With this, and this argument is shared in different ways by those in favor of the market and the privatization of health and the SUS, as well as by those historical sanitarians who defend the SUS, there are many studies and theories on management in the field of Collective Health, contributing in a way to creating an environment free of analyses of the emphasis on the institutional reorganization of the SUS, currently emphasizing regions and health networks, which since 2000 gained presence in the public debate, even driven by the re-founding of the Abrasco Policy, Planning, and Management Commission, which had its first meeting in 2002.

Nevertheless, considering the SUS has been the target of lethal blows, a lack of analyses in human and social sciences does not help the necessary and urgent re-politicization of the struggle for health as a social right. Bringing health management together as public administration and associating it with political analysis is a complex issue (Farah, 2011FARAH, M. F. S. Administração pública e políticas públicas. Revista de Administração Pública, Rio de Janeiro, v. 45, n. 3, p. 813-836, 2011. DOI: 10.1590/S0034-76122011000300011
https://doi.org/10.1590/S0034-7612201100... ).

Thus, contrary to what the history of the constitution of the field of Collective Health led by Abrasco shows when we visit the programs of the meetings and congresses of Social and Human Sciences, Policy, Planning, and Management, as well as the Brazilian Congresses of Collective Health, social and human sciences, and political science, they walk close to each other, but in parallel most of the time, becoming the great interlocutor of epidemiology and studies of health social determinants.

What is proposed here has no prescription, but the simple attempt of pointing out some paths, equally dubious in this time of uncertainty and perplexity. But the current challenges of the SUS call on the specialists in the field to cultivate their specificities, seeking to create threads of connection that expand our capacity for analysis to understand social, cultural, and political health questions beyond the health area. Perhaps a first effort lies in the search for analyses and dialogues outside the field of Collective Health, produced by social scientists not linked to the area, in order to overcome a dichotomy that, except for classical authors, the area of Collective Health is unknown or ignored by social scientists not linked to health, and vice versa. The efforts are still insufficient, given the magnitude of the task of understanding the place of health today, in the State and in politics. Also, because the experience of health achievements took place from within the State, with specialists with political commitments occupying strategic positions in public institutions of the three spheres of government. And, from 2016, sanitarians were radically expelled from the State apparatus. It is a completely new situation that challenges our historical experience.

On the other hand, the achievements in health since 1988 were made during the the country’s re-democratization, linked to a project of generous social development, civilizing (Sergio Arouca, sanitary doctor and politician) for society. Now, in a much worse situation than then, it is about resisting and, to a large part, resuming those achievements. For that, bringing together scientists from many areas of the humanities with other scientists from other areas will help formulate a new project for the nation, communicating with society and the leadership of prominent political and social subjects, and from there seek to regain a societal defense of the SUS.

The national starting point is unfavorable in the sense that the population is caught between situations of extreme hunger, food insecurity, unemployment and underemployment, and without the possibility of a future after almost five years of governments not only incompetent, but that practice necropolitics and aporophobia in public actions, bringing an anti-civilizing government project. However, a proposal that points to this possibility of resuming the democratic construction of society and the State is possible and desirable. For that, the social sciences, with highly qualified professionals, can carry out and systematize studies already made in the many areas that Collective Health can absorb, if it turns its eyes outward as well, taking as an example Gastão Wagner de Souza Campos’ provocative proposal (as he states) launched in 2013 to make the SUS a public autarchy with the organizational nucleus of the existing health regions. Reorganizing the SUS may even be interesting. However, this is not the fundamental issue, but the role and place of the autarchies in the current project (and in the future project, to be elaborated) within the State, the mechanisms for their public control, given the characteristics of the Brazilian State accentuated by these latter governments. Does the SUS become, as an autarchy, vulnerable to the pressures and demands of the private sector and the distortions of what is understood as an effectively public health policy? What do the experiences of regulatory agencies and many existing public health authorities teach us?

Analyses to rethink the theories and practices of the previous Brazilian Sanitary Reform have already been made (Fleury, 2018FLEURY, S. (org.). Teoria da Reforma Sanitária: diálogos críticos. Rio de Janeiro: Editora Fiocruz, 2018.). It is now a question of renewing our eyes and being propositional so that we can capture the new complexities and fractions of society, besides bringing instruments to formulate projects with which it identifies, because it recognizes in them the possibility of responding to its needs and expectations.

The SUS showed society its force in facing the COVID-19 pandemic, despite the efforts of the national government to trigger pro-virus measures and against the defense of the population’s health, being able to face these adverse conditions efficiently, either at the state level (in a few cases) or at the municipal level (in many cases), despite the issues of mismanagement always pointed out. Society began to recognize the SUS as something positive, against ideological discourses of decades prior; now we need to bring back this force and carry forward the struggle so that the SUS, as a public good of society, is recognized and defended; and this defense has enormous social mobilization, another of its characteristics. Health organizes and mobilizes social segments, as demonstrated by the past, but does not maintain this mobilization. Social, political, and sanitary leaders, among many others, must be supported by social forces that effectively recognize the SUS as part of their future project. However, it is necessary to understand other analysis perspectives on the participation of social movements in public policies and public management, a production that, although traditional in the area of Collective Health, has gained importance in social sciences, bringing new perspectives to understand the phenomenon.

We must try to understand why our current society is so fragmented and segmented, or, as some name it, fractured (Cohn, 2020COHN, A. As políticas de abate social no Brasil contemporâneo. Lua Nova, São Paulo, n. 109, p. 129-160, 2020. DOI: 10.1590/0102-129160/109
https://doi.org/10.1590/0102-129160/109... ). Its polytraumas (in the plural, redundancy is purposeful) are numerous. One must learn to recognize, respect, and contemplate them in our studies and proposals. Immediately, the binary analyses that marked the beginning of the constitution of the field of Collective Health no longer have space in this purpose. On the other hand, one cannot risk seeking a transdisciplinarity that clears the specificities of each analysis perspective. As in democracy, seeking the coexistence of the different disciplines is necessary based on the enrichment of the understanding of reality that oppresses us and amazes even the less optimistic, given the size of the democratic setback (social, political, institutional) that it has demonstrated. Carlos G. Gadelha has already called on our collective to assemble what he called “utopian energies, ideas, and public policies”. Let us move forward, as a utopia is a means to make us walk, as Fernando Birri recalled.

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