Obstacles to SUS universalization: tax expenditures, labor union demands and health insurance state subsidy. / Obstáculos à universalização do SUS: gastos tributários, demandas sindicais e subsídio estatal de planos privados.

In the light of the comparative analysis of health systems, we discuss three strategic phenomena for the SUS universalization, as follows: a) health tax expenditures; b) State funding of private plans for public servants; and c) trade union's demand for private health plans. Among the ideal types of health systems, SUS is universal in law, but hybrid in practice: Beveridgian in primary health care (PHC) and mixed in specialized/hospital care; without really being universal (public spending is only 43% of total health expenditure). There is a massive state subsidy to the private sector, through health tax expenditures (30% of the federal health budget) and financing of private plans for public servants, which generates incoherence, segmentation of the health system and inequities. Despite the general support to the SUS, the union movements have been using private health plans in collective recruitment (76% of them), reinforcing the private sector. Reducing health tax expenditures - including state funding of servants' private plans - would significantly increase the SUS budget and facilitate articulation between health workers and trade unionists, bringing the high strength of unions closer to the long struggle for the universality of the SUS and PHC.

À luz da análise comparada de sistemas de saúde (SS), discutimos três fenômenos estratégicos para a universalização do SUS: a) os gastos tributários em saúde; b) o financiamento estatal de planos privados de servidores públicos; c) a demanda sindical por planos privados. Dentre os tipos-ideais de SS, o SUS é universal na lei, mas híbrido na prática: beveridgeano na atenção primária à saúde (APS) e misto no cuidado especializado/hospitalar; sem ser universal na realidade (gastos públicos são só 43% dos gastos totais em saúde). Há grande subsídio estatal ao setor privado, via gastos tributários em saúde (30% do orçamento federal na saúde) e financiamento de planos privados para servidores públicos, o que gera incoerência, segmentação do sistema de saúde e iniquidades. Apesar do apoio genérico ao SUS, os movimentos sindicais vem usando planos de saúde na contratação coletiva (76% deles), reforçando o setor privado. A redução dos gastos tributários em saúde - incluindo o financiamento estatal dos planos privados de servidores - aumentaria significativamente o orçamento do SUS e facilitaria a articulação entre sanitaristas e sindicalistas, aproximando a grande força dos sindicatos da longa luta pela universalidade do SUS e da APS.

[From yoga to psychosocial care in Primary Health Care: a hermeneutic study on the ethical values and principles of the Yoga Sutras of Patañjali]. / Do yoga para a atenção psicossocial na Atenção Primária à Saúde: um estudo hermenêutico sobre valores e princípios éticos do Yoga Sutra de Patañjali.

The scope of this article is to interpret ethical values and principles of the yoga tradition and discuss them with a view to possible contributions to psychosocial care in Primary Health Care (PHC). A theoretical-hermeneutic study was conducted, in which concepts contained in the Yoga Sutras of Patañjali were interpreted from the standpoint of mental health. It was revealed that the values found in the texts can enrich the existing practices of yoga for PHC users (who suffer from afflictions inherent to life) by providing ideas and guidelines that promote a sense of liberation from suffering. Such values and ethical principles can be incorporated into the discussions in PHC and psychosocial care, such as the reduction of iatrogenic disorders and unnecessary medication (quaternary prevention). It can also contribute to the relativization of biomedical power, stimulation of empathy and participation of users in care, with their subjective repositioning, multiplying autonomous ways of managing suffering and building networks of psychosocial support. The conclusion drawn was that the values of the Yoga Sutras may be present in various domains of PHC, which might provide a broader understanding of what 'the practice of yoga' means.

O presente artigo tem como objetivo interpretar valores e princípios éticos da tradição do yoga e discuti-los visando possíveis contribuições para a atenção psicossocial na Atenção Primária à Saúde (APS). Foi realizado um estudo teórico-hermenêutico, em que conceitos presentes na escritura Yoga Sutra de Patañjali foram interpretados sob o enquadramento da saúde mental. Constatou-se que os valores encontrados na escritura podem enriquecer as práticas de yoga atualmente existentes voltadas para os usuários da APS (que sofrem com aflições inerentes à vida) ao fornecerem ideias e diretrizes que favorecem um sentido de libertação do sofrimento. Tais valores e princípios éticos podem ser incorporados às discussões presentes na APS e na atenção psicossocial, como redução da iatrogenia e da medicalização desnecessária (prevenção quaternária), relativização do poder biomédico, estímulo ao exercício da empatia e da participação dos usuários nos cuidados, com seu reposicionamento subjetivo, pluralizando formas autônomas de manejo do sofrimento e construindo redes de apoio psicossocial. Concluiu-se que os valores do Yoga Sutra podem estar presentes em diversos âmbitos da APS, o que daria um entendimento expandido sobre o que significa uma "prática de yoga".

[Complementary and alternative medicine and social medicalization: lack of definitions, risks, and potentials in primary healthcare]. / Práticas integrativas e complementares e medicalização social: indefinições, riscos e potências na atenção primária à saúde.

