- Email: [email protected]
The impact of the Brazil experience in Latin America
Comment
death (mostly cardiovascular),11 adds substantial excess mortality for years. This important shift in our understanding has important public health implications and merits priority in research funding. For the foreseeable future, glucocorticoids—with their rapid and profound anti-inflammatory effect, safety profile,5 and low cost—will remain the most viable candidate for first-line adjunctive treatment. In agreement with the published work on glucocorticoids, Meijvis and colleagues3 report a rapid and sustained decrease in circulating inflammatory markers during dexamethasone administration. This finding sharply contrasts with the effect of statin treatment in community-acquired pneumonia.12 However, in Meijvis and colleagues’ study,3 dexamethasone’s early therapeutic benefits were lost within 2–3 days of discontinuation of treatment and inflammatory marker concentrations were much the same as those of controls. Within the new pathophysiological model,9,10 the duration of glucocorticoid treatment directed at achieving clinical resolution should be deemed inadequate. We strongly urge future trials to extend the duration of anti-inflammatory treatment to achieve biological resolution and prevent rebound inflammation. A longer duration of glucocorticoid treatment—similar to those for acute respiratory distress syndrome8 and Pneumocystis jirovecii pneumonia—in conjunction with secondary prevention8 would maximise the improvement in morbidity and mortality during and after hospitalisation. We thank Meijvis and colleagues for identifying new benefits for community-acquired pneumonia and the Genetic and Inflammatory Markers of Sepsis investigators9,10 for expanding our understanding and creating new
research opportunities to improve the lives of patients with pneumonia. *Marco Confalonieri, G Umberto Meduri Pneumology Department, University Hospital of Trieste, Trieste 34149, Italy (MC); and Memphis Veterans Affairs Medical Center and Division of Pulmonary, Critical Care, and Sleep Medicine, University of Tennessee Health Science Center, Memphis, TN, USA (GUM) [email protected] We declare that we have no conflicts of interest. We thank David Armbruster for critical review of this Comment. 1
2 3
4 5
6
7
8
9
10
11
12
Armstrong GL, Conn LA, Pinner RW. Trends in infectious disease mortality in the United States during the 20th century. JAMA 1999; 281: 61–66. Kaplan V, Clermont G, Griffin MF, et al. Pneumonia: still the old man’s friend? Arch Intern Med 2003; 163: 317–23. Meijvis SCA, Hardeman H, Remmelts HHF, et al. Dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial. Lancet 2011; published online June 1. DOI:10.1016/S0140-6736(11)60607-7. Niederman MS, McCombs JS, Unger AN, Kumar A, Popovian R. The cost of treating community-acquired pneumonia. Clin Ther 1998; 20: 820–37. Annane D, Bellissant E, Bollaert PE, et al. Corticosteroids in the treatment of severe sepsis and septic shock in adults: a systematic review. JAMA 2009; 301: 2362–75. Confalonieri M, Urbino R, Potena A, et al. Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med 2005; 171: 242–48. Meduri GU. An historical review of glucocorticoid treatment in sepsis. Disease pathophysiology and the design of treatment investigation. Sepsis 1999; 3: 21–38. Meduri GU, Annane D, Chrousos GP, Marik PE, Sinclair SE. Activation and regulation of systemic inflammation in ARDS: rationale for prolonged glucocorticoid therapy. Chest 2009; 136: 1631–43. Kellum JA, Kong L, Fink MP, et al, for the GenIMS Investigators. Understanding the inflammatory cytokine response in pneumonia and sepsis: results of the Genetic and Inflammatory Markers of Sepsis (GenIMS) Study. Arch Intern Med 2007; 167: 1655–63. Yende S, D’Angelo G, Kellum JA, et al, for the GenIMS Investigators. Inflammatory markers at hospital discharge predict subsequent mortality after pneumonia and sepsis. Am J Respir Crit Care Med 2008; 177: 1242–47. Cesari M, Penninx BW, Newman AB, et al. Inflammatory markers and onset of cardiovascular events: results from the Health ABC study. Circulation 2003; 108: 2317–22. Yende S, Milbrandt EB, Kellum JA, et al. Understanding the potential role of statins in pneumonia and sepsis. Crit Care Med 2011; published online April 21. DOI:10.1097/CCM.0b013e31821b8290.
