The collective level as a dimension for creation within the field of Public Health

 

O coletivo como plano de criação na Saúde Pública

 

El colectivo como plan de creación en la Salud Pública

 

 

Liliana da Escóssia

Departamento de Psicologia, Universidade Federal do Sergipe, Rua Manoel Andrade, 2156, Coroa do Meio, Aracaju, SE, Brasil, 49.035-530 <liliana.em@infonet.com.br>

Translated by Maria Aparecida Gazotti Vallim
Translation from Interface - Comunicação, Saúde, Educação, Botucatu, v.13, supl. 1, p. 689 - 694, 2009.

 

 

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ABSTRACT

A discussion about collective practices within the field of public health, based on two perspectives, is presented. On the one hand, an expansion of the concept of collective is proposed, initially, by questioning the way in which this term has been used in human and social sciences since the modernity project. Meanwhile, some paths to access another way to understand it, defined as transindividual, are presented. On the other hand, the possibility of experiencing this concept within collective public health practices is analyzed, starting from the experience of developing and implementing the National Humanization Policy of the Ministry of Health (Humaniza-SUS).

Keywords: Collective. Public Health. Humanization. Transindividual. Simondon. Public health practice.

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RESUMO

Apresenta-se uma discussão sobre as práticas coletivas no campo da saúde pública, a partir de uma dupla articulação: de um lado, propõe-se uma ampliação do conceito de coletivo, problematizando, inicialmente, o modo como ele tem sido utilizado nas ciências humanas e sociais, desde o projeto da modernidade, ao mesmo tempo em que apresenta algumas via de acesso a um outro modo de apreensão do coletivo, denominado como transindividual; de outro, analisa-se a possibilidade de experimentação do conceito nas práticas coletivas de saúde pública, a partir da experiência na construção e implementação da Política Nacional de Humanização do Ministério da Saúde (Humaniza-SUS).

Palavras-chave: Coletivo. Saúde pública. Humanização. Transindividual. Simondon. Prática de saúde pública.

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RESUMEN

Se presenta una discusión sobre las prácticas colectivas en el campo de la salud pública a partir de una doble articulación: por un lado se propone una ampliación del concepto de colectivo cuestionando inicialmente el modo como se ha utilizado en las ciencias humanas y sociales desde el proyecto de la modernidad, al mismo tiempo en que se presentan algunas vías de acceso a otro modo de aprehensión del colectivo denominado trans-individual; por otro lado se analiza la posibilidad de experimentación del concepto en las prácticas colectivas de salud pública a partir de la experiencia en la construcción e implementación de la Política Nacional de Humanización del Ministerio de la Salud (Humaniza-SUS).

Palabras clave: Colectivo. Salud pública. Humanización. Trans-individual. Simondon. Practica de salud publica.

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The collective is what in an individual action
makes sense to others... (Simondon, 1989, p.187)

Several policies and programs of Public Health in Brazil have stimulated, through principles and guidelines, the exchange of knowledge among professionals, team work, and the dialog between the health system administrators, workers, users and their families that are part of the health systems, since they are considered to be essential aspects to consolidate the Brazilian Unified Health System (Sistema Único de Saúde- SUS). As a result, there has been a valorization of the creation of collective spaces in the daily care and management practices, such as meetings of teams, departments, management collegiate, managers, workers' as well as users' assemblies, therapeutic groups, workshops, among others.

We can say that there is, in the Collective Health field, a relative agreement on the need to create and guarantee those spaces. The question we propose to debate is: how can we conceive and experience these collective spaces? Or even beyond: are we always talking about the same thing when we refer to the collective level?

Analyzing the historical constitution of the term "Collective Health", L'Abbate (2003, p.270) states that "relations between the collective and the individual levels are historical evaluators of most importance to the whole constitution of collective health and to understand its field of knowledge and practices". The author also states that the variation of meanings given to the collective in social sciences as well as its impreciseness have made this concept adequate to be used in the field of health, due to its diversity. Then, she highlights some connotations of the collective in social sciences, such as: "the collective/group of individuals; the collective/interaction of elements; the collective as joined effects or consequences of social life; the collective becoming social as a specific field which is structured by practices" (L'Abbate, 2003, p.268).

