ABSTRACT

This essay analyzes the dynamics of Brazilian medical practice’s corporate action in the COVID-19 pandemic, from March 2020 to July 2021, from documents and institutional material of national medical entities, student organizations, groups of nationally reputed physicians, and journalistic articles and scientific literature publications on the subject. This period is marked by the politicization of the corporate agenda and the alignment with the denialist discourses of Jair Bolsonaro’s administration. It is argued that this process stems from a previous politicization: the clash against the More Doctors Program from 2013, the year of its launch, to 2019, when the Government deactivated it. The two historical moments reveal the dual denialism of the medical corporation, emphasizing weaknesses, contradictions, and dilemmas of the profession’s crossroads, which will require internal and social dialogues for a new consensus on corporate identity and the professional project of Medicine. Understanding the intertwining, disputes, and meanings of the dynamics and directions of the corporate action of Medicine allows identifying structural problems of political roots that prevent further advances in the consolidation of the Unified Health System.

KEYWORDS
Physicians; Societies, Medical; COVID-19; More Doctors Program

Introduction

The COVID-19 pandemic poses significant challenges to healthcare professionals. Uncertainties and gaps regarding scientific evidence for disease management permeate the daily life of health systems and services in the global backdrop. We witness exhaustive working hours, high frequency of contagion and death of workers, and weak professional regulation to circumvent distribution problems and staff shortages in a health crisis¹1 Ricci G, Pallotta G, Sirignano A, et al. Consequences of Covid-19 Outbreak in Italy: Medical Responsibilities and Governmental Measures. Front Public Health. 2020; (8):588852.,²2 Zapata T, Buchan J, Azzopardi‐Muscat N. The health workforce: Central to an effective response to the COVID‐19 pandemic in the European Region. Int J Health Plann Manage. 2021; (36):9-13..

Effective measures to control the virus require management policies for the Health Workforce (HW), considering different attributes of the professionals involved³3 Nittayasoot N, Suphanchaimat R, Namwat C, et al. Public health policies and health-care workers’ response to the Covid-19 pandemic, Thailand. Bull World Health Organ. 2021; (99):312-8.,⁴4 World Health Organization. Health workforce policy and management in the context of the COVID-19 pandemic response: interim guidance. Geneva: WHO; 2020. [acesso em 2021 mar 15]. Disponível em: https://apps.who.int/iris/handle/10665/337333.
https://apps.who.int/iris/handle/10665/3... . Gaps in planning the expansion and adequacy of care capacity and the need to incorporate new skills and leadership in the qualification of human resources to expand responses to global public health emergencies⁵5 Czabanowska K, Kuhlmann E. Public health competences through the lens of the Covid‐19 pandemic: what matters for health workforce preparedness for global health emergencies. Int J Health Plann Manage. 2021; (36):14-9.,⁶6 Hawkins R, Ruebush E, Plescia M. Public Health Strengths During the COVID-19 Response. J Public Health Manag Pract. 2021; (27):329-31. became evident.

Such aspects are expressed in the Brazilian HW, which also has a high level of inequity concerning contagion and lethality, risk perception, and protection given to health professionals. We observe issues regarding the scarce primary supplies and infrastructure in services that exacerbate working conditions and increase workers’ exposure to the virus⁷7 Duarte MMS, Haslett MIC, Freitas LJA, et al. Descrição dos casos hospitalizados pela COVID-19 em profissionais de saúde nas primeiras nove semanas da pandemia, Brasil, 2020. Epid. Serv. Saúde. 2020; (29):e2020277.,⁸8 Lotta G, Fernandez M, Corrêa M. The vulnerabilities of the Brazilian health workforce during health emergencies: Analysing personal feelings, access to resources and work dynamics during the COVID-19 pandemic. Int J Health Plann Manage. 2021; (36):42-57.,⁹9 Viana Campos AC, Pereira Colares Leitão L. Letalidade da COVID-19 entre profissionais de saúde no Pará, Brasil. J Health NPEPS. 2021; (6):22-34..

The medical category represents this process due to historically unresolved issues, such as insufficient supply and inadequate territorial distribution of professionals; training gaps; and weaknesses of its incorporation into the Unified Health System (SUS)¹⁰10 Oliveira APC, Gabriel M, Poz MRD, et al. Desafios para assegurar a disponibilidade e acessibilidade à assistência médica no Sistema Único de Saúde. Ciênc. Saúde Colet. 2017; (22):1165-80.,¹¹11 Maciel Filho R, Branco MAF. Rumo ao interior: médicos, saúde da família e mercado de trabalho. Rio de Janeiro: Ed. Fiocruz; 2008. [acesso em 2019 out 24]. Disponível em: http://books.scielo.org/id/64g49.
http://books.scielo.org/id/64g49... ,¹²12 Miotto BA, Guilloux AGA, Cassenote AJF, et al. Physician’s sociodemographic profile and distribution across public and private health care: an insight into physicians’ dual practice in Brazil. BMC Health Serv Res. 2018; (18):299.,¹³13 Balzan NC, Wandercil M. Formando médicos: a qualidade em questão. Aval Rev Aval Educ Super Camp. 2019; (24):744-65.. The core character of the profession in assisting the population is also highlighted by the mobilization of several experts, given the scope of COVID-19 manifestations and sequelae. In this aspect, the work of epidemiologists, public health professionals, and family and community doctors is also relevant.

Reviewing intervention strategies during and after the pandemic requires the involvement of organizations representing Medicine. We understand that the political orientation and positions of entities and medical groups can influence (and be influenced by) government decisions. The category’s interests in protecting professionals and adherence and articulation of coping policies are evident in the corporate agenda.

