A New Look at Worker Health: Reflections for the construction of an intervention proposal

— The present study aims to seek preventive measures that minimize the impacts on workers' health. The theoretical dialogues are structured from the concepts that make up the field called Occupational Health. Under this approach, it has an interdisciplinary character and is epistemologically based on a social constructivist conception. Theoretical reflections on the subject go beyond the foundations that influence and shape the theoretical plan and advance towards the construction of an intervention proposal for the work relationships that cause illness. As a result, it can be concluded that workers, exposed to occupational hazards in their work environment, must constitute a concern for Brazilian public health, and must be a constant object of public policies and effective measures that ensure the fundamental right to health of the worker.


INTRODUCTION
Worker's Health in Brazil requires a new look at this field of knowledge, whose theoretical approach should dialogue with several other areas in order to achieve its main purpose, which is to analyze and intervene in work relationships that cause diseases and injuries to workers' health.
In Brazil, development policies have traditionally been restricted to economic aspects and have been traced in a parallel or poorly articulated way with social policies, with the latter bearing the burden of possible damage to the health of the population, workers in particular and the environment.
From this point of view, the integrated approach to the interrelationships between issues of worker safety and health, the environment and the development model adopted in the country, translated by the productionconsumption profile, currently represents a major challenge for the Brazilian State.
It is true that the scarcity and inconsistency of information on the real health situation of workers make it difficult to define priorities for public policies, the planning and implementation of workers' health actions, in addition to depriving society of important instruments for improving the living and working conditions.
In this context, Occupational Health is an area in permanent construction, referenced by the concepts of promotion, surveillance and participation in health, which aim at the recovery and rehabilitation of the health of workers subjected to risks and injuries arising from the environment and working conditions. (MARTINS et al, 2017).
Thus, the present study was motivated by the need to deepen this debate in the academic and scientific sphere, aiming at the implementation of prevention measures that minimize the impacts on workers' health.

