Keeping rights healthy

A Right to Health: Medicine, Marginality, and Health Care Reform in Northeastern Brazil
Jessica Scott Jerome
2015, University of Texas Press
196 pages, hardback

ONE of the great ironies of the progressive and ambitious public healthcare reforms carried out in Brazil after 1988 was that they were introduced in a broader climate of neoliberal economic reforms that may ultimately have circumscribed their reach. As Jessica Scott Jerome suggests, it is one thing to establish a universal right to healthcare in law, but quite another to establish it in culture such that it achieves its intended objective. Scott Jerome’s study of healthcare in a favelaof Fortaleza in the northeastern state of Ceará following the introduction of the 1988 constitution, which established healthcare as a right, and the subsequent creation of Brazil’s Sistema Único de Saúde (SUS, or Unified Healthcare System) offers some valuable lessons for other countries, not least the UK where the National Health Service – a universal system premised on an understanding of citizen rights – is in crisis. Funding shortfalls and an exodus of staff as a result of low pay and poor conditions are straining the NHS at the seams, but what has never really been researched is the impact of generational attitudes in Britain upon the current problems of the country’s healthcare system. That is because the debate about healthcare in the UK, and in particular about the future of the NHS, is being conducted in a radically different environment to that of when it was created in 1948. Private medicine has always continued to exist alongside the NHS, but has expanded greatly since the neoliberal reforms in the 1980s of Prime Minister Margaret Thatcher and was enmeshed with the NHS itself under Tony Blair after 1997. It stands to reason, therefore, that the generation of 1948 and thereafter is going to have a very different view of the NHS than the generation of 1980. The new perspective that Scott Jerome offers is anthropological: the right to health is interpreted differently among different social classes and demographics, and that shapes its impact and, presumably, its future. Her ethnographic research into the ideologies and practices of healthcare is hugely revealing because it demonstrates that the fulfilment of rights may not be a simple question of making them available, especially among the poorer citizens for whom they were mainly intended. She writes: “The perception and practice of healthcare reform and its attendant expansion of civil rights depends upon one’s generational and socioeconomic position in the intricate social landscape of the favela.” [p 149] Her research indicates that older residents of the favela often attribute free healthcare to their participation in the labour market or residence in a big city, meaning their rights are partially undermined by an ethos that understands these as belonging to particular categories of citizens, especially those in formal labour markets. Younger people, by contrast, especially the upwardly mobile, also challenge the conceptualization of healthcare as a right. They often tend to embed observations about public healthcare within narratives of economic failure and anxieties about social status. By this perspective, shaped by neoliberalism and hence reinforced by the consumer culture that they have grown up in, accessing public healthcare represents failure and is, as a result, humiliating. In this book Scott Jerome makes a valuable contribution to how we can understand healthcare as a right. If her lessons were to be correctly applied in policy, they might offer a way of reinvigorating public healthcare in countries such as the UK by countering the negative impact of some socioeconomic and demographic factors upon public attitudes towards the NHS, something the ideologues who would like to see the end of all state provision cynically tap into. – GO’T