Speaking for the people: representation and health policy in the Brazilian Amazon

摘要

This thesis examines representation, a key but relatively neglected issue in contemporary democratic theory, through an ethnography of engagements between indigenous representatives and the state in the Brazilian health sector, which has pioneered the adoption of participatory and deliberative “new democratic spaces”. Part I, “Locating Representation”, argues that contemporary debates that privilege the creation of new democratic spaces as a response to the shortcomings of representative democracy ignore the importance of these spaces’ own issues of representation. The section goes on to outline the context for the research (which was conducted at the national level and in two sites in the Amazon region), describing the process of action research and multi-sited ethnography. The main body of the thesis makes the case for developing a situated understanding of three dimensions of representation: the representation of issues for political debate and policy deliberation; the representation of different social groups in relation to the state; and the representation of the process of democratic engagement itself. Part II, “Representing Health” examines the contrasting understandings of health expressed by two groups of policymakers and bureaucrats – those managing Brazil’s national health system, the SUS, and those responsible for the Indigenous Health Subsystem of the SUS – and by shamanic practitioners and other indigenous health experts. Part III, “Representing People” examines the discourses and mediation roles of indigenous representatives operating in new democratic spaces, and the contrasting representation strategies of two regional indigenous movement organisations who took on management of outsourced services within the Indigenous Health Subsystem. Part IV, “Representing Democracy”, examines three cases of indigenous representatives’ engagement with the state through new democratic spaces in the health sector, and concludes by analysing the potential for new approaches to representation to contribute both to the political inclusion of marginalised minorities and to the broader reinvigoration of democracy.