BIOMEDICAL RESEARCH SEN YTS Background Studies DOCUMENTS DEPARTMENT LIBRARY DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service National Institutes of Health I yo BIOMEDICAL RESEARCH ~~ IN LATIN AMERICA: BACKGROUND STUDIES Editor Charles V. Kidd, Ph.D. Research Professor of Public Policy George Washington University U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service National Institutes of Health NIH Publication No. 80-2051 April 1980 For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402 Views expressed in this publication in no way reflect the opinions of the Fogarty International Center, the Na- tional Institutes of Health, the Depart- ment of Health, Education, and Welfare, or any other agency of the Federal Government. @’ Ge . NL CONTENTS Foreword, «oo os ama 45s Hm RE 288 HARES 22 woman sa os swine rs wh vii Pre aC «ove ve mame AEE TEE HERG EIR IEEE a wwe a aw ix CONIEDULOTS. « . « «+ itv tess avsnr senses sassasnnmsssssanssense xi Abbreviations and ACTONYMS. . . . «oot viii e eee eee xii 1. Background of Biomedical Research in Latin America Cliarles V. Kd. . . © coves sss amumsss samme sss smmmom ss sma 1 DevElOPIMENT . oo viv tt ee eee 1 Cultural, Political, and Economic Background. . .................. 8 Shifts Between External and Internal Support. . .................. 11 Observations on Specific Countries. . . ......... cov. 16 Relative Strengths of Biomedical Research Fields ................. 24 2. Roles of Ministries of Health and Social Security Systems Alfredo L. Bravo . . . .. .. ci 31 Introduction. . . . oo it it ee ees 31 Ministries of Health . . . . .. 32 Social Security SyStems . . . . . «cio i iii reas 33 Relations Among National and International Institutions . . .......... 40 Appendix: Current Basic Research Topics in IMSS. . ............... 43 3. Support by Multinational Agencies Charles V. Kidd. . . . ooo sso ssissinisnaassnsaes sas sans 49 Introduction. . . «ot tiie ee eee ees 49 The Pan American Health Organization. . . ..................... 52 4. Health Manpower Migration in the Americas Alfonso Mejia. . . ... oii 67 IMrOAUCHION. + vv ev vv evenness vr mss aa sas ma sss mms sss 67 Dimensions and Directions . . . ...... 68 Characteristics of Migrant Physicians. . . ....................... 79 Factors Influencing Migration . . .............. 81 Consequences of Migration . . ...............c... i L.. 89 POHCIEE . . ov eve vv wvmmms crs mma ss a mmm ss sin das sume 90 CONCIUSIONS « «vt te ee ee ee ee ee eee eet eee 94 5. Parasitic Illnesses as a Public Health Problem Amador Neghme. . . .... eee 99 SUMMAIY . © ott tt tt tee e ene ame et tae aea tases sane Problems Produced by Parasitic Illnesses . . ..................... 99 Investigations of Interest in Public Health . ..................... 103 Final Considerations . .... .... c.count. 108 iii iv Biomedical Research in Latin America 6. Current Trends in Zoonotic Disease Studies Luis V.Meléndez. . . .......... uit. 113 Introduction. . . . . ... ee 113 Areal... eee 113 Area Il ©. eee eee 117 rf | KT 118 ARAIV cc. i st anew ss 1 HBR E28 FHEU RLF SPUN £28 PEE BE EE © 120 AIOAY viii i uname s s A RURB AES HUFL E+ 2 PHAAF LF 22 BEEF 2 58 HO 121 Area Vl... ovna vi sinnmid is nina iss 2s RAED ESR HREM T + 3 0 122 CONCIISIONS . + cov sv sr mmm sss mmmn sss sma Eds 43 GHAR SL E28 124 Appendix: Research Topics at Various Schools of Veterinary Medicine. . . ............... 125 7. Research on Environmental Health Abel Wolman and Frank Butrico . ............ uu uieuo.. 127 Introduction and Summary. . . ........ 127 Research Institutions . . . . ....... 128 Walle o ovv iv non m a st s BEBE RS FS SMARTS BHR EE FERRE EE 129 Al: 555s is 00a tt 18 RNEASY ARETE II RAARSE LLB AHA £520 131 Industrial Hygiene. . . ... ee 132 Solid Wastes. . oo... eee 133 Disease Control Through Environmental Control. . . ............... 133 The Ecological Approach ................................. 134 Role of the Pan American Health Organization. .................. 135 Appendix: Investigations Carried on at ERIS, Guatemala ............ 136 8. Cancer Research Pelayo Correa. . ........... . 139 Introduction. . . ..... Le 139 Background : : sc ssnvsiis aman isanasssiss5umaiss Rnaai ass 139 Research on Cancer Epidemiology ........................... 141 National Cancer Research Activities . . ........................ 143 Facilities for Clinical Studies . . . ............................ 162 Information Exchange . . . . wvwnoisspnumssonnsnn sss nmunss os 162 9. Research on Diabetes Mellitus Mariano Garcia Viveros. . . ......... i. 165 Introduction. . . . ...... 165 History of Diabetes Research in Latin America. .................. 165 Organization of Diabetes Research . . . ........................ 167 Distribution of Diabetes Research in Latin America. ............... 168 Dighetes Research In Merion. cov uso ss vum iss pmmmno ss mmmmn sea 170 Findings and Recommendations. . ........................... 172 Appendix: Sources of Publications on Diabetes Mellitus in International Journals by Latin American Authors, 1974-77 ...... 177 Contents v 10. Research on Mental Health René Gonzalez . . . ...... ou unuininnnannnnnaneenan 179 INtrOdUCHION. © oo te ee ee ee eee ee ee eee 179 AreasofCurrent Research. ......... citi iii iene inns 180 Education and Training . . ........ cia 185 Administration of Services . . . . Lo... 186 CONCIUSIONS © + oo ot te ee ee ee ee eee eee ees 186 11. High-Altitude Research CarlosMonge C. . . o.oo iio 187 INtrOdUCHION. © © oo eee ee ee ee ee eee 187 Sites for High-Altitude Research. . .. ......................... 190 Specialized Institutes and Centers for High-Altitude Research . .. . comin nse EER SEP GREE Es Em a mb 191 ReSEArCh ATES. . «vv vii tee t tee eee issn aaaaaaane senna 193 The Problem of Human Acclimatization at High Altitudes. . . ......... 197 The Problem of Public Health in the High Andes Region. . ........... 199 The Future of High-Altitude Health Research... ................. 199 A Developmental Plan for High-Altitude Health Research... ......... 200 12. Medical and Human Genetics Research Heber Villalobos C. . . .. cove ete ie ieee eee ee 205 Definitions. « «vo oie ee ee eee eee eee 205 Scientific Developments . . . . «cov viet eee 205 Centers for Genetic Research. . . .............. i. 207 Priorities for Research: Recommendations. . .................... 209 Identification and Removal of Obstacles: Recommendations. . . ....... 211 13. The Health Impact of Earthquakes Claude de Ville de Goyer . ...........iueuenmenenenennn 215 Definition of the Problem. . . ...... iii 215 Health Problems . . . . oc citi it ieee eee iiss seers eens 218 Operational Problems. . . ............ i 220 Political Problems . . . . «ooo ees 222 Approaches to Solutions. . . ...... Li 223 Primary Research Areasand Trends . . ........................ 225 Role of International Organizations . ..............c... o.oo... 230 TOAEY : : : cons ssammanursewmmmme smmbad 85 EMBANRE 2 SEE vo eo 235 FOREWORD The Fogarty International Center, established in 1968, is the only organi- zation within the Federal Government specifically designated to support ad- vanced studies in the health sciences from an international perspective. Al- though there are differences in politics, economics, and social structure, communication among countries can contribute to the expansion of bio- medical knowledge, and ultimately to the improvement of health care through- out the world. With this in mind, the Center has supported a number of studies of various aspects of health systems, medical education, public health, and biomedical research in other countries as background for enhancing mutually benefi- cial collaborative scientific relationships. These countries have included the U.S.S.R., the People’s Republic of China, the Scandinavian countries, and the United Kingdom. This is our first publication with Latin America as its focus. The National Institutes of Health, of which the Center is a component, has had long, close ties with principal research institutions in Latin America. There, as elsewhere, biomedical research is continually evolving: new interests, new institutions, and new interrelationships are emerging, and new capabilities are being developed. We felt it was time to examine some facets of the Latin American scene that provide the “climate” for biomedical research, with the hope that such a background study would suggest new avenues of collaboration for scientists, health specialists, and administrators, particularly in the United States. With the cooperation and advice of the Pan American Health Organization, we invited Latin American experts to prepare surveys on significant aspects of the topic and asked Dr. Charles V. Kidd to organize the material as well as contribute to it. In the process, Dr. Kidd visited eight of the countries and talked with a variety of persons concerned with biomedical research, ranging from government officials to medical students. Dr. Kidd has a particularly appropriate background for this task. He is presently Research Professor of Public Affairs, George Washington University. He has held senior level positions in the Federal Government, once having been an Associate Director of NIH, and has served as member or chairman of a number of U.S. delegations to international conferences on education, science, and technology in addition to vii viii Biomedical Research in Latin America serving as consultant to a number of foundations and international organi- zations. He has always had a keen interest in biomedical matters and in Latin America. No single volume can do full justice to such a background study covering a number of countries and a large geographic area. Latin America cannot be treated as a single entity; it is a group of nations, each having similarities and differences. Our various audiences will undoubtedly have differing opinions as to the relative importance of the topics presented here; nevertheless we hope that this book will stimulate readers to seek further information and develop new ideas. We are sincerely grateful to Dr. Kidd and the contributors for the many hours of work that made this volume possible. Inquiries regarding this publication and other geographic studies of the Center should be addressed to Dr. Joseph R. Quinn, Deputy Director, and Chief, International Cooperation and Geographic Studies Branch, Fogarty International Center, National Institutes of Health. Edwin D. Becker, Ph. D. Acting Director Fogarty International Center PREFACE This collection of papers deals with various disciplines and disease entities in biomedical research. Some of the papers concern administrative matters, but most of them involve the substance of science. All monetary references are in terms of U.S. dollar equivalents. Each author has tried to present a balanced, complete picture of research on a particular subject. Completeness, however, does not mean full detail. An effort has been made to note the principal sites for research. This presents two obvious problems. First, although the authors are well informed, they may have overlooked some significant laboratories. Second, judgment as to what constitutes a major center for research in a given field is to a certain degree arbitrary. An effort was made to reuse articles on all major disease entities and prob- lems and on the major medically related disciplines, except those covered comprehensively by recent books or articles. Nutrition is not included because a definitive book is being written by Dr. Abraham Horwitz. Unfulfilled com- mitments have unfortunately left gaps in such important fields as cardio- vascular diseases. All specialized areas of research are influenced by general forces that affect all of science, not only biomedical science. A brief review of these factors (chapter 1) precedes the more technical presentations in the contributed papers. Biomedical research is also strongly influenced by attitudes and activities of ministries of health and social security systems (chapter 2). Most countries of the region need technical and economic help from multinational organi- zations, which play an important role in the nature and effectiveness of bio- medical research in the region. The Pan American Health Organization is particularly important (chapter 3). A discussion of the complex phenomenon of migration of professionals from Latin America (chapter 4) follows. The important field of parasitic illness as a public health problem is the subject of the next essay (chapter 5), and this is succeeded by a description of the work in progress on the zoonoses (chapter 6). Research on the environment—water, air, industrial hazards, solid wastes— is the topic of the next essay (chapter 7), following which are sections dealing with the current state of research in communicable diseases and cancer (chap- ter 8), diabetes (chapter 9), and mental health (chapter 10). X Biomedical Research in Latin America The final part of the book is devoted to three research areas of particular significance to Latin America: high-altitude physiology and adaptation (chap- ter 11), human and medical genetics (chapter 12), and earthquake hazards (chapter 13). Unfortunately, problems faced 10 years ago in developing effective biomed- ical research in Latin America continue to be problems today. The countries that were preeminent a decade ago still contain the major research centers. Accordingly, much of the background is not new, and heavy reliance has been placed on earlier publications. The most important single source has been Health Research in Latin America (Pan American Health Organization Sci- entific Publication No. 275, October 1973). Nonetheless, there have been some changes, and the most significant recent developments are pointed out in the text. The editor is indebted to many people. First are the authors of the various papers who took time from their busy lives to contribute to this volume. The staff of the Fogarty International Center of the National Institutes of Health was unfailingly helpful. In addition to contributing a number of papers, the staff of the Pan American Health Organization provided insight and guidance. Finally, many national leaders of science, as well as professors and students took time to talk fully and frankly with me about the general background for biomedical research during a trip to eight Latin American countries in January 1978. My impressions were gathered by extensive interviews in Latin America and a draft chapter was reviewed by a group of experienced Latin American scientists who met in Key Biscayne, Florida, on July 25-27, 1978. I am in- debted to them for their critical review of chapter 1, and to the staff of PAHO for additional comments; but the ultimate responsibility for the chapters is mine. Charles V. Kidd CONTRIBUTORS Alfredo Bravo, M.D. 767 Vespucio Sur Santiago, Chile Frank A. Butrico, Chief Division of Environmental Health Pan American Health Organization Washington, D.C. Pelayo Correa, M.D. Professor of Pathology Louisiana State University Medical Center New Orleans, Louisiana Mariano Garcia Viveros, M.D. Instituto Nacional de la Nutricion Hospital de Enfermadades de la Nutricion Av. San Fernando y Vto. Tlalpan. Mexico, 22, DF Dr. René Gonzales Pan American Health Organization Washington, D.C. Charles V. Kidd, Ph. D. Research Professor of Public Policy George Washington University Washington, D.C. Dr. Alfonso Mejia World Health Organization Geneva, Switzerland Luis V. Meléndez Pan American Zoonoses Center Buenos Aires, Argentina Dr. Carlos Monge C. Professor of Medicine Universidad Peruana Cayetano Heredia, Apartado 5045 Lima, Peru Amador Neghme R., M.D. President of the Academy of Medicine Institute of Chile Classification 1349 Santiago, Chile Heber Villalobos C., M.D. Medical Genetics Unit Faculty of Medicine University of Zulia Maracaibo, Venezuela Claude de Ville de Goyet, M.D. Pan American Health Organization Washington, D.C. Jose Whittembury Professor of Biophysics Universidad Peruana Cayetano Heredia, Apartado 5045 Lima, Peru Abel Wolman Professor of Sanitary Engineering The Johns Hopkins University Baltimore, Maryland ABBREVIATIONS AND ACRONYMS AID Agency for International Development ALAD Latin American Diabetes Association [Asociacion Latinoamericana de Diabetes] AMA American Medical Association BIREME Regional Library of Medicine and Health Sciences CAREC Caribbean Epidemiology Center CELADE [Centro Latinoamericana Demografica] CEPANZO Pan American Zoonoses Center CEPIS Pan American Center for Sanitary Engineering and Environmental Sciences CESMEC [Centro de Estudios, Medicion y Certificacion de Calidad] (Chile) CETESB [Companhia Estadual de Tecnologia de Saneamento Basico e de Defesa do Meio Ambiente] (Brazil) CIDA Canadian International Development Agency CIECCA [Centro de Investigaciones y Entrenamiento para el Control de la Calidad del Agua] (Mexico) CIFCA [Centro Internacional de Formacion en Ciencias Ambientales para Paises de Habla Espanola] CNM Cuauhtemoc National Medical Center CNPQ National Research Council of Brazil Colciencias Colombian Fund for Scientific Investigation COMLURB [Companhia Municipal de Limpieza Urbana] (Brazil) CONACYT National Council on Science and Technology of Mexico [Consejo Nacional de Ciencia y Tecnologia de México] CONICYT National Council for Scientific and Technical Inves- tigation DISCA Division of Investigations on Environmental Pollution [Division de Investigaciones sobre Contaminacion Ambiental] (Venezuela) ECLAMC Latin American Cooperative Society on Congenital De- formities xii EEE EERI ELISA EMC ETAPA FDA FEEMA FINEP FIPEC FMG FSESP FUNDACENTRO FUNTEC GATLA GDP GML GNP HUD IACI IARC ICAITI ICBF ICITEX IDB IMSS INAS INCAP INCYTH INISI INSERM Xiii European equine encephalitis Earthquake Engineering Research Institute Enzyme-linked immunosorbent assay Encephalomyocarditis [Empresa de Teléfonos, Agua Potable y Alcan- tarillado] Food and Drug Administration (United States) State Foundation of Engineering of the Environment [Fundacio Estadual de Engenharia do Meio Ambiente] (Brazil) Financial Agency for Studies and Projects Research Fund of the Bank of Brazil Foreign medical graduate [Fundacion de Servicio Especial de Salud Publica] [Fundagio Centro Nacional de Seguranga, Higiene e Medicina do Trabalho] Research Fund of the National Development Bank Group for the Treatment of Acute Leukemia Gross domestic product Gorgas Memorial Library Gross national product Department of Housing and Urban Development (United States) Inter-American Child Institute International Agency for Research on Cancer Central American Institute of Investigation and In- dustrial Technology [Instituto Centroamericano de Investigacion y Tecnologia Industrial] (Guatemala) Family Welfare Agency (Colombia) Institute for Manpower Training and Education (Colombia) Inter-American Development Bank Mexican Institute of Social Security [Instituto Mexicano de Seguro Social] National Institute of Health (Colombia) Institute of Nutrition of Central America and Panama [Instituto Nacional de Ciencia y Técnica Hidricas] (Argentina) Institute for Health Research (Costa Rica) French National Institute of Health and Medical Research [Institut National de la Santé et de la Récherche Medicale] Xiv IRHE ISSSTE IVIC LACRIP LSU NIH OAS OMS OPS PAHO PANAFTOSA PASB PHS PLAD PMSG REDPANAIRE SAIS SANEPAR SEMAPA TCDC UICC UNAM UNCTAD UNDP UNDRO UNESCO UNITAR uv UWI VEE WB WHA WHO Biomedical Research in Latin America [Instituto de Recursos Hidraulicos y Electrificacion] (Panama) Social Security and Service Institute for Government Workers [Instituto de Seguridad y Servicio Social a los Trabajadores] Venezuelan Institute for Scientific Research [Instituto Venezolano de Investigaciones Cientificas] Latin American Cancer Research Information Program Louisiana State University (United States) National Institutes of Health (United States) Organization of American States World Health Organization [Organizacion Mundial de la Salud (Sp.)] [Organisation Mondial de la Santé (Fr.)] Pan American Health Organization Pan American Health Organization Pan American Foot-and-Mouth Disease Center Pan American Sanitary Bureau Public Health Service (United States) Latin American Diabetes Plan Gonadotropin from serum of pregnant mare [Red Panamericana de Muestro Normalizado de la Contaminacion del Aire] [Sociedad Agricola de Interés Social] (Peru) [Saneamiento de Panama] [Servicio Municipal de Agua Potable y Alcantarillado] Technical cooperation among developing countries International Union Against Cancer Autonomous University of Mexico United Nations Conference for Trade and Development United Nations Development Program United Nations Disaster Relief Office United Nations Educational, Scientific, and Cultural Organization United Nations Institute for Training and Research University of Valle [Universidad del Valle] University of the West Indies Venezuelan equine encephalitis World Bank World Health Assembly World Health Organization BACKGROUND OF BIOMEDICAL RESEARCH IN LATIN AMERICA Charles V. Kidd Development! History The foundations for biomedical research in Latin America were laid near the beginning of the 20th century by the efforts of a few talented individuals working in a culture and an environment that were usually indifferent, if not hostile, to science. Funds for salaries, equipment, and supplies were often in- adequate, and developing laboratories suffered the consequences of frequent political change. In the face of such difficulties, these heroes of science not only carried on research but also served as prime advocates for establishment of a scientific tradition and government recognition for science. From the start, medicine has been one of the three most prominent and prestigious professions in Latin America, together with law and the priesthood. In earlier years, medical faculties tended to be stronger than science faculties; and, until recently, the practice of medicine has provided a more powerful economic base for individual investigators than have other fields of science. Many physicians were wealthy and had the leisure required for research. In addition, the presence of patients in hospitals with clinical laboratories provided the resource needed for research with little or no incremental expenditures, a condition that existed in no other field of science. Finally, the research was clearly related to an important human concern: health. Not only was this field relatively advanced, but medicine and biology were the sciences most obviously I This chapter contains a substantial number of generalizations that are not backed up by data. Most of these statements are inherently judgmental and not susceptible of proof by using quantitative data. The author chose to concentrate on verifying judgments rather than on seeking numbers that are, in any event, nonexistent, difficult to find, or irrelevant. 2 Biomedical Research in Latin America relevant to the solution of human problems. These influences gave research in biology and medicine an early, forceful impetus. The lead became cumulative, since talent attracted talent and money attracted money. As a consequence, the biomedical sciences have been the strongest area of science in Latin America as a whole and in most of the individual countries. Accordingly, when outside sources provided assistance to the development of science, medicine became the natural focus of attention. An important development of the past tew years, however, has been the strengthening of research in fields other than health. Establishment of national research councils and similar groups has led to recognition of the need for balanced development of science, particularly in the larger countries that have the required resources. Though health research has become stronger in absolute terms, in most major countries it now assumes a smaller proportion of the total national research effort. Nevertheless, biomedical research retains a favored position. With a few outstanding exceptions, leadership in research has shifted to a generation that has reached maturity since World War II. This group has some common characteristics: high intelligence, driving purpose, excellent training, high scientific attainment, and an urge to progress and change in research despite a generally conservative or apolitical orientation. The process of selection for advanced education and training, and the obstacles to a research career, are such that those who come to the forefront are exceptionally able and highly moti- vated. The single-minded drive of this relatively small band of leading investi- gators is impressive. These scientists usually possess not only mastery of their own field but a keen sense of the general deficiencies of science in their coun- tries. They are often leaders in university affairs as well as in social and political matters. They have persisted in carrying on their own work, training students, and working for support of science, often in the face of obstacles that are almost insuperable. They have sacrificed income, status, peace of mind, and prestige. As one investigator noted, “Only obsessive people can do research in Latin Amer- ica”; another observed, “A scientist in Latin America must be a masochist.” One important factor, seen in country after country, is the strong influence of training abroad and the relative increase in the proportion of persons who have received part or all of their advanced education in the United States. For a number of years, World War II made it impossible for Latin America to maintain its traditionally close ties with the educational and cultural institutions of France, Germany, and other European countries. As a consequence, the United States replaced Europe as the major site for advanced training in bio- medical and other sciences. Students were exposed to a different system of education—with more freedom of action, smaller classes, greater informality between professor and students, and more independence in the pursuit of their research—and were given an opportunity to broaden their experience through collaborative programs. They recognized the benefits that accrued from working Charles V. Kidd 3 on a full-time basis. Since returning to their respective countries, many have become leaders in teaching and research. The existence of this group of leaders is perhaps the most important single favorable force affecting biomedical re- search—indeed, all research—in Latin America. At the same time, it must be recognized that not all those who studied abroad emerged as leaders. Some came back and did repetitious research, using expensive equipment. For others, there were no research opportunities—or only inferior ones. Particularly in recent years, there has been an increase in the sense of auton- omy, independence, and self-confidence of investigators. Though they often have scientific colleagues and friends in Europe and the United States, and though many of their values have been formed by graduate education abroad, they have a strong sense of their own worth, their own obligations, and the importance of building their own strong science. These qualities have become particularly important in the years since 1970 when outside support for bio- medical science has been curtailed. Fundamental Obstacles and Some Possible Solutions? It would be dishonest to ignore some serious fundamental obstacles to the conduct of biomedical research in Latin America. Basic investigation in general is scarce, not very original, and often repeti- tive. This can be attributed to two closely interrelated factors: (1) scarcity of adequately prepared and motivated scientific investigators and (2) lack of policies favorable to science, of financial aid, of a basic infrastructure, and of an atmosphere conducive to scientific and intellectual creativity. Fundamental scientific investigation is carried out almost exclusively at the universities. During the last decade, they have been subjected to diverse pressures, particularly movements to increase student enrollment without increasing human and financial resources. Consequently, instructors have become overburdened with teaching tasks and have been forced to curtail their plans for fundamental scientific investigation. Most investigative projects are clinical or, at best, related to aspects of diagnosis or therapeutics, projects that are easy to carry out with the precarious resources available, since they are the results of doctors’ professional activities in hospitals and in private practice. Epidemiological investigations are also being made because laboratory or regional state public health institutes are interested in those studies. Never- theless, most studies are limited to parasitic infections in neighborhood areas. 2Dr. Amador Neghme originally wrote this section as a part of chapter 6. However, because of its general applicability it has been included in this background chapter. Dr. Kidd is responsible for the remainder of the chapter. 4 Biomedical Research in Latin America Very few include the entire national territory and none includes the entire continent. There are no regional laboratories for reference, and only a few investigative institutes are equipped to offer adequate postgraduate instruction. During the last decade, the teaching of parasitology in medical schools has been reduced. Until the end of the 1960’s many of these schools devoted sufficient time to theoretical and practical study, and allowed the use of in- structional and practical approaches, even the development of research in- volving parasitoses. Now they limit themselves to a few lecture sessions and demonstrations of the morphology of parasites. The number of doctors dedi- cated to instruction has been significantly reduced, and most of them teach part-time. Currently there are few medical professionals who can perform some scientific investigations in addition to teaching; those who do undertake such projects choose research that—along with the trial of new drugs—is favored by the pharmaceutical industry. Consequently, medical students and young professionals receive segmented information; they do not live in an atmosphere of scientific creativity and, therefore, are not motivated to enroll in para- sitology programs and carry out research in this field. Few universities have serious, organized postgraduate studies, with require- ments such as advanced courses in the preparation of a thesis related to one specialty. Even in universities offering such programs, there is a lack of quali- fied professors, and it is increasingly difficult to attract high-quality young people to the field of parasitic illnesses. Furthermore, the economic advantages offered by the practice of other professions in many Latin American countries also have an effect. This general situation, which affects all scientific research, should be radi- cally modified if one wants to promote the investigation of parasitology. In other words, investigation in this field cannot be strengthened unless the general status of scientific investigation is resolved first. Mechanisms for financing scientific investigations that are not subject to bureaucratic control inside or outside of universities exist in very few Latin American countries; but in some areas, councils or foundations for support of scientific investigation are administered by scientific investigators, research projects are reviewed by other investigators, and financial aid is granted without interference by administrative authorities. Once a project has been approved, the principal investigator receives funds for the research, with wide freedom for investment, as long as this person submits documented accounts every 6 or 7 months. The authorization allows acquisition of supplies, equipment, reagents, bibliographies, and books. In addition, the investigator can hire technical personnel, pay salary supplements for personnel working on an exclusive basis, and pay for study-related travel or attendance at conferences. Charles V. Kidd 5 In general, wherever these foundations have been established, they have had a favorable impact on science. In those laboratories, departments, or insti- tutes of parasitology having an atmosphere conducive to creativity and in- structors of high intellectual and moral quality, there has been a notable in- crease in the number of investigations. Thus these facilities have come to serve as models for all Latin American countries. The first step toward creating a more favorable environment for biomedical research in Latin America is the creation of autonomous foundations for financing scientific investigations administered by the best researchers. Such foundations would provide indispensable evaluation of currently existing laboratories or departments, inside or outside of universities, to determine directors’ scientific qualifications and personal expertise in managing, aiding, and orienting the training of young investigators. This evaluation should be based on the quality and originality of the directors’ scientific work and on the number of investigators they have helped prepare. If a director’s quali- fications are not favorable, his laboratory should receive little or no support. Once investigative laboratories have been identified, foundations would provide resources for renovating and improving their equipment, instruments, and basic infrastructure. Directors would be authorized to present aid requests to foundations in order to finance plans that would be carried out by young investigators. National scholarships are essential to the education of scientific investi- gators. Rarely do universities grant scholarships for the education of research workers in parasitology. Students sent to more developed countries do not find adequate resources or facilities for their research projects or libraries for keeping themselves informed when they return. Consequently, they tend to emigrate or leave the university and enter private practice. Universities with approved laboratories should be encouraged to organize postgraduate studies, with the prior consent of the science faculty, if it exists. One of the prerequisites for the degree “magister” or “maestro” or “doctor” of sciences, with mention of parasitology, should be completion of study plans for conducting original scientific investigations. Basic preparation should always begin in the investigator’s own country or in neighboring Latin Ameri- can countries where similar life conditions exist. Postgraduate students should carry out didactic and scientific activities with a formative scope under the supervision of capable scientific advisers. Later, when students have obtained the “magister” degree, they should do research in more advanced countries, but their doctorates should be earned in the country of origin. Once the doctorate has been completed, young investigators should find adequately paid positions and should be aided in the continuation of their research, whenever possible, at the institutions from which they graduated. Finally, a central obstacle to the creation of a fully effective biomedical research program is lack of money. Because of underfunding, trained people 6 Biomedical Research in Latin America and facilities are underutilized to a serious degree in every country in Latin America except Brazil. This situation exists in part throughout the developing world. Only 3 percent of the world’s health research budget goes for diseases of the poor in tropical areas. About $30 million is being spent annually on tropical diseases affecting 2 billion people, while $800 million is being spent on cancer research in the United States alone. Relative Current National Efforts In a sense, it is artificial to speak of Latin America as a single entity because of wide differences in cultures, societies, political systems, economic status, rates of development, and status of universities throughout the area. These differences are reflected in the state of development of biomedical research. To provide a framework for discussion, we will separate countries into three categories, each having many common characteristics as far as health research is concerned. Group I. Together, the eight countries in group I—Argentina, Brazil, Chile, Colombia, Commonwealth Caribbean, Mexico, Peru, Venezuela—account for 70 percent of the economic product of Latin America. They also account for about 90 percent of the resources—people, equipment, buildings, operating funds—devoted to health research. They have 90 percent of the university students, and they have diverse and relatively large biomedical research struc- tures. Their scientific communities publish 93 percent of all scientific articles emanating from Latin America in internationally recognized journals (table 1). Indeed, 78 percent of these articles are the work of scientists from only three countries: Argentina, Brazil, and Mexico. Each country in group I has a fairly elaborate university system that con- ducts a wide variety of investigations, both basic and applied. The best labora- tories are superbly equipped and are housed in modern buildings. Influential national research bodies exist, but the availability of funds varies widely. Each country finances all but a small part of its health research from its own resources and has a substantial group of distinguished investigators, along with a solid tradition of research. The links of the biomedical research communities to the world scientific community are relatively diverse and strong, despite the political turmoil and economic instability that have threatened research tradi- tions in some nations. Typically, these countries have ministries of health that support research on a small scale as a means of increasing the effectiveness of the health measures for which they are responsible. All of them have univer- sities, but the stability of the universities as a base for research differs widely. Group II. The seven countries in group II—Bolivia, Costa Rica, Cuba, Ecuador, Guatemala, Guyana, and Uruguay—are quite diverse, but alike in that none has a national research structure comprising more than one strong investigative center. Within the second group are some countries that have Charles V. Kidd 7 TABLE 1. Authors Publishing in International Scientific Journals, 1975, by Latin American Country Number of Country Articles Percent Group I 3,537 93 Argentina 929 Brazil 1,047 Chile 336 Colombia 104 Commonwealth Caribbean 110 Mexico 696 Peru 81 Venezuela 234 Group II 205 4 Bolivia 10 Costa Rica 40 Cuba 45 Ecuador 12 Guatemala 34 Guyana 11 Uruguay 53 Group III 51 3 (Honduras, El Salvador, Panama, Paraguay, Dominican Republic, Haiti, Nicaragua, Belize, French Guiana) Grand total 3,793 100 This tabulation refers to the number of authors, not the number of papers. It is reason- able to assume that the number of papers published per year per author does not differ widely by country, so the number of authors is a reasonable approximation of the scope of scientific effort. Source: Reproduced with permission from H.H. Szmant, Science 119: 1173-1182, © 1978 American Association for the Advancement of Science. Further reproduction prohibited without permission of copyright holder. individual investigators of international reputation, but the countries do not possess the resources required for a relatively large and varied research effort. In some, such as Guatemala and Panama, laboratories financed and largely 8 Biomedical Research in Latin America staffed by international organizations [Central American Institute of Investi- gation and Industrial Technology (ICAITI), Guatemala; Institute for Nu- trition of Central America and Panama (INCAP), Guatemala and Panama or other countries (Gorgas Memorial Laboratory) account for almost all na- tional research. Group III. Research of any kind is conducted on a very small scale in the nine countries of this group—Belize, Dominican Republic, El Salvador, French Guiana, Haiti, Honduras, Nicaragua, Panama, and Paraguay. To provide a world perspective in terms of journal articles, the total scien- tific output of all Latin American countries is about 2.5 percent of the output of the United States, half that of India, and about equal to that of the Nether- lands. It should be noted that classification of research in terms of the strength of national efforts is somewhat unfair, because research is done by individuals and groups, not by nations. The fact that excellent research is done in a small country in no way diminishes its excellence. Cultural, Political, and Economic Background All science is embedded in the culture, economic circumstances, and political life of the country where it is carried out. These forces are generally not ap- parent when developments in narrow scientific sectors are considered, but their strength becomes evident when science is considered as an entity. Cultural Influences Science can develop apart from culture only to a limited degree. In Latin America, many fundamental factors tend to retard this development.3 The late Bernardo Houssay, in his frank and perceptive analysis, noted some of these factors: ® Lack of broad understanding of the nature of science, of the nature of training for science, and of the conditions necessary for the effective pursuit of science; ® Diversity, individualism, and a search for personal prestige that tend to inhibit cooperation; ® The tradition of the inferiority of manual work; ® An approach to education that stresses description and definition rather than critical conceptual thinking; 3References 1-9 provide insight into fundamental aspects of Latin American culture that create difficulties for the rapid development of research. Charles V. Kidd 9 eA tendency to dogmatism; eA failure to observe obligations to others and to rules in general; eA tendency to give greater weight to friendship and family than to ob- jective factors in making decisions. To the extent that such traits are common, they militate against the devel- opment of science. In a perceptive article on science and technology planning in Mexico 91, Wionczek stated some general principles applicable to all Latin American countries: There is a need to recognize that science and technology problems in the context of general underdevelopment differ basically from those en- countered by science and technology in the advanced world. One of the major obstacles for the advancement of science and tech- nology in a country like Mexico originates from the divorce between local R&D activities and educative and productive systems. The domestic science and technology system in an underdeveloped country must be defined as comprising not only all the units dedicated to R&D, but R&D supporting activities and mechanisms—whether public or private—intermediating between the R&D institutions and higher learning bodies and productive enterprises as well. We know precious little about the intrarelations, particularly in the context of underdevelopment, present inside the continuum known as R&D, and the simplistic proposition that every country needs to support in a similar way all parts of that continuum is open to many criticisms. Science and technology policy problems cannot be meaningfully handled just by scientists and technologists if only because science and technology is not a specialized sector but it affects all and every phase of social, economic, cultural and even political life. Political Influences One of the most significant single factors inhibiting the healthy growth of science in Latin America is political instability. Instability means not only rapid changes of power at the top of government, but all types of civil unrest, from agitation by university students to terrorism. Rapid changes in uni- versity, institute, or laboratory leadership in response to shifts in political power or bureaucratic maneuvering; rapid and unpredictable shifts in program emphasis; the imposition of ideological tests on individuals; uncertainty about the future; and a sense of personal and professional insecurity all tend to erode the concentration and continuity that are essential to productive research. Conversely, a stable environment—one that can absorb change without dis- rupting institutions and generates a sense of personal security and reasonable institutional continuity — tends to favor research. In this limited context, i.e., in reference to research, the ideological basis for the government is unim- portant. Instability and rapid change may be necessary to the attainment of 10 Biomedical Research in Latin America human values, but temporary or permanent harm to research must be accepted as one of the costs of political instability. Economic Influences Most countries in Latin America are poor, although only Haiti is in the group designated by the United Nations as the “poorest of the poor.” These coun- tries are characterized by average per capita incomes that are shockingly low in comparison with Europe, Japan, and the United States (table 2). The av- erage gross domestic product was only $480 in 1975, as compared with $3,800 in the United States. Moreover, the gap between income levels in Latin America and the developed regions is growing. Those countries that have substantial biomedical research programs are the larger ones with relatively prosperous cities, islands of wealth and culture in a sea of poverty. Because of their sheer size they can invest significant sums in research despite low per capita production. Even so, economic constraints limit investments in science and in biomedical research. Inflation has hindered investigations in many countries by making importation of equipment or supplies difficult, by reducing the real value of salaries to the poverty level, by cutting the net worth of governmental support, and by undermining confidence in the future. However, political instability has been a more troublesome impediment to research than has inflation. TABLE 2. Gross Domestic Product per Capita in Latin America and Selected Industrialized Countries (1960 prices) Country or Percent Increase Area 1960 1965 1970 1960-70 Latin America 368 408 467 126 United States 2,467 3.013 3.353 135 Japan 425 653 1,094 257 European Economic Community 966 1,184 1,466 151 Source: Reproduced with permission from H.H. Szmant, Science 119:1173-1182, © 1978 American Association for the Advancement of Science. Further reproduction prohibited without permission of copyright holder. Charles V. Kidd 11 Shifts Between External and Internal Support The development of biomedical research in Latin America has been charac- terized as having a modest beginning stimulated several decades ago by a small group of imaginative and brilliant investigators. This was followed by a period when external support became quite significant and the Rockefeller Founda- tion was extremely influential. Later, in the 1960’s, both the U.S. Govern- ment and private foundations provided extensive support. In the 1970s, sharp restrictions were placed on foreign funds, and there has been increasing reliance upon support from domestic and multinational agencies. Therefore, a critical factor in the future progress of biomedical research in Latin America will be the willingness and ability of various governments to support such research. The past evolution of sources of support has been so important that it will be traced in some detail. National Governments Biomedical research in Latin America has always been funded primarily by national governments, which support most university medical schools and institutes. National governments build buildings and pay salaries, and these two items constitute the bulk of the costs of biomedical research. In the past, however, very little money was provided for actual research: for supplies, equipment, experimental animals, laboratory reagents, extra technicians, and the overall costs generated by research itself. In this circumstance, relatively small amounts of money from other sources could energize existing resources toward research. This happened over several decades as private foundations, mostly those in the United States, and foreign governments, mostly the U.S. Government, supported biomedical research. Foundations The Rockefeller Foundation pioneered in providing external funds for research in Latin America, and there is a widespread feeling of gratitude for its under- standing and able staff. The foundation supported an extensive campaign against yellow fever, hookworm disease, and malaria. Many persons trained in these campaigns later became leaders in medical education and research. Foundation programs ranged from the most applied to the most fundamental research, with consistent emphasis on training so that there would be a con- stantly increasing number of persons contributing to progress in these fields. The foundation offered stable support, which is particularly important in the development of a department or institution or in highly experimental scien- tific projects. Through the mechanism of “matching funds,” the foundation has increased the involvement of Latin American institutions in supporting 12 Biomedical Research in Latin America their own programs and scientists. Between 1955 and 1963 the foundation provided $20 million to 12 Latin American countries for health research and training. As a result of a policy decision made in 1963, however, the Rockefeller Foundation reduced its traditional support of biomedical fields and now concentrates its efforts abroad on agricultural research, population dynamics, and strengthening developing centers of learning in the emerging nations, primarily in Africa. The foundation is continuing its support for the develop- ment of a limited number of Latin American training centers in the biomedi- cal sciences, particularly the University of Valle in Cali, Colombia, and the Federal University of Bahia in Brazil. The medical school at Cali has trained large numbers of basic and clinical medical scientists from at least 13 other Latin American countries. For a time, the change in the policy of the Rockefeller Foundation was counteracted somewhat by the activities of other private foundations. The Milbank Memorial Fund stressed medical education and studies of national resources, particularly manpower. The Kellogg Foundation stimulated research and training, especially in public health. The Ford Foundation invested sub- stantial sums in university development, particularly in the development of new patterns of graduate education in the sciences, and more recently in basic research in reproductive physiology and social and economic aspects of nu- trition. However, the funds provided by these foundations have also declined over the course of time, and the era of major influence by U.S. foundations on biomedical research in Latin America has ended. The continuing help of foundations is useful but is no longer a central force on a continental scale. Foreign Governments During the 1960’s the predominant outside assistance to biomedical re- search in Latin America was provided directly by the U.S. Government, pri- marily by the National Institutes of Health. The annual volume of support in the form of research grants and contracts reached a peak of $3.7 million in 1963, distributed roughly as follows: Agency Amount (x $1 million) National Institutes of Health 2.8 Department of Defense 5 Other 4 Total 3.7 Charles V. Kidd 13 In 1964, 125 grants were awarded to investigators in 12 countries. In some countries, such as Chile, these grants were a major force in building the bio- sciences in the nation. Throughout the continent, the support was substan- tial, and most of the outstanding investigators in the region were financed. This led to a closely woven, extensive net of personal and professional relation- ships: advanced training in the United States expanded as the research support increased, and the number of college relationships increased. However, after 1964 support from the U.S. Government declined. Total awards dropped from 138 in 1964 to 20 in 1976, and the dollar volume of awards dropped from $2.8 million to $1.5 million. These declines were particularly precipitous and disruptive in countries where investigators had been well supported by U.S. funds. It is significant that grants from private foundations and government declined simultaneously. Decline in the total support of biomedical research in Latin America by the US. Government over the period 1964-76 was accompanied by two important changes: (1) the amounts supplied to the Pan American Health Organization actually increased as a consequence of a general decision on the part of the United States to rely to a greater degree upon international organizations, and (2) a decision was made to provide a higher proportion of funds for specific tasks agreed upon in advance, as contrasted with smaller grants for basic research. While support from the United States was declining, funds from other countries were increasing somewhat, but not enough to offset the decline in funds from the United States. Most of the aid from Europe is in the form of exchange of students and professors and in opportunities to use European research facilities. France, Great Britain, Germany, and Sweden are among the countries making most of these cooperative opportunities available. Some European and Japanese agencies and universities have established agreements with institutions in Latin America for the development of coop- erative research in parasitic diseases, including contributions of human re- sources and elements of work. For example, in recent years certain Japanese universities have made agreements with Brazilian national entities for basic research into Chagas’ disease and toxoplasmosis; others have allied themselves with Guatemalan institutes to carry out cooperative research in onchocer- ciasis. Through an agreement with the Osvaldo Cruz Foundation, the Deutsch Gesellschaft fur Technisch Zusammenarbeit of West Germany supplied an eminent German investigator to the Osvaldo Cruz Institute and provided him with equipment to conduct basic research on Trypanosoma cruzi and Chagas’ disease, with the collaboration of national investigators. Similar agreements have linked other German institutes with the universities of San Marcos and Cayetano Heredia in Lima to assist them with equipment for their respective institutes of tropical medicine. The British Overseas Development Adminis- tration has helped by sending technical people specializing in the study of 14 Biomedical Research in Latin America Chagas’ disease to Brazil. Through agreements with other universities it has also provided biologists, parasitologists, and entomologists for selected in- quiries in this area. Some of them are distinguished professors of the London School of Hygiene and Tropical Medicine whose stay in Brazil has been fi- nanced by the Wellcome Trust. The most important factor during this period of net decline in outside support has been the degree to which Latin American governments have in- creased their support of biomedical research, notably in Mexico, Venezuela, Colombia, and Brazil. How is this period of transition from heavy reliance on foreign governments to greater reliance upon national resources to be assessed? The large programs of external assistance—primarily from the United States—had both helpful and harmful effects. The funds provided a strong stimulus to productive investi- gators. In some countries, like Chile, the funds were the major factor in ele- vating the quality of the entire national effort. Investigators who studied in universities and hospitals in the United States now form a substantial pro- portion of the leaders in biomedical research. This training provided not only technical competence but also new views on the organization of universities and graduate education. While investigators in Latin America who were supported by foreign funds welcomed the aid, they and other observers worried about some fundamentally undesirable consequences of heavy reliance upon foreign funds. Inappropriate training and role models. In the United States and Europe students often acquire skills and values that are inappropriate in their home countries. One means of coping with this problem is to send people abroad for study only after training opportunities in the region have been exhausted and only when there is reasonable assurance of a stable career when they return. The earlier tendency to look abroad for guidance in such matters as in- stitutional governance and administration, research and planning, and patterns of graduate education was fostered by financial dependence on foreign funds. In Latin America there are models of well-planned university development, sophisticated research planning, first-class postgraduate education, good ad- ministration of research institutes, experienced national agencies for scien- tific promotion and policy, successful international regional cooperation, and promising efforts at combining basic and applied research. Their existence does not advocate isolation of the region or suggest that everything done there deserves to be emulated. On the other hand, Latin Americans clearly have *This paragraph was contributed by Dr. Amador Neghme. Charles V. Kidd 15 much of value to learn from one another. Accordingly, more attention is being paid to successful regional models before hasty adoption of outside models. Inappropriate division of responsibility. When too much money for biomedical research is received from external sources, a government may tend to ignore its responsibility to finance this work. This has been the case in some countries in Latin America when outside assistance was considerable. Over the long run, the health of science in a country depends on support by the nation itself; it is unwise to have any major area of national concern dependent on outside sources for an extended period of time. Inappropriate research priorities. In the past, foreign funds supplied specifi- cally and solely for research were relatively minor and included such cate- gories as special chemicals and laboratory supplies (e.g., glassware), equipment, research animals, and technicians. These amounted to 10 to 15 percent of total research costs. Yet the foreign countries that determined how this relatively small sum was spent exercised a strong influence over large segments of the health research programs of many Latin American countries. The ability of external bodies to exercise such strong influence over na- tional research priorities has been resented more often, it is true, by those concerned with national policies and goals than by the responsible scientists who have usually been glad to receive the external funds. Most of the research funds supplied by the U.S. Government (rather than foundations) have been directed not to the development of science in Latin America or to problems important to the region but to the financing of research relevant to the tasks of various parts of the U.S. Government. This money was, of course, extremely helpful to individual investigators and labo- ratories, as well as in the development of science in the countries concerned. From the standpoint of the national policies of the Latin American coun- tries, however, the fundamentals of the system itself were at times question- able. For example, U.S. grants and contracts were designated almost entirely for sophisticated laboratory research related to chronic diseases. This field is important in Latin America, but the characteristics of research supported by U.S. sources are not the same as those that would result from carefully considered national decisions made by the Latin American countries them- selves. Indeed, U.S. grants were often made to individual investigators without reference to university or national authorities. This was often a distinct strength from the standpoint of science because it protected individuals from various unproductive impediments, but it had a negative aspect in that no provision was made for consideration of needs broader than those of the individual scientists. The tendency of outside research support to distort national priorities may exist in the case of foundation and international organization support as well. For instance, the entire research effort of at least one Latin American medical school is directed toward a single subject: birth control. This poses in 16 Biomedical Research in Latin America dramatic form a question as to the extent to which the urgency of problems, as contrasted with the merit of a scientist, should govern the allocation of funds. However, an assessment of the effect of outside support must take into account the fact that if those funds had not been available, it is improbable that the national governments would have supplied additional local funds for research on problems of high domestic concern. Finally, the importance of basic research must be emphasized. Stressing self-determination does not mean that countries would or should choose to take a short-sighted view of research priorities. Every country is well advised to foster basic research. Such research, when it is of high quality, is important to the training of good scientists and can contribute to the solution of applied problems; it elevates the status of all research in a country and places investi- gators in the mainstream of scientific development. Multinational Agencies A prominent aspect of the financing and planning of biomedical research in Latin America over the past decade has been a decline in outside support provided by individual nations and an increase in the influence of multinational agencies. This important topic is treated at length in chapter 3. Observations on Specific Countries Many of the realities of biomedical research in Latin America can be grasped only by looking at specific strengths and weaknesses in individual countries. In the following pages, extremely condensed thumbnail sketches provide illus- trations that cover both the giants of Latin America and other countries with more modest efforts. Brazil The major country with the most positive attitude toward science is Brazil. In that country, which currently has a solid economic base, there is a strong national structure for science and technology, augmented by a vigorous science support program in the state of Sao Paulo. The National Research Council and the Sdo Paulo research fund spent a combined total of $38.9 million on fellowships and research support in 1978, and this sum continues to rise. About 20 percent of the expenditures, or $7.8 million, are in the biomedical field, a remarkably high proportion. In addition to these funds, large amounts are invested in research by the Financial Agency for Studies and Projects (FINEP), by the research fund of the National Development Bank (FUNTEC), and by the research fund of the Bank of Brazil (FIPEC) (table 3). Charles V. Kidd 17 There are strong diversified biomedical research programs in Sido Paulo, Rio de Janeiro, Belo Horizonte, and Brasilia, complemented by less compre- hensive but high-quality activities in Bahia, Curitiba, and Porto Alegre. Funds are available to support an increasing number of programs for the training of students to the master’s and doctoral levels. Laboratories in all biomedical fields are well equipped, even though foreign exchange problems currently restrict imports. Scientists feel secure in their laboratories and look with confidence to the future. Their salaries are high relative to those in other countries. That of a full-time senior professor approximates $25,000 per year in federal universities and $36,000 per year at the University of Brasilia and some universities in Sao Paulo. The bottlenecks in Brazil involve neither people nor funds but a shortage of good ideas and programs for these available resources. In addition, there is an equipment problem generated by severe shortages of foreign exchange.’ During recent years, scientific contacts between Brazil and Canada, Great Britain, West Germany, France, and Japan have increased, while those with the United States have decreased. In total, foreign support for research in Brazil has declined sharply. Some, but not much, international support is available from PAHO and some from the OAS. Fortunately, the country has more than compensated for this decrease in external funds. While this is essentially healthy, it has had one unfortunate side effect: a decrease in TABLE 3. Research and Scholarship Expenditures of the National Research Council of Brazil and the Foundation for Research Development of Sido Paulo, 1976 (in millions of dollars; 18 cruzeiros = $1) Type of National Research S3o Paulo Expenditure Amount Council Research Fund Fellowships 21.4 15.8 5.6 Research support 17.5 11.4 6.1 Total 38.9 27.2 11.7 NRC data: Relatorio de Actividades, CNPQ, 1976; SPRF data: Fundagdo de Ampara a Pesquisa de Estado de Sao Paulo, Manual de Informagdes, 1976. Source: Personal communication from Edwardo Oswaldo Cruz. 5Brazil accepted a very large amount of scientific equipment from Eastern Europe in partial payment for coffee imports. Unfortunately, the equipment was no good (with the exception of Zeiss instruments), and the imports killed an infant domestic instrument industry. 18 Biomedical Research in Latin America the international contacts of Brazilian scientists. In addition, severe shortage of foreign exchange has required stringent limits on foreign travel and on purchase of equipment. In fact, the most serious barrier to increasing the volume and quality of biomedical research in Brazil is the lack of equipment. Mexico Biomedical research in Mexico can be examined from different viewpoints, each leading to a different assessment. One way of examining biomedical research is to compare the effort with that of other countries. In this light, it is clear that the Mexican research program is one of the strongest in Latin America. There are a number of outstanding biomedical research centers in Mexico City. The Institute of Nutrition, which is particularly strong in endocrinology, diabetes, and diseases resulting from molecular defects, is one. Despite recent restrictions on the research budget, the quality of research remains high. Another strong center is the Autonomous University of Mexico (UNAM), where work in the bio- medical sciences is concentrated in the Institute of Biomedical Studies (1976 operating budget: $1.25 million) and the Institute of Biology (1976 operating budget: $2 million). A third important center is the Institute of Cardiology. The strongest organization in basic biomedical science is the Center for Re- search and Advanced Studies of the National Polytechnical Institute. This center is autonomous and has extremely high standards. Departments related to biomedical research are physiology and biophysics, biochemistry, cellular biology, genetics and molecular biology, and pharmacology and toxicology. The Mexican Institute of Social Security (IMSS) is a major institution concerned with preventive medicine, quality of medical care, training of biomedical personnel, and support of clinical and biomedical research. IMSS commands the largest health-related budget in Mexico (10 billion pesos, or $800 million), with a basic research budget on the order of 28 million pesos (over $2 million). Of the 30,000 M.D.’s in Mexico, 10,000 are involved in the operation of IMSS, and about 10 million patients are being served. The main operation is in Mexico City, and new units are being developed in Vera Cruz, Guadalajara, and Monterrey. IMSS is committed to the principle that a research program is a necessary component of effective health care. The IMSS research program is discussed in chapter 2. The Hospital Infantil has a vigorous research program that is particularly strong in pediatrics and nutritional disorders of children. The biomedical research program is part of a total national research effort that has been expanding steadily. National R&D expenditures rose from $88 million in 1973 to $135 million in 1976, of which about 10 percent is spent for biomedical research. Foreign support has always been a small Charles V. Kidd 19 part of the Mexican investment in biomedical research, so withdrawal of these funds has not shocked the system. There is, however, another way to examine the status of biomedical re- search in Mexico. It can be measured against an ideal, and when this is done, many defects appear. In Mexico, as in Brazil, there have been extensive critical examinations of the role of science and technology in development under the guidance of the national research councils. One of the most impressive reports in Mexico is the National Indicative Plan for Science and Technology produced in 1976 under the auspices of the National Council for Research and Tech- nology. A section of this report is devoted to medicine and health (pp. 168- 175). It is remarkable for its frank analysis of deficiencies and for a set of priorities that, if adopted, would markedly change the composition of bio- medical research over the years. The report states: Research and development in medicine and health has followed a model typical of the more advanced countries, where urban medicine, with costly technical support, predominates. In Mexico, medical research concentrates on basic biomedical research, whose immediate application is limited, and on some problems related to urban medicine. The fact that practically no adequate research is undertaken on health problems peculiar to under- developed countries is a direct outcome of the adoption of the patterns existing in advanced countries. However, in the last few years research has been undertaken in nutrition employing an approach which is more com- patible with national problems. The report proceeds to point out that except for a few institutions, salaries are so low that scientists cannot dedicate themselves completely to research. The research community is still quite small and still heavily dependent upon the United States for equipment and servicing. The quality of university education is declining overall, but clever and successful efforts are being made to provide first-rate instruction to the top 10 percent of the students. (These problems have also been described in reference 10.) The National Indicative Plan for Science and Technology proposes a vigorous national plan to deal with all of these problems—a plan drawn from La Ciencia y la Tecnologia en el Sector Medicina y Salud: Diagnostica y Poli- tica, a report prepared in 1976 by leaders of the research community. Whether there is sufficient institutional stability to make the plan effective remains to be seen. Argentina In Argentina, biomedical research has a long, distinguished history. The broad educational base of the country, combined with a generally high cultural level and a sound economy, produced generations of biomedical investigators of high international quality in many fields. Unfortunately, since the early days of Peron this development has been interrupted by political turmoil that has 20 Biomedical Research in Latin America had severe adverse economic repercussions and has produced waves of harass- ment of those who have opposed whatever regime has been in power. Funds made available by the Government for biomedical research are concentrated in government laboratories. Very little money is provided for research in uni- versities, where the salary scale remains low. All these factors have com- bined to reduce the vigor of biomedical research in Argentina. On the other hand, points of excellence remain in a few privately financed laboratories. For example, Luis Leloir and his colleagues continue to do first-rate work in the private Campomar Foundation, the site of the Nobel Prize investigations of the late Bernardo Houssay. Chile Biomedical research in Chile, highly concentrated in Santiago, continues to be productive under extremely trying conditions. The difficult economic situation, whose adverse effects are magnified by the indifference of the Government to universities and to science, has forced investigators to work with obsolete equipment and with resources so limited that some lines of investigation have had to be abandoned. The poor financial condition of hospitals has severely limited clinical research. It is a tribute to the dedication of the small group of biomedical investigators that they have continued to work at science. The strongest biomedical research enterprise in Chile—in terms of resources, scientific productivity, and applicability to problems of health—is the nutrition-centered research program of the Institute of Nutrition and Food Technology of the University of Chile. Chile is the prime example of a country that built an excellent biomedical research structure largely on the basis of outside support and has not replaced the decreased flow of foreign funds with domestic funds. Venezuela In Venezuela, science has been well supported financially. For a time, oil production income removed money as the limiting factor on scientific in- vestigation. Grants for research supplied by the National Council for Scien- tific and Technological Investigations (CONICYT) rose rapidly from a level of $6 million (24 million bolivares) in 1974 to $16 million (65 million boli- vares) in 1977. Of this, 15 percent (about $2.4 million) was for medical sci- ence and technology [11]. In addition, funds on a modest scale were available from private sources, such as crude petroleum. The S-year economic plan for 1976-80 (Primer Plan Nacional de Ciencia y Tecnologia, Periodo 1976-80) contemplates rapid growth of support for science, but recent eco- nomic setbacks cast doubt upon the feasibility of this plan. Charles V. Kidd 21 The most important limiting factor is the lack of trained manpower, which the Government is attempting to overcome by operating the most extensive training program in the history of Latin America—the Gran Marescal de Aya- cucho program. This activity ranges from the undergraduate through the post- doctoral level. Of the 9,000 students sent abroad for study in 1977, half enrolled in colleges and universities in the United States. In a few years, the supply of scientists and other specialists should be adequate. A second serious problem in Venezuela is the institutional structure for biomedical science. While there are active centers of biomedical research in Venezuelan universities, particularly the Institute of Experimental Medicine at Central University in Caracas, the universities with significant biomedical research activities have been plagued by continuing disruption. An outstand- ing independent research institute, Instituto Venezolano de Investigaciones Cientificas (IVIC), is located near Caracas, and there are some specialized biomedical research institutes in the city itself. The total institutional structure is far from ideal, however. In 1978, the immediate economic future of Venezuela was not bright. After the income of the Government rose from $3 billion in 1973 to $10 billion in 1974, economic difficulties multiplied. A $52 billion 5-year develop- ment plan, which in retrospect was over-ambitious, faltered. It became evident that there were not enough technicians, engineers, and managers in the country to operate the expanded efforts. Then oil revenues dropped, necessitating curtailment of government expenditures, and therefore in 1978 the outlook for support of science was not nearly so favorable as it was in 1974 and 1975. Colombia In Colombia, research in the social sciences related to health is particularly strong. Private foundations from the United States, the World Health Organi- zation (WHO), and the Government of Colombia—through the Ministry of Health and the Family Welfare Agency (ICBF)—have for years organized and financed studies of morbidity and mortality, experimental health care de- livery, maternal and child health systems, and nutrition programs. Typically, these are conducted as combined demonstration, training, and research pro- grams. The National Institute of Health of Colombia (INAS) carries on a varied research program encompassing such fields as transmission of yellow fever and Venezuelan equine encephalitis, parasitology, tuberculosis, leprosy, and Chagas’ disease. The primary task of the Institute is vaccine production. For example, it produced 1 million doses of yellow fever vaccine in 1977, of which 200,000 were exported to Argentina and 350,000 to Venezuela. Most of the resources of the laboratory are devoted to production, and the 22 Biomedical Research in Latin America research projects are financed on a small scale. The laboratory has been trou- bled by political interference with programs and personnel. Biological and medical research are concentrated in universities—the Uni- versity of Antioquia in Medellin, and the National University and the Uni- versity of the Andes in Bogota—and in a few research institutes. Research in universities, particularly in Cali and Medellin, has been dealt severe blows as a consequence of student disruption. At Medellin a number of investigators have joined private institutes, but in Cali the deterioration from an earlier high status has been severe. The Colombian Cardiovascular Center, the National Cancer Institute, the Neurological Institute, and the Colombian Diabetes Association conduct research in their respective fields of interest. While the Government provides basic support for universities through the Ministry of Education, research is financed by the Colombian Fund for Scientific Investigation (Colciencias). The fund is 10 years old and has largely replaced foreign moneys, which have been sharply cut back. Support of re- search projects has risen from $600,000 in 1972 to $3 million in 1978, an im- pressive increase. In total, Colombia spends less on biomedical research than it did during the peak years a decade ago when much money was provided by the United States. However, the funds are now Colombian or international, and this makes the situation healthier in general. Nonetheless, biomedical research in Colombia continues to face severe handicaps. Disruption of universities has been mentioned. Academic salaries remain so low—about $6,500 per year, with a few professors making as much as $11,000 per year—that exclusive dedication to research and teaching is rare. Physicians can multiply their incomes many times by shifting from academic medicine to private practice in the cities. Operating costs of hospitals are severely underfinanced so that clinical research is virtually impossible, with the exception of the military hospital. Colombian scientists are not trained well to write scientific articles, and their output is limited. Expensive equipment is underutilized. Colombia has stressed the training of scientists for a number of years. A major national agency, the Institute for Manpower Training and Education (ICITEX), operates an effective program for study in other countries, and more scientists go abroad as Fulbright scholars—a total of 974—than from any other Latin American country. The effect of this training effort has been offset substantially by the loss of physicians through migration to the United States. The drain from Colom- bia has been more severe than that from any other Latin American country, but the flow has now virtually ceased because of new restrictions in the immi- gration laws of the United States. Charles V. Kidd 23 As a consequence of training programs and of tolerable, if not comfortable, working conditions for scientists, there are substantial numbers of investi- gators in the 30- to 45-year age bracket. In contrast, there are relatively few scientists in this productive age range in Chile and Peru. All in all, the biomedical research effort is small in relation to the major health problems of the nation, which include a severe threat of rapid spread of malaria, a Chagas’ disease problem of unknown dimensions, heavy inci- dence of enteric diseases, and high infant mortality. Costa Rica Costa Rica is a small, prosperous, stable country (its population is 1 million as compared with the 9 million population of Sao Paulo) with a small biomedical research program of high quality. The Costa Rican National Council for Scientific and Technological In- vestigations is active in such fields as international cooperation, popularization of science, preservation of national resources, formation of national research policy, and support of research. Relationships between the council and the Government are close and cordial. The council participates fully in the national planning process at a high level, primarily through its chairman. This is un- usual in Latin America. The total budget of CONICYT increased from $270,000 in 1974 to $900,000 in 1975, $635,000 in 1976, and $1 million in 1978. Of the total expenditures in 1976, $245,000 was provided for support of research in the form of 25 project grants. Eleven investigators in biomedical fields received $80,000, about one-third of the total. Of the 11 investigators, 8 were associ- ated with the University of Costa Rica, 2 with the Children’s Hospital in San José, and 1 with the Association for Hematology. Biomedical research is concentrated in the University of Costa Rica, where the most significant sites for biomedical research are the Institute for Health Research (INISI) and the Cell and Molecular Biology Laboratory. INISI con- centrates on child nutrition and growth, diarrheal diseases of children, and microbiological studies. The Cell and Molecular Biology Laboratory con- centrates on insect-virus-plant systems, the molecular biology of tropical parasites responsible for endemic human diseases, and studies of organization of genetic material in vertebrates. A Center for Virology is associated with the Cell and Molecular Biology Laboratory. It has a fully equipped electron microscope installation (including a scanning electron microscope), donated by the Japanese Government. Clinical and public health research is carried on in the Children’s Hospital, and small-scale research in malaria, filariasis, Chagas’ disease, and diarrheal diseases is conducted in the Ministry of Health. 24 Biomedical Research in Latin America With respect to the future, Costa Rica faces problems in biomedical re- search that have been generated by its astounding success in reducing child mortality and death from infectious diseases over the past decade. The country must begin to deal with the emergence of chronic diseases as major causes of death. Peru Biomedical research in Peru is imperiled by the poor economic situation of the country, which over the past few years has declined from a low base. The latest data on research expenditures [12] are for 1975, and in that year the total national investment in research was $175,000 (197 million soles). Of this amount, $117,000 was for biology and $58,000 for all medical science and technology. Virtually no funds for biomedical research came from out- side the country. The two major centers for biomedical research are San Marcos University and Cayetano Heredia, a private university. A moderate amount of clinical research is carried on in the hospitals of Lima. Excellent work continues in high-altitude physiology and endocrinology despite eco- nomic obstacles. Research in public health is at a very low level. Relative Strengths of Biomedical Research Fields The various chapters of this report deal with fields of research by discipline and disease entity. They do not, however, compare the relative strengths of these fields. Which fields are relatively strong in terms of quality and quantity of re- search? First, one can identify individuals, laboratories, and institutes that constitute points of excellence, as contrasted to fields of excellence. The points of excellence are important in their own right as a way of setting levels of as- piration and as an affirmation that work as good as any in the world is being done by Latin Americans. For example, the work of Houssay and Leloir on carbohydrate metabolism is of Nobel Prize quality. Similarly, investigations in neurophysiology in Brazil, Uruguay, and Chile have been of outstanding international quality, as has research on the physiological effects of high altitude in Peru. Yet these noteworthy examples of research do not necessarily signify strong fields of science, because laboratories that produce many good students and much good science are scarce. On the other hand, genetics has been a strong science in Latin America, and its center of strength has been Brazil. The impetus for its growth was provided by the collaboration of an inspired Brazilian teacher, O. Dreyfus, and an equally inspired American, T. Dobzhansky. These men created in Brazil a gen- eration of investigators, substantially supported by the Rockefeller Founda- tion, who established a firm research tradition. Charles V. Kidd 25 Biochemistry has emerged forcefully in a number of countries, among them Argentina, Brazil, Chile, and Mexico. Here there has been a fortunate combination of stimuli through international organizations, effective training of Latin American students in some of the best laboratories of the world, and capable leaders within a number of countries. Both genetics and biochemistry, it should be noted, are relatively new disciplines in Latin America, and it may be that the absence of established professorial posts of the traditional type in these fields has actually been a positive factor in their development. Nutrition is relatively strong in Latin America, where there are many out- standing nutritionists and many excellent research centers. Among them are the Institute of Nutrition in Mexico City, the Institute of Health Investigation at the University of Costa Rica, and the Institute of Nutrition and Food Technology in Santiago. In addition, INCAP is a prominent multinational nutrition center associated with the Pan American Health Organization. Partly as a cause and partly as an effect of regional strength, there is a Latin American Journal of Nutrition. Large-scale financing of nutritional research has come from multinational sources, from foundations, and from individual govern- ments outside Latin America. This support has been sustained long enough to permit training of mature investigators and establishment of strong, stable laboratories. Now the burden of support for nutritional research is shifting to national governments. All in all, nutritional research is perhaps the best ex- ample of a sophisticated blending of basic and applied research directed toward a major cause of disease and death in Latin America. Some fields of research are clearly growing in both quantity and quality. One of these is reproductive physiology, which has been given a strong impetus from both foundations and international organizations. Laboratories in Argen- tina, Chile, and Uruguay are linked in this effort. Their concern is linked to the larger population problem. One encounters here the tension between the principle of guiding research toward problems of highest significance and the principle of selecting for backing the most able investigators, regardless of their fields. There is no obvious solution to this problem; both principles are valid and should be pursued simultaneously. Scientists tend toward support of merit; nonscientists, toward support of important problems. Immunology is another field that is becoming more significant but is not yet of major strength. The impetus has been provided primarily by PAHO- WHO immunology research and training centers in Brazil and Mexico. This area of investigation serves as the basis for many kinds of applied research. Microbiology and parasitology are well-developed sciences. They are par- ticularly important because much of the research is useful locally but will not be adequately supported by outside sources. 26 Biomedical Research in Latin America Second, one can identify fields of health research that are underdeveloped. For many reasons, modern clinical research has not been as strong as labora- tory research. The older tradition that clinical research consists of description of unusual cases has persisted widely. The modern concept of linking labora- tory and clinical research to search for scientifically verifiable phenomena has rarely been applied. This kind of research requires intensive, broad train- ing, and persons with this background have been scarce. Moreover, clinical research is expensive, and often the costs must be borne largely by hospitals that have no research funds. The Pan American Health Organization has recognized these obstacles and has initiated a program to overcome them. While clinical research in Latin America has in the past tended to be de- scriptive and based upon one or a few cases, over recent years modern clinical research has become strong in a few centers. One is the Clinical Center in Sdo Paulo, which is outstanding not only because of the breadth of the staff and quality of the facilities but also because of the depth of its research program. The IMSS hospital in Mexico City is superbly equipped and has well-trained people. The third major center of clinical research is Lanarils Institute of Experimental Medicine in Buenos Aires. There the shortage of funds is offset by an abundance of good ideas. Epidemiology is a relatively underdeveloped field. It is true that important epidemiologic work has been part of a number of investigations, including first-rate studies of comparative mortality and abortions in different cities and of air pollution. In addition, epidemiology has been included in the cur- riculum for the master of public health degree; however, epidemiology itself has not been strong in Latin America, perhaps because mathematics has been strong in only a few Latin American universities. Since sound epidemiologic research is an absolute prerequisite to the effec- tive design and operation of public health programs, it may well be that the most effective approach is to continue to press for expansion and emphasis on epidemiologic training in public health education programs and to insist on sound epidemiology in connection with major economic development programs, such as the Trans-Amazon Highway and the extensive colonization plans for the Amazon basin. A large multinational effort in this direction is indicated. Research in public health administration and practice has lagged behind laboratory research, and the relative position of such research has not im- proved over the past decade. Latin American physicians typically are trained to be practitioners. They are attracted to metropolitan areas where economic, social, educational, and cultural opportunities are most plentiful. Departments of preventive medicine are often weak or nonexistent, and there are only 10 schools of public health in the entire region. Public health measures are ad- ministered by ministries of health. In some countries these ministries have proud traditions of accomplishment, including research. In others, however, Charles V. Kidd 27 the attainment of a continuing, professional level of public health adminis- tration has proved difficult, and accordingly there has been little or no re- search. Another factor that may account for the relative lag in public health research is that this type of inquiry is strongly affected by local traditions and practices. Consequently, it is difficult to transfer experience from one country to another. Laboratory research, on the other hand, while affected by local conditions, is conducted more uniformly throughout the world because train- ing in one country is relatively easily transferred to and used in another coun- try. Nevertheless, research in public health has become more productive over the past decade, notably in Chile, Colombia, and Mexico. One special branch of study that should be encouraged is investigation through the techniques of industrial engineering and operations research of the efficiency of management of hospitals, clinics, and public health opera- tions. Resources are so scarce that intensive endeavors to use them most effectively are indicated. Accelerated efforts along these lines by both multi- national agencies and national governments are warranted. One example of such research is the program for applying industrial engineering to health serv- ices conducted by the Instituto Tecnologico y de Estudios Superiores at Mon- terrey, Mexico. While a moderate amount of research in chronic diseases in Latin America is appropriate, the existing emphasis should not be radically increased. It should be shifted, instead, toward improvement of scientific and medical communications so that research results from world laboratories are quickly and effectively disseminated. Virology is not so strong in Latin America as it should be, despite the regional significance of viral diseases. Reasons for this are not entirely clear, but some apparent causes may be mentioned. Modern virology requires equip- ment, materials, technicians, and animal facilities not readily available in Latin America. Moreover, many lines of advanced research in virology can be carried on effectively only where protein chemistry, immunology, and molecular genetics are strong. To a substantial degree, virology research in Latin America has been conducted by investigators from the United States in laboratories not associated with local institutions, and this has not encouraged the develop- ment of Latin American virologists or laboratories. All these factors have inhibited development of strong virologic research in Latin America, despite the existence of some small, isolated groups doing good research. Since 1970 there has been a trend toward emphasis upon research that will contribute directly to the solution of health problems. Among the larger countries, this trend is particularly noticeable in Mexico and Brazil. It is similar to the movement to make scientific research more directly applicable to social problems, which has been strong in Europe and the United States. National research bodies are the administrative agents through which influence is exerted on the biomedical research community. In neither Brazil nor Mexico 28 Biomedical Research in Latin America has the trend been toward indiscriminate, heavy-handed pressure to abandon basic research in favor of narrowly defined applied research. In summary, the total biomedical research effort in Latin America is to some extent consistent with the major demographic, health, and adminis- trative characteristics of the region (table 4). TABLE 4. Health Indicators in the Americas Northern Mid- Tropical Temperate America America Caribbean South America South America Area (million sq km) 21.5 2.5 0.2 13.7 4.1 Population (millions) 237 79 27 180 39 Population density (per sq km) 11 32 114 13 10 Population growth (%o/yr) 0.9 3.2 1.9 29 1.4 Population under age 20 (% of total) 35 57 51 54 . 40 Median age of population (yrs) 29 17 19 18 26 Urban population (% of total) 71 57 48 59 81 Diet (kg-cal/person/day) 3,300 2,500 2,300 2,500 2,900 Gross national product ($ per capita) 5,480 670 680 530 1,120 Crude birth rate (per 1,000 population) 18 44 35 38 26 Death rate (per 1,000 population) 9 10 11 10 9 Life expectancy at birth (M-F [years]) 69-72 50-65 54-66 53-64 61-69 Infant mortality (per 1,000 live births) 18 66 69 90 62 Physicians (per 10,000 population) 15.5 5.1 54 53 15.2 Nurses and midwives (per 10,000 population) 62.5 7.0 13.9 4.9 5.0 Hospital beds (per 10,000 population) 72.5 12.2 32.6 27.5 48.5 Table provided by Dr. Pelayo Correa. Source: Reproduced with permission from W.P.D. Logan, World Health Statistics Report 29:682-697, 1976. 29 Charles V. Kidd References 1: 2. 10. 11. 12. Atcon, R. The Latin American universities. /n Die Deutsche Universitatszeitung (a German journal; date and pages not available). Garcia, R. The Latin American universities. /n Ruth Gruber (ed), Science and the New Nations. New York: Basic Books, 1961, pp. 230-237. Herrera, A. Social determinants of science policy in Latin America. J Dev Stud 9:19-37, 1972. Houssay, B.A. El pasado y el futuro de la ciencia en la América Latina. Ciencia e Investigacion 10:52-60, 1954. Houssay, B.A. La libertad académica y la investigacion cientifica en la America Latina. Ciencia y Tecnologia, Vol. 5, No. 19. Departamento de Asuntos Culturales (Seccion Ciencia y Tecnologia). Washington, D.C.: Pan American Union, 1960. Houssay, B.A. Importancia del adelanto cientifico para el desarrollo y la pros- peridad de las Américas. Ciencia Interamericana 1:1, 1960. Roche, M. Science in Spanish and Spanish American civilization. /n Civilization and Science, in Conflict or Collaboration? Amsterdam: Elsevier, 1972, pp. 143-160. Scherz, L. El Camino de la Revolucion Universitaria. Santiago, Chile: Editorial del Pacifico, 1968. Wionczek, M. Science and technology planning in Mexico and its relevance to other developing countries. Interciencia 2(6):328-334, 1977. Soberén, G., and J. Martuscelli. Los Diez Grandes Temas de la Medicina Mexicana. Simposio Syntex, April 16, 1977. CONICYT. Potencial Cientifico y Tecnologico de las Actividades de Investigacion y Desarrollo en el Pais, 1975. OAS Potencial Cientificotecnologico del Peru, Estudios Sobre el Desarrollo Cienti- ficotecnologico, No. 22. Departamento de Asuntos Cientificos, 1975. ROLES OF MINISTRIES OF HEALTH AND SOCIAL SECURITY SYSTEMS Alfredo L. Bravo Introduction There is a strong logical argument for government support of biomedical re- search in Latin America. Disease is debilitating. It is both a result and a cause of poverty. Determination of the causes of disease through research can lead, and has led, to reductions in rates of sickness and death. Indigenous research is necessary to judge which health technologies should be developed internally and which should be imported. Furthermore, delivery of health services can be made more effective and less costly by research. A country that fails to accept the validity of these and related considerations runs the risk of having its technical services become obsolete, thereby widening irreversibly the existing gap between science and technology in industrialized countries. All of these arguments are familiar and persuasive. They were spelled out in more detail in chapter 1 and are summarized here as background for the sub- ject of this chapter: the current and the optimum roles played by ministries of health, social security systems, universities, and research institutes in the planning and conduct of biomedical research in Latin America and the Carib- bean region. What position have ministers of health taken on the issue of biomedical research? It would be reasonable to assume that they have endorsed the sig- nificance of biomedical research, and this is indeed the fact. In 1963, Latin American ministers of health adopted this rather weak state- ment at Punta del Este [1]: It is suggested that the governments carry out an evaluation of health re- search being performed in their countries, as well as the resources available for the training of researchers, in order to bring them in line with the other priorities of the national development plans. In 1973, a stronger statement on the subject was adopted by assembled ministers of health [2]: Poor health represents a great obstacle to economic development. Research is a vital means of identifying the causes of diseases and achieving preven- tion, finding solutions, and tracing guidelines for the better use of the 31 32 Biomedical Research in Latin America available resources. Although in some countries research is increasing rapidly, the rate of increase for the entire hemisphere is inadequate. Despite such rhetoric, ministers of health have not in fact played a very important role in medical research, except in one area. That area—research on the organization, financing, and delivery of health services—is not covered in this report. Indeed, a survey prepared for a 1973 meeting of American ministers of health revealed the following: During the past 5 years there has been considerable reduction of the sup- port for investigative activities provided by governments and foundations in this area, while over the same period there has been an increase in the funds supplied to several countries by international organizations and nongovernmental internal sources. A more realistic group of goals and a keener recognition of problems to be solved in the biomedical research area was set forth by a symposium convened in 1973 as part of the final annual meeting of the Committee for the Evalu- ation of Scientific Investigation of the Pan American Health Organization: Although significant research is carried out in Latin America in such fields as genetics, biochemistry, nutrition, reproductive physiology, immunology, and parasitology, shortages exist in clinical investigations, epidemiology, virology, and administration of public health; . . . the most significant fac- tors preventing the development of science in Latin America are political instability, rigidity of the university structure, and unrestricted admission of students to medical schools. This is a rather depressing set of conclusions: Governmental support for biomedical research is declining in Latin America as a whole, and the reasons are deeply rooted in institutional forms and political factors. Furthermore, to these factors can be added the pervasive, depressing consequences of lim- ited governmental resources in relation to the tremendous demands placed on governments. Ministries of Health In all the countries under review, the Ministry of Health is the agency in charge of formulating the health policy of the country; drawing up plans for its implementation; coordinating available resources; guiding activities of the health services; and, at the same time, providing direct services to certain population groups. Promotion of health and disease prevention are invariably a specific and primary responsibility of the Ministry of Health, which also frequently assumes responsibility for training auxiliary personnel. In general, most ministries of health supervise laboratories for public health, production of sera and vaccines, and control of pharmaceutical products. Funds for the ministries are provided solely from the general budget of the country. In no country is the money sufficient to permit the ministry Alfredo L. Bravo 33 to fulfill adequately all the obligations imposed on it by law. Great diffi- culties are encountered in financing even those projects that are rigidly re- quired by law. Scientific research is not among these priorities and is there- fore without exception financed at a low level. Legally and financially, it is easier for ministries to participate indirectly in biomedical research proj- ects via financial contributions to other national institutions and to various research centers and institutes supervised by the Pan American Health Or- ganization. It is interesting to observe that in 1919 Great Britain had to determine whether to place responsibility for biomedical research within the Ministry of Health or to establish a new Medical Research Council. The latter course was taken, for two reasons. First, the judgment was that the ministry’s op- erating responsibilities for public health would tend to depress the research role or leave it underfunded. Second, it was thought that whatever research was supported by the ministry would be overly concerned with the solution of immediate operating problems, with inadequate attention to longer-range problems. The parallels with the situation in Latin America are interesting. Without a conscious decision’s having been made, there has been a general movement to develop biomedical research mostly in institutions outside the ministries— such as hospitals, social security systems, research institutes, international research centers, and universities—thus leaving the ministries concerned for the most part with the public health area. Within this area, there are wide differences in the actual scope and content of research supported by the ministries. Social Security Systems General The social security systems of a number of Latin American countries, such as Argentina, Brazil, Colombia, Costa Rica, and Chile, support biomedical research, but in a rather limited way. The Mexican Institute of Social Se- curity is unique in having a fully developed medical research program. The primary function of social security systems, including those parts related to health, is to redistribute wealth in order to give services or pur- chasing power to the so-called “passive population,” consisting basically of vulnerable children, the aged, and disabled people. However, social security systems often participate indirectly in health-related activities; for instance, they organize and administer medical services to their members and bene- ficiaries. Usually, participation is restricted to supplying ambulatory medical and hospital services, along with limited dental and pharmaceutical services, to subscribers, their wives, and children up to a certain age, depending on the 34 Biomedical Research in Latin America system. All these services are narrowly defined by law and subject to strict administrative and economic controls. Social security is financed by direct contributions from employers, workers, and Government. These three groups keep a sharp eye on the use of social security funds, and administrators must report to their sponsors periodically, as well as upon request, how they spend their money. Accordingly, administrators of social security systems are par- ticularly careful with their expenditures and investments. The governing boards of these institutions, where all three groups are represented, have the authority to use some of the money for activities that are not specifically defined by law, such as scientific research. Social security administrators must present a good case, well founded and with cogent arguments, showing why results of the research are bound to produce an increase in the quality of services if governing boards are to be persuaded to support research. Rarely are these arguments convincing. The scientific know-how and the investigative function of a university can join productively with the financial resources of the social security system. The result of this symbiosis can be creation of the necessary conditions for establishing a program of biomedical research and a plan for producing in- vestigators, with obvious advantages to both institutions. Unfortunately, this cooperation is rarely found. However, as was mentioned earlier, the one out- standing example is the Mexican Institute of Social Security, whose coopera- tion with the National Autonomous University of Mexico supplies an excellent model for definition of common objectives and coordination of resources. Because of the outstanding nature of their program, and in the hope that thoughtful officials in other countries may be stimulated by the example of Mexico, the medical research program of that country under the social security system will be discussed here in some detail. The Mexican Institute of Social Security History. The Mexican Institute of Social Security (IMSS) set up a department of clinical research in 1966. Its main purpose was to elevate the quality of clinical studies undertaken by individual physicians on their own initiative. This department was enlarged, beginning in 1975, by the addition of a sub- division for research responsible to the Training and Research Services Admin- istration under the direct supervision of the IMSS general subdirector for medicine. Structure. The subdivision for research comprises the department of ex- perimental medicine, the department of clinical research, and the department of public health research (see figure 1). Furthermore, there is the scientific research council, the technical support group, and the office for project control and evaluation. The department of experimental medicine research is decen- tralized and performs its functions in a research unit at the large Cuauhtemoc 1 Training and Research Services Administration 1 1 Subdivision for Research Office for Project Control lo and Evaluation IMSS Scientific Research Council Subdivision for Training 1 1 Department of Experimental Medicine Research Department of Public Health Research Department of Clinical Research Technical Support Group ——, tT Research Unit of National Research Center Western Biomedical Research Unit! Monterrey Lab for Biomedical Research Mérida Biomedical Research Unit 1 Under construction. projected. Figure 1. Organization of the Mexican Institute of Social Security for Training and Research. OARIg " OPAIJ[V S€ 36 Biomedical Research in Latin America National Medical Center in Mexico City. This organization is large and complex (figure 2). It is the entity shown at the lower left of the preceding organization chart as Research Unit of National Research Center. The Western Biomedical Research Unit is currently under construction in Guadalajara. It will be dedi- cated primarily to the study of reproductive biology and hematology, and will be second in size only to the one located in Mexico City. The department of clinical research consists of a laboratory of biomedical research in Monterrey, dedicated primarily to toxicological and pharmacolog- ical studies (saturnism is particularly frequent in the area). A unit of bio- medical research is presently under construction in Mérida. The scientific research council, part of the subdivision for research, is composed of the heads of major departments, laboratories, and units. This council deals with matters requiring scientific judgments that affect all parts of the organization. For example, the council must approve all projects that are financed by IMSS or involve the use of its facilities. In effect, the council has the authority to shape the research program and direction of the total undertaking. While the most significant decisions have direct bearing on the work of the research staff, some decisions have international implications. For example, many U.S. investigators have asked for permission to perform studies in Mexico, particularly pharmacological studies involving therapeutic trials. The council also maintains the National Registry of Scientific Research Projects, which identifies projects of similar nature in an effort to avoid useless duplication. In accordance with the decentralization guidelines used through- out IMSS, local research committees work in close cooperation with the council and an ethics committee. Size and cost. About 100 full-time professional personnel are involved in biomedical research and the number is increasing (table 1). Of these, 75 have an M.D. degree and about 25 have a Ph. D. degree in one of the bio- medical sciences. A few staff members have an advanced degree in the social sciences. There is almost one technical and support person for every profes- sional; and the staff is well trained, experienced, and productive. The laboratories are in modern buildings and are fully equipped. As noted above, new facilities are being constructed in Guadalajara and Mérida. TABLE 1. IMSS Staff Involved in Biomedical Research Projects, 1975 Professional personnel 10S Technical personnel 67 Support personnel 16 Fellows 11 Total 199 CNM Scientific Research Unit Reproduction Biomathematics Biochemistry Experimental Experimental Neurophysiology Pathology Psychiatric Biology Division Division Surgery and Clinical Division Division Division Division Division Pharmacology Division Sections Sections Sections Sections Bi b Sections Sections a. | | Laboratories Support Cell biology Electro- Steroid Biotherapy Experimental Psycho- Groups i i i Operatin, atholo; harmacolo Molecular computing biosynthesis P 2 p 34 . p! zy Nutrition Personnel biology Experimental Organic rooms Plectron Dag 4 biology administration . . 