Vamos a la playa !

Voltarei no ano que vem, se tiver condições físicas em ler e escrever todos os dias. No ano que se encerra foi particularmente difícil manter atualizada a temática desse blogue. Agradeço às três centenas de leitores fiéis, que sempre reclamam da ausência em vários períodos.

Em janeiro, na Rádio USP, se iniciará o programa Saúde Global, onde temas de interesse geral na área da saúde serão apresentados por mim e, depois serão disponibilizados no aqui.

Enquanto isso, "vamos a la playa"...

Brasilíadas: sugestões de leitura

1. leitura rápida: Estudos Avançados da USP (edição 64, nov/dez de 2008) sobre Epidemias e, de quebra comentários sobre Machado e Rosa.

2. para quem gosta de polêmica: O povo de Luzia, em busca dos primeiros americanos, de Walter Neves e Luiz Piló, editora Globo.

3. para quem quer conhecer Pernambuco: Epidemiologia, políticas e determinantes das doenças crônicas no Brasil, de Eduardo Freese (coordenador), editora da UFPE.
4. para quem se chocou com Bye-bye Brasil de Cacá Dieguez: The Xavánte Transition, de Carlos Coimbra, Nancy Flowers, Francisco Salzano e Ricardo Santos.

Lusíadas: leituras de fim de ano

1. leitura rápida:Revista de História da Biblioteca Nacional (dezembro de 2008): "Angola é aqui, nossa história africana".

2. para engenheiros e candidados a MBA: Sagres, a revolução estratégica, de Luiz Fernando da Silva Pinto, 11a edição, Editora SENAC.

3. para nutricionistas e gourmets: No tempo das especiariarias, de Fábio Pestana Ramos, Editora Contexto.

4. para quem se prepara para a FUVEST 2010: Por mares nunca dantes navegados, de Fábio Pestana Rmanos, Editora Contexto

5. para apreciadores de romance histórico: Equador, de Miguel Souza Tavares, editora Nova Fronteira, presente do amigo secreto.

6. da série não empresto a nínguém: Goa, história de um encontro, de Catarina Portas e Inês Gonçalves. editora Almedina.

Além da Big Pharma

Sou da época do professor de biologia que fazia um círculo no quadro-negro com o nome SOL e, afirmava que sem essa essa estrela de quinta grandeza não haveria vida no planeta Terra.

Recentemente, dermatologistas e, hoje oftalmologistas (Folha de S.Paulo) passaram a considerar os raios emitidos pelo Astro-Rei como perigososos aos seres humanos. Obviamente, a Sundown continua agradecendo à possibilidade de aumentar a sobrevida dos humanóides e, agora a RayBan se sente regojizada em poder proteger os incautos Homo sapiens.

Novamente, recomendo que seja traduzido "Skin, a natural history" de Nina G. Jablonski. A revista Science comentou "Jablonski show us that skin, be it thick or thin, is the true mirror of soul".

Começando o centenário da descrição da Doença de Chagas

Prognostic impact of Chagas disease in the United States

American Heart Journal Volume 157, Issue 1, Pages 22-29 (January 2009
José Milei, MD, PhD, Roberto Andrés Guerri-Guttenberg, MD, Daniel Rodolfo Grana, VMD, Rubén Storino, MD, PhD
A prior publication from our group reported the fact that Chagas disease is underdiagnosed. This review will summarize several aspects of Chagas disease in the United States including modes of transmission, which will demonstrate that clinicians should be more aware of the disease and its consequences.
Trypanosoma cruzi is present in many animal species spread throughout most of the United States. Chagas disease also reaches the North American continent through immigration, making it more frequent than expected. Apart from immigration, non-endemic countries should be aware of transmissions through blood transfusions, organ transplantations, or mother-to-child infections.
In conclusion, it is possible that many chagasic cardiomyopathies are being misdiagnosed as “primary dilated idiopathic cardiomyopathies.” Recognizing that there is an evident threat of Chagas disease present in the United States will allow an increase of clinician's awareness and hence will permit to correctly diagnose and treat this cardiomyopathy. Health authorities should guarantee a generalized screening of T cruzi of blood donors, before organ donations, and of pregnant women who were born or have lived in endemic areas.

Crack se espalha no país

O Estadão nesse domingo repercutiu pesquisa recente do CEBRID sobre consumo de crack no país. Não encontrei os dados no site do CEBRID, mas isso não importa. Os dados são impressionantes e, muito semelhantes aos observados nos Estados Unidos. Em São Paulo, onde há queda, o consumo se mudou para a área rural e pequenas cidades, embora a cracolândia - bem menor - ainda resista.

O mais importante nesse caso foi a discussão sobre a relação crack e homicídio. Aparentemente, há uma relação relativamente direta entre os dois fenômenos.

Na extensa reportagem há dois momentos que seriam engraçados, se não fossem dramáticos.

O primeiro do responsável pelo programa de saúde mental do Ministério que reclama da falta de leitos, que ele mesmo reduziu. O segundo, de professor universitário cujo discurso leva a concluir que as taxas de homicídio se reduziram em São Paulo por causa do PCC que teria organizado o crime.
Em 20 anos, crack alcançou todo o País
Bruno Paes Manso
Os primeiros relatos sobre o consumo de crack no Brasil surgiram em 1989, entre crianças que viviam nas ruas do centro de São Paulo, um ano antes da primeira apreensão da droga feita pela polícia na cidade. Feito do cozimento da cocaína com bicarbonato de sódio, potente, barato, famoso pela fissura que causa nos viciados, sempre em busca da próxima dose, 20 anos depois do começo da epidemia em São Paulo o crack migrou para os demais Estados e o mercado da droga se consolidou em todo o País.A droga já teve o uso identificado entre consumidores das 27 capitais brasileiras, principalmente jovens e pobres, conforme pesquisas do Centro Brasileiro de Informações sobre Drogas Psicotrópicas (Cebrid). Em São Paulo, Rio, Porto Alegre e Salvador, 39% dos pacientes que procuraram os principais centros de tratamento ambulatorial e hospitalar tinham problemas com crack, duas vezes mais do que os pacientes viciados em cocaína, segundo o Centro de Pesquisa em Álcool e Drogas da Universidade Federal do Rio Grande do Sul.No Rio, onde o Comando Vermelho proibiu que o crack fosse comercializado na década de 1990, a droga chegou com força há cinco anos."É um tsunami e a principal preocupação atual nas comunidades. Favelas como Manguinhos e Jacarezinho têm cracolândias deprimentes", diz Sílvia Ramos, do Centro de Estudos de Segurança e Cidadania da Universidade Cândido Mendes.No Estado de São Paulo, a apreensão de crack pela polícia bateu recorde neste ano, alcançando até setembro 731 quilos, 10% mais do que o total de todo o ano passado. No mesmo período, diminuiu a quantidade de maconha e cocaína apreendida. Para piorar, o problema migrou para municípios paulistas de pequeno e médio porte, alcançando trabalhadores rurais das plantações de cana-de-açúcar.Em São José do Rio Preto, cidade de 450 mil habitantes do interior do Estado, há pelo menos 1.200 viciados em crack sendo acompanhados pelo programa de redução de danos à hepatite e HIV. "Nove mulheres estão grávidas", diz a coordenadora de Saúde Mental de São José do Rio Preto, Denise Doneda. A gravidade do crescimento da comercialização do crack foi um dos principais pontos de discussão do encontro de colegiado dos coordenadores de saúde mental ligados ao Ministério da Saúde, ocorrido em novembro. De Dourados, em Mato Grosso do Sul, veio o relato de que o crack estava sendo consumido entre comunidades indígenas que vivem perto de centros urbanos. "Existe grande dificuldade para lidar com o problema porque a abordagem ao viciado é complicada e não existem leitos hospitalares à disposição para o tratamento", diz Pedro Gabriel Delgado, coordenador Nacional de Saúde Mental do Ministério da Saúde.A disseminação do uso em pequenas cidades brasileiras também foi outro ponto destacado no encontro. Em Estados nordestinos, que demoraram a sentir o drama do crack, a droga já aparece entre as preferidas dos usuários. Em Pernambuco, o crack começou a chamar a atenção entre os anos de 2001 e 2002, principalmente na região metropolitana do Estado. Atualmente, já atinge o agreste e o sertão - área tradicional da maconha.Quixadá, no Ceará, e Picos, no Piauí, são outros municípios que registram problemas com o crack. Em Salvador, viciados que se concentram em cracolândias no centro histórico são chamados de sacizeiros, em referência ao cachimbo usado no consumo. "Em 2004, 25% da droga consumida no Recife era crack. Em 2006, chegou a 50%", diz José Luiz Ratton, coordenador do Núcleo de Pesquisas em Criminalidade, Violência e Políticas Públicas de Segurança da Universidade Federal de Pernambuco.É na Região Sul, no entanto, que atualmente o problema aparece de forma mais dramática. No Paraná, três das cidades mais violentas do Brasil, Foz do Iguaçu, Guaíra e Curitiba, sofrem os efeitos da chegada do crack. Nas quatro principais maternidades de Porto Alegre, nasceram neste ano 117 crianças filhas de mães viciadas. A Secretaria de Saúde do Estado estima que existam atualmente 50 mil viciados na droga. "Duas coisas ajudaram essa disseminação pelo Brasil. Primeiramente, a natureza do produto, forte, barato e bem-aceito entre os mais pobres. Depois, a disseminação das rotas de cocaína para o Sul e o Centro-Oeste", afirma Fernando Francischini, secretário Antidrogas de Curitiba, ex- delegado da Polícia Federal responsável pela prisão do traficante Juan Carlos Ramirez Abadía.

