Scielo RSS <![CDATA[Revista Panamericana de Salud Pública]]> http://www.scielosp.org/rss.php?pid=1020-498920040003&lang=en vol. 15 num. 3 lang. en <![CDATA[SciELO Logo]]> http://www.scielosp.org/img/en/fbpelogp.gif http://www.scielosp.org <![CDATA[<B>Elimination of rubella and congenital rubella syndrome in the Americas</B>: <B>another opportunity to address inequities in health</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300001&lng=en&nrm=iso&tlng=en <![CDATA[<B>Seroprevalence of antibodies against rubella virus in pregnant women in Haiti</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300002&lng=en&nrm=iso&tlng=en OBJECTIVE: To assess the seroprevalence of immunity to the rubella virus in pregnant women in Haiti attending the Obstetrics and Gynecology Department of the State University Hospital, in the capital city of Port-au-Prince, in order to help with the introduction of the rubella vaccine for the population and provide protection for women of reproductive age in the country. METHODS: This cross-sectional study was done between February 2002 and May 2002. A total of 503 pregnant women were tested for rubella-specific immunoglobulin G antibodies, using enzyme immunoassay; 8 of those women were later excluded because they did not know their age, leaving 495 women in the analysis. RESULTS: Of the 495 participants included in our analysis, 471 of them (95.2%) were seropositive; only 24 of them (4.8%) were seronegative (susceptible). A statistically significant difference (P = 0.02) was found in the rate of seronegativity for rubella virus between the pregnant women living in the Port-au-Prince area (17 of 426 women, or 4.0%) and those living in rural areas (7 of 69 women, or 10.1%). In terms of age, 81 of the 495 (16.4%) women were under 21 years old. CONCLUSIONS: This study is an important first step in addressing the issue of prevalence of rubella virus infection among Haitian women and in dealing with the still-underrecognized public health problem of congenital rubella syndrome in Haiti. We recommend additional research that uses randomized sampling and includes a significant proportion of women from rural areas of the country.<hr/>OBJETIVO: Determinar la seroprevalencia de la inmunidad al virus de la rubéola en mujeres embarazadas que se atienden al Departamento de Obstetricia y Ginecología del Hospital de la Universidad Estatal, en Puerto Príncipe, capital de Haití, a fin de contribuir a introducir la vacunación de la población contra la rubéola y proteger a las mujeres en edad reproductiva en el país. MÉTODOS: Este estudio transversal se realizó entre febrero y mayo de 2002. Se evaluó la presencia de anticuerpos de tipo IgG específicos contra la rubéola en 503 embarazadas mediante un inmunoensayo enzimático. Posteriormente se excluyó a 8 mujeres debido a que no sabían su edad. RESULTADOS: De las 495 participantes estudiadas, 471 (95,2%) tenían seropositividad; solo 24 de ellas (4,8%) mostraron seronegatividad (susceptibilidad). Se encontraron menos mujeres seronegativas entre las residentes de Puerto Príncipe (17 de 426, 4,0%) que entre las residentes de zonas rurales (7 de 69, 10,1%) (P = 0,02). En relación con la edad, 81 (16,4%) de las 495 mujeres embarazadas estudiadas eran menores de 21 años. CONCLUSIONES: Con este estudio se da el primer paso hacia evaluar la prevalencia de la infección por el virus de la rubéola en mujeres haitianas y hacia el enfrentamiento de un problema de salud que todavía no ha sido reconocido en toda su magnitud: el síndrome de la rubéola congénita en Haití. Se recomienda emprender estudios adicionales con muestreos aleatorios que abarquen una fracción significativa de mujeres provenientes de zonas rurales. <![CDATA[<B>Nutritional status of Naporuna children under five in the Amazon region of Ecuador</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300003&lng=en&nrm=iso&tlng=en OBJETIVOS: Evaluar el estado nutricional de los niños indígenas naporunas menores de 5 años de la región amazónica del Ecuador e identificar los factores de riesgo de desnutrición que afectan a esta población. MÉTODOS: Se realizó un estudio transversal en la provincia de Orellana, al nordeste del Ecuador, entre junio de 2001 y febrero de 2002. Se realizaron entrevistas domiciliarias en 30 comunidades elegidas al azar y se aplicó un cuestionario que recogió los datos sociodemográficos y de paridad de las madres de niños menores de 5 años, así como los datos demográficos y antropométricos de los niños, la historia de su lactancia y las enfermedades que ellos padecieron en las dos semanas previas a la encuesta. Se realizó también un examen clínico a cada niño. El diagnóstico de anemia fue clínico y se basó en el examen de la conjuntiva ocular. La asociación estadística entre las diferentes variables se determinó mediante la prueba de la ji al cuadrado, y se emplearon la corrección de Yates y la prueba exacta de Fisher de dos colas cuando el número de observaciones era 5 o menos. Los factores de riesgo de la desnutrición crónica y del bajo peso se identificaron mediante análisis de regresión logística. RESULTADOS: En total se entrevistó a 189 madres de 347 niños menores de 5 años. De ellos, 307 niños (88,5%) participaron en el estudio. Se observó desnutrición crónica en 22,8% de los niños, 26,4% presentaban bajo peso y 9,8% padecían de desnutrición aguda. La prevalencia de desnutrición crónica grave fue de 7,5%, la de bajo peso grave de 4,9% y la de aguda grave de 1,6%. En total, 5 (1,6%) niños presentaron indicadores de desnutrición crónica y aguda. La mayor prevalencia de desnutrición crónica se observó en el grupo de edad de 48 a 59 meses y la mayor prevalencia de bajo peso grave y de desnutrición se detectó en el grupo de 12 a 23 meses. Los factores determinantes estadísticamente significativos de desnutrición crónica fueron vivir en una comunidad sin acceso a alguna carretera, el número total de niños en la familia (> 7), y la presencia de infecciones respiratorias agudas y de distensión abdominal el día del examen. La distensión abdominal y la palidez conjuntival a la exploración física fueron los factores pronósticos en relación con el bajo peso. CONCLUSIONES: Las prevalencias de desnutrición aguda y crónica y de bajo peso encontradas en niños naporunas menores de 5 años son más elevadas que las observadas en otras poblaciones amazónicas. Se requieren estudios adicionales que determinen la prevalencia de parasitosis y anemia y que evalúen las costumbres alimentarias y el tipo de dieta de las comunidades indígenas para obtener un cuadro más completo de su situación nutricional. Se recomienda poner en marcha un plan de monitoreo dirigido a evaluar las tendencias nutricionales de esta población.