Revista Panamericana de Salud Pública/Pan American Journal of Public Health

This document outlines the methodology of the Salud, Bienestar y Envejecimiento (Health, Well-Being, and Aging) survey (known as the "SABE survey"), and it also summarizes the challenges that the rapid aging of the population in Latin America and the Caribbean imposes on society in general and especially on health services. The populations of the countries of Latin America and the Caribbean are aging at a rate that has not been seen in the developed world. The evaluation of health problems and disability among older adults in those countries indicates that those persons are aging with more functional limitations and worse health than is true for their counterparts in developed nations. In addition, family networks in Latin America and the Caribbean are changing rapidly and have less capacity to make up for the lack of protections provided by social institutions. The multicenter SABE study was developed with the objective of evaluating the state of health of older adults in seven cities of Latin America and the Caribbean: Bridgetown, Barbados; Buenos Aires, Argentina; Havana, Cuba; Mexico City, Mexico; Montevideo, Uruguay; Santiago, Chile; and São Paulo, Brazil. The SABE survey has established the starting point for systematic research on aging in urban areas of Latin America and the Caribbean. Comparative studies of these characteristics and with this comparative nature should be extended to other countries, areas, and regions of the world in order to expand the knowledge available on older adults.

El presente documento reseña la metodología de la encuesta SABE y los desafíos que impone a la sociedad en general y a los servicios de salud en particular el rápido envejecimiento de la población en América Latina y el Caribe. La Región esta envejeciendo a un ritmo que no se ha observado en el mundo desarrollado, y la evaluación de problemas de salud y discapacidad indica que los adultos mayores están envejeciendo con más limitaciones funcionales y peor salud que sus semejantes en países desarrollados. Además, las redes familiares están cambiando rápidamente y tienen menos capacidad de suplir la falta de protección social institucional. El estudio multicéntrico SABE se creó con el objetivo de evaluar el estado de salud de las personas adultas mayores de siete ciudades de América Latina y el Caribe: Buenos Aires, Argentina; Bridgetown, Barbados; La Habana, Cuba; Montevideo, Uruguay; Santiago, Chile; México, D.F., México y São Paulo, Brasil. La encuesta SABE establece el punto de partida para la investigación sistemática del envejecimiento en zonas urbanas de la Región de América Latina y el Caribe. Se recomienda que estudios de estas características y con este ánimo comparativo se extiendan a otros países, zonas y regiones, para enriquecer el conocimiento sobre las personas adultas mayores.

Only one half (50.1%) of all older adults in Latin America currently receive benefits under some form of social protection system for the elderly, either through social assistance or social security programs, or have access to a savings plan for old age in the form of individual capitalization accounts (ICA) based on mandatory or voluntary contributions. The other half enjoys no social protection at all; its consumer and health needs are covered through accrued assets, voluntary family transfers, or charitable deeds. Social security pension plan reforms and the creation of social-security-based savings plans for old age in the form of ICA have failed to yield the expected results in terms of coverage and benefits. Overall, reforms have led to the dismantling of social-security-based social protection systems for the elderly without creating alternative mechanisms for social protection. This document describes the various social protection systems and savings plans for old age that are in place in countries of the Region and looks at current challenges in terms of correcting "government failures" and applying policies that will redress "market failures," so that the working population can count on having enough resources to satisfy its consumer and health needs after retirement.

Keywords: social security, pensions, demographic transition, aged, Latin America, Caribbean Region.

In the developing countries of the world, an aging of the population in general is occurring at the same time that the life expectancy of older adults is increasing. The results of this double aging process are especially striking for health care services because of the concurrent epidemiologic transition, which has led to infectious diseases being replaced by noninfectious, habitually chronic diseases that occur predominantly in older age. In these circumstances, older adults begin to predominate among the patients whom physicians in Latin America now serve, and in the near future, older adults will constitute the immense majority of those patients. To respond to this situation, the training of professionals responsible for providing care to older adults should be improved, and the preparation of specialists in geriatric medicine should be enhanced both quantitatively and qualitatively. Future doctors should have the knowledge, abilities, and attitudes to enable them to appropriately serve this population segment. With these aims in mind, structures and procedures should be established that make it possible to impart the specific contents of geriatric medicine during medical school not only as a part of the traditional vertical teaching of the core curriculum of geriatric medicine, but also through the horizontal teaching of some of the material in other subjects. This article discusses why, with what objectives, with what contents, with what procedures, and with what staffing and materials the training of professionals in geriatric medicine should be carried out, and why it is time to give priority to this undertaking. Putting into place the measures proposed in this article should facilitate the incorporation of this subject matter into the curricula of the medical schools of Latin America.