The impact of the Brazil experience in Latin America Published Online May 9, 2011 DOI:10.1016/S01406736(11)60437-6 See Series page 2042 See Series Lancet 2011; 377: 1778, 1863, 1877, 1949, and 1962
1984
The Brazil Series in The Lancet shows that rapid progress can be made in public health and clinical care when necessary conditions are met. The authors, a seasoned group of Brazilian public health leaders, are key actors in this process. They narrate what has gone right, the forces that shaped progress, the main achievements, past and present problems being faced, and challenges ahead. The papers show the key role of securing universal access to health as vital for vaccine-preventable infectious diseases,
diarrhoea and malnutrition, maternal mortality, and, more recently, in controlling AIDS by providing free antiretroviral therapy at point of entry—an impressive account of joint efforts, supported by successive governments, to expand preventive and curative health care in response to growing public demand. How did this experience contribute to changes in other countries within and beyond the region? Traditional economic thinking in the past by bilateral and multilateral international assistance was that countries www.thelancet.com Vol 377 June 11, 2011
should first achieve economic growth before spending on social programmes.1,2 Investing in physical infrastructure (roads, bridges, factories) was necessary for social progress; countries should accumulate wealth before they could afford the provision of health, education, and other benefits to lower-income groups, and cheap labour was considered “not so bad”. Brazil showed the opposite—ie, you need to invest in human and social capital to achieve and sustain economic growth. This concept has been validated in Mexico over the past decades through the Progresa/Oportunidades programme,3 which showed that conditional direct-income transfers strengthen coverage and effectiveness of health, nutrition, and other social programmes. Thanks to this, children are healthier, growing better, and achieving gains in education faster than that predicted from economic growth alone.4 Universal education and health-insurance schemes now operate or are being established in many countries in the region. Bolivia, for example, called for zero malnutrition after electing its first indigenous President— Juan Evo Morales Ayma (Evo)—providing access to health and food for young children, and additional income transfers for families in poverty.3,5 These programmes are now influencing policies in other Andean countries (Peru and Ecuador) and also in Central America; these regions are furthest behind in health and social progress while indigenous origin is an added handicap.6,7 Brazil clearly shows the virtuous cycle of democratic advances supporting gains in health leading to further popular support for democracy. This process occurs only if the democratic process is allowed to function on the basis of majority rule respecting basic rights of all. Empowering the trouble makers is a democratic virtue because it provides a legal framework for change. As a young student in the early 1960s, I had the opportunity to meet Joao Goulart (the 24th President of Brazil until deposed by a military coup d’état in 1964) when he visited Chile soon after his election, and Cesar Victora and colleagues8 in the Series provide a synthesis of how military rule in Brazil affected the country. Repressive governments spread to Argentina, Chile, Uruguay, and elsewhere in the 1970–80s, marked by widespread disappearances, torture, and exile of many politicians, students, and writers, filmmakers, and other artists. However, times have changed for Latin America; the Soviet Union fell and US marines have been busy in other parts of the world. So when Evo decided to nationalise www.thelancet.com Vol 377 June 11, 2011
Corbis
Comment
foreign gas and petroleum enterprises, he justified it by indicating that the profits would now go to support human and social development. In fact most companies negotiated satisfactory compensation.9 In the not so distant past, such nationalisation would have meant efforts for regime change because the “rights” of foreign capital were being violated. On the other hand, the fall of the Soviet empire and the blurring of the idealistic mirage of Castro’s paradise in Cuba have opened new ways to look, assess, and judge what is best for different countries facing diverse challenges. Latin Americans are no longer tightly defined by ideology being for or against given dogmas, but are progressively pragmatic and able to better judge the benefits and risk of either a rampant capitalist or a closed state economy. Good governance is essential for public health advances, responsive governments are a good starting point…by the people, for the people, and with the people is even better. In Brazil, democratic governance in response to popular demands with participation of all people and a solid market economy worked in synchrony to spin the wheel of fortune, to benefit most if not all people.10,11 It would be difficult to understand the process of change leading to public health improvements without crediting the social movements and forces that catalysed it.12–14 The virtuous cycle of power, entrusted by the people to a political process responsive to the health and wellbeing of all, is the true engine of the massive health improvement observed. We, physicians and health professionals, are merely instruments to expedite progress; sometimes we can push along with our commitment when in positions of power 1985
Comment
and responsibility. In Brazil those who were intolerant to business as usual were responsible for making injustices a thing of the past; and for placing progress towards a better world at the top of the priority list. Brazil has given us a reason to be proud of our profession in this ever-changing environment. Having managed racial, cultural, and political diversity better than most countries, Brazil gives us a great opportunity to see soccer players dancing samba as the ball enters the goal, and the girl from Ipanema as she walks to the sea dressed for Carnival, all part of a collective global aspiration to be melhor do mundo, the best in the world. This sense of national purpose and pride provides the strength with which the country collectively addressed the challenge of better health for all. Brazil stands united in facing not only its World Cup, 2014, and Olympics, 2016, challenges of being the best, but also the need to continue addressing social and health improvement for all its people, all races, and all creeds. We wish the people and the new Government of Brazil continued success.
