THE DAI LY ROUTI NE OF PATI ENTS I N TUBERCULOSI S TREATMENT I N BASI C HEALTH
CARE UNI TS: A PHENOMENOLOGI CAL APPROACH
1Elisabet e Pim ent a Ar aúj o Paz2 Ant onia Mar gar et h Moit a Sá3
Paz EPA, Sá AMM. Th e d ai l y r o u t i n e o f p at i en t s i n t u b er cu l o si s t r eat m en t i n b asi c h eal t h car e u n i t s: a ph en om en ological appr oach . Rev Lat in o- am En fer m agem 2 0 0 9 m ar ço- abr il; 1 7 ( 2 ) : 1 8 0 - 6 .
Th is st u dy pr esen t s a ph en om en ological r ef lect ion on t h e daily car e r ou t in e of pat ien t s in TB t r eat m en t . I t aim ed t o under st and t he r out ine of t r eat m ent deliv er ed at t he pr im ar y healt h car e ser v ice. Phenom enological int er v iew s w er e car r ied out w it h pat ient s infect ed w it h TB and healt h pr ofessionals at Pr im ar y Car e Unit s in Belém , PA, Br azil. Repor t s w er e or ganized in unit s of m eaning and analy zed accor ding t o Mar t in Heidegger ’s fr am ew or k. Her m eneut ics r evealed t hat infect ed people fear t he disease and it s consequences, car e is pr ovided in an im per sonal w ay, r esponsibilit y for t he t r eat m ent is em phasized by pr ofessionals and assum ed by pat ient s, an d pr of ession als’ beh av ior is pr edom in an t ly based on t h e biom edical t ech n ical st an dar d. We con clu de t h at t her e is a gap bet w een t he t r eat m ent offer ed and t he expect ed hum anized t r eat m ent w it h a view t o successful cont r ol of t he disease.
DESCRI PTORS: pu blic h ealt h ; t u ber cu losis; ph en om en ology
LO COTI DI ANO DEL TRATAMI ENTO DE PERSONAS ENFERMAS DE TUBERCULOSI S EN
UNI DADES BÁSI CAS DE SALUD: UN ABORDAJE FENOMENOLÓGI CO
Est e ar t ículo pr esent a r eflexiones sobr e lo cot idiano asist encial del t r at am ient o a los por t ador es de t uber culosis, fu n dam en t ada en la fen om en ología. Tu v o com o obj et iv o com pr en der lo cot idian o asist en cial del t r at am ien t o de t uber culosis, r ealizado en ser vicios básicos de salud. El est udio fue desar r ollado con por t ador es de t uber culosis y pr ofesionales de salud en Unidades Básicas de Belém , PA. Se r ealizar on ent r ev ist as fenom enológicas con los par t icipant es. Los discur sos fuer on or ganizados en Unidades de Significado y , después, analizados a par t ir del m ar co t eór ico de Mar t in Heidegger . La h er m en éu t ica m ost r ó qu e los en f er m os t em en la en f er m edad y su s consecuencias, el cuidado que se r ealiza de m odo im per sonal, la r esponsabilidad por el t r at am ient o enfat izada p or los p r of esion ales y asu m id a p or los en f er m os y q u e y las con d u ct as d e los p r of esion ales se p au t an , pr edom inant em ent e, por las nor m as t écnicas del discur so biom édico. Se concluy e que ex ist e un hiat o ent r e el t r at am ient o ofr ecido y el t r at am ient o hum anizado que se pr et ende alcanzar con la finalidad de obt ener éxit o en el cont r ol de la enfer m edad.
DESCRI PTORES: salu d pú blica; t u ber cu losis; fen om en ologia
COTI DI ANO DO TRATAMENTO A PESSOAS DOENTES DE TUBERCULOSE EM UNI DADES
BÁSI CAS DE SAÚDE: UMA ABORDAGEM FEN OMEN OLÓGI CA
Est e ar t igo apr esen t a r ef lex ão sobr e o cot idian o assist en cial do t r at am en t o aos por t ador es de t u ber cu lose, fundam ent ada na fenom enologia. Tev e com o obj et iv o com pr eender o cot idiano assist encial do t r at am ent o de t uber culose, r ealizado em ser viços básicos de saúde. O est udo foi desenvolvido com por t ador es de t uber culose e pr of ission ais de saú de em Un idades Básicas de Belém , PA. Realizou - se en t r ev ist a f en om en ológica com os par t icipan t es. Os discu r sos f or am or gan izados em Un idades de Sign if icação e, após, an alisadas a par t ir do r efer encial de Mar t in Heidegger . A her m enêut ica m ost r ou que os doent es t em em a doença e suas consequências, o cuidado que se r ealiza de m odo im pessoal, a r esponsabilidade pelo t r at am ent o enfat izada pelos pr ofissionais e assum ida pelos doent es e que e as condut as dos pr ofissionais se paut am , pr edom inant em ent e, pelas nor m as t écn icas d o d iscu r so b iom éd ico. Con clu i- se q u e h á u m h iat o en t r e o t r at am en t o of er ecid o e o t r at am en t o hum anizado que se pr et ende alcançar com v ist as ao êx it o no cont r ole da doença.
