Using concepts from geography, a doctoral thesis defended at the Institute of Geosciences (IG) demonstrates that the Brazilian territory is “dependent SUS” and that all people residing here, including foreigners, use and depend on the Unified Health System in one way or another. otherwise. It was his master's project on a municipal herbal medicine program in Campinas, later validated as doctoral research by the qualification committee, that allowed geographer Luis Henrique Leandro Ribeiro to read the SUS as a health macrosystem, thus characterized by the plurality of networks techniques and policies, organizations and command centers, scales of action and flows, and the ability to shape and be shaped by the specificities of each place.

“Medical-hospital assistance is just one of the components of this macrosystem, but the most remembered when we refer to it, which leads to the simplistic equation that 75% of Brazilians are 'SUS dependent' and 25% can afford health plans; that SUS is for the poor”, observes Luis Ribeiro. “This is wrong, as reading it as a macrosystem shows that the majority of highly complex procedures (almost 100% of transplants, for example) are carried out by the SUS; that more than half of doctors work in the system; that the greatest experts have their training with public resources; that the best health research centers are still public; and that in immunization campaigns and urgency and emergencies, the SUS acts hegemonically, as well as in prevention and primary care actions.”

Guided by professor Márcio Cataia and financed by Fapesp, the thesis entitled “Territory and health macrosystem: phytotherapy programs in the Unified Health System (SUS)” intends, in the author's words, to read the SUS in its visibilities and invisibilities, both in what is remarkable and extraordinary, as well as commonplace and unnoticed. “The motto of the research was to understand how the SUS integrates various complementary and alternative medicine practices into traditional medicine – and how the territory conditions and is conditioned by the existence of phytotherapy programs in the system. I remembered a case of burns at a gas station in Campinas, when the patient was prescribed aloe vera gel produced by a municipal compounding pharmacy that serves the public network – one of the pioneering services in the country.”

With the aim of analyzing, from a geographical point of view, how the municipal service manages to promote technical synergy between local knowledge and the political strategy of production and distribution of herbal medicines, Luis Ribeiro investigated 14 herbal medicine programs and went to the field in 24 municipalities, totaling 81 interviews in the four Brazilian macro-regions. “We follow the definition of the 'four Brazils' by Milton Santos and Maria Laura Silveira, in reference to the Concentrated Region (Southeast and South), Central-West, Northeast and Amazon. This regionalization is based on the differential diffusion of the technical-scientific-informational environment throughout the territory – modernizations expressed both in the formation of the Unified Health System and in the recent appreciation of medicinal plants and herbal medicines.”

HISTORIC

According to Ribeiro, in the midst of the Counterculture of the 1960s, a global movement emerged to value the use of medicinal plants on new bases, intensified by environmentalist ideas (Stockholm Conference on the Environment, in 1972), and later by the Conference on Primary Health Care (1978), which resulted in the Declaration of Alma-Ata (Kazakhstan), in support of the adoption of more preventive medicine in national systems. In Brazil, so-called complementary and alternative medicine practices began to be disseminated in the 80s, in the context of redemocratization, when some municipalities began to adopt them on their own.  

According to the researcher, in the 90s, after the creation of the SUS, there was an increase in the number of phytotherapy programs. “The Campinas program, for example, arose from conversations between a doctor and health center users, identifying the most used species and for what purposes. The doctor turned to CPQBA [Pluridisciplinary Center for Chemical, Biological and Agricultural Research] at Unicamp, which carried out botanical identification and validated the efficacy and safety of the plants. Of more than 60 species initially surveyed, around ten were validated to enter the system.”

Luis Ribeiro points to the National Policy on Medicinal Plants and Phytotherapeutics, established in 2006, as the great disseminator of herbal medicine programs in the SUS, which were 21 in 1997 and jumped to 346 in 2008 and 815 in 2012. “One problem is that, in qualitative analysis, we identified a phase before and after the government policy: before there were around 80% of municipal compounding pharmacies and 20% of private ones – indicating a predominance of horizontal programs, linked to local practices and knowledge, closer to the ideal of the Brazilian Health Reform movement that culminated in the founding of the SUS.”

