An approach to the public x private antinomy: unveiling relationships for public health

 

Uma abordagem da antinomia 'público x privado': descortinando relações para a saúde coletiva

 

Un abordaje de la antinomia publico-privado: revelando relaciones para la salud colectiva

 

 

Giovanni Gurgel Aciole da Silva

Hygienist, M.Sc. and Ph.D. in Public Health (State University of Campinas - Unicamp, Brazil) Adjunct Professor of the Medical School at Federal University of São Carlos (Universidade Federal de São Carlos/SP – UFSCar)

Translated by Evanir Brunelli
Translation from Interface - Comunicação, Saúde, Educação, Botucatu, v.10, n.19, p. 7-24, Jan./June 2007.

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ABSTRACT

This paper is about the relation established between our recognition of "public" and our understanding of "private". This is a major task for everyone devoted to making health policies feasible, inasmuch as the presence of both health care systems is regularly noticed in Brazil, namely through the Brazilian National Health Care System (Sistema Único de Saúde – SUS) and the Supplemental Health Care Program (Saúde Suplementar). In addition to retrieving the meanings ascribed to the terms "public" and "private" within a historical and critical approach, this paper attempts to understand the relation of such elements by articulating them in two modern macro-dimensions: the economic and the political. As the construction of meanings and senses for both terms is restored, it points to the existence of an interpenetrating relationship between them, which goes far beyond the dichotomic, withstanding tendency that prevails in common sense.

Key words: publich health; health systems; Supplemental Health Care; Brazilian National Health Care System; public and private.

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RESUMO

Propõe-se descortinar a diferença entre o que reconhecemos como público e o que entendemos como privado, além dos maniqueísmos ou simplificações do senso comum. Tarefa particularmente importante para todos os que se debruçam na viabilização das políticas de saúde, e haja vista a convivência de dois sistemas de atenção à saúde em nosso país: o SUS e a Saúde Suplementar. Para compreender os significados emprestados aos termos 'público e privado', abordam-se as interfaces existentes entre ambos, a partir da recuperação histórico-crítica de elementos, articulados em duas macrodimensões da modernidade: a econômica e a política. Ao resgatar a construção da babel de significados e sentidos com que são adjetivados os dois termos, conclui-se haver mais uma relação de interpenetração entre ambos do que a tendência dicotômica e de oposição em que comumente os colocamos.

Palavras-chave: saúde pública. sistema de saúde. SUS (BR).

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RESUMEN

Este trabajo plantea la diferenciación entre lo que reconocemos como 'publico' y como 'privado', más allá de las simplificaciones y maniqueísmos del sentido común. Diferenciación muy importante para todos ustedes que, como nosotros, estamos envueltos en la implantación de políticas de salud verdaderamente públicas, e considerando la existencia de dos sistemas en nuestro país: el SUS (Sistema Único de Salud) e el Sistema Suplementar de Salud. Para esta diferenciación, nuestro artículo aborda las interfaces existentes entre los términos 'público' y 'privado' y parte de la recuperación histórico-crítica de los elementos articulados en dos macrodimensiones de la modernidad: la dimensión económica y la dimensión política. Después de tal trayecto, este trabajo revela existir una relación de interpenetración entre ambos más que la tendencia dicotómica y de oposición en que comúnmente los colocamos.

Palabras clave: salud pública. sistema de salud. SUS (BR).

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INTRODUCTION

The structuring process of the Brazilian National Health Care System (SUS) – a set of actions and services based upon concepts such as universality, integrality, resoluteness, and humanization; resource rationalization with integrated management, ascending planning, hierarchy and regionalization; national scope with decentralization at local levels, and co-responsibility of all government scopes; and the opening to community participation institutionalized through sectorial councils – has produced a steady increase in demands and a reorganization of services as it tries to provide answers, more often than not, to the dynamics of social demands.

The inner dynamism of society, which came into sight in the 1980's through the appealing scenarios concerned with the set of citizenship rights, positioned not only the struggle for a better health in evidence: the customer issue was also in the highlights.  This is how the National Congress came to pass the Organic Law of SUS in the same year (1990) as well as the so-called Consumer Defense Code. Since 1991, one year after the legal establishment of SUS, the regulation process of Private Health Care Insurance Plans has taken place, which caused the National Congress to pass Law 9656 on June 3, 1998 (CARVALHO, 2003) and led to the creation of the Brazilian National Agency for Supplemental Health (ANS) in 2000. This reorganization process rectifies the omission of the 1988 Federal Constitution itself and of the 1990 Health Organic Law, which had not even mentioned the need to regulate this sector and ended up inserting the topic of private health market in the government agenda (BAHIA, 2001).

Henceforth, new social dynamics generated by such legislation discloses the false stability and the considerable fetishistic character found in the "health care" defended by the private plans. This sector is then plunged in an agenda of conflicts and complaints concerning the interest disputes related to the government, health insurance and other medical service providers, and users/consumers.  Such scenario is noticeably influenced by social mobilization, which starts to require alternative ways to deal with the private health care system and to which the absence – or insufficiency – of a regulating legislation becomes a relevant issue (ACIOLE et al., 2003).