DESCRI TORES: saú de pú blica; t u ber cu lose; f en om en ologia
1Ar t icle based on par t ial r esult s of t he r esear ch pr oj ect “ Sit uações de saúde doença no cot idiano assist encial de enfer m agem em saúde colet iva”, Escola de
Enfer m agem Anna Ner y, Univer sidade Federal do Rio de Janeir o, Brazil; 2Ph.D. in Nur sing, Adj unct Pr ofessor, Escola de Enfer m agem Anna Ner y, Univer sidade
Federal do Rio de Janeir o, Br azil, e- m ail: bet e.paz@gm ail.com ; 3Doct or al St udent , Assist ant Pr ofessor, Univer sidade do Est ado do Par á, Brazil, e- m ail:
m ar gar et hm sa@gm ail.com .
I NTRODUCTI ON
D
i v e r se f a ct o r s, i n t r i n si c t o p r o f e ssi o n a l act iv it y in healt h, do not alw ay s answ er t he challengesh ea l t h ser v i ces f a ce t o p r o m o t e p r o b l em so l v i n g ,
qualified and hum anized car e. Hum an lim it at ions ar e
am ong t hese fact or s: t he r ealit y of t he disease, t he
im possibilit y of alw ay s cur ing it or ev en t ak ing car e
of pr oblem s in t h e best possible w ay, dif f icu lt ies t o
pr ov ide aid in h ealt h ser v ices an d t h e u su al r ealit y
of pr ox im it y t o deat h am ong pat ient s w it h diseases.
Per m eat ing t his set of fact or s, t her e is an aspect of
gr eat im por t ance in pr ofessionals’ pr act ice in dealing
w i t h h u m a n d i m e n si o n s, i n cl u d i n g e m o t i o n s a n d
affect iv it y, w hich should per m eat e t he r elat ion am ong
nur ses, t echnicians, pat ient s and fam ily m em ber s( 1).
Th r o u g h o u t t h e h i st o r y o f h u m a n i t y, m en
hav e been at t em pt ing t o appr opr iat ely concept ualize
t h e h e a l t h - d i s e a s e p r o c e s s . At e a c h f o r m u l a t e d
concept , lim it at ions t hat put in check it s v alidit y and
f u n c t i o n a l i t y i n t h e e x p l a n a t i o n p r o c e s s a r e
appoint ed, as w ell as coping st r at egies. I t has been
o b se r v e d a l m o st a l w a y s t h a t t h e p r o p o sa l o f t h e
new est for m ulat ed concept is t o ov er com e past ones
w it h a pr et en sion t o pr ov ide t h e “ fin al ver sion ”, t h e
m ost r elev ant concept on t he t opic( 2).
Th e r epr esen t at ion of h ealt h an d disease is
also r elat ed t o t h e d eg r ee of k n ow led g e r eg ar d in g
t h is pr ocess an d t h e r esou r ces av ailable for copin g,
w h ich can b e ob ser v ed in each h ist or ical p er iod of
h u m a n i t y( 2 ). Be i n g h e a l t h y, si ck , i n p a i n , w e a k ,
u n c o m f o r t a b l e a r e w a y s p e o p l e p e r c e i v e t h e s e
in t er act ion s w it h t h e en v ir on m en t , social con dit ion s
and phy sical condit ions t hat follow in life. The need
t o k now , r epr esent and cope w it h diseases is par t of
h u m a n b e i n g s a n d p e r m e a t e s t h e i r w h o l e l i f e i n
s o c i e t y i f o n e c o n s i d e r s t h a t t h i s i s o n e o f t h e
har dships t o be ov er com e in t he cour se of life.
Br azil occu pies t h e 1 6t h posit ion am on g t h e
22 count r ies t hat concent r at e 80% of t he t uber culosis
load in t h e w or ld. Th e est im at ed pr ev alen ce is 5 8 /
100, 000 inhabit ant s, 50 m illion of infect ed people ar e
l i k el y t o d ev el o p t h e d i sease, 1 1 1 , 0 0 0 n ew cases
a n d 6 , 0 0 0 d e a t h s a y e a r. Th e r a t e s o f cu r e a n d
t r e a t m e n t a b a n d o n m e n t a r e 7 5 a n d 1 2 % ,
r esp ect iv ely( 3 ).
To r e d u c e t r e a t m e n t a b a n d o n m e n t a n d
i n cr ease cu r e r at es, t h e DOTS ( Di r ect l y Ob ser v ed
Tr eat m en t Sh or t Cou r se) st rat egy r ecom m en ded b y
t h e Wo r l d Hea l t h Or g a n i za t i o n ( W HO) f o r p r i o r i t y
co u n t r i e s h a s b e e n su cce ssf u l l y i m p l e m e n t e d i n
sev er al Br azilian cit ies. I t s im p lem en t at ion h as n ot
b een h om og en eou sly, h ow ev er, som e cit ies in São
Paulo and Rio de Janeir o hav e pr esent ed good r esult s
in r elat ion t o pat ien t s’ t r eat m en t . Th ese r esu lt s ar e
v e r y d i f f e r e n t f r o m o t h e r B r a z i l i a n S t a t e s t h a t
pr esen t h igh in ciden ce of cases lik e Rio Gr an de do
Sul, Par á and Bahia, w hich did not m anage t o m ak e
it feasible in local healt h unit s( 3).
