Domhnall MacAuley: primary care in Brazil

Domhnall MacauleyFive of his pregnant patients were dead. Three murdered by drug dealers when they couldn’t pay their bills and two killed by the police.  A very different maternal mortality in frontline general practice.  Marcello Garcia Kolling, a GP in Curitiba, and president of the 2º Congresso Sul Brasileiro de Medicina de Família e Comunidade, estimates that 20% of his teenage patients are already hooked on crack cocaine.  And yet, Marcello is part of one of the most innovative and exciting initiatives in world medicine. I visited his practice, one of 300 almost identical health centres in Curitiba, which is fully paperless with electronic referrals to hospital and radiology, electronic medication requests to the in-house pharmacy (with a limited range of government supplied medications), and an attached teaching room suitable for 20 patients.  Their patient records are held at a central computer and if a patient moves into the area, has an accident or attends hospital, their record can be accessed immediately.  And, it surprised me that even in this deprived neighbourhood where drugs are a huge problem, there were no bars on the windows, no violence, and no fear of robbery at the health centre.

Primary care is based on the PSF (Programa Saúde da Família, or Family Health Programme), where a  team, made up of  a single doctor with nurses, nursing assistants, and support staff but also including community health workers and perhaps even a psychologist, look after a fixed geographical area of about 3,000 patients. Community health workers, local women embedded in the community who know their families well, visit every home in their patch and enable them to access everyday health care. They have 2-3 weeks training by the doctor and nurse following national guidelines. Already 250,000 have been trained. One interesting unintended outcome is that some local women who may be best suited could be excluded because they are unable to read and write. Is there a role for lay health workers in the UK? It struck me that, with increasing fragmentation of the community nursing services, problems with health visiting, specialisation and professionalisation within nursing, we have lost the traditional link between the community and their family doctors. This innovation from the developing world might offer a solution even in developed countries.

General practice research in Brazil is on the threshold of massive expansion. Bruce Duncan, a senior academic, who moved from the US more than 25 years ago and who leads the department at Universidade Federal do Rio Grande do Sul, told me of much increased funding for training and research. They have just built a new investigative unit at his university and are developing their research programme. Indeed, they have a problem quite unlike other countries- they have the funding but don’t have the critical mass of expert researchers to take forward their ideas. He is a major figure in the profession- I heard later that the government supplied his clinical textbook of ambulatory care free to every health centre in the country.

General practice education in is transition. There are roughly 300,000 doctors in Brazil, 30,000 working in primary care  but perhaps only 3,000 have undergone foundation training similar to our GP training schemes. You need not have undertaken training to enter general practice so it is important to offer an educational experience that residents value. Similarly, general practitioners should, like other doctors, collect postgraduate education credits by attending conferences or completing educational modules ( not unlike BMJ Learning) to endorse their continued specialist recognition- but, of course, they can continue to practice without it.

Palliative care does not exist in Brazil. There is a minimal service available linked to oncology but no community outreach or primary care service. And, GPs are often afraid to take it on. This may mean that when patients are discharged from hospital on morphine, their family doctor may discontinue it and switch to less effective analgesia. Inevitably, this pushes the patients back to hospital for pain relief. Demography may be the driver- this is a very young country and inevitably palliative care will become a community necessity.

Smoking ages your skin. When I saw this message, together with a picture of a prematurely aged young woman, on the back of a cigarette package, I was impressed with the potential public health impact. But, an academic from Santa Cruz told me of their rather unique problem. Santa Cruz is a tobacco city. The economy, employment, government, and community are all almost entirely dependant on the tobacco industry. Whole families are involved in harvesting tobacco,  the industry supports almost every aspect of community development and even bumper stickers carry the message “Tobacco pays my bills.” The medical school and indeed, his department of epidemiology, must whisper their concerns quietly.

Acknowledgement: I attended this congress as one of the speakers and met some  wonderful people. My knowledge and experience is limited to the short period of time I spent in this vast country so I hope this piece accurately reflects what happens elsewhere. I have no reason to think otherwise.

Domhnall Macauley is primary care editor, BMJ