Book Review: A Right to Health: Medicine, Marginality, and Health Care Reform in Northeastern Brazil

A Right to Health: Medicine, Marginality, and Health Care Reform in Northeastern Brazil. Jessica Scott Jerome, Austin: University of Texas Press, 2015, 177 pp.

In A Right to Health, Jessica Scott Jerome enters familiar territory in the medical anthropology literature on Brazil, examining notions and practices of citizenship and consumerism as they relate to health-seeking behaviors. Brazil’s 1988 constitutions established health as a right belonging to all and a duty of the state. The government’s expanded role in health care, however, has largely been played out through neoliberal approaches to governance, creating paradoxical privatizations of public practices and politicizations of private demands. Jerome treats these intricate relationships with precision, bringing entangled webs into sharp focus. She does this with a detailed historical context that adds to the contemporary phenomena greater clarity and significance.

Jerome grounds her study in Pirambu, a peripheral community in the northeastern city of Fortaleza where she conducted fieldwork visits from 1999 to 2009. In the first part of the book, Jerome provides a succinct but thorough history of health, social services, and citizenship in Pirambu with close contextual consideration of national and state-level developments. In archived newspapers articles, Jerome uncovers a history of political action by members of the Pirambu community demanding basic services from the government. Jerome finds these demonstrations predate similar urban movements in Brazil, taking place at a time when social services were being extended to formal laborers rather than all citizens. Jerome contrasts these movements with how a younger generation in Pirambu understands the role of markets and individual initiative as drivers of economic mobility.

In the second part of the book, Jerome examines specific programs and practices where the broad categories of citizenship, consumer, and health are contested. She discusses the use of local health councils to guide health policies, considers a government program to standardize the use of traditional remedies, examines the role of reciprocal and paternalistic relationships in health-seeking behaviors, and revisits in greater depth the generational divide in market aspirations and political consciousness in Pirambu. These chapters draw on the historical background from the first part of the book while introducing the reader to several interlocutors in rich but concise vignettes.

The history of incremental expansion of labor benefits and citizens’ rights Jerome reviews is palpable in the lived experience of Pirambu residents. Among Jerome’s interlocutors is Isabella, a woman whose main concern was whether her adopted daughter could legally inherit her plot of land. When Isabella dies of a stroke, her daughter Vera is able to claim the land. The city plans to build a pedestrian boulevard on the land, and Vera receives a new apartment from the government. When Jerome returns on her last visit, Vera is pregnant and trying to convince her mother-in-law to pay for private prenatal visits, though she has the right to free visits in the public health care system. As Jerome crisply describes:

Community residents confronted a health care system rooted in an ideology of individualized human rights layered on top of a social life deeply embedded in older systems of patronage and reciprocity and a neoliberal economic context that celebrated market exchange and individuals’ ability to fulfill their own needs and interests. (p. 8)

A Right to Health reaches its crests in stories like Isabella’s and Vera’s. Jerome meticulously traces the role and significance of historical developments such as the achievement of land rights and contemporary trends such as economic development projects in the mishmash of everyday lived experiences.

The later chapters of A Right to Health are significant, in part, for providing alternative narratives to previous trends and findings in medical anthropologic literature. Jerome tells of a failed attempt of create a health council in Pirambu, where local community members might have helped guide health system practices. Pirambu residents in attendance are not interested in demanding specific treatments, as the physician tasked with the council seems to expect.

Though residents often bemoan the general lack of medications in public pharmacies, their demands are principally and broadly for safety and sanitation. This is in contrast to findings in medical anthropology literature of a predominance of claims for health technologies, especially pharmaceuticals. Similarly, notable recent scholarship has documented the important role of courts in accessing medical treatments for Brazilians (Biehl 2013). Jerome, however, finds her interlocutors to be suspicious of law and the courts. Isabella refuses to go to court to try to guarantee inheritance rights for her daughter, and Vera borrows clothing and prepares her speech to go to see a city official for fear he will be dismissive of her.

These accounts are important for contextualizing previous findings but also for what they may say about current theories of rights, knowledge, and health. However, the precise descriptions of historical and contemporary phenomena in A Right to Health are not always leveraged to inform or contest current theories and understandings. In an apparent divergence from the main themes of the book, Jerome introduces the reader to Farmácia Viva, a program to standardize the use of traditional remedies. Though the program would appear to legitimate local knowledge, Jerome deftly demonstrates it as a project to supplant authority over traditional remedies and replace these remedies with biomedical approaches. Despite the richness of the material, Jerome does not seem to engage with the theory of science or knowledge production to further claims or contest conventions. One hopes this may be a focus of the author’s future work.

In addition to the issues noted above, this brief volume touches on other topics, such as the role of private colleges in social aspirations, the moral discourse of social mobility, the divergences in understanding public and private services between generations, and the part of public health programs in promoting individualized notions of care. A Right to Health provides a lucid narrative of rights as cultural practice at a time when rights discourse is prevalent, even mundane. Jerome accomplishes this examination in a way that does not threaten right-based approaches to health but exposes their localized meaning.

The clear prose and descriptive focus make the book appropriate for broad use in undergraduate coursework in anthropology, global health, human rights, or Latin American studies. Those familiar with the medical anthropology literature from Brazil will find narratives set in detailed historical contexts that contrast productively with previous findings. Those seeking an introduction to the social scientific literature on Brazil health care, perhaps at the graduate level, may find the work a well-researched and clearly presented resource and useful starting point. Readers interested in human rights may enjoy a thorough account of how
rights are variously employed, rejected, and transformed by actors in pragmatic and creative ways.

Reference Cited

Biehl, J.
2013 The Judicialization of Biopolitics: Claiming the Right to Pharmaceuticals in Brazilian Courts. American Ethnologist 40:419–436. http://doi.org/10.1111/amet.12030.

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