[Decline and social inequalities of infant mortality caused by diarrhea]. / Declínio e desigualdades sociais na mortalidade infantil por diarréia.

This ecological study describes the temporal trend from 1977 to 1998, and spatial patterns of infant mortality from diarrhea in the city of Salvador, Bahia State, Brazil. The annual proportional of infant mortality and specific-cause mortality rate were estimated. Spatial units of geographical zones within the city's urban area were utilized for administrative purposes, which were aggregated according to quartile of living conditions indicators. Over the study period, the diarrhea-induced infant mortality rate decreased 91.9%. The mortality risk from diarrhea in the lowest living condition strata was 90% greater than in the highest conditions. Also, infant mortality due to diarrhea increases proportionally as living conditions worsen, which necessitates a review of the control policies concerning this important public health problem. Although the infant mortality rate declined during the study period, social inequalities related to infant mortality due to diarrhea persist, reflecting a continuing poor social development.

[The political and administrative context of the implementation of Health Districts in the State of Bahia, Brazil]. / O contexto político-administrativo da implantação de Distritos Sanitários no Estado da Bahia, Brasil.

This investigation was conducted in order to determine the political and administrative context prevailing during the implementation of health districts in the state of Bahia, Brazil. The documentary review includes laws, agreements, and contracts at the State and Federal levels from 1987 to 1989. This period corresponded to the first phase of the State government after the 1986 elections. Information was also obtained from key informants and former directors of the State Secretariat of Health at the central level. We describe how the policy for regionalization by territory and population was formulated, and we review both State and national planning procedures, identifying the events leading to the decision to create health districts. We list the political instruments related to this decision and analyze the positions of the various actors in the Brazilian Health System in relation to this strategic choice. Brief comments are given about the difficulties faced by this proposal during the period studied.

[Trends and spatial distribution of mortality from external causes in Salvador, Bahia State, Brazil]. / Evolução e distribuição espacial da mortalidade por causas externas em Salvador, Bahia, Brasil.

Since 1980, external causes (ICD-9 E800-E999) have been ranked as the second leading causal group for mortality in Brazil, thus becoming a major public health problem. This study aimed to describe spatial distribution trends for violent deaths in the urban setting of Salvador, a city in Northeast Brazil, for the years 1988, 1991, and 1994. An ecological study was conducted, and mortality data were obtained from death certificates and the archives of the Institute for Forensic Medicine. There was an increase of 34.6% in the number of deaths from external causes between 1988 and 1994. The highest mortality rates were among men from 20 to 29 years of age (from 192.0 to 262.0/100,000) and those 65 years and over (from 188.7 to 258.1/100,000). Homicides were the leading cause of violent deaths in about 75.0% of neighborhoods. The authors discuss the need for comprehensive public policies and an interdisciplinary approach to elucidate the causes and deal with the problem of violence.

[Infant mortality and living conditions: the reproduction of social inequalities in health during the 1990s]. / Mortalidade infantil e condições de vida: a reprodução das desigualdades sociais em saúde na década de 90.

An ecological study was conducted to determine the infant mortality trend from 1991 to 1997 and to analyze its relationship to living conditions in Salvador, Bahia State, Brazil. Inequality patterns in infant death were analyzed by spatial distribution and a compound socioeconomic index. The data showed a decline in the infant mortality rate, with neonatal deaths and perinatal causes playing a growing role. Despite this overall trend, the infant mortality rate increased in 1992, and it was only in 1997 that it returned to the 1991 level. This fact was interpreted as related to worsening living conditions during that period. Spatial distribution highlights the persistence of health inequalities; education was the variable with the most significant correlation rate. When distributed according to the living conditions index (LCI), both the infant mortality rate and proportional infant mortality showed a linear increase from the intermediate stratum (20.4 per mil ) to the lowest (29.3 per mil ) and from the highest stratum (5.3%) to the lowest (13.3%), respectively. The authors conclude that despite the reduction in the total infant mortality rate, the persistence of social inequalities and a social process that hinders improvement of living conditions are responsible for the inequalities observed in infant mortality.

[Collective health: a "new public health" or field open to new paradigms?]. / Saúde coletiva: uma "nova saúde pública" ou campo aberto a novos paradigmas?

