Social medicine, feminism and the politics of population: From transnational knowledge networks to national social movements in Brazil and Mexico

ABSTRACT

This article examines the role of national actors articulated with an explicitly counter-hegemonic transnational knowledge network (TKN) mobilising around social medicine in policy debates on population control and family planning. It focuses primarily on Brazil, using Mexico as a shadow case to highlight salient points of contrast. In doing so, it makes two contributions to larger debates about TKNs. First, it highlights the plural and contested nature of the knowledge production they enact, underscoring contestation around a global reproductive regime that consolidated around family planning. Second, it underscores how the position and relative influence of actors articulated with TKNs is shaped by political and institutional contexts at the national level, producing variable opportunities for the mobilisation of applied knowledge. Reflecting its advocates’ embeddedness in larger opposition movements to authoritarian states, social medicine had a greater influence on these debates in Brazil, where synergies with a resurgent feminist movement reinforced a shared insistence on comprehensive women’s healthcare and increased the salience of sterilisation abuse on the political agenda.

KEYWORDS:

• Transnational knowledge networks
• social medicine
• feminism
• family planning
• Latin America

Scholars have called attention to the growing importance of transnational knowledge networks (TKNs) in global governance in public health and other areas of development.¹ Such networks can articulate, with varying degrees of formalisation, public and private actors at the local, national and supranational levels, potentially including government agencies, international organisations, foundations, research institutes, professional associations, corporations and nongovernmental organisations (NGOs). TKNs link ‘the production, collection and movement of knowledge to technologies of government’ through the coordination of research, intellectual exchange and ‘capacity-building’ activities such as academic scholarships and professional trainings (Stone, 2013, p. 44). Through the Foucauldian lens of governmentality, one can understand them as ‘assemblages of forms of practical knowledge, with practices of calculation and types of authority and judgments’ (Ilcan & Phillips, 2008, p. 713). Scholars have hailed TKNs for encouraging horizontality, flexibility and innovation; placing overlooked issues on the policy agenda and incorporating local actors and knowledge into the policymaking process (Kothari et al., 2016). More critical assessments have underscored their embeddedness in cartographies of knowledge production long shaped by geopolitical imbalances and their reliance on technocratic rather than democratic forms of legitimation (Bang & Esmark, 2009; Natividad, Fiereck, & Parker, 2012).

This article examines the role of TKNs in the politics of population control and family planning as they played out in Latin America’s two most populous countries, Mexico and Brazil. The Cold War politics of population policy is noteworthy as a site deeply marked by north–south tensions in which TKNs played an early, central and strategic role. Through the funding and coordination of demographic research centres, fellowships, trainings and fertility and attitudinal surveys, a global network of international agencies and foundations, bilateral aid organisations and NGOs fostered the production and dissemination of applied knowledge to promote the creation of national population programmes and ultimately changes in gender norms and reproductive practices in the global south. This reliance on networks of state and non-state actors and capacity-building activities to promote knowledge production in the global south responded in part to (geo)political sensitivities surrounding this project, to avoid the appearance of neocolonial imposition while building a consensus on population dynamics (Barrett, Kurzman, & Shanahan, 2010; Connelly, 2008). But as the historian Matthew Connelly (2003) reminds us, it is easy to misread the history of population control and family planning through a top-down focus on the discourses and policy prescriptions of global elites and institutions. Such an approach ignores the national actors that selectively embraced, rejected or adapted global prescriptions. Indeed, the field mobilised an array of diverse, if overlapping globalised constituencies – feminists, neo-Malthusians, development planners, environmentalists, demographers and healthcare professionals, among others – in ways that played out differently in different national contexts.

The article seeks to contribute to this literature in two ways. First, it highlights the plural and contested nature of knowledge production enacted by TKNs around a global reproductive regime constructed around family planning. Second, it underscores how national political and institutional contexts shape the position and influence of national actors articulated with TKNs, producing different opportunities for the mobilisation of knowledge. To be clear, my intention here is not to posit a unidirectional flow of ideas and political energy from transnational networks to national movements, nor to suggest that transnational networks necessarily have a declining influence over time. The framing in the title, ‘From (TKNs) to national social movements,’ rather, is intended to denote an analytic move, focusing attention on how actors’ embeddedness in national polities conditions the selective deployment and the salience of the knowledge circulated by TKNs. Knowledge-production is understood here, in the Gramscian sense, not as the activity of individual intellectuals but as encompassing internally differentiated institutionalised fields of social relations within which various forms of collective knowledge are produced and distributed. It thus encompasses activities not just in the academy or research laboratories but in other institutions such as state bureaucracies and NGOs (Crehan, 2017).

