The Lancet : México, virada histórica ou mera propaganga?

Júlio Frenk, médico, professor e médico sanitarista "está" há seis anos Ministro da Saúde do México. Não sei se continuará no novo governo de Felipe Calderón. Nas páginas do The Lancet (texto com livre acesso para quem se credenciar na página http://thelancet.com) ele apresenta os resultados fantásticos obtidos na sua gestão. Frenk é acadêmico respeitável. Porém, como desconheço a realidade mexicana, não tenho como avaliar sua gestão. Os exemplos mostrados no texto indicam que há semelhanças com o Brasil, mas aparentemente estamos mais avançados em termos organizativos e, principalmente temos com o SUS, um arcabouço jurídico mais avançado do que o mexicano. Abaixo, reproduzo o ABCDE daquilo que seria a gestão adequada de um Ministro da Saúde, tal como publicado hoje no The Lancet.

Comentários transformados em reconhecimento a brasileiros:

A de Agenda, com destaque para o entendimento com o Ministério da Fazenda local (Adib Jatene que o diga o quão importante é o relacionamento com a área financeira); B de Budget ( ao ex-deputado Eduardo Jorge ao ex-Ministro José Serra e todos que lutaram pela emenda constitucional 29 e, continuam exigindo a sua regulamentação); C de Capacity (homenagem às universidades brasileiras, institutos de pesquisa como Fiocruz e Butantã e à FAPESP); D de Deliverables (sem menção, não temos prioridades); E de Evidence (ainda uma proposta não hegemônica, vale somente para economia para pobres, mas não para o alto custo)

Bridging the divide: global lessons from evidence-based health policy in Mexico

Julio Frenk, The Lancet Agenda The first ingredient for success is to advance the health agenda amidst competition for attention and public resources. Especially in their interaction with ministers of finance, health officials can make use of global evidence showing that, in addition to its intrinsic value, a well-performing health system contributes to the overall welfare of society by relieving poverty, improving productivity, increasing educational abilities, developing human capital, generating employment, protecting savings and assets, enhancing competitiveness, and directly stimulating economic growth with a fairer distribution of wealth. Budget By placing health at the centre of the broader development agenda of a country it is possible to endow it with the degree of priority that it deserves. Such priority enhances the negotiating power of ministers of health in their quest for increased budgetary support. In too many developing countries, current investment is simply not enough to face the growing demands placed on health systems by the double burden of disease. The Mexican experience shows the value of legislating specifi c entitlements and the associated resource requirements. Use of evidence on the value of health for development can help convince policy makers to mobilise more money for health, but the capacity to deliver more health for the money must also be demonstrated. Capacity There is no substitute for long-term investments in capacity building. These efforts should be focused on two main areas. The first refers to health-service delivery, through investments in physical infrastructure and, most importantly, in human resources. The second has to do with the development of institutions that can undertake the necessary research to generate sound evidence for policy. In Mexico, the current reform has reaped the benefits of 20 years of sustained efforts to establish and nurture organisations such as the National Institute of Public Health and the Mexican Health Foundation. These centres of excellence have produced relevant research and policy analysis, trained researchers who occupy key policy-making positions, and done independent and credible evaluations. Deliverables A key ingredient to garner public support for a reform is to identify and communicate its specific benefits. The best way to do so is to focus on priority diseases and risk factors. In this way, the public can link abstract financial and managerial notions to concrete deliverables. A fundamental lesson from the Mexican experience is that health-system capacity can be built up through the scale-up of effective preventive and therapeutic interventions against specific priority problems. Evidence Evidence derived from scientific knowledge has an empowering effect to transform health systems. There is a growing international consensus that the creation and diffusion of knowledge is one of the major driving forces for health progress. While research is a value in itself, an essential part of culture, knowledge also has an instrumental value as a means to improve health. This improvement is achieved through three mechanisms. First, and most obviously, knowledge gets translated into new and better technologies, such as drugs, vaccines, and diagnostic methods. Second, knowledge is also gained by individuals, who use it to structure their everyday behaviour in key domains like personal hygiene, feeding habits, sexual behaviour, and child-rearing practices. In this way, knowledge can empower people to modify their lifestyles and promote their own health. The power derived from knowledge also allows individuals to become informed users of services and citizens conscious of their rights. Third, knowledge becomes translated into evidence that provides a scientific foundation for decision-making both in the delivery of health services and in the formulation of public policies.