Throughout the 14 years since the creation of SUS and of the Consumer Defense Code, however, Brazil's structural economic adjustment crisis has increased in relation to the new global capitalism injunctions, and it reflects upon the organization of public policies. In this process, vital sectors such as health and education have faced the use of segmented, focal, and compensatory policies that restrain the Federal scope of action at the least – more precisely, at a basic set of procedures – whereas the private market has been increasingly expanded. This situation reveals a given tension and crisis placed before the consolidation of a broad, efficient, and universal health care model, which also feeds the dynamism and the tension that stands within society.

The liberal approach (or neoliberal, as it seems to be a preferred terminology) clearly reveals the size that the "public" is supposed to fit in so that it does not impair the "private": the public agent is either expected to act before the absence of the private agent or get out of the scene so the immanent harmony of private relations is not jeopardized. At most, the State is supposed to provide market regulation, though not as much as to refrain market thriving and consolidation. Where market conditions are absent or insufficient, the State is expected to be put either into corrective or compensatory action. Moreover, the State must be restricted to a set of specific functions, though sufficiently generic ones, so that its competitiveness with the private sector is kept away. In this process, State and Market are, in the position of emblematic sectors of the public/private duality, recognized as antagonistic, separate, diverse entities, although they remain steadily linked by the social network where they establish themselves and, at the same time, are established by this same network.

As a matter of fact, prophets and apostles of market supremacy are focused on defending a premise according to which an invisible hand shall contribute to self-regulation and be in charge of producing a fair and egalitarian distribution of wealth.  The liberal project uses this acknowledgment to strengthen restatements about the supremacy of market in relation to state, reinforcing for the latter the role of being a stumbling-block to the general conditions for economic development: a place of inefficiency, wastefulness, inoperativeness, and hindrance to the plenitude of the former. Mainly for this reason, the State must be renovated so that it may fit the new reality supported in (and by) the supremacy of market in general. Such concept runs contrary to the proposals made by the movement known as Sanitary Reform, which upheld the construction of a solid public policy anchored in the State as an agent, under the action of governments committed to the change of the medical-sanitary conditions of the Brazilian population.

The present days have brought forward the features of the relationship – complementary, supplemental, partnership – which the private sector might have in relation to the public sector and vice versa. In Brazil, a pretty much essential political fight is held around the consolidation of projects whose core is concerned with the singular role played by the State as well as with its configuration. This overlooks an ideological context where manifold public space models can be recognized, which is only invisible if in it we do not paint the colors of Ercília¹ (COSTA, 2002). Particularly in relation to health, the discussion is related to the deepening of roots that have been shaping two health care systems: a state-owned and a private one, in addition to the bonds that link them.

Within such ideological context, a practically insurmountable distance is asserted on a daily basis through the acknowledgment of the difference between the public system user versus being a consumer of private system health care plans, which is revealed through the strategies and actions by means of which the professional corporations as well as the social movements, for instance, fight for projects and ways of organizing the assistance to health and disease. As far as health is concerned, this cleavage has been ideologically supported in terms of separating "users" from "consumers". Moreover, it is framed by taking two opposed pairs as starting points: preventive versus curative, primary health network versus hospital, collective action versus individual action, public health versus medicine, freedom of choice versus control, and briskness and efficiency versus bureaucracy, recklessness, long lines, and regulation.

Furthermore, this separation encompasses clichés that reinforce the prevalence of both positive and negative values for each system, respectively. Therefore, both public and private systems occupy niches where they present a certain "incompatibility of temper", i.e., what is public cannot and should not be confounded with what is private, and vice versa. Such incompatibility gets mixed with the ideological wrap that involves both systems – for what we know from the common sense in these terms is that there is a link between "public" and government activity; and "private" as a synonym for individual, particular initiative. The view that prevails in public health does not seem to be any different, for instance; a sector that has dealt with the denomination of public as a synonym for state-owned; and that uses such synonymy when technically/politically structuring the project of a national health care system (ELIAS, 1999). 

These issues lead us to the complex process of understanding the Babel of meanings and senses surrounding the "public—private" pair. They have qualified and affected them profoundly in regard to the common sense within an antinomic position to, after all, comprehend the political and economic dimensions that make it possible to enhance the understanding of the relational nature that lies in-between.

 

THE POLYSEMY OF "PUBLIC" AND ITS ANTINOMY WITH "PRIVATE"

The word public can be found as a reference to everything that can be viewed and heard by everyone and it is largely broadcast. As Arendt (1999) puts it, being seen and heard by others is important owing to the fact that each one sees and hears from different angles: and this is the conceptual basis for the construction of the "ordinary", the sharing purpose; it is within such diversity that the manifestation of the world's reality takes place in a trustworthy manner. On its turn, the interchange of positions and of several divergent, supplementary points of view requires specific mechanisms of selection, legitimacy, and representativeness of what constitutes a major interest for everyone, regardless of individual concerns.

Due to this connotation attached to the ordinary issue, one of the meanings ascribed to the term refers to the notion of collective, which, on its turn, leads to the idea of open space, where an indefinite number of subjects – or individuals – come along. Hence, we are bound to call public the events that are accessible to everyone exactly like when we talk about public places or public buildings, public fame or reputation. And, however, its connection with the private can be verified already at this point: in all such spaces the opposite notion will always be present – the sense of private, particular, individual.