To develop these arguments, I examine national instantiations of an explicitly counter-hegemonic TKN mobilising around the banner of ‘social medicine’ or ‘collective health.’ Since the late 1960s, social scientists and healthcare specialists in Latin America mobilised, initially through informal networks and regional conferences and eventually through university-based research centres and academic programmes (Duarte, 1991). The movement posed an epistemological challenge to the biologizing, medicalizing and individualising tendencies of mainstream epidemiology and public health, calling for the incorporation of social scientific methodologies and approaches, particularly historical materialism, into health research. In ways that echoed the contemporaneous Latin American project of dependency theory, researchers focused critically on questions like the social determination of health and illness, the production of medical knowledge and the formation of human resources in healthcare, with the goal of producing applied knowledge to confront persistent health disparities specific to Latin American conditions of dependent development (Laurell, 1982; Waitzkin, Iriart, Estrada, & Lamadrid, 2001). The movement gained an important institutional foothold in the Pan-American Health Organization (PAHO), with the arrival of the Argentine physician and sociologist Juan César García in 1966, who worked initially in its Human Resources Development Department and subsequently as Director of Research, until his death in 1984, a position from which he and his colleagues promoted regional seminars, research, scholarships and publications (Nunes, 2015). Since 1984, its principal transnational expression has been the Latin American Association of Social Medicine (ALAMES) founded that year, consolidating as a TKN that produces counter-hegemonic knowledge and policy alternatives to the dominant healthcare prescriptions of the World Bank and other international agencies (Almeida, 2006).

The inscription of family planning within larger projects of economic development and geopolitical oppositions made it a potential bridge between advocates of social medicine and Latin American feminist movements, which experienced a contemporaneous resurgence in the 1970s. In both Brazil and Mexico, this resurgence occurred against the backdrop of authoritarian governments confronting opposition movements demanding democratic and sometimes revolutionary change. Synergies between feminists and advocates of social medicine found much greater expression in Brazil, in part reflecting the latter’s institutional location within these larger polities. This influence contributed to the course of women’s health activism and policy by reinforcing the salience of sterilisation abuse and an insistence on women’s comprehensive healthcare, ultimately delaying the passage of a National Family Planning Law until 1996, over two decades after Mexico’s. This article focuses primarily on Brazil, given the much greater influence of social medicine on feminist politics there, with particular attention to debates on female sterilisation, around which (geo)political contestation often crystalised. Mexico is discussed primarily as a shadow case to highlight salient political contrasts. The article draws on a larger research project on sexual and reproductive rights movements’ engagement with healthcare. This project has involved extensive research in archives belonging to social movement organisations, public health institutes, state agencies and international foundations as well as 81 interviews in Mexico and 100 in Brazil with sexual and reproductive rights activists, health officials and other relevant political actors.

The politics of population

Until the 1970s, the prevailing view among Mexican and Brazilian political elites regarding population policy might be summarised by the famous phrase first uttered by the nineteenth-century Argentine liberal Juan Carlos Alberdi, ‘To govern is to populate’ (Gobernar es poblar). In both countries, this essentially pronatalist view had deep historical roots, linked to geopolitical concerns that territorial security and social progress required the occupation of vast empty tracts of land by national populations (Fonseca Sobrinho, 1993; Welti-Chanes, 2011). Pronatalist understandings informed public policies in various areas, from the criminalisation of abortion to early protections for maternal-child health. Mexico’s General Population Laws of 1934 and 1947, for example, established the state’s obligation to increase population size through immigration and ‘natural growth,’ involving the promotion of marriage and social protections for mothers and children. Brazil’s 1934 constitution introduced stipulations that called for protecting mothers and children and supporting families with numerous offspring. Mexico’s Sanitary Code of 1949 and Brazil’s Criminal Infractions Law of 1941 banned advertisements for birth control, remaining on the books until 1973 and 1979 respectively. While enforcement of these laws was lax – contraceptives, for instance, came to be advertised and freely dispensed by pharmacies for the purposes of menstrual regulation – they nonetheless shaped the public face of a double discourse that powerfully influenced the political landscape (Márquez, 1984; Mora Bravo, 2017; Werneck Vianna, 1977).

The 1974 World Population Conference at Bucharest framed the geopolitical backdrop against which changes in official government positions in both countries began to take shape. Deep divisions emerged leading up to that conference between global south countries, organised as the Group of 77, and countries of the global north. Against the premise advanced by the latter that overpopulation impeded economic development and must be contained, the G-77 inverted the causal arrow, countering that if economic development happened, fertility declines would follow. Mobilising around the banner, ‘Development is the best contraceptive,’ the G-77 pushed back against the single-minded focus on population growth as the cause of all ills. Conflict also centred on particular tactics, including quantitative targets for population growth and ‘acceptors’ of contraceptives and the use of incentives and disincentives to promote them. At stake in these debates were competing biopolitical framings that inscribed family planning as either a tool to achieve aggregate goals or an individual human right, demanding state protection. This debate found echo among advocates of family planning in Mexico and Brazil, who routinely distinguished it from demographic control.

Brazilian and Mexican officials at the Conference echoed the G-77 position. The Brazilian military government (1964–1985) officially broke with pronatalism, spelling out what came to be called the ‘Brazilian Demographic Policy,’ stipulating that population policy is a matter of national sovereignty; that birth control is a family decision, not the government’s; but that the state must provide contraceptives and information to ensure access across class lines (Rodrigues, 1983). Despite this discursive shift and inclusion of family planning in the II National Development Plan of 1974, the government took little action, reflecting the contentious political dynamics surrounding the issue. In 1977, its attempt to include family planning for the first time in a public health programme for high-risk pregnancies met such broad resistance that the project was never implemented (Costa, 1999). In 1983, the regime’s efforts took a surprising turn, with the announcement of the Program of Integral Attention to Women’s Health (PAISM). PAISM was widely hailed as a victory by feminist activists and bore the strong imprint of social medicine, as I elaborate below, though again, implementation fell short. While the right to family planning was incorporated in the 1988 Constitution, a National Family Planning Law regulating services, including sterilisation, was only passed in 1996 after protracted, heated contestation.

