Fiebre reumatica y Tercer Mundo: opinan desde Brasil
I think this theme of Rheumatic Fever Prevention was very well taken, and perhaps can call attention to all of us for some other critical aspects of prevention not sufficiently considered in a paradigm that just considers the natural history of diseases beginning and finishing in the individual patient, in his personal behavior, reposing quite exclusively in secondary prevention.
My personal experience started with Rheumatic Fever secondary prevention and Congenital Heart Disease in the 1950s, but since the beginning it remained clear that Benzatine Penicillin given to acute cases of RF and chronic cases of RHD was of benefit just to the detected susceptible individuals, not for control of the disease in the community. It could not prevent the first attacks. The success of this strategy must be contemplated from the individual cases point of view, most in developed countries with better conditions of life and good access to health care services.
Secondary prevention is necessary to the detected susceptible individual cases and is better than nothing, but it was already demonstrated that the downtrend of RF in the world, begun much time before the availability of Penicillin and preceding the specific prevention programs.
In the 1970s we developed in our State a program directed for school-children, with a tentative approach to the diagnosis and treatment of sore throat, including health education of children and families.
Through joint experience with PAHO, WHO, WHF and UNESCO, at the end of the 1980s and into the next decade, we started a new tour de force, including a plan of an extensive and well controlled project in Bangladesh with support of EC, that unhappily could not be realized, even with money availability.
Today we are studying the social-determination of health/disease, and we are convinced that with the approach to the strict classical medical resources, we will not trespass this hardcore resistance where are the causes of the causes (recalling our late master Geoffrey Rose).
The same reasoning must to be applied to all other cardiovascular diseases and to other chronic diseases. We are fascinated by the discovery of the risk factors and description of their distribution through populations, our achievements through medicines for hypertension, cholesterol control, and heart failure; invasive procedures for diagnosis and treatment, surgeries, organs transplantation and so on...
Without human development, culture, education, economical and political stability we will benefit just a few individual cases.
Talking of social determination, we need to consider all interpersonal and inter-group relationships, not just considering rich and poor people. All human beings need respect, identity, a chance of self-expression and personal development inside the community. It may be called a utopia, but who some time ago could imagine what we are contemplating today?
The health gradients in our city among districts follow the socio-economic gradient. The burden of diseases, including CVD, is three or four times higher between extremes, even considering that we are reaching better levels of human development, what may be expressed also by the great level of control of Rheumatic Fever, that was our dream fifty years ago. We need to recognize that amelioration of the indicators and taxes are not direct effect of our original public health programs.
Our contribution probably was more valuable as health promotion, in public education, calling attention to the possibility of conquering better conditions of life, valorizing health and human rights, and demonstrating that not all diseases are a fatality, but can be controlled by collective mobilization and partnership, not just medical.
Pardon this discourse, but I think we are already good doctors and specialists pursuing professional excellence and good health for our clients, but we need also to be better world citizens looking beyond the fence of the traditional medical dominion.
Our ProCOR network is an example of the feasibility of connection of good will people, but we are not exploiting all of our power and responsibility inside our communities throughout the world. We could not just follow the wake of the traditional science, but we are sufficiently strong to be creative and give the necessary jump to reach what is evident (as did the example of Professor Bernard Lown before): Rheumatic Fever was quite completely controlled in several countries; other problems like infant mortality, under-nutrition were also somewhere controlled; the success obtained at the level of some individuals in the control of risk factors could be also achieved collectively, if they were be considered as components of communities with relationships that should be approached.
Sincerely yours
Aloyzio Achutti