Inducción sanitaria de los cribados: impacto y consecuencias. Aspectos éticos

Geoffrey Rose e o princípio da precaução: para construir a prevenção quaternária na prevenção

A prevenção tem sido medicalizada gerando danos iatrogênicos frequentes. Isso demanda prevenção quaternária (P4): evitar medicalização/intervencionismo desnecessários e danos iatrogênicos correlatos. Apresentamos, neste artigo, uma articulação conceitual orientadora da P4 na prevenção. Geoffrey Rose distinguiu entre medidas preventivas “redutivas” (reduzem riscos derivados da vida moderna, como sedentarismo e ultraprocessados na alimentação) e “aditivas” (adicionam fatores artificiais protetores, como vacinações, rastreamentos, fármacos hipolipemiantes). O grande potencial de danos das medidas preventivas aditivas exige aplicação sistemática do princípio da precaução. Este orienta que, havendo dúvidas científicas sobre danos potenciais significativos de uma atividade, o Estado deve ativamente evitá-los, por meio de atribuição do ônus da prova de eficácia/segurança da atividade aos proponentes, exploração de alternativas inofensivas e aumento da participação pública na decisão. Tal aplicação, crucial para a P4 na prevenção, amiúde não ocorre em práticas preventivas de alta prevalência e iatrogenia.

[Early detection or screening in the prevention of prostate cancer?]

Prostate cancer (PC) is the most common malignancy in men in the developed world and the second leading cause of cancer death in men in the USA, behind lung cancer. In Europe, it is the third leading cause of cancer death in men (after lung and colorectal cancers). The role of PC screening is currently being questioned. The following article summarises the most relevant epidemiological aspects of PC, as well as major clinical trials of PC screening, and recommendations of the various medical scientific associations on whether or not to screen for PC.

[Longitudinality, prestige, good reputation (social and professional) and general/family medicine. Clinical and public health aspects. SESPAS Report 2012]

The reform of primary care in Spain in 1984 focussed mainly on skills and knowledge (physician training and working hours) and material resources (new buildings). The reform did not succeed in improving longitudinal care nor did it give primary care physicians greater power, that is, the reform did not increase coordination or strengthen the central role of the family physician in services provision. The lack of longitudinality has persisted over the years since the working methods that encourage it (and its resulting clinical and public health benefits) have not been stimulated. Longitudinality is the personal relationship established over the years between general practitioners and their patients and is defined as (a) care by the same family physician of most of the patient's problems throughout his or her life, and (b) the recognition by patients and the population of a stable source of care to be used for initial contact and for the follow-up of problems. The tendency in the medical profession and society at large is to respond to an increasing number of health problems more quickly and intensely, with increasingly powerful means and with a greater number of specialists. In turn, this tendency makes medical activities dangerous. To counteract this tendency, a motto of "less is better" should be adopted, implying greater longitudinality. Many initiatives could improve longitudinality, such as incentives for not moving, increasing the capitation component of remuneration to nearly 50%, broadening the range of general practitioners' skills, including family members in the same patient list, and transforming the role of specialists into that of consultants.