The case of Mexico was quite different. As the presidential candidate (and heir apparent) of the ruling Institutional Revolutionary Party (PRI), Luis Echeverría responded to World Bank president Robert McNamara’s call to make family planning a conditionality for lending by reiterating Alberdi’s famous expression, ‘To govern is to populate’ (Mora Bravo, 1986). During his presidency (1970–76), however, Echeverría oversaw a dramatic reversal that would eventually lead to adoption of some of the most problematic tactics in the global repertoire. In 1974, prior to the Bucharest Conference, the government promulgated a new National Population Law that created a National Population Council (CONAPO) to coordinate policy. Though Mexico’s statement at Bucharest echoed the G-77 position and excluded any reference to quantitative targets, its first National Family Planning Program, launched in 1977 under Echeverría’s successor José López Portillo, called for reducing population growth from 3.2% in 1976 to 2.5% by 1982 and 1% by 2000 (Mora Bravo, 1986). It also set targets for the number of new acceptors and active users and subsequently for consultations and acceptance of specific methods, which were applied from the federal, state and municipal levels to individual health centres (Navarro & Manautou, 1986).

The Program for Surgical Contraceptives was also launched in 1977 and by 1982 had performed 122,888 cases of female sterilisation, almost entirely postnatal. These were initially conducted in public hospitals, requiring patients to be at least 30, with at least 4 children, and ‘the husband’s consent,’ though these requirements were subsequently dropped to increase numbers. An internal assessment of the programme identified a ‘lack of motivation among medical and paramedical personnel, which made it difficult to convince patients.’ To resolve it, specialised family planning services and personnel were incorporated into hospitals and health centres, including mobile health services for rural areas, verticalising services (SSA, n.d., pp. 2–3). Three-day site visits were also instituted for all health centres entering the programme and surgical units showing ‘low output.’ Of the 249 surgeons evaluated in 242 site visits in 1982, 92 had not received any training and 13 were considered inadequately trained (p. 4). Recalling his visit in 1984 to villages with fewer than 2,500 residents as part of a team sent by the Mexican Social Security Institute to evaluate its family planning programme, Joseph Potter (1999) recalled that the practitioners interviewed gave ‘nearly uniform answers’ in terms of the number of children they thought women should have, the methods they recommended and the suitability of sterilisation as a postpartum method. Reflecting both socialisation within the public health system and ‘guidelines and priorities transmitted down the chain of supervision,’ the result, he concluded, was a highly interventionist approach (pp. 717–18). Though changes were subsequently implemented, particularly after the International Conference on Population and Development at Cairo in 1994, a 1996 survey conducted by CONAPO of clinics, hospitals and practitioners providing family planning services in rural areas of nine states found that normative guidelines were not well-known but that virtually all doctors knew their institutions had quantitative targets and over half had targets for their personal performance (cited in Potter, 1999, pp. 721–722). While the Mexican government has taken steps to institute improvements, charges of forced sterilisation and other forms of ‘obstetric violence,’ particularly in indigenous communities, have periodically been brought to national and international human rights bodies (Menéndez, 2009).

The table below shows the percentage of women of reproductive age, married or in unions, using any contraceptive method in both countries over time, and the percentage of this group using selected methods. The growing reliance on female sterilisation is striking, used by over half of this population in Brazil by the mid-1990s and in Mexico by 2009. Also worth noting is the reversal of this trend in Brazil in the 1990s. While not entirely attributable to the passage of the Family Planning Law in 1996, this reversal is particularly noteworthy, given that the growing practice of sterilisation in the earlier period occurred in semi-clandestine ways, its cost not covered by the public health system or private insurance plans, generally performed in conjunction with cesarean sections or other procedures (Caetano, 2010; Potter, 1999) (Table 1).²

Table 1. Percentage of married or in-union women of reproductive age* using any contraceptive method; and those using selected methods as a percentage of all married or in-union women of reproductive age using contraceptives.

	Brazil			Mexico
	1986	1996	2006–7	1976–77	1987	1995	2009
Any method	66.2	76.7	80.3	30.3	52.7	66.5	72.5
Female sterilisation	40.5	52.3	36.2	8.9	35.3	41.1	50.1
IUD	1.5	1.4	2.4	18.8	19.4	22.0	–
Pill	38.1	27.0	30.8	35.6	18.4	12.6	–

Source: Calculated from, United Nations Population Division, http://www.un.org/en/development/desa/population/publications/dataset/contraception/wcu2015.shtml.

*The 1986 Brazil survey includes women ages 15–44; the others include women ages 15–49.

A final point might be made to situate this story in political context. While both governments officially abandoned pronatalist stances in the 1970s, with Mexico going further to institute national family planning policies, these changes grew out of an earlier history of mobilisation around the issue by nongovernmental actors. Population growth in Latin America, I should note, received growing attention from international organisations during the 1960s, due partly to a greater focus on the region by established actors and partly to new actors’ entry into the field. Most notably, USAID established a population office in 1965 and soon became the largest donor to family planning efforts in the region (Bertrand, Ward, & Santiso-Gálvez, 2015). The role of three national actors engaged in the debate is worth underscoring, all of which were heavily articulated with TKNs.

