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Latin America

2000; Elsevier BV; Volume: 26; Linguagem: Inglês

10.1016/s0301-5629(00)00196-4

1879-291X

Giovanni Guido Cerri, Ilka Regina Souza de Oliveira,

Global Public Health Policies and Epidemiology

Latin-American kaleidoscopeThe Latin-American continent presents multifaceted and contradictory socio-economic aspects, mixing up the characteristics of developed countries with those of countries in the process of development.In a population context, medicine is practised in different and variable levels of quality, according to the economic conditions available in each region of the continent. The extremes are present all over. They are characterised through the coexistence of small medical offices in the rural areas of each country with sophisticated islands of virtuosity and research at the main university centres.The title “Latin-American kaleidoscope” tries to explain the complexity of the demographic process of this continent concerning the social and the sanitary conditions. The analysis of the socio-economic scenery demands more than a simple and naive vision of dual classifications, which only considers the archaic and the modern, the poor and the rich, the city and the country. This analysis requires a deeper examination that may consider the complexity and dynamism of the whole Latin-American social environment, taking into consideration the particularities of each country.Health inLatin America: a general viewMany changes have been identified, in the last decades, concerning the standard rates of Latin-American morbi-mortality. Life expectancy has increased, and infectious-parasitic diseases have decreased as well as infant and maternal mortality rates. In spite of these facts, there is still a heterogeneous incidence of illnesses related to social and regional life conditions, which are attached to the main changes observed in the demographic dynamism of the Latin-American countries.During this period, the structural differences of the population distribution between the urban and the rural areas have increased significantly. An increase in the average urbanisation rate has been observed as reaching levels of about 90% of population concentration in urban areas such as in the south-east of Brazil (Table 1). This disorganised distribution has made the public funds and resources, which were destined for education and basic sanitation, insufficient in the urban areas. On the other hand, the rural inhabitants were excluded from the labour-force context, a fact that restricted their access to public health services. The analysis of these elements highlights the peculiarities of the epidemiological profile perceived among the Latin-American countries.Table 1Urban and rural population distribution in Brazil, 1950–1991.legendSources:PeriodUrban population growth rate (%)Rural population growth rate (%)Total population growth rate (%)1950–1960aIBGE, Censos Demográficos (in IBGE, 1990);5.241.573.041960–1970aIBGE, Censos Demográficos (in IBGE, 1990);5.220.572.891970–1980aIBGE, Censos Demográficos (in IBGE, 1990);4.44−0.622.481980–1990bIBGE/DEPOP, v. 1. Censo Demográfico de 1991, análises preliminares.2.96−0.611.93legend Sources:a IBGE, Censos Demográficos (in IBGE, 1990);b IBGE/DEPOP, v. 1. Censo Demográfico de 1991, análises preliminares. Open table in a new tab Brazil in focusA trustworthy map of regional discrepancies and social disparities in Brazil can be idealised by considering some simple epidemiological parameters such as the infectious endemic diseases, infant and maternal mortality rates and the distribution of different cancer modalities (breast and cervix cancer). In this way, it has been observed that, in the past 50 years, in spite of having mother–infant mortality and infectious diseases rates diminished slowly but unceasingly, the incidence of female neoplasms [cervix (Table 2 ) and breast (Table 3 ) cancer] is still high.Table 2Cervix cancer incidence: geographic localization and selected periods.legendCoefficients per hundred thousand, standardised per age. Modified from Koifman S: Incidência de câncer no Brasil. In: Os muitos Brasis: saúde e população na década de 80. Minayo MCS, org.—2.ed. Hucitec, São Paulo, 1999.RegionCoefficientBelém—BR (1987)75.2Goiânia—BR (1988)48.9São Paulo—BR (1978)35.1Porto Alegre—BR (1987)31.2Costa Rica (1983–87)26.1Cuba (1983–87)20.0Japão (1983–87)13.2EUA (1983–87)10.4Canadá (1983–87)9.2Suíça6.2legend Coefficients per hundred thousand, standardised per age. Modified from Koifman S: Incidência de câncer no Brasil. In: Os muitos Brasis: saúde e população na década de 80. Minayo MCS, org.