Deu no JN: bloqueio do sarampo na Bahia.

Na fase ufanística que se encontra esse blog, não dá para negar registro à reportagem do Jornal Nacional (12/01/07) mostrando a ação da Secretaria de Estado da Saúde da Bahia em fazer o bloqueio dos casos de sarampo descritos no sertão baiano. Talvez, trazido por um europeu que visitou o garimpo. Um trabalho sanitário que mostra a organização de vários serviços de saúde pública no país. O SUS representou um avanço relativamente menor no Rio de Janeiro e em São Paulo comparado aos demais estados (e, mesmo no interior do Estado do Rio), por isso haja um certo desconforto em aceitar a melhoria que o SUS representa.

Fundação Gates: dúvidas, muitas dúvidas.

Reproduzo abaixo, o post de Paulo Moreira Leite, (http://www.estadao.com.br/blogs/paulo) que discorre sobre a fundação Bill Gates a partir de reportagem do Los Angeles Times. Já critiquei aqui a questão da "vacina do amarelão" que estimulada pela Fundação Melinda e Bill Gates estará sendo produzida no Brasil (Instituto Butantan) para ser aplicado em algumas áreas do país. As prioridades do país devem ser estabelecidas no próprio país a partir da realidade concreta. Minas Gerais está com taxas ascendentes de homicídio na região metropolitana, o Jeca Tatu (se existir) com amarelão, coitado, morre de anemia, mas por sangramento devido a arma de fogo.

Bill Gates e o mito do capitalista bondoso Fiquei impressionado com uma reportagem do Los Angeles Times sobre a Fundação de Bill Gates, a mais rica do planeta, com orçamento de U$ 70 bilhões. Você e eu já lemos muitas reportagens sobre as filantropias dessa fundação. A reportagem do Los Angeles Times (reproduzida pelo Estado) mostra que a Fundação "doa pelo menos 5% de seu orçamento todos os anos, e com isso evita pagar a maioria dos impostos." Já os 95% restantes são investidos "em companhias ranqueadas entre as piores poluidoras americanas, companhias farmacêuticas que estabelecem preços para remédios fora do alcance de pacientes" e assim por diante. Conforme o jornal, investimentos que totalizam pelo menos U$ 8,7 bilhões foram feitos "em companhias que contrariam a filosofia de preocupação social da fundação."Esse tipo de descoberta não chega a ser novo. Boa parte das empresas brasileiras deixam de pagar impostos devidos para realizar investimentos de marketing -- com o nome de apoio cultural. Outras empresas investem uma migalha social -- para receber banquetes privados. Sou um otimista e acredito na espécie humana. Mas é bom desconfiar um pouco mais da humanidade depois que Milton Friedman lembrou que não existe almoço grátis.

China: cobrança em hospital público

Depois da demonstração da nossa "superioridade" sobre o sistema americano na distribuição de insulina, abaixo reproduzo um resumo de reportagem publicada hoje com acesso livre no The Lancet (http://thelancet.com) que relata os protestos violentes contra cobrança de atendimento em hospital público, isso na República Popular da China, tida como "socialista", "comunista". If the Chinese mandarins now drawing up a major overhaul of their country's health-care system needed a reminder about the urgency of their task, it was provided in violent fashion at the end of last year with a hospital riot in the birthplace of Deng Xiaoping. About 2000 protesters went on the rampage in Guangan, Sichuan Province, in November after reports that a young boy was denied life-saving treatment because his guardians could not afford the £50 treatment fee. Although the facts of the case are disputed, it highlights the growing sense of public unease about a profit-orientated health-care system in which doctors are suspected of worrying more about payment than their patients' lives.

Distribuição de Insulina: dilema nos EUA, realidade em São Paulo.

Hoje, nos Estados Unidos está em debate a distribuição de insulina a diabéticos conforme reportagem de The New York Times. Em São Paulo, nas unidades básicas de saúde, a insulina é distribuída gratuitamente desde.......1984! No Hospital das Clínicas desde.....1944?? Eu testemunhei momentos de discontinuidade tanto nas UBS como no HC, mas houve mais oferta de medicamento do que demanda. Acreditem. Hoje, tanto nas UBS (grátis) como nas "Farmácia Popular" (preço reduzido), há insulina para todos. Depois, falam mal do sistema público.

obs.1 não tenho idéia da distribuição fora de São Paulo, por isso omiti a informação.

obs2. Nos anos 70/80 havia a idéia de que produzir insulina era uma atividade estratégica para um país, daí a Biobras em Montes Claros, MG. Essa é outra história a ser recontada.

