The day the text about our conversation began to be written, I realized that it was his birthday. Válter Fonseca was born on 19 September 1986, in Setúbal. In that same moment, I sent a brief happy birthday note via Linkedin, a network that places emphasis on a person's professional career and always keeps some formalism between contacts. The thank you reply arrived immediately. Work is, of course, the area to which he dedicates most of his time, especially now that he integrates the DGS management staff, particularly in times of pandemic. It is not an easy task that allows one to switch off just because the weekend or the evening are here.
Becoming a doctor was a conviction from an early age, motivated by the desire to help others. His passion for mathematics and science showed that it would not make sense to follow an alternative path. Later, he would become a loyal viewer of the American series Emergency Room, realizing that what he wanted was the action that the series showed, the front line where the most serious cases are dealt with.
He entered the Faculty of Medicine of the University of Lisbon in 2004, as a student, and thus fulfilled all the expected goals and many others for pure vocation. He was Anatomy, and Physiological Biochemistry and Disease Mechanisms Junior Assistant. Currently he is Assistant Professor of Pathophysiology and Medicine II, but soon he realized that it was Internal Medicine that fascinated him. Vítor Augusto, internal medicine doctor at São Bernardo Hospital, in Setúbal, gave him the final inspiration to continue in the same area. “ Dr Vítor was encyclopaedic and systematic”.
Looking back, he knows that he lived there the best years of his life and says, assertively, and with a maturity that does not reveal his 34 years of age, that what he is today he owes to the FMUL Medical Degree. I wanted to be on the front line, not to remedy small issues, but to change destinies, or at least touch upon them, he explains. "I liked to fix everything since I was a child", what was complex became something that had to be exactly in his own way. After deconstructing things, he built them again. “Bownie” could be a living account of those times, the teddy bear whose belly he opened up and stitched back, and who is still with him today. Even now, resisting such a medical attack, “Brownie” has a new caregiver, Carolina, 3 years old, one of the four great women in Válter's life.
His maternal grandmother is another one of his great inspirations. He refers to her when, in a flashback, he tries to understand where his personality came from. His mother and his wife, Catarina, were also a topic of confidence, the former because she did everything so that teenager Válter had the best conditions to study and be what he wanted most in life, the latter for giving him space to invest in his career at such a primordial moment like now.
Medicine never run in the family. He assumes that he has always enjoyed learning and studying. He disliked the humanities and physical training, but ended up being a top swimmer for Clube Naval Setubalense, an imposition by his father who almost drowned as a child. The 3 and a half hours of daily training 3 times a week enabled predicting that in order to reach the ambitious high school goals, it was necessary to make choices. In his childhood, he was a Boy Scout, which turned out to be particularly advantageous now that he is on a leadership position.
Knowing how to take a lost group to the destination, inside a forest, and without direction guidelines, is a talent gained through persuasion, logical reasoning, but above all through the merit of knowing how to assume that one also fails. But even with so many advantages, Válter Fonseca understood that, as one path is chosen over another, he had made a choice, his academic future.
Perhaps because today he is also a lecturer, there is a melancholy in him with gratitude for the high school maths teacher, "she explained the Cartesian framework and drew, with a red Tupperware lid, a circle on the board with such a detail ...!".
It is interesting to watch people in real time when they report or think about something. The eyes speak before words, or expose memories in a way that the mind does not intend to show. The moment we met in person and I got up, while waiting for him in the meeting room, I saw only the Director of the DGS Quality Department, tall, with grey-blue eyes and light brown hair, in an ocean blue suit and leather cufflinks of the same colour, contrasting with the white shirt that could be used for the first time. Prudent and following the protocol, the geometric gestures of his arms and discipline of his hands showed a barrier of proximity and time that ended up breaking almost immediately afterwards.
Let us go back in time. The Faculty of Medicine was always at the root of all his major actions. After completing the Integrated Master degree, he did a Ph.D. in Immunology and defended his thesis in 2018, under the supervision of Professor and Researcher Luís Graça. Válter Fonseca quickly became a scientific reviewer and consultant for the DGS. In addition to all these roles, there was still time to conduct research at Luís Graça's Laboratory. His scientific curriculum enabled him to write several papers and collect praises and prizes.
Without ever breaking the link to Health, he has taken on a new role, this time in the Directorate-General. On 2 November 2018, he assumed the role of Director of the Department of Quality in Health, initially substituting a retired member. He officially applied for the post in a public call at the end of 2019 and took office in January 2020. When I asked him why he ended up at the DGS so early in his life, he explained that everything had started in 2012 when he was doing his internship. After completing the medical degree, one of his professors, Henrique Luz Rodrigues, challenged Válter Fonseca to work in one of the Departments of the Directorate-General of Health.