3 microsc ependence Biochemistry of design and chemistry Foseops and toxicity Bromatoly Accounting eproducti biostatistics i a reproduction Mechaniiin oF Neurobiology Purchasing, Clinical Neuroendo- hormonal Neuropathology storage, and Genetics stinology action Histochemistry inventory Protein Audiovisual Medicinal Immunology MlesHe ans and machine hormones chemistry lab. Medical ie museography Documentation center Figure 2. Organization of the Research Unit of the Cuauhtemoc National Medical Center of IMSS. OARI{ “TT OpPaIJTY LE 38 Biomedical Research in Latin America The research program is well financed. Salaries are such that they attract and retain not only high-quality professionals but the most competent tech- nicians and support personnel. Space and equipment are more than adequate, and patients are available for clinical research. Although there is a defined research program, senior investigators are free to follow productive research leads. How much this costs is difficult to say because in many respects the re- search program is interwoven with the total medical program. The net cost added to the budget by the biomedical research effort—salaries for full-time staff plus money for supplies and equipment—might approximate $25,000 per year per professional, or $2.5 million in all. The total cost of the program, including costs of clinical research absorbed by the hospitals of the system and contributed services by other professionals, could easily reach three to four times that amount, i.e., $7.5 to $10 million. Program. The IMSS research program is directed at major health problems through heavy emphasis upon basic biological phenomena (appendix). For example, much research focuses on the population problem, which is ap- proached through studies in molecular biology, cell biology, biochemistry, genetics, neuroendocrinology, hormones, and steroids that relate to the re- productive process. A substantial proportion of research is concerned with basic phenomena and processes equally relevant to chronic and communicable diseases. Much effort is devoted to public health programs and problems. For ex- ample, the molecular biology section is evaluating the family planning program of IMSS. The drug dependency and toxicology section is conducting clinical toxicological studies. The entire effort of the department of public health research is devoted to work indicated by its title. Investigations include epidemiological studies on environmental hazards, population dynamics, venereal diseases, malnutri- tional diseases and salmonellosis, and violence as it relates to health. Although the list of projects in progress shows current lines of emphasis, actual results from prior research can be shown better by examining publi- cations. The record for 1975 is a useful, though limited, guide to past concen- trations of effort (table 2). There were 65 publications, a substantial output. Of this total, 48 percent were in genetics and biochemistry of reproduction, and 29 percent were in immunology and neurophysiology. All other fields combined accounted for only 23 percent of the publications. Both the publications and the list of research projects indicate that much of the research is directly relevant to disease problems, and a substantial portion is high-quality basic biomedical research aimed at extension of knowledge of fundamental biological processes. How is this concentration justified in a Alfredo L. Bravo 39 TABLE 2. Publications of IMSS Biomedical Research Staff 1975. Research Areas Number Percentage Genetics 18 28 Biochemistry of reproduction 13 20 Immunology 10 15 Neurophysiology 9 14 Steroid biosynthesis 5 8 Protein hormones and mechanisms of hormonal action 7 10 Biology of nutrition 3 5 Total 65 100 country that faces urgent communicable disease problems, high infant mor- tality in some areas, and intensive nutritional difficulties? The answer is threefold. First, Mexico is a country with a large, diversified, and advanced scientific structure. Without basic biomedical research aimed at international quality, the endeavor would be seriously deficient. The IMSS program represents a national effort toward fulfillment of that goal. Second, the biomedical research program of IMSS exists in the context of a worldwide network of laboratories, all of which are devoted to health prob- lems of countries that have large groups of very poor citizens. Within the narrower context of PAHO-supported research in Latin America there is a comprehensive program devoted almost entirely to communicable and para- sitic diseases, as well as to nutrition (see chapter 3). Third, IMSS is part of a large national biomedical research effort. In Mexico City there are other research institutes of outstanding reputation. These include the National Institute of Science and Technology, which contains a world-famous laboratory for the study of the nutritional status of children, and equally outstanding institutes of cardiology and nutrition. There is also an institute for communicable diseases under the Ministry of Health. These laboratories concentrate on the fields suggested by their names, so no need exists for the IMSS program to replicate their efforts. Training activities. The biomedical research program of the IMSS encom- passes a variety of high-quality training programs, for example, the program for training to a master’s degree and to a doctorate in scientific research. Since the fellowships available from IMSS for this purpose are in great demand, the training program no doubt will attract some of the most talented medical school graduates. Training is achieved via a research residency. So far, no rotating research internship is available, although there is hope of establishing one in the near future. It would consist of 3 months of biomathematics and 3 40 Biomedical Research in Latin America months of biochemistry as a common requirement for all master’s degree candidates. Furthermore, there is the possibility that a program will be es- tablished for the training of clinical investigators, one that would be open to physicians who desire to establish themselves in any of the clinical specialties as well as to others seeking specific clinical training. Training would consist of the following stages: (1) pre-degree, comprising research assistant I and research assistant II; and (2) postgraduate, comprising rotating internship and research residency (1 to 3 years, depending on the specialty). Summary. All things considered, the IMSS biomedical research program is one of the largest, most fully developed, most advanced, best housed and equipped, best staffed, and most productive single biomedical research pro- grams in Latin America. On the other hand, some smaller research laboratories surpass the IMSS effort in their more narrowly defined areas of interest. These are described in the chapters dealing with research in specific disciplines and on specific diseases. Relations Among National and International Institutions In those countries with substantial biomedical research efforts, there is typi- cally a complex web of interrelationships among a number of types of insti- tutions that conduct research. The primary agencies are national research councils, ministries of health, social security agencies, academies of medicine, universities, industrial laboratories, research institutes, and private foundations. The role of government is most significant in all of these interrelationships. Governments provide underlying support for universities, e.g., space, salaries of professors, and basic operating expenses. Governments typically fund national research councils and influence their priorities. International lab- oratories are financed by governments, as are international organizations, of which PAHO is by far the most significant (see chapter 3). In addition, govern- ments support specialized institutions of various kinds. National Research Councils During the past few years, most of the countries in Latin America have estab- lished national councils for scientific and technical research (better known under the acronym CONICYT) that have been largely responsible for the advancement of science. They have proved to be a formidable instrument for promoting activities and channeling funds required by scientific research in general and biomedical research in particular. National research councils have two primary functions: (1) formulation of national science policy and pri- orities, and (2) support of research by grant or contract and by advanced training. The research support function places them in close contact with Alfredo L. Bravo 41 universities and other laboratories. Biomedical research is typically only one area of concern to national research councils, but it is an important one. Universities The traditional function of universities has been, and continues to be, directed toward development of professionals, training of specialists, continuing ed- ucation, and scientific research, including training of investigators. In contrast with ministries and social security systems, where research is a secondary activity, research in universities is a basic function; accordingly, universities are in a good position to justify expenditures and request additional funds for this purpose. The most significant sites for biomedical research within universities are medical schools, schools of public health, and engineering schools (particularly departments of bioengineering). Some university departments in the basic sciences, such as departments of biochemistry outside the medical school, conduct important biomedical research. Universities absorb rather than generate funds for research, and lines of emphasis are strongly influenced by the priorities of those who provide funds specifically for research, i.e., national research councils, national ministries, international organizations, private foundations, and foreign governments. Universities are unique in the scale on which they combine research and advanced training. They are virtually the sole source of scientists and engineers. Other institutions, such as research institutes, often provide highly specialized training but the universities are the major agents for supplying M.D.’s and Ph. D.’s trained in clinical and basic biomedical research. International Organizations Various international organizations, especially the Pan American Health Organization (PAHO or, as it is known in Spanish, OPS), promote and cata- lyze activities in the field of biomedical research (see chapter 3). The Pan American Health Organization has not only promoted orientation and administrative improvements in the health area, but has also created, expanded, and developed 27 Pan American centers and institutes of research covering a variety of scientific, technological, ecological, and modern adminis- trative fields. Furthermore, PAHO plays a vital role in the planning and exe- cution of biomedical research projects performed by these centers and insti- tutes and even administers them at times with financial support from the countries involved. This association between Latin American countries and PAHO has proved to be most effective. Research efforts have yielded some excellent results, and native investigators have been given the opportunity to 42 Biomedical Research in Latin America work on problems affecting their own countries, within their own borders, under satisfactory professional and economic conditions. Financially, the association has been highly useful for expediting the channeling of public funds necessary for research, a task that cannot be readily accomplished by the respective ministries themselves, because of the rigid limitations of their functions. One of the major problems facing biomedical research in Latin America has been poor communication within the region. Generally, communication between Latin America and the United States and Europe has been better than that between Latin American countries. This has been particularly harm- ful because of the small scale and relative isolation of many laboratories. For biomedical research to prosper in Latin American and Caribbean countries, an essential factor is establishment of an efficient information and communication system between scientists and investigators in this area and other research centers in the United States, Europe, Asia, and other con- tinents. This function is currently being performed very efficiently by the Regional Library of Medicine (BIREME), in Sao Paulo, Brazil, a combined venture of the medical school of the Universidad Paulista; the National Library of Medicine, located in the United States; and the Pan American Health Organi- zation. BIREME was created for the purpose of developing a center of sci- entific communication, which would make available to health personnel and investigators in Latin America an extensive collection of biomedical publica- tions and documentation. This requirement has been fulfilled, and today the library is in a position to organize courses for librarians as well as international conferences and seminars for biomedical information. The library is connected to the MEDLINE system for rapid search and retrieval of bibliographic material and is also equipped with an audiovisual center [3]. During the past few years, a series of symposia and special meetings has been held for the purpose of improving communications between biomedical scientists, especially between researchers. Some of these meetings have been sponsored by PAHO, while others have been held under the sponsorship of foreign institutions such as the Wellcome Trust and the Medical Research Council of the United Kingdom, the U.S. Army Medical Research Command, and the U.S. National Institutes of Health. Furthermore, BIREME has a permanent scientific evaluation committee that meets periodically upon the request of the director. BIREME furnishes an excellent example of international coordination and cooperation: a large North American medical agency, the National Library of Medicine, has joined forces with a prestigious Latin American university, the Paulista Medical School, under the sponsorship of the Pan American Health Organization, to create and manage a new large center. This event has resulted in an extraordinary improvement in the dissemination of information required Alfredo L. Bravo 43 to promote the development of biomedical research in Latin America and in the Caribbean. Furthermore, the Regional Library of Medicine is also being used to train specialists in biomedical communications. References 1. Pan American Health Organization. Meeting of the Ministers of Health Study Group. Official Document No. 51, December 1963. 2. Pan American Health Organization. Ten Year Health Plan for Americas. Official Docu- ment No. 118, January 1973. 3. Pan American Health Organization. Annual Report of the Director. Official Document No. 136, August 1975. Appendix Current Basic Research Topics in IMSS Molecular Biology Section Kinetic study of the enzymes participating in the Krebs cycle of the ejaculated human spermatozoon Biochemical characterization of the human endometrial estrogen receptor Steroid biosynthesis in endocrine and paraendocrine tissues Study of a new menstruation inducer Estrogen receptors in target organs Evaluation of the IMSS family planning program Cell Biology Section Mucopolysaccharide production kinetics in murine and human fibroblasts Study of cellular synchronism in vitro and in vivo Effect of gonadal steroids at the cell level In vitro study of new antileukemia drugs Reproduction Biochemistry Section Identification of macromolecular spermatozoid components by column chromatography and electrophoresis Macromolecular metabolism of the normal endometrium under various pathological and experimental conditions Participation of the ions, hormones, and secretions of the female genital tract in the “capability” process of the human spermatozoon Biochemical composition of the endometrium Mechanisms of metabolic regulation in the spermatozoon Membrane structure and function of the spermatozoon Intrauterine denutrition 44 Biomedical Research in Latin America Clinical Research Section Gonadal endocrinology in man, under normal and pathological conditions Hormone concentration in the tissues of the reproduction system Prostaglandin, blood, and tissue levels—effects on the reproductive organs Mechanism of action of hormonal contraceptives and intrauterine devices Study of uterine and tubal contractility Biochemistry of human gonads, uterus, and tubes Histology and biochemistry of adnexal organs Sterility and infertility in the woman and in the man Genetics Section Chromosomal instability in newborns under phototherapy Endocrinological studies in gonadal dysgenesis Pituitary hormone bank Extraction and purification of human calcitonin Extraction and purification of gonadotropin from the serum of the pregnant mare (PMSG) Gel acrylamide electrophoretic serum protein patterns in normal individuals and in cancer patients Gel acrylamide electrophoretic protein patterns in umbilical cord serum and in maternal serum Circadian rhythms of serum proteins in normal women and in women with benign and malignant diseases of the breast, studied by discontinuous electrophoresis Fetal hemoglobin in normal individuals and in patients affected by benign malignant diseases Steroid Biosynthesis Section Study of steroid sulfatase and the role of sulfate steroids in endocrine tissue Enzyme kinetics in the biosynthesis of steroid hormones in normal endocrine tissues and during distinct experimental conditions Participation of cytochrome P-450 in steroid metabolism Organic Chemistry Section Synthesis of antigens and generation of antibodies Synthesis of 6-beta-hydroxyprogesterone hemisuccinate Synthesis of 4-hydroxyandrostendione hemisuccinate Synthesis of 19-hydroxyprogesterone hemiterephthalate Synthesis of 2-hydroxymethylene-testosterone 2-hemisuccinate Synthesis of 19-hydroxymethyl-androstendione 19-hemisuccinate Caryotype-phenotype correlations Clinical definition of genetic diseases Congenital metabolic errors Genetic aspects of abortion Plasma glycoproteins in human pathology Longitudinal studies of twins Growth and development of Turner’s syndrome under hormone therapy Alpha-fetoprotein in human pregnancy Alfredo L. Bravo 45 Neuroendocrinology Section Effect of hormones on central nervous system Nervous regulation of oxytocin and prolactin secretion Effect of oral contraceptives on the sexual and social behavior of primates Hormone Section Body growth and growth hormone Normal and pathological mechanisms of insulin secretion Body composition, energy metabolism, and hormonal adaption in infantile protein- caloric denutrition Hormonal patterns in childhood and in adolescence Determination of pituitary gonadotropins in human plasma during the study of sterility and infertility Studies of the effect of gonadotropins in the membrane structures of mammalian gonads Distribution and isolation of various cell types in the rat testicle Hormonal Mechanisms of Action Section Steroid-protein interaction mechanism Levels of steroids in the plasma and in tissues Medicinal Chemistry Laboratory Synthesis of pharmacologically active compounds Isolation and structure of the active principles in natural products Division of Experimental Surgery Selective methods for the breeding of mice, rats, and hamsters Clinical applications of silicones and similar materials Experimental amebiasis Division of Experimental and Clinical Pharmacology Motility and excitability of the human spermatozoon Excitability and contractility of the uterine muscle Electrolytic metabolism Drug toxicology Laboratory of Biomembranes Biomembranes and cancer Changes of tumor-specific antigens and antibodies Cancer serodiagnosis 46 Biomedical Research in Latin America Division of Neurophysiology Quantitative methods for neurological and psychiatric diagnosis: EEG, EMC, nerve con- duction velocity, spinal monosynaptic reflex, analysis of EEG frequency, provoked cortical potentials, deep cerebral tracings, and stereotaxic surgery Neurohumoral mechanisms in the regulation of sleep (cerebrospinal fluid and topoperfusion) Epilepsy Pain and physiology of the frontal lobe Auditory and vestibular physiology Experimental Pathology Section The chromosomes in neoplasia Biology of trophoblastic tumor Gynecologic pathology subsequent to the use of contraceptives Electron Microscopy Section Effects of contraceptive methods on the ultrastructure of the female genital organs Effect of drugs on cytoplasmatic organelles at various levels of cellular organization Pathology and physiology of the digestive tract Cell biology of Entamoeba histolytica Reproduction biology —male genital organs Host-parasite relationship Neurological Section Morphophysiology of the central nervous system—ultrastructure and neurochemistry Development of the central nervous system—ultrastructure and neurochemistry Neuropathology Section Frequency of neurological diseases in the autopsy material at the National Medical Center Cerebral cysticercosis: morphological characteristics of the host parasite reaction, frequency and mortality Frequency and characteristics of gliomas in autopsy material Frequency and characteristics of cerebral hemorrhage associated with arterial hyper- tension Histochemistry Section Phagocytosis Investigation of the protease-antiprotease equilibrium Cyclic-AMP Cyto-localization of enzymes Histochemical diagnosis of diseases Immunology Section Histocompatibility in transplants and tumors Phagocytosis Alfredo L. Bravo 47 Psychopharmacology Section Model of amphetamine psychosis for determining the possible etiology of human psychosis Biological availability of drugs Cerebral and behavioral effects of marihuana from various areas of the country Development and evaluation of methods for the quantitative determination of various drugs and metabolites in biological fluids Behavioral and emotional changes in the Mexican child Evaluation of the therapeutic effectiveness of psychotropic drugs Drug Dependency and Toxicology Section Experimental drug dependency Clinical toxicology Laboratory of Nutrition Biology Participation of transfer ribonucleic acids and of aminoacyl-tRNA synthetases in the regulation of protein biosynthesis Effect of various environmental factors on the specific growth rate and the protein pattern of the alga cianoficea spirulina maxima Regulation of glycoprotein biosynthesis in various experimental and pathological conditions Department of Public Health Research Information systems Registry and epidemiology of neoplasias Epidemiological studies on environmental hazards Population dynamics fertility and fertility restrictions Epidemiology of venereal diseases Diagnosis of the health-disease state Epidemiology of.nutrition disorders Epidemiology of salmonellosis Violence as a health problem SUPPORT BY MULTINATIONAL AGENCIES Charles V. Kidd Introduction Because of the decline in funds provided directly by the governments of de- veloped countries (primarily the United States) and by private sources (pri- marily U.S. foundations) for biomedical research in Latin America, the nations of the region have become more heavily dependent upon their own efforts. However, many aspects of biomedical research can be developed effectively only through outside assistance, and multinational agencies seem destined to play a progressively more important role in meeting these needs. A number of international agencies have supported biomedical research directly or indirectly in Latin America. By far the most important of these is the Pan American Health Organization (PAHO), and a description of its pro- gram forms the bulk of this chapter. Other agencies, however, also play a significant role, and will be mentioned briefly. World Health Organization The World Health Organization (WHO), of which PAHO is the agent for the Western Hemisphere, 1 directly supports some research in Latin America, but the major portion of the research support comes through contributions to PAHO. In 1977, for example, funds from WHO amounted to $22 million, or 31 percent of PAHO’s $70 million obligations [1, p. 192]. Only a small fraction of this amount was ultimately spent for research. In the future, one of the most significant relationships between WHO and PAHO will be the WHO- UNDP Special Program for Research and Training in Tropical Diseases, which PAHO has an illustrious history extending back decades before WHO was established. The sense of independent identity, strong morale, and close identification with the govern- ments and health workers of the region has at times made the relationship with the um- brella organization somewhat uneasy. 49 50 Biomedical Research in Latin America originated in deliberations of the WHO Advisory Committee on Medical Research in 1974, 1975, and 1976. The committee recognized that there have been tremendous advances in biomedicine leading to sophisticated treatment of many hitherto incurable diseases, but that no new vaccines or drugs for pre- vention and treatment of tropical diseases have appeared over the past three decades [2, p. 17]. What of the tropical diseases that are, as they have always been, a major plague of humanity? Here the natural lag between discovery and application has been prolonged and continuing. The broad base of knowledge available has not yet been exploited for a concerted attack against the tropical dis- eases. They have benefited, of course, from some of the “fallout” of re- search. But in relation to the number of people they affect and their impact, they have been grossly neglected. The late Professor Jacques Monod, a Nobel Prize winner in molecular biology, called this neglect “a disgrace.” A mere pittance of money and effort goes towards tropical disease research. Total worldwide annual expenditures devoted to research on all tropical diseases is about US $30 million, the cost of building a few miles of motorway. The World Health Assembly accepted this line of argument? and estab- lished a special unit to develop a specific program. The UNDP collaborates by giving financial assistance, through initiation and management of the tropical diseases research funds, and by logistical support. The program will concen- trate at first on malaria, schistosomiasis, filariasis (including onchocerciasis), trypanosomiasis (initially including African sleeping sickness and later South American Chagas’ disease), leprosy, and leishmaniasis. All these diseases are major causes of illness and death in Latin America, and research on all of them—as noted elsewhere in this chapter—is being conducted on a small scale in Latin America. Emphasis will be placed first on Africa, and a center has been established by the Government of Zambia. Sophisticated guidelines that augur well for the success of the program have been developed. The approach will stress development of any practical tool needed to solve the problems of the selected diseases—drugs, vaccines, biological control of reactors, and diagnostic methods, especially immuno- diagnosis. However, the full range of relevant disciplines will be brought to bear: fundamental biological sciences such as immunology, cell biology, and biochemistry; epidemiology; operations research: nutrition; economics; and anthropology. Specific lines of attack will be selected by scientific working groups, thereby placing major questions of scientific strategy in capable hands. The program will encompass a global training scheme in recognition of the importance of expanding the pool of competent people, and it may involve strengthening World Health Assembly Resolution WHA29.71, 1976. Charles V. Kidd 51 selected institutions. As far as possible, existing institutions will be used. Also contemplated is widespread collaboration between laboratories in de- veloped countries, where much of the required basic research is carried on and advanced technology on a large scale is available, and the developing countries, where tropical diseases can be studied in their widely varying natural environ- ments. Finally, the program will be well funded, primarily through special contributions by governments, agencies, and foundations, with additional funds from the regular budgets of WHO and UNDP. The initial yearly cost of the special program will be about $15 million to $20 million. The mag- nitude of this effort can be assessed by comparing it with existing worldwide expenditures of $30 million per year on tropical disease research and training, and with the $5 million annual expenditure on the total PAHO biomedical research program. The nature and extent of PAHO involvement with the program, which may develop into the single most important factor affecting biomedical research in Latin America, is being worked out. The PAHO Advisory Committee on Medical Research has noted the interest of the Latin American region in the research problems associated with Chagas’ disease. A scientific working group has been established under the tropical disease program to examine past and current research on Chagas’ disease and to draw up a strategy for an expanded program. The Organization of American States Since 1969, the Organization of American States (OAS) has funded and administered a program of research and development for the Latin American countries. Although it does not support research in biomedicine or clinical medicine, it does provide research grants and training. The Inter-American Development Bank The Inter-American Development Bank has been active in the health field primarily through extension of loans to assist with the design and construc- tion of water treatment facilities. It has also aided medical education, and indirectly, biomedical research, through provision of loans to finance the production of inexpensive medical tests. The United Nations Development Program The United Nations Development Program (UNDP) has financed an interesting and significant graduate program for research and training in the Andean area [3]. The countries involved are Bolivia, Colombia, Chile, Ecuador, Peru, 52 Biomedical Research in Latin America and Venezuela. The heart of the idea is to mobilize the scientists of the in- volved countries to accelerate scientific and technological developments in biology related to health, nutrition, agriculture, etc.; to promote study of biological problems related to development and human welfare; and to stimu- late integration of the efforts of universities in these fields. Cooperative re- search and training courses figure prominently in the effort. For the first 15 months of operation, UNDP provided $350,000 and the participating countries provided an estimated $340,000. UNESCO furnishes logistic support. The Pan American Health Organization Summary3 In 1961, through the initiative of the director, Dr. A. Horwitz, a modest program was inaugurated for aiding the investigation of problems related to the promotion of health and disease control. It is now the most extensive and influential multinational program of health-related research in the hemisphere. In 15 years, this program initiated 150 projects to which the Pan American Health Organization gave financial aid. During this period, PAHO identified relevant projects and sought financial support from national and international agencies and foundations. Approved projects ranged from basic research to clinical and epidemiological studies. Here an important role has fallen to the Medical Research Advisory Committee, consisting of outstanding professors and investigators from the Western Hemisphere. In the field of parasitic diseases, projects dealing with malaria and the problems that complicate the fight against this parasitosis have been approved: evaluation of new insecti- cides, research into resistance mechanisms of the South American Anopheles to insecticides, cytogenetic studies of species of South American Anopheles in order to identify the eventual association of various karyotypes with the capacity of each species to transmit plasmodia, studies of new species of larvivorous fish, investigation into pathogenic sources of mosquitoes, methods of protection for antimalarial precautions, and research into immunology and chemotherapy. In addition, the Universities of New York and New Mexico have continued their cooperation in the development of an antimalaria vaccine. The Pan American Health Organization has also lent its support to two WHO/ PASB centers for research and training in immunology, one at the Butantan Institute of Sdo Paulo, Brazil, and the other in Mexico City. Among the in- vestigations that have been carried out are studies concerning humoral and cellular immunity in Chagas’ disease and amebiasis. 3rhis section was contributed by Dr. Amador Neghme. Charles V. Kidd 53 In 1970 PAHO initiated a program to promote development of outstanding investigators in clinical research. The program was expanded in 1973 to sub- sidize projects designed to help resolve significant problems in Latin America and to encourage exchange of investigators from similar and related fields. The subsidies, although small, have averaged $5,000 and have demonstrated their positive effect by contributing to the financing of activities that could not receive funding from any other source. The total investment between 1973 and 1976 was $350,000 for 75 subsidies, some of which covered studies of parasitic diseases. Certainly this amount is insignificant and should at least be doubled to include research on parasitic diseases because of their importance to health, particularly in rural and suburban city areas. During the first 15 years of existence of the PAHO Advisory Committee for Medical Research, 216 technical reports and 31 scientific monographs were published. Of these, approximately 20 percent were related to parasitic diseases and their vectors, an important topic for researchers [4, 5]. PAHO should strengthen and expand its publications program to include additional reports and works produced in conferences, seminars, symposia, and study groups dealing with matters of interest to researchers in parasitoses; this should be done even though the meetings may not have been sponsored or organized for that reason. Nature and Scope of the Research Program The PAHO research program is designed to provide the knowledge needed to make operating programs (disease control, environmental health services, family health, health services, and human resources) more effective. It has a number of related segments. The first, and by far the largest, consists of the activities of research and training centers operated under PAHO/WHO auspices. Most of the total PAHO research investment is devoted to operation of these centers, which receive substantial additional support—considering the centers as a group—from national budgets and from other international agencies. A second, much smaller, part of the PAHO program consists of grants for research and research training to individual investigators and laboratories that are not administered by PAHO. As is true of research centers, PAHO is generally one of a number of sources of support. Projects vary widely in size. Some are large continuing studies, such as the important Longitudinal Study of the Effects of Malnutrition on Physical Growth and Mental Development, carried on by INCAP staff members with extensive international collaboration. Others represent small fractions of the time of individual investigators over the course of a year. For example, 48 projects on zoonoses are reported. All of them are carried on by the staff of the Pan American Zoonoses Center, and two staff members report work on seven projects apiece. PAHO’s total 54 Biomedical Research in Latin America current annual investment in research approximates $5 million. A few under- takings are on a large scale, but most research projects are understaffed and underfunded, so that investigations are sometimes undertaken on such a small scale that it is impossible to produce definitive findings. Unfortunately, this deficiency is inherent in underfunding. Another segment of the PAHO program consists of training activities, ranging from specialized instruction for laboratory technicians to Ph. D. training in advanced countries. In addition, the organization invests substan- tially in the dissemination of scientific information, an important part of any comprehensive research program. Finally, PAHO serves as an agent to stimu- late research that it does not finance. To provide a point for comparison, total PAHO expenditures for all purposes were $70 million in 1977. Of the regular PAHO budget of $29 million provided by the member states, research expenditures approximated $2 million.4 Although about 70 percent of these funds are from sources outside the Organization’s regular budget, PAHO plays an important catalytic function in securing this support and in identifying projects that can effectively use it [6,p. 2]. The scale of the PAHO regular budget annual investment of about $1.5 million for the entire region can be contrasted with the biomedical research investment of Mexico, which amounts to about $15 million per year, or to that of Brazil, which is of the same order of magnitude. It would be a serious mistake, however, to assess the PAHO effort solely in terms of the amount of money involved. Often small amounts of money suffice to energize research, although this fact should not be allowed to ob- scure the overriding importance of chronic underfunding of biomedical re- search in Latin America. Relatively small expenditures can bring investigators together, produce a consensus on research priorities, provide for scientific visits, and provide specialized training. Often the funds, expertise, initiative, and leadership provided by PAHO serve to attract additional funds. In other cases, leader- ship and funds from other sources affect PAHO priorities. In many respects support for biomedical research in Latin America is more complicated than support for biomedical research in developed countries. Not only must research itself (auxiliary personnel, equipment, supplies, field work, etc.) be supported, but the entire structure and environment within 4 vo ob . : . It is impossible to give an exact research expenditure figure because so much re- search is carried on as an integral part of operations. However, a precise figure is not needed to provide a valid perspective on the magnitude of the program as measured in money. Figures on the total PAHO budget are drawn from Report of the Director of PAHO, Quadrennial, 1974-77; Annual 1977, Washington, D.C., Official Document No. 158, August 1978, page 191. Charles V. Kidd 55 which research is carried out must be strengthened. This includes such meas- ures as improvement of health statistics, better access to scientific publi- cations, and standardization of reagent and laboratory procedures. Special attention must be paid to training people and establishing conditions that permit them to work effectively. All this must be accomplished in the face of sharp competition for funds, demands that the application of existing knowledge to urgent health problems take highest priority, and frequently lukewarm support from ministries of health. In response to these pressures, PAHO is forced to seek research funds from any available resource to supplement its own chronically tight budget. Na- tional governments, private foundations (mostly in the United States), private health associations, and international agencies have provided supplemental funds. This assistance has been essential to the growth of the PAHO biomedical research program. At the same time, heavy reliance upon these sources has a tendency to accentuate their de facto influence over PAHO’s research pri- orities. Over the years, the PAHO Advisory Committee on Medical Research has considered this problem, and its latest judgment was made in 1976 [6,p.4]: The criticism has sometimes been made that the PAHO research program lacks balance in its support of the different health problem areas and that some of the areas receiving support—such as nutrition—are relatively over- funded. It should be recalled, however, that in the absence of substantial, uncommitted, regularly budgeted PAHO research funds, the only way to have a significant program in these 15 years was to attempt to marry the research priorities of the Organization to those of granting agencies. This “match-making” effort has been rather successful, and the resulting program not too different from the ideal one PAHO would have, if it were to pay for it in full. Nonetheless, given adequate funds, more adequate support would certainly be provided for health care, virology, epidemiology, and selected chronic dis- eases of increasing importance. In fact, the advisory committee noted: “It was stressed that whereas previously there had been a strong emphasis on nutrition, there is now an additional need for operational research in several areas” [6,p.4].5 Organization Since the PAHO research program primarily supports the operating program of the organization, responsibility for the conduct of most of the research is lodged in the operating divisions. Data supplied by WHO indicate the following areas of particular research emphasis: nutrition, 38 percent; zoonoses, 13 percent; epidemiological surveillance, 11 percent; parasitic diseases, 8.6 percent. Research on all communicable diseases, all chronic dis- eases, statistics and information systems, environmental health, mental and dental health, nursing, and biostatistics absorbs under 3 percent of the PAHO budget. 56 Biomedical Research in Latin America Central staff. A small headquarters staff is responsible for the general research policies of the organization, provision of staff support, the Advisory Committee on Medical Research, liaison with other multinational organizations on research matters, arrangement of international scientific meetings, and assistance in fund raising. Centers. The site for most of the PAHO-sponsored research is the set of 12 centers operated by the organization. These centers report to the appropriate operating divisions. They are such an important element of the program that they are described individually in the following section. Advisory Committee on Medical Research. PAHO established the Advisory Committee on Medical Research in 1962. From its inception, this group has been composed of internationally recognized biomedical investigators from Latin America, North America, and Europe. In earlier years the group concen- trated on reviews of reports on research that PAHO helped support. More recently, the committee has broadened its scope to encompass a review of the research needs of Latin America, including suggested priorities and the role of PAHO in meeting these needs. The committee has recommended that emphasis be given to research on development of more effective and eco- nomical health services, improvement of nutrition, control of communicable diseases, and environmental health. Each of these fields has been examined in detail, and specific research areas of high priority have been identified. For example, in the area of nutrition the following fields were stressed: clinical and subclinical malnutrition and evaluation during pregnancy, nutrition and infection, nutritional anemias and iron and folic acid deficiencies, vitamin A deficiency, and endemic goiter and cretinism. To an increasing degree, the committee is becoming involved with evalu- ation of the research programs of the various centers operated by PAHO. One of the first activities was examination of the feasibility of collaborative nutrition research. The programs of the Institute of Nutrition for Central America and Panama, the Caribbean Food and Nutrition Institute, and the Latin American Center for Perinatology and Human Development were re- viewed to assess their capability to conduct collaborative research on the effects of nutritional anemia on the mother, fetus, infant, and child and to develop technologies for provision of adequate nutrition during the prenatal period. Apart from its technical responsibilities, the committee serves as a means of informing PAHO staff members of the capabilities of individuals and lab- oratories and of the problems faced by investigators in the region. Finally, the committee has been the primary agent for stressing the significance of research as a part of a total health program. Although the committee is advisory, PAHO staff pay careful attention to its recommendations. Charles V. Kidd 57 PAHO Centers Over the past 16 years, PAHO has established about a dozen specialized cen- ters for science, training, and research related to diseases and other health- threatening problems. PAHO centers have common characteristics. Their work is in fields where national efforts need supplementation. Investigation is concentrated on matters of interest to many or all countries in the region. Primary emphasis is placed on providing services, information, and education, and an environ- ment in which health-related research is focal. This approach, which is essen- tial to an effective disease control program, is difficult to establish and sustain in a university. Among the problems that the centers have in common is the fact that re- search that is not associated with universities often tends to diminish in terms of vitality and effectiveness as the staff ages. Sometimes the absence of stu- dents removes a stimulating element from the research environment. Generally, the problems that are the reason for the existence of centers are somewhat intractable and require a substantial proportion of route work. Furthermore, these factors sometimes generate financial difficulties. All in all, management of a set of disease-oriented centers poses complex administrative problems, but the record of PAHO in this respect is good. Institute of Nutrition of Central America and Panama. The Institute of Nutrition of Central America and Panama (INCAP), established and financed by the Central American countries and Panama, is devoted to overcoming the severe nutritional problems of the subregion. Its approaches encompass train- ing, demonstrations, education, development of new sources of protein, and development of dietary supplements (such as iodized salt for goiter and sugar fortified with iron for anemia and with vitamin A). The research program re- lates in substantial part to these activities. The INCAP research program is more extensive than that in any other PAHO center. The work of INCAP investigators in such fields as protein- calorie malnutrition and their longitudinal studies of the effects of malnu- trition on physical growth and mental development have added substantially to knowledge in these areas and have attracted international attention and support. The nutrition program is pieced together financially in a manner that typifies the entire PAHO research effort. Nutrition program projects are fi- nanced by the following organizations: World Health Organization (2); U.S. National Institutes of Health (6); Research Corporation (4); U.S. Agency for International Development (4); Research Corporation, International Devel- opment Research Center; NIH, INCAP, University of Chicago, Nutrition Foundation; Williams Waterman Research Foundation; Government of Gua- temala, Pan American Health and Education Foundation, W.K. Kellogg Foun- dation; Grant Foundation; and UK. Freedom from Hunger Campaign. Only 58 Biomedical Research in Latin America one of the projects is carried on by an investigator who is not a member of a PAHO center. The Caribbean Food and Nutrition Institute. The Caribbean Food and Nutrition Institute is one of the PAHO/WHO centers to promote technical cooperation among developing countries—in this case, the English-speaking countries of the Caribbean. The work of the center is strongly oriented toward solution of practical nutrition problems, e.g., diagnosis of the food and nu- trition status of population groups; establishment and strengthening of nu- trition programs and units; training of nutrition workers; and elevation of standards for diagnosis, prevention, and treatment of nutritional disorders. The unit performs practical operations research designed to make the health programs more effective. The Latin American Center for Perinatology and Human Development (Mantroedeo). This center has carried on a highly regarded research program for a number of years, encompassing both basic and applied research. It has done important work on reducing risks to mothers and infants during preg- nancy, at birth, and during the prenatal period. For example, in the area of basic research the center has studied new phospholipids found in the amni- otic fluid and their influence on pulmonary maturation of the fetus. In the area of applied research, the center has demonstrated that routine use of drugs such as oxytocics, analgesics, and anesthetics is costly and potentially dangerous. The center has disseminated these findings and has advocated strongly the view that these drugs should be used only under well-defined abnormal conditions. The Immunology Research and Training Centers (Sdo Paulo and Mexico City). Improved understanding of immunology is fundamental to diagnosis and treatment of communicable and many chronic diseases. However, Latin America has been poorly endowed with qualified immunologists and immuno- logical laboratories. PAHO decided to remedy these deficiencies by establishing two institutes for research and training in immunology —one in Sdo Paulo and one in Mexico City. The Sido Paulo center is active in teaching immunology at a number of Brazilian universities and in training graduate students at the center. It has been instrumental in studying the immunology of Chagas’ disease and in character- izing immunogenic fractions from rattlesnake venom and immunosuppressive mechanisms induced by certain parasites. The center in Mexico City also engages in training and research. It has agreements with 18 immunology university departments and research institute laboratories under which cooperative research and training take place. The center works actively with the immunology and immunochemistry department of the School of Biological Sciences of the National Polytechnic Institute, and with the School of Medicine of the National Autonomous University of Mexico. The research program covers virtually every field of immunology. Charles V. Kidd 59 The Pan American Center for Sanitary Engineering and Environmental Sciences.® The Pan American Center for Sanitary Engineering and Environ- mental Sciences (CEPIS), located in Lima, is an important institution for provision of technical assistance to the countries of the region on matters such as air and water pollution, industrial hygiene, water and sewage treatment, solid waste disposal, water analysis, and systems analysis. Assistance is pro- vided through consulting, collaborating in planning national projects, enlisting aid from numerous multinational agencies, drafting legislation and regulations, convening international conferences, organizing training courses at the center, advising on curricula in engineering schools, and disseminating technical and administrative information. The research program of the center backs up the technical program. More than 50 research projects, some very small, have been undertaken in such fields as efficacy of metallic coagulants, removal of arsenic from water, and operation of air pollution sampling equipment. The need for the center is intensified by the obstacles to effective research on environmental problems. Although there are a few notable exceptions, most environmental health research programs in the region exhibit common deficiencies—manpower shortages, research structures irrelevant to national development problems, insufficient funding and facilities, and inadequate access to and dissemi- nation of information [6, p. 16]. The Pan American Zoonoses Center. The Pan American Zoonoses Center (CEPANZO), located in Buenos Aires, has as its major mission the control of animal diseases that are important to man. These diseases include brucellosis, bovine tuberculosis, rabies, hydatidosis, salmonellosis, cysticercosis, leptospi- rosis, and anthrax. The primary activity of the center is provision of services— assisting countries in preparing, conducting, and evaluating zoonoses pre- vention, control, and eradication programs. The Pan American Foot-and-Mouth Disease Center. The Pan American Foot-and-Mouth Disease Center (PANAFTOSA), one of the few in the world for dealing with this potentially devastating disease, has just celebrated 25 6See chapter 5 for a fuller discussion of research in these fields in Latin America. "In contrast with work at the other PAHO centers, none of these projects are listed in Research in Progress, 1976. That volume lists nine research projects in environmental sciences and engineering. Four, supported by PAHO and the Swiss Government, are conducted at the University of San Carlos, Guatemala City; four are conducted with PAHO support at the University of Chile, Santiago. 60 Biomedical Research in Latin America years of productive work. Most of the effort of the laboratory is devoted to provision of technical and administrative assistance in the prevention, control, and eradication of foot-and-mouth disease. The center provides diagnostic services for the entire region. It conducts epidemiological surveys to determine where the disease is occurring. The personnel of the center train laboratory workers and coordinate intercountry agreements for border surveillance designed to stop the disease from spreading. All these control activities are backed up by a research program. Scientists at the center identify and type new virus strains, improve methods of concen- trating and purifying viruses, produce new vaccines, and conduct research required to improve vaccine production, distribution, and administration. The Caribbean Epidemiology Center. The Caribbean Epidemiology Center, established in 1975, is one of the newest PAHO centers. Its primary missions are to conduct surveillance of diseases in the area, to provide assistance in epidemics, and to furnish diagnostic services and training in parasitology and bacteriology. The research program buttressing service activities includes seroepidemiologic surveys and studies of rabies and leptospirosis, cardio- vascular diseases (with the support of the Medical Research Council of the United Kingdom), gastroenteritis in young children (with the support of the Government of Trinidad and Tobago and the International Development Research Center of Canada), and immunological problems of streptococcal disease (supported by Rockefeller University). The Pan American Center for Human Ecology and Health. This center was established in 1975 to conduct assessments of the effects of social and eco- nomic development activities on human health. Its goal is to analyze existing ecological threats to health, to project ecological and health consequences of developmental efforts, and to provide assistance to governments in designing, installing, and operating appropriate environmental control standards and strategies. At the moment, a research program is not planned. Since the staff will reach a level of only 9 persons and an annual projected budget of about $600,000 only after 5 years have elapsed, operational problems will consume the full resources of the center. Research and Reference Center for Vector Biology and Control. This center, established in 1976 in Maracay, Venezuela, has as its primary mission control of the vectors responsible for transmission of Chagas’ disease. This is an extremely complex biological-ecological problem because there are so many wild and domestic animals that carry the parasite responsible for the disease, and there are so many strains of the parasite. The work of the center encom- passes epidemiology, more precise determination of the natural history of the disease, studies of insecticides, and training activities. Charles V. Kidd 61 Research on Chronic Diseases® All noncontagious morbid conditions classified as noncommunicable chronic diseases exhibit at least one of the following characteristics: they are perma- nent, they induce irreversible pathological changes, they require specialized rehabilitation, they necessitate long periods of medical surveillance and atten- tion. This definition encompasses the various pathological conditions that follow genetic disorders, metabolic alterations, environmental contamination, and hazardous habits. It includes various cardiopathies, obesity, diabetes, chronic respiratory diseases, arterial hypertension, arteriosclerosis, neurological diseases, traumatic lesions, arthropathies, and malignant neoplasias. The varied nature of these diseases necessitates greatly different techniques for investiga- tion, diagnosis, treatment, prognosis, and epidemiology. Cardiovascular diseases, cancer, diabetes mellitus, and other chronic diseases have assumed great importance as causes of illness and death in the highly industrialized countries. In 1970, the European branch of the World Health Organization reviewed cardiovascular disease mortality in 28 European coun- tries. Percentage of deaths due to this condition in Yugoslavia was 29 for males and 35.6 for females, as compared to 52.4 and 58.1, respectively, for Sweden and Hungary. In Latin America, cardiovascular disease is acquiring greater significance because of the improved control of communicable diseases and increased life expectancy at birth, as well as cultural and environmental changes associated with growing urbanization and industrialization. Naturally, the impact exerted by these variables differs from country to country. As an example, diseases of the heart and arteries—together with other long-lasting diseases such as cancer, diabetes, neurological disorders, arterial hypertension, liver cirrhosis, and cholecystopathies—account for two-thirds of the total mortality of the population between the ages of 15 and 74 years in 10 large urban centers of Latin America. The percentage of deaths due to cardiovascular disease in 26 countries of the region varies from 2.9 to 43.8; for cancer the variation ranges from 2.1 to 21.5. Accordingly, it is quite evident that efforts to control this problem are encountered with increasing frequency in the health programs of various countries. Within the framework of their health ministries, Argentina, Brazil, Chile, Colombia, Cuba, Ecuador, Mexico, Peru, and Venezuela have already organized technical units dedicated to chronic noncommunicable diseases, and other countries in the region are organizing similar units, whose responsi- bility is to outline well-defined program policies and guidelines. 