Complementary and Alternative Medicine (CAM) need to be increasingly understood in the academic and research setting, given their growing inclusion in health institutions and scientific studies. However, vague definitions or broad generalizations are common in the Brazilian scientific literature, an example of which is the relationship between CAM and social medicalization. This study aims to discuss the medicalizing and de-medicalizing potential of the use of CAM, especially in primary healthcare (PHC). This essay summarizes the underlying lack of definition concerning the medicalizing and de-medicalizing potential of various CAM, based on the selected literature, which reports theoretical and empirical convergences. The exercise of CAM in the clinical context has a medicalizing potential, due to its positive, expanded, and holistic conception of health and its etiological multidimensionality, potentially generating so-called "holistic illness", which has been reported theoretically and empirically. CAM also have de-medicalizing potential, depending on the practitioner, due to greater interpretative flexibility, contextualization, singularization, users' participation in the care, closer clinical relationship, the values and traditions of some CAM, diversity of interventions, and the potential for enrichment of self-care. The medicalizing or de-medicalizing potential of various CAM is activated by their practitioners, and the context of PHC tends to favors the de-medicalizing potential.

As Práticas Integrativas e Complementares em Saúde (PICS) deveriam estar cada vez mais compreendidas no ambiente acadêmico e de pesquisa, dada sua crescente inserção nas instituições de saúde e em pesquisas científicas. Entretanto, comumente há conceituações ou generalizações temerárias na literatura científica brasileira, sendo exemplo a relação das PICS com a medicalização social. O objetivo deste trabalho é discutir o potencial medicalizante e desmedicalizante do uso de PICS, especialmente na atenção primária à saúde (APS). Trata-se de ensaio que sintetiza a indefinição referente ao potencial simultaneamente medicalizante e desmedicalizante de várias PICS, baseado em literatura selecionada, que registra convergências teóricas e empíricas. O exercício de PICS em contexto clínico tem potencial medicalizante, devido ao seu conceito positivo, ampliado e holístico de saúde e sua multidimensionalidade etiológica, podendo gerar o chamado "adoecimento holístico", observado teórica e empiricamente. Tal exercício apresenta também potencial desmedicalizante, dependente do praticante, devido a maior flexibilidade interpretativa, contextualização, singularização e participação do usuário no cuidado, relação clínica mais próxima, valores e tradições de algumas PICS, diversidade de intervenções e seu potencial de enriquecimento do autocuidado. O potencial medicalizante ou desmedicalizante de várias PICS é ativado por seus praticantes, e o contexto da APS é favorável ao segundo.

Las Medicina Complementaria y Alternativa (MCA) deberían estar cada vez más comprendidas en el ambiente académico y de investigación, dada su creciente inserción en las instituciones de salud y en investigaciones científicas. No obstante, comúnmente existen conceptualizaciones o generalizaciones temerarias en la literatura científica brasileña, siendo un ejemplo la relación de las MCA con la medicalización social. El objetivo de este trabajo es discutir el potencial medicalizante y desmedicalizante del uso de MCA, especialmente en la atención primaria en salud (APS). Se trata de un ensayo que sintetiza la indefinición referente al potencial simultáneamente medicalizante y desmedicalizante de varias MCA; basado en literatura seleccionada, que registra convergencias teóricas y empíricas. El ejercicio de MCA en un contexto clínico tiene potencial medicalizante, debido a su concepto positivo, ampliado y holístico de salud y su multidimensionalidad etiológica, pudiendo generar el denominado "padecimiento holístico", observado teórica y empíricamente. Tal ejercicio presenta también potencial desmedicalizante, dependiente del practicante, debido a una mayor flexibilidad interpretativa, contextualización, singularización, así como la participación del usuario en el cuidado, una relación clínica más cercana, valores y tradiciones de algunas MCA, diversidad de intervenciones y su potencial de enriquecimiento con el autocuidado. El potencial medicalizante o desmedicalizante de varias MCA se activa mediante sus practicantes y el contexto de la APS es favorable al segundo.

Profile of acupuncture use among primary care physicians working in the Brazilian public healthcare system.

BACKGROUND: An introductory acupuncture course has been offered to primary health care physicians and family medicine residents in southern Brazil since 2011. OBJECTIVE: To analyze the profile of acupuncture utilization of primary care physicians who completed an introductory course of acupuncture between 2011 and 2018. METHOD: A survey using an electronic questionnaire was sent to all 119 physicians who completed the course. RESULTS: Fifty-five physicians answered the questionnaire. The majority of them reported continuation of the practice of acupuncture in scheduled appointments and on spontaneous demand. The most commonly used principles of point selection were traditional acupuncture point function, myofascial trigger point needling and point protocols. As barriers to the practice of acupuncture, time limitation and inadequate physical space were predominant. The participants described the problem-solving potential of the procedure and good patient acceptance as facilitators. The most common problems treated with acupuncture were musculoskeletal pain, and mood and anxiety disorders. A reduction in referrals to specialists and reduced prescription of pain medications were also reported. Most physicians answered that they often combined acupuncture with other medications or associated acupuncture with other complementary practices. The main adverse events reported by the participants were vascular trauma and fainting. CONCLUSION: Most primary care physicians who completed the introductory course and answered the survey still used acupuncture in their routine, primarily for the management of musculoskeletal conditions and mental health conditions. These physicians reported reductions in specialist referrals and prescription of pain medication after integrating basic acupuncture skills into primary care practice.

Characteristics and performance of professionals of the Expanded Family Health and Basic Healthcare Centers.

