Brazil as a middle income country with rich experience in economic, socio-political and health spheres is a model for studying contemporary public health issues. The country is having double burden of disease and has extreme of political, economic and health inequalities in the world. The emergence of non-communicable diseases as global issues as the United Nations General Assembly Special Session (UNGASS)
Brazil is a federative republic that covers 8·5 million km² or 47% of the South American continent and has an estimated population of 190 732 694 in 2010. It is the world's ï¬fth most populous country. The population is multi-ethnic; in 2008, about half the population self-classiï¬ed their race or skin color as brown (43·8%) or black (6·8%), and 0·6% thought of themselves as indigenous to Brazil. Brazil can therefore be described as a country of continental dimensions with widespread regional and social inequalities and undergoing economic, demographic and epidemiologic transition.(1)
A nation in transition and NCDs
The situation in Brazil concerning NCDs is not different from other lower and middle income countries (LMICs )as it was reported that in 2007, about 72% of all deaths in Brazil were attributable to NCDs (cardiovascular diseases, chronic respiratory diseases, diabetes, cancer, and others). This is compared to 10% attributed to infectious or parasitic diseases, and 5% to maternal and child health disorders. The disease burden also falls mainly on NCDs with neuropsychiatric disorders accounting for greatest portion at 18%.(2) The morbidity and mortality due to NCDs are greatest in the poor population as the country is noted for social and economic inequalities. There have been some declines in NCD deaths especially for cardiovascular and chronic respiratory diseases. These are related to the successful implementation of health policies that led to decreases in smoking and the expansion of access to primary health care. On the other hand, the prevalence of diabetes and hypertension is rising due to excess weight associated with unfavorable changes of diet and physical activity.(2)
The past three decades has seen Brazil undergoing a demographic transition; the proportion of the population older than 60 years doubled and urbanization increased from 55·9% to 80%. Fertility rates decreased (5·8 in 1970 to 1·9 in 2008), as did infant mortality (114 per 1000 live births in 1970 to 19·3 per 1000 live births in 2007). As a result, life expectancy at birth increased by nearly 40%, to 72·8 years in 2008 []On the economic front, between 1991 and 2008, Brazil's gross domestic product doubled and the poverty index decreased from 68% in 1970 to 31% in 2008.(1)
The general living conditions have also changed substantially with some unhealthy lifestyle exposing the population to a greater risk of chronic disease. Geographical and social inequalities in disease and death pattern exist especially in the poorest north and northeast regions. The less privileged ethnic and racial groups especially the brown or black skin color tend to bear a disproportionately large share of the burden example, higher prevalence of hypertension and diabetes mortality.
Translating into economic terms, according to conservative estimates by WHO deaths and burden of resulting from just three NCDs (diabetes, heart disease, and stroke), will lead to a loss of economic output of US$4·18 billion between 2006 and 2015.(2)
The top five NCDs
The main chronic disorders are neuro-psychiatric disorders (19%), cardiovascular diseases (13%), chronic respiratory diseases (8%), cancers (6%), musculoskeletal diseases (6%), and diabetes (5%).Besides neuropsychiatric disorders, the four major NCDs accounted for 58% of all deaths in 2007.
CVD
Cardiovascular mortality remains high. By WHO data, Brazil's 2004 mortality attributable to cardiovascular disease, 286 per 100 000 people, is third South American countries behind Guyana and Surinam. The mortality burden as expected affects poor people in the society. These diseases also account for the greatest cost of hospital admission within the national health system.
Diabetes
A national registry for diabetes and hypertension, SisHiperDia, which was started in 2002 had 1·6 million cases of diabetes registered. Out of the registered 4·3% had a diabetic foot disorder and 2·2% a previous amputation, 7·8% had renal disease, 7·8% had a previous myocardial infarction, and 8·0% had a previous stroke. This is reflects the mortality registry data of mortality in people with diabetes being 57% more than that of the general population.
Cancer
In men, mortality rates of lung, prostate, and colorectal cancer are increasing, that of gastric cancer decreasing, and that of esophageal cancer stable. In women, mortality rates of breast, lung, and colorectal cancers have risen, while those of cervical and gastric cancer have declined. Declines in deaths attributable to cervical cancer over the past two decades, especially in state capitals, have paralleled improved screening practices, which were introduced in the 1980s and enhanced since 1998. In rural parts of the north and northeast regions (areas with restricted access to screening) mortality rates are still rising. Cervical cancer incidence in Brazil, overall, is still very high, with rates close to those of countries with the highest incidence: Peru and some African states. This ï¬nding is consistent with the very high prevalence (14-54%) of human papillomavirus in surveyed Brazilian women.
