Introduction

The principles of the Unified Health System (UHS) [Sistema Único de Saúde – SUS], the Brazilian Public, Universal and Unified Health System, requires innovative interventions and strategies, especially in relation to Primary Health Care actions. Almost 30 years ago the Family Health Program (FHP) [Programa Saúde da Família – PSF] was implemented by the Brazilian Ministry of Health (MH) [Ministério da Saúde – MS] in 1994. In 2006 it was redefined as the Family Health Strategy (FHS) [Estratégia Saúde da Família – ESF]. Since its beginning there have been many advances related to increasing health surveillance and establishing bonds between professionals and users.

However, we verified that the FHS has not strongly promoted the reorganization of the health system. Organizational and political-institutional dimensions have hindered intersectoral actions that can address the social determination of health. The performance of the FHS has been reflecting the prescriptive character, with little respect for the differences among the political, social, economic, and cultural contexts, resulting in few changes in the strategies to approach the problems. For instance, we can mention the few intersectoral policies formulated as initiatives at the local level. This aspect directly interferes in the guarantee of integrality, both regarding access to all levels of care, and in the integration of health promotion, prevention, and recovery practices ( Silva et al., 2013; Mendes et al., 2017).

The FHS entails expectations of creating a fairer and more effective health system, as it favors greater proximity to the population’s demands and seeks new forms of intervention based on the promotion and prevention of health issues. Simultaneously, the FHS actions evidence the contradictions and deficiencies of a precarious health system. Especially weaknesses resulting from a mercantilist health logic and/or those that favor high technological cost interventions, often inaccessible and ineffective for most of the population’s demands ( Cecílio & Reis, 2018).

The National Primary Care Policy (NPCP) [Política Nacional de Atenção Básica – PNAB] was established in Brazil in 2006 ( Ministério da Saúde, 2006). In 2011, it was amended ( Ministério da Saúde, 2011), bringing significant advances and guarantees for the implementation of public Primary Care (PC). It plays the essential role of care coordinator and organizer of the Health Care Network (RAS), including the creation of the Family Health Support Center ( Ministério da Saúde, 2008) and the definition of specific funding. The second update made to the PNAB in 2017 ( Ministério da Saúde, 2017) brought severe discontinuities, causing considerable instabilities for the PC. Among them, we highlight: a) the change of NASF as the Family Health Support Center to the Expanded Center for Family Health and Primary Care (NASF-PC). This significant changed the work process, which was based on matrix support as its main action strategy, to a more ambulatory action that includes the so-called traditional Basic Units. That is, without FHS and with a work logic very different from that instituted in the FHS; b) the nonrequirement of a minimum number of families/people per Community Health Workers (CHW), making possible the existence of Family Health Teams (FHT) with only one CHW; c) unprecedented insertion of differentiated services and actions in the PC, the so-called essential standard and extended standard. The first refers to actions, basic procedures of access and quality, while the second aims to achieve high standards of access and quality ( Melo et al., 2018).

This new version of the PNAB triggered important discussions about the relativization of universal coverage, segmentation of access, and difficulties in the organization of work processes. This led to a weakening of the achievements in Brazilian PC. Scholars and institutions in the field have placed themselves forcefully in defense of a PC with quality access and actions in care ( Melo et al., 2018; Morosini et al., 2018). To add to the already installed picture of instability and risk of PC, in 2019 the Prevent Brazil Program was launched, which brought the new funding model for this level of health care ( Ministério da Saúde, 2019). Despite severe criticism, Prevent Brazil removed the transfer of the fixed and variable Fund for Primary Care (FPC); introduced a model of transfer from the federal government to the municipalities based on the number of people registered (much lower than the actual number of users), and established a new form of payment based on performance ( Morosini, Fonseca & Baptista, 2020).

The Council of Municipal Health Secretaries of the São Paulo State [Conselho de Secretários Municipais de Saúde do Estado de São Paulo – COSEMS/SP] and the National Health Council [Conselho Nacional de Saúde – CNS], as well as several other institutions in the field of Collective Health, were against this proposal, which was built without any popular participation. The Expanded Center for Family Health [Núcleos de Apoio à Saúde da Família – NASF] is a strategy that has suffered from lack of funding; the transfer based on performance is not clear enough in the proposal; the traditional basic units now have funding like the FHS, that is, Prevent Brazil imposes a significant worsening in the consolidation of the FHS, of the CBS, and of the SUS itself, with considerable threats to its guidelines.

Despite this dismantling scenario, the FHS practice continues to promote actions that bring the health system, teams, and communities closer together, through monitoring and home visits in the territories where families live. The role of Community Health Workers (CHWs), as professionals who compose the public healthcare team, is strategic, because they promote closer ties with the families, future referrals, and monitoring of treatments and care provision. This professional becomes a fundamental link for the efficiency of the FHS proposal. In addition to knowing the community well, this professional lives in the same territory.

This place of mediation occupied by CHW is very complex. They face pressures of the most diverse demands. From family and other relationship-related problems to social issues such as poverty and other forms of urban violence and its correlates (such as drug trafficking and drug use). Situations that mark the daily life of everyone in the community, making it very difficult to fulfill the SUS precepts ( Brito et al., 2014; Castro-Silva et al., 2014).