<hr/>OBJECTIVES: To assess the nutritional status of Naporuna children under five years of age from the Amazon region of Ecuador, and to identify risk factors for developing malnutrition in this population group. METHODS: A survey-based cross-sectional study was carried out in Orellana, a province in northeastern Ecuador, between June 2001 and February 2002. Household interviews were conducted in 30 communities chosen at random, and a questionnaire was used to record the following: the social and demographic characteristics and parity of mothers having children under five years of age, and the children's demographic and anthropometric characteristics, history of breastfeeding, and medical conditions suffered over the two-week period just prior to the survey. Each child was also subjected to a physical examination. Anemia was diagnosed clinically by conjunctival exam. The statistical association among variables was determined by means of the chi-square test, with use of Yates' correction and Fisher's exact test (two-tailed) when there were 5 observations or less. Risk factors for chronic malnutrition and underweight were determined by means of logistic regression. RESULTS: Overall, 189 mothers of 347 children under five were interviewed. Of these 347 children, 307 (88.5%) participated in the study. Chronic malnutrition was found in 22.8% of the children; 26.4% were underweight, and 9.8% had acute malnutrition. Moreover, 7.5% had severe chronic malnutrition; 4.9% were severely underweight, and 1.6% had severe acute malnutrition. A total of 5 children (1.6%) showed signs of both chronic and acute malnutrition. The largest prevalence of chronic malnutrition was found in the 12-23 month age group. Risk factors for chronic malnutrition that were statistically significant included living in an area without access to a road, the total number of children in the family (>7), and the presence of an acute respiratory infection or abdominal distension on the day the physical examination was performed. Abdominal distension and pale conjunctiva on physical examination were predictive for underweight. CONCLUSIONS: Among the Naporuna children under 5 years of age included in this study, the prevalences of acute malnutrition and underweight appeared to be higher than had been previously detected among other populations in the Amazon region. More studies on the prevalence of parasitic infections and anemia and on the feeding practices and dietary habits of indigenous communities are needed in order to better understand their nutritional intake. A program for monitoring the diet of indigenous peoples is necessary and should be established. <![CDATA[<B>A community-based breast cancer screening program for medically underserved women</B>: <B>its effect on disease stage at diagnosis and on hazard of death </B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300004&lng=en&nrm=iso&tlng=en OBJECTIVE: Earlier studies by this research team found that medically underserved minority women in the Miami-Dade County area of the state of Florida, United States, were in need of breast cancer screening and that there were problems with availability, accessibility, and acceptability of services. In response, a community-based comprehensive breast cancer screening program called the Early Detection Program (EDP) was developed. The specific purpose of this study was to assess the effect that EDP participation had on stage at diagnosis and on hazard of death. METHODS: Existing data from the Florida Cancer Data System (FCDS), a statewide cancer registry, were linked with data from the EDP. In December 1998 we assembled a multiethnic (African-American, black Hispanic, white Hispanic, and white non-Hispanic) retrospective cohort with the following inclusion criteria: all women aged 40 and older with breast cancer diagnosed and staged at University of Miami/Jackson Memorial Medical Center (which is located in the city of Miami, Florida) from January 1987 through December 1997. EDP participants were medically underserved, that is, they resided in lower socioeconomic areas and/or had limited or no health insurance to cover medical costs. Subjects identified as EDP participants were compared to nonparticipants with respect to disease stage at diagnosis and hazard of death. Logistic regression and Cox regression models were used for analysis. RESULTS: EDP participants were 2.4 times as likely (95% confidence interval = 1.71 to 3.43) to present with a diagnosis of localized cancer as were nonparticipants, even after controlling for race and age at diagnosis. EDP participation was independently associated with both earlier diagnosis and reduced hazard of death. CONCLUSIONS: Participation in the EDP increases the likelihood of early detection of breast cancer and reduces the hazard of death for medically underserved women in the Miami-Dade County area of Florida. Interestingly, white Hispanics showed a better survival than did both African-Americans and white non-Hispanics. Our research also demonstrates the value of utilizing existing cancer registry data to evaluate a community-based program such as the EDP.<hr/>OBJETIVO: En estudios previos de este colectivo de investigadores se encontró que las mujeres pertenecientes a las minorías subatendidas desde el punto de vista médico en la zona del Condado de Miami-Dade, en el estado de la Florida, Estados Unidos de América, necesitaban someterse a un tamizaje para la detección de cáncer de mama y que la disponibilidad, accesibilidad y aceptación de estos servicios planteaban dificultades. En respuesta a ello se elaboró un programa comunitario integral para el tamizaje del cáncer de mama, denominado Programa de Detección Temprana (PDT). El propósito específico de este estudio fue evaluar el efecto que tuvo la participación en el PDT sobre el estadio de la enfermedad en el momento del diagnóstico y sobre el riesgo de muerte. MÉTODOS: Los datos existentes en el Sistema de Datos sobre Cáncer de la Florida -un registro de cáncer que abarca a todo el estado- se enlazaron con los datos del PDT. En diciembre de 1998 se conformó una cohorte retrospectiva multiétnica (mujeres afroestadounidenses, hispanas negras, hispanas blancas y blancas no hispanas) según los siguientes criterios de inclusión: mujeres de 40 años de edad o más con cáncer de mama diagnosticado y estadificado en el Jackson Memorial Medical Center (hospital escuela de la Universidad de Miami situado en la ciudad de Miami, Florida) entre enero de 1987 y diciembre de 1997. Las participantes del PDT eran mujeres con necesidades médicas subatendidas, es decir, residían en zonas con malas condiciones socioeconómicas, no tenían un seguro de salud que cubriera los gastos médicos, o tenían un seguro limitado. Se compararon las participantes en el PDT con las mujeres que no participaron en el PDT en cuanto al estadio de la enfermedad en el momento del diagnóstico y el riesgo de muerte. Para el análisis se emplearon modelos de regresión logística y de Cox. RESULTADOS: Las participantes del PDT tuvieron 2,4 veces más posibilidades de tener un cáncer localizado en el momento del diagnóstico que las mujeres que no