Keywords: education, medical, undergraduate; geriatrics; Latin America.

Objective. The growing burden of mental disorders in Latin America and the Caribbean has become too large to ignore. There is a need to know more about the prevalence of mental disorders and the gap between the number of individuals with psychiatric disorders and the number of those persons who remain untreated even though effective treatments exist. Having that knowledge would make it possible to improve advocacy, adopt better policies, formulate innovative intervention programs, and apportion resources commensurate with needs.
Methods. Data were extracted from community-based psychiatric epidemiological studies published in Latin America and the Caribbean from 1980 through 2004 that used structured diagnostic instruments and provided prevalence rates. Estimates of the crude rates in Latin America and the Caribbean for the various disorders were determined by calculating the mean and median rates across the studies, by gender. In addition, data on service utilization were reviewed in order to calculate the treatment gap for specific disorders.
Results. Nonaffective psychosis (including schizophrenia) had an estimated mean one-year prevalence rate of 1.0%; major depression, 4.9%; and alcohol use abuse or dependence, 5.7%. Over one-third of individuals with nonaffective psychosis, over half of those with an anxiety disorder, and some three-fourths of those with alcohol use abuse or dependence did not receive mental health care from either specialized or general health services.
Conclusions. The current treatment gap in mental health care in Latin America and the Caribbean remains wide. Further, current data likely greatly underestimate the number of untreated individuals. The epidemiological transition and changes in the population structure will further widen the treatment gap in Latin America and the Caribbean unless mental health policies are formulated or updated and programs and services are expanded.

Key words Mental health, mental disorders, mental health services, health resources, health policy, Latin America, Caribbean Region.

Objetivo. La creciente carga de trastornos mentales que afecta a las poblaciones de América Latina y el Caribe es demasiado grande para hacer caso omiso de ella. Por lo tanto, es una necesidad impostergable conocer la prevalencia de los trastornos mentales y la brecha de tratamiento, que está dada por la diferencia entre las tasas de prevalencia verdadera y las de las personas que han sido tratadas, que en algunos casos es grande pese a la existencia de tratamientos eficaces. Si se dispone de mayor informacion, se hace más factible 1) abogar mejor por los intereses de las personas que necesitan atención, 2) adoptar políticas más eficaces, 3) formular programas de intervención innovadores y 4) adjudicar recursos en conformidad con las necesidades observadas.
Métodos. Los datos se obtuvieron de estudios comunitarios publicados en América Latina y el Caribe entre 1980 y 2004. En esas investigaciones epidemiológicas se usaron instrumentos diagnósticos estructurados y se estimaron tasas de prevalencia. Las tasas brutas de diversos trastornos psiquiátricos en América Latina y el Caribe se estimaron a partir de las tasas media y mediana extraídas de los estudios, desglosadas por sexo. También se extrajeron los datos correspondientes al uso de servicios de salud mental para poder calcular la brecha en el tratamiento según trastornos específicos.
Resultados. Las psicosis no afectivas (entre ellas la esquizofrenia) tuvieron una prevalencia media estimada durante el año precedente de 1,0%; la depresión mayor, de 4,9%; y el abuso o la dependencia del alcohol, de 5,7%. Más de la tercera parte de las personas afectadas por psicosis no afectivas, más de la mitad de las afectadas por trastornos de ansiedad, y cerca de tres cuartas partes de las que abusaban o dependían del alcohol no habían recibido tratamiento psiquiátrico alguno, sea en un servicio especializado o en uno de tipo general.
Conclusiones. La actual brecha en el tratamiento de los trastornos mentales en América Latina y el Caribe sigue siendo abrumadora. Además, las tasas actuales probablemente subestiman el número de personas sin atención. La transición epidemiológica y los cambios en la composición poblacional acentuarán aun más la brecha en la atención en América Latina y el Caribe, a no ser que se formulen nuevas políticas de salud mental o que se actualicen las existentes, procurando incluir en ellas la extensión de los programas y servicios.