First, university-based demographic research centres became key sites for the production of demographic knowledge about national population dynamics, and indeed, global actors extensively promoted demographic research as a first step toward the adoption of national family planning programmes (Connelly, 2008). In 1957, the United Nations established the Latin American Demography Center (CELADE) in Chile. It was the second of seven UN regional and interregional demographic research and training centres created by 1982 to train demographers, produce and standardise statistical knowledge and offer governments technical assistance. In the early 1960s, CELADE launched its Program of Comparative Fertility Surveys in Latin America (PECFAL). Grounding the so-called KAP (Knowledge-Attitudes-Practices) surveys in the region, the programme coordinated pioneering research on reproductive practices, initially in seven metropolitan areas, including Mexico City and Rio de Janeiro, and subsequently in rural areas (Berquó & Baltar da Rocha, 2005; Zarate Campos & González Moya, 2013). In Mexico, the Center for Economic and Demographic Research (CEED) founded at the Colegio de México in 1964, was particularly influential. Its Masters Program in Demography, the first in Latin America, trained experts throughout the region, and its researchers produced studies that laid the groundwork for policy and consulted with government agencies working with population policy and statistics-keeping. On the eve of the government’s embrace of family planning, for instance, the Mexican interior minister called on then CEED director Gustavo Cabrera – the first director of the Masters Program and among the first Mexican demographers trained at CELADE – and demographer Susana Lerner to draft the proposal for the country’s Family Planning Law of 1974.³

Second, private-sector family planning organisations also entered the public sphere in the 1960s. While not the first or only such organisations, the most important were the Brazilian Civil Society for Family Welfare (BEMFAM) in Brazil and the Foundation for Population Studies (FEPAC) in Mexico (rebaptised the Mexican Family Planning Foundation, MEXFAM, in 1983). Both were founded in 1965 and became affiliates of the International Planned Parenthood Federation (IPPF) two years later. IPPF had had a limited Latin American presence in its Western Hemisphere Region, with only one affiliate in 1961 (Puerto Rico, alongside six others from Anglophone countries). As the first such event in the region, its VIII International Conference, held in 1967 in Santiago at the invitation of Chilean President Eduardo Frei, gave a ‘seal of legitimacy to family planning,’ and within five years, virtually all Latin American countries had affiliated organisations.⁴ In addition to building national networks of family planning clinics, BEMFAM and FEPAC also engaged in biomedical and social research and extensive education efforts, organising seminars targeting doctors and other professionals. They also spearheaded efforts to press national governments to adopt national family planning programmes, efforts that to some extent aligned these organisations with an authoritarian political status quo.

Finally, the Catholic Church also became a key player in global and national debates on population policy. Key encyclicals issued at the Second Vatican Council sanctioned the use of ‘natural’ birth control methods within a paradigm of ‘responsible parenthood’ (Humanae Vitae, 1967) and recognised a government role in addressing problems derived from ‘accelerated population growth’ (Popularum Progressio, 1968) While the Church undoubtedly influenced reproductive politics in Mexico as well, particularly sustaining restrictions on abortion, the Brazilian Church gained a more direct role shaping the course of women’s health policy. For example, it negotiated directly with the Health Ministry team that designed PAISM, resulting in its incorporation of ‘natural methods’ and the exclusion of others, like IUDs, which it considered abortifacient (Fonseca Sobrinho, 1993). While retaining some leverage in official circles, the Brazilian Church also occupied a unique institutional position that extended its influence across the ideological spectrum. A Latin American movement of liberation theology found among its strongest expressions in Brazil, where the Church became a leading voice in the democratic opposition to the military regime and a key agent fostering progressive social mobilisation via grassroots Christian base communities.

In Mexico, FEPAC, CONAPO and the CEED constituted an arena of knowledge production that was institutionally positioned to undergird early family planning policy, selectively grounding the work of TKNs in the national polity. To be clear, this is not to suggest that demography was inextricably bound to a global project of population control. There were counter-hegemonic voices within Latin American and Mexican demography, and indeed, within the CEED. As Felitti (2012) observes, the fact that many Latin American countries under pressure to institute family planning programmes in fact had relatively low population densities, though often concentrated in rapidly growing cities, heightened a critical awareness that the problems cited were really about distribution, not scarcity. A historical-structural school developed within Latin American demography – like social medicine influenced by dependency theory – which articulated this critique, finding expression, for instance, in the Population Commission of the Latin American Social Science Council (CLACSO). The institutional constellation of CONAPO-CEED-FEPAC, however, strengthened positions within the national polity that were generally supportive of the government’s policy directions and echoed global concerns over population growth. In Brazil, advocates mobilising around the banner of collective health – participants in an explicitly counterhegemonic TKN – became as significant, in part because of synergies with a resurgent feminist movement. I turn now to that story.

Transnational knowledge networks and counter-hegemonies

Again, a transnational movement advancing social medicine found different institutional expressions and levels of influence at the national level, conditioned by advocates’ embeddedness in national polities, with implications for debates on family planning and women’s health. In Mexico, its primary institutional expression is the Masters Program in Social Medicine, established in 1975 at the Autonomous University of Mexico (UAM)-Xochimilco, with the idea of creating a Latin American research and training centre that would attract scholars and students from throughout the region.⁵ The UAM-Xochimilco had itself been founded only the previous year. Its rector Ramón Villarreal had worked with Juan César García at PAHO, and PAHO worked closely with the Program’s architects ‘to develop [its] curriculum, look for staff and finance scholarships.’⁶ While the programme remains an important research centre nationally and regionally, its influence on national policy has been circumscribed by larger dynamics associated with the country’s democratic transition, particularly by the marginalisation of the partisan left, which coalesced around the Party of the Democratic Revolution (PRD) in the late 1980s. The PRD has yet to capture the presidency but maintains a stronghold in Mexico City, holding the executive there since 1997. Social medicine’s most direct policy influence, notably, occurred in the capital, with the appointment of Asa Cristina Laurell, one of the founders of the Masters Program and a leading figure in the regional movement, as health secretary (2000–2006) (Laurell, 2003; Pêgo & Almeida, 2004).