Guerra dos stents: perda para os dois lados.

A Boston Cientific e a Johsson & Johnson estão travando há mais de um ano uma guerra para mostrar que tem o melhor stent com medicamento no mercado. Ambas patrocinaram trabalhos que as favorecem, cada uma a seu tempo. Agora, duas apresentações no World Congress of Cardiology recém terminado em Barcelona, Espanha, reduziram as expectativas desse tipo de stent em relação ao tradicional. O melhor texto explicando a confusão é de hoje do The New York Times. Mas, voltaremos ao tema porque essa é uma questão central na organização da assistência ao infartado no Brasil. Interessante, que o estudo citado, o suíco Basket, não nega o uso desses stents, somente limita a sua indicação.

A grosso modo há um aumento considerável no gasto do atendimento ao infartado no mundo todo porque progressivamente os tratamentos mais adequados vão sendo superados por outros mais caros. Muitas aspas em adequados e superados.

Stent Makers Hurt by Reports About Safety By BARNABY J. FEDER Published: September 8, 2006 (copyright NYT) Shareholder qualms about growth prospects for the $5 billion coronary stunt business yesterday shook the stocks of Boston Scientific and Johnson & Johnson, the two leading stent makers. Shares of Boston Scientific fell 3.3 percent, or 57 cents, to $16.70. The stock of Johnson & Johnson, whose overall business is less dependent on stents, fell 46 ceNts, to $63.46. The declines came after a stream of reports about stent safety from a European medical meeting. Those included the disclosure yesterday that Boston Scientific had quietly told federal regulators this summer that new analysis of the company’s accumulating safety data found that patients using its best-selling Taxus stent had a slightly greater but statistically clear risk of developing potentially deadly blood clots compared with older stent designs. Among the earlier reports at the meeting was a Swiss study suggesting that in some patient groups the Cypher stent of Johnson & Johnson posed even higher long-term clotting risks than Taxus. Stents are metal sleeves inserted in arteries to keep them propped open after medical procedures to clear blockages. Although some are used during heart bypass surgery, most coronary stents are inserted as a follow-up to angioplasty, a less invasive procedure in which the blockage is cleared from inside the artery by inflating a balloon. The balloon and stent are delivered to the heart area via a long catheter inserted into a blood vessel in the patient’s thigh. Stents were first used in the 1990’s. The original designs were bare metal devices. Cypher, introduced in the United States in 2003, and Taxus, which was cleared for sale in 2004, are drug-coated devices. The coatings are meant to combat the tendency of arteries to form new blockages, a process called restenosis. Although the drug-coated devices cost more than $2,000 on average, compared with $800 or so for bare metal devices, they rapidly supplanted the older designs in the United States and now account for 85 percent to 90 percent of the market. Analysts said that the stock market reaction reflected fears that growth in the stent market would slow and that more doctors would prescribe the less profitable bare metal products. Word of Boston Scientific’s report to regulators, whom it met with on Aug. 1, and the news that Food and Drug Administration officials then asked Johnson & Johnson for more data on its Cypher stent, was reported yesterday in The Wall Street Journal.

PNAS: progestágeno levando a redução auditiva

A médica capixaba Patrícia Guimarães é a primeira autora no Proceedings of the National Academy of Sciences de pesquisa realizada na University of Rochester Medical School com 124 mulheres entre 60-86 anos. Foram 3 grupos: estrógeno-progestágeno, somente estrógeno para histerectomizadas e grupo controle . O primeiro grupo apresesentou redução auditiva maior quando comparada ao dos participantes dos outros dois braços de experimentação. O artigo em versão completa pode ser lido no site da revista.