II. WORKER'S HEALTH
The relationship between work, health and illness was not always a focus of attention. During antiquity, slave labor was interpreted as punishment or stigma, synonymous with tripalium or instrument of torture. With the advent of the Industrial Revolution, the relationship with work was modified. The "free" worker starts to sell his work force, becoming hostage to the capitalist production system, being subjected to strenuous working hours, human agglomeration and unhealthy environments conducive to the proliferation of infectious diseases and the dangerousness of the machines that were responsible for mutilations and deaths (MINAYO-GOMEZ; THEDIM-COSTA, 1997).
In this context, the field that came to be called Workers' Health was constituted from two different conceptions of health and work: Occupational Medicine and Occupational Health.
Occupational Medicine, as a medical specialty, emerged in the 19th century in England with the Factory Act, being the first relevant legislation in the field of worker protection. Thus, the presence of a doctor inside the factories represented both an investigation of the causes that led to theillness, as a way of recovering workers' health, fundamental for the emerging production line and industrialization. Centered on the figure of the doctor, within the scope of work, it reflects a propensity to isolate specific risks and act on their consequences, medicalizing their symptoms or associating them with a legally recognized disease. Likewise, the diagnosis of diseases in the selection phase works as a way of preventing the hiring of individuals whose health is compromised (MINAYO-GOMEZ; THEDIM-COSTA, 1997).
In the teachings of Mendes and Dias (1991, p. 341): "the consumption of the workforce, resulting from the submission of workers to an accelerated and inhuman process of production, demanded an intervention, under penalty of making the survival and reproduction of the process itself".
According to the authors, the concern with promoting medical services to workers also began to be reflected in the international scenario with the creation, in 1919, of the International Labor Organization (ILO), which started to propagate the proposal of Occupational Medicine, through the Recommendations 97 and 112 which deal, respectively, with the Protection of Workers' Health and Occupational Medicine Services.
From the point of view of Lacaz (2007), occupational medicine services play an important role in the study of the causes of absence from work, in the recruitment of personnel and in the analysis of occupational diseases and accidents, aiming at a healthier workforce. , the control of absenteeism and the rapid return to production.
The gigantic industrial effort undertaken during and after the Second World War evidenced the relative impotence of the field of occupational medicine in the intervention of health problems caused in that period, resulting in significant changes in the productive process from the technological evolution and the emergence of new diseases. to workers' health (MENDES; DIAS, 1991).
Therefore, Occupational Health emerges as a more comprehensive proposal than Occupational Medicine: The rational, "scientific" and apparently unquestionable answer translates into the expansion of medical practice aimed at the worker, through intervention in the environment, with the instruments offered by other disciplines and other professions. "Occupational Health" appears, above all, within large companies, with the trait of multi and interdisciplinarity, with the organization of progressively multiprofessional teams and the emphasis on "industrial" hygiene, reflecting the historical origin of medical services and the prominent place of industry in "industrialized" countries (MENDES; DIAS, 1991, p. 343).
Despite this significant expansion to the field of Occupational Health, in practical terms, the same limitations related to the field of Occupational Medicine occur, since protection measures end up being restricted to specific interventions on the most evident risks. The use of individual protection equipment is emphasized, to the detriment of other collective protection instruments. Safety standards are established as a form of symbolic prevention, attributing the burden of accidents and illnesses to the workers themselves, resulting in a double penalty (MACHADO; MINAYO-GOMES, 1995).
Indeed, the discussion on Workers' Health in Brazil emerges from Collective Health, which seeks to know and intervene in work and health-disease relationships: Power relations give Occupational Health a greater ability to control capital over work, contributing to a scenario of worker alienation and to the construction of the counter-hegemonic field of Workers' Health (LACAZ, 2007).
In a context of critical reflection, the concepts and practices of the models in force until then, related to Occupational Medicine and Occupational Health, are overcome, generating a new way of dealing with the workhealth relationship in work environments and introducing care practices to workers' health (MINAYO-GOMEZ et al, 2018).
From a theoretical-conceptual point of view, the following position is adopted in this study: Workers' health is configured as a field of interdisciplinary strategic practices and knowledge -technical, social, political, human -multiprofessional and interinstitutional, aimed at analyzing and intervening in work relationships that cause diseases and injuries. Its reference frameworks are those of Collective Health, that is, promotion, prevention and surveillance (MINAYO-GOMEZ et al, 2018, p. 1964.
Therefore, Workers' Health arises from the need for the State to intervene more effectively in the relations of the production process, in order to promote more dignified working conditions for workers.
According to Draibe (2012), studies focused on economic development have opened a new course of investigation, where social policy is thought of in the broader context of the relationship between the State, economic development and social protection systems. The institutions of the social protection system in latedeveloping countries, together with wage labor, are instruments of compensation through a social security system, where health policies are presented as one of the main models of social policy, as this is the case of workers' health in Brazil, which will be discussed below.

III. WORKER HEALTH IN BRAZIL
In Brazil, public health emerged as a social issue at the beginning of the 20th century, together with capitalism, in the midst of the coffee export economy, reflecting the advancement of the division of labor, the emergence of wage labor and the acceleration of urbanization and industrial development. Collective Health represents a bet on new assumptions, methods and social practices, which since its origin has three disciplinary areas of training: social sciences (more recently, human and social sciences), epidemiology and administration and planning (more recently, called policy and planning), which consequently must dialogue with each other to build a health system that is intended to be universal, equitable, comprehensive and public (MARSIGLIA, 2013).
In this light, it is necessary to consider that public policies, especially health policy, is a state policy and not a government policy, and as such, it must assume the defense of the constitutional principle of health as a right of all and State duty. Guided by the assumptions of collective health, workers' health arises from the need to intervene more effectively in the relations of the production process, adopting the basic principles of the SUS: universality, integrality, equity and social participation.
It is an area under permanent construction, referenced by the concepts of promotion, surveillance and participation in health, which aim at the recovery and rehabilitation of the health of workers subjected to risks and injuries arising from the environment and working conditions (MARTINS et al. , 2017).
The historical process of building a health policy expresses, through public agendas, the different political, economic and social moments that involve the relations between the State, society and the market (ANDRADE et al, 2012).
As noted, worker protection in Brazil occurs late, when compared to developed countries. It was only in 2004 that the movement to build a public policy aimed at workers' health gained strength, an intersectoral movement, composed of Working Groups with representatives appointed by the Ministries of Planning, Health, Social Security, Labor and Finance, which culminates in the National Policy on Safety and Health at Work (PNSST), which is now implemented by the Ministries of Labor and Employment, Health and Social Security (ANDRADE et al., 2012).