I declare that I have no conflicts of interest. 1 2 3
4
5
6
7
8
9 10 11 12
Ricardo Uauy Institute of Nutrition, University of Chile, Santiago, Chile; and Department of Nutrition and Public Health Interventions Research, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK [email protected]
13 14
Hagen EE. How economic growth begins: a theory of social change. J Soc Issues 1963; 19: 20–34. Rostow WW. The stages of economic growth. Econ History Rev 1959; 12: 1–16. Hoddinott J, Bassett L. Conditional cash transfer programs and nutrition in Latin America: assessment of impacts and strategies for improvement. Nov 21, 2008. http://www.rlc.fao.org/es/prioridades/seguridad/ingreso3/ pdf/ifpri.pdf (accessed March 22, 2011). Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA 2004; 291: 2563–70. Pelletier DL, Frongillo EA, Gervais S, et al. Nutrition agenda setting, policy formulation and implementation: lessons from the Mainstreaming Nutrition Initiative. Health Policy Plan 2011; published online Feb 3. DOI:10.1093/heapol/czr011. Hotez PJ, Bottazzi ME, Franco-Paredes C, Ault SK, Periago MR. The neglected tropical diseases of Latin America and the Caribbean: a review of disease burden and distribution and a roadmap for control and elimination. PLoS Negl Trop Dis 2008; 2: e300. Ruel MT, Menon P. Child feeding practices are associated with child nutritional status in Latin America: innovative uses of the demographic and health surveys. J Nutr 2002; 132: 1180–07. Victora CG, Aquino EML, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; published online May 9. DOI:10.1016/S0140-6736(11)60138-4. Kohl B. Bolivia under Morales: work in progress. Latin Am Persp 2010; 37: 107–22. Hall A. From Fome Zero to Bolsa Família: social policies and poverty alleviation under Lula. J Latin Am Stud 2006; 38: 689–709. Ferreira FHG, C, Leite PG, Litchfield JA. The rise and fall of Brazilian inequality: 1981–2004. Macroecon Dynam 2008; 12: 199–230. Valla VV. Health and education: university, NGOs, and public policy in Brazil. Latin Am Persp 1994; 21: 104–16. Abers R. From ideas to practice: the Partido dos Trabalhadores and participatory governance in Brazil. Latin Am Persp 1996; 23: 35–53. Bourne R. Lula of Brazil: the story so far. Berkeley and Los Angeles, California, USA: University of California Press, 2008.
The English strategy to reduce health inequalities Published Online November 12, 2010 DOI:10.1016/S01406736(10)62055-7 See Editorial Lancet 2010; 376: 1617 For the Lancet UK Policy Matters website see http:// UKpolicymatters.thelancet.com/
1986
England is the first European country to pursue a systematic policy to reduce socioeconomic inequalities in health. When the Labour party came into power in 1997, it immediately commissioned an expert report1 to develop a comprehensive programme to tackle health inequalities.2,3 The strategy has recently come to an end with the 2010 parliamentary elections, which brought a Conservative and Liberal Democrat coalition into government. So did this strategy reduce health inequalities? The strategy was structured around two overall targets: to narrow the gap in life expectancy between areas and the difference in infant mortality across social classes by 10% in 2010. The strategy was underpinned by 12 headline indicators (specific targets for intermediate outcomes) and 82 departmental commitments (specific
actions by various governmental departments), which together should ensure timely delivery of targets. The departmental commitments included reduction in child poverty, Sure Start, smoking cessation services, primary care in inner cities, and better access to treatment for cancer and cardiovascular disease. The total budget exceeded £20 billion.3 Official reviews give a clear picture of the results.4–8 While the departmental commitments were mostly met, only about half of the headline indicators were achieved and the outcome targets were completely missed. Some of the headline indicators show reduced inequalities, but others, including those that matter for inequalities in life expectancy or infant mortality, suggest stable or even increased inequalities between socioeconomic groups (table). The gap in life expectancy grew, because the www.thelancet.com Vol 377 June 11, 2011
