ABSTRACT

The COVID-19 pandemic has produced new demands for services in healthcare systems around the world. In Brazil, the SUS became the object of interest of the media, which made efforts to cover government actions and the system’s capacity to control the pandemic. This study aims to analyze articles from the newspaper ‘Folha de São Paulo’ (FSP), regarding the meanings produced about the Unified Health System (SUS) in the COVID-19 pandemic. 231 articles were analyzed, among the 524 published in the period from January to May 2020, following the established inclusion criteria. The corpus was categorized in four senses: constitutional SUS, problem SUS, disputed SUS and active SUS. The reflection on the diversity of meanings attributed to the SUS points to the need to expand the capture of the dimensions of the SUS.

KEYWORDS
COVID-19; Mass mídia; Hermeneutic; Public health

Introduction

In January 2020, the World Health Organization (WHO) declared a situation of Public Health Emergency of International Importance (ESPII)^{11 Organização Pan-Americana da Saúde. Histórico da pandemia de COVID-19. OPAS. [acesso em 2022 jul 22]. Disponível em: https://www.paho.org/pt/covid19/historico-da-pandemia-covid-19.
https://www.paho.org/pt/covid19/historic...} and, in March the same year, given the initial spread of the Coronavirus, recognized the COVID-19 pandemic. Ever since, more than a health crisis, COVID-19 has caused a large global crisis with social, economic, cultural, environmental and communicational impact.

The pandemic was followed, right from the start, by the quick spread of misinformation, making it essential to respond by spreading reliable information. The press coverage and that of other communication media plays then an essential role, given the way how they influence people’s perception on health and, therefore, on prevention behaviour and their search for health services^{22 Taberner JS, Leite PC, Cutait MM, et al. A influência da mídia nos atendimentos cardiológicos de urgência: O caso Bussunda. Rev Assoc Med Bras. 2007 [acesso em 2021 jul 22]; 53(4):335-7. Disponível em: https://www.scielo.br/j/ramb/a/CvT6r8MNbbWdsvWtvvWGGLH/.
https://www.scielo.br/j/ramb/a/CvT6r8MNb...} . It is in that sense that the the press coverage should be part of the effort to fight the pandemic.

In Brazil, journalistic communication about health affects the way how the population perceives their right to a universal and free health system^{33 Cardoso JM, Rocha RL. Interfaces e desafios comunicacionais do Sistema Único de Saúde. Ciênc. Saúde Colet. 2018 [acesso em 2022 jul 22]; 23(6):1871-1879. Disponível em: https://www.scielo.br/j/csc/a/pTXBdCDZGJGbpX93xQd3gGK/.
https://www.scielo.br/j/csc/a/pTXBdCDZGJ...} , potentially enabling the population to have a better understanding of the Unified Health System (SUS), and the public health and health-disease processes.

From this perspective, in order to understand the role played by the media in the dispute of meanings about health, it becomes relevant to study media narratives and practices concerning health, considering the meanings the media vehicles produce, the arguments they resort to, the sources they use and the images they build, that is, the understanding of how the media mediates the information.

This investigation aims to identify and analyze the meanings produced by the ‘Folha de São Paulo’ news outlet (FSP) about the SUS during the COVID-19 pandemic, in a corpus consisting of publications taken place between January and May 2020. It is a newspaper with large national circulation, having an impact on public discussion in Brazil^{44 Folha é o jornal mais nacional do país e o de maior audiência e circulação. A Folha de São Paulo. 2021 mar 27. [acesso 2022 jul 22]. Disponível em: https://www1.folha.uol.com.br/poder/2021/03/folha-e-o-jornal-mais-nacional-e-o-de-maior-audiencia-e-circulacao.shtml.
https://www1.folha.uol.com.br/poder/2021...} . Thus, the Observatory of Political Analysis in Health (OAPS), through its Media and Health Axis, whose research is part of the ‘Analysis of Health Surveillance Models and Strategies of the COVID-19 Pandemic (2020-2022)’ project, investigated the narratives published in the first four months since the arrival of COVID-19 to the country.

Theoretical prospects

For the analysis of meanings, this qualitative study resorts to a literature review, noting that several analytical perspectives allow exploring the meanings of journalistic narrative: there is the interpretive analysis, in which the reader puts himself in the place of the author of the text, observing his movements and the questions that the text seeks to answer towards its horizon of expectations^{55 Gadamer HG. Verdade e método: traços fundamentais de uma hermenêutica filosófica. Petrópolis: Vozes; 1997.} when analysing the plot, the language resources that compose the narrative, the author-reader interaction, and the arguments structured in the text, this being its privileged locus^{66 Ricouer P. Teoria da interpretação: o discurso e o excesso de significação. Lisboa: Edições 70; 2009.}. In the work of interpreting the meanings that arise, says Ricoeur^{66 Ricouer P. Teoria da interpretação: o discurso e o excesso de significação. Lisboa: Edições 70; 2009.}, what one wants to understand in a text is not the event itself, but its meaning, in the sense that if every discourse is an act, an event, what can be grasped and understood from it is its meaning or sense, rather than its intention. Still, according to Critelli^{77 Critelli DM. Analítica do sentido: uma aproximação e interpretação do real de orientação fenomenológica. São Paulo: Brasiliense; 1996.(132)}, the meaning is, “[...] another direction that appeals, a request that makes itself heard, an obstinate appeal that insinuates and pursues”. It differs from significance because this one “[...] is direct, literal, explicit, closed in on itself, univocal [...]” whereas the text “is full of primary, secondary tertiary or even quaternary senses”^{88 Saramago J. Todos os nomes. São Paulo: Companhia das Letras; 1999.(135)}.