Um alerta: celebridades científicas e médicas irão dominar a cena

Para quem considera que o jornalismo chegou ao fundo do poço com o livro publicado sobre o "caso Eloá"; e, para quem acha que se passou da conta no "caso Isabela Nardoni"; e, finalmente para aqueles que qualquer notícia sobre o caso "ex-qualquer coisa de Suzana Vieira" foi o limite do suportável, aguardem o pior.

Na área médica e científica, a situação caminha para a consagração de celebridades, sejam pessoas físicas ou jurídicas. Quem leu ministro afirmar que o centro de gravidade da ciência e tecnologia se moveu para hospitais privados sente o despautério. Quem viu presidente, ministros, governador e prefeito paparicando um centro de cardiologia de hospital privado sentiu a barra. Quem vê pesquisador mais interessado em aparecer em coluna social a publicar um artigo científico e, depois reclamar de bancas de julgamento sabe do que se trata. Quem lê blogue de cientista prometendo a cura dos males da humanidade também entende o problema sério com o qual nos deparamos.

Em breve, teremos o Datena criticando a escolha de projetos do Instituto Nacional de Ciência e Tecnologia, a Hebe Camargo indicando o seu candidato preferido para professor titular e, por aí caminharemos.

Ao invés, de estudar para um concurso acadêmico, o candidato será entrevistado no Jô Soares e, utilizará esse fato como ponto alto de seu currículo acadêmico.

Ao CAPES, sugiro que novos critérios sejam estabelecidos como menção em coluna social. A única dúvida: menção em Mônica Bérgamo (Folha) ou Sônia Racy (Estadão) devem ser consideradas ambas como Qualis A? Citação na Vejinha seria Qualis B, porque regional, mas em Veja, seria Qualis A, correto?

Ao CNPq e à FAPESP sugiro que pagamento de assessoria de imprensa (serviços de pessoa jurídica) seja permitido na solicitação de qualquer projeto, afinal não é justo que somente quem tem cônjuge rico possa ter seu esquema de promoção.

Porque o câncer não superará as doenças cardiovasculares no Brasil em 2020

A imprensa repercutiu essa apresentação o IARC afirmando que as mortes por câncer superarão as por doenças cardiovasculares em 2020. Não há um único estudo sobre o tema, trata-se de mera especulação , a não ser que na China e India, o hábito tabágico se espalha. Mas, o tabagismo também aumenta o número de mortes por doença cardiovascular.

No Brasil, esse quadro não acontecerá porque a prevalência:

1.de hipertensão é muito elevada quando comparada aos países europeus e EUA.

2. do tabagismo nunca foi elevada como na Europa, EUA e Ásia.
3. da obesidade e do diabetes está em elevação e, terá impacto na mortalidade cardiovascular como já se observa no EUA.
O mais grave da afirmativa do IARC é desconhecer que o espectro das doenças cardiovasculares naõ se restringem à sindrome coronariana aguda e à doença cerebrovascular. Essas duas entidades clínicas são manifestações do fenômeno aterosclerótico-hipertensivo que evoluirá para acometer outros órgãos (rins, retina, córtex cerebral) e funções (renal, visual, cognitiva, auditiva).

Cancer set to overtake heart disease as top global killer December 11, 2008 Lisa Nainggolan and Nick Mulcahy
Aarhus, Denmark - Cancer is set to overtake cardiovascular disease to become the leading cause of death worldwide by 2010, according to a new report [1] from the International Agency for Research on Cancer (IARC), a division of the World Health Organization (WHO). President of the American Heart Association (AHA), Dr Tim Gardner, told heartwire he applauds the new report and looks forward to working with cancer organizations to tackle risk factors that increase the likelihood of both cancer and cardiovascular disease.
According to the IARC report—which is a call to action asking governments to help fund cancer-prevention and research initiatives and international tobacco-control policies—the burden of cancer doubled globally between 1975 and 2000 and is set to double again by 2020 and nearly triple by 2030.
The report—which was discussed at an event in Atlanta this week called Conquering Cancer: A Global Effort—says that low- and middle-income countries will experience the impact of higher cancer incidence and death rates more sharply than industrialized countries.
The factors they have identified as predictive of an increase in cancer deaths are the very same factors that are going to result in more cardiovascular deaths, too.
This is also true of heart disease—just last week, as reported by heartwire, researchers predicted that 85% of cardiovascular deaths worldwide would occur in low- and middle-income countries by 2030. However, the authors of this article stressed that there still exists "a window of opportunity" to prevent the epidemic from reaching its full potential and magnitude.
Among the reasons stated by the IARC for the growing cancer burden is the adoption in less well-developed countries of "Western" habits, such as tobacco use and high-calorie, high-fat, and trans-fat diets.
"Obviously, this new cancer report is an important prediction," Gardner told heartwire. "The risk and demographic factors they have identified as predictive of an increase in cancer deaths are the very same factors that are going to result in more cardiovascular deaths, too, so we are on the same track." US deaths from cancer and heart disease currently declining
The news on cancer in developing countries is in contrast with another recent report that shows cancer incidence and death rates for men and women in the US continuing to decline [2].
The number-one and number-three killers in the US currently are coronary heart disease and stroke, respectively, says the AHA [3].
And while the nation has already made progress in reducing death rates from these two conditions, Gardner says that without a concerted effort to reduce some key risk factors, such as obesity and physical inactivity, "the momentum of reducing heart disease and stroke deaths will be lost. We will see our children developing heart disease earlier. This could reverse the progress in cardiovascular death rates that we have seen over the past decade."
We are not jealous about our position in terms of heart disease being the number-one killer.
"We are not jealous about our position in terms of heart disease being the number-one killer; it's a distinction none of us want to have," he added. "The AHA has been working for decades to move out of that 'top spot' of being the number-one killer. But unless we can do better in reducing some of these risk factors in the US, it may be a long time before we can shed the title of number one."Smoking is the easiest target
Cigarette smoking accounts for nearly 440 000 of the more than 2.4 million annual deaths in the US, and there are catastrophic predictions for the number of deaths that will occur due to smoking in developing countries. In India, for example, new research published earlier this year forecasts that by 2010 around one million deaths per year there will be attributable to smoking.
"Tobacco use is an enormous health burden across the globe and makes a significant contribution to deaths from both cancer and cardiovascular disease," Gardner adds.
"We applaud the findings of the IARC report. We're very concerned about smoking rates in the US and newly developed countries, and we are really working very hard on trying to deal with that—the one risk factor that can most easily be targeted."
Sources
Leading US cancer organizations unite against the growing global cancer burden [press release]. December 9, 2008. Available at: http://www.eurekalert.org/pub_releases/2008-12/acs-luc120908.php.
Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin 2008; 58:71-96.
American Heart Association. American Heart Association comment on the International Agency for Research on Cancer, World Cancer Report [press release]. December 11, 2008. Available at: http://americanheart.mediaroom.com/index.php?s=43&item=625.

Prevenção do Câncer de Próstata: melhor do que InCa e SBU

Abaixo, um artigo do New England Journal of Medicine bem melhor do que as opiniões enviesadas da Sociedade Brasileira de Urologia e "a posição firme e decidida" do Instituto Nacional do Câncer. Aliás, um dos momentos mais infelizes do ano, foi o protagonizado por ambos, Sociedade e Instituto.

Screening for Prostate Cancer among Men 75 Years of Age or Older. Michael Barry.