death (mostly cardiovascular),11 adds substantial excess mortality for years. This important shift in our understanding has important public health implications and merits priority in research funding. For the foreseeable future, glucocorticoids—with their rapid and profound anti-inflammatory effect, safety profile,5 and low cost—will remain the most viable candidate for first-line adjunctive treatment. In agreement with the published work on glucocorticoids, Meijvis and colleagues3 report a rapid and sustained decrease in circulating inflammatory markers during dexamethasone administration. This finding sharply contrasts with the effect of statin treatment in community-acquired pneumonia.12 However, in Meijvis and colleagues’ study,3 dexamethasone’s early therapeutic benefits were lost within 2–3 days of discontinuation of treatment and inflammatory marker concentrations were much the same as those of controls. Within the new pathophysiological model,9,10 the duration of glucocorticoid treatment directed at achieving clinical resolution should be deemed inadequate. We strongly urge future trials to extend the duration of anti-inflammatory treatment to achieve biological resolution and prevent rebound inflammation. A longer duration of glucocorticoid treatment—similar to those for acute respiratory distress syndrome8 and Pneumocystis jirovecii pneumonia—in conjunction with secondary prevention8 would maximise the improvement in morbidity and mortality during and after hospitalisation. We thank Meijvis and colleagues for identifying new benefits for community-acquired pneumonia and the Genetic and Inflammatory Markers of Sepsis investigators9,10 for expanding our understanding and creating new
research opportunities to improve the lives of patients with pneumonia. *Marco Confalonieri, G Umberto Meduri Pneumology Department, University Hospital of Trieste, Trieste 34149, Italy (MC); and Memphis Veterans Affairs Medical Center and Division of Pulmonary, Critical Care, and Sleep Medicine, University of Tennessee Health Science Center, Memphis, TN, USA (GUM) [email protected] We declare that we have no conflicts of interest. We thank David Armbruster for critical review of this Comment. 1
2 3
4 5
6
7
8
9
10
11
12
Armstrong GL, Conn LA, Pinner RW. Trends in infectious disease mortality in the United States during the 20th century. JAMA 1999; 281: 61–66. Kaplan V, Clermont G, Griffin MF, et al. Pneumonia: still the old man’s friend? Arch Intern Med 2003; 163: 317–23. Meijvis SCA, Hardeman H, Remmelts HHF, et al. Dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial. Lancet 2011; published online June 1. DOI:10.1016/S0140-6736(11)60607-7. Niederman MS, McCombs JS, Unger AN, Kumar A, Popovian R. The cost of treating community-acquired pneumonia. Clin Ther 1998; 20: 820–37. Annane D, Bellissant E, Bollaert PE, et al. Corticosteroids in the treatment of severe sepsis and septic shock in adults: a systematic review. JAMA 2009; 301: 2362–75. Confalonieri M, Urbino R, Potena A, et al. Hydrocortisone infusion for severe community-acquired pneumonia: a preliminary randomized study. Am J Respir Crit Care Med 2005; 171: 242–48. Meduri GU. An historical review of glucocorticoid treatment in sepsis. Disease pathophysiology and the design of treatment investigation. Sepsis 1999; 3: 21–38. Meduri GU, Annane D, Chrousos GP, Marik PE, Sinclair SE. Activation and regulation of systemic inflammation in ARDS: rationale for prolonged glucocorticoid therapy. Chest 2009; 136: 1631–43. Kellum JA, Kong L, Fink MP, et al, for the GenIMS Investigators. Understanding the inflammatory cytokine response in pneumonia and sepsis: results of the Genetic and Inflammatory Markers of Sepsis (GenIMS) Study. Arch Intern Med 2007; 167: 1655–63. Yende S, D’Angelo G, Kellum JA, et al, for the GenIMS Investigators. Inflammatory markers at hospital discharge predict subsequent mortality after pneumonia and sepsis. Am J Respir Crit Care Med 2008; 177: 1242–47. Cesari M, Penninx BW, Newman AB, et al. Inflammatory markers and onset of cardiovascular events: results from the Health ABC study. Circulation 2003; 108: 2317–22. Yende S, Milbrandt EB, Kellum JA, et al. Understanding the potential role of statins in pneumonia and sepsis. Crit Care Med 2011; published online April 21. DOI:10.1097/CCM.0b013e31821b8290.