participaban (intervalo de confianza de 95%: 1,71 a 3,43), incluso después de ajustar los resultados según la raza y la edad en el momento del diagnóstico. La participación en el PDT estuvo asociada de manera independiente con un diagnóstico más temprano y con un menor riesgo de muerte. CONCLUSIONES: La participación en el PDT aumenta la probabilidad de detectar tempranamente el cáncer de mama y reduce el riesgo de muerte en mujeres con necesidades médicas subatendidas en la zona del Condado de Miami-Dade, en el estado de la Florida. Las mujeres hispanas de raza blanca mostraron una supervivencia más larga que las afroestadounidenses y que las mujeres blancas no hispanas. Esta investigación también demuestra el valor de usar los datos obtenidos de los registros de cáncer existentes para evaluar programas comunitarios como el PDT. <![CDATA[<B>Availability of essential drugs in two regions of Minas Gerais, Brazil</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300005&lng=en&nrm=iso&tlng=en OBJETIVO: Avaliar a disponibilidade de medicamentos essenciais em localidades com índice de desenvolvimento humano < 0,699. MÉTODOS: Foram pesquisados 69 estabelecimentos, entre almoxarifados municipais, unidades ambulatoriais públicas, unidades privadas, unidades filantrópicas e farmácias comerciais. Foram entrevistados os profissionais de saúde diretamente responsáveis pelo controle dos estoques e dispensação dos medicamentos. Também foram consultados documentos e registros institucionais. Uma lista de 21 medicamentos essenciais traçadores, selecionados dentre aqueles mais utilizados no Programa Farmácia Básica do Estado de Minas Gerais, foi definida como parâmetro para as medidas de disponibilidade. Para cada medicamento traçador foi verificada a disponibilidade no momento da visita e ao longo dos 12 meses imediatamente anteriores à pesquisa de campo. Também foi calculada a disponibilidade de cada um dos medicamentos essenciais traçadores para cada tipo de estabelecimento incluído na pesquisa de campo. RESULTADOS: A disponibilidade de medicamentos essenciais nos almoxarifados municipais foi de 52,0%; nas unidades públicas de saúde, 46,9%; e nas unidades ambulatoriais filantrópicas e privadas, 41,0% e 38,1%, respectivamente. Nas farmácias privadas, a disponibilidade de medicamentos essenciais alcançou 81,2%. CONCLUSÃO: Há baixa disponibilidade e descontinuidade na oferta de medicamentos essenciais no setor público, penalizando indivíduos vulneráveis. As farmácias privadas são a principal fonte de medicamentos essenciais. Os resultados indicam a necessidade de divulgar e implementar o conceito de essencialidade no país.<hr/>OBJECTIVE: To investigate the availability of essential drugs in municipalities with a human development index < 0.699. METHODS: We surveyed 69 institutions, including municipal pharmacies, public clinics, private and philanthropic health units, and commercial pharmacies, in 19 municipalities of the state of Minas Gerais, Brazil. The municipalities were chosen according to the following selection criteria: (1) a human development index (HDI) < 0.699 (the HDI for the entire state of Minas Gerais in 1991) in the microregion where the municipality was located; (2) the municipality had to be the seat of government for the microregion where it was located; (3) there had to be at least two eligible institutions (belonging to the public, private, or philanthropic sectors) in full functioning in the municipality during the survey period. Health professionals who were directly responsible for stock control and drug dispensation at the institutions surveyed were interviewed. Institutional documents and records were also reviewed. A list of 21 tracer essential drugs, which were selected among the drugs most widely employed in the State of Minas Gerais’ Basic Pharmacy Program, was used to measure availability. The availability of each tracer drug was calculated at the time of the site visit and for the 12-month period immediately before the survey. In addition, the availability of tracer drugs was calculated for each type of institution surveyed. RESULTS: The availability of essential drugs in municipal pharmacies was 52.0%; in public health clinics, 46.9%; and in philanthropic and private health units, 41.0% and 38.1%, respectively. In commercial pharmacies, the availability of essential drugs reached 81.2%. CONCLUSION: The availability of essential drugs in public facilities is low and varies widely, with the result that persons who need such drugs the most are often those who lack access to them. Private pharmacies are the main source of essential drugs. The results of this study point to the need to seek increased awareness and implementation of the concept of essential drugs throughout the country. <![CDATA[<B>Estimate methods used with complex sampling designs</B>: <B>their application in the Cuban 2001 health survey</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300006&lng=en&nrm=iso&tlng=en OBJETIVOS: En el presente trabajo se discuten las particularidades de tres métodos de estimación de parámetros simples -medias, totales y porcentajes, y sus respectivos errores estándar-, así como de los modelos de regresión logística, en el análisis de los datos de muestras complejas. MÉTODOS: Se tomaron los datos de la Segunda Encuesta Nacional de Factores de Riesgo y Afecciones Crónicas No Transmisibles, realizada en Cuba en el año 2001. Se usó un diseño muestral complejo estratificado y por conglomerados polietápicos. Los estratos estuvieron conformados por las 14 provincias de Cuba y el municipio especial Isla de la Juventud, mientras que los conglomerados fueron las áreas geográficas muestrales (AGEM), manzanas y secciones. Las muestras se ponderaron en proporción inversa a las probabilidades de selección y para la estimación se realizó una estratificación por sexo y grupo de edad (15-34, 35-54, 55-74 y 75 años o más). Las varianzas se estimaron mediante las aproximaciones de Taylor. Se compararon tres métodos estadísticos: el análisis convencional, que da por sentado que los datos provienen de un muestreo simple aleatorio; el análisis ponderado, que solo toma en consideración los pesos muestrales para obtener las estimaciones; y el análisis con ajustes, que toma en cuenta la desigualdad en las probabilidades de selección y el efecto de la conglomeración en los datos. RESULTADOS: Las estimaciones puntuales obtenidas mediante las tres estrategias de análisis fueron similares. Los errores estándar estimados para la prevalencia de sobrepeso obtenidos por el análisis convencional se subestimaron en 19,3% y para la prevalencia de hipertensión en más de 11,5% en relación con los otros métodos. El análisis ponderado generó valores de los errores estándar mucho menores que los calculados por otros métodos. Resultados similares se encontraron al estimar los valores de la razón de posibilidades. CONCLUSIONES: Los métodos de análisis que toman en cuenta la estructura de los datos y las características del diseño ofrecen una visión más realista del problema estudiado. Con ellos se obtienen estimaciones más precisas de los parámetros y de sus errores estándar. La frecuencia con que se encuentran datos procedentes de diseños muestrales complejos en estudios epidemiológicos y de salud pública exige una mayor utilización de estos métodos y de los paquetes estadísticos que los contemplan.