THIS SPECIAL ISSUE OF THE JOURNAL 'SAÚDE EM DEBATE' celebrates the 40th anniversary of the Brazilian Center for Health Studies (Cebes) and its first edition. It was in 1976 that a group of young health professionals, who took the 1st Specialization Course in Public Health at the local level - from the School of Public Health of the University of São Paulo (USP), created Cebes and the periodic. They were militants or sympathizers of the Brazilian Communist Party (PCB) or the Popular Action, but instead of distributing pamphlets, they decided to disseminate the Marxist critical thinking in the health area through a periodic. The political situation was favorable: the country was in the beginning of a process of political transition that, although considered to be very long, inspired expectations of new public policies, especially in the field of health, since community health programs and extension of coverage programs had just been initiated.

The creation of Cebes was extensively discussed at the XXVIII Meeting of the Brazilian Society for the Advancement of Science (SPBC) in July 1976, in Brasília. During that period, the annual SPBC meetings became a sounding board for the growing opposition to the bureaucratic-authoritarian military government in academia. The announcement of Cebes and the journal 'Saúde em Debate' had a significant presence of students and young professors and researchers, particularly in the field of social and preventive medicine, but also in other areas such as the humanities. Since November 1976, several meetings have been held to launch the periodic 'Saúde em Debate' in various regions and cities of the country, such as: São Paulo, Brasília, Sorocaba, Campinas, Belo Horizonte, Rio de Janeiro, Vitória, Salvador, Londrina and many others. Those meetings stimulated the creation of nuclei of the entity, which in addition to organizing debates on health issues, also disclosed the magazine, in which campaigns were made to obtain members, whose contributions were indispensable to ensure the circulation of 'Saúde em Debate'.

We celebrate 40 years of Cebes and 'Saúde em Debate'! In the Judeo-Christian and Islamic traditions, inspired by the Bible, the number 40 has a special symbolic value: it refers to a time of preparation and ordeal prior to something new - the flood lasted 40 days and 40 nights; The Jewish people spent 40 years in the desert before reaching the promised land; Jesus fasted for 40 days before starting his mission... In the case of Cebes and 'Saúde em Debate', however, there has apparently been an inversion: the new, the Sanitary Reform initiated by the Cebes and expressed in the recognition of health as a social right and in the creation of the Unified Health System (SUS), is now culminating in a time of probation with the Constitutional Amendment No. 95, dated December 15, 2016, promulgated by the Chamber of Deputies and the Federal Senate, establishing the New Fiscal Regime, with a 20-year term and which will have serious consequences in guaranteeing the right to health, for which Cebes has been working for 40 years. However, perhaps appearances are deceiving, and the regression will undresses that the new has not yet arrived.

Since its creation, Cebes has denounced the inequities and perversities of the health system and calls for the need of reforms. This formed a 'coalition in defense of the Sanitary Reform', which was expanded in the 1980s with the participation of sanitarians who were working in community health programs and extension of coverage of public health services programs, and especially with the participation of the Brazilian Association of Collective Health (Abrasco), with the support of health professionals' movements and entities. In this context of 'political transition', this 'coalition', that is, the Sanitary Movement, moved and found inspiration in the dream and utopia of the social right to health and of a new health system, unified, 'permanently controlled by the population'. That dream and that utopia were asserted in the document 'Democratization and health' presented by Cebes in 1979 at the First Symposium on National Health Policy of the Health Commission of the Chamber of Deputies. The document was widely publicized in 'Saúde em Debate' under the title 'The Democratic Issue in Health'. It should be emphasized that the reference to democracy went far beyond the dominant discourse of 'political transition', for it expressed a conception very dear to the Sanitary Movement: only with the advance of democracy and citizenship, could the social right to health and a system of and universal health be consolidated.