The present essay is an exploratory study of the historical and institutional background of the so-called "crisis in public health", aimed at identifying the new trends and perspectives for the paradigmatic transformation of the health field in the context of the current international panorama of economic and cultural globalization. First, the rhetoric of health is analysed in historical perspective, briefly considering the main elements of the discourse of the ideological movements that historically built the social field of health. Medical Police, Social Medicine and Public Health are included as representative of such movements in 19th century Western Europe. After the Flexnerian turn, these movements were followed by Preventive Medicine, Community Health, Primary Health Care and Health Promotion, which dominated the scene particularly in the second half of the 20th century. The authors also summarise recent concerted PAHO efforts to debate the theory and practice of Public Health in the Americas, vis à vis the emerging demands of the economic, political and social context of Latin American countries. In this regard, the need for a common political agenda is emphasized, with the convergence of three topics-sectorial reform, "Renovation of Health for All" and the "new public health", covering the conceptual, methodological and operative domains. Secondly, a brief systematic account of the conceptual landmarks of the Collective Health movement, as carried through in the two last decades in Latin America, is presented, focusing more particularly on its potential for building up both a domain of transdisciplinary knowledge and a universe of practices. As a field of knowledge, it contributes to the study of health-disease phenomena in populations as a social process, investigating the production and distribution of disease in society as an aspect of social reproduction, and analysing health practices as a labor process integrated into the other social practices. As a universe of practices, Collective Health focuses on its models or action guidelines four objects of intervention: policies (forms of power distribution); practices (behavior modification; culture; institutions; knowledge production; institutional, professional and relational practices); technologies (organization and regulation of productive resources and processes; bodies/environments), and instruments (means of production of interventions). Finally, it is concluded that, although not being in itself a paradigm, Collective Health, as a movement committed to the social transformation of health, presents some possibilities of articulation with new scientific paradigms capable of approaching the health-disease-care object with due regard to its historicity and complexity.

[Inequalities in mortality, space and social strata]. / Desigualdades na mortalidade, espaço e estratos sociais.

OBJECTIVE: A description of the mortality differentials in Salvador, Bahia, Brazil, is presented. METHODS: An ecological study was carried out. The city was divided into 75 information areas and its population into six social strata. Standardized Mortality Rates, Age Specific Mortality Rates, Proportional Infant Mortality and the Proportional Mortality Ratio were calculated for each region and social strata. Data were obtained from Death Certificates and the Populational Census. RESULTS: The mortality ratio difference between the strata with best living conditions and the poorer strata ranged from 43.1% to 142.0% which corresponds to an inequality ratio ranging from 1.4 to 2.4. When that analysis was carried out in smaller areas, these differences reached 656.3%. CONCLUSIONS: These findings show the persistence of health inequalities in Salvador in more serious disproportion than that found in other studies. Despite the methodological problems related to the nature of the data and the study, project the authors it was highlight, the meaning of this kind of research concerned with new approaches to health planning and health promotion.

[Violence and social inequalities: mortality rates due to homicides and life conditions in Salvador, Brazil]. / Violência e desigualdade social: mortalidade por homicídios e condições de vida em Salvador, Brasil.

INTRODUCTION: Some studies have been questioning the association between poverty and violence. This study's purpose is to assess the distribution of homicide indicators associated with living conditions in Salvador, Brazil. METHODS: A cluster study for the years 1991 to 1994 was carried out including the 75 data centers of the city of Salvador, BA, Brazil. Using death certificates for the study period, yearly mortality rates and mortality ratios were estimated. The 1991 census data of monthly wages and years of education for all family providers were used to define a four-category variable related to living conditions. Mortality rates due to homicide and the relative risk regarding the lowest living condition area were calculated for each social stratum. The 95% confidence intervals were calculated using the Confidence Interval Analysis software. RESULTS: The highest mortality rates due to homicide were seen in the poorest areas. The relative risk due to homicide for the lowest and the highest living condition areas was statistically significant at 5% level and ranged from 2.9 to 5.1. CONCLUSIONS: The data show a strong association between social inequalities and homicide in this urban area, emphasizing the importance of crime reduction programs.