Despite recognizing the variety of meanings coming from the definitions mentioned above, we identify, in all of them, a contrast between the collective and the individual dimensions. This way of conceiving the collective is originated from a dichotomous approach of reality, i.e., a way of thinking reality in a fragmented, hierarchical form,   based on relations of opposites. We identify this approach as a characteristic of modernity. This logic of thinking and analyzing the world has become hegemonic since the XVII century and has been creating, throughout the centuries, pairs of opposites such as: individual-collective, science-art, technology- culture, subject-object, nature-culture, mind-body, manual labor-intellectual work, psycho-social, health-illness, normal-pathological.  These polarizations operated among the dimensions of what is real are, according to Veyne (1982), false problems resulting from a naturalizing and substantialist view, whose most perverse effect is the restriction of modern Western thinking and the reductionism and impoverishment of their deriving practices.

Therefore, this work does not refute an individualist view and chooses the opposite side, adopting a collectivist point of view. That would mean to be stuck to what we are debating, to a conception of the world that takes beings, whether physical, biological, psycho or social, as diagnosed a priori, without taking into account the processes that produce them. Our aim is, on the one hand, to provide some means to access other ways of understanding the collective, a collective that stands as an alternative to dichotomies established between individual and society, or between inner psychological structures and the external features of a social world; and, on the other hand, to demonstrate how this concept may (or may not) be experienced in collective practices of Public Health, based on our experience as participants in the creation of the National Policy of Humanization of the Ministry of Health (HumanizaSUS).

In previous studies (Escóssia, Mangueira, 2006; Escóssia, Kastrup, 2005; Escóssia, 2004), based on authors such as Deleuze, Guattari, Foucault, Canguilhem, Lourau, Tarde e Simondon, we stated that it is possible to understand the concept of collective as going beyond a historically constituted excluding and dichotomous view. We have shown that, in order to do so, it is necessary to "give visibility to another type of logic – a logic that focuses on engendering, on the process that precedes, integrates and constitutes beings. The logic of relations or philosophy of relationship, as Veyne (1882) called it in order to differ it from the philosophy of objects" (Escóssia, Kastrup, 2005, p.297).

We refer to a specific way of understanding the relation of terms which involves a process of assemblage (agencements), within space-time – a relational plan that produces the terms. We do not refer to a relation of terms that are already established. Relations change according to the circumstances, actions and passions, always producing new terms or providing new meanings to these terms. That is to say that meaning is conceived not through an unchangeable nature of terms, but through assemblage/relations, which take(s) place between terms in every place and historical moment. The "place-environment" of meaning, as stated by Michel Serres in The Mestizo Philosophy (Filosofia Mestiça, 1993).

From this philosophy of relation results a concept of "collective" whose definition is not based on the opposite of "individual", once neither does it coincide with a totalized social level nor with an interaction of beings already individuated. It is a concept of collective to be understood as resultant from two distinct, but inseparable, plans. These plans intersect and deconstruct binarism: the plan of forms and the plan of powers. The plan of forms is the plan of organization and development of forms (Deleuze, Parnet, 1998), the plan of what is institutionalized (Lourau, 1995), the plan of Law. It refers to already established forms – either individual or collective. As examples of collective forms, we can mention: social groups, communities, society. The plan of powers is the one of constitution/creation of forms – individual and social. It is also defined as the "plane of immanence" (Deleuze, Parnet, 1998), the instituting plan (Lourau, 1995), or the plan of relations (Veyne, 1982).