8 This section was contributed by Dr. Jorge Litnak. 62 Biomedical Research in Latin America In most of the countries in this area there are no available data regarding the prevalence and distribution of various conditions classified as chronic noncommunicable diseases. Consequently, all the current investigations have a common epidemiologic denominator intended to improve knowledge regarding the magnitude and characteristics of the problem. This is actually a basic step toward assigning priorities and planning rationally for future implementation of control programs by public health organizations, in order to reduce the incidence or alter the natural course of these diseases and improve services. The limited financial resources for investigational programs make rigorous selection of priorities mandatory. Not only is there little information regarding the epidemiology of chronic diseases in these countries, but the risk and cir- cumstantial factors involved in their pathogenesis and evolution in Latin Ame- ican populations are generally unknown. Therefore, studies must be performed in various countries on well-defined populations in order to evaluate the viability and effectiveness of control programs and to establish suitable tech- niques and procedures applicable to epidemiological studies. Furthermore, it is necessary to determine ways for developing adequate systems of informa- tion that will allow rational adaptation of available technology. At this stage in the development of programs for control of chronic diseases in Latin America, as a result of the heterogeneity in distribution and extent of the problem, epidemiological and operational investigations performed at the subregional level, i.e., between countries, are of great significance. The Pan American Health Organization has undertaken the promotion and coordi- nation of such investigations, with the participation of countries where these diseases have acquired increasing significance. The aim of PAHO is to demon- strate the feasibility and effectiveness of epidemiological studies and of pre- ventive and therapeutic measures, in hopes of expanding coverage at national and regional levels. Seven countries (Argentina, Bolivia, Brazil, Chile, Ecuador, Peru, and Venezuela) are participating in a cooperative study on the prevention of rheumatic fever, while 10 countries (Argentina, Barbados, Bolivia, Brazil, Colombia, Cuba, Chile, Ecuador, Peru, and Venezuela) are involved in a pilot study on the control of hypertension, using a common protocol compiled by PAHO. PAHO is also coordinating a study on diabetes mellitus, the Latin American Diabetes Plan (PLAD), with the participation of Argentina, Brazil, Colombia, Peru, the Dominican Republic, Uruguay, and Venezuela. The primary objective of this investigation is standardization of diagnostic tests for diabetes and the prevalent study methods in order to make possible comparable research. In addition, PAHO has established an information project regarding the investi- gation of cancer in Latin America (LACRIP), which is coordinated with the International Cancer Research Data Bank Program set up at the U.S. National Cancer Institute. Charles V. Kidd 63 LACRIP, which was established as a comprehensive information facility to provide an objective outlook regarding the study of cancer in Latin America, should improve communications among investigators and assist in identification of new areas of joint basic and clinical activities in the field of epidemiological investigations. During the first 6 months of operation of the project, summary reports from more than 120 current investigational projects were forwarded for inclusion in the CANCERLINE data base. Eight countries have been the most active participants in this project: Argentina, Brazil, Colombia, Costa Rica, Chile, Mexico, Peru, and Uruguay. Furthermore, the PAHO Regional Library of Medicine, with headquarters in Sao Paulo, is cur- rently screening more than 700 published Latin American articles for inclusion in CANCERLINE. Areas of Special Emphasis PAHO continues to identify areas requiring research, define research problems, suggest research approaches, identify qualified investigators and institutions in both developed and developing countries, and seek out sources of support. Over the years, discussions of the Advisory Committee on Medical Research have led to intensified research efforts in a number of fields, including immu- nology, epidemiology, perinatal studies, and genetics. The most recent effort to stimulate research has been in the field of health services [7, p. S]. A technique often used is to appoint a committee composed of outstanding experts in high-priority fields to study and report on actions required to strengthen research in a given area. Some of the fields in which this has been done are dengue, yellow fever, and Aedes aegypti, meningococcal disease (particularly cerebrospinal meningitis), Chagas’ disease, medical and human genetics, and the arboviruses. Typically, these reviews lead to identification of needed research and of qualified investigators, as well as efforts to secure funds for research. Scientific Communication Effective communication is one of the indispensable preconditions for the advancement of science. The entire structure of science rests upon exchange of knowledge and ideas among scientists, and those who are not in the main- stream of the flow of current information are badly handicapped. For this reason, Latin American scientists frequently cite isolation as a major obstacle to productivity. PAHO has attacked this problem in a number of ways. International scientific meetings. In recent years, PAHO has sponsored a number of scientific meetings on research areas important to the region: e International Symposium on Research and Control of Onchocerciasis (Washington, 1974) 64 Biomedical Research in Latin America ® International Symposium on Chagas’ Disease Research (Belo Horizonte, 1975) ® International Symposium on the Mycoses (Brasilia, 1977) ® Symposium of Biologicals (Mexico City, 1977) ® Laboratory Procedures in Mycology (San José, 1977) Scientific publications. PAHO has established its own highly regarded series of scientific publications and helps support scientific reports issued under other auspices. The papers and discussions at all international scientific meetings appear as high-quality monographs. For example, several publications on Chagas’ disease have been issued recently [4,89]. Development of national research policies. Communication in the bio- medical research field extends beyond technical matters to encompass such areas as development of national policies and structures for biomedical re- search. Here the Latin American countries have much to learn from each other. To facilitate exchange of experience on research policies and struc- tures, PAHO has initiated a series of meetings by groups of Latin American countries. The first of these, attended by representatives from Cuba, the Dominican Republic, Haiti, and Mexico, was held in November 1977. The topics discussed included definition of priorities, national structures for re- search, laboratory organization and management, evaluation of results, dif- fusion of findings, training of personnel, and financing of research. Similar meetings will be held until all countries have had an opportunity to exchange information and views. The Regional Library of Medicine and Health Sciences. The Regional Library of Medicine and Health Sciences (BIREME), located in Sio Paulo, has as its central mission the dissemination of information on medicine and biomedical sciences to schools and laboratories throughout the region. Without the advanced technology of BIREME—fast and cheap reproduction of printed material, use of the computer to file and retrieve information, facsimile trans- mission, and automated access to other computerized files—modern medical and biomedical research literature would be available to only a few schools and laboratories. The library is well launched on this ambitious undertaking. The growth of its services is summarized below. Service 1974 1977 Reprints provided 34,000 41,000 Bibliographies compiled 2,300 2,400 MEDLINE searches made 2,100 2,700 BIREME, financed by funds from a number of sources’ but with most Supported by PAHO, with the aid of funds provided by the Government of Brazil, the U.S. National Institutes of Health, and other nations. It is in Sido Paulo. Charles V. Kidd 65 of its current support provided by Brazil, is linked to the U.S. National Li- brary of Medicine and has access to the MEDLINE bibliographic system. In various Latin American countries today, many libraries suffer from re- ductions in their acquisitions budgets that force them to limit their subscrip- tions to scientific journals and reference works as well as current research documents. This complicates access to scientific information and discourages investigators who often unknowingly duplicate research because of inadequate bibliographic resources. The national centers of information and documenta- tion that have been developed in some countries have improved this situation, although they have not spread widely throughout Latin America. BIREME has received extraordinary contributions that have allowed some of these centers to reestablish programs of dissemination of scientific information concerning infectious and parasitic diseases. References 1. Pan American Health Organization. Annual Report of the Director, 1977. Washington, D.C.: PAHO, 1978. 2. World Health Organization. Tropical Diseases. Geneva: WHO, 1978. 3. Allende, J.E. Desarrollo de la Biologia en América Latina, Un Enfoque Regional. UNESCO Regional Office for Science and Technology in Latin America. 4. Pan American Health Organization. New Approaches in American Trypanosomiasis Research. Scientific Publication No. 318. Washington, D.C.: PAHO, 1976. 5. Pan American Health Organization. Onchocerciasis in the Western Hemisphere. Scien- tific Publication No. 298. Washington, D.C.: PAHO, 1975. 6. Pan American Health Organization. Advisory Committee on Medical Research. Report to the Director, 15th meeting, June 13-17, 1976. 7. Pan American Health Organization. Advisory Committee on Medical Research. Report to the Director, May 2-5, 1978. 8. Pan American Health Organization. Quantitatively Standardized Complement-Fixation Methods for Critical Examination of Antigens Prepared from Trypanosoma cruzi. Scientific Publication No. 319. Washington, D.C.: PAHO, 1976. 9. Pan American Health Organization. Chagas’ Disease. Scientific Publication No. 347. Washington, D.C.: PAHO, 1977. HEALTH MANPOWER MIGRATION IN THE AMERICAS Alfonso Mejia Introduction The international displacement of highly trained health manpower, and its potential for increasing the gap within and between nations as regards equity of access to health services, has been a constantly recurring theme in both na- tional and international discussions. Attempts to define the causes and con- sequences of this phenomenon have often led to vehement debate. In the major donor countries, some authorities persist in their preoccupation with the loss of needed talent; others wonder whether professional health per- sonnel could be absorbed if emigration suddenly ceased or if large numbers of such personnel were obliged to be repatriated; and still others are concerned about the relevance to their country’s needs of the kind of education provided locally or brought back by nationals schooled abroad. In the major recipient countries, many are fearful that a heavy dependence on foreign health man- power may lead to a lower standard of health care, while others claim that some care for all is better than no care for some; in addition, there are those who again deplore the loss to the donor country, while others feel there is no loss when the donor country cannot economically employ the health workers it produces. In view of the international community’s growing concern and numerous calls for action regarding brain drain! —of which the migration of professional For the sake of brevity, the term “Region” will be used to refer to all Central and South American countries. When reference is made to a particular part of the Region (geographical or linguistic), that part will be specifically designated, e.g., Central America, South America, Latin America (countries where the speaking language is either Spanish, Portuguese, or French), and West Indies (i.e., only the English-speaking countries, par- ticularly Barbados, Guyana, Jamaica, and Trinidad and Tobago). 1 Among the resolutions adopted to date on this subject are six by the United Nations General Assembly, three by the United Nations Economic and Social Council, three by the General Conference of UNESCO, and one by UNCTAD. 67 68 Biomedical Research in Latin America health workers is an important component —and at the request of its member states,” the World Health Organization (WHO) undertook a worldwide study analyzing the migration of physicians and nurses from the perspective of several types of country groupings, e.g., geographical, economic, and political. The following discussion is based on that study and addresses not only the dimension, directions, determinants, and consequences of health manpower migration as they pertain to Central and South America, but also the implica- tions of migration for the future. It must be noted from the outset that because there was no readily avail- able information on the movement of either physicians or nurses into the Region or between countries of the Region, only a partial picture emerged — that of movement to countries outside the Region. Thus, while it was possible to gage the gross loss to individual countries of the Region and to the Region as a whole, it was not possible to gage net loss—or net gain, which might be the case for a few of the more affluent countries of the Region. However, there is fairly sound evidence, which will be discussed below, to the effect that relatively few physicians who move to the United States from the Region return to their homelands. Dimensions and Directions Movement of Physicians In 1972, there were some 207,000 physicians in Central and South America. At the same time, about 12,000 physicians from the Region—almost exactly the number produced there in 1970—were found outside the Region. Of the latter, nearly 11,300—or 90 percent—were in the United States, where they represented about 17 percent of all foreign medical graduates (FMG’s) in that country at the time. Among the 11,300 were some 400 U.S.-born physicians (about 4 percent) who had received their training in the Region. Most of the remaining 1,300 physicians were in Canada and Europe [1]. Of the emigrant physicians from the Region, the largest numbers were from Cuba, Mexico, Argentina, and Colombia, which together accounted for nearly two-thirds of the total (table 1). In relation to domestic stock, the countries with the largest percentages abroad were Cuba (44 percent), the Dominican Republic (34 percent), and Haiti, which had more outside the country than inside. Countries with the lowest proportions abroad were Brazil, Uruguay, Venezuela, and Panama—each with 2 percent or less. As a whole, the Region lost about 6 percent of its stock of physicians: over 5 percent were lost to the United States alone. 2Resolutions WHA22.51, WHA24.59, and WHA 25.42. TABLE 1. Stock of Physicians in Central and South America, Estimated Number Abroad, and Estimated Number in United States, 1972 Physician Number Number in Percent Percent Stock Abroad us. Outside U.S. in U.S. Country A B C (B+ A) (C+ A) Argentina 49,900 1,734 1,536 3.5 3.1 Bolivia 2,143 199 188 9.3 8.8 Brazil 59,573 624 497 1.0 0.9 Chile 4,506(G) 340 257 1.3 $7 Colombia 10,317 1,246 1,161 12.1 113 Costa Rica 1,067 36 26 3.4 24 (1970) Cuba 7,000 3,060 2,999 43.7 42.8 (1968) Dominican Republic 2,220 752 722 339 32.5 Ecuador 2,292 193 183 8.4 8.0 El Salvador 952 181 128 19.0 13.4 Guatemala 1,208 152 135 12.6 11.1 (1971) Haiti 412 534 391 129.6 94.9 Honduras 689 65 65 9.4 9.4 (1973) Mexico 38,000 1,718 1,622(E) 4.5 4.3 Nicaragua 1,357 116 96 8.5 71 Panama 1,209 49 29 4.1 2.4 Paraguay 1,071 115 105 10.7 9.8 Peru 8,023 808 754 10.1 9.4 Uruguay 3,250(X) 96 66 3.0 2.0 Venezuela 11,222 275 222 2.5 2.0 West Indies 1,253 263 83 20.9 6.6 Total 207,664 12,556 11,265 6.1 54 G, in government service; X, coverage unknown; E, estimate. Figure for Mexico in column C does not include U.S.-born medical graduates. For a breakdown of West Indies data, see table S. Sources: Column A data from World Health Statistics Annual, 1972, Vol. 3, Geneva: World Health Organization, 1976. Column B data from unpublished World Health Organization document HMD/76.4. Column C data from Profile of Medical Practice, prepared by S. Vahovich and P. Ahemne, Chicago: AMA Center for Health Services Research and Development, 1973. BIO] OSUOJTV 69 70 Biomedical Research in Latin America Each year more than 100 physicians from the Region have entered Canada as immigrants—nearly half originating in the West Indies. Compared to the annual flow to the United States—over 900 in 1973—the flow to Canada is very small. Similarly, the flow to the United Kingdom is relatively small, i.e., about 40 new registrants annually (excluding those from the West Indies, who form a special group that will be described below) [17]. Changes over time. Annual flow from South America to the United States remained fairly steady until 1970 when the U.S. Government made it easier for FMG’s who had entered the country on temporary visas to become perm- anent immigrants. As a result, a number of those already in the country trans- ferred to permanent status. Additionally, there was an increase in the number entering with temporary visas, presumably with the hope of being granted permanent status later. The net effect was that the annual number of new entries of immigrant and nonimmigrant physicians from South America to the United States rose from about 600 in 1970 to 946 in 1973, or from 8 percent of the total number of physicians entering in 1970 to 12 percent of the total entering in 1973. Thus while the proportion from South America increased by 4 percent, that from Europe decreased by 5 percent, and that from Asia remained about the same, about 40 percent of the total [4]. There have also been changes in the countries from which the migrant physicians derive. Between the years 1956 and 1970, the biggest changes were (1) a considerable rise in the proportion of immigrant physicians from Colombia, Paraguay, and Uruguay; and (2) a considerable fall in the proportion from Brazil and Peru [5]. Regarding changes over time in the number of medical graduates from the Region as a whole, the number in the United States increased by about 3,500 between the years 1970-74, an increase of 36 percent during the 4-year period. While there was an increase from all countries of the Region, the biggest absolute increases appeared in the numbers from Mexico, Cuba, Argentina, and Colombia (table 2). Percentage increases were greatest for Costa Rica, the West Indies, Venezuela, and Chile, all of which exceeded 100 percent. It is noteworthy that while the total number increased by 18 percent between the years 1970-72, it increased by only 15 percent between the years 1972-74. The only countries for which the percentage increase was bigger for the years 1972-74 than for the previous 2 years were Guatemala, Mexico, and Panama. Mexico’s bigger increase may have been due to the large number of U.S. nationals among the medical graduates from Mexico. On the other hand, among countries where the percentage increase for the period 1972-74 was considerably smaller than the increase for the 2 previous years were Costa Rica (58 percent vs. 136 percent), Venezuela (34 percent vs. 67 percent), and Colombia (8 percent vs. 22 percent). Movement Within the Region. There is very nttle documented information on migration within the Region, although such movement is known to occur Alfonso Mejia 71 TABLE 2. Increase in Medical Graduates From Central and South America in the United States, 1970-74 Increase in Number (Percentage increase) Country 1970-72 1972-74 1970-74 Argentina 223 207 430 17) (13) 32) Bolivia 42 48 90 29) (26) (62) Brazil 120 122 242 32) (25) (64) Chile 81 106 187 (46) 41) (106) Colombia 209 90 299 22) (8) 31) Costa Rica 15 15 30 (136) (58) (272) Cuba 242 201 443 9) (7) (16) Dominican Republic 93 73 166 (15) (10) (26) Ecuador 36 16 52 (24) 9) (335) El Salvador 37 35 72 41) 27) (79) Guatemala 26 38 64 (24) (28) (59) Haiti 62 48 110 (19) 12) 33) Honduras 16 7 23 (33) (11) 47) Mexico 286 449 735 (16) (21) (40) Nicaragua 18 13 31 (23) (14) (40) Panama 6 11 17 (26) (38) (74) Paraguay 29 22 51 (38) 21) 67) Peru 136 96 232 (22) (13) (38) Uruguay 20 14 34 43) 1 (74) Venezuela 89 15 164 67) (34) (123) West Indies 37 39 76 (80) 47) (165) Total increase 1,823 1.725 3,548 Total percentage increase (18) (15) (36) Data include about 5 percent of graduates born in the United States. Sources: 1970 data from Profile of Medical Practice, prepared by S. Vahovich and P. Aherne, Chicago: AMA Center for Health Services Research and Development, 1973; 1972 data from J.N. Haug and B.C. Martin, Foreign Medical Graduates in the United States, 1970, Chicago, AMA, 1971; 1974 data from Profile of Medical Practice, 1976. 72 Biomedical Research in Latin America and may even be considerable. The following isolated items of information tend to confirm this notion: ® A health manpower study in Colombia [8] found that 21 percent of a sample of physicians surveyed had moved abroad—65 percent to the United States. The relationship of this proportion to the known number of Colombian physicians in the United States indicates that in the early 1970’ a total of 1,800 Colombian physicians (equivalent to 17 percent of domestic stock) were abroad, 625 of them in countries other than the United States. Aside from the few in Canada and the United Kingdom, the whereabouts of the remainder—about 550, or half the number in the United States—is unknown. Presumably they are in other countries of the Region. ® A study of Ecuadorian physicians who graduated between 1961 and 1970 [9] showed that 136 were abroad in 1973, 35 percent in the United States and 55 percent in other countries of the Region (Colombia 27 percent, Mexico 15 percent, Venezuela 9 percent, and elsewhere 4 percent). ® Two studies [10, 11] show considerable numbers of Paraguayan phy- sicians in other countries of the Region—228 in Argentina in 1970, 60 in Uruguay in 1967, and 19 in Brazil in 1970—four times the number of Para- guayan physicians in the United States in 1970. The biggest information gap regarding the movement of physicians within the Region concerns its richest country, Venezuela, which is known to attract considerable numbers of other types of manpower and presumably physicians as well. Movement Into the Region. What little documented information there is indicates that there were 17 foreign physicians in Costa Rica in 1970 and 37 in Honduras in 1973 [12]. Whether or not they were from outside the Region was not indicated. A study in Colombia [13] found that 3 percent of the physicians in Colombia in 1965 were foreign-born. Relating this percentage to 1972 stock leads to an estimate of some 310 foreign-born physicians in Colombia that year. It was also reported [14] that 356 foreign professionals worked in the field of “medical sciences” in Colombia during the period 1959-68. Of these, 190—or 53 percent—came from within the Region and the remainder from outside, 113—or 32 percent—from Europe, 43—or 12 percent— from the United States, 9 from Asia, and 1 from Africa. Movement of Medical Students With regard to medical students from the Region, there is considerable move- ment both within and outside the Region. The importance of such movement lies in the fact that these individuals constitute a high-risk group for permanent emigration once they graduate. The education brought back by returning graduates may be irrelevant to the priority needs of their country (although, in some cases, not necessarily less relevant than the education they would Alfonso Mejia 73 have received had they studied in their homeland). Although no information is available as to what proportions of those medical students who study abroad remain there, it is important to be aware of the size of the movement and its implications for permanent emigration and thus for health manpower planning and development. In many countries of Africa, for example, the problem is not so much one of losing locally trained physicians as it is of not regaining those nationals who obtained medical education outside the country. It would be desirable to investigate the extent to which this is true in Central and South America. Two studies have been carried out in recent years on the movement of medical students. One, by the United Nations Educational, Scientific, and Cultural Organization (UNESCO), [15] relates to the academic year 1972-73 and covers the whole world. The second [16] relates to the academic year 1971-72 and, while it concerns only the Americas, has better coverage of medical schools in Central and South America. The data presented in table 3, which refer to undergraduate medical education, are based on both sources and show that 7.366 students from the Region were enrolled as undergraduates in medical schools in countries other than their own—61 percent of them in schools within the Region, 36 percent in Europe, and only 2 percent in the United States. Conversely, in the academic year 1971-72 there were 9,000 foreign medical students in the Region’s schools, of whom 2,000—or 22 percent—were U.S. citizens and nearly 5,000 came from other countries of the Region [16]. The main host to students of other countries of the Region is Argentina—not Mexico, where the number of foreign students is larger, but most are citizens of the United States (table 4). Whereas in Mexico only 41 percent of the foreign students come from other countries of the Region, in Argentina 70 percent do so. Table 3 shows the situation of the countries in the Region as regards stu- dents who went abroad for medical education. Percentage of total enrollment accounted for by enrollment abroad varies from 100 percent for those coun- tries with no medical schools to less than 1 percent for Argentina, Brazil, and Mexico. The overall average is 4.6 percent. Both Brazil and Mexico have ex- panded their medical schools at a rapid rate and can accommodate students seeking medical education. Countries with the highest proportion of students abroad—aside from Guyana and Trinidad and Tobago, which have no medical school—are Bolivia, Costa Rica, Haiti, Honduras, Nicaragua, Panama, Paraguay, and Peru. Of these, only Peru expanded its domestic enrollment between 1967 and 1971. The figures in table 9 confirm the theory that the proportion of students studying abroad is related to their difficulty in gaining admission to medical schools at home [16]. This shows that restricting domestic production of physicians does not necessarily restrict the supply of physicians. Excluding those countries having fewer than 150 students abroad, countries with a particularly high proportion enrolled within the Region were Bolivia, TABLE 3. Estimated Number of Central and South American Undergraduate Medical Students Abroad, 1971-73 Estimated Number Enrolled in Enrollment Other Central and South Percent Country of American United Other Number Number Total Abroad Nationality Countries States Europe Countries Abroad at Home (E+F) (E=+G) A B C D E F G H Argentina 98 4 40 0 142 29,891 30,033 0.5 Bolivia 622 0 123 0 745 1,788 2,533 29.4 Brazil 84 0 50 2 136 44,074 44,210 0.3 Chile 182 6 87 0 275 2,546 2,821 9.7 Colombia 286 1 249 0 536 4,547 5,083 10.5 Costa Rica 109 1 92 0 202 282 484 41.7 Cuba 36 35 416 0 487 - - - Dominican Republic 24 3 62 0 89 4,087 4,176 2.1 Ecuador 83 1 75 0 159 4,638 4,797 33 El Salvador 157 0 17 0 174 2,179 2,353 7.4 Guatemala 27 0 22 0 49 1,830 1,879 2.6 Guyana* 0 19 25 2 46 0 46 100.0 Haiti 111 7 234 2 354 532 886 40.0 Honduras 156 3 67 0 226 761 987 229 Jamaica 13 37 9 0 59 504 563 10.5 Mexico 13 9 36 6 64 41,675 41,739 0.2 Nicaragua 280 0 88 0 368 312 680 54.1 Panama 435 7 189 17 648 147 795 81.5 Paraguay 557 0 9 0 566 411 977 57.9 Peru 1,019 0 465 0 1,484 3,487 4971 29.9 Trinidad & Tobago* 0 25 31 17 73 0 73 100.0 Uruguay 6S 0 9 0 74 2,674 2,748 2.7 Venezuela 116 0 291 3 410 6,232 6,642 6.2 Total 4,473 158 2,686 49 7,366 152,597 159,476 4.6 *Countries with no medical school. Total mentioned in column A is slightly lower than that mentioned in text because of incomplete nationality breakdown in some countries. Column C includes 13 enrolled in Canada. Column G: overall average of 4.6 percent excludes Cubans enrolled abroad. Sources: Estimates are based on data for academic year 1971-72 (M.1. Rodriguez, Educacibén Médica ¥ Salud 8(4): 360-389, 1974) combined with those for 1972-73 (Foreign Students in Medical Schools, Paris: UNESCO, 1974). YL BOLIQWY UTR UT [OIBISAY [BOIPOWIOIg Alfonso Mejia 75 TABLE 4. Undergraduate Foreign Medical Students in Major Host Countries (1971-72) Central and South American Host Country Total Number U.S. Citizens Citizens No % No % Mexico 3,231 1,853 57 1,331 41 Argentina 3,000 17 1 2,113 70 Brazil 1,104 2 2 409 37 Venezuela 362 7 2 131 36 Dominican Republic 199 3 3 186 93 Uruguay 195 0 0 111 57 Ecuador 137 1 1 132 96 Colombia 131 12 9 100 76 Chile, El Salvador, Paraguay, Peru, Honduras, Nicaragua, and Panama. Sig- nificantly, six of these eight were among countries with the highest propor- tion studying anywhere outside their country. We can conclude that, of those students who do not gain admission to a medical school in their homeland, those from countries that have many medical students studying abroad are more inclined to enroll in schools within the Region, while those from coun- tries that have relatively few students studying abroad tend to go outside the Region, mainly to Europe. Cuba, Haiti, and Venezuela had a significantly large proportion of students enrolled in Europe, perhaps for different reasons. Migrant Cuban physicians use Spain as a way station to the United States; medical students probably follow the same route. Haitians tend to study in schools where the language of instruction is French—hence France is a place of study for those going abroad. Why 410 Venezuelan students were studying abroad—nearly 300 of them in Europe—is unclear, given that Venezuela has sufficient capacity to accommodate the demand for medical education. One reason may be the prestige associated with qualifying in foreign lands. Of the 2,686 students enrolled in Europe, over 2,000 were in Spain—423 from Peru, 415 from Cuba, 227 from Colombia, and 215 from Venezuela. Presumably Spain was preferred mainly for reasons of language. It is impossible to say how many of such students subsequently migrate to the United States, given that once in the United States they are counted as Spanish medical graduates and their identity as Cubans, Colombians, etc., disappears in the statistics. With regard to physicians of the Region who go abroad for postgraduate studies, most go to the United States and a few to Canada. Very few go to 76 Biomedical Research in Latin America other countries of the Region, notably Brazil, Chile, and Colombia. In 1970, a total of 2,660 medical graduates from the Region were enrolled in training programs in the United States, where they constituted 16 percent of all FMG’s enrolled in those training programs and 27 percent of those from the Region in the United States at that time. The countries with the most postgraduate students in the United States were, in order of magnitude, Argentina, Mexico, Colombia, Cuba, Peru, Haiti, Brazil, and the Dominican Republic [6]. Movements of Nurses Each year some 750 nurses from the Region are licensed or registered for practice outside the Region [1]. This number was equivalent to 0.9 percent of domestic stock in 1972. If the West Indies are excluded, i.e., if only Latin America is considered, the number being licensed abroad each year falls to 250, or 0.3 percent, of stock—a truly negligible amount. These figures are important only because the total stock of professional nurses in Latin America is very low—about 77,300 for a population of some 270 million people. Most of the 250 Latin American nurses have been licensed in the United States [17]. As a percentage of domestic stock, the proportions being licensed abroad are highest for Haiti, 8 percent per annum, (5 percent in the United States); Cuba, 2.1 percent being licensed annually in the United States, a figure that may be declining because of the decrease in emigration for politi- cal reasons; the Dominican Republic, 1.6 percent; and Nicaragua, 1.7 per- cent [1]. The number of Latin American nurses entering the United States as immi- grants is about double the number being licensed; in 1970, about 440 entered the United States, and fewer than 250 were licensed. The discrepancy probably arises because data on immigrants include those who, although they describe themselves as nurses, are in reality nursing auxiliaries. There is very little documentation on the movement of nurses within the Region, although such movement is known to exist. A Pan American Health Organization (PAHO) report [18] indicates the following: ® In 1965 160 Colombian nurses—some 14 percent of domestic stock— had migrated: 90 to the United States; 48 to other countries of the Region (21 to Venezuela, 11 to Panama, 4 to Ecuador, and 12 to other countries); 18 to Europe; and 3 to other countries of the world. ® Of the 464 graduates of the principal nursing schools in Bolivia, 114 had migrated: 69 to the United States; 39 to other countries of the Region (16 to Peru, 13 to Venezuela, 6 to Brazil, and 4 to other countries); and 6 to other parts of the world. ® Of the 414 living graduates of the National School of Nurses in Ecuador, 78 had migrated—47 to the United States and 31 to other countries of the Region. Alfonso Mejia 77 The above figures suggest that about twice as many nurses from the Region go to the United States as move within the Region, the latter being about 125 professional nurses per year. The West Indies—A Special Case The picture of migration as regards English-speaking countries of the West Indies (hereafter referred to only as West Indies) is considerably different from that for Latin America. This area is not only a sizable donor of physicians and a source of numerous medical students abroad but a recipient of foreign-born physicians and of returning nationals who obtained their medical education abroad. The University of the West Indies (UWI), in Jamaica, is the only English- language medical school in the area. This fact obscures the picture of migration from the West Indies to the United States because all medical graduates of UWI who go to the United States are referred to as “Jamaican medical graduates.” In 1972, there were 83 such physicians in the United States, only 37 of whom were nationals of Jamaica. Table 5 shows the migration picture as it concerns medical graduates of UWI. The figures are estimates based on proportions reported in a study of TABLE 5. Stock of Physicians in the English-Speaking West Indies; Physicians From the West Indies Located Outside Central and South America, 1972 Average Annual Percentage of Estimated Estimated Number Entering Stock Abroad Stock Number Abroad Number in U.S. Canada (B+ A) Country A B C D E Barbados 140 20 5: 5 14.3 Guyana 191 60 24 7 314 Jamaica 490 95 37 22 19.8 Trinidad & Tobago 432% 68 8 14 15.7 Other West Inaies 320 20 7 2 6.2 Total 1,573 263 81 50 16.7 *1971. Figures in columns B and E do not include physicians born in the West Indies but trained in the United Kingdom. Sources: Data in column A from World Health Statistics Annual 1972, Vol. 3, Geneva: WHO, 1976. Estimates in column B based on data in J.H. Bruinsma, West Indian Medical Journal 19(2):91-93, 1970 and unpublished WHO document HMD/76.4. Estimates in column C based on data in Profile of Medical Practice, Chicago: AMA Center for Health Services Research and Development, 1976. Estimates in column D based on data in J.N. Haug and B.C. Martin, Foreign Medical Graduates in the United States, 1970, Chicago: AMA, 1971. 78 Biomedical Research in Latin America physicians who graduated from UWI during the period 1954-65 [19]. In addition to the 83 in the United States, there were about 30 in the United Kingdom and an estimated 150 in Canada—in all, about 260, or 21 percent of physician stock in the West Indies. In addition to the graduates of UWI, considerable numbers of physicians who were born in the West Indies but trained in the United Kingdom are also abroad. Over 90 percent of West Indians in the United Kingdom in 1966 had been trained there [21]. One can thus assume that most of those in the United Kingdom in 1970 were also trained there. It is probable that many of them are children of an earlier wave of migrants to the United Kingdom, where they grew up and became citizens. Between 1962 and 1966, 81 West Indies-born physicians left the United Kingdom—68 to return to the West Indies (63 of these had graduated in the United Kingdom) and the rest to return to other developed countries, pre- sumably Canada and the United States. This means that : ® The West Indies was an importer of medical education in the 1960’s— returnees from the United Kingdom being equivalent to about half the annual production of physicians in the West Indies. This is no longer so, however; the UNESCO study [15] found only two West Indian medical students en- rolled in the United Kingdom in 1972-73. ® A good many West Indies-born physicians in the United States are iden- tified as U.K.-trained, and possibly some entering Canada indicate the United Kingdom as country of last permanent residence. In both instances, the iden- tity of these individuals as West Indians is not apparent in the statistics. Some countries of the West Indies, notably Jamaica, are also recipients of physicians. In Jamaica, of the physicians listed on the register in 1967, 20 per- cent were foreign. In Guyana in 1972, 21 percent were foreign [1]. There is also a considerable movement of UWI graduates between countries of the West Indies [19]. Table 6 shows that only Jamaica experienced a net gain. TABLE 6. Movement and Location of UWI Medical Graduates (percentages) Origin of Location of Country Graduates Graduates, 1970 Jamaica 44.4 46.7 Trinidad & Tobago 12.4 2.5 Barbados 9.2 3.3 Guyana 18.3 6.2 Small West Indies 13.1 7.2 Unknown 6.2 Foreign 2.6 22.9 Total 100.0 100.0 Source: Reproduced with permission from Bruinsma, J.H., West Indian Medical Jour- nal 19:91-93, 1970. Alfonso Mejia 79 The situation with regard to emigration of nurses is similar to that of physicians, but less well documented. Nurses trained in the West Indies are licensed in the United States at the rate of about 90 per year (70 of whom come from Guyana and 20 from elsewhere). Nearly 300 are licensed annually in Canada, and 132 were registered in the United Kingdom in 1973. Together these constitute an outflow of 500 per year, or an annual loss of nearly 17 percent of stock [1]. The West Indies is also the source of a large number of nursing students in the United Kingdom—the nearly 8,000 enrolled in 1965-66 constituted 51 percent of all foreign nursing students in the United Kingdom at that time. Since then, their number has fallen—to 4,815 in 1972-73, or 24 percent of the total [22]. In 1973, one-third of all West Indian nursing students in the United Kingdom had been recruited in their country of origin. As a result of economic difficulties in the United Kingdom that have reduced employment opportun- ities for foreign nurses, the number of nursing students coming from the West Indies will probably fall and/or a greater number will be repatriated and thus increase domestic stock. Characteristics of Migrant Physicians Age A study of foreign medical graduates in the United States in 1970 [6] shows that there were 9,929 graduates from Central and South America. Most were very young; while 47 percent of all the FMG’s were under age 40 and 13 percent were over age 60; of those coming from the Region (excluding Cu- bans), 58 percent were under 40 and 20 percent were over 60. The Cuban physicians are a special case; over half were aged 40-59, an indication that most of these may be of the group that entered the United States as a part of the mass exodus from Cuba during the years 1957-68. Most of the physicians from the Region were recent graduates. One would therefore expect more than an average proportion to have been in graduate education programs, but only 26 percent were, as opposed to 29 percent of all FMG’s. Regarding certification by the Board of Medical Examiners, 12 percent of physicians from the Region, as opposed to 16 percent of all FMG’s, were certified. Whereas 15 percent of all FMG’s were women, only 8 percent of the physicians from the Region were women. Six percent of all FMG’s were employed by the Government, while 7 percent of physicians from the Region were thus employed; 88 percent were nonfederally employed, as opposed to 92 percent of all FMG’s. Physicians from the Region were more inclined to work in nonmetropolitan areas than were FMG’s as a whole, 13 percent as opposed to 9 percent. This larger proportion for physicians from the Region was due to the 19 percent of physicians from Mexico and the 17 percent of those from 80 Biomedical Research in Latin America Cuba who were practicing in nonmetropolitan areas. This is in sharp con- trast to the 6 percent of Argentinian physicians who were located in non- metropolitan areas. Physicians from these three countries constituted 60 percent of the Region’s medical graduates in the United States in 1970. Of the medical graduates from the Region, 517—or S percent—were interns. Four years later the number of interns had declined to 439, despite an increase in total numbers from the Region. The number of residents also fell—from 2,610in 1970 to 2,460 in 1974 [23]. Kinds of Practice As is true of all FMG’s and of physicians graduated in North America, about 90 percent of the Region’s physicians are engaged in patient care. The big dif- ferences between the kinds of practice are: (1) only about 40 percent of FMG’s are engaged in office practice, while 67 percent of physicians graduated in the United States are so engaged;and (2) 46 percent of the FMG’s from the Region are residents and full-time hospital staff, while only 20 percent of those graduated in North America practice in these settings (table 7). TABLE 7. Percentage Distribution of Graduates From the Region in Relation to All FMG’s and All Graduates From North American Schools, by Type of Practice, 1970 Graduated in Graduated in Area of Activity North America All FMG’s the Region Patient care Office-based 67 39 39 Interns 3 6 6 Residents 11 25 23 Full-time staff 9 20 23 Total 90 89 91 Other professional activity Medical teaching 2 2 2 Administration 4 2 2 Research 3 6 5 Other 1 1 1 Total 10 11 10 Grand total 100 100 100 Figures refer only to those on whom information was available. Source: Based on data in J. Haug and R. Stevens, Inquiry 10(1):19-25, March 1973. Alfonso Mejia 81 Return to Homeland Relatively few migrant physicians return to their homelands after a stint abroad. The findings from an 8-year followup study of a cohort of FMG’s in the United States [24] showed that of the Region’s graduates in the United States in 1963, about 15 percent were no longer there in 1971; presumably they had returned to their homeland. The return rate for all FMG’s was 18 percent; for Asians it was 27 percent, and for Europeans 13 percent. Another study [25] showed that for every eight graduates from the Region who enter the United States, one leaves. If Cuban graduates are excluded, the ratio is 7:1. For Colombians, the ratio is 9:1. A study carried out in the United King- dom [21] showed that graduates originating in the West Indies are more inclined to leave the United Kingdom than are those originating in other areas of the world. Whereas the average rate of departure was 71 percent, the rate for the West Indies was 81 percent (Barbados 82 percent, Jamaica 84 percent, Trinidad and Tobago 85 percent, and Guyana 68 percent). A study based on American Medical Association (AMA) data for 1968 and 1973 [26] analyzed the whereabouts of cohorts of Colombian medical graduates who had migrated to the United States and found that in most cases the migration was permanent. However, those who had returned to Colombia were twice as likely to have been born in smaller towns as were those who had remained in the United States. While a comparison of migrants with nonmigrants was not possible, it would be interesting to know the mi- gration rate of medical graduates who were born in small towns as compared with the rate for those born in metropolitan areas. This could have policy implications with regard to medical school admission. The study also found that most Colombian physicians migrated to the United States within 5 years after graduation from medical school and that those who returned to Co- lombia within that 5-year period did not, on the whole, reemigrate to the United States. The remainder of those who returned to Colombia did so within 5 to 10 years after graduation, and a small proportion of them reemigrated to the United States. Reemigration to the United States represented about 1 out of every 6 returnees and 1 out of every 34 emigrants. Factors Influencing Migration Many theories have been put forth as to what causes migration and why mi- grants choose certain countries of destination rather than others. Perhaps the most convincing theory (so convincing in fact that it may be considered a truism) is that migration is the result of the interplay of various forces— political, social, economic, legal, historical, cultural, educational, etc., opera- ting at both ends of the migratory axis. Traditionally, these forces have been classified as “push” forces (those operating in the donor country) and “pull” 82 Biomedical Research in Latin America forces (those operating in the recipient country). Without both sets of forces operating in unison, migration would not, for the most part, occur. In other words, no matter how strong the “pull” forces, large-scale migration will not take place from countries where strong “push” forces do not exist. The cause of these forces is another story, the theme of which centers on the overall international problem of unequal development, and the moral of which is that pulling forces will always be present in the world and that each country that does not want to lose manpower will need to examine its own pushing forces and devise ways of converting these to forces that act to the country’s benefit. The WHO study of health manpower migration investigated a number of factors assumed to be associated with migration throughout the world and found that, whatever the factors at play, the largest outflows of health man- power relative to stock were suffered by the poorest group of developing countries. If the countries of Latin America (i.e., excluding the West Indies) are grouped by the size of physician outflow relative to stock (as indicated in table 1), those countries having the highest losses are seen to be also those with the lowest gross domestic product (GDP) per capita, the lowest rate of life expectancy at birth, and the poorest physician coverage per 10,000 popula- tion (table 8). Whereas all those countries that lost less than 5 percent of their stock of physicians had a per capita GDP exceeding $600, a life-expectancy rate of 61 or more, and 6 or more physicians per 10,000 population, the heavy- loss countries generally had a per capita GDP below $500, a life expectancy rate under 61, and fewer than 6 physicians per 10,000 population. It appears to follow from this that the poorer the country, the more unhealthy the people, the greater the need for care, the fewer the physicians per unit of population, and the greater the emigration. The adage that people emigrate because the grass is greener elsewhere makes sense only to the extent that “greener” is more clearly defined. If greener means merely more income per se—all other factors being equal—it is unlikely that much emigration will occur. If, however, it means an opportunity for the individual to be gainfully employed in the profession of choice —as opposed to the lack of such opportunity in the homeland —then the propensity to emigrate becomes strong. There are many reasons why people generally prefer to remain in their homelands; among them are close ties with family, commun- ity, and culture. If they can find satisfactory employment at home—other things, including the political situation, being equal—they remain at home. Thus, the crucial factor is whether such employment exists. In the case of physicians, for example, the number who can find employ- ment depends critically on the amount of money available for care of the sick and promotion of health. That amount, in turn, is highly dependent on a country’s state of affluence (although it must be noted that a few countries have managed to raise the level of health with relatively modest funds by using such funds in a more cost-effective manner). For each level of affluence, as Alfonso Mejia 83 TABLE 8. Gross Domestic Product per Capita, Life Expectancy at Birth, and Physicians per 10,000 Population in Central and South American Countries, Grouped According to. Percentage Loss of Physicians Through Emigration, 1972 Life Expectancy Per Capita GDP at Birth Physicians per $) (yrs) 10,000 Population Country A B C Low loss (5%) Argentina 1,055 64 20.9 Brazil 611 61 6.0 Costa Rica 673 68 6.0 Mexico 755 63 7.0 Panama 854 67 7.7 Uruguay 744 66 11.0 Venezuela 1,312 65 10.2 Medium loss (5-9%) Bolivia 222 47 4.1 Chile 643 64 4.5% Ecuador 292 60 35 Honduras 308 54 2.5 Nicaragua 485 53 6.8 High loss (10+%) Colombia 376 61 4.6 Dominican Republic 462 58 52 El Salvador 307 58 25 Guatemala 390 53 2.3 Haiti 106 45 0.8 Paraguay 298 61 4.1 Peru 385 56 5.5 *In government service. Percentage loss reflects outflow, not net flow. Sources: Data in column A from Yearbook of National Accounts Statistics 1975, Vol. 3, New York: United Nations, 1976. Data in column B from Health Sector Policy Paper, Washington, D.C.: International Bank for Reconstruction and Development, 1975 and World Almanac and Book of Facts, New York and Cleveland: Newspaper Enterprise Association, 1976. Data in column C from A.R. Adorno, Revista Médica del Paraguay 11(1):3643, 1970. measured by per capita GDP, there is a specific number of physicians per unit of population that a country can hope to employ, i.e., economically sustain. With the use of relationships developed in the WHO multinational study, it can be shown that all but three of the countries listed in table 8 had more physicians per 10,000 population in 1972 than they could satisfactorily em- ploy. The three exceptions were Venezuela, Chile, and Guatemala. According to available data, Venezuela has only a small outflow of physicians and may, 84 Biomedical Research in Latin America on balance, have a net inflow. (As was mentioned earlier, one of the major flaws in the statistics for the Region is the lack of data on inflow. Thus, the loss indicator reflects only outflow, not net flow.) In the case of Chile, the picture is additionally blurred by the fact that the stock of physicians reported includes only those in government service, i.e., 4,506 in 1972, as shown in table 1. The total number in Chile in 1968 was nearly 5,200 and could well have been about 6,000 in 1972. Chile’s outflow, therefore, would have been about 5.7 percent of stock in 1972 instead of 7.5 percent. In two countries of the Region the migration pattern does not appear to conform to the theory of economic sustainability. Guatemala had a high loss in spite of the fact that its economy could have supported not only those physicians who re- mained in the country but also at least twice as many as had emigrated. Rea- sons other than economic ones must account for this. Argentina, on the other hand, had over twice as many physicians per 10,000 population in 1972 as its economy would warrant, yet it suffered only a 3.5 percent loss of stock. This paradox is worthy of investigation. It is noteworthy, also, that for Haiti, the exceedingly high percentage loss (more Haitian physicians are outside than inside the country) served to reduce that country’s physician coverage to al- most exactly the level it can economically sustain. The influence of GDP on the sustainable number of physicians can be modified to a certain extent by varying the total proportion of national in- come allocated to health. In most of the countries listed in table 8 the gov- ernment expenditure on health is low. Around 1972, the health budget as a percentage of GDP was less than 1 percent in a number of these countries (Brazil 0.2 percent, Mexico and Ecuador 0.3 percent, Costa Rica 0.6 percent, Haiti 0.7 percent, and Colombia 0.9 percent). The highest proportions were spent in Chile (3.4 percent), Venezuela (3.3 percent), and Peru (3.2 percent). Government expenditure on health, as a proportion of total government expenditure, ranged from 22 percent in Nicaragua to 2.5 percent in Brazil and Ecuador. Government expenditure on health per person ranged from $42.92 in Venezuela to $0.78 in Haiti [30]. Private expenditure on health is conditioned by the proportion of people who have sufficient income to allow a portion of it to be spent on health care. The more evenly a given national income is distributed, the greater the number of people who can afford to pay for health care and the greater the amount of money available to employ health manpower. This is a particularly critical factor in countries where the poor are so poor that they cannot afford any health care at all. In a study of income distribution for the World Bank [31], nine countries of the Region (Honduras, Ecuador, Colombia, Brazil, Peru, Jamaica, Mexico, Panama, and Venezuela) were classified under “high in- equality,” while five (the Dominican Republic, Guyana, Uruguay, Chile, and Argentina) were classified under “moderate inequality.” None was classified under “low inequality.” Alfonso Mejia 85 In contrast with most of the countries listed in table 8, the four specified countries of the West Indies (Barbados, Guyana, Jamaica, and Trinidad and Tobago) had fewer physicians than their GDP level indicated they could support. If one restricts the measure to physicians trained at UWI, Jamaica in fact experienced a net inflow of physicians during a sizable outflow. In this, Jamaica typifies a sort of country quite unknown outside the British Common- wealth of Nations, i.e., the donor/recipient country. Although on balance Jamaica is a recipient—as are Nigeria, the United Kingdom, Australia, etc.