[Decrease and inequalities of infant mortality in Salvador, 1980-1988]. / Decréscimo e desigualdade da mortalidade infantil: Salvador, 1980-1988.

This study sought to describe the changes in mortality among infants under one year of age in different areas of the city of Salvador, Bahia, during the period 1980-1988. This was done using estimates of variation in two indicators: proportional infant mortality and the coefficient of infant mortality. Values for the first indicator were separated into low, intermediate, high, and very high quartiles for 1980 and then calculated again using 1988 data. The second indicator was derived from the estimated number of live births using the rate of 33.4/1,000 inhabitants for 1980 and 31.4/1,000 for the years thereafter. The results showed that infant mortality in that age group had declined over the period, but that at the end of the period inequalities persisted in the distribution of infant deaths, which confirmed that conditions remained adverse for certain segments of the population.

Decline and unevenness of infant mortality in Salvador, Brazil, 1980-1988.

Data relating to infant mortality in Salvador, Brazil, were analyzed in order to determine how infant mortality evolved in various parts of the city during the period 1980-1988. This analysis showed sharp drops in the numbers of infant deaths, proportional infant mortality (infant deaths as a percentage of total deaths), and the infant mortality coefficient (infant deaths per thousand live births) during the study period despite deteriorating economic conditions. It also suggested that while these declines occurred throughout the city, the overall distribution of infant mortality in different reporting zones remained uneven. Among other things, these findings call attention to a need for further investigation of the roles played by various health measures (including immunization, control of respiratory and diarrheal diseases, encouragement of breast-feeding, and monitoring of growth and development) and of reduced fertility (resulting from birth spacing, use of contraceptives, and female sterilization) in bringing about declines in infant mortality during hard economic times.

PIP: Infant mortality has declined since the 1940s in the Americas and specifically in Brazil. Infant mortality in Brazil was 65 deaths/1000 live births regardless of the recession. The aim of this study was to determine the patterns of change in infant mortality in 76 reporting zones in Salvador, Brazil, between 1980 and 1988, based on death records and decedent's place of residence. Data were analyzed in terms of changes in proportional infant mortality and the infant mortality coefficient. Quartiles were set at low (3.9 to 17.1 deaths/100 total deaths), intermediate (17.9 to 25.8), and high (37.5 to 52.5). Averages of each quartile were computed for 1980 and 1988 and compared. Live birth rates were used in computing the infant mortality coefficients; deaths/1000 live births were grouped by low, intermediate, and high, and average values calculated for 1980 and 1988. The problems of distortion in using these data are discussed. The results show declines in proportional infant mortality from 17.4% to 30.8% of total mortality and in infant mortality coefficients from 71.9 to 31.6 deaths/1000 live births. Proportional infant mortality declined by 43.5% between 1980 and 1988; the coefficient of infant mortality decreased by 56.1% for the same period. The absolute number of deaths also declined. In the quartile analysis, the rates of decline were greatest for intermediate, high, and very high proportional infant mortality and for the coefficient of infant mortality. There was also uneven distribution of deaths in different quartiles. The geographic location of reporting zones is visually displayed; it is apparent that there were few very high zones in 1988 and a sharp reduction in high zones for proportional infant mortality. The map of average infant mortality coefficients shows marked declines in very high zones; there were increases in areas with low and intermediate coefficients. Suggestions for additional research were to evaluate a longer time series and to analyze the influence of socioeconomic change on the declines.

[Regional distribution of violence: mortality from external causes in Salvador (Bahia), Brazil]. / Distribuição espacial da violência: mortalidade por causas externas em Salvador (Bahia), Brasil.

