Overview of health risk factors in Brazil
Marcia C. Castro,
14 Feb 2014
Brazil has made significant progress in reducing infectious diseases, although problems still persist. Currently non-communicable diseases (NCDs) represent the largest mortality and morbidity burden in the country. This situation may become more critical as the population ages and the prevalence for being overweight and obese increases. Brazil has a historically good record of facing health challenges through large scale campaigns. It most recently became the global leader in tobacco control, despite being among the top 5 producers of tobacco in the world. This article discusses historical and current pattern of mortality, morbidity and associated risk factors in Brazil, particularly when faced with structural demographic change. It also discusses government programmes, such as the Family Health Strategy and the Strategic Action Plan to tackle NCDs.
Health campaigns in Brazil: A brief history
Several historical events related to public health in Brazil since the Republic era, ranging from discovery of new diseases, to novel control methods of malaria, to large scale campaigns, played an important role in the past and to some extent set the context for what we observe now in the country. An important event in creating a momentum for change was a speech delivered by a physician named Miguel Pereira, in 1916, at the Medical School in Rio de Janeiro. While referring to expeditions that assessed the health conditions of rural areas in the North and Northeast regions [1-6], he stated that rural Brazil was an enormous hospital . Poor health conditions of the poor and rural populations were seen as an obstacle to economic development. Sanitation movements, which brought together physicians, scientists, intellectuals, and politicians, resulted in major reforms of the sanitary services in the country. Important milestones included the creation of the Pro-Sanitation Movement in 1916, of the National Department of Public Health in 1920, and of the Ministry of Education and Public Health Affairs in 1930 .
Large scale (and mostly vertical) campaigns were launched to address specific diseases such as yellow fever, bubonic plague, smallpox, and malaria. This model of intervention gained momentum, and many of these campaigns received support from the Rockefeller Foundation. There are campaigns still present in Brazil, such as the National Immunization Day against Poliomyelitis .
Crucial to the understanding of current health risk factors in Brazil is the demographic transition that brought about major changes to the structure of the population, coupled with patterns of economic growth and social changes that have been observed since the mid-20th century.
Brazil experienced high population growth between 1940 and 1960, an average of 2.8% per year. After a similar growth between 1960 and 1970, the growth started to decline in the 1970s (2.5%), reaching an average of 1.64% per year during 1991 and 2000 , and 1.17% between 2000-2010. The total fertility rate (TFR) remained at high and relatively constant levels between 1940 and 1960 . A modest and slow decline since the early 1900s and small oscillations in fertility in the 1950s and 1960s have been reported [9,11]. Nevertheless, important demographic transformations started in the mid-1960s. In four decades the TFR experienced a dramatic decline: from 6.3 in 1960 to 2.3 in 2000 [9,10,12], and the 2010 Population Census indicated a TFR of 1.9. This decline occurred in all regions and across different socioeconomic groups.
Regarding mortality, in the 1940s life expectancy in Brazil was below 50 years . By 2012, the number increased to 74.6 (71 for males and 78.3 for females) . Most of the gains in life expectancy were a direct result of the decline in infant mortality (IMR) . Brazil had an IMR of 162 per 1,000 live births in 1930; between 1930 and 1970, IMR declined by 29.2%, and between 1970 and 2005, it was reduced by 79.7% . According to the 2010 Population Census, IMR was 15.6.
As a result of these changes in mortality and fertility, the age structure of the population became older. In 1950 the median age of the population was 18, with 41.8% of the population concentrated in ages younger than 15, and 4.3% aged 60 or older. In 2010 the median age increased to 27, with 24.1% of the population younger than 15, and 10.8% aged 60 or older. In the wealthiest regions of the country (Southeast and South), the median age of the population is even higher, 32 .
In addition, it is worth highlighting that (i) the population became more urbanised: from 36.2% in 1950 to 84.4% in 2010; and (ii) the population had better access of infrastructure. Access to electricity increased from 68.5% in 1980 to 99.5% in 2012; 25.8% of the population had access to sanitation in 1980 and 97.4% in 2012; while 47.5% had access to piped water in 1980, while in 2012 this figured increased to 84.3%.
Figure 1: Temporal trends of some factors
Source: Castro MC, Simões CCS. Spatio-temporal trends in infant mortality in Brazil. Population Association of America, 2010 Annual Meeting, Dallas, TX. 2010:248
National income increased between the 1960s-1990s more than 3 times, accompanied by an augmentation of social disparities . Brazil became one of the most unequal countries worldwide – Brazil ranked 2nd in income concentration in 1998 , and in 1999 it was the country with the highest ratio between the average income of the 20% richer and the 20% poorer, above 30 .
Since 2001 a steady decline in inequality has been observed, with the Gini Index decreasing from 57.1 in 2001 to 50.5 in 2012 [21,22]. This decline was observed in 80% of Brazilian municipalities (http://atlasbrasil.org.br/2013/pt/).
The pattern of disease burden in Brazil has also been changing, particularly since the 1950s. The proportion of total deaths due to infectious diseases decreased from almost 50% in 1930 to about 5% in 2007 [23,24]. In contrast, in 2007 approximately 72% of all deaths were attributable to non-communicable diseases (NCDs) including cardiovascular diseases (the main cause of death), chronic respiratory diseases, diabetes, cancer, and others, including renal diseases .
Regarding infectious diseases, Brazil observed important successes/partial successes, and some failures. Among the successes are: the control of vaccine-preventable diseases, the reduction in mortality by diarrhea, and the control of Chagas disease. Partial successes include the control of leprosy, schistosomiasis, malaria, hepatitis, HIV/AIDS and tuberculosis. Among the failures are the control of dengue and visceral leishmaniasis .