In Brazil, on the other hand, the larger and more politically influential movimento sanitario erupted in the 1970s, finding institutional expression in numerous graduate and undergraduate programmes around the country, professional associations and independent organisations (Nunes, 2016). Key among these was the Brazilian Center for Health Research (CEBES), founded in 1976, which published the journal Saúde em Debate. CEBES occupied a unique institutional position within a changing public sphere, as a social movement organisation that bridged the academy and other institutions. Reflecting many of its members’ participation in clandestine leftist organisations, particularly the Brazilian Communist Party (PCB), CEBES replicated the left’s model of party cells, creating ‘nuclei,’ or discussion groups, throughout the country. CEBES activists had ongoing discussions about its institutional role in the context of abertura, the gradual democratic opening announced by the military government in the late 1970s. By 1978, abertura had restored alternative spaces for critical debate in universities and health sector unions, precipitating a ‘crisis’ in CEBES’s second oldest and largest nucleus, in Rio de Janeiro, by drawing mobilisation elsewhere. Responding to the crisis, the CEBES National Assembly of Delegates rejected the functional segmentation of opposition across unions, parties and universities. Instead, it called for a ‘synergistic’ relationship and approved a programme defining its nuclei’s essential role as unifying struggles by articulating networks across popular movements, unions, women’s groups and other organisations.⁷ An editorial appearing in Saúde em Debate in 1980 explicitly linked this institutional position to knowledge production in Gramscian terms. Against the constraints of the individualising and proprietary intellectual work performed in universities and of the intellectual work of organising and applying existing knowledge that occurred in healthcare bureaucracies, bound by a political project, CEBES was in a unique position to move from ‘specialist’ to ‘leader’ by collaboratively developing ‘counter-policies … and new models of actions.’⁸ The synergies created by this institutional position would mark CEBES’s relationship with feminism.

Sanitaristas’ knowledge-production and medical practice reflected their embeddedness in larger movements opposing rightwing authoritarianism at both the national and regional levels. For example, Albertina Takiuti Duarte, a gynecologist and early activist with CEBES and the PCB, recalled organising a sort of ‘red cross group’ in the mid-1970s that provided medical attention to relatives of political prisoners and leftist exiles living clandestinely in the city. This experience, she recalled, fostered exchanges within clandestine networks that contributed to a pioneering study on women’s health: ‘We would invite a woman from Chile, for instance, to tell us about healthcare organisations in Chile – in Uruguay, in Argentina – about women’s movements. This created the basis for us to conduct the study.’ Obtaining letters of support from the United Nations Office in Brazil and the progressive São Paulo Archdiocese, activists coordinated a study in 49 maternity hospitals, presenting their results at the First Diagnostic of the Paulista Woman. That conference, held in City Hall in October 1975 to mark the UN International Women’s Year, in turn prompted the establishment of the Brazilian Women’s Development Center, among the first organisations of a resurgent feminist movement.⁹

The related epistemological and political stakes of sanitaristas’ work was suggested by a dispatch that Health Minister Paulo de Almeida Machado sent to President General Ernesto Geisel in 1977. The report regarded with suspicion a draft document presented at the Fourth Special Meeting of Health Ministers at PAHO, which recommended that health centres ‘raise community awareness to promote the institutional changes needed to improve income distribution and social justice.’ Noting ‘the same tone used by the groups of social medicine and community medicine in Brazil, with roots in Allende’s Chile,’ it celebrated the effective coordination by health officials from Argentina, Brazil, Chile, Uruguay and Paraguay at the meeting to achieve a ‘more discrete tone,’ transposing the right-wing military alliance Operation Condor to the field of public health. The dispatch also reported on a recent sanitarista conference in São Paulo, warning of the ‘infiltration of CEBES’ and the outsized role of departments of social, preventive or collective medicine in medical education. ‘Previously,’ it lamented, ‘Every professor methodically taught the appropriate preventive measures in analyzing each sickness and even, among the most skilled, each sick person.’ Now that these departments were attracting ‘students with a greater vocation for social problems,’ it recommended that the government maintain ‘an attitude of reserve’ toward these departments, ‘looking into their gradual emptying’ while promoting undergraduate public health courses ‘with a focused curriculum, [that left students] little time for fun in the area of “social” sciences’.’¹⁰