Comentário: a reposição hormonal estrogênica-progestagênica era a a fonte da juventude, agora até se associa com perda auditiva. Qual será o próximo desfecho pior para a reposição hormonal?

J&J -Natrecor: lucros caem, a razão prevalece?

Será que estamos chegando à idade da razão nos estudos clínicos? Depois da festa dos anos 90 e início dos anos 00 quando a ordem no FDA americano era liberar o mais rapidamente possível os medicamentos com a argumentação de que a demora estaria provocando mortes, o momento parece outro, depois do caso Vioxx e, da independência cada vez maior dos editores de revistas médicas. A Johnson & Johnson´s está assumindo que o neseretide, um análogo do peptídeo natriurético B necessita de estudo com grande número de participantes com desfechos de qualidade como mortalidade e insuficiência renal. Investirá US$100 milhões tudo isso depois de cinco anos de aprovação. Abaixo o texto do The Wall Street Journal contando um pouco da história desse medicamento, que parecia promissor, mas o lançamento precoce e, alguns resultados indesejados, levaram que o “feitiço, voltasse contra o feiticeiro”.

Todas as informações do medicamento podem ser lidas também em http://www.natrecor.com, com destaque para o ocorrido no ensaio ProAction. J&J Names Institute to Lead Trial of Its Natrecor Heart Drug. (copyright WSJ 2006)

J&J’ Sciso unit named Duke Clinical Research Institute to lead a 7,000-patient trial to test the safety and efficacy of its heart-failure drug Natrecor. The announcement comes more than 15 months after an expert panel led by a Harvard University cardiologist recommended such a study in the wake of concerns that the medicine might increase the risk of death or kidney failure within 30 days of treatment among patients hospitalized with acute heart failure. The Cleveland Clinic also will help lead the study. By naming two prestigious centers to run a large-scale study, expected to cost more than $100 million, the company is making an important investment in the future of the drug, known generically as nesiritide -- albeit a commitment that some critics would like to have seen earlier. Robert M. Califf, director of the Duke institute at Duke University in Durham, N.C., will serve as chairman of the study and lead "a global consortium of academic leaders who will conduct the study with the type of independence" intended to instill confidence among cardiologists and patients in the findings. Natrecor was approved in 2001 on the basis of studies demonstrating its ability to quickly improve symptoms of shortness of breath among patients suffering from what doctors call acute decompensated heart failure, and it was a strong performer for J&J, which is based in New Brunswick, N.J. But the lack of data to resolve safety concerns has undermined physician confidence in the drug in the past year, contributing to a significant drop in sales. Dr. Califf said the study is also an opportunity to make an important advance for patients for whom there are few effective remedies. More than one million U.S. patients are admitted to hospitals with acute decompensated heart failure a year and as many as 8% die in the hospital. When he began his career in a coronary care unit in 1980, Dr. Califf said, there were two kinds of patients: those with unstable chest pain called acute coronary syndrome that leads to heart attacks, and those with acute heart failure. Medicine has made major strides against heart attacks since, but almost no progress for acute heart failure. "Patients come in feeling like they're drowning and there is a very high rate of death and readmissions," Dr. Califf said. Natrecor helps relieve shortness of breath, "but what is not settled is what are the longer-term effects," he said. "I'm glad there's now a commitment to get the trial done." The study, whose precise design has yet to be finalized, is expected to first evaluate safety and efficacy at 30 days after treatment. Enrollment of patients -- about half from North America and the rest from elsewhere around the world -- is expected to begin in the first half of next year. Dr. Califf said the first results should be ready in two to three years

WSJ: Merck se auto-absolve do caso Vioxx.