The Federal Government’s response to the health emergency was marked by tensions and political disputes from March 2020 to July 2021, based on denialist discourses that disregard scientific recommendations for control, such as rejecting social distancing, embracing the ‘herd immunity’ concept, falsely opposing preservation of the economy and human life, questioning the vaccine’s safety, and advocating the use of drugs without proven efficacy for the so-called ‘early treatment’¹⁴14 Barberia LG, Gómez EJ. Political and institutional perils of Brazil’s Covid-19 crisis. The Lancet. 2020; (396):367-8.,¹⁵15 Campos GWS. O pesadelo macabro da Covid-19 no Brasil: entre negacionismos e desvarios. Trab Educ e Saúde. 2020; (18):e00279111.,¹⁶16 Sodré F. Epidemia de Covid-19: questões críticas para a gestão da saúde pública no Brasil. Trab Educ e Saúde. 2020; (18):e00302134.,¹⁷17 Daniels JP. Health experts slam Bolsonaro’s vaccine comments. The Lancet. 2021; (397):361..

In the same period, the profession’s performance dynamics evidenced contradictory narratives and positions in response to the pandemic, politicizing the corporate agenda and aligning political interests of medical groups with President Jair Bolsonaro’s Government. In this sense, the ramifications of the Government’s stance have increasingly been reflected in the divergences and controversies within professional representation and public opinion.

This essay argues that the predominance of an ‘organic’ articulation of national corporate and governmental agendas and the ensuing tensions in the COVID-19 pandemic results from a previous politicization: the corporate action’s dynamics in clashing against the Mais Médicos (More Doctors) Program (PMM) launched by the Dilma Rousseff government in 2013.

The period medical entities questioned the PMM consolidated a growing opposition to the Federal Government, given the incidence of the program in the medical flagships since its origins and consolidated in the courses of these organizations. The PMM program revealed accumulated tensions between the category and the Federal Government since 2003 when the dialogue with other stakeholders was expanded around changes in priority medical training work and regulation policies¹⁸18 Dias HS. Do diálogo à ruptura: interações governo-corporação médica na política nacional de trabalho e educação na saúde. [tese]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2018. 187 p..

This process also comprises expressive actions in defense of the 2016 presidential impeachment, highlighting, as in other historical moments, the ‘liberal-conservative’¹⁹19 Campos GWS. Os médicos e a política de saúde: entre a estatização e o empresariamento: a defesa da prática liberal da medicina. São Paulo: Editora Hucitec; 1988. corporative direction. Reestablishing the medical agenda, symbolized by the end of the PMM, found shelter in Jair Bolsonaro’s Government (2019), an alignment that defined the course of the doctors’ political action in the COVID-19 pandemic as of 2020.

This essay aims to analyze the dynamics of corporate action in Brazilian Medicine during the COVID-19 pandemic. The medical corporation is defined as the identification and defense of professional interests by the set of entities and representative groups of doctors. Furthermore, medical work dynamics incorporate disputes, divergences, and oppositions of these professional bodies.

We analyzed documents and institutional material collected on the pages and social networks of national medical entities, especially the Brazilian Medical Association (AMB), which is active in professional qualification and granting expert titles, and the Federal Council of Medicine (CFM), professional practice inspection body; medical student organizations; and a group of nationally reputed doctors. Other sources included journalistic articles and scientific literature publications on the topic addressed.

The clash between the medical corporation and the PMM (2013 to 2019) and its alignment with the federal response to the COVID-19 pandemic (March/2020 to July/2021) are addressed in the following two sections. The final section presents reflections on the paths of the category in Brazil during this period, considering Medicine’s dilemmas and prospects and its political action dynamics.

The clash of the medical corporation against the Mais Médicos Program (2013 to 2019)

In 2013, the launch of the PMM by the Dilma Rousseff government caused a strong reaction from medical entities. The government program focused on several historical struggles in the category, such as fighting against the expansion and questioning the quality of medical schools, the mandatory revalidation of foreign certificates, and advocating for a national public State career²⁰20 Alessio MM, Sousa MF. Programa Mais Médicos: elementos de tensão entre governo e entidades médicas. Interface - Comun Saúde Educ. 2017; (21):1143-56.,²¹21 Gomes LB, Merhy EE. Uma análise da luta das entidades médicas brasileiras diante do Programa Mais Médicos. Interface - Comun Saúde Educ. 2017; 21:1103-14.,²²22 Rios DRS, Teixeira C. Mapeamento da produção científica sobre o Programa Mais Médicos. Saúde e Soc. 2018; (27):794-808..

The reaction involved the release of a unified position letter from the CFM, the AMB, the National Federation of Doctors (FENAM), and the National Association of Resident Doctors (ANMR)²³23 Conselho Federal de Medicina, Associação Médica Brasileira, Federação Nacional dos Médicos, et al. Residentes. Carta das entidades médicas aos brasileiros. Brasília, DF: CFM; AMB; FENAM; ANMR; 2013.. The disagreements stirred a tense climate, culminating in several legal challenge measures and a search for parliamentary support to overthrow the initiative²⁴24 Soares CM, Freitas MS, Teixeira CF, et al. Análise do posicionamento das Entidades Médicas - 2015-2016. Saúde debate. 2017; 41(esp3):74-86..

A movement of confrontation was articulated at the XII National Meeting of Medical Entities (ENEM), convened as an emergency, covering educational institutions and professionals from the public and private care network, with the category’s demonstrations and strike threats. Medical students relied on FENAM’s support to occupy the rectories, protesting the proposal to expand the graduation period to eight years and involve professors in mentoring program participants²⁵25 Silva VO, Rios DRS, Soares CLM, et al. O Programa Mais Médicos: controvérsias na mídia. Saúde debate. 2018; 42(117):489-502.,²⁶26 Colleta RD. Federação de médicos e estudantes apoiam ocupação de faculdades contra o “Mais Médicos”. O Estado de São Paulo. 2013 jun 26. [acesso em 2021 jun 13]. Disponível em: https://saude.estadao.com.br/noticias/geral,federacao-de-medicos-e-estudantes-apoiam-ocupacao-de-faculdades-contra-o-mais-medicos,1057696.
https://saude.estadao.com.br/noticias/ge... .

Alleging that there was no dialogue and an authoritarian governmental position, the medical corporation broke up with the Federal Government, and representatives of the entities withdrew from forums, commissions, and institutional workgroups. At the same time, it sought to step up its work in the National Congress due to the discussions and negotiations regarding the conversion of the PMM’s Provisional Measure into law.