Over the course of democratisation, the movimento sanitario eventually established a hegemonic position in defining the direction of healthcare reform, in part facilitated by its position within the public sphere. In contrast to the political marginalisation of the partisan left in Mexico, the Brazilian Democratic Movement (MDB), as the only officially recognised opposition party under military rule, united a broad-based opposition movement that ranged from centrist liberals to sectors of the revolutionary left. Within this broad coalition, the sanitaristas were well-positioned to influence national healthcare debates, no less so because of the number of activists affiliated with the Brazilian Communist Party, which at the time operated clandestinely within the MDB. The political scientist Sonia Fleury, an important leader of the movement who participated in both CEBES and the PCB, refers to an oppositional strategy of occupying state healthcare bureaucracies that began in municipalities and states won by the opposition and proceeded to the national level when the healthcare system operated by the National Social Security and Healthcare Institute (INAMPS) fell into crisis in the 1980s: ‘The dictatorship lacked competent technical specialists who could rationalise the system, so they called this group on the left which had already gained prominence and whose ideas already appeared with the idea of rationalisation.’¹¹ In 1985, the movement leader Hésio Cordeiro was appointed to head INAMPS. The following year, sanitaristas dominated VIII National Healthcare Conference, where the proposal to create the country’s Unified Healthcare System (SUS) was hammered out. The inclusion of SUS, along with the right to healthcare, in the 1988 constitution marked the movement’s most important victory, though its subsequent implementation was sharply constrained by neoliberal austerity.

In addition to being better positioned to influence national health policy than their counterparts in Mexico, sanitaristas also demonstrated somewhat greater openness to the women’s health concerns being introduced into national public spheres by feminist movements, which experienced a contemporaneous resurgence in the 1970s. Unlike the case in Mexico, an important Foucauldian current emerged among sanitaristas relatively early in Brazil. In 1974, Foucault gave a series of lectures at the Institute of Social Medicine (IMS) at the State University of Rio de Janeiro. The Institute created the first Masters Program in social medicine in the country that same year, like the UAM-Xochimilco, with strong collaboration from PAHO. This Foucauldian current heightened critical attention to bodily discipline, sexuality and the family among sanitaristas.

In neither country was the relationship between advocates of social medicine and feminists free of tensions. To some extent, the former shared the left’s tendency to subordinate identity-based ‘specific struggles’ to the larger class-based ‘general struggle.’ In the case of social medicine, this translated into an emphasis on class-based inequities and universal healthcare over sector-specific demands and a tendency to dismiss feminist demands as secondary, if not outright conservative. Catalina Eibenschutz, one of the founders of the Masters Program at the UAM-Xochimilco, recalled that these topics had only entered the research agenda very recently and in a limited way:

There is very little on gender and sexuality in social medicine [in Mexico]. There is a space in psychology and another with questions of gender, but these have arisen primarily in the last 10 or 15 years … The first discussions did not admit anything besides class interests between the state and society; no mediations.¹²

Ana Maria Costa, an early activist with the Brazilian feminist movement and CEBES who worked in the Health Ministry where she became the principal architect of PAISM, recalled her position as one of the few dual militants participating in both movements and ‘a certain mocking assessment of feminism [among sanitaristas], as if feminism were a petit bourgeois struggle that brought individual, not collective, issues onto the stage.’ Population control and family planning, however, bridged the concerns of feminists and sanitaristas:

There was not much communication at first [between the movements]. There were a few instances. For instance, the movimento sanitario constructed a formal political plank on family planning … The argument for demographic control was very strong in the 1970s. The feminist movement was very inspired by the thinking of the Boston Feminist Collective, and also French feminists, for whom the question of autonomy over the body and autonomy of choice were central. The movimento sanitario critiqued that line of thought although not based on autonomy over the body but of autonomy of the population against demographic control … for national sovereignty.¹³

Because of its inscription in larger debates on economic development and geopolitics, very much bound with social medicine’s attention to the social determination of health in contexts of dependent development, population control thus became an important early bridge between both movements. In 1977, the CEBES nucleus in Rio de Janeiro and the feminist Brazilian Women’s Center organised a panel discussion decrying the government’s announced intention to incorporate family planning into its programme for ‘high-risk pregnancy,’ an initiative, again, that never got off the ground.¹⁴ At its National Assembly of Delegates in 1980, CEBES defined demographic policy (along with environmental and workplace health and national healthcare policy) as three key priorities in the upcoming years, calling on its nuclei to engage in research, denunciations and mobilisation around the issue.¹⁵ Several nuclei created family planning commissions. Feminists in the CEBES nucleus in São Paulo created a Women’s Health Group, which published a short-lived bulletin Mulher e Saúde. One issue included translations of several articles on women’s health by Giovanni Berlinguer, the Italian professor of social medicine, brother of then General Secretary of the Italian Communist Party Enrico Berlinguer and a frequent interlocutor of Latin American activists.