Simondon (1989, 1964) calls this instituting plan of power "transindividual plan" and states that it is related to the collective level, understood as a space-time relation between the individual and the social levels, the space of intrinsic elements. This is the plan of creation or co-engendering of individual and social forms, the origin of all changes, the plan of movement. The author emphasizes the inevitable relation between those two plans when he refers to the key concept of his thought – individuation, defined as a process of taking form. To him, every individuated being – an individual, a social group, an institution – retains, after its individuation, a pre-individual background which is possible to be mobilized at any time. And that is what makes psycho or social living beings always incomplete and in a permanent process of individuation.

This individuation process takes place when there is an intersection of these two plans – the plan of forms and the plan of powers – and constitutes what Simondon calls transindividual collective. The transindividual collective is, therefore, the instituting and molecular plan of the collective. However, it is mobilized in/ and by the field of forms, what confirms the idea that they are distinct, but inseparable. It is clear that the transindividual collective is not a transcendent plan – it is not in another world – but it is a concrete plan of ethical and political practices and relations: an immanent plan.

Consequently, some questions arise: have all and every "so called" collective practices in Public Health had the power to mobilize this pre-individual and molecular plan of the collective, allowing the movement of creation and transformation of forms? Or have specific practices blocked access to this plan of creation, working for the permanence and crystallization of certain institutionalized forms?

Take an institutional device that is often experienced in Public Health as an example: the management collegiate. As the name says, its objective is to implement processes of shared management through the participation of subjects and groups in the institutional processes of formulation, decision, planning, implementation and evaluation. However, in daily practices, we can frequently see the bureaucratization of those spaces, which are reduced to formally instituted representations. As representatives or spokesmen, their members operate a strange protagonist role, in which they do not allow to be affected by the other or by what emerges as different, and become impermeable to changes. They do not access the relational plan, once neither do they interact with the others in their differences nor they get involved in the movement that goes on in these spaces. A space resultant from this way of functioning, despite being called collective, demonstrates to be insufficient to guarantee the access to the plan of construction of subjects and groups.

Although this text does not aim at entering the debate of representative democracy and participative democracy, we would like to point out that this seems to be one more effect of the lack of articulation, highlighted by Santos (1997), between these two important dimensions of democratic practices: representation and participation. We could say that a specific way of operating representativeness excludes the dimension of participation, once it takes place in the relational plan.

Among the strategies to experience the concept of transindividual collective – as the plan of powers and the plan of creation – we highlight a method to work with collectives  that has been formulated and experienced by the National Humanization Policy of the Ministry of Health (Política Nacional de Humanização do Ministério da Saúde – hereafter: NHP) 

The NHP was created in 2003 and, as it was made clear by Benevides and Passos (2005), it has found, since its beginning, two challenges: a conceptual one and a methodological one. From the conceptual point of view, there was a need to review the problem of humanization by pushing the boundaries of the concept beyond its established meaning. As stated by the authors, "against an idealization of human being, the challenge is to redefine the concept of humanization based on a 're-enchantment of the concrete' or of the "SUS that works" (Benevides, Passos, 2005, p.390-1). We should think of human beings not as having an ideal figure, but taking into account their concrete existences, and considering their normative diversity and changes experienced in collective movements.

From the methodological point of view, the challenge was to propose a change in the way of doing, working, and producing in the field of health; considering that  was a task for all the ones who are involved in the construction of public health policies.

From that point on, the NHP has defined its principles, directions, devices and a working method to attend and manage the SUS: the triple inclusion method, which points out the importance of collective spaces in order not to imprison the powers in an instituted health model. By method, we understand the conduction of a process or the way it is conducted and, in the  case of the triple inclusion method, there is an unfoldment of three intersected plans: the plan of inclusion of different subjects (managers, workers and users) in order to produce autonomy, protagonism and co-responsibility; the plan of inclusion of institutional and social evaluators or of phenomena that destabilize the traditional models of care and management - embracing and enhancing the process of changes; and the plan of inclusion of the collective – social movements, networks and groups.

This method has been frequently experienced as an institutional support, an activity carried out by consultants and supporters of the NHP in the municipal, state and federal health networks and services, whose objective is to trigger, in an inseparable way, the processes of production of health and subjectivity. Understanding device as something that makes a method work, we can say that the institutional support is a device that embodies procedures or technologies that make us see and speak (Foucault, 1979).