—2.ed. Hucitec, São Paulo, 1999. Open table in a new tab Table 3Female breast cancer incidence: geographic localization and selected periods.legendCoefficients per hundred thousand, standardized per age. Modified from Koifman S: Incidência de câncer no Brasil. In: Os muitos Brasis: saúde e população na década de 80. Minayo MCS, org.—2.ed. Hucitec, São Paulo, 1999.RegionCoefficientPorto Alegre—BR (1987)76.2EUA (1983–87)72.1Canadá (1983–87)70.8Suíça68.5São Paulo—BR (1978)65.5Belém—BR (1987)40.5Goiânia—BR (1988)38.8Cuba (1983–87)35.0Costa Rica (1983–87)26.7Japão21.9legend Coefficients per hundred thousand, standardized per age. Modified from Koifman S: Incidência de câncer no Brasil. In: Os muitos Brasis: saúde e população na década de 80. Minayo MCS, org.—2.ed. Hucitec, São Paulo, 1999. Open table in a new tab The Brazilian medical and governmental entities have been trying to avoid the maintenance of this socio-economic diversity in the new millennium by creating ways for epidemiological tracking and for monitoring therapeutic programmes countrywide. The results of these campaigns might produce public health programme plans strongly recommended for the reality of each region of the country.This socio-economic context advocates the creation of basic health units formed by qualified professionals able to care for the population on a wide range. For such conditions, following the modern medical precepts based on evidence, the active participation of supporting methods of diagnosis is desirable. Currently, ultrasound is highlighted among other imaging modalities, because of its inherent characteristics such as low cost, versatility and noninvasive profile.Ultrasound in Latin America: a general portraitUltrasound has acquired great importance in the Latin-American socio-economic context, assuming wider extensions in the past years. This diagnostic method was introduced into Latin America in the 1970s, by those medical doctors who could foresee its coming importance (Rivero and Himmelstine 1992Rivero M.A.C. Himmelstine L.G. ABC de la Ultrasonografı́a Médica. Comunicación Gráfica y Representaciones, Ciudad de Mexico1992Google Scholar). For their specialisation, some countries such as the U.S., Canada, the U.K., France, Italy, Germany, Spain and Japan among others were chosen for their advanced development in this field. As a consequence, Latin-American ultrasound has assumed some particularities, combining the North-American methodological pragmatism with the clinic-artisan Asian-European approach, brought from these centres.The first professionals to deal with ultrasound sprang from several medical areas such as gynaecology and obstetrics, radiology, cardiology, gastroenterology and nephrology. In caring for patients, they were able to apprehend the central role played by this new methodology to obtain medical information impelled by simple, noninvasive and low cost characteristics of ultrasound. Therefore, several clinical studies, which included field tracking protocols, were made up, reaching such a refinement as to establish the correlation between the pathological and the ultrasound findings of some rural endemic-parasitic diseases prevailing in our environment (Cerri et al 1984Cerri G.G. Alves V.A.F. Magalhães A. Hepatosplenic schistosomiasis Mansoni Ultrasound manifestations.Radiology. 1984; 153: 777-780PubMed Google Scholar) (see Fig. 1, Fig. 2 ). Fig. 2Northeast rural environment of Brazil.View Large Image Figure ViewerDownload (PPT)The technological evolution of the ultrasound equipment has allowed a significant expansion of the limits of the diagnostic investigation, increasing the degree of complexity of the speciality.The introduction of the vascular mapping with the colour Doppler ultrasound has emphasised the participation of ultrasound toward studies of the pathophysiological processes of illness. This fact has placed ultrasound in an outstanding position among the other diagnostic imaging modalities. The rapid development of this speciality has made essential a complete and constant recycling of the professionals, leading to perspectives of special training in areas such as fetal medicine. Thus, the professional qualification that initially could be done roughly in short periods of time has become more demanding, requiring longer periods to contemplate all new technical achievements.Future perspectivesThe development of ultrasound as a speciality has been associated with an uncontrolled augmentation of the number of doctors engaged in its practice. Consequently, many congregating societies of these professionals were