Bridling at Insulin’s Cost, States Push for Generics Kate Medley for The New York Times Rose McDaniels working at the Great Harvest Bread bakery in Jackson, Miss. She spends more than 10 percent of her income on insulin. The drug cost state Medicaid programs $500 million in 2005. And in the face of an epidemic of diabetes, the governors are asking why there is no cheaper generic version of a drug that, in one form or another, has been used since the 1920s. Rose McDaniels is wondering, too. She is a bakery worker in Mississippi, the state with the highest incidence of the disease. The $115 a month she spends on insulin consumes more than 10 percent of her income. She sometimes cuts back her dosage to make it from payday to payday, though she knows the risks. "I’m trying to make it until the next available dollar I can spare,” she said. The issue involves questions of politics and profits, as well as science. Insulin is caught in a commercial tug of war between brand-name drug companies that want to protect their franchises and generic drug makers that want to produce their own insulin products. Recently, each side has stepped up efforts to advance its side of the argument, and there are signs that Congress is ready to make life easier for generic drug companies. People with diabetes in this country, as well as government and private insurers, spend a combined $3.3 billion a year on insulin. Analysts say the price of insulin might drop by 25 percent if generic versions became available.

Now, as the nation’s diabetes rate climbs, political pressure is mounting on the Food and Drug Administration to open the door to generic versions. And Gov. Haley Barbour of Mississippi, a Republican, and 10 other governors have asked the F.D.A. to ease the way for generic insulin. “To have a lower-cost solution for our very large diabetic population is in the interest of the state and the interest of these people,” Governor Barbour said.

In Congress, some members see the generic-insulin issue as having implications for the nation’s health care bill that go well beyond diabetes treatments. Insulin is one of the most widely used of a growing category of drugs known as biologics — medicines, made from living organisms, that are the fastest-growing segment of pharmaceutical spending. Many believe that if generic insulin is approved, that would open the door to development of generic versions of other, more complex biologics. Some include popular and expensive treatments for rheumatoid arthritis, cancer and other diseases that cost tens of thousands of dollars a year. The colorectal cancer drug Avastin, for example, costs $4,000 a month. Some generic drug manufacturers say that a first step would be for the F.D.A. to adopt guidelines explaining the testing and documentation that would be required for the approval of insulin. The 11 governors from states with high Medicaid spending on insulin are pressing for such guidelines, and generic drug manufacturers say they need them to proceed with applications for insulin. But the issue has been clouded by a series of regulatory delays by the F.D.A. The agency announced in 2001 that it was developing guidelines for approving generic insulin and human growth hormone, another widely used and long available biologic.

Those guidelines have never been released, however, partly, critics say, because of pressure from the Biotechnology Industry Organization, which represents the brand-name makers of biologic drugs. The association argues that the same shortcuts to approval that are granted for conventional generic drugs are not applicable to biologics, even simple ones like insulin. Those shortcuts include an exemption from the long clinical testing required for approval of brand-name drugs. The trade group has been working to make sure generic drug companies cannot piggyback on the clinical studies done by drug innovators.

The F.D.A. says that it is studying the issue, but believes that it is more appropriate to develop guidelines that would apply to all biologics rather than to issue guidelines for individual products like insulin and human growth hormone. The agency has said it will release a scientific background paper this spring that examines the issue. But Senator Orrin Hatch, a Utah Republican, and Representative Henry Waxman, a California Democrat, asked last year why the guidelines for insulin and human growth hormone had not been released. “There is simply no excuse — scientific, legal or otherwise — for the F.D.A. to delay the release of these guidelines,” the lawmakers said in a letter to the F.D.A.

As Congress looks for ways to reduce health care spending and broaden access to drugs, Mr. Waxman, who heads the House Oversight and Government Reform Committee, has said that legislation encouraging the development of generic biologics is one of his top priorities.

O crime não compensa, mesmo. Ex-detentos morrem muito mais.

Apesar da tradição ocidental em "glamourizar" (existe esse verbo?) o crime e criminosos, desde o "O Poderoso Chefão" de Mário Puzo até "O Guri" de Chico Buarque, ser mal não compensa. Além de vaga cativa no inferno, o caminho a ele é mais curto. Vejam, o resumo do artigo abaixo publicado no The New England Journal of Medicine sobre mortalidade de ex-detentos.