Due to being thorough from the point of view of scientific evidence, in addition to using systematic methodologies of scientific evidence, he joined a team working on a set of clinical standards to guarantee the quality and uniformity of healthcare provision in Portugal, based on the most recent scientific evidence. That is why 2012 marked his presence at the DGS as a scientific consultant, a decision he did not make lightly, only after much reflection. He started to do the latest scientific validation of the various norms, assuming the role of last goalpost before publication. At the age of 30, it was not easy to assess who had taught him.
More than other people’s expectations, he says that the most difficult to manage are his own personal expectations and demands.
After several attempts at interview and dates that kept being postponed due to the pandemic and lockdown, the opportunity to finally to meet people in person again came. In times of pandemic, not meeting one of our Professors at the DGS would be wasting a tempting opportunity.
You told me that before accepting your first role at the DGS, you needed to reflect a lot. Why was that? Was it so that you felt you were ready for this challenge?
Válter Fonseca: The challenge seemed very big. I was starting my internship and I knew that I would need to do scientific evaluations and validations of documents prepared by people for whom I had the greatest professional respect and many of them were my professors at the Faculty. These people had an experience invariably superior to mine. I asked myself how I would feel in the positive confrontation with people who had another level of experience and knowledge. Then there was something else, the time factor. I have always had difficulty accepting challenges when I know that, at the outset, I am unable to do what is required. When starting my internship, it was necessary to know if I would be able to meet the requirements regarding three aspects: the internship, teaching and scientific consultancy.
The big temptation is to ask you right away about the decision to formally apply for the position you hold now, Director of the Quality Office...
Válter Fonseca: Just imagine how much reflexion I had to do. (he laughs for the first time, looking relaxed).
But let me go back in your path, to better understand who you are and the weight of the responsibility you have today. Do you want to explain why you say it was the 6 years at the faculty that informed your character and made you who you are today?
Válter Fonseca: Maturity is always underlying. I already had strong views, but I became even more like that. If in adolescence we are concerned with what others may think of us, the opposite occurs at the Faculty. As I am very focused, I was perhaps more lonely during high school, but at the faculty, I managed to have some social life and address some of these aspects. It was also when I met Catarina, my wife. I remember Dr Vítor Augusto, who inspired me to be like him one day. I was in year 3. In class he asked us about the possible causes of a patient's coma. We knew at once 2 or 3 causes, but he gave 20 more possibilities. I listened to him and thought, "one day I want to be like him". You know I talk about this because it explains the way I am, I don't like to know something without questioning why everything is as it is. At the Faculty, I managed to ask these questions in many ways, "but why is this so?", "Why can't we follow a path?". This is the advantage of Internal Medicine, we deal with reasoning a lot, because there is no clear answer, sometimes no description of symptoms. We are like the patient's detectives.
It was also in year 3 that I met Professor Afonso Fernandes, who taught us Pathological Anatomy and Disease Mechanisms. It was the last year he taught. This subject (Disease Mechanisms) caused a profound impact on me because it showed why we see something happening. Sometime later, a colleague told me that it seemed that the patients I most liked to follow were those who were dying.
Did you want to be a front line doctor to try to reverse the situation of the patients in the last line?
Válter Fonseca: Correct. I was particularly fond of patients in the Emergency Room, Intensive Care, or Internal Medicine, as they were the ones who were worse off. It was with these people that I felt I could play a more significant role.
And how does one deal with frustration when one can't help someone?
Válter Fonseca: It was a learning experience, it took some time. The confrontation with frustration increases throughout life.
It increases?
Válter Fonseca: I think so. I think it mostly concerns the professional path. Frustration increases because we realize that we are getting smaller and the world is getting bigger. We become bigger physically, but smaller in terms of strength in the world. We realize how unreachable a system can be and if we think about how the world works, we are in fact very small. The world has thousands of years of construction. It reminds me of some of Kafka's books about the absurdity of facing something that one can't control. Either the person who is caught by the system, or as in the novel “The Castle”, when the person wants to reach the system and fails. Perhaps my current duties also show me that we are increasingly living in such a world.
Can these pandemic moments lead us to a world described by Kafka?
Válter Fonseca: (He remains silent for a long time) I don't know, I really don't know... I think the "originality" of this moment was not in Kafka's mind. The system is as it is, and now one may notice more how it works because it is not working in its routine. But the fact is that nothing is predictable. The system, as we live it, endures and has very good things, because it is resilient, but it also has bad things, because in order to be resilient, we have to be very inert. And all this that we are talking about is very complex in itself, but also very complex to explain ... (sighs). And now I ask you, even if Kafka had managed to explain this complexity, how many people would have read it?
