Academic journal article Anthropological Quarterly

Visions of Care: Medicalization and Public Patienthood in Sao Paulo, Brazil

Academic journal article Anthropological Quarterly

Visions of Care: Medicalization and Public Patienthood in Sao Paulo, Brazil

Article excerpt

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As I arrive at the clinic on a Tuesday afternoon, Dr. Flávia Monteiro catches me in the hall to ask if I want to interview a patient she thinks might be of particular interest to me. "It's a very interesting case," she insists, "very medicalized-she thinks everything is wrong with her." During my first meeting with physician and professor Dr. José Torres, he presents one of the clinic's central goals and struggles as working against the "overly medicalizing practices" of other health care services. During an early afternoon of observation in the clinic, a medical resident gushes about his critical theory reading group and its focus on medicalization. One week in mid-July, I accompany a group of clinic staff members attending a conference on the "Medicalization of Education and Society" as part of their ongoing professional development. In an all-staff general meeting, providers bemoan their "medicalized" patients even as they wonder aloud how best to care for them.

Medicalization was everywhere. Invoked constantly in daily work, staff meetings, and hallway conversations, and raised repeatedly in my interviews and discussions with various health professionals, the language of medicalization was common currency in the clinic, a ubiquitous part of a vernacular to which I was not yet wholly accustomed. Having come to the Centro de Saúde Escola (CSE), a teaching clinic in Sao Paulo, to study primary care in Brazil's public health care system in the summer of 2013, I had been greeted with Foucault-quoting physicians working to explicitly achieve a non-reductionist, theoretically and politically informed, highly progressive vision of health. These doctors, themselves also scholars of philosophy, critical theory, and public health, had been involved with the clinic since its early years, helping to shape its organization, commitments, and values while working as attending physicians. As I listened to them narrate histories of the clinic, while following the everyday life of care between patients and providers, I came to understand the clinic as a critical space for thinking through a distinct approach to health and care. Medicalization, it became apparent, did some kind of work for the clinic staff, standing in for both a critique around which they could rally and the productive imagining of its alternative.

Emerging through and alongside a leftist political movement and the newly enshrined right to health in Brazil's 1988 democratic constitution, since its inception in the late 1970s the CSE has sought to provide highquality, comprehensive primary health care to the population it serves. Founded and run by a group of sanitaristas or "public health doctors" working at the intersection of social science, medicine, and philosophy, the clinic promotes a distinct vision of care based on the idea of saúde ampliada, a broader conception of health care with a particular understanding of patient-provider relationships and an attention to the interrelationships between medicine and social life (ABRASCO 1982, Alvim 2013, Ayres 2009, Nunes 2013). As a teaching clinic affiliated with the University of Sao Paulo's (USP) Department of Preventive Medicine, the CSE emphasizes the ideals of collective health, "humanization," and integralidade, integral (or comprehensive) care (Ayres 2013, Martini 2008, de Mattos 2009).

Against biomedicine's much-theorized reductionist, objectifying gaze (Foucault 1994, Good 1994, Kleinman 1988), there is a strong sense of purpose at work in the clinic, a kind of oppositional stance through which the staff understand themselves as working against other ways of thinking about health or delivering primary care. In this view, as Dr. Torres explained to me, "the social is never seen as separate," and clinical interactions with patients are understood as both opportunities for promoting population and individual health, and as an entry point into the community, a way of better understanding the social context in which their patients live. …

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