We will point out, in the following paragraphs, three functions updated in effective practices of institutional support that enable it to be a device capable of accessing the instituting plan of powers or the plan of transindividual collective: the intersection function, the tranversalization function and the transduction function.

The intersection function appears whenever principles, guidelines, devices and subjects operate as references or vectors that trigger the collective action at the same time that other references, knowledge and practices are built within the movement of intervention itself. More than a starting point, the support works as an intersection of ideas, experiences, expectations and emotions, and creates conditions and possibilities to produce a common plan, a relational plan, a plan that affects the collective.

The transversalization function is related to increasing the capacity of communication between subjects and groups (Guattari, 1981) and of intersection of elements and heterogeneous flows, material and immaterial. It refers to the ethics of connectivity in processes (Simondon, 1989) that searches to overcome vertical and horizontal communication logics, which are individualizing in themselves. Deleuze points out the power of those connections when he states that: "the collective problem, then, is to institute, find or recover the maximum of connections. For connections (and disjunctions) are nothing other than the physics of relations, the cosmos" (Deleuze, 1997, p.62). In this sense, expanding communication is an experience that fits in the plan of production of collectives, or, in other words, transversality is a concept in the field of the collective and relational experience – an experience that goes beyond and constitutes both individuals and groups.

As far as the transduction function is concerned, we consider that the ways of including subjects, evaluators and collectives is transductive when it takes place through actions and movements that are gradually transferred from an area to the other in various directions, producing attractions, involvement, meetings and changes. The emphasis of a transductive action lies in a boundary zone or in the interface between subjects, between networks, between subjects and networks, between subjects and technologies of care or management. They are, in these cases, places- in-between and established temporalities or temporalities in process of being established. This quasi-localization and multiple temporality is what provides the groups – those collective spaces in which the support action takes place – with the status of relational spaces, in which what matters is not to support or analyze the subjects individually, but the collective and the work processes, the affective games, the relations of power and knowledge that cross the professional corporations, the users and their territories.

Then, to state that the transindividual collective is a relational plan does not mean to reduce it to formal spaces of meetings, workshops, group or inter-individual dynamics. By analyzing the spaces of management collegiate, we can notice that, depending on the way they are conducted and occupied, those spaces of democratic representation may operate as obstacles to transindividual collective experience. However, it is also in spaces like these that the overlapping of the plan of forms and the plan of powers may occur, producing this experience. What makes the difference is the way of operating, doing things, which makes use of devices. In this sense, the spaces of collegiate operate as collective devices when they use the triple inclusion method – of subjects, evaluators and collectives.

The challenge is, thus, to stimulate the permanent movement of creation of collective spaces, but, at the same time, to turn them into spaces of intersection and assemblage (agencements). "Assembling" means to be in the middle, at the meeting point of two worlds. To assemble with someone does not mean to replace them, imitate them or identify yourself with them: it is to create something that is neither in you nor in the other, but between the two, in this common, impersonal and sharable space-time that all the collective assemblage reveals.

We need to remember, however, that the potentialities of a transidividual collective brings possibilities, and not guarantees, of its occurrence. We know that the connectionist capitalism and its resultant institutional dynamics may reabsorb the political potential of the collective and the common levels, destroying them and making them work for it. This is always the imminent risk. Therefore, in a policy of Public Health, we shall not reify, naturalize these concepts, but take them as contingent concept-devices which always answers, partially and provisionally, the problems that each time and political circumstance presents. It will never be too much to recall Foucault, who states that  " you can't find the solution of a problem in the solution of another problem raised at another moment by other people" (Dreyfus, Rabinow, 1995, p.256). As Foucault, we believe that a policy of the collective is not a policy for long lasting solutions to the problems, but a permanent collective experience of problem solving, identification of dangers and ethical-political choices.

 

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