In addition to these difficulties, the CHW also suffers from the new guidelines imposed since the last PNAB. It brought not only the possibility of constituting FHT with only one CHW, but also the integration of the CHW actions with the Endemic Control Worker (ECW). This in a confusing way, with several crossings, and the prospect of the CHW exercising functions that were previously exclusive to the nursing professional within the FHT.

Therefore, while we must value the field of possibilities of this worker actions, we must problematize the working and performance conditions, as Tomaz (2002) does when pinpointing the fact that there are two trends about the role of CHW: the “superheroization” and “romanticization” of these professionals, overloading them with several demands, whose resolution goes beyond their performance field and, overall, the healthcare field itself.

Home visits (HV) is an important care instrument from the perspective of Primary Health Care. It has been shown as one of the main activities established for CHW by the Ministério da Saúde (2001). From HV, this professional can develop a bond with the attended families and know their unique care needs ( Pereira & Oliveira, 2013).

In this sense, we are committed to valuing intersubjectivity as a strategy to approach the way of life and the concrete needs of people and communities ( Gonzalez-Rey, 2015). Affect, from the historical and dialectical materialist perspective, contributes – as do the categories of activity, language, and conscience – to the understanding of the dialectical process of social inclusion/exclusion. According to Sawaia (2011), in her studies on social exclusion, it was observed that the situation of exclusion from basic rights, including feelings of humiliation, shame, and other negative affects, generate suffering, which she called ethical-political suffering.

In addition, other studies in the field of Community Social Psychology emphasize the politicization of everyday life as a new way of developing social participation. This takes place from a dialectical relationship between individual interests/needs and community demands ( Sawaia, 2011; Freitas, 2020; Moitinho & Castro-Silva, 2013).

Based on the reference of the qualitative research framework, participatory research can bring important contributions to the addressed issue, because the research subjects are considered as protagonists in the planning and conduction of the entire process. It is worth noting that participatory research originating in Latin America is mainly valued for its emancipatory character, since it aims at social transformation. This potential for transformation can be understood by contextualizing the struggles for democracy in countries such as Brazil, Chile, Argentina and others that suffered from military dictatorships ( Gohn, 2010; Martin-Baro, 2017).

For Schmidt (2008), participatory research of an ethnographic character provides a favorable field for education in health, and its theory and methods contribute to this education of an ethical nature. Schmidt (2008) points out that research on health encompasses Human and Social Sciences, composing the field of research that is not only medical-related. Thus, there is a place of proper and respectable epistemological and ethical differences. According to the author, “[...] ethics is a home, a way of inhabiting the world and a place for updating values and attitudes. [...] it is involved in the human choices that create worlds and in the ways of valuing and experiencing these worlds” ³ ( Schmidt, 2008, p. 392).

These choices presuppose autonomy and are directly linked to the topic of education, considering that “[...] ethics in research cannot and should not remain restricted to the level of norm, rule, and law or to the exclusively legal level” ( Schmidt, 2008, p. 393). Hence, the subject who does not achieve autonomy and lives heteronomy, acts without criticism and reflection, accepting laws and norms, a path that distances this subject from ethical choices. Thus, Schmidt questions “[...] how to prevent norms and rules of conduct in research from becoming devices for evading responsibility, reflection and judgment proper to the autonomous individual who forges ethics and who is forged by it?” ( Schmidt, 2008, p. 393).

We believe that this theoretical-methodological perspective raises an effort to improve the articulation between the aspects of public health policies and the Social Sciences and Humanities, as actions that value the ethical-political commitment in the search to confront the consequences of social inequality ( Paulo & Brandão, 2018; Silva et al., 2012).

Therefore, we reflected on the ethical-political role of CHW practices in the FHS, in territories marked by social exclusion. Specifically, based on participatory research, we highlighted aspects of an affective bond development as a potentiating element of actions that transform reality, based on citizenship and rights.

Methodology: building a shared path

Qualitative research has been strongly emphasized in the healthcare field, specifically in public health. This is formed by an interdisciplinarity that evokes subjectivity in its analyses, mainly to think about the principles of the SUS. This reflection takes place with the emergence of Social Sciences and Humanities in research on health, as the research questions are related to problems of human existence, which do not find answers in traditional research methods, specifically regarding the positivist science ( Bosi, 2012).

In this sense, Minayo (2017) reflects on social research as investigations of human beings embedded in society, institutions, relationships, life stories, and symbolisms. In this conceptual construction, the author defines social research in health as: “[...] all investigations that address the health/disease phenomenon, its representation by several actors who work in the field: political and service institutions and professionals and users.” ( Minayo, 2010, p. 47).

Demo (2012) pays attention to the following question: what methodology does the phenomenon under study require? For example, when analyzing the number of people involved in a manifesto for improvements in the SUS, this is a research of a quantitative nature. But to deepen the motivations, desires, and expectations that some of these people have in relation to this manifesto, qualitative research is required.