Public policies tend to show a relative constancy in which changes take place in the form of increments, but can be interrupted by relatively abrupt changes. Extension of coverage programs in the 1970s and the Integrated Health Actions (AIS) in the 1980's pointed to the growing institution of a public primary health care network and to the integration between the Ministry of Health, the state and municipal secretariats of Health, and the National Institute of Medical Assistance of Social Security (Inamps). The document 'The Democratic Issue in Health' and the Sanitary Reform movement contributed, however, to more abrupt changes: the proposals approved at the VIII National Health Conference in 1986, and consecration of the social right to health and creation of the SUS by Federal Constitution of 1988.

Such achievement was obtained for the great mobilization of the members of the Sanitary Movement, favored by their strong presence in State apparatuses, by the technical knowledge they had as to the organization of health systems and services, and by the expectation of new public policies, in addition to the support of movements and entities of the health area and some other sectors: Ecclesial Base Communities (CEB) and Popular Movement for Health (MOPS). However, the text of health in the Constitution does not reflect an aspiration or a clamor of popular sectors or a society in general. One suggestive indicator of this is the number of subscribers to the popular health amendment, 54, 133 versus more than 3 million of the Agrarian Reform amendment.

Still, the new text on health was not without significant repercussion. It produced a new health policy: the Inamps was extinguished, and the SUS was organized in a relatively short time, with advances far beyond than if it were only a poor system for the poor. Its greatest problem would be underfunding. However, that problem is much more than only financial. It is an 'analyzer', that is, revealing of the fact that hierarchical society - the political and economic elites, the middle classes, the big businessmen, and the organized workers -, as well as the private sector and important contingents of health workers, is not adhering to the SUS and defending the right to health for all. Such relationship has been mirrored in the actions of successive governments that have directly or indirectly subsidized health plans and private health services.

While the 'coalition' in defense of the Sanitary Reform had a backlash, but continued to fight through its nucleus, the Sanitary Movement, and in the last decade through the Brazilian Sanitary Reform Forum, the 'coalition in defense of the private sector', which already in the 1987-1988 Constituent Assembly guaranteed its action under article 199, continued to be intensified through an internationalization and financialization policy. While sanitarians dreamed of a social democratic welfare state based on the recognition of universal social rights, the security system was surreptitiously moving towards a liberal welfare state in which the state provides only minimal benefits to the low-income population and stimulates private insurance and health care plans for the higher-income population. That option was denuded, in an arrogant and cruel way, when the illegitimate government that settled with the dismissal of President Dilma Rousseff, in 2016, instituted through the Constitutional Amendment No. 95 the practice of freezing and reducing expenses in health, education and social development and proposed the reduction of pensions and social benefits through the Proposal of Constitutional Amendment No. 287, presented to the Chamber of Deputies on December 5, 2016, currently awaiting the creation of a Temporary Committee by the Bureau.

Is the Citizen Constitution of 1988 being torn apart, or is the distance between the legal Brazil and the real Brazil getting clearer? In any case, after 40 years, new obstacles are set to be overcome by Cebes, for the struggle for democratization must continue, but it can no longer be restricted to institutional and academic spheres. It is necessary to privilege the popular participation and popular spaces, a direction that is shown in this commemorative number when discussing deliberative and popular participation. From that perspective, the issues are put first and foremost for the Cebes nuclei. Those are being called upon to build means to advise and intensify popular movements and entities and to support popular or grassroot education projects.

The current context of coup has everything to discourage us. At the moment, resorting to the classics that discussed the formation of the Country does no harm, despite its misunderstandings. Francisco Jose de Oliveira Vianna (1883-1951) and Sérgio Buarque de Holanda (1902-1982) pointed out the distance between the legal Brazil and the real Brazil, but while the former was convinced that only a strong state could surpass such distance, the latter placed in the real Brazil itself the possibility of changes. The conviction of Oliveira Vianna was already disqualified by the unfolding of our history. We remain, then, with the conviction of Sérgio Buarque de Holanda, and continue the struggle without ever losing hope.

Cebes is what it does and does what it is!

Cornelis Johannes van Stralen
President of Cebes (2015-2017)
José Ruben de Alcântara Bonfim
Director of Cebes (2015-2017)
President of Cebes (1976-1978 and 1978-1979)

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