Prostate-cancer screening with the prostate-specific antigen (PSA) test remains one of the most controversial issues in modern medicine. The U.S. Preventive Services Task Force (USPSTF), an independent group of experts supported by the Agency for Healthcare Research and Quality under a mandate from Congress, recently revised its recommendations regarding prostate-cancer screening. The USPSTF concluded that "the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years," but it now "recommends against screening for prostate cancer in men age 75 years or older."1 In its 2002 statement, the task force did not recommend for or against screening in either age group. The implication of the new recommendation for medical practice is that clinicians should discuss the potential benefits and known harms of screening with men between 50 and 74 years of age, but not necessarily with older men.
Why change the recommendation for men 75 or older, at least given the continuing dearth of evidence from randomized trials that addresses the tradeoff between the benefits and harms of prostate-cancer screening in men of any age? The task force believes that at least a moderate amount of evidence now makes it possible to conclude that the known harms of screening outweigh the possible benefits for this age group.
This statement does not imply that prostate cancer is an unimportant problem among men 75 or older; in fact, as the statement acknowledges, 71% of deaths due to prostate cancer — almost 20,000 annually in the United States — occur after the age of 75. Moreover, it does not mean that no men 75 or older could possibly benefit from screening. After all, there are relatively healthy men in their late 70s and even early 80s harboring high-grade cancers that are likely to kill them; early detection and attempted curative treatment might prevent these men from dying from prostate cancer. So why not continue to offer screening after the age of 74?
First, the effectiveness of attempted curative treatment for prostate cancer among men 75 or older appears to be low or negligible. In the only published randomized trial comparing the effect of radical prostatectomy with a strategy of "watchful waiting" for men with clinically localized prostate cancer, the benefit of radical prostatectomy was statistically significant but small, with an absolute difference of 5.4 percentage points in the rate of death due to prostate cancer at 12 years (which has not widened with continued follow-up). This difference means that about 18 radical prostatectomies would have to be performed to prevent a single death from prostate cancer over a 12-year period.2 However, in subgroup analyses at both 10 and 12 years of follow-up, even this level of effectiveness appeared to be confined to men 65 years of age or younger. Men 75 or older were not enrolled, presumably because they were considered less likely to benefit from surgery.
It is important to note that less than 10% of subjects in this Scandinavian trial had their prostate cancer diagnosed through screening. The long average lag time between a detectable increase in the PSA level — 5 to 10 years — and the development of clinical cancer, as well as the possibility of overdiagnosis associated with PSA screening, suggests that an even smaller benefit may be seen in the U.S. Prostate Cancer Intervention versus Observation Trial (PIVOT), in which about three quarters of participants had their cancer diagnosed through PSA screening. Results from PIVOT are expected in 2010. As in the Scandinavian trial, men 75 or older were not enrolled.
The effect of competing hazards would also attenuate the benefit of screening and attempted curative treatment for men 75 or older. Given the slow growth of most prostate cancers and the resultant long lead times between detectability and clinical disease, men may need to live much longer than 10 years to reap the benefits of PSA screening — and of course, preventing a death from prostate cancer does not bestow immortality. For example, out of 1000 75-year-old male nonsmokers, 19 would be expected to die of prostate cancer over the next 10 years, whereas 430 would be expected to die of other causes.3 Even if a few of the deaths from prostate cancer could be prevented within this time frame, the effect on overall mortality would be small. And fewer older men than younger men would still be alive beyond 10 years to reap any delayed benefits of screening; for example, life expectancy for men surviving to the age of 85 is about 6 years.
Whereas the benefits of screening attenuate with age, the harms increase. PSA levels are strongly age-dependent, so at any given PSA threshold, older men will have substantially higher risks of both requiring a prostate biopsy and being diagnosed with prostate cancer. For example, about 6% of men in their 60s, 21% in their 70s, and 28% in their 80s would be expected to have a PSA level above 4.0 ng per liter,4 a common threshold for considering a prostate biopsy. Regular PSA screening roughly doubles the risk that men will have to face a diagnosis of prostate cancer over the next 10 years, but many of these cancers would never present clinically. Given that the risk of prostate cancer is also age-related, this effect will be greatest among older men. And finally, the risks of both postoperative death and complications of radical prostatectomy are age-related, escalating after the age of 75.5
Given the unfavorable trade-off between the possible benefits and known risks of prostate-cancer screening after the age of 74, I believe the USPSTF recommendation is sound. As with all guidelines, clinical judgment should be used in its application. For example, given the relationship between self-rated health and life expectancy, a clinician might consider having a discussion about PSA screening with (not simply testing) men in their late 70s who rate their own health as "excellent" but discontinue screening discussions at the age of 75 if self-rated health is "good," at the age of 70 if self-rated health is "fair," and at the age of 65 if self-rated health is "poor." These thresholds roughly correspond to a remaining life expectancy of 10 years, a threshold below which other guidelines — for example, those from the American Cancer Society — have recommended against screening. Any threshold, of course, is inevitably somewhat arbitrary.
Considering the ongoing controversies surrounding prostate-cancer screening, evidence from randomized trials about benefit and harms would be welcome indeed. The large, ongoing trials of PSA screening in the United States (the Prostate, Lung, Colorectal, and Ovarian, or PLCO, Cancer Screening Trial), Europe (the European Randomized Study of Screening for Prostate Cancer, or ERSPC), and the United Kingdom (Prostate Testing for Cancer and Treatment, or Protect) will eventually help to resolve some of these controversies — the first two trials should produce results over the next 5 years. However, none of the findings from these trials will bear directly on the question of whether screening is appropriate for men 75 or older, since men in this age group were excluded from all three.
Population-based studies of PSA testing in the United States have shown fairly high levels of screening among men in their late 70s and even in their 80s. The new recommendations from the USPSTF should prompt clinicians and patients to think twice, or even three times, before ordering PSA tests for cases in which screening is especially likely to do more harm than good.

Mais uma vez, as vitaminas não contam

Uma vez mais, a perspectiva de prevenção do câncer com uso de vitaminas não consegue ser provado em dois ensaios clínicos publicados em JAMA, hoje.
Vitamins E and C in the Prevention of Prostate and Total Cancer in Men: ThePhysicians' Health Study II Randomized Controlled Trial JAMA http://jama.ama-assn.org/cgi/content/abstract/2008.862v1?etoc
Effect of Selenium and Vitamin E on Risk of Prostate Cancer and Other Cancers: The Selenium and Vitamin E Cancer Prevention Trial (SELECT) http://jama.ama-assn.org/cgi/content/abstract/2008.864v1?etoc
Editorials: Randomized Trials of Antioxidant Supplementation for Cancer Prevention:First Bias, Now Chance--Next, Cause http://jama.ama-assn.org/cgi/content/full/2008.863v1?etoc