Release from Prison — A High Risk of Death for Former Inmates Ingrid A. Binswanger, M.D., Marc F. Stern, M.D., Richard A. Deyo, M.D., Patrick J. Heagerty, Ph.D., Allen Cheadle, Ph.D., Joann G. Elmore, M.D., and Thomas D. Koepsell, M.D. Background The U.S. population of former prison inmates is large and growing. The period immediately after release may be challenging for former inmates and may involve substantial health risks. We studied the risk of death among former inmates soon after their release from Washington State prisons. Methods We conducted a retrospective cohort study of all inmates released from the Washington State Department of Corrections from July 1999 through December 2003. Prison records were linked to the National Death Index. Data for comparison with Washington State residents were obtained from the Wide-ranging OnLine Data for Epidemiologic Research system of the Centers for Disease Control and Prevention. Mortality rates among former inmates were compared with those among other state residents with the use of indirect standardization and adjustment for age, sex, and race. Results Of 30,237 released inmates, 443 died during a mean follow-up period of 1.9 years. The overall mortality rate was 777 deaths per 100,000 person-years. The adjusted risk of death among former inmates was 3.5 times that among other state residents (95% confidence interval [CI], 3.2 to 3.8). During the first 2 weeks after release, the risk of death among former inmates was 12.7 (95% CI, 9.2 to 17.4) times that among other state residents, with a markedly elevated relative risk of death from drug overdose (129; 95% CI, 89 to 186). The leading causes of death among former inmates were drug overdose, cardiovascular disease, homicide, and suicide. Conclusions Former prison inmates were at high risk for death after release from prison, particularly during the first 2 weeks. Interventions are necessary to reduce the risk of death after release from prison.

O Exterminador do Passado: a saga continua.

O Governador da Califórnia, Arnold Schwarzenegger volta a sua proposta de estender a cobertura de assistência médica aos 6,5 milhões (quase um quarto) de habitantes do estado que não possuem qualquer tipo de cobertura. Abaixo, a notícia de hoje, no The Wall Street Journal. Schwarzeneger que protagonizou o Exterminador do Futuro, agora como homem público tenta exterminar o passado (vergonhoso) da ausência de seguridade na assistência médica. A questão será como financiar essa proposta em um estado com problemas fiscais, mas com uma riqueza econômica ímpar. Essa atitude de um governador republicano poderá estimular a maioria democrata no Congresso a avançar na proposta de cobertura universal.

Schwarzenegger Embarks On Fight for Health Plan California Gov. Arnold Schwarzenegger proposed a sweeping plan to mandate universal health care in the nation's most-populous state, putting forth measures that would require employers to pay into the health-care system as well as tax hospitals and doctors to help offset medical coverage's spiraling costs. The move makes Mr. Schwarzenegger, a Republican, the latest governor to try to tackle a problem -- covering the uninsured -- that the federal government has been unable to solve. Massachusetts Gov. Mitt Romney, who is seen as a Republican contender for the presidency, struck a bipartisan deal with his state's legislature last year mandating universal health care in the Bay State. Mandates for some employers to pay more of their share if they don't already have been passed in Vermont and Maryland, as well as New York City and San Francisco. Maryland's law was thrown out by a federal judge last year after a legal challenge. California, with 36 million residents, could influence other states to follow suit. But Mr. Schwarzenegger also faces potentially one of the fiercest battles of his political career, because his plan calls for some level of sacrifice from many of the parties affected. The governor anticipated criticism in his remarks yesterday to a Sacramento gathering of his staff and business executives, saying the long-term rewards of having lower medical costs would make the pain worthwhile. "It appears we are taking something away from everyone here," Mr. Schwarzenegger said by video link as he recuperated from a broken leg injury he suffered while skiing over the holiday break in Sun Valley, Idaho. "But when you look at the math, they actually benefit. Everyone is left with a better deal, even though everyone has to chip in." The governor said his plan to charge a "dividend" of 2% on doctors' revenue and 4% on hospitals' would be more than offset by what his office estimates would be $10 billion to $15 billion in new money coming into the medical system from so many people being insured, as well as a proposed increase in the state's Medi-Cal plan. California now has about 6.5 million people who are uninsured or underinsured, a higher level than any other state. According to the Census Bureau, 15.9% of Americans lacked health insurance in 2005; in California, it was 19.4%. The Schwarzenegger plan drew some skepticism. "There may be some unintended consequences," said Joel Fox, president of the Small Business Action Committee in Sacramento, in a panel discussion organized by the governor's administration after the speech. "For example, will some businesses opt out of covering employees and go into the pool [of state-insured workers], thus overwhelming the pool? Will some companies cherry-pick their employees so that they hire those more easily covered, instead of guys like me that are older?" Allan Zaremberg, president of the California Chamber of Commerce, questioned whether the plan would really make health care more affordable for those who already are insured. Mr. Zaremberg said the taxes on doctor and hospital revenues could be passed onto consumers and the companies that already provide insurance in higher premiums. Others praised the plan. Officials of Blue Cross of California called it "bold and visionary," singling out the provision to provide medical coverage to all uninsured children in the state, even those of illegal immigrants. "Taking each part separately, there's something for everyone to hate, but taken as a whole, there's a lot to like," said Bruce Bodaken, chairman, president and Chief Executive of Blue Cross of California. Some other business leaders, including the chief executive of California-based grocery titan Safeway Inc., are also backing the plan. One reason: They already pay to fund medical plans for their employees, and resent the competitors who don't. On balance, the governor likely will have a tougher time persuading members of his own party to back the measure than the Democratic lawmakers who control the California Legislature. Indeed, Mr. Schwarzenegger's plan isn't hugely different from versions recently proffered by state Senate President Don Perata and Assembly Speaker Fabian Nunez. Mr. Nuñez said in an interview that he just had a few issues with the governor's plan -- most important, that it would shift money from one program for the poor into this health-care program. "On its face, this is a good start," Mr. Nuñez said.