—it loses a considerable number of physicians, mainly to the more affluent coun- tries of the Commonwealth, e.g., Canada and the United Kingdom. The com- monality of language, traditions, patterns of medical education, etc., makes, or made, it fairly easy for Jamaican physicians to adapt to those countries. The extent to which this flow will slacken as a result of more restrictive regu- lations now in force in Canada and the United Kingdom remains to be seen. The other countries of the West Indies seem to be losers of physicians (when only UWI graduates are considered), but since information is not available on the inflow to those countries, nothing can be concluded as to net flow. If the emigration of physicians can be attributed, at least in part, to an excess of physicians in relation to effective economic demand for their serv- ices, then it seems unrealistic to pour more money into expanding the supply of physicians. Revolutions apart and perhaps notwithstanding, effective eco- nomic demand for physician services can grow only to the extent that GDP grows and is more evenly distributed; and even then it may take some time before the sustainable level of physician stock in some countries catches up with the actual level. Under such circumstances there should be, if anything, a cutback in production rates, accompanied by increased production of health workers who are less costly to train and maintain but who are, nevertheless, appropriate for the tasks to be performed. In Latin America the opposite seems to be happening; medical education facilities and enrollment are expanding rapidly in a number of countries (table 9). In 1967-68 there were 100 medical schools, and by 1971-72 there were 158 schools (a 58 percent increase). During the same period, Brazil alone opened 42 new medical schools, making a total of 73 in 1971-72 [16]. More recent information suggests that there are at least 45 more medical schools in the Region than were officially reported for the year 1971-72 (3 more in Brazil, 5 more in Colombia, and 37 more in Mexico—totals of 76, 14, and 62 respectively). This would bring the overall total for the Region up to 203 medical schools, double the number officially reported as existing in 1967-68. Between the years 1967-68 and 1975-76 the number in Brazil more than doubled, that in Colombia doubled, and that in Mexico trebled. It is apparent from table 2 that expansion is slowly beginning to be reflected in the higher number of graduates from the Region found in the stock of physicians in the United States in 1974 as opposed to 1970—e.g., 242 more 86 Biomedical Research in Latin America TABLE 9. Expansion of Medical Schools and Medical Student Enrollment in Central and South America Between Academic Years 1967-68 and 1971-72 Students Number of Schools Number Enrolled Increase Country 1967-68 1971-72 1967-68 1971-72 (%) Brazil 31 73 21,907 44,074 102 Mexico 21 25 20,127 41,675 107 Argentina 9 9 27,790 29,891 8 Colombia 7 9 3.572 4,547 27 Venezuela 6 7 5,491 6,232 13 Peru 4 6 2,580 3,487 33 Bolivia 3 3 2,179 1,788* - Chile 3 5 2,320 2,546 10 Ecuador 3 5 1,660 4,638 179 Cuba 2 3 4,516 7,098 57 Dominican Republic 1 2 1,109 4,087 268 Other 11 11 4,994 9,686 94 Total 100 158 98,245 159,749 63 *Refers to only two schools. Source: Reproduced with permission of the Pan American Health Organization from M.I. Rodriguez, Educacion Médica y Salud 8:360-389, 1974. from Brazil, 299 more from Colombia, and 735 more from Mexico. The higher number from Mexico may be due partly to the higher number of United States nationals returning home after graduation in Mexico. While there have been increases from the three countries where medical school expansion was the greatest, the increases were not so great as might be expected. The probable explanation is that because medical education takes 6 years in Brazil and Mexico and 7 years in Colombia, a number of students had not yet graduated and those that had graduated and recently migrated did not figure in the 1972 migration data. In the case of Brazil, another possible explanation is that the rapid rate of growth in gross national product (GNP) per capita (6 percent per year over the period 1965-73) has increased new employment opportunities. The number of students enrolled in the Region’s medical schools increased from 98,245 in 1967-68 to 159,759 in 1971-72—reflecting an increase of 63 percent (table 9). In this 4-year period the number enrolled in Brazil increased by over 22,000 (a 102 percent increase) and that in Mexico by over 21,000 (a 107 percent increase). The expansion of enrollment in Mexico is due partly to the larger number of students from the United States who were studying there in the early 1970’s. With the current expansion of places in schools in Alfonso Mejia 87 the United States and the special effort being made to accommodate American citizens who have had at least 2 years of training abroad, the numbers of Americans studying in Mexico are expected to decline. While the overall percentage increase of enrollment in Argentina is rather small for the 4-year period considered, it has been reported [32] that in the past few years at least one medical school (faculty of medicine, University of Buenos Aires) has greatly liberalized its admission policy. As a result, first year admissions to the school increased from 2,433 in 1973 to 12,499 in 1974—an increase of over 10,000, or 414 percent, in a single year. Stated otherwise, there were 5 times as many first-year admissions in 1974 as in the preceding year, and 13 times as many admissions in 1974 as in 1969. This massive increase is more than anything a response to the large-scale demand for medical education as a part of the growing demand for university edu- cation in all fields, and it is not limited to Argentina alone. As can be seen in table 9, medical school enrollment has increased considerably in most coun- tries of the Region. This demand does not appear to be related to demand for services. Moreover, without the necessary increase in institutions and equipment—as is the case in Argentina, where there was no increase in the number of medical schools—the result is crowding, lower-quality teaching, inadequate learning, poor student evaluation, etc. The products of such a system may find it difficult to obtain employment in the country, particularly if the supply of physicians outstrips the demand. Emigration may be the only solution for many such graduates. It is too early to measure the full impact of the 63 percent increase in enrollment in the Region in relation to emi- gration from the Region, although, as indicated in table 2, the numbers found in the United States in 1974 reflect notable increases over those found there in 1970. An interesting point that emerged from one study [16] is that countries that have been reluctant to expand medical education have seen large numbers of their nationals going abroad for study. If those students were to return home after graduation, they could well defeat the purpose of the national policy. The main conclusion to be drawn from this is that demand for medical education seems to be totally unrelated to employment opportunities in the home country—and far less to the actual need for manpower—and that the demand is unsuppressible. If countries are not to end up by producing physicians for the export market, they must consider the numbers they can afford to employ, i.e., their sustainable level. Thus the level of 8 physicians per 10,000 population—the target set for the year 1980 according to the Ten-Year Plan for the Americas— would be well above the level sustainable by most countries in the Region. Even on the assumption that per capita GDP in real terms will double by the year 2000, fewer than half the countries of the Region would be able to afford 88 Biomedical Research in Latin America at least 8 physicians per 10,000 population—namely, Argentina, Brazil, Bar- bados, Chile, Costa Rica, Jamaica, Mexico, Panama, Trinidad and Tobago, Uruguay, and Venezuela. The lesson to be drawn from the above is that countries with modest means should not focus primarily on production of physicians to meet their people’s needs for health services and care. Moreover, the whole notion of the health team and the way it should function needs rethinking from the per- spective of efficiency and cost-benefit. In the WHO study of migration it was found that physicians are more prone to migrate from countries where the ratio of supporting staff per physician is low. In this respect the Region as a whole has an extremely top-heavy health manpower structure: In 1972 there were 206,411 physicians in the Region (excluding the West Indies) and only 77,302 professional nurses, the ratio being 0.4 nurse per physician compared with 2.5 in the United States. In addition to the professional nurses, there were some 176,500 nursing personnel in other categories (aides, auxiliaries, assistants, etc.). Even with all these included as support staff, the ratio is 1.2 per physician. Obviously, in such cases the physician is obliged to perform tasks normally performed by nursing personnel—a situation that is not only uneconomic but leads to job dissatisfaction and, eventually, to the physician’s migration. In purely economic terms, money used to train one physician could be used to train a large number of other types of health manpower. Although data are not available on the opportunity cost of training one physician in the Region, it is reported that in Pakistan the number of personnel that could be trained for the cost of training one physician is as follows: 4 nurses, 24 medical assistants, 24 health visitors, 60 midwives, or 60 sanitary inspectors [33]. One of the factors most central to all theories on physician migration is irrelevant education. In developing countries, physicians who are products of an education system oriented to disease patterns of developed countries and using irrelevant teaching methods and facilities will tend to migrate to coun- tries where their acquired skills can be used more productively. The question of relevancy of medical education is closely tied to the question of compo- sition of the health team; both need investigation. Not all factors that act as a push on physicians act only on physicians. In addition to the ever-present pull forces in such countries as the United States and the push forces specific to medical manpower, there are factors that act on all types of manpower, the most important being the political factor. The charting of data on immigration to the United States from Latin American countries shows a remarkable coincidence between immigration peaks and political upheavals in certain Latin American countries, notably Cuba and Chile. A study of brain drain from Argentina to the United States during the period 1950-70 showed a significant correlation between political crises in Argentina and peaks of physician immigration from Argentina [34]. Alfonso Mejia 89 Consequences of Migration The impact of migration has been measured in various ways, e.g., the number of years of training time lost by donors and gained by recipients, the amount of money lost or gained, the loss or gain of health manpower relative to pop- ulation. Among the social costs attributed to the emigration of physicians is meager coverage of rural populations and urban poor. Given the low economic support base in most countries of the Region and the fact that most have more phy- sicians than they can effectively employ, it is questionable whether restricting physician migration or attempting to repatriate those abroad would improve the coverage of such populations. It is more likely that the pool of unemployed or underemployed would increase—as in India, for example, where the re- patriation program was stopped mainly for that reason [35]. Poor rural coverage is more a symptom of the disease that causes migration than a direct consequence of migration. It is virtually impossible to separate causes from effects, given that most factors that are basically symptomatic of low income and development levels are often both cause and effect of those levels. Although it might be interesting to hypothesize, for example, as to what the physician-population ratio might be had there been no emigration, the exercise remains academic as long as improvements in the ratio, particularly in regard to underserved populations, are unrealizable. On the other hand, loss of a trained physician represents a lost investment equal to the cost of the education involved. Estimates of the cost of educating a physician vary considerably. A United Nations Institute for Training and Research (UNITAR) report [36] indicates $6,000 as the average cost of edu- cating a physician, while the World Bank [28] indicates $29,000 as the cost in 1965. Using an estimate of $20,000 (the World Bank’s estimate for Guate- mala was $19,200), one can state that the 12,556 physicians from Central and South America who were located outside the Region represent a lost invest- ment equivalent to about $250 million or $1 per head of population. Among variables not accounted for in such calculations are the cost of primary and secondary education, where the medical education was obtained, and who bore the cost of the education. In the case of a Bolivian physician who received his education in Spain at his own expense, returned to his country for a while, and then went to the United States, all the above variables become important in ascertaining who owes what to whom. The real significance of a loss quantifiable in monetary terms lies in the fact that money used to train those physicians who subsequently migrated would have been better used to train other types of health workers less inclined to migrate. Assuming $20,000 as the cost of medical education per head in Colombia, for example, the lost investment would be equal to $25 million, more than half the government expenditure on health in 1971 [28]. For this 90 Biomedical Research in Latin America amount, about 8,300 nurses could have been trained. This would have re- sulted in Colombia’s having 1.1 nurses per physician instead of the current 0.3. Inasmuch as there appears to be a correlation between physician emigration and low numbers of supporting staff for physicians, consideration should be given to this matter. Policies Every country is concerned, in varying degrees, about whether supply, distribu- tion, productivity, and utilization of its health personnel are adequate for ful- filling requirements for health services. These requirements vary not only in accordance with changes in the scope and nature of health problems and of the science of health care but also in response to an ever-evolving social, political, and economic situation. Changes in requirements imply the need for changes in health manpower policies, plans, and practices. Where such changes are made, the intensity and direction of health manpower migration are likely to be affected. The discussion that follows outlines some policies and practices that have implications for health manpower migration. Consideration is given first to those in countries of Central and South America and second to coun- tries that are major recipients of health manpower from that Region. Policies in Central and South America Most countries of the Region offer incentives of one sort or another to encour- age health manpower to remain in the country and especially to work in the country’s underserved areas. Among the incentives offered particularly to physicians serving in hardship areas are housing and transportation facilities, supplements to basic salaries, permission to devote part of their time to private practice, and—after completion of service in hardship areas and depending on the length of such service—opportunities for fellowships and preferential admission to more attractive and senior posts. The types and values of these incentives vary from country to country [37]. A few countries have also initiated repatriation schemes. In Colombia, according to a scheme initiated in 1968, returnees are offered a 3-year contract to serve as university professors or research fellows. In addition to the basic salary corresponding to the type of job the returnee agrees to perform, the candidate receives an annual supplement of $6,000, an allowance of $1,500 for moving costs, travel expenses for self and dependents, and exemption from import taxes on household effects and automobile. The Colombian Government also enacted legislation to establish an employment service for returnees [36]. In Argentina, the repatriation scheme initiated in 1964 provides only for exemptions from payment of customs duties on imported household effects, automobile, and equipment essential to the work of the returnee [18]. Alfonso Mejia 91 In some countries, e.g., Argentina, Chile, Colombia, and Jamaica, post- graduate facilities have been established to obviate the need for physicians to go abroad for advanced training. Moreover, as noted earlier, there has been a considerable increase in both number of medical schools and enrollment of medical students in undergraduate education programs. In some countries, health workers themselves take action to force changes in policies. In Colombia, for example, physicians undergoing postgraduate training went on strike in the late 1960s to demonstrate dissatisfaction with the prevailing training conditions. Further dissatisfaction with working con- ditions under the social security program resulted in a prolonged strike by physicians in 1976. An interesting recent development in the Americas is the decision of the Andean Pact countries (i.e., Bolivia, Chile, Colombia, Ecuador, Peru, and Venezuela) to subscribe to the terms of an agreement for the cooperative development of manpower (HIPOLITO UNANUE). In this regard, consid- eration is being given to creation of health manpower units in ministries of health; establishment of an intercountry health manpower advisory group; training of specialists, including those in the health field, for strengthening the integration of political and technical aspects of the health sector within the Region; promotion of health manpower studies; and exchange of health experts for specific assignments. Also of interest is the adoption, by countries of the Region, of a convention to recognize studies, diplomas, and degrees in higher education granted within the Region—the purpose being to make the best use of educational facilities in the Region; to ensure the highest degree of mobility of teachers, students, research workers, and members of the professions within the Region; and to guarantee full employment and prevent migration of talent to highly in- dustrialized countries [38]. Perhaps the most important step being considered in some countries is the move toward primary health care and training large numbers of auxiliary health workers to provide such care. It is reported [39] that the Brazilian scheme for rural social security (FUNRURAL) has been remarkably successful in improving rural health services and has facilitated recruitment and retention of physicians in rural areas. The extent to which most of the measures outlined above have been im- plemented has not been ascertained, and even where implemented, their effect on patterns of migration is yet to be determined. In the case of compulsory service in rural areas, for example, there are those who feel that even where special allowances are awarded, such service only postpones the date of emi- gration. As for the increased production of professional health manpower in countries that can ill afford the cost of such manpower, this can serve only to create a larger pool of potential migrants. 92 Biomedical Research in Latin America Policies in Major Recipient Countries The major recipients of health manpower from the Region are the United States and, to a much lesser extent, Canada and the United Kingdom. Until very recently the policy in each of these countries was such that incoming professional health workers were welcome and could find employment. Within recent years, however, all three countries have taken steps toward rely- ing more heavily on domestic supplies of health manpower. In Canada, federal immigration regulations were so amended in February 1975 that graduates of foreign medical schools entering Canada as landed immigrants must either have made prior arrangements for employment in positions for which no Canadian citizen or legal Canadian resident was avail- able, or must be proceeding to a destination designated as being persistently in short supply of physicians [40]. In the United Kingdom, the number of overseas-awarded medical qualifi- cations recognized by the General Medical Council as warranting full regis- tration is gradually diminishing as local production of physicians is increasing. Additionally, in 1975 the council introduced tests of linguistic proficiency and of professional knowledge and competence for individual physicians applying for temporary registration. A candidate who fails either of these tests cannot be registered, even temporarily [41]. The need to accommodate an increasing number of unemployed British nurses has led to a sharp cutback not only in the number of foreign-trained nurses being admitted to practice but also in the number of foreign students admitted for training in nursing. In this respect, English-speaking countries of the Caribbean, from which many stu- dents have been coming to the United Kingdom for training and service in hospitals, are likely to be strongly affected. Perhaps the strongest effect on health manpower migration from the Region will be caused by the U.S. Health Professions Educational Assistance Act [42], which essentially aims at production of more primary care practitioners and improvement of health services in manpower-shortage areas. The law, which became effective on January 10, 1977, and will remain in force for at least 5 years, declares that there is no longer an insufficient number of phy- sicians and surgeons in the United States and that there is no further need to accord preference to alien physicians and surgeons with respect to ad- mission to the United States. More specifically, the act requires the following: ® Foreign physicians wishing to enter the United States as immigrants on the basis of professional skills (preference categories 3 or 6 of the Immigration and Nationality Act), as special immigrants from the Western Hemisphere, or as nonpreference immigrants must pass parts I and II of the National Board of Medical Examiners examination (or an equivalent as determined by the sec- retary ) and be competent in written and oral English; Alfonso Mejia 93 e Foreign physicians may enter the United States as exchange visitors (J visa) only on condition that a school of medicine and an affiliated hospital have agreed in writing to provide the individual’s training, _the individual, in addition to meeting the above-mentioned require- ments, will be able to adapt to the educational and cultural environment in the United States and will have had adequate prior training, _the individual’s country has given written assurance that upon com- pletion of training the individual will be appointed to a position where acquired skills will be utilized fully, _the individual will stay in the United States no more than 2 years unless additional training is specifically requested by the country of origin. (Requirements pertaining to exchange visitors may be waived until Decem- ber 31, 1980, in situations where there might be a substantial disruption in the health services provided by the graduate training program in which the alien seeks to participate. However, in granting waivers, the Attorney General must ensure that the total number of aliens participating in such programs any time after January 10 does not exceed the number participa- ting on January 10, 1977); e Foreign physicians who are in the United States as exchange visitors and wish to apply for permanent residence status are no longer eligible, simply on the basis of permission from their country, for a waiver of the requirement that they first return to their country for a period of 2 years. e Foreign physicians are no longer allowed to enter the United States as persons of “distinguished merit and ability” coming to perform services of an exceptional nature requiring such ability (H visa) unless they have a specific invitation, from either a public or a nonprofit private educational or research entity, to teach or to conduct research or both. With immigration virtually precluded and with visas for study, teaching, and research sharply restricted, the movement of foreign health manpower into the United States for permanent residence is expected to drop gradually to ex- tremely low levels. In countries that produce more highly skilled health workers than their health services can effectively and productively employ, which appears to be the case in a number of countries of the Region, the problem may become one of how to absorb the equivalent of those who seek migration as an alternative to unemployment or underemployment in their homelands. For individual physicians and nurses the problem may become one of finding other coun- tries where they might be gainfully employed. With restrictions in Canada, the United Kingdom, the United States, and in the Federal Republic of Germany as well, and given the rather precarious employment situation in other countries of Western Europe, the direction of migration from countries of the Region may change considerably, as long as current push forces continue 94 Biomedical Research in Latin America to operate in those countries. One outcome may be a move toward more pros- perous and stable countries within the Region. Another may be a move toward oil-exporting countries of Asia and Africa, where the effective economic demand for health manpower is increasing. Another possible effect of res- trictions in the major recipient countries may be a reorientation, in the coun- tries of the Region, of policies and plans for development and utilization of health manpower. Conclusions There is sufficient evidence to substantiate the order of magnitude of the outflow of health manpower, particularly physicians, from Central and South America to provide a guide for policy and action. The net flow, however, remains to be determined; therefore, the flow of health manpower between countries of the Region and the inflow from outside the Region are important areas for future investigation. A large part of the migration appears to be due to imbalances between the supply of, and the effective economic demand for, the particular type of health manpower involved. The consequences of migra- tion can be considered negative only to the extent that the individuals involved could have been productively employed in the health services of their home- land; but if that were the case, they might not have migrated in the first place. The loss of time and money invested in training health manpower who migrate is not so much a consequence of migration as it is a consequence of poor planning, i.e., the failure to invest such resources in those types of manpower whose employment and productivity within the country can be reasonably assured. To document information on health manpower migration remains nothing more than an interesting but empty academic exercise unless the findings are used as a basis for effecting change, if change is warranted. Given that migration of health manpower is, for the most part, the result of unrealistic health manpower policies and plans, it follows that the focus of change should be on development and implementation of realistic health manpower policies and plans. What is realistic will depend on the objectives. If the objective is merely to curb the migration of health manpower, a realistic policy would be to start reducing the supply to the amount actually or likely to be required to meet the demand, if such a reduction has not already occurred as a result of migration. If, on the other hand, the objective is to improve the health of the country’s people, realistic policies and plans would be those that take into account the following: (1) what the people need now and may need in the future by way of services and care for the promotion of health and the cure of disease; (2) what types of health workers and how many of each type would be required to perform the tasks to be undertaken, keeping in mind that for Alfonso Mejia 95 certain tasks, auxiliaries may prove to be more appropriate and cost effective than professional personnel and that communities can be organized to perform health work; and (3) what constraints—political, economic, administrative, social, and cul- tural—would need to be neutralized, circumvented, or otherwise reconciled. The above suggests that there are different ways of interpreting health manpower. One is to view health manpower as serving demand, in which case realistic health manpower policies and plans will be those geared to meeting that demand; accordingly, health manpower produced in excess of demand may well turn out to represent a lost investment for the country that made the investment in education. Another way is to view health manpower as serving a need, or it may be examined in terms of policies and plans. And finally there is the reality of constraints that, if ignored during the planning process, can render useless even the most exquisite of plans. At the risk of being repetitious, we note again that health manpower migra- tion, like most migration, is basically only a symptom of deeper problems and that the desire or need to migrate is bound to lessen as these problems are resolved. Thus, it is not enough for donor countries merely to lament migration, to wash their hands of the affair by laying the blame entirely on recipient coun- tries, and to continue requesting more migration studies. There are good reasons to believe that donor countries have failed to utilize what is already well known about migration as a basis for decisionmaking. This failure may well be a lack of national will to tackle the underlying problems. In the major recipient countries, particularly the affluent industrialized ones, there appears to be a great reservoir of moral concern about their role in the loss of skilled manpower from the developing world. While it would be nice to think that such moral concern would be the primary force that might induce the major recipient countries to help the donors in overcoming the problems underlying migration, the fact remains that there are even stronger reasons for doing so—the main one being the growing political and economic power of the developing world and thus the broader interdependency between the developed and the developing worlds. At a time when many basic assumptions about the world economic order are being challenged and the developing world is assuming a stronger role in the shaping of international institutions, there is good reason to believe that the self-interest of affluent countries can be secured only if it is merged with a growing enlightened regard for the global interest. The general structure of international politics and economics will no longer make it practical for devel- oped countries to attempt unilaterally to arrange, on their own terms and in their interest solely, the major issues between them and the developing world. It is not sufficient that the major recipient countries individually and uri- laterally take measures—as they are doing—to curb the inflow of physicians. 96 Biomedical Research in Latin America Such measures will not automatically and immediately solve, for the donor countries, the problems underlying migration, such as overproduction of physicians to meet the export market—a market major recipient countries either explicitly or implicitly stimulated over the past decade. Through bi- lateral negotiations and in the context of the new concept of technical coop- eration, perhaps a more mutually beneficial approach to regulating health man- power migration may be found. International agencies such as WHO could play an important role in such negotiations. References 1. World Health Organization. Multinational study of the international migration of physicians and nurses. Country-specific migration statistics. (Unpublished WHO document HMD/76.4) 2. World Health Organization. World Health Statistics Annual 1972, Vol. 3. Geneva: WHO, 1976. 3. American Medical Association. Profile of Medical Practice (prepared by S. Vahovich and P. Aherne). Chicago: AMA Center for Health Services Research and Develop- ment, 1973. 4. Stevens, R., et al. Physician migration reexamined. Science 190:439442, 1975. 5S. National Science Foundation. Scientists, engineers and physicians from abroad; trends through fiscal year 1970. Washington, D.C.: NSF, 1972. 6. Haug, J.N., and B.C. Martin. Foreign Medical Graduates in the United States, 1970. Chicago: American Medical Association, 1971. 7. American Medical Association. Profile of Medical Practice. Chicago: AMA Center for Health Services Research and Development, 1976. 8. (Colombian) Ministry of Public Health and Colombian Association of Medical Faculties. Study of Human Resources for Health and Medical Education in Co- lombia: Methods and Results. Bogota: Ministry of Public Health, 1972. 9. Yepes, R.F., et al. Migracion de médicos. AFEME:7-10 (year not available). 10. Adorno, A.R. Emigracion de profesionales médicos. Rev Med del Paraguay 11: 36-43, 1970. 11. Canese, A. El éxodo de los profesionales paraguayos. Rev Med del Paraguay 11: 29-43,1970 12. World Health Organization. World Health Statistics Annual 1971, Vol. 3. Geneva: WHO, 1976. 13. (Colombian) Ministry of Public Health and Colombian Association of Medical Schools. Study of Health Manpower and Medical Education in Colombia. Wash- ington, D.C.: PAHO, 1967. 14. Hoyos, G.E. The outflow of professional manpower from Colombia. Bogota, 1979. (Unpublished document) 15. United Nations Educational, Scientific, and Cultural Organization. Foreign Students in Medical Schools. Paris: UNESCO, 1974. 16. Rodriguez, M.I. El estudiante de medicina—su distribucion en las Américas, 1971- 1972. Educ Med Salud 8:360-389, 1974. 17. American Nurses Association. Facts about nursing: a statistical summary (editions for the years 1960-1974). New York: American Nurses Association 18. Pan American Health Organization. Subcommittee on Migration. Migration of Health Personnel, Scientists and Engineers from Latin America. Scientific Publica- tion No. 142. Washington, D.C.: PAHO, 1966. 19. Bruinsma, J.H. A study of the movement and location of U.W.I. medical graduates, classes 1954-1965. West Indian Med J 19:91-93, 1970. 20. (Canadian) Immigration Division. Immigrant arrivals: physicians and surgeons (unpublished document). Alfonso Mejia 97 21. 22. 2. 24. 2S. 26. 27. 28. 29. 30. 31. 32. 33. 34. 3s. 36. 37. 38. 39. 40. 41. 42. Gish, O. Doctor Migration and World Health; the Impact of the International Demand for Doctors on Health Services in Developing Countries. Occasional papers on social administration No. 43. London: G. Bell, 1971. British Council. Overseas Students in Britain (statistical reports for years 1959 to 1973 inclusive). London: British Council Students Centre. Annual report on graduate medical education in the United States. JAMA 234: 1354-1356, 1978S. Haug, J., and R. Stevens. Foreign medical graduates in the United States in 1963 and 1971: a cohort study. Inquiry 10:19-25,1973. Butter, I. The migratory flow of doctors to and from the United States. Med Care 9:17-31, 1971. Yankauer, A., and J. Arias. Studies of the migration of Colombian medical grad- uates. I. Secular trends and permanency of migration to the USA (unpublished document). United Nations. Yearbook of National Accounts Statistics 1975, Vol. 3. New York: United Nations, 1976. International Bank for Reconstruction and Development. Health Sector Policy Paper. Washington, D.C.: IBRD, 1975. World Almanac and Book of Facts 1977. New York and Cleveland: Newspaper Enterprise Association, 1976. Pan American Health Organization. Health Conditions in the Americas, 1969- 1972. Scientific Publication No. 287. Washington, D.C.: PAHO, 1974. Hols, C., et al. Redistribution with Growth. London: Oxford University Press, 1974. Casiraghi, J.C. Masificacion estudantil. Conferencia Pan-Americana de Educagio Médica (VI) y Congresso Brasileiro de Edugdcao Médica (XIV). Rio de Janeiro, 1976. Bowers, J.Z., and M. Rosenheim (eds). Migration of Medical Manpower (papers from an International Macy Conference). New York: The Josiah Macy, Jr., Foun- dation, 1971. Oteiza, E. Emigracion de profesionales, técnicos y obreros calificados argentinos a los Estados Unidos—analisis de las fluctuaciones de la emigracion bruta, julio 1950 a junio 1970. Desarollo Econémico 10:429-454, 1970-1 971. Ritterband, P. The Non-Returning Foreign Student: The Israeli Case. New York: Colombia University, 1968. United Nations Institute for Training and Research. The Brain Drain From Five Developing Countries—Cameroon, Colombia, Lebanon, the Philippines, Trinidad and Tobago. New York: UNITAR, 1971. Israel, E. Incentives offered to civil servants in the medical field for services in remote, semi-rural and rural areas (unpublished WHO document —WHO/SHS/ 76.1). Conférence internationale d’Etats en Vue de 1’Adoption de la Convention régionale sur la Reconnaissance des Etudes et des Diplomes de Enseignement supérieur en Amérique Latine et dans la Région des Caraibes, Mexico, 15-19 juillet 1974. Rap- port final (unpublished document ED-74/COREDIAL/4). Chiarelli, C.A. Social security for rural workers in Brazil. Int Labour Rev 113:159- 169, 1976. Arnold, C.R. Manpower planning—the view from the licensing body. Forum (Jour- nal of the Association of Canadian Medical Colleges) 9:11-15, 1976. (Great Britain) General Medical Council. Annual report for 1975. London: Office of the Council, 1976. (U.S.) Department of Health, Education, and Welfare. Fact Sheet: Health Profes- sions Educational Act of 1976 (PL 94-484). Bethesda, Maryland: HRA, 1976. PARASITIC ILLNESSES AS A PUBLIC HEALTH PROBLEM Amador Neghme Problems Produced by Parasitic Illnesses Background Knowledge of the distribution and prevalence of parasitic infection and ill- nesses is still deficient, since health and medical assistance services provide few resources for their investigation and control. In addition, universities have also restricted resources for investigation. Many more laboratories capable of performing parasitological and serological diagnoses are needed. There is even greater need for personnel involved in parasitology such as laboratory workers and technicians prepared in parasitology and serology as applied to diagnostics. Finally, available statistical information is incomplete’and unrealistic. Mandatory reporting of most parasitic illnesses is not required. Most ill- nesses occur in marginal populations in rural and suburban areas, which lack medical and health assistance services. When doctors identify the causative parasites or have positive immunodiagnostic tests, they do not report the cases to health authorities. In medical facilities, the policy of notification is generally limited to infectious illnesses. For these reasons, the prevalence of parasitic disease is under-reported, the true demand for medical attention is ignored, and very few studies are available that show the costs produced by some parasites. These can be very high if calculated on the basis of cost for hos- pitalization, loss of time at work, and the resulting physical infirmity [1,2]. The accelerated rate of population growth worries statisticians and directors of health institutions because of its deleterious impact on levels of life and health in important suburban sectors of large cities. The average growth rate in Latin America and the Caribbean countries is 2.8 percent. According to figures given by the Population Reference Bureau, Inc., around the middle of 1975, inhabitants of these countries were approaching 324 million. Of these, approximately 34 million lived in cities with more than 100,000 people. It was estimated that at least 290 million people lived in urban areas with fewer than 100,000 inhabitants and in rural areas. The director of the Pan American Health Office at that time, Dr. Abraham Horwitz [3], estimated that 37 99 100 Biomedical Research in Latin America TABLE 1. Estimated Prevalence of Some Parasitoses Among 120 Million Rural Inhabitants of Latin America Parasitosis Estimated Percentage People Infected (millions) Amebiasis 20 24 Giardiasis 15 18 Toxoplasmosis 30 36 Ascaridiasis 40 48 Trichocefaliasis 40 48 Uncinariasis 30 36 Chagas’ disease - 10 Schistosomiasis - 15 percent of the population lived in rural areas lacking a basic economic infra- structure. If one makes calculations based on various surveys of parasitic infections in some countries and then generalizes to all 120 million inhabitants of rural Central and South America, one obtains the minimum number of individuals infected with parasites with some other more frequently occurring parasitoses (table nk. Even now, few statistical data are available concerning mortality produced in Latin America by parasitic illnesses. The program of inter-American investi- gation of urban mortality, begun in 1960 by the Pan American Office of Health in conjunction with the National Institutes of Health [22], revealed interesting data concerning deaths caused by parasitic illnesses—such as Chagas’ disease, amebiasis, and cestodiasis—in some Latin American cities (table 2). The wide disparity in mortality rates can be attributed to the fact that in most cases death occurred in a rural area or in a hospital center that was far from a large city and did not perform autopsies. Often, regional hospitals of larger areas also lack facilities to perform autopsies. The one exception is the city of Riberdo Préto, which is located in an area of endemic American trypano- somiasis and has a hospital that receives patients from an extensive rural sector. This explains the mortality rate of 82.5 per 1000 inhabitants in that city. dn formation concerning the morbidity of some of the parasitic illnesses of various countries throughout the region is given in references 4-9. The annual reports of the Director of the Pan American Health Organization (1971-76) [10] and the basic reference documents of the Third Special Meeting of the Health Ministers also discuss the prevalence and control of some parasitic endemics [11]. Some reports by groups of experts called together by WHO or PAHO and published in the series of technical reports contain useful information about epidemiology and the treatment and control of various parasitic ill- nesses [12-21]. TABLE 2. Mortality for Parasitic Illnesses Investigated in Ten Latin American Cities, Annual Rates per 100,000 Inhabitants Mexico Ribeirdo Sido Illness Bogota Cali Caracas Guatemala La Plata Lima City Préto Santiago Paulo Malaria 0.1 0.9 - 0.2 - - - - - - Chagas’ disease 0.3 - 2.7 1.3 0.7 - - 82.5 0.2 4.0 Amebiasis 1.6 2.7 1.9 2.9 - - 4.6 - 0.7 0.1 Cestodiasis (Hydatidosis & cysticercosis) 0.4 - 0.1 0.8 0.4 1.7 0.3 2.6 1.4 0.3 Source: Data from R.R. Puffer and G.W. Griffith, Patterns of Urban Mortality, Washington, D.C.: Pan American Health Organization, 1967. swydaN Iopewy 101 102 Biomedical Research in Latin America Investigations were continued from 1968 through 1970 by another study of infant mortality [23], which covers approximately 35,000 deaths of infants and children under 5 years of age, from 15 different regions of several Latin American countries. Its findings verify the seriousness of parasitic illnesses in Central and South America by showing that Chagas’ disease caused 13 deaths (7 in the province of San Juan and 1 in Chaco, Argentina; 3 in the state of Sdo Paulo [Ribeirdo Préto], Brazil; and 2 in Chile), and congenital toxoplasmosis caused 18 deaths (11 in the state of Sdo Paulo). This investi- gation provides other evidence of the role of parasites as a cause of death or as elements associated with other etiologies. These data are summarized in table 3. TABLE 3. Parasitic Diseases as Causes of Death in Children Under Age 5 in 15 Projects (Rates per 100,000 Inhabitants) Amebiasis Helminthiases Underlying Associated Underlying Associated Project No. Rate No. Rate No. Rate No. Rate Argentina Chaco province - - - - - - - - San Juan province - - - - - - - - Bolivia 2 1.3 1 0.6 1 0.6 10 6.3 Brazil Recife 1 0.8 1 0.8 16 12.9 346 279.2 Ribeirdo Préto - - - - 1 12 32 38.8 Sdo Paulo 1 0.4 - - 5 21 92 37.7 Canada Sherbrooke - - - - - - - - Chile - - - - - - - - Colombia Cali 7 6.9 2 2.0 3 4.9 S51 50.4 Cartagena 32 37.2 18 20.9 10 11.6 120 139.5 Medellin 17 18.2 7 7.5 6 6.4 72 72.2 El Salvador 87 69.4 10 8.0 14 1.2 268 213.9 Jamaica Kingston-St. Andrew - - - - 3 1.6 5 2.7 Mexico Monterrey 156 71.6 41 18.8 8 37 80 36.7 United States California - - - - - - - - Total 303 14.4 80 3.8 69 3.3 1,076 51.3 Source: Reproduced with permission from R.R. Puffer and C.V. Serrano, Patterns of Mortality in Childhood, Washington, D.C.: Pan American Health Organization, 1973. Amador Neghme 103 Investigations of Interest in Public Health Since current information is scarce and fragmentary, it is important to under- take epidemiologic studies and investigations to gain better understanding of the frequency and distribution of parasitoses in various communities and of sick people throughout Latin America. For this, it will be necessary to organ- ize a number of regional and national diagnostic and reference laboratories to serve as support, after identifying those already existing and improving them in accordance with the directives of cognizant authorities. It is also important to organize programs at the local, regional, and inter- national levels to instruct professional and technical support health personnel in the methods and techniques of serological and parasitological diagnosis and in the control of parasitic illnesses. These didactic activities should be accom- panied -by a program for their continued improvement and implementation. Epidemiologic investigations of parasitic illnesses should use direct or indirect methods of parasitologic diagnosis, especially serologic tests. To ensure statistical validity, these tests should be made on random samples that are representative of the entire population.’ In addition, it is important to in- vestigate the effects of individual cases of infection on families. Seroepidemiology, practiced with highly efficient methodology and titrated antigens and controlled with quantitative methods, now offers the most favor- able outlook for better knowledge of the morbidity of parasitic illnesses [24] ; therefore, research laboratories should evaluate the techniques and antigens used in order to standardize and perfect them. An example of this type of investigation is the National Test for the Prevalence of Trypanosomic Infection in Brazil, which has been carried out by the Institute of Tropical Medicine of So Paulo since 1976 in collaboration with the superintendent of public health campaigns of the Public Health Ministry. The investigation, still in progress, involves serologic examination of 2 percent of the population living in rural areas of municipalities or geographical microregions of Brazil. It is calculated that investigators will examine 1.6 million people at random who are repre- sentative of the population at large. Blood samples are processed in a network of laboratories to which the Institute of Tropical Medicine distributes reagents, titrated antigens, and lyophilic blood serum patterns. The samples are analyzed in the network of regional laboratories that use the anti-IgG immunofluores- cence test. By the end of 1977, approximately 500,000 blood samples were taken. Approximately 7 percent of the first 300,000 samples were positive for trypanosomic infections, although in some regions of southern Brazil, up to 20 21 Venezuela, the division of rural endemics of the Ministry of Health and Social Assistance is presently carrying out this type of test at the national level in order to establish indexes of prevalence for the most frequent intestinal helminths (personal communication from Dr. Sifontes, 1977). 104 Biomedical Research in Latin America percent positive test results have been obtained. For greater security, the Insti- tute of Tropical Medicine controls for examinations performed by other labora- tories by using immunofluorescence and immunoenzymatic tests (ELISA).3 Use of intercountry investigations is also desirable through utilization of personnel and resources available to public health institutes. An example of this type of teamwork on the institutional level is the work on nutritional anemia in the third trimester of pregnancy by a group of investigators in seven American countries, coordinated by PAHO [25]. Every day parasitologists are becoming more concerned with the role of the humoral and cellular immune responses in the natural evolution of a parasitic disease, as well as the role of malnutrition—its synergistic effect associated with chemotherapy and its repercussions for pregnancy and the puerperium, the fetus, and the neonate. These important aspects should be investigated because of their influence on maternal and infant health. The antiparasitic therapeutic arsenal is continually being updated, thus testifying to the interest of doctors and the pharmaceutical industry in iden- tifying more effective drugs with a broader spectrum of action, less toxicity, better tolerance, and lower cost [S]. The tendency is to search for drugs that can be administered in a single oral dose. Investigation of variations in thera- peutic response—individual or genetic differences in metabolism of a drug, adverse reactions and intolerances, and the possibility of harming an unborn child—will contribute to perfection of drug administration without risk for the patient and will facilitate administration of mass dosage for control and prevention in entire communities. To achieve these goals, in 1977 the Latin American Federation of Parasitologists (with support by Charles Pfizer Co.) called together a group of Latin American clinical parasitologists, who de- veloped tentative standardization procedures for evaluating medicines in various Latin American countries. It was concluded that “Rapid population increases, along with migration, urbanization, culturation, and transculturation, contribute to the formation of communities living on the margin of sanitary facilities, even in the larger cities. These social phenomena should be taken into consideration during epidemiologic investigations and the formulation of comprehensive health plans, where parasitologic disease cannot be ignored,” [26] and that, therefore, parasitologists and epidemiologists should meet with educators, sociologists, and cultural anthropologists. 