Chronic respiratory diseases
There is a significant decrease in the prevalence of chronic respiratory diseases with chronic obstructive pulmonary disease (COPD) by 28·2% and asthma by 34·1% which also reflects in hospital admissions decreasing in adults aged 20 years or older by 32% and 38% respectively between 2000 and 2007. This could be due to improvements in access to health care, decline of smoking among others. The main COPD risk factors include tuberculosis and indoor pollution. A Brazilian nationally representative survey revealed that asthma was 28% lower in rural than urban area and are related to industrialization and urbanization.
Risk factors
The four above NCDs have common risk factors and are tobacco use, alcohol intake, obesity and physical inactivity.
TOBACCO USE: Two nationwide surveys show that the prevalence of smoking in people aged 18 years or older declined substantially in Brazil, from 34·8% in 1989 to 22·4% in 2003. This results in reduction in chronic respiratory diseases including COPD and lung cancers.
ALCOHOL ABUSE: 45% of Brazilian adults abstain from the consumption of alcohol yet the proportion of excessive drinking and dependence is high. Alcohol dependency varies from 9% to 12% of the entire adult population, more in men than women. Alcohol dependence is found to be higher in young adults and those with intermediate levels of education and income. This has resulted in age-adjusted mortality from mental and behavioral disorders due to use of alcohol increasing by 21% from 1996 to 2007.
PHYSICAL INACTIVITY: In 1996-97, a nationwide survey showed that only 3·3% of Brazilian adults reported doing the minimum recommended level of 30 min of leisure-time physical activity at least 5 days per week. This together with unhealthy diet predisposes to obesity which is a risk factor for cardiovascular diseases
UNHEALTHY FOOD: These are processed foods, high sodium diet and added sugar. Due to urbanization and globalization fewer people cook at home with basic traditional foods, such as rice, beans, and vegetables and majority buying street food or fast food containing more oil and salts; and foods containing added sugar like cookies ,biscuits and fizzy drinks. National estimates on sodium intake show a daily consumption of about 4 g per person, twice the maximum recommended intake. Poverty also leave people without choice but eat unhealthy food, therefore there is obesity among the poor in mainly urban areas as well as the rich.
Mental health in Brazil
This second part of the essay will dwell on neuro-psychiatric conditions which constitute the greatest of the disease burden in Brazil and has been identified with increased alcohol consumption, socioeconomic inequality and aging of the population. Globally about 14% of the disease burden has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. (3)
The burden of neuropsychiatric disorders
Most of the burden from neuropsychiatric disorders is due to depression, psychoses, and disorders attributable to alcohol misuse. (2) Depression is said to affect 5-10% of adults in a survey and is more prevalent in metropolitan São Paulo.(4,5) Depression and common mental disorders (CMD) are more prevalent in people with lower levels of education and income, and in people who were unemployed. Due to aging population, of neurodegenerative diseases (Parkinson's and Alzheimer's disease) dementia is becoming a major public health issue. (5) The role of alcohol in the development of neuro-psychiatric and behavioral disorders has been long established.(6)
Mental disorders have negative consequences on the society as a whole. The economic and social impact includes human capital losses, decrease in highly skilled and educated manpower, and loss of productive workforce, unemployment, homelessness poverty and premature deaths.(7,8) Violence and criminality are also associated with some mental disorders.(9) Some also affect the normal development of children rendering them disabled for life.
Treatment
Treatment of neuropsychiatric disorders take place at different levels namely psychiatric hospital, general hospitals with psychiatric beds, custody- psychiatric hospitals run by prison service, psychosocial community centers, primary health care units and community residential facilities. There are 5259 Psychiatrists, 12377 Psychologists, 11958 Social workers, 3119 Psychiatric nurses and 2661 Occupational Therapists working for the Unified Health System.(5) There is unequal distribution of care-givers in different regions of the country, the number of psychiatric hospitals is inadequate in all regions, and the urban areas have more human resource than rural areas. There are also more psychologists than psychiatrists and acute shortage of psychiatric nurses. (5) Treatment available for neuropsychiatric conditions are psychoactive drugs (anxiolytics, anticonvulsants, and antidepressants), psychotherapy, and electroconvulsive therapy (ECT) and exercise therapy.(10-13)The CAPS are meant to provide day hospital care or intensive care for severe mental disorders.(5) . The distribution of anti-psychotic medication is by the general community health workers and is meant to reduce relapse and re-admission rates.