Segue abaixo, reportagem do The Wall Street Journal sobre a auto-absolvição da Merck Sharp Dohme no caso Vioxx. Apresentei em negrito, o único parágrafo onde o relatório pago pela própria empresa se auto-recrimina e, cita comportamentos pouco aceitáveis em relação aquilo que chamou de médicos "anti-Vioxx" ou "anti-Merck". Lembro que quando a análise do braço cardiovascular do Vioxx foi publicado, os médicos brasileiros "pró-Vioxx" e "pró-Merck" não perderam tempo em defender o produto.

By JOHN CARREYROU and HEATHER WON TESORIEROSeptember 7, 2006; Page D3 Copyright The Wall Street Journal. An outside investigation ordered by Merck & Co.'s board largely exonerated the drug maker's management of any wrongdoing in developing and marketing the painkiller Vioxx, citing much of the same evidence that critics say shows Merck acted irresponsibly. Plaintiffs' attorneys dismissed the investigation as a whitewashing exercise. Merck faces more than 14,200 lawsuits alleging that Vioxx caused heart attacks and strokes. So far, the company has won four cases that have gone to trial and lost four. Summarizing the results of a 20-month investigation, retired U.S. District Judge John S. Martin Jr. took up 27 allegations that critics have leveled against Merck, ultimately rejecting the central elements of each one. Mr. Martin is with the law firm Debevoise & Plimpton LLP. Merck's management believed Vioxx was safe until the company withdrew the drug from the market in September 2004 and never intended to mislead the Food and Drug Administration or the public, Mr. Martin's report says. "Critics contend that senior officials at Merck knowingly put patients at risk of cardiovascular events rather than jeopardize the profits that Merck generated from the sale of Vioxx," the report says. "We have concluded that there is no basis for such a claim." Plaintiffs' attorney Christopher Seeger called the report "a legal brief on behalf of the company." He added: "If law firms like Debevoise said anything negative about the companies that hire them to do these reports, they'd never be hired by a big company again." At a news conference to present his findings, Mr. Martin said the report was "positive because that's what we found." Investigations commissioned by companies' boards of directors have a mixed record of credibility, says Edwin Stier, a partner at the law firm Stier Anderson LLC, who has conducted several such probes and used to head the criminal division of the U.S. attorney's office in New Jersey. "This report should be scrutinized with a great deal of skepticism," Mr. Stier says. But, "I think it's a mistake to automatically assume that an investigation is a whitewash because there's so much money at stake." Analysts have projected Merck could face legal liability on Vioxx of anywhere between $4 billion and $30 billion. If Mr. Martin's report had laid blame on Merck's management, it would have been sure to feed the litigation frenzy. Mr. Martin was assisted in his investigation by a team of lawyers and paralegals from Debevoise. The firm spent a collective 53,000 hours reviewing tens of millions of documents and interviewing dozens of Merck scientists and executives, as well as outside experts. However, none of the interviews were recorded and notes were taken by hand. The interviews aren't included in the report's appendices. Merck said it would pay the law firm $21 million for its services. Mr. Martin's investigation found that some of Merck's sales tactics were overly aggressive, but it pinned the blame on individual employees and said upper management was either not aware of or didn't condone those practices. One of them involved "neutralizing" physicians that sales representatives had identified as "anti-Vioxx" or "anti-Merck" with payments, support for their clinical studies, trips to "elegant" locations such as New York or Hawaii, and medical-school grants. The report says these were merely recommendations and there is no evidence they were ever acted upon. The report also noted that a promotional aid called "the Cardiovascular Card" used by Merck sales representatives to pitch Vioxx to doctors didn't include data from a 2000 clinical trial that showed a higher incidence of heart attacks and strokes among patients who took Vioxx. But it excused this by saying that Merck provided a separate letter describing that trial to doctors who asked about it. The report accepted Merck scientists' explanation that, at the time, they believed the higher rate of heart attacks and strokes detected among Vioxx patients in that clinical trial was due to the beneficial effects of the drug Vioxx was being compared to, rather than any negative effects of Vioxx itself. Outside scientists have frequently rejected that theory. The report says an email that former Merck research head Edward Scolnick sent to colleagues in March 2000 after learning of the results of that trial, in which he acknowledged the cardiovascular data and called it "a shame," was merely an initial reaction. Subsequent emails show Dr. Scolnick changed his mind upon further reviewing the data, and he became convinced that Vioxx was safe, the report says. At the news conference, Mr. Martin called Dr. Scolnick "brilliant

