Print version ISSN 1414-3283
Interface (Botucatu) vol.4 no.se Botucatu 2008
O ensino da homeopatia e a prática no SUS
La enseñanza de la homeopatia y las practica en el servicio Unificado de Salud brasileño
Wania Maria Papile GalhardiI,i, Nelson Filice de BarrosII
IPhysician of the Department of Collective Health, Jundiaí Faculty of Medicine.<firstname.lastname@example.org>
IISociologist of the Department of Social and Preventive Medicine, Faculty of Medical Sciences, State University of Campinas
Translated by Philip Sidney Pacheco Badiz
Translation from Interface - Comunicação, Saúde, Educação, Botucatu, v.12, n.25, p. 247 - 266, Abr./Jun. 2008.
This study focuses on the formation of the homeopathic physician as one of several actions developed to humanize medical practice. In Brazil, this action occurred outside institutions of higher learning until 2003, when a course specializing in homeopathy was implanted at the Jundiaí Faculty of Medicine (Faculdade de Medicina de Jundiaí, FMJ), with pedagogical practice and attendance for public health service users. The objective of the work was to evaluate the formation of the homeopathic physician at the FMJ and the perceptions of the users, health professionals, professors, course tutors and the faculty council regarding homeopathy and the course. This qualitative study used interviews, the focal group technique and questionnaires. Three analytical categories emerged from the data: a) referential understanding in homeopathy; b) homeopathy as a new paradigm for teaching and attendance within public health; and c) the general course structure. In conclusion, the teaching of homeopathy in university-level institutions with clinical pedagogical practice oriented toward public health is a viable practice.
Keywords: Homeopathy. Integrality. Teaching. Attendance. Public Health System.
Este estudo focaliza a formação do médico homeopata com uma das ações desenvolvidas para humanizar a prática médica. No Brasil, essa ação aconteceu fora das Instituições de Ensino Superior (IES) até 2003, quando foi implantado o curso de especialização em homeopatia na Faculdade de Medicina de Jundiaí (FMJ), com prática pedagógica e atendimento aos usuários de Saúde Pública. O objetivo do trabalho foi avaliar a formação do médico homeopático na FMJ e as percepções de usuários, profissionais de saúde, professores e tutores do curso, e congregação da faculdade, sobre a homeopatia e o curso. O estudo, de natureza qualitativa, utilizou entrevistas, técnica de grupo focal e questionários. Três categorias analíticas emergiram dos dados: a) conhecimento do referencial em homeopatia; b) homeopatia como o novo paradigma de ensino e assistência em saúde pública; c) estrutura geral do curso. Concluiu-se pela viabilidade do ensino de homeopatia em IES com prática pedagógica clínica orientada à saúde pública.
Palavras-chave: Homeopatia. Integralidade. Ensino. Assistência. Sistema Único de Saúde.
Este estudo enfoca la formación del médico homeopata con una las acciones desarrolladas para humanizar la práctica médica. En Brasil esta acción tuvo lugar fuera de las instituciones de enseñanza superior (IES) hasta 2003 en que se implantó el curso de especialización en homeopatía en la Faculdade de Medicina de Jundiaí (FMJ) del estado de São Paulo, con práctica pedagógica y atendimiento a los usuarios de Salud Pública. El objeto del trabajo ha sido evaluarla formación del médico homeopata en la PMJ y las percepciones de usuarios, profesionales de salud, profesores y tutores del curso y congregación de la facultad, sobre la homeopatía y el curso. El estudio, de naturaleza cualitativa, ha utilizado entrevistas, técnica de grupo focal y cuestionarios. De los datos emergieron tres categorías analíticas: a) conocimiento del referencial en homeopatía; b) homeopatía cono el nuevo paradigma de enseñanza y asistencia en salud pública; c) estructura general de curso. Se concluye la viabilidad de la enseñanza de homeopatía en IES con práctica pedagógica clínica orientada a la salud pública.
Palabras-clave: Homeopatía. Integralid. Ensenãnza. Asistencia. Sistema Único de Salud.
Homeopathy was introduced to Brazil in 1840 by the French homeopathic physician Benoit Mure and its diffusion oscillated, directly influenced by sociohistorical, economic and cultural factors, with periods of recognition, ascension and decadence. According to Luz (1996), homeopathy is marked by different phases of its history in Brazil, with a high point in the 1970s and 80s, identified by the revival of the teaching of homeopathy and its recognition as a medical specialization in 1979 by the Brazilian Medical Association and soon thereafter, in 1980, by the Federal Council of Medicine. During these years, the implantation and development of numerous formative institutions in homeopathy occurred in the country, including the resurgence of associations like the São Paulo State Homeopathy Association (Associação Paulista de Homeopatia, APH).
In 1981, the Brazilian Homeopathic Medical Association (Associação Médica Homeopática Brasileira, AMHB) was created, a corporative organ with the following objectives: establishing directives for courses in the formation of the homeopathic physician; regulate the teaching of and standardize the concession of the "Title of Specialist in Homeopathy". Currently, courses for formation in homeopathy are offered to medical graduates as a specialization, with a course load of 1,200 hours, distributed over two or three years. These are ministered by teaching entities that compose the Council of Formative Entities in Homeopathy (Conselho de Entidades Formadoras em Homeopatia), created in 1997, to handle issues like: establishing teaching goals, exchanges between formative entities, planning and stimulating research (Luz, 1999).
