Chinese medicine in Brazil

Introduction

Acupuncture and Chinese medicine have been used for a long time in Brazil and has been increasingly accepted by the population and the health professionals (1).

In Brazil, traditional Chinese medicine (TCM) practice began with the arrival of the first Chinese immigrants to Rio de Janeiro in 1810. In 1908, the Japanese immigrants brought in Japanese acupuncture, although it was restricted to the colony.

In 1958, Friedrich Spaeth, a physiotherapist, responsible for the spread of acupuncture in Brazilian society in the 1950s, began teaching this ancient practice in Rio de Janeiro and Sao Paulo. In 1972, he founded the Brazilian Association of Acupuncture. This association remains active until today, but not like that with its original mission and purpose. It has lost its political or unifying influences and is just one of the many acupuncture schools offering different programs.

It is believed that in the State of Sao Paulo there are around 30,000 acupuncturists. This estimate is from the State Union of Acupuncturists of Sao Paulo (SATOSP). It is estimated that in Brazil there are more than 50,000 professionals working with acupuncture or methods related to Chinese medicine. The Federation of Acupuncturists of Brazil (FENAB) states that in Brazil there are around 160,000 people practicing acupuncture (1,2).

The president of SATOSP reminds that the real total number of practitioners cannot be established as there is no official registry of acupuncturists and there are also a large number of practitioners with a bachelor degree in health profession. They practice acupuncture as a specialty so they do not always call themselves acupuncturists.

This paper aims to present information related to the use of acupuncture by Brazilians, education in Brazil in relation to Chinese medicine and acupuncture, the steps of the regulation of these practices, as well as the use and legality of Chinese medicine products among Brazilians.

Regulation and reality of acupuncture and Chinese medicine studies in Brazil

As there is no official list of practitioners, there is also no official list for the schools or institutions that offer programs on acupuncture and Chinese medicine. A basic research on the electronic database of Brazilian Ministry of Education presents a total of 60 different institutions offering acupuncture program with postgraduate level.

In Brazil until now, there has been no acupuncture or Chinese medicine college or university with bachelor, master or doctorate degree (3).

However, there is an important exception related to official acupuncture education. The date of June 7^th, 2002, is the graduation day of the first and only 17 Brazilian acupuncturists with a bachelor’s degree, following the failure of attempts by the Brazilian Medical Board to stop the program. It is a group of brave students who did not accept offers and pressure to transfer to other programs with full scholarship and decided to fight for a diploma in acupuncture.

Acupuncture education in Brazil is now basically offered in two different ways: (I) open courses where everyone can study acupuncture after at least completing the high school level of education; (II) post graduation courses where people with a bachelor degree in any health profession can study and receive an official certificate with full validity from the Ministry of Education. It shall be mentioned that in the South of Brazil there is a higher education program in acupuncture, which is not bachelor’s degree level. This program has recently won a judicial dispute against the Federal Board of Medicine that tried to prevent the continuity of the course. The same situation is valid for Chinese herbs programs, Tui Na programs and so on (4).

The only exception is the massage for which there is an official program. It is considered as a mid-level education, accredited by the state and valid throughout the country.

At present, EBRAMEC, which stands for Brazilian College of Chinese Medicine, is the largest organization dedicated to Chinese medicine in Brazil. Its main building is about 4,000 square meters large. It has branches in more than 15 different cities and states around Brazil, with a history of 16 years. EBRAMEC has a total of about 1,500 students enrolled in different levels of education related to Chinese medicine (5).

Since the founding in 2001, EBRAMEC has grown steadily and has established cooperation with renowned institutions from different countries in order to promote high quality education, including a number of famous Chinese Medicine Universities in China.

In a recent internal study, 508 application files of EBRAMEC students and former students enrolled in acupuncture programs were randomly selected and manually reviewed and analyzed, in order to obtain different data such as: gender, age, enrolled program, weekly or monthly programs, pre graduation degree and so on.

Our findings during this descriptive study may be applicable to other institutions and present a possible scenario for a better understanding for those interested in acupuncture education in Brazil (5).

It is interesting to note that there is a very large difference between females (77%) and males (23%) enrolled in acupuncture programs, as in Figure 1, which can be understood as that more and more women are achieving their professional goals and are seeking for a more rewarding occupation, such as acupuncture. Basically, all the reviewed classes have a higher number of women compared to men.

Figure 1 Graphic demonstration of the percentage of students divided by gender.

