This study is a theoretical and reflective essay. Its purpose is to present three concepts that, in Habermasian terms, can be described as reconstructive:⁽¹⁾ that is, theoretical constructs which, starting from the critique of concretely lived experiences, point toward innovative horizons based on existentially and politically emancipatory ideals for the reconstruction of practices – in this case, health practices. By adopting a hermeneutic-philosophical perspective⁽²⁾ as a foundation and critical reconstruction as a horizon, this reflection seeks to contextualize the setting from which the concepts presented and discussed here arise, as well as the practical interests that motivated both their development and the way they are addressed by the author of this essay, who participated in the movement described.

Therefore, this work represents a comprehensive interpretative movement, an argumentative circle that moves from a totality of meaning serving as a reference for examining the concepts to be discussed – in this case, the ethical, political, and technical context of Brazilian Health Reform – to the parts that one wishes to describe and interpret–namely, the reconstructive concepts – which, in turn, enrich the understanding of that reference totality, configuring the so-called hermeneutic arc.⁽³⁾

The current state of healthcare in Brazil, which has partially realized the ideals of the reform movement discussed here but still faces significant challenges, such as the underfunding of the healthcare system, the precariousness of work in health services, and the persistence of structural obstacles to reducing the vulnerability of various population groups, makes the ideals and practical challenges addressed in this essay particularly relevant. It is also believed that the conceptual reconstructions proposed within the Brazilian context may be inspiring and pertinent to other national realities and to the critical global health movement.⁽⁴⁾

With this aim, the essay begins by briefly describing the context from which this reflection originated, namely the scenario of Brazilian healthcare reforms and the process of technical and political reconstruction of healthcare policies that followed. It then outlines three conceptual constructs that emerged within this scenario for the proposed reconstruction of Brazilian public healthcare: the concepts of comprehensiveness, vulnerability, and care. In discussing these constructs the essay highlights how sociocultural identities may serve as general guidelines for healthcare insofar as they enrich the diagnosis of health situations beyond traditional biomedical parameters and favor preventive actions, treatments, and rehabilitation that are more appropriate to the needs and interests of the populations concerned. Underlying this line of argument is the restoration of a practical, dialogue-based, and interdisciplinary understanding of rationality in healthcare, proposed as an "antidote" to the conservative and "desubjectivizing" effects that may arise when healthcare becomes dominated by the instrumental excesses of biomedical scientism.

The public health landscape was profoundly affected worldwide in the early 1980s by the AIDS pandemic. Globally, the re-emergence of an infectious disease of such serious magnitude and consequences had a significant impact on healthcare institutions and practices. Traditional epidemiological tools and preventive strategies were challenged and criticized for being insufficient to address the complex determinants of the epidemic. Moreover, the uncritical reproduction of stereotypes and prejudice often aggravated the inability to produce effective responses to control AIDS.⁽¹¹⁾

In Brazil, within the scenario described above, studies based strictly on probabilistic risk analysis and preventive strategies focused primarily on individual behavior were soon perceived as at least inadequate, if not potentially harmful, to the reconstructive processes underway within Brazilian healthcare reforms. The increasing politicization of healthcare epidemiology issues and the growing recognition of relationships between illness and social determinants, such as gender, race/ethnicity, age, social class, beliefs, and religion, appeared to be reduced to simplistic interpretations, often summarized by the formula "misinformation=infection."

Earlier experiences, such as the PAISM and mental health programs focused on deinstitutionalization and psychosocial reintegration of individuals with mental illness, offered alternative models. In addition, the critical tradition of Brazilian epidemiology, largely resistant to reducing epidemiology to a purely auxiliary technical instrument for biomedical research, contributed to shaping a differentiated response within Brazilian public health in relation to the AIDS epidemic. At the same time, the expansion of popular participation during the years of the country's redemocratization enabled individuals directly or indirectly affected by the epidemic to organize collectively and advocate for their rights as human beings and citizens.

This context helps explain why the perspectives of vulnerability and human rights became central paradigms for analyzing the determinants of the AIDS epidemic and for guiding responses aimed at preventing new cases and providing care for affected individuals within the Brazilian context. It also helps explain why this conceptual framework advanced significantly in Brazil, both in terms of its incorporation into public policies and its implementation within healthcare services.⁽¹²⁾

In the context of the AIDS epidemic, the vulnerability framework emphasized the need to incorporate categories and methods derived from the human sciences, particularly anthropology, into healthcare research and intervention. Through this perspective, the dynamics of the distribution and progression of infection and illness were shown to reflect underlying social inequalities. These inequalities were linked to historical processes and entrenched relationships of domination and oppression within Brazilian society.

Homosexual identity was among the first and most visible contexts in which the relationship between oppression and vulnerability to the AIDS epidemic became evident. This group was among the earliest to be affected in epidemic proportions in Brazil, and stigma and discrimination associated with socially perceived "deviant practices" contributed to patterns of neglect in public policies and healthcare services addressing the seriousness of the epidemic.