In the current scenario of Brazilian university education, homeopathy has different insertions, such as: the Postgraduate Course in Homeopathy at the Jundiaí Faculty of Medicine (Faculdade de Medicina de Jundiaí) in the State of São Paulo; in the Medical Residency in Homeopathy at the Gaffrée and Guinle University Hospital of the School of Medicine and Surgery at UNIRIO (Hospital Universitário Gaffrée e Guinle da Escola de Medicina e Cirurgia da UNIRIO), Rio de Janeiro, where the discipline "Homeopathy Medical Course" ("Matéria Médica Homeopatia") is obligatory; as well as being present in numerous medical schools as an optional discipline within the graduate curriculum, e.g., São Paulo Medical School (Escola Paulista de Medicina), São Paulo Faculty of Medical Sciences at the University of São Paulo (Faculdade de Ciências Médicas da Universidade de São Paulo) and the Clinics Hospital of the Faculty of Medical Sciences at the University of Campinas (Hospital das Clínicas da Faculdade de Ciências Médicas da Unicamp). However, the great majority of courses for the formation of specialists continue to be ministered outside the country's medical schools.
In 2003, the Postgraduate Course in Homeopathy at the Jundiaí Faculty of Medicine (Curso de Pós-Graduação em Homeopatia, da Faculdade de Medicina de Jundiaí, CPGH-FMJ) was created, where the teaching practice occurs with the Brazilian Public Health System (Sistema Único de Saúde, SUS) in the municipality of Jundiaí. The course project was elaborated by a group composed of homeopathic physicians, dentists and pharmacists. These professionals study and apply homeopathic clinical practice as detailed by Hahnemann in the sixth edition of The Organon of the Healing Art (Hahnemann, 1984). The group attended patients at the APH for approximately five years, followed by experience in basic health care attendance at Pinheiros Health Center, in São Paulo, for two years. After these experiences, in August of 2003, the CPGH-FMJ was initiated, differentiated by the follow characteristics: it was linked to a medical teaching institution; inserted in the SUS, with the approval of Municipal Health Council (Conselho Municipal de Saúde, COMUS, 2004); inserted into the municipal network of secondary outpatient care clinics; and was part of the system of reference-counter reference of the public health service of Jundiaí.
This work analyzed the general formation of the homeopathic physician by the CPGH-FMJ; and more specifically: modifications in the practice and conduct of doctors-students of the CPGH-FMJ, from their enrollment in the course; the perception of the Professors and Preceptors of the CPGH-FMJ and the Faculty Council of the FMJ regarding homeopathy and the course; the perception of health professionals of the Specialization Clinic/Nucleus of Integrated Health regarding homeopathy and homeopathic care within the SUS; and the perception of the users, undergoing homeopathic treatment within the public services of Jundiaí.
In May of 2006, Regulation no. 971 of the Ministry of Health was published, which established the National Policy of Integrative and Complementary Practices (Portaria nº 971: Política Nacional de Práticas Integrativas e Complementares, PNPIC) for the SUS (Brazil, 2006); which deals with the regulation of the implementation, the implementation, the guarantee of access of the entire population to the practices, the evaluation of the practices, scientific research and the financing of all actions necessary for the feasibility of the policy.
Regarding the research
In 2004, a case study of the CPGH-FMJ was initiated, adopting a qualitative methodology that considers the vision, the judgment, the point of view of the interlocutors; the study seeks to deepen and widen understanding, whether of a social group, an organization, an institution, or of a policy (Minayo, 2004); the study permits the in-depth analysis of wide- ranging and systematic information collected from people, at events, involving disease episodes, programs, organizations, etc. (Tobar & Yalour, 2001; Lüdke & André, 1986).
The subjects analyzed here interact with each other during their daily routine, since they are: students, users, health administration professionals, professors and preceptors. They occupy the same physical space, relating daily in the organization of homeopathic medical attendance and interface exists in the doctor-patient, professor-patient and health professional-patient relationships. The remaining subjects, members of the Faculty Council of the FMJ, represent the "power" in the field of health before the Medical Institution and the local society, such that in their perceptions and perspectives the vehemence of their "speeches" is highlighted, which could contribute to the solidity and institutionalization of the homeopathic medical rationality.
Data collection was conducted by means of in-depth interviews and the application of semi-structured questionnaires. The students responded to questionnaires every six months: at one month after beginning the course (March 2004); at six months, after initiating clinical practice in the outpatient service (August 2004); and after completing the course (June 2005). The professors and preceptors responsible for teaching and clinical practice in homeopathy responded to a questionnaire in April 2004; the director of the FMJ was interviewed in June 2005 and the remaining members of the Faculty Council responded to a questionnaire in August 2005. Health professionals assigned outpatient shifts were interviewed collectively, using a technique adapted for focal groups, in August 2004. Users receiving homeopathic treatment at the outpatient service responded to a questionnaire six months after initiating the service (August 2004) and 18 months after initiating the service (August 2005).
A qualitative methodology technique was developed to analyze the data. It should be understood that analyzing the qualitative data means "working through" all the material obtained during the research, i.e., the observations, interview transcripts, analyses of documents, and other available information. First, this implies organizing the material, dividing it into parts, relating these parts and seeking to identify within them tendencies and relevant patterns. Following this, the tendencies and patterns are reevaluated, searching for "nuclei of meaning", analysis categories and relations to infer a higher level of abstraction (Minayo, 2004; Lüdke & André, 1986; Bardin, 1977).
The categories for the analyses elected in this research were: basic and referential knowledge of homeopathy, which permitted analysis of the perceptions that the subjects had regarding homeopathy and what made them seek it out in their lives, as a medical rationality and therapeutic method; homeopathy as a new teaching and public health attendance paradigm in the SUS, which permitted analysis of the repercussions of this new paradigm in the lives of the different subjects involved with it, changes in conduct, its acceptance in the field of health, its application and development in the FMJ and the SUS; and the general course structure, which permitted analysis of the quality of that taught (Table 1).
In the different roles that the subjects exert, the perspectives and perceptions complemented and solidified each other, allowing the researcher to analyze the conditions and benefits of the object studied. Thus, it was possible to confirm what each of the subjects analyzed perceived, visualized and expected regarding: homeopathy and homeopathic treatment in the Public Health Service and Postgraduation Course in Homeopathy at the Jundiaí Faculty of Medicine.
