CARMEN: Country Profiles
In search of more efficient ways to prevent non-communicable diseases, PAHO developed the CARMEN concept in late 1995, as a practical tool to assist member countries to meet the challenge of achieving Health for All.
In Barbados, attention to unintentional injuries is focused primarily on motor vehicle-related injuries. A factor that contributes to traffic injuries is the explosion in the number of vehicles on the roads, currently estimated at 60,000 (the country's population is approximately 250,000). Other contributors include narrow and congested streets, a lack of sidewalks for pedestrians, the absence of seat belt legislation or effective laws governing drinking and driving, and the perception that road safety issues are "mundane." On the other hand, the country does not have high-speed roads and most drivers tend to travel short distances.
The Ministry of Public Works, Transport and Housing (MOPWTH) is the governmental agency most actively involved in addressing injury prevention (i.e., road safety). However, it was noted that injury prevention activities often are developed and piloted by non-governmental organizations (NGOs) rather than by the government. The Ministry of Health concurred with this assessment; by its own admission, it "has not been actively involved" in injury prevention and control efforts. The Road Safety Association (RSA), a volunteer-run NGO established in the 1970s, has been the "prime mover" advocating for road safety legislation and programs. The RSA strives to work "hand-in-hand" with the MOPWTH, the Ministry of Health, the police, and private insurance agencies; however, its representative noted that traffic injury prevention and control activities are a "very fragmented effort" and collaboration across agencies is sporadic.
In 1993, external causes accounted for a mortality rate of 68.45 per 100,000 and were the second leading cause of mortality for all ages in Brazil. In 1996, external causes were the leading cause of mortality for individuals aged 5-49 years. The financial and social costs are dramatic. According to the Ministry of Health, the increase in mortality and morbidity due to external causes has caused a change in the demand for health care services in the country. A complex and multifactorial set of risks have converged to create the current situation, including broad social factors such as the deterioration of social networks, the concentration of populations in urban centers, unemployment, violence, and increased consumption of alcohol, as well as more specific factors such as the degradation of working conditions and driving at high speeds. Such circumstances are responsible for the large increase in traffic accidents, occupational injuries, homicides, suicides, injuries from firearms and blunt objects, home injuries, intoxications, poisonings, drownings, falls, burns, and medical injuries.
The government recognizes the importance of primary (prevention), secondary (care), and tertiary (rehabilitation) actions, estimating that for every US $1 spent on prevention, it saves $10 US in care and $1000 US in rehabilitation. The Secretaría de Assistência à de Saúde has established the office of Coordenação de Emergência e Trauma, which is coordinating actions in prevention, emergency care (pre-hospital and hospital), and rehabilitation. The central focus of its plan of action is emergency care and, specifically, pre-hospital care.
The site visit focused on traffic-related injuries. Although there is no national coordinated program, some cities have local programs. At the state level, some states have addressed the problem more than others. For example, the Companhia de Engenharia de Tráfego (CET) has compiled data on traffic accidents for São Paulo since 1981. Belo Horizonte identifies black spots on roadways, and Brasilia has an educational prevention campaign and law enforcement with cameras at certain intersections.
In Chile, Cancer is the 2second leading cause of death and cervical cancer is the leading cause of death in Chilean women aged 20-44 years old.
In 1990, annual mortality from cervical cancer was approximately 12 deaths per every 10,000 women.
In 1997, the estimated population for Chile was 14, 625,000 with approximately 85% of the population living in urban areas.
For four decades, the National Cancer Program has been a priority of the Ministry of Health and in 1997 the Ministry declared cervical cancer a high priority.
The National Cancer Program has been supported financially and technically by WHO/PAHO from its beginning.
Since 1993, the Program for Prevention and Control of Cervical Cancer has been developing a National Reference Library.
In 1993, the Program received resources from the World Bank and since 1994 the Ministry of Health has been annually contributing 150 million pesos.
Red-PAC will complement the national effort.
Chile is currently undergoing a reform in its health sector as a consequence of the globalization of its economy and the return to democracy. The Reforma del Sector Salud is a process to address the country's epidemiologic and demographic changes, deep socioeconomic inequalities, and their consequences on health. The reforms also seek to address the insufficiency of past programs in terms of financing and organization.
National health priorities have been set as part of the reform process. Criteria included
The top priority among the 16 national health policies (Prioridades de Salud País 1997-1999, Documento de trabajo para la discusión, Ministerio de Salud, Mayo 1997) is "accidents" or unintentional injuries. Specific programs are to be targeted by age groups, with a focus on home and school accidents for children, traffic accidents for adolescents and adults, occupational injuries for adults, and home accidents for the elderly.