3M. Camargo, personal communication, February 1978. AR. Campos and A. Atias, personal communications. Amador Neghme 105 Principal Lines of Investigation Based on the preceding considerations, investigation of parasitic diseases is of the utmost importance for public health in Latin America. There remain, of course, numerous other interesting research areas in which the initiative of some parasitologists has led to the organization of special study facilities. For all parasitic diseases, unknowns in physiopathology, biochemistry, and immunology constitute open areas for research. Causes of variations in para- sitoses from one continent or region to another and geretic differences in metabolism of medications are not fully known. Variations that parasitic illnesses undergo because of biologic and ecologic changes introduced into the environment by man need to be understood, as well as the selective action of antiparasitic drugs. Malaria has reappeared in some Latin American countries during the last few years [27], and researchers continue to seek diligently for a good poly- valent, well-tolerated, easily administered antimalaria therapy to control this disease. Resistance of Plasmodium falciparum to the 4- aminoquinoleinics has been shown in various regions of South and Central America, and resistant strains are spreading, possibly through immigration of carriers to zones where they were previously unknown. The recent rediscovery of P. falciparum in Panama can be explained in this manner [28]. More than 250,000 chemical compounds have been studied and some highly active drugs have been identified to treat infections caused by P. falciparum and P. vivax [16]. Some of these new antimalarial drugs have demonstrated effective action against the tissular schizonts of P. vivax. In addition, methods for evaluating antimalarial effects in animal models, especially monkeys, rodents, and birds, have been perfected. Thus, Young et al. [28] infected the nocturnal monkey Aotus trivirgatus with Panamanian strains of P. vivax, a discovery preceded by the demonstration of Geiman and Meagher [29] involving transmission of two strains of P. falciparum in the same species of monkey. Aotus trivirgatus, like Macaca mulatta and other species of primates, has acquired great importance in experiments with antimalarial drugs, and there is much interest in preserving the species in its natural surroundings and in breeding it. The search continues for other species of primates susceptible to human plasmodia. This new situation has given considerable prestige to the study of malaria in monkeys [30]. Furthermore, use of primates is acquiring more significance in experimental medicine. An increase in experimental studies in other parasitic illnesses can be predicted for the future through the use of primates, especially in the histoprotozooses. Association of parasites with viruses, bacteria, or fungi influences their pathogenic power and therefore affects the pathogenesis of parasitic diseases, a matter that has scarcely been explored. Similarly, the biology of vectors and 106 Biomedical Research in Latin America their role in the transmission of mixed infections by viruses, bacteria, and parasites have also been poorly researched. Special emphasis should be placed on basic research that encompasses relationships between parasite and host, and between these two and the en- vironment. A tentative list of suggested investigations follows: Man-Parasite Relationships There is a need for physiopathological, biochemical, and immunological studies of the relationship between parasites in man and vice versa, applying the most modern technology and biochemical, radioisotopic, scintigrams, immunological analyses, etc., to obtain more exact knowledge of the pathology of parasitic diseases. Preference should be given to investigations of those parasitoses limited to Latin America, such as Trypanosoma cruzi and Chagas’ disease; Leishmania spp. and mucocutaneous leishmaniasis; Bartonella bacil- liformis and bartonellosis, or Carrion’s disease. Research should be encouraged in other diseases that are highly prevalent in Latin America and produce serious pathology: Plasmodium spp. and malaria; Echinococcus granulosus and hydatidosis; Cysticercus cellulosae and cysticercosis; Schistosoma mansoni and schistosomiasis. Intestinal protozooses and geohelminthiasis, especially Necator americanus and Ancylostoma duodenale, will be studied soon, along with other parasitic zoonoses (trichinellosis, cestodiasis, fascioliasis) and parasitoses whose occur- rence is still limited to certain regions but is spreading into other geographical areas— Onchocerca volvulus and onchocerosis and others that have been discovered recently: Diphyllobothrium pacificum, Angiostrongylus costari- censis, and human angiostrongilosis. Immune Response It would be beneficial to understand more fully the immune responses of patients and the causes of their variation (genetic, endocrine, nutritional, etc.). Such experimental work might involve participation of investigators from such fields as immunology, human genetics, endocrinology, nutrition, and pathology. The diet and nutritional state of the host can influence fre- quency and severity of parasitic illnesses. Thus it is necessary to investigate these at the regional and national levels for each of the parasites mentioned. Of special interest is identification and exact characterization of parasitic antigens, their role in immunology, and their eventual application for diagnosis. Experiments With Primates Experimentation with animals will employ primates rather than humans whenever possible since primates are easily obtained in most regions of tropical Amador Neghme 107 America [30]. Other species will be used as necessary, with preference given to those maintained by inbreeding. Whenever possible, the species of parasites will be known strains which have been grown in artificial media and tissue cultures. Results of these experiments will be comparable with clinical experi- ments, and a correlation will be established between the mechanisms of cellular penetration in vertebrate animals and man and those observed in tissue cul- tures. Differences in the mechanisms of cellular penetration for distinct strains or species of intracellular parasites will also be compared. (After penetration, Leishmania spp. is exposed to secretions produced by lysosomes. This does not seem to happen with 7. cruzi. Toxoplasma gondii, on the other hand, does not invade cells with numerous phagocytes and is not expelled through the secretions of lysosomes.) Closely related to the phenomenon of cellular pene- tration is knowledge of the structure of the membrane of parasitic protozoa. For this, the previously mentioned species could be subjected to a careful chemical characterization of the membranes and immunological techniques that use fluorescent antibodies to determine the possible role of the membrane to antigens in the penetration of protozoa (Agosin, 1978, personal communi- cation). Histopathological studies of living human and animal tissue which has been naturally or experimentally infected with parasites should be made with the electron microscope. Biochemistry of Parasites Investigations by T. von Brand [31] and M. Agosin and others [32] have opened an important area of research in parasitology, one that very few Latin American investigators are following at present. This line of investigation is fundamental for exact comprehension of the action mechanism of chemical substances, and it requires researchers who are skilled in biochemistry, molec- ular biology, protein chemistry, and genetics. Parasitologists in multidisci- plinary scientific institutes have easier access to these specialized researchers. Few parasites that are extremely prevalent in Latin America have been studied from a biological point of view. The biochemistry of their immediate hosts and biological vectors has also been ignored. These investigations should in- clude biochemical immunology. Related to the refinement of current immuno- logical techniques is the analysis of parasitic antigens and their biosynthesis as well as development and evaluation of effective, well-tolerated vaccines that can protect persons exposed to various causal agents (malaria, Chagas’ disease, schistosomiasis). The biochemistry of parasites will elucidate many problems, for example, some aspects of the biochemistry of hemo- and histoparasitic protozoa such as differences between blood and tissue forms observed in tissue cultures. The recent discovery of the in vitro culture of erythrocytic forms of P. falci- parum [33], in addition to representing a potential source of antigens for mass 108 Biomedical Research in Latin America vaccination, will also facilitate research in molecular biology and the phenome- non of resistance to specific medications. Another area that still has not been covered in developing countries is the characteristics of contractile proteins in protozoa and parasitic helminths. These proteins, principally actine and myo- sine, could be the theme of important genetic studies at the molecular level. Results of these studies could be used for a better understanding of the action of drugs.’ The same can be said of investigations of drug metabolism in both host and parasite. It will be necessary to find methods of better understanding the function of tissues of parasites and of analyzing toxifying enzymes and enzymatic products, as recently demonstrated by Agosin and others in T. cruzi [32]. In spite of the investigations of Layrisse and others of anemia in parasitoses [34], factors affecting blood coagulation in some parasitoses such as uncinariasis (hookworm disease) and other parasitoses that cause bleeding- induced anemia are still unknown. Fundamental Investigations o f Other Parasitic Diseases Equally important is an understanding of the mechanisms whereby parasites invading blood circulation affect clotting (Schistosoma spp.) and their possible relationship with the regulating mechanisms of immunology called modulation in schistosomiasis [35]. The Department of Coordination and Scientific Development of PAHO organized an international symposium in March 1975 in Belo Horizonte, Brazil, and invited outstanding researchers in the field of Chagas’ disease from 19 Latin American countries. All aspects of this parasitosis were reviewed and a detailed plan for future investigations was outlined. Scientific Publication 318 of that organization [13] contains the work presented; the discussions, the research that was recommended for the vector, the parasite, the host response, and clinical aspects of the disease, along with diagnosis, epidemiology, and treatment. With such complete documentation we need not provide details on this subject. Final Considerations In the past, PAHO has promoted research in epidemiology and methods of controlling parasitoses. The recommendations adopted in the Conference of Public Health Ministers of the Americas in October 1972 are mostly those of PAHO [11,36]. Among other accords, the following evolved for the decade of 1971-80: 5 7 LL. M. Agosin, personal communication. Amador Neghme 109 e To control infectious and intestinal parasitoses because of their elevated morbidity and mortality; e To better understand the frequency and distribution of Chagas’ disease and schistosomiasis and to encourage programs for their control; e To promote the active participation of the community in the programs against parasitic diseases; e To reduce the transmission of malaria to the lowest possible level in areas with 17.3 million inhabitants where progress depends on surmounting serious operational and technical problems; ® To achieve eradication in areas of 74.5 million inhabitants where available resources increase the likelihood of success. The goal for 1980 specifies an incidence of malaria of 0.5 per thousand inhabitants. These admirable aims, however, have not yet influenced decisions, politics, or the national health institutes of all the countries. If they are im- plemented, they will lessen the heavy burden that parasitoses still impose on extensive sectors of the Latin American population. According to Dr. Abraham Horwitz [3]. former director of the Pan American Sanitary Office, “The common problem is that 37 percent of the Latin American population still does not have access to minimum health services. There are 108 million in- habitants who are not offered the opportunity to satisfy a vital necessity.” Perhaps there is no more characteristic sign of the times than the paradox resulting from the opposition between the industrialized countries and the developing world. In the former, parasitic and infectious diseases have ceased being serious health problems and the concern is the so-called *‘sick- nesses of civilization” —products of the effects of man on the environment. On the other hand, in Latin America, vast sectors of marginal populations bear the heavy burden of the suburban and rural “ills of poverty.” Parasitic and infectious diseases represent a tangible measure of this poverty. These diseases are favored by the living conditions and worsened by malnutrition, ignorance, and poverty [1]. Without a dynamic continental research program for parasitic diseases in their epidemiological and fundamental aspects, improvements in the health of most Latin American countries will never be realized. This program requires as a sine qua non the solution to problems previously described, especially the current shortage of human and financial resources. References 1. Neghme, A., and R. Silva. Ecologia del parasitismo en el hombre. Bol Of Sanit Panam 60:313-329, 1971. 2. Neghme, A., and R. Silva. A hidatidose como problema médico, sanitario e social e esbogo bésico para sua profilaxia. Rev Ass Med Brasil 16:279-286, 1970. 3. Horwitz, A. Informe Anual para 1972 del Director de la Oficina Sanitaria Panameri- cana. Introduccion. Official Document No. 124. Washington, D.C.: PAHO, 1973. 110 10. 11. 12. 13. 14. 18. 16. 17 18. 19. 20. 21. 22. 23. 24. 28. 26. 27. 28. Biomedical Research in Latin America Lacaz, C. da S., R.G. Baruzzi, and W. Siqueira, Jr. Introdugio a Geografia Médica do Brasil. Editora Edgard Blucher Ltda. Editora da Universidade de Sao Paulo. Sao Paulo, Brasil, 1972. Botero, D. Clinical trial methodology in intestinal parasitic diseases. Clin Pharmacol Ther 19:630-637, 1976. Fraiha, H. Panorama atual das parasitoses na Amazonia. Instituto Evandro Chagas. Fundagdo Servigo de Satde Piblica. Belém, Brasil: Ministerio de Saude, 1977. Maldonado, J.F. Helmintiasis del hombre en America (editorial). Cientifico-Médica, Barcelona, 1965. Ministerio de Salud Publica Colombia y Asociacién Colombiana de Facultades de Medicina. Estudios de recursos humanos para la salud y la educacién médica en Colombia. Parasitismo Intestinal. Bogotd, Colombia, 1969. Istituto Italo-Latino Americano. Seminario Internazionale sulle malattie parasit- arie de importanza sociale in America Latina (18-21 Ottobre 1971). In collabo- razione con P’lstituto Superiore di Sanita. Roma, 1972. Organizacién Panamericana de la Salud. Informe Anual del Director. Documentos oficiales Nos. 116, 124, 131, 139, 143, y 150. Washington, D.C.: OPS. Organizacién Panamericana de la Salud. III Reunién Especial de Ministros de Salud de las Américas. Proposiciones de cambio y estrategia para la década 1971-1980. Washington, D.C.: OPS, 1972. Organizacién Panamericana de la Salud. Informe de un Grupo de Estudio sobre la Enfermedad de Chagas. Washington, D.C.: OPS, 1970. Pan American Health Organization. New Approaches in American Trypanosomiasis Research. Scientific Publication No. 318. Washington, D.C.: PAHO, 1976. Pan American Health Organization. Onchocerciasis in the Western Hemisphere. Scientific Publication No. 298. Washington, D.C.: PAHO, 1975. World Health Organization. Amoebiasis. Technical Report Series No. 421. Geneva: WHO, 1969. World Health Organization. Chemotherapy of Malaria and Resistance to Anti- malarials. Technical Report Series No. 529. Geneva: WHO, 1973. World Health Organization. WHO Expert Committee on Filariasis. Third Report. Technical Report Series No. 542. Geneva: WHO, 1974. World Health Organization. Developments in Malaria Immunology. Technical Report Series No. 579. Geneva: WHO, 1975. World Health Organization. Resistance of Vectors and Reservoirs of Disease to Pesticides. Technical Report Series No. 585. Geneva: WHO, 1976. World Health Organization. Ecology and Control of Vectors in Public Health. Technical Report Series No. 561. Geneva: WHO, 1975. Organizacién Mundial de la Salud. Helmintos transmitidos por el suelo. Serie Informes Técnicos No. 277. Ginebra: OMS, 1972. Puffer, R.R., and G.W. Griffith. Patterns of Urban Mortality. Scientific Publication No. 151. Washington, D.C.: PAHO, 1967. Puffer, R.R., and C.V. Serrano. Patterns of Mortality in Childhood. Scientific Publication No. 262. Washington, D.C.: PAHO, 1973. Kagan, 1.G. Advances in the immunodiagnosis of parasitic infections. Z. Parasitenkd 45:163, 1974. Cook, J., J. Alvarado, A. Gutnisky, M. Jamra, J. Labardini, M. Layrisse, J. Linares, A. Loria, V. Maspes, A. Restrepo, C. Reynafarje, L. Sdnchez-Medal, H. Vélez, y F. Viteri. Las carencias nutricionales y la anemia en Latinoamérica. Bol Of Sanit Panam 72:215-228, 1972. Neghme, A. Impacto en la salud de las enfermedades parasitarias en América Latina. Rev Méd Chile 106:62-65, 1978. Palacios, S.F. Problemas que dificultan el desarrollo normal de los programas de erradicacion de la malaria. Bol Of Sanit Panam 79:375-388, 1975. Young, M.D., and C.M. Johnson. Plasmodium falciparum malaria in Panama resis- tant to 4-aminoquinoline drugs. Am J Trop Med Hyg 21:13-17, 1972. Amador Neghme 111 29. 30. 31. 32. 33. 34. 35. 36. Geiman, Q.M., and M.J. Meagher. Susceptibility of a new world monkey to Plasmo- dium falciparum from man. Nature 215:437-439, 1967. Coatney, G.R., W. Collins, McW. Warren, and P. Contacos. The Primates Malarias. Washington, D.C.: U.S. Government Printing Office, 1971. Von Brand, T. Biochemistry of Parasites, 2d ed. New York: Academic Press, 1973. Agosin, M., C. Naquira, J. Paulin, and J. Capdevila. Cytochrome P-450 and drug metabolism in Trypanosoma cruzi, effects of phenobarbital. Science 194:195-197, 1976. Trager, W., and J. Jensen. Human malaria parasites in continuous culture. Science 193:673-675, 1976. Layrisse, M., and A. Vargas. Nutrition and intestinal parasitic infections. Prog Food Nutr Sci 1:645-667, 1975. Warren, K.S. Modulation of immunopathology and disease in schistosomiasis. Am J Trop Med Hyg 26:113-119, 1977. Organizacién Panamericana de la Salud. Plan decenal de salud para las Américas. Informe final de la III Reunién Especial de Ministros de Salud de las Américas. Documento oficial No. 118. Washington, D.C.: OPS, 1973. hi CURRENT TRENDS IN ZOONOTIC DISEASE STUDIES Luis V. Meléndez Introduction Information on zoonoses research in Latin American and Caribbean coun- tries is not readily available. Research in this field is carried out in only a few institutions. Information received from a survey of research at more than 52 faculties and schools of veterinary medicine is given in the appendix at the end of this chapter. Most of the zoonotic studies are carried out by national institutions inter- ested in human and animal health. The Pan American Health Organization (PAHO) through its department of animal health has been collaborating with the Latin American countries in the development and establishment of programs for prevention, control, and eradication of those zoonotic diseases of primary importance to each country. A great deal of information on this field is compiled by PAHO officers stationed in each country. In the following brief summary of their obser- vations for 1977, the countries have been grouped in the six geographical areas established by PAHO for working purposes. Area | Characteristics Area | comprises 22 administrative-geographic units on the mainland of South America (Venezuela, Guyana, Surinam, and French Guiana) and 18 islands or groups of islands in the English, Dutch, and French Caribbean (including Bermuda in the North Atlantic). Although an accurate estimate is not available, it is safe to say that the total population of these countries exceeds 18 million (Venezuela, 12 million; Jamaica, 2 million; Trinidad and Tobago, 1 million; Guyana, 750,000; Barba- dos, approximately 250,000; and Surinam, 376,000). They vary in size from small independent or autonomous units such as Anguilla, with 34 square miles 113 114 Biomedical Research in Latin America and a population of slightly over 6,000, to Venezuela, with 352,295 square miles and slightly under 12 million population. Zoonoses Brucellosis. In 1977 brucellosis was one of the main concerns of animal health authorities in many countries of area I. Barbados, Jamaica, and Venezuela have included it in their animal health programs, which are supported and admin- istered by PAHO/WHO/ UNDP. In Jamaica brucellosis testing was accelerated during 1977. The animal health project was extended until December 31, 1977, with an additional contribution from the United Nations Development Program (UNDP) of $187,000. Since its initiation, this project has provided satisfactory support for brucellosis and tuberculosis campaigns. Reactor rates for the last 6 months of 1977 were slightly lower than those of the previous 20 months. Bovine bru- cellosis declined from 0.78 percent to 0.75 percent. In Barbados brucellosis testing was completed in 8 of the 11 parishes. During 1975-76, 3,870 head of cattle were tested, with 30 card test-positive (0.7 percent). The animal and human health project responsible for brucellosis testing was progressing satisfactorily, with impressive community-wide impact, until the effect of the UNDP financial crisis was felt. Since January 1977, financing of this project has been assumed by PAHO. The Government of Barbados has given this project its highest priority. The Venezuelan census of 1974 accounts for 9 million head of cattle, 50.07 percent females over 2 years of age, and 10.44 percent heifers below 1 year of age on 112,576 farms. During 1975, of 269,522 rapid serum agglutination tests performed, 7,446 had positive results. Elimination of reactors is slow and unsatisfactory. According to law, calves 3-8 months of age must be vaccinated with strain 19 vaccine. In 1975, only 131,584 doses were administered; thus, only 13.9 percent of the total cattle population was vaccinated. In 1977, only 116,220 calves were vaccinated. According to information received from laboratories, 230,000 doses have been produced and sold. Rabies. Although the incidence of mongoose rabies in Grenada has been substantially reduced, that in domestic animals has increased. However, not a single case of human rabies has been reported in Grenada since 1971. There is no evidence of any substantial decrease in canine rabies in Venezuela, the only rabies-endemic country in area I. Bovine rabies, transmitted by vampire bats, is endemic in Venezuela and French Guiana, and cases are occasionally recorded in Trinidad and Tobago. There is an extensive vampire bat population in Surinam, Guyana, and Trinidad and Tobago. The lack of fluorescent antibody techniques in diagnostic laboratories limits rabies recording. Luis V. Mélendez 115 Tuberculosis. Bovine tuberculosis has long been recognized as a disease that can cause great financial loss to both the cattle and swine production indus- tries, as well as serious illness in humans, especially children. The Jamaica animal health project has produced tangible results in development of human resources, building of institutions, and revitalization of agriculture capabilities. In the first 6 months of 1975, more than 21,000 animal TB tests were admin- istered, a 100 percent increase over the same period in the preceding year. During 1976 a total of 894 farms were covered, among which 68 infected herds were discovered. On these farms 218,759 animals were tuberculin tested, yielding 644 positive results, or an infection rate of 0.30 percent as compared with 0.72 percent in the preceding year. Bovine tuberculosis testing has been accelerated in Jamaica. Four parishes have completed initial testing, three during 1975. Approximately 100,000 cattle (two-thirds of those eligible) were tested during a 2.5-year period. Reactor rates for the last 6 months of 1975 were slightly reduced from those of the previous 20 months; cattle tuberculosis declined from 0.87 percent to 0.56 percent. The Venezuelan tuberculosis program is summarized below: Year Animals tested Number positive Percent positive 1974 236,786 704 0.30 1975 179,325 1,304 0.72 1977 271,682 1,019 0.15 Hydatidosis. The countries of area I have no hydatidosis programs, and this disease has not been recorded, probably because there are no diagnostic facil- ities and no slaughterhouse controls. Leptospirosis. Leptospirosis afflicts both humans and animals throughout the world. It is widespread in the Caribbean region. Distribution of the disease is not well known there is a lack of information due to the inability of diag- nostic laboratories to confirm human and animal cases. Human leptospirosis has been recognized as an important disease in Bar- bados for many years. In the June 1975 issue of the Caribbean Epidemiology Center (CAREC) Surveillance Report the 220 cases reported between 1968 and 1974 were reviewed. For this period a case fatality rate of 13.9 percent was reported, with 159 cases (73.9 percent) occurring in males and 56 cases (26.1 percent) in females. Laborers, tradesmen, domestic servants, and agricultur- al workers were the major occupational categories affected. During 1972 the Veterinary Diagnostic Laboratory collaborated with the Pan American Zoo- noses Center (CEPANZO) located in Argentina on a serological survey of leptospirosis in domestic animals and rodents. There was evidence of the disease in all categories of livestock and in dogs, cats, and rats. The microscopic agglutination test used showed the highest titer in cattle (1/12,000) and rela- tively high percentages of infection in all species, most of which fall within the autumnalis-fort-bragg serotype. 116 Biomedical Research in Latin America Of the 113 rats submitted to the Veterinary Diagnostic Laboratory during 1975, 16 were positive upon microscopic examination of urine or kidney cultures. Of the 38 mice submitted that year, 2 were positive on microscopic observation of kidney suspension. Early in 1975, the Government of Barbados-PAHO/WHO/UNDP animal and human health project began an intensive investigation of leptospirosis in both humans and animals. Of 73 human fever cases admitted to the casualty department of Queen Elizabeth Hospital, Bridgetown, showing symptoms compatible with leptospirosis, 10 (13.7 percent) were positive. Two of these patients died, giving a case fatality rate of 20 percent. Data for 1976 and 1977 are similar to those for previous years. In addition to the sample already forwarded to CEPANZO, further sam- ples have been collected for testing: cane workers, 532: sanitation workers, 31; fever cases, 103 (32 of these are repeats); cattle, 4,131; sheep, 124; goats, 30; swine, 61; horses, 12; dogs, 5. The veterinary diagnostic laboratory is not yet able to provide the required diagnostic capability. Through the animal and human health project, the public is being made aware of problems connected with rodents. The Barbados Agricultural Society, one of the main sources of rodent bait on the island, reported that 37,816 pounds had been sold in 1975, as compared with 11,393 pounds in 1974. Through the Enmore Health Center, the Ministry of Health distributed 2,059 pounds of free bait to those who requested it, and 1,919 pounds were applied through the rodent control unit. This token amount would have to be in- creased tenfold to produce really effective results. A detailed study of leptospirosis in high-risk occupational groups was carried out in 1976; 265 human serum samples were sent to CEPANZO for testing, in addition to 95 samples from patients at the Queen Elizabeth Hos- pital. A total of 184 samples of animal serum were tested at CEPANZO. Infecting serotypes were identified by microagglutination tests, and serum from 104 rodents and mongooses, 14 other animals, and 44 humans was cultured. In Jamaica, recent serological surveys have established responsiveness to Leptospira organisms in various species, including man. Of 271 caprine, canine, porcine, and cattle samples, 85 were positive. Venezuela has reported 301 bovine, 5 caprine, 15 equine, and 56 porcine leptospirosis cases, 63 more than in the preceding year. The animal health project has established a leptospirosis research and control unit in the Vet- erinary Research Institute in Maracay, Venezuela. Equine encephalitis. In the past decade equine encephalitis has become a real threat to the health and economy of Latin American countries. Caribbean countries are highly vulnerable to introduction of the disease by race horses and by indiscriminate use of inactivated virus type vaccine. Yet few cases Luis V. Mélendez 117 have been reported recently: 6 in 1974, 3 in 1975, 7 in 1976, and none in 1977. Area II Characteristics Area II includes Cuba, the Dominican Republic, Haiti, and Mexico. The total population of these countries is 83.7 million, and they cover some 2.2 million square kilometers. Excluding Cuba, the area contains approximately 31 million bovines, 6 million sheep, 15 million swine, 11 million goats, 12 million equines, and 204 million poultry. Of the Mexican bovine population, 50 percent are beef cattle, 40 percent dairy cattle, and 10 percent are used for labor. Zoonoses Equine encephalitis. Cuba has been free of equine encephalitis since August 1972, when the last outbreak of European equine encephalitis (EEE) was reported. However, the epizootic surveillance campaign and the vaccination program are being continued. The last outbreak of Venezuelan equine enceph- alitis (VEE) in Mexico was reported in September 1972. Vaccination has been restricted to states that are known to be more vulnerable to the disease, and zoosanitary surveillance has been increased. One means is the use of susceptible animals as sentinels in critical areas. Brucellosis. Because of conformance with the national regulations, 2.6 million bovines in Cuba are free of brucellosis. In the Dominican Republic, a sample study under the program for the prevention and control of bru- cellosis determined that the national prevalence of the disease was 4.4 per- cent. The sample included 10,840 bovines from 904 farms. Another 87,468 animals were examined under the regular brucellosis control program. On the basis of these results and the sample study, the prevalence was estab- lished at 6.2 percent. In Mexico, preventive and control measures were pro- moted among the milk producers’ associations to increase production and deal with problems related to brucellosis. Bovine tuberculosis. Cuba has 2.6 million bovines that are free of tubercu- losis. In the Dominican Republic, 150,645 tuberculin tests were administered during 1977; of these 1,034 were positive and 235 suspect (1.3 percent). As with brucellosis, preventive and control measures were promoted in Mexico to deal with tuberculosis. Rabies. At present, only carnivores are affected by rabies. Preventive vacci- nation is conducted throughout Haiti, 35,000 dogs and cats having been vaccinated during 1977. Authorities in Haiti and the Dominican Republic 118 Biomedical Research in Latin America have discussed the possibility of a jointly conducted eradication program. In Mexico, the vaccination and vampire bat control programs have been extended in the 10 states where paralytic rabies is known to exist in order to protect 4 million bovines from the disease. Other Zoonoses Because of its sporadic appearance and its generally subacute or chronic course, leptospirosis does not cause significant economic losses to the Cuban stock-raising industry. Personnel Training In 1977 over 250 veterinarians graduated from Cuban universities, thereby giving great impetus to animal health care. In the Dominican Republic, veter- inary students are required to work with the animal health program in an effort to obtain the collaboration of stockbreeders and farmers. Area III Characteristics The Central American countries and Panama have a combined territory of 530,445 square kilometers. The livestock population has been estimated at approximately 10 million bovines, 1.5 million equines, 2.4 million swine, and 893,000 ovines and caprines. There are some 39 million poultry (table 1). Zoonoses Brucellosis. Brucellosis transmitted to humans by direct contact or as a result of ingestion of products from infected animals is widespread in the Central American isthmus. Unfortunately, as it is not a notifiable disease, there is scarcely any information about human cases. Of a total of 272,961 bovines tested, 6.7 percent reacted positively, and 64.2 percent of the 3,321 farms that were surveyed proved to be infected. Tuberculosis. Bovine tuberculosis is of relatively low prevalence in the area. Of the 1,668 farms that were surveyed, only 26 percent were found to be infected and of the 124,375 bovines that were sampled, 1 percent reacted positively. Of 376,527 bovines that were slaughtered, 1.8 percent had been condemned for tuberculosis. In 1977, Costa Rica secured a $9.3 million loan from the Inter-American Development Bank (IDB) to set up a program aimed at control and eradication of bovine brucellosis and tuberculosis. TABLE 1. Estimated External, Demographic, and Educational Indicators in the Central American Isthmus, 1977 Entire Indicator Costa Rica El Salvador Guatemala Honduras Nicaragua Panama Isthmus External Human population (thousands) 2,111 4,524 6,839 3,439 2.559 1,823 21,438 Density (inhabitants/km?) 41.47 216.09 62.44 30.68 18.41 24.09 40.41 Rurality (%) 57.76 58.04 63.85 63.38 49.36 49.00 87.73 Animal population (thousands) Bovines 1,643 1,108 1,900 1,689 2,249 1,361 9,998 Equines 101 103 250 185 750 143 1,541 Pigs 21S 354 449 S11 650 179 2,367 Goats S 10 110 19 8 - 153 Ovines 0.6 3 702 30 - - 740 Poultry 3,863 4,094 18,000 2,298 6,000 4,276 39,533 Cagines 211 452 683 343 255 182 2,141 Area (km®) 50,900 20,935 108,889 112,088 139,000 75,650 530,445 Demographic growth rate (per 1000) 23.15 34.0 28.9 32.0 29.0 24.7 28.62 Education Literacy (%) 89.9 59:3 45.9 58.0 52.6 82.2 64.68 Sources: Data from Organization of American States, Centro Health Organization. Latinoamericana Demografica, Inter-American Development Bank, Pan American ZOPURIN "A SIN] 611 120 Biomedical Research in Latin America Equine encephalitis. During the period under review, sporadic outbreaks of VEE were reported. There was no evidence of this disease in four of the countries of the area, but a fifth reported 23 cases. Cysticercosis. Nicaragua and Honduras are the countries most heavily affected with bovine cysticercosis. Of 217,217 bovines slaughtered in those countries, 8.5 percent were condemned on account of this zoonosis. There was no information available regarding swine cysticercosis. One country reported 23 cases of clinical neurocysticercosis in humans, and 36 cases were diagnosed after postmortem examination. Rabies. Rabies is still a major source of concern for health authorities, children being particularly at risk. The highest death rates were recorded in Honduras and El Salvador: 0.30 percent and 0.18 percent, respectively. In Costa Rica and Panama, the last known cases occurred in 1971 and 1973, respectively. Canine rabies showed an average increase of 124.1 percent in 1977 throughout the area, as compared to 1976. It should be noted, however, that canine rabies has been under control in Panama since June 1973. On the other hand, the incidence of bovine rabies reportedly declined about 17 percent compared to the previous year, whereas in other species it showed a 57 percent increase. Other Zoonoses Other zoonoses, such as hydatidosis, distomatosis, and leptospirosis, have been diagnosed, but their scope and significance for humans are not known. Total estimated losses for the area due to the above-mentioned diseases amount to $46.8 million. Area IV Characteristics Bolivia, Colombia, Ecuador, and Peru are included in area IV. Their combined area is 3.7 million square kilometers. Zoonoses Rabies. In Bolivia, 33,518 animals were vaccinated against bovine rabies, and 29 cases were confirmed as positive. Four cases of human rabies were re- ported in Colombia in 1977, and there were three outbreaks of bovine rabies, 75 animals dying. Twenty-four cases of human rabies and at least 584 cases of animal rabies were reported in Ecuador. Although the disease broke out on 15 farms in the forest area of Peru, with a loss of 108 bovines, the metro- politan area of Lima-El Callao was free of rabies. Luis V. Mélendez 121 Brucellosis. Of the 2,917 samples from Santa Cruz and El Beni, Brazil, 13.6 percent were positive. In Colombia, which has a national brucellosis control program, calves are routinely vaccinated with strain 19 vaccine. In 1977 3.89 percent of the 130,372 animals tested were infected with the disease, and a total of 558,625 calves were vaccinated. Of the 8,881 animals tested for brucellosis in Ecuador, 66 reacted positively. Under Peru’s national program for the control of caprine brucellosis, Rev. 1 vaccine is administered, and the human incidence of Bang’s disease has declined. Under the bovine brucellosis control program, strain 19 vaccine is used. A total of 758 herds comprising 25,026 animals were reported to be free of the disease. Tuberculosis. In Colombia, 350 animals from three infected farms were tested for tuberculosis; of these, 37 reacted positively. In Peru, 775 herds with a total of 30,376 animals were reported free of the disease, and 40,658 bovines were in the process of being declared free. Encephalitis. During 1977, 41 cases of VEE were diagnosed clinically in Colombia, and 64,427 equines were vaccinated with TC-83 vaccine. Although no cases were reported in Ecuador, 93,879 equines in areas considered es- pecially vulnerable to the disease were given locally produced inactivated TC-83 vaccine in the continuing effort to achieve permanent control of the disease. Modified live virus vaccine was used in vulnerable areas of Peru, where there were no cases reported. Hydatidosis. A pilot program for hydatidosis control was continued at the Sociedad Agricola de Interés Social (SAIS) Tupac Amaru in Peru. Only 4 of the 262 samples tested were positive to E. granulosus, indicating the satis- factory progress of the program. Food Supply and Protection All the countries in area IV are aware of the problems affecting their animals and taking steps to solve the animal health problems, consequently increasing livestock production as necessitated by the growing demand for animal pro- tein. Furthermore, each of the countries is concerned that food supplies be safe for human consumption. Area V Characteristics Brazil, the only country in area 5, has an area of 8.5 million square kilometers and a population of 66 million. The country has 90.8 million bovines, 129,000 buffalo, 10.6 million equines, 41.1 million swine, 24.5 million sheep, 11.5 million goats, and 280 million poultry. 122 Biomedical Research in Latin America Zoonoses Rabies. Brazil produced 9.8 million doses of antirabies vaccine in 1977. Modi- fied and attenuated live virus vaccine is used, and there is a program for control of vampire bats, which are the chief agents in the spread of the disease. Brucellosis. The prevalence of brucellosis ranges from 0.17 percent to 11.63 percent, depending on the area under study. The disease has been identified in cattle, swine, and sheep. The national control program includes voluntary vaccination, diagnosis and voluntary slaughter of reactors, certification of free herds and areas, and health education. Zoonoses Control At the state level there are structures for zoonoses control in the Department of Health and Agriculture; and there are also animal disease research centers for personnel training, zoonoses control services, quality control of veterinary products, research, and specialized diagnosis. According to national policy, the country’s resources are coordinated in order to institute more effective meas- ures for the control of zoonoses. Brazil is collaborating with several other countries toward this end. It has 23 schools of veterinary medicine and more than 500 training schools for agricultural technicians. Area VI Characteristics Area VI comprises countries in the southern cone of South America: Argen- tina, Chile, Paraguay, and Uruguay. Their total area is 4.1 million square kilometers, and their population is 40.7 million (1975). Area VI contains 75.6 million bovines, 56.7 million sheep, 6.3 million swine, 5.6 million goats, 4 million equines, and 81.6 million poultry. Three countries of the area are among the few nations of the world that have large amounts of meat for domestic consumption and considerable surplus for export as well. They have surpluses of other foods, including products of animal origin, and their joint production of grains for human consumption and industrial use is significant. These nations have the most important reserve of food for human consumption on the American continent—possibly in the entire world. This is significant, considering that malnutrition on the South American continent is prevalent and increasing rapidly. Zoonoses Brucellosis. Under the Argentine brucellosis control program, vaccination of 3- to 6-month-old calves with strain 19 vaccine has been extended to many Luis V. Mélendez 123 areas of the provinces. The compulsory vaccination program covers 17.8 million hectares and includes 79,000 stockbreeders—nearly all of the two major milk sheds of the country. During 1977, 2.9 million doses of the vac- cine were administered to 683,000 calves in the compulsory vaccination area and to 2 million calves in the voluntary vaccination area. A field trial with Rev. 1 vaccine for the control of caprine brucellosis was conducted in the province of San Luis. Under the Chilean brucellosis control program, an attempt is being made to eradicate bovine brucellosis from the northern and southern parts of the country, where the prevalence is low. In the central-southern part of the country, 150,000 calves (approximately 59 percent) have been vaccinated with strain 19. For 1978 it was planned that the percentage be increased. Results of a sample survey in this area indicated that prevalence rates were low (2.64.9 percent) in several regions. The highest rates appeared in the region around Valdivia and Osorno, where only dairy cattle are raised. The long-standing habit of vaccinating adult cows, rather than calves, may have had a bearing on these high rates. A matter for further research is the finding that in several dairy farms of this region where artificial insemination is prac- ticed, the effectivity rate for the first insemination is about 80 percent. This fact does not seem to be in keeping with the high percentage of reactors. It would be desirable to establish what percentage of reactors is due to natural infection. The compulsory vaccination of calves with strain 19 is being continued throughout Uruguay. Rabies. Buenos Aires, Argentina, made great progress during 1977 in the control of canine rabies. Following an intensive vaccination campaign during the last quarter of 1977, no cases of human rabies were reported and there was a spectacular decrease in canine rabies—a very promising development. In Chile, 19 cases of animal rabies were reported during 1977, a deterioration. However, there were no cases of human rabies. Hydatidosis. Intense interest on the part of Argentinian public health and agriculture authorities in the control of hydatidosis has led to planning and implementation of control programs in several provinces. In collaboration with the Pan American Zoonoses Center, several seroepidemiologic surveys were conducted to determine the prevalence of the disease in humans and several laboratory workers were trained in immunodiagnosis of the disease. A pilot project for control of echinococcosis in dogs was initiated. In 1978 a hydatidosis control project was started in an area of Chile that contains 50 percent of the country’s sheep. This area has the highest prevalence rates of hydatidosis in sheep (almost 60 percent) and bovines (40 percent), as well as in humans. Health and agriculture agencies will collaborate with stock- breeders’ associations in carrying out the project. 124 Biomedical Research in Latin America The Artigas Plan, a hydatidosis control program, was initiated in the ad- ministrative district of Artigas, Uruguay. It comprises the following measures: (1) reduction of the number of dogs in rural establishments and private homes to the number established by the authorities, (2) sworn statement on owner- ship of dogs, (3) payment of an annual license fee for each dog, and (4) dosing of all dogs every 45 days with praziquantel. Tuberculosis. Tuberculin testing in 1977 showed a satisfactorily low level of bovine reactors in Uruguay. In 1977, the benefits of the so-called ‘certified milk system” were extended to the whole community. Under this system, milk processing plants, which are located in every district of the country, are re- quired to pay a 15 percent bonus to dairy farm operators who have tuber- culosis-free herds. The producers are reimbursed for this payment by the Government. At least once a year all animals belonging to producers who have complied with the certified milk system are tuberculin tested. In 110,000 tests conducted during 1977, 41 positive reactors (0.03 percent) and 82 suspects (0.07 percent) were detected. Meat inspection of 1.2 million bovines in slaughterhouses resulted in only 213 partial or total condemnations for tuberculosis. Other Zoonoses In 1977 Paraguay contracted with the Inter-American Development Bank for a $5.3 million loan to finance the second stage of the national foot-and- mouth disease control plan. A revision of the animal health project including programs for control of brucellosis, rabies, and bovine tuberculosis was sub- mitted to the IDB. Conclusions Limitation of financial resources for control programs is the main obstacle to attainment of the goals and objectives set forth in these programs. There- fore it is extremely important that international funding agencies; private foundations; and national, state, and local institutions give more attention to the prevention, control, and eradication of zoonoses. An attempt has been made to standardize regulations governing trade in animals and animal products in relation to various diseases. Consequently an agreement between Argentina and Paraguay was signed in 1977, establish- ing an Argentine-Paraguayan commission and two frontier subcommittees. Similar agreements have been signed by Bolivia and Argentina and by Paraguay and Bolivia. Under an agreement between Uruguay and Brazil, a coordinating commission and several frontier subcommittees were established. Preparations are being made for a bilateral agreement between Uruguay and Argentina. Luis V. Mélendez 125 Some institutions have already developed programs for prevention, control, and eradication of zoonoses: the Division Nacional de Zoonosis of the Secre- tary of Health in Colombia and the Center for Zoonoses Control in Sao Paulo Brazil. Through its Zoonoses Center in Buenos Aires, Argentina, PAHO is * helping interested countries to develop and establish programs controlling diseases transmitted from animals to man, particularly those of high priority in the Caribbean and countries of Latin America. Appendix Research Topics at Various Schools of Veterinary Medicine Brazil Universidade Federal do Rio Grande do Sul, Facultade de Veteringrial: Epidemiological aspects of hydatidosis in dogs of Municipio de Viamdo, RS Biology of Dermatobia hominis in Rio Grande do Sul Biology of Cochlyomia hominivorax in Rio Grande do Sul Fasciola hepatica—Ecology of Lymnae columella Colombia Facultad de Medicina Veterinaria y Zootecnia Bogota: e Diagnosis by agar immunodiffusion of ram epididymitis caused by Brucella ovis e Brucellosis reactors among workers at two slaughterhouses e Canine zoonoses in the city of Bogota during 1972 e Use of the complement fixation test to distinguish reactions due to vaccination from those due to brucellosis Investigation of Trichinella spiralis in muscles of rats from different areas of the city of Bogota Prevalence of equine salmonellosis in rural establishments of the savanna of Bogota Prevalence of Clostridium perfringens (welchii) in the udder of the cow Prevalence of brucellosis in the remote posts of Bonza and Mansilla Prevalence of brucellosis in cattle herds of the district of Quindio Effects of foot-and-mouth disease vaccine on the production of milk Collection of bibliographical references on toxoplasmosis and development of an immunofluorescence technique for its diagnosis National epidemiologic guide for veterinary medicine Ynformation provided by Prof. Jodo C. Athayde Diaz. Director. 2nformation provided by Dr. Pedro J. Lazaro Bustos, Dean. 126 Chile Universidad de Chile, Facultad de Medicina Veterinaria”: Biomedical Research in Latin America Serology of swine brucellosis in the eastern plains of Colombia, using four tests and a statistic computerized model Diagnosis of major zoonoses at the University Hospitals of Bogota Research on Trichinella spiralis in slaughterhouses of Bogota Hydatidosis as a public health and animal health problem in Colombia Serologic research on Q fever in cattle Serologic survey on leptospirosis and brucellosis in swine Brucellosis in dogs from Bogota 3 Prevalence of bovine tuberculosis in the province of Santiago, and estimated eco- nomic losses Prevalence of the primary complex at the retropharyngeal level, and typing of isolated Mycobacteria Economic losses due to swine parasitic zoonoses in Chile Suckling mouse brain rabies vaccine. Some considerations on the sterility of the raw material Some parasitic diseases in the province of Linares. Distomatosis, hydatidosis, trichinosis, cysticercosis Enzyme polymorphism in adult Fasciola hepatica. 1. Esterases Contribution to the study of hydatidosis in the municipality of Cauquenes Protein and enzyme polymorphisms in adult Fasciola hepatica Prevalence of swine erysipelas in the province of Santiago Vaccination with strain 19 by the conjunctival route. Field trials Typing of species of the genus Mycobacterium isolated from swine Investigation of the role of M. avium in bovine metritis Vaccination of adult bovines with a reduced dose of strain 19 by the conjunctival route Diagnosis of trichinosis Study on the prevalence of bovine brucellosis, province of Aconcagua Neutralizing rabies antibodies development curve in dogs from breeding colonies Purification of fixed rabies virus Humoral immunity response in calves vaccinated at 60 days with strain 19 Status of rabies in Chile. Analysis of the 5-year period 1972-76 Study of the biological and biochemical properties of E. rhusiopathiae isolated from swine Adaptation of the rabies virus in cell cultures Evaluation of the intracutaneous test for the diagnosis of leptospirosis in swine Universidad Austral de Chile, Facultad de Medicina Veterinaria, Valdivia? Serologic diagnosis of canine brucellosis in farmers’ settlements of the municipality of Frutillar, Province of Llanquihue Epidemiologic study of brucellosis in dogs and the human population at risk Canine leptospirosis in a rural property of the municipality of Mafil, province of Valdivia Antigenic analysis of Taenia solium and Taenia hydatigena and their larval stages Epidemiologic study of Fasciola hepatica in the south of Chile Echinococcosis in dogs of the rural area of the province of Valdivia Epidemiologic survey of brucellosis by Brucella abortus in exposed human popu- lation from an area of the municipality of Frutillar Information provided by Dr. Santiago Inostroza Hood, Dean. Yintormation provided by Dr. Julio Flores Villanueva, pro-Dean. RESEARCH ON ENVIRONMENTAL HEALTH Abel Wolman and Frank A. Butrico Introduction and Summary Within its boundaries Latin America has a population of some 320 million people, with the prospect—unless stemmed—of 650 million by the year 2000. This outlook is grim, because no answer to the problem is now available; and indeed, there is no agreement on the nature of the problem. The matter is complex and delicate, with sensitive political and religious overtones. While the answers to the problem, if they exist, will be only in part technological and biological, this area of investigation is important. The primary significance of rapid population growth in terms of disease control complicates the central problem. A country with a rapidly rising population is one with a high proportion of its population under 5 years of age, and one of extreme poverty. The poverty of the countries and the large number of children in a group particularly vulnerable to malnutrition and enteric diseases frustrate control efforts. The health situation in Central and South America is dominated by high sickness and death rates resulting largely from low levels of personal hygiene and absence of elementary sanitation, such as water supply and waste disposal. The data are reminiscent of the communicable diseases situation in the United States more than half a century ago. They demonstrate clearly that, even today, the major causes of morbidity and mortality are still enteric diseases. Some of these, such as typhoid fever and shingellosis, are on the increase rather than on the decline. It remains dramatically true that for some decades to come the most widespread diseases will probably be those transmitted by human feces. With unprecedented urbanization and industrialization since World War II, Latin America finds itself further confounded by the increasing morbidity and mortality challenges of the modern world. Heart diseases, cancer, and cerebrovascular diseases press for investigation and development of preventive measures. The search in Latin America for causation of these diseases can 127 128 Biomedical Research in Latin America hardly parallel the vast resources devoted to these efforts in the more eco- nomically favored countries of the Western World. Disease patterns differ in developed and developing countries (table 1). Strategies for prevention and cure of disease threats are unusually difficult because of vast differences in population density, occupation, income, polit- ical and social organization, religion, culture, and attitude. Research oppor- tunities and practices are similarly highly variable, when public officials and private agencies are pressed to resolve a century of past problems and an emerging set of even more subtle and less demonstrable health insults today. Basic health problems of the developing Central and South American countries will remain essentially the same for decades and are related to the following factors: ® Poor housing and living conditions (tuberculosis, yaws, syphilis, leprosy, Chagas’ disease) ® Conditions permitting fecal-oral transmission (diarrhea, dysentery, cholera, typhoid) ® Malnutrition ® Inadequate control of vectors (malaria, filariasis, schistosomiasis, try- panosomiasis, onchocerciasis) ® Airborne diseases (influenza, pneumonia, measles, mumps, whooping cough). Biomedical research in Latin America has quite properly emphasized these disease groups. Much effort has been directed toward their biological, phys- iological, and pathological aspects. This effort should be continued and ex- panded. At the same time, much more research should be done on environ- mental factors that contribute to many of these diseases. It is as accurate to identify impure water as a source of disease as it is a microorganism. The data in table 2 indicate the extent of enteric diseases in Latin America. Some are increasing. Research Institutions Most environmental health research in Latin America is carried on predomi- nantly by governmental and international organizations. The most prominent international organization is the Pan American Health Organization (PAHO). The most prominent national organizations are those associated with ministers of health and universities (particularly schools of public health). Some re- search is conducted by special purpose governmental organizations. Some of the activities of ministries deserve special mention. The urgency of environ- mental problems has resulted in establishment of a number of special organi- zations outside ministries of health. (See the appendix for a list of typical re- search activities.) Abel Wolman and Frank Butrico 129 TABLE 1. Percentage Distribution of Deaths by Cause in Selected Population Models Cause of Death Developing Country Developed Country Parasitic infections and respiratory diseases 43.7 10.8 Cancer 3.7 15.2 Circulatory diseases 14.8 32.2 Traumatic injury 3.5 6.8 All other causes 34.3 35.0 Total 100.0 100.0 Source. Reproduced with permission from Health, Sector Policy Paper, Washington, D.C.: World Bank, March, 1975. TABLE 2. Selected Communicable Diseases in Latin America, Number of Cases, 1975-76. Typhoid Bacillary Country Fever Dysentery Amebiasis Argentina 2,635 NI NI Brazil 5,024 NI NI Chile 13,170 NI Ecuador 4,133 NI El Salvador 2,455 16,108 5,741 Guatemala 2,764 3,632 14,408 Honduras 1,467 4,960 26,404 Mexico 2.7711 5,976 115,856 Nicaragua 1,275 3,459 8,554 Peru 11,598 5,506 2,233 Venezuela 189 40 16,760 Dominican Republic 2,049 NI NI NI, no information. Water Considerable effort has been devoted to evaluation of lower cost methods of water treatment.! This has led to development of manuals, design techniques. This research was carried out at the Pan American Center for Sanitary Engineering and Environmental Sciences (CEPIS) in collaboration with the University of Oklahoma and the Agency for International Development (AID), in treatment plants in Cochabamba, Bolivia; Cuenca, Ecuador; and Prudentdpolis and Linhares, Brazil. The agencies involved are Empresa de Teléfonos, Agua Potable y Alcantarillado (ETAPA) in Cuenca, Servicio Municipal de Agua Potable y Alcantarillado (SEMAPA) in Cochabamba, Fundagao de Ser- vicio Especial de Salide Publica (FSESP) in Linhares, and Saneamiento de Panama (SANEPAR) in Prudentopolis. 