<hr/>OBJECTIVES: To look at the individual features of three different methods used to estimate simple parameters-means, totals, and percentages, as well as their standard errors-and of logistic regression models, and to describe how such methods can be used for analyzing data obtained from complex samples. METHODS: Data from Cuba’s Second National Survey of Risk Factors and Non-Communicable Chronic Ailments [Segunda Encuesta Nacional de Factores de Riesgo y Afecciones Crónicas No Transmisibles], which was conducted in 2001, were studied. A complex, stratified multi-stage cluster sampling design was used. Cuba’s 14 provinces and the municipality of Isla de la Juventud served as the strata, while the clusters consisted of sampled geographic areas (SGA), blocks, and sectors. Samples were weighted in inverse proportion to their probability of being selected, and estimates were performed by sex and age group (15-34, 35-54, 55-74, and 75 or more years). Taylor approximations were used to estimate variances. Three statistical methods were compared: conventional analysis, which assumes all data were obtained through simple random sampling; weighted analysis, which only takes into account the weight of the samples when performing estimates; and adjusted analysis, which looks at all aspects of the sampling design (namely, the disparity in the probability of being included in the sample and the effect of clustering on the data). RESULTS: The point estimates obtained with the three different types of analytic methods were similar. Standard error (SE) estimates for the prevalence of overweight and of arterial hypertension that were obtained by conventional analysis were underestimated by 19.3% and by more than 11.5%, respectively, when such estimates were compared to those obtained with the other two analytic methods. On the other hand, weighted analysis generated SE values that were much smaller than those obtained with the other two types of analyses. The same pattern was noted when odds ratios were calculated using the different methods. CONCLUSIONS: Analytic methods that take into account the way the data are structured as well as the study design give a more realistic picture of the problem under study and provide more exact estimates of the study parameters and their SE than conventional analytic methods. Because data from epidemiologic and public health research are often obtained through complex sampling designs, the methods described in this paper and the statistical packages that utilize them should be used more widely. <![CDATA[<b>Changes in health indicators related to health promotion and microcredit programs in the Dominican Republic</b>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300007&lng=en&nrm=iso&tlng=en OBJECTIVE: To assess the impact of health promotion programs and microcredit programs on three communities in the Dominican Republic. One community had only the health promotion program, one community had only the microcredit program, and one community had both a health promotion program and a microcredit program. This pilot project examined the hypothesis that the largest changes in 11 health indicators that were studied would be in the community with both a health promotion program and a microcredit program, that there would be intermediate changes in the community with only a health promotion program, and that the smallest changes would be in the community with only a microcredit program. METHODS: The health promotion programs used community volunteers to address two major concerns: (1) the prevalent causes of mortality among children under 5 years of age and (2) women's health (specifically breast and cervical cancer screening). The microcredit program made small loans to individuals to start or expand small businesses. Outcome measures were based on comparisons for 11 health indicators from baseline community surveys (27 households surveyed in each of the three communities, done in December 2000 and January 2001) and from follow-up surveys (also 27 households surveyed in each of the three communities, in June and July 2002, after the health promotion program had been operating for about 13 months). Households were randomly chosen during both the baseline and follow-up surveys, without regard to their involvement in the microcredit or health promotion programs. RESULTS: The health indicators improved in all three communities. However, the degree of change was different among the communities (P < 0.001). The community with parallel microcredit and health promotion programs had the largest changes for 10 of the 11 health indicators. CONCLUSIONS: Multisector development is known to be important on a macroeconomic scale. The results of this pilot project support the view that multisector development is also important on a microeconomic level, given that the parallel microcredit and health promotion programs resulted in greater change in the measured health indicators than either program alone. As far as we authors know, this is the first published study to quantify changes in health indicators related to parallel health promotion and microcredit programs as compared to control communities with only a health promotion program or a microcredit program.<hr/>RESUMEN OBJETIVO: Evaluar el impacto de programas de promoción de la salud y de microcréditos en tres comunidades de la República Dominicana. Una comunidad tenía solo un programa de promoción de la salud, otra contaba solo con un programa de microcréditos y una tercera comunidad contaba con ambos programas. Este proyecto piloto evaluó varias hipótesis: que los mayores cambios en los 11 indicadores de salud estudiados se verificarían en la comunidad que contaba tanto con un programa de promoción de la salud como con un programa de microcréditos; que habría cambios intermedios en la comunidad que solo tenía el programa de promoción de la salud, y que los menores cambios tendrían lugar en la comunidad que contaba solo con el programa de microcréditos. MÉTODOS: Los programas de promoción de la salud pusieron a voluntarios de la comunidad a hablar con la población acerca de dos grandes problemas: 1) las causas de mortalidad entre niños menores de 5 años de edad y 2) la salud de las mujeres (específicamente, el tamizaje del cáncer de mama y cervicouterino). El programa de microcréditos facilitaba préstamos personales pequeños para establecer o ampliar pequeñas empresas. Se compararon los valores de 11 indicadores de salud registrados durante las