The synergy created between feminism and the movimento sanitario in Brazil played out in several ways in relation to women’s health policy. Most importantly, it reinforced a shared insistence on attention to women’s comprehensive healthcare, as opposed to vertical family planning programmes, and a critical attention to the structural conditioning of health and healthcare. With regard to the growing rates of female sterilisation, for instance, this extended to a problematization of structural conditions shaping what would come to be understood as ‘informed consent.’ In an article appearing in Saúde em Debate, Ana Maria Canesqui (1981), a professor of social medicine at the University of Campinas and member of the CEBES nucleus in that city, took aim at the distinction commonly drawn between demographic control and family planning by advocates of the latter. Canesqui argued that this ‘at best liberal’ distinction, presented family planning as an extension of a humanitarian welfare state that assumed the obligation to present contraceptive methods and information to couples as a matter of redistribution. Ultimately, Canesqui contended, this framing abstracted the state from its entanglements with economic and political interests, including those of pharmaceutical corporations; and the doctor-patient consultation, from the structural contexts that led to this individualised exchange. This larger structural focus was particularly relevant because, as the feminist women’s health activist Carmen Barroso (1984) observed at the time, a great number of tubal ligations performed in the country occurred ‘not as the result of direct coercion or manipulation’ but as a ‘free’ choice made by women as ‘conscious moral agents,’ though amid structural constraints that left very few alternatives (p. 172). Barroso explicitly framed her argument as an examination of problems that went beyond sterilisations without ‘informed consent,’ shedding light on the ‘social determinative factors’ that conditioned such consent, including women’s position in the home and labour market, patriarchal culture, the commoditization of health and demographic policies (p. 179). Notably, this shared early feminist and sanitarista critique of social forces that overdetermined women’s ‘free’ choice to get sterilised, which implied the need for intersectoral policies to foster greater social equity, would be reduced to measures designed to insure informed consent in the National Family Planning Law of 1996 by regulating the doctor-patient consultation.

The synergy between feminism and the movimento sanitario also had important policy and political repercussions. Dual militants active in both movements played a central role crafting and running the two most important early policy experiments in women’s comprehensive healthcare, the Women’s Health Program created in 1983 in São Paulo following the election of opposition Governor Franco Montoro, and PAISM at the national level. Sanitaristas also created institutional spaces that feminists would occupy. In addition to seats in various healthcare councils created under SUS as oversight bodies that incorporated civil society, the VIII National Healthcare Conference of 1986, where the architecture of SUS was hammered out, was followed by several thematic conferences, including the First National Conference on Women’s Rights and Health, which followed municipal and state conferences to elect delegates. Thematic groups at the conference produced recommendations. The Group on the Rights of Human Reproduction called on the state to assume responsibility for making contraceptives and information available to women; to ban foreign involvement in national population policy; and to ‘veto’ the participation of individuals and organisations engaging in ‘controlist practices’ as Brazilian representatives in international forums. Black feminist organisations became a leading voice condemning such practices, and the Black Women’s Identity Group called for the banning of sterilisation without expressed, informed consent, particularly in cases targeting racially and ethnically marginalised groups, and for punishment of such practices as genocide in other instances. Conference recommendations also reaffirmed the sanitarista project, calling for the institutionalisation of SUS and for comprehensive healthcare for women within it (Conferência Nacional de Saúde, 1987).

Politically, both movements also enunciated a forceful repudiation of the work of family planning organisations, particularly the most politically active, BEMFAM, which was seen as aligned with the global project of population control and the military government. For some years, BEMFAM had cultivated ties with political leaders. Between 1967 and 1988, it signed almost 2,000 contracts with state and municipal governments to provide family planning services (Fonseca Sobrinho, 1993). In the federal congress, BEMFAM promoted the creation of the Parliamentary Population and Development Studies Group, a cross-party caucus disproportionately composed of right-wing lawmakers, whose principal objective was to create a National Family Planning Program. The Group established a congressional inquiry commission in 1983 to look into ‘problems related to population growth in Brazil.’ The commission’s final report included a bill to create such a programme and a national population council along the lines of Mexico’s CONAPO. BEMFAM worked closely with the Armed Forces Chief of Staff and the congressional commission to produce the bill (BEMFAM, 1984). Reflecting striking contradictions within the state, it was in his testimony at these hearings that the Health Minister announced the launching of PAISM, which was intended to break not just with vertical family planning programmes but with the narrow focus on women’s reproductive capacity of traditional programmes of maternal-child health. Both feminists and sanitaristas repudiated the commission’s bill as ‘controlist,’ counterposing it to PAISM. These two opposing coalitions would clash around family planning until passage of the National Family Planning Law in 1996. Alongside these, a national Pro-Life movement took shape, articulated with a Church that was becoming more conservative as the country returned to formal democracy, in part due to Pope John Paul II’s concerted efforts to weaken liberation theology in the region.

The contentious debates that produced the 1996 law reflected the persistent centrality of ‘mass sterilization’ on the feminist agenda and the government’s failure to live up to its promise of comprehensive women’s healthcare. While PAISM facilitated the development of noteworthy pilot projects, particularly where local women’s organisations exercised oversight, it was never effectively implemented across the healthcare system, limited in part by the institutional shortfalls and underfunding that characterised the larger implementation of SUS (Almeida, 2005; Costa, 1992). Against this backdrop, the question of sterilisation persisted, with significant mobilisation around the issue by black feminist organisations in the late 1980s. This activism led to the creation of parliamentary inquiry commissions in three state assemblies, the City Council of Salvador, Bahia, and eventually one at the federal level, directed by Benedita da Silva, a federal deputy of the Workers Party and the first black woman elected to the post. That commission’s report, written by the sanitarista feminist Ana Maria Costa, produced a proposal that would eventually become the Family Planning Law approved in 1996. That law and subsequent implementing regulations instituted several requirements designed to ensure informed consent for sterilisation procedures, including a minimum age of 25; at least two living children; a 60-day waiting period after the initial request, during which information on the implications of the procedure and reversible alternatives must be provided; a 42-day waiting period after childbirth except in medically prescribed circumstances; and consent of the partner or spouse. While it is beyond the scope of this article to fully examine the politics surrounding its passage, Caetano (2014) has found that its subsequent implementation has been, once again, spotty. According to a 2006 survey, for instance, despite the 42-day waiting period after childbirth, 58.7% of the procedures reported were performed during cesarean sections and another 9.0% after ‘normal childbirth’ (PNDS, 2006). Despite limitations in the law’s material effects, its political effects were quite striking, effectively closing a decades-long debate and removing the issue from the feminist agenda.