130 Biomedical Research in Latin America and criteria appropriate to the unique social and economic conditions of the region. Studies on the evaluation of the performance of new water treatment methods are being conducted at the plant at El Imperial, Canete, Peru, in collaboration with the general directorate of sanitary works of the Ministry of Housing and Construction. Financial support is provided by the Interna- tional Development Research Center. This plant was designed to incorporate the results of previous operational research efforts. The eternal question of the survival rate of coliform and streptococcus organisms in fresh and saline waters is being explored in a fresh water estuary in Guaiba and in salt water in Guanabara Bay, both in Brazil. In these same estuaries, pollutant dispersion is being investigated via radiocative isotopes and Rhodamine B. One of the ironies of the present environmental situation is the question- ability of chlorine as a disinfectant of water. This chemical, used for almost three-quarters of a century, has probably saved more lives than any other chemical; but limited studies, carried out in the United States and charac- terized by some as epidemiologically superficial, suggest that the reaction of chlorine with organics in water produces a number of halo-organics. At least one of these, chloroform, is carcinogenic. Since all the features involved in these reactions are highly variable in frequency and in magnitude, some de- tailed studies are already under way and many more are being planned before changes in or substitutes for chlorine may be reasonably required. When land is inundated, oxygen requirements of flooded vegetation become a problem. This question is being evaluated on the Uruguay River where a large reservoir will be created by the Salto Grande Dam. Similar studies, conducted jointly with U.S. universities, are in progress on Lake Maracaibo in Venezuela and in Sao Paulo. In addition, information is being acquired on the distribution of phyto- plankton and zooplankton in the San Roque Reservoir on the Primero River in Argentina. The effect of toxic substances ongpotable waters is under scrutiny in the waters of the Paraiba River, with its diversion into the intake of the water treatment plant of the public supply for Rio de Janeiro. The water quality of various rivers is a matter of continuing concern. Hence, detailed studies are under way on the reaction rates of dissolved ox- ygen, with special reference to their application to water quality models. Among the rivers studied are the Paraiba, Cauca, Bogota, Medellin, Guaiba, and Iguaza. Other aspects of hydrology and water quality, unrelated to en- vironmental health, are under simultaneous investigation. Nine national agen- cies, under the general guidance of PAHO and CEPIS engineers, are developing a plan for the best use of the Bay of Cartagena. Colombia is a prime mover in this effort. Abel Wolman and Frank Butrico 131 Generalized computer models are being used as a research tool for the study of dissolved oxygen, bacteriological data, and some physical-chemical param- eters. In all these endeavors, detailed system analysis methodology is being ap- plied. In this multidisciplinary approach, often carried on in collaboration with CEPIS and its consultants, government agencies are active participants. Areas being explored are water quality simulation models, economic optimi- zation models for water resources development and water quality management, optimal metering policies for water supply agencies, environmental data processing, waste water treatment plant design models, and investment priority models for sanitary works. While the term “waterborne diseases” brings to mind communicable disease groups, potable water—pure water—may be incriminated in cardiovascular disease. Investigations have been intensified in the last two decades, since early work in Japan and the United States suggested a correlation, if not a causal relationship, between such syndromes and ill-defined soft waters. Dozens of papers on such investigations have since been published in England, Germany, Holland, Finland, and the United States. These inquiries disclosed a whole series of possible causative ingredients in water, paralleled by similar constituents in food and air. Unfortunately, the day of demonstrated specific causality is not yet at hand. Nonetheless, some recent official documents carry the statement that cardiovascular diseases are, in fact, causally related to soft water. Further research is necessary before precipitate action is ordered to abandon, adjust, or remove one source of supply in favor of another. This aspect of the relation of water to disease is noted not to suggest that investigations of the subject should be accentuated in Latin America, but to point out the unexpected manner in which environ- ment can affect health. Air Except for some special cases (the Arroyo smelter in Peru) and a few major cities (México City, Sao Paulo, Santiago), air pollution—although increasing— is not a major health problem as compared with other striking causes of mor- bidity and mortality. The impact of pollutants in the air upon the health and 2g0me of the institutions in which water pollution research is being carried out are Companhia Estadual de Tecnologia de Saneamento Basico e de Defesa do Meio Ambiente (CETESB), Sio Paulo, Brazil; Centro de Investigaciones y Entrenamiento para el Control de la Calidad del Agua (CIECCA), México, D.F., México; Fundagao Estadual de Engen- haria do Meio Ambiente (FEEMA), Rio de Janeiro, Brazil; Division de Investigaciones sobre Contaminaciéon Ambiental (DISCA), Caracas, Venezuela; Instituto Nacional de Ciencia y Técnica Hidricas (INCYTH), Buenos Aires, Argentina. 132 Biomedical Research in Latin America safety of man in Latin America has yet to be studied. National statistics do not usually list diseases such as emphysema, bronchitis, and others presumably related to air contaminants. This deficiency makes even epidemiologic inquiry extremely difficult. In light of these considerations, the rather scattered endeavors noted below represent a reasonably rational allocation of effort. CEPIS coordinates the activities of the Red Panamericana de Muestro Normalizado de la Contaminacion del Aire (REDPANAIRE). Approximately 120 monitoring stations throughout Latin America and the Caribbean coun- tries measure a limited number of parameters, using standardized techniques and reporting procedures. Similarly, CEPIS is collaborating with the World Health Organization (WHO) in establishing a global air quality monitoring network. Twenty-seven stations in nine countries have been selected, with the results to be transmitted to Geneva. In 1977, three comparison stations were installed in Lima, Santiago, and Sdo Paulo to assess the validity of measure- ment techniques. Occasionally, CEPIS has cooperated with Peru and other countries on research projects directed primarily toward determination of previously unmeasured pollutants in a particular country. Unfortunately, research conducted independently of CEPIS is sporadic or episodic. Where research is being pursued, it is invariably related to or assisted by PAHO. This is the case in Venezuela, via the Division of Investigations on Environmental Pollution (DISCA). In Mexico, the sub-secretariat of the environment has a similar responsibility. The State of Rio de Janeiro provides an official interest in air pollution via a State Foundation of Engineering of the Environment (FEEMA). Sido Paulo created an agency for similar purposes, known as Companhia Estadual de Technologia de Saneamiento Basico e de Defesa do Meio Ambiente (CETESB). The Institute of Sanitary Engineering of the University of Buenos Aires covers some of the appropriate functions in Argentina. Chile uses the Institute of Hygiene of Workers and of Atmospheric Contamination. Industrial Hygiene In spite of a long history of interest in the exposure of man to occupational hazards in Latin America, not much research is in progress. Proposals for joint studies with CEPIS have been presented to CETESB in Sio Paulo (monitoring of work environments) and the Institute of Occupational Health in Lima, Peru (calibration of direct-reading equipment). The proposals have not yet been developed into actual projects. The use and control of pesticides, as well as their impact upon man and the environment, continue to be of major interest. Work by Instituto Centroameri- cano de Investigacion y Tecnologia Industrial (ICAITI) has proceeded over the years, with several recent conferences in Central America. Abel Wolman and Frank Butrico 133 In the field of prevention of occupational hazards, a good deal of applied research has been under way for a long time in national laboratories of Argen- tina, Brazil, Chile, and Mexico and under international auspices in Guate- mala. Solid Wastes Research and investigations on solid waste management in the countries are limited, despite the importance of the problem. Some work is being done on recovery of waste heat and recycling of wastes at Companhia Municipal de Limpieza Urbana (COMLURB), in Rio de Janeiro, Brazil, but much more work in this area is needed. Disease Control Through Environmental Control In many cases the discovery of effective communicable disease control meas- ures have preceded the discovery of the biological “cause” of disease, or complete understanding of the mechanisms of disease transmission. Perhaps the best known of these was the discovery of the relationship between drinking water from the town pump and the spread of typhoid fever long before the typhoid bacillus was identified. This pragmatic, epidemiologic shortcut to control is still valid and is not pursued actively enough. Another example of a potential shortcut is available in the case of Chagas’ disease. Despite the dramatic discovery within a period of 1 year of the vector and the chain of infection leading to Chagas’ disease, decades have gone by and control of the disease seems no closer than it did before the etiology was worked out. The comprehensive research effort has been productive in scien- tific terms, but the disease eludes control. Given the prevalence of the disease and its debilitating effects, along with the failure of conventional research, it would be hard to find a more striking example of the need to attack disease by the environmental route. The vector of Chagas’ disease—a beetle—spends its life in houses, protected by the cracks of the walls. Although simple, inexpensive surfacing of the interiors of even 3 Argentina: Instituto Nacional de Tecnologia Industrial, Buenos Aires; Facultad de Ingenierfa Quimica, Universidad Nacional del Litoral, Santa Fe. Brazil: Faculdade de SaGde Publica, Universidade de Sio Paulo, Sdo Paulo; Fundag¢io Centro Nacional de Seguranga, Higiene e Medicina do Trabalho (FUNDACENTRO), Sao Paulo. Chile: Insti- tuto de Higiene del Trabajo y Contaminacién Atmosférica, Servicio Nacional de Salud, Santiago; Centro de Estudios, Medicién y Certificacion de Calidad (CESMEC), Corpora- cién de Fomento de Chile, Santiago. Mexico: Subdireccién de Ensefianza e Investigacion, Secretaria del Trabajo y Prevision Social, México, D.F., Mexico. International: Instituto Centroamericano de Investigacién y Tecnologia Industrial (ICAITI), Guatemala, Gua- temala. 134 Biomedical Research in Latin America adobe houses would significantly reduce the incidence of this disease, this solution has not been pursued. The situation is curious, since housing for the poor has been studied in Latin America for decades. It is undoubtedly true that a major effort to improve housing for millions of people would require astronomical capital funds; nonetheless, it is also true that minor changes, such as that noted above, plus simple amenities of water supply and sanitary removal of wastes, would bring major health dividends. Another example of the potential power of the environmental approach is found in the case of schistosomiasis and onchocerciasis, which have been studied for decades in North America, Latin America, and Africa. Most of the investigations have been directed toward the biology of vectors, chains of transmission and vector-host interrelationships, improved diagnosis, easier and more precise identification of vectors, and searches for adequate therapies. However, the promising environmental approach to control of these two im- portant parasitic diseases does not receive the careful analysis and investigation being devoted to their biologic, physiologic, and immunologic characteristics. Wide areas of research in hydrology, geomorphology, and human habits are relatively neglected. For example, onchocerciasis has recently been discovered in Amerindians in Northern Amazonas. The disease agent (Mansonella ozzardi) has been identified and sand flies and black flies are implicated as vectors, at least by the preliminary studies. This situation, like others, poses challenges to preventive environmental measures. The Ecological Approach One of the important scientific developments of the past two decades has been enhanced appreciation of the extreme importance of interrelationships that exist in nature, of their complexity and their fragility. The ecological approach to disease is becoming more prevalent and can be illustrated by examples of research in Latin America. The Gorgas Memorial Institute of Tropical and Preventive Medicine, Inc., a nonprofit laboratory in Panama, financed by U.S. governmental and private sources, has been vigorously engaged in ecological studies of important tropical diseases. This approach is of growing importance because large-scale construc- tion projects are becoming increasingly characteristic of the region. Such proj- ects always disturb the environment, often on a massive scale, and often with unforeseen consequences. One of these consequences can be establishment of new conditions favoring the spread of disease. Yellow fever, dengue, and Venezuelan equine encephalitis remain virtually permanent threats, not only to the regions discussed here but also to North America. Therefore, it is en- tirely possible that ecological changes may result in explosive proliferation of the vectors of these diseases. Abel Wolman and Frank Butrico 135 The Gorgas Memorial Institute is examining the ecological consequences of construction of the Bayano hydroelectric plant in eastern Panama and the major Pan American highway through the jungle area of the border between Panama and Colombia. The scientific consequences of these studies are so im- portant that the Pan American Health Organization, the World Bank, and the Panama Instituto de Recursos Hidraulicos y Electrificacion (IRHE) are coop- erating in the endeavors. Role of the Pan American Health Organization While the important role of PAHO in all aspects of biomedical research in Latin America is discussed elsewhere (see chapter 3), a few words on its sig- nificant role in stimulating environmental research are appropriate here. The Pan American Health Organization is expanding its manpower develop- ment activities to strengthen existing national and regional training institutions, including giving technical guidance in updating curricula. PAHO is also collab- orating with Centro Internacional de Formacion en Ciencias Ambientales para Paises de Habla Espanola (CIFCA), a United Nations Development Program (UNDP)-financed center in Spain that is prepared to make available funds for development of teaching facilities for short- and long-term training programs— the latter to the doctorate level in certain environmental specialties. There is continued emphasis on identifying national and regional collaborat- ing institutions to complement the research and investigations being con- ducted at universities and at the Pan American Center for Sanitary Engineering and Environmental Sciences in Lima and the Pan American Center for Human Ecology and Health in Mexico City. Over the past 4 years, PAHO has been instrumental in directing grants and loans from international agencies to establish a number of institutions that are now functioning effectively in developing appropriate technology to solve national and regional environmen- tal health problems. Many of these institutes now in operation have been men- tioned earlier; others are in various stages of development. These efforts to strengthen national institutes are in keeping with the wishes of the U.N. member countries themselves, in furthering the concept of technical cooperation among developing countries (TCDC, i.e., to help and learn from each other and not to rely too heavily on technical assistance from industrialized countries). TCDC received world attention at an international conference in Buenos Aires, Argentina, in March of 1978. The experiences of the Central and South American countries constituted an important contri- bution to this conference. 136 Biomedical Research in Latin America References 1. Pan American Health Organization. Reported Cases of Notifiable Diseases in the Americas, 1970-1972. Washington, D.C.: PAHO, 1975. 2. Pan American Health Organization. Weekly Epidemiological Report, January 26, 1977. Washington, D.C.: PAHO. 3. United States, 95th Congress, first session, 1977. House Document 95-39: 48th annual report on Gorgas Memorial Laboratory, fiscal year 1976. 4. Pan American Health Organization, Caribbean Epidemiology Center. Surveillance Report on Mansonella Ozzardi, Vol. 3, No. 1, January 1977. 5S. Wolman, A. Health priorities in human ecology and environmental pollution. Bull Pan Am Health Organ 8(4): 351-353, 1974. 6. Wolman, A. The environment and disease. Bull Pan Am Health Organ 10(3): 247-252, 1976. 7. Wolman, A. Environmental sanitation in urban and rural areas: Its importance in the control of enteric infections. Bull Pan Am Health Organ 9(2): 157-159, 1975. 8. Wolman, A. Health and economic aspects of hardness and corrosiveness of public water supplies. J] Am Water Works Assoc, April 1976, pp. 216-217. 9. Weller, T.H. Manson’s schistosomiasis. Am J Trop Med Hyg 25(2): 208-216, 1976. 10. Pan American Health Organization. Annual Report of the Director, 1975. Official Document No. 143. Washington, D.C., PAHO, 1976. 11. World Bank. Health. Sector Policy Paper, March 1975. Appendix Investigations Carried on at ERIS/Guatemala 1. The Eutrophication of Lake Amatitldn, Carlos E. Mufioz P., September 1973 2. Investigation of the River Contamination in the Southern Basin of the Guatemala Valley, Fritz Conradin and Carlos E. Mufioz, September 1973 3. Pilot Plant for the Treatment of Sewage, Arturo Pazos S., September 1973 4. Problems in the Collection and Proper Disposition of Solid Wastes in Areas With Limited Economic Resources, Guillermo Guzman Chinchilla, September 1973 §. Water Demand, Octavio Cordon M. and Otoniel Samayoa B., August 1971 6. Selection, Fabrication and Calibration of Venturis in Guatemala, R.O. Cordén and Manuel Prado, August 1971 7. Procedures to be Followed in the Formation of Activated Sludge in Pilot Plant, Arturo Pazos S. 8. Preliminary Investigation of the Gaseous and Solid Contaminants in the Areas of Major Traffic in the Urban Areas of Guatemala City, Luis Gustavo Cordero A. and Alba Tabarini de Abreu, April 1971 9. Procedures and Preliminary Results of a Limnological Investigation in the Lake of Atitlan, Luis E. Garcia and Alba Tabarini de Abreu, February 1972 10. Sanitary Engineering and the Integral Use of Hydraulic Resources, Carlos Mufioz and Luis E. Garcia, February 1972 11. Stream Pollution, Carlos E. Mufioz, Fritz Conradin, Alba Tabarini de Abreu, and Sonia Fl6rez, June 1975 12. Preliminary Report of the Pilot Plant for Sewage Treatment by a “Percolation Tower.” Experiences in Guatemala, Arturo Pazos Sosa, September 1976 Abel Wolman and Frank Butrico 137 13. Final Report of the Investigation of Carbon Monoxide in the Zones of Greater Traffic in the Urban Areas of Guatemala City, Alba Tabarini de Abreu, July 1975 14. Eutrophication of Lake Amatitlin, Alba Tabarini de Abreu, August 1975 15. Preliminary Report on the Investigation of Rural Sanitation: Programas de Inves- tigacién y Otras Actividades, Universidad de San Carlos de Guatemala (School of Engineering); Programs of Investigation. University of San Carlos, Guatemala (School of Engineering); Informe Final sobre el Programa Consejo Federal Suizo, Gobierno de Guatemala. Universidad de San Carlos, Guatemala, OMS/OPS. CANCER RESEARCH Pelayo Correa Introduction A comprehensive review of activities related to cancer research in Latin Amer- ica would require the joint efforts of a team of specialists in several major areas of research and a series of site visits to the main centers of investiga- tion. This chapter is not intended to be comprehensive; it is based on the experience of one Latin American researcher who, having had the oppor- tunity to develop a research program in one Latin American country and help other researchers in several Latin American countries develop similar projects, has concentrated his efforts in the areas of geographic pathology and epide- miology of cancer. Investigators drawn from other disciplines may fill in the gaps on other research in Latin America. Background There have been several previous attempts to evaluate research activities in Latin America, mainly by the Pan American Health Organization (PAHO) [1, 2]. These give an adequate account of the general problems facing research- ers in Latin America and should be consulted by interested readers. No attempt will be made here to analyze positive and negative factors discussed in these publications, but some of the factors will be mentioned when necessary to help explain the settings prevailing in Latin America. Indeed, one of the factors had a direct bearing on the preparation of this report: i.e., isolation of research teams, due to lack of adequate communication systems. Very few medical journals published in Latin America enjoy transnational circulation and most of them are not indexed in international reference sources. Recently the Pan American Health Organization, with the collaboration of the National Cancer Institute, has established a mechanism to help overcome these obstacles: the Latin American Cancer Research Information Program (LACRIP). “Latin America” is a rather vague, general term applied to American coun- tries with a strong cultural background of Mediterranean-European origin. Some Central and South American communities, like Jamaica and the Guianas, are predominantly of an English or Dutch cultural background; while others, 139 140 Pelayo Correa like the Spanish-speaking populations of Texas and New Mexico, which would qualify for the term, are not included in the group for reasons of political- administrative-geographic boundaries. This chapter will deal mainly with those countries that have strong racial and cultural Spanish or Portuguese (Iberian) roots, reflected mainly in the official language of the country. There is great racial and socioeconomic diversity in Latin America. Some communities are of almost pure Spanish stock, while others are of almost pure Indian stock, frequently within the same country. Similarly, one country may harbor subpopulations close to the extremes of wealth and poverty. Most of the available national scientific data on health indicators, therefore, represent averages of the contributions of diverse subpopulations, and very few attempts have been made to provide specific data for well-defined, homogeneous sub- groups of the population. A general idea of the health, demographic, and economic conditions of the area can be obtained from the data for regional groupings compiled by Logan around 1972 (table 1) [3]. Latin America in general is characterized by low gross national product, high birth rates and population growth, high infant mortality, very young populations with high indexes of dependency, and inade- quate health delivery systems. More recent figures show some improvement in economic parameters, a greater tendency to urbanization, and a slight decrease in the rate of population growth. Indicators of suboptimal health are more accentuated in tropical and subtropical areas than in the temperate “southern cone” of the hemisphere. There are marked differences in the indexes between specific countries (table 1). Three main health delivery systems are found in Latin America. The oldest is a network of charity hospitals supported by the State from special tax sources, in many cases funded by national lotteries. These hospitals have limited resources and take care of an expanding indigent population. Many TABLE 1. Quality of Life in the Western Hemisphere Country Index* Country Index* United States 100 Brazil 67 Canada 95 Ecuador 67 Uruguay 87 Dominican Republic 64 Argentina 85 El Salvador 64 Costa Rica 85 Peru 59 Panama 80 Nicaragua 53 Venezuela 79 Guatemala 51 Chile 77 Honduras 51 Mexico 73 Bolivia 43 Paraguay 73 Haiti 32 Colombia 68 *Physical quality life index developed by the Overseas Development Council, based on life expectancy, literacy, and infant mortality. Biomedical Research in Latin America 141 are teaching hospitals of medical schools and have some facilities for private patients. These hospitals have suffered the impact of an increased patient load due to accentuated demographic growth in recent decades, and many of them, as a result, have deteriorated in terms of quality of medical care. The second system is represented by Social Security institutes created by most governments 30 to 40 years ago as semiautonomous entities to care for the health needs of nongovernment (private industry) salaried personnel. These institutions are primarily supported by contributions paid by employers and employees. For the most part their budgets have kept pace with inflation, and the institutes have gradually extended their population coverage. They have built excellent networks of hospitals; have kept a permanent staff of medical, paramedical, and administrative personnel; and without question represent the outstanding method of health delivery in Latin America. Most keep excellent records of the population eligible for medical services, and these records are used repeatedly for fiscal planning and administrative control but rarely for health care or research purposes. The system has suffered from interference of government and party politics in the past, but in some countries it is acquiring enough internal dynamics to ensure stability. Such a system represents a great hope for future medical research, and some steps in that direction can be cited already. Association with medical schools and univer- sities would be potentially beneficial for Latin American medicine, but so far only a few countries have taken firm steps to combine the two. An example of this association is the use of Social Security hospitals in Mexico for teaching purposes. The third system of health care is the private sector—so far, of minimal significance in cancer research. Recent political difficulties in State-supported medical schools have led in some countries to establishment of new private medical schools, but it is too early to tell what impact—if any—they will have on cancer research. Research on Cancer Epidemiology Development of cancer research activities in Latin America has been somewhat slow in the past but has begun to pick up speed and broaden in scope in recent years. The earliest studies were based on rather incomplete mortality statistics and on series of cases observed at large hospitals. Mortality data were con- siderably improved by the PAHO special study [4]. Attempts to organize cancer registries were made some years ago in several countries, and those in Brazil, Colombia, Cuba, and Puerto Rico were successful, whereas other registries had a successful initial period and deteriorated afterwards. The registry in Cali, Colombia, has been a leader in the successful group. It was developed by collaboration between the Universidad del Valle (UV) and the Biometry Branch of the U.S. National Cancer Institute (NCI). Some of the 142 Biomedical Research in Latin America reasons for its success probably have to do with its having limited its task to an area (the city of Cali) commensurate with its resources, having maintained a permanent interest in utilization of data, and having had adequate consul- tation facilities with international experts in the field who helped develop local staff in early phases of the project. It has developed a collaborative program with Louisiana State University (LSU) that has led to extension of activities of the group to other Latin American countries. The two institutions (LSU and UV) drew up a training program and carried out three workshops on cancer epidemiology especially addressed to Latin American researchers with potential for developing programs in their own countries. These were held in Recife, Brazil (1975), Brasilia (1976), and Quito, Ecuador (1977). Two of the workshops were addressed especially to pathologists, and the third, sponsored by the International Agency of Cancer Research, was directed especially to public health workers. Fellowships for additional in-depth training in U.S. universities have been given to candidates who will return to their bases to work on cancer epidemiology. The Cali-LSU program is working very closely with the Brazilian and Peruvian registries and has organized new reg- istries in Bolivia and La Plata (Argentina), where especially interesting epi- demiological situations have been identified. Epidemiology research basically depends on the availability of populations with contrasting cancer experience, which is determined by two main forces: genetics and environment, the latter mainly as it relates to lifestyles of indi- viduals. From this standpoint, Latin America offers opportunities that are difficult to match. It would be hard to find a group of culturally linked coun- tries with more diversity in genetic composition and lifestyle patterns than Latin America. The other main requisite for epidemiology research is avail- ability of scientists and trained personnel, primarily epidemiologists, statisti- cians, and pathologists. The majority of epidemiologists and statisticians in Latin America are not engaged in cancer research. Instead, they are involved with research in the field of infectious diseases since it is usually argued that there are more important health problems in this area. The greatest differential in death rates between developed and developing countries is in infant mor- tality [3]. In most cases the etiologic agent related to the immediate cause of death is infectious in nature; but among other important factors, not fully evaluated at present, is insufficient protection of children by adult members of the society, a direct result of the high dependency rate of the population. It could then be argued with statistical backing that prevention of one adult death has more beneficial impact on the community than prevention of the death of one infant. Cancer is the second most frequent cause of death in adults in most Latin American countries, and its importance as a serious public health problem is gradually being recognized by the medical and public health profession. With luck, this will bring more researchers and resources into the field of cancer epidemiology. Pelayo Correa 143 Official mortality statistics in Latin America for neoplastic diseases usually are not very reliable, especially in the many areas where death certificates are of poor quality. A milestone of progress in this area is the PAHO study di rected by Dr. Ruth Puffer. It provided data on 10 Latin American cities representing the main socioeconomic complexes, and compared them with San Francisco and Bristol. Table 2 shows the death rates for the main local izations of neoplastic diseases in the study. It points to some of the most prominent and interesting situations deserving analytical study, such as the very high rates of uterine cervical cancer in most tropical countries as well as in Chile; the very high rate of gastric cancer in the Andean region and the south of Brazil; and the high rates of lung, bladder, colon, and breast cancer in Argentina, as well as the low frequency of those tumors in most other Latin American countries. Studies of cancer morbidity have been conducted in a few Latin American countries. They require establishment of cancer registries to collect and process data for the calculation of incidence rates, with permanent staff and special budget allocations. The third volume of Cancer Incidence in Five Continents, which collects reliable incidence figures around the world, included data from the following registries of Latin American populations: Puerto Rico; Cuba; Cali, Colombia; and Sdo Paulo and Recife, Brazil. The first volume included data from Chile, where a national cancer registry was in operation but was unfortunately discontinued. A cancer registry of metropolitan Lima has been in operation for some time and is being reorganized. New registries have been established recently in La Paz, Bolivia, and La Plata, Argentina. Table 3 shows examples of age-adjusted incidence rates for populations of Spanish or Portuguese background appearing in the third volume of Cancer Incidence in Five Continents. Data for Connecticut, U.S.A., and Miyagi, Japan, are included for comparative purposes. Despite the limited geographic areas covered, the available data give a general idea of the distribution of cancer in Latin America and point to many opportunities for cancer research. The registries now in operation have limitations, especially in the number of in- vestigators available for analytical studies. In some instances, epidemiologists and statisticians from schools of public health and departments of preventive medicine of medical schools are becoming interested in the data and the material of cancer registries, but much more activity in this area is highly desirable. National Cancer Research Activities In spite of the difficulties involved in reporting on the research programs of every country, an attempt will be made to mention some of the lines of re- search in those countries in which the author has been able to secure infor- mation by personal knowledge or by answers to a questionnaire about cancer TABLE 2. Age-Adjusted Annual Death Rates per 100,000 Inhabitants Ages 15-74, Malignant Neoplasms, 1962-64 All City Sites Esophagus Stomach Colon Larynx Lung Breast Cervix Bladder Lymphoma Leukemia Men Bogota 115.2 8.1 45.2 1.5 2.1 9.1 - - 34 8.1 3.6 Bristol 155.8 4.4 19.7 6.7 1.3 60.1 - - 5.5 6.6 4.2 Cali 96.6 4.0 33.8 2.7 1.9 8.8 - - 3.9 4.1 2.2 Caracas 128.2 34 27.6 4.2 4.0 24.0 - - 75 1.7 3.8 Guatemala 98.0 3.7 34.6 1.8 4.9 6.0 - - 34 3.9 3.8 La Plata 182.6 9.2 20.8 7.8 7.0 59.0 - - 14.6 7.0 5.2 Lima 112.5 4.0 30.3 3.9 1.7 17.9 - - 2.3 6.9 6.1 México 62.2 2.0 8.3 2.6 2.6 7.8 - - 3.6 2.2 3.0 Ribeirdo Préto 137.6 8.6 41.8 4.1 11.5 9.4 - - 6.5 6.4 54 San Francisco 128.2 5.3 10.0 8.8 2.2 37.0 - - 3.37 2:3 3.4 Santiago 127.6 6.0 38.3 2.2 3.1 23.7 - - 1.3 4.7 4.9 Sio Paulo 102.6 8.5 26.0 4.1 4.6 14.8 - - 3.6 4.2 4.5 Women Bogota 128.0 4.0 38.4 2.7 - 35 9.7 19.3 1.6 53 3.7 Bristol 97.3 1.7 7.8 5.5 0.2 6.8 28.7 5.6 2.1 4.0 29 Cali 120.0 - 14.7 2.5 0.4 2.9 12.9 43.5 2.1 3.2 1.6 Caracas 114.2 3.2 14.2 2.6 - 5.7 15.1 20.5 0.4 4.1 39 Guatemala 110.0 0.9 24.4 25 0.6 2.0 10.7 25.5 0.9 25 1.8 La Plata 103.1 1.9 10.9 7.8 0.4 29 234 8.6 0.5 34 3.0 Lima 133.5 21.3 34 0.2 5.5 17.9 38.2 1.5 4.9 4.7 México 94.9 0.5 5.8 2.0 0.7 22 11.3 27.8 0.4 3.0 3.5 Ribeirdo Préto 87.1 1.2 16.0 3.8 1:3 6.1 15.7 11.1 - 1.7 33 San Francisco 98.9 1.1 6.4 8.1 - 8.8 19.0 8.3 1.2 54 8.0 Santiago 121.2 3.7 19.5 24 0.3 5.0 14.8 21.0 0.3 5.2 3.8 Sido Paulo 95.9 1.6 17.0 4.9 - 2.9 15.9 12.4 0.7 3.1 2.5 Source: Reproduced with permission from R.R. Puffer and G.W. Griffith, Patterns of Urban Mortality, Washington, D.C.: Pan American Health Organization, 1967. vl BOTIOWY UTR UI YOIBASIY [BOIPAWIOIG TABLE 3. Age-Adjusted (World Population) Incidence Rates of Malignant Neoplasms All Sites Stomach Colon Larynx Lung Breast Cervix Prostate Except Skin Males Females Males Males Males Males Females Females Males Brazil Recife 181.0 205.1 243 2.8 8.5 15.7 41.9 58.1 22.6 Sao Paulo 230.6 199.0 49.5 8.7 14.1 25.0 47.3 21.5 16.3 Colombia, Cali 167.7 211.0 44.5 32 6.5 18.6 27.8 62.8 19.8 Cuba 169.9 147.0 14.3 6.9 8.5 44.7 28.0 19.5 18.0 United States Connecticut 285.9 238.1 13.5 30.1 7.8 33.7 71.4 9.8 37.3 New Mexico (Spanish) 1579 177.1 18.6 8.7 2.7 16.7 324 1.3 34.3 El Paso (Spanish) 192.6 265.0 21.2 93 1.6 227 52.3 80.9 43.5 Puerto Rico 174.0 146.7 23.3 5.0 6.4 15.4 25.4 25.6 21.4 Japan, Miyagi 184.7 127.7 84.6 5.6 2.0 20.0 13.0 13.8 2.7 Spain, Zaragoza 186.0 133.2 33.8 6.5 12.4 23.5 30.6 4.1 17.7 Source: Cancer Incidence in Five Continents, Vol. 3, J.A.H. Waterhouse, C.S. Muir, P. Correa, and J. Powell, eds., Lyon: International Agency for Research on Cancer (IARC Scientific Publications No. 15), 1976. Selected populations and sites. Ba110)) OAR[od 94! 146 Biomedical Research in Latin America research activities, which he sent to Latin American medical schools, teaching hospitals, health services, and ministries of education and health. The list is incomplete, but provides some examples of ongoing activities. Mexico One of the most important and best equipped medical institutions for research on cancer epidemiology is the Mexican Institute of Social Security (IMSS). It has abundant demographic and socioeconomic information on record and a captive population of about 15 million people, for whom it provides practically all medical care, in its extensive network of hospitals and clinics. Many IMSS subscribers continue in the system after retirement. Numerous isolated research projects related to cancer epidemiology are carried out by different units of the system; prominent examples include those originating in the oncologic hos- pital, and its screening, diagnostic, and treatment facilities for female genital cancer. An attempt was made to organize facilities for data analysis at a central level, starting with a population-based registry for Mexico City. This project failed for internal reasons and perhaps because it attempted to accomplish too much from the start, without the necessary infrastructure. A smaller city could well provide the experience and the model needed for a more extensive cancer registry project. Executives of IMSS have not yet realized the extraordinary potential of their system for cancer research purposes. Understandably, they are focusing on medical care delivery and do not seem to have adequate mech- anisms to train a cadre of epidemiologists who could bring incalculable benefits to the system and to their patients. Another important contribution is being made by the Universidad Auto- noma de Mexico, with multiple departments of pathology and clinical medi- cine scattered throughout an extensive hospital network. An example is pro- vided by the scientific staff of the Hospital General, where excellent studies of descriptive epidemiology have been made, not only in the area of oncology but in that of infectious and metabolic diseases. The hospital is part of the system of the Ministry of Health, which also administers a very extensive cervical cancer screening program that has produced valuable epidemiologic information. The Mexican Association of Gastroenterology has taken the lead in planning and carrying out epidemiological studies in the field of gastrointestinal cancer. At the present time, it is engaged in a descriptive study that could serve as the basis for future analytical investigations provided epidemiologic advice is secured and implemented. Mortality statistics show that Mexico’s largest single problem in neoplastic diseases is uterine cervical cancer, which is expected to decline as preventive measures are implemented. Breast cancer ranks second in frequency. The overall cancer death rate for men in Mexico City is one of the lowest in Latin Pelayo Correa 147 America. Mexican urban men seem to have escaped the major epidemics found in other countries. This pattern is changing, however, as shown in table 4 [5]. It seems that lung cancer is gradually becoming the leading cause of death; indeed, all indications are that the country is on the verge of an epi- demic of lung cancer that has not yet caught the eye of public health authorities. Central America The main Central American focus of activity in cancer epidemiology research is in Costa Rica. Conditions in that country lend themselves almost ideally to cancer epidemiology research: stable population, marked geographic contrast, good systems of health delivery, and acceptable statistical infrastructure. The main bottleneck is the shortage of epidemiologists dedicated to cancer re- search. Several publications have adequately covered the area of descriptive epidemiology of gastrointestinal and gynecological cancer [6, 7]. Gastric cancer rates in Costa Rica are second only to those in Japan, and a number of descriptive and analytical investigations of the subject have been made. Sub- groups of the population with high and low risk have been identified and TABLE 4. Frequency Rank of Death Rates for the Five Most Frequent Malignant Neoplasms, Mexican Males, 1963-73 Rank 1963 1965 1967 1969 1971 1973 Country I ST ST ST ST ST ST 1I PR PR PR LG LG LG III LK LK LK PR PR PR Iv LF LF LG LK LK LK Vv LX LX LF LF LX LF Federal District I ST ST ST ST ST LG II PR LK LG LG LG ST III LK PR LK LK LK PR Iv LF LF PR PR PR LK Vv LG LG LF LF LF LF ST, stomach; LG, lung; PR, prostate; LK, leukemia; LF, lymphoma, LX, larynx. Source: Reproduced with permission of Secretaria de Salubridad y Asistencia from R. Olper, Salud Piiblica de México 5:543-553,1975. 148 Biomedical Research in Latin America correlated with the prevalence of premalignant lesions of the gastric mucosa. But the full potential of genetic and environmental research has hardly been scratched. Recent changes in the systems of health delivery have resulted in centralization of policymaking for the Public Health and Social Security hospital networks. It is too early to tell if the new administration will be far- sighted enough to take advantage of the natural population laboratory at its disposal. El Salvador offers similar opportunities for cancer research. Cancer frequency in that country has been described [8], and many valuable publi- cations on the subject can be found in medical journals. Guatemala has an interesting situation, with its Indian stock and its excellent research facilities in the area of nutrition. Colombia Three main centers of research activity in cancer epidemiology in Colombia are in the cities of Bogota, Medellin, and Cali. The Instituto Nacional de Cancerologia in Bogota carries out a series of clinical, epidemiological, and laboratory investigations in different neoplastic diseases. The institute coordi- nates a national cancer registry based mainly on pathology reports collected at the local level and submitted to Bogota for processing, tabulation, and analysis. The registry has described basic patterns of cancer distribution in the republic, which comprises a variety of climatological and ethnic subgroups. The same team of epidemiologists and clinicians surveyed the prevalence of cervical cancer and dysplasias in several communities. In coordination with the National Registry, a special, more in-depth project of cancer registration is being carried out in the region of El Quindio, a rural community of coffee farmers. A special study of lymphomas being conducted at the institute has re- sulted in several epidemiologic publications in local medical journals. Another interesting epidemiologic and laboratory study of the institute has to do with the carcinogenic effect of bracken fern, which is of great economic importance to the cattle industry of the country. In Medellin, a series of studies on the epidemiology of gastrointestinal cancer and its precursor lesions was initiated in the department of pathology of the Universidad de Antioquia Medical School, with records and material going back approximately 40 years. These studies have recently extended to the genetic aspects of familial intestinal polyposis, including pedigree studies and genetic markers. A cancer registry of the affiliates of the Colombian Institute of Social Security established 10 years ago in the same city basically covers several hundreds of thousands of salaried workers in private industry. Cancer incidence rates for different organ sites have been calculated and compared with figures from registries covering other Colombian populations. Hypotheses have been formulated based on the differences found, and some of them are being tested by analytical studies such as a case-control study of Pelayo Correa 149 cancer of the lung and larynx, whose incidence seems to be related to the kind of cigarettes preferred by the local populations. In Cali the activities center around the cancer registry, founded in 1962 in the department of pathology of the medical school of the Universidad del Valle to cover the population of the city of Cali. It publishes incidence figures regularly in Cancer Incidence in Five Continents and has contributed many scientific publications in national and international journals, covering studies of cancer of the respiratory, gastrointestinal, genital, and lymphoreticular systems. These papers have described the pattern of respiratory and urinary cancers associated with black tobacco smoking, the patterns of Hodgkin's disease associated with different socioeconomic strata, and the patterns of colon cancer in different socioeconomic classes and its relationship to polyps. A favorable characteristic of the registry is the heavy migration to the city from other areas of Colombia, a characteristic that has been exploited by local investigators to identify cancer patterns of migrants from other ecologic systems, such as the rural Andes and the tropical coast. These contrasts have carried over to precursor lesions of gastric cancer, which in turn have led to further epidemiological field work in rural areas. Combined with ecologic and laboratory studies, this field work has advanced considerably the knowl- edge of gastric cancer etiology and led to formulation of epidemiology models that are being tested in laboratories throughout the world. The Cali epidemio- logical unit is intimately connected with the study of pathology of cancer and precursor lesions. It has served as a training center for other Latin Ameri- can investigators who are adopting the Cali model to establish registries and studies in their own countries. Venezuela Much of the cancer epidemiology activity of Venezuela is centered in the Ministry of Health and the Instituto Venezolano de Investigaciones Cientificas (IVIC). The Ministry of Health is carrying out a study of early detection of gastric cancer using mobile X-ray units and is planning to set up several cancer registries in the country. The IVIC has been interested in immunologic aspects of gastric cancer and is carrying out field studies, including collection of blood samples for immunologic laboratory studies, in several areas of the country. Peru A cancer registry has existed in the metropolitan area of Lima since 1968. It is under the Ministry of Health and forms part of the epidemiology program of the Instituto Nacional de Enfermedades Neoplasticas. It covers a population of over 3 million people with large groups of migrants from different regions of the country. The registry published a monograph describing the main findings 150 Biomedical Research in Latin America in 1973, as well as a more detailed analysis of its experience with leukemia [9]. The registry is being reorganized to improve coverage and facilitate additional epidemiologic studies. Scientific personnel of the institute have also conducted epidemiologic studies, some of which dealt with the peculiar epidemiological features of Hodgkin’s disease and other lymphomas present in the area. The institute participates in several international clinical trials as well, especially in the field of breast cancer. Brazil Brazil has the most structured governmental organization for cancer epidemi- ology in Latin America. The Ministry of Health has a national cancer division in charge of the program. The division publishes one of the few regular scien- tific journals in Latin America that are exclusively dedicated to neoplastic disease: the Revista Brasileira de Cancerologia. The division has an information network covering most of the cancer treatment centers in the country. This serves as a mechanism for surveillance of the centers and can be used as a gross indicator of the distribution of disease and of the prominent time trends that deserve more in-depth investigation. In addition, the division works in close collaboration with a network of cancer registries. The Sido Rwulo registry is run by the staff of the School of Public Health of the University of Sao Paulo and serves not only as a cancer epidemiology study center but also as a train- ing center for Brazilians and other Latin Americans. The registry of Pernam- buco (Recife) is closely associated with the Federal Medical School and its departments of pathology and preventive medicine. It serves a tropical popu- lation with peculiar cancer patterns such as a high incidence of cancer of the rectum and very low gastric and colonic cancer rates. In spite of Recife’s climatic conditions, which are similar to those of tropical Africa, Burkitt’s tumor and hepatocellular carcinomas are relatively rare. The registry of Belém del Para covers a relatively small population but has been in operation long enough (more than 10 years) to be useful as an indicator of the cancer pattern in this community surrounded by the Amazon jungle. A large registry covers Porto Alegre, one of the southern states of Brazil. Bolivia Interesting racial and environmental situations exist in Bolivia, but so far very little advantage has been taken of them for epidemiologic studies. Some genetic studies of the Indian population have been made. A large number of people live at an altitude approximately 4,000 meters above sea level. A cancer registry has recently been organized in La Paz, and some analytical studies of gallbladder carcinoma, the most frequent internal cancer in that city, have been initiated. Pelayo Correa 151 Chile A long tradition of cancer epidemiology research exists in Chile. Unfortu- nately, political turmoil has disrupted it to some extent, and only in very recent years have there been signs of slow recovery. Several areas have been the focus of study. The first was a national cancer registry that took advantage of the unified health care delivery system of the Servicio National de Salud. It provided valuable information on descriptive cancer epidemiology but unfortunately was dismantled before it could lead to more in-depth studies. No signs of revival of the national registry or of any of its geographic areas have been detected by the author. The second area of productive work is related to uterine cervical cancer and includes descriptive epidemiology and comprehensive screening programs that not only served the purpose of early diagnosis but contributed to studies of the epidemiology of precursor stages of neoplasia. The third area refers to study of gastric cancer epidemiology and includes descriptive analytical and environmental studies. A Japanese scientific mission is collaborating with Chilean investigators in a broad program of population screening for gastric cancer. The role of nitrate fertilizers has been studied by several investigators and is being pursued currently by means of a National Institutes of Health (NIH) grant to the University of California. Important contributions in the field of endocrinology and neoplasia have been made by the Institute of Experimental Medicine, especially by Lipschutz and Iglesias. Argentina The frequency of cancer in Argentina resembles the patterns of Western Europe and North America more than it does that of Latin America. This is known mainly through mortality statistics, such as those of the PAHO study. Particularly remarkable is the high rate of colon and lung cancer. The incidence of esophageal and bladder carcinoma is also higher than expected. Some studies of the relationship of these patterns with smoking have been con- ducted. The city of Buenos Aires is too big for a cancer registry, but it serves as a center for studies of relative frequency, mostly conducted in the Academy of Medicine and in some of the excellent specialty hospitals in the city. A prominent center for the study of neoplasia of the lymphoreticular system is the Latin American Group for the Treatment of Acute Leukemia (GATLA), which has an international reputation and participates in clinical trials of leukemia and lymphoma patients. A cancer registry has recently been estab- lished in La Plata, where the size, stability, and representativity of the popu- lation offer good opportunities for future studies. TABLE 5. Specialized Centers of Cancer Research and Training in Latin America Postgraduate Country Number of New Patients Training Courses Institution Beds Admissions Registered Services* (Positions) (Location) Research (c. 1974) Argentina Buenos Aires Hospital Central de Radiaciones 150 1,720 9,600 R Ch Yes Oncology Nuclear Medicine (7) Special Symposia Instituto Angel H. Roffo 76 1,100 - Exp - Oncology Chemical carcinogenesis; Clinical research (University of Herpes virus; nitroso Professional Ed. Buenos Aires) compounds; immu- Reg nology; endocrine me- tabolism; clinical trials Bolivia La Paz Instituto C. Arteaga 30 383 198 SR Ch - General Oncology Clinical research Brazil Belém Instituto Ofir Loiola 50 1,394 1,416 SR Ch Reg Yes General Oncology - 1) Minas Gerais Centro de Estudios e Pesquisas Oncoldgicas 100 1,800 1,500 SR Ch Yes Clinical Oncology Clinical trials (10) Hospital Borges da Costa 111 - 3,345 SR Ch Yes Clinical Oncology - (10) (Federal University) Mercy Hospital 314 2,170 1,012 SR Ch Yes Yes - (M2. Medical School) Guabirotuba Erasto Gaertnes Hospital 100 1,000 1,650 SR Ch No For medical students - Sl BOLIQUIY UTIBT UI YOIBaSay [BOIPAWIONg Postgraduate Country Number of New Patients Training Courses Institution Beds Admissions Registered Services* (Positions) (Location) Research (c. 1974) Brazil (cont’d.) Jodo Pessoa Laureano Foundation 82 665 1,298 SR Ch No Yes - (Paraibo Medical School) Porto Alegre Santa Rita Hospital 96 1,224 1,096 SR Ch No Yes Clinical trials Recife Pernambuco Cancer Hospital 160 1,739 3,493 SR Ch Reg Yes Yes Clinical trials Rio de Janeiro Mario Kroef Hospital 148 890 4,180 SR Ch Reg Yes Yes - Gynecology Institute Federal University 8 - 160 SR Ch Yes Yes Immunotherapy National Cancer Institute 221 1,831 1,490 SR Ch Exp Yes Yes Tumor specific antigens; (65) trials in immunotherapy and chemotherapy; leukemia and melanoma Santo Cristo Oncologic Hospital 125 902 1,848 SR Ch No Yes - Sao Paulo . Camargo Hospital - Prudente Foundation ~~ 324 5,467 4,004 SR Ch Yes Experimental chemo- Exp (35) Yes therapy with local flora extracts on Erlich sar- coma; bone transplants; in vitro chemotherapy BA110)) 0AR[3d €S1 TABLE 5. Specialized Centers of Cancer Research and Training in Latin America (cont’d.) Postgraduate Country Number of New Patients Training Courses Institution Beds Admissions Registered Services* (Positions) (Location) Research (c. 1974) Chile Santiago Hemato-oncology Institute Hospital Clinico 20 200 100 SR Ch Yes Yes Clinical trials 3) (U. Catolica) C.P. Correa Radium Institute 92 1,120 1,485 SR Ch Yes Yes Hormonal influence in Exp (10) (U. of Chile) cancer biology Institute of Experimental Medicine - - Exp No No Chemical carcinogenesis; hormonal carcinogenesis; 80 transplantable tumor lines Colombia Bogota Cancer Institute 144 1,800 6,329 SR Ch Exp Yes Yes Viral oncogenesis; Epidemiology Immunology; Herpes virus; lymphomas; clinical trials Cuba Havana Institute of Oncology 405 5,075 2,400 SR Ch Yes Yes Epidemiology ; cell Exp Reg (30) cultures; clinical trials Dominican Republic Cibao Institute 15 150 315 SR Ch No - Epidemiology of female genital cancer Guatemala Cancerology Institute 90 1,067 857 SR Ch No Yes - PSI BOLIQWY UTJET UI YOIBASAY [EOIPaWIONg £1100) OAR[o] Postgraduate Country Number of New Patients Training Courses Institution Beds Admissions Registered Services* (Positions) (Location) Research (c. 1974) Mexico Veinte de Noviembre Hospital 60 925 1,899 SR Ch Reg No Yes - (U. of México) General Hospital Yes Oncology Unit 111 970 - SR Ch Reg Yes (U. of México) ® C.M.N. Oncological Hospital 186 5,101 5,581 SR Ch Yes Yes