OBJECTIVE: To analyze the characteristics and performance of the teams of the Expanded Family Health and Basic Healthcare Centers (Nasf-AB) of Santa Catarina state. METHOD: A multicenter study implementing mixed methods, a sample of 149 municipalities (50.5% of the state) and 359 professionals through applying a survey and collective interviews with five teams of 43 professionals. Quantitative data were analyzed using descriptive statistics, and qualitative data were subjected to thematic analysis. RESULTS: There were 11 professions integrated to the Centers with a predominance of psychologists (27%), physiotherapists (18%) and nutritionists (18%). The professionals were mostly women (88%) aged between 30 and 39 years (50.4%), with their performance involving shared care, collective activities of their professional core, group activities and individual care to users. Professionals participate in the intermediation, regulation or evaluation of referrals from Primary Care to other points of the Network. The interviews revealed a set of actions of technical care and technical-pedagogical support and specialized actions. CONCLUSION: Despite operational difficulties, the Expanded Family Healthcare Centers have been supporting Family Healthcare teams, strengthening Primary Care.

O coração no yoga: um estudo hermenêutico sobre a ontologia das upaniṣad's / The heart in yoga: a hermeneutic essay on the ontology of the upaniṣad's

RESUMO O yoga vem passando por um processo de transformações e conformação à racionalidade médico-científica chamado 'medicalização do yoga', com afastamento das reflexões acerca do ser presentes na sua fonte védica. Orientado por uma tradição hermenêutica indiana, este ensaio investigou sentidos para os termos hṛdayam ('coração') e yoga, frente à atual inserção desta última no âmbito da prevenção cardiovascular. Na tradição védica, o coração possui significado distinto do órgão médico: o termo também é utilizado para se referir ao 1) intelecto e ao 2) locus do Eu (ātmā). Entre outros significados, yoga é visto como um artifício cognitivo que visa à discriminação entre o real e o aparente. Nessa tradição, a saúde do coração aponta mais para uma condição existencial - da ignorância do Eu - e seus efeitos (egotismo, aversões, desejos etc.) do que para os fatores de risco cardiovascular explorados nas pesquisas e nos cuidados clínicos. Tal visão poderia servir como prevenção quaternária aos efeitos adversos da introjeção e reificação dos fatores de risco, e aponta para outra direção na compreensão e atuação do yoga nos serviços de saúde, destacando a importância de aprofundar reflexões filosóficas sobre o yoga e outras práticas integrativas e complementares presentes no Sistema Único de Saúde (SUS).

ABSTRACT Yoga has been undergoing a process of transformation and adaptation to medical-scientific rationality, referred to as the 'medicalization of yoga', with a distancing from reflections on being present in its Vedic source. Guided by an Indian hermeneutic tradition, this essay investigated meanings for the terms hṛdayam ('heart') and yoga, in the context of the current integration of the latter into cardiovascular prevention. In the Vedic tradition, the heart holds a distinct meaning from the medical organ; the term is also used to refer to 1) intellect and 2) the locus of the Self (ātmā). Among other meanings, yoga is seen as a cognitive tool aimed at discriminating between the real and the apparent. In this tradition, heart health points more towards an existential condition - ignorance of the Self - and its effects (egotism, aversions, desires, etc.) than towards the cardiovascular risk factors explored in research and clinical care. Such a perspective could serve as quaternary prevention against the adverse effects of the introjection and reification of risk factors, indicating a different direction for understanding and implementing yoga in healthcare services. It underscores the importance of deepening philosophical reflections on yoga and other integrative and complementary practices within the Unified Health System (SUS).

Scheduling models and primary health care quality: a multilevel and cross-sectional study.

OBJECTIVE: To evaluate whether the scheduling model influences the perception of the user about the quality of primary health care centers. METHODS: This is a cross-sectional and population-based study that measured the quality of centers by the Primary Care Assessment Tool (PCATool-Brazil), applied to adult users (n = 409) from 11 health centers in Florianópolis, state of Santa Catarina. Multilevel analysis was used to verify the relationship between the score of general quality of the primary health care and the scheduling model. The independent variables (age, skin color, scheduling model, panel size by primary health team, poverty ratio as income proxy, number of health teams, presence of economically interest areas, number of medical appointments in one year per primary health team, number of people treated in one year per health team), with p < 0.20 were selected for the multilevel model, which was adjusted with aggregates of information from users and health centers. RESULTS: The health center that used advanced access had a general score of 7.04, while those using a weekly carve-out had a score of 6.26; the carve-out every 15 days, score of 5.87; and the traditional carve-out, score of 6.29. CONCLUSIONS: The scheduling model of advanced access had a positive effect on the quality of primary health care, in the perception of users.

Prevalence and associated factors with integrative and complementary practices use in Brazil.

The aim of the current study was to investigate the prevalence of the use the integrative and complementary practices (ICP) and its associated factors in Brazil. Data was obtained from the cross-sectional National Health Survey 2013 (NHS), which had 145,580 adults aged 18 or over were interviewed. The outcome was the use of any ICP over the last 12 months and independent variables were macro-region, sex, age, educational attainment, skin color/race, and chronic disease. The results show that the prevalence of ICPs use in Brazil was 4.1%, while the most used types were medicinal plants and phytotherapy (2.5%), acupuncture (0.9%) and homeopathy (0.6%). The prevalence of ICPs use was higher in the North Region, among older people, women, participants with higher educational attainment, and with a higher number of chronic diseases. The findings from the current study provide valuable evidence that can inform future evidence-based public policies in Brazil.