Corporate unity and support from opposition parliamentarians resulted in the Government withdrawing from extending the course duration. However, the arrival of doctors to work in PHC without diploma revalidation, especially in the Cuban case brokered by the Pan American Health Organization, remained in the program’s law. Xenophobic protests from Brazilian doctors²⁴24 Soares CM, Freitas MS, Teixeira CF, et al. Análise do posicionamento das Entidades Médicas - 2015-2016. Saúde debate. 2017; 41(esp3):74-86. marked the arrival of professionals from that country.

Some mismatches in the coping strategy with the category were evident in the legislative process, dividing the AMB and the CFM, with the former’s refusal to accept the results of negotiations by the Council, which assigned the role of temporary registration of participating doctors to the Ministry of Health (MS). Backed by opposition parliamentarians, the AMB counter-argued that the councils granting the registration was a historic achievement of the category, therefore, non-negotiable²⁷27 Mensagem de Ronaldo Caiado a todos os médicos do Brasil. Ordem dos Médicos do Brasil. 2014 jan 20. [acesso em 2021 jun 13]. Disponível em: https://ordemdosmedicosdobrasil.blogspot.com/2014/01/mensagem-de-ronaldo-caiado-todos-os.html.
https://ordemdosmedicosdobrasil.blogspot... .

These conflicts and the insufficient small advances made in the Legislature led to persistent internal tensions and clashes with the Government. With the enactment of the PMM law, the defeat of the entities raised questions from medical groups regarding the legitimate and effective representation by national entities on the political agenda, which incorporated new organizations in the fight against the program.

Additionally, in 2013, historically represented by the National Executive Directorate of Medical Students (DENEM), the medical student movement saw the emergence of the Brazilian Association of Medical Students (AEMED-BR), which aimed to assume national student representation under the flagship of training quality and expanding students’ voice. Its work was characterized by its proximity to the AMB, which formalized it as an academic scientific department of the entity²⁸28 Associação dos Estudantes de Medicina do Brasil. Home. [acesso em 2021 jun 13]. Disponível em https://pt-br.facebook.com/AEMEDBR/.
https://pt-br.facebook.com/AEMEDBR/... ,²⁹29 Fundação Oswaldo Cruz, Escola Politécnica de Saúde Joaquim Venâncio. Agenda controversa. 2016 jun 3. [acesso em 2020 maio 5]. Disponível em: https://www.epsjv.fiocruz.br/noticias/reportagem/agenda-controversa.
https://www.epsjv.fiocruz.br/noticias/re... .

DENEM sought to reinforce the non-recognition of the representative legitimacy of AEMED-BR, which, in turn, considered it an ideologically left-wing entity. DENEM also took a stand against the PMM, albeit differently than the unified medical entities’ rejection. With less corporate content, albeit with convergent themes, it signaled an intensification of the private educational market, substandard work conditions, and the doctor-centered nature of the program, limiting structural changes in the SUS³⁰30 Direção Executiva Nacional dos Estudantes de Medicina. Deliberações dos Grupos de Discussão e Trabalho do ECEM Rio de Janeiro 2012 e ECEM Belém 2013. [local desconhecido]: DENEM; 2014.,³¹31 Direção Executiva Nacional dos Estudantes de Medicina. Resultado dos grupos de discussão e trabalho do 44o Encontro Científico dos Estudantes de Medicina. [local desconhecido]: DENEM; 2014..

The protests and announced strikes in several states projected a group of doctors, initially articulated with FENAM, who also implemented, in 2013, the creation of the Brazilian Doctors Association (OMB), based on questions about the inability of traditional entities such as AMB and CFM to bar measures such as the Mais Médicos and the presidential vetoes of parts of the professional regulation law (the medical act law) sanctioned that year.

The OMB was formalized as an associative entity in November 2013, with an expected leading role in corporate policy, aiming at professional advocacy and influencing SUS reforms. It signaled gaps in the performance of existing entities, considering that the organization of a bench of medical parliamentarians and a certain permissiveness with allegedly incompetent³²32 Ordem dos Médicos do Brasil. Home. [acesso em 2021 jun 13]. Disponível em: https://ordemdosmedicosdobrasil.blogspot.com.
https://ordemdosmedicosdobrasil.blogspot... public health managers is insufficient. The 2013 OMB is not the materialized proposal to merge the AMB and the CFM, part of the corporate agenda of the early 2000s, without concrete developments.

The fight against the PMM became part of an opposition agenda to the Dilma government and started to guide a broader set of criticisms of the actions that involved the health policy and strategic initiatives of the Workers’ Party governments, such as the Growth Acceleration Program (PAC). Problems in the management of public resources were highlighted, strengthening an association with movements linked to Lava Jato Operation, triggered in March 2014, and the anti-corruption measures advocated by the Federal Public Prosecutor’s Office.

These dynamics were also motivated to rebut positions due to the doctors’ rejection of the internalization proposed in the Mais Médicos. The category’s non-adherence was also justified by the structurally deficient services and the lack of a medical career in the SUS²⁵25 Silva VO, Rios DRS, Soares CLM, et al. O Programa Mais Médicos: controvérsias na mídia. Saúde debate. 2018; 42(117):489-502.. Frequent editorials and articles from entities were produced to this end, along with a counter-argument that the problem resided in the poor territorial distribution.

In 2014, the electoral context escalated the category’s aversion to the Dilma government, which ran for reelection with an agenda of continuity and expansion of the Mais Médicos. This backdrop paved the way for a greater approximation of medical groups and entities with the opposition candidates, materializing, in the second round, with public statements and participation in the campaign of candidate Aécio Neves, who ran for the Brazilian Social Democracy Party. AMB’s deliberative council formalized an institutional position against the current President³³33 Associação Médica Brasileira. Jornal da Associação Médica Brasileira. 2014; 55(1392):1-34..