IV. NATIONAL OCCUPATIONAL HEALTH AND SAFETY POLICY (PNSST)
The publication of the National Policy on Safety and Health at Work (PNSST), through Presidential Decree No. 7,602, of November 7, 2011, represents a historic milestone in work-health and disease relations in Brazil. It is the first official document that deals with the responsibilities and actions that must be developed by the government for the protection and recovery of workers' health and presents the following objectives: the promotion of health and the improvement of the worker's quality of life and the prevention of accidents and damage to health arising from, related to work or that occur in the course of it, through the elimination or reduction of risks in the work environments (BRAZIL, 2011, p. 9).
In its initial proposal, the PNSST defines guidelines, institutional responsibilities and mechanisms for financing, management, monitoring and social control, within the scope of workers' health. In this way, Occupational Health is placed as a broad and collective responsibility of the State, whatever its form of insertion in the labor market, whether formal or informal, private or public ( The guidelines listed express a set of prioritized common objectives and explain the respective fundamental strategies for their operationalization, and imply the triggering of actions that, embodied in a work plan, will be instruments for implementing the Policy. In this context, the guidance for the State to fulfill its role as employer, ensuring protection measures in the field of Workers' Health, should be highlighted: [...] in guaranteeing basic citizenship rights, it is necessary that the formulation and implementation of government policies and actions be guided by transversal and intersectoral approaches. From this perspective, worker safety and health actions require a multiprofessional, interdisciplinary and intersectoral action capable of contemplating the complexity of productionconsumption-environment and health relations (BRASIL, 2004, p. 3).
The PNSST stands out for being a universal and inclusive policy, as it includes in its role of protection "all men or women who carry out activities to support themselves and/or their dependents, whatever their form of insertion in the market of work, in the formal or informal sector of the economy" (BRASIL, 2004, p. 4).
In this sense, the National Plan for Safety and Health at Work published in April 2012, aiming to facilitate the implementation of this Policy, details its operational aspects, listing as its first objective the "inclusion of all Brazilian workers in the National System of Promotion and Protection of Safety and Health at Work -OSH". To this end, among its strategies, it included the "preparation and approval of OSH legal provisions for Workers in the three spheres of government" (BRASIL, 2012).
On the other hand, the constitutional text defines the powers of the Union, States and Municipalities. The Union organizes, maintains and carries out labor inspection exclusively (article 21, XXIV) and legislates, privately, on labor law (article 22, I). The Union, together with the States, the Federal District and Municipalities, take care of public health and assistance, the protection and guarantee of people with disabilities (art. 23, II). The Union, the States and the Federal District legislate concurrently on social security, health protection and defense (art. 24, XII).
It should be noted that the Union's exclusive competence to legislate on Labor Law does not overlap, nor does it conflict, with the competence of States and Municipalities to issue, in a supplementary way, norms for the protection and defense of health, in particular of the worker, as they are located in different, autonomous fields, although connected by the legal interest that is intended to be protected.
Despite the vast existence of protective norms aimed at workers' health in Brazil, it is noted that many categories of workers still live in conditions similar to slavery, and their health-work relationship is not prioritized by state action.
It is in this sense that the effort to define a government policy is inserted, which articulates the competences and norms in the scope of Work, Social Security and Health, to which, more recently, the actions of the Ministry of the Environment have been added.
Indeed, the PNSST aims to promote the improvement of workers' quality of life and health, through the continuous articulation and integration of Government actions in the field of production, consumption, environment and health relations.

V. CONCLUSIONS
In view of the above, it can be concluded that the field called Worker's Health is consolidated from the implementation of preventive actions capable of transforming the main causes of illness into epidemiological information that promote constant improvement in workers' health care, as opposed to the hegemonic conceptions of medicine and occupational health.
Indeed, workers, exposed to occupational risks in their work environment, must constitute a concern for Brazilian public health, and must be a constant object of public policies and effective measures that ensure the fundamental right to health, according to constitutional dictates. .
Theoretical reflections on the subject go beyond the foundations that influence and shape the theoretical plan and advance towards the construction of an intervention proposal for the work relationships that cause illness.
This study is of great relevance to expand and discuss workers' health from the perspective of a State with greater effectiveness in public policies aimed at workers, which, despite playing a fundamental role in society, did not have their health-work relationship prioritized.
That said, without intending to exhaust all the developments contained in this study, it is expected that its reflections will serve as a bridge to new proposals aimed at workers' health care.