encuestas iniciales (27 viviendas encuestadas en cada una de las tres comunidades) realizadas entre diciembre de 2000 y enero de 2001 y las encuestas de seguimiento (27 viviendas encuestadas en cada una de las tres comunidades) realizadas entre junio julio de 2002, después de que el programa de promoción de la salud había estado en marcha por alrededor de 13 meses. Tanto en las encuestas iniciales como en las de seguimiento, las viviendas se seleccionaron de forma aleatoria, independientemente de su relación con los programas de microcréditos o de promoción de la salud. RESULTADOS: Los indicadores de salud mejoraron en las tres comunidades, pero la magnitud de los cambios fue diferente en cada una (P < 0,001). La comunidad con programas paralelos de microcréditos y de promoción de la salud presentó los mayores cambios en 10 de los 11 indicadores de salud evaluados. CONCLUSIONES: Se sabe que el desarrollo multisectorial es importante a escala macroeconómica. Los resultados de este proyecto piloto avalan el criterio de que el desarrollo multisectorial es también importante a escala microeconómica, ya que los programas paralelos de microcréditos y de promoción de la salud produjeron mayores cambios en los indicadores de salud evaluados que cualquiera de esos dos programas individualmente. Hasta donde conocen los autores, este es el primer estudio publicado en que se cuantifican los cambios en los indicadores de salud relacionados con programas paralelos de promoción de la salud y de microcréditos y en que dichos cambios se comparan con los observados en comunidades de control que solo contaban con un programa de promoción de la salud o con un programa microcrediticio, pero no ambos. <![CDATA[<B>Tuberculosis among city jail inmates in Campinas, São Paulo, Brazil</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300008&lng=en&nrm=iso&tlng=en OBJETIVO: Descrever a situação da tuberculose nas prisões da Cidade de Campinas, Estado de São Paulo, Brasil. MÉTODOS: Realizou-se um estudo retrospectivo dos casos notificados de tuberculose em presidiários no período de 1993 a 2000. Foram avaliados dados de 4 293 detentos dos quatro presídios que constituem o complexo penitenciário da região. Foram utilizadas informações do banco de dados em tuberculose do Departamento de Medicina Preventiva e Social da Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP). RESULTADOS: Observou-se um pico de incidência da tuberculose em 1994 (1 397,62 notificações em 100 000 indivíduos). A menor taxa foi observada em 1999 (559,04). Predominou a faixa etária de 25 a 34 anos (62,6%) e a AIDS como doença associada (49,9%). A forma preponderante de tuberculose foi a pulmonar (91,9%), com baciloscopia de escarro positiva em 70,3%. A maioria dos presidiários não tinha realizado tratamentos prévios (75,4%). O abandono de tratamento chegou a 49%. Houve cura em apenas 20,8% dos casos no período estudado. CONCLUSÕES: A incidência intermediária de tuberculose observada neste estudo pode estar relacionada à subnotificação. A freqüência de falência do tratamento ainda é baixa. No entanto, o abandono, como fator que facilita a propagação de micobactérias resistentes na comunidade, causa preocupação. O controle da tuberculose nas prisões deveria ser parte rotineira das intervenções direcionadas a eliminar a doença na comunidade e a prevenir a resistência às drogas antituberculose.<hr/>OBJECTIVE: To describe the incidence of tuberculosis among inmates of the municipal prison system in the city of Campinas, State of São Paulo, Brazil, from 1993 through 2000. METHODS: A retrospective study was carried out of the number of cases of tuberculosis that were notified among inmates over the study period. This involved reviewing data from a total of 4 293 inmates who were held in the four prisons that comprise Campinas' municipal prison system. Data were obtained from the tuberculosis database belonging to the Department of Social and Preventive Medicine of the School of Medical Sciences at the State University of Campinas. RESULTS: The incidence of tuberculosis peaked in 1994 (1 397.62 cases per 100 000) and was lowest in 1999 (559.04 cases per 100 000). Most cases of tuberculosis occurred in inmates in the 25 to 34 year age group (62.6%). Acquired immunodeficiency syndrome (AIDS) was the disease most commonly associated with tuberculosis (49.9%), which was most often pulmonary in type (91.9%), with positive sputum smears in 70.3% of the inmates tested. Most inmates had not received treatment before (75.4%). The treatment dropout rate reached 49%, and a cure was achieved in only 20.8% of the cases notified over the study period. CONCLUSIONS: The incidence of tuberculosis observed in this study was moderate when compared to incidence rates found in other studies of prison inmates, but this could be due to underreporting. The frequency of treatment failure noted was low, since patients who were treated under supervision showed good adherence and were cured in the majority of cases. However, the high treatment dropout rate seen in the study is alarming because it could facilitate the spread of drug resistant strains of Mycobacterium tuberculosis to the community at large. Controlling tuberculosis among prison inmates should be part of routine interventions aimed at eliminating this disease from the community and at preventing resistance to antituberculosis therapy. <![CDATA[<B>Tratamiento antiviral eficaz en pacientes con hepatitis B resistente a la lamivudina</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300009&lng=en&nrm=iso&tlng=en OBJETIVO: Descrever a situação da tuberculose nas prisões da Cidade de Campinas, Estado de São Paulo, Brasil. MÉTODOS: Realizou-se um estudo retrospectivo dos casos notificados de tuberculose em presidiários no período de 1993 a 2000. Foram avaliados dados de 4 293 detentos dos quatro presídios que constituem o complexo penitenciário da região. Foram utilizadas informações do banco de dados em tuberculose do Departamento de Medicina Preventiva e Social da Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP). RESULTADOS: Observou-se um pico de incidência da tuberculose em 1994 (1 397,62 notificações em 100 000 indivíduos). A menor taxa foi observada em 1999 (559,04). Predominou a faixa etária de 25 a 34 anos (62,6%) e a AIDS como doença associada (49,9%). A forma preponderante de tuberculose foi a pulmonar (91,9%), com baciloscopia de escarro positiva em 70,3%. A maioria dos presidiários não tinha realizado tratamentos prévios (75,4%). O abandono de tratamento chegou a 49%. Houve cura em apenas 20,8% dos casos no período estudado. CONCLUSÕES: A incidência intermediária de tuberculose observada neste estudo pode estar relacionada à subnotificação. A freqüência de falência do tratamento ainda é baixa. No entanto, o abandono, como fator que facilita a propagação de micobactérias resistentes na comunidade, causa preocupação. O controle da tuberculose nas prisões deveria ser parte rotineira das intervenções direcionadas a eliminar a doença na comunidade e a prevenir a resistência às drogas antituberculose.