I n t h e d aily r ou t in e of ou t p at ien t clin ics at
basic healt h unit s t hat offer t he Tuber culosis Cont r ol
Pr og r am , t h e car e d eliv er ed t o in f ect ed p at ien t s is
b a se d o n r e l a t i o n s t h a t v a r y f r o m p a t i e n t s’ t o t a l
s u r r e n d e r t o p r o f e s s i o n a l c a r e t o t r e a t m e n t
abandonm ent for per sonal r easons or r easons link ed
t o t h e car e r eceiv ed at t he healt h ser v ice.
I n gener al, healt h car e pr act ices cause r ev olt
d u e t o t h e p r essu r e ex er t ed b y d em an d , ex cessiv e
b u r eau cr acy an d w or k p r ocesses t h at d o n ot f av or
hum anized healt h car e. I n t his cont ex t , pr ofessional
a c t i o n s a r e p r e s e n t e d a s “ d e h u m a n i z e d ” a n d
t ech n ically lim it ed( 4 - 5 ).
I f a chr onic t r eat m ent , lik e t he TB t r eat m ent ,
pr esen t s n u an ces t h at can con t r ibu t e t o it s su ccess
or, on t he cont r ar y, t o negat ive out com es t hat r esult
in abandonm ent or deat h, w e ask : What is not clear
t o t h o s e w h o w o r k w i t h a s o s o c i a l l y c o m p l e x
d i se a se ? W h a t t o d o a t t h e se r v i ce s t o a ch i e v e
effect iv e indicat or s? What at t it udes should be adopt ed
t o m i n i m i ze d i so r d er s TB i m p o ses o n t h e l i v es o f
pat ien t s an d f am ily ?
T h i s s t u d y a i m e d t o g e t t o k n o w t h e
d i m en si o n o f t h e t r ea t m en t f o r p r o f essi o n a l s a n d
people w it h t uber culosis, t hr ough t he under st anding
of t h e t u ber cu losis t r eat m en t r ou t in e car r ied ou t in
b asic h ealt h ser v ices.
METHOD
The st udy used Heidegger ’s phenom enology
m et h od , w h ich is t h e d escr ip t ion of t h e g en esis of
t h e p h en om en on , d escr ip t ion of essen ces, w ay s of
bein g, m ak in g t h em v isible. Th is st u dy w as car r ied
ou t in a pu blic in st it u t ion at t h e St at e Un iv er sit y of
Pa r á a n d t w o h ea l t h u n i t s i n Bel ém d o Pa r á , PA,
B r a z i l . T h e s e l f - a d m i n i s t e r e d a n d s u p e r v i s e d
t h er ap i es o f t h e t u b er cu l o si s co n t r o l p r o g r am ar e
o f f er ed a t t h ese ser v i ces. Tw en t y - o n e p a t i en t s i n
least 3 0 day s an d older t h an 1 8 y ear s par t icipat ed
i n t h e s t u d y, i n a d d i t i o n t o 2 1 p r o f e s s i o n a l s :
p h y si ci a n s, n u r ses, so ci a l w o r k er s, p sy ch o l o g i st s,
n u r sin g t ech n ician s an d on e com m u n it ar ian h ealt h
ag en t . Ph en o m en o l o g i cal i n t er v i ew s w er e u sed t o
collect dat a.
Et hical pr inciples r ecom m ended for r esear ch
inv olv ing hum an beings w er e obser v ed and appr ov al
w as ob t ain ed f r om t h e Resear ch Et h ics Com m it t ee
at t he Anna Ner y Nur sing School, Feder al Univ er sit y
of Rio d e Jan eir o. Th e p r oj ect an d ob j ect iv es w er e
p r e s e n t e d t o p a r t i c i p a n t s a n d i n t e r v i e w s w e r e
r eco r d ed af t er t h ey r ead an d si g n ed t h e f r ee an d
in f or m ed con sen t t er m .
Aft er aut hor s com plied w it h t he r equir em ent s
of t he st udied inst it ut ions, t hey got fam iliar w it h t he
r esear ch en v ir on m en t so as t o pr ev iou sly k n ow t h e
r out ine of t he car e unit s.
D i sco u r se an al y si s w as car r i ed o u t i n t w o
s t a g e s . I n t h e f i r s t s t a g e , t h e m e a n i n g u n i t s
ad d r essin g t h e v ag u e u n d er st an d in g of su b j ect s in
r e l a t i o n t o w h a t w a s a sk e d w a s e l a b o r a t e d . Th e
v a g u e a n d a v e r a g e u n d e r st a n d i n g w a s o r g a n i ze d
fr om t he t r anscr ipt ions of par t icipant s’ discour se. The
m ost r epeat ed t hem es w er e collect ed, based on t he
m e a n i n g s u s e d b y s u b j e c t s t o e x p r e s s t h e i r
ex per iences. I t is t he m ost im m ediat e under st anding
o f w h a t t h e y e x p e r i e n c e i n t h e i r d a i l y l i f e a n d
charact er ist ic of t he ont ic w ay, t hat is, t he im m ediat e
w o r l d o f b u sy d ai l y l i f e. I n t h e seco n d st ag e, w e
so u g h t t o u n v e i l t h e m e a n i n g t h a t su p p o r t s t h e
ex ist en ce of t h e su b j ect s in t h e d y n am ics of t h eir
life w it h t u ber cu losis by lin k in g w h at h ad been said
a n d i t s i n t e r p r e t a t i o n , w h i c h i s t h e s e a r c h f o r
m ean i n g . To b ase t h i s an al y t i cal an d h er m en eu t i c
in t er p r et at ion , Heid eg g er ’s p h ilosop h ical f r am ew or k
w as u sed( 6).