Auriculotherapy in primary health care: A large-scale educational experience in Brazil.

Auriculotherapy consists of physical stimuli applied to the outer ear and is commonly associated with traditional Chinese medicine (TCM). The authors present and discuss the development of a course that offers a semi-on-site auriculotherapy course for Brazilian primary health care (PHC) professionals. The course was funded by the Brazilian Ministry of Health and developed at the Federal University of Santa Catarina in 2015 by a team of experts in auriculotherapy. It consisted of 75 h of distance learning (five sequential modules) and 5 h of on-site learning. The modules included the following items: (1) introduction to integrative practices; (2) ear reflexology; (3) introduction to TCM; (4) biomedical view of auriculotherapy; and (5) auriculotherapy in PHC. The teaching material included a workbook for each module, 14 video lectures and an interactive ear (online resource) to study location and application to the main auricular points. The on-site lectures follow a structured script of ear palpation techniques, auricular seed insertion practice and clinical case discussions, under the supervision of trained instructors. The course was offered in 2016 and 2017 and on-site lectures took place in 25 cities, covering all Brazilian regions, in coordination with municipal or state boards of health. A total of 4273 health professionals concluded the training and their evaluation of the course was highly positive. The Brazilian experience of large-scale training shows the potential to disseminate auriculotherapy in the context of PHC, given that its practice is fast, easy to learn, safe, effective for different health problems and well accepted by the patients.

[Supply of Integrative and Complementary Health Practices in the Family Health Strategy in Brazil]. / Oferta de Práticas Integrativas e Complementares em Saúde na Estratégia Saúde da Família no Brasil.

The article analyzes the supply of Integrative and Complementary Health Practices in the Family Health Strategy (FHS), based on the agreement between answers by administrators and health professionals. This was a quantitative descriptive-exploratory study using two databases, the National Survey on Integrative and Complementary Practices in Health in the Unified National Health System (SUS) and the National Program for Improvement of Access and Quality of Basic Care (PMAQ). According to the administrators, the supply of Integrative and Complementary Health Practices was present in the FHS in 26.7% of the municipalities participating in the National Survey, compared to 25.5% of the municipalities according to the health professionals in the PMAQ. Of the 1,478 municipalities that participated in both surveys, in 8.6% there was an agreement of answers on the supply of Integrative and Complementary Health Practices in the FHS. The municipalities with the greatest agreement in the supply were those with small populations and greater coverage of basic care. The small proportion of municipalities with this supply according to both administrators and health professionals supports the hypothesis that the health professionals are the main force responsible for the expansion of Integrative and Complementary Health Practices in the SUS, as compared to initiatives by administrators. This scenario reflects the need for administrators to take greater stock of what is developed in the FHS to strengthen Integrative and Complementary Health Practices and to mobilize the institutional resources for their maintenance and expansion.

O artigo apresenta análise da oferta das Práticas Integrativas e Complementares em Saúde (PICS) na Estratégia Saúde da Família (ESF), a partir da convergência da resposta de gestores e profissionais. Trata-se de uma pesquisa quantitativa descritivo-exploratória, utilizando dois bancos de dados: o Inquérito Nacional de Práticas Integrativas e Complementares em Saúde no SUS e o Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ). De acordo com os gestores, a oferta de PICS esteve presente na ESF de 26,7% dos municípios participantes do Inquérito e em 25,5% dos municípios do PMAQ, segundo os profissionais. Dos 1.478 municípios que participaram das duas pesquisas, em 8,6% deles houve convergência da oferta de PICS na ESF. Os municípios com maior convergência na oferta são de pequeno porte populacional e com maior cobertura de atenção básica. A pequena quantidade de municípios com oferta reconhecida por gestores e profissionais reforça o pressuposto de que são os profissionais os principais responsáveis pela expansão das PICS no SUS, em detrimento de iniciativas da gestão. Esse cenário caracteriza a necessidade de apropriação por parte dos gestores do que é desenvolvido na ESF, para o fortalecimento das PICS e a mobilização de recursos institucionais para sua manutenção e ampliação.

El artículo presenta un análisis de la oferta de Prácticas Integradoras y Complementarias en Salud (PICS), dentro la Estrategia Salud de la Familia (ESF), a partir de la convergencia en la respuesta de gestores y profesionales. Se trata de una investigación cuantitativa descriptiva-exploratoria, utilizando dos bancos de datos: la Encuesta Nacional de Prácticas Integradoras y Complementarias de Salud en el SUS y el Programa Nacional de Mejora de Acceso y Calidad de la Atención Básica (PMAQ). De acuerdo con los gestores, la oferta de PICS estuvo presente en la ESF de un 26,7% de los municipios participantes en la Encuesta Nacional y en un 25,5% de los municipios del PMAQ, según los profesionales. De los 1.478 municipios que participaron en las dos investigaciones, en un 8,6% de ellos hubo convergencia de la oferta de PICS en la ESF. Los municipios con mayor convergencia en la oferta son de pequeño porte poblacional y con mayor cobertura de atención básica. La pequeña cantidad de municipios con oferta reconocida por gestores y profesionales refuerza la presuposición de que son los profesionales los principales responsables de la expansión de las PICS en el SUS, en detrimento de iniciativas de la gestión. Este escenario caracteriza la necesidad de apropiación por parte de los gestores de lo que se desarrolla en la ESF, para el fortalecimiento de las PICS y la movilización de recursos institucionales para su mantenimiento y ampliación.