As we refer to the public at a show or a soccer match, for example, the current idea immediately alludes to the collective system of spectators, the audience of such event, which comprises, however, private audiences, i.e., individuals. The expression public gathering displays the notion of public recognition, of a collective happening, again appropriated by a particular element: the private agent who held the reception and the private individuals who attend the meeting. On its turn, public reputation, i.e., the public character within a name or fame, supports a group of personal features that pursue – or possess – the celebrity-to-be, and whose obtainment has been the social focus in present days, though stemming from older times from which the assignment of an intangible value for fame and recognition started (HABERMAS, 1984).

The expression public building, on its turn, is connected to a double idea: the former recognizes the building as an accessible place for everybody. Thus, it is available for everyone who reaches out to it; the latter refers to buildings that paradoxically do not need to be open for public attendance as they simply accommodate state-owned institutions. This is the public authority, and such attribute is due to its duty to promote public welfare, the well-being that is common to every citizen, creating and maintaining premises either for the maintenance of its power or for the performance of its duty. 

The expressions public service or public health are immediately overlapped by the idea of a collective belonging, as something unfolding therefrom:  it belongs to everybody though it does not belong to anyone in particular. Everybody enjoys the sensation of possessing or being able to access the services, but nobody may claim its private possession, although they can enjoy it individually. So the notion of collective belonging is also present in the privacy of access as well as in the enjoyment of concrete services and actions simultaneously shared by everybody, although experienced in a particular singularity. Here, once again, the public comprises the private!

Therefore, the word public seems to spread polysemies. Public is connected to welfare, collective interest, a general, universal notion of belonging, whereas private practically means particular, individual interest. The communal domain is a public asset: the well and the market square are aimed at common use. These are public, accessible, ordinary, collective spots; opposite there is the particular, separate, private sphere. The scope of the public sector confronts the private, i.e., "the private is the liberation of the core of the landed property itself as well as of the public range" (HABERMAS, 1984:78).

The notion of collective generates another meaning for public: public opinion. This refers to a way of manifesting the collective will and the exercise of a given critical opinion formed by a reflective public that comprises private subjects, which receives a meaningful mediation on part of communication media and advertising.  According to HABERMAS (1984), as public opinion and its critical role evolved, it consolidated itself as the public that is capable of forming opinion, which will later produce the thinking that is colonized as common sense. For this author, the public opinion individual (or subject) is the public that forms the opinion – a critical role that the world of life would play upon both political and economic systems and, at the end, would refer to advertising, i.e., the knowledge through an unlimited number of individuals.

Public opinion plays an important political role: the consolidation of bourgeois thinking and the colonization of such space through opinion formers, through the formers of common sense. These are the public whose members read, think, express themselves, and consolidate a common world image in the likeness of what is read and heard. This is a fundamental action since the fall of absolutist regimens and the ascent of the new bourgeois class in the fight for political hegemony as well as for the conquest of power, which practically forces "every nation to adopt the bourgeois ways of production, (...) to embrace the so-called civilization, that is, to become bourgeois" (MARX & ENGELS, 1998 [1848]: 44). 44).

As Habermas (1984) sees it, the formation of a given public opinion, a collective for private subjects, will position itself as a separating element between State and Society, i.e., between public range and a private range. Through public opinion, the former interposes the State and society's needs; the latter corresponds to the sector of merchandising interchange and social work, including families and their intimate bounds.  Furthermore, the private sector also encompasses the "public sphere" as it comprises private individuals. According to Habermas, a piece of dialectics can be verified then: State socialization on one side; society's progressive nationalization on another. Meanwhile, a re-politicized social sphere appears between both, which escapes the distinction between public and private:  the public opinion.

For Gramsci (2000:265), public opinion "is strictly linked to political hegemony, that is, the point of contact between 'civil society' and 'political society', between consensus and power". From this condition derives the fact that the State, "when willing to start a not very popular action, creates the adequate public opinion in a preventive way", i.e., it organizes and centralizes certain civil society elements so that the aimed interests are contemplated. As the political contents of the political will transformed into public opinion can be disagreeing, (...) "there is a fight for the monopoly of public opinion organizations – newspapers, political parties, parliament – so that a unique power is able to standardize the national opinion and the national political will, dissolving the disagreeing parts into a cloud of individual and inorganic dust'. An unhearing fight is formed in the dispute for the prevalence of a public opinion where a unique force prevails. In this fight, obtaining consensus of what constitutes the public power, the sense of public importance does not necessarily requires the opinion or the will of the majority and it does not bear a permanent feature. It is as volatile and unstable as the internal dynamics of society, split in diverse social groups.

The public opinion flows into the scope of the media, a condition that has deeply changed its meaning: from holding a political function it has become an attribute of the one who awakens the public opinion – the advertiser.  Such transformation takes place through the appropriation – on part of an individual or a group of individuals – of the material conditions to rouse the public opinion through mass communication media: TV, radio, and newspapers. It is no longer aroused, though yielded from the interests – either manifest and/or concealed, but essentially private – that incite the production of communication as well as the broadcast of information in capitalistic societies around the world. Once again, it is not possible to escape from the abduction of the public within the private, even when such an emphatic expression is in evidence:  public opinion!

