Health education in rural Brazil
Oswaldo Cruz Foundation – by Nísia Trindade Lima and Marcos Chor Maio
The relationship between public health and rural populations in societies that endured colonial domination and post-colonial inequalities is an important theme in global health history. One of the thorniest issues is health education, which has a history of the use of vertical campaign models based on guidelines taken straight out of Western medicine (usually without any recognition of folk healing practices).
The advent of so-called magic bullets such as chloroquine and DDT made the post-World War II era a time of optimism about scientific knowledge and its ability to achieve positive social outcomes. Health was also seen as a factor in economic development, while the habits and beliefs of rural people were identified as a hurdle to the processes of improvement. It was around then that the Institute of Inter-American Affairs – the principal US agency for technical assistance in the field of health – and the Institute of Social Anthropology signed an agreement that would engage anthropologists in health programmes in Latin America. Its guidelines relied especially on the research of Robert Redfield, above all his concept of ‘folk culture’, according to which rural people constitute a specific subculture characterised by routine resistance to modernisation.
Applying this concept in health research, anthropological studies emphasised the perception that reliance on available knowledge was the weakest link in the mechanics of health protection. One of the identified discrepancies was the fact that in many locations what health teams considered as advances were not interpreted the same way by the people themselves. This was true in relation to the malaria campaign in Peru, where DDT was used on a broad scale; although the malaria rate was reduced, inhabitants did not associate this development with DDT spraying. Similar examples were found in many other countries in Latin America, reinforcing the importance of analysing cultural contexts before the promotion of health initiatives.
In the Brazilian experience, there was nothing novel about identifying rural populations as backward. Research from the 1940s, such as the work by sociologist Emilio Willems, stressed the unequal development of Brazilian society while also advocating that the social scientist take on a role as a crucial actor in processes of change.
The guidelines of international bodies and the work of sociologists like Willems deeply affected the activities of the Special Public Health Service (Serviço Especial de Saúde Pública, SESP); this agency was created in 1942 as part of a cooperation agreement between the Brazilian and US governments. During the 1950s, SESP became a broad-ranging agency that incorporated social scientists in its health education work, primarily in the form of Brazilians with advanced postgraduate training in the USA. Sociologists and anthropologists were expected to guide this work by training other professionals and conducting community research. They also played the role of intermediaries, interpreting medical discourses for the general population. Yet their role was in fact much broader, especially as they observed problems in the field not always attributable to ‘resistance’ within rural populations; instead, problems of social mobilisation were more commonly linked to the ways in which the health programmes were conceptualised and run. Such observations were frequently made at the health centres set up by SESP in a number of municipalities (these institutions focused on maternal and child health). As these centres tried to devise innovative methods, such as courses for midwives, major points of tension developed between the population and health personnel; these conflicts became important objects of study by social scientists employed by SESP.
Studies produced in the 1950s point out that the training of SESP personnel was in tune with the cultural values of large urban centres but out of step with rural realities. Communities were, therefore, offered what was supposedly a less impersonal type of service through community health workers (visitadoras), who checked the overall health status of children and pregnant women, and also provided counselling to the population in general. Gaining people’s confidence required a certain degree of familiarity – and this was not always present. Rates of staff turnover also often caused health workers associated with SESP to feel like strangers within the communities they were tasked with serving.
At the same time, these SESP workers were instrumental in shifting understandings of so-called cultural resistance – their critiques of the form of health programmes caused new notions of reform to take hold, wherein poverty was presented as the main block to bringing rural populations into the process of economic and social development. While these dissonant voices did not discard the precepts of health education, they favoured fostering the documentation of rural people’s living conditions. They also grappled with challenges that remain with us to this day: the insertion of social policies that fight poverty in larger health national and international projects.
Nísia Trindade Lima is Vice-President of Teaching, Information and Communication, and a Researcher and Professor in the Postgraduate Programme in the History of Sciences and Health, at the Oswaldo Cruz Foundation. Marcos Chor Maio is Researcher and Professor in the Postgraduate Programme in the History of Sciences and Health at the Oswaldo Cruz Foundation.