Produção Nacional
Revisado por pares
A Brazilian perspective
1997; Elsevier BV; Volume: 349; Linguagem: Inglês
10.1016/s0140-6736(97)90087-8
ISSN1474-547X
Autores Tópico(s)Biotechnology and Related Fields
ResumoThe concept of tropical medicine as a medical specialty has varied considerably according to the operational needs of each period and/or country. The concept in South America has moved away from the practice of medicine (all medicine) in the tropics to restrict itself to diseases that are endemic in the intertropical regions and less common or even non-existent in the temperate zones (the pathologies exotiques of the French authors). In many countries, including Brazil, tropical medicine has become inextricably linked to parasitic and helminthic diseases, which are associated with poverty, crowding, lack of sanitation, and patterns of land occupation.In the late 1800s and early 1900s, institutes were established in Rio de Janeiro and São Paulo, the largest Brazilian cities, to help combat the then endemic and epidemic diseases. Arguably, the driving force behind the creation of these institutions was an economic one, the control of diseases being necessary to allow the vital flow of European migrants to continue, to maintain the country's maritime trade (the fear of tropical diseases, especially yellowfever, was driving ships away from Brazilian ports), and to permit the occupation of vast tracts of unexplored land. These institutes bred generations of renowned investigators, Carlos Chagas being the most famous.Today, Brazil is the eighth largest economy in the world, and its market size in pharmaceuticals ranks even higher. Sadly, Brazil also comes near the top of the table for inequality of wealth distribution, and this is reflected in the quality and type of medical care available. The wealthy have access, through private physicians and health insurance, to treatment that is virtually identical to what is offered in the best centres in Europe and the USA while the vast majority of the population receives substandard medical attention from governmental institutions. For the rich, new drugs and treatments are available almost as soon as they are in developed countries, and their physicians are, to a large extent, acquainted with the principles of modern practice, including evidence-based medicine. For the less well off, newer (and older) drugs and diagnostic tools are unavailable or have very limited availability, regional differences are enormous, and for their physicians the marketing representatives of the drug companies are the major source of new medical information.Over the past three decades, Brazil has gone through major social and economic transformations, becoming a predominantly urban, industrialised society. In the same period, the relative importance of health-related problems also changed considerably. For the country as a whole, infant mortality and child malnutrition rates, although still substantial, were much reduced; ancient scourges like smallpox and poliomyelitis were eradicated and remarkable progress was achieved in the control of tetanus, diphtheria, measles, and other vaccine preventable diseases; vector-borne Chagas disease was virtually eliminated. On the other hand, tuberculosis remains a major cause of morbidity and mortality; and there has been a worrying recrudescence in malaria in the Amazon region plus the urbanisation of leishmaniasis and the reintroduction of cholera and dengue into several parts of the country.1Monteiro CA Lunes RF Torres AM A evolução do país e de suas doenças.Informe Epidemiol SUS. 1996; 5: 7-14Google Scholar An increase in life expectancy and a continuous decline in fertility rates have left Brazil with an ageing population,2Monteiro MFG Alves MIC Aspectos demográficos da população idosa no Brasil.in: Veras R Terceira idade: um envelhecimento digno para o cidadão do futuro. Relume Dumará, Rio de Janeiro1995Google Scholar and the chronic and degenerative diseases typical of affluent societies have become major causes of morbidity and mortality.1Monteiro CA Lunes RF Torres AM A evolução do país e de suas doenças.Informe Epidemiol SUS. 1996; 5: 7-14Google ScholarAs the spectrum of disease in Brazil changed, so did the practice of the physician trained in tropical medicine. The growing number of antimicrobial drugs available, the development of better diagnostic techniques, and the increasing number of immunocompromised individuals contributed to the emergence of infectious diseases as an important medical specialty. Since these often difficult to diagnose and manage, but potentially treatable, conditions affect an urban and more affluent population, a new and profitable niche in the market was slowly created, and this was to be enlarged by the arrival of AIDS. To a large extent this market niche was occupied by physicians trained in tropical medicine who had greater familiarity with microbiology. Also, the potential (or perceived) transmissibility of some infections, that acted as a repellent for physicians trained in other specialties, was no novelty for those brought up in tropical medicine. This migration from tropical medicine to infectious diseases was also experienced by those in research. These movements of physicians, scientists, and research funds are reflected in the fact that the Brazilian Society of Infectious Diseases (founded in 1981) is now larger and more influential than the long established Brazilian Society of Tropical Diseases.But tropical medicine is far from obsolete or condemned to disappear. In an age of intense and rapid movements of people and goods, any transmissible agent is a potential global threat. In Brazil, as elsewhere, emerging and reemerging infectious diseases are becoming important public health challenges.1Monteiro CA Lunes RF Torres AM A evolução do país e de suas doenças.Informe Epidemiol SUS. 1996; 5: 7-14Google Scholar To diagnose, treat, prevent, and control these diseases, a familiarity with epidemiology, microbiology, and entomology is vitally important. These disciplines have long been part of the basic training of the specialist in tropical medicine, and as these reemerging diseases become recognised as local and global threats the practice of tropical medicine may reacquire its former prestige. Brazilian scientists, taking advantage of the solid infrastructure built to support research in infectious diseases, will certainly make important contributions, as Chagas did earlier this century.Changes in the scope and practice of tropical medicine in Brazil have for the most part been brought about by the social and economic transformations experienced by Brazilian society and by the development and land occupation policies of successive governments. Although Brazil has become an important contributor to medical knowledge and although the transfer of information and technology is almost instantaneous, the incorporation of medical advances into routine practice is restricted to the affluent. Thus, the future of tropical medicine in this country will