A Discussion with Dr. Nelson Rodrigues dos Santos, President, Institute of Applied Public Health Law, Campinas, Sao Paulo, Brazil
With: Nelson Rodrigues dos Santos Berkley Center Profile
August 12, 2014
Background:
As part of the Education and Social Justice
Project, in August 2014 undergraduate student Adam Barton interviewed Dr. Nelson Rodrigues dos Santos, a
public health physician, former coordinator of the Brazilian National Board of
Health, and current president of the Institute of Applied Public Health Law in
Campinas, São Paulo. In this interview, dos Santos reflects on the current
state of public health in Brazil and the work of Pastoral in health education.
Could you tell me about the
public healthcare system in Brazil and the role of community health education
in that system?
I would start by saying this: a good healthcare system, in any part of the world, has its roots in the community. Why? Because it is the only work that effectively carries out actions to prevent disease and allow for early diagnoses—life-saving processes that are both inexpensive and low-tech. Primary health care, when well functioning, is able to either avoid or resolve early between 80 percent and 90 percent of all diseases.
Dr. Zilda’s Pastoral strengthened Brazil’s primary care system greatly. She was not able to use other medical professionals, so she made incredible use of community workers; simple “professionals” that reside in the communities they serve. Dr. Zilda [Arns Neumann] worked to find and identify those community members with the aptitude and desire to participate in the healthcare system to serve their community. These workers live in the community, know the psychology of the community, know the suffering of the community, and that knowledge gives them a potential utility thrice that of most professionals.
This, however, is an uphill battle that is fighting the privatized Brazilian healthcare system in which over 60 percent of services are purchased in the market. Our primary care system is not empowered to resolve 80 to 90 percent of the needs of the population—it solves 20 to 30 percent at best. This is a massive and saddening inversion of healthcare goals. So I want you to remember this well: the most important part of our health system is community work.
What are the most serious problems in today’s health care system, particularly with regard to public health?
The main problem is that the Brazilian population continues to contract preventable diseases, and when these diseases are contracted they are not diagnosed until much later. With these late diagnoses, treatment is incredibly expensive. Because Brazil’s healthcare system cannot afford these diagnoses and late treatments for advanced diseases for the whole of the nation, the majority of the population is waiting six months, one year, two years, to have a vital surgery or a more sophisticated exam. Consultations with specialists can take years to make, by which time many have already died—the toll of human suffering is tremendous.
So, thinking about the trends that you are seeing in the realm of public health, what do you think will be the key issues in maternal and early childhood health that Pastoral will have to face?
I think that Pastoral will continue doing what it is doing now; it is a very consistent organization, and should not stop doing its work in fostering solidarity through community involvement. Primary care here in Brazil will always be founded in the community, and Pastoral has a rich community experience in solidarity and training appropriate primary care professionals. One particularly worrisome trend, though, is around the trend toward cesarean surgery. In a normal population, no more than 15 percent of pregnancies will require cesarean surgery. In Brazil, that number is reversed to where 85 percent of the population is having C-sections. This, however, is largely a result of unhealthy market forces, as natural birth does not provide any profit for the hospitals.
Could you tell me about the structure of the Brazilian health system and where Pastoral fits in on the municipal level?
The relationship between Pastoral and the healthcare system is very good. We have three federal powers: national, state, and municipal. Because the municipalities are having funding cut at the national level, and because the municipal governments are those that have control over primary health care, we are seeing much difficulty in providing quality primary care in today’s system. Pastoral could do well, then, to continue strengthening its ties with municipal health departments in order to ensure that they maintain their role in providing primary health care to their citizens.
Because it is not part of the federal government’s policy to give priority to primary care, our system of primary care resolves 20 percent, in some regions up to 30 percent, of preventative issues, with over 80 percent of the population coming in with late diagnoses and treatments, thereby preventing municipalities from being able to afford the massive costs associated with the specialized care that the vast majority of the population needs. The problem that emerges here, then, is that—because in cases of urgent care, legal penalties are incurred by the municipality if needs are not met—virtually all of a municipality’s financial resources are going to meet urgent and specialized care needs. This creates a vicious circle, as no money is left over for primary care, resulting in increased emergent care costs.
What is the formal connection like between Pastoral and local health departments? How do they work together?
Given Pastoral’s deep interest in advocacy, it is well represented in most health departments at the national and state levels. The problem, though, is that health departments themselves have no political force over matters related to primary care. The other problem is that many who serve as representatives in the health departments have vested political or market interests, and thus push private insurance plans, plans which offer federal tax breaks to private companies, which correspond to a 150 percent net profit over that which is actually paid.
What do you think has led Pastoral to have such incredible success in the area of community health education?
The valuing of solidarity. I have not been using that word “solidarity” just because solidarity is a superior human value independent of remuneration, of the material values that mark the human experience. Solidarity is a collection of attitudes and behaviors that go beyond material possibilities. It is about the desire to help from the heart. When the people see a public official working for them, they see someone fulfilling an obligation. When the service comes from a place of solidarity, however, the people see reflected the warmth of the human spirit, and are inclined to trust more deeply. The impact is magnified tenfold.
Is there anything else that you would like to add?