RESULTS
Th e v a g u e u n d e r st a n d i n g o f t u b e r cu l o si s a n d i t s
t r eat m en t
Unit 1 – The confir m at ion of t he t uber culosis diagnosis
sh ak es pat ien t s’ lif e
Use r s a t t e m p t t o so l v e t h e p r o b l e m s t h e
disease is cau sin g t o t h em . I n gen er al, pat ien t s do
not sear ch for healt h ser v ices r ight at t he beginning
of t h eir r esp ir at or y sy m p t om s an d , w h en t h ey d o,
t h eir h ealt h is alr ead y w eak en ed . Th u s, w h en t h ey
discover t he t uber culosis diagnosis, a t r agedy happens
in t heir liv es and leav es t hem bew ilder ed.
…w hen I hear d I had t he disease, m y w or ld collapsed.
( I nt er v iew 8 – I nfect ed) .
We feel com plet ely out of t he w or ld, it ’s ver y har d,
com plicat ed, especially in t he fir st t hr ee m ont hs. I t r ied t o live
m y life as nor m ally as possible. ( I nt er view 6 – I nfect ed) .
…t he fir st day for t hem is chaos, t hey feel t hey’r e t he
w or st people in t he w or ld, cr y, don’t accept , t hink t hey ar e going
t o die…( I nt er view 9 – Pr ofessional) .
…I alw ay s t r y t o be car eful w hen I giv e t hem t he
diagnosis because it ’s a shock, even w hen t he pat ient alr eady
suspect s it , lot s of people cr y ( I nt er v iew 10 – Pr ofessional) .
T h e i n t e r v i e w e e s ’ s t a t e m e n t s s h o w t h e
i m p a c t s u f f e r e d b y s o m e o n e i n f e c t e d w i t h
t u b er cu l o si s a n d i t s n eg a t i v e ef f ect s b eca u se t h e
d i s e a s e i s v i e w e d a s a s o c i a l p u n i s h m e n t .
Pr of ession als w h o w or k in t h e Tu b er cu losis Con t r ol
Pr og r am k n ow t h e af f l ict i on t h at accom p an i es t h e
m om ent of t he diagnosis and pat ient s ar e aw ar e t hat
t u b e r cu l o si s, w h e n n o t t r e a t e d , p r o g r e sse s t o a
sev er e co n d i t i o n o f p h y si ca l d ef i ci en cy, su f f er i n g ,
p ain , r esp ir at or y d if f icu lt ies an d d eat h . Th is is t h e
d i s e a s e ’ s c l o s e s t p o s s i b i l i t y , w h i c h r e q u i r e s
pr ofessionals t o adopt a sensit iv e, k ind and r espect ful
at t it ude at t he m om ent t uber culosis is confir m ed and
adh er en ce t o t r eat m en t is ex pect ed.
Un i t 2 – Th e t u b er cu l o si s t r eat m en t h as d i f f er en t
m eanings for t hose infect ed and for t hose who t reat it
D e sp i t e r e co m m e n d a t i o n s t o a d o p t D OTS
st r at egies in t he ser v ices, w e obser v e t hat t he daily
oper at ion of t he t r eat m ent by pat ient s w it h t uber culosis
is as difficu lt as in t h e self- adm in ist er ed t r eat m en t ,
d u e t o ch an g es t h at i n t er f er e i n t h e co n t i n u i t y o f
act ivit ies, such as st udying or being punct ual at w or k.
…I can’t work because of t he t reat m ent , which em ployer
w ill w ant his em ployee m issing w or k t w ice a w eek or once a
m ont h? So, working is out of t he quest ion. There’re no condit ions,
w e do t he t r eat m ent but cannot w or k. And w hen I st ar t ed t he
t r eat m ent I had t o t ake an inj ect ion ever y day in t he fir st t w o
m ont hs, I had t o t ake it ever y day w hen I st ar t ed it ... ( I nt er v iew
5 – I nfect ed) .
I had t o st op doing m any t hings I like t o do, had t o
st op w alking in t he sun, r ain, having a m or e nor m al daily life, I
had t o st op st udying t o com ply w it h t he t reat m ent , st op w orking,
An ot h er im por t an t aspect of t h e m edicat ion
t reat m ent is t he im posit ion of a rout ine of obligat ions.
