Published by Oxford University Press on behalf of the International Epidemiological Association
ß The Author 2008; all rights reserved.
International Journal of Epidemiology 2008;37:689–691
doi:10.1093/ije/dyn141
EDITOR’S CHOICE
Latin America: old and new challenges
Shah Ebrahim
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
E-mail: [email protected]
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
689
690
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Challenges to health protection in Latin America. The World Congress of Cardiology 2008, held in
Buenos Aires, Argentina suffered from opportunistic ‘ambush marketing’ by Coca Cola—‘Fabrica de
Felicidad (Making Happiness)’—at the entrance to the meeting. An innocent public might well assume
that cardiologists approve of Coca Cola by the association of the two images. One wonders who
benefited?
Figure 1
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.
References
1
2
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.
Hackett M, Melgar-Quiñonez H, Pérez-Escamilla R,
Segall-Corrêa A. Gender of respondent does not affect
3
4
5
6
7
8
the psychometric properties of the Brazilian Household
Food Security Scale. Int J Epidemiol 2008;37:766–74.
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.
Nájera-Ortiz JC, Sánchez-Pérez HJ, Ochao-Dı́az H,
Arana-Cedeño M, Salazar-Lezama MA, Martı́n 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.
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.
Genser B, Strina A, dos Santos L et al. Impact of a citywide 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.
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.
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.
Reprinted Int J Epidemiol 2008;37:694–95.
LATIN AMERICA
9
10
11
12
Carvalheiro JdR, Gadelha P. Commentary: Carlos Chagas:
predecessor of Epidemiology in Brazil. Int J Epidemiol
2008;37:701–3.
Moncayo A, Commentary: the lucid reasoning of Carlos
Chagas. Int J Epidemiol 2008;37:697–98.
Goldbaum M, Barreto ML. Commentary: the contribution
and example of Carlos Chagas. Int J Epidemiol
2008;37:695–96.
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
14
15
691
Scazufca M, Seabra CAF. São Paulo portraits: ageing in a
large metropolis. Int J Epidemiol 2008;37:721–23.
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.
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.