Esperança em nova vacina para malária

A Hopeful Beginning for Malaria Vaccines. William E. Collins, Ph.D., and John W. Barnwell, M.P.H., Ph.D.
An effective human malaria vaccine has been sought for over 70 years, with little success.1 A successful malaria vaccine used in conjunction with other control interventions would help reduce and eventually eliminate the considerable global disease burden caused by malaria. Many different antigens have been identified as potential targets for malaria-vaccine development. One of these, the repetitive sequence of four amino acids in the circumsporozoite antigen on the surface of the sporozoite of Plasmodium falciparum, arguably the most important of the human malarias, is the basis for the RTS,S vaccine.2 This vaccine was subjected to extensive studies involving human volunteers, the results of which indicated a potential protective efficacy of about 40% when the vaccine was used in combination with an effective adjuvant therapy.3,4 Subsequently, a number of field studies have indicated that in endemic areas, this vaccine could have a rate of efficacy of about 30% against clinical disease and about 40% against new cases of infection.5,6 This is the first candidate malaria vaccine to show significant protection in laboratory- and field-based clinical studies.
The evaluation of the safety and efficacy of malaria vaccines in infants and children is of utmost importance because most deaths and illness from malaria occur in these age groups, in areas of moderate-to-high transmission. In this issue of the Journal, Abdulla et al.7 describe their safety and immunogenicity trial in which the RTS,S vaccine was used in combination with the AS02D adjuvant (ClinicalTrials.gov number, NCT00289185 [ClinicalTrials.gov] ). The RTS,S/AS02D vaccine had a reasonable safety profile as compared with the control hepatitis B vaccine, and anticircumsporozoite-antibody titers were detectable in more than 98% of the infants receiving the RTS,S/AS02D vaccine. In this trial, RTS,S was given along with other vaccines for children (a vaccine containing diphtheria and tetanus toxoids, whole-cell pertussis vaccine, and conjugated Haemophilus influenzae type b vaccine), according to the Expanded Program on Immunization (EPI) schedule. There was no interference with immune responses to the EPI vaccines. This result suggests that it will be feasible to provide RTS,S together with other routine children's vaccines, making its delivery in endemic areas much easier and less costly. During the 6-month period after immunization, the incidences of malarial infection and clinical disease in the RTS,S group were reduced by 65% and 59%, respectively. There was a correlation between a reduced risk of infection and increased circumsporozoite antibody titers. There was no association, however, between a reduction in the incidence of clinically active malaria and an increased circumsporozoite-antibody titer.
Also in this issue, Bejon et al.8 report on a phase 2b safety and efficacy trial of the RTS,S vaccine combined with the AS01E adjuvant, in children 5 to 17 months of age (NCT00380393 [ClinicalTrials.gov] ). The RTS,S/AS01E vaccine was associated with fewer severe adverse events than the control rabies vaccine. Overall, there was an unadjusted rate of efficacy of 60% against all episodes of P. falciparum clinical malaria, with anticircumsporozoite-antibody titers detectable in more than 99% of the recipients of the RTS,S/AS01E vaccine. However, as in the trial by Abdulla et al., there was no evidence that protection against clinical disease was correlated with anticircumsporozoite titers in children vaccinated with RTS,S/AS01E. The AS01E adjuvant used by Bejon et al. was developed to enhance the immune response to the circumsporozoite target antigen and, it was hoped, provide greater efficacy than the AS02D adjuvant used by Abdulla et al. and in earlier clinical studies of RTS,S.
A comparison of the two articles reveals that the mean circumsporozoite antibody titers among the children receiving the RTS,S/AS01E vaccine were approximately 10 times that among those receiving the RTS,S/AS02D vaccine. However, although the overall mean antibody titers were lower with the AS02D adjuvant, both in the trial by Abdulla et al. and in a previous trial involving infants in Mozambique,9 the protection against infection and clinical disease was similar to that in the trial of AS01E by Bejon et al. In the studies by Abdulla and Bejon and their colleagues, the efficacy against clinical disease did not differ whether AS01E or AS02D was used as an adjuvant, but the efficacy with either is greater than the 30% rate reported in a previous trial.6 Whether the higher antibody titers associated with the use of AS01E might translate into a longer duration of protective efficacy for the RTS,S vaccine remains to be demonstrated.
The correlation of reduced incidence of infection with higher antibody levels is encouraging and intuitive, given the biologic basis of infection. Correlations between antibody levels and protection against disease are more difficult to reconcile in the context of the biologic features of malaria and the target of this vaccine. In humans, there are two main developmental stages of the malaria life cycle: the exoerythrocytic stage in the liver, involving the sporozoite and hypnozoite, and the erythrocytic stage in the blood, involving the merozoite. Immunity acquired against one form of the malaria parasite does not operate against other forms. Sporozoites — the target of RTS,S — are injected into humans through mosquito bites, infect hepatocytes, and initiate the development of other liver-stage parasites. One sporozoite produces thousands of merozoites that parasitize erythrocytes to initiate the blood stage of infection, which in turn produces the clinical disease of malaria. Thus, if immune responses generated by "leaky" pre-erythrocytic vaccines such as RTS,S fail to block just a single sporozoite from invading or developing in the hepatocyte, then a blood-stage infection will follow, and typical paroxysmal fevers and, perhaps, severe malarial disease will manifest.
Although the results of Abdulla et al. and Bejon et al. are promising, the baseline incidence of malaria was low in each study area. Evaluations of vaccine-efficacy studies can be complicated by the introduction of insecticide-treated bed nets and artemisinin-based combination drug treatments through ongoing control programs across sub-Saharan Africa.10 Recent reports indicate that, in some areas in which malaria is endemic, such as in the Gambia in West Africa and Kenya and Tanzania in East Africa, there have been dramatic reductions in the malarial disease burden.11,12
However, as the RTS,S vaccine heads into phase 3 trials in 2009, large areas across Africa still have moderate-to-intense malaria transmission. Malaria transmission of yet higher intensity, with greater and more continuous assault by mosquito-injected sporozoites, could affect the efficacy of this vaccine.6 This is the first malaria vaccine to reach this stage of development, and it will be essential to learn how it performs in areas of more intense transmission. Only then will we have a clear idea of what effect it will have on the well-being of children in Africa and elsewhere and its role in malaria control. It is, indeed, a hopeful beginning.
No potential conflict of interest relevant to this article was reported.
Source Information
From the Malaria Branch, Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta. The opinions expressed in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. This article (10.1056/NEJMe0808983) was published at www.nejm.org on December 8, 2008. It will appear in the December 11 issue of the Journal.
References
Druilhe P, Barnwell JW. Pre-erythrocytic stage malaria vaccines: time for a change in path. Curr Opin Microbiol 2007;10:371-378. [Medline]
Gordon DM, McGovern TW, Krzych U, et al. Safety, immunogenicity, and efficacy of a recombinantly produced Plasmodium falciparum circumsporozoite protein-hepatitis B surface antigen subunit vaccine. J Infect Dis 1995;171:1576-1585. [ISI][Medline]
Stoute JA, Slaoui M, Heppner DG, et al. A preliminary evaluation of a recombinant circumsporozoite protein vaccine against Plasmodium falciparum malaria. N Engl J Med 1997;336:86-91. [Free Full Text]
Kester KE, McKinney DA, Tornieporth N, et al. Efficacy of recombinant circumsporozoite protein vaccine regimens against experimental Plasmodium falciparum malaria. J Infect Dis 2001;183:640-647. [CrossRef][ISI][Medline]
Bojang KA, Milligan PJ, Pinder M, et al. Efficacy of RTS,S/AS02 malaria vaccine against Plasmodium falciparum infection in semi-immune adult men in The Gambia: a randomised trial. Lancet 2001;358:1927-1934. [CrossRef][Medline]
Alonso PL, Sacarlal J, Aponte JJ, et al. Efficacy of the RTS,S/AS02A vaccine against Plasmodium falciparum infection and disease in young African children: randomised controlled trial. Lancet 2004;364:1411-1420. [CrossRef][Medline]
Abdulla S, Oberholzer R, Juma O, et al. Safety and immunogenicity of RTS,S/AS02D malaria vaccine in infants. N Engl J Med 2008;359:2533-2544. [CrossRef]
Bejon P, Lusingu J, Olotu A, et al. Efficacy of RTS,S/AS01E vaccine against malaria in children 5 to 17 months of age. N Engl J Med 2008;359:2521-2532. [CrossRef]
Aponte JJ, Aide P, Renom M, et al. Safety of the RTS,S/AS02D candidate malaria vaccine in infants living in a highly endemic area of Mozambique: a double blind randomised controlled phase I/IIb trial. Lancet 2007;370:1543-1551. [CrossRef][Medline]
Snow RW, Guerra CA, Mutheu JJ, Hay SI. International funding for malaria control in relation to populations at risk of stable Plasmodium falciparum transmission. PLoS Med 2008;5:e142-e142. [Medline]
Ceesay SJ, Casals-Pascual C, Erskine J, et al. Changes in malaria indices between 1999 and 2007 in The Gambia: a retrospective analysis. Lancet 2008;372:1545-1554. [Medline]
O'Meara WP, Bejon P, Mwangi TW, et al. Effect of a fall in malaria transmission on morbidity and mortality in Kilifi, Kenya. Lancet 2008;372:1555-1562. [Medline]

PLOS: doenças negligenciadas nos Estados Unidos

Neglected Infections of Poverty in the United States of America
Peter J. Hotez. Department of Microbiology, Immunology, and Tropical Medicine, The George Washington University and Sabin Vaccine Institute, Washington, D.C., United States of America
Abstract
In the United States, there is a largely hidden burden of diseases caused by a group of chronic and debilitating parasitic, bacterial, and congenital infections known as the neglected infections of poverty. Like their neglected tropical disease counterparts in developing countries, the neglected infections of poverty in the US disproportionately affect impoverished and under-represented minority populations. 1The major neglected infections include the helminth infections, toxocariasis, strongyloidiasis, ascariasis, and cysticercosis; the intestinal protozoan infection trichomoniasis; some zoonotic bacterial infections, including leptospirosis; the vector-borne infections Chagas disease, leishmaniasis, trench fever, and dengue fever; and the congenital infections cytomegalovirus (CMV), toxoplasmosis, and syphilis. These diseases occur predominantly in people of color living in the Mississippi Delta and elsewhere in the American South, in disadvantaged urban areas, and in the US–Mexico borderlands, as well as in certain immigrant populations and disadvantaged white populations living in Appalachia. Preliminary disease burden estimates of the neglected infections of poverty indicate that tens of thousands, or in some cases, hundreds of thousands of poor Americans harbor these chronic infections, which represent some of the greatest health disparities in the United States. Specific policy recommendations include active surveillance (including newborn screening) to ascertain accurate population-based estimates of disease burden; epidemiological studies to determine the extent of autochthonous transmission of Chagas disease and other infections; mass or targeted treatments; vector control; and research and development for new control tools including improved diagnostics and accelerated development of a vaccine to prevent congenital CMV infection and congenital toxoplasmosis.

Brasileiro vence concurso do The Lancet

O médico Enrique Falceto de Barros, recém formado na Universidade Federal do Rio Grande do Sul venceu com mais cinco concorrentes o prêmio Young Voices In Research for Health do The Lancet e do Global Forum for Health Reseaarch. Para ler a monografia de Enrique, clique aqui.

Winners of the 2008 essay competition, Young Voices in Research for Health
The Lancet, together with the Geneva-based Global Forum for Health Research, is pleased to announce the winners of the 2008 essay competition, Young Voices in Research for Health. The theme of this year’s contest was research for climate change and health. Essayists were asked to devise research questions on the topic as it applies to vulnerable populations around the world.
Almost 300 entries were submitted, from 66 countries. A shortlist of 42 was chosen by a team of judges from the Global Forum and The Lancet. Six winners were selected from the shortlist.
The six winners, whose essays are posted here, are Enrique Falceto de Barros (Brazil), Philippa Bird (UK), Lester Sam Geroy (Philippines), Rhona Mijumbi (Uganda), Marame Ndour (Senegal), and Charles Salmen (USA).