Chile has specifically targeted motor vehicle-related injuries as well as other unintentional injuries in its programs and policies. Traffic-related injuries are the leading cause of deaths from injuries, followed by drownings. The Ministry of Health has created a centralized office within the Department of Epidemiology to coordinate its injury prevention and control efforts. In 1993, the Comisión Nacional de Seguridad del Tránsito was established by supreme decree by the President of the Republic with representation from 9 ministries. In 1994, the government enacted a document entitled Política Nacional de Seguridad del Tránsito. This model of establishing policy is also being applied to other unintentional injuries.
In 1990, accidents and violence accounted for one-fourth of all deaths from "defined causes" in Colombia. Violence is a particulary strong contributor to Colombia's injury trends. In 1995, homicide was the country's leading cause of both death and years of potential life lost. More than 1 out of every 5 families has lost a family member due to homicide.
In 1995, approximately 20% of all "violent deaths" were due to motor vehicle accidents (18% if measured in terms of years of potential life lost). Pedestrians constitute half of all motor-vehicle related fatalities, and are also the group most affected by non-fatal traffic injuries. Referring to increases in traffic accident mortality from 1992 to 1995, a recent Ministry of Health report notes that the prevention of motor vehicle-related deaths "will require a considerable effort on the part of the health sector in the years to come". A report by the country's National Resource Center on Violence notes that "although traffic accidents are not the leading public health priority in Colombia, they can be prevented more easily [than intentional injuries], at less cost, and with a more immediate impact."
Factors contributing to rising traffic injury rates include the flood of imported cars that has entered Colombia in recent years, the proliferation of high-speed roads in urban sectors that also are frequented by pedestrians, the increasing number of elderly pedestrians resulting from population aging, and more drivers under age 25. Other problems, associated with poor city planning, include the placement of "pedestrian bridges" (which allow pedestrians to cross busy streets) in locations inconvenient to bus stops. Observers also have suggested that the climate of violence in Colombia promotes a "violent, competitive, and intolerant attitude" in drivers that frequently is aggravated by alcohol use.
Approximately 10% of the years of potential life lost (YPLL) to "violent deaths" are due to unintentional injuries other than traffic accidents. In 1995, 28.7% of fatal injuries in this category were caused by drownings, followed by falls (23.9%), burns (9.1%), occupational injuries (7.4%) and other types of injury events. The majority of fatal unintentional injuries, excluding motor vehicle crashes, occur in men and individuals over the age of 60, although falls among construction workers affect a significant number of men in the younger age groups.
Policy directives originate a the national level, where "what should be done" is specified. However, the country's municipalities usually develop specific laws and regulations, and traffic-related prevention activities tend to be initiated by staff in local Secretariats of Health or Transport. As a result, laws and programs vary widely by city and region. Some observers suggest that behaviors also vary by location; Cali residents, for example, are reputed to "respect the rules more" and have more of a "civic" orientation that the residents of Bogotá. In the early 1990s, Colombia witnessed several health care reforms, including "Law 100" (passed in 1993), which established distinct health care financing structures for workers and the indigent. Ministry of Health officials emphasize that the funding mechanisms established by Law 100 generate resources for health promotion an disease prevention activities, including injury prevention. In addition, the National Highway Prevention Fund (Fondo Nacional de Prevención Vial) funds traffic safety activities.
In Costa Rica mortality from cervical cancer declined during 1965 to 1973, since then mortality from cervical cancer has stabilized to approximately 10 deaths per every 100,000 women.
During the decade of 1984 to 1993, Costa Rica has reported an average of 118 annual deaths from cervical cancer.
The site visit to the Dominican Republic was specifically to review the development of the Plan Nacional para la Reducción de Muertes por Accidentes de Tránsito (PLANREMAT) of the Subsecretaría de Estado Técnica de Slaud of the Ministry of Health. The principle focus of the country's injury prevention programs is in the area of motor vehicle-related injuries, considered to be the priority national health problem. In a country with roughly 8 million inhabitants, approximately 3,000 deaths are estimated to be caused by traffic accidents each year.
In Ecuador, mortality from cervical cancer has not declined in the last 30 years.
Cervical cancer is responsible for the deaths of approximately 700 women annually, with figures higher than the occurred due to maternal mortality (309) and pulmonary tuberculosis (429).
In Quito, an average of 135 new cases of invasive cancer are diagnosed every year, 32.9% of which are diagnosed in very advanced stages with poor prognosis.
The first stage is planned to begin in two demonstration sites: the province of Quito and Manabí. Both of these provinces are developing a Program for Prevention and Control of Cervical Cancer.