created, tending to an autonomous operation.Only recently in Brazil, the necessity of compartmentalisation of this expanding diagnostic modality has become obvious. So, the main medical representative entities regarding ultrasound practice or have consensually elected the Brazilian College of Radiology as the official representative of this speciality toward the governmental authorities. This corporate entity congregates other imaging diagnostic specialities such as nuclear medicine, radiotherapy as well as radiology, assuming a normative role, moderating, coordinating and favouring the establishment of rules as well as the practice of ultrasound.The present and future challenge resides in creating and organising a group of preestablished conditions, defining a responsible and authoritative way of practising ultrasound. In this way, a new concept for a unique speciality could permit ultrasound to become the most adequate diagnosis methodology for the Latin-American continent. Latin-American kaleidoscopeThe Latin-American continent presents multifaceted and contradictory socio-economic aspects, mixing up the characteristics of developed countries with those of countries in the process of development.In a population context, medicine is practised in different and variable levels of quality, according to the economic conditions available in each region of the continent. The extremes are present all over. They are characterised through the coexistence of small medical offices in the rural areas of each country with sophisticated islands of virtuosity and research at the main university centres.The title “Latin-American kaleidoscope” tries to explain the complexity of the demographic process of this continent concerning the social and the sanitary conditions. The analysis of the socio-economic scenery demands more than a simple and naive vision of dual classifications, which only considers the archaic and the modern, the poor and the rich, the city and the country. This analysis requires a deeper examination that may consider the complexity and dynamism of the whole Latin-American social environment, taking into consideration the particularities of each country. The Latin-American continent presents multifaceted and contradictory socio-economic aspects, mixing up the characteristics of developed countries with those of countries in the process of development. In a population context, medicine is practised in different and variable levels of quality, according to the economic conditions available in each region of the continent. The extremes are present all over. They are characterised through the coexistence of small medical offices in the rural areas of each country with sophisticated islands of virtuosity and research at the main university centres. The title “Latin-American kaleidoscope” tries to explain the complexity of the demographic process of this continent concerning the social and the sanitary conditions. The analysis of the socio-economic scenery demands more than a simple and naive vision of dual classifications, which only considers the archaic and the modern, the poor and the rich, the city and the country. This analysis requires a deeper examination that may consider the complexity and dynamism of the whole Latin-American social environment, taking into consideration the particularities of each country. Health inLatin America: a general viewMany changes have been identified, in the last decades, concerning the standard rates of Latin-American morbi-mortality. Life expectancy has increased, and infectious-parasitic diseases have decreased as well as infant and maternal mortality rates. In spite of these facts, there is still a heterogeneous incidence of illnesses related to social and regional life conditions, which are attached to the main changes observed in the demographic dynamism of the Latin-American countries.During this period, the structural differences of the population distribution between the urban and the rural areas have increased significantly. An increase in the average urbanisation rate has been observed as reaching levels of about 90% of population concentration in urban areas such as in the south-east of Brazil (Table 1). This disorganised distribution has made the public funds and resources, which were destined for education and basic sanitation, insufficient in the urban areas. On the other hand, the rural inhabitants were excluded from the labour-force context, a fact that restricted their access to public health services. The analysis of these elements highlights the peculiarities of the epidemiological profile perceived among