Ivan Illich's second social critique of Health

Na Nêmesis da Medicina, Ivan Illich expôs os elementos essenciais da sua primeira crítica da saúde, afirmando que a ampla industrialização da saúde e medicalização da vida na sociedade moderna faz aparecer diversas formas de iatrogênese ou danos à saúde, como resultado da perda da capacidade de ação autônoma das pessoas perante a enfermidade, a dor e o envelhecimento. Na segunda crítica social da saúde, Illich trata do surgimento de uma nova iatrogênese social, a iatrogênese do corpo, que resulta de uma espécie de obsessão com a saúde corporal e com sua produção através de atividades físicas, dietas etc. em aparente condição de autonomia. Trata-se de um consumismo do corpo saudável, que responde menos à ação dos médicos e mais às informações difundidas pelos meios de comunicação e pelos agentes terapêuticos não-oficiais.In The Nemesis of Medicine, Ivan Illich displayed the essential elements of his first critique of health, stating that the widespread industrialization of healthcare and the medicalization of life in modern society create several forms of iatrogenesis or damage to health, as a result of people losing the capacity to behave autonomously vis à vis disease, pain and aging. In the second social critique of health, Illich deals with the manifestation of a new social iatrogenesis resulting from a sort of obsession with bodily health and its production through physical activities, diets, etc. in a condition of apparent autonomy. This is "healthy body" consumerism, which responds less to the actions of physicians and more to information publicized by the media and by unofficial therapeutical agents.En Nemesis de la Medicina, Ivan Illich expuso los elementos esenciales de su primera crítica de la salud, indicando que una industrialización extensa de la salud y la medicalización de la vida en la sociedad moderna crean varias formas de iatrogénesis o daños a la salud, que resultan de la pérdida de la capacidad de comportamiento autónomo de las personas ante la enfermedad, el dolor y el envejecimiento. En la segunda crítica social de la salud, Illich se ocupa del surgimiento de la iatrogenesis del cuerpo, que es una clase de obsesión con la salud corporal y con su producción a través de actividades físicas, dietas etc. en condiciones aparentes de autonomía. Ésta iatrogenesis es un consumismo del cuerpo saludable y no responde directamente a los comandos y a las intervenciones de los médicos sino que depende de la información que difundida por los medios de comunicación y por los agentes terapéuticos no oficiales

PERSPECTIVAS CRÍTICAS ACERCA DA RELAÇÃO ENTRE SAÚDE E DESENVOLVIMENTO COM FOCO NOS PAÍSES BRIC

The well-known interpretation of development as an equivalent of economic growth and industrialization is examined in its roots in American international cooperation in the post-war era and correlated with the doctrine of ECLAC about the vicious circle between poverty and disease. It is shown that later targets of international health policies came to highlight problems that affect the whole population, regardless of their level of income. Two contemporary approaches to this question are discussed: Amartya Sen’s notion of health as a human capacity, and innovation in health technologies as a Schumpeterian proposal.  The theoretical assumptions of these two approaches are discussed vis-à-vis contextual data of BRIC countries, so as to evaluate their health problems and development possibilities.A bem conhecida interpretação do desenvolvimento como crescimento econômico e industrialização é analisada em suas origens em programas e polí- ticas internacionais após a guerra de 1940 e correlacionada com a doutrina da Cepal acerca do círculo vicioso entre doença e pobreza. É evidenciado que a evo- lução posterior das políticas internacionais de saúde veio a enfatizar os problemas que afetam o conjunto da população, independentemente de seu nível de renda. Dois enfoques contemporâneos da questão são discutidos: a saúde como capaci- dade humana, de Amartya Sen, e a inovação tecnológica em saúde, como uma proposta de inspiração schumpeteriana. Os pressupostos desses dois enfoques são comentados vis-à-vis os dados contextuais dos países Bric, de modo a avaliar seus problemas de saúde e possibilidades de desenvolvimento

Perspectivas emancipatórias sobre a saúde e o Bem Viver diante das limitações do processo de desenvolvimento brasileiro

RESUMO No contexto da Rio+20 e na perspectiva da garantia da saúde de todos, este ensaio discutiu um novo tipo de pensar e de realizar a participação dos povos, tradicionalmente explorados e excluídos por efeito dos modelos de desenvolvimento capitalistas e colonizadores da vida humana e da natureza. Para tanto, o ‘desenvolvimento brasileir o’foi analisado com foco no agronegócio e suas contradições, e criticado mediante a concepção do Bem Viver. Foi proposto aqui vincular a ideia do Bem Viver às demandas dos povos que lutam por outro mundo possível e que poderão ser concretizadas mediante dimensões contra-hegemônicas de poder, de saber e de direitos, no âmbito de um projeto emancipatório

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030