The reflections on the ethical-political role of the CHWs' practices in the FHS, in territories marked by social exclusion, using participant research as a methodological guide, are based on research data from 2011 to 2013. During this period 19 meetings of the research management group took place, which were recorded in field diaries and peer-reviewed. This material was the main source for the results analysis. However, it should be mentioned that socio-demographic, epidemiological and public health policy information, especially about this territory, was updated.

In this sense the the research titled: “A Potência De Ação De Agentes Comunitários De Saúde Na Estratégia De Saúde Da Família Da Vila Dos Pescadores No Município De Cubatão” funded by the National Council for Scientific and Technological Development [Conselho Nacional de Desenvolvimento Científico e Tecnológico – CNPq], Public Notice MCT/CNPq 14/2011, was developed in Vila dos Pescadores (VP), in the mangrove region of Cubatão, in the state of São Paulo, Brazil. VP originated in the 1960s and is part of the scope concerning transformations in the urban space over the last decades, where an exacerbated pattern of social exclusion is demonstrated. It is worth highlighting the serious problem of the local basic infrastructure, especially in relation to the stilt houses located on Casqueiro River, where waste and garbage are directly deposited in the tide, passing alongside and under the houses. Since this is an area of irregular occupation, the government does not commit to improvements in local infrastructure. According to statistical and epidemiological data, VP is considered a region of high vulnerability in the municipality of Cubatão.

According to the São Paulo Social Vulnerability Index [Índice Paulista de Vulnerabilidade Social – IPVS] ( Ferreira et al., 2006), Cubatão has 21.2% of the population in the High Vulnerability group and 21.0% in the Very High Vulnerability group. That means that 42.2% of its population exhibits low socioeconomic status, with the heads of the households presenting, on average, low income, and low formal education level.

The latest data from the State System of Data Analysis (SEADE) reveal that the city of Cubatão had 130,025 inhabitants, occupying an area of 142.3 km², which results in a demographic density of 910 inhabitants/km², much higher than the density of the State of São Paulo, which is 168.79 inhabitants/km² ( SEADE Municípios, 2021). It is the only non-coastal municipality in Baixada Santista and has an economic profile predominantly focused on industry, unlike the state and national plans that present services as the main economic activity ( SEADE Municípios, 2021).

In the epidemiological aspect, the latest data on infant mortality recorded for the State of São Paulo, 11.5 deaths per thousand live births in 2011, a number that has been reducing in recent decades (63% since 1990 and 31% in relation to 2000). The municipalities analysis of São Paulo State showed that Baixada Santista is the region with the highest infant mortality rates (16.87). In this region the highest rate was in the municipality of Guarujá (23.0) and the lowest in Santos (13.0). The municipality of Cubatão had a rate of 15.3 ( SEADE Municípios, 2012).

Based on the reference participatory methods, it is worth describing aspects of the research design process. Initially, we considered the sociohistorical and institutional context involved. This implied retrieving the proposal of a university whose political pedagogical project comprises a commitment to improving the communities’ living conditions. Since the beginning of the undergraduate program, visits to different territories of the municipalities that compose Baixada Santista were promoted. These were analyzed and discussed based on the interdisciplinary training of students, favoring a broader understanding of the health-disease-care process. Ultimately, strengthening the principles of the SUS ( Capozollo et al., 2013).

The effort of this university campus is to encourage the connection with different public and private institutions as well as social organizations in the region. They already gave rise to dialogues and exchanges between different social actors related to healthcare institutions. The authors highlighted the initiative of holding the Permanent Health Forum of Baixada Santista. It was implemented from the discussions of professionals’ groups in the Pre-Congress on Public Health of Baixada Santista, held at Federal University of São Paulo – Campus da Baixada Santista, on August 25 and 26, 2011. In this event, the challenge of articulating the university and public health services regarding education was discussed, especially in relation to the topic of health care in the mental health network in the cities of Baixada Santista. Henceforth, this event continues to be held, updating the region’s health interests and demands ( Silva et al., 2014).

Thus, from an operational point of view, it is worth noting that the negotiations could contemplate the interests of the social actors involved (University and the Public Health Service of Cubatão) and that the research objectives were consistent with the political-institutional moment of the municipality and/or the family health unit (FHU), favoring the process of legitimizing the development of the research.

The formation of this social-institutional network contributed to advancing in the search for the university’s legitimacy as a partner of society (Junqueira et al., 2013). Based on the history of social movements, nowadays the authors realize that the ethical issue and social commitment are indicators of the institutions’ integrity. Given the advance of economic globalization and neoliberalism, the authors perceive that social institutions become bureaucratic entities aiming to alleviate the consequences of social inequality, making them bureaucratic and little in tune with the development of citizenship and autonomy ( Viana, 2019; Dardot & Larval, 2017).

This background served as the basis for negotiations with the municipal health department regarding the establishment of this partnership, including the choice of the location for the research.