<hr/>OBJECTIVE: To describe the incidence of tuberculosis among inmates of the municipal prison system in the city of Campinas, State of São Paulo, Brazil, from 1993 through 2000. METHODS: A retrospective study was carried out of the number of cases of tuberculosis that were notified among inmates over the study period. This involved reviewing data from a total of 4 293 inmates who were held in the four prisons that comprise Campinas' municipal prison system. Data were obtained from the tuberculosis database belonging to the Department of Social and Preventive Medicine of the School of Medical Sciences at the State University of Campinas. RESULTS: The incidence of tuberculosis peaked in 1994 (1 397.62 cases per 100 000) and was lowest in 1999 (559.04 cases per 100 000). Most cases of tuberculosis occurred in inmates in the 25 to 34 year age group (62.6%). Acquired immunodeficiency syndrome (AIDS) was the disease most commonly associated with tuberculosis (49.9%), which was most often pulmonary in type (91.9%), with positive sputum smears in 70.3% of the inmates tested. Most inmates had not received treatment before (75.4%). The treatment dropout rate reached 49%, and a cure was achieved in only 20.8% of the cases notified over the study period. CONCLUSIONS: The incidence of tuberculosis observed in this study was moderate when compared to incidence rates found in other studies of prison inmates, but this could be due to underreporting. The frequency of treatment failure noted was low, since patients who were treated under supervision showed good adherence and were cured in the majority of cases. However, the high treatment dropout rate seen in the study is alarming because it could facilitate the spread of drug resistant strains of Mycobacterium tuberculosis to the community at large. Controlling tuberculosis among prison inmates should be part of routine interventions aimed at eliminating this disease from the community and at preventing resistance to antituberculosis therapy. <![CDATA[<B>Vinculan la seropositividad al virus del herpes humano 8 con el cáncer de próstata</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300010&lng=en&nrm=iso&tlng=en OBJETIVO: Descrever a situação da tuberculose nas prisões da Cidade de Campinas, Estado de São Paulo, Brasil. MÉTODOS: Realizou-se um estudo retrospectivo dos casos notificados de tuberculose em presidiários no período de 1993 a 2000. Foram avaliados dados de 4 293 detentos dos quatro presídios que constituem o complexo penitenciário da região. Foram utilizadas informações do banco de dados em tuberculose do Departamento de Medicina Preventiva e Social da Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP). RESULTADOS: Observou-se um pico de incidência da tuberculose em 1994 (1 397,62 notificações em 100 000 indivíduos). A menor taxa foi observada em 1999 (559,04). Predominou a faixa etária de 25 a 34 anos (62,6%) e a AIDS como doença associada (49,9%). A forma preponderante de tuberculose foi a pulmonar (91,9%), com baciloscopia de escarro positiva em 70,3%. A maioria dos presidiários não tinha realizado tratamentos prévios (75,4%). O abandono de tratamento chegou a 49%. Houve cura em apenas 20,8% dos casos no período estudado. CONCLUSÕES: A incidência intermediária de tuberculose observada neste estudo pode estar relacionada à subnotificação. A freqüência de falência do tratamento ainda é baixa. No entanto, o abandono, como fator que facilita a propagação de micobactérias resistentes na comunidade, causa preocupação. O controle da tuberculose nas prisões deveria ser parte rotineira das intervenções direcionadas a eliminar a doença na comunidade e a prevenir a resistência às drogas antituberculose.<hr/>OBJECTIVE: To describe the incidence of tuberculosis among inmates of the municipal prison system in the city of Campinas, State of São Paulo, Brazil, from 1993 through 2000. METHODS: A retrospective study was carried out of the number of cases of tuberculosis that were notified among inmates over the study period. This involved reviewing data from a total of 4 293 inmates who were held in the four prisons that comprise Campinas' municipal prison system. Data were obtained from the tuberculosis database belonging to the Department of Social and Preventive Medicine of the School of Medical Sciences at the State University of Campinas. RESULTS: The incidence of tuberculosis peaked in 1994 (1 397.62 cases per 100 000) and was lowest in 1999 (559.04 cases per 100 000). Most cases of tuberculosis occurred in inmates in the 25 to 34 year age group (62.6%). Acquired immunodeficiency syndrome (AIDS) was the disease most commonly associated with tuberculosis (49.9%), which was most often pulmonary in type (91.9%), with positive sputum smears in 70.3% of the inmates tested. Most inmates had not received treatment before (75.4%). The treatment dropout rate reached 49%, and a cure was achieved in only 20.8% of the cases notified over the study period. CONCLUSIONS: The incidence of tuberculosis observed in this study was moderate when compared to incidence rates found in other studies of prison inmates, but this could be due to underreporting. The frequency of treatment failure noted was low, since patients who were treated under supervision showed good adherence and were cured in the majority of cases. However, the high treatment dropout rate seen in the study is alarming because it could facilitate the spread of drug resistant strains of Mycobacterium tuberculosis to the community at large. Controlling tuberculosis among prison inmates should be part of routine interventions aimed at eliminating this disease from the community and at preventing resistance to antituberculosis therapy. <![CDATA[<B>Criterios para la detección temprana de los casos de SARS</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300011&lng=en&nrm=iso&tlng=en OBJETIVO: Descrever a situação da tuberculose nas prisões da Cidade de Campinas, Estado de São Paulo, Brasil. MÉTODOS: Realizou-se um estudo retrospectivo dos casos notificados de tuberculose em presidiários no período de 1993 a 2000. Foram avaliados dados de 4 293 detentos dos quatro presídios que constituem o complexo penitenciário da região. Foram utilizadas informações do banco de dados em tuberculose do Departamento de Medicina Preventiva e Social da Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP). RESULTADOS: Observou-se um pico de incidência da tuberculose em 1994 (1 397,62 notificações em 100 000 indivíduos). A menor taxa foi observada em 1999 (559,04). Predominou a faixa etária de 25 a 34 anos (62,6%) e a AIDS como doença associada (49,9%). A forma preponderante de tuberculose foi a pulmonar (91,9%), com baciloscopia de escarro positiva em 70,3%. A maioria dos presidiários não tinha realizado tratamentos prévios (75,4%). O abandono de tratamento chegou a 49%. Houve cura em apenas 20,8% dos casos no período estudado. CONCLUSÕES: A incidência intermediária de tuberculose observada neste estudo pode estar relacionada à subnotificação. A freqüência de falência do tratamento ainda é baixa. No entanto, o abandono, como fator que facilita a propagação de micobactérias resistentes na comunidade, causa preocupação. O controle da tuberculose nas prisões deveria ser parte rotineira das intervenções direcionadas a eliminar a doença na comunidade e a prevenir a resistência às drogas antituberculose.