the Latin-American countries.Table 1Urban and rural population distribution in Brazil, 1950–1991.legendSources:PeriodUrban population growth rate (%)Rural population growth rate (%)Total population growth rate (%)1950–1960aIBGE, Censos Demográficos (in IBGE, 1990);5.241.573.041960–1970aIBGE, Censos Demográficos (in IBGE, 1990);5.220.572.891970–1980aIBGE, Censos Demográficos (in IBGE, 1990);4.44−0.622.481980–1990bIBGE/DEPOP, v. 1. Censo Demográfico de 1991, análises preliminares.2.96−0.611.93legend Sources:a IBGE, Censos Demográficos (in IBGE, 1990);b IBGE/DEPOP, v. 1. Censo Demográfico de 1991, análises preliminares. Open table in a new tab Many changes have been identified, in the last decades, concerning the standard rates of Latin-American morbi-mortality. Life expectancy has increased, and infectious-parasitic diseases have decreased as well as infant and maternal mortality rates. In spite of these facts, there is still a heterogeneous incidence of illnesses related to social and regional life conditions, which are attached to the main changes observed in the demographic dynamism of the Latin-American countries. During this period, the structural differences of the population distribution between the urban and the rural areas have increased significantly. An increase in the average urbanisation rate has been observed as reaching levels of about 90% of population concentration in urban areas such as in the south-east of Brazil (Table 1). This disorganised distribution has made the public funds and resources, which were destined for education and basic sanitation, insufficient in the urban areas. On the other hand, the rural inhabitants were excluded from the labour-force context, a fact that restricted their access to public health services. The analysis of these elements highlights the peculiarities of the epidemiological profile perceived among the Latin-American countries. Brazil in focusA trustworthy map of regional discrepancies and social disparities in Brazil can be idealised by considering some simple epidemiological parameters such as the infectious endemic diseases, infant and maternal mortality rates and the distribution of different cancer modalities (breast and cervix cancer). In this way, it has been observed that, in the past 50 years, in spite of having mother–infant mortality and infectious diseases rates diminished slowly but unceasingly, the incidence of female neoplasms [cervix (Table 2 ) and breast (Table 3 ) cancer] is still high.Table 2Cervix cancer incidence: geographic localization and selected periods.legendCoefficients per hundred thousand, standardised per age. Modified from Koifman S: Incidência de câncer no Brasil. In: Os muitos Brasis: saúde e população na década de 80. Minayo MCS, org.—2.ed. Hucitec, São Paulo, 1999.RegionCoefficientBelém—BR (1987)75.2Goiânia—BR (1988)48.9São Paulo—BR (1978)35.1Porto Alegre—BR (1987)31.2Costa Rica (1983–87)26.1Cuba (1983–87)20.0Japão (1983–87)13.2EUA (1983–87)10.4Canadá (1983–87)9.2Suíça6.2legend Coefficients per hundred thousand, standardised per age. Modified from Koifman S: Incidência de câncer no Brasil. In: Os muitos Brasis: saúde e população na década de 80. Minayo MCS, org.—2.ed. Hucitec, São Paulo, 1999. Open table in a new tab Table 3Female breast cancer incidence: geographic localization and selected periods.legendCoefficients per hundred thousand, standardized per age. Modified from Koifman S: Incidência de câncer no Brasil. In: Os muitos Brasis: saúde e população na década de 80. Minayo MCS, org.—2.ed. Hucitec, São Paulo, 1999.RegionCoefficientPorto Alegre—BR (1987)76.2EUA (1983–87)72.1Canadá (1983–87)70.8Suíça68.5São Paulo—BR (1978)65.5Belém—BR (1987)40.5Goiânia—BR (1988)38.8Cuba (1983–87)35.0Costa Rica (1983–87)26.7Japão21.9legend Coefficients per hundred thousand, standardized per age. Modified from Koifman S: Incidência de câncer no Brasil. In: Os muitos Brasis: saúde e população na década de 80. Minayo MCS, org.