I n t he super vised m odalit y, daily or w eekly at t endance
t o t ake m edicat ion is r equir ed, w hich does not alw ays
p e r m i t t h e p e r f o r m a n c e o f p r e v i o u s l y r o u t i n e
act ivit ies. The pat ient also acknow ledges t he losses a
debilit at ing disease lik e t uber culosis im poses on t he
individuals’ body and disposit ion. Healt h pr ofessionals
a l s o a c k n o w l e d g e d i f f i c u l t i e s p a t i e n t s f a c e f o r
t r eat m en t adh er en ce bu t , becau se t h ese dif f icu lt ies
do n ot r epr esen t t h e sam e dim en sion in t h eir liv es,
t h e s e a r e l i t t l e e x p l o r e d i n c a r e d y n a m i c s . Th e
follow ing r epor t s of pr ofessionals illust r at e t his issue:
…w hat m at t er s t o us is t he dur at ion of t he t r eat m ent ,
six m ont hs of t reat m ent , because im proving t he sym pt om s alone
w on’t solve his pr oblem ( I nt er view 2 – Pr ofessional) .
…t he im por t ant t hing is t o or ient t he pat ient t o adher e
t o t he t r eat m ent because it doesn’t help if w e do ever yt hing,
pr escr ibe t he m edicat ion, schedule a r et ur n visit for t he next
m ont h if he isn’t int er est ed in t he t r eat m ent , so w e have t o
r ecom m end t aking t he m edicine ever y day… ( I nt er view 12 –
Pr ofessional) .
Th e a v a i l a b i l i t y o f m e a n s, r e so u r ce s a n d
p r o f e s s i o n a l s l i n k e d t o t h e Tu b e r c u l o s i s Co n t r o l
Pr og r am d oes n ot assu r e su ccess in t h e t r eat m en t
and cure of people w it h t uberculosis. The professionals’
at t it ude, ev en w hen t hey em phasize t he im por t ance
o f t r e a t m e n t t o o b t a i n cu r e , co u l d a l so f o cu s o n
w elcom in g t h e per son in h is( er ) sin gu lar it y an d n ot
only em phasizing t he follow - up, t he t r eat m ent cont r ol.
Un it 3 – Th e t u ber cu losis t r eat m en t pr esen t s m an y
d i f f i c u l t i e s t o p a t i e n t s , w h i c h a r e n o t a l w a y s
u n der st ood by pr of ession als
Follow in g t h e t r eat m en t accor din g t o h ealt h
p r of ession als’ r ecom m en d at ion s is alm ost alw ay s a
d i f f i cu l t t ask f o r p at i en t s b ecau se t h e t h er ap eu t i c
schem es m ix at least t hr ee m edicat ions of pr olonged
use and, despit e t heir efficacy, pat ient s st ar t t o r epor t
digest iv e discom for t , nausea, v om it ing and diar r hea.
…at t he beginning you w ant t o give up because t he
m edicat ion side effect s ar e t oo m uch, it m ade m e feel ver y sick,
had t o go hospit al, m y pr essur e w ould go up, I felt w eak, it w as
r eally bad. At t he beginning of t he t r eat m ent I ’d only lie in bed,
had no energy t o do anyt hing, now I feel I have m ore disposit ion,
even w ant t o go back t o w ork, I feel really w ell… I ’m feeling really
w ell, j ust m y blood pr essur e is alt er ed, I get sw ollen and m y
bones ache, but I ’ll get t o t he end of t he t r eat m ent … ( I nt er view 7
– I n f ect ed) .
…it ’s r eally difficult t o t ake all t hese m edicat ions t he
w ay t hey t old m e t o. The r ed ones ar e easier , but t he w hit e ones
( pause) , t hese are difficult t o sw allow . Thanks God I ’m already at
t he end of t he second m ont h and t hey t old m e I w on’t t ake t hese
anym or e. When I t ake t he m edicat ion I feel sick, get w eak and
feel j ust like lying. At t he beginning it w as w or se because I got
sickness, st om achache, vom it ing, but t hen it all passed. Now , I
only have back pain and t ir edness, but t hey t old m e it is like t his,
I have t o be pat ient ‘cause it ’ll get bet t er . I alm ost can’t close m y
hands because of m y j oint pain, som et im es I feel like st opping
t he m edicat ion, but I t hink about m y fam ily, m yself and keep
going, but I ’m get t ing bet t er ( I nt er view 15 – I nfect ed) .
The healt hcar e r out ine im poses a m echanized
dy nam ics, w hich is not r eflect ed upon and does not
favor t he exchange of subj ect ivit y bet w een t hose w ho
deliver care and t he recipient s of such care( 6- 7). Ther e
is lit t le t im e t o answ er individual dem ands during t he
sh if t s of t h e ou t pat ien t clin ic. Pr of ession als h av e t o
per for m m an y act iv it ies an d t h ese dem an ds im pede
t hat t hey pr ovide exclusive car e t o each pat ient , w hich
r ein f or ces t h e pr ev alen ce of t ech n ical f or m alizat ion .
This is per ceiv ed in t he ex cer pt s below .
…I or ient , say he is going t o st ar t t he DOTS t r eat m ent ,
will have supervised m edicat ion, always orient about t he disease,
t he t im e of t r eat m ent , m edicat ion side effect s, t he im por t ance of
t h e t r e a t m e n t , t a l k a b o u t f o o d , h y g i e n e a n d a b o u t t h e
pr ofessionals at t he unit w it h w hom he is going t o t alk: nur se,
psy chologist , social w or k er . I t is an or ient at ion for t hem t o
under st and t his is a cur able disease; t he t r eat m ent is fast , six
m ont hs ( I nt er v iew 3 – Pr ofessional) .
The pat ient w it h t uber culosis needs pr oper at t ent ion.