FT: vacina da malária pode demorar sem apoio do G-7

The Financial Times (07/09/06/) revela que a Glaxo-Smith Kline, divisão de vacinas, informa que o esforço para a introdução da vacina da malária poderá ser retardado se não houver garantia dos países do G-7 em comprar o produto para ser aplicado em áreas endêmicas de malária. A GSK gastou US $25 milhões em seis anos em pesquisas que permitirá a fase final dos ensaios clínicos em 2007 e, recebeu também quantia equivalente da Bill & Melinda Gates Foundation. Segundo, o FT, "G8 officials working on plans to develop "advanced market commitments" (AMCs), by which government donors will pledge to buy agreed quantities of any successfully developed new vaccines or medicines. The initiative will provide a way of motivating pharmaceutical companies to develop cures and prevention techniques for diseases in the developing world, for which the commercial appeal is low because of the limited ability of the countries in need to pay.GSK and a number of other pharma companies have endorsed the idea of AMCs, which would provide them with enough certainty to continue investing in diseases otherwise considered too unpredictable.Italy, supported by the UK and Canada, have backed the idea of AMCs, as has the US. However, France, Germany and Japan have proved more reluctant". (destaque em negrito meu)

Comentário: as somas em jogos são minúsculas e, ridículas perto do esforço de guerra, ou das barreiras fronteiriças e aeroportuárias gastos por esses países. Se efetiva, a vacina contra a malária representaria um grande redução na mortalidade na infância na África. A proposta "AMC" é da maior importância e, pode ser solução para outras situações, como a já citada nesse bloq em relação à Doença de Chagas.

Na verdade, estamos falando do G-7, porque a Rússia não consegue nem cumprir em casa o calendário clássico de vacinação.

FDA: Coração artificial aprovado.

O FDA (Food and Drug Administration) aprovou (05/09/06) o primeiro coração artificial para comercialização chamado AbioCor para pacientes em insuficiência cardíaca terminal. A decisão do FDA foi oposta ao comitê de especialista, contrário à liberação em votação apertada (7/6). A aprovação foi baseada em um pequeno estudo de 14 pacientes tratados entre 2001 e 2004. O aparelho aumentou a sobrevida em média 5,2 meses, embora um paciente sobreviveu por 18 meses. A idade de indicação é entre 25 a 50 anos, com peso de no mínimo 80 kg ou mais alto que 1,78 m. O aparelho custará US $250.000,00.

Comentário: apesar do preço estratosférico e da indicação restrita, casos anteriores mostram que há risco de que o "complexo médico - industrial - midiático" com o respaldo de ONGs iniciem um processo de sensibilização para dispensação do equipamento pelo SUS.

Conselhos de saúde na imprensa leiga: no meio do horror, um espaço para Stuart-Mill

Domingos, feriados e, principalmente feriadões são momentos de leitura mais cuidadosa de jornais e revistas. Poucos artigos interessantes com análises originais, a maioria segue a linha da auto-ajuda ou da intimidação à saúde do leitor, caso ele ou ela não siga os conselhos dos entrevistados. Primeiro foram os psicólogos/psiquiatras/psicanalistas, depois médicos em geral, agora professores de educação física com algum tipo de treinamento tibetano, falam da vida com um conhecimento próprio do Dalai Lhama. Os palpiteiros das várias profissões desconhecem como o "conhecimento" que divulgam de forma incompleta foi concebido. Pior ainda, eles não medem os efeitos negativos de recriminações ou de sugestões divulgadas relacionadas ao chamado "estilo de vida".