Use of Complementary and Alternative Medicine in primary healthcare in Florianópolis, Santa Catarina, Brazil: user perception. / Utilização de Medicinas Alternativas e Complementares na atenção primária à saúde de Florianópolis/SC, Brasil: percepção de usuários.

This is a partial analysis of the outcome of a survey looking at user perception of the institutional use of Complementary and Alternative Medicine (CAM) in Florianópolis healthcare centers. Structured interviews were applied to users treated with CAM in the locations offering this option most often, using data-based theory as a theoretical-methodological reference. For the most part, the use of CAM was proposed by basic health professionals (the operators of biomedical care), initially as a preferred alternative to biomedicine. Interviewees preferred CAM, associating it to fewer side-effects. Users mentioned enhanced dialog with professionals to negotiate treatment forms. The hypothesis emerged that CAM could be the initial treatment option in a large number of cases, saving conventional treatment for subsequent use if necessary, or in some cases as the single or complementary treatment. This enables drafting an expanded flow using CAMs in primary healthcare. New studies and institutional experience are required to investigate this hypothesis, expanding the use of CAM in an ecology of institutional care.

Apresenta-se análise parcial dos resultados de pesquisa que investigou as percepções de usuários sobre o uso institucional de Medicinas Alternativas e Complementares (MAC) nos centros de saúde de Florianópolis. Realizaram-se entrevistas semiestruturadas com usuários tratados com MAC nos locais com maiores ofertas, usando como referencial teórico-metodológico a teoria fundamentada em dados. Na sua maioria, o uso de MAC era proposto pelos profissionais da atenção básica (operadores do cuidado biomédico), inicialmente de forma alternativa e preferencial à biomedicina, e houve comum preferência dos entrevistados por essa forma de uso, devido aos menores efeitos colaterais atribuídos às MAC. Usuários referiram diálogo aumentado com os profissionais devido à negociação sobre as forma de tratamentos. Emergiu a hipótese de que as MAC podem ser um tratamento alternativo inicial em parte significativa dos casos, ficando o convencional como retaguarda para uso posterior se necessário, ou complementar ou único em outras situações. Isso permite esboçar um fluxo ampliado da presença das MAC na atenção primária à saúde. Novas pesquisas e experiências institucionais são necessárias para investigação dessa hipótese, que amplifica o uso das MAC numa 'ecologia de cuidados institucionais'.

Revisitando Whitaker: psicofármacos e cuidado em Saúde Mental na Atenção Primária à Saúde / Revisiting Whitaker: psychotropic drugs and Mental Health care in Primary Health Care

RESUMO Os Problemas de Saúde Mental (SM) e o uso indiscriminado de psicofármacos são problemas de grande relevância para a Atenção Primária à Saúde (APS) e a saúde pública. O objetivo deste ensaio é apresentar uma fundamentação atualizada da tese de Robert Whitaker, desenvolvida no livro 'Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental'. É apresentada uma síntese do livro, acrescida de comentários sobre determinados temas, visando à melhor ancoragem científica dos argumentos. A tese defendida é que se deve evitar prescrever o uso de psicofármacos; e, caso seja iniciado o uso, que seja como sintomático agudo pelo menor tempo possível. Os argumentos giram em torno de que há evidências favoráveis apenas para redução de sintomas, para algumas dessas drogas e para curtos períodos de uso. Com seu uso crônico, há piora em longo prazo quanto à estabilidade, autonomia e funcionalidade social, com problemas graves de abstinência. Especialmente na APS (e também nos serviços especializados em SM), os profissionais deveriam ter uma abordagem mais crítica dos psicotrópicos e investir em outras abordagens terapêuticas, para fazerem algo melhor, menos iatrogênico e tão ou mais eficaz para os pacientes com problemas de SM no longo prazo.

ABSTRACT Mental Health (MH) issues and the indiscriminate use of psychotropic drugs are a great deal of a problem for the Primary Health Care (PHC) and public health. The aim of this article is to show an updated basis from Robert Whitaker theses in his book 'Anatomy of an epidemic: magic bullets, psychiatric drugs and the astonishing rise of mental illness'. It is presented a synthesis of the book, with specific comments about some topics, aiming for better scientific base of the arguments. The thesis endorses that prescribing psychotropic drugs must be avoided; and, if required, it must be as an acute symptomatic scenario for the least time as possible. The study has positive evidence that a few of these drugs only reduces symptoms, for a short period of time. If chronic used, in a long-term scenario, it seems to actually reduce stability, autonomy and social functionality, leaving the user with serious abstinence from the drug. Specially in PHC (and also in MH specialized services), professionals should have a mindful and discerning approach to psychotropic drugs, and invest in other therapeutic strategies, in order to do something better, less iatrogenic and as effective or more for the mental health patients in the long term.