I n m y exper ience, if t he pat ient does not r eceive t his, he doesn’t
finish t he t r eat m ent … I spend at least 45 m inut es t o an hour
wit h a pat ient wit h t uberculosis at t he beginning of t he t reat m ent ,
so I explain ever yt hing since, how he got infect ed, w hat t he
disease causes, t he t r eat m ent , w hat can happen if he skips t he
t r eat m ent , com m unicant s, diet . Ever yt hing t o clar ify, and even
so, t her e’r e people w ho abandon t he t r eat m ent ( I nt er v iew 17 –
Pr o f essi o n al ) .
Pat ien t s u n der t r eat m en t h av e pain , gast r ic
d i sco m f o r t , n a u sea , v o m i t i n g , a m o n g o t h er m o r e
frequent m anifest at ions, w hich underm ine physical and
em ot ional resist ance. Educat ing pat ient s regarding t he
d i se a se , t r e a t m e n t , a n d p o t e n t i a l si d e e f f e ct s o f
m ed icat ion , an d also v alu in g t h eir com p lain t s, ar e
a m o n g t h e m a i n f a ct o r s t h a t e a se a d h e r e n ce t o
t h er apy( 8 ). Pr of ession als deal w it h t h ese com plain t s
but do not seem t o v alue t hese com plaint s because
p at ien t s k eep su f f er in g w it h ad v er se ef f ect s, w h ich
conduct s alr eady descr ibed in t he t echnical st andar ds
o f t h e co n t r o l p r o g r a m . Or i e n t a t i o n n o t t o st o p
t r eat m ent , em phasized dur ing consult at ions, does not
alw ay s assur e confidence t hat a disease t hat m ak es
t h em f eel so w eak an d socially v u ln er ab le can b e
o v e r co m e .
Unit 4 – For professionals, t he cure of t uberculosis is
d i r e ct l y r e l a t e d t o t h e p a t i e n t ’ s r e sp o n si b i l i t y i n
follow ing t he t r eat m ent
An ot h er aspect t h at cau gh t ou r at t en t ion is
t he r esponsibilit y for t he t r eat m ent success. Pat ient s
assum e or are im pelled t o assum e such responsibilit y
because, since t he beginning, t hey ar e infor m ed t hat
t h e y b e a r t h e l a r g e st sh a r e o f r e sp o n si b i l i t y f o r
rem ission of clinical condit ion and disease cont rol. This
behav ior can be obser v ed in t he follow ing r epor t s.
…we t ry t o explain t o t hem t hat t he t reat m ent will largely
depend on t hem , t hat it is essent ial t o know t hey w ill have t he
responsibilit y t o com ply wit h t he t reat m ent up t o t he sixt h m ont h,
f ollow ou r r ecom m en d at ion s… if t h ey f ollow t h e t r eat m en t
accor dingly, follow our or ient at ion, t hey w ill cer t ainly get cur ed
( I n t er v iew 7 – Pr ofessional) .
…I gu ess t h at it ’s im por t an t : ex plain t h at h e h as
condit ions t o t ake t he t r eat m ent and be cur ed, and it lar gely
depends on him , because t he unit is available t o give him all
or ient at ion he needs, car e, but obt aining cur e also depends on
t he pat ient ( I nt er v iew 11 – Pr ofessional) .
Appar ent ly, pr ofessionals do not assum e
co-r esponsibilit y foco-r t he t co-reat m ent and t he pat ient is t he
only one responsible for it s success. The healt h syst em
a l r e a d y o f f e r s d i a g n o s i s , f r e e t r e a t m e n t a n d
professionals t o at t end people, so t hat pot ent ial failures
w i l l b e a c o n s e q u e n c e o f n o n - c o m p l i a n c e w i t h
r ecom m endat ions, ev en t hough t her apeut ic schem es
com bine at least t hr ee m edicat ions of pr olonged use
a n d m i g h t ca u se d i g est i v e d i sco m f o r t , w ea k n ess,
int ense it ching, j oint pain and ot her adv er se effect s
t hat m ay lead pat ient s t o r ej ect m edicat ion and giv e
up t r eat m ent because t heir qualit y of life is ser iously
af f ect ed( 9 ).
DI SCUSSI ON OF RESULTS – HERMENEUTI CS
Th e p r o d u ce d u n i t s o f m e a n i n g w e r e t h e
st a r t i n g p o i n t f o r t h e a n a l y si s o f t h e r e p o r t s o f
p r o f essi o n al s an d p at i en t s u n d er an t i - t u b er cu l o si s
t r e a t m e n t , t h a t i s, h e r m e n e u t i cs. Th e se a r ch f o r
m ean in g an d in t er p r et at ion w as d ev elop ed as f r om
t he r eading of descr ipt ions cont ained in t he unit s, t o
seize t he m eanings t hat em er ged fr om t heir r epor t s.
An au t or( 1 0 ) p r esen t s t h e con t r ib u t ion of Heid eg g er
t o h e r m e n e u t i c s , h e s a y s : “ u n d e r s t a n d i n g i s
t r iv ialized, per m eat es all m om ent s in life, so t hat it
a r e w e w h o h a v e t h e m e a n i n g o f e x i st e n ce . Th e
p r a c t i c a l w a y o f b e i n g i n t h e w o r l d o p e n s u p
possibilit ies of under st anding, so t hat under st anding
w o u l d n o t e x i st i f o n e co u l d n o t u n d e r st a n d t h e
cont ex t it em er ges in”.
