Quaternary Prevention Manifest / Prevención cuaternaria, presente y futuro

Family and community doctors in Lima, Perú. CIMF conference, August 2017.

Recently published: Quaternary Prevention: present and future.

Official statement of the WONCA SIG QP&O.

Available in Archivos de Medicina Familiar y General (on line Journal), Argentina.

Languages available: ESP, PORT, EN, FR, IT.

Document first communication was done at XV Congreso de la FAMFyG – Buenos Aires, Argentina, 2016 by Jorge Bernstein y Ricardo La Valle.


Round table. Quaternary Prevention(P4) or first do not harm/Mesa redonda. Prevención Cuaternaria (P4) o primero no dañar/Mesa redonda. Prevenção Quaternária (P4) ou primeiro não prejudique/Table ronde. Prévention quaternaire (P4) ou d’abord ne nuire pas

Siguiendo el vínculo Round table. Quaternary Prevention(P4) or first do not harm.


[en] Quaternary prevention (P4), born from a reflection on the doctor-patient relationship, began as an answer of family doctors facing overmedicalization. It aims to protect the patient or population against the danger of medicine. Harmful effects can appear with preventive activities (example: prostate cancer screening by PSA) as well as by therapeutic interventions (example: disruptive medicine). P4 promoted by the World Organization of Family Doctors (WONCA) is practiced in different ways around the world through the activity of the WONCA Special Interest Group on Quaternary Prevention and Overmedicalisation (P4&O).
There are multiple initiatives and backgrounds of P4. All these multiple initiatives that lead to P4 have their origin in denouncing the inadequacies of the Hegemonic Medical Model and the excesses perpetrated in the pursuit of profit. There are many schools of thought that try to solve this situation, such as “Medicines Based on …” These contributions are valuable but usually point to a single dimension of the problem so they do not change the situation too much. The P4, however, have understood the centrality of the political and economic dimensions and, that is why, P4 has become a movement.
P4 has understood that the root causes far exceed the limits of medicine, have understood that the problem includes ethical, political, economic and epistemological aspects of medicine. It is for this reason that the definition of P4 has shifted to the function of foundational idea since the movement that has been generated around this concept has surpassed this initial definition centered in a, yet complex, but still medical vision. P4 has understood that a new model of medicine and a new pact with society is necessary.
P4 is a counter-hegemonic movement with predominant development in peripheral countries. This movement includes many other perspectives developed in the central countries but is the only one that has an ideological position that discusses the current paradigm of medicine that legitimates the same causes that give rise to P4, proposing to think a new way of practice the medicine that includes Ethical values, other forms of knowledge and the return to human medicine for humans with place for uncertainty, compassion, the encounter between people and non-commodified.
Justice in health care is a central aspect of this new way of conceiving the medicine that we propose. Remember what Rudolf Virchow said in the nineteenth century “Physicians are the natural advocates of the poor and social problems fall largely under their jurisdiction. Medicine is a social science, and politics is nothing more than medicine in large scale”. We must reformulate our contract with society and for this we must be very clear that our loyalty must always be with the sick, the poor and those who are weak. For this new contract we must also take into account the magnitude of the power that has been given to us and to live up to such responsibility.
In the Rio manifesto (2016) we propose to “Avoid and denounce the naturalization of: hunger, exclusion, manipulation, inequality, violence, racism, exploitation, which harm health more than “diseases”” . There is a better and fairer world, let’s fight to get it!
More about P4 on

Quaternary Prevention Manifest / 5 languages versions

Quaternary prevention, present and future.
To the memory of Mario G. Acuña

“Quaternary prevention (P4) is the collection of health activities that attenuate or avoid the consequences of unnecessary or excessive interventions in the health system, mostly originated in the medicalization and the commercial approach promoted by interests opposed to those of the patients. As a result, we’re not only facing the health system but also the economic and social systems. We advocate for a scientific medicine, one that is humane and ethical, accessible to
those who need it and based on equity. Therefore, our actions are necessarily political and their content is democratic.” (fragment)

On the WICC web page are available five languages PDF versions.

La Prévention quaternaire, présent et futur
Manifiesto por la Prevención Cuanternaria
Prevenção quaternária: presente e futuro
Quaternary prevention, present and future
Prevenzione quaternaria, presente e futuro

Please follow clicking on each title.