The CPGH-FMJ in the perception of the students
The number of students enrolled in the course was eight. All had concluded other medical specializations, except one, and had graduated in the 1980s or 90s, with one graduating in 2002 (Table 2). Therefore, they knew and had practiced the allopathic medical rationality for at least 10 years.
They had chosen to practice homeopathy as another possible treatment for their patients, especially for chronic diseases, and because they had witnessed the positive results of treatments to which, above all, their children had been submitted. A certain inquietude was also common among the students and a feeling of responsibility for those who solicited their help. They presented a strong interest in resolving, in bringing relief to health "problems" that were not always serious, but were responsible for causing discomfort and alterations in daily life. This inquietude was identified in extracts like those that follow: "treating diseases is not the same as treated sick individuals" (S1); "allopathic practice frustrated me, this was not the kind of medicine that I wanted to do" (S2); "medicating chronic disease was difficult" (S3); "a ampler vision of the patient" (A4); "I couldn't cure patients with palliative care" (A5); "there is a lack of resoluteness in allopathic care for chronic diseases" (A5); "something that proportioned more contact with the patient [ ] before I had a hurried way of working [ ] even when I took more time I couldn't be more thorough" (S8).
In the first month of clinical practice, the student concerned themselves with perceiving the details of patient clinical history, with the intention of identifying peculiar symptoms that could assist in the choice of the homeopathic medication; they became more attentive to detail, seeking the patient's symptomatic totality and, even outside the course, they were more perceptive of details in the medical consultations they attended. Thus, the students reported: "I have paid more attention to certain details concerning the patient's clinical condition [ ] [and] endeavor to recover well-being in its totality" (S6); "I continue to act as an allopath, occasionally, I feel like reworking the patient's disease history and treating the disease homeopathically" (S3); "I'm familiarizing myself with the methodology and seeing its efficacy" (S4).
After completing six months, in August 2004, they felt greater facility and security in the elaboration of the homeopathic medical history and the medication diagnosis, though they emphasized the delay in the case study. Student 1 affirmed: "I feel more secure and the idea of applying the concepts and initiating the consultation no longer scares me". In the discourse of the other students, expressions of greater security in the practice, though with caution, when they affirmed: "partial cure only produces immediate relief" (S1); "I feel prepared for the practice in my daily routine, I feel like this project should keep growing [ ] whenever possible, I'm available to assist in this project" (S1).
One student indicted that the study of homeopathy was better than the individualized study of the organs and physiology. The student also highlighted the lack of knowledge of allopathic doctors concerning homeopathic practice, for him, "the vision [ ] according to the Organon, is far superior to that provided by individualized study of the organs and physiology [ ] allopathic conduct is seriously lacking in those who don't know about homeopathy" (S4). In the same period, one student became critical in relation to allopathy, relating this to the fact of being "more critical with my allopathic practice, because I feel more impotent" (S6); another referred to the satisfaction with homeopathic treatment, both from the doctor's point of view and the patient's: "this type of attendance brings enormous satisfaction, not only for the doctor, but also for the patient" (S7); and yet another emphasized the disposition of the professors and preceptors to teach, as a factor of great importance, considering them as "people with considerable disposition for teaching and transmitting knowledge" (S8).
In August of 2004, some students also highlighted attendance in their private practices. They felt more confident. Their justifications for initiating the practice were distinct, but lead toward confidence: "I manage to feel greater security when attending at my office [ ] I was excited by at least three cases" (S5); I manage to see my patients differently, I am able to discern the development of their diseases better than before and this is only the beginning, because I only have a little experience with homeopathy" (S4); "I've begun to apply homeopathy in cases of chronic disease, it seems like a better option" (S5).
In general, the students emphasized the need to continue studying, to understand the theory and to gain access to a large number of consultations. They indicated the importance of the outpatient clinic in their learning and attributed the possibility of acquiring the confidence needed to it.
Some students identified homeopathy as a way of humanizing the health consultation: "I can provide a more complete and humanist consultation" (S7); "my practice ahs improved a lot, [ ] I'm considering details that before I didn't consider, but that are party of the patient as a whole, [ ] the course has given me a more humanized vision of attendance" (S5).
In June of 2005, the end of the course, the students affirmed that they were satisfied, though they realized the need for continued refinement. They perceived that the homeopathic medical rationality has solid theoretical bases, where each case deserves an individualized study. They had studied the results of the treatments, knew how to follow each patient attended and considered that they had made a good choice. The speech of Student *8 is worth highlighting: "when I entered the course I didn't know anything, it was [a friend] [ ] who called me to do the course [ ] it would be good to occupy my time with something, [ ] I took a shot at something that turned out to be something else, [ ] I'm 100% satisfied [ ] homeopathy is not like I thought, it's much better [and] [ ] I used on some of my patients who got better."
In the same period, an important aspect regarding the lack of recognition of the scientific character of homeopathy was approached, which is highlighted as a discouraging factor for choosing it as a medical specialization, "if I knew the history of homeopathy, the lack of recognition [ ] in Brazil and the world, I would never have taken the course, [ ] never!" (S5). However, the same student declared that "the satisfaction in really changing the physical and mental health of a patient, in a positive, significant and long-lasting way is indescribably wonderful, I'm still touched by the results [ ] now I have renewed hope of treating chronic diseases, something that you lose or get used to ignoring over time [using] conventional medicine".
At the end of the course, the students emphasized the improvement in the quality of the doctor-patient relationship, the development of critical awareness, technical autonomy and reaffirmed the importance of the vision of symptomatic totality, as in this extract of the discourse of Student 4, who affirmed that "the whole of the patient is composed of details that interrelate much more than we appreciate as non homeopaths".