The study design occurred when, having chosen the location, the authors proposed to discuss the form and level of participation of the actors involved. The proposal was that the development of the research engaged the active participation of managers and health professionals. Hence, the group of researchers proposed the formation of an inter-institutional group with all researchers (professors from different areas of public health and students, highlighting graduate students from the Interdisciplinary Program in Health Sciences) and representatives of the public health service. This group was called Management Group (MG), composed of: managers at the central level, managers at the local level, healthcare professionals working in the health unit and CHW.

Vila dos Pescadores was chosen based on a suggestion on the part of the municipality’s primary care coordination, considering the high vulnerability characteristics of the neighborhood and the need to improve primary care actions in the territory:

Many questions concerning the territories of Cubatão, the CHW, and the research were discussed. Thus, managers M. and G. proposed the research to be conducted in the Family Health Program ( Programa Saúde da Família – FHP) of Vila dos Pescadores, due to the access to the territory, the research profile, and the ease of contact with the local manager (MG, Field diary, April 20, 2012).

The research steps carried out between 2011 and 2013 were: 1– exploring the territory to understand the organization of the health system, the social and community organization, and the organization of the FHU; 2– carrying out participant observations of the CHW practices, recorded in field diaries; and 3– conducting semi-structured interviews, which were recorded and transcribed, to understand their life and work trajectories. The subjects were eight CHW, four managers of the public health service in Cubatão, and four professionals from the FHU. It is noteworthy that the selection criteria of the research subjects considered time performing these functions greater than one year, availability to participate in the research, and nomination by peers.

Pieces of information were initially systematized by skimming the material from which the main empirical categories emerged, organized in descriptive-analytical tables. Data analysis was performed through depth-hermeneutics, which proposes the analysis of cultural phenomena, socio-historically contextualized, and a methodology that privileges cultural phenomena and their symbolic forms, within structured contexts ( Thompson, 1995).

All ethical procedures were followed according to the guidelines of the Research Ethics Committee, under CAAE: 06454412.3.0000.5505, according to recommendations on research ethics established in Brazil. The Informed Consent Form was obtained from the participants.

Analysis and Discussion of Results: affective bonds as a political exercise in the practice of CHW

From the contextualization of the research organization steps detailed in the methodology, especially the formation of the MG, we focused on presenting the research results emphasizing the main aspects of the following processes: developing bonds and sharing experiences.

Immersion in the field made the relationship established among participants involved and researchers more complex. Some students had never entered a place with such precarious housing, including severe lack of basic sanitation infrastructure. These aspects were outlined in the reports of students in their field diaries. When visiting the territory for the first time, they stated:

In the passage of stilt houses, the smell was horrible, and I found it a complicated task, not to say a dangerous one, to pass through the fragile woods, randomly arranged, forming an unpredictable bridge. Many houses were formed by pieces of different shapes and sizes of wood (MG, Field diary, October 02, 2012).

This excerpt demonstrates the reality of the contrasting social classes. L. states that, at first, it was impossible to have an idea of the community size, but when circulating through the territory they had the dimension of the village immensity, which has over 10,000 residents (MG, Field diary, November 09, 2012).

These contrasts and conditions undoubtedly evoke a series of issues related to the production of health associated with social determinations, that is, this territory expresses a structural socioeconomic precariousness ( Albuquerque & Silva, 2014). No wonder the discussions and reflections of professionals working at the Family Health Unit of VP portray a very complex life context.

One day I went to her house. “I’m hungry, ma’am...” there was only children, and this disabled girl... I said “oh my God, oh my God, oh my God! Go get half a dozen eggs!” My first attitude! I said, “where are your parents?” “They went to Cubatão to get paid.” “Now? And did they make food for you?” “No.” In the kitchen, spoiled rice... everything was spoiled... I cooked them some rice, scrambled eggs, and feed it to the girl and she ate it like a desperate animal (CHW C., Report, April 05, 2012).

Hunger and overburdening the care of children and youth is part of the reality of single working mothers and families in this territory as this excerpt shows.

Mrs. M., she is a lady who has a leg ulcer. She had a bedridden daughter, who recently passed away... in her early thirties... There’s no income... no home! It’s a space, with loose tiles, half falling... one room... There are now 11 people living in the house. Chicken, dog, duck, all in the same place, with no hygiene... Then we keep thinking, I was going there, I saw that girl, her daughter, before she died, she was already in a quite poor state... Then they took her away, her finger was like that size... she had leprosy, that kind of thing, then she was hospitalized for a whole week and died in the hospital (CHW T., Report, April 11, 2012).

This passage demonstrates the dramatic living conditions of a family in this territory. Despite living in VP, some CHW mentioned that they have not lost their capacity of feeling indignation as for the new and diverse situations they face every day. “[...] We must take care not to lose the capacity to be indignant at the situation in which those people live, of poverty and great vulnerability, and not to be conformed with it, to naturalize what is unnatural” (MG, Field diary, April 27, 2012).

This excerpt features the category "indignation". The term “indignation” means “anger aroused by something unjust, unworthy, or mean” (Merriam-Webster’s Dictionary, 2004, 633). For Spinoza “Indignation ( indignatio) is a hate toward someone who has done evil to another” ( Spinoza, 1973, p. 223). Conversely, Hessel (2011) leads the reader to reflect on the struggle for democracy and human rights, in addition to serving as a stimulus to motivation and a call to face indifference.