Quaternary Prevention Library and Resources / Biblioteca Virtual de Prevención Cuaternaria / Biblioteca Virtual de Prevenção Quaternária / Bibliothèque virtuele et ressources sur la prévention quaternaire

Quaternary Prevention Library and Resources (QP Library)
Biblioteca Virtual de Prevención Cuaternaria (Biblioteca Virtual P4)
Biblioteca Virtual de Prevenção Quaternária (Biblioteca Virtual P4)
Bibliothèque virtuele et ressources sur la prévention quaternaire

Collaborative Database on Quaternary Prevention Resources and References.
Base de datos colaborativa de recursos y referencias bibliográficas sobre Prevención Cuaternaria.
Base de Dados Colaborativa de Recursos e Referências sobre Prevenção Quaternária.Réseau collaboratif de ressources et de références en matière en Prévention du Quaternaire.1 Quaternary

Prevention Bibliography Committee / WONCA SIG Quaternary Prevention and Overmedicalization Comité de Bibliografía en Prevención Cuaternaria / Grupo de Interés en Prevención Cuaternaria y Sobremedicalización de WONCA Comitê de Bibliografia sobre Prevenção Quaternária / Grupo de Trabalho de Prevenção Quaternária e Sobremedicalização WONCA Comité Bibliographie sur Prévention Quaternaire / Groupe d’intérêt spécial WONCA sur la Prévention Quaternaire et la Surmédicalisation.

Background and development of the idea

Since the beginning of the work on Latin American networks on Quaternary Prevention, it has been necessary to provide a database and resources with the objective of disseminating the concept and its application. This idea has been in our minds and discussions for a long time. From the first face-to-face meeting of the Special Interest Group on Quaternary Prevention and Overmedicalization of WONCA (November 2016, Rio de Janeiro, Brazil), we decided to undertake the implementation of this idea. The current platform has been designed to be augmented from various sources and shared with whomever necessary. The documents and materials that are uploaded to the platform can be shared through an Excel document. The entries have been coded with the multilingual terminology of general practice and family medicine, Q-Codes ( ).2

Four languages document: English, Español, Português, Français / Documento en cuatro lenguas: English, Español, Português, Français / Documento em quatro idiomas: Inglês, Espanhol, Português, Français / Document en quatre langues: Inglés, Espagnol, Portugais, Français

Authorship / Autoría / Autoria / Auteur: Comité de Bibliografía en Prevención Cuaternaria / WONCA SIG Quaternary Prevention and Overmedicalization. Pizzanelli M, La Valle R, Jamoulle M. 2017

To collaborate contact:

More details available / Disponible / Disponibel / Ce est disponible à l’adresse:

Published on / Publicado en / Publicado em / Publié en :

Quaternary Prevention Manifest: version in Italian / Manifiesto por la Prevención Cuaternaria: traducido al italiano

A new translation of the Quaternary Prevention Manifest. Now in Italian!
Thank´s to Ernesto Mola
Follow the link:


Nueva versión del Manifiesto por la Prevención Cuaternaria (Manifiesto de Río de Janeiro/2016)

Gracias a Ernesto Mola

Vea el documento en:

Primer Foro Europeo sobre Prevención y Atención Primaria/First European Forum Prevention and Primary Care/ Premier forum européen prévention et soins primaires

See the program:

Quaternary Prevention agenda

Marc Jamoulle: From the clinical practice to the concept of Quaternary prevention

John Brodersen: Quarternary prevention – a new definition proposal

Leo Pas: Mental health – a rational strategy to avoid underdiagnosis and overtreatment

Carlos Martins: Possible strategies to reduce unnecessary tests

Bruno Heleno: Overdiagnosis in cancer screening with a focus on lung cancer screening with low dose CT-scans

Maciek Godycki-Cwirko: Prevention: regulated or recommended?

Mateja Bulc: strategies in DEPRESCRIBING

Jasna Vucak: OTC self prescribing medication: more good or harm?

Family and Community Medicine Summit; Costa Rica 2016/ Cumbre de Medicina Familiar de San José de Costa Rica 2016



Acces to the synthesis document:



Documento de síntesis sobre Prevención Cuaternaria / Cumbre de Medicina Familiar de San José de Costa Rica 2016, WONCA / CIMF.

