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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.80 no.1 Rio de Janeiro Jan./Feb. 2005
The commitment of the Brazilian Society of Dermatology with the elimination of leprosy: are we also responsible for the failure in achieving this goal?
Fernando Terra, founder of SBD in 1912, was also the pioneer of the educational-assistantship integration for leprosy when he created the intern's residency in the then Hospital dos Lazaros in Rio de Janeiro, in 1913. The first interns were Aguiar Pupo and Oswaldo Portugal. Along the same lines, Eduardo Rabello in 1920, in the midst of the Carlos Chagas reforms, coordinated the "Prophylactic Inspection of Leprosy and Venereal Diseases", the first national public policy for control of the endemic that was effective until the end of the decade. This policy was severely criticized by the sanitary authorities of the time, not just for permitting isolation in the home, which contradicted the recommendation of segregating these patients, but also for being considered together with the venereal diseases. Another aspect of the reforms was administrative decentralization, leaving the incumbency of executing control programs to the states.
During the period known as the New State, compulsory isolation was included in a vertical program which was implemented with priority by the then president Getulio Vargas. The management of the policy for leprosy control became the sanitary authorities' responsibility. Only 56 years later, now in the New Republic, the onus was returned to the dermatologists, initially for seven years and, after a brief interregnum, for three more years. During that period, the implantation of polychemotherapy/WHO and the dissemination of the concept of a cure for the disease demanded a major restructuring of the program. The task of formulating plans for national action was passed to advisory committees; these included managers in state governments (macro-regional representation), the recently created MORHAN, the scientific societies and various professional disciplines involved in specific activities. Such an effort resulted in a great increase of the critical mass applied to the problem and was responsible for implementation of a single effective therapeutic strategy for the Country, with a reduction of 80% in the prevalence of the disease and 15% of the deformities among new cases, besides the first initiatives for elimination of the disease to be organized on a municipal level.
The purpose this brief history of the control of leprosy in Brazil is to clarify the real participation of members of SBD in the carrying out of these policies on a national scale, especially in view of the existence of documents issued by the World Health Organization that indicate that we were responsible for failure of the goal to eliminate the disease and consequently failure to control the Brazilian endemic. It should be underscored that the local and regional participation by dermatologists in throughout this history has been small and, at this time, only three states have dermatologists in state management positions. A recent study by the SBD via the Internet, covered 22% of the associates (1,122) and obtained a response from 28% of these regarding whether they were participating in activities for Leprosy control-the answer was positive in 54% of the respondents.
Nevertheless the SBD, in 1948, provided the stimulus for dermatologists/leprologists to found the then named: Brazilian Association of Leprology. It created its Department of Hansenology in 2003. In the future, the next administration of SBD will include among its priorities the following campaigns: the inclusion of Leprosy in the continuing education curriculum, the strengthening of university services and participation in public information activities with an emphasis on the early diagnosis of leprosy through campaign programs.
Thus, the SBD must not cease to manifest its perplexity in relation to the extinction of the Technical Area of Sanitary Dermatology, in the Ministry of Health, which has been replaced by a vertical program for the elimination of leprosy. In view of this fact, the SBD demands to participate in the formulation of current plans for elimination of the disease, a pertinent responsibility since it deals with public policies in areas in which it is involved. It should be unnecessary to refer to the great importance of the dermatoses that, in general, are among the first three causes that demand ambulatory health services. In our experience of contact with the FHP teams, their need for information regarding leprosy also extends to STDs/Aids, tegumentary leishmaniasis, pyodermatitis, pemphigus foliaceus, superficial and deep mycoses, pharmacodermias, and childhood dermatoses - these being among the more prevalent dermatoses. The decentralization of health services should not exclude the participation of specialists but should reallocate them in a system of reference and cross-reference in order to minimize the possibility of mistakes during the diagnostic and therapeutic management, besides favoring a permanent multidisciplinary education.
We are of the opinion that the historical dichotomies existent between the clinical and preventive models in medicine, and between the academic and the practical service have been provoking unnecessary conflicts, at times compromising the effectiveness of public policy. Irrespective of the management's particular educational background, every effort should be made to include, and not to exclude partnerships.
Maria Leide Wand Del Rey
Adjunct professor of Dermatology/FM/UFRJ and Coordinator of the Leprosy Department of the SBD
Prof. Ph.D. of the University of Amazonas/Dep. of Collective Health, Director of the Foundation of Tropical Medicine of the Amazon and President of SBD
Ph.D. in Tropical Medicine - University of Brasília and Vice-president of SBD
Heitor de Sá Gonçalves
Ph.D. in Dermatology at Federal University of Ceará and 2nd Secretary of SBD