Dilma’s reelection frustrated the expectations of the PMM’s closure from 2015 onwards, exacerbating tensions around the program’s unfolding, such as the implementation of the National Registry of Medical Specialists, a campaign promise made by the current President. Despite some willingness to resume dialogue with the MS, more evident in the medical unions and in FENAM²⁴24 Soares CM, Freitas MS, Teixeira CF, et al. Análise do posicionamento das Entidades Médicas - 2015-2016. Saúde debate. 2017; 41(esp3):74-86., the political crisis installed since the 2014 election result and the advance of the Lava Jato Operation led to the corporation’s rejection of the re-elected Government.

The National Registry of Medical Specialists was formalized by decree in August 2015 but overturned in a corporate articulation with the Legislature, which replaced it with another one fully proposed by the medical corporation³⁴34 Associação Médica Brasileira. Jornal da Associação Médica Brasileira. 2016; 56(1402)1-36., in growing demonstrations for the President’s stepdown, loss of her popularity, and eventful relationship with the National Congress.

Support for impeachment demonstrations, Lava Jato, Judge Sergio Moro, and the movements around the anti-corruption discourse³⁵35 Conselho Federal de Medicina. Jornal Medicina CFM. 2016; 31(254):1-12.,³⁶36 Associação Médica Brasileira. Jornal da Associação Médica Brasileira. 2017; 57(1403): 1-37. consolidated an association with right-wing parties and parliamentarians. Stakeholders gave the reception and voicing of the corporation’s demands in this field, such as Senator Ronaldo Caiado and Representative Luiz Henrique Mandetta, both doctors, with mandates from the Democrats party.

The conservative political orientation was confirmed to be the majority in Brazilian Medicine also in this period, supporting an alignment with the anti-Workers’ Party stance, widely explored in the positions of the corporation’s groups and entities. We should remember, for example, that AMB asked the Federal Supreme Court to disqualify former President Dilma since the Senate had preserved her political rights when voting impeachment.

However, a counterpoint was the emergence of the National Network of Popular Doctors (RNMMP) in 2015, gathering medical professionals and students with an agenda focused on defending the SUS and articulating with popular movements, political parties, and unions. The network is present in all Brazilian regions, reaching 14 states in July 2021³⁷37 Rede Nacional de Médicas e Médicos Populares. Home. [acesso em 2021 jul 15]. Disponível em: https://medicospopulares.org/.
https://medicospopulares.org/... .

A little later, in March 2016, the Group of Doctors for Democracy emerged in Ceará, questioning the legitimacy of the positions of national (CFM and AMB) and regional (Ceará Doctors’ Union) entities regarding adherence to the stepdown of the President, considered a coup d’état. In Bahia, the group became official in July, with an agenda like Ceará and participation in the Bahian medical movement, presenting slates in union and regional council elections in that state.

These groups preceded the Brazilian Association of Doctors for Democracy (ABMMD), founded in October 2019, with the representation of doctors from ten states, also in contrast to the declared opposition to the Federal Government. Its work occurred initially in state groups in the context of impeachment, reaffirming the existence of progressive and humanist doctors close to the Left in defense of democracy³⁸38 Rede Nacional de Médicas e Médicos Populares. Associação Nacional de Médicas e Médicos pela Democracia. [acesso em 2021 jul 15]. Disponível em: https://medicospopulares.org/https://abmmd.com.br/.
https://medicospopulares.org/https://abm... .

The presidential removal in 2016 was considered by the corporation the end of ideological interference with ‘evidence-based Medicine’, a narrative adopted to question the training of Cuban doctors; and the so-called negative bias given to the category by the Government³⁹39 Associação Médica Brasileira. Jornal da Associação Médica Brasileira. 2016; 56(1401):1-34.. An expected reversal of the PMM set in, such as the interrupted expansion of medical schools, the reversal of the permission to work with non-revalidated diplomas, and the implementation of the State career.

The corporation’s relationship with the MS was resumed during the Temer government (May/2016 to 2018), receptive to the new organizations that originated in the fight against the PMM. AEMED-BR and OMB leaders were received in meetings with the Minister of Health in favor of reviewing the role and size of the SUS, discussed during the Ricardo Barros administration²⁹29 Fundação Oswaldo Cruz, Escola Politécnica de Saúde Joaquim Venâncio. Agenda controversa. 2016 jun 3. [acesso em 2020 maio 5]. Disponível em: https://www.epsjv.fiocruz.br/noticias/reportagem/agenda-controversa.
https://www.epsjv.fiocruz.br/noticias/re... . In the period, AEMED-BR expanded regionally and influenced traditional representations of the category, expressed in the election of one of its founders to the presidency of ANMR in 2018⁴⁰40 Associação Médica Brasileira. Jornal da Associação Médica Brasileira. 2018; 58(1407esp):1-32..

The favorable dialogue facilitated the acceptance of claims such as the Ministry of Education’s suspended opening of new medical courses for five years, some government commitment to prioritize Brazilian doctors in the PMM, and articulations of the Parliamentary Front for the Defense of Medicine, launched in 2017, with the support of the then Representative Luiz Henrique Mandetta.

On the other hand, the State Career and the National Examination for the Revalidation of Medical Diplomas (Revalida) did not advance, limiting the expectations of the resumed dialogue and the definitive shutdown of the PMM by the Temer administration. Thus, the corporation felt some frustration due to the impossibility of fully enforcing its agenda on the program, which was well evaluated by the population and defended by many municipal managers.

In 2018, these issues were discussed at the XIII ENEM, followed by the release of the ‘Manifesto of Doctors in Defense of Brazilian Health’⁴¹41 Conselho Federal de Medicina, Associação Médica Brasileira, Federação Nacional dos Médicos, et al. Manifesto dos Médicos em Defesa da Saúde do Brasil’. [Brasília, DF]: CFM; AMB; FENAM; FMB; ANMR; 2018., delivered to presidential candidates. It aimed to influence the campaigns’ health proposals, reaffirming the defense of the State medical career, the revalidation of foreign medical diplomas, respect for the ‘Medical Act’ and control of the training quality and the number of medical schools.

