On mosaics and consensus: Gaudí, Brazil and rheumatoid arthritis
Licia Maria Henrique da Mota
PhD in Medical Sciences, Medical School, Universidade de Brasília - FMUnB; Collaborating Professor of Internal Medicine of the Rheumatology Service, FMUnB; Advisor in the Post-Graduation Program, FMUnB
Rheumatoid arthritis (RA) is a progressive, systemic and chronic disease characterized by impairment of the synovial membrane, mainly of peripheral joints. Untreated disease results in radiographic joint damage, functional disability, and early mortality. Its prevalence is estimated in 0.5%-1% of the world population.1
The neo-Gothic Catalan architect Antoni Placid Gaudí i Cornet (1852-1926) is one of the several personalities possibly affected by RA. His plastic conceptions became famous worldwide and symbols of Barcelona, where he spent most of his life.2
Since childhood, Gaudí might have been affected by a type of rheumatism, possibly juvenile idiopathic arthritis, despite the lack of records on deformities characteristic of that disease. The long resting periods and limitation imposed to the youngster by that possible joint disease might have deeply influenced his way of observing and portraying nature.2
Among the several modalities of Gaudí's artistic representation, trencadís stands out, a millenary decorative form of art, a type of mosaic created from broken tile shards, small pieces of ceramic, forming brightly-colored patterns that integrate harmoniously.
Brazil, with its harmonious mixture of ethnicities, cultures, and beliefs in its vast territory, can be symbolically compared with a fabulous Gaudí's mosaic - very different pieces composing a unique cohesive whole.
However, maintaining the cohesion and harmony when dealing with all the diversity of the Brazilian macroregions, with their markedly distinct economic and social scenarios, aiming at homogenizing conducts and practices for managing chronic diseases, is not an easy task.
That was the challenge of the Rheumatoid Arthritis Committee of the Brazilian Society of Rheumatology (BSR) when writing down the 2012 Consensus of the BSR for the treatment of RA.3 The consensus is an educational tool, rather than a guideline, which allows their authors to add the experts' experience and opinion to scientific evidence.
If on the one hand, as a publication, the consensus loses in terms of recommendation and evidence grading, it wins as an educational tool by valuing the experience of those who cope with the difficulties of daily practice in managing the disease. It is also similar to a mosaic, with the opinions of the experts who participate in its elaboration, often different and conflicting, harmonizing in a final document united by the amalgam of scientific evidence.
Assessing the peculiar characteristics of Brazil, a huge country, unique in its socioeconomic aspects, how to do a harmonious mosaic/consensus using so different pieces?
We would have to undoubtedly consider scientific evidence and the great advances in the knowledge of the pathophysiological mechanisms of RA, with the development of new therapeutic classes and the implementation of different strategies of patients' treatment and follow-up, such as intensive disease control and intervention at the initial phase of symptoms.1
It was imperative that the elevated costs related to RA management resulting from both direct and indirect factors, and which compete for the (limited) resources of health in other essential interventions, be assessed.
In a moment of epidemiological transition, the consensus/ mosaic should indicate that not only comorbidities, such as systemic arterial hypertension, coronary artery disease, and diabetes mellitus, so prevalent in our population, should be considered important factors in the follow-up of patients with RA, but endemic-epidemic transmissible diseases, although not yet an important problem of public health in Brazil, should also be contemplated in the document.
The 2012 Consensus of the BSR for the treatment of RA was elaborated aiming at providing recommendations for the treatment of RA in Brazil, considering the peculiar characteristics of our country, such as drug availability, socioeconomic status of the population, pharmacoeconomic aspects, and occurrence of several endemicities. In accordance with the publication of the Guidelines for the Treatment of RA, the Consensus provides 20 recommendations and a flowchart for the medicamentous management of the disease.
Gaudí, renowned for the esthetic of his art, was also a man of high spirituality - at the Vatican, there is an ongoing beatification process of the architect.4 In his moments of introspection, Gaudí used to write and authored some famous quotes, one of which is as follows: "The creation continues incessantly through the media of man, but man does not create... he discovers."
Recent North-American and European guidelines for the treatment of RA have been published, and the scientific evidence that supported them is the same that supports ours. Thus, we did not aim at creating recommendations completely different from those that have been scientifically proved and are currently accepted as correct for the treatment of RA, but at discovering a way to adapt them to Brazilian reality.
That is our mosaic.
1Mota LMH, Cruz BA, Brenol CV, Pereira IA, Fronza LS, Bertolo MB et al 2011 Consensus of the Brazilian Society of Rheumatology for diagnosis and early assessment of rheumatoid arthritis. Rev Bras Reumatol 2011;51(3):199-219.
2Azevedo VF, Diaz-Torne C. The arthritis of Antoni Gaudí. J Clin Rheumatol 2008;14(6):367-9.
3Mota LMH, Cruz BA, Brenol CV, Pereira IA, Fronza LS, Bertolo MB et al 2012 Consensus of the Brazilian Society of Rheumatology for treatment of rheumatoid arthritis. Rev Bras Reumatol 2012;52(2):135-74.
4Terragona JM. Antoni's Gaudí beatification. Available from: http://www.antonigaudi.org/Eng/443/443/1.htm [Acessed on December 17, 2011]
Publication in this collection
26 Mar 2012
Date of issue