In this perspective, the research activities sought possibilities of resignifying these affections beyond indignation or other affections that would paralyze a more critical attitude toward such situations. We consider that the principles of Sociohistorical Psychology bring important references for analysis when it emphasizes awareness processes as a strategy for the subjects’ performance ( Martin-Baró, 2017). According to this author, the awareness process involves three aspects: 1) Human beings transform themselves by transforming their reality and, from a pedagogical point of view, this takes place through dialogue; 2) these subjects gradually decode the conditions that generate oppression and suffering and, accordingly, they develop a critical awareness of their reality, resulting in new social praxis; and 3) this process, from a dialectical perspective, generates new possibilities for understanding and knowing about oneself and one’s social environment. This awareness process ultimately aims at the strengthening of individuals and the community, considering that people become stronger as they realize that many situations of oppression – that they often live in isolation and alone – are also experienced by people surrounding them.

However, considering the weakening context of community mobilization and organization, especially in territories marked by social exclusion, awareness processes demand more from community leaders and public service professionals. This “more” suggests an ethical-political commitment to transforming reality. In practice, it means enabling the construction of democratic spaces for exchange and dialogue between those involved, including collectively constructing other non-pathologizing views of everyday life ( Freitas, 2014; Martin-Baró, 2017). Thus, the base of the research development demanded attention to the situations brought up from the daily practice of the CHW.

[...] We created a presentation with them so that they could explain successful work situations at the CHW meeting in the municipality. Rosangela also stated that the CHW enjoyed the opportunity to think and reflect on their daily practice in the community (Field diary, August 17, 2012).

This and the following excerpts bring the interaction researchers-CHW and demonstrate the exchange of knowledge as well as reflection for possible transformations. In this sense, the formulation of strategies to enable the involvement of CHW also provided ways of learning about the research and reflecting on the work within the community.

Then, Professor R. leads the group by doing another activity, using the room’s wall as a board and some trimmed papers, asking the CHW to think about what questions they would like to ask the Community Leaders of the community if they were interviewing them (Field diary, August 17, 2012).

This excerpt addresses important questions development and strategies created by the CHWs for community leaders, both from the same territory. Handing out folders, which each agent customized in their own way, was a symbolic act that represented the union of the agents with the research (Field diary, August 17, 2012).

In studies conducted by Montero (2010), community empowerment is conceived as a dynamic process that requires constant updating of the interests and degree of involvement of social actors. The author explains this through the notion of participation-commitment:

Defining participation detached from commitment, or commitment separated from participation, does not account for the phenomenon that occurs in organized communities, therefore, definitions based only on having a part of something, on being part of something, on forming part of a group defined on the basis of externally constructed criteria, or that separate the two aspects of the binomial, do not fully account for the phenomenon (free translation) ( Montero, 2010, p. 187).

We believe that this notion of participation-commitment is a good example for new efforts toward a more authentic engagement for the improvement of people’s living conditions and social transformation. Hence contributing to the resignification of struggles against several forms of oppression, power asymmetries, and de-ideologization of everyday life ( Montero, 2010, Martin-Baró, 2017).

Likewise, we can consider, based on the Critical Social Psychology, new epistemological and methodological references. As we move away from a traditional psychology, focused on individualizing and psychologizing parameters, approaches that value the production of socio-historically and culturally contextualized subjectivity are necessary, indicating the need for a perspective toward a symbolic and relational production ( Gonzalez-Rey, 2015; Hepworth, 2006; Montero, 2010; Guzzo & Lacerda, 2007). Accordingly, sharing and valuing the participation of CHW in various steps of the research, for instance, in the elaboration of the script for interviews aimed at community leaders, gave rise to an unparalleled enthusiasm.

Seeing the girls asking questions was also an empowering aspect of the research camaraderie. I saw how excited they were to come up with their ideas for the questions. One worker even joked about it, demanding the answer to be shown later, illustrating the researcher’s spirit in them. Since they have chosen the leaders of their community, behind this decision there must be biased questions, which are of extreme value for research as a whole (Field diary, October 10, 2012).

The encouragement of more participatory activities also favored greater emotional availability in which they allowed themselves to express the suffering generated in moments of great anguish. At these times, it was important to listen and welcome in such a way to give feedback on the fact that such situations were complex and complicated. Therefore, it was possible to contribute to the denaturalization of suffering, according to Sawaia’s (2011) ethical-political conception, as it was generated due to an adverse context and in the case of poverty and several forms of violence.

While reading a speech on the slideshow, the CHW Alessandra was moved by her own transcribed speech. She looked at the excerpt, read it silently, and when she was about to read it aloud, she began to cry. There was silence for a few seconds in the room [...]. Professor B. tried to comfort her, reinforcing the seriousness of the situation she experienced. When A. got better, she said “it was difficult, because we can’t help everyone, one food basket alone doesn’t help” (S.I.C.) (Field diary, August 2012).