O sofrimento futuro pode ser evitado: o yoga como estratégia na prevenção primária das doenças cardiovasculares / Future suffering can be avoided: Yoga as a strategy in the primary prevention of cardiovascular diseases

Resumo Este estudo tem como objetivo avaliar o yoga como recurso para a prevenção primária das doenças cardiovasculares (DCV) no contexto da Atenção Primária à Saúde (APS), considerando o fenômeno da medicalização. Para tanto, realizou-se um ensaio, baseado na abordagem hermenêutico-filosófica, em que elementos da tradição do yoga foram colocados em interface com a racionalidade biomédica, o processo de antecipação e o discurso sobre os fatores de risco, presentes na atual lógica da prevenção primária. Observou-se que certos conceitos do yoga se opõem ao processo antecipatório, sendo que a incorporação destes pelo usuário pode impedir a excessiva medicalização do risco, gerada em função de expectativas de controle sobre doenças e sofrimentos futuros. Os resultados apontam que a inserção de parâmetros, valores e conceitos do yoga dentro de discussões nos grupos da APS podem contribuir para a maior autonomia dos usuários ao ampliar os atuais discursos sobre os fatores de risco, com maior apreciação para as questões psicológicas e emocionais que subjazem ao desenvolvimento das DCV. Como conclusão, observa-se a necessidade de futuros estudos que investiguem conceitos presentes na tradição do yoga que não somente as já conhecidas e bem exploradas técnicas psicofísicas, para a prevenção primária das DCV.

Abstract This study aims to evaluate yoga as a resource for the primary prevention of cardiovascular diseases (CVD) in the context of Primary Health Care (PHC), considering the phenomenon of medicalization. To this end, an essay was conducted, based on the hermeneutic-philosophical approach, in which elements of the yoga tradition were placed in interface with biomedical rationality, the anticipation process and the discourse on risk factors, present in the current logic of primary prevention. It was observed that certain concepts of yoga are opposed to the anticipatory process, and the incorporation of these by the user can prevent the excessive medicalization of risk, generated due to expectations of control over future diseases and suffering. The results point out that the insertion of parameters, values and concepts of yoga within discussions in the PHC groups can contribute to the greater autonomy of users by expanding the current discourses on risk factors, with greater appreciation for the underlying psychological and emotional issues that underlie the development of CVD. As a conclusion, there is a need for future studies that investigate concepts present in the yoga tradition, not only the already known and well explored psychophysical techniques, for the primary prevention of CVD.

[Chinese medicine/acupuncture: historical notes on the colonization of a body of knowledge]. / Medicina chinesa/acupuntura: apontamentos históricos sobre a colonização de um saber.

Western colonialism influenced the encounter between traditional and modern knowledge from the nineteenth century onwards, resulting in the overlapping of Western medicine as a privileged form of knowledge. In 1958 the hybridization between Chinese and Western medicines became official under the name of traditional Chinese medicine and, through the development of biomedical research on acupuncture, it distanced itself from traditional knowledge. This essay presents historical changes experienced by Chinese medicine/acupuncture and discusses the effects of its absorption by modern medical reasoning from a postcolonial standpoint. The conclusion was that the scientism of Chinese medicine did not broaden its therapeutic potential and resulted in the loss of its epistemological authority.

O colonialismo ocidental influenciou, a partir do século XIX, o encontro entre saberes tradicional e moderno, resultando na sobreposição da medicina ocidental como modo privilegiado de conhecimento. Em 1958 oficializou-se, sob o nome de medicina tradicional chinesa, a hibridização entre as medicinas chinesa e ocidental e, por meio do desenvolvimento da pesquisa biomédica sobre a acupuntura, cresceu o distanciamento do saber tradicional. Este ensaio aborda mudanças históricas sofridas pela medicina chinesa/acupuntura e discute, sob a óptica pós-colonial, os efeitos de sua absorção pela racionalidade médica moderna. Concluiu-se que o cientificismo na medicina chinesa não ampliou seu potencial terapêutico e resultou na perda de sua autoridade epistemológica.

Evaluation of Primary Health Care performance in Florianopolis, Santa Catarina, Brazil, 2012: a cross-sectional population-based study. / Avaliação do desempenho da Atenção Primária à Saúde em Florianópolis, Santa Catarina, 2012: estudo transversal de base populacional.

OBJECTIVE: to evaluate the performance of Primary Health Care (PHC) in Florianopolis, SC, Brazil. METHODS: this was a cross-sectional population-based study with adults living in the catchment areas of the Health Centers (HC) located in the Northern Health District of Florianópolis in 2012; the Primary Care Assessment Tool (PCATool-Brazil) was applied do assess the presence and extent of PHC characteristics. RESULTS: of the 598 interviewees, 68,4% reported that they considered PHC centers to be their usual source of care; while the usage subdimension of the First Contact Access characteristic was the best evaluated (8.4; 95%CI 8.2;8.6), the service delivery subdimension of the First Contact Access/subdimension accessibility was the worst evaluated (3.5; 95%CI 3.3; 3.6); four (36.6%) of the eleven PHC centers evaluated had a high overall and essential PHC score, although their overall mean score was low (6.4; 95%CI 6.2;6.5). CONCLUSION: considering the PHC model evaluated by PCATool-Brazil, PHC services need to be improved, especially with regard to their process and structure components.

Why is quaternary prevention important in prevention?

Quaternary prevention consists in the identification of persons at risk of excessive medicalization and their protection against new unnecessary interventions, avoiding iatrogenic damages. Here, we argue about the importance of quaternary prevention in specific primary and secondary prevention. The recent great development of preventive medicine, biomedicalization of risks and their treatment as if they were diseases, and the powerful influence of the commercial interests of pharmaceutical industries on the production of medical-sanitary knowledge alter classifications, create diseases and pre-diseases, lower cutoff points, and erase the distinction between prevention and healing. This situation converts larger amounts of asymptomatic persons into sick individuals and diverts clinical attention and resources from sick persons to the healthy, from older adults to young persons, and from the poor to the rich. Quaternary prevention facilitates and induces the development and systematization of operational knowledge and guidelines to contain hypermedicalization and the damages of preventive actions in professional care, especially in primary health care.