Eles conseguem espaço porque vendem um produto inexistente: a vida eterna e sem conflitos; Porém, essa questão não é nova. Trata-se de objeto da filosofia e da ética há muito tempo. Duas frases são fundamentais a serem lembradas, a primeira de John Stuart-Mill (1806-1872): "o único objetivo para o qual o poder pode ser justamente exercido contra o desejo de qualquer membro de uma sociedade civilizada é para evitar dano aos outros. Exercer o poder contra o desejo de um cidadão unicamente para evitar um prejuízo físico ou moral a ele próprio, não constitui justificativa aceitável." ( do original em Three essays: On liberty, representative government, the subjection of women (original 1859, London: Oxford University Press: "the only purpose for which power can be rightfully exercised over any member of a civilised community against his will is to prevent harm to others. His own good, either physical or moral, is not sufficient warrant") . A segunda bem mais recente de Ian Markham: "os pais tomam decisões por seus filhos na crença que isso é o melhor para eles. Permite-se aos pais o direito de ser paternalista. Contudo, médicos não são pais e adultos não são crianças. Embora seja tentador ao médico usar o seu conhecimento para decidir o que é o melhor, o respeito a autonomia do indivíduo deveria impedir tal ato". (traduzido de Markham, Ian S. Ethical and legal issues. Br Med Bull1998: 54:1011-21: "parents make decisions for their child in the belief that this is for the child's good without the child's permission. Parents are permitted to be paternalistic. However, doctors are not parents and adults are not children. Although it is tempting for the doctor to use their expertise to decide what is best, respect for an individual's autonomy should forbid this".)

Alho, batata e limão para o HIV: a receita do Ministro sulafricano.

Eu também concordo com a carta enviada por mais de 50 cientistas pedindo a demissão do Ministro da Saúde da África do Sul. Ignorância pode matar mais do que conflitos armados.

Mr Thabo Mvuyelwa Mbeki President Republic of South Africa Union Buildings West wing 2nd Floor Government Avenue Pretoria 4 September 2006 Dear President Mbeki We are members of the global scientific community working on HIV/AIDS who wish to express our deep concern at the response of the South African government to the HIV epidemic. HIV causes AIDS. Antiretrovirals are the only medications currently available that alleviate the consequences of HIV infection. The evidence supporting these statements is overwhelming and beyond dispute. Much credit for the impressive advancement of HIV science belongs to scientists and clinicians based in South Africa and elsewhere on the African continent. Their expertise should play a critical role in alleviating the awful consequences HIV has caused to South African society. We are therefore deeply concerned at how HIV science has been undermined by the South African Minister of Health, Dr Manto TshabalalaMsimang. Before and during the XVI International AIDS Conference, Dr TshabalalaMsimang expressed pseudoscientific views about the management of HIV infection. Furthermore, the South African government exhibition at the Conference featured garlic, lemons and African potatoes, with the implication that these dietary elements are alternative treatments for HIV infection. There is no scientific evidence to support such views. Good nutrition is important for all people, including people with HIV, but garlic, lemons and potatoes are not alternatives to effective medications to treat a specific viral infection and its consequences on the human immune system. Over 5 million people live with HIV in South Africa. According to the best estimates of South African actuaries, over 500,000 people without access to antiretrovirals have reached the stage of HIV disease when they now require these medicines to save their lives. We commend the South African Department of Health's Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa released on 19 ovember 2003. This plan committed to treating over 380,000 people by this time in the public health sector. Unfortunately, fewer than half of that target number are currently receiving treatment in the public sector. Many people are therefore dying unnecessarily. We are also deeply concerned by the proliferation of unproven remedies being marketed in South Africa, some of them with the implicit or even explicit support of the Minister of Health. Slick marketing practices cause people not to take proven medications, or at best to waste money on false hopes. We condemn all those who profit from this type of quackery, at the expense of the sick and dying. We echo the words of Mr Stephen Lewis, special advisor to the UN Secretary General, that South Africa's response to AIDS is "obtuse, dilatory and negligent".

