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Should mainstream public health
After more than two decades of dictatorial government, Brazil began a new democratic era in 1985. The new constitution, elaborated and promulgated in 1988, stated that “health is an universal right and a State obligation guaranteed by social and economic policies aimed at reducing the risk of diseases and other ill-related events and by universal and egualitarian access to a health care system oriented towards health promotion, protection and recovery”, (Federal Constitution of Brazil, Article 196, 1988). Following this, Article 3 of Law 8080 enacted in 1990, stated that “ food, housing, sanitation, the environment, work, income, education, transportation, leisure and the access to essential goods and services are all important health determinants; therefore, health status reflects the social and economic organization of the country”.
These legal documents incorporated the rationale used by national and international public health movements to understand and elaborate global strategies for achieving good standards of health. On these grounds, we expected that the ministry of health would have defined effective policies to improve the health of Brazilians. Unfortunately, the ministry of health has failed to assume its constitutional responsibility. More than a decade after the constitution of 1988, limited advancements in health services organisation and healthcare delivery have been achieved so far; health standards in Brazil are still low for large segments of our population, and curative oriented programmes are still given priority over disease prevention and health promotion. Considering that this pattern of health service organisation occurs in most nations we must ask—is this an acceptable standard, or a generalised mistake?
In my opinion, at least two major issues need to be tackled. Firstly, at the political level, health policies are included as an isolated sector of the social agenda, which, by its turn, is considered secondary to the economic agenda. From this perspective, the health sector has its focus limited to the effects rather than the causes of diseases. In addition, we must consider the tendency to individualise or privatise health risks.1,2 This tendency is reinforced by the over-emphasis of individual based risk factors identified by epidemiological studies, and leads to a health system that targets individuals rather than populations.3,4
Both of these issues are related to the mainstream “biomedical” understandingof health, which gives more relevance to diseases than to their causes. Shifting the emphasis to the causes of disease requires the promotion of broad social and economic policies that seek to improve all aspects of life. As a result, the development of guidelines for a ministry of health in consonance with the Brazilian Constitution and laws depends on: (1) reorganisation of the State administration, with health as a central and strategic goal of the social and economic agendas; and (2) prioritisation of epidemiological research and practice that elucidates the intricate and complex effects of biological, environmental, and social factors on health, and actions that target populations rather than individuals. We epidemiologists need to share the view that the important part of the risk factors in the contemporary world are not “natural” but generated by actions of human beings, not as individuals but as members of societies. As consequence, these risk factors must be modified by societal actions.5
Should mainstream public health