The unfolding of the 2014 political crisis, emphasizing the impeachment of Dilma in 2016 and the disqualified candidacy of former president Lula, affected the 2018 elections. In Medicine, this backdrop expressed the course of corporate political action: conservative, liberal, right-wing, and anti-Workers’ Party. This position was aligned with the candidacy of Jair Bolsonaro, who committed to a medical career and the obligation of the Revalida, sealing the support of doctors and their representative entities, with minority resistance from the RNMMP and ABMMD.

Support for Bolsonaro’s successful campaign guaranteed the medical corporation space in the governmental decision-making process from 2019 onwards. Former Representative Luiz Henrique Mandetta, one of the entities’ allies in the fight against the PMM, assumed the post of Minister of Health, with staff from national and regional entities. One example was the appointment of doctor Mayra Pinheiro, of the Ceará Doctors’ Union, to the Health Labor and Education Management Secretariat (SGTES).

Doctors played a central role in the Government’s actions that culminated in the closure of the Mais Médicos in 2019, preceded by the end of the partnership with Cuba, which ordered the return of the medical staff participating in the PMM due to criticism from the President-elect. The category’s ‘lobby’ resulted in the postponement of calls for foreign professionals in 2018 to expand the participation of Brazilian professionals⁴²42 Pinheiro BJ. O lobby da classe médica que influenciou a decisão de encerrar o programa. El Pais. 2019 jun 6. [acesso em 19 de junho de 2021]. Disponível em: https://brasil.elpais.com/brasil/2019/02/06/politica/1549488445_129358.html.
https://brasil.elpais.com/brasil/2019/02... .

The favorable environment to advance at last in the corporate agenda gave the medical entities a pro-government behavior. The permeability of the federal administration initiated in 2019 to its claims resulted in recognition of authorship and, thus, in defense of the government initiatives proposed that year: the Doctors for Brazil Program and the Agency for the Development of PHC (ADAPS), milestones of the end of the PMM, and the Revalida law – both sanctioned with presidential vetoes demanded by the entities⁴³43 Conselho Federal de Medicina. Jornal Medicina CFM. 2019; 34(298):1-12,⁴⁴44 Associação Médica Brasileira. Jornal da Associação Médica Brasileira. 2019; (1411):1-35..

The corporation considered Doctors for Brazil and ADAPS the realization of the medical career. However, the focus on PHC in remote areas, and the provision for professional inclusion through a scholarship in the first two years, followed by recruitment through the Consolidated Labor Laws (CLT), indicated the opposite⁴⁵45 Giovanella L, Bousquat A, Almeida PF, et al. Médicos pelo Brasil: caminho para a privatização da atenção primária à saúde no Sistema Único de Saúde? Cad. Saúde Pública. 2019; (35):e00178619.. The proposal presented was quite different from the original claim, inspired by the career of the federal judiciary to achieve professional interiorization.

The RNMMP and the National Health Council mobilized to resist and fight against these initiatives, indicating the risk of expanding SUS commercialization⁴⁶46 Centro Brasileiro de Estudos de Saúde. Posição da Rede Nacional de Médicas e Médicos Populares sobre ADAPS e novo financiamento da APS. 2019 nov 20. [acesso em 2021 maio 18]. Disponível em: https://cebes.org.br/posicao-da-rede-nacional-de-medicas-e-medicos-populares-sobre-adaps-e-novo-financiamento-da-aps/20848/.
https://cebes.org.br/posicao-da-rede-nac... and the threats to the opening of PHC to the private sector⁴⁷47 Morosini MVGC, Fonseca AF, Baptista TWF. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cad. Saúde Pública. 2020; (36):e00040220..

The pro-government alignment of the medical corporation in the COVID-19 pandemic (March/2020 to July/2021)

The onset of 2020 was influenced by the good relationships of the medical entities with the Federal Government, after the achievements with Revalida and the ‘medical career’ (end of the PMM) in 2019. The positive assessment of officers of the representatives of the Government’s behavior was not affected by the declaration of the COVID-19 pandemic by the World Health Organization (WHO).

Initially, the entities’ concerns revolved around the validation of care protocols and pressures for ensuring the supply of personal protective equipment and preservation of stocks of medical and hospital supplies and medicines in COVID-19 reference services. At that time, there were no further questions about the Government’s role in the pandemic response.

This environment changed, motivated by the pronouncement of President Bolsonaro, minimizing the severity of the crisis and the social distancing recommended by experts and implemented by governors and mayors. Divergent reactions to the presidential narrative came from the Brazilian Societies of Immunizations, Infectious Diseases and Hypertension, and the São Paulo Medical Association. The Brazilian Medical Federation reacted by reaffirming the importance of science in addressing the health emergency⁴⁸48 Federação Médica Brasileira. É preciso confiar na ciência e nos médicos! 2020 mar 25. [acesso em 2021 jul 7]. Disponível em: http://portalfmb.org.br/2020/03/25/e-preciso-confiar-na-ciencia-e-nos-medicos/.
http://portalfmb.org.br/2020/03/25/e-pre... .

Denialism guided the Federal Government’s response, marked by controversies about promoting the early use of drugs without scientific efficacy. This issue started a crisis with the then Minister of health, Luiz Henrique Mandetta, who had asked the CFM for a position on the prescription of chloroquine and hydroxychloroquine for COVID-19 amid controversy over the results of efficacy tests. The divergent stance of the presidential discourse resulted in the Minister’s dismissal.

In April 2020, the CFM published an opinion authorizing Brazilian doctors to prescribe chloroquine/hydroxychloroquine⁴⁹49 Conselho Federal de Medicina. Parecer no 4/2020. Considerar o uso da cloroquina e hidroxicloroquina, em condições excepcionais, para o tratamento da COVID-19. Brasília, DF: CFM; 2020.. Followed by the AMB, it adopted a narrative of defense of professional autonomy, transferring responsibility and consent to the doctor and his patient. As a result, the uncertainties about the disease and the high number of deaths were used to justify using the substance, which was considered to have few side effects. Thus, the repercussion of the decision led CFM’s President to claim that it was an authorization with no connotation of recommendation to doctors⁵⁰50 Gullino D, Ferreira P. Conselho de Medicina diz a Bolsonaro que não há evidência de benefício da cloroquina, mas autoriza prescrição por médicos. Jornal O Globo. 2020 abr 23. [acesso em 2021 jul 7]. Disponível em: https://oglobo.globo.com/brasil/conselho-de-medicina-diza-bolsonaro-que-nao-ha-evidencia-de-beneficio-da-cloroquina-mas-autoriza-prescricao-por-medicos-1-24389317.
https://oglobo.globo.com/brasil/conselho... .

