Editor's Choice |
Latin America: old and new challenges
E-mail: Shah.ebrahim{at}lshtm.ac.uk
This issue is devoted to Latin America, and is intended to provide a link with the World Congress of Epidemiology, Porto Alegre, Brazil in September 2008. We expect this congress to exceed attendance at previous International Epidemiology Association world meetings by about 5-fold. A large epidemiology following in Latin America reflects a sense of solidarity among epidemiologists in the region, a willingness to participate and a thirst for knowledge. Perhaps, most importantly, in Latin American countries epidemiology is seen more as an applied discipline with social and political motivations than in most other countries. The links between epidemiology and public health are strong, vastly increasing the numbers attending our scientific meetings.
Our guest editors, Cesar Victora and Laura Rodrigues, have done an excellent job of commissioning commentaries and selecting excellent scientific papers from a flood of manuscripts in response to the call for papers. Selection of papers is always difficult and I hope readers enjoy the choices made and join me in thanking our guest editors for all the hard work involved.
Reviewing the scientific papers published in this themed issue demonstrates major interests in topics that would not be considered ‘mainstream’ epidemiology: household expenditure on health care,1 evaluation of household food security scale,2 morbidity and mortality in relation to health care indicators,3 health services for tuberculosis,4 health insurance and cervical cancer screening,5 impact of sanitation intervention6 and evaluation of access to PAP smears in Peru,7 for example. A continued sense of relevance, of socially pioneering work that has the ability to change the health of populations and the lives of individuals is clearly seen. Long may it continue!
The roots of Latin American epidemiology are eulogized by commentators on our reprint of Carlos Chagas’ report ‘A new disease entity in man: a report on etiologic and clinical observations’,8 originally published almost a century ago. The focus on finding ‘solutions to the concrete problems of society’ exemplified by Carlos Chagas9 remains a major part of contemporary Latin American epidemiology. Rapid reductions in incidence have been reported between 1990 and 2006, attributable to the obvious hygiene principles of using insecticides against the insect vector and improvements in housing, in particular the cracked walls in which the insect lives and breeds.10 Chagas specifically highlighted the danger of being bitten while lounging against such walls. Remarkably, stored biological samples from one of the original patients described by Chagas were examined recently, demonstrating the simultaneous presence of two strains of Typanosoma cruzi and the potentially complex pathogenesis of the disease.11
So despite the initial epidemiologic success in identifying the cause, why has T. cruzi remained a neglected yet widely prevalent disease in Latin America? Gürtler and colleagues highlight the opposition and envy of colleagues in slowing initial progress, followed by improvements in diagnosis and control measures. 12 However, drug treatments and insecticides remain under-used and control efforts are hampered by neglect of the vulnerable populations who lack strong political voices. They consider that an integrated approach with social participation is needed.
The bidirectionality in which Chagas disease is caused by poverty and is poverty-promoting indicates the importance of enlightened health systems in development. Brazil has established a unified health system based on principles of universal coverage, integrated care and equity so it is surprising to learn that Brazil is listed as one of the top countries for ‘catastrophic’ health expenditure. An evaluation of the issue reveals out-of-pocket expenditure is equally high across all income groups, with drug costs making up a substantial part of the costs1—equity achieved, but the costs are still too high.
Disappointingly, this issue contains no scientific evaluations of prevention and control of Chagas disease in the modern era. But a photo essay on ageing in São Paulo13 and an analysis of life course risk factors for dementia in the São Paulo Ageing & Health Study14 indicate that new challenges that rapidly ageing populations now face—in addition to the continued and unfinished business of prevention and control of infectious diseases. Undoubtedly, there will be challenges ahead for protecting the public health against chronic diseases as indicated by the picture.
The cohort profiled in this issue is the 1993 Pelotas (Brazil) birth cohort study that was set up using similar methods to the 1982 Pelotas cohort, enabling comparisons between mothers and their children in the two cohorts.15 Large changes in maternal and perinatal health were found over the short time interval between the cohorts. Unfortunately, resources to maintain the cohort have been scarce so only subsets have been followed up in the intervening time between birth and 11 years. The Pelotas cohorts provide a major resource for understanding the life course determinants of chronic diseases, directly estimating the burden of diseases and for surveillance of the changing trends in health and disease in a rapidly changing country. Establishing and sustaining cohort studies in the developing world represents a sound investment for building the health care and research capacity. Carlos Chagas would have approved of such investment.
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References
1 Barros AJD, Bertoldi AD. Out-of-pocket expenditure in a population covered by the Family Health Program in Brazil. Int J Epidemiol (2008) 37:758–65.
2 Hackett M, Melgar-Quiñonez H, Pérez-Escamilla R, Segall-Corrêa A. Gender of respondent does not affect the psychometric properties of the Brazilian Household Food Security Scale. Int J Epidemiol (2008) 37:766–74.
3 Cavalini LT, Ponce de Leon ACM. Morbidity and mortality in Brazilian municipalities: a multilevel study of the association between socioeconomic and healthcare indicators. Int J Epidemiol (2008) 37:775–83.
4 Nájera-Ortiz JC, Sánchez-Pérez HJ, Ochao-Díaz H, Arana-Cedeño M, Salazar-Lezama MA, Martín Mateo M. Demographic, health services and socioeconomic factors associated with pulmonary tuberculosis mortality in Los Altos Region of Vhiapas, Mexico. Int J Epidemiol (2008) 37:786–95.
5 Reyes-Ortiz CA, Velez LF, Camacho ME, Ottenbacher KJ, Markides KS. Health insurance and cervical cancer screening among older women in Latin American and Caribbean cities. Int J Epidemiol (2008) 37:870–78.
6 Genser B, Strina A, dos Santos L, et al. Impact of a city-wide sanitation intervention in a large urban centre on social, environmental and behavioural determinants of childhood diarrhoea: analysis of two cohort studies. Int J Epidemiol (2008) 37:831–40.
7 Soldan VAP, Lee FH, Carcamo C, Holmes K, Garnett GP, Garcia P. Who is getting Pap smears in urban Peru? Int J Epidemiol (2008) 37:862–69.
8 Chagas C. Reprints and reiterations: a new disease entity in man: a report on etiologic and clinical observations; in The Challenge of Epidemiology, PAHO Publications, 1981. (2008) 37:694–95. Reprinted Int J Epidemiol.
9 Carvalheiro JdR, Gadelha P. Commentary: Carlos Chagas: predecessor of Epidemiology in Brazil. Int J Epidemiol (2008) 37:701–3.
10 Moncayo A. Commentary: the lucid reasoning of Carlos Chagas. Int J Epidemiol (2008) 37:697–98.
11 Goldbaum M, Barreto ML. Commentary: the contribution and example of Carlos Chagas. Int J Epidemiol (2008) 37:695–96.
12 Gürtler RE, Diotaiuti L, Kitron U. Commentary: Chagas disease: 100 years since discovery and lessons for the future. Int J Epidemiol (2008) 37:698–700.
13 Scazufca M, Seabra CAF. São Paulo portraits: ageing in a large metropolis. Int J Epidemiol (2008) 37:721–23.
14 Scazufca M, Menezes PR, Ricardo Araya, et al. Risk factors across the life course and dementia in a Brazilian population; results from the São Paulo Ageing and Health Study (SPAH). Int J Epidemiol (2008) 37:879–90.
15 Victora CG, Hallal PC, Araújo CLP, Menezes AMB, Wells JCK, Barros FC. Cohort profile: The 1993 Pelotas (Brazil) Birth Cohort Study. Int J Epidemiol (2008) 37:704–09.
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