Quito, the capital of Ecuador, is located in the Andean Region. The city has a population of approximately 1,300,000 inhabitants, 60% of which live in a state of poverty. The project would benefit nearly 175,000 women.
The province of Manabí, located on the Pacific Coast, encompasses 20,000 km2 and has an estimated 1,200,000 inhabitants.
More than 50% of the population lives precariously in rural areas, with difficult access to services. The project would benefit approximately 130,000 women.
In Ecuador, cervical cancer has been proposed as a public health problem, together with accidents, violent acts and hypertension.
The Program for Prevention and Control of Cervical Cancer is being developed by the Society of Cancer (SOLCA) in Quito and Manabí.
In the laboratories of SOLCA-Quito and SOLCA-Manabí important steps have been made to standardize systems, to advance the preparation of standard manuals and procedures and to introduce improvements into the processes of stain and systems of registries and report.
Ecuador has requested support from PAHO to reorient their Program for Prevention and Control of Cervical Cancer. The proposal of the regional evaluation system/international Pan American Cytology Network is to strengthen the programs under way to the extent that it promotes the quality of work in the cytological laboratories and aims to improve the quality of diagnoses.
In Jamaica, "injuries and poisoning" are the third leading cause of morbidity in the country. In the 15 to 44 are group, motor vehicle-related injuries, assaults, and other accidents are the leading cause of both morbidity and mortality. Efforts to prevent unintentional injuries have focused primarily on road accidents and road safety, perhaps because road accidents are estimated to cost the the country $39 million per year (US$) and contribute to 50% of all hospital cases. With a Cabinet-level subcommittee on road safety and a Road Safety Office within the Ministry of Local Government and Works, there is evidence that road safety is prominent as a public policy issue. The prevention of unintentional injuries (accidents) and intentional injuries (violence) also is perceived as a "high priority" by the Ministry of Health.
The responsibilities of the government Road Safety Office include:
The Road Safety Office works closely with the non-governmental National Road Safety Council (NRSC), founded in the early 1990s. The NRSC plays an important role in developing and implementing public education programs; lobbying for the promotion of road safety; and facilitating coordination between relevant ministries, organizations, and stakeholders. Although non-governmental, the NRSC has an official "mandate" from Parliament; Jamaica's Prime Minister serves as the Council's Chairman and one-half of its funding comes from the government. In 1996-97, the NRSC derived an additional 43% of its budget from the private sector (banking and insurance industries), with the remainder (7%) coming from PAHO. Currently, the NRSC is limited to making policy recommendations; however, it is considering the possibility of becoming a statutory body, which would endow it with the authority to make policy.
In Mexico cervical cancer has the highest rate of incidence caused by malignant neoplasms in the general population.
According to figures from the histopathological registry of neoplasms, in Mexico in 1994 there were 14,554 new cases of this neoplasm. The number of registered deaths caused by cervical cancer was 4,365.
In Mexico, the female population group at risk (between 25 and 64 years old) is estimated to be approximately 19,000,000 women.
For Mexico, diminishing the incidence and mortality of cervical cancer is a national priority. All the health institutions, as well as other groups from the public and private sector (professional associations, The Institute of Oncology, etc.) share this initiative.
As a part of this program PAHO is supporting the monitoring and evaluation of the project in the state and Nayarit, the demonstration site.
In the context of the Program the National Institute of Diagnosis and Epidemiological Reference (INDRE) has reformulated its work strategy in order to fulfill its mandate of seeking quality control in the cytopathology laboratories in the country.
Within the Ministry of Health, which includes 117 cytology laboratories and 257 cytologists, an evaluation system of skill ("proficiency") has been established for cytologists. The 1st stage includes a laboratory inspection and microscope repair.
As of February 1999, 30% of the microscopes were found to need repair or substitution and 80% of the cytologists did not possess the minimum skill level required and therefore needed training.
A system of regional/international evaluation such as Red-PAC that promotes the quality of reading of gynecological cytopathology will complement h the national effort. In Mexico, the National Institute of Diagnosis and Epidemiological Reference (INDRE) would become the focal point of Red-PAC and would proceed with the 1st laboratory selection.
"Accidents" are the third leading cause of death and hospitalization in Mexico, and the leading cause of death for children ages 1-14. In 1996, approximately 707,000 individuals (out of a total population of 93 million) were involved in accidents. Considering all causes of death, 8% of mortality in 1996 was due to accidents (up from 5.3% in 1970), with someone dying from injury-related causes every 15 minutes. Motor vehicle crashes were the most significant cause of injury mortality in 1996 (40.5% of all accident-related deaths), followed in descending order by falls, drowning, poisoning, firearm injuries, and "other" injuries. Motor vehicle crashes are not evenly distributed throughout the country, however, in 1990, 70% occurred in just 22 municipalities, including Mexico City and Guadalajara. Injury-related deaths in 1996 occurred primarily to individuals between the ages of 15 and 64 (65.5%); however, almost one-fifth (17.2%) of such deaths were to children under age 15, who also experienced more than one-third (37%) of all reported accidents. The most frequent locations associated with injury mortality were public roads and streets or the home.