With the term private, in opposition to the polysemy of public, synchronically with public opinion, the idea of market was associated:   a place of private producers, deprived of the public function or the public dimension (state-owned). Therefore, private means being excluded, deprived of the State apparatus. So now the market is outside the State apparatus, and private is going to be associated with market.  Therefore, the private takes a strong connection with the production and the circulation of both merchandising and services as the space where manufacturers and consumers take action, either individual or collective, acting according to their most immediate and direct interests. The market is understood as a territory where human beings, when in free action, are considered equal and do without a regulating power as their production and consumption relations move towards equilibrium. The more equilibrium is attained, the less dependent they become from an outer force – for if this occurs, dissension and conflict turn out to be the price to be paid. According to this point of view, the market becomes the temple of freedom!

On the opposite sense, the public is reinforced as synonymous with state-owned, an attribute that refers to the legitimate operation – and in agreement with the capabilities – of an apparatus equipped with the monopoly of the lawful use of power – and, at the same time, supplied with and legitimated by the representativeness that it assumes to regulate the collective, daily life. The public refers to the established State, whose enhanced and diversified functions require the use of a specific task force, in addition to legislators and technicians endowed with a role that turns them into public servants. They receive such denomination because, as State servants, they are invested with a public function: their activities are public ones and the buildings, premises, and establishments where they exercise their authority are called public. On the other side there are private persons, private jobs, private businesses, and private homes – the true market core.

For Sorj (2000), this opposition constitutes one of the most common antinomies of modern society. With both, the common sense has associated meanings that present a distinction between the two scopes of activities. Two words, two opposed meanings, two production domains! The author points out that both Anglo-Saxon and European traditions form different meanings for these two domains. In the former, the public space is formed from the individual as a conveyor of group interests who entrusts the government to act as public services or civil services, thus behaving according to universal, previously arranged norms. In the latter, both corporations and State are the representatives of welfare and public interest. The European tradition considers that the individual and the republican State represent the nation, i.e., the heir of values from the French tradition guided by equality, fraternity, and liberty, though here the State takes up the guardianship of common values and acquires a tutelary power over individual actions, once these might put the republican values at stake.

A common problem to both of them, according to the author, is that other fundamental institutions for the social reality are not recognized: they are based upon moral and institutional principles of a nature other than the individual and the state-owned, which are integrated to society – as the family, which is transformed by modernity and by the capitalistic model –; or a militant, political order, as the racial and sexual minorities. According to him, this issue should be taken into special account as it constitutes the cornerstone as an alternative to the pendular movement that State and market will establish between each other.

On the other hand, two features derive from the constitution of the public within the individualistic perspective: on the one hand, the opposition between State/individual does not exist, with specific space for several types of intermediate associations and institutions, whose boundary is the individual freedom only; on the other hand, the problem resides in how to construct a common denominator, i.e., the values that allow the establishment of solidarity and collective identity.

At last, although the term public receives a strong connotation that links it to the common thing, to the collective, in a presumed superiority over the private, the particular, the individual, or vice versa, we propose the abandonment of such tendency and even the clear, separatist demarcation between them. Above all, we consider this opposition of polarities a simplification process. According to this point of view, the public/private relation cannot – and shall not – be solved out through simplistic resolutions. After all, it is fundamental to disclose the non-confusion of state-owned as synonymous with public as it is to quit the idea of private as non-state-owned. As we see it, the power of public lies in the relevance to understand the private and vice versa, in a world that claims for a continuous reinterpretation and that is constantly pointing out to relationships of interpenetration. It is yet necessary to think over the existence of a motion between these two sectors, which is not exactly distinguished by the clientele that either offers or renders services, nor by the ideological valuation imprinted on them (ACIOLE, 2003a). 

This antinomy requires investigation under the essential and, moreover, necessary assumption that the reference to the public asset is not away from being an interpellation of the private within a dialectical relationship. After all, as proposed by Grau (1998), we can admit a public dimension for privacy within the personal field, which must be defended, as well as for the competition within the economic field, which should be limited. Such relationship has to be comprehended in double set of possibilities: either in the economic dimension, which establishes the private as a place of production, or in the political dimension, an almost correlative dimension, which assigns the place of politics to the public, represented by the State. Both are constructions of modernity.

 

THE POLITICAL AND ECONOMIC DIMENSION WITHIN THE 'PUBLIC/PRIVATE' RELATIONSHIP

Karl Marx (1996) is the one who reveals the political and economic connections between public and private within the capitalistic means of production. He expands and goes beyond the boundaries once reached by Adam Smith and David Ricardo. The political connection through the corporative-institutional solution represented by the State within a public dimension – which we are going to examine ahead. The economical connection owing to the means of production that, in capitalism, is going to spot mechanisms involved in its accomplishment: the public – the socially required working time, available at everybody's hands; and the private – the appropriation through capital, which the new means of production will require to be restricted to just a few.

According to Marx, the market is the element that makes up the social relations of the new means of production as a place of circulation and exchange of capital: at one position, the workforce purchasers, i.e., the proprietors of capital, are found in the market. At another, the dealers, who once simply owned their workforce, which is now turned into typical merchandise, the main product to be obtained in the market.