The impact of the Brazil experience in Latin America Published Online May 9, 2011 DOI:10.1016/S01406736(11)60437-6 See Series page 2042 See Series Lancet 2011; 377: 1778, 1863, 1877, 1949, and 1962
1984
The Brazil Series in The Lancet shows that rapid progress can be made in public health and clinical care when necessary conditions are met. The authors, a seasoned group of Brazilian public health leaders, are key actors in this process. They narrate what has gone right, the forces that shaped progress, the main achievements, past and present problems being faced, and challenges ahead. The papers show the key role of securing universal access to health as vital for vaccine-preventable infectious diseases,
diarrhoea and malnutrition, maternal mortality, and, more recently, in controlling AIDS by providing free antiretroviral therapy at point of entry—an impressive account of joint efforts, supported by successive governments, to expand preventive and curative health care in response to growing public demand. How did this experience contribute to changes in other countries within and beyond the region? Traditional economic thinking in the past by bilateral and multilateral international assistance was that countries www.thelancet.com Vol 377 June 11, 2011
should first achieve economic growth before spending on social programmes.1,2 Investing in physical infrastructure (roads, bridges, factories) was necessary for social progress; countries should accumulate wealth before they could afford the provision of health, education, and other benefits to lower-income groups, and cheap labour was considered “not so bad”. Brazil showed the opposite—ie, you need to invest in human and social capital to achieve and sustain economic growth. This concept has been validated in Mexico over the past decades through the Progresa/Oportunidades programme,3 which showed that conditional direct-income transfers strengthen coverage and effectiveness of health, nutrition, and other social programmes. Thanks to this, children are healthier, growing better, and achieving gains in education faster than that predicted from economic growth alone.4 Universal education and health-insurance schemes now operate or are being established in many countries in the region. Bolivia, for example, called for zero malnutrition after electing its first indigenous President— Juan Evo Morales Ayma (Evo)—providing access to health and food for young children, and additional income transfers for families in poverty.3,5 These programmes are now influencing policies in other Andean countries (Peru and Ecuador) and also in Central America; these regions are furthest behind in health and social progress while indigenous origin is an added handicap.6,7 Brazil clearly shows the virtuous cycle of democratic advances supporting gains in health leading to further popular support for democracy. This process occurs only if the democratic process is allowed to function on the basis of majority rule respecting basic rights of all. Empowering the trouble makers is a democratic virtue because it provides a legal framework for change. As a young student in the early 1960s, I had the opportunity to meet Joao Goulart (the 24th President of Brazil until deposed by a military coup d’état in 1964) when he visited Chile soon after his election, and Cesar Victora and colleagues8 in the Series provide a synthesis of how military rule in Brazil affected the country. Repressive governments spread to Argentina, Chile, Uruguay, and elsewhere in the 1970–80s, marked by widespread disappearances, torture, and exile of many politicians, students, and writers, filmmakers, and other artists. However, times have changed for Latin America; the Soviet Union fell and US marines have been busy in other parts of the world. So when Evo decided to nationalise www.thelancet.com Vol 377 June 11, 2011
Corbis
Comment
foreign gas and petroleum enterprises, he justified it by indicating that the profits would now go to support human and social development. In fact most companies negotiated satisfactory compensation.9 In the not so distant past, such nationalisation would have meant efforts for regime change because the “rights” of foreign capital were being violated. On the other hand, the fall of the Soviet empire and the blurring of the idealistic mirage of Castro’s paradise in Cuba have opened new ways to look, assess, and judge what is best for different countries facing diverse challenges. Latin Americans are no longer tightly defined by ideology being for or against given dogmas, but are progressively pragmatic and able to better judge the benefits and risk of either a rampant capitalist or a closed state economy. Good governance is essential for public health advances, responsive governments are a good starting point…by the people, for the people, and with the people is even better. In Brazil, democratic governance in response to popular demands with participation of all people and a solid market economy worked in synchrony to spin the wheel of fortune, to benefit most if not all people.10,11 It would be difficult to understand the process of change leading to public health improvements without crediting the social movements and forces that catalysed it.12–14 The virtuous cycle of power, entrusted by the people to a political process responsive to the health and wellbeing of all, is the true engine of the massive health improvement observed. We, physicians and health professionals, are merely instruments to expedite progress; sometimes we can push along with our commitment when in positions of power 1985
Comment
and responsibility. In Brazil those who were intolerant to business as usual were responsible for making injustices a thing of the past; and for placing progress towards a better world at the top of the priority list. Brazil has given us a reason to be proud of our profession in this ever-changing environment. Having managed racial, cultural, and political diversity better than most countries, Brazil gives us a great opportunity to see soccer players dancing samba as the ball enters the goal, and the girl from Ipanema as she walks to the sea dressed for Carnival, all part of a collective global aspiration to be melhor do mundo, the best in the world. This sense of national purpose and pride provides the strength with which the country collectively addressed the challenge of better health for all. Brazil stands united in facing not only its World Cup, 2014, and Olympics, 2016, challenges of being the best, but also the need to continue addressing social and health improvement for all its people, all races, and all creeds. We wish the people and the new Government of Brazil continued success.