Throughout the entire formation period of the first class, the outpatient installations were precarious, both in terms of physical structure and equipment. However, the students emphasized the importance of the outpatient clinic to their learning and attributed it with the possibility of acquiring the necessary confidence. In some ways, they considered it to be unsubstitutable to their learning: "the outpatient clinic was great, because we were always doing evaluation about how the attendance went, what could improve, we'd discuss the case, we'd discuss which were the key symptoms and why [ ] its very instructive"(S2); "cases discussed with coherence"(S3); "this practice made us feel secure" (S3); "I couldn't forget the heat of the rooms [ ], but what was that compared to the result obtained [ ] the outpatient clinic was unsubstitutable - like every consultation was a stone in the foundation of a construction" (S4); "with clinical practice we acquired experience [ ] in the clinical management of our patients" (S7). Another student also highlighted as an important aspect to their learning during clinical practice, the "opportunity to work and socialize with other competent professionals and such interesting people, both the teaching staff and the student body" (S8).
Preparation of the medications prescribed was always done immediately after the end of each consultation, by one or two students, under the supervision of the professors or preceptors, since it was part of the course to develop a critical spirit in relation to the quality of the pharmaceutical service, in reference to ethics, professionalism, technique and raw materials. The episode of medication preparation stimulated different types of reactions in the students, as the reports show: "its great learning to make the medications, but this leads to a delay in the consultations"(S1); "lack of a pharmacy is a problem, manipulating remedies is interesting during the learning process" (S2); "[ ] I think it's a major benefit that the patient can leave the consultation with their medication" (S8).
Briefly, regarding the expectations and perceptions of the students, it is possible to affirm that there was a high degree of satisfaction, with recognition of their evolutive trajectories in the principals of the homeopathic medical rationality, in the practical learning, in the sedimentation of the concepts and in the verification of the result of the treatments applied. It was identified that these positivities of the course were of fundamental importance for the motivational and self-confidence aspects of the students; with developments in the stimulus to want to be practicing homeopaths and in the creation of an atmosphere of confidence to treat the sick.
The CPGH-FMJ in the perception of the professors and preceptors
There were six interviewees in these categories, one pharmacist and the remainder doctors (Table 3). The course coordinator and invited professors did not participate in the research. The interviewees affirmed their expectations in relation to growth in the credibility and institutionalization of homeopathic therapy, as well as in relation to teaching and research development. They emphasized the poor physical conditions of the outpatient clinic, the precariousness of the medical equipment and furniture and the lack of a local adequate pharmacy. However, they highlighted that the number of consultations realized and the case discussions were adequate for the learning process: "the number of consultations was good and the good quality of the discussions in the clinic" (P1).
One of the goals they established was the preparation of the student for attendance in the SUS: "attend a new case for an hour, [ ] including choosing the medication. [ ] realize the follow-up in 30 minutes, dealing with the intercurrences [ ] and ethically, with humane attendance" (P2); "the patients coherently, prescribing also with coherence" (PPh).
The professors and preceptors considered that the work schedule of clinical practice, besides being fundamental to the formation of the specialist, permitted the approximation of the professor with the student in the daily routine, which facilitates the teaching-learning relationship: "the quality of the teaching is optimized by the student-professor proximity, which has favored the daily clinical routine" (PE); "with a certain knowledge of other courses, I'm sure that the work schedule for the outpatient clinic is fairly extensive and adequate for good formation [ ] students have the opportunity to follow a good number of consultations per period and thus progress in their understanding" (PPh).
Finally they highlighted that despite the precarious conditions of the physical structure for teaching, the students of the first class of the CPGH in the SUS received a good education and were competent to attend for the SUS with quality and ethics.
The CPGH-FMJ in the perception of the Faculty Council of the FMJ
The faculty Council is composed of 28 members: the director, full and assistant professors, one representative of the graduate students and one representative of the population (Table 4). In a meeting in August 2005, a questionnaire was handed to the 23 members present and, of these, 15 returned the questionnaire.
It can be understood from the perspectives and perceptions reported that the Faculty Council members, except one (C12), had some positive reference related to homeopathy. In general, they recognized homeopathy as a complementary practice to conventional medicine that should be inserted in the medical school, since it is a medical specialization. However, they emphasized that the permanence of the course, the inclusion of homeopathic disciplines in the graduation curriculum and integration with of the remaining departments of the faculty are linked to the realization of scientific research, to "be seen as a complementary medicine [ ] and capable of working with the other specializations" (C1); and "to prove its scientificity, by means of research in the teaching institution" (C8).
The Faculty Council members were unanimous in indicating the insertion of homeopathy into the graduation curriculum, as an optional discipline or of experimental character, although they made clear their lack of knowledge regarding the structure of the course and the homeopathic medical rationality.
They believed in the opportunity to develop integration with the other departments: "this is a medical specialization in its phase of scientific recognition, based on its theoretical foundation in research and recognized publications" (C8); "It's important that young doctors know about homeopathy as yet another specialization option, the possibility exists of it becoming part of the medical curriculum"(C1); "in the incorporation of disciplines into medical graduation, I believe that the should be an experimental period"(C2); "conduct research in the area, in the research nucleus of the FMJ" (C10); "the goals and methodologies should be duly presented to the teaching and student bodies for a clearer perception of the course structure" (C8).
Perception of the administrative professionals of the secondary care outpatient clinic of the SUS - Jundiaí
Two filing clerks, five reception and information clerks, one nurse and a social worker of the clinic were interviewed (Table 5). Health professionals of the SUS have always had access to the conventional medical rational and had no prior reference to homeopathy. One the professionals (R1) reported that a niece received treatment and obtained significant improvement in a short period: "I have a niece, who has terrible allergy, treated here by Dr. X and in 40 days she's great". The same reported that a doctor, when overhearing her comment about her niece, launched a challenge: "if she [the niece] is cured, he [the doctor] promises he will take the homeopathy course" (R1).