Boanerges de Souza Massa: história finalizada

Boanerges formou-se em medicina na USP em 19

Boanerges de Souza Massa: história finalizada

Boanerges formou-se em medicina na USP em 1965 (ano a confirmar). Durante muito tempo foi uma figura mítica na Faculdade, pouco se falava dele, a maioria das vezes como se fosse ou um louco irresponsável ou um agente policial disfarçado. (assim ouvi mais de uma vez nos anos 70) Nunca foi alçado à condição de "herói da resistência". Alguns lembravam dele por uma cirurgia realizada em ambiente clandestino em um militante da Ação Libertadora Nacional (ALN) que fora baleado. Eduardo Manzano e Heloisa L. Manzano, médicos que moram em Porto Nacional e, se formaram com ele, afirmam que o viram no início dos anos 70 e, mantinham a descrição de Boanerges em seu livro "Memórias de um casal de médicos nas barrancas do Tocantins" como a de um sujeito estranho. (expressão a confirmar, transcrita pela memória do blogueiro)

Nessa semana, duas publicações, uma transcrita no Correio Braziliense de um livro que não foi publicado de autoria do próprio Exército nos anos 80 e, a outra o livro Sem Vestígios de Taís Morais trazem informação nova. Boanerges de Souza Massa era militante do Movimento de Libertação Popular (MOLIPO), uma dissidência da ALN esteve em Cuba, montou um foco guerrilheiro no oeste baiano e, foi preso em Goiás em 1971.Após sessão de tortura foi conduzido à Bahia para reconhecer o local e, na volta foi executado em um sítio em Formosa, Goiás.

O secretário dos direitos humanos, Paulo de Tarso Vannuchi, ex-militante da ALN, ex-aluno da FMUSP poderia conduzir o reconhecimento póstumo de Boanerges, como mais um daqueles da Casa de Arnaldo que tombaram nos anos de chumbo.

P.S recomendo o livro Sem Vestígios onde descreve as "memórias" de Carioca, um agente da repressão política. Há momentos horríveis como a descrição da morte de David Capistrano. Porém, a autora poderia ter revisado melhor algumas passagens onde derrapa em gongorismos e redundâncias. Mas, o pior foi a nota de rodapé, que inimigos de José Dirceu utilizaram fora de contexto, com a interpretação de que o ex-presidente do PT e ex-chefe da Casa Civil teria sido agente duplo (uma mera suposição do Carioca, sem base fática).

BMJ: uma vez mais a emigração de profissionais de saúde da África.

Globalisation spurs migration of healthcare workers from poor nations; John Zarocostas
Globalisation has made it easier for rich nations to "pull in" skilled migrants such as healthcare workers from poor nations, says a report from the International Organization for Migration, which promotes humane and orderly migration. Such migrants include a large number from sub-Saharan Africa, the region with the greatest shortage of healthcare personnel, and the trend is unlikely to abate, the report says.
"Their [rich countries’] ability to offer higher pay, better working conditions and greater opportunities in safer environments will continue to pull foreign health workers until supply exceeds demand," says the report.
It says that the search for employment is at the heart of most migration and concludes that pressures "are set to increase."
There are "more than 200 million international migrants in the world today, two and a half times the number in 1965," it says, and most countries are now simultaneously countries of origin, transit, and destination.
Nearly a quarter of foreign trained doctors in countries of the Organisation for Economic Co-operation and Development were trained in sub-Saharan Africa, and the report suggests a series of possible policy options to limit the negative effects of emigration on the countries of origin.
Countries of destination should continue to develop guidelines for recruiting skilled professionals from poor nations, the report recommends, but it emphasises that self imposed restraints on recruitment by public sector employers "have not been effective in limiting the migration." It says that "exhorting private-sector employers to recruit ethically" is also likely to prove equally ineffective.
"These [guidelines] can serve as a benchmark against which civil society organisations and the nationals and governments of destination and origin countries can evaluate the practice of destination countries."
Anita Davies, a public health specialist at the International Organization for Migration, said that the World Health Organization has taken the lead by preparing a global code of recruitment of health workers, in consultation with other relevant agencies and stakeholders.
A draft has been sent out for comment and will be presented to WHO’s governing board for consideration in January. If agreed, it will be sent to the annual World Health Assembly for adoption.
The report says that policy innovations can help to mitigate some of the risks to poorer nations of diminished service access and availability. These schemes include flexible, multi-use, multi-annual work permits that may allow poor nations of origin to manage flows more effectively and thus avoid critical shortfalls in the provision of health care. Such schemes may include fixed term contracts to train or work for a period in a rich nation and may also include commitments to upgrade their own healthcare system with the support of a destination country.
The report estimates that Lesotho and Namibia have lost more than 30% of their physicians to emigration and that this percentage rises to more than 50% in Malawi, Tanzania, and Zambia and to 75% in Mozambique. Every year 1000 doctors emigrate from South Africa, says the report, and an estimated 30% to 50% of all South African medical school graduates emigrate to the United Kingdom or the United States annually. Doctors from South Africa make up just under 10% of all foreign trained doctors in Australia and 7% in the UK, it says
However, it points out that South Africa is also the destination for skilled health workers from other parts of Africa, including Botswana, the Democratic Republic of Congo, Ghana, Nigeria, and Zimbabwe.
South Africa has the highest ratio of doctors to population on the continent, at 56.3 per 100 000 people, whereas in the Democratic Republic of Congo the figure is only 6.2 per 100 000.
The report says that South Africa has tried to deal with staff shortages in the public health sector by hiring Iranian and Cuban health personnel to work in rural areas.
Meanwhile, a joint working paper by the OECD and WHO on international health mobility in Canada concludes that foreign trained doctors accounted for more than 22% of Canada’s total in 2005-6.
Among rich OECD nations, New Zealand had the highest proportion of foreign trained doctors, with 36%, it says.
The joint study also found that in 2005 about 15% of newly registered doctors in Canada were trained in countries from the WHO list of countries with critical shortages of health personnel. The corresponding figure for the UK was 46% and that for the US was 39%.
But the report also shows that in 2006 about 8000 Canadian trained doctors were practising in the US. It says that differences in income and availability of positions were often among the reasons cited for emigrating

