Airton Stein attending the GIN Annual Conference in Geneva, Switzerland (September 2025). Image is from: https://www.linkedin.com/pulse/community-shaped-me-airton-stein-reflects-nkkce/
Professor Dr Airton Stein has dedicated more than two decades to advancing evidence-based guidelines and improving health quality on a global scale.
A Family Physician for 41 years in Conceicao Community Health Service and professor at the Federal University of Health Sciences of Porto Alegre, Brazil, for 25 years.
Airton Tetelbom Stein Graduated in Medicine at the Pontifical Catholic University of Rio Grande do Sul (1981), Family Physician at Rio Grande do Sul Health Secretariat, Master Medical Sciences, Federal University of Rio Grande do Sul (1989), Master’s degree in Community Health For Developing Countries – London School of Hygiene and Tropical Medicine (1990) and Doctorate in Medical Sciences, Federal University of Rio Grande do Sul (1998). Associate editor of the Brazilian Journal of Epidemiology and the Scientific Journal of the Hospital de Clínicas de Porto Alegre – Clinical Biomedical. Member of the Editorial Board of the journal Scientific Reports, from the Nature group.He was Provost of Research and Graduation courses, Head of the Department of Public Health, and Full Professor of Public Health at the Federal University of Health Sciences of Porto Alegre until January 2025, when he retired. Airton was awarded an Honorary FGIN in 2024.
He was a professor in the Professional Master’s Program in Health Technology Assessment at the Conceição Hospital Group and in the Postgraduate Course in Health Sciences at UFCSPA. He served as President of the Brazilian Society of Family and Community Medicine and contributed to the development of the Family Health Strategy in Brazil. He has also retired from the Conceição Hospital Group after 41 years as a general practitioner. He remains a tutor in the Information Technology and Management postgraduate course at UFCSPA. He has greatly contributed to teaching and implementing guideline concepts in South America.
Andy Haines worked as a GP and researcher before realising that the greatest thing he could do for human health was to reveal its critical connection to the health of our planet. In 1991, he warned that the changes expected in the world’s climate would worsen health in many ways, writing in the BMJ that ‘more resources, and some fundamental changes in policy, are needed to avert potential catastrophe’. Awarded the 2022 Tyler Prize for Environmental Achievement by LSHTM
Hello and welcome to Medic’sVoices.com, where we talk to the key opinion leaders in health and medicine around the world. Today, Andy Haines in the UK talks to Airton Stein in Brazil.
Andy Haines: I wanted to start by asking you how you got into primary care, and why you decided to go into primary care, because it was still quite unusual in Brazil at the time when you started your career. Perhaps we can start from that point, and let me ask you to reflect on those early years of your career.
Airton Stein: I chose primary health care as the setting of my medical practice through a combination of factors from my early exposure as a teenager. As a Brazilian, one can easily identify that the main problem is living in a very unequal society. And I identified that I could help improve this situation somehow as a family physician. Even before medical school, I had been engaged in community activities for vulnerable communities. Being a medical student in Brazil, from 1976 to 1980, meant studying under military dictatorship, when universities were tense spaces with limited freedom of expression and a sense that politics was always close at hand even if not openly discussed. Training was very hospital focused, with little attention to primary care and social issues, despite clear inequities in access to care. At this period, even during medical school, there were signs of a broader movement towards a more universal and equitable health systems. So that’s sets the scene, and that’s why I chose primary health care.
AH: That takes me to the second point which is about the early years of the Family Health Program. But let’s start with the early years of the program and how it has evolved over time.
AS: During my training in family medicine, I became increasingly aware of how many community health needs remained beyond what I could address in individual consultations. Even though I had a very good training in physical and mental conditions, this often felt insufficient in the face of broader and persistent gaps while considering social determinants, and the Family Health Program tried to accomplish this. It is interesting that the ‘causes of the causes’ which drew me towards training in epidemiology at the time, was because the field was gaining strength through inspiring professors like Bruce Duncan and Maria Inês Schmidt who were leading the teaching of clinical epidemiology and editing one of the first primary health care textbook in Portuguese. And you too (AH) have contributed to this book. It was game changing at that period. Most books were from the US, and of course, the context was completely different. And, primary health care was not presented as a valued career path during my medical training. It was rarely recognized as a legitimate medical specialty.
Webpage of The Community Health Agents Programme (Programa Agentes Comunitários de Saúde).
Primary health care really started when the federal government identified local experiences such as the one that I was involved in Porto Alegre, the Community Health Agents Programme (Programa Agentes Comunitários de Saúde). https://www.gov.br/saude/pt-br/composicao/sgtes/mais-saude-com-agente
And there were, of course, several other good initiatives throughout the country, but very isolated. The federal government then stated that this should be a priority for the health system. So the National Health Service in Brazil, then starting in primary health care, put a lot of emphasis on the family health strategy. This was one of the reasons I decided to go more into epidemiology and how to do research to identify the benefits of the family health program. There were several research works carried out by researchers from Brazil and from elsewhere to identify the impact in the quality of life of the Brazilian population after in the implementation of family health program and by 2024 the Family Health Strategy had achieved coverage of approximately 80% of the Brazilian population. A substantial body of independent research indicates that it has been effective in demonstrating improvements in primary health care sensitive conditions and performance measured by primary care assessment tools, indicators such as increasing breastfeeding rates, high immunization, coverage, and despite advances, important challenges remain particularly in addressing the growing burden of chronic diseases where is a still fragmented health system has limited effectiveness. And I think this is the major issue. The Brazilian health system has improved considerably in relation to infectious disease and maternal and child care but for chronic diseases, which has a high burden and mortality rate, the health system is not well prepared for this epidemic of chronic diseases. This is always a challenge. And I think it’s not only an issue in Brazil because you have to have a much more structured health system to deal with chronic diseases.