Technical cooperation strategies of the Pan American Health Organization in the new phase of mental health services reform in Latin America and the Caribbean

The beginning of the new millennium coincided with the start of a new phase in the reform of mental health services in Latin America and the Caribbean. This new phase has imposed new priorities and prompted new technical cooperation strategies at the international level. This piece points out the main characteristics of the first phases in the reform of mental health services in Latin America and the Caribbean, discusses the factors that led to the phase that started in 2001, and describes the strategies and the technical cooperation activities of the Pan American Health Organization to deal with the challenges that have arisen in the current stage of reform. The piece also considers the prospects for international cooperation in this field, as well as the advantages of establishing a program for the reform of mental health services in the Americas that would contribute to the combined efforts of governments and international organizations in an action plan with defined objectives. The piece recommends taking advantage of the celebration of the 15th anniversary of the Declaration of Caracas in order to launch an action plan that gives new impetus to mental health services reform in the Americas.

Key words Mental health, health care reform, Latin America, Caribbean region.

La entrada en el nuevo milenio coincidió con el inicio de una nueva fase de la reforma de los servicios de salud mental en América Latina y el Caribe. Esta nueva fase ha impuesto nuevas prioridades e inspirado nuevas estrategias de cooperación técnica a escala internacional. En el presente artículo se mencionan las características principales de las primeras fases de la reforma de los servicios de salud mental en América Latina y el Caribe, se discuten los factores que llevaron a la fase iniciada en 2001 y se describen las estrategias y acciones de cooperación técnica desarrolladas por la Organización Panamericana de la Salud para enfrentar los desafíos surgidos en la etapa actual de la reforma. Además, se exponen algunas reflexiones sobre las perspectivas de la cooperación internacional en este campo, así como las ventajas de establecer un programa regional para la reforma de los servicios de salud mental que facilite el trabajo conjunto de los gobiernos y de las organizaciones internacionales en un plan de acción con objetivos definidos. Se recomienda aprovechar la celebración del decimoquinto aniversario de la Declaración de Caracas para lanzar un plan de acción regional que dé un nuevo impulso a la reforma de los servicios de salud mental.

OBJECTIVE: Elevated serum total homocysteine (tHcy) is considered an independent risk factor for cardiovascular disease. The objective of this study was to develop the first-ever information on the prevalence of hyperhomocysteinemia and its determinants in a population in Costa Rica.
METHODS: A cross-sectional study was conducted to determine serum levels of tHcy, vitamin B12, folate, and creatinine, as well as the presence of the genotype TT for the methylenetetrahydrofolate reductase (MTHFR) enzyme. Additionally, dietary vitamin intakes and other lifestyle risk factors were assessed. A total of 399 Costa Rican adults from the central valley of the country (where the capital city, San José, is located), aged 20 to 40 years, participated in this study in the year 2000. Analyses of variance were performed for continuous variables, and the chi-square test was used for categorical data. Spearman correlation tests were calculated to determine associations between variables. Three linear regression analyses and one binary logistic model were developed in order to determine the predictors for homocysteine levels in the population studied.
RESULTS: The overall prevalence of hyperhomocysteinemia (> 15 µmol/L) in the population was 6%, 31% of the population were in the range of 10 to 15 µmol/L, 29% had the genotype TT for the enzyme MTHFR, 18% presented a vitamin B12 deficiency (< 165 pmol/L), and none of the persons had low serum folate levels (< 7.0 nmol/L). No significant associations were found between tHcy and age, smoking, consuming alcohol, or dietary vitamin intake.
CONCLUSIONS: Only serum vitamin B12 levels and the genotype TT of the enzyme MTHFR were considered significant predictors of high serum tHcy levels in the Costa Rica population studied.

Factores genéticos y alimentarios y otros aspectos del estilo de vida que determinan las concentraciones séricas de homocisteína en adultos jóvenes en Costa Rica

OBJETIVO: La elevación de las concentraciones séricas de homocisteína total (tHci) se considera un factor que influye de forma independiente en el riesgo de sufrir trastornos cardiovasculares. El objetivo del presente estudio ha sido aportar los primeros datos que jamás se han reunido acerca de la prevalencia de hiperhomocisteinemia y sus factores determinantes en una población costarricense.
MÉTODOS: Se llevó a cabo un estudio transversal a fin de determinar las concentraciones séricas de tHci, vitamina B12, folato y creatinina, así como la presencia del genotipo TT respecto de la enzima reductasa del metilenotetrahidrofolato (RMTHF). También se examinaron la ingestión de vitaminas y otros factores de riesgo relacionados con el estilo de vida. Participaron en el estudio, que se realizó en 2000, 399 adultos costarricenses de 20 a 40 años de edad del valle central del país (donde está San José, la capital). Se realizaron análisis de la varianza en el caso de las variables continuas, y se aplicó la prueba de ji al cuadrado en el caso de datos categóricos. Se efectuaron pruebas de correlación de Spearman para determinar la asociación entre distintas variables. Se llevaron a cabo tres análisis de regresión lineal y un modelo logístico para datos binarios a fin de determinar qué factores servían para pronosticar las concentraciones de homocisteína en la población estudiada.
RESULTADOS: La prevalencia general de hiperhomocisteinemia (>15 µmol/L) en la población fue de 6%; en 31% de la muestra se detectaron concentraciones entre 10 y 15 µmol/L; en 29% se halló el genotipo TT respecto de la enzima RMTHF; 18% tuvieron deficiencia de vitamina B12 (<165 pmol/L), y nadie tuvo bajas concentraciones séricas de folato (<7,0 nmol/L). No se hallaron asociaciones significativas entre tHci en el suero, edad, hábitos tabáquicos, el consumo de alcohol o la ingestión de vitaminas.
CONCLUSIONES:  Solamente las concentraciones séricas de vitamina B12 y el genotipo TT respecto de la enzima RMTHF mostraron tener valor pronóstico con respecto a las concentraciones séricas de tHci en la población costarricense aquí estudiada.