The passage shows that this search for a closer relationship with the routine and interests of CHW increasingly strengthened the ethical-political commitment of the research to these professionals and the community, that is, the aim was to achieve an effective contribution by transforming that reality. The notion of friendship deemed as a political exercise, that is, experimenting with new forms of sociability and community ( Ortega, 2000), helped us to understand that friendship can be developed in the public space instead of being restricted to the intimacy of closer relationships.

Friendship promotes encounters that instigate changes and the friend, in this line of thought, is not a mirror in which we seek a reproduction of our image. Nietzsche (1998 as cited by Ortega, 2000) was the first to break with this tradition of the notion of friendship in which proximity, equality, and agreement place the friend not as an unconditional adhesion, but rather as one who urges and challenges us to transform ourselves. Emphasizing moments of asymmetry and nonreciprocity favors an emotional space in which heterogeneity is possible and the alterity in the relationship with the other is preserved ( Ortega, 2000). Hence, we are not valuing dissensions and conflicts, but mainly for us to move away from the consensus.

In turn, Derrida (1997, as cited by Ortega, 2000) highlights the idea of deconstruction in the field of ethics and politics, which allows an opening to the other, to tolerance toward difference and conflict as ways to foster singularity and the otherness. This notion contributes to questioning the limits between the subject and the other, demonstrating that this subject is always “contaminated” in this relationship.

According to Ortega (2000), it was necessary to learn to cultivate a “good distance” in affective relationships, as an excess of closeness and intimacy leads to confusion, and only distance allows respecting the other and promoting the sensitivity and kindness necessary to perceive their otherness and uniqueness. Cultivating a good distance, from the point of view of developing this friendship, implied being aware of the contradictions expressed in some tense moments, for example, when one of the CHW voiced her distrust of the purpose of the research.

However, when the CHW were asked about this group (MG), Lina replied that it was another way of inspecting their work. Everyone was somewhat perplexed by her statement, and Professor Maria Fernanda said: “Take a moment to stop and look at what we do… is very important” (Field diary, October 27, 2012).

The excerpt reminds us of the need to practice reflexivity. From this perspective, we consider it useful to read reality from a sociohistorical and cultural approach, based on a historical-dialectical materialist basis, insofar as historicity and criticism are parameters for the analysis of social phenomena. This means valuing the character of reflexivity, that is, humans think about themselves, and their world permeated by the historical context in which they live ( Maia, 2013).

The awareness of historicity takes place within a network of events disseminated in the fabric of society. Those historical times allowed social agents a reflective understanding, a new understanding of themselves. They saw themselves in the mirror of their own way of life, of their anxieties ( Maia, 2013, p. 71).

The frequency of the meetings enabled the development of a bond of trust and complicity, which aroused the curiosity to know more about these “outsiders,” coming from “that Public University.” In this sense, we organize some of the MG meetings at the educational institution.

At the meeting the following week in Vila dos Pescadores they spoke very well about our gathering at University. They said we should provide more moments like that. That day, some were engaged in helping to organize interviews with community leaders. C., one of the quietest CHW during the MG meeting, incorporated the research in such a way that she even gave the following suggestion: “we should give feedback on the results of these interviews to the population, in the form of a presentation” (Field diary, September 28, 2012).

From the welcoming and friendship developed in the MG meetings, good gatherings could take place. These are defined here as spaces for exchange and empowerment of the subject’s power to act, capable of overcoming the barriers of individualism and envisioning, in the public sphere, possibilities of achieving happiness ( Spinoza, 1973 as cited by Sawaia, 2011). Spinoza speaks of the passion that drives human beings to meet; it is through the other that they discover themselves. The concept of power of action, from Spinoza’s ethics, encompasses affectivity as an important element in the subjects’ process of emancipation.

Final considerations

From teaching, extension, and research activities, since 2009, a frequent and intense insertion in the routine of Family Health Units and in the territories of municipalities in the region has been made feasible. This approach started through extension activities aimed at CHW with the purpose of providing psychosocial support, due to the suffering resulting from the work routine in the territory. This situation becomes more delicate due to the place of mediation these professionals occupy between the health service and the community. We note that the main resource of the CHW’s actions is the construction of an affective bond, developed from HVs, which aim at welcoming and sensitive listening. Nevertheless, we observed that very little of the bond formed with the users of the health service results in deepening the knowledge of the health-disease process and people’s care. Thus, from this experience with CHW, we consider that there is a division between care, in the dimension of the socio-affective bond and the strengthening of health promotion, prevention, treatment, and rehabilitation of health issues. This division hinders the development of health practices as a citizen’s right, resulting in a disqualification of the main prerogative of the FHS, which aims to provide comprehensive care to subjects and the community. Furthermore, it emphasizes the split between technique (healthcare practices based on a biomedical perspective) and politics (weak politicization of health initiatives as a citizen’s basic right). We believe that the university can provide important support to these professionals regarding the production of knowledge that is more engaged with the strengthening of their political role and, consequently, of the potential to transform these realities that confront us day after day.

