Epidemia de ZIKA. Retos y oportunidades, el caso de Brasil ... y de Venezuela?
THE LANCET
Volume 387, No. 10019, p633, 13 February 2016
Comment
Offline: Brazil—the unexpected opportunity that Zika presents
Richard Horton
Published Online: 03 February 2016
Brazil is (understandably) upset. At WHO's Executive Board meeting last month, one Geneva official told me that the country's delegation was refusing to back resolutions it might otherwise have supported because the Brazilian Ministry of Foreign Affairs opposed the World Bank's country rankings. Brazil is classified by the Bank as an upper-middle-income country, along with its near neighbours Colombia, Ecuador, Paraguay, and Peru. Unfortunately for the Bank (and WHO), Brazil doesn't see itself as a middle-income nation. It has higher aspirations. Adding further insult, in 2015 the Bank promoted Brazil's rivals, Argentina and Venezuela, to high-income status. A high-income country is defined by a gross national income per person equal to or above US$12 736. Brazil falls just short at $11 530 (2014). Brazil has long been sensitive to the judgment of others. When WHO published its World Health Report in 2000, the government and country's health leadership were hurt and outraged. WHO ranked Brazil 125th out of 191 nations (Venezuela was placed 54th and Argentina 75th). Brazil can certainly be proud of its progress towards better health. But in his history of infectious diseases, Epidemics Laid Low (2006), Patrice Bourdelais argues that a high-income country is one that has succeeded in conquering epidemics—which is why Brazil's "public health emergency of international concern" is not only a national tragedy, but also an international humiliation. President Dilma Rousseff has issued statements of defiant resistance. But Zika arrives at a perilous moment for Brazil. The country's economy is shrinking, while unemployment and inflation are rising. These pressures have further threatened an already fragile health system. Writing in The Lancet in 2011, Mauricio Barreto and colleagues identified dengue as a major "failure" in Brazilian public health. The main vector of dengue, Aedes aegypti, is also the vector for Zika. Persistent past failed efforts to control dengue in Brazil mean that the likelihood of controlling Zika quickly today is low.
But, with thoughtful leadership, Brazil can turn this epidemic into a force for advantage. At moments of epidemic danger, one naturally focuses on the actions of nations to control the outbreak. But turn that question around: what are the likely actions of an epidemic on a nation? Epidemics change governments. Political leaders could have no clearer signal that it is their responsibility to protect the health of their people (governments, not doctors, defeat epidemics). Those leaders understand that their nation's political, economic, and social stability depends on health. This realisation has consequences. Laws are enacted to protect health. New investments are made into medical science (political progress depends on scientific progress). New institutions are created to channel the best scientific advice to decision makers. Universal free and high-quality health care becomes a public priority. And leaders understand that securing and sustaining public trust is essential for public order. Epidemics change the relationship between doctors and the state. The number, income, status, and power of doctors (and their institutions) are enhanced. Doctors sharpen their demands—and they seek (and usually win) greater input into political decisions. Epidemics change the public conception of disease. Diseases are no longer seen as pathologies of the body. They also become pathologies of the environment. Health is no longer a quality within the pure control of the individual. It is something that depends on the organisation of society. Epidemics reshape knowledge. Reliable data assume supreme political importance. Politicians demand instant access to these data. Research becomes a vital tool to improve political judgment. New fields of knowledge are created. Rapid and transparent communication of new findings becomes a necessity. Epidemics change publics. Public expectations rise. People welcome strong government action, but they become wary of the state's coercive power. The public is less tolerant of those thought to harbour disease (or the risk of disease). Stigma flourishes. Health becomes a public obsession. People lobby governments to take health more seriously. Quacks and charlatans prosper. Epidemics change societies. Epidemic disease precipitates a political crisis. Society is restructured and reformed. The idea of progress is redefined (reversals are possible). A consensus builds around the right to health. In sum, epidemics can accelerate as well as destroy human development. Zika will only be one moment in the long struggle to advance the health of those nations currently affected. But that moment is an opportunity that should not be lost.
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