Palabras clave: Enfermedades cardiovasculares, homocisteína, estilo de vida, factores de riesgo, Costa Rica.

The use of bibliographic databases by Spanish-speaking Latin American biomedical researchers: a cross-sectional study

OBJECTIVE: To describe how Spanish-speaking biomedical professionals in Latin America access and utilize bibliographic databases.
METHODS: Based on a MEDLINE search, 2 515 articles published between August 2002 and August 2003 were identified that dealt with and/or had authors from 16 countries: Argentina, Bolivia, Chile, Colombia, Costa Rica, Cuba, Ecuador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela. The search was limited to references to basic science, clinical science, or social medicine. A survey was sent by e-mail to researchers who lived in 15 of the 16 countries (the exception being Nicaragua). The survey asked about the researcher's area of work (basic science, clinical science, or public health), the level of skill in using databases, the frequency and type of access to the databases most utilized, the impact from not having access to the full text of articles when preparing a manuscript, and how the respondent usually obtained the full-text version of articles.
RESULTS: A total of 586 e-mail messages with the survey were sent out, and 185 responses were received (32%). The databases most utilized to obtain biomedical information were MEDLINE (34.1%), general search engines (Google, Yahoo!, and AltaVista) (15.9%), on-line journals (9.8%), BIREME-LILACS (6.0%), BioMedNet (5.4%), the databases of the Centers for Disease Control and Prevention of the United States of America (5.2%), and the Cochrane Library (4.9%). Of the respondents, 64% said they had average or advanced abilities in using MEDLINE. However, 71% of the respondents did not use or were not aware of the MEDLINE Medical Subject Headings (MeSH), a controlled vocabulary established by the National Library of Medicine of the United States of America for indexing articles. The frequency of accessing the databases was similar in all the countries studied, without significant differences in terms of the type of access (authorized access to commercial databases, unauthorized access to those databases, or access to databases available for free) or the level of abilities. Of the respondents, 87% said they had not included important references in the articles that they had published because they had not had access to the full text of those items, and 56% said they had cited articles that they had not read in full. In addition, 7.6% of the respondents admitted to unauthorized use of limited-access databases, such as through borrowed passwords or copied disks. More than two-thirds of the respondents said they obtained the full text of articles through photocopies or directly from the authors.
CONCLUSIONS: In order to encourage scientific output by Latin American researchers, more of them need to be trained in the use of the most frequently used databases, especially MEDLINE. Those researchers also need to have expanded access to the biomedical literature.

Key words: Databases, bibliographic; access to information; Latin America.

