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Health Surveillance and the Sphynx
Gonzalo Vecina Neto
Article in Folha de São Paulo (Tendências/Debates )
2 December 1998
As far as Brazilian society is concerned, health surveillance is a heavily
bogus sphinx. Just like the mythological character, health surveillance
either is understood by, or is devoured by its interlocutor. But if
the regulatory function of the health surveillance authorities is correctly
carried out, it will lead to a more civilized society as a whole.
The main responsibility of health surveillance in a modern State is
to exercise control over the risks which can arise from the production,
marketing and consumption of goods and services. Surveillance should
be able to guarantee, for example, that a medicine can go through the
above three phases and retain as it does so the effects promised on
the descriptive insert sold with the particular drug, and at the same
time without causing side effects over and above those which are outlined
in the contra-indications. To live without having to take unnecessary
risks is the right of any modern citizen. That is called civilization.
In the more developed countries of the world this idea has begun to
evolve to provide many clear benefits to the consumer. This means that
not only must the risks be eliminated but the benefits must also be
sought out. However, this is the subject of another chapter, given the
fact that in Brazil we have not even reached the stage of eating risk-
free hearts of palm.
Health surveillance, when it regulates the process on a value scale,
should help to bring about a better market, in addition to controlling
risks. When a given product benefits from effective control by health
surveillance, it benefits consequentially from being more competitive
in the current globalised economy. State supervision of manufacturing
processes is a fundamental key to Brazil being viewed as a respected
producer in this market, as well as for it to stand a better chance
of selling its products abroad. It is worth recalling at this point
that health surveillance has a direct role to play in the production
of almost 20% of our country's GDP.
It is therefore a pity that much of what is outlined above is in fact
illusory. In Brazil, this important function of the Modern State (vital,
and not simply a way of complying with the minimum requirements of liberal
discourse) has to date been consigned to the realm of fantasy, in view
of the fact that the difficulties we have to face are enormous and well-known.
The manager of National Health Surveillance has, on average, spent only
eight months in the post at a time (what private business would be able
to deal with that kind of turnover at the top?). The technical staff
are recruited on precarious employment terms and with no career prospects.
And there is no information system to enable the organisation to keep
track of companies, products, or what is happening as far as consumers
are concerned.
For example, in 1997 there were eight officially recorded deaths in
Brazil resulting from food poisoning, while in the USA there were around
9.000 notifications of food poisoning-related deaths. It is clear that
we have no idea of what is happening on the consumer front. In 1997,
the United States Food and Drugs Agency (FDA) ordered the pharmaceutical
drugs industry to withdraw ("recall") 3.625 medicines. In
Brazil, over the same period, no recalls at all were made. Is this because
Brazil is a fount of excellence in these matters? It is obvious that
it is not.
While the diagnosis is well known by all, so is the solution. We need
to set up an autonomous organ: a Health Surveillance Agency, under the
aegis of the Ministry of Health, and politically linked through a work
plan to be executed in accordance with public policies (a management
contract) which would enable pharmaco-surveillance to become familiar
with both manufacturers and their products and to exercise systematic
surveillance as well as carrying out a range of other functions. This
Agency should be a body endowed with job tenure for its management staff.
In other words, the management staff should be able to remain in their
posts when the government changes, and only move on when managers clearly
demonstrate that they are incapable of carrying through the policies
of the
State, the guardian of which is whatever government happens to be in
power at the time). Moreover, it should be an organisation which can
offer secure careers accessible exclusively only on the basis of public
examination - appropriately remunerated careers which have some prospect
of advancement.
In fact, "appropriate remuneration" has been completely misunderstood
by the Brazilian government bureaucracy. There exist three distinctive
classes of public employees: civil servants who are in charge of controlling
the money, civil servants that collect taxes and the rest of the civil
service clan. The
first are certainly privileged individuals compared to the last category.
The latter have nothing to do with significant financial aspects of
government, but because they do work with food and medical drugs, among
other products, they are relegated to an inferior plane.
Whoever proposed such a model, it is the negation of equality before
the law. My understanding on the contrary is that three parallel equalities
exist in which each of the different clans tries to acquire the overlapping
responsibilities pertaining to the rest. The State has to find a solution
for each type of problem. What I mean is that the solution for the personnel
area as far as Health Surveillance is concerned is contained in that
space in society in which the problems of industry, commerce and consumption
of goods and services are found.
So if we are aware of what to do in these circumstances, why don't we
get on and do it ? For three years, this proposal has been gathering
dust in the Ministry of Health. Every time the proposal tried to make
it from the Ministry and into Congress it has been obstructed by the
"carry on as always brigade" who enjoy tying administrative
reform to the rules of equality before the law. But we know that to
come up with an old solution to the problem is worse than doing nothing.
At this particularly critical time for Brazil, a time when we could
take a courageous step forward, given that we can count on the rare
statesmanlike abilities of Fernando Henrique Cardoso and a committed
and well-intentioned Health Minister in the shape of José Serra,
we should not allow ourselves to be defeated by an outmoded view of
the role of the State in society.
Getting back to the "Sphynx " analogy. If the productive sectors
which come under the control of surveillance and our society - which
has had to accept fake medicines and eat rotten palm hearts - do not
both wish to be eaten in turn, then we should stand up and make our
voices heard.
Gonzalo
Vecina Neto
Director-President of ANVISA
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