Duas críticas às normativas dos Núcleos de Apoio à Saúde da Família / Two criticisms of the Family Health Support Centers regulations / Dos críticas a las normativas de los Núcleos de Apoyo a la Salud de la Familia

Resumo Estudos empíricos identificaram insuficiências e precariedades na atuação de apoio matricial dos Núcleos de Apoio à Saúde da Família. Este artigo, baseado em experiências assistemáticas diversas e literatura selecionada, defende duas teses interligadas que criticam aspectos das normativas federais originais para atuação desses Núcleos: uma concepção − implícita nas normativas − de atenção primária à saúde como cenário de ações situadas apenas em campos de competência compartilháveis, por um lado; e a opção de inserção desses Núcleos relativamente fora do fluxo assistencial dos usuários, por outro. Argumenta-se que ambas, provavelmente, geraram efeitos adversos envolvidos nos problemas de atuação desses Núcleos: contribuíram para a superestimação dos seus resultados esperados, para o seu subaproveitamento e subdesenvolvimento institucional e para a precarização da sua legitimidade, dificultada com a Política Nacional de Atenção Básica de 2017 e atingida gravemente com o desfinanciamento federal em 2019. Defende-se o aperfeiçoamento dos Núcleos de Apoio à Saúde da Família e sugere-se sua inserção no fluxo assistencial entre a atenção primária à saúde e a atenção secundária, para reduzir o isolamento entre ambas e aperfeiçoar a coordenação personalizada do cuidado, facilitar a legitimidade dos 'matriciadores', o apoio matricial e a educação permanente dos profissionais.

Abstract Empirical studies have identified shortcomings and precariousness in the matrix support activities of the Family Health Support Centers. This article, based on diverse unsystematic experiences and selected literature, defends two interconnected theses that criticize aspects of the original federal regulations for the performance of these Nuclei: a conception - implicit in the regulations - of primary health care as a scenario for actions located only in fields of shareable competences, on the one hand; and the option of inserting these Centers relatively outside the care flow of users, on the other. It is argued that both, probably, generated adverse effects involved in the problems of operation of these Nuclei: they contributed to the overestimation of their expected results, to their underutilization and institutional underdevelopment and to the precariousness of their legitimacy, hampered by the 2017 National Primary Care Policy and seriously affected by the federal underfunding in 2019. The improvement of the Family Health Support Centers is defended and their insertion in the care flow between primary health care and the secondary care, to reduce the isolation between the two and improve the personalized coordination of care, facilitate the legitimacy of collaborative care, matrix support and the continuing education of professionals in Brazil.

Resumen Estudios empíricos identificaron carencias y precariedades en las actividades de apoyo matricial de los Núcleos de Apoyo a la Salud de la Familia. Este artículo, basado en diversas experiencias asistemáticas y literatura seleccionada, defiende dos tesis interconectadas que critican aspectos de las normativas federales originales para el funcionamiento de estos Núcleos: una concepción - implícita en las normativas - de la atención primaria de salud como escenario de acciones ubicadas únicamente en campos de competencia compartibles, por un lado; y la opción de inserción de estos Núcleos relativamente fuera del flujo de atención a los usuarios, por el otro. Se argumenta que ambas, probablemente, generaron efectos adversos involucrados en los problemas de funcionamiento de estos Núcleos: contribuyeron a la sobreestimación de sus resultados esperados, a su subutilización y subdesarrollo institucional y a la precariedad de su legitimidad, obstaculizada por la Política Nacional de Atención Primaria de 2017 y gravemente afectada por la falta de financiación federal en 2019. Se defiende el perfeccionamiento de los Núcleos de Apoyo a la Salud de la Familia y se sugiere su inserción en el flujo asistencial entre la atención primaria a la salud y secundaria, para reducir el aislamiento entre ambas y mejorar la coordinación personalizada de la atención, facilitar la legitimación de los 'matriciadores', el apoyo matricial y la formación permanente de los profesionales en Brasil.

[Specialized outpatient care in the Unified Health System: how to fill a void]. / Atenção especializada ambulatorial no Sistema Único de Saúde: para superar um vazio.

The structuring of specialized outpatient care is a bottleneck in the operation of the Unified Health System. Based on a brief discussion about this void in an organizational model, we propose the federal induction of a format of specialized services from the experiences of Centers of Support for Family Health (NASF). They adapted matrix operations and constitute an excellent prototype for the organization of specialized outpatient care. It allows for equal access and maximum proximity to the specialized care of the reality of primary care users, the personal relationship and the close relationship between the family health teams and medical and non-medical specialists, enabling mutual lifelong learning, negotiated regulation and increased efficacy of primary care. Municipal experiences of Florianopolis and Curitiba are synthesized as partial examples of the proposal. the structure of care in mental health of Florianópolis, all organized as a matrix support is briefly described; and we focus on the change in the action of the support teams of Curitiba, which gradually began to engage, involve and mediate the relationship between basic and specialized care. This format can be expanded to most medical specialties.