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OBJETIVO:  Caracterizar cómo los profesionales biomédicos hispanoparlantes de América Latina acceden a y utilizan las bases de datos bibliográficas.
MÉTODOS: A partir de una búsqueda en MEDLINE se identificaron 2 515 artículos publicados entre agosto de 2002 y agosto de 2003 por autores de Argentina, Bolivia, Chile, Colombia, Costa Rica, Cuba, Ecuador, Guatemala, Honduras, México, Nicaragua, Panamá, Paraguay, Perú, Uruguay y Venezuela. La búsqueda se limitó a referencias de las ciencias básicas y clínicas y de la medicina social. Se envió una encuesta por correo electrónico a los autores que efectuaron su investigación y residían en alguno de los países estudiados. En la encuesta se exploraron el área de desempeño del investigador (ciencias básicas, clínicas o salud pública), el nivel de destreza en la utilización de las bases de datos, la frecuencia y el tipo de acceso a las bases de datos más empleadas, el impacto de la carencia de los textos completos en el momento de escribir un manuscrito y la vía mediante la cual los encuestados solían conseguir el texto completo de los artículos.
RESULTADOS: Se enviaron en total 586 mensajes con la encuesta y se recibieron 185 respuestas (32%). Las bases de datos más utilizadas para obtener información biomédica fueron MEDLINE (34,1%), los motores de búsqueda generales (Google, Yahoo! y Alta Vista) (15,9%), las revistas en línea (9,8%), BIREME-LILACS (6,0%), BioMedNet (5,4%), las bases de datos del Centro para el Control y la Prevención de Enfermedades (CDC) de los Estados Unidos (5,2%) y la Biblioteca Cochrane (4,9%). De los encuestados, 64% indicaron tener habilidades medias o avanzadas en la utilización de MEDLINE. Sin embargo, 72% no utilizaban ni conocían los MeSH ("medical subject headings", términos estandarizados fijados por la Biblioteca Nacional de Medicina de los Estados Unidos para hacer búsquedas en bases de datos bio-médicas). La frecuencia de las consultas a las bases de datos fue similar en todos los países estudiados, sin diferencias significativas en cuanto al tipo de acceso (formal, informal o libre) y el grado de habilidad. Del total, 87% reconocieron no haber incluido referencias importantes en artículos publicados por no disponer del texto completo y 56% afirmaron haber citado artículos que no habían leído. Además, 7,6% de los encuestados reconocieron haber consultado bases de datos de acceso restringido mediante claves prestadas o discos copiados. Más de dos tercios de los autores manifestaron que obtenían los textos completos de los artículos mediante fotocopia o directamente de los autores.
CONCLUSIONES:  Es necesario entrenar a los investigadores latinoamericanos en la utilización de las bases de datos de uso más frecuente —especialmente MEDLINE— y mejorar su acceso a las fuentes bibliográficas biomédicas, como medidas esenciales para fomentar el desarrollo de la producción científica en la Región.

Neoliberal health sector reforms in Latin America: unprepared managers and unhappy workers

This work analyzes the neoliberal health sector reforms that have taken place in Latin America, the preparation of health care workers for the reforms, the reforms' impacts on the workers, and the consequences that the reforms have had on efficiency and quality in the health sector. The piece also looks at the process of formulating and implementing the reforms. The piece utilizes secondary sources and in-depth interviews with health sector managers in Bolivia, Colombia, Costa Rica, the Dominican Republic, Ecuador, El Salvador, and Mexico. Neoliberal reforms have not solved the human resources problems that health sector evaluations and academic studies had identified as the leading causes of health system inefficiency and low-quality services that existed before the reforms. The reforms worsened the situation by putting new pressures on health personnel, in terms of both the lack of necessary training to face the challenges that came with the reforms and efforts to take away from workers the rights and benefits that they had gained during years of struggles by unions, and to replace them with temporary contracts, reduced job security, and lower benefits. The secrecy with which the reforms were developed and applied made workers even more unified. In response, unions opposed the reforms, and in some countries they were able to delay the reforms. The neoliberal reforms have not improved the efficiency or quality of health systems in Latin America despite the resources that have been invested. Nor have the neoliberal reforms supported specific changes that have been applied in the public sector and that have demonstrated their ability to solve important health problems. These specific changes have produced better results than the neoliberal reforms, and at a lower cost.

Key words: health sector reform, health personnel, Latin America.

Neoliberal reforms in health services in Latin America: a critical view from two case studies

Neoliberal reforms have promoted privatization and decentralization as strategies to improve equity, efficiency, and the quality of health services. In this piece the impact of these reforms in Latin America is critically analyzed, and the impacts of privatization in Colombia and of decentralization in Mexico are detailed. These two cases show that after 10 years of privatization in Colombia and 20 years of decentralization in Mexico the reforms have had the opposite of the desired effect: They have not improved equity, have increased health expenditures, have not increased efficiency, and have not shown a positive impact on quality. Public health programs in Colombia have deteriorated, while decentralization in Mexico has had a very high cost, without achieving the proposed objectives. It is officially accepted that decentralization in Mexico has increased inequity, and that new reforms implemented in 2003 promote vertical programs. Health systems based on regulated competition are not the most suitable ones for Latin America. Latin American countries should improve their health systems in line with the principles stated in the Declaration of Alma Ata and according to their own national experiences.

Key words: health sector reform, decentralization, privatization, Latin America, Colombia, Mexico.