From this understanding of the complexity of the production and the analysis of meanings in a narrative, this study seeks to find the propositional content, what the discourse actually ‘says’ about the SUS in the journalistic discourse, looking at where it points to and at where the expectation horizon of the reader is found. These are meanings that are presented, with greater evidence, in their propositional content, which stands out to the reader as main object, semantic core, and is supported by arguments. It starts from the understanding of the journalistic text as a discourse when reflecting on what is said and what is not said in language, or even on what is privileged and what is silenced^{99 Cavalcante CC. Os sentidos do Sistema Único de Saúde na mídia impressa do Ceará um estudo do jornal O Diário do Nordeste. 2014. [dissertação]. Rio de Janeiro: Instituto de Comunicação e Informação Científica e Tecnológica em Saúde, Fundação Oswaldo Cruz; 2014.}.

Furthermore, a review of the scientific literature on the SUS served as a reference for the analysis of meanings, understanding signification as meaning and reference^{66 Ricouer P. Teoria da interpretação: o discurso e o excesso de significação. Lisboa: Edições 70; 2009.}. Focusing on the steps ahead, difficulties and setbacks in the Health Reform process in Brazil over the 30 years since the SUS was founded, three categories that define the SUS in this literature were listed:

1. The constitutional SUS, in which the propositional content of the narrative highlights the SUS as a right of society, conquered through social struggles that were inscribed in the Constitutional Charter of 1988 and is, therefore, a State policy^{1010 Teixeira CF, Souza LEP, Paim JS. Sistema Único de Saúde (SUS): a difícil construção de um sistema universal na sociedade brasileira. In: Paim JS, Almeida Filho N, organizadores. Saúde Coletiva: teoria e prática. Rio de Janeiro: MedBook; 2014. p. 121- 137.,1111 Ciarlini ALA. Direito à saúde e respeito à Constituição. In: Santos NR, Amarante PDC, organizadores. Gestão pública e relação público privado na saúde. Rio de Janeiro: Cebes; 2010. p. 87-100. [acesso em 2020 jul 31]. Disponível em: http://idisa.org.br/img/File/GC-2010-RL-LIVRO%20CEBES-2011.pdf#page=24.
   http://idisa.org.br/img/File/GC-2010-RL-...} that points to a horizon of meaning of the SUS as a universal right to health and a SUS that is strategic for facing the population’s health problems^{1212 Santos NR. Desenvolvimento do SUS, rumos estratégicos e estratégias para visualização dos rumos. Ciênc. Saúde Colet. 2007 [acesso em 2022 jul 22]; 12(2):429-435. Disponível em: https://www.scielosp.org/pdf/csc/2007.v12n2/429-435/pt.
   https://www.scielosp.org/pdf/csc/2007.v1...} .

2. The SUS that presents problems and challenges, in which the narrative highlights a system that historically has to cope with issues such as management challenges^{1414 Mendes A, Weiller JAB. Renúncia fiscal (gasto tributário) em saúde: repercussões sobre o financiamento do SUS. Saúde debate. 2015 [acesso em 2021 out 10]; 39(105):491-505. Disponível em: https://www.scielosp.org/pdf/sdeb/2015.v39n105/491-505/pt.
   https://www.scielosp.org/pdf/sdeb/2015.v...} , underinvestment^{1212 Santos NR. Desenvolvimento do SUS, rumos estratégicos e estratégias para visualização dos rumos. Ciênc. Saúde Colet. 2007 [acesso em 2022 jul 22]; 12(2):429-435. Disponível em: https://www.scielosp.org/pdf/csc/2007.v12n2/429-435/pt.
   https://www.scielosp.org/pdf/csc/2007.v1... ,1414 Mendes A, Weiller JAB. Renúncia fiscal (gasto tributário) em saúde: repercussões sobre o financiamento do SUS. Saúde debate. 2015 [acesso em 2021 out 10]; 39(105):491-505. Disponível em: https://www.scielosp.org/pdf/sdeb/2015.v39n105/491-505/pt.
   https://www.scielosp.org/pdf/sdeb/2015.v...} and even divestment^{1515 Menezes APR, Moretti B, Reis AAC. O futuro do SUS: impactos das reformas neoliberais na saúde pública: austeridade versus universalidade. Saúde debate. 2019 [acesso em 2021 out 10]; 43(5):58-70. Disponível em: https://www.scielosp.org/pdf/sdeb/2019.v43nspe5/58-70/pt.
   https://www.scielosp.org/pdf/sdeb/2019.v...} , problems leading to a distortion in the principle of universality and restricting the system to only serving the poor^{1616 Paim JS. O que é o SUS? Rio de Janeiro: Fiocruz; 2009.,1010 Teixeira CF, Souza LEP, Paim JS. Sistema Único de Saúde (SUS): a difícil construção de um sistema universal na sociedade brasileira. In: Paim JS, Almeida Filho N, organizadores. Saúde Coletiva: teoria e prática. Rio de Janeiro: MedBook; 2014. p. 121- 137.} and to providing unequal access to its services^{1717 Cordeiro HA, Conill EM, Santos IS, et al. Por uma redução nas desigualdades em saúde no Brasil: qualidade e regulação num sistema com utilização combinada e desigual. In: Santos NR, Amarante PDC, organizadores. Gestão pública e relação público privado na saúde. Rio de Janeiro: Cebes; 2010. p. 129-151. [acesso em 2021 out 10]. Disponível em: http://idisa.org.br/img/File/GC-2010-RL-LIVRO%20CEBES-2011.pdf#page=24.
   http://idisa.org.br/img/File/GC-2010-RL-...} .