[Traditional and Complementary Medicine in Brazil: inclusion in the Brazilian Unified National Health System and integration with primary care]. / Medicina Tradicional e Complementar no Brasil: inserção no Sistema Único de Saúde e integração com a atenção primária.

This study aimed to analyze the inclusion of Traditional and Complementary Medicine in Brazilian Unified National Health System (SUS) and its integration with primary healthcare (PHC). A qualitative study drew on institutional data, indexed articles, and case studies in selected Brazilian cities: Campinas (São Paulo State), Florianópolis (Santa Catarina State), Recife (Pernambuco State), Rio de Janeiro, and São Paulo. The analysis adopted the perspective of inclusion of Traditional and Complementary Medicine in the healthcare network and its integration with primary healthcare, based on the following dimensions: presence of Traditional and Complementary Medicine on the municipal agenda; position in the services; mode of access to Traditional and Complementary Medicine; Traditional and Complementary Medicine practitioners; types of practices; demand profile; and potential for expansion in the SUS. The authors identified and characterized four types of inclusion and integration of Traditional and Complementary Medicine, whether in association or not: Type 1 - in primary healthcare via professionals from the family health teams - Integrated; Type 2 - in primary healthcare via professionals with full-time employment - Juxtaposed; Type 3 - in primary healthcare via matrix-organized teams - Matrix Organization; Type 4 - in specialized services - Without Integration. The combination of types 1 and 3 was considered a potential guideline for the expansion of Traditional and Complementary Medicine in the SUS and can orient the growth and integration of Traditional and Complementary Medicine with primary healthcare. The growing presence of Traditional and Complementary Medicine in the SUS requires conceiving its strategic expansion, while existing experiences should not be wasted.

Percepção de médica(o)s e enfermeira(o)s da Saúde da Família sobre o uso da auriculoterapia em problemas de Saúde Mental / Family Health doctors' and nurses' perceptions of the use of auriculotherapy for Mental Health problems / Percepción de médicos y enfermeros de la Salud de la Familia sobre el uso de auriculoterapia en problemas de Salud Mental

Técnicas não farmacológicas são consideradas cada vez mais importantes no cuidado aos Problemas de Saúde Mental (PSM). Exploramos a percepção de médicas(os) e enfermeiras(os) da Atenção Primária à Saúde (APS) do Distrito Sanitário Norte de Florianópolis/SC sobre o uso da auriculoterapia em PSM, via questionário on-line autoadministrado, qualiquantitativo. Os dados qualitativos receberam análise temática. Responderam aos questionários 44 profissionais (57% do total convidado). Das(os) respondentes, 57% das(os) enfermeiras(os) e 43% das(os) médicas(os) tinham formação em auriculoterapia e 93% a utilizavam e/ou indicavam para PSM. Foram referidos bons resultados clínicos com auriculoterapia em PSM comuns, sobretudo relacionados aos sintomas depressivos e ansiosos, incluindo insônia e dores associadas; além de contribuições positivas para o acolhimento, a humanização, a ampliação do cuidado e do autocuidado, e a redução de psicofármacos/medicalização. Na percepção das(os) participantes, a auriculoterapia é eficaz e útil no cuidado a PSM comuns na APS.(AU)

Non-pharmacological interventions are considered increasingly important in care for mental health problems (MHP). We explored the perceptions of primary care doctors and nurses working in the Norte de Florianópolis/SC health district regarding the use of auriculotherapy for MHP using a self-administered on-line qualitative and quantitative questionnaire. Thematic analysis was used to analyze the qualitative data. Forty-four professionals (57 per cent of the total number invited to participate) responded the questionnaire. Fifty-seven per cent of the nurses who responded the questionnaire and 43 per cent of the doctors had training in auriculotherapy and 93 per cent used and/or recommended the technique for MHP. The respondents reported good clinical results from the use of auriculotherapy for common MHP, especially those related to symptoms of depression and anxiety, including insomnia and associate pain; as well as positive contributions with regard to welcoming, humanization, expansion of care and self-care, and a reduction in the use of psychotropics/medicalization. According to the participants, auriculotherapy is an effective and useful technique in care for common MHP in primary health care.(AU)

Las técnicas no farmacológicas se consideran cada vez más importantes en el cuidado de los problemas de salud mental (PSM). Exploramos la percepción de médicas y médicos, así como de enfermeras y enfermeros de la Atención Primaria de la Salud (APS) del Distrito Sanitario Norte de Florianópolis (Estado de Santa Catarina) sobre el uso de la auriculoterapia en PSM, vía cuestionario on-line autoadministrado, cualicuantitativo. Los datos cualitativos pasaron por análisis temático. Respondieron 44 profesionales (el 57% del total invitado). De los respondedores, el 57% de las enfermeras o enfermeros y el 43% de las médicas o médicos tenían formación en auriculoterapia y el 93% la utilizaba o recomendaba para PSM. Se refirieron buenos resultados clínicos con auriculoterapia en PSM comunes, sobre todo relacionados a los síntomas depresivos y ansiosos, incluyendo insomnio y dolores relacionados, además de contribuciones positivas con relación a la acogida, humanización, ampliación del cuidado y autocuidado y reducción de psicofármacos/medicalización. Conforme la percepción de los participantes, la auriculoterapia es eficaz y útil en el cuidado de las PSM comunes en la APS.(AU)