More than four decades after the first case of AIDS was detected in Brazil, large-scale media campaigns directed consistently toward this population group remain relatively limited. Within healthcare services, sexual orientation often remains an invisible identity dimension that does not effectively guide the organization of care capable of responding to issues such as sexual rights. Individuals within this group frequently experience physical and psychological violence, and in many situations invisibility becomes a strategy for survival. Such conditions produce a cycle that hinders public recognition and the promotion and protection of rights. Consequently, despite the advances achieved by the Brazilian AIDS control program, homosexual populations continued to be disproportionately affected in the 1990's, with HIV transmission rates among younger individuals remaining particularly concerning. An example illustrating these challenges is the veto by the National Congress, driven by evangelical representatives, of initiatives aimed at distributing educational materials designed to combat homophobia in Brazilian schools during the administration of President Dilma Rousseff. These debates were later reinforced during the presidency of Jair Bolsonaro, under pressure from conservative political actors.

Studies on vulnerability have also contributed to understanding the limited effectiveness of AIDS prevention and treatment policies among women. When epidemiological indicators were analyzed according to sex distribution, the impact of universal access to antiretroviral therapy and preventive strategies was not uniform. While the growth rate of the epidemic began to decline among men at the end of the 1990s and early 2000s, this decline was less pronounced among women. Similarly, the reduction in AIDS-related mortality during this period was significantly smaller among women. Gender-focused research has highlighted several contributing factors, including lower perception of risk, delayed access to diagnosis and treatment, prioritization of care for partners and children over personal health needs, cultural and relational barriers to negotiating safe sexual practices, including situations involving physical violence, and the limited integration of sexual and reproductive rights within primary healthcare services.

Similar patterns of vulnerability have also been observed in relation to race/ethnicity. Research indicates that Black populations in Brazil, particularly Black women, experience heightened exposure to the epidemic and encounter greater barriers to protection and healthcare access. More broadly, Black communities remain vulnerable to numerous health challenges associated with the long-term social consequences of slavery and the historical absence of comprehensive policies promoting social inclusion and equity.⁽¹³⁾

Adolescents and young adults living with AIDS also face significant challenges. This generation, sometimes described as one that "should not have survived"⁽¹⁴⁾ but whose lives were extended through antiretroviral treatment, now confronts new forms of social inclusion and life-course challenges. Many continue to live within social conditions shaped by the same factors that contributed to their initial vulnerability, compounded by the persistent stigma associated with the disease.

The potential of the human rights framework as a reference point for identifying social differences that translate into inequality and oppression is, therefore, evident. At the same time, it offers guidance for developing policy strategies aimed at addressing and overcoming such inequalities.⁽¹⁵⁾ A human rights perspective also seeks to promote equality when differences lead to discriminatory practices while protecting diversity when demands for uniformity suppress individual or collective identities.⁽¹⁶⁾

Interest in dialogue between healthcare practices and social markers of differences is not limited to diagnosing situations of vulnerability or defining public health policies and actions.⁽¹⁷⁾ As already indicated, implementing the principle of comprehensiveness and incorporating vulnerability and human rights into concrete actions depends on the reconstruction of healthcare processes.⁽¹⁸⁾

Transformation perspectives on healthcare needs by considering different socially shaped identities and relationships generates tensions with traditional ways of organizing healthcare, which are predominantly based on biomedical interpretations of health-disease processes.⁽¹⁹⁾ As discussed earlier, these tensions require space for integrating the various purposes of healthcare work. This integration involves linking different forms of knowledge, agents, and service sectors, and, very importantly, developing new forms of interaction between healthcare providers and recipients of care. It also requires renewed understandings of clinical practice. The reconstructive proposal for the technical core of healthcare discussed here is referred to as "Care" with a capital C, in order to distinguish it from other established uses of the term in everyday language.

Care is proposed as a regulatory idea rather than a fixed technological model of care technology. It may be summarized as the search for healthcare actions constructed through dialogical interactions, with an active interest in the practical meaning⁽²⁰⁾ of individuals' experiences of health and illness. Such interactions aim to generate a shared understanding of objectives and strategies for healthcare.⁽²¹⁾ This change in perspective is illustrated in the following diagram (Figure 1).

Several important aspects are highlighted in this diagram. First, it emphasizes that, despite the structural differences and asymmetries that may exist between participants in healthcare relationships, the care proposal seeks to recognize that beyond the positions of professionals and service users, both are subjects who interact through and by means of technical practices. This recognition carries several implications that should not be overlooked. Recipients of healthcare actions are not merely individuals presenting morphological or functional abnormalities who seek treatment or prevention. Rather, they are people with histories, values, experiences, and social relationships that shape their identities. These identities influence not only the specific characteristics of their healthcare needs but also the ways in which they request, interpret, and accept the healthcare actions proposed to them.⁽²²⁾ These dimensions confer practical meaning to healthcare needs and responses and form the central core of care. As subjects, individuals do not passively accept being reduced to objects of knowledge or intervention, even if healthcare professionals sometimes assume such reduction implicitly.