3. A SUS that is a field of dispute, where the semantic core of the narrative refers to the power struggle concerning the model of care, still strained by the traditional privatist-hospital-centered model and the sanitary model which preceded the creation of the SUS^{1818 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 well as the public-private relationship and management model^{1919 Ibanez NE, Vecina Neto G. Modelos de gestão e o SUS. Ciênc. Saúde Colet. 2007 [acesso em 2021 dez 31]; 12(supl):1831-1840. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232007000700006&lng=en&nrm=iso.
   http://www.scielo.br/scielo.php?script=s... ,2020 Mendes JMR, Garcia MLT, Oliveira EFA, et al. Gestão na saúde: da reforma sanitária às ameaças de desmonte do SUS. Text. Cont. 2011 [acesso em 2021 out 10]; 10(2):331-344. Disponível em: https://www.redalyc.org/pdf/3215/321527169011.pdf.
   https://www.redalyc.org/pdf/3215/3215271...} .

In this study, we also chose to observe and capture new categories containing emerging definitions of the SUS.

Material and methods

The methodology consisted of document analysis of texts published on the FSP website. For search purposes, the key-word “SUS” was used in a time frame ranging from November 1st, 2019 to May 6th, 2020, when the study was started. 702 texts were found and it was noted that the first publication of the aforementioned newspaper on the new coronavirus, in this corpus, took place on January 22, 2020. All texts prior to this publication were excluded from the study, whereas the total number of texts for actual investigation was 524. These were read in full, being made use of a data production instrument on the Google Forms platform containing 13 guiding questions with the purpose of identifying, in the said speech or propositional content, the meanings assigned to the SUS that would guide the analysis.

All texts that suggested the assignment of meanings to the SUS were included, even when that was not the main object of the publication, using as exclusion criteria: texts that did not suggest any meaning about the SUS; other texts which only cited the SUS without developing a narrative; and also those that addressed the SUS outside the context of the pandemic as found in readers’ forums and duplicate articles.

After completing the forms, the responses were compiled in the Google’s Data Studio tool for analysis and, through a first reading, the first meanings were identified, that is, what was found to be the central object of the text, corresponding to one of the categories arising from the reference literature. In addition to these, another meaning was identified in the narratives in the context of a pandemic which refers to the SUS as something active, searching for solutions, mobilizing players and attracting cooperation from society.

Thus, the following categories were adopted for an in-depth reading: a) the Constitutional SUS, relating to the universal right to health as defined by the Federal Constitution and understood as strategic for facing the pandemic; b) the Problem SUS, due to underfunding, mismanagement, inequality of access, and threat of collapse; c) The Dispute SUS, being source of dispute between federative and political entities, amid a power struggle and the tension existing between the public and private segments of the health system and; d) the Active SUS, which emerged from the data as an empirical category, expressing the effort of professionals and managers in their fight against the pandemic, with emphasis on the concrete actions undertaken by the SUS on the various levels of care, this including creativity, innovation and cooperation with the private sector . In other words, publications that showed the SUS as a combatant, active, and ready to fight entity.

The methodology also included the validation of the categories among the researchers in order to confirm or reassign the text to another category, according to the meaning understood by the researchers in their dialogue. It is noted that the texts are full of meanings, of which the predominant ones were categorized.

For the analysis of the meanings in the texts, verbal devices were observed in addition to the propositional content, and an attempt was made to interpret the horizon of expectations to which the text pointed.

Results

From the set of 524 texts, 231 of them complied with the criteria established and were analyzed based on the four categories already mentioned.

The distribution in time of journalistic texts is shown in graph 2: 1.3% in January; 3% in February; 48.7% in March; 41.8% in April; and 5.2% in May. It is observed that the largest number of publications took place in the period after the announcement of the official statement of the pandemic by the WHO, which triggered political, economic and social events.