The heated controversies around sterilisation that marked the history of family planning policy in Brazil are particularly noteworthy in comparison with Mexico. Undoubtedly Mexican feminists have periodically raised questions and presented complaints to human rights bodies involving abuses related to sterilisation in the country, recently framed around ‘obstetric violence.’ Perhaps most notably, the Tribunal to Defend Reproductive Rights organised by the Women’s Health Network of the Federal District in 1996, a mock trial that heard 27 cases of violations of reproductive rights, included the case of a woman who had been sterilised without her consent in the public health system. Overall, however, the question never assumed the centrality it did in Brazil for feminists or on the political agenda more broadly (Menéndez, 2009). The difference is particularly striking when one considers that the Mexican government in fact implemented a much more neo-Malthusian project through the public health system, while the charges that feminists and sanitaristas levelled against the Brazilian government largely concerned sins of omission, particularly its lack of oversight over private-sector family planning organisations articulated with transnational networks.

Conclusions

Full attention to all the reasons for these differences is beyond the scope of this piece. What this article has attempted to do, rather, is to use population policy as a window to explore how institutional contexts at the national level selectively condition the position and influence of TKNs mobilising around public policy, themselves understood in the plural.

Specifically, above I highlighted how the articulation of a counterhegemonic TKN mobilising around social medicine found different levels of influence and priorities in Mexico and Brazil – particularly around women’s health – in ways that responded to national-level institutional dynamics associated with gradual processes of formal democratisation. In Brazil, the institutional position of feminists and sanitaristas within a broad opposition movement to military rule reinforced both political synergies between the movements and the latter’s influence on national healthcare policy and hence capacity to leverage knowledge. Such possibilities were largely precluded in Mexico, where the influence of social medicine has been constrained by the fate of the left and national healthcare policy has taken a radically different course (Pêgo & Almeida, 2004). Here, one might counterpose the project of social medicine with that of another TKN important to population policy. In Mexico, demographers more closely aligned with a global project of population control were able to leverage other forms of knowledge and ultimately shape the course of family planning policy, strengthened by institutional bases at CONAPO, the Federation for Population Studies and the Center for Economic and Demographic Studies at the Colegio de México. National actors, of course, are not mere mouthpieces for transnational networks (which themselves are internally diverse). This article, nonetheless, has highlighted how institutionalised fields of knowledge production at the national level constrain and channel opportunities for them to adapt, produce and ultimately mobilise applied knowledge.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. I would like to thank Francesca Degiuli, Hosu Kim, Jean Halley, Jaime Amparo Alves, as well as the reviewers of this article and the editors of Global Public Health for their very helpful feedback on earlier drafts of this piece.

2. United Nations Development Program, ‘Other Funds and Programs: United Nations Funds for Population Activities - Proposed Projects and Programmes,’ March 29, 1983, DP/FPA/PROJECTS/REC/8, http://web.undp.org/execbrd/archives/sessions/gc/30th-1983/DP-FPA-PROJECTS-REC-8.pdf, accessed January 25, 2018.

3. Dr. Susana Lerner, in discussion with author, January 23, 2017; Welti-Chanes, 2011.

4. IPPF/WHR, Forty Years of Saving Lives with Family Planning: An Anniversary Publication, New York: IPPF/WHR, Inc., pp. 11–12. Sophia Smith Collection, Smith College, Una Elizabeth Jacobs Papers, Box 3.

5. ‘Editorial’ Salud Problema, Oct. 1978, 3, p. 3.

6. Catalinas Eibenschutz, Professor of Social Medicine and one of the founders of the Masters Program at the UAM-Xochimilco in discussion with author, Mexico City, July 23, 2012.

7. CEBES, Programa de Trabalho do CEBES para 1978/79, Saúde em Debate, no. 6, Jan–Mar 1978, pp. 5–6; Editorial, Saúde em Debate, no. 7–8, Apr–Jun 1978, pp. 3–4.

8. ‘Editorial,’ Saúde em Debate, no. 9, Jan–Mar 1980, pp. 1–2.

9. Albertina Takiuti Duarte, in discussion with author, São Paulo, July 23, 2017.

10. Paulo de Almeida Machado, ‘Despacho com o excelentíssimo senhor Presidente da República,’ Nov. 3, 1977, Centro de Pesquisa e Documentação de História Contemporânea do Brasil, Fundação Getúlio Vargas, Ernesto Geisel Papers, EG pr 1974.04.25, Rio de Janeiro.

11. Sonia Fleury, in discussion with author, Rio de Janeiro, February 24, 2012.

12. Catalina Eibenschutz, in discussion with author, Mexico City, July 23, 2012.

13. Ana Maria Costa, in discussion with author, Brasilia, June 29, 2013.

14. ‘Controle da natalidade em discussão’ Saúde em Debate, no. 4 (Jul–Sept. 1977), pp. 84–85.

15. ‘Editorial,’ Saúde em Debate, no. 10, Apr–Jun 1980, pp. 3–4.