WSJ: falta de enfermeiros nos EUA levando a greves e aumento de salário.

The Wall Street Journal (05/09/06) relata que a redução de enfermagem nos hospitais americanos está propiciando greves e, consequentemente aumento de salários conforme mostrado nesse gráfico. O texto do WSJ é preciso sobre o que se passa no país: Given the shortage of nurses nationwide -- a report released in December by the American Hospital Association said U.S. hospitals needed roughly 118,000 nurses to fill vacant positions -- those companies are trying to woo nurses with special bonuses and wages that are far above the average. In addition to hiring out-of-state nurses as replacements, staffing companies try to lure nurses at nearby hospitals with high pay and bonuses to cross picket lines during their vacations. Comentário: a política de redução de custos em hospitais com corte na folha salarial, ao contrário da indústria automobilística que pode substituir operários por máquinas novas, é catastrófica com piora de qualidade e, inevitavelmente levando a greve reinvidicativa forte o suficiente para conseguir aumento salarial. A saída de contratação de mão de obra externa, principalmente das Filipinas, parece que está alcançado o seu limite.

Merck tem 5 anos para dobrar faturamento.

Isto É Dinheiro (6/06/09) apresenta a situação da indústria farmacêutica americana que poderá perder nos próximos cinco anos US$ 72 bilhões devido a perda de patentes de remédios como, por exemplo, os fabricados pelo laboratório Merck nos EUA (aqui, Merck Sharp&Dohme, MSD) que deixará de ter a patente do Zocor e Fosamax. Segundo consultores, a empresa deverá agregar mais US$20 bilhões ao faturamento atual de US$20 bilhões. Uma tarefa difícil para a empresa que enfrenta nos EUA, a batalha jurídica do Vioxx. A MSD conseguiu aprovar duas vacinas, o Gardasil para o papilomavírus (câncer de colo de útero) e Rotateq (rotavírus), Januvia ( fosfato de sitagliptina, inibidor da DPP-4, para o diabetes). Informa o texto que a MSD está interessada em abrir centros de pesquisas fora dos EUA, no Brasil, por exemplo. Essa proposta cairia muito bem apoiando os centros de pesquisa clínica que estão sendo instalados nas universidades com financiamento do Ministério da Saúde.

Comentário: trata-se de uma situação interessante, onde tanto o país poderá ganhar com o incremento da pesquisa e da inovação no país com o aporte de recursos dessa empresa na montagem ou financiamento de um ou mais centros de pesquisa ou poderá perder muito se converter o SUS em comprador desses novos produtos sem qualquer crítica. Essa é a possibilidade maior de ocorrer porque é sempre difícil controlar o lobby poderoso na mídia e entre médicos e organizações governamentais para implementar a compra de vacinas nas três esferas de governo.

Em cinco anos saberemos como colaboramos com a meta da MSD para dobrar seu faturamento: como sócios deles ou como fregueses.

O plebiscito já foi, mas a realidade continua: arma em casa aumenta risco de suicídio.

Um estudo de pesquisadores suiços publicado no American Journal of Public Health comparou em vários países a posse de armas em domicílio e a proporção de suicídios por arma de fogo em casa. O resultado foi que nos países onde desde 1980 houve redução de armas em casa, a chance de alguém da família se matar é menor.Os países onde essa associação foi bem marcante foram Noruega, Reino Unido, Canadá, Australia, e Nova Zelândia. O abstract desse texto pode ser lido na página da revista em

http://www.ajph.org/cgi/content/abstract/AJPH.2005.075812v1?papetoc

Apesar do resultado do plebiscito em outubro de 2005, o recado continua presente: arma em casa somente serve para fornecer equipamento para bandido e, aumentar o risco de suicídio.