Having been invited to write an Editorial for the present issue of the Brazilian Journal of Occupational Medicine, at the time the members of the Executive Board of the National Association of Occupational Medicine (ANAMT 2016-2019) complete their term of office, and after having learned of the rich content of the contributions it carries, I decided to come back once again, even if briefly, to a subject close to my heart and that has fascinated me - and also at times been a source of distress and concern - for 47 years, since 1972, i.e. when I began my work in occupational medicine.
I must confess I used to feel more optimistic in the past, and let me say that my current despondency has nothing to do with my age - I'm almost 74 -, but with the seemingly growing deviance of the role of occupational medicine in Brazil.
Whenever I ponder on what is done in the name of occupational medicine I wonder whether such practices are compatible with the medical profession to begin with, and then whether they are or not proper to this field. On many occasions I have expressed my discontentment with dysfunctions, harms and evils allegedly done in the name of occupational medicine, and my critical attitude has triggered hostile, even outrageous reactions.
Therefore I take profit of the kind invitation to contribute to this section, which grants editors and guests freedom of thought, to reflect on what I believe to be the object and the subject of occupational medicine by going more than 300 years back, to the Italian physician Bernardino Ramazzini (1633-1714) and his ageless book Diseases of Workers (1700)1.
One may assume that 319 years is more than enough time for Ramazzini's doctrine on the need, relevance and value of medical actions for the health of workers to have consolidated. Yet the opposite may also be true: the passage of time might have made his doctrine be all but forgotten. Ramazzini was a physician and a professor of medicine, not a proper occupational physician. Nevertheless, I'm persuaded he was a true workers' doctor. Workers were the target of his clinical work, as well as the ultimate reason for his innovative doctrine of workers' protection and defense, especially in the face of the asymmetry of forces and power that has always signaled the path of our most vulnerable brothers and sisters!
Many other great masters contributed over time to strengthen Ramazzini's doctrine. In this short essay I chose to focus on another celebrated physician, the German pathologist Rudolf Virchow (1821-1902), perhaps one of the most prominent doctors of the nineteenth century. He left us precious teachings, for instance, his categorical assertion that "medicine is a social science, and politics is nothing else but medicine on a large scale." And also "physicians are the natural attorneys of the poor, and the social problems should largely be solved by them"2,3.
A discussion of this brilliant physician should consider, even if briefly, his many facets: the pathologist - he was among the creators of scientific general pathology, the social reformer - with his contribution to the creation of social medicine, the anthropologist, the archeologist, the biologist, the historian, the writer, the editor, and the politician. Virchow was one of the very few people who are both multiple and unique, who stand out in anything they do. He had vision and sensitiveness to investigate the microscopic universe of cells, of tissues, organs and system, to also reach to the macroscopic level of normal and pathological anatomy. And still far beyond: to the larger social and political universes, his insights contributing to the understanding of the people's, social, national and global problems.
While the teachings of the father of general pathology and social medicine are no longer celebrated in the present time, it is worth noticing that one among the fundamental principles in the Brazilian Code of Medical Ethics states that "the entire focus of the physicians' attention is on the health of human beings, for which purpose they should act with the utmost zeal and the best of their professional ability4." And also "physicians should strive to improve human labor through the elimination and control of the risks to health inherent to job tasks4." These commandments apply to each and every physician! If so, what would one say about the duties of occupational physicians?
According to the International Commission on Occupational Health (ICOH) International Code of Ethics for Occupational Health Professionals "The primary aim of occupational health practice is to safeguard and promote the health of workers, to promote a safe and healthy working environment, to protect the working capacity of workers and their access to employment5". A mere three or four commandments summarize the reason for existence of occupational medicine, especially as per the challenge posed in the title of this editorial.
For the sake of brevity, it is time to conclude this essay, and I do so by bringing a question asked by the philosopher and educator Mario Sergio Cortella in the title of one of his most pleasant books: Why do we do what we do?6 This question - which is the title of both the book and one of its chapters-may be reproduced here with the same lightness and seriousness as its author's. He asks what he qualifies as "the most important questions on 'judgment day'." To be sure, not a religious, and much less a legal 'judgment day,' but at an invisible and merciless ethical, or perhaps bioethical court. These are the four most important questions:
Why did you do what you did?
Why didn't you do what you didn't do?
Why did you do what you shouldn't have done?
Why didn't you do what you should have done?
Under the inspiring light of the illustrious physicians Ramazzini and Virchow, and bearing in mind the clear ethical commandments for all physicians, and also those for occupational physicians, I suggest each and all us try and answer Cortella's four questions, not out of fear of the verdict on 'judgment day,' but as an opportunity to reflect on and reassess (eventually also rectify and realign) our practice. And at the collective and institutional
1. Mendes R. A atualidade da obra de Ramazzini, 300 anos depois. In: Ramazzini B, editor. As Doenças dos Trabalhadores [Internet]. 4th ed. Translation: Raimundo Estrêla. São Paulo: Fundacentro, 2016 [cited on Sept. 19, 2019]. p. 289-297. Available at: http://www.fundacentro.gov.br/biblioteca/biblioteca-digital/publicacao/detalhe/2016/6/as-doencas-dos-trabalhadores
2. Brown TM, Fee E. Rudolf Carl Virchow: medical scientist, social reformer, role model. Am J Public Health. 2006 [cited on Sept. 19, 2019];96(12):2105-5. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1698150/
3. Eisenberg L. Rudolf Ludwig Karl Virchow, where are you now that we need you? Am J Medicine. 1984 [cited on Sept. 19, 2019];77(3):524-32. Available at: http://www.amjmed.com/article/0002-9343(84)90114-1/fulltext
4. Conselho Federal de Medicina. Código de Ética Médica: Resolução CFM nº 2.217, de 27 de setembro de 2018, modificada pelas Resoluções CFM nº 2.222/2018 e 2.226/2019. Brasília: Conselho Federal de Medicina, 2019 [cited on Sept. 19, 2019]. 108 p. Available at: https://portal.cfm.org.br/images/PDF/cem2019.pdf
5. International Commission on Occupational Health (ICOH). International Code of Ethics for Occupational Health Professionals. 2012 [cited on Sept. 19, 2019]. Available at: http://www.icohweb.org/site_new/multimedia/core_documents/pdf/code_ethics_eng_2012.pdf
6. Cortella MS. Por que fazemos o que fazemos? Aflições vitais sobre trabalho, carreira e realização. São Paulo: Planeta; 2016.