Legal abortion and transsexualization cannot be taboo in the SUS, says the new secretary

The new national secretary of primary health care, doctor Nésio Fernandes, 40, says the health ministry must resume the “civilizing agenda” and decentralize legal abortion services and the transsexualization process in the SUS (Healthcare System unified), issues fought by the bolsonarists militancy.

“The law already says that any maternity hospital can have a legal abortion. It’s not a procedure that is foreign to their daily lives. But who is going to raise this issue, civil society? The state,” Fernandes said in an interview with Sheet.

For him, the transsexualization process can be expanded. Since 2008, SUS has offered access to hormones and genital and body modification surgeries for trans women and, since 2013, also for trans men and transvestites.

He also claims that foreigners can return to the Mais Médicos program, especially in distant cities, but without the cooperation agreement previously signed with Cuba. The plan is to fill vacancies by opening public tenders for those who graduated in the country, or studied abroad and did the Revalida (which validates the diplomas of doctors who graduated abroad and want to work in Brazil).

The secretary also proposes partnerships with schools and dialogue with religious institutions to strengthen the vaccination campaign.

In 2020, Fernandes participated in a venture to send a ten-year-old girl, pregnant after a rape, to Pernambuco to perform a legal abortion, a situation that led to protests by extremists and the actions of former minister Damares Alves.

What is the change in primary care that should be noted in relation to the Bolsonaro government? The environment we want to build here is the one that characterizes the SUS. These civilization programs discuss abortion, gender-based violence, sexual reproductive health, social determinants of health involving race and color, vulnerable populations. These are always topics that gain great prominence and depth in the SUS prima. Get HIV, LGBTQIA+ agenda, we need to get it back fast.

All these advanced programs must have in Saps [Secretaria de Atenção Primária à Saúde] an environment of freedom of thought, criticism, elaboration and proposal of public policies, because we do not need a Ministry of Health or secretariats that only publish technical notes.

How can the government resume “civilizing agendas”? It is necessary to organize a network which, from the moment of the attraction of primary care, allows, in the event of suspicion of violence, that the community health agent, the doctor, the nurse, all recognize the situation, to prevent to rape. If there’s a rape, take that kid out of the situation.

Then there must be integration with the Single Social Assistance System, the guardianship council, a direct relationship with the Public Prosecutor of each region. If that child who is a victim of rape ends up becoming pregnant, she must be diagnosed quickly in order to access, with the lowest risk, legal abortion.

We need a maternal network that performs the abortion, decentralized. I had to take a ten-year-old girl from Espírito Santo to Pernambuco. I have agreed with everyone to remain silent, secret, until the procedure is completed.

Due to the religiosity of community health workers, doctors, nurses, [eles] welcoming the pregnant child as a mother. ‘Hi mom, listen to your heart [do bebê].’ They naturalize violence in that suffering, preventing that child even from being encouraged to exercise his autonomy, his decision. And it does not repair the victim from the point of view of psychological suffering.

Then you need NASF (family health support centres) with a psychologist, with a social worker in all primary care.

The law already says that any maternity hospital can perform a legal abortion. It is not a procedure foreign to their daily life. But who will raise this issue, civil society? It has no normative power, no power of induction, of financing. Who has this is the state. It is up to the Ministry of Health to force the entire chain of public power, state and municipal public, contracted private providers, to provide services and guarantee dignity and access.

Do you intend to define a specific public policy on legal abortion? Will professionals be instructed, if a woman arrives with a reported case or who appears to be pregnant from rape, not to treat her as a “mom,” but as a victim? No doubt. It is necessary to establish policies from regulations to funding, monitoring, evaluation. Otherwise it’s not politics, it’s a note of intent, a protocol, it’s a desire based on academic inspiration. Public policy must have it all.

I’m not saying I’ll do it next month. It’s something within that debate to discuss issues that have been protected in this recent period. We need to preserve the institution of the Ministry of Health, so that it leads all the complex discussions with advanced positions.

So, in general, the Ministry of Health cannot deny debates such as legal abortion… …process of transsexualization of the population.

For the transsexualization process, is it necessary to create a new procedure or structure in the SUS? We already have some services in Brazil, so they can be strengthened, others must be created, we have states that have no services, not even the outpatient service.

Is it the government’s idea to decentralize this kind of service? Sure, because the trans population isn’t that big. How much these people suffer, how much they can resign themselves, have another quality of life if they can go through a process of transsexualization, from psychological treatment, to psychiatric support, to drugs, to surgical procedure, if they have access to the civil right to be able to change the name. It is not possible that all states do not have a service like this implemented and established.

How does this kind of issue play out under a conservative Congress? You do not need it. This is already at the discretion of the public power, it can now open [o serviço], has resources from the Ministry of Health, has funding channels. You don’t need Congress for that. This is pacified. I’m just discussing legal abortion, abortion already pacified.

What is the vaccination proposal? Today, just the audiovisual campaign is not enough, just the mobilization campaign. We need a mobilization with the schools. The older the age, the lower the vaccination coverage. Especially from three and four years, the coverage is lower. Where are the 3, 4 year olds? At Schools. Either we mobilize education on this agenda or we cannot carry this campaign forward.

Lula spoke in dialogue with churches for vaccination. I am Baptist, my dialogue with believers is very good. In Espírito Santo, we managed to get the Pentecostal bishops, the Assembly of God, the rabbi, the priest vaccinated, all on the same day.

Not all of them are deniers, Bolsonarists, there is a good crowd there. This group can talk. I think vaccination is an agenda to help resume dialogue with religion.

Can foreign doctors, including Cubans, strengthen Mais Médicos? At the opening of the public notice for foreigners who have not been revalidated they can apply. The first phase will be for professionals registered in Brazil, Brazilians or foreigners. The second is for Brazilians educated abroad and the third for foreigners. [sem diploma validado].

As long as there is a deep Brazil, the periphery, and we don’t change the content of values, training, profile, class of medicine much, we will need decades to recruit doctors on a mandatory basis, and one of the best ways is provisional registration.

What is the proposal to welcome the Mais Médicos and Médicos Pelo Brasil programs? The path is the unification of programs. Both will be part of a single strategy. You have a shortage of doctors, but you also have a shortage of other professionals. You can’t put the psychologist inside the inside of the inside [do Brasil]. There is a shortage of speech therapists in large centres. Everything is missing.

What should be the future of ADAPS [Agência para o Desenvolvimento da Atenção Primária à Saúde, criada no governo Bolsonaro para administrar o Médicos Pelo Brasil]? The agency is undergoing a process of reformulation and improvement in which other competencies and responsibilities can be incorporated. It’s a subject that will take months to mature. It can also be a tool to implement telehealth. Or it can be an experience that consolidates other public sector hiring milestones.

A large part of the budget for primary care is managed with parliamentary amendments to municipal funds, without following regional priority criteria. The amendments are decided in December. The ones we will perform [em 2023] already passed. The challenge is being able to assemble a good portfolio [de ações para as emendas], have a mature, Republican debate with Congress to qualify the question next year. We will not put an end to the parliamentary amendment, this is an objective phenomenon, this is part of the Brazilian political culture, very difficult.


Nesio Fernando, 40 years old

Evangelical, member of the PCdoB and doctor trained in Cuba, he was Secretary of Health of the Espírito Santo, from 2019 to 2022, and president of Conass (National Council of Health Secretaries).

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