—2.ed. Hucitec, São Paulo, 1999. Open table in a new tab The Brazilian medical and governmental entities have been trying to avoid the maintenance of this socio-economic diversity in the new millennium by creating ways for epidemiological tracking and for monitoring therapeutic programmes countrywide. The results of these campaigns might produce public health programme plans strongly recommended for the reality of each region of the country.This socio-economic context advocates the creation of basic health units formed by qualified professionals able to care for the population on a wide range. For such conditions, following the modern medical precepts based on evidence, the active participation of supporting methods of diagnosis is desirable. Currently, ultrasound is highlighted among other imaging modalities, because of its inherent characteristics such as low cost, versatility and noninvasive profile. A trustworthy map of regional discrepancies and social disparities in Brazil can be idealised by considering some simple epidemiological parameters such as the infectious endemic diseases, infant and maternal mortality rates and the distribution of different cancer modalities (breast and cervix cancer). In this way, it has been observed that, in the past 50 years, in spite of having mother–infant mortality and infectious diseases rates diminished slowly but unceasingly, the incidence of female neoplasms [cervix (Table 2 ) and breast (Table 3 ) cancer] is still high. The Brazilian medical and governmental entities have been trying to avoid the maintenance of this socio-economic diversity in the new millennium by creating ways for epidemiological tracking and for monitoring therapeutic programmes countrywide. The results of these campaigns might produce public health programme plans strongly recommended for the reality of each region of the country. This socio-economic context advocates the creation of basic health units formed by qualified professionals able to care for the population on a wide range. For such conditions, following the modern medical precepts based on evidence, the active participation of supporting methods of diagnosis is desirable. Currently, ultrasound is highlighted among other imaging modalities, because of its inherent characteristics such as low cost, versatility and noninvasive profile. Ultrasound in Latin America: a general portraitUltrasound has acquired great importance in the Latin-American socio-economic context, assuming wider extensions in the past years. This diagnostic method was introduced into Latin America in the 1970s, by those medical doctors who could foresee its coming importance (Rivero and Himmelstine 1992Rivero M.A.C. Himmelstine L.G. ABC de la Ultrasonografı́a Médica. Comunicación Gráfica y Representaciones, Ciudad de Mexico1992Google Scholar). For their specialisation, some countries such as the U.S., Canada, the U.K., France, Italy, Germany, Spain and Japan among others were chosen for their advanced development in this field. As a consequence, Latin-American ultrasound has assumed some particularities, combining the North-American methodological pragmatism with the clinic-artisan Asian-European approach, brought from these centres.The first professionals to deal with ultrasound sprang from several medical areas such as gynaecology and obstetrics, radiology, cardiology, gastroenterology and nephrology. In caring for patients, they were able to apprehend the central role played by this new methodology to obtain medical information impelled by simple, noninvasive and low cost characteristics of ultrasound. Therefore, several clinical studies, which included field tracking protocols, were made up, reaching such a refinement as to establish the correlation between the pathological and the ultrasound findings of some rural endemic-parasitic diseases prevailing in our environment (Cerri et al 1984Cerri G.G. Alves V.A.F. Magalhães A. Hepatosplenic schistosomiasis Mansoni Ultrasound manifestations.Radiology. 1984; 153: 777-780PubMed Google Scholar) (see Fig. 1, Fig. 2 ). The technological evolution of the ultrasound equipment has allowed a significant expansion of the limits of the diagnostic investigation, increasing the degree of complexity of the speciality.The introduction of the vascular mapping with the colour Doppler ultrasound has emphasised the participation of ultrasound toward studies of the pathophysiological processes of illness. This fact has placed ultrasound in an outstanding position among the other diagnostic imaging modalities. The rapid development of this speciality has made essential a complete and constant recycling of the professionals, leading to perspectives of special training in areas such as fetal medicine. Thus, the professional qualification that initially could be done roughly in short periods of time has become more demanding, requiring longer periods to contemplate all new technical achievements. Ultrasound has acquired great importance in the Latin-American socio-economic context, assuming wider extensions in the past years. This diagnostic method was introduced into Latin America in the 1970s, by those medical doctors who could foresee its coming importance (Rivero and Himmelstine 1992Rivero M.A.C. Himmelstine L.G. ABC de la Ultrasonografı́a