The opinion disregarded the positions of the infectious diseases, intensive care, and pulmonology societies, contrary to the authorization of the off-label use of chloroquine/hydroxychloroquine in initial symptomatic cases, besides those of the Brazilian Society of Immunology and the National Academy of Medicine (ANM)⁵¹51 Sociedade Brasileira de Imunologia. Parecer Científico da Sociedade Brasileira de Imunologia (SBI) sobre a utilização da Cloroquina/Hidroxicloroquina para o tratamento da COVID-19. São Paulo: SBI; 2020.. The confirmed ineffectiveness by new clinical research led to the suspension of tests by the WHO and a request to abandon the use of substances by the Brazilian Society of Infectious Diseases and the ANM. In parallel, the MS published guidelines for early drug therapy with the drugs⁵²52 Brasil. Ministério da Saúde. Orientações do Ministério da Saúde para Manuseio Medicamentoso Precoce de Pacientes com Diagnóstico da Covid-19. [data desconhecida]. [acesso em 2021 jul 7]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/orientacoes-manuseio-medicamentoso-covid19-pdf.
https://www.gov.br/saude/pt-br/centrais-... .

The setting already evidenced the dissemination of the prescription of these drugs by doctors across the country, involving their distribution within the so-called ‘COVID Kit’ by SUS managers and private plan operators⁵³53 Esteves B. Jalecos em guerra. Revista Piauí. ed. 196. 2020 out. [acesso em 2021 jul 19]. Disponível em: https://piaui.folha.uol.com.br/materia/jalecos-em-guerra/.
https://piaui.folha.uol.com.br/materia/j... . At that time, some severe side effects from the use of ivermectin, one of the drugs in the kit⁵⁴54 Carvalho C. Ao menos quatro pacientes que tomaram “kit-Covid” aguardam transplante de fígado em hospitais de SP. Jornal O Globo. 2021 mar 24. [acesso em 2021 ago 2]. Disponível em: https://oglobo.globo.com/brasil/ao-menos-quatro-pacientes-que-tomaram-kit-covid-aguardam-transplante-de-figado-em-hospitais-de-sp-1-24938473.
https://oglobo.globo.com/brasil/ao-menos... , were reported.

Now spearheaded by General Eduardo Pazuello, after the departure of another medical minister, Nelson Teich, in office for 29 days, the MS expanded ‘early treatment’ for different disease conditions while escalating the purchase of chloroquine and its production by the Brazilian Army⁵⁵55 Castro C. O gasto público do governo com cloroquina em 4 atos. Nexo Jornal. 2021 fev 12. [acesso em 2021 jul 13]. Disponível em: https://www.nexojornal.com.br/expresso/2021/02/12/O-gasto-p%C3%BAblico-do-governo-com-cloroquina-em-4-atos.
https://www.nexojornal.com.br/expresso/2... . The narrative of the AMB and the CFM favoring the doctor’s autonomy remained, incorporating the Brazilian Society of Cardiology in July.

The Government’s ‘early treatment’ propaganda also gained strength through the articulation with the ‘Brazil Movement overcoming COVID’, motivated by successful experiences and criticism of ‘traditional science’, which would be influenced by ideological and economic interests in medical societies⁵⁶56 Alvim M. O grupo de “10 mil” médicos pró-cloroquina que se aproximou de Bolsonaro com ‘evento histórico’. BBC News Brasil. 2020 set 3. [acesso em 2021 jul 28]. Disponível em: https://www.bbc.com/portuguese/brasil-53994532.
https://www.bbc.com/portuguese/brasil-53... . The relationship with the President of the Republic dates to February 2020, evidenced in August, during a presidential event for early treatment, with the presence of leaders and members of CFM and AMB⁵⁷57 Brasil. Ministério da Saúde. Tratamento precoce contra Covid-19 é defendido por médicos para aumentar chance de cura. 2020. [acesso em 2021 jul 13]. Disponível em: https://www.gov.br/pt-br/noticias/saude-e-vigilancia-sanitaria/2020/08/tratamento-precoce-contra-covid-19-e-defendido-por-medicos-para-aumentar-chance-de-cura.
https://www.gov.br/pt-br/noticias/saude-... .

This movement coalesced into the Doctors for Life Association COVID-19, which aimed to establish a network of doctors questioning the vaccine’s safety and in favor of early treatment, which organized manifestos to the authorities and public opinion⁵⁸58 Associação Médicos pela Vida Covid-19. [acesso em 2021 jul 13]. Disponível em: http://medicospelavidacovid19.com.br.
http://medicospelavidacovid19.com.br... . Its relationships with corporate and power bodies facilitated the wide dissemination of misinformation in the media, even representing a minority share of Brazilian doctors.

Members of these groups originate from local medical movements of a conservative and religious nature, such as the ‘Ainda Há Bem’ (There is still Good) movement in Ceará, which opposes the decriminalization of abortion. The public support of government parliamentarians and members of the Bolsonaro government, notably the SGTES Secretariat, Mayra Pinheiro, highlights the bridges built with these stakeholders, pro-Bolsonaro businesspeople, and the pharmaceutical industry finance their actions⁵⁹59 Correia M. Movimento de médicos que mistura aborto com cloroquina tem ligações com Ministério da Saúde. A Pública. 2021 abr 19. [acesso em 2021 jul 13]. Disponível em: https://apublica.org/2021/04/movimento-de-medicos-que-mistura-aborto-com-cloroquina-tem-ligacoes-com-ministerio-da-saude/.
https://apublica.org/2021/04/movimento-d... ,⁶⁰60 Quem está por trás do “informe publicitário” negacionista e pró-cloroquina em jornais. Brasil de Fato. 2021 fev 24. [acesso em 2021 jul 14]. Disponível em: https://www.brasildefato.com.br/2021/02/24/quem-esta-por-tras-do-informe-publicitario-negacionista-e-pro-cloroquina-em-jornais.
https://www.brasildefato.com.br/2021/02/... .