Nota bilingüe / ESP

Por vez primera, una cumbre Iberoamericana de Medicina Familiar y Comunitaria, dedicó un espacio de jerarquía para el concepto de “Prevención Cuaternaria”.

Esto permitió que se abordara en un grupo de trabajo, sobre tres aspectos relativos a la aplicación del concepto: a) la importancia de incorporarlo en la formación médica, b) los aspectos vinculados a la trasmisión del concepto a la comunidad, c) los aspectos político institucionales a los que nos lleva el encare de Prevención Cuaternaria.

Han participado muchos colegas y en la elaboración de los documentos preliminares y en este documento de resumen. Aunque muy contundente, en realidad solo muestra una apretada síntesis de todo lo trabajado durante mas de 8 meses.

Quisieramos agradecer el esfuerzo de todos los compañer@s de Iberoamérica que participaron en este trabajo luego de varios e intensos intercambios. Su aporte ha sido destacado aunque tal vez no aparezcan sus nombres explicitamente en la publicación, ni con la jerarquía que se merecerían.

Todo este trabajo ha hecho posible tener hoy un Grupo de Especial Interés en Prevención Cuaternaria y Sobremedicalización en WONCA, desde octubre del año pasado y comunicado en la Conferencia Mundial de Río de Janeiro, Brasil, en noviembre de 2016.

Tambien agradecer a la Revista Brasileira de Medicina de Família e Comunidade por comunicar y publicar.

Publicación accesible en español, portugues e ingles en:


Quaternary Prevention / Iberoamerican Family Medicine Summit of San José, Costa Rica 2016, WONCA / CIMF. Summary document

Bilingual Note / ENG

For the first time, an Ibero-American summit of Family and Community Medicine, dedicated a space of hierarchy to discuss Quaternary Prevention concept.

This allowed a working group to deal with three aspects related to the application of the concept: a) the importance of incorporating it into medical training; b) aspects related to the transmission of the concept to the community; c) Institutional and Political aspects to which the issue of Quaternary Prevention is linked.

We would like to thank the efforts of all our colleagues from Latin America who participated in this work after several intense exchanges. Their contribution has been highlighted although they may not appear explicitly in the publication, nor with the hierarchy they deserve.

All this work has made possible to have a Quaternary Prevention and Overmedicalization SIG in WONCA from October and officially communicated during the World Conference in Rio de Janeiro, Brazil (November 2016).

Also, thank the Brazilian Journal of Family and Community Medicine ( Revista Brasileira de Medicina de Família e Comunidade) for communicating and publishing.

Publication available in English/Spanish/Portuguese at:


Miguel Pizzanelli MD, WONCA Special Interest Group:Quaternary Prevention & Overmedicalization Convenor / Chair.

Quaternary Prevention Manifest / Manifiesto por la Prevención Cuaternaria


Tha WONCA executive council has approved, during the  Rio De Janeiro Meeting, Nov 2016 the creation of the WONCA Special Interest Group in Quaternary Prevention

The launch has been followed by the publication of a Manifesto

see below in 4 languages:

Source: Jamoulle M; WICC web page.
“Manifiesto por la Prevención Cuaternaria”

La salud como resistencia: un manifiesto por la prevención cuaternaria

Compartido en la plataforma  No Gracias

Este documento ha sido suscrito por mas de 100 colaboradores y luchadores de la prevención cuaternaria, en el mundo. Si bien contiene un posicionamiento my Latinoamericano, esperamos traducirlo a varios idiomas para lograr aún, una mayor difusión por su importancia.

Fue elaborado bajo la iniciativo y liderazgo del grupo de trabajo de P4 de Argentina en colaboración con el grupo de trabajo de P4 de CIMF y de lideres de todos los países de la región. Fue presentado en la Conferencia Mundial de Rio de Janeiro (5 de noviembre de 2016), en la primera reunión presencial del Grupo de especial interés en Prevención Cuaternaria de WONCA, recientemente creado.

Hemos dedicado este manifiesto, en honor a nuestro colega y amigo Mario Acuña, quien añoró siempre un futuro mejor para la medicina familiar, comunitaria y general y fue impulsor y referente de la Prevención Cuaternaria en la región.

Miguel Pizzanelli