A Psychiatric Reform Law was passed in 2001 to deinstitutionalize and reinforce the rights of individuals with mental illness, which led to the introduction of outpatient services such as psychosocial care centres (CAPS) and psychosocial support and rehabilitation for those leaving psychiatric hospitals (the Return Home program).(14) Care is now provided in the community and gives opportunity for free access to a variety of mental health services and essential psychotropic medicines. With the introduction of this law, there has been a reduction of 20 000 psychiatric hospital beds between 2001 and 2010. The number of community-based psychosocial care centres has more than tripled (from 424to 1541) and the number of therapeutic services has increased by ï¬ve times (from 85 to 475).(1)
Funding is inadequate and the allocation to mental health does not correspond to the burden caused by psychiatric illness, which accounts for almost 19% of all disease burdens. Only 2.35% of the health budget is allocated to mental health and of this 49% is spent on psychiatric hospitals and 15% on community services. (15)
Public Health and Mental health
Civil society and governmental organizations as well as patient/relatives groups are actively participating in mental care. The Brazilian Center on Human Rights and Mental Health has recently been created and is composed of universities, government and civil society participants who ensure patient 's are upheld. (5) Patient and family associations are growing and playing an important role in psychiatric care.
Mental health is being integrated into the primary health care system (PSF) with courses available for training primary care professionals namely, general physician, nurse and health workers .This integration facilitate better care, avoidance of relapse and referrals to specialized psychiatric treatments for those who need such care. In the area of research, in 2005 an amount of granted nearly two million dollars for specific mental research projects such as those for violence, minorities, treatment of psychotic patients, and l service organization by the National Division of Mental Health and the Brazilian National Council for Scientific and Technological Development (CNPQ) have recently (2005).(5)
It is accepted that the most effective public-health actions are usually those that target populations often through legislation or regulations. Targeting individuals to change their lifestyles without the necessary legislation and improvement in living conditions to make healthy choices leads to failures. Brazil has over the years taken measures to prevent the NCD menace. Among these is legislation on tobacco control which has yielded results in the reduction of cardiovascular and chronic respiratory diseases.(2)
The anti-alcohol policy includes educational actions, advertisement and sale regulations, law enforcement for drinking and driving, and provision of care for those with alcohol-related problems. There have been obstacles in enforcing this legislation due to the powerful alcohol and advertising industry which have succeeded to maintain beer advertisements during major sports and cultural events.
The way forward
Though much has been achieved in general in controlling NCDs there is a reason not to be overoptimistic because there been recent rises in self-reported binge drinking, and the major rise in the age-adjusted mortality from mental and behavioral disorders due to misuse of alcohol among the elderly and adolescent. (16,17,17)The future is bleak if extra effort is not put in place by all stakeholders to seek inter-sectoral approach and solutions.
The following suggestions are being made to help address to current situation.
Health systems approach to mental health issues (patient-oriented health care, private-public sector collaboration, combination of health promotion, preventive and curative measures).
Development of realistic national targets, goals and strategies on mental health through participatory approach involving all stakeholders.
Evidenced based care in all level of mental care, from research to action
Increase health budget allocation for mental health with emphasis on research, evidenced based and feasible health promotion and preventive activities. An increment of mental health budget to 5% of total health has been suggested.
Much emphasis on social/citizens/population level rather than individual measures in health promotion and prevention (tackle social determinants as well as risk factors)
Social and economic support for the aged who due to urbanization and globalizations are very vulnerable with little or no family support.
Civil society organizations should be supported to play their advocacy role especially put pressure on the alcohol production and advertising industries.
Need for stronger legislation since self-regulation and advertisement has not yielded the desired results.(18)
Address issues of the social and economic inequalities between the rich south and southeast regions and poorer north and north-east regions as well as underprivileged ethnic groups.
Patients should be supported to play major role in management of their conditions, that is, informed and activated patients supported by prepared proactive practice team (chronic care model/self- management support)
Screening adolescent in educational institutions for alcohol and substance abuse and elderly men since it is scarcely done.(19)
Setting up multiple-level surveillance system, that is, to go beyond survey to surveillance of mental conditions.
In conclusion, the fight against NCDs in Brazil and other countries especially LMIC needs global effort in all fronts with the academia, health practitioners, researchers, civil society, philanthropist, patients and politicians working together as was done for the HIV/AIDS menace. Politicians hold the key since they control the funds and resources and the upcoming UNGASS on NCDs in in the right direction to put the fight against NCDs of the global agenda. Due to the current economic problems, the road looks rough but with cooperative and concerted effort the battle could be won. Action now or we live to regret. Public health specialist must spread the gospel of health promotion and prevention as the way forward.