The geographer found that in the second phase this relationship was reversed: in 815 municipalities, 80% used industrialized herbal medicines and 20% used municipal pharmacies, indicating programs that were more insensitive to the practices and heritage of the places. “It is a process of co-opting these programs by the rationality of biomedicine – understood here not only by its technical, scientific, clinical and laboratory basis, but also by its association with a corporation of professionals (in this case, doctors), large companies (equipment, pharmaceutical inputs and service providers) and the State. This is what ended up predominating in the SUS phytotherapy subsystem.” 

CONSTRAINTS

The author of the thesis highlights that the model for the country's programs is Farmácia Viva, from Ceará, which is responsible for all stages of production: cultivation of green mass, processing, workshop or compounding pharmacy (for ointments, gels, capsules , syrups) and dispensing. “Professor Francisco Matos created Farmácia Viva in 1983, based on the garden at the Federal University of Ceará. He became famous for his travels throughout the Northeast, surveying and identifying species in communities: he combined local practice and knowledge with technical-scientific-informational capacity and standards.”

However, it is rare for a program that manages to complete all the stages, according to Luis Ribeiro, who created a table summarizing the “constraints and factors limiting the existence of the phytotherapy subsystem in the SUS”, the main ones being: discontinuities and ruptures due to changes in the municipal government and resistance from managers and doctors; and lack of control over raw materials and difficulties in purchasing and acquiring inputs in the input market, due to untrained suppliers and the quality of products. “Of the programs I visited, most were deactivated by Anvisa to adapt their laboratories to standards.”

The geographer notes that even in the State of São Paulo, which has the most widespread and widespread technical, scientific and information variables, there are obstacles to including herbal medicines in the public system. “It is the state of the Concentrated Region where the most programs are created – and where the most are extinguished. São Paulo has the largest number of universities and professionals trained in complementary practices, more than 80% of the herbal medicine industry (in addition to a good share of extract production) and the three main wholesalers of medicinal plants. But if these variables enable a policy to incorporate these practices, at the same time there is a high rate of mortality, interruption or discontinuity of experiences.”

INVISIBILITIES

During the research, the author of the thesis says he identified two fields of invisibilities of the SUS, as the main structuring force of the Brazilian health macrosystem. “One of the fields is the deliberate production of a SUS that is 'not seen', mainly by large media companies (print and television), a certain 'silencing' of the presence of the SUS. Another field of invisibilities lies in the relative inability or limitation of the SUS in reading, recording and incorporating local practices and knowledge, remaining silent about these cultural and institutional legacies.”

The researcher observes that both invisibilities are expressions of the duality of the SUS: two forces that move it, one of which is its founding force in the Constituent Assembly, aiming for a public and universal health system. “The Brazilian health macrosystem is dual, but not dualistic: it realizes health as a social right and the system as a space for political transformation, but it also gives space to a force that realizes health as a commodity and locus of capital accumulation.”

To carry out its actions, the system needed a material base, such as health units, which began to exist in a sufficient and more integrated way in the Brazilian territory from the 1970s onwards. The issue is that much of this materiality is beyond direct control. of the single and public management of the system. “The military dictatorship promoted an intense transfer of this hospital and outpatient base to large private groups. The pharmaceutical industry, part of the necessary materiality, was already privately based, and the arrival of multinationals resulted in the internationalization of production in the 1950s. And diagnostic and therapeutic support services, which emerged with greater intensity from the 80s onwards, are also largely private or corporate.”

Luis Ribeiro concludes that a difficulty for the SUS, therefore, is having part of the material base following a mercantile logic, which will be accentuated with the unrestricted opening of the area of ​​health services and providers to foreign capital approved in January 2015. “There is a force of inertia that hinders the insertion of non-hegemonic practices into the SUS (including phytotherapy), as well as its fullest realization as a project of political transformation, which is largely due to the hegemonic directive force of the macrosystem: biomedicine as association between medical corporations, large companies and the State.”

Publication

Tese: “Territory and health macrosystem: phytotherapy programs in the Unified Health System (SUS)”

Author: Luis Henrique Leandro Ribeiro

Advisor: Márcio Cataia

Each: Institute of Geosciences (IG)

Financing: Fapesp