Through their workforce, individuals are socially organized by historically determined moods. They produce objects, produce themselves and produce the survival of the species. The equation between workforce consumption at a given time period is the actual factor that brings forth the value of products generated by human work. Such time period used by the workforce at the production line is defined by the organization of the historically built society according to its interests and needs: owing to this fact, it might be possible to mention the working time that is socially required as an asset to define product value. The value suggests human work generalization as a merchandise, inasmuch as it has been the engine that leads to the development of modern society and capitalism.

Marx (1996) goes farther by saying that the "equivalent" factor constitutes the mechanism that leads to the private appropriation of the collective working process performed by individual subjects. When carefully scrutinized, such mechanism turns out to build a revolutionary, modern conceptualization on the concept of property, which is no longer a fixed and firmly positioned asset acquired by its possessor in a way or another; on the contrary, the human being becomes its very own origin, more precisely the body and the power contained in this body, which he called 'workforce'.

From the ability of the workforce to produce a surplus beyond required to obtain conditions for survival, and from the ability of capital to pay for the acquisition of such force, always closer to the limit of satisfying the material needs required by the worker to survive, results the expropriation of this surplus, which constitutes the surplus value: an essential unit captured by the capital in its work conversion form! Work converted into capital was the capacity to acquire work captured by the capital. A genesis of the contradictory relation upon which lies, however, the possibility of private appropriation of collective commodity.

In its piece of criticism over Marx, Arendt (1999) points out to the evolutionist angle from which Marx regarded modern society as being superior in relation to previous ones as to the elementary level of the property issue, which establishes the separation between public and private. As a matter of fact, perhaps more concerned with the boundaries between public and private than Marx was, she arguments that the German militant philosopher had taken a dimension of work – labor, involved in the survival as well as in the relation of hostile nature transformation – as fully synonymous with work. When questioning this aspect, Arendt searches in the Greek the connection between private possession and public life, emphasizing that the dimension involved with survival was restricted to the private sphere, in addition to being entirely void of a public dimension. This was, however, stuck in an interdependence relationship because, in order to enjoy public life, the individual was not able to be expropriated from the possession of private assets, including a private home and freedom. The difference between private and public lies, therefore, on the distinction between what must be disclosed and what must be concealed. In addition, such distinction resides in the supremacy of what used to be considered as public – the polis – over the private – the oikos; although it was the property of the latter, comprising land and slaves, that guaranteed the possibility of being present in the former.

The public life was a collective practice exerted by free human beings who were, therefore, proprietors, within an unsettled immediacy, when exercising their individualities with no representativeness, encompassing two activities: the action (praxis) and discourse (lexis), representing the human achievement itself. In the modern world, such spheres present fewer differences between each other: politics has become a function of society. Action, discourse and thought are superstructures underlying social interest. In the face of this, the modern society sets out rules to its members, which are held for equals, and it expects from each one a certain type of general behavior.

Although Arendt, as well as Marx, states that the modern society is devoted to human needs, she disagrees that, in the modern case, such needs are guided by the fact that work has now been centrally positioned in the new society, assuming the domain of public concern, since it is from its exploitation that capital is built and reproduced.   In this concern, she reminds us that it is not so relevant for a nation to be composed of equal or unequal human beings, as the contemporary society requires its members to act as members of a huge family holding a single opinion and a unique interest. Furthermore, the society is always bound to equalization, under any circumstances, by presenting equality as a modern sign, an intrinsic element that gathers the social together.  According to her, the victory of equality in the modern world stems from the legal and political recognition of the fact that society has conquered the public sphere and that distinction and difference have been reduced to private issues for the individual.

By considering that the divergences between Arendt and Marx may derive from the fact that both observed reality from different perspectives, Wagner (2002) stresses that none has ever believed in market principles as a solution for modern human issues because one cannot rely on an ever-balanced market and because the market cannot solve current social problems by itself. As capital accumulation mechanisms work up through productive transformation, which highlights the event of free time as a conquest of human beings for the next century – even as a free time deprived of subsistence means – and generates a sensation of losing the ordinary world's durability, such statement belongs to the belief according to which the problem of the world of work is a political as much as an economic issue.

Moreover, one is bound to consider the transition from the concept of 'economic', which until the XVII century was linked to the circle of home chores, of the pater familiae, and then starts to be market-oriented. According to Habermas (1984), this is so because both activities and relations of dependence, so far confined to the range of domestic economy, surpass the threshold of home budget. When it happens, they emerge in the light of public sphere, i.e., they are publicized.

Habermas (1984) ponders that the development of the public sphere is intrinsically linked to the development of capitalism and modernity. It will follow the changes arising from the organization of modern State and the ones brought to public life and to the organization of society, insofar as it is an almost exclusive bourgeois domain.  For him, the evolution of the liberal model of changes at the mercantile stage of capitalism by means of conjoining the concentration of capital and of the organization of large companies will produce vertical relationships of imperfect competition, independent prices, and social power in private hands, generating noteworthy crises in the antagonistic structure of society, and will make urgent the need of a strong coercive element – the State – endowed with representativeness and power to appoint the collective interests as its target and its function, which end up as the police and the bureaucracy of the modern State. Through such representativeness, the State is understood as an internal space able to establish criteria and values that guide free trade practices; the recipients of its power – the private persons submitted to this representativeness – make up a public.