“We learn, as medical students, the scientific language. But when you interact with patients, you have to address in a way that communicates well. Sometimes medical schools don’t provide these skills and community health workers are specialized on how to communicate everyday problems and everyday needs.”
AH: Absolutely. How important do you think the contribution of the community health workers has been? When I first came Brazil, one of the things that really interested me, and impressed me, was the role of these community health agents, as they’re called, who are recruited from the local community and who have responsibility for a defined number of families. I thought they were such an important member of the primary health care team. In fact, when we first came to Brazil, we were trying to communicate the way in which general practice was run in the UK but, more recently, we’ve also tried to import some of the ideas and innovations from Brazil into the UK, particularly the idea of the community health worker model through people like Matthew Harris. It’s a two way process of learning. I wondered what your reflections were on the importance of the community health worker approach.
AS: Yes, It’s a two way street… We learn, as medical students, the scientific language. But when you interact with patients, you have to address in a way that communicates well. Sometimes medical schools don’t provide these skills and community health workers are specialized on how to communicate everyday problems and everyday needs. I was reading about the epidemic of Ebola in Congo, and in Uganda. The people are very poor in these areas, and isolated, the schools are out, the health care service is only available for treating Ebola. They don’t care about the other problems, they don’t have time to be involved. And the main problem, that no one is really talking about, is violence against women and girls. And, during this period of the Ebola outbreak, that’s a big problem. And, in Brazil nowadays, violence against women is a major problem. I don’t see the physicians and the health team well prepared to deal with this as it’s very complex, and very difficult to deal. People have very quick consultations, where they only deal with the reason for encounter and not the main issues, such as how to deal with these complex problems that communities have to solve, especially during financial, instability. People focus only on how to survive. It’s a survival kit nowadays is in these countries, especially in vulnerable populations.
AH: one person who really helped us to understand more about people’s beliefs and how to communicate was Cecil Helman, anthropologist and GP. I wondered if you could say a few words about Cecil’s contribution. Because he was extraordinary talented in understanding the needs of individuals, but also the community. And I’m sure that he was engaged in the topic as gender violence would be one in which he was deeply concerned. But he had a very wide ranging impact through his work in Brazil, and he complemented the epidemiological approach with the anthropological approach.
AS: He was a good friend and he stayed in my house when he came to Porto Alegre. I enjoyed Cecil very much. And it was very interesting to see his mindset. One aspect, which people tend not to highlight very much, especially medical professionals, is the role of folk healers in the community. They think it’s a waste of time, that you should not rely on these people. And he wanted to learn the beliefs. And one of the things that I recall from one of his lectures was that, as physicians and health professionals, we want to provide screening to identify a cervical cancer, for example. And Cecil would say that people who need to survive day by day are not worried about cancer in some years to come. So, timing is essential in how to deal with people who have a different priority. As physicians we want to improve the prognosis for middle and high income people, not the poor ones who don’t know if they are going to die by the end of the day.
Yesterday in Rio, two workers were killed by the police. One of them was using a tool at the back and the police killed him because they thought it was a gun. It was in a very poor neighbourhood. So if you’re in a poor neighbourhood, you’re more likely to die, not from any illness, but due to a poorly conducted police intervention. So this is the setting.
Another thing… when I did my MSc at the London School of Hygiene and Tropical Medicine I was complaining to Cecil that our good friends in Brazil hadn’t kept in touch with my wife and myself. At that time it was much more difficult than nowadays and letters were the way to keep in touch. He said, ‘they are in a civil war, they don’t have time to talk with someone who is not in this setting.’ So, it is essential to take into account what happens in the local area. And, I always say, when I give a lecture, you have to think globally and act at local level. Adaptation is a very relevant skill, especially for those who want to apply evidence based medicine. Of course you have to rely on sound studies, but you have to take into account the local area, the context. It’s interesting, even in cities like Porto Alegre, the teaching hospital is completely different from another hospital that takes care of the public in the National Health Service, and may not be science or research focused hospital. The environment is completely different. What I’m trying to address here is that you have to take into account the context in what you do.
“Evidence shows that scaling up primary care through coordinated national strategy rather than fragmented initiatives, combined with multidisciplinary teams responsible for defined populations, is highly effective. And the use of community health workers is a distinctive and impactful feature of Brazilian model.”
AH: And, that translation from the high level to the local is very important. With your recent interest in planetary health, how you translate that into local action, is also very relevant.