Médica. Comunicación Gráfica y Representaciones, Ciudad de Mexico1992Google Scholar). For their specialisation, some countries such as the U.S., Canada, the U.K., France, Italy, Germany, Spain and Japan among others were chosen for their advanced development in this field. As a consequence, Latin-American ultrasound has assumed some particularities, combining the North-American methodological pragmatism with the clinic-artisan Asian-European approach, brought from these centres. The first professionals to deal with ultrasound sprang from several medical areas such as gynaecology and obstetrics, radiology, cardiology, gastroenterology and nephrology. In caring for patients, they were able to apprehend the central role played by this new methodology to obtain medical information impelled by simple, noninvasive and low cost characteristics of ultrasound. Therefore, several clinical studies, which included field tracking protocols, were made up, reaching such a refinement as to establish the correlation between the pathological and the ultrasound findings of some rural endemic-parasitic diseases prevailing in our environment (Cerri et al 1984Cerri G.G. Alves V.A.F. Magalhães A. Hepatosplenic schistosomiasis Mansoni Ultrasound manifestations.Radiology. 1984; 153: 777-780PubMed Google Scholar) (see Fig. 1, Fig. 2 ). The technological evolution of the ultrasound equipment has allowed a significant expansion of the limits of the diagnostic investigation, increasing the degree of complexity of the speciality. The introduction of the vascular mapping with the colour Doppler ultrasound has emphasised the participation of ultrasound toward studies of the pathophysiological processes of illness. This fact has placed ultrasound in an outstanding position among the other diagnostic imaging modalities. The rapid development of this speciality has made essential a complete and constant recycling of the professionals, leading to perspectives of special training in areas such as fetal medicine. Thus, the professional qualification that initially could be done roughly in short periods of time has become more demanding, requiring longer periods to contemplate all new technical achievements. Future perspectivesThe development of ultrasound as a speciality has been associated with an uncontrolled augmentation of the number of doctors engaged in its practice. Consequently, many congregating societies of these professionals were created, tending to an autonomous operation.Only recently in Brazil, the necessity of compartmentalisation of this expanding diagnostic modality has become obvious. So, the main medical representative entities regarding ultrasound practice or have consensually elected the Brazilian College of Radiology as the official representative of this speciality toward the governmental authorities. This corporate entity congregates other imaging diagnostic specialities such as nuclear medicine, radiotherapy as well as radiology, assuming a normative role, moderating, coordinating and favouring the establishment of rules as well as the practice of ultrasound.The present and future challenge resides in creating and organising a group of preestablished conditions, defining a responsible and authoritative way of practising ultrasound. In this way, a new concept for a unique speciality could permit ultrasound to become the most adequate diagnosis methodology for the Latin-American continent. The development of ultrasound as a speciality has been associated with an uncontrolled augmentation of the number of doctors engaged in its practice. Consequently, many congregating societies of these professionals were created, tending to an autonomous operation. Only recently in Brazil, the necessity of compartmentalisation of this expanding diagnostic modality has become obvious. So, the main medical representative entities regarding ultrasound practice or have consensually elected the Brazilian College of Radiology as the official representative of this speciality toward the governmental authorities. This corporate entity congregates other imaging diagnostic specialities such as nuclear medicine, radiotherapy as well as radiology, assuming a normative role, moderating, coordinating and favouring the establishment of rules as well as the practice of ultrasound. The present and future challenge resides in creating and organising a group of preestablished conditions, defining a responsible and authoritative way of practising ultrasound. In this way, a new concept for a unique speciality could permit ultrasound to become the most adequate diagnosis methodology for the Latin-American continent.