Referencias

Albuquerque G. S. C., & Silva M. J. S. (2014). Sobre a saúde, os determinantes da saúde e a determinação social da saúde. Saúde em debate; 38(103), 953-965. https://doi.org/10.5935/0103-1104.20140082

Bosi, M. L. M. (2012). Pesquisa qualitativa em saúde coletiva: panorama e desafios. Ciência Saúde Coletiva, 17(3), 575-586. https://doi.org/10.1590/S1413-81232012000300002

Brito, R. S., Ferreira, N. E. M. S., & Santos, D. L. A. (2014). Atividades dos Agentes Comunitários de Saúde no âmbito da Estratégia Saúde da Família: revisão integrativa da literatura. Saúde Transformação Social, 5(1), 16-21. http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S2178-70852014000100004&lng=pt&tlng=pt.

Capozzolo, A. A., Casetto, S. J., & Henz, A. O. (Orgs.). (2013). Clínica comum: itinerários de uma formação em saúde. Hucitec.

Castro-Silva, C. R., Chiaperini, P., Frutuoso, M. F. P., & Morell, M. G. P. (2014). Extensão universitária e prática dos agentes comunitários de saúde: acolhimento e aprendizado cidadão. Saúde Sociedade, 23(2), 677-688. https://doi.org/10.1590/S0104-12902014000200026.

Cecílio, L. C. O., & Reis, A. A. C. (2018). Atenção básica como eixo estruturante do SUS: quando nossos consensos já não bastam! Cadernos de Saúde Pública, 34(8), e00136718. https://doi.org/10.1590/0102-311X00136718

Dardot, P., & Laval, C. (2017). A nova razão do mundo. Boitempo.

Ferreira, M. P., Dini, N. P., & Ferreira, S. P. (2006). Espaços e dimensões da pobreza nos municípios do Estado de São Paulo. São Paulo em Perspectiva, 20(1), 5-17. http://produtos.seade.gov.br/produtos/spp/v20n01/v20n01_01.pdf

Freitas, M.F.Q. (2020). Análise de necessidade e inserção na comunidade: Relações na Perspectiva da psicologia social comunitária. In Polli, G. M., Antunes, M. C. (Orgs.) Intervenções em psicologia comunitária e da saúde: Teoria e prática. (pp. 19-37). Juruá.

Gohn, M. G. (2010). Movimentos sociais e redes de mobilizações civis no Brasil contemporâneo. (2a ed.). Vozes.

González-Rey, F. (2015). Pesquisa Qualitativa em Psicologia. Cengage Learning.

Guzzo, R., & Lacerda, F. (2007). Fortalecendo em tempo de sofrimento: reflexões sobre o trabalho do psicólogo e a realidade brasileira. Revista Interamericana de Psicologia, 41(2),231-240. http://www.psicorip.org/Resumos/PerP/RIP/RIP041a5/RIP04125.pdf

Hepworth, J. (2006). The emergency of critical Health psychology: can it contribute to promoting public health? Journal of Health Psychology, 11(3), 331-341.

Hessel, S. (2011). Indignai-vos!. Ediciones Leya.

Jacobi, P. (2002). Políticas sociais locais e os desafios da participação citadina. Ciência e Saúde Coletiva, 7(3), 443-454. http://www.scielo.br/pdf/csc/v7n3/13024.pdf

Maia, C. A. (2013). História das ciências: uma história de historiadores ausentes. UERJ/ FAPERJ.

Martín-Baró, I. (2017). Crítica e libertação na Psicologia: estudos psicossociais. Vozes.

Melo, E. A., Mendonça, M. H. M., Oliveira, J. R. & Andrade, G. C. L. (2018). Mudanças na Política Nacional de Atenção Básica: entre retrocessos e desafios. Saúde em Debate, 42(esp.1), 38-51. https://doi.org/10.1590/0103-11042018S103

Mendes, R., Frutuoso, M. F. P., & Silva, C. R. D. C. (2017). Integralidade como processo intersubjetivo de construção de práticas em território de exclusão social. Saúde em Debate, 41, 707-717.

Minayo, M.C.S. (2017). O Desafio do Conhecimento: pesquisa qualitativa em saúde. (17a ed.). Hucitec.

Ministério da Saúde [MS]. (2001). Programa Agentes Comunitários de Saúde: PACS. Brasília: Ministério da Saúde. http://bvsms.saude.gov.br/bvs/publicacoes/pacs01.pdf

Ministério da Saúde [MS]. (2006). Gabinete do Ministro. Portaria nº 648 de 28 de março de 2006. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para o Programa Saúde da Família (PSF) e o Programa Agentes Comunitários de Saúde (PACS). https://bvsms.saude.gov.br/bvs/publicacoes/prtGM648_20060328.pdf

Ministério da Saúde [MS]. (2008). Gabinete do Ministro. Portaria nº 154 de 24 de janeiro de 2008. Cria os Núcleos de Apoio à Saúde da Família – NASF. https://bvsms.saude.gov.br/bvs/saudelegis/gm/2008/prt0154_24_01_2008.html

Ministério da Saúde [MS]. (2011). Gabinete do Ministro. Portaria nº 2.488 de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2488_21_10_2011.html

Ministério da Saúde [MS]. (2017). Gabinete do Ministro. Portaria nº 2.436 de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html

Ministério da Saúde [MS]. (2019). Gabinete do Ministro. Portaria nº 2.979 de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do Sistema Único de Saúde, por meio da alteração da Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017. https://www.in.gov.br/en/web/dou/-/portaria-n-2.979-de-12-de-novembro-de-2019-227652180

Mish, F. C. (Ed.). (2004). Merriam-Webster's collegiate dictionary (Vol. 1). Merriam-Webster.