be greatly influenced by the economic models that Brazil chooses to adopt. The concept of tropical medicine as a medical specialty has varied considerably according to the operational needs of each period and/or country. The concept in South America has moved away from the practice of medicine (all medicine) in the tropics to restrict itself to diseases that are endemic in the intertropical regions and less common or even non-existent in the temperate zones (the pathologies exotiques of the French authors). In many countries, including Brazil, tropical medicine has become inextricably linked to parasitic and helminthic diseases, which are associated with poverty, crowding, lack of sanitation, and patterns of land occupation. In the late 1800s and early 1900s, institutes were established in Rio de Janeiro and São Paulo, the largest Brazilian cities, to help combat the then endemic and epidemic diseases. Arguably, the driving force behind the creation of these institutions was an economic one, the control of diseases being necessary to allow the vital flow of European migrants to continue, to maintain the country's maritime trade (the fear of tropical diseases, especially yellowfever, was driving ships away from Brazilian ports), and to permit the occupation of vast tracts of unexplored land. These institutes bred generations of renowned investigators, Carlos Chagas being the most famous. Today, Brazil is the eighth largest economy in the world, and its market size in pharmaceuticals ranks even higher. Sadly, Brazil also comes near the top of the table for inequality of wealth distribution, and this is reflected in the quality and type of medical care available. The wealthy have access, through private physicians and health insurance, to treatment that is virtually identical to what is offered in the best centres in Europe and the USA while the vast majority of the population receives substandard medical attention from governmental institutions. For the rich, new drugs and treatments are available almost as soon as they are in developed countries, and their physicians are, to a large extent, acquainted with the principles of modern practice, including evidence-based medicine. For the less well off, newer (and older) drugs and diagnostic tools are unavailable or have very limited availability, regional differences are enormous, and for their physicians the marketing representatives of the drug companies are the major source of new medical information. Over the past three decades, Brazil has gone through major social and economic transformations, becoming a predominantly urban, industrialised society. In the same period, the relative importance of health-related problems also changed considerably. For the country as a whole, infant mortality and child malnutrition rates, although still substantial, were much reduced; ancient scourges like smallpox and poliomyelitis were eradicated and remarkable progress was achieved in the control of tetanus, diphtheria, measles, and other vaccine preventable diseases; vector-borne Chagas disease was virtually eliminated. On the other hand, tuberculosis remains a major cause of morbidity and mortality; and there has been a worrying recrudescence in malaria in the Amazon region plus the urbanisation of leishmaniasis and the reintroduction of cholera and dengue into several parts of the country.1Monteiro CA Lunes RF Torres AM A evolução do país e de suas doenças.Informe Epidemiol SUS. 1996; 5: 7-14Google Scholar An increase in life expectancy and a continuous decline in fertility rates have left Brazil with an ageing population,2Monteiro MFG Alves MIC Aspectos demográficos da população idosa no Brasil.in: Veras R Terceira idade: um envelhecimento digno para o cidadão do futuro. Relume Dumará, Rio de Janeiro1995Google Scholar and the chronic and degenerative diseases typical of affluent societies have become major causes of morbidity and mortality.1Monteiro CA Lunes RF Torres AM A evolução do país e de suas doenças.Informe Epidemiol SUS. 1996; 5: 7-14Google Scholar As the spectrum of disease in Brazil changed, so did the practice of the physician trained in tropical medicine. The growing number of antimicrobial drugs available, the development of better diagnostic techniques, and the increasing number of immunocompromised individuals contributed to the emergence of infectious diseases as an important medical specialty. Since these often difficult to diagnose and manage, but potentially treatable, conditions affect an urban and more affluent population, a new and profitable niche in the market was slowly created, and this was to be enlarged by the arrival of AIDS. To a large extent this market niche was occupied by physicians trained in tropical medicine who had greater familiarity with microbiology. Also, the potential (or perceived) transmissibility of some infections, that acted as a repellent for physicians trained in other specialties, was no novelty for those brought up in tropical medicine. This migration from tropical medicine to infectious diseases was also experienced by those in research. These movements of physicians, scientists, and research funds are reflected in the fact that the Brazilian Society of Infectious Diseases (founded in 1981) is now larger and more influential than the long established Brazilian Society of Tropical Diseases. But tropical medicine is far from obsolete or condemned to disappear. In an age of intense and rapid movements of people and goods, any transmissible agent is a potential global threat. In Brazil, as elsewhere, emerging and reemerging infectious diseases are becoming important public health challenges.1Monteiro CA Lunes RF Torres AM A evolução do país e de suas doenças.Informe Epidemiol SUS. 1996; 5: 7-14Google Scholar To diagnose, treat, prevent, and control these diseases, a familiarity with epidemiology, microbiology, and entomology is vitally important. These disciplines have long been part of the basic training of the specialist in tropical medicine, and as these reemerging diseases become recognised as local and global threats the practice of tropical medicine may reacquire its former prestige. Brazilian scientists, taking advantage of the solid infrastructure built to support research in infectious diseases, will certainly make important contributions, as Chagas did earlier this century. Changes in the scope and practice of tropical medicine in Brazil have for the most part been brought about by the social and economic transformations experienced by Brazilian society and by the development and land occupation policies of successive governments. Although Brazil has become an important contributor to medical knowledge and although the transfer of information and technology is almost instantaneous, the incorporation of medical advances into routine practice is restricted to the affluent. Thus, the future of tropical medicine in this country will be greatly influenced by the economic models that Brazil chooses to adopt.
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