Circuncisão e prevenção da aids: vale a pena ler texto do NEJM

Circumcision — A Surgical Strategy for HIV Prevention in Africa.
Ingrid T. Katz, M.D., M.H.S., and Alexi A. Wright, M.D.
In a radical departure from earlier strategies, public health officials are now arguing that circumcision of men should be a key weapon in the fight against infection with the human immunodeficiency virus (HIV) in Africa. Recent studies have shown that circumcision reduces infection rates by 50 to 60% among heterosexual African men. Experts estimate that more than 3 million lives could be saved in sub-Saharan Africa alone if the procedure becomes widely used. But skeptics argue that efforts to "scale-up" circumcision programs on the continent that has the fewest physicians per capita may draw funds away from other necessary public health programs, ultimately threatening already tenuous health care systems.
How circumcision prevents HIV transmission is not completely understood, but scientists believe that the foreskin acts as a reservoir for HIV-containing secretions, increasing the contact time between the virus and target cells lining the foreskin's inner mucosa. Early evidence of circumcision's protective effect dates back to the late 1980s. Researchers working in Africa and Asia noticed that HIV-prevalence rates differed dramatically among neighboring regions and were often lowest in areas where circumcision was practiced. More than 40 observational studies followed, but most researchers remained skeptical about the results. Then, in 2002, Bertran Auvert, professor of public health at the University of Versailles, launched one of the first randomized, controlled trials of circumcision in Orange Farm, South Africa, a community with a low rate of circumcision and a high prevalence of HIV infection. After the 12-month interim analysis, the data and safety monitoring board decided to stop the trial. The data were clear: circumcision reduced the rate of HIV infection among heterosexual men by 60%.
Since then, two other randomized, controlled clinical trials in Kenya and Uganda have confirmed the results from South Africa. Both were stopped early because of overwhelmingly positive results. The research teams thought it was unethical to require men in the control group to wait 24 months before undergoing circumcision. A few men had already obtained off-protocol circumcisions, but since the study results were released, the demand has skyrocketed. "We have three operating rooms running every day," said Ronald Gray, lead author on the Ugandan study and professor at the Johns Hopkins Bloomberg School of Public Health. "We have done about 1000 surgeries in 3 months — after completing all of the surgeries for trial participants."
Researchers have also found that circumcision provides increased protection against the human papillomavirus, herpes simplex virus, syphilis, and chancroid. But the most compelling evidence is still for HIV prevention, argues Roger Shapiro, a researcher at Harvard School of Public Health who is helping to implement a pilot program to offer infant circumcision in Botswana: "Circumcision isn't a new scientific breakthrough, but it works. It is the only proven medical intervention that can complement condom use and improve protection. If we had this level of data for a vaccine or a microbicide, you can bet there would be a massive push for immediate scale-up."
Key distinctions between penile surgery and less-invasive methods of HIV prevention, however, may hinder momentum. For one thing, some African officials remain wary of circumcision because of concerns about cost and safety. Currently, physicians are performing most circumcisions, but many countries are hoping to decrease costs by training a cadre of lower-level health care workers (such as medical or clinical officers and nurses) to fill the provider gap that many countries face. Adequate training is essential, however, since complication rates ranged from 1.7 to 3.6% among HIV-negative men in the trials (as compared with rates of 0.2 to 2.0% associated with infant circumcision in the United States). Most complications were minor — pain or bleeding — but higher complication rates have been reported outside trial settings. One recent report indicated that severe complications developed in 18% of men, and 6% had permanent adverse sequelae including mutilation of the glans, excessive scarring, and erectile dysfunction. Inadequate sterilization procedures and surgical instruments were probably important factors in the higher rates, but Daniel Halperin, senior research scientist at Harvard School of Public Health, argues that high complication rates primarily reflect a problem with training, not with the procedure itself: "Circumcision can be performed safely, with relatively few complications, anywhere in the world, if clinicians are trained properly."
Policymakers are also struggling with complex cultural barriers in societies where circumcision is not part of mainstream practice. In countries such as South Africa, for example, most men are not circumcised, but certain subpopulations, including the Xhosa ethnic group, practice circumcision of boys as a rite of passage into manhood. Many South Africans frown on the practice, and after several young Xhosa boys died from circumcision-related complications, then-President Thabo Mbeki signed a bill banning (with some religious and medical exceptions) circumcision in boys under 16 years of age. Some fear that the deaths associated with traditional circumcision have prevented expansion of the program in South Africa, but others argue that offering clean, safe medical circumcision to these communities could be lifesaving.
Many public health researchers fear that there are deeper reasons for some African governments' skepticism. Some speculate that Africa's colonialist history has left these leaders with lingering suspicions about possible oppression, which have long taken the form of "deep denial regarding HIV treatment and prevention in certain regions of Africa," according to Francois Venter, clinical director of HIV management and reproductive health at the University of the Witwatersrand in South Africa. Others reference the dark history of surgical interventions deployed in the name of public health, citing the Indian sterilization camps of the 1970s. All agree that implementation of circumcision on a national level will require in-country champions and strong political will to succeed. "Currently all of the funding is coming from Western nations," says Venter, "and this makes people suspicious."
To counterbalance perceptions of Western intrusion, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) is working with local governments and public health partners to create an acceptable and sustainable model for implementing circumcision programs. "Countries are going to have to scale-up according to their own goals," said Catherine Hankins, chief scientific adviser to the Joint United Nations Program on HIV/AIDS (UNAIDS). "We are not setting any international agendas." UNAIDS, the World Health Organization (WHO), and their partners have set up a Web site (www.malecircumcision.org) to allow interested countries to trade information directly.
Most people involved in scaling up adult male circumcision recognize that the surgery is a costly endeavor and a socially complex intervention that may compromise other public health priorities. Venter argues, "In South Africa, we have many other competing health issues, including maternal and child health and tuberculosis, which still need much more support." Nevertheless, he remains a proponent of circumcision as a means for getting young men into the health care system to help protect them against HIV and educate them about safe sex practices.
Major international funders, including the Bill and Melinda Gates Foundation and PEPFAR, agree that ramped-up circumcision efforts must be funded as add-on services to guarantee that they will not detract from other programs. Although PEPFAR has granted $26 million for circumcision programs in 13 African countries — Botswana, Kenya, Rwanda, Zambia, South Africa, Lesotho, Malawi, Mozambique, Tanzania, Uganda, Namibia, Ethiopia, and Swaziland — implementation has been highly variable.
In order to optimize HIV-prevention measures, officials from WHO and UNAIDS are advising that countries offer a minimum package of services in addition to circumcision, including HIV testing, screening for sexually transmitted infections, promotion of condom use, and counseling on safer sex. Such a comprehensive approach is meant to address concerns that circumcised men may adopt riskier behavior because they feel protected after undergoing the procedure. Despite these concerns, Gray and others have shown that there are no differences between the sexual behaviors of circumcised men and those of uncircumcised men — reassuring news, since many researchers and policymakers see circumcision programs as an opportunity to engage young men and women in HIV prevention. Robert Bailey, lead author on the Kenya study and professor of epidemiology at University of Illinois at Chicago, has noticed more participation of sexual partners in voluntary HIV counseling and testing since circumcision programs started.
Reaching women through other prevention methods is important because there is no direct evidence to date that circumcision reduces the risk of transmission from men to women. In a small substudy, Ugandan researchers circumcised HIV-positive men and then followed their HIV-negative female partners to see whether their risk of infection was reduced. Data presented earlier this year did not demonstrate a benefit — a failure the researchers attributed to a sample size too small to allow differences to reach statistical significance. Indirect evidence from modeling, however, suggests that women will ultimately benefit from circumcision programs that reduce the HIV prevalence among men.
Although circumcision has increasing support from researchers, donors, and politicians, its status as a non–behavior-based intervention may ultimately be its biggest obstacle. Neil Martinson, deputy director of the Perinatal HIV Research Institute at the University of the Witwatersrand in South Africa, summarizes this concern: "People are used to policies that target behaviors, but circumcision is a surgical intervention — it's cold, hard steel — and that doesn't always go down well." Ultimately, as programs move forward, the scale-up of circumcision will require strong political backing, adequate funding, and leaders to champion the cause to ensure that it is a safe, low-cost option available throughout Africa.

Demitir Jack Bauer, acabar com a tortura

Futuro Presidente dos EUA, Barack Obama: demissão sumária de Jack Bauer.

Secretário dos Direitos Humanos, Paulo de Tarso Vanucchi: menos bravatas em auditórios com ar condicionado e caça aos Jack Bauers tupiniquins.

Who is Jack Bauer? Dr Homer Drae Venters MD (publicado no The Lancet)
A patient of mine, Kofi, once asked me, “Who is Jack Bauer?” I felt a little queasy because the patient, question, and answer all shared a common element, torture. I first met Kofi when I was a resident, only 1 year into my training in assessing survivors of torture who were seeking asylum at the Bronx Human Rights Clinic, New York, USA. The application of these people can be strengthened by medical examination of the physical and mental sequelae of torture. Before fleeing his country, Kofi endured several brutal detentions, as part of government persecution of his ethnic group. During his assessment at the Bronx Human Rights Clinic, Kofi described in detail the beatings, stabbings, and various humiliations that his government had perpetrated on him. Kofi then underwent a laborious 3-h physical examination, cataloguing every scar and musculoskeletal and neurological finding. The final part of this examination was to assess Kofi's psyche for the inevitable consequences of his experiences. Several months later, Kofi's asylum application was granted; we have continued to see each other for his primary-care needs. So what of Jack Bauer?
Kofi has taken a deep interest in the politics of his adopted country, and has watched every US presidential debate so far. During one debate, a scenario was put to all the candidates, that can be summed up as the torture dilemma: terrorists have struck on US soil; the authorities have detained suspects, and have reason to think that some may possess knowledge of another imminent attack. The presidential candidates were asked whether to torture or not to torture. Only one candidate, Senator John McCain of Arizona, unequivocally responded in the negative; the others advocated various forms of so-called enhanced interrogation: a phrase which gives torture a more palatable label, and perpetuates the false impression that torture enhances interrogation. The most popular and memorable response came from Representative Tom Tancredo of Colorado, who responded: “I'm looking for Jack Bauer at that time, let me tell you”. Jack Bauer is the immensely popular character from the Fox TV show 24, who regularly relies on his own version of enhanced interrogation. Jack Bauer makes torture popular.
Somewhere in the fog of war, terror, and politics, we have become accustomed to the idea of torture. Recent polling shows that American acceptance of torture is increasing, from 36% in 2006 to 44% in 2008.Additionally, more than half of Americans support torture in some situations, and an equal number support the practice of so-called rendition to other countries for the purpose of torture.During prime-time television, this approval of torture is generated and reflected by Jack Bauer, roughing up prisoners in a weekly struggle to protect the country. As I chatted with Kofi about how we arrived at this acceptance of torture in the USA, he said, “You have no idea what you would do to your neighbour if you thought he would harm your family.” Kofi went on to explain that acceptance of torture can arise from a heightened level of fear, that overcomes good judgment and gives way to inhumanity. For him, tribal fears and animosities paved the way for his persecution. For Americans, Kofi observed, a toxic fear of terror has allowed torture to emerge as an accepted practice.
A central argument against torture is exemplified by Senator John McCain's belief that torture is inherently un-American. Senator McCain believes that to torture is to debase our national identity. George Washington, as a general in the American War for Independence, observed British troops executing surrendered American prisoners, and banned any retaliation in kind, stating: “Treat them with humanity, and let them have no reason to complain of our copying the brutal example of the British Army in their treatment of our unfortunate brethren”.4 In torturing, even out of fear for our survival, we lose our virtue and identity as a nation. Virtually every US president since George Washington has endorsed his rebuttal of torture as un-American, as has President-elect Senator Barack Obama. If we cannot torture because of who we are, the damning question then becomes: who have we become if we accept torture? The use of torture undoubtedly has consequences for the external identity of a nation as well. Referring to revelations of torture by US forces in Iraq, historian Alfred McCoy writes that it has “subtly subverted American rhetoric about democracy and has damaged the nation's moral leadership in the Middle East”.5 The use of torture by US forces was not new;6 but the photographs from Abu Ghraib in Iraq forced people to ask if systematic use of torture was consistent with the ideals of democracy and freedom.
A second critique of torture is that it simply does not work. Torture apologists often appeal to a desire to get tough, and the reported need to increase the amount of information extracted from so-called high-value detainees. Without widespread understanding of the ineffectiveness of torture, the debate often devolves into duel by anecdotes. But analysis of interrogations has shown torture to be ineffective. One of the most successful US interrogators during World War 2, Marine Corps Major Sherwood Moran, eschewed torture as counterproductive. During interrogations of Japanese prisoners, Moran observed that brutality “played right into the hands of those who were determined not to give away anything of military importance”. By contrast, Moran's success was based on the approach to “forget, as it were, the ‘enemy’ stuff, and the ‘prisoner’ stuff. I tell them to forget it, telling them I am talking as a human being to a human being”.7
After World War 2, the US Military Intelligence Field manual was updated to state that the USA “prohibits the use of coercive techniques because they produce low quality intelligence. The use of force is a poor technique as it yields unreliable results, may damage subsequent collection efforts, and can induce the source to say whatever he thinks the interrogator wants to hear”. A 2006 report by the National Defense Intelligence College reviewed all available evidence on interrogation techniques and concluded “…studies of the role of assault in promoting attitude change and in eliciting [false] confessions revealed that it was ineffective. Belief changes and compliance were more likely when physical abuse was minimal or absent…although pain is commonly assumed to facilitate compliance, there is no available scientific or systematic research to suggest that coercion can, will, or has provided accurate useful information from otherwise uncooperative sources”. In his book, Torture and the Ticking Bomb, Robert Brecher further deconstructs the usefulness of torture, particularly in the type of scenario presented in the debate watched by Kofi. Brecher concludes that in matters of extreme urgency or importance, a nation would be ill-served to turn to the least reliable method of interrogation.
These two arguments against torture, though compelling, still fall flat when I think of Kofi. Each of these criticisms addresses a larger context: our national identity and our national security. However, the most abhorrent aspect of torture is what Kofi and other survivors of torture often reveal to their physicians. That one human being picked up a knife and cut into another. Or suspended them from the ceiling while they were beaten. Or raped them. Or burned them. Long after his scars healed and he adjusted to the aches in his joints, Kofi has continued to struggle with mental anguish from being tortured. We are tempted by the glamour and raw charisma that we project onto Jack Bauer, the illusion of protection, and the lure of vigilante justice. But the raw truth of torture is that whatever the original motive, the torturer and the tortured are transformed into a perpetrator and a victim of violence. The torturer visits inhumanity on his victim, but also on himself and the surrounding community. Athar Yawar notes the relation between the use of torture and the inexorable decay of social fabric, as cruelty and inhumanity becomes pervasive and normative.