<hr/>OBJECTIVE: To describe the incidence of tuberculosis among inmates of the municipal prison system in the city of Campinas, State of São Paulo, Brazil, from 1993 through 2000. METHODS: A retrospective study was carried out of the number of cases of tuberculosis that were notified among inmates over the study period. This involved reviewing data from a total of 4 293 inmates who were held in the four prisons that comprise Campinas' municipal prison system. Data were obtained from the tuberculosis database belonging to the Department of Social and Preventive Medicine of the School of Medical Sciences at the State University of Campinas. RESULTS: The incidence of tuberculosis peaked in 1994 (1 397.62 cases per 100 000) and was lowest in 1999 (559.04 cases per 100 000). Most cases of tuberculosis occurred in inmates in the 25 to 34 year age group (62.6%). Acquired immunodeficiency syndrome (AIDS) was the disease most commonly associated with tuberculosis (49.9%), which was most often pulmonary in type (91.9%), with positive sputum smears in 70.3% of the inmates tested. Most inmates had not received treatment before (75.4%). The treatment dropout rate reached 49%, and a cure was achieved in only 20.8% of the cases notified over the study period. CONCLUSIONS: The incidence of tuberculosis observed in this study was moderate when compared to incidence rates found in other studies of prison inmates, but this could be due to underreporting. The frequency of treatment failure noted was low, since patients who were treated under supervision showed good adherence and were cured in the majority of cases. However, the high treatment dropout rate seen in the study is alarming because it could facilitate the spread of drug resistant strains of Mycobacterium tuberculosis to the community at large. Controlling tuberculosis among prison inmates should be part of routine interventions aimed at eliminating this disease from the community and at preventing resistance to antituberculosis therapy. <![CDATA[<B>Estadísticas de cáncer de los Estados Unidos, 2004</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300012&lng=en&nrm=iso&tlng=en OBJETIVO: Descrever a situação da tuberculose nas prisões da Cidade de Campinas, Estado de São Paulo, Brasil. MÉTODOS: Realizou-se um estudo retrospectivo dos casos notificados de tuberculose em presidiários no período de 1993 a 2000. Foram avaliados dados de 4 293 detentos dos quatro presídios que constituem o complexo penitenciário da região. Foram utilizadas informações do banco de dados em tuberculose do Departamento de Medicina Preventiva e Social da Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP). RESULTADOS: Observou-se um pico de incidência da tuberculose em 1994 (1 397,62 notificações em 100 000 indivíduos). A menor taxa foi observada em 1999 (559,04). Predominou a faixa etária de 25 a 34 anos (62,6%) e a AIDS como doença associada (49,9%). A forma preponderante de tuberculose foi a pulmonar (91,9%), com baciloscopia de escarro positiva em 70,3%. A maioria dos presidiários não tinha realizado tratamentos prévios (75,4%). O abandono de tratamento chegou a 49%. Houve cura em apenas 20,8% dos casos no período estudado. CONCLUSÕES: A incidência intermediária de tuberculose observada neste estudo pode estar relacionada à subnotificação. A freqüência de falência do tratamento ainda é baixa. No entanto, o abandono, como fator que facilita a propagação de micobactérias resistentes na comunidade, causa preocupação. O controle da tuberculose nas prisões deveria ser parte rotineira das intervenções direcionadas a eliminar a doença na comunidade e a prevenir a resistência às drogas antituberculose.<hr/>OBJECTIVE: To describe the incidence of tuberculosis among inmates of the municipal prison system in the city of Campinas, State of São Paulo, Brazil, from 1993 through 2000. METHODS: A retrospective study was carried out of the number of cases of tuberculosis that were notified among inmates over the study period. This involved reviewing data from a total of 4 293 inmates who were held in the four prisons that comprise Campinas' municipal prison system. Data were obtained from the tuberculosis database belonging to the Department of Social and Preventive Medicine of the School of Medical Sciences at the State University of Campinas. RESULTS: The incidence of tuberculosis peaked in 1994 (1 397.62 cases per 100 000) and was lowest in 1999 (559.04 cases per 100 000). Most cases of tuberculosis occurred in inmates in the 25 to 34 year age group (62.6%). Acquired immunodeficiency syndrome (AIDS) was the disease most commonly associated with tuberculosis (49.9%), which was most often pulmonary in type (91.9%), with positive sputum smears in 70.3% of the inmates tested. Most inmates had not received treatment before (75.4%). The treatment dropout rate reached 49%, and a cure was achieved in only 20.8% of the cases notified over the study period. CONCLUSIONS: The incidence of tuberculosis observed in this study was moderate when compared to incidence rates found in other studies of prison inmates, but this could be due to underreporting. The frequency of treatment failure noted was low, since patients who were treated under supervision showed good adherence and were cured in the majority of cases. However, the high treatment dropout rate seen in the study is alarming because it could facilitate the spread of drug resistant strains of Mycobacterium tuberculosis to the community at large. Controlling tuberculosis among prison inmates should be part of routine interventions aimed at eliminating this disease from the community and at preventing resistance to antituberculosis therapy. <![CDATA[<B>Método de detección viral comparado con la prueba citológica periódica para el tamizaje de mujeres</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300013&lng=en&nrm=iso&tlng=en OBJETIVO: Descrever a situação da tuberculose nas prisões da Cidade de Campinas, Estado de São Paulo, Brasil. MÉTODOS: Realizou-se um estudo retrospectivo dos casos notificados de tuberculose em presidiários no período de 1993 a 2000. Foram avaliados dados de 4 293 detentos dos quatro presídios que constituem o complexo penitenciário da região. Foram utilizadas informações do banco de dados em tuberculose do Departamento de Medicina Preventiva e Social da Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP). RESULTADOS: Observou-se um pico de incidência da tuberculose em 1994 (1 397,62 notificações em 100 000 indivíduos). A menor taxa foi observada em 1999 (559,04). Predominou a faixa etária de 25 a 34 anos (62,6%) e a AIDS como doença associada (49,9%). A forma preponderante de tuberculose foi a pulmonar (91,9%), com baciloscopia de escarro positiva em 70,3%. A maioria dos presidiários não tinha realizado tratamentos prévios (75,4%). O abandono de tratamento chegou a 49%. Houve cura em apenas 20,8% dos casos no período estudado. CONCLUSÕES: A incidência intermediária de tuberculose observada neste estudo pode estar relacionada à subnotificação. A freqüência de falência do tratamento ainda é baixa. No entanto, o abandono, como fator que facilita a propagação de micobactérias resistentes na comunidade, causa preocupação. O controle da tuberculose nas prisões deveria ser parte rotineira das intervenções direcionadas a eliminar a doença na comunidade e a prevenir a resistência às drogas antituberculose.