Entre o viver e o morrer: as concepções sobre os determinantes sociais da saúde na política nacional do câncer e de cuidados paliativos

Abstract

The dissertation analyzes the incorporation of the Social Determinants of Health (SDH) into the National Cancer Care Policy and the National Palliative Care Policy in Brazil, based on the theoretical framework of historical and dialectical materialism. Drawing on the perspective of the social determination of health, the study understands the health-disease process as a historical and contradictory phenomenon embedded in the relations of production and social reproduction under capitalism, rather than as a natural event or the result of individual choices. The research adopts a qualitative approach, developed through a bibliographic review in the fields of Social Work, Collective Health, and Latin American Epidemiology, as well as documentary analysis of normative frameworks and official data sources. The study first distinguishes between the **social determination of health** and the **social determinants of health**. While the former understands health as an expression of the social relations of production and the structural contradictions of capitalism, the latter tends to privilege factors such as income, education, and territory, thereby fragmenting the analysis of social reality. In mediating the population's living and health conditions, the State normatively recognizes the right to health while simultaneously implementing targeting and privatization measures that deepen social health inequalities. In this context, the State counter-reform has materialized through the privatization of public policy management, introducing market-oriented logic into the public health system. This model contradicts the principles of the Brazilian Health Reform, such as universal access, the comprehensive concept of health, and effective public financing, reorienting the Unified Health System (SUS) toward market interests. SDH explanatory models shift the focus of analysis from social structures to isolated factors and variables, without capturing the historical determinations that produce health inequalities. Accordingly, the dissertation also problematizes the use of the categories of inequities and vulnerabilities, which emphasize identifying groups at greater risk of illness and barriers to access while failing to address the historical and structural determinations that produce these conditions. Regarding cancer, disparities are evident in access to early diagnosis, treatment, and end-of-life care, all of which are influenced by class, race, and territory. The incorporation of the SDH into the National Cancer Care Policy and the National Palliative Care Policy, both situated within the context of State counter-reforms, reveals the unequal distribution of health conditions expressed through the structural relations that permeate Brazilian society. In the state of Maranhão, social health inequalities reflect the particularities of Brazil's dependent capitalism by combining poverty, structural racism, precarious living conditions, and the regional concentration of health services. The study highlights that Maranhão has only five specialized oncology services and two palliative care services within the Unified Health System (SUS), most of which are located in the

state capital, São Luís. The dissertation concludes that inequalities in the health- disease process and end-of-life conditions are not residual expressions of health

policies but rather structural outcomes of a model of social organization that, under neoliberal hegemony, subordinates social rights to the accumulation of capital.