In this condition, the State deeply interferes with the interchange of commodities and with social work through laws and administrative regulations in connection with the prevalent interests that search for minimal disturbances in the ideal conditions of the economic production process. This imprints a peculiar ambiguity to the regulation and organization of space: they accept being regulated as well as they want to be left free to develop their initiatives. In addition, the ambiguity of State interventionism in the market tends to be linked to the interests of the bourgeois society and, at the same time, it is supposed to be constituted in a separate way. This peculiar ambivalence ends up allocating itself in specific sites: the public regulation to the State and the private initiative to the market. Both State and Civil Society will form, after all, two distinct spheres: the public and the private. By resisting interventionism, the civil and bourgeois society is made up in compensation for the authority of State; the State, on its turn, is anchored in a private interest that is peculiar to the ones who control the power of state, which is consolidated as something tangible only by the ones who are subordinated to it, i.e., private persons excluded from public power participation.

The regulation, on its turn, will be exerted as a function ascribed to a specific group: the legislators. The solution given to common life in western capitalist societies implies the separation between society – polis – and the institutional spaces that gradually acquire a concrete form in large frameworks.  So modern parliaments, albeit gaining something of representation for the polis, actually do not even look like real for most common citizens (BOBBIO, 1997). Through such two-way track, the elaboration of highly subtle mechanisms of domination and control is developed within the production and reproduction of the material conditions for reproductiveness, which were later on called hegemony by Gramsci (2000).

According to Arendt (1999), what we currently denominate society can be deemed as a group of economically organized families that form a single superhuman family, whose political organization is called nation, whose daily businesses must be dealt with by a national and huge domestic administration; a condition that maybe impairs our understanding of the division between the public and private spheres, i.e., between the sphere of the polis and the sphere of the family. Meanwhile, even though the dissolution between each other has advanced, the present society has not banned the intrinsic relationship between belonging to a private home, exerting political freedom and having conditions of access and consumption of services and commodities provided by the capitalist society as reasons of modernity.

Nevertheless, modernity will dematerialize the property issue as an immanent condition for public life, under the perspective of establishing citizenship attained through granting the recognition of an overabundance of rights. These are typified as civil rights, political rights, and social rights, in addition to being related to historical periods of development of the capitalist society and of the complexity of social relations contained within. They also typify specific answers of the State to political and collective demands through predefined historical periods (MARSHALL, 1967, apud DONNANGELO, 1976). Under this double transformation, the disclosure of the social makes the dilution between social classes deeper (according to the Marxist standpoint, the classes are marked by the position occupied in the capitalistic means of production) through the weakening of the delimiting power of the boundaries existing between them. So the "social" consists of a space of interpenetration of both public and private, in juxtaposition to the development of the capitalist society and to the deepening of the social division into classes.

The formation of the 'social' leads the public sphere to decompose through the alteration of its political functions, the structural changes in relationships between the public sphere and the private sector. This change characterizes the current modern relationship between the public and private spheres, through which an interpenetration process takes place, i.e., a portion of the private sphere gradually becomes public, whereas the public is actually placed at the service of the private interests by which it is dominated. This separation is at issue when social forces conquer public authority competences, which results from the constitutionalization process through which a politically active public sphere passes through, i.e., from the transference of public competences to private entities, from the emergency of the social issue mediated by the affirmation of rights (HABERMAS, 1984).

Modernity, which started off in the XIX century, is marked by the emergency of a middle class culture where hedonistic as well as sensualistic necessities rule. These necessities are socially produced through body care and cultural pleasure enjoyment, in association with a hypochondriac concern about health and to which the medical response will be fully adequate (ROSEN, 1994; GAY, 2002). Exactly like the consolidation and the prevalence of the bourgeois means of production, however, the development of capitalism in its manifold stages also comprises a history marked by the development of sequential crises that triggered off the organized fight of the ones who were mainly affected by recession and economic scarcity: the workers (HOBSBAWM, 2002a; 2002b).

The social rights that were specifically aimed at the social classes and segments that were less favored within the context of the crisis were a response of the new State, which incorporated new functions in order to keep the balance of the means of production. This conservative intention presupposed the extension of its legitimacy basis, which would be obtained through the participation of other populations within the enjoyment of the common product. Such participation implied the socialization of either the common product or portions of it through the action of the State within the control and regulation of market activities in order to guide the production and discipline the collective effort to consume as a public policy, i.e., it seems to point towards the necessity of a "domestication" of the capitalistic impetus (BORON, 1994).

The introduction of the "social" allows, therefore, recognizing the translation made by the masses in relation to the economic antagonisms turned into political conflicts. As the non-proprietors take hold of dimension and size, the poverty issue emerges as a social issue and as a problem for the action of the State, i.e., a part of the social private sphere becomes publicly relevant. The process of changing public power into social power reveals the failure of disconnecting the public sphere before private interests as the very own conditions under which the privatization of interests should occur were brought into the dispute of organized interests. This fact dissolves the sector as in the one where private people – when united in a public (collective) – regulate the general issues for their interchange among themselves, i.e., the liberal view of public sphere.