One of the professionals reported the efficiency of and demand for homeopathy, due to the number of homeopathic pharmacies in existence. Another, because they believed in the lower cost of the medications: "I think it's good, we see so many pharmacies" (R2); "I've heard people say that it was because homeopathy is much cheaper" (R3). One of the professionals suggested that they should obtain qualifications, to answer the questions of users about homeopathy. They identified that information given to the users were insufficient and that this made greater use more difficult, "training for the administrative staff with the homeopathy staff should exist, because the public arrive with insufficient information and the staff are unprepared, I feel that I need this in my work" (R4). Some interviewees were already aware that for the doctors of rheumatology clinic in the same building, homeopathy already functioned as a Complementary Medicine, which was confirmed by the report: "the rheumatologists liked it [homeopathy] said that patients are going to appear, some patients are already doing both, which even diminished their medications [allopathic]".
The attention given to the patient, the difference in homeopathic disease history and the tranquility and satisfaction of the user in the waiting room were marked facts perceived by the professionals. The emphasized the vision of "totality" and the individualization of the medication: "the patient is not a foot or a head"(R2); "he knows that the medication is only for him" (R1). They also indicated the attendance as humane: "patients feel unique" (R1); "it seems that the homeopathy patients are different, they're calmer. It's more humane!" (R2). They didn't forget to report the difficulties with room availability, with marking consultations and the difficulties in understanding that all the homeopaths, except the pediatrician, attended general clinical problems. Another mention was about the high demand for the service, which resulted in a delay in marking consultations: "in contact with patients, we tell them that it takes a while to mark a consultation and the patients say [ ] no, we'll wait as long as needed, no problem!" (R1); "One thing's for sure, the demand has increased and we need to open more hours!" (R2).
One of the subjects made clear all the difficulty encountered for the implantation of attendance in homeopathy in the SUS, since it was an activity different from those inserted in the Municipal Health System: "it's an outpatient clinic that marks consultations differently, for a longer period, the doctors are methodical"; "this different form of agenda made our work more difficult, the doctor marks the follow-up, only the consultation is marked by the Basic Health Unit. The impression is that the doctor works for the whole team; that makes it more difficult"; "I was responsible for arranging the rooms, it brought me serious problems, this way of looking at things".
The professionals perceived the principals of the homeopathic medical rational by dealing with the users and working with the professors and the students. They also understood that the calm and patience of the user, while waiting for an hour in the agenda is a consequence of the good doctor-patient relationship. The same subjects recognize the benefits that the treatment proportions and feel the need to be better informed in order to clarify the routine doubts of the users.
Homeopathic treatment within the public health system in the perception of the users
The number of patients analyzed (Table 6) was 44, subdivided according to the frequency that they presented symptoms at the onset of treatment: daily (Dailies, 2005, 2004); weekly (weeklies, 2005, 2004); monthly and periods longer than a month (Monthlies, 2005, 2004). The objective of this classification was to create a way of perceiving possible reductions in acute crises in frequency, intensity and duration over the evolution of the homeopathic treatment.
The first users attended at the homeopathy outpatient clinic were public servants, the Municipal Health Secretary and other Secretaries, who were the first to hear about the existence of the service and had easy access. It was also this group who were principally responsible for divulging and forwarding other patients. Thus, in general, the users were oriented buy other users and friends, though some reported that they had been looking for attendance within this model for some time.
The patients perceived the difference in the homeopathic medical consultation, above all, by the types of questions, the level of detail and the vision of totality. It is possible to identify their perceptions in the statements: "very good, because it encompasses the person as a whole and not just the symptoms" (Dailies, 2004); "I thought the homeopathic consultation was better, the fact that I had already been medicated and it resolved nothing. Now I'm better" (Monthlies, 2004); "never had an experience like this, no professional has scoured the depth of my case, I think that it saved my life!" (Dailies, 2004); "the homeopathy consultation is very good, better than conventional consultations" (Monthlies, 2004). One user attributed self-knowledge to the level of detail of the homeopathic consultation: "it was data collection for self-knowledge and a global understanding of the problems that affected me" (Dailies, 2004). The users also highlighted the interest of the professionals in the resolution of their problems, comparing it to the attention received from other professionals: "the doctors pay attention to the patients" (Dailies, 2004); "I even found it strange at first, since some don't even look directly at you, and they pay a lot of attention to you" (Monthlies, 2004): "I liked the consultation because the people [doctors] are interested, they're very responsible and competent" (Dailies, 2005).
The results obtained with homeopathic treatment were reported with satisfaction, since the improvements allowed the users to exert their daily activities without the interference of the disease: "I can make lunch without having to wipe my nose and wash my hands" (Weeklies, 2005); "I don't have to worry anymore about the smell of cleaning products" (Dailies, 2005); "before I spent a lot of time stuck in bed" (Dailies, 2005); "improvement in the performance of daily tasks, with greater serenity, calm and capacity, after the onset of treatment" (Weeklies, 2004).
Reports concerning the reduction in the duration and frequency of crises and non-use of antibiotics and other medications were notable, even when adverse conditions continued: "this year I felt bad only twice, I work under a lot of pressure, tasks accumulate, the situation is the same, but before I suffered more with the stress" (Monthlies, 2005); "I'm feeling better [ ] I'm still nervous, but I don't use lexotan" (Weeklies, 2005); "the remedy is only one drop a day, it seems like it doesn't make any difference, but later you see that you improved, it's helping me stop using antibiotics" (Dailies, 2005).
Besides attending the SUS, the consultations have didactic objectives, which demands the presence of three or four students and the preceptor. Observation showed that this was not an inhibiting factor, on the contrary, since as one user stated: "having a medical board in attendance is great" (Dailies, 2004).
