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On-line version ISSN 1678-4561Print version ISSN 1413-8123
Ciênc. saúde coletiva vol.9 n.4 Rio de Janeiro Oct./Dec. 2004
Evidence that the majority of deaths due to chronic non-communicable diseases (CNCD) occur in developing countries and that the projections for the next twenty years are discouraging was fundamental in stimulating the World Health Organization to initiate various proposals aimed at confronting and reducing the problem, and to promote international discussions on this subject in various locations. A publication in a featured issue of the journal Ciência & Saúde Coletiva on the subject of CNCD in Brazil is therefore opportune.
Approximately seven decades after CNCD first became apparent as the principal cause of death in Western countries of the Northern hemisphere, the mid-60s heralded the beginning of the history of CNCD in Brazil. Pioneering information on the subject dates from 1984 when Bayer and Paula published the first historical series on proportional mortality by groups of causes in Brazil, during 1930-1980. In this report, the rising curve of circulatory diseases crosses that of infectious and parasitic diseases, by that time in decline. This publication is the researchers' classical reference for scientific data on the subject in Brazil and is widely used by politicians and health planners. From that moment on, researchers sought to understand and explain the reasons for these changes, building what came to be called "incomplete epidemiological transition" by some and "epidemiological polarization" by others. This model contrasts with those of the great majority of other countries, including Latin American countries with a similar social profile to that of Brazil. The transition as such is still under discussion but pioneering analyses carried out at the end of 2003 on the burden of disease in Brazil showed the progression of this transition, according to the DALY indicator, with CNCD now responsible for more than 66% of this burden. However, prolonged polarization still persists, with another set of diseases or situations typical of underdevelopment responsible for 23% of the total burden of disease.
On the other hand, despite the still constraining social inequity that exists in Brazil in this 21st century, one of the largest in the world, the population continues to age at an accelerated rate, increasing the bases that favor the occurrence of CNCD. Aging, associated with a lack of the necessary infrastructure to adequately promote healthcare and provide sufficient and timely primary prevention of CNCD, leads experts to predict an increase in morbidity, with frequent simultaneity of diseases or disabilities. On the other hand, secondary prevention is not fully guaranteed. It is important to mention the growing concern regarding the onus of CNCD on the Social Security system and consequently on society as a whole, largely and improperly represented today by situations related to the occurrence of CNCD in younger age-groups. Despite these affirmatives, the epidemiological profile of CNCD in the country is drawn from the mortality statistics which, despite their shortcomings, are those capable of including, without distinction, Brazilians of every social category, independently from the social heterogeneity of the more than five-thousand municipalities in the country.
The population morbidity due to CNCD is completely unknown throughout practically the entire country except for data on hospitalization within the national health system. The majority of what is known is drawn from just one sector of the country that of poverty, of low education levels, of greatest exposure to the social and environmental stressors, and lack of access to good quality medical care. The percentage of the population with access to private health insurance, i.e. the percentage with the highest income level, highest education level, with different, but not always better behavior and attitudes, and with access to the best standard of medical care, is frequently excluded from the analysis or under-represented. These contrasts in behavior between users of the national health system and those with access to private medical care are presented in this featured issue, confirming the important differences in behavior when faced with risk factors, as well as access and use of health services for the early detection of CNCD.
The persistence of social inequities and their consequences continue to be discussed exhaustively worldwide, including the principal determinants of CNCD, beginning before birth. Strategies for the promotion and prevention of these groups of causes constitute another global concern, particularly in view of new evidence on the epidemics of CNCD and/or their risk factors (obesity, diabetes, metabolic syndrome). In parallel, "inflammation" is constantly being confirmed as one of the most important precursors of atherosclerosis and its outcome. In fact, the inflammatory process has a direct relationship with metabolic syndrome whose components include both obesity and hyperglycemia. These aspects are, today, one of the main public health concerns both in more developed countries and in many developing countries.
Because of the situations previously mentioned, as well as others that had already been identified and linked to CNCD, the World Health Organization has proposed a Plan of Global Strategy to combat CNCD based on healthy diet, physical activity and health, all supported with evidence. Other important proposals made by the World Health Organization directed at the epidemiological surveillance of CNCD in developing countries are supported by the Health Surveillance Department of the Ministry of Health, which already has various basic documents required for carrying out these proposals.