Mortality and morbidity for NCDs are greatest among the poor. Age-standardised mortality due to NCDs registered a 20% decline between 1996 and 2007, mostly for cardiovascular and chronic respiratory diseases . Thedecline was associated with reductions in smoking and expansion of the primary health care. Indeed, standardised mortality rates for cardiovascular disease decreased from 287.3 per 100,000 people in 1980 to 161.9 in 2003 (the disease with largest decline in the same period was stroke: from 95.2 to 52.6 per 100,000 people ). However, diabetes and hypertension are increasing, as is the prevalence of overweight and obesity in the population .
Current situation regarding risk factors
In 2006 the Brazilian Ministry of Health established the annual 'Telephone-based Surveillance of Risk and Protective Factors for Chronic Diseases' (VIGITEL), comprising state capitals and the Federal District (about 54,000 interviews a year). It allows the analysis of risk and protective factors of NCDs found in the adult population (aged 18 years or older) .
Brazil has made important progress towards reducing smoking: the prevalence of smoking in 2011 was 14.8%, a major decline from 34.8% in 1989 (as reported by the National Survey on Health and Nutrition (PNSN)) [25,28,29]. This was achieved through several preventative legal actions commenced in 1996 (eg, increase taxes, use of picture warnings on cigarette packs, and bans/restrictions on advertising) .
While a long time series on physical activity in Brazil is not available, data from VIGITEL shows that about 15% of the adult population engaged for at least 30 minutes in some type of physical activity for at least five days a week in 2010, with the most active being young and well educated males. About 14% were inactive, and 28.2% reported to watch three hours or more of TV a day .
The nutritional transition in Brazil is of crucial importance and one of the greatest challenges ahead : while the prevalence of child stunting declined, the prevalence of overweight and obesity has significantly and steadily increased in the recent past [32,33]. In 2011 the overweight incidence among adults was 48.5% (52% among men and 45% among women); in 1974-75 the overweight incidence was 18.6% among males [34,35]. The prevalence of obesity has increased from 11.4% in 2006 to 15.8% in 2011. This is also a concern among children aged 5-9: in 2008-9, 33.5% and 14.3% of these children were overweight and obese, respectively .
The distribution of risk and protective factors is not equal among social groups. Smoking, consumption of meat with visible fat, and obesity are more common among the less-educated, while physical activity during leisure time and the recommended consumption of fruits and vegetables (five portions a day, five or more times a week) are higher among the population with 12 or more years of schooling. In addition, the highest increase in the prevalence of being overweight was observed in the North and Northeast regions (the poorest), while the increase in the prevalence of obesity was higher in the South and Southeast (the wealthiest) .
Brazil has gone through major demographic, economic and social changes, and the epidemiological transition is still ongoing. While major achievements on the health arena have been observed, important challenges remain. Regarding NCDs, for example, the number of deaths due to cardiovascular disease has increased since 1980, mainly a result of the changes in the age structure of the population that is becoming older (and thus more elderly are exposed to the risk of chronic diseases) . The standardised mortality rates, however, have been declining, mainly a reflection of declines in smoking and improved access to basic health care .
Regarding access to health care, the Family Health Program, implemented in 1994, aimed at improving access to primary health care, utilising a community-based approach for local care provision. Health care services are provided by a team comprised of at least one physician, one nurse, one nurse assistant, and up to six community health workers; some teams may also include a dentist and two assistants. Each team is responsible to provide care for up to 1,000 families (or approximately 4,500 people) in a determined geographical area . As of December 2013, 64.7% of the population was reached by community health agents, and 56.4% covered by family health teams (with marked regional differences) (http://dab.saude.gov.br/portaldab/historico_cobertura_sf.php).
Currently, one of the most pressing challenges regarding NDCs is the significant and steady increase in the overweight and obese population (children, adolescents and adults). To address that challenge and others, in 2011 the Brazilian Ministry of Health launched the Strategic Action Plan to tackle NCDs in the country. The Plan aims at preparing Brazil to cope with and restrain NCDs in the next 10 years. It addresses four main groups of diseases (cardiovascular, cancer, chronic respiratory, and diabetes) and their shared modifiable risk factors (smoking, alcohol abuse, physical inactivity, unhealthy diet, and obesity). It describes guidelines and measures to be taken concerning: a) surveillance, information, evaluation, and monitoring; b) health promotion; and c) comprehensive care . The suggested national goals of the programme are: reduce premature mortality rate (< 70 years old) caused by NCDs at 2% a year; reduce prevalence of obesity among children; reduce prevalence of obesity among adolescents; restrain obesity among adults; reduce prevalence of alcohol abuse; increase leisure time physical activity levels; increase fruit and vegetable consumption; reduce the average salt consumption; reduce prevalence of smoking; increase coverage for mammograms exams among 50 to 69-year-old women; increase coverage for cervical cancer preventive exam among 25 to 64-year-old women; and treat 100% of women diagnosed with precursory lesions of cancer.
In summary, on one hand Brazil has made significant progress in reducing infectious diseases, although problems still persist. On the other hand, NCDs currently represent the largest mortality and morbidity burden in the country, which can become more critical considering the ageing population and the increasing prevalence of overweight and obesity. The successful implementation of the Strategic Action Plan to tackle NCDs (described above) will be crucial in the years to come. Historically, Brazil has shown a good record of facing health challenges, and most recently became the world leader in tobacco control, despite being among the top 5 producers of tobacco in the world [30,38]. The future is yet to be written.
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