The users emphasized the importance of the free attendance and the medications, since they couldn't afford to pay for private treatment. This type of attendance is practically nonexistent in accords and health plans, thus restricting it to the privately-owned services of professionals in their own consultancies: "being treated with homeopathy in the SUS [ ] is great, excellent [ ] the attendance is of the best quality and free" (Dailies, 2005); "it's free and you receive the medications, that's very good" (Dailies, 2004) ; "I think it's great, since the cost is nothing and your health is great" (Dailies, 2004); I hope they don't remove the service, because I know many people who are well after this treatment, including me" (Dailies, 2004).
Based on the discourse of the users, it can be affirmed that the evolution of homeopathic treatment diminished the frequency, intensity and duration of acute crises, promoting a significant improvement in the disease and in the quality of life, reducing the demand for other medical services, the use of allopathic medications and, consequently, diminished spending on health.
The theme of this research was the teaching of homeopathy and the problem, the analysis of a specific postgraduation course in the homeopathic rationality, within an Institute of Higher Education and oriented toward the Brazilian Public Health System (SUS). The project was structured as a Case Study and more than fifty different subjects, with different degrees of involvement in the course, responded to different data collection instruments.
The majority of the data was treated qualitatively; while the discussion proposed, based on the results presented above, seeks to answer why formation in homeopathy oriented for the SUS is important. For this, presentation of the theoretical-conceptual view that oriented the work is fundamental.
The questions raised in this project were indentified within the field of health that delimits a social space, in which it is possible to visualize a significant increase in debates regarding the so-called Alternative and Complementary Medicines. Investigation confirms that, throughout the 1960s and 70s, discussions concerning alternative practices were in opposition to and intended to exclude allopathic practices. However, a rupture in the logic of this discourse occurred and, from the 1980s onward, the concept of Complementary Medicines developed, with an inclusive perspective between different medical rationalities; while at the end of the 1990s, the concept of Integrative Medicine was introduced, with the proposal of producing a paradigm that integrated the differences in the field of health (Barros, 2000).
The notion of field was developed by Bourdieu (apud Barros, 2000, p.122-3), in the sense of delimiting an specific arena for disputes between subjects, collective or individual, for capital that conform to care-cure policies, services and practices. Thus, in the words of the author, the field: "is the place, the space of competition of a concorrential fight, [ ] in which the stake is the monopoly of scientific authority inseparably defined as technical capacity and social power; or of competence, while the capacity to speak and act legitimately (i.e., in an authorized and authoritative way) is socially sanctioned by a specific agent."
In the context of the field of health, homeopathy is, therefore, only one of the agents, with questions to be analyzed in the interprofessional sphere in the disputes that are established with other medical rationalities, especially biomedicine, and the interface with economic and political questions and health techniques; and, in the intraprofessional sphere, in relation to the perspectives developed by the different groups and tendencies that practice homeopathy. This can be synthesized in the words of Rosenbaum (2006), when he states that "homeopathy is not against biomedicine, it is a different way of getting to know the body. It dialogues with medicine because the patient needs to maintain treatments from all sides. Any type of benefit, especially in severe infirmities, is welcome".
In this discussion, we propose an in-depth investigation of the following elements of homeopathy in the field of health: first, that it is a non-hegemonic interprofessional agent, that is, it is among the dominated agents of the field of health; second, that intraprofessional homogeneity does not exist, meaning that there is not a single homeopathic project in the field of health; third, that it still represents an "alternative", which guarantees physicians an escape route from suffocating structures in the field of health; four, the disinformation concerning the principals of this rationality among health professionals in expressive, amplifying the spaces that permit reproduction of preconceptions and prejudices; and five, contact with the homeopathic rationality provokes changes in people's cultural and social values.
In relation to homeopathy not having hegemonic power, being among the dominated agents in the field of health, the economic question observed in the interviews with different subjects in the research is discussed. Nowhere in the public sphere is the financial question mentioned in relation to the use of homeopathy; although, in several reports, the diminished use of allopathic medications is evident, as well as the improvement of chronic diseases and reduction in acute crises. This leads to an interpretation that with a the larger number of patients in homeopathy, compared to other treatments, there will be a significant reduction in the health "machine", with a consequent reduction in costs. Galvão (1999) considered that the smaller number of patients attended in the homeopathy service in relation to clinical medicine and pediatrics, which, in principal, could mean greater cost for the service, should be compared with the reduction in the number of consultations that generate complementary exams and referrals and the lower costs of homeopathic medication, aspects that indicate diminished overall costs of the treatment.
However, the need for investment in contracting human resources and the purchase of medications is not yet on the agenda of any of the agents in the field of health, demonstrating the clear option for investment in the dominant biomedicine model.
There are signs of a possible change in position for homeopathy in the field of health with the publication of PNPIC, since it foresees the "guarantee of financing" capable of assuring the development of the set of essential activities for good practice in homeopathy, considering the technical peculiarities, such as: access to the supplies inherent to the practice of homeopathy - Homeopathic Repertoire and Homeopathic Medical material in print and software; access to homeopathic medications from the perspective of implantation and/or adequation of public pharmacies that manipulate homeopathic medications, i.e., the inclusion of homeopathy in the Policy of Pharmaceutical Assistance, in the three spheres of attendance; stimulus for the implantation of projects for the production of homeopathic matrices in official laboratories, projects and programs of formation and permanent education that assure specialization and refresher courses in homeopathy for professionals of the SUS, in combination with the Poles of Permanent Education in Health, adequation of the physical structuration of services, for which the Ministry of Health annually makes available federal financing (National Health Fund, Fundo Nacional de Saúde) with co-financing by the states and municipalities for the structuration of homeopathic attendance services and in the publicizing of and information concerning basic knowledge of Homeopathy for health professionals, managers and users of the SUS, considering participative methodologies and popular knowledge.
