A public health emergency, such as the association between the Zika virus and microcephaly, is a situation in which scientific thought, the logic of health management, and common sense tend to come together around one general idea: You need to add together every effort to address the spread of the issue and its most serious and immediate consequences. Given this imperative, criticism is suspended, and reflection and political actions are delayed since, in this context, they are seen as digressions of rapid and pragmatic responses.
However, precisely because of their severity, these situations cannot be wasted as provocations of analyses with more permanent impacts on the structural issues that impose the conditions for the outbreak of an epidemic and explain the limited capacity to address its effects. It is in this sense that recovering the concepts of the social determination of the health-disease process is appropriate and necessary.
Particularly with regard to the triple Zika-Dengue-Chikungunya epidemic, the basic procedure is to highlight the villainy of Aedes aegypti and the accountability of the population – expressed hegemonically in the 'health education' campaigns. To a great extent, these campaigns have the effect of erasing the failure of the intersectoral public policies and the centrality of the economic and social dynamics, emphasizing messages of the individualization both of the risk and of the control of their factors.
The simulation that we are facing a novelty contributes to obscuring the social determinants of the disease, particularly since Aedes and its transmission potential have been known in public health ever since the early twentieth century. More recently, we have noted its constant presence in the news on dengue every year ever since the 1990s. This procedure – treating the Zika virus as if it were a surprising phenomenon – puts on the back burner the addressing of issues related to living conditions, which are connected to the main causes of the epidemic, including those resulting from the lack of sanitation, such as water supply and waste collection for the impoverished populations.
Such problems, as opposed to being new, are historical components in the Brazilian health situation, deteriorated due to the deepening of social and environmental issues arising from the accelerated, precarious, and thoughtless urbanization processes, including in the context of the large construction ventures and migration processes connected to them.
However, the set of structural issues involved in this health-disease dynamic, to which we would like to draw attention, in particular, is associated with training and work in health and, more particularly, to a type of work and training that is little valued socially: That of the health workers, whether community workers or endemics agents.
As soon as the most worrisome information about the microcephaly-Zika epidemic spread, and given the need to make public action visible, important movements taking place in two tips of the health system were reported on: In the research area and in direct actions in the territories. Community health workers and endemic disease control agents, already an important part of the dengue control program, which was created in 2002, reemerge on the scene, accompanied by the military, in a national call to act mainly in the control of Aedes aegypti breeding sites and in the detection of clinical situations meriting particular attention, albeit with uncertain referrals.
Part of this mobilization effort is accompanied by a device that has become increasingly stable in building these health workers' professional qualification profile: Brief training, focused on specific issues and interventions that cannot – because they are unable to – overcome the absence of a more solid training. What we understand as 'solidity' would be represented by training on a technical level, a policy that has been continually weakened in government agendas, both at the federal and at the city level. This dispersion of training policies is compounded by the precariousness of the bonds, via outsourcing, that make it even more unlikely there will be investments in extended training and that assumes non-temporary employment ties.
One result of this regression in these workers' qualification process is that, at a time like that of the current epidemics, there is the reading that 'field workers' are marginally qualified to exercise the broad and complex set of activities assigned to them (including everything from individual guidance on signs and symptoms to managing environmental issues, in addition to community mobilization).
Furthermore, known issues in the Unified Health System working dynamics, such as the low level of integration of endemics control agents in primary care teams or the difficulty of forming a working team to foster professional autonomy, are brought up less to problematize these situations and more to justify the obstacles that stand in the way of this 'fight against epidemics.'
Insofar as training is concerned, specifically with regard to the Zika virus, understanding, for example, the benefits and, in particular, the short and medium-term risks of using technologies – such as modifying the genetics of the mosquitoes and the use of larvicides and fogging, which are still mistakenly presented as alternatives – involves understanding social and biological processes. Such understanding, by the health worker, demands more than lectures, rather also commitment to professional education in health. This is not a commitment to be sustained from a tactical perspective, dominated by the sense of urgency that runs through our imagination when the theme is health and, moreover, when it sets the horizon of controlling only one or two diseases.
We state, here, that training that provides a more consistent understanding of the social and biological bases that are at the foundation of the health issues has a direct link with the possibilities of intervening in them in an operational and immediate dimension, but also in dimensions that dialog with their historical and social causes.
Finally, the current situation may also be an opportunity to interrupt this cycle of reproducing the biologicist control discourse, which, through health workers and the media, reaches the territories and contributes to delaying politically critical positions and, therefore, one that is more capable of dealing with the triple epidemic and other future epidemics which, although not yet fully known, have already been announced.
Angélica Ferreira Fonseca
Scientific Editor
Publication Dates
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Publication in this collection
May-Aug 2016