The resurgence of the pandemic and the collapse of the health system in Manaus (AM) in early 2021 exposed the Federal Government’s failure to adopt reversal measures while prioritizing the launch of the TrateCov application, which recommended citizens to use early delivery of COVID-19 drugs. Its negative repercussion motivated the CFM to ask for the discontinuation of the measure. At the time, positions from the Infectiology and Pulmonology and Phthisiology societies reaffirmed the drugs’ inefficacy⁶¹61 Sociedade Brasileira de Pneumologia e Tisiologia. Posicionamento da Sociedade Brasileira de Pneumologia e Tisiologia sobre o colapso em Manaus e tratamento preventivo e precoce da covid-19. 2021 jan 17. [acesso em 2021 jul 13]. Disponível em: https://sbpt.org.br/portal/wp-content/uploads/2021/01/Posicionamento-SBPT-tratamento-precoce-COVID19-17-01-2021-1.pdf.
https://sbpt.org.br/portal/wp-content/up... .

This context and the troubled start of emergency immunization against the disease motivated the release of a letter from former CFM presidents and advisers asking for the entity’s stance in favor of vaccination and non-pharmacological measures. An attempt was made to show the Council’s perception of omission at a crucial moment of purchasing and distributing vaccines against COVID-19, trivialized by the Government⁶²62 Martins L. Médicos do CFM participaram de reunião de “gabinete paralelo” com Bolsonaro. UOL. 2021 jun 2021. [acesso em 2021 jul 13]. Disponível em: https://noticias.uol.com.br/saude/ultimas-noticias/redacao/2021/06/08/cfm-gabinete-paralelo-bolsonaro-conselheiros.htm?cmpid=copiaecola.
https://noticias.uol.com.br/saude/ultima... .

After the election of a new Board in 2021, the AMB broke with the denialist view aligned with the Government, starting to condemn the use of ineffective drugs against COVID-19 and defending social distancing and the use of masks – measures reiterated by the ANM in a note of condolence for the death of one of its members due to COVID-19, Doctor Ricardo Cruz⁶³63 Médico Ricardo Cruz, um dos cirurgiões mais respeitados do país, morre de Covid-19. Jornal O Globo. 2020 dez 8. [acesso em 2021 jul 13]. Disponível em: https://oglobo.globo.com/brasil/medico-ricardo-cruz-um-dos-cirurgioes-mais-respeitados-do-pais-morre-de-covid-19-24787121.
https://oglobo.globo.com/brasil/medico-r... .

The CFM maintained its pro-chloroquine position, now isolated among traditional entities, denying review of the authorizing opinion of April 2020. It insisted on the lack of scientific consensus on the drug’s effectiveness and the medical autonomy narrative. An attempt to reduce criticism was the defense of effective non-pharmacological measures and investigation of adverse events from the off-label use of COVID-19 drugs⁶⁴64 Conselho Federal de Medicina. Nota do CFM aos médicos e à população; Reflexões sobre o enfrentamento da pandemia de covid‐19. 2021 mar 25. [acesso em 2021 jul 13]. Disponível em: https://portal.cfm.org.br/wp-content/uploads/2021/03/notaoficialcfmcovid.25.03.2021.pdf.
https://portal.cfm.org.br/wp-content/upl... .

In contrast to the low support for non-pharmacological measures, one item on the corporate agenda that stood out consisted of articulations to judicially bar individual and group requests (one of them was from the governors of the Northeast) to allow doctors trained abroad to work. Raised as a possibility to help SUS managers to provide doctors during the pandemic, Revalida’s flexibility was the object of bills that also did not advance due to the entities’ lobby⁶⁵65 Lazzeri T. Apesar da pandemia, CFM dificulta alternativas de validação de diplomas estrangeiros. The Intercept Brasil. 2021 maio 10. [acesso em 2021 jul 13]. Disponível em: https://theintercept.com/2021/05/10/apesar-pandemia-cfm-dificulta-alternativas-validacao-diplomas-estrangeiros/.
https://theintercept.com/2021/05/10/apes... .

In April 2021, the establishment of the Parliamentary Commission of Inquiry (CPI) in the Federal Senate to investigate the role of the Federal Government in the pandemic highlighted more aspects of corporate alignment with the Federal Government. A gathering of representatives of the Doctors for Life Association COVID-19, pro-chloroquine doctors, including Doctor Nise Yamaguchi, and representatives of the CFM, with the President of the Republic, was revealed. It was an informal meeting articulated by Doctor Osmar Terra and fulfilled the role of a ‘parallel office’ to support the negationist agenda⁶⁶66 ‘Gabinete paralelo’ de Bolsonaro teve presença de conselheiros do CFM. Rede Brasil Atual. 2021 jun 8. [acesso em 2021 jul 13]. Disponível em: https://www.redebrasilatual.com.br/saude-e-ciencia/2021/06/gabinete-paralelo-de-bolsonaro-teve-presenca-de-conselheiros-do-cfm/.
https://www.redebrasilatual.com.br/saude... .

Denialism also prevailed within the MS, in the figure of the doctor Mayra Pinheiro, from SGTES, known as ‘Captain Chloroquine’. Even after the departure of two doctor ministers, her permanence revealed that access to the Government, achieved in 2019, imposed ideological submission and narratives contrary to scientific evidence, defended in the clash against the PMM.