In relation to the nonhomogeneity of the homeopathic project in the field of health, the different perspectives brought to this rationality by different subjects are discussed; thus, for example, it was possible to identify in this work that the students of the CPGH-FMJ sought expansion of their knowledge regarding the therapeutic methods, while the patients sought a way to resolve their ills, mostly chronic diseases or those for which explanations do not exist in biomedicine. However, they all came across a medical rationality that, while it has the same cosmology as biomedicine, differs in relation to medical doctrine - with an in-depth notion rarely developed by biomedicine, that of vital energy - and the therapeutic system, which seeks to identify for each patient, the medication that is similar in energy for disease production and health.
From this interaction, it can be concluded that a transformation occurred in the students: in that which the patient-disease relationship represented to them, since they began to value the need to recover the integrality of the disease, which places the patient at the center of attention, something that has been lost in the mechanistic action of biomedicine; and in that which the doctor-patient relationship demanded, since in Hahnemannian Homeopathic Methodology, a strengthening and humanization of the relationship is promoted due to the visualization of the physical, psychological, social and cultural dimensions of each sick person.
Briefly, regarding the expectations and perceptions of the students, it is possible to affirm that there was a high degree of satisfaction, with recognition of their evolutive trajectories in the principals of the homeopathic medical rationality, in practical learning, in consolidation of the concepts and in the verification of the results of the treatments applied. The study identified that these positivities of the Course proved to be of fundamental importance for the motivational aspects and self-confidence of the students, with developments in the stimulus to want to practice as homeopaths and in the creation of an atmosphere of trust for treating patients.
It is important to recall the study by Salles (2001), which indicated that among the principal deficiencies perceived during the formation of the specialist was the lack of supervised practice by experienced homeopaths with the aptitude and ability to teach. As verified in this study, such practice was very enriching for the student of the CPGH-FMJ.
This remits to a much wider discussion regarding: What is the best model for a homeopathic service? How should the treatment of acute and chronic diseases be considered? How the medications should be inserted in the Policy of Pharmaceutical Assistance at the last minute? These questions were not investigated in this study, but it did identify that the CPGH-FMJ students understood that to be inserted into a service demanded the following actions: acting ethically; performing clinical diagnoses and complementing with laboratorial exams whenever necessary; performing medication diagnoses; being clear abut the patient's prognosis; and being cautious about removing allopathic medications. Certainly, as they developed such understanding, they also began to work on caring for the reputation of the homeopathic medical rationality, with the aim of integrating it into the different services of the SUS.
The students demonstrated that they perceived the differences in the medical rationalities, as defined by Luz (200): in conventional medicine, the weight of the subjective and individual symptoms is minimally valued for diagnosis, while being centered in technological procedures; in contrast, in homeopathic medicine, the symptoms presented by the patient express the diagnosis, since they permit diagnosis of the disharmony in the unique subjects.
In the perception of the Faculty Council members, the need to scientifically prove the benefits proportioned by Homeopathic Medicine exists, only thus, can it be legitimized before the medical-academic community. However, scientific research is also consolidated by the PNPIC, which solicits the inclusion of these practices in lines of SUS research, supported by a partnership with Education Entities, Associations and Universities and to which financial resources should be designated.
Although it has encountered numerous obstacles and setbacks, the process of the institutionalization of homeopathy in Brazil has occurred slowly, in a way that integrates it into the body of institutions and medical practices developed in the country. However, as Galvão (1999) remembers, it is worth highlighting that, in general, it is institutions associated with the reproduction of biomedical knowledge, such as Medical Schools or Hospitals, who are most against the insertion of alternative medicines in institutional spaces.
Publication of Regulation no. 971 helps to legitimize the "vitalist" medical rationality and, moreover, relativize the mechanistic paradigm of conventional medicine. In this case, the medical corporation begins to accept the inclusion of other "strange" rationalities with occidental medicine at the same time that it vindicates the monopoly of professional practice (Queiroz, 2006). In the perception of administrative professionals, agreement with the PNPIC was evident regarding the necessity to invest in popular education and in reference to the difficulties of implantation, such that insufficiency of resources, the SUS model centered on the disease and the nonexistence of local political policies were identified.
Socializing information for population groups creates the possibility of knowledge, choices, evaluations and invigoration. Thus, explaining the principals of homeopathy can mean the legitimization of its practice. The PNPIC, in turn, clarifies the measures to be adopted to generate such information, which are: including Homeopathy on the agenda of social communication activities of the SUS; producing publicity materials aimed at the promotion of actions of information and publicizing of homeopathy directed at workers, managers and health councilors, as well as the professoriate and student body in the areas of health and the general community; supporting and strengthening innovative actions of information and publicizing of homeopathy in different cultural languages; identifying, articulating and supporting popular education experiences - information and communication concerning homeopathy; providing technical or financial support to projects for the qualification of professionals that work in the Health Strategy for the Family and Programs for Community Health Agents, considering the combination of actions and initiatives for Permanent Education in Health in the SUS.
Based on the perceptions of the users, it can be affirmed that the evolution of homeopathic treatment diminished the frequency, intensity and duration of acute crises, promoting significant improvement in the disease and in quality of life, diminished demand for other medical services, diminished use of allopathic medications and, consequently, diminished overall spending on health. Besides this, getting to know what the user of the health service thinks, values and needs is already "half the battle" to implementing changes in favor of a public service that attends the demands of the population (Campello, 2001). Moreira Neto (1999) also verified in his study, a high degree of satisfaction among the users, related to trust in the service, a good doctor-patient relationship and improvement in the quality of life of the individuals, because it proportioned improvements in health. He also characterized homeopathy as a low-cost therapy and qualitatively appreciated by the users of the SUS.