For the age part of this study, it is noticed that 420 out of 508, which is 83% of all students, are over of 31 years old as it is possible to observe in Figure 2. This information indicates that possibly most of them decided to study acupuncture in order to change their original profession, to complement their original profession or in some way establish a new direction for life. These possibilities were further explored when each student’s prior education was also analyzed and we noted that only 22% did not have a higher education degree prior to studying acupuncture.

Figure 2 Graphic demonstration of percentage of students divided by age.

A large number of students seek acupuncture as a possible specialty or part of their own previous profession, such as physiotherapy, nursing, or pharmacy and so on. These students normally enroll in the postgraduate program offered by EBRAMEC as it is accredited by Brazilian Ministry of Education.

The study demonstrates that most of the students (56%) are seeking acupuncture as a postgraduate program and that is understandable as the national boards of different professions have recognized or established acupuncture as a professional specialty.

Regulation and reality of the professional practice of acupuncture and Chinese medicine in Brazil

The Board of Physiotherapy is the first professional board to recognize acupuncture as an occupational practice in 1985 thanks to Special Resolution 219. Its members are legally allowed to practice acupuncture as part of their profession (6).

This first official recognition from a professional board influenced other boards to issue similar resolutions for their members. Some even set the standard and duration of education, the area of practice, and the expected obligations. The following is a sequence of resolutions from different boards: Resolution 219/1985; Biomedicine Resolution 0002/1986; Veterinary Medicine Resolution 625/1995; Western Medicine Resolution 1455/1995; Nursing Resolution 197/1997; Pharmacists Resolution 353/2000; Occupational Therapist Resolution 221/2001; Audiologist Resolution 272/2001; Psychologist Resolution 05/2002; Physical Education Resolution 069/2003.

Although acupuncture is widespread in Brazil and is associated with the credibility of other health professionals, it associated with Chinese medicine which is still unregulated and freely practiced.

Specifically speaking, acupuncture has already existed in the Brazilian Classification of Occupations (CBO) in four different modes (acupuncturist, physiotherapist acupuncturist, acupuncture doctor and psychologist acupuncturist). It is protected by the State Unions registered in the Ministry of Labour. Unfortunately, until now there have been no official regulations on acupuncture or Chinese medicine in Brazil. There is a bill that is being analyzed in order to possibly become a regulation, but there is no specific date for political evaluation of this bill.

The bill is from the House of Representatives (PL 1549/2003), presents a broad overview of the regulation and mentions the possibility of an academic degree in acupuncture, which would be the best way to improve the level and quality of professional education. It includes the possibility to recognize the same or similar degrees obtained from official educational institutions of other countries, and allows training in postgraduate courses for those professionals who have previously graduated from healthcare programs (7).

On August 20^th, 2019, PL 1549/2003, after 16 years, was finally fully approved in the House of Representatives and was sent to the Senate, where it will go through the ordinary legislative process. It shall be pointed that this bill was initially presented and promoted by SATOSP, but in recent years, before approval in the House of Representatives credits will be granted to FENAB as the main body that seeks to connect with congress representatives and senators to explain the importance of approving PL 1549/2003.

As long as the bills are not voted in Brazil, the Federal Constitution guarantees the free professional practice of acupuncture. In addition, through resolutions and norms the professional councils and associations would protect the patients who seek acupuncture as a treatment.

The Federal Constitution of Brazil in its 5^th article, 2^nd paragraph, explicitly establishes that “no one shall be forced to do or refrain from doing anything except by law” and this is one of the strongest arguments used for the free practice of acupuncture by anyone, not restricted by any specific profession (2,4,6).

Therefore, the right of acupuncture practice in Brazil remains open to anyone who has the true desire to acquire relevant knowledge.

The argument of the Constitution has two sides, as Yin and Yang in Chinese Philosophy. One is that there is no restriction in any way and no profession can control or dominate acupuncture by itself, but on the other hand, anyone, even without the proper education or knowledge, can claim to be an acupuncturist.

It must be pointed out that in recent years the Federal Council of Medicine has been trying to control the practice of acupuncture and limit the use of acupuncture only to physicians through lawsuit, propaganda in media and a new law for physicians, which would make them exclusive to practice acupuncture.

Those attempts at a monopoly on acupuncture by the Federal Council of Medicine have all been thwarted in court, but it still intends to control the practice of acupuncture through new bills that will certainly be challenged in court as it was done previously.

It is also important to point out that on September 26^th, 2013, an official Technical Note was issued by the Ministry of Health. In the department, Heider Aurelio Pinto, who coordinates Integrative and Complimentary Practices, mentioned that there was no legal impediment to the practice of acupuncture, as well as for other methods of Chinese medicine, by different health professionals.