Constitutional SUS

The Constitutional SUS category corresponds to 19% (44) of the set of texts analyzed, referring to (i) the universal right to health and (ii) the strategic character of the SUS to face the pandemic, in, respectively, 32 and 12 texts.

In the context of the health emergency, in some articles, former ministers, businessmen and organizations (non-government and partisan) are the voices that, in the narrative, extol the relevance of health networks and professionals for keeping the SUS alive. In the article entitled ‘Lights of hope in the midst of a pandemic’^{2121 Boudunki N. Luzes de esperança em meio a pandemia. A Folha de São Paulo. 2020 mar 30. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/colunas/nabil-bonduki/2020/03/luzes-de-esperanca-em-meio-a-pandemia.shtml.
https://www1.folha.uol.com.br/colunas/na...} , the following excerpt stands out:

Other articles warn that the SUS has been forgotten over the years and that, in the health crisis, it is the country’s main resource for controlling the pandemic, as can be seen in the article ‘Budget Shortsightedness’, signed by Delfim Neto^{2222 Netto AD. Miopia orçamentária. A Folha de São Paulo. 2020 maio 6. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/colunas/antoniodelfim/2020/05/miopia-orcamentaria.shtml.
https://www1.folha.uol.com.br/colunas/an...} , former -minister of the economy during the military dictatorship:

As for the article entitled ‘Suspending confinement ahead of time can make testing program unfeasible, says OECD’^{2323 Pinto AES. Suspender confinamento antes da hora pode inviabilizar programa de testes, diz OCDE. A Folha de São Paulo. 2020 abr 20. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2020/04/suspender-confinamento-antes-da-hora-pode-inviabilizar-programa-de-testes-diz-ocde.shtml.
https://www1.folha.uol.com.br/equilibrio...} , it highlights the history and accumulation of experience of the SUS, making of it a powerful system that should be strengthened.

However, the President of the Republic’s position of denying the pandemic and of escaping the role of the Brazilian State for fighting it becomes a fact of great repercussion in the newspaper, as seen in the article of 02/12/2020, entitled ‘Providence in the face of crisis is to mitigate arrogance and Bolsonaro does the opposite, says Ciro’^{2424 Linhares C. ‘Providência diante de crise é atenuar arrogância e Bolsonaro faz o oposto’, diz Ciro. A Folha de São Paulo. 2020 mar 12; Política. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/poder/2020/03/providencia-diante-de-crise-e-atenuar-arrogancia-e-bolsonaro-faz-o-oposto-diz-ciro.shtml.
https://www1.folha.uol.com.br/poder/2020...} , in which former minister Ciro Gomes criticizes the President of the Republic’s conduct with regard to the responses given to the health and economic crisis engendered by the COVID-19 pandemic and remarks the importance of the SUS and of the universities to refraing the virus in the country.

Also noteworthy is the text entitled ‘The strengthening of the State after the pandemic is not something guaranteed’^{2525 Bucci MPD. Fortalecimento do Estado depois da pandemia não está garantido. A Folha de São Paulo. 2020 abr 20. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/ilustrissima/2020/04/fortalecimento-do-estado-depois-da-pandemia-nao-esta-garantido.shtml.
https://www1.folha.uol.com.br/ilustrissi...} which discusses the prospects of the SUS in the period following the health crisis and acknowledges that

The strategic character of the SUS is related to the idea of hope given its potential to face the crisis and is highlighted in news reports recognizing its importance in controlling the COVID-19 pandemic, inscribing it in a logic of incitement to its defense, thus reinforcing its relevance and the need to strengthen the health care network, highlighting the SUS as an ‘advantage’ in the face of the global health emergency.

This narrative is present in the media studied from January to May 2020, with its highest peak being found in the period studied on 03/25/2020, when four journalistic texts were published with an emphasis on this content. Among them, there is the article ‘The pandemic is an opportunity to accelerate or annihilate the autocratic project’^{2626 Mendes CH. A pandemia é uma oportunidade para acelerar ou aniquilar o projeto autocrático. A Folha de São Paulo. 2020 mar 25. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/colunas/conrado-hubner-mendes/2020/03/a-pandemia-e-uma-oportunidade-para-acelerar-ou-aniquilar-o-projeto-autocratico.shtml.
https://www1.folha.uol.com.br/colunas/co...} , in which the author criticizes Jair Bolsonaro, especially his crisis management and denialist stance, stating that “The crisis is factual, visible and infectious too. It demands science and scientists, the State and the SUS, apart from intelligence and honesty”^{2626 Mendes CH. A pandemia é uma oportunidade para acelerar ou aniquilar o projeto autocrático. A Folha de São Paulo. 2020 mar 25. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/colunas/conrado-hubner-mendes/2020/03/a-pandemia-e-uma-oportunidade-para-acelerar-ou-aniquilar-o-projeto-autocratico.shtml.
https://www1.folha.uol.com.br/colunas/co...} , thus positioning the SUS as necessary to effectively face the current health crisis.