I n int er pr et ing t he fact icit y of being infect ed
b y t u b er cu losis, w e can id en t if y t h at , w h en p eop le
g et sick d u e t o t h e in f ect ion b y Koch ’s b acillu s, a
m aj or t hr eat is pr esent ed: t hat of being subj ugat ed
by t he disease. Tuber culosis is a t hr eat t hat becam e
co n cr et e, b ecau se, f r o m a f ear ed d i sease, i t n o w
dom inat es t he indiv idual. About t he fear, Heidegger( 11)
sa y s t h a t “ …w h a t o n e f e a r s h a s t h e ch a r a ct er o f
t h r ea t …w h a t o n e f ea r s co m es t o o n e’ s en co u n t er
b e c a u s e i t p o s s e s s e s a c i r c u m s t a n t i a l m o d e o f
dam age… Fear confounds and m ak es one lose one’s
m ind…” and opens up t o a w or ld full of not im agined
t h r e a t s, su ch a s b e i n g r e j e ct e d , t h e t h r e a t o f a
p h y sical d ef icien cy t h at can m ak e t h em u n ab le t o
m aint ain nor m al r elat ionships and com m it m ent s. TB
depr iv es people of t h e au t on om y of life.
An ot h er m ar k ed aspect in t h e pat ien t s’ lif e
i s t h e d i f f i cu l t y t o co r r e ct l y f o l l o w t h e t r e a t m e n t
because of t he t ox icit y chem ot her apy can cause. The
s e v e r i t y o f a d v e r s e e f f e c t s i s k n o w n b y h e a l t h
p r o f e s s i o n a l s , a s w e l l a s t h e m e a s u r e s f o r i t s
cor r ect ion, t hough, accor ding t o t he pat ient s’ r epor t s,
i t s e e m s t h a t p r o f e s s i o n a l s d o n o t v a l u e t h e i r
c o m p l a i n t s , a s i f t h e y w e r e e v i t a b l e , a n d a s i f
pat ient s should w ait unt il such effect s nat ur ally st op.
A s p a t i e n t s , t h e y a r e e n c o u r a g e d t o o v e r c o m e
t r a n s i t o r y d i f f i c u l t i e s c a u s e d b y t h e t r e a t m e n t ,
because t he ult im at e obj ect iv e is t he cur e. Yet , t hese
difficult ies leav e per m anent m ar k s in pat ient s’ liv es.
This w ay of being r einfor ces t he im per sonal
char act er t hat pr ev ails in healt h car e env ir onm ent s,
w hich show t hat t he m ain concer n is w it h t he healt h
pr oblem an d n ot w it h t h e per son w h o pr esen t s t h e
h e a l t h p r o b l e m . I n H e i d e g g e r, w e s e e t h a t
im p er son alit y u su ally d om in at es r elat ion s b et w een
people and t hat , alt hough t his is one w ay of being, it
i s n o t t h e m o st a p p r o p r i a t e w a y o f d e a l i n g w i t h
t h em( 1 1 ). Pr of ession als act im m ed iat ely, con cer n ed
pat ien t s. Th is im per son al car e does n ot en able on e
t o be in som eone else’s shoes, t he pat ient ’s( 6).
An ot h er aspect t h at cau gh t ou r at t en t ion is
t h e r e sp o n si b i l i t y a ssu m e d b y p a t i e n t s r e g a r d i n g
t r eat m en t su ccess. Th e r epor t s sh ow t h e im per iou s
need t o cont r ol and assur e t hat pat ient s w ill cor r ect ly
f o l l o w p r e scr i p t i o n s. He i d e g g e r a p p o i n t s t h a t t h e
h u m an b ein g is r esp on sib le f or h is( er ) ow n w ay of
being( 11). When pr ofessionals see pat ient s w ho need
t o r ecov er, t h ey ar e su b j ect t o w h at is d et er m in ed
by public healt h car e st andar ds. The out com e of t he
t e c h n i c a l - s c i e n t i f i c h e a l t h d i s c o u r s e , a l r e a d y
i n co r p o r a t e d b y so ci e t y, i s i n v a r i a b l y co n cr e t i ze d
t h r ou gh t h e su pply of n on - au t h en t ic car e. Th is car e
c o u l d h a v e a n e n l a r g e d m e a n i n g , a n d i n c l u d e
p r ot ect i on an d con cer n w i t h t h e ot h er( 4 ), w h i ch i s
differ ent fr om w hat has been obser v ed: dealing w it h
p eop le t h r ou g h d om in at ion .
Con cer n w it h t h e r eest ablish m en t of h ealt h
is com m on t o p at ien t s an d p r of ession als, h ow ev er,
t h i s co n cer n h as d i st i n ct ch ar act er s f o r b o t h . Fo r
p a t i en t s, t h e t r ea t m en t r ep r ese n t s r e co v er i n g a n
alt er ed r out ine and, t o achiev e it , t hey follow m edical
r ecom m endat ions as closely as possible, ev en if t hey
m ean t o giv e up pleasant act iv it ies in t heir daily life.