The purpose of the main Brazilian authorities of acupuncture and state unions is the comprehensive regulation of acupuncture, so that possible monopoly disputes cease to exist and the Brazilian population can take advantage of acupuncture for their health.

Besides the private practice of acupuncture, its use was introduced in the Outpatient Information System - SIA/SUS in 1999, through Ordinance No. 1230/GM2, and it was strengthened by Ordinance 971, published by the Ministry of Health in 2006. It approved the National Policy for Integrative and Complementary Practices in the Unified Health System (SUS) (8-10).

Since the final report of the 8^th National Health Conference in 1986, the introduction of alternative healthcare practices within the scope of public health services has been sought.

However, it was only in 2006, through the National Policy for Complementary and Integrative Practices, that non-medical professionals were allowed to act as acupuncturists within the Brazilian National Health System (SUS).

This document defines that the SUS approaches and resources should be integrated to stimulate disease prevention and health recovery by natural means. It is also suggested that there should be an emphasis on spending more time in the first consultation visit and listening to the patients’ complaints, the development of the therapeutic relationship and the integration of the human being with the environment and society.

Regulation and reality of Chinese herbal therapy in Brazil

In 2014 ANVISA (National Health Surveillance Agency), directly dependent on the Ministry of Health, issued two important resolutions that may be related to the import, distribution and use of products related to Chinese medicine, more specifically related to products for the practice of Chinese herbal medicine (2).

Special Resolution RDC 21 of April 25^th, 2014, deals with the manufacturing and marketing of Chinese medicine products. It has established a trial period of 3 years from the date of publication to monitor the use of TCM products in the country and these products are not subject to sanitary registration.

Based on this Resolution, Chinese medicine products are considered to be formulations obtained from raw materials of plants, minerals and fungi (macroscopic fungi) according to the techniques of Chinese medicine and are present in the Chinese Pharmacopoeia. The use of raw materials of animal origin is prohibited in formulations to be marketed in Brazil.

A very important aspect of this Resolution is that Chinese medicine products are not subject to sanitary registration, which makes the import and distribution process simpler than those related to medicines.

Special Resolution RDC 26 of April 13, 2014, deals with the registration of herbal medicines and the registration and notification of a new category of products described as traditional herbal products.

Traditional herbal products are considered those obtained with the exclusive use of plant raw materials whose safety and efficacy is based on a safe and effective use on data published in technical and scientific literature and are designed to be used without the supervision of a physician for diagnostic purposes, prescription or monitoring.

As Chinese medicine is an ancient health practice and its herbal products have been used for thousands of years, this special ANVISA Resolution could also be an interesting option for the regular entry and distribution of Chinese medicine products through the possibility of a simpler and more direct registration process.

Level of acceptance by Brazilian population

Brazilian population has been accepting Acupuncture and other Integrative Medicine Practices more and more in recent years.

After the establishment of the National Policy for Complementary and Integrative Practices, an increase of the acupuncture treatment could be observed so that, for example, the acupuncture applications in patients of the Unified Health System (SUS) of São Paulo grew by 567% from 2007 to 2011, according to the report from the State Department of Health. In 2011, there were a total of 264,400 technical applications of acupuncture in public services in the State of Sao Paulo, while in 2007 this figure was just 39,600. Thus, it can be observed that there has been a constant increase in the use of acupuncture in SUS (10,11).

In another recent study, it was observed that the number of municipalities that joined the practice of acupuncture in SUS has increased by 64.13% in two years. It also showed the highest growing rate in the south and north of Brazil, compared to other regions it was 1,512.27% and 389.50% respectively.

A research carried out with 300 people, divided on the basis of three different religious beliefs, described that 67.33% of the participants would accept acupuncture treatment, and 22.4% of those who would not accept acupuncture mentioned fear of needles as the main reason; another research found that 67% mentioned fear of needles as a reason for not accepting acupuncture. This could be related to a cultural aspect of Brazilian population where it is common to use the words “needle” or “injection” or “vaccine” as a kind of eventual punishment for children who misbehave (12,13).

Acknowledgments

I would like to acknowledge the support from staff of Faculdade EBRAMEC on providing the raw data from the students.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Ramon Calduch Farnòs) for the series “Regulation of Chinese Medicine in the Different Countries of the World” published in Longhua Chinese Medicine. The article has undergone external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/lcm-2021-004). The series “Regulation of Chinese Medicine in the Different Countries of the World” was commissioned by the editorial office without any funding or sponsorship. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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