BMJ  2004;329:753-754 (2 October), doi:10.1136/bmj.329.7469.753

Editorial

Academic medicine as a resource for global health: the case of Brazil

Improving population health demands stronger academic input

The world has witnessed enormous changes in population health in recent years. The main sources of disease burden are now non-communicable diseases, and death and injury from external causes such as accidents, homicide, and suicide.¹ This shift has demanded entirely new organisational structures and expertise within the health sector at a time of great increase in technology and, consequently, in health costs. These changes have been especially difficult to assimilate in developing countries, which must also continue to deal with a large burden of communicable diseases such as AIDS. To overcome these challenges, the World Health Report 2003 recommends strengthening health systems by centring action on primary health care and by integrating health promotion and disease prevention across all levels of care on behalf of the entire population.²

The campaign to revitalise academic medicine offers an excellent opportunity to question how academics can respond to these challenges.^{3 4} The case of Brazil, a large middle income country with marked social inequalities striving to improve population health, provides an example.

Until the 1980s public health, medical care, and education in Brazil were pieces of a fragmented whole. Publicly financed health care was limited to unevenly supported emergency room and hospital treatment, coupled with a primary care system dedicated almost exclusively to management of infectious diseases and to maternal and child care. Public health agencies focused their activities on infectious diseases, especially vaccine preventable and endemic parasitic diseases. Medical education was almost exclusively performed within university hospitals oriented towards tertiary care. The implicit goal of most students was to become, like their academic mentors, a specialised "private physician." The interface between training in clinical medicine and public health would be better described as a gap.

Over the past two decades, much has changed. Publicly financed health care has been unified and reformed extensively. The national health system (Sistema Único de Saúde, SUS) now covers more than 70% of the population and strives for complete medical coverage, at all levels, providing care for chronic illnesses and high technology procedures such as transplantation. A family medicine model of primary care has been adopted, based on multiprofessional health teams led by doctors and nurses, serving registered, geographically delimited populations.⁵ Each team includes several salaried members of the community. This new model is expanding rapidly and now, in its eleventh year, provides coverage for almost 40% of the population.⁶ Public health activities such as disease surveillance, health promotion, and community based prevention have expanded and now include recognition of chronic diseases, injuries, and accidents.

Academic medicine has also changed in Brazil. Clinical epidemiology, central to evidence based medicine and vital to creating the bridge between clinical medicine and public health, has been introduced into many curriculums, both in medical schools and in postgraduate training. Evidence based textbooks have been written for the Brazilian context.⁷ Additionally, post-residency training is now offered in more than 300 masters or doctoral programmes in health related fields throughout the country, representing a major resource for capacity building and research.

To align academic medicine more directly with the SUS, the Ministry of Health has instituted regional centres for training within the new primary care model⁸; redirected residency slots to family medicine; expanded in-house training for core personnel of the health system at local, state, and national levels; and funded programmes to help medical schools to make their curriculums more relevant to practice within the SUS. National funding for research and prizes for academic excellence are increasingly awarded to work that will help solve the problems faced by the SUS.

The national health service now depends on academic support to develop and identify innovations that should be translated into effective health actions,⁹ to crystallise the state of the art into clinical and public health guidelines,¹⁰ to monitor the provision of care,¹¹ and to evaluate health system initiatives.¹² Academic input also buffers the system against undue alterations resulting from shifts in the prevailing political winds, parties, and players.

Yet improving population health in Brazil will demand even greater academic participation. Can academic medicine meet these challenges? Only through change. Our experience is that change from within the academic structure is painfully slow in coming, making external incentives from the government and other key institutions vitally important.

In this regard, the pharmaceutical and technology industries provide incentives through funding research, medical gatherings, and other forms of continuing medical education. Their frequently massive commercial expenditures, however, often overwhelm more rational approaches to healthcare provision. In countries like Brazil with still limited governmental action and expertise in technology assessment, it is vital that academic medicine continues to question the ground rules for its partnerships with industry while strengthening its partnerships with the national health system.

School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS Brazil 90470-280, (bbduncan{at}orion.ufrgs.br)

School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS Brazil 90470-280

---

Competing interests: None declared.

References

1. Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2002. Boston: Harvard University Press, 1996.
2. World Health Organization. World health report 2003: shaping the future. Geneva: WHO, 2003.
3. Clark J, Smith R. BMJ Publishing Group to launch an international campaign to promote academic medicine. BMJ 2003;327: 1001-2.[Free Full Text]
4. Tugwell P. Campaign to revitalise academic medicine kicks off. BMJ 2004;328: 597.[Free Full Text]
5. Ministério da Saúde. Programa de Saúde da Família. Ministry of Health, Brazil. http://portal.saude.gov.br/saude/area.cfm?id_area=149 (accessed 13 Sep 2004).
6. Ministério da Saúde. Agentes comunitários de saúde, equipes de saúde da família e equipes de saúde bucal, em atuação—competência junho/2004. Ministry of Health, Brazil. http://portal.saude.gov.br/saude/arquivos/pdf/planilhapsf_agosto_2004.pdf (accessed 13 Sep 2004).
7. Duncan BB, Schmidt MI, Giugliani EJR. Medicina ambulatorial, condutas de atenção primária baseadas em evidências. 3rd ed. Porto Alegre: ArtMed, 2004.
8. Secretaria de Gestão do Trabalho e da Educação na Saúde. Saúde investe em polos de educação permanente. Ministry of Health, Brazil. http://portal.saude.gov.br/saude/visualizar_texto.cfm?idtxt=19906 (accessed 13 Sep 2004).
9. Barreto SM, Pinheiro AR, Schieri R, Batista Filho M, Schmidt MI, Lotufo P, et al. Estratégia global da OMS para alimentação saudável, atividade física e saúde. Epidemiologia e Serviços de Saúde 2004 (in press).
10. Picon PD, Beltrame A. Protocolos clínicos e diretrizes terapêuticas—medicamentos excepcionais. Porto Alegre: Gráfica e Editora Pallotti, 2002.
11. Lima-Costa MF, Barreto SM, Giatti L. [Health status, physical functioning, health services utilization, and expenditures on medicines among Brazilian elderly: a descriptive study using data from the National Household Survey]. Cad Saude Publica 2003;19: 735-43.[Medline]
12. Toscano CM, Mengue SS, Fischer MI, Schmidt MI, Duncan BB, Fuchs SC, et al. Avaliação do plano de reorganização da atenção à hipertensão arterial e ao diabetes mellitus no Brasil. Pan American Health Organization. http://www.opas.org.br/prevencao/site/temas_documentos_detalhe.cfm?id=46&iddoc=134 (accessed 14 Sep 2004).

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Related Articles

Academic medicine: who is it for?: Medical profession needs to care about academic medicine and promote it

Hanamaraddi T Gangal
BMJ 2005 330: 362. [Extract] [Full Text]

Academic medicine needs a global agenda
BMJ 2004 329: 0. [Full Text]

Who cares about academic medicine?

Jocalyn Clark and Peter Tugwell
BMJ 2004 329: 751-752. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

• Gangal, H. T (2005). Academic medicine: who is it for?: Medical profession needs to care about academic medicine and promote it. BMJ 330: 362-362 [Full text]  
• Clark, J., Tugwell, P. (2004). Who cares about academic medicine?. BMJ 329: 751-752 [Full text]  

Rapid Responses:

Read all Rapid Responses

Brazilian Guidelines for High Cost Drugs

Paulo D Picon, et al.
bmj.com, 11 Oct 2004 [Full text]