Molecular biology; Exp (36) (U. of México) immunology; clinical trials Spanish Hospital 35 364 323 SR Ch Reg No Yes Clinical trials National Cancer Institute 61 1,341 4,106 Reg Exp No Yes Tissue culture; clinical trials Peru Arequipa Goyeneche Hospital 22 257 366 SR Ch Reg No Yes Clinical trials Lima Central Hospital #2 60 1,500 400 SR Ch Reg Yes Yes - (13) (U. of San Marcos) Altitude Research Inst. - - - Exp No Yes Effects of hypoxia on metastasis; chemical carcinogenesis; immu- nology National Neoplastic Diseases Institute 142 3,204 2,057 SR Ch Reg Yes Yes International clinical (33) (U. Cayetano Heredia) trials; epidemiology o> an TABLE §. Specialized Centers of Cancer Research and Training in Latin America (cont’d.) Postgraduate Country Number of New Patients Training Courses Institution Beds Admissions Registered Services* (Positions) (Location) Research (c. 1974) Puerto Rico Ponce Andrés Grillasca Clinic 56 944 818 SR Ch Exp No Yes Experimental radio- (U. of Puerto Rico) therapy Rio Piedras Gonzalez Martinez Hospital 138 1,176 1,151 SR Ch Reg Yes Yes - San Juan P.R. Nuclear Center - - - R Reg Exp Yes - Experimental radio- therapy Comprehensive Cancer Center 50 889 655 SR Ch Reg Yes Yes Radiation carcino- Exp 7) (U. of Puerto Rico) genesis; clinical trials Santurce Cancer Central Program 195 5,533 5,846 SR Ch Reg Yes Yes Radiobiology ; Hesper Exp 4) (Dept. of Health) virus; immunology; epidemiology 9S1 BOLIQUWIY UIE UI YOIBASay [EOIPaWIOrg BOI110)) OAR[o] Postgraduate Country Number of New Patients Training Courses Institution Beds Admissions Registered Services* (Positions) (Location) Research (c. 1974) Uruguay Montevideo Manuel Quinetle Hospital 30 - 405 SR Ch Reg Yes Yes Clinical trials (6) (U. of Uruguay) Institute of Radiology 45 - 784 SR Ch Reg No Yes Clinical trials (Ministry of Health) Venezuela Caracas Pedro Machado Hospital 150 1,401 1,067 SR Ch Exp Yes Yes Tissue culture; snake Reg (14) venoms; clinical trials *R, radiotherapy; C, chemotherapy; Exp, experimental; S, surgery; Reg, registry Source: Data compiled from UICC Technical Report, Vol. 23, Lyon, International Agency for Research Against Cancer, 1977. LST TABLE 6. Cancer Research Activities in Latin America Institution Area of Main Publications Funding Positive Negative Principal Interest Local Foreign Local Foreign * Factors Factors Main Need Investigator Argentina Buenos Aires Angel H. Roffo Institute Immunology Over Over Own Sources IARC Established Economic Fellowships and E.S. de Lustig Chemical carcino- 20 50 investigators grants M. Braun genesis Equipped Experimental laboratories National Academy of Medicine Hematologic Established - - A. Pavlovsky neoplasia Many Many - - investigators C.D. Pasqualini Hematologic Research Institute Clinical and Concentration of experimental patients La Plata Experimental Oncology Laboratory Hospital S. Roque Immunopathology 7 - Oncology School - Trained Basic science Economic support H.O. de Carli Mainetti Foundation Epidemiology - - Oncology School NCI(LSU) Cancer pattern Economic Economic support R. Drut Cancer Registry atypical for Latin America Biochemistry Dept. . Medical School Ministry of Social Welfare Cancer Epidemiology Cancer - Ministry - Cancer pattern Lack of govern- Economic support 0. Mercuri Environment rates University ment support Bolivia Cancer Registry of La Paz Epidemiology 3 3 Local hospitals NCI(LSU) Ethnic and ecologic Low priority in Research expertise J. Rios factors health plan Brazil Belém Ofir Loiola Institute Cervical cancer - - National Cancer - High rates of Lack of research Train people in J. Monteiro Leite Division cervical cancer attitude research approach 8S1 BOLIDWY une ur YoIeasay [edIpawoIg Institution Area of Main Publications Funding Positive Negative Principal > Interest Local Foreign Local Foreign* Factors Factors Main Need Investigator oN S Brazil (cont’d.) a Recife g Cancer Registry of © Pernambuco Epidemiology 2 2 National Cancer NCI(LSU) Cancer pattern Economic Trained M. Ricardo ® Division researchers Cytodiagnostic Center Cervical cancer S - National Cancer Population at risk Community More personnel M. Pontes Cunha prevention Division education Porto Alegre Santa Rita Hospital Epidemiology 1 - Cancer - Population Economic Research N.T. Hester Association screening fellowships Sdo Paulo Cancer Registry - School of Public Health Epidemiology 6 2 State and Federal NCI(LSU) Immigration Economic Scientific AP. Mirra Trained personnel interchange Health Butantan Institute Lymphoma several several National Cancer - - - Scientific J.C. Machado Division interchange Salvador Beneficencia - Ana Nerg. Hospital Gynecologic 17 - - - = - AM. Silvany cancer Colombia Cali Cancer Registry Epidemiology 8 20 Valle University NCI(LSU) Cancer pattern Trained personnel More researchers ~~ C. Cuello Migration Medellin Social Security Registry Epidemiology 3 1 Social Security NCI(LSU) Captive population Trained personnel More researchers H. Restrepo Institute 6S1 TABLE 6. Cancer Research Activities in Latin America (cont’d.) Institution Area of Main Publications Funding Positive Negative Principal Interest Local Foreign Local Foreign* Factors Factors Main Need Investigator Costa Rica San Juan Hospital - Ministry of Health Epidemiology 1 4 Ministry of - Stomach cancer Lack of support Economic L. Moya Health rate J. Salas Chile Concepcion Natural Products Laboratory Anti-cancer 13 61 University NIH-NSF Ecologic conditions Lack of trainees, Economic M. Silva properties of Bonn support local plants University Santiago Nuclear Energy Commission Clinical radio- 2 4 Government Requested Population at risk Economic Economic R. Baeza therapy (PAHO) University of Chile Gastric cancer 10 1 University NCI - Japan Govt. High incidence Economic Economic A. Csendes Department of Obstetrics and Gynecology Cervical cancer several several University PAHO Trained personnel Low priority in Economic C. Gomez Laboratories health plans Mexico Pathology Department General Hospital Ultrastructure 22 5 University - - - - J. Alvores Nicaragua Medical School UNAN Gynecologic tumors s - University - Cancer pattern Lack of resources Economic U. Guevara 091 BOLIOWY UBT UT YOIBasay [BOIPIWOrg Institution Area of Main Publications Funding Positive Negative Principal Interest Local Foreign Local Foreign* Factors Factors Main Need Investigator Panama Oncologic Institute Cervical and - - Ministry of - Cancer pattern Lack of resources Economic M. Fernandez gastric cancer Health Paraguay National Cancer Institute Epidemiology Clinical studies 5 3 - - Cancer pattern Lack of resources Economic M. Riveros Peru Neoplastic Diseases Institute Clinical trials 192 107 Government PAHO Population at risk Lack of incentives Economic E. Caceres Epidemiology NCI(LSU) for research L. Olivares Cancer Registry El Salvador Social Security Institute Epidemiology several 4 Social Security - Population Economic Research N. Astacio Institute support Venezuela Institute of Scientific Investigations Immunology 19 10 Government - Adequate funds Not enough Scientific F. Merino researchers interchange *JARC, International Agency for Research on Cancer; LSU, Louisiana State University ; NCI, National Cancer Institute; NSF, National Science Foundation; PAHO, Pan American Health Organization. Source: Information supplied by respondents to survey conducted by author. BAI1I0)) OAB[d 191 162 Biomedical Research in Latin America Facilities for Clinical Studies Most general and university hospitals in Latin America have treatment facilities for cancer patients, especially for those with the most frequent kinds of cancer such as gastric, cervical, and breast tumors. A recent survey conducted by the International Union Against Cancer provided some data on specialized cancer research and treatment centers, and these are summarized in table 5. To complement existing information, the author submitted a questionnaire to medical schools, cancer hospital research institutes, and ministries of health and education in Latin America. Summaries of responses to the questionnaire are given in table 6. Information Exchange Recently, through the joint efforts of PAHO and the National Cancer In- stitute, a program to provide information on cancer research in Latin America, LACRIP, has been established, operating from the Washington office of PAHO. It keeps records and disseminates information on institutions engaged in cancer research. Such data are provided to the Internationa! Union Against Cancer (UICC) for its International Directory of Specialized Cancer Research and Treatment Establishments and to the NCI Internationai Cancer Research Data Bank. As of February 1978, LACRIP had a file of 126 recent publications on cancer in Latin America. They cover a wide range of subjects, especially those more pertinent to Latin America: e.g., epidemiologic and clinical aspects of carcinomas of the cervix and stomach, as well as lymphomas and leukemias. LACRIP files also contain summaries of 232 ongoing cancer research proj- ects in Latin America dealing with a variety of basic and applied research approaches. In the area of basic research, mainly molecular biology and virology, it lists 6 projects in Argentina, 4 in Brazil, 4 in Colombia, 3 in Chile, and 2 in Mexico. In the area of clinical studies, primarily diagnostic and ther- apeutic techniques, it lists 13 projects in Argentina, 12 in Chile, 10 in Brazil, 8 in Peru, 7 in Costa Rica, 4 in Mexico, 4 in Colombia, 3 in Uruguay, and 2 in Venezuela. In the area of epidemiology, frequently involving immunology and pathology aspects, there are 13 studies in Argentina, 13 in Colombia, 11 in Chile, 10 in Brazil, 10 in Mexico, 4 in Uruguay, 3 in Peru, and 1 in Venezuela. Four experimental studies are listed for Argentina, 3 for Brazil, and 2 for Mexico. The above are only partial listings of ongoing activities in the field. The scientific literature contains information on some other important activities not adequately covered above, but it would be impossible to mention all of them. Interested readers may request specific information from LACRIP Pelayo Correa 163 (Pan American Health Organization, Washington). At least two Latin Ameri- can journals are specifically dedicated to cancer: Quirén in Argentina, and the Revista Brasileira de Cancerologia in Brazil. Many Latin American medical journals report on cancer research results. A specialized library for Latin Amer- ica (BIREME) in Sao Paulo, Brazil, offers bibliographic services on special request. References 1. Pan American Health Organization. Science Policy in Latin America. Scientific Publication No. 119. Washington, D.C.: PAHO, 1966. 2. Pan American Health Organization. Migration of Health Personnel, Scientists and Engineers from Latin America. Scientific Publication No. 142. Washington, D.C.: PAHO, 1966. 3. Logan, W.P.D. World health-related indicators. World Health Stat Rep 29:682- 697,1976. 4. Puffer, R.R. and G.W. Griffith. Patterns of Urban Mortality. Scientific Publication No. 151. Washington, D.C., PAHO, 1967. 5. Olper, R. Epidemiologia de las Neoplasias. Salud Publica de México 5:543-553, 1975. 6. Moya de Madrigal, L. Cancer del tracto alimentario en Costa Rica. Bol Of Sanit Panam 76:300-313, 1974. 7. Moya de Madrigal, L., N.R. Assal, and P.S. Anderson. Cancer de los Organos de la Reproduccion en Costa Rica. Bol Of Sanit Panam 81:345-354, 1976. 8. Infante Diaz, S. Cancer en El Salvador. El Salvador: Ministerio de Educacion, 1966. 9. Galvez Brandon, J. Un Programa de Registro de Incidencia de Cancer en Lima Metropolitana. Lima, Peru: Ministerio de Salud, 1973. - RESEARCH ON DIABETES MELLITUS Marciano Garcia Viveros Introduction Virtually all disciplines of medicine are involved in the study and handling of diabetic patients—from genetics, which studies the hereditary transmission of diabetes and analyzes its frequency in the population; gynecology and obstetrics, which deal with the hormonal interrelationships of the hypothal- amic-hypophyseal-ovarian axis, handling of the pregnant diabetic patient, and the effect of the disease on the infant; biochemistry and pharmacology, which are engaged in explaining the primary metabolic disorders and the most suitable pharmacological handling; neurophysiology, which analyzes the inter- hormone relationships with the physiological processes of nutrition, digestion, absorption, and substrate metabolism—to neurology, cardiology, nephrology, ophthalmology, orthopedics, dermatology, urology, and other subspecialties concerned with the study and treatment of complications resulting from diabetes mellitus. Collaterally, study of the disease and treatment of the patients involve specialists who are not necessarily physicians—such as nurses, technicians, chemists, social workers, computer programmers, physicists specializing in radioactive elements, mathematicians—and who form part of an enormous human team in the fight against diabetes mellitus. History of Diabetes Research in Latin America Research in Latin America, insofar as diabetes mellitus is concerned, goes back only a few years. In 1930, in a professional thesis, Dr. B. A. Houssay [1] published the first results on the diabetogenic action of the extracts of the hypophysis in laboratory animals. Twenty-seven years later he was awarded the Nobel Prize in medicine, and to date he is the only Latin American who has received that award in the field of endocrinology. Houssay’s work has given hope to those who live in the southern cone of the Latin American continent and desire knowledge of the treatment of this disease. As a non-Argentine 165 166 Biomedical Research in Latin America physician, I wish to express my appreciation not only for the work he has done but also for enabling Argentina to remain at the head in this wide field of pathology. The historical records of research and the practice of medicine in Latin America go back to the Cddice Badiano [2], analyzed and translated by Father Bernardino de Sahagun in the 17th century, in which reference is made to a description of Addison’s disease and of diabetes mellitus, and to Martin de la Cruz, who treated the latter with the quichatli root and stated, . . on the other hand there will be a tlowing of saliva, and the excessive thirst will be calmed if one takes a drink made from the herbs cited below, ground in very clean water. The “electoria,” which is a crystal- like precious stone of the size of a sweet pea and is found in the craw of gallinaceous birds as attested by Pliny, shall be added to it; and a flying fish, and a squab shall be added . . . A Brief Treatise on Surgery and the Cure of Certain Diseases was published in Mexico in 1579. Its author, Father Agustin Farfin, was the first graduate physician on the American continent; he promoted the study of anatomy and knowledge of the individual in health and sickness [4]. Dr. Marco Joseph Salgado, a native of Puebla, Mexico, furthered research in physiology and endocrinology and was the author of the first publication on this subject in Latin America, one chapter of which was devoted to nutrition and its effect on certain diseases [5]. In 1751, with the same purpose in mind, Joseph Francisco de Malpica published his Alexipharmaco, in which the benefits of fasting and of foods in the handling of certain diseases are stressed. In 1829, Dr. Juan Manuel Gonzéilez Urefia published Medical Reflections on Diabetes Generally; and Particularly on the Disease Known in the State of Michoacan Under the Same Name [6]. On this same subject are therapeutic works such as those of Dr. J. Schiede, who in 1836 reported a case of diabetes treated with creosote [7]; Dr. Manuel E. Carpio, who in 1836 referred to the beneficial effect of calcined magnesia [8]; Dr. Miguel Jimenez, who in 1840 thought he was curing diabetes with quinine sulfate; and of Dr. H. Backer, who in 1894 proposed the hypodermic application of strychnine arsenate [9]. Thought was given to the pathogeny of the disease as shown in editorials in the Medical Gazette of Mexico in 1869 [10] and Dr. Rafael La Vista’s article in the Journal of Pathological Anatomy and Medicine and Surgery in 1896 [11]. Other aspects of the disease were reported; Dr. Vicente Fernandez cited the discovery of reagents for the determination of glucose in the urine by means of “lithophelic™ acid extracted from the urinary calculi of ruminants [12]. Complications of diabetes were analyzed by Dr. Oscar Simon, who atri- buted the *balanoposthitis” to microscopic fungi lodged between the glans penis and the prepuce and advised these patients, as a prophylactic measure, to apply lotions of plain water with the addition of a little phenic acid and a Marciano Garcia-Viveros 167 powder of undisclosed formula after each micturition [13]. Furthermore, Dr. H. Verneuil [14] described the consolidation of fractures in diabetic patients followed over a period of 11 years, in whom he observed “the perni- cious effect of the disease on consolidation, which occurred late, imperfectly, or was nonexistent.” Early in the 20th century, Dr. Francisco de P. Miranda [15] dealt with care of diabetic patients and performed valuable dietetic studies up to the beginning of the insulin era. Dr. Salvador Zubirin [16-18] furthered progress in the field in Mexico not only as a result of his own clinical experience, but also as a result of his extraordinary spirit as a teacher and instigator of research. He was director of the National Institute on Nutrition of Mexico City, which can be called the birthplace of Mexican endocrinology. Knowledge of the present state of research on this disease in Latin Amer- ica—centers of investigation, research, and medical care; their research lines; their future: and their basic approach for international support—implies knowl- edge of work already done, most of which is gained through publications and papers given at international and local conferences. There are undoubtedly many places that, because of limited resources, have been unable to make their work known internationally—even though their local work through specialized clinics, patient courses, or patients’ clubs is no less beneficial to those who suffer from the disease. Organization of Diabetes Research Latin America includes 20 countries with a total population of approximately 340 million [19]. In each country there are schools of medicine, biology, and chemistry, which in one way or another are involved in the study of diabetes. Health services and hospital care services in each of the member countries handle epidemiologic and care aspects, although the great majority are limited to clinical research, studies of local characteristics in patient care, and reports on results obtained with respect to control of the disease with drugs. Implicitly involved in research on diabetes mellitus are the two great areas of this discipline, basic and clinical research. The first includes physiology, chemistry, pharmacology, neuroendocrinology, neurophysiology, and histo- pathology; the second includes those areas covered by genetics, epidemiology, and clinical work resulting from treatment of the disease and its complications. The recently organized Latin American Diabetes Association (ALAD) now has 133 active members from 18 countries, 2 of whom are from the United States. These members do not constitute the total number of specialists living in Latin America; rather, they are the ones who are interested in collabo- rating and sharing their experiences with what might be termed a regionalistic spirit, though the disease shows no geographical preferences. Working commit- tees were formed in ALAD, under the president, Dr. Mario Sanchez Medina, 168 Biomedical Research in Latin America of Bogota, Colombia, for the specific purpose of combining the work of each of the fields dealing with diabetes mellitus: epidemiology, scientific, continuing education, audiovisual education, medicosocial, reproduction and diabetes, nutrition and diabetes, study of infantile and juvenile diabetes, and the com- mittee for the study of diabetes, with its three subcommittees: pathogenesis, degenerative lesions, and treatment. The primary function of the scientific committee, whose coordinator is Dr. Ricardo R. Rodriguez, of Buenos Aires, Argentina, is counseling and support of research in Latin America. Its prin- ciples and objectives are the following: ® To coordinate activities of different work groups; ® To control publications for use by association members; ® To propose work that merits financial support to the executive com- mittee; ® To compile progress reports; ® To act as adviser in preparation of projects and evaluation of results; ® To report on scientific meetings and conferences; ® To select subjects to be covered in meetings, courses, conferences, etc., by ALAD members; ® To coordinate activities of committees in which research is the basic function, e.g., diabetic neuropathy; virus, immunology, and cell culture; diabetic angiopathy; infantile and juvenile diabetes; and pathogenesis, treat- ment, and epidemiology. In May 1977, ALAD held its Third Latin American Conference on Diabetes in the city of Lima, Peru, with participation by 288 of its active members (total attendance was 485). Distribution of Diabetes Research in Latin America The scientific productivity of a country can be measured indirectly by the number of papers submitted to regional and international meetings, and the number of publications in international journals. A review of Latin American participation in congresses on endocrinology and in the International Diabetes Federation in recent years yielded the following information: A total of 440 papers were presented at the Sixth Pan-American Conference of Endocrinology [20] held in Mexico City in 1965. They were subdivided into 35 groups, 4 of which were devoted to diabetes mellitus and classified as follows: pre- diabetes; prevalence of diabetes mellitus in Latin America; hypoglycemic drug action mechanisms; and insulin regulating mechanism. There was a greater number of papers on epidemiology and the action of hypoglycemic drugs than on basic research. At the Eighth Pan-American Conference of Endocrinology in Buenos Aires, Argentina, in 1974 [21], a total of 191 papers were presented. Nine years after the Mexico City conference, the Buenos Aires conference showed clearly Marciano Garcia-Viveros 169 that the interest of researchers had shifted to physiopathological aspects, and the papers prepared in Argentina were outstanding in both number and quality. The Seventh Conference of the International Diabetes Federation [22] had been held 4 years before, in 1970, also in Buenos Aires. Approximately 38 percent of the papers submitted dealt with basic research, whereas 61 percent belonged to the clinical field. Most basic research is conducted by biochemists, pharmacologists, and physiologists who are not inclined to submit works to eminently clinical conventions; therefore, an analysis was made of the papers dealing with diabetes that were presented at two Latin American conventions on physiological sciences [22-24]. The Ninth Convention, held in the city of Mendoza, Argen- tina, covered a total of 425 papers, 16 (3.7 percent) of which dealt with subjects related to diabetes mellitus. At the 12th Latin American Convention on Physiological Sciences, held in the city of Bogota, Colombia, in 1975, 126 papers were submitted. Six (4.7 percent) were related to diabetes mellitus. A number of conclusions may be drawn from analysis of these data, and one of them is that the number of Latin American countries actively engaged in diabetes mellitus-related research is very few; nonetheless, among these, Argen- tina stands out not only as the country that has submitted the largest number of papers on work done, but as the center of research that can compete with that of any other country in the world in scientific quality. Brazil, Chile, Venezuela, Peru, Uruguay, Colombia, and Mexico follow Argentina in order of importance, though this order may not be strictly accurate. To identify the most outstanding medical research, teaching, and care centers in terms of their work on diabetes mellitus, we checked publications on the subject at the Center of Scientific and Humanistic Information of the National Autonomous University of Mexico [25]. This center publishes Alerta, a monthly review of the bibliography of 5,000 magazines covering all fields of sciences and humanities. Contributions to world literature on specific subjects have been broken down by country since 1974 in this publication. The appendix lists reports on diabetes mellitus from Latin American countries that were published in international journals between 1974 and 1977. Each of these 30 research units, from 6 of the 20 Latin American countries, published one or more basic works. Fifty percent were from Argentina, 20 percent from Brazil, 16.6 percent from Chile, 6.6 percent from Peru, and 3.3 percent from Venezuela and Mexico. Unquestionably, Argentina, Brazil, and Chile have made the greatest contribution, reflecting indirectly their interest in this field of medicine. Furthermore, the quality of this work is evident by virtue of its acceptance for publication in refereed journals of international repu- tation. The low number of clinical works is, perhaps, an indication of the slight interest of these publications in this aspect, since local or national criteria are involved in handling the disease. 170 Biomedical Research in Latin America In spite of the fact that Latin American research institutions and medical care centers devote a large portion of their time to analysis of the effectiveness of pharmacological products in the treatment of diabetes, their results are not submitted to international literature since—in the great majority of cases— they are sponsored and used by the industries that manufacture them. In this connection, it should be pointed out that a large number of care centers that attend diabetic patients through a specialized department obtain their income from studies of phases II and III of drugs that, for legal reasons, cannot be performed in countries of greater economic development. Obviously, the devotion of clinical researchers to study of drugs substantially reduces time available for other types of research, even though it is from pharmacological industries that they receive a goodly part of their support. Thus, it is evident that in Latin America current research in diabetes is very limited; that most of it, of good quality scientifically, is conducted in the basic areas of physiopathology, biochemistry, histopathology, etc.; that more than 50 percent of basic research is done in Argentina; that the rest is restricted to Chile, Brazil, Peru, Venezuela, and Mexico, with the last three playing a minimum role insofar as international projections are concerned; and that research in which the other Latin American countries are involved is basically clinical and without international impact. Diabetes Research in Mexico Owing to the nationality of the writer of this monograph, it was thought advisable to analyze the current situation in Mexico. Therefore, an analysis was made of Basic Statistics on the National Scientific and Technological System published as a result of the information obtained through the survey conducted by the National Council on Science and Technology of Mexico [CONICYT] in 1974 [26]. All centers and agencies engaged at the time in any type of research—whether scientific or technological —were polled, and the following data were obtained: In 1974, there were 9,287 research projects, 1,432, or 15.5 percent, of which were in the field of health and hygiene. Thirty-five, or 2.5 percent, of these 1,432 projects were related to research in diabetes mellitus; this repre- sents 0.35 percent of the total number done in Mexico. With regard to health- and hygiene-related projects, 7.8 percent, or 113, corresponded to the basic area; of these, 37 (32.7 percent) were conducted in centers of higher educa- tion, 72 (63.7 percent) in decentralized care and research agencies, and 4 (3.6 percent) in private institutions. In the case of research applied to the area of health, there were 1,179 (82.3 percent) studies, 303 in centers of higher learning, 605 in decentralized care and research agencies, and 261 in other departments. Of the remainder of the research projects in the field of Marciano Garcia-Viveros 171 health, 128 (9.9 percent) were devoted to experimental development. Thus, 82 percent of research work in the area of health in Mexico is devoted to applied research, 7.8 percent to basic research, and 9.9 percent to experimental development. Health research is conducted in 234 research units, 38.3 percent of which are decentralized care and research agencies, 28.6 percent federal government agencies, 31.2 percent centers of higher learning, and 0.85 percent private educational centers. Diabetes studies are being conducted in the following Mexican centers: ® National Polytechnic Institute, Center for Advanced and Higher Learn- ing, departments of physiology and biophysics, department of cell biology, Mexico, D.F.; ® National Polytechnic Institute. National School of Biological Sciences, cell biology department, Mexico, D.F.; ® Autonomous University of Mexico, School of Medicine, departments of biochemistry, pharmacology, and experimental surgery; ® Mexican Social Security Institute, department of scientific research, sections on genetics, molecular biology, and protein hormones; ® Hospital of Gynecology and Obstetrics No. 1, Research Laboratory; ® Dr. Fernando Quiroz Gutiérrez Hospital Center, Social Security and Service Institute for Government Workers; ® DIF Pediatric Hospital. Integral Family Development, department of endocrinology; ® Children’s Hospital of Mexico, department of endocrinology; ® National Nuclear Energy Institute; ® National Institute on Nutrition, departments of reproductive biology, genetics, diabetes and lipid metabolism, and experimental surgery; ® Autonomous University of San Luis Potosi, department of internal medicine, diabetes clinic; ® Autonomous University of Nuevo Ledn, department of physiology; ® University of Guadalajara, departments of anatomy and public health; ® Autonomous University of Coahuila, department of pathological anat- omy; ® University of Guanajuato, department of endocrinology; ® University of Veracruz, Institute of Medicobiological Studies; ® General Maximino Avila Camacho Mother-Child Center; ® National Autonomous University of Mexico, Institute of Research in Applied Mathematics and in Systems, Mexico, D.F. The 35 research projects concerning diabetes originated in 26 departments mentioned above. It is particularly interesting to note that of these centers, 8 are universities and polytechnic institutes, which are institutions of higher learning, but the country has 38 learning centers where medicine is taught; this means that only 21 percent of these centers devote part of their time to research in the field of diabetes mellitus. Only five of the research centers in 172 Biomedical Research in Latin America Mexico have clinical and research departments for diabetes study as well as providing medical assistance to patients. Based on population studies conducted in Mexico, the following facts can be seen as having a detrimental effect on the diabetes situation at present and especially in the future [26, 31]. ® At present Mexico has a population of 65.4 million inhabitants and a growth rate of 3.3 percent. ® Of this population, 33 percent has guaranteed health care services through agencies such as the IMSS, ISSSTE, Mexican Petroleum, Mexican National Railway, and private enterprise. ® Fifty percent of the population (32 million) relies on government health services. ® Eighty percent of the population lives in towns of fewer than 1,000 inhabitants; thus, of the 97,580 towns in 1970, 83,705 were occupied by fewer than 1,000 people. ® The highest birth rate occurs in these small population groups. ® Of the medical and paramedical personnel in the country, 54.5 percent are with the social security institutions that take care of 33 percent of the population; 21.6 percent belong to government care institutions that take care of 50 percent of the population; and 15.3 percent are professionals not affiliated with the cited institutions. ® Most of the medical personnel are located in towns of more than 10,000 inhabitants, which represent only 15 percent of the entire number of towns in the country. Findings and Recommendations In view of these findings, and given the hereditary nature of the disease, the growth rate, and the fact that countries with the highest birth rates have the fewest financial resources, we must take measures to assure that the disease does not create financial and social public health problems—financial in the sense that diabetes patients usually become a burden on the health service and on their workplaces, since their productivity declines faster than that of the rest of the population, and social in the sense that the diabetes patient becomes a burden for the family, since medical care is so costly. Inasmuch as the entire population of Latin America in 1978 was estimated at 340 million inhabitants [32] and, according to surveys, the number of diabetics ranges from 2 to 4 percent of the population, 6.8 to 13.6 million people suffer from the disease, a number equivalent to the combined popula- tion of Costa Rica, El Salvador, and Guatemala or half of the population of Argentina. While the disease has a low mortality rate (2 per 100,000), it is a disabling disease; it is the second cause of total or partial blindness; it is a factor of Marciano Garcia-Viveros 173 predisposition to cardiovascular and cerebrovascular complications; and en- hances the risk of lower-limb amputations. The disease, owing to its physio- pathological characteristics, can be associated with infectious diseases—prin- cipally kidney and respiratory— thus restricting the productive, intellectual, and physical capacities of the patient. No data are available on diabetes as it relates to lost man-hours, disease complications, and the ‘“costs-per-day-per-bed” of institutional and hospital care. (Patients with lower-limb infections, amputations, kidney, vascular, brain, and myocardial complications occupy hospital beds for many days, even weeks.) In addition, little is known about the general public’s awareness of diabetes mellitus, its form of hereditary transmission, its greater incidence in relation to obesity and the exaggerated ingestion of carbohydrates, the impor- tance of diet and exercise in its control, the greater incidence among multipara and obese women, etc. As physicians, with a scientific and sophisticated mentality, we think more about how to normalize glycemia figures or detect the enzyme or hormone error of the disease than we do about efforts to prevent it or reduce its incidence by providing information that will make patients responsible for their own health. Many human and financial resources are spent in solving health problems that could have been prevented if patients had known how; therefore, in diabetes, as well as in many other medical specialties, guiding and educating the population can bring dividends in the form of health, human working capacity, and money saved. This does not mean that basic research should be eliminated. On the con- trary, productive capacity and adequate research know no nationality; they benefit science and humanity. However, in view of the characteristics of the Latin American population and the characteristics of the disease itself, research in diabetes should be encouraged primarily in the areas of epidemiology, education, and rehabilitation. It is essential that centers of medical care, research, and higher learning in each country recognize the importance of the disease and that medical and nursing students be aware of the significance of their work in rural areas, guiding and counseling diabetic patients and their families. Persons already suffering from the disease cannot possibly be cared for by creating care centers in each of the towns. Ideally, public health fi- nancial resources should be used only to maintain health and prevent disease, and raising awareness levels of the population can go a long way toward attain- ment of this goal. Specifically, this can be done by organizing committees (1) to distribute information on the disease in each country and region, for the purpose of re- ducing the birth rate in families with diabetic members; (2) to prove with numbers the impact of the disease on the productivity of the sufferer; (3) to evaluate the actual cost for the family and the medical centers in terms of attention, care, and rehabilitation of the diabetic with complications; and (4) to evaluate the results of the use of all possible means of mass information on 174 Biomedical Research in Latin America the attitude of patients and their families in a national educational campaign in which all specialists in the country could participate either directly or indirectly. Research ondiabetes mellitus would thus have to address the social, economic, epidemiological, and cultural aspects of the disease, rather than its clinical and basic aspects. Nonetheless, work at those centers where top- quality research of this last type is being carried on should be encouraged and supported financially. The existence of an organization such as ALAD suggests the feasibility of developing a program of priorities for areas of research in Latin America. The Research Committee, whose purpose has already been outlined, could identify basic research centers whose capacity and productive quality merit financial and human support in the achievement of their goals, and at the same time, determine those countries whose productivity is minimal or restricted to reproducing projects already completed in other countries; ALAD could direct and support studies best suited to the human and technical capacity of each nation. Ignorance of recent advances in different basic or clinical areas promotes initiation and development of projects that, when evaluated, often prove to be mere repetitions. If ALAD keeps researchers up to date on the most recent publications on diabetes through its representatives in each coun- try, it could prevent losses of time and money. In addition, a center for collect- ing references on the subject and distributing lists of publications periodically to each member could reduce the indicated risks. Insofar as clinical research is concerned, it is essential to encourage each center to prepare projects designed to evaluate the following aspects: ® Number of patients attended in the institution; ® Number of members in the patient’s family who are potential diabetics; ® (lassification of cases according to age of patient, form of the disease, and development time of the disease; ® Type and degree of existing complications attributable to the disease; ® Evaluation of therapy, both in the case of the disease itself and of its complications; ® Material resources in each institution for control of complications; ® Evaluation of socioeconomic impact of the disease on each patient and family; ® Evaluation of “time lost” from work attributable to the disease; ® Evaluation of “bed-days” and financial resources intended for patients hospitalized as a result of complications due to the disease; ® Evaluation of each patient’s knowledge of the disease, the personal manner of looking at the disease, the impact of information in the press, radio, etc., on the patient and on treatment of the disease; ® Evaluation of the influence of charlatans on the patient’s attitude in the face of the disease and how the patient follows prescribed medical treatments. Marciano Garcia-Viveros 175 These are facets of clinical studies that many specialists might term “dull” and of no interest whatsoever for the development of science, but at a given moment they may be of real value in establishing patient handling standards, an educational approach with respect to the population, socioeconomic re- percussions to be faced in labor matters, a rational manner of setting up care centers for patient rehabilitation, and—lastly—a strategy for dealing with the disease according to specific characteristics of each country. The committees on epidemiology and education of ALAD are not in a position to set up adequate programs without specific information from each country and each region; their work through institutions of higher learning must be backed by results of studies prepared in that area of the country where professionals are to operate. It is not surprising that programs have been planned on the basis of results obtained in other countries with entirely dif- ferent ethnological, economic, social, cultural, and nutritional characteristics. It seems, therefore, that the experience of nations with a high degree of scientific and care development must be used in evaluating each country in order to provide adequate support for actual needs. In regard to educating the public, existing material of proven effectiveness can be adapted to the particular characteristics of each country. Insofar as basic research is con- cerned, technological dependence on equipment, reagents, and radioactive and immunological material is undoubtedly the greatest obstacle. If the more highly developed countries—those that have the necessary materials—were willing to promote and encourage this field of research, it is quite likely that the productive capacity of Latin American researchers would prove to be equal to that in any country in the world. References 1. Houssay, B.A., and A. Biasotti. Rev Soc Argent Biol 6:8, 1930. 2. Sahagin, F.B. de. Historia General de las cosas de la Nueva Espafia. México: Ed. Porrua, 1956. 3. de la Cruz, M. Libellus de Medicinalibus Indorum Herbis. Mexico, D.F.: Instituto Mexicano del Seguro Social, 1964. 4. Farfan, F.A. Tratado breve de Cirugia y cura de algunas enfermedades que en estas tierras, mas comunmente suele haber, del Giplacdindimos y companofies y de otros miembros; citado por Leon, N. Gac Med Mex 10(1):11, 1915. 5. Salgado, M.I. Cursus Medicus Mexicanus, citado por Leon, N. Gac Med Mex 10(1): 46, 1915. 6. Gonzalez Urena, M. Reflexiones médicas sobre la Deabetis en General: y especial- mente acerca de la enfermedad que con el mismo nombre se conoce en el estado de Michoacan. Michoacan, México: Imprenta Galvan, 1829. 7. Schiede, J. Curacion del diabetes mellitus per ol creas de magica. Periddico de la Academia de Medicina de México 1:368, 1836. 8. Carpio, M.E. De la diabetes. Periodico de la Academia de Medicina de México 1:368, 1836. 9. Backer, H. Inyecciones hipodérmicas de arseniato de estricnina, en la diabetes azucarada. La Medicina Cientifica 7(12):193, 1894. 176 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 28. 26. 23. 28. 29. 30. 31. 32. Biomedical Research in Latin America Patogenia de la diabetes (editorial). Gac Med Mex 4:201, 1869. Lavista, R. Notas acerca de la naturaleza y patogenia de la diabétes. Rev Anat Pat Clin Med Quirurg 1:72, 1896. Fernandez, V. El Acido litofélico como reactivo de la orina diabetica. Gac Med Mex 9(16):309, 1874. Simé6n, O. Tratamiento de la balano-postitis de los diabéticos. La Escuela de la Medicina 4(13):206, 1883. Verneuil, H. Consolidacion de las fracturas en los diabéticos. La Escuela de la Medicina 5(13):170, 1883. Miranda, F. de P. Nuevas formulas para el calculo de dietas de diabéticos. Gac Med Mex 57(2):181, 1926. Quifiones, M. La insulina en el tratamiento de la diabetes mellitus. Gac Med Mex 57(2):181, 1926. Miranda, F. de P. Indicaciones del tratamiento de la diabetes por insulina. Gac Med Mex 58(6):321, 1927. Zubiran, S. La diabetes funcional. Gac Med Mex 71(2):303, 1941. CEPAL Information Service. Notas sobre la Economia y el Desarrollo de América Latina. January 1978. VI Congreso Panamericano de Endocrinologia. Excerpta Médica No. 99, 1965. Libro de resumenes del Octavo Congreso Panamericano de Endocrinologia. Buenos Aires, Argentina, 1974. XI Congreso Latinoamericano de Ciencias Fisiologicas. Acta Physiol Lat Am 23(6), 1973. XI Congreso Latinoamericano de Ciencias Fisiologicas. Resumenes de Comuni- caciones libres. Supplement. Volume 23, 1973. XII Congreso Latinoamericano de Ciencias Fisiologicas, Resimenes de Comuni- caciones libres. Supplement. Acta Physiol Lat Am 25(4), 1975. Alerta. Revista de Informacion Multidisciplinaria en la Universidad. Centro de Informacion Cientifica y Humanistica. Universidad Nacional Autonoma de México. Capitulo “Trabajos Producidos en América Latina. 1973-1977. Estadisticas basicas sobre el sistema cientifico y tecnologico nacional. (Periodo de captaciéon 1973-1974). Consejo Nacional de Ciencia y Tecnologia. México, D.F., 1977. Educacion de Pregrado en Medicina y Enfermeria. Sub-secretaria de Planeacibn. Secretaria de Salubridad y Asistencia. México, D.F., 1977. Direccion General de Estadistica. Secretaria de Salubridad y Asistencia. México. Datos proporcionados por la Direccidon de Bioestadistica de la Secretaria de Salu- bridad y Asistencia. México. Datos de la Comisiin Méxta Coordinadora de Actividades de Salud Publica, Asis- tencia y Seguridad Social, México. Estadisticas de Servicios Médicos y de Salud. Direccibn General de Estadistica. Secretaria de Industria y Comercio. México, 1975. América Latina: Situacion demografica alrededor de 1973 y perspectivas para el afio 2000. Naciones Unidas. Consejo Econémico Social. Comision Econémica para América Latina. Segunda Reunién Latinoamericana sobre poblacion. México, D.F., 1975. Marciano Garcia-Viveros 177 Appendix Sources of Publications on Diabetes Mellitus in International Journals by Latin American Authors, 1974-77 San Felipe Clinic and Archbishop Loayza Hospital, Lima, Peru. Institute of Biological Sciences, Catholic University of Chile, Santiago, Chile. School of Medicine of the National Northeastern University, Argentina. Italian Hospital, Endocrinology Department, Buenos Aires, Argentina. Center for Diabetes and Nutrition of the “José de San Martin” General Hospital, Buenos Aires, Argentina. Biological Sciences, Catholic University, Santiago, Chile. Department of Biology, School of Sciences. University of Chile, Santiago, Chile. School of Pharmacy and Dentistry and School of Medicine of Ribeirdo Préto, So Paulo, Brazil. Department of Physiological Sciences, School of Dentistry of Aracotuba, Sio Paulo, Brazil. Endocrinology Service, General San Martin Institute, La Plata, Argentina. Center of Nuclear Medicine and Center of Diabetes and Nutrition. José de San Martin General Hospital, Buenos Aires, Argentina. Endocrinology Unit. P. de Elizalde Hospital, Buenos Aires, Argentina. Atomic Energy Institute, Sio Paulo, Brazil. San Marcos National University, Lima, Peru. Endocrinology Service of the Prof. Dr. R. Finochieto Polyclinic, Buenos Aires, Argentina. Institute of Pathology, School of Medicine. University of Buenos Aires, Argentina. General Hospital. School of Medicine of the University of Sio Paulo, Brazil. University of La Plata. School of Medical Sciences, La Plata, Argentina. National University of Cordoba. School of Medical Sciences, Cordoba, Argentina. University of Chile. Department of Nutrition and Food Technology, Santiago, Chile. Catholic University of Chile. Department of Medicine, Santiago, Chile. Institute of Neurobiology. Laboratory of Neurochemistry, Buenos Aires, Argentina. National Polytechnic Institute. Center for Advanced Studies, México, D.F. Central University of Venezuela, Caracas, Venezuela. School of Medical Sciences. Chair of Biochemistry, La Plata, Argentina. University of Buenos Aires. School of Medicine. Institute of Physiology, Buenos Aires, Argentina. School of Medicine of Ribeirdo Préto. Department of Pathology, Ribeirdo Préto, Brazil. University of Sao Paulo. Department of Histology, Sao Paulo, Brazil. Integral Medical Care Unit. Rivadavia Peralta Ramos. Nutrition Service, Buenos Aires, Argentina. Center of Research on Reproduction. School of Medicine. University of Buenos Aires, Argentina. 10 RESEARCH ON MENTAL HEALTH René Gonzalez Introduction Latin American researchers have often discussed the severity and magnitude of mental health problems affecting the people of their region; they have stressed the importance of increasing their knowledge and of searching for solutions that fit the different circumstances in each country. The volume of research has increased markedly, but it is still low. There is a discrepancy between the strongly expressed desire to secure a better understanding of the nature of mental health problems and the small number of research publications. The reasons for low research productivity throughout the area were ana- lyzed by Seguin and Mariategui in the VIIIth Latin American Congress of Psychiatry held in Acapulco, Mexico, in 1975[1]. These reasons are still valid, the most important ones being the limited number of persons dedicated to research, the lack of training centers in this field, and the fact that the few investigators who exist were trained abroad and find it difficult to separate the influence of their training site from their research. Other significant factors include lack of financing and inadequate planning. A few studies carried out before World War II were clinically oriented. Almost all of them were undertaken by psychiatrists who utilized clinical material from hospitals. It was not until after the 1960’s that a greater impetus developed and more varied investigations were conducted. Psychologists, soc- iologists, and anthropologists, in addition to physicians, began to participate. Nurses and social workers became involved to a lesser degree. There were epidemiologic, sociologic, neurophysiologic, and psychopharmacologic inves- tigations, as well as clinical studies. A few research centers, usually linked to academic institutions, were formed. 179 180 Biomedical Research in Latin America Areas of Current Research In 1968 the Inter-American Council of Psychiatric Associations held its first conference on studies of mental health in the Americas. The recommendations of the conference represent the consensus of Latin American psychiatric leaders and mental health authorities from the countries represented. With respect to promotion of research, the conference made several recommenda- tions still worth examining 10 years later [2]. Section III of the report states: A. It is recommended that departments of research initially dedicate themselves to performing epidemiologic studies, social studies of the evaluation of treatment, and the utilization of data. These studies require a minimum amount of specialized equipment and allow a maximum degree of practical application and adaptation of investigation results to the local situation. B. [It is recommended that] regional or local research groups [be encouraged] to hold periodic meetings and to publish their own journals as a means of rapidly communicating results applicable on the local level. C. Studies of special clinical categories, as well as the following aspects, are recom- mended: 1. The formulation of common international criteria for the classification of mental illnesses, the description of symptoms, and the estimation of morbidity. This includes the determination of indexes of both social as well as individual morbidity. 2. The establishment of an international coordinated system for the notification of data. 3. Studies of the behavioral aspects of population dynamics. Attitudes toward family planning, factors intervening in out-of-wedlock births among adolescents, the socio- psychologic correlation of family size, the influence of population density, and other related topics should also be included. 4. The incidence, etiology, social functioning, and rehabilitation of the mentally retarded. 5. Problems of youth and the elderly. 6. The influence of malnutrition during the early stages of life on mental develop- ment and behavior. 7. The effect of migration on adaptation, with special reference to the establish- ment of preventive services. 8. Studies of various sources of community self-help, community systems of social control, and community solutions to mental health problems such as alcoholism. These studies should include the problem of the concepts, beliefs, and background concerning psychiatric conditions and their treatment that constitute the local popular tradition (folk- lore) of each culture. 9. The multiple functions of the family as related to child development, the main- tenance of the function of adults, and the support of the elderly. 10. Problems of cultural change, cultural conflicts, cultural shock, and acculturation in specific areas. Implementation of these recommendations has not been uniform. Some lines of investigation such as the influence of nutritional factors, problems re- lated to acculturation and social change, and difficulties of the mentally retarded have held the attention of various investigators in diverse countries. Other areas, such as population dynamics, public attitudes, and problems of René Gonzalez 181 children and youth, have received less emphasis, while mental health aspects of aging have been studied scarcely at all. Psychiatric epidemiology, problems re- lated to drug dependence, and studies of psychopharmacology have received a moderate amount of attention. Clinical research, on the other hand, has had paramount importance in academic circles as well as among individual investi- gators. Epidemiologic Studies Interest in epidemiology has remained uniformly high during the last 15 years, especially in Argentina, Chile, Colombia, and Peru. The most commonly used methods have been surveys using questionnaires, or semistructured interviews. As might be expected, the majority of the investigations have been descriptive in nature, but in a few cases there have been attempts to test some hypothesis, particularly in relation to the epidemiology of alcoholism. The journal Acta / Psiquiatrica y Psicologica América Latina published two volumes that summarized the state of the art of epidemiology up to 1970. One of them refers to general psychiatric epidemiology [3] and the other to the epidemiology of alcoholism [4]. Latin American researchers seem to be interested in displaying the unique- ness of their countries and even in indicating differences in their respective psychiatric pathologies. Nonetheless, their interest in looking for common etiologies and obtaining comparable results is also evident. To this end, various groups of psychiatrists and psychologists have proposed operational definitions and methods that are applicable to all of their countries. In the field of alco- holism they have achieved moderate success. Epidemiological studies have been carried out on problems of mental disorders among the general population, as well as among indigenous groups and inhabitants of marginal neighborhoods of large cities. One study center (department of psychiatry, Universidad del Valle, Cali, Colombia) participated in the World Health Organization international study of schizophrenia [5S]. Various studies of suicide in urban areas have been performed, and two (Lima and San Salvador) are currently being carried out under the auspices of the Pan American Health Organization (PAHO). In Cuba, interest in this phenomenon has been awakened and a field study is being prepared. Neurological Investigations Some neurological studies include investigations of various aspects of mental health, for example, studies of epilepsy carried out in Colombia, Chile, Cuba, Mexico, and Venezuela, and a study of Huntington's disease proposed for Venezuela. 182 Biomedical Research in Latin America Social Psychiatry Studies Perhaps Peru is the Latin American country where the greatest interest in social psychiatry has been demonstrated. Caravedo, Rotondo, and Mariategui’s book [6] brings together a number of studies carried out during the 1950’. Since then, numerous works have been published in