Epidemiologistas brasileiros em alta: César Victora e Jarbas Barbosa.

Apesar da política federal não ler nem aquilo que está à disposição na página eletrônica do próprio Ministério da Saúde, a vida continua. César Victora da Universidade Federal de Pelotas é motivo de homenagem de uma página no The Lancet. (http://www.thelancet.org) e Jarbas Barbosa depois de uma carreira brilhante na vigilância epidemiológica do Ministério está se mudando para Washington, para chefiar essa área na Organização Panamericana de Saúde.

Ao dois, parabéns!

PS. Jarbas em entrevista ao Estadão comete o ato inusistado de reconhecer erros na condução de política de controle da dengue. Muito boa essa auto-crítica porque até há pouco tempo somente médicos e enfermeiros erravam, sanitaristas sempre estavam certos, o mundo é que passou a girar na direção inversa.

Regionalismo e o gosto pelo marketing: a falência a epidemiologia.

Um correspondente anônimo questionou o fato de eu destacar em demasia que os homicídios ocorrem com mais intensidade muito mais fora do eixo RJ-SP ao contrário do senso comum. . Alega que sou "regionalista do sudeste". Errado, muito pelo contrário. Estou mostrando que a vida de um brasileiro fora de São Paulo e Rio de Janeiro deve ser considerada tanto quanto dos habitantes dessas duas metrópoles. Hoje, nos jornais os governadores de Rio e São Paulo estão exigindo mais verbas federais para segurança. E, Pernambuco, com altas taxas, não mereceria muito mais recurso, proporcionalmente a São Paulo e Rio de Janeiro?

Na minha opinião, sim. Essa é a diferença entre a política baseada na impressão e, aquela com base na realidade. A epidemiologia deveria ser uma forma de guiar as políticas públicas. O Ministério da Saúde e as Fundações de Apoio a Pesquisa estaduais se esforçam financiando projetos de pesquisa com esse foco. Mas, a "grande política" - governo federal e estadual - despreza a realidade da população, priorizando as necessidades de aliança política. Bem, para quem já pariu duas inutilidades como o "Fome Zero" e a primeira "Farmácia Popular" provindas de marqueteiros, não há porque a epidemiologia esperar qualquer tipo de reconhecimento.

Homicídios: ranking dos aglomerados urbanos

Recebi um desafio de mostrar a posição de todas as cidades brasileiras no ranking das taxas de homicídio. Impossível. O adequado é calcular para os 56 aglomerados urbanos, tal como definidos pelo IBGE, que correspondem a 51,3% da população brasileira. Calculei para o triênio 2002-04 somente homens entre 10 e 79 anos. Os valores em (x100.000 habitantes) são apresentados para os aglomerados acima do valor do conjunto dos aglomerados.

ranking

Vitória=189,1; Recife=169,9; PortoVelho=142,0;Caruaru=139,7; Petrolina/Juazeiro=139,3;Maceió=135,5;Rio de Janeiro=122,7;Cabo Frio= 116,8; Belo Horizonte=114,6; São Paulo=108,1;Macapá=103,9; Cuiabá= 100,7; Baixada Santista=92,1;todas cidades=91,4;

tendências no período 1996-2004

(1) francamente declinante: São Paulo, Macapá, Cuiabá, Baixada Santista.

(2) discretamente declinante: Vitória, Recife, Rio de Janeiro

(3) francamente ascendente: Porto Velho, Belo Horizonte, Maceió, Petrolina/Juazeiro, Cabo Frio,

(4) estável: Caruaru

Esses dados, todos oficiais e nunca constestados, porque foram enviados pelos próprios governos estaduais mostra que a questão da violência não é um problema do eixo Rio-São Paulo, unicamente. Se, assim for considerado haverá erros importantes nas políticas de segurança pública. Leia-se, manobras policiais boas de mídia e, péssimas de efetividade.

Posso enviar o resultados dos demais aglomerados a quem se interessar.