Pr ofessionals, based on scient ific k now ledge, believ e
t h e t r eat m en t is t h e ad eq u at e cou r se t o f ollow in
or der t o achiev e goals defined t o cont r ol t he disease.
This w ay, t hey play t heir social r ole.
I n t h i s m o d e o f c a r e d e l i v e r y , t h e
p r o f essi o n a l ’ s co n cer n i s n o t ef f i ci en t l y em p l o y ed
becau se t h e pr of ession al assu m es t h e ot h er ’s place
an d leav es n o ch an ce f or t h e pat ien t t o par t icipat e
in decision s r elat ed t o h is( er ) con dit ion . Th u s, w h at
m u s t b e d o n e i s a l m o s t a l w a y s u n i l a t e r a l l y
est ablished( 6- 7). This is a par adox ical sit uat ion as, at
t he sam e t im e, it cr eat es dependency on pr ofessional
c a r e . Pr o f e s s i o n a l s , i n t u r n , i n s i s t t h a t t h e
r esp on sib ilit y f or a su ccessf u l ou t com e m ain ly lies
w it h t he pat ient .
This at t it ude lim it s t he under st anding of t he
disease pr ocess t o it s biological aspect s, w hile t her e
a r e o t h e r f a c t o r s i n v o l v e d i n t h e p r o c e s s t h a t
culm inat ed w it h t he per sons’ disease, w ho now need
t r eat m ent and car e. Their life hist or y cannot be denied
or p r ov isor ily let asid e f or t h e sak e of on e k in d of
t r eat m en t .
FI NAL CONSI DERATI ONS
When one r eflect s on t he pr act ice of healt h
pr ofessionals in r elat ion t o a disease as fr equent as
t u b e r cu l o si s, o n e a l so r e f l e ct s o n t h e co n ce p t o f
hum anizat ion, w hich is ex pect ed in ser v ices w or k ing
in t h e Sin g le Healt h Sy st em , of t en t im es t h e m ain
access av ailable t o solv e t h e popu lat ion ’s pr oblem s.
Th e co n cr e t i za t i o n o f a ct i o n s i n t h e Tu b e r cu l o si s
Con t r ol Pr ogr am in dicat es t h er e is a lot t o be don e
t ow ar d s t h e u n d er st an d in g of t h e ot h er ’s m ean in g
of life.
Th i s a s p e c t , n o t y e t e m p h a s i z e d i n t h e
r ou t in e of ou t pat ien t clin ics t h at at t en d people w it h
t u b er cu losis w as also h ig h lig h t ed in Ay r es( 4 ), w h en
t h e au t h or ap p oin t ed t h e n eed f or d ialog b et w een
int er locut or s com m it t ed t o let t heir ex per iences enr ich
t h e m an ag em en t of a d isease t h at en t ails san it ar y
i m p l i cat i o n s i n t h e co l l ect i v e an d p er so n al sco p e.
At t en t iv e list en in g , ad eq u at e con d u ct s, v alor izat ion
of t he m eaning of self- car e and pat ient s’ ex per iences
ar e essen t ial elem en t s in h u m an ized car e.
We under st and t hat nur sing’s m ain obj ect iv e
i n b a s i c h e a l t h s e r v i c e s i s t h e h u m a n b e i n g ,
o f t e n t i m e s u n h e a l t h y , w h o e x p e c t s , f r o m
p r o f e s s i o n a l s , s u p p o r t o r s o l u t i o n f o r h i s ( e r )
pr oblem s( 1). To assum e car e as an aut hent ic concer n,
i t i s n e ce ssa r y t o a d o p t a t t i t u d e s o f r e sp e ct a n d
con sider at ion w it h t h e ot h er, r espect in g t h e bein g’s
ont ological or iginalit y because t his car e m eans zeal,
at t ent ion and helping t he ot her t o be fr ee t o his( er )
closest being( 11). I t is necessar y t o ack now ledge t hat
t he t echnical- scient ific k now ledge in healt h pr act ices
d o e s n o t p o s s e s s a l l p o s s i b i l i t i e s o f c a r e . I t i s
im por t an t t o sh ar e an d v alu e t h e ex per ien ce of t h e
ill as an essent ial elem ent in t he effect iv e car e t hat
enables t he ot her t o be fr ee in or der t o be cur ed.
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1 . W a l d o w V R. Cu i d a r : e x p r e s s ã o h u m a n i z a d o r a d a en fer m agem . Pet r ópolis ( RJ) : Vozes; 2 0 0 6 .
2. Hegenber g L. Doença: um est udo filosófico. Rio de Janeir o: FI OCRUZ ; 1 9 9 8 .
3 . Ru f f in o- Net t o A, Villa TCS. Tu ber cu lose: im plan t ação do D O T S e m a l g u m a s r e g i õ e s d o B r a s i l , h i s t ó r i c o e p ecu l i ar i d ad es r eg i o n ai s. Sã o Pa u l o : I n st i t u t o d o Mi l ên i o r ed e TB; 2 0 0 6 .
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Dep ar t am en t o d e At en ção Básica. Man u al Técn ico p ar a o cont r ole da Tuber culose: cader nos de at enção básica. 6ª ed Br asília ( DF) : MS; 2 0 0 2 .
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