This perception was also identified in the work by Campello (2001), who concluded that the patient experiences the attention required to speak about what torments them and finds a space to talk about themselves with someone who listens attentively to their report, who stimulates them to remember how the disturbances are processed and what the contributory factors for the reactions and the feelings are under different circumstances.
Moreover, the homeopathic medical rationality represents an "alternative", which guarantees physicians an escape route from suffocating structures in the field of health, since the satisfaction and benefits proportioned by the practice were rapidly publicized among the users of the SUS and the specialist physicians of the service, contributing to a large increase in demand. This probably influenced the perspectives of the team of specialists of the outpatient clinic and the local managers of the SUS, especially for the treatment of chronic nontransmissible diseases, respiratory and allergic diseases, psychosomatic disorders and the consequent reduction in medication consumption. Thus, the repercussion of attendance/teaching in the public health network in the municipality of Jundiaí has strengthened the idea of the development of homeopathy in the SUS and the FMJ. This practice is supported, once again, within the directives outlined by the PNPIC, in which the premise of the development of homeopathy in multidisciplinary character for the professional categories present in the SUS is affirmed in consonance with the level of attendance - emphasis on basic care: in basic care units, attendance according to spontaneous and referred demand; in Family Health units, which possess a professional homeopath as a Family Health physician, who should be given the opportunity to practice homeopathy; supporting and strengthening initiatives for homeopathic attendance in specialized attendance, emergencies, intensive care units, palliative care units or in hospital wards. Homeopathy should be incorporated complementarily and technical-scientific interchange aimed at the exchange of knowledge and information related to field experiences in homeopathic attendance should be established.
The perception of disinformation concerning the principals of this rationality by health professionals and the Faculty Council, amplifying the spaces that permit reproduction of preconceptions and prejudices, has important implications for the creation of a homeopathic culture within the SUS. However, as far as we are aware, the CPGH-FMJ is the first course linked to a university-level institute with practice and teaching within the SUS in Brazil; moreover, the importance of uniting homeopathy with formal higher education is in the possibility of developing scientific research and the approximation of different medical rationalities, promoting a truce in the "hidden war" within the field of health.
With this experience, it is possible that we are initiating a new phase in the history of homeopathy in Brazil, beyond those reported by Luz (1996). Among the problems that require in-depth reflection are the implications of this union on graduation. Some of the questions in the curricular reform in medical courses demand the introduction of an integral vision of the individual, oriented by the SUS, which are the core nuclei of investigative experience. Therefore, besides disciplines concerning homeopathy in the curriculum schedule, the possibility of the participation of graduate students in homeopathy outpatient clinics, efficacy in the consolidation of learning and in the stimulation of scientific research is also visualized.
At present: the formation and transmission of knowledge concerning the principals of homeopathy find support in Regulation no. 971, which aims, first, to promote the development of projects and programs that assure education in homeopathy to professionals of the SUS; and, second, to promote the inclusion of the homeopathic rationality in graduate and postgraduate courses strictu and lato sensu for health area professionals, to promote discussion regarding homeopathy in the process of modifying the teaching of graduation and to advance and support, together with the Ministry of Education, projects for Residency in Homeopathy, with the involvement of Educators in Homeopathy and with financial and technical support from the Ministry of Health.
Observation revealed that in the perception of users and health professionals, contact with the homeopathic rationality provokes changes in people's cultural and social values. Thus, Sólon (2000) analyzes: homeopathy as a therapeutic method acts by transforming the cultural appropriation of the patient-disease relationships, recovering the historical identity of the patient that has been lost in the mechanistic approach to health.
The homeopathy consultation "per se" induces the individual to reflect, to recover their subjectivity, their thinking, valorization of the "I" in the sociocultural environment, in nature, in familial relations and in work. In this sense, medicine, the promoter of health, conceives a holistic and integrative perspective.
A further important characteristic should be added that appears in modern culture, the valorization of subjectivity, the subject as constructor of his/her personal, familial relationships and his/her personal identify. The discovery of self, the preoccupation with self-development and reflexibility, which makes an individual much more than a communicator of their culture, he/she can collaborate in the construction of worlds (Queiroz, 2006).
It can be concluded that perfect adequation of the rationality to the principals of the SUS occurred, since the following were fulfilled: a) universalization - every citizen has the right to health and access to whatever type of service they require; b) equity - every individual should be equal within the SUS and should be attended in their needs; c) integrality - health and people should be seen as a whole, however, this does not only depend on the professional; d) social control - referring to the Municipal Health Council.
This is in agreement with the arguments of Galvão (1999) regarding the proximity of the homeopathic model with the proposal for health promotion, since, in homeopathy, Hahnemann establishes a link between individual health and the most probable cause of an acute disease, as well as the most significant moments of the entire clinical history of a chronic disease, in order to discover its fundamental cause, taking into consideration the physical constitution of the patient, their character (including their psychism and mind), their occupations, their habits and way of life, their social and domestic relationships, their age, sexual function etc. For Hahnemann, the physician is a conserver of health, if they know the factors that disturb the health, that provoke and sustain the disease, they can figure out how to dispel these from healthy people.
Pay attention to the approximation of homeopathy with public health, since, at the same time as it emphasizes the use of medication in the prevention and cure of diseases, it highlights the role of physician as an agent of social transformation.
In conclusion, through the reflections in this study, which achieved the satisfaction of users, administration workers, students, preceptors and professors involved in the experience, it was possible to understand that teaching the Homeopathic Rationality in Institutions of Higher Learning is feasible, with clinical-pedagogical practice oriented for the Brazilian Public Health Service (SUS).
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Reflexibility is considered by Giddens (1991; 1997) as a condition that permits an individual to develop a consciousness that can be separate and, like a spectator, be aware of itself even while involved in the drama of life in its multiple dimensions.