I think that I would add that Pastoral da Criança is, in practice, a shining example of what a partnership between the state and a philanthropic organization should be. Pastoral serves as proof that this partnership can exist, and that it can be strong. I say this because in the last 20 years, thousands upon thousands of NGOs have popped up in Brazil. I would say that more than half of these NGOs receive financial resources from the state, and yet the communities that they serve never see any form of benefit. There is even a term that we have in Brazil, “NGO-ism,” which is a strategy through which private initiatives exploit the value of solidarity in order to collect resources from the state without returning anything useful to the community. Pastoral, however, is an eternal example of what an NGO should be, and must continue to be held as that model for strong partnership for as long as possible.
I would start by saying this: a good healthcare system, in any part of the world, has its roots in the community. Why? Because it is the only work that effectively carries out actions to prevent disease and allow for early diagnoses—life-saving processes that are both inexpensive and low-tech. Primary health care, when well functioning, is able to either avoid or resolve early between 80 percent and 90 percent of all diseases.
Dr. Zilda’s Pastoral strengthened Brazil’s primary care system greatly. She was not able to use other medical professionals, so she made incredible use of community workers; simple “professionals” that reside in the communities they serve. Dr. Zilda [Arns Neumann] worked to find and identify those community members with the aptitude and desire to participate in the healthcare system to serve their community. These workers live in the community, know the psychology of the community, know the suffering of the community, and that knowledge gives them a potential utility thrice that of most professionals.
This, however, is an uphill battle that is fighting the privatized Brazilian healthcare system in which over 60 percent of services are purchased in the market. Our primary care system is not empowered to resolve 80 to 90 percent of the needs of the population—it solves 20 to 30 percent at best. This is a massive and saddening inversion of healthcare goals. So I want you to remember this well: the most important part of our health system is community work.
What are the most serious problems in today’s health care system, particularly with regard to public health?
The main problem is that the Brazilian population continues to contract preventable diseases, and when these diseases are contracted they are not diagnosed until much later. With these late diagnoses, treatment is incredibly expensive. Because Brazil’s healthcare system cannot afford these diagnoses and late treatments for advanced diseases for the whole of the nation, the majority of the population is waiting six months, one year, two years, to have a vital surgery or a more sophisticated exam. Consultations with specialists can take years to make, by which time many have already died—the toll of human suffering is tremendous.
So, thinking about the trends that you are seeing in the realm of public health, what do you think will be the key issues in maternal and early childhood health that Pastoral will have to face?
I think that Pastoral will continue doing what it is doing now; it is a very consistent organization, and should not stop doing its work in fostering solidarity through community involvement. Primary care here in Brazil will always be founded in the community, and Pastoral has a rich community experience in solidarity and training appropriate primary care professionals. One particularly worrisome trend, though, is around the trend toward cesarean surgery. In a normal population, no more than 15 percent of pregnancies will require cesarean surgery. In Brazil, that number is reversed to where 85 percent of the population is having C-sections. This, however, is largely a result of unhealthy market forces, as natural birth does not provide any profit for the hospitals.
Could you tell me about the structure of the Brazilian health system and where Pastoral fits in on the municipal level?
The relationship between Pastoral and the healthcare system is very good. We have three federal powers: national, state, and municipal. Because the municipalities are having funding cut at the national level, and because the municipal governments are those that have control over primary health care, we are seeing much difficulty in providing quality primary care in today’s system. Pastoral could do well, then, to continue strengthening its ties with municipal health departments in order to ensure that they maintain their role in providing primary health care to their citizens.
Because it is not part of the federal government’s policy to give priority to primary care, our system of primary care resolves 20 percent, in some regions up to 30 percent, of preventative issues, with over 80 percent of the population coming in with late diagnoses and treatments, thereby preventing municipalities from being able to afford the massive costs associated with the specialized care that the vast majority of the population needs. The problem that emerges here, then, is that—because in cases of urgent care, legal penalties are incurred by the municipality if needs are not met—virtually all of a municipality’s financial resources are going to meet urgent and specialized care needs. This creates a vicious circle, as no money is left over for primary care, resulting in increased emergent care costs.
What is the formal connection like between Pastoral and local health departments? How do they work together?
Given Pastoral’s deep interest in advocacy, it is well represented in most health departments at the national and state levels. The problem, though, is that health departments themselves have no political force over matters related to primary care. The other problem is that many who serve as representatives in the health departments have vested political or market interests, and thus push private insurance plans, plans which offer federal tax breaks to private companies, which correspond to a 150 percent net profit over that which is actually paid.
What do you think has led Pastoral to have such incredible success in the area of community health education?
The valuing of solidarity. I have not been using that word “solidarity” just because solidarity is a superior human value independent of remuneration, of the material values that mark the human experience. Solidarity is a collection of attitudes and behaviors that go beyond material possibilities. It is about the desire to help from the heart. When the people see a public official working for them, they see someone fulfilling an obligation. When the service comes from a place of solidarity, however, the people see reflected the warmth of the human spirit, and are inclined to trust more deeply. The impact is magnified tenfold.
Is there anything else that you would like to add?
I think that I would add that Pastoral da Criança is, in practice, a shining example of what a partnership between the state and a philanthropic organization should be. Pastoral serves as proof that this partnership can exist, and that it can be strong. I say this because in the last 20 years, thousands upon thousands of NGOs have popped up in Brazil. I would say that more than half of these NGOs receive financial resources from the state, and yet the communities that they serve never see any form of benefit. There is even a term that we have in Brazil, “NGO-ism,” which is a strategy through which private initiatives exploit the value of solidarity in order to collect resources from the state without returning anything useful to the community. Pastoral, however, is an eternal example of what an NGO should be, and must continue to be held as that model for strong partnership for as long as possible.
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