More Doctors Program’: the most audacious social action since the National Immunization Program

The program, as described, can efficiently help control tropical diseases by implementing major local impact interventions

More Doctors for Brazil Program (PMMB) is more than simply allocating doctors in the Countrys poor regions: it is an ambitious program to strengthen the entire populations primary health attention, prioritizing extremely poor regions, indigenous sanitary districts and high socially vulnerable regions, as the large cities suburbs. For the first time in over 500 years of Brazilian history, doctors are living at the indigenous sanitary district, firmly and continuously working to solve the harsh problems that threaten these peoples preservation. The program has delivered the required proximity between city managers and health teams, who understand the community’s demands, visit their houses, follow treatment and control of endemic diseases, perform childcare, prenatal follow-up, hypertensions and diabetes, besides assisting spontaneous demands.

Tutor of the PMMB, Dra. Dorcas Lamounier, said the Program involves building, remodeling and expanding Basic Health Units across the Country, besides qualifying family health teams. In many Brazilian cities, the Program has been the first time populations experience full-time doctors who live in their cities. For many other cities, this has been the first experience with any sort of basic attention services played by complete teams harmonized to primary health attention principles, she said.

For the expert, PMMB, as described, can effectively contribute to control tropical diseases by implementing major local impact interventions, although still in an early stage. As an example, during the 52^nd Congress of the BSTM, there were wide debates about the importance of involving basic health services and reducing visceral leishmaniasis lethality. Since the Basic Health Unit is the patients gateway to the Unified Health System, it offers great opportunities for early diagnosis of diseases as visceral leishmaniasis that, in other ways, would evolve to severeness or death. The idea is simple: a community agent identifies a patient with prolonged fever and informs the doctor. The doctor would then identify splenomegaly by physical examination and the output would be obvious – it could be leishmaniasis. From this point on everything is carried out quickly and the patient does not have to wait for two or three months for diagnosis, as usually happens in Brazilian endemic regions.

Successful experiences controlling Aedes aegypti were widely reported during the 2015 Zika outbreak in Brazils northeast, and teams creatively and enthusiastically organized joint efforts to control the mosquito, carried meetings and speeches, receiving full support from community leaders and general population. According to her, it is clear this instructive work, very relevant for the performance of programs doctors, brings better and longer-lasting results if compared to the usual diagnosis and treatment medical practice. Dr. Dorcas reminds that when the first microcephaly cases were detected in some Northeastern states, family health teams gathered efforts to detect and refer these children, visiting every newborn and taking notes of cephalic perimeter by the end of every life week, which is the most sensitive period for measurement. In addition, during these visits, they tell about the dangers of the Aedes and ways to combat the mosquito. The Program, while an agent of Family Health Strategy actions, can effectively cooperate with the control of vector-borne tropical diseases, but despite the great intervention potential, the involvement of Family Health Strategy teams controlling vector-borne diseases is still low, she adds.

Starvation and violence epidemic Vs. More Doctors

For the Programs tutor in Piauí, PMMB can also help reduce other epidemics. Primary health attention has great power over povertys most immediate consequence, which is starvation, malnutrition. This happens, by two fundamental mechanisms: breaking the infection-malnutrition-infection chain and leading to accessible eating habits. Malnutrition is intrinsically related to infections, notably among children: they acquire an infection, whether it is diarrhea, pneumonia or any other and become undernourished and, before post-infectious nutritional recovery, they acquire a new infection and become even more undernourished, she says adding that avoiding infectious diseases through basic health orientations and vaccination (here, Basic Attention plays a very important role) is the best tool to prevent malnutrition.

Most poor families have enough resources to guarantee their basic meals, but infections place an additional expense that frequently cannot be met. Besides this, encouraging breastfeeding, advising about weaning and post-infectious feeding, breaking food taboos that discourage accessible foods and give a false superiority of industrialized food, can make a huge difference between being hungry and being nourished. As an example, it is common that children in rural areas are not given protein, carbohydrate and vitamin rich regional fruits, from their backyards because their parents believe they are not intended for children. The same way, these children and people recovering from any illness are warned not to eat eggs, pork or game, which may be almost costless, while they are encouraged to purchase meat, dairy products and other industrialized food, which spoils family income and add no benefits. This simple and impacting orientation is routine for basic attention health professionals in the PMMB.

When asked about the programs power to interfere in the violence rise striking Brazil, Dr. Dorcas says the complexity of the factors involved cannot be solved by isolated actions, but reducing social inequalities in unarguably the major priority. In addition to that, in the long run, this is the aimed goal while strengthening primary health actions, today lead by the More Doctors Program. Vaccinated, nourished and early treated when sick children will have much better conditions to study, process, compete in the violent market and claim their rights. Besides this, family health strategy programs focus teenagers as priorities in education programs aiming to prevent drug use, especially alcohol and tobacco, and violence, which are todays greatest problems among poor and vulnerable populations, she stressed.

Senate extends More Doctors for more three years

On August 24, the Provisory Act 723/2016, which extends, for three more years, the term for doctors of the More Doctors Program hired by exchange programs. The bill favors Brazilian doctors who graduated abroad and foreign doctors who currently do not hold a revalidated diploma in Brazil. The matter was approved as Bill of Law 16/2016 and waits for presidential sanction. Currently, 2,340 Brazilian cities only offer medical attention through the More Doctors Program, the same program that suffered strong resistance by some social sectors when created.

According to the government, at the time the program was created, a diagnosis of these professionals shortage was set and it pointed that the poorest regions and vulnerable populations were those with proportionally less doctors. The Program currently counts with 13 thousand foreign doctors, but the interest of Brazilian doctors has grown every new public notice.

Dr. Dorcas emphasizes that if the program were shut down today, everything built along these three years would crumble very shortly since all these actions demand time and perseverance to solidify, what will only be achieved after a few decades of hard work. Many communities where today doctor is present would have none. Incomplete teams would be unable to develop their duties. The immunization program would weaken, prenatal follow-up, growth and child development tracing would be partially or fully terminated in several cities, she argues while ensuring endemic diseases as tuberculosis and leprosy diagnosis and treatment would undergo a great negative impact. Without primary attention, health problems that could be solved in site would evolve to greater complexity and return to crowd secondary and tertiary attention hospitals that barely felt the relaxation of a repressed demand.

Medical supply in priority areas with major participation of foreign doctors is the programs emergency part that, on the other hand also signal the implementation of medical schools in priority regions, with new curricular guidelines, prepared to form a general physician able to fully attend the needs of local communities. The program also foresees the increase of openings for Family and Community Medical Internships, in a way every first year of Medical Internship programs are performed in basic attention services. At last, the PMMB foresees professional qualification in graduate courses as Professional Masters in Family Health in National Network, approved by CAPES in 2015 aiming to qualify professionals working with family care and basic attention in Brazil, in accordance with fundamental principles of the Unified Health System and the More Doctors Program. All this will surely be enough to qualify and persuade the Brazilian doctor and other health professionals to continue a work that has just begun.…