A determinação social da saúde no campo da saúde do trabalhador

contradições, desafios e oportunidades

Abstract

The historical trajectory from occupational medicine to workers’ health expresses a process of epistemological, political, and ideological disputes about the meaning of health and the role of work in the production and reproduction of life. Occupational medicine, which emerged in industrial England in the 19th century, was structured as an instrument of mediation between capital and labor, aimed at ensuring productivity and the adaptation of workers’ bodies to the demands of the production process. Occupational health arose in the context of industrial transformations during and after World War II, marked by accelerated production growth and the intensification of work-related accidents and diseases. In response to these challenges, the model expanded the strictly medical focus of occupational medicine by incorporating knowledge from engineering, toxicology, and applied social sciences, leading to a multiprofessional and interdisciplinary approach. In the 1960s and 1970s, workers’ movements fueled criticism of the medicalized and individualizing model, paving the way for workers’ health, grounded in the principles of Latin American social medicine, which recognizes work as central to the health–disease process. Despite this history of struggle, workers’ health remains a little-known field even among professionals within Brazil’s Unified Health System (SUS), including those working in collective health. The National Policy on Workers’ Health (PNSTT), established only in 2012, still develops largely in parallel and remains poorly integrated with other health policies that compose the SUS. As an example, health promotion actions often encourage the adoption of a “healthy lifestyle,” including adequate nutrition, regular physical activity, smoking cessation, reduction of alcohol consumption, and stress control. But how can such practices be effectively adopted without first identifying the factors that either hinder or condition these habits? How can one maintain a “healthy lifestyle” while subjected to exhausting work schedules such as the 6×1 work regime? How can stress in the workplace be reduced when the prevailing logic — even within health management services under the SUS — is that of productivity and a culture of harassment, which, far from being merely “cultural,” functions as an instrument of coercion and discipline over workers, reinforcing the need to intensify labor exploitation in the current phase of capitalist development? Although within the SUS this area is formally named “workers’ health,” which could imply recognition of the centrality of work in the health–disease process, the prevailing approach remains that of the social determinants of health, aligned with the World Health Organization and, therefore, reductionist in relation to the structural processes that determine workers’ illness. Data from the “Smartlab” platform show a growing number of work-related mental disorders (WRMD) reported in the national notification system (SINAN), with twice as many records in 2024 compared to 2022 — totaling more than 4,800 cases in the country. Even though Ministry of Health regulations identify psychosocial risk factors in the workplace — such as excessive workloads, harassment, and pay-per-production systems —, the proposed interventions frequently point to individualized actions focused on self-care and self-management of stress, or on environmental changes following the logic of occupational health. Not coincidentally, on official Ministry of Health websites addressing burnout prevention, recommendations such as “avoid contact with negative people, especially those who complain about work or others” can be found — a notion that completely denies the collective and structural nature of this form of illness. In training programs on workers’ health for professionals of the Health Care Network, it is common to identify cases of work-related illness — particularly mental suffering — among the health workers themselves, who are often subjected to precarious conditions and work hours as exhausting as those of the populations they serve. Nevertheless, the individualizing logic of the capitalist system and the lack of class consciousness can, paradoxically yet predictably, hinder the recognition of others’ suffering and its relationship with work, reproducing in practice the “employer’s interest” — manifested, for instance, in the denial of medical certificates or in the refusal to acknowledge the relationship between illness and work by those whose role should be to safeguard workers’ health. This contradiction also reveals itself in the challenge of implementing a Workers’ Health Policy in a context of public-service devaluation and fragile employment relations within the SUS workforce itself, both in health care and management. The struggle for awareness in defense of workers’ health — in contrast to occupational health or occupational medicine — takes place even among peers in the public sector, health professionals, and the population at large, who, by reproducing the dominant class ideology, blame the injured worker or naturalize and romanticize child labor. It is important to note that the apparent misalignment between the identification of the processes that make the working class ill and the proposed health policies within the SUS is not a mere technical inconsistency, but rather an expression of the State’s structural role in defending the interests of the dominant class. This character has been evident since the creation of the SUS and has been reinforced by recent measures, such as the government’s “Agora Tem Especialistas” (“Now We Have Specialists”) program. Despite advances and setbacks, the very existence of the PNSTT within the SUS represents a spark of resistance and possibility, keeping alive the perspective of a critical health care approach committed to the real interests and needs of the working population. In this sense, rescuing the concept of social determination of health becomes ever more necessary, reaffirming the central role that the mode of production of life plays in shaping and sustaining the health of the collective.