Academic medicine as a resource for global health: the case of Brazil

The world has witnessed enormous changes in population health in recent years. The main sources of disease burden are now non-communicable diseases, and death and injury from external causes such as accidents, homicide, and suicide.¹ This shift has demanded entirely new organisational structures and expertise within the health sector at a time of great increase in technology and, consequently, in health costs. These changes have been especially difficult to assimilate in developing countries, which must also continue to deal with a large burden of communicable diseases such as AIDS. To overcome these challenges, the World Health Report 2003 recommends strengthening health systems by centring action on primary health care and by integrating health promotion and disease prevention across all levels of care on behalf of the entire population.²

The campaign to revitalise academic medicine offers an excellent opportunity to question how academics can respond to these challenges.³,⁴ The case of Brazil, a large middle income country with marked social inequalities striving to improve population health, provides an example.

Until the 1980s public health, medical care, and education in Brazil were pieces of a fragmented whole. Publicly financed health care was limited to unevenly supported emergency room and hospital treatment, coupled with a primary care system dedicated almost exclusively to management of infectious diseases and to maternal and child care. Public health agencies focused their activities on infectious diseases, especially vaccine preventable and endemic parasitic diseases. Medical education was almost exclusively performed within university hospitals oriented towards tertiary care. The implicit goal of most students was to become, like their academic mentors, a specialised “private physician.” The interface between training in clinical medicine and public health would be better described as a gap.

Over the past two decades, much has changed. Publicly financed health care has been unified and reformed extensively. The national health system (Sistema Único de Saúde, SUS) now covers more than 70% of the population and strives for complete medical coverage, at all levels, providing care for chronic illnesses and high technology procedures such as transplantation. A family medicine model of primary care has been adopted, based on multiprofessional health teams led by doctors and nurses, serving registered, geographically delimited populations.⁵ Each team includes several salaried members of the community. This new model is expanding rapidly and now, in its eleventh year, provides coverage for almost 40% of the population.⁶ Public health activities such as disease surveillance, health promotion, and community based prevention have expanded and now include recognition of chronic diseases, injuries, and accidents.

Academic medicine has also changed in Brazil. Clinical epidemiology, central to evidence based medicine and vital to creating the bridge between clinical medicine and public health, has been introduced into many curriculums, both in medical schools and in postgraduate training. Evidence based textbooks have been written for the Brazilian context.⁷ Additionally, post-residency training is now offered in more than 300 masters or doctoral programmes in health related fields throughout the country, representing a major resource for capacity building and research.

To align academic medicine more directly with the SUS, the Ministry of Health has instituted regional centres for training within the new primary care model⁸; redirected residency slots to family medicine; expanded in-house training for core personnel of the health system at local, state, and national levels; and funded programmes to help medical schools to make their curriculums more relevant to practice within the SUS. National funding for research and prizes for academic excellence are increasingly awarded to work that will help solve the problems faced by the SUS.

The national health service now depends on academic support to develop and identify innovations that should be translated into effective health actions,⁹ to crystallise the state of the art into clinical and public health guidelines,¹⁰ to monitor the provision of care,¹¹ and to evaluate health system initiatives.¹² Academic input also buffers the system against undue alterations resulting from shifts in the prevailing political winds, parties, and players.

Yet improving population health in Brazil will demand even greater academic participation. Can academic medicine meet these challenges? Only through change. Our experience is that change from within the academic structure is painfully slow in coming, making external incentives from the government and other key institutions vitally important.

In this regard, the pharmaceutical and technology industries provide incentives through funding research, medical gatherings, and other forms of continuing medical education. Their frequently massive commercial expenditures, however, often overwhelm more rational approaches to healthcare provision. In countries like Brazil with still limited governmental action and expertise in technology assessment, it is vital that academic medicine continues to question the ground rules for its partnerships with industry while strengthening its partnerships with the national health system.