The rich city of Campinas as a local example of inequities in health

The largest city of Brazilian inland, with more than one million inhabitants, Campinas is located in the heart of the state of São Paulo, the richest, most populous and industrialized one in the country. Campinas is the center-city of a metropolitan region comprising 19 towns, with more than 2.6 million inhabitants. Concentrating some of the major companies installed in the country, Campinas Metropolitan Region is responsible for 3% of Brazilian GDP and has the most recognized academic poles in Brazil and Latin America.

The public expenditure on health in Campinas was 26% of the annual budget in 2012, ie 11% more than predicted by the Constitution. The annual municipality expenditure in 2012 only with complications related to hypertension, heart attack and stroke was more than R$ 16 million. The local government has launched some public health initiatives against non-communicable diseases (NCDs), such as: mental health, elderly health (including hypertension and diabetes protocol), tobacco control and child health.

Background of NCDs in Campinas

Brazil, like other emerging economies, faces a growing number of non-communicable diseases. The NCDs account for 74% of the causes of mortality in the country. Despite being an important technological and academic pole, the NCDs account for 86 % of the causes of mortality in the city.

In spite of having a high HDI (0.81) in comparison with the Brazilian average (0.73), 80% of the patients at Campinas do not control blood sugar, cholesterol and blood pressure regularly. A study conducted in the metropolitan region of Campinas in 2003 showed that the early mortality rate (under 60y) by stroke was 23.27%, heart attack 30.39%, cardiac failure 12.57% and diabetes 20%.

According to the National Agency of Health, in 2012, 51% of the Campinas population depended exclusively on the public health sector. The fact that less 3% of the acute stroke population arrives in time to be treated in hospitals and the inefficiency of some technocratic health responses motivated me to study especially the populational, the preventive measures and the role of NCDs' risk factors.

With the purpose of evaluating the local impact of the global public health policies against NCDs, I carried out a research in the city of Campinas that proved to be a local example of the inequities in health, in spite of its vast public health system, high HDI and the Brazilian health system based on universal health coverage.

Regarding the causes of mortality, these results revealed a huge disparity between the north and south Campinas' regions, with double incidences of stroke, hearth attack, hypertension and diabetes in the underserved population.

Despite its health initiatives against NCDs, the local government is facing some challenges, such as:

1. The current stagnant economy reduced the national health budget and it will certainly interrupt or reduce public health policies against NCDs. On the contrary, Professor David Stuckler (Oxford University) has proved that, during the economic recession, the government should invest more in health,
2. Recently 1.4 million people lost their private health insurance in Brazil due to unemployment,
3. The significant increase of old infectious diseases such as Dengue that also impact the local resources against NCDs,
4. 32% of children between 5 and 9 years old are overweight or obese in the south of the city associated to the high sugar and salt intake in all over the country,
5. The "freeze"of public funds announced on 29 March 2019 with a 2.2 billion real slice of the Science Ministry’s budget. Funds for research will be cut by 42% and certainly will impact the country’s flagship science project, the synchrotron light source Sirius under construction in Campinas.

To achieve the agreed goal to reduce premature mortality due to NCDs of 25% by 2030, as part of the Sustainable Development Goals 3.4 agenda, a significant increase in action to reduce consumption of unhealthy commodities is vital —mainly tobacco, alcohol, and ultra-processed food and drink products. National and local governments, non-governmental organizations, academics, and civil society should consider also what the appropriate role of the private sector will be in NCD prevention and control.

A whole range of possibilities against NCDs risk factors is economically viable and various solutions are not so expensive. But not only partnerships between different actors are fundamental to reduce high mortality by NCDs locally. Our health system should take into account the social determinants of health to reduce the individual and collective socioeconomic impact through the primary health care that controls risk factors, empowers people and educates for self-care. The all levels of government should take action and assume their responsibilities regarding to international treaties, national legislation, advertisements, regulatory bodies and taxes. Dealing with the stakeholders from tobacco, alcohol, ultra-processed food and sweet drink industries is only a part of the game.

The suggestion proposed by Sergio Moro, the Minister of Justice to create a working group to evaluate the reduction of cigarette taxes to combat smuggling, is far from being the best solution for health and violates Brazil's commitment to the Framework Convention on Tobacco Control (WHO FCTC).

Future generations will be affected by the decisions we make today. Each of us has a choice: continue with the current disastrous situation or take the challenge of investing in the prevention of NCDs. Financing the prevention of chronic diseases is also a way of saving our scarce resources.

I developed a pilot project for underserved population located in the south region of the city to reduce the socioeconomic impact of NCDs which includes:

• health education for primary and secondary prevention and public awareness;
• e-health for monitoring NCD risk factors
• and a sustainable access to healthy food through urban community gardens.

If you want to share solutions, ideas or know more details about this pilot project, please do not hesitate to contact me.

Maria Carolina Loureiro