In this way, the SUS, as inscribed in the Federal Constitution of 1988, is a right of all and a duty of the State, and gains visibility in the media during the pandemic period, leaving in the horizon of expectation the understanding that its existence and strengthening are needs of the Brazilian society.

Problem SUS

The meaning of the SUS being a problem and the challenges implied by that were made evident in texts relating the SUS to failures, mismanagement, inefficiency and risk of collapse, in addition to the challenges already found in the literature as in the case of underfunding and inequality, all of them understood as hindrances when facing the pandemic. This meaning was interpreted in 87 (37.7%) texts, the largest number among those that make up the corpus of this research.

The collapse significant appears recurrently related to the SUS, appearing, for the first time on the timeline, in an article published on 02/27/2020, entitled ‘What will happen now that Brazil has its first case of coronavirus?’^{2727 Varella D. O que acontece agora que o Brasil tem seu primeiro caso de coronavírus? A Folha de São Paulo. 2020 fev 27. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/colunas/drauziovarella/2020/02/o-que-acontece-agora-que-o-brasil-tem-seu-primeiro-caso-de-coronavirus.shtml.
https://www1.folha.uol.com.br/colunas/dr...} , when the virus first arrived in the country. Since then, the infrastructure capacity of the SUS to serve the entire population is questioned both at the hospital level and at that of the primary care network of services, with a capillarity seen as insufficient to respond to the health crisis, whose control is conditioned to the number of seriously ill patients existing and the adoption of a set of prevention measures.

The threat of the SUS collapsing^{2828 Colluci C. ‘SP terá que fazer uma gestão de leitos de UTI para que o sistema não entre em colapso’, diz David Uip. A Folha de São Paulo. 2020 mar 19. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2020/03/sp-tera-que-fazer-uma-gestao-de-leitos-de-uti-para-que-o-sistema-nao-entre-em-colapso-diz-david-uip.shtml.
https://www1.folha.uol.com.br/equilibrio...} occupied a significant space in the narratives produced about the COVID-19 pandemic throughout the first five months of news reports published on the ‘Folha de São Paulo’ (FSP) newspaper. Terms such as ‘collapse’ and ‘overload’ were mentioned as references to the health system and were present in most texts.

The arguments used in these texts are, mainly, the high occupancy rates of hospital beds in Brazilian municipalities and the importance of adopting the necessary strategies to mitigate the risk of the system collapsing: social distancing, the increase in the number of tests, the opening of new beds and the purchase of personal protective equipment and other necessary items for hospital care of most serious cases, such as respirators.

Some news reports<sup>2929 Cancian N. SP, Rio, DF, Ceará e AM podem entrar em fase de aceleração descontrolada do coronavírus. A Folha de São Paulo. 2020 abr 4. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2020/04/sp-rio-ceara-df-e-am-podem-entrar-em-fase-de-aceleracao-descontrolada-do-coronavirus-diz-ministerio.shtml.
https://www1.folha.uol.com.br/equilibrio...

30 Pasquini P. UTIs de hospitais públicos de SP chegam perto da capacidade total. A Folha de São Paulo. 2020 abr 17; Saúde. [acesso 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2020/04/utis-de-hospitais-publicos-de-sp-chegam-perto-da-capacidade-total.shtml.
https://www1.folha.uol.com.br/equilibrio... -3131 Canzian F. No ritmo atual, as UTIs podem lotar na segunda quinzena de maio. A Folha de São Paulo. 2020 abr 8. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/cotidiano/2020/04/no-ritmo-atual-utis-podem-lotar-na-primeira-quinzena-de-maio.shtml.
https://www1.folha.uol.com.br/cotidiano/...</sup> address the economic dimension that a collapse of the health system would have, emphasizing the need for greater financial resources to be allocated to the SUS, forecasting expenditures on high-complexity care for patients with COVID-19 and on the future impacts of the coronavirus over the Public Health System.

Still, the meaning of a collapse of the SUS was brought by a third group of texts that addressed historically vulnerable social groups that would have their situation worsened in a context of failure of the system, given their exclusive dependence on the SUS, or even addressed how the pandemic would contribute for the intensification of inequalities in Brazilian society, as is the case of housemaids and delivery service workers.

Finally, in most of the texts that make up the research corpus, the threat of collapse is accompanied, in the narratives, by manifestations of different social players in defense of the SUS and they include: its appreciation as a universal right to health; recognition of its historic underfunding; and the need for joint efforts to strengthen the system in a context of a pandemic and in the face of a real threat of collapse. On 04/13/2020, in an article that gathers interviews, entitled ‘Coronavirus will leave a bitter legacy to be solved, say experts’^{3333 Cucolo E. Coronavírus deixará herança amarga para ser resolvida, dizem especialistas. A Folha de São Paulo. 2020 abr 13. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/mercado/2020/04/coronavirus-deixara-heranca-amarga-para-ser-resolvida-dizem-especialistas.shtml.
https://www1.folha.uol.com.br/mercado/20...} , a representative of a humanitarian organization says that

The underfunding of the SUS appears in 22 of the analyzed texts as a chronic problem since the system was implemented, worsening over the years and getting more accentuated by Constitutional Amendment 95. As a consequence, in the face of the COVID-19 pandemic, the SUS has limitations to its potential to respond to the health demands of the Brazilian population, as seen in the article ‘Coronavirus reaches the Supreme Court and accumulates with other crises already installed in the country’^{3434 Machado E. Coronavírus chega ao STF e se acumula a outras crises já instaladas no país. A Folha de São Paulo. 2020 mar 19. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/poder/2020/03/coronavirus-chega-ao-stf-e-se-acumula-a-outras-crises-ja-instaladas-no-pais.shtml.
https://www1.folha.uol.com.br/poder/2020...} .

