London School of Hygiene & Tropical Medicine

Major progress has been made in reducing the burden of infectious diseases in Brazil as part of a "remarkable" success story for health in the South American country, according to researchers on a series of papers published in The Lancet.

After decades of marked social change, including the introduction of unified healthcare for all, Brazil can also celebrate a reduction in mortality from chronic diseases and huge inroads into improving maternal and child health. But the nation still faces problems - including some infectious diseases such as dengue and leishmaniasis, rising obesity and a high number of murders and road deaths.

The Lancet's Series on Health in Brazil takes a comprehensive look at the consequences of changes in Brazil such as the creation of the Unified Health System (Sistema Unico de Saude/SUS) in 1988 which marked a crucial turning point. Key improvements in infrastructure have also been made over the past few decades - for example, in 1970 only a third of homes had indoor water compared with 93% by 2007. Edited by leading child health epidemiologist Professor Cesar Victora, of the Universidade Federal de Pelotas, Brazil, who is an honorary professor at the London School of Hygiene & Tropical Medicine, the Series issues a call for coordinated action to continue improving and concludes by saying: "The challenge is ultimately political, requiring continuous engagement by Brazilian society as a whole to secure the right to health for all Brazilian people."

Professor Laura Rodrigues, who was born and trained in Brazil but has worked at the London School of Hygiene & Tropical Medicine since 1981, co-authored one of the six papers in the series. The infectious disease epidemiologist and Head of the Faculty of Epidemiology and Population Health said that although deaths by external causes remain too high, the situation in Brazil overall is a "remarkable success".

"Brazil is changing and this Series explores the stories behind the changes," she says. "It looks at the links between political and economic development and healthcare, and shows that changes in those areas have had a clear impact on the health and wellbeing of Brazil's population. The overall picture in Brazil is a remarkable success.

"There is a lot to be learned from this Series - in particular in the context of Brazil's position in the world and attitudes to national healthcare. We are seeing a significant rearrangement of countries' positions in global terms."

In their paper - studying successes and failures in the control of infectious diseases -
Professor Mauricio Barreto, of the Instituto de Saúde Coletiva and Federal University of Bahia, Salvador-Bahia, Brazil (an LSHTM alumnus), and colleagues including Prof Rodrigues examine why some programmes have worked and others have not.

Control of diseases such as cholera, diarrhoea, Chagas disease, and those preventable by vaccination such as tetanus and polio have all been successful, having each provided universal access to preventable measures and to treatment free at the point of use. According to the paper, these policies need to be reinforced due to challenges such as increasing prevalence and transmission of drug resistance.

They describe the HIV/AIDS plan, which is the largest distributor of free antiretrovirals in the world, as a partly successful programme (although no less successful than in most developed countries) and point out that tuberculosis control has also improved, partly due to increased HIV control and also specific roll out of treatment programmes, especially those offering directly supervised treatment.

But a small number of failures are noted. Dengue fever is a new public health problem, with some 3.5 million cases reported in the past decade, with 12,000 leading to the more serious dengue haemorrhagic fever, and some 900 deaths. Rates of the most serious forms of Dengue are six times what they were in the 1990s with no safe vaccine available.
Visceral leishmaniasis control is also poor, with current efforts focusing on control of the sandfly vectors and removing domestic animals that can act as reservoirs. The only available treatment currently is highly toxic and while accessible and suitable in urban areas with medical support, this toxicity makes treatment in remote rural areas inappropriate.

The authors conclude: "A pressing need exists to develop new treatments and vaccines for those diseases which have proved difficult to control. In Brazil, biomedical and epidemiological research is thriving, as is public health research into infectious diseases, with much collaboration with developing and developed countries...the fast growth in medical research must be sustained-efforts must go towards identification of new treatments (eg, for leishmaniasis) new vaccines (eg, for dengue) and more effective ways to deliver specific care."

In a Comment for the Series, Ricardo Uauy, Professor of Public Health Nutrition at the London School of Hygiene & Tropical Medicine, says Brazil's "sense of national purpose and pride provides the strength with which the country collectively addressed the challenge of better health for all".

Exploring the impact of the Brazil experience in Latin America, he argues that Brazil turned traditional thinking that countries should first achieve economic growth before spending on social programmes on its head. "Brazil showed the opposite - ie, you need to invest in human and social capital to achieve and sustain economic growth," he writes. "In Brazil those who were intolerant to business as usual were responsible for making injustices a thing of the past; and for placing progress towards a better world at the top of the priority list. Brazil has given us a reason to be proud of our profession in this ever-changing environment."