Not many …
Válter Fonseca: Few, yes, so we must use mass communication. I remember the Pandemic Flu in 2009 and the turmoil in the NHS and some fear, but it did not have the same impact as today. I have learned from some people that “a pandemic, or an international public health emergency, is a health crisis, but it is much more a social crisis”. But I would add that, in the 21st century, it is even more a communication crisis. This new dimension of communication can be very damaging. Passing the right messages, making ourselves understood is difficult, especially when the speed of information is staggering.
Communication can then be the dangerous weapon.
Válter Fonseca: It can be dangerous, yes.
And why? Is it because there too much talk about the same topic, the pandemic? Or is it how it is talked about?
Válter Fonseca: The problem is not the number of times the subject is spoken about, it depends more on how the subject is spoken and how the communication spaces are directed. It is important to understand who are the people called to speak. I think that everyone should give opinions and have the opportunity to speak, but this participatory model starts from the principle that our opinion, and especially our expertise, are respected. This excessive mixture of spaces and spheres of influence in areas other than ours, may not be beneficial.
But isn't this relationship between wisdom and fierce curiosity that brings magic to those who teach? Because you also play that role, that of Professor.
Válter Fonseca: One of the conditions I made before accepting this position was the possibility of continuing to teach, and, had there been any legal constraints, I might not have accepted it. The connection to the Academy is the connection to the world of intellectual freedom, to a free world of knowledge and constant growth. Being able to contribute to what our students are and their future is very rewarding… This question of learning or teaching and being confronted is a test of humility. Some time ago, I was at a conference and came across some of those names that I deeply admire, people of immense intelligence and eloquence. And these people not only do not mind being questioned by others who listen to them, but they like to hear it and say that these questions create great opportunities for solutions.
Let us move forward to the moment when you were formally appointed, after a public call, as Director of the Department of Quality in Health of the DGS. At a time when Health suffers one of its greatest upheavals in history, you take on the position right in the Quality Department ... How has it been managing this role?
Válter Fonseca: (he remains silent) The truth is that it has been difficult, I took over at a particularly difficult time for Health. And being difficult does not mean that it cannot be done, but it does mean that it is difficult. It must be done, because the people who are here make an enormous effort to make decisions, not for themselves, but for others. But does it mean that for it to go well, it can't be difficult? I have a small picture in my office that says “difficult roads often lead to beautiful destinations”. And it is like that, there is in fact a path because what we are experiencing is unprecedented, the whole world is faced with a situation that it does not control. There is an organism with its own dynamics and clear pathophysiology and with a natural history of the disease that is happening live. From a medical point of view, it is a huge challenge. For epidemiologists, it is the largest study ever and they are doing it live. All of this has a huge impact in terms of uncertainty. Then, a public health emergency begins to be a health crisis, where health professionals play a huge role in its management. The point is that these health professionals are based on the following: there is a problem, and the immediate answer is to search the literature to respond to the situation. In this case, the literature search, when it all started, was zero. So, this fundamental step to support the evidence doesn't even exist. Now there is a little more, but the evidence is very little. So you see, we have decision-making instruments that do not rely on the usual foundations in clinical decision-making.
How does one decide based on uncertainty?
Válter Fonseca: That is the question. One decides based on risk. We have to take risks in decisions that are not always the right ones. The decision is made assuming the risk of the decision. We still try to adapt the decision quickly and with great flexibility and then we have to be very transparent. We have to assume that, in fact, there is uncertainty.
The point is that transparency always presents some inevitable vulnerability. But public opinion is harsh to rely on uncertainty. One never forgives vulnerability involving the highest entity that manages Health. How do these forces balance?
Válter Fonseca: It is a delicate balance. I have heard very interesting expressions over the past months that illustrate these times well. One of them says that "what we are experiencing is a huge sociological experience". You know that this idea reminds me of my boy scout times and those situations when we had to follow maps and plans, whose outcome we could not predict. In some situations in these orienteering activities, I was the one who guided the group. With two paths, a decision had to be made, but the uncertainty was huge. So, how can the team be with us if we only have uncertainty? First, that team has to recognize that the leader is intrinsically capable, even if he decides badly, he has to make a new decision quickly. Then, it must be borne in mind that “a non-decision is always worse than a bad decision”. In uncertainty decisions, it is necessary to transmit confidence and this starts by explaining the steps of the decision path. We can get it right and there we are, but if we fail we have to monitor ourselves and, at the slightest sign, act.
Did you ever choose the wrong path on these undefined maps?
Válter Fonseca: As a boy scout, once. The leader must always recognize when he fails. But then you have to come up with alternatives and, often, to convince others you have to give in, know how to "negotiate". Negotiation is a curious aspect, I always found it strange, as if it were a “purchase”. But that's not just that, there is a lot of diplomacy involved. Last year, I did a training course in Health management and took negotiation classes and then my idea changed. To motivate is to negotiate, it is just that we do not give it that name.
