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Editorial
REVISTA PAULISTA DE MEDICIN AYe s, we have bananas
(and also he alth statistics data):
Brazilian-base d Me dicine
• Paulo Andrade Lo tufo
Carmen Miranda was the mo st impo rtant Bra-zilian singer just befo re and after Wo rld War II. She was also very po pular in the United States, singing and dancing wearing a strange hat full o f pineapples and bananas. It was o ne o f the many stereo types abo ut Brazil and Latin American created by Ho llywo o d film-makers.
In the same way, the epidemio lo gical pro file o f the Brazilian po pulatio n has been blurred o ver the decades with the stereo type o f being a no n-industri-alized co untry (when in fact gro ss industrial pro duc-tio n surpassed agricultural pro ducduc-tio n during the 1930’s), and being a place with serio us “ tro pical dis-eases”. Curio usly, altho ugh infectio us diseases were until recently co nsidered to be the mo st impo rtant co mpo nent o f mo rtality in Brazil, cardio vascular dis-eases have been the main cause o f deaths fo r the who le co untry since the 1960’s (and the primary cause o f death in São Paulo and Rio de Janeiro since the 1940’s). In co ntrast to this stereo type, a seminal paper in Circulatio n, the leading cardio lo gy jo urnal,1 o n the emerging epidemic o f cardio vascular disease in de-velo ping co untries, has emphasized the epidemio lo gy o f cardio vascular diseases in Brazil fro m a different viewpo int in co mpariso n with co untries in Asia o r Af-rica. The autho rs cited data o btained fro m the o fficial health statistics o f Brazil that were used in theses2,3 and published in Brazilian jo urnals.4-6 All o f these were summarized in a publicatio n by the InterAmerican Heart Fo undatio n.7
In this paper, the autho rs have stressed a po int o f view that the pro file o f cardio vascular disease var-ies between develo ping co untrvar-ies, thus: “ the State o f
São Paulo , in Brazil, experienced declines o f 33.6% fo r men and 40.6% fo r wo men in age-standardized car-dio vascular diseases rates between 1970 and 1992. De-spite this decrease, the mo rtality rates in the 45-64-year-o ld age gro up in São Paulo , Po rto Alegre and Rio de Janeiro are repo rted to be as high as o r nearly equal to rates in Eastern Euro pe. The cumulative mo rtality rate fro m co ro nary heart disease is 42% fo r Brazilian men belo w the age o f 65 years co mpared with 25% in industrialized co untries. Death fro m acute myo cardial infarctio n in Brazilian men between the ages o f 35 and 44 years is stated to be three times higher than in the United States o r Canada”.1 This is a go o d example o f ho w the o fficial health statistics can be used to de-scribe o ur reality and co mpare Brazil with o ther co un-tries witho ut putting into the same basket co unun-tries like Argentina and Ango la with different so cio eco -no mic develo pment, o r like Mexico and India with dis-tinct cultural traditio ns. Thus, it beco mes po ssible to po stulate a new type o f epidemio lo gical transitio n witho ut using stereo types like “develo ped co untries = declining heart disease mo rtality, vs. emerging co un-tries = rising cardio vascular disease burden”.
This is all very interesting, as fo reign research-ers have been able to co nsider a po int o f view that do es no t have acceptance in the Brazilian public health agenda. The Ministry o f Health do es no t have an o ffi-cial po licy fo r the mo st impo rtant killer in this co un-try, despite having spent mo re than $1 billio n o n medi-cines fo r AIDS.
This fact has o ccurred because bo th Brazilian physicians and scientists have had a serio us pro blem in studying o ur peo ple and o ur diseases. Their
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ence fo r referring to American o r Euro pean data is a serio us cultural pro blem amo ng well-educated peo ple here. It is a pro blem “… that merits co nsideratio n as the glo bal eco no my bears do wn in Brazil and feeds a lo ng-held lo ve o f what is fo reign”.8
Over the recent histo ry o f Brazil, o ne explana-tio n fo r this habit has been the lack o f statistical data abo ut Brazil. This is partially true because during the military dictato rship, so me health statistics were co n-sidered as a “natio nal security affair”. Ho wever, since the mid-1990’s, the databank o f the Brazilian Ministry o f Health has been available o n line, and it is no w mo re co mmo n to see papers addressing the epide-mio lo gical pro file o f Brazil. Ho wever, even to day Bra-zilian scientists are referring to these papers less fre-quently in co mpariso n with citatio ns o f articles ad-dressing epidemio lo gical pro files fro m o verseas.
