Prevenção quaternária na atenção primária à saúde: uma necessidade do Sistema Único de Saúde

Abstract

IntroduçãoO caráter medicalizador 1,2 e intervencionista da racionalidade 3 e da prática médico-científica começou, há algum tempo, a deixar entrever várias de suas limitações e mazelas, classificadas por Illich 1 em três tipos de iatrogenias: clínica, social e cultural. A iatrogenia clínica, relativa aos danos causados pela intervenção médica no indivíduo, a mais palpável e melhor percebida pelos saberes e métodos científicos, cresceu tanto, que ganhou dimensão coletiva e populacional, tornando-se recentemente a terceira maior causa de morte nos Estudos Unidos da América 4 . Suscitou, assim, o reconhecimento acadêmico e social de seu potencial danoso em grande escala. Em paralelo, dentro da própria categoria médica, um conceito nascia intimamente relacionado à iatrogenia clí-nica e à medicalização social, cuja apresentação é objetivo deste artigo: a prevenção quaternária.O nascimento e a prática deste conceito vêm de uma reação à iatrogenia nascida dentro da própria categoria médica, vinculada à prática e à ética do cuidado. Seu lugar e significado ainda não estão bem estabelecidos, mas certamente ele merece atenção e debate na saúde pública e no Sistema Único de Saúde (SUS), dado seu potencial de contribuições à área. Em tempos de grande extensão da atenção primária à saúde no Brasil via Estratégia Saúde da Família, é grave o fato de quase não haver discussão na Saúde Coletiva e no SUS sobre a prevenção quaternária, ARTIGO ARTICLE 2012Cad. Saúde Pública, Rio de Janeiro, 25(9)

Differentiating clinical care from disease prevention: a prerequisite for practicing quaternary prevention

“…In clinical care scenarios, it is difficult to request or predict favorable outcomes. What we expect is technical correctness and ethical professionalism 4 .…”

“…The aim is to protect users of health services from inappropriate and iatrogenic interventions 1,2 . Other meanings for P4 have been proposed, as summarized by Starfield et al 3 , and its importance to the Brazilian Unified National Health System (SUS) can be found in Norman & Tesser 4 .…”

“…For instance, being conceptually and complementarily inserted in Leavell & Clarke's problematic and questionable disease natural history model 12 , P4 could theoretically mean a reinforcement of what it intends to reform, limit or even transform. However, as a critical synthesis stemming from primary health care professionals, the P4 proposition can lead to changes in preventive practices at all levels of prevention, by suggesting attitudes and systematizing the available scientific knowledge for coping and managing the overemphasis on prevention, medicalization, and its excessive iatrogenic effects 4 . Thus, P4 is considered here as actions that realize practical and technical developments towards an ethical, attitudinal, epistemological, and political resistance to the excesses of medicalization, preventivism, and iatrogenic effects in clinical and institutional settings.…”

“…In this regard, the abbreviated acronym for quaternary prevention (P4) makes it even simpler to convey its ideas than the three quoted lines above. This linguistic pragmatism facilitates communicating with primary health care professionals, usually responsible for caring for the country's entire population in universal public health systems with strong primary health care provision, as intended by the SUS 4 . Thus, the P4 concept fosters the systematization and development of practical and technical frameworks with regards to the discussions on excesses of bio-medicalization and preventive care.…”

Acesso ao cuidado na Estratégia Saúde da Família: equilíbrio entre demanda espontânea e prevenção/promoção da saúde

“…The relationship between cost and benefits of this screening begins to be inconclusive or negative, questioning the generalized indication of mammography screenings, since radiotherapy in low-risk groups (women with pathological findings resulting from the screening) can bring important consequences, such as excess mortality attributed to heart failure (27%) and lung cancer (78%) Jørgensen, 2013). Therefore, proposals for organized screening programs (Brazil, 2010) need to be reviewed in the light of new evidence, so that information within the organized programs is decoded in a language that is easy to understand, which also portrays the potential harms (Spiegelhalter, 2011); empowering patients (in the case above, the women) to make decisions about their health and their bodies and help professionals to exercise quaternary prevention, essential to the quality of PHC Tesser, 2009).…”