The article entitled ‘Encouraging social isolation means valuing life, health and respect’^{3535 Teixeira RR, França-Junior I. Incentivar o isolamento social significa valorizar a vida, a saúde e o respeito. A Folha de São Paulo. 2020 mar 26. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2020/03/incentivar-o-isolamento-social-significa-valorizar-a-vida-a-saude-e-o-respeito.shtml.
https://www1.folha.uol.com.br/equilibrio...} , published on 03/26/2020, makes the following statement:

Still in relation to the SUS problems highlighted by the FSP, the issue of inequality is illustrated by the difficulties of access to the health system by different population groups - the black, the elderly and the poorest, who, in this context, become even more vulnerable; and by the unequal distribution of health services in Brazilian regions such as the South-East compared to the North region or the urban center compared to the urban periphery.

It is interesting to note that, although there is this sense of the SUS being a problem, on the horizon of expectation there seems to be not a perspective of it being inefficient, but, on the contrary, a criticism of the underfunding that restricts the system’s performance.

The SUS being disputed

The disputes pervading the process of building and strengthening the SUS, with progress made and setbacks, gain prominence and become more accentuaded in the analyzed corpus. The power struggle that involves this process was observed in a set of narratives that show tensions between managers at different levels of the federation. This sense was present in a total of 30 (13%) of the texts studied.

As an example of this dispute of narratives about the SUS’ actions in the context of the pandemic, there is the article entitled ‘Mandetta says that full quarantine will be a disaster and criticizes motorcades’^{3636 Onofre R, Garcia L. Mandetta diz que quarentena total será desastre e critica carreatas. A Folha de São Paulo. 2020 mar 28. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2020/03/mandetta-diz-que-quarentena-total-e-desastre-e-critica-carreatas.shtml.
https://www1.folha.uol.com.br/equilibrio...} , of 03/28/2020, in which the then minister discards vertical isolation (restricted to risk groups) as well as lockdown, “total interdiction of the economic and social system, adopted in countries like Italy”, classifying it as a disaster for the entire country, while, on the other hand, criticizing the motorcades of the president’s supporters who were against any restrictive measure whatsoever.

The tension around drug treatment, as in the case of Chloroquine treatment, the drug defended by Bolsonaro and criticized by Mandetta, is also shown by the FSP in the same article, in which the latter states: “Chloroquine is not a panacea. It is not the medicine that came to save humanity”^{3636 Onofre R, Garcia L. Mandetta diz que quarentena total será desastre e critica carreatas. A Folha de São Paulo. 2020 mar 28. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2020/03/mandetta-diz-que-quarentena-total-e-desastre-e-critica-carreatas.shtml.
https://www1.folha.uol.com.br/equilibrio...} .

Regarding the comparison made between the public and private health systems, the SUS is generally referred to in a discursive logic that builds the image of a more efficient private system, with more resources and fewer problems than the SUS. Comparisons are often made by using quantitative metrics relating to number of beds, occupation of vacancies, or inputs, whereas the tensions are reported in contexts of dispute over funding, inputs, relevance in the provision of health services and single waiting list proposal, as well as the compulsory acquisition of beds and equipment from the private sector for the SUS.

In the news published on 05/06/2020, entitled ‘Teich criticizes the ‘taking’ of ICUs from the private network and asks for a solution with cooperation’^{3737 Coletta RD, Cancian N. Teich critica ‘tomada’ de UTIs da rede privada e pede solução com cooperação. A Folha de São Paulo. 2020 maio 6. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2020/05/teich-critica-tomada-de-utis-da-rede-privada-e-pede-solucao-com-cooperacao.shtml.
https://www1.folha.uol.com.br/equilibrio...} , the then Minister of Health positions himself against the coercive nature of the seizure of beds from the private initiative, given that, in his words,

The Meaning of the SUS as an object of dispute reveals internal conflicts within the government, where groups that hold the power of command in the country are representative of private interests in the health sector. On the one hand, the atitudes of defending the SUS (Mandetta), or of defending the private sector (Teich), are two sides of the same problem: valuing the SUS in times of health crisis in order to assist poor populations. On one side, there was a minister who indeed wore the SUS ‘jersey’ and ended up defeated, whereas, on the other side, there was the minister who replaced him and defended the private sector, saying it should not be coerced into opening vacancies to serve the ‘SUS patients’.