I declare that I have no conflicts of interest. 1 2 3
4
5
6
7
8
9 10 11 12
Ricardo Uauy Institute of Nutrition, University of Chile, Santiago, Chile; and Department of Nutrition and Public Health Interventions Research, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK [email protected]
13 14
Hagen EE. How economic growth begins: a theory of social change. J Soc Issues 1963; 19: 20–34. Rostow WW. The stages of economic growth. Econ History Rev 1959; 12: 1–16. Hoddinott J, Bassett L. Conditional cash transfer programs and nutrition in Latin America: assessment of impacts and strategies for improvement. Nov 21, 2008. http://www.rlc.fao.org/es/prioridades/seguridad/ingreso3/ pdf/ifpri.pdf (accessed March 22, 2011). Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA 2004; 291: 2563–70. Pelletier DL, Frongillo EA, Gervais S, et al. Nutrition agenda setting, policy formulation and implementation: lessons from the Mainstreaming Nutrition Initiative. Health Policy Plan 2011; published online Feb 3. DOI:10.1093/heapol/czr011. Hotez PJ, Bottazzi ME, Franco-Paredes C, Ault SK, Periago MR. The neglected tropical diseases of Latin America and the Caribbean: a review of disease burden and distribution and a roadmap for control and elimination. PLoS Negl Trop Dis 2008; 2: e300. Ruel MT, Menon P. Child feeding practices are associated with child nutritional status in Latin America: innovative uses of the demographic and health surveys. J Nutr 2002; 132: 1180–07. Victora CG, Aquino EML, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; published online May 9. DOI:10.1016/S0140-6736(11)60138-4. Kohl B. Bolivia under Morales: work in progress. Latin Am Persp 2010; 37: 107–22. Hall A. From Fome Zero to Bolsa Família: social policies and poverty alleviation under Lula. J Latin Am Stud 2006; 38: 689–709. Ferreira FHG, C, Leite PG, Litchfield JA. The rise and fall of Brazilian inequality: 1981–2004. Macroecon Dynam 2008; 12: 199–230. Valla VV. Health and education: university, NGOs, and public policy in Brazil. Latin Am Persp 1994; 21: 104–16. Abers R. From ideas to practice: the Partido dos Trabalhadores and participatory governance in Brazil. Latin Am Persp 1996; 23: 35–53. Bourne R. Lula of Brazil: the story so far. Berkeley and Los Angeles, California, USA: University of California Press, 2008.
The English strategy to reduce health inequalities Published Online November 12, 2010 DOI:10.1016/S01406736(10)62055-7 See Editorial Lancet 2010; 376: 1617 For the Lancet UK Policy Matters website see http:// UKpolicymatters.thelancet.com/
1986
England is the first European country to pursue a systematic policy to reduce socioeconomic inequalities in health. When the Labour party came into power in 1997, it immediately commissioned an expert report1 to develop a comprehensive programme to tackle health inequalities.2,3 The strategy has recently come to an end with the 2010 parliamentary elections, which brought a Conservative and Liberal Democrat coalition into government. So did this strategy reduce health inequalities? The strategy was structured around two overall targets: to narrow the gap in life expectancy between areas and the difference in infant mortality across social classes by 10% in 2010. The strategy was underpinned by 12 headline indicators (specific targets for intermediate outcomes) and 82 departmental commitments (specific
actions by various governmental departments), which together should ensure timely delivery of targets. The departmental commitments included reduction in child poverty, Sure Start, smoking cessation services, primary care in inner cities, and better access to treatment for cancer and cardiovascular disease. The total budget exceeded £20 billion.3 Official reviews give a clear picture of the results.4–8 While the departmental commitments were mostly met, only about half of the headline indicators were achieved and the outcome targets were completely missed. Some of the headline indicators show reduced inequalities, but others, including those that matter for inequalities in life expectancy or infant mortality, suggest stable or even increased inequalities between socioeconomic groups (table). The gap in life expectancy grew, because the www.thelancet.com Vol 377 June 11, 2011