In an analysis of state tyranny, Riadh Abed similarly observes that the dehumanisation of the individual torturer and the acceptance of his acts “leads to the erosion of accepted social norms of behavior and the normalization of violence”.
As physicians, we have a responsibility to oppose torture. We treat many patients who describe torture, and many more who have experienced it, but cannot bring themselves to disclose it. If Kofi is correct that irrational, overwhelming fear can lead to inhumanity, we should stoke the fires of reason. Three areas for intervention exist for us as physicians. First, we can educate ourselves (as students, residents, and attending physicians) about torture as a public-health issue, its prevalence in our patient populations, and how it affects our ability to deliver care. In recognising torture as a form of violence affecting many of our patients, we can develop standards of screening, medical education, and patient information that facilitate good medicine. When physicians become more knowledgeable about the effects and prevalence of torture, we can begin to detect and, when necessary, treat the adverse effects of torture among our patients. Second, we should strengthen ties with human-rights organisations, lending the credibility and resources of our profession to this endeavour. Just as physicians eventually became integral to campaigns against child abuse and intimate-partner violence, we should now join the international effort against torture. In their landmark report, Medicine Betrayed, the British Medical Association stated that physicians who are aware of torture “have a positive obligation to make those activities known”.

Finally, we should proceed in the least partisan manner possible. The political nature of torture is inescapable. But we will need to cast this discussion in terms of violence, public health, and our ability to deliver medical care to our patients. By bearing witness to the brutality visited on Kofi and others, we may be able to care for our patients better, while helping to eliminate public acceptance of torture.

Sensacionalismo e ciência: mamografias e circuncisão

Shah Ebrahim é editor do International Journal of Epidemiology e, um arguto observador da cena mundial. Abaixo, um texto instigante exigindo mais ação e menos sensacionalismo ou de como o culto às celebridades nos desvia de questões da maior importância, como a prevenção da aids.

Media hype: good or bad for patients and the health care system?Shah Ebrahim
E-mail: shah.ebrahim@lshtm.ac.uk
Kylie Minogue develops breast cancer and the associated publicity might well be expected to increase young women's demand for breast screening. Kelaher and colleagues1 demonstrate the expected increase in breast imaging (about 20%) in the months following publicity. Interestingly, the biopsy rate did not change in younger women and declined in older women. The odds of surgical procedures following biopsy also fell markedly. These findings led the investigators to propose that the media furore affected doctors as well as patients, leading to a retraction of usual evidence-based practice in the months after the publicity. Is this a good or a bad thing? Celebrity disease is something that can be used to good public effect—notably Ronald Regan's Alzheimer's disease diagnosis contributed to moving dementia syndromes from Cinderella status to high National Institutes of Health funding opportunities in the United States.
But what about preventing breast cancer given rising incidence rates (http://info.cancerresearchuk.org/cancerstats/types/breast/incidence/). Kylie Minogue was young but was at risk due to nulliparity—a powerful risk factor, first recognized in the 1920s by Janet Lane-Clayton.2 The Million Women study has demonstrated the importance of number of children and breast feeding, among other risk factors,3 prompting Valerie Beral, its director, to urge greater research on prolactin, a hormone that increases in late pregnancy and regulates lactation, at a recent UK National Cancer Research Institute conference.
While there are plenty of ‘orphan’ or neglected diseases craving publicity, AIDS is not one of them. The theme of this issue is human immunodeficiency virus—do we still need upper case to denote its importance? Usually associations of social inequalities and disease are negative—it is the poor that suffer. In an analysis of the Tanzanian HIV/AIDS indicator survey, higher standard of living was associated with increased odds of HIV infection, whereas there was no evidence of association with education.4 Higher occupational status was associated with HIV in women but unemployed men were at greater risk than working men. These findings indicate that simplistic notions of HIV risk among rich and poor need to be more nuanced in appreciating what is clearly a complex social matrix of risk.
Perhaps the greatest success in the last year has been the randomized trial evidence, building on a decade of observational epidemiology, demonstrating the reduction in risk of infection due to male circumcision. Many doubted the original observational evidence, so it is particularly gratifying to see how large robust clinical trials have been implemented and pooled to provide strong, compelling evidence of benefit in terms of relative risk reductions as big as a halving of risk.5 On a recent visit to South Africa, in a particularly high prevalence location, I asked about how this new evidence was going to change policies, practices and research directions locally. ‘Not at all’ was the reply.
The prospect of persuading young men to have circumcisions is not everyone's favourite challenge, but it does seem important that preventive surgical initiatives are evaluated and that private sector circumcisions are safely performed, for example. Londish and Murray's6 paper in this issue follows in the steps of previous attempts to model the effects of male circumcision using a wider range of covariates than in previous models. They conclude that targeting of interventions to younger men with risky sexual behaviours is the most effective strategy. In an accompanying commentary, Gray and colleagues7 question whether models will persuade reluctant health service providers and funders to invest in services. They note that several obvious conclusions derive from commonsense: the impact of circumcision is clearly going to be greatest in high HIV incidence but low circumcision prevalence places; circumcising men who are HIV positive is unlikely to be helpful and may increase transmission of infection to sexual partners; opting for infant circumcision, rather than adolescent and adult surgery, will delay any impact by 20 or more years.
HIV modelling also gets some criticism in Elizabeth Pisani's remarkably entertaining and insightful book, The Wisdom of Whores,8 reviewed in this issue by John Cleland from the London School of Hygiene and Tropical Medicine9. Pisani was a student of demography at the School and went on to build a successful career in HIV modelling having been a journalist formerly. The story she tells is of misdirection of research effort and resources as individuals and institutions attempt to get their share of the action. I took this with me for holiday reading and was not disappointed. I recommend you read Cleland's review, get a copy of the book and read it too—whether you are in the HIV field or not.

Morte por falhas dispara no SUS ou Falhas disparam na imprensa?