The development of assistance mechanisms surely corresponded to these effects either in public or in private – more to the former than to the latter. Such intervention conformed itself in practically all the capitalist European societies under formation. Specifically in England, throughout the manifold stages of capitalistic development, the assistance to poverty involved medical assistance as well. It reveals the tutelary character of society in relation to these masses (DONNANGELO, 1976; ROSEN, 1994). This tutelage is also a reaction against the latent fear generated by the presence of highly movable groups that are perceived as dangerous to society – or even a reaction against the cyclic periods of crises and ruptures, which endanger institutional stability and may be recognized in specific periods of time.

These interventions play a double role – to a certain extent, they satisfy the interests of the less favored economically. They can also reject them but, above all, they take part of the interest to maintain the system's equilibrium, which cannot be granted only by the free market. As an example, the formulations of Keynes (1996) made in the aftermath of the war pointed to the incapability of getting full employment as one of the main drawbacks of the economic society, in addition to the arbitrary and unequal distribution of wealth and revenues. They also proposed the state intervening with the economic activity by means of adopting a taxation system and an interest rate settlement. They were also prompt to adopt other steps so that investments could guarantee full employment. However, they admitted that this did not imply the exclusion of adjustments and formulas of every kind to allow the State to cooperate with private enterprise: this presupposition has been recovered in certain formulations of current governments, which does not disclose the bourgeois character of its origins.

According to Heilbroner (1996), the Keynesian formulations, whose set of social policies resulted in the so-called Welfare State, led to the enhancement of State functions, insofar as it assumes the role of a planning organism, a market freedom regulator, following the breakdown of the most orthodox liberal standpoint. Analyzing this stage of the capitalism development, Boron (1994; 2002) points out that this social and economic experience resulted in a contradictory effect: the bourgeoisie cannot do without State hypertrophy – otherwise, as the real functioning of mature capitalism shows, and despite the refusals that turned its prophets into ultraliberal beings – and the working class is not willing to restore the achieved social advancements in its long-lasting fight against bourgeoisie, which are then crystallized in the Welfare State. Oliveira (2000), for instance, ponders that the bourgeois public sphere – either in the "habermasian" perspective of space of private subjects in relation to the State or in the "marxian" perspective of place of capital competition – was processed by the Welfare State as a non-bourgeois feature. So the Welfare State configures an outer regulation either in relation to private subjects or to workforce market, leading to noticeable changes (either internal or external) for the working class.

At last, being a permanent focus of tensions lays at the basis of the relationship between the two spheres – the public and the private; a relation that has gradually become troublesome insofar as the masses of non-proprietors, downtrodden people are increased, which will, through public interventions in the private sector, pursue victory against the capital concentration tendency and struggle to make their participation disclosed. Increasing and decreasing at different cycles along history, it will produce focuses of demands to which the State will attempt to respond, albeit stuck to the interests of keeping the system balanced and the maintenance of its own legitimacy. The size of the interpenetration through which it allows itself to be run through by both proprietors and non-proprietors is the factor that will provide conditions for legitimacy and publicity with which such "public interest" will be identified, in addition to the type of constitution that it will actually attain, as well as the assessment that it will receive in the shape of public opinion (HABERMAS, 1984).

 

FINAL REMARKS

As the emblematic traits of the political and economic connection that recovers the "public x private" antinomy are gathered together, we are able to draw a few conclusions and possibilities of use. The first remark to be made is that exploring such antinomy from a critical viewpoint reveals a double theoretical/practical importance: it is of great relevance for the understanding of the policy that is comprised within the historical process recovering the western societies and it is essential to comprehend the systemic relationships involving economic agents, either public or private, in the production and delivery of commodities and services. This is a fertile soil where the fields of politics and economics cyclically merge.

It can act as an analyzer, on its turn, of the complexity surrounding the relationships underlying the State/Market binomial. That is why they stand for the concrete soil where societal projects are disputed: projects that organize the diverse moods – public and private – of delivery, production, and access to commodities such as health. Within this social production sector, forces in dispute use the medicine/public health binomial as a structural element and search to allocate each of these practices as organically linked to one of the binomial poles, which has jeopardized the dialogue between them (ACIOLE, 2003).

A third way of meaning derives from the fact that from collective ideas, the ones of common belonging and public opinion, one is able to endow a commodity, a service or an individual with a unique force of meaning as its assignment of a public character or of importance for the collectives is emphasized (HABERMAS, 1984). This way of meaning imprints intangible place, power and value to commodities such as health, which gains public, collective importance, though it does not necessarily lead to the supremacy of the State element. As a social issue and as an organized system of services and actions, Health presents an undeniable duplicity either in conceptual or operational terms, where one can notice the interaction of both individual and collective, State and market, and public and private dimensions. This feature has made it an object of intense dispute of ideological interests, especially within the economic and political dimensions. In the Brazilian case, this dispute makes up a very own culture for each of the terms (public and private) as a twofold health system is formed: the public (state-owned) and the private.