Healthcare professionals themselves are also subjects shaped by sociocultural experiences, values, and personal histories. These elements influence their professional practices and shape the ways in which they interact with both technoscientific knowledge and with the individuals seeking care.

Following this reasoning, and drawing on the reflections of Ricoeur⁽²³⁾ personal identities shaped by sociocultural experiences are not expressed as the continuation of a single stable core of the self (sameness), but rather as an ongoing construction of identity (ipseity). From this perspective, attention must also be given to the relational character of identities as they emerge in encounters with others within care practices. Physicians, nurses, psychologists, and other professionals are not defined solely by stable professional identities; rather, their identities are continually reconfigured through interaction with the individuals who seek care. In this sense, it is the dynamic nature of intersubjective encounters, rather than pre-established professional or personal identities, although these remain influential, that shapes the character of care within healthcare actions.

Within these intersubjective contexts, which are also shaped by the affective dimensions present in any interpersonal encounter, knowledge circulates and organizes interactions by establishing normative and objective standards that guide decisions regarding what should be done and how it should be done. In conventional healthcare practice, biomedical technosciences generally maintain a hegemonic role in defining the objects of intervention and the purposes and means of action. In contrast, the concept of Care proposed here seeks to promote complementarity between different forms of knowledge.

Such knowledge is frequently introduced into healthcare encounters by professionals, but not exclusively by them. Service users also possess substantial forms of knowledge about their own experiences, and access to information continues to expand through digital and electronic media. In this context, technoscientific knowledge must diversify and become open to interdisciplinary dialogue in practice, particularly with the human sciences. As discussed earlier, biomedical knowledge must be situated within the concrete realities of individuals and communities.

However, Care also requires forms of knowledge that are not strictly technical. Practical knowledge is necessary so that decisions made are not only technically effective but also wise and ethically grounded in their purposes and means. Knowledge derived from everyday life, experiences, and cultural traditions, often treated as secondary or even as irrelevant, should instead become an integral component of care practices. This knowledge provides access to what may be described as the existential meaning attributed to healthcare needs and to the ways in which individuals seek to address them. Such meanings connect healthcare actions with people's aspirations and possibilities and wills as human beings.

In summary, Care can be understood as a combined construction of biomedical and humanistic knowledge, integrating technoscientific and practical forms of understanding. It unfolds through a shared search for responses to healthcare needs rooted in people's everyday lives and informed by the practical meanings associated with their "projects of happiness" (Figure 2).

Within this framework, the two poles between which healthcare practice operates, technical efficacy and practical success, become productively interconnected when patients' ethical values, moral commitments, and concrete life interests (their "projects of happiness") are considered as normative horizons guiding healthcare decisions. These horizons emerge from the constructive integration of diverse forms of scientific and experiential knowledge.

The guiding role of social markers of differences within care becomes sufficiently clear within the scope and limitations of this study, which does not aim to provide a comprehensive overview of the topic. In both the diagnosis of vulnerabilities and the development of proposals for prevention, treatment, and rehabilitation, whether at the macro level of policy formulation and programmatic actions or at the interpersonal level of clinical practice, these markers shape identities in ways that not only indicate the concrete living conditions of specific population groups but also reveal the normative patterns underlying prevailing healthcare practices, thereby enabling critical reflection on their validity.

When social markers are incorporated into healthcare practices, they can function as analytical tools that help synthesize possibilities for technical efficacy and the requirements for practical success within diverse care contexts. The set of reference points mobilized in this process, which relate to relatively generalizable forms of social organization and action, together with their physical, mental, cultural, and institutional dimensions, supports the integration of healthcare needs and demands as dynamic and provisional totalities of meaning. In this way, reflection on healthcare knowledge and practices also requires continuous consideration of their purposes and normative orientations.

However, this important function may be undermined if the approximate, provisional, and contextual nature of these broad categories, such as gender, age, or race, is not taken into account. When such categories are treated as absolute or as direct expressions of a supposed "substance" of social life, the pursuit of Care may become as problematic as the rigid application of absolutized categories derived from biomedical technosciences.

For this reason, and consistent with the broader concern regarding the reconstruction of healthcare practices guided by the philosophical horizons of comprehensiveness, vulnerability, and Care, it remains essential to pose critical questions within different practical contexts: What does it mean, in ethical and political terms, to adopt perspectives based on gender, race/ethnicity, or age when reflecting on or acting within healthcare? How can the differentiation produced by these perspectives be incorporated into concrete healthcare processes? And what impacts do these processes generate for health, for individuals, and for social groups?