Psychiatric reform law comes into effect in Brazil

POLICY AND PEOPLE

Yellow fever threat in India ndian health experts have been alarmed by rising numbers of Aedis aegypti mosquito—the key vector of yellow fever—around seaports and airports. Experts are concerned that the virus may be introduced into India if precautions are not taken. India and other Asian countries have so far been free from the virus which is found in Africa and South America. Studies by the National Institute of Communicable Diseases (NICD) and the National AntiMalaria Programme in different parts of India have pointed towards this increasing trend. Under the International Health Regulation of 1969, all international airports and seaports should be kept free from larvae and adult mosquitoes and their index should be less than 1%. K S Gill and colleagues from the NICD note that the first A aegypti survey in 1948 in Calcutta, Chennai, Cochin, and Vishakhapatnam ports indicated the presence of Aedes only in Calcutta. According to the report, the larval premises index at international

seaports, increased from 8·8% in 1997 to 29·6% in 2000 in Calcutta, from 0% in 1964 to 22·8% in 1999 in Chennai, and from 0% in 1961 to 12·19% in 1995 in Bombay.

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The larval index has also been constantly rising at international airports: from 0% in 1978 to 26·9% in 2000 in Calcutta, 13·5% in 1998 to 38·8% in 1999 in Chennai, 0% in 1956 to 9·2% in 1995 in Bombay. In Delhi, it rose from 0% in 1977 to 60·7% in 2000. Experts point out that yellow fever could be introduced to India through the unnoticed arrival of any subclinically infected patient or

mosquitoes infected with yellow fever carried on aircraft or ships. NICD officials claim that it is the responsibility of the civil aviation and seaport authorities to keep the mosquito populations under check. They also say that India, with an unvaccinated and susceptible population, is a yellow fever “receptive area”. A aegypti is seen in abundance in both urban and rural areas. “The only missing link in the chain of disease transmission is the yellow fever virus”, says K K Datta, director of NICD. “This is a cause of serious concern”, a senior WHO official in Delhi told The Lancet. “Given the eastward movement of the virus, we are very concerned about the introduction of yellow fever in this part of the world”, he added. “The Aedes population in India is definitely increasing”, said Datta. “If this rising trend is not checked via regular monitoring, the chance of introduction of yellow fever will increase”, he added. Sanjay Kumar

Psychiatric reform law comes into effect in Brazil razil’s psychiatric reform law was approved and came into effect this month, after 12 years of debate and voting in both houses of Congress. The law’s text has changed substantially during this time, according to Valentim Gentil Filho of the University of São Paulo. It has shifted emphasis from hospital-based care to communitybased care, and ensures patients’ rights and allows health authorities to regulate involuntary hospital admission. The approved law does not forbid the construction of new public psychiatric hospitals or the establishment of new psychiatric beds in hospitals paid by the public health system, as earlier versions of the law approved by congress have (see Lancet 1999; 353: 568). “With the approved law it will be possible to modernise our mental health-care system, closing old mental hospitals, and substituting them with modern ones”, says Gentil Filho. According to Miguel Roberto Jorge, president of the Brazilian Association of Psychiatry, the law is in fact an advance. “It seems to

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promote a hierarchy of health-care services, from community attention to hospital care, including specialised clinics and rehabilitation centres, among others”, he says. “We also believe that the law reaffirms an important role for the multiprofessional health-care team, which is welcomed by our association.” “Nothing absurd was approved, such as the banning of psychiatric hospitals or electroconvulsive therapy, and it represents a milestone in civil rights for patients”, says Jair Mari of the Federal Universidade of São Paulo. Much of the treatment in Brazil is still based on hospital care. According to Alfredo Schechtman, from the mental health programme in the Ministry of Health, there are 60 000 psychiatric beds financed by the public-health system, which cost US$200 million last year. These hospitals receive about US$12 per patient per day. “This represents 90% of our mental-health expenditure in 2000”, he says. “Non-hospital costs were only US$18 million.” The price paid to doctors for office visits is

not included in this sum, but a consultation by a doctor is worth only about US$1 within the public-health system. There has already been a gradual closing of hospital beds in Brazil, even before the new law. In 1990, according to Schechtman, there were 85 000 psychiatric beds, 25 000 more than today. “Where have all these people gone?” asks Gentil Filho. “There has not been a reallocation of resources to assist these people, and extra-hospital care numbers are much below what they already should be.” Mari agrees: “The law will have no impact in health care if it’s not followed by an increase in mental health-care expenditure.” On April 6, during the ceremony in which the law was approved, the Ministry of Health announced plans to pay a monthly sum, probably about US$140, for patients discharged after long periods in hospitals. Minister of Health Jose Serra also announced that all psychiatric hospitals are to be audited. Claudio Csillag

THE LANCET • Vol 357 • April 28, 2001

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