The CPI also exposed the Government’s conduct of Medicine for the reactions to the treatment provided to deponent government doctors. CFM sent a letter to the Federal Senate President denouncing what it called the CPI’s toxic environment in the arguments of Nise Yamaguchi and Mayra Pinheiro. The body also published a motion of repudiation, demanding respect and civility in the CPI hearings, with public support from the President of the Republic⁶⁷67 Muratori M. Bolsonaro posta vídeo do presidente do CFM com críticas à CPI da COVID. Estado de Minas. 2021 jun 3. [acesso em 2021 jul 13]. Disponível em: https://www.em.com.br/app/noticia/politica/2021/06/03/interna_politica,1273240/bolsonaro-posta-video-do-presidente-do-cfm-com-criticas-a-cpi-da-covid.shtml.
https://www.em.com.br/app/noticia/politi... .

Questioning the legitimacy of representation fell again to ABMMD and RNMMP, who released a note of repudiation of the CFM’s behavior, blaming it for the deaths and supporting ineffective treatments. These organizations submitted a document to the CPI requesting an investigation by the Board⁶⁸68 Associação Nacional de Médicas e Médicos pela Democracia, Rede Nacional de Médicas e Médicos Populares. O Conselho Federal de Medicina na Pandemia de Covid-19; pela apuração das responsabilidades da atual diretoria na CPI da Pandemia. Fortaleza: ANMMD; RNMMP: 2021.. The ANM and the National Academies of Sciences and Pharmaceutical Sciences also acted in defense of scientific evidence as a guide to facing the pandemic.

Corporate medicine at a crossroads

The dynamics of the Brazilian medical corporation performance in the COVID-19 pandemic exposed weaknesses, contradictions, and dilemmas of the profession, revealing the crossroads situation of the category. The political, social, and professional repercussions impose efforts of internal dialogues and in society to build other consensuses around the corporate identity and Medicine’s professional project.

The politicization that marks the paths to bar the PMM and highlights the Government’s stance on the pandemic produces dual corporate denialism. The fight against the program symbolized the denial of a policy that, even with limits, aimed to change the chronic shortage of professionals. The number of doctors practically doubled in 20 years, reaching the mark of 500 thousand in 2020 (ratio of 2.4 doctors/1,000 inhabitants). However, they remained concentrated in the capitals (5.65/1,000 inhabitants versus 1.49/1,000 inhabitants in the inland regions)⁶⁹69 Scheffer M. Demografia Médica no Brasil 2020. 2020. [acesso em 2021 ago 5]. Disponível em: https://www3.fm.usp.br/fmusp/conteudo/DemografiaMedica2020_9DEZ.pdf.
https://www3.fm.usp.br/fmusp/conteudo/De... and the private sector.

Moreover, it evidenced the rejection of professional training changes. In 2014, within the PMM, the National Curriculum Guidelines (DCN) for Medicine emphasized interdisciplinary training, focused on PHC and health needs (already been designed since 2001)⁷⁰70 Brasil. Governo Federal. Programa Mais Médicos; o novo currículo. [data desconhecida]. [acesso em 2021 jul 13]. Disponível em: http://maismedicos.gov.br/o-novo-curriculo.
http://maismedicos.gov.br/o-novo-curricu... . With the PMM, registrations of family and community doctors increased by more than 30% as the departure of Cuban doctors, which began in 2018, registered a 10% shortage⁷¹71 Gomes CBS, Gutiérrez AC, Soranz D. Política Nacional de Atenção Básica de 2017: análise da composição das equipes e cobertura nacional da Saúde da Família. Ciênc. Saúde Colet. 2020; (25):1327-38..

The revival of the corporate agenda, obtained with the Bolsonaro government, further distanced the profession from a social perspective, which was crucial in realizing the SUS. In return for the government opening, which responded with a controversial proposal for a medical career and generic pro-Revalida legislation, the corporation positioned itself in line with scientific denialism, a hallmark of federal behavior in response to the health crisis.

These work dynamics offer common elements supporting the observed denialisms. One of them is the narrative of physician freedom and autonomy, a central and original aspect of the corporate agenda. On the one hand, its use to reject state interventions that threaten corporate leadership in the desired professional self-regulation; on the other hand, its controversial advocacy, within the limits of professional ethics, as a permissive strategy for the negationist governmental discourse.

Another highlight is the selective defense of scientific evidence guiding professional training and practice. The criticism of the work of doctors with diplomas not revalidated by the PMM in the PHC of the SUS emphasized evidence-based Medicine, supposedly ignored in that public policy, while such concern is not evident in the same intensity in the pandemic. This contradiction reveals medical education gaps, particularly in the critical analysis of studies and interpretation of evidence. The alleged concern with the quality of training becomes questionable.

Fighting against quackery, structuring the professionalization of Medicine, weakens in the face of accepting ineffective treatments for COVID-19, blurring the boundary separating the ‘professional’ and the ‘non-professional’, even if the formal qualification for the exercise of the profession has been achieved. Noteworthy are also the weakened ethical commitments of non-harm and non-exposure of patients to unnecessary risks and impacts the doctor’s social legitimacy, threatening people’s bonds of trust and the doctor-patient relationship.

The two stages presented evidenced the emergence of medical groups and organizations that contest the capacity for political articulation and the legitimacy of traditional representative entities, such as the AMB and the CFM. They also strain the institutional limits of formal and legal representation, enabling more explicit ideological and partisan preferences. Also, these movements acquire political power and influence practices in Medicine projects for society.

This process results in escalating politicization within the corporation, with fragmented, divided, and polarized interests and values underlying the medical category. It also highlights its inclusion in the international/global backdrop of anti-vaccine and anti-science movements and economic interests, which, while not new, require a deeper understanding of the effects of the relationship with the pharmaceutical industry and the market for experimental/ineffective treatments.

In the relationship with the SUS, the pro-Government’s alignment pointed to contradictions between the entities’ explicit support for the Government and weakened health financing bases, which hinder the corporation’s aspirations included in the Government plan elected in 2018. For example, how to implement the federal medical career under a contractionary tax regime?

This study adopted an analytical perspective that values the relationships between medical entities, different groups representing the profession, and political and governmental authorities. Understanding the intertwining, disputes, and meanings of the dynamics and directions of the corporate action of Medicine facilitates the identification of structural problems with political roots that prevent further advances in the consolidation of the SUS.

References

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