(Válter Fonseca's secretary enters the room and hands him a small post-it note with a long message on it. He reads it subtly without stopping talking and without losing his reasoning)
What can we tell about you in 2 years from now? (when the current term ends)
Válter Fonseca: When I started I had a meeting with the Department, to listen to the whole team that is older than me. This group has taught me a lot about administration and people management. But I'm a doctor, I will never cease to be, and we have a very hard professional experience early in life, confronting stress, having early contact with a lot of information, as well as connection to others who experience, sometimes, drama, death, or pain. But at the same time, one lives relatively controlled, from a professional point of view, because we are either in the hospital or in the health centre, where contact with realities and people is a little more controlled. When we leave this environment, we lack elements. Still, I think it is an asset for a person and I think that as long as I and everyone else find me useful, as long as my opinion can be considered and my ideas discussed, I am comfortable. When it's over, it's over. Two years from now I can't tell you what will become of me. Do you know why? Because all my planning when I came here, collapsed. I joined in January and the pandemic arrived in March. Everything I had planned to do collapsed. It just did. But I will certainly be a person who gained a strong experience and lived through a very unusual reality. This brings me enormous personal and professional enrichment, which in other routine circumstances would take much longer to acquire. The Directorate-General of Health suddenly also had to adapt to realities that were not its core business, sports, education, are examples of this. This required a great capacity for flexibility and constant learning.
Do you miss the Laboratory and the Clinic?
Válter Fonseca: I miss the diagnosis challenges, I miss some moments of humanity and contact with people. I miss seeing the patient the next day and ask if he feels better and hear "yes, thank you", which translates into immediate emotionally-related feedback. As for hospital shifts and ending them, I don't miss them so much. (he laughs). Above all, I miss the Laboratory I miss being able to speak, think and have complete intellectual freedom.
Do you feel that this freedom is more restricted at the DGS?
Válter Fonseca: We need to weigh well the scope that our words can have. Here, what we say can gain such a proportion that we don't even have the capacity to measure its reach. This forces us to be more reflective. Now, this care with what is said cannot make us cold, or cause loss of opinion, otherwise we also do not exercise the position well. To mobilize people, we need to put emotion in the things we do and tell the truth. This pandemic can be an alert for humanity, so it is important to give space to Science and not overshadow it, waiting for it to answer everything. Science is undoubtedly the basic path, but it needs space, it cannot overshadow all other areas.
In this vast group of scouts we are all part of, what message do you want to pass on about the best way forward on an unmapped trail?
Válter Fonseca: (he thinks for some time carefully) We will always follow a path based on scientific evidence and what it brings to us; but balanced among all sectors of society. Even for me, who has a scientific background, this is a moment of great humility for Science. Science is not the last stronghold of humanity. It gives many answers and has helped in the evolution of Humankind in the past centuries, but it does not provide all the answers. This can make us a little more human again.
You have told me a lot about the 4 women in your family and the references of the elders for you. One of your women is still very young, Carolina, your 3 year old daughter. In many years to come, when Carolina talks about her father, what would you like her to take as a reference?
Válter Fonseca: (He gets emotional. He tries to start answering, but he needs time to get back on his feet) What I want most is for Carolina to be a great woman, with strong views. That she understands the world in its great complexity and that she realises that at times like these, there was a call and a mission that the father had to follow, which had and has some consequences in the time that I can spend with her. The thing I least want is that, therefore, there is any damage to her education in these adverse times. But I know that I count on a great woman, my wife and the mother of my daughter, Catarina, who has let me to do what I am doing at the DGS.
With natural frankness, he tells me that, in order to get closer to the range of the more experienced people around him, he reads a lot, increasingly more. So he tries to keep up with the maturity that only age brings. He does not want to fail people working with him, because he knows that only by reading and studying intensively, he is able to review the times he never lived. Passionate about World History, he is also passionate about literature. The novels that were his first big choice are now interspersed with much more varied readings. He has instinctive admiration for the work of João Lobo Antunes, but warns that he only knows how to convey his ideas, never with the eloquence that he had.
In the limbo between the mission of adding something bigger to his country, and Carolina's temporary physical absence, Válter Fonseca is a promise of his own time. Young, updated and with public and institutional responsibility, he sees the pandemic not as punishment, but as learning opportunity. As a man of Medicine and Science, he hopes that they will not forget the best that Humanity has, which is having itself.
“I don't know what awaits us, but I know what worries me: is that medicine, excited by science, seduced by technology and stunned by bureaucracy, erases its human face and ignores the unique individuality of each person who suffers, because although increasingly more ways to treat are invented, how to alleviate suffering without empathy or compassion has not yet been discovered.”
João Lobo Antunes - Ouvir com outros olhos (Gradiva) – 2015
Joana Sousa
Editorial Team