Moitinho, L. S. L., & de Castro-Silva, C. R. (2013) Aspectos psicossociais de uma intervenção comunitária na periferia de São Paulo. Revista Psicologia: Teoria e Prática, 15(1), 92-104. http://www.redalyc.org/pdf/1938/193826310008.pdf

Montero, M. (2010). Critica, autocritica y cosntruccion de teoria em la psicologia social latinoamericana. Revista Colombiana de Psicologia, 19(2), 177-191. http://www.revistas.unal.edu.co/index.php/psicologia/article/view/13156/34432

Morosini, M. V. G. C.; Fonseca, A. F. & Lima, L. D. (2018). Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde. Saúde em Debate, 42(116), 11-24. https://doi.org/10.1590/0103-1104201811601

Morosini, M. V. G. C., Fonseca, A. F. & Baptista, T. W. F. (2020). Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cadernos de Saúde Pública, 36(9), 1-20, https://doi.org/10.1590/0102-311X00040220

Ortega, F. (2000). Para uma política da amizade: Arendt, Derrida & Foucault. Relume- Dumará.

Paulo, F. D. S., & Brandão, C. R. (2018). Pesquisa participante e a educação popular: luta e resistência a partir de Paulo Freire e de educadoras populares. Revista Panorâmica online, 24, 256-268. http://revistas.cua.ufmt.br/revista/index.php/revistapanoramica/article/viewFile/763/19191991

Pereira, I. C., & Oliveira M. A. C., (2013). O trabalho do agente comunitário na promoção da saúde: revisão integrativa da literatura. Revista Brasileira de Enfermagem, 66(3), 412-419. https://doi.org/10.1590/S0034-71672013000300017

Sawaia, B. B. (2011). O sofrimento ético-político como categoria de análise da dialética exclusão/inclusão. In B. B. Sawaia. As artimanhas da exclusão: análise psicossocial e ética da desigualdade social (pp. 99-120). Vozes.

Schmidt, M. L. S. (2008). Pesquisa participante e formação ética do pesquisador na área da saúde. Ciência & Saúde Coletiva, 13(2), 391-398. http://www.scielo.br/pdf/csc/v13n2/a14v13n2.pdf

SEADE Municípios. (2021). Fundação Sistema Estadual de Análise de Dados. Perfil Municipal Cubatão. Recuperado de: https://municipios.seade.gov.br/

SEADE Municípios. (2012). Fundação Sistema Estadual de Análise de Dados. Índice Paulista de Vulnerabilidade Social Versão 2010 - Metodologia. Recuperado de: http://ipvs.seade.gov.br/view/pdf/ipvs/metodologia.pdf

Silva, C. R. C. e, Mendes, R. M., Moraes, R. C. P., Anhas, D. M., & Rosa, K. R. M. (2014). Participação social e a potência do agente comunitário de saúde. Psicologia & Sociedade, 26(spe2), 113-123. https://doi.org/10.1590/S0102-71822014000600012

Silva, C.R.C., Mendes, R., & Nakamura, E. (2012). A dimensão da ética na pesquisa em saúde com ênfase na abordagem qualitativa. Saúde Sociedade, 21(1), 32-41. https://www.scielo.br/scielo.php?pid=S0104-12902012000100005&script=sci_abstract&tlng=pt

Silva, L. A., Casotti, C. A., & Chaves, S. C. L., (2013). A produção cientifica brasileira sobre a Estratégia de Saúde da família e a mudança no modelo de atenção. Ciência & Saúde Coletiva. 18(1), 221-232. http://www.scielo.br/pdf/csc/v18n1/23.pdf

Spinoza, B. (1973). Ética. In Os Pensadores. Abril.

Thompson, J. (2011). Ideologia e cultura moderna: teoria social crítica na era dos meios de comunicação de massa. Vozes.

Tomaz, J. B. C. (2002). O agente comunitário de saúde não deve ser um "super-herói". Interface – Comunicação, Saúde e Educação, 6(10), 75-94. http://www.scielosp.org/pdf/icse/v6n10/08.pdf

Viana A. L., & da Silva H. P. (2018). Meritocracia neoliberal e capitalismo financeiro: implicações para a proteção social e a saúde . Ciência e Saúde Coletiva, 23(7), 2107-2118. http://www.scielo.br/pdf/csc/v23n7/1413-8123-csc-23-07-2107.pdf

Notes

Author notes

¹ Correspondence about this article should be addressed Carlos Roberto Castro-Silva: carobert3@hotmail.com

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