Acting SUS

The Acting SUS meaning appears, in the corpus, in a total of 70 (30.3%) texts, related to the context of the COVID-19 pandemic and emphasizing the actions of struggle, creativity, innovation and awakening of hope and cooperation from society and even from the private sector. These articles highlight actions and efforts of SUS professionals and managers in the fight against the pandemic.

This meaning is among the most present ones in the analyzed texts, especially regarding the relation of the SUS to the signifier ‘fight’, understood as a dispute between different SUS projects in society^{3838 Souza LEPF, Paim JS, Teixeira CF, et al. Os desafios atuais da luta pelo direito universal à saúde no Brasil. Ciênc. Saúde Colet. 2019 [acesso em 2021 out 10]; 24(8):2783-2792. Disponível em: https://www.scielosp.org/article/csc/2019.v24n8/2783-2792/pt/.
https://www.scielosp.org/article/csc/201...} , as well as referring to the context of collective mobilizations. The same meaning appears in a set of texts that bring narratives built to inform about actions already effectively implemented or in progress, aimed at strengthening the SUS at different levels of care. It is characterized, therefore, by the presence of devices, mainly verbal, in the texts that compose it, such as ‘buy’, ‘acquire’, ‘test’ ‘work for’, ‘guarantee’, ‘enlarge’, ‘partnership’, ‘hire’, ‘new tests’ and ‘new beds’.

‘All you need to know about the new coronavirus Sars-CoV-2’^{3939 Tudo o que você precisa saber sobre o novo coronavírus Sars-CoV-2. A Folha de São Paulo. 2020 jan 22. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2020/01/veja-o-que-se-sabe-ate-agora-sobre-o-coronavirus-chines.shtml.
https://www1.folha.uol.com.br/equilibrio...} is the title of the first article that shows this meaning. Published on 01/22/20, the day after the WHO signaled the high-risk nature of the pandemic, it informs about what was already known about the new virus until then, and mentions the SUS in the midst of management efforts to acquire supplies and medicines for public hospitals.

In reporting on initiatives resulting from cooperation between public and private subsystems, universities and civil society, the texts show cooperation actions in narratives that reflect the complementary nature of the participation of the private sector in the SUS. Donations and voluntary work aimed at strengthening public hospitals, the availability and expansion of SUS beds from philanthropic hospitals and Santa Casas (Brazilian hospital network), and the incitement to support and strengthen the SUS by the Brazilian productive sector, namely industries and universities, are also highlighted.

Creativity, improvisation and solidarity emerge to cooperate in responding to the needs and demands for equipment. As in the news report of April 1, 2020, entitled ‘Diving masks will be used in the treatment of patients with coronavirus’^{4040 Trindade L. Máscaras de mergulho serão usadas no tratamento de pacientes com coronavírus. A Folha de São Paulo. 2020 abr 1. [acesso em 2021 out 10]. Disponível em: https://www1.folha.uol.com.br/cotidiano/2020/04/mascaras-de-mergulho-serao-usadas-no-tratamento-de-pacientes-com-coronavirus.shtml.
https://www1.folha.uol.com.br/cotidiano/...} , where the use of diving masks adapted to fit artificial respirators is announced, in order to be used in the treatment of COVID-19, implemented through cooperation between private entities.

Also, news was produced about new tools, services and inputs launched by the management of the SUS, at a state or federal level, in an innovative and creative way to respond to the challenges engendered by the pandemic. For example, articles on automatic call services and the Coronavirus SUS app created by the Ministry of Health (MS), as well as on the new COVID-19 diagnostic kit, developed by the Oswaldo Cruz Foundation (Fiocruz).

There is, in the production of the Acting SUS meaning, a certain originality in the journalistic coverage of the system. It is not common, according to the experience of the daily struggle of SUS workers, to gain some visibility in the media. To a large extent, the SUS has been supported, over the years, by the militant effort of managers and health professionals, who continue the uninterrupted struggle for the Brazilian Health Reform, which began in the 1970s.

Discussion

Studies dedicated to journalistic coverage have pointed to the systematic association of the SUS with failures^{33 Cardoso JM, Rocha RL. Interfaces e desafios comunicacionais do Sistema Único de Saúde. Ciênc. Saúde Colet. 2018 [acesso em 2022 jul 22]; 23(6):1871-1879. Disponível em: https://www.scielo.br/j/csc/a/pTXBdCDZGJGbpX93xQd3gGK/.
https://www.scielo.br/j/csc/a/pTXBdCDZGJ... ,4141 Silva GM, Rasera EF. A construção do SUS-problema no jornal Folha de S. Paulo. Hist. cienc. saude-Manguinhos. 2014 [acesso em 2022 jun 20]; 21(1). Disponível em: https://www.scielo.br/j/hcsm/a/39MMgrRqVhbvWsVFzNzQ4hN/abstract/?lang=pt.
https://www.scielo.br/j/hcsm/a/39MMgrRqV...} , stimulating and maintaining the perception of an inefficient SUS throughout its 30 years of existence. Some studies^{4242 Castanheira D, Faulhaber C, Gerschman S. O papel da mídia na construção da agenda governamental para o SUS no Rio de Janeiro. RECIIS (Online). 2018 [acesso em 2021 out 10]; 12(3):292-309. Disponível em: https://www.reciis.icict.fiocruz.br/index.php/reciis/article/view/1455/2227.
https://www.reciis.icict.fiocruz.br/inde... ,4343 Menezes K. As representações do SUS na mídia. Rep. Soc. Com.: dial. constr. 2015; (117).} point out that journalistic publications on the SUS highlight the insufficiency of responses to the population’s health problems and the incompetence of Brazilian health authorities.