<hr/>OBJECTIVE: To describe the incidence of tuberculosis among inmates of the municipal prison system in the city of Campinas, State of São Paulo, Brazil, from 1993 through 2000. METHODS: A retrospective study was carried out of the number of cases of tuberculosis that were notified among inmates over the study period. This involved reviewing data from a total of 4 293 inmates who were held in the four prisons that comprise Campinas' municipal prison system. Data were obtained from the tuberculosis database belonging to the Department of Social and Preventive Medicine of the School of Medical Sciences at the State University of Campinas. RESULTS: The incidence of tuberculosis peaked in 1994 (1 397.62 cases per 100 000) and was lowest in 1999 (559.04 cases per 100 000). Most cases of tuberculosis occurred in inmates in the 25 to 34 year age group (62.6%). Acquired immunodeficiency syndrome (AIDS) was the disease most commonly associated with tuberculosis (49.9%), which was most often pulmonary in type (91.9%), with positive sputum smears in 70.3% of the inmates tested. Most inmates had not received treatment before (75.4%). The treatment dropout rate reached 49%, and a cure was achieved in only 20.8% of the cases notified over the study period. CONCLUSIONS: The incidence of tuberculosis observed in this study was moderate when compared to incidence rates found in other studies of prison inmates, but this could be due to underreporting. The frequency of treatment failure noted was low, since patients who were treated under supervision showed good adherence and were cured in the majority of cases. However, the high treatment dropout rate seen in the study is alarming because it could facilitate the spread of drug resistant strains of Mycobacterium tuberculosis to the community at large. Controlling tuberculosis among prison inmates should be part of routine interventions aimed at eliminating this disease from the community and at preventing resistance to antituberculosis therapy. <![CDATA[<B>Oil exploitation in the Amazon basin of Ecuador</B>: <B>a public health emergency</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300014&lng=en&nrm=iso&tlng=en Desde la década de 1970, el petróleo ha sido una de las principales fuentes de ingresos del Ecuador y ha servido como "motor impulsor" de la economía nacional. La mayor parte del petróleo ecuatoriano se extrae en la cuenca amazónica del nordeste del país. Desde que comenzó la explotación petrolera, compañías extranjeras y la empresa petrolera estatal Petroecuador han extraído más de dos mil millones de barriles de petróleo crudo de la Amazonía ecuatoriana. A lo largo de este proceso se han liberado al medio ambiente miles de millones de galones de desechos sin tratar, gas y petróleo crudo. Este artículo analiza el impacto ambiental y sanitario provocado por el desarrollo petrolero en la región amazónica del Ecuador. Por ejemplo, el análisis del agua de varias corrientes fluviales de la localidad ha demostrado la presencia de altas concentraciones de productos químicos derivados del petróleo en las zonas petrolíferas en explotación. Los estudios epidemiológicos han encontrado un mayor riesgo de sufrir síntomas asociados con el petróleo y abortos espontáneos en las mujeres que viven en las proximidades de los campos petroleros. También se ha encontrado una incidencia excesiva de cáncer. Se necesitan intervenciones locales, nacionales e internacionales para evitar que se empeoren los efectos negativos que ejerce sobre el medio ambiente y la salud el desarrollo petrolero. Estas intervenciones deben abarcar un sistema de monitoreo y remediación ambiental, consultas a la comunidad y participación comunitaria, mecanismos para hacer cumplir las leyes que protegen el medio ambiente y la salud de la población, y cambios en las políticas comerciales dirigidos a lograr la sostenibilidad en materia ambiental y la justicia social. <![CDATA[<B>Los directores de revistas científicas definen medidas para fomentar la investigación de los problemas de salud mental en países en desarrollo</B>]]> http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892004000300015&lng=en&nrm=iso&tlng=en Desde la década de 1970, el petróleo ha sido una de las principales fuentes de ingresos del Ecuador y ha servido como "motor impulsor" de la economía nacional. La mayor parte del petróleo ecuatoriano se extrae en la cuenca amazónica del nordeste del país. Desde que comenzó la explotación petrolera, compañías extranjeras y la empresa petrolera estatal Petroecuador han extraído más de dos mil millones de barriles de petróleo crudo de la Amazonía ecuatoriana. A lo largo de este proceso se han liberado al medio ambiente miles de millones de galones de desechos sin tratar, gas y petróleo crudo. Este artículo analiza el impacto ambiental y sanitario provocado por el desarrollo petrolero en la región amazónica del Ecuador. Por ejemplo, el análisis del agua de varias corrientes fluviales de la localidad ha demostrado la presencia de altas concentraciones de productos químicos derivados del petróleo en las zonas petrolíferas en explotación. Los estudios epidemiológicos han encontrado un mayor riesgo de sufrir síntomas asociados con el petróleo y abortos espontáneos en las mujeres que viven en las proximidades de los campos petroleros. También se ha encontrado una incidencia excesiva de cáncer. Se necesitan intervenciones locales, nacionales e internacionales para evitar que se empeoren los efectos negativos que ejerce sobre el medio ambiente y la salud el desarrollo petrolero. Estas intervenciones deben abarcar un sistema de monitoreo y remediación ambiental, consultas a la comunidad y participación comunitaria, mecanismos para hacer cumplir las leyes que protegen el medio ambiente y la salud de la población, y cambios en las políticas comerciales dirigidos a lograr la sostenibilidad en materia ambiental y la justicia social.