To a large extent, such dichotomy builds a pendular movement between different modes – universal and restricted – of organizing the delivery of products, services and actions for the population, whose size varies according to the greatness and to the notions comprised by public and private; and from which the greatness of accesses permitted by the same notions derive. Being different in their political nature and supplemental/complementary in a clear economic connection, these subsystems generate a hesitating public opinion for the common sense, whose basis is dichotomic, in favor of one or other way of rendering assistance or taking care of the life of both individuals and groups.

Finally, taken by the impossibility of merging formal democracy and substantive democracy, or between political democracy and economic democracy, our attention should be devoted to the country where we live in, which presents a remarkable income concentration so much that we are able to distinguish two nations within the same territory: a hybrid that has once been named as "Belindia" (a mixture of Belgium and India). The former is the proprietor of almost the entire social wealth, whereas the latter, not exactly a minority, is contented with, or sees itself compelled to survive on the leftovers from the main table where the private feast takes place. How can one think and live the relationships between public and private within such a scenario? What is the size of space suitable for "public" and "private"? After all, what is "public"? What is "private"? Thinking continuously over these issues and attempting to get an answer to them is fundamental to bring more light into the daily life that we have been through! This should be so for the consolidation of a truly public – and for the public – health care system, which is able to establish a dialogue between the social totality and its contradictory aspects.

 

REFERENCES:

ARENDT, H.; A condição humana. 9. ed. Rio de Janeiro: Forense Universitária, 1999, 352 p.

BAHIA, L.; O mercado de planos e seguros de saúde no Brasil: tendências pós-regulamentação. In NEGRI, B.; DI GIOVANNI, G. (ORG.). BRASIL: Radiografia da Saúde. Campinas: IE/UNICAMP, 2001.

BOBBIO, N.; Liberalismo e democracia. São Paulo: Brasiliense, 1997. 2ª reimpressão, 100 p.

BORON, A. A.; Estado, Capitalismo e Democracia na América Latina. Rio de Janeiro: Paz e Terra, 1994, 272 p.

_____; A coruja de Minerva: mercado contra democracia no capitalismo contemporâneo. Petrópolis: VOZES, 2001, 421 p.

CARVALHO, E. B.; A Regulamentação dos Planos e Seguros Privados de Assistência à Saúde no Brasil: a reconstrução de uma história de disputas. Dissertação de Mestrado. Campinas: DMPS/FCM/UNICAMP, 2003.

COSTA, S.; As cores de Ercília: esfera pública, democracia, configurações pós-nacionais. Belo Horizonte: Editora da UFMG, 2002.

DONNANGELO, M. C. F.; Saúde e Sociedade. São Paulo: Duas Cidades, 1976. 124 p.

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GAY, P.; O Século de Schnitzler: a formação da cultura da classe média 1815-1914. São Paulo: Companhia das Letras, 2002. 348 p.

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HABERMAS, J.; Mudança estrutural da esfera pública. Investigações quanto a uma categoria da sociedade burguesa. Rio de Janeiro: Tempo Brasileiro, 1984. 398 p. (Biblioteca Tempo Universitário, nº 76. Série Estudos Alemães).

HEILBRONER, R.; A História do Pensamento Econômico. São Paulo: Nova Cultural, 1996, 319 p. (Coleção Os Economistas).

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_____; A Era dos Impérios 1875-1914. 7 ed. Rio de Janeiro: São Paulo: Paz e Terra, 2002b.l 546 p.

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MARX, K. & ENGELS, F.; Manifesto comunista. 1. reimpressão. São Paulo: Boitempo Editorial, 1998 [1848], 254 p.

OLIVEIRA, F. de; Privatização do público, destituição da fala e anulação da política. In OLIVEIRA, F. de; PAOLI, M. C. Os Sentidos da democracia. 2. ed. Petrópolis: VOZES, 2000, p. 55-81.

ROSEN, G.; Uma História da Saúde Pública. São Paulo - Rio de Janeiro: HUCITEC – Editora da UNESP – ABRASCO, 1994. 423 p. (Coleção Saúde em Debate, nº 74)

SORJ, B.;  A nova sociedade brasileira. Rio de Janeiro: Jorge Zahar Editor, 2000.166 p.

WAGNER, E. S.;  Hannah Arendt & Karl Marx: O mundo do trabalho. 2. ed. Cotia: Ateliê Editorial, 2002.

 

 

 

Address:
Universidade Federal de São Carlos – Departamento de Medicina
Rodovia Washington Luiz, SP 310 - KM 235
São Carlos/SP - CEP 13565-905
E-mail: giovanni@power.ufscar.br

 

 

1 This is a reference to Italo Calvino's Invisible Cities, where he narrates the fictitious meeting of Marco Polo and the emperor Kublai Khan, who asks the merchant to describe his empire. The city of Ercilia is among the localities described by Marco Polo. The inhabitants of Ercilia have the strange habit of indicating their social and affective relationships by using ribbons in different colors. Thus, from each house stems a profusion of ribbons in different colors to symbolically – though publicly – show each type of existing relationship. We might wonder such colors adopted in nowadays' daily life: what degree or load of publicization does life support? Is there a certain degree of privatization that we should and could be able to consider as being of intrinsic value for what is turned public?