The aim of this paper was to describe the geographic distribution of mortality resulting from external causes during 1991 within the city of Salvador, Bahia, Brazil. Mortality indicators were calculated in terms of deaths from external causes and in terms of specific types of violence. Of the deaths in that year, 15% were due to external causes, corresponding to a mortality rate of 78/100,000 inhabitants. The homicide death rate was 32.2/100,000 inhabitants, and the traffic-related death rate was 21.8/100,000 inhabitants. The elderly, young adults, and teenagers were at higher risk of death from violent causes. Among the elderly, 38% of the deaths were from car accidents and 28% from falls. Among teenagers, homicides were the main cause of death, especially in males between 15 and 29 years of age. Our results show that the geographic distribution of violent deaths in Salvador is uneven. Such deaths occur mainly in poorer neighborhoods, which have higher violent death rates than average for the city of Salvador. There is a need for prevention and control measures, including public policies and public health activities, focusing on the areas that have the greatest risk of death from external causes.

Spatial distribution of proportional infant mortality and certain socioeconomic variables in Salvador, Bahia, Brazil.

PIP: The spatial distribution of infant deaths in each zone of the city of Salvador, Brazil, in 1980 was examined and related to selected socioeconomic and health care variables. The spatial distribution of infant mortality (defined as the ratio of infant deaths to total deaths in Salvador) was uneven, ranging from 3.9% in a zone in the center of the old city near the water to 52.5% in an outlying area. There was a direct correlation between proportional infant mortality and low income. The proportion of low-income families was 23.1% in the quartile containing the lowest rates of infant mortality compared with 97.7% in the quartile containing the highest such rates. Also noted was an inverse relationship between proportional infant mortality and water consumption. Similarly, the percentage of substandard housing (shacks) was directly associated with infant mortality, rising from 2% in the 1st quartile (low infant mortality) to 43% in the 4th quartile. There was additionally an inverse correlation between the average number of physicians per inhabitant and proportional infant mortality, with a rate of 5.7/10,000 inhabitants in the 1st quartile compared with 1.8 in the 4th. Overall, analysis of the spatial distribution of infant deaths in Salvador reveals that an especially high proportion of those dying were infants residing in certain zones of the city, most notably outlying neighborhoods and slums. The results further point to an important association between certain socioeconomic and sanitation variables and infant mortality. The fact that the highest correlation coefficient found in the present study was between proportional infant mortality and the percentage of low-income families underscores the significant role that economic structure plays in infant mortality. There is a need both to redefine the urban development model prevailing in Latin America and to reorient the aims of the health sector.^ieng

O movimento pelo planejamento de saúde na América Latina / The movement for health planning in Latin America

Descreve-se o desenvolvimento de concepções e técnicas do planejamento de saúde na América Latina, procurando discutir alguns determinantes sociais da sua emergência nesses países e da sua incorporação pelo Estado através de politicas sociais planificadas do planejamento.. descreve quatro momentos para o planejamento de saúde na América Latina. O primeiro caracteriza-se pela elaboração de técnicas como é o caso da CENDES/OPS. No segundo, ocorre uma difusão do processo de planejamento e uma autocrítica quando os planos nacionais de saúde foram considerados documentos que nunca se implementaram. O terceiro momento envolve a revisão das deficiências metodológicas e a ênfase sobre sobre os aspectos organizacionais (sistêmicos) e políticos do objeto do planejamento. Finalmente, o quarto momento corresponde à segunda metade da década de 70, quando foram elaborados guias para formulação de politicas de saúde. Conclui-se que na atual conjuntura o planejamento de saúde tem encontrado seu espaço de viabilidade no âmbito das chamadas "politicas racionalizadoras". O seu desenvolvimento dependera da redefinição das relações sociais de produção e das forma históricas de resolução dos conflitos de classe.

Redefinicoes do ensino da medicina preventiva e social. / Redefinitions in teaching preventive and social medicine

Reexaminando as principais modificacoes introduzidas no ensino da Medicina Preventiva e Social nos ultimos anos, o trabalho indica que tais modificacoes revelam nao so os limites impostos a esse ensino pela atual organizacao dos servicos de saude, mas, sobretudo, o carater profundo do "dilema preventivista".Analisa as bases conceituais de uma estrategia que permita a aproximacao do ensino de Medicina Preventiva e Social das instituicoes e programas de saude. Esta proposta e exemplificada pelo programa da disciplina Saude Publica e Medidas de Profilaxia, do Departamento de Medicina Preventiva da Faculdade de Medicina da UFBA, que e discutido desde os seus antecedentes, em 1975, ate a elaboracao do novo programa de 1980