Actions to prevent disabilities integrated by health care services:
Reality or utopia?
Marcos Túlio Raposo,
Ana Virgínia de Queiroz Caminha,
Caroline Santos Adimarães,
Jéssica Souza Britto
e Lorena dos Santos Duarte.
During the course of Hansen’s disease, the peripheral nerves, the skin and its attachments are compromised (1, 2). Neural damage can result from the direct action of the Hansen’s disease bacillus or from an immune response against this microorganism, which results in an inflammatory process in the nerve, impairing its normal functioning. Both mechanisms compromise the autonomic nerve functions (production of sweat, control of blood vessel contraction, for example), motor (muscle strength) and sensory (temperature, touch and pain) of the areas they supply (3-5) and can lead to disabilities (6, 7). Some people react to infection more intensely than others, involving other organs, aggravating the condition of the disabilities (2, 3, 8).
Depending on the time elapsed, Hansen’s disease disabilities may be present at the time of diagnosis, which may be mitigated or remain stabilized with specific treatment. In another direction, they may worsen or become irreversible if they are not recognized and treated appropriately in a timely manner (2, 8).
Disabilities occur most frequently in the nose, eyes, hands and feet, compromising aesthetics and function. They can be measured by means of simplified neurological assessment (SNA) - a detailed clinical examination of nerves and their functions - from which the Grade of disability (GD) for eyes, hands and feet is established (9), in a grid thus defined: G0D (Grade zero disability) indicates that there are no disabilities due to Hansen’s disease; G1D confirms that there is decreased sensitivity in the cornea or decreased strength in the eyelids (no apparent deformity), alteration in palmar and/or plantar sensitivity, decreased strength in the hands and/or feet (no visible disabilities); G2D is applicable to situations of severe impairment, with visible disabilities in the eyes, hands and/or feet caused by Hansen’s disease (1).
Because of the complexity of Hansen’s disease, when talking about its treatment, it must be understood that it involves not only drug treatment, but a much more comprehensive set of measures, such as prevention of disabilities (PD). This corresponds to a broad and well-structured process that makes up the therapeutics of the disease, with the aim of avoiding the occurrence of physical, emotional, socioeconomic damage (1, 10) and requires multiprofessional intervention (2). This process is made up of a set of measures, applicable at the different levels of care, aimed not only at the person affected by the disease, but also at the collective and its surroundings, in order to prevent disabilities, activity limitations and participation restrictions (11), such as: health education; early diagnosis, timely and regular treatment with MDT, contact surveillance; early detection and adequate therapeutic management of reactionary conditions; self-care; support for maintaining emotional condition and social integration (1).
After the patient's reception and admission to the health service, he/she should have his/hers needs identified and receive the support of the team to face the disease. The actions toward to prevent disabilities involve, at least: neurological examination through the SNA; evaluation of the GD; monitoring of neural function during and after MDT(12); health education and self-care measures; adaptation of work tools and for daily life; making of orthoses, footwear adaptations; and physiotherapy and/or occupational therapy interventions (10).
Although advances in Hansen’s disease treatment in last decades are acknowledged, the comprehensive approach still remains insufficient, as the incorporation of PD, rehabilitation, functional assessment and stigma mechanisms need to be ensured and made available to all patients through equal access with timely treatment (2).
For a country responsible for 13% of the world's total new Hansen’s disease cases in 2019 (13), actions to prevent disabilities have not yet reached the goal of implementation and enforcement. The reality of health services is worrying, as Brazil is currently immersed in a context of multiple difficulties imposed by the Covid-19 pandemic (14), (15) with a devastating policy of reducing support for science (16, 17), underfunding and increasing dismantling of the Public Health System known SUS (18-20). In the midst of this compromising scenario, it remains challenging that, in the face of large general user demands and insufficient coverage of the family health strategy, actions to prevent disabilities should be offered satisfactorily and that comprehensive care should be provided to persons affected by Hansen’s disease, as proposed in the Global Strategy for Hansen’s disease 2016-2020 in line with the Sustainable Development Goals (21).
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