AS: Especially after the Covid situation in Brazil, with vaccine denial and an overall lack of planning for the whole country, it was a mess. And this denial causes big problems in society as it’s very polarized and its most important in how we approach community needs and identify the priorities and try to communicate as well as possible.
AH: And that brings us back to the community health workers, because they are selected from the community, and they’re the best people to communicate evidence in their own way to the community. They also can help build up trust between the health system and the broader community and often with people who are been marginalized by current structures. They play a very important role in that.
So, let me ask you about the lessons from Brazil and how they can be applied, and how can they support other countries aiming to develop primary health care? A lot of the ideas of the family health program were developed in Brazil, but there were external influences from other countries, from Canada, from Cuba, from the UK. And, Costa Rica as well. Brazil is now seen as a great international model and many people come to Brazil to look to Brazil for leadership. So, could you just say a few words about what you think the lessons are and how Brazil can help develop primary health?
AS: Brazil’s experience with primary health care offers valuable lessons for countries seeking to strengthen their system. Meaningful progress is possible even amid political, economic and social constraints when there is sustained commitment from key stakeholders, particularly under the leadership of general practitioner. And this is something that I always stress. General practitioners should be identified as leaders in the community and of course, in the health system. And evidence shows that scaling up primary care through coordinated national strategy rather than fragmented initiatives, combined with multidisciplinary teams responsible for defined populations, is highly effective. And the use of community health workers is a distinctive and impactful feature of Brazilian model.
Decentralization has been crucial, allowing local authorities to adapt implementation to their specific context. And substantial research demonstrates that adherence to core primary care attributes, as described by Barbara Starfield who defined the core elements of primary health care such as access, continuity of care, coordination, cultural competence, is essential for achieving effective and equitable health systems. So I think that, even though there are ups and downs, the Brazilian experience emphasized in real life experience, that it’s very effective. And this has been shown in research done by Brazilian researchers and those from other countries, independent research that it wasn’t government based, research showing the importance of primary health care. We’re going to have a national conference of general practice in Porto Alegre next year, after 22 years, so it will be very interesting.
Having said that, talking with Brazilian general practitioners, Brazil currently faces significant structural, financial and systematic challenges that I want to highlight. Some colleagues actively working in the field say the system is unable to adequately address key issues, including a weak career structure in general practice, precarious employment contracts, low team stability and poor continuity of care is often not prioritized by managers.
And there are some other concerns, including heavy workloads, high stress by all the team, limited access to secondary and tertiary service, and high turnover among younger physicians. These factors contribute to a fragmented system with inadequate information infrastructure, limited implementation of clinical guidelines, poorly coordinated referral pathways, and shortage of essential medicines and diagnostic resources. There are some very good examples in primary health care that are supported by the local government, that are very effective, and people are very happy on working in primary health care in certain areas. But I would say these are the exceptions. These are the successful stories that are presented in research papers. But overall the picture is not very glamorous.
“A bottom up approach is my theme. People try to identify the top level, the ones who can say nice things. But the most important is a bottom up approach. That’s what we learn in primary health care, isn’t it?”
AH: There are still very difficult challenges but, on the other hand, when you look back to 40 years ago, it has come a long way, and so one has to compare it with what it was like all those years ago. There have been big improvements although, as you say, there’s still a long way to go. Let me conclude by asking you to reflect a bit on the current stage in your professional life. You are no longer in clinical practice, but you’re still very active. Could you say a few words about what you’re doing, how that relates to your earlier experience?
AS: I’m amazed that I’ve been invited to several medical schools and family practice residency programs to address guidelines, about planetary health, how to pursue a career in general practice, and the importance of primary health care. And I’m still involved in research and I’ve been in contact with very high level, methodology researchers from around the world. And I am quite happy to share this experience with, and especially with, residents. I’ve been invited to journal clubs, to discuss critical appraisal and research in internal medicine and gynaecology. And I’ve been supporting these two groups as a result of good relations with colleagues in these specialties, due my expertise in these areas. But, I’m interested in developing critical appraisal and so I’m happy to help locally where there is a need to improve. And, I see this especially in Rio Grande do Sul, after the extreme climate event, even compared to other states in Brazil. It used to be a very developed area, especially in terms of capacity building, people who were trained in universities and residency trainings in the state, that could compete everywhere in the country and elsewhere. But nowadays it’s low profile. And one has to identify what has happened to this local environment that was so fruitful, that has lost track. So I’m trying to help, to reflect, and also to improve local conditions. And their self-esteem, this is really important. And also to identify local needs. A bottom up approach is my theme. People try to identify the top level, the ones who can say nice things. But the most important is a bottom up approach. That’s what we learn in primary health care, isn’t it?
AH: You’ve alluded to these very powerful floods, which really devastated, Rio Grande do Sul, I think your work really exemplifies how you’re linking these planetary level crises, changing climate and so on. But as you say, focusing very much on the lessons from primary care, which is about bottom up community engagement, working with colleagues to improve the conditions on the ground.
So, thank you so much for your inspiring career and all the work. It’s been absolutely wonderful to talk to you again. Our friendship has gone on for so many decades and we look forward to many more years of friendship. Thank you so much.