A variety of attempts have been made to focus attention on the public health and socioeconomic impact of injuries in Mexico. At the national level, one of the earliest initiatives was a governmental decree in 1961 to establish a Consejo Nacional para la Prevención de Accidentes (National Accident Prevention Council), which was affirmed by a second decree in 1987 and a third official mandate in March of 1988. As a further indicator of attention to the problems associated with injuries, the country has held 3 national conferences on accident and injury prevention, with the most recent in 1994. The first compilation of injury statistics was published in the early 1990s (Anuario Estadístico de Accidentes), and in 1994 an injury-specific surveillance system (Sistema de Vigilancia Epidemiólogica de Lesiones por Causa Externa [SVELECE]) was established as part of the country's National Epidemiologic Surveillance System (Sistema Nacional de Vigilancia Epidemiológica). Mexico has gathered systemic data on pesticide poisonings since 1988, and conducts ongoing surveillance in 14,500 selected worksites.
In 1995, Mexico established a "Basic Packet of Health Services" that represents the minimum set of health services (including clinical, public health, and health promotion services) that should be available to all citizens. Included in the "Basic Packet" are public health priorities (i.e. primary causes of death, illness, or disability) for which effective and low-cost preventive or therapeutic measures exist. "Accident prevention and initial treatment of injuries" are one of the Packet's 12 components, a fact that is perceived by health professionals as a symbol of heightened government commitment to injury prevention.
In addition to federal initiatives, a number of injury prevention and control measures have been undertaken by states and localities. Mexico has been actively involved in the international "Healthy Cities" movement. Participating municipalities have addressed a range of injury-related topics, including the prevention of pesticide poisoning, preparedness for natural disasters, and restrictions on the sale of alcohol.
Injury rates in Trinidad & Tobago are among the highest in the Americas. Injuries are the leading cause of mortality for males and females 1 to 44 years of age. In 1990, injuries were responsible for almost half (47%) of male mortality in the 15-44 age group, one-fifth (20%) of mortality for women ages 15-44, and one-third (33%) of the deaths in children ages 10-14. "Acute injury" is one of the most frequent reasons for medical consultations with general practitioners, and injuries are the single most important cause of hospital admissions. Although motor vehicle accidents account for the greatest number of unintentional injury deaths (followed by falls and drownings), the number of traffic fatalities has been declining and dropped to its lowest level in three decades after Trinidad & Tobago implemented seat belt legislation in 1995.
The Ministry of Health, which perceives health threats such as communicable diseases and diabetes to be "bigger problems," does not play a central role in injury prevention. Where road safety in concerned, the Traffic Management Branch of the Ministry of Transport is somewhat more active in developing and implementing interventions. In addition, Trinidad & Tobago is the host country for the Caribbean Epidemiology Centre (CAREC), a regional agency with 21 member countries. In cooperation with Ministries of Health, CAREC monitors and assesses disease and injury trends and assists member countries in developing public health responses. In 1984, CAREC and WHO convened a 12-country meeting to discuss the region's need for road safety legislation (the Caribbean Workshop on Prevention and Care of Motor Vehicle Injuries). Since that time, CAREC has played a frank and "aggressive" role in lobbying for attention to the problem of motor vehicle and other injuries.
In 1994, approximately 1,300 deaths were reported from cervical cancer. This is higher than deaths caused by maternal mortality (340) and pulmonary tuberculosis (200). The project will begin with a pilot plan in the state of Aragua, where the Program for Prevention and Control of cervical cancer is already operating.
Aragua is located in Northern Venezuela on the coast of the Caribbean, 50 km from the capital. It is an area of great industrial and livestock development. The state is 7,041 km2, with a population of 1,344,099 people, of which 85% live in urban areas and only 12.3% have access to health care services. The beneficiaries of the project will be approximately 275, 540 women.
In the state of Aragua, the Program for Prevention and Control of Cervical Cancer is implemented by the Health Corporation (CORPOSALUD). Progress has been made in the monitoring of women with abnormal PAP smears, however quality control of the laboratory has been delayed.
Venezuela has requested support from PAHO to reorient the strategies of their Program for Prevention and Control of Cervical Cancer. The proposal of the regional evaluation/international Red-PAC is to strengthen the programs under way to promote quality of work in the cytological laboratories and aims to improve the quality of diagnoses.