Altho ugh a go o d impro vement in health statis-tics has been o bserved, the Brazilian databank pre-sents so me limitatio ns due to lack o f medical care in rural areas, and surprisingly, a high pro po rtio n o f ill-defined deaths certified in the city o f Rio de Janeiro since the early 1990´s due to vagaries in lo cal laws. As the co verage o f the mo rtality system o ver the who le co untry is lo wer than 90 percent and the pro po rtio n o f ill-defined cases is nearly 20 percent fo r the who le co untry (against almo st 100 percent co verage and less than 5 percent o f ill-defined deaths in the main cities o f Brazil), studies that target using these rates must be evaluated cautio usly. Mo st o f them do no t lend themselves to tempo ral analyses and internatio nal
co mpariso ns when the who le co untry is co nsidered in analyses. On the o ther hand, o ther analyses fro m the states o f Sao Paulo and Rio Grande do Sul, and fro m the main metro po litan areas, are a go o d surro gate fo r the co mprehensio n o f Brazilian epidemio lo gical pro -files. The appro priate use o f this data requires so me skills in health statistics and the co rrect definitio n o f the po pulatio ns and diseases to be analyzed. A go o d start wo uld be to read a seminal bo o k o n health sta-tistics9 and o ther bo o ks that have described the epi-demio lo gy o f chro nic diseases in Brazil.10-12
To impro ve the quality o f medical co mmunica-tio n and to spread the use o f Brazilian health statistics data, the São Paulo Medical Jo urnal, Diagnó stico & Tratamento , and the o fficial site o f the Asso ciação Paulista de Medicina are launching a series o f articles related to o ur reality. This series will be called Brazil-ian-based Medicine. When the printed versio n o f this issue o f the Jo urnal has been mailed, an article o n “Uses and Misuses o f Mo rtality Data” will be made available fo r reading o n o ur website. In the next issue o f the Jo ur-nal, an impo rtant review o f Infant Mo rtality will be pub-lished. Our intentio n is to sho w to Brazilian physicians and all scientists aro und the wo rld (the Jo urnal can be reached thro ugh the Scielo site: www.scielo .br) ho w Brazilians live “fro m the wo mb to the to mb”.
Finally, as Carmen Miranda sang half a century ago : Yes, we have bananas (and also health statistics data).
Paulo Andrade Lotufo, MD, PhD.
Edito r, São Paulo Medical Jo urnal, Directo r, General Internal Unit, Ho spital Universitário , Universidade de São Paulo , São Paulo , Brazil.
1. Srinath-Re ddy K, Yusuf S. Em e rging e pide m ic o f cardio vascular diseases in develo ping co untries. Circulatio n 1998;97:596-601 2. Lo tufo PA. As do enças cardio vasculares no Brasil: estudo de caso da
tendência da mo rtalidade no Estado de São Paulo , 1970-1989. São Paulo , 1993. Faculty of Public Health, University of São Paulo. [Master Dissertation] 3. Lo tufo PA. Mo rtalidade preco ce po r do enças crô nicas nas capitais de regiõ es metro po litanas do Brasil. São Paulo , 1996. Faculty o f Public Health, University o f São Paulo . [Do cto ral Thesis].
4. Lo tufo PA, Lo lio CA. Tendência da mo rtalidade po r do ença isquêmica do co ração no Estado de São Paulo , 1970-1989. Arq Bras Cardio l 1993:61:149-53.
5. Cho r D, Fo nseca MJ. Cardio vascular diseases. [Co mments o n early mo rtality in Brazil]. Arq Bras Cardio l 1995;64:15-9.
6. Lo tufo , PA. Premature mo rtality fro m heart diseases in Brazil. A co mpariso n with o ther co untries. Arq Bras Cardio l 1998;70:321-5.
References
7. InterAmerican Heart Fo undatio n. Cardio vascular and Cerebro vascular Dise ase s in the Am e ric as. Dallas, Te xas: Inte rAm e ric an He art Fo undatio n, Inc; 1996.
8. Allen RM. Glo bal Imperialism at its Mo st Fashio nable. In: Levine RM, Cro citti JJ, edito rs. The Brazil Reader. Histo ry, Culture and Po wer. Durham, No rth Caro lina: Duke University Press; 1999.
9. Laurenti R, Mello -Jo rge MH, Lebrao ML, Go tlieb S. Estatísticas de Saúde. São Paulo : Edito ra Pedagó gica e Universitária; 1987. 10. Minayo MC, o rg. Os Muito s Brasis: saúde e po pulação na década de
80. São Paulo -Rio de Janeiro : Hucitec/ABRASCO; 1995.
11. Mo nteiro CA, o rg. Velho s e no vo s males da saúde no Brasil: a evo lução do país e de suas do enças. São Paulo : Hucitec-NUPENS/USP; 1995. 12. Lessa I. O adulto brasileiro e as do enças da mo dernidade. São Paulo
-Rio de Janeiro : Edito ra Hucitec-Abrasco ; 1999.