The question of the State’s responsibility for the health of the population is present in this corpus. However, it should be noted that the period of the health emergency is accompanied by a government that denies the pandemic and science itself, does not recognize the right to health and life and demobilizes, from the beginning, any scientifically proven protection and prevention action, whether individual or collective^{4444 Recuero R. Desinformação, mídia social e COVID-19 no Brasil. Relatório, resultados e estratégias de combate. Pelotas: MIDIARS; 2021. [acesso em 2022 jun 20]. Disponível em: https://wp.ufpel.edu.br/midiars/files/2021/05/Desinformac%CC%A7a%CC%83o-covid-midiars-2021-1.pdf.
https://wp.ufpel.edu.br/midiars/files/20...} . This stance, from an ethical, moral and health point of view, seems to somehow harm the interests of the FSP, which modifies its narrative about the SUS.

In this sense, the coverage of the FSP makes room for narratives in defense of the constitutional SUS, of the right to health, making clear the advantages of a universal health care system, especially in world-wide health crisis, and giving rise to voices of health professionals and managers who creatively struggle seeking solutions and attracting cooperation, solidarity and the growing recognition by the Brazilian society for this great health system built with much difficulty in broad and extensive democratic processes.

Despite the lack of visibility of the National Health Council and other SUS management bodies, this is an Acting SUS, driven by players who fight to make it operate in response to the health emergency.

The beginning of the FSP’s journalistic coverage of the COVID-19 pandemic took place in January and triggered the meaning of SUS related to the struggle. Perhaps this can be considered a ‘turning point’ of the newspaper’s views, shifting from seeing the SUS as a problem, a traditional stance already described in the literature, towards a ressignification^{4141 Silva GM, Rasera EF. A construção do SUS-problema no jornal Folha de S. Paulo. Hist. cienc. saude-Manguinhos. 2014 [acesso em 2022 jun 20]; 21(1). Disponível em: https://www.scielo.br/j/hcsm/a/39MMgrRqVhbvWsVFzNzQ4hN/abstract/?lang=pt.
https://www.scielo.br/j/hcsm/a/39MMgrRqV...} .

In this new context, whatever is troublesome relates to the pandemic, making evident, on the one hand, the threat of there being a collapsed SUS - a meaning activated in numerous articles - and, on the other hand, the SUS that is ready to fight, referring to the actions undertaken by SUS managers and workers to cope with the pandemic.

In any case, the FSP coverage of the SUS in the context of the pandemic does mention the Problem SUS meaning, no longer mobilizing only the SUS as something about to collapse, but also giving visibility to the rich and, at times, successful efforts made in society to respond to the challenges posed by the current health crisis.

Final remarks

The study shows the diversity of meanings that are assigned to the SUS in the Brazilian society, which are, in any case, reflected in the analyzed texts. If, in other contexts, the mainstream media, like other social players, devalued the SUS, the health emergency caused by the COVID-19 pandemic, with all the drama and uncertainties that came along with it, mobilized other views and perspectives that demand the right to health, the need for investment and strengthening, and even the recognition of the SUS as a national heritage.

The appreciation of the SUS by the FSP as a system of universal right to health during the period of the new coronavirus pandemic contributed to understanding the possibility of expanding the scope of society’s view of the SUS through the media, shifting the gaze from the effects of structural problems to the causes of such problems as in the case of underfunding. The study of the FSP texts reaffirmed the understanding of the importance of the circulation of meanings about the SUS in society, bringing it closer to the project included in the 1988 Constitution, where its participative and universal character is made clear. By providing visibility to the system’s capacity to respond to the pandemic, due to its capillarity in all regions of the country, to the structure of diversified services for health care, and to health programs and policies and their connection with various social segments in defense of citizenship and the SUS, journalistic coverage is shown to be a dynamic and lively political action that plays a crucial role.

Future investigations into press coverage of the SUS in the context of the pandemic, and also in the face of other health problems, are relevant to produce analyses of the Brazilian print media, showing the plurality of meanings about the SUS existing in society. Furthermore, the need for journalism to expand its coverage is highlighted in order for it to be able to capture the various dimensions of the SUS, besides its weaknesses, and offer society a vision of this great historical undertaking, recognized as the most inclusive social policy in health in the world.

Acknowledgements

We would like to thank researchers Daniela da Silva Baumgarten, Gessinayde da Silva Queiroz and Marta Cristina Rocha Costa for their collaboration in carrying out this work.

References

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