Novamente, repito: não sou crítico da mídia. Mas, depois do 'aumento da aids em mais letrados', agora o Estadão publica que "Morte por falhas dispara no SUS". Eles comparam um período, janeiro a agosto de 1998 com o mesmo intervalo de meses em 2008. Apresentam que houve aumento da proporção de óbitos decorrentes de atos médico-hospitalares de 1 para cada 478 mortes em 1998 para 1 para 147 em 2008. Muito estranho. Primeiro, de onde vieram os dados de 2008? Desconheço tamanha velocidade de apuração. Segundo, a origem da informação é a declaração de óbito e, obviamente com o decorrer do tempo, a qualidade melhora. No caso específico, a subnotificação diminui. Terceiro, a declaração de óbito está longe de ser instrumento adequado a verificar erros na atenção médica.

Ou seja, não dá concluir nada, exceto que erros são mais comunicados agora do que antes, mas talvez em número menor.

A queda dos homicídios em São Paulo

Na revista Espaço Aberto da USP há uma reportagem que sintetiza pesquisa da Secretaria Municipal de Planejamento de São Paulo sobre a queda das taxas de homicídio na cidade publicada no livro Olhar São Paulo - Violêncai e Criminalidade. A tendência é semelhante à ocorrida no restante do estado. O dado importante e, relativamente previsível é que a distribuição espacial continua ainda sendo diferenciada na cidade.

A reportagem completa pode ser lida clicando aqui.O livro Olhar São Paulo – Violência e Criminalidade, já está disponível para a população no site da Sempla . As estatísticas da Secretaria de Estado da Segurança Pública podem ser conferidas aqui.

Aids em mais escolarizados

Esse blogue não faz parte dos "midia watchers". Porém, quando informações totalmente defeituosas são mantidas na imprensa, não há como ficar calado.

O Estadão, ontem e, a Folha, hoje insistem em repercutir notícia de que "aumenta o número de casos de aids entre mais escolarizados".

A leitura do relatado mostra a incapacidade de se trabalhar com conceitos mínimos em epidemiologia. Primeiro equívoco: a informação compara 1997 com 2007, justamente o período onde houve mais aumento de pessoas com escolaridade superior. Segundo equívoco: aumento proporcional não significa risco maior!!!! Simplesmente, pode ter havido queda muito expressiva entre aqueles com escolaridade inferior à universitária.

Bem, não somente a imprensa precisa ser criticada. Informações como essa precisam primeiro ser publicadas em órgãos com revisão por pares e, somente depois serem divulgadas ao grande público.

Entrevista ao ELSA Brasil

Entrevista na sala de imprensa do site do Estudo Longitudinal de Saúde do Adulto, o ELSA. (http://www.elsa.org.br)
Dr. Paulo Andrade Lotufo leciona na Faculdade de Medicina da Universidade de São Paulo e é superintendente do Hospital Universitário da instituição. No ELSA Brasil, Lotufo é pesquisador principal e coordenador do Centro de Investigação SP.
Em entrevista ao site ELSA, o médico, autor de vários estudos epidemiológicos sobre doenças cardiovasculares, debate o andamento deste tipo de pesquisa no Brasil, além de falar sobre as crenças e tratamentos relacionados à atual conjuntura de aumento de doenças crônicas não transmissíveis no país.
ELSA Brasil: No Brasil, houve uma transição das principais causas de morte, de doenças infecciosas para as enfermidades crônicas não transmissíveis, em destaque as cardiovasculares. Como o senhor encara as condições do Sistema Único de Saúde para atender a população brasileira dentro desse novo contexto?

Paulo Lotufo: A transição epidemiológica em etapas é descrita somente com finalidades didáticas. De fato, o perfil das doenças se modifica no tempo de forma desigual tanto espacial como socialmente. Por exemplo, a mortalidade por doenças infecciosas é suplantada pela cardiovascular no Brasil nos anos 60, mas no Rio de Janeiro e São Paulo isso aconteceu vinte anos antes, em 1940. Mas, mesmo nessas cidades, a transição foi desigual de acordo com os segmentos sociais. Se essa dinâmica da incidência de doenças não é de assimilação fácil por cientistas, para os planejadores de saúde ela é muito mais difícil. De certa forma, o SUS está uma geração em descompasso com a realidade. Exemplifico: somente agora a hipertensão e diabetes foram alvo de uma política efetiva de controle com o co-pagamento de medicamentos nas farmácias. Aliás, um sucesso que o próprio governo federal não divulga e capitaliza a seu favor. Porém, essa proposta de assistência farmacêutica já era defendida pelos pesquisadores da época há mais de 20 anos, sem qualquer eco no Ministério e secretarias da saúde, cujos dirigentes raciocinavam como se o país estivesse nos anos 50. Agora, temos uma pletora imensa de idosos em pronto-socorros com insuficiência cardíaca, doença pulmonar obstrutiva e fraturas de fêmur, por um lado, e redução expressiva das taxas de fecundidade e natalidade, por outro lado. Mas, ainda há iniciativas em criar institutos da criança ou assemelhados pelo país afora.
E.B.: Estudos epidemiológicos sobre a efetividade de programas e serviços de saúde direcionados à prevenção e ao tratamento de doenças cardiovasculares têm sido desenvolvidos no Brasil?

P.L.: Sim, há cada vez mais estudos. A iniciativa do Ministério da Saúde, em conjunto com as Fundações de Amparo a Pesquisa do PPSUS, foi excelente. Aqui em São Paulo, na equipe que desenvolve o ELSA no Hospital Universitário, realizamos dois projetos. Um dos projetos identificou as internações evitáveis, por isso chamado de EVITA, e criou tecnologias de ação na atenção primária a programas de prevenção cardiovascular. Em breve, estaremos oferecendo um curso de especialização em doenças crônicas não-transmissíveis dirigidas inicialmente a médicos para que atuem na promoção de saúde, prevenção primária e secundária, aplicando os conhecimentos desse projeto. O outro projeto, com apoio do CNPq e FAPESP, é o Estudo de Morbidade e Mortalidade do Acidente Vascular Cerebral (EMMA) que estuda incidência, sobrevida e incapacidade com base hospitalar na fase 1, a mortalidade na fase 2 e a prevalência na fase 3. As informações dessa pesquisa orientarão a execução de ações de prevenção, tratamento e reabilitação.
E.B.: Existem muitas crenças errôneas em relação às doenças cardiovasculares, entre elas as de que tais males atingem apenas idosos e homens. Como evitar que tais idéias continuem se propagando, inclusive entre os profissionais da área médica?

P.L.: Sim, havia um estereótipo de que o “cardíaco” era um paulista ou carioca investidor da Bolsa de Valores, que habitava a ponte-aérea Rio-SP. Coube à atual geração de epidemiologistas demolir essa bobagem. O risco de morte por acidente vascular cerebral de um habitante da periferia de São Paulo ainda é o dobro do morador de regiões afluentes. Apesar da incidência e prevalência maior entre homens e idosos, as taxas de mortalidade na faixa dos 45-64 anos no Brasil ainda são das maiores quando comparadas à de outros países, principalmente entre as mulheres.
E.B.: Ainda que as doenças cardiovasculares sejam a principal causa de morte entre as mulheres, a preocupação com a saúde cardíaca feminina é recente. O que o reconhecimento desse dado implica no atendimento médico da mulher?
P.L.: A mulher é vítima da ginecologia, sempre gosto de brincar com o meu colega, Edmundo Baracat, professor de ginecologia aqui na USP. Incrível, mas mesmo setores feministas sempre viram a assim chamada “saúde da mulher” como algo relacionado à genitália e às mamas. Há uma obsessão em relação ao câncer, mas a chance de morte por doença cardiovascular é cinco vezes maior do que morrer por neoplasia de mama. O ELSA será um momento para testar a minha hipótese de que a sobrecarga de trabalho da mulher brasileira traz conseqüências terríveis refletidas na obesidade, tabagismo, hipertensão e diabetes.
E.B.: Em que estágio se encontra o campo de pesquisas epidemiológicas em doenças cardiovasculares no Brasil?
P.L.: Repetimos aqui uma seqüência que outros países já trilharam. Primeiro, os estudos de mortalidade pela simplicidade e baixo custo; depois, os inquéritos populacionais, caros e com muitos dados, mas com potencial baixo em comprovar hipóteses; agora, estamos com o ELSA avançando nos estudos observacionais. O próximo salto para 2012 será um ensaio clínico de grande envergadura. Aqui, em São Paulo, além das “mulheres ELSA, EMMA, EVITA”, temos também o projeto Avaliação do Grau de Aterosclerose em Adultos e Adolescentes, o AGATAA, que tem como objetivo avaliar populações específicas para verificar o grau de aterosclerose. O primeiro estudo está sendo realizado em pacientes HIV positivo em uso ou não de terapia antiretroviral. Um grande equívoco é insistir em estudos de prevalência, quando coortes ou ensaios clínicos trazem muito mais respostas às nossas indagações.
E.B.: E o que representa o ELSA neste cenário?
P.L.: Não sou modesto. O ELSA é um sucesso porque conseguiu colocar as doenças cardiovasculares e o diabetes na agenda da pesquisa epidemiológica brasileira. Ele é incrivelmente complexo, com muitas variáveis em estudo e, muitos desfechos a serem conferidos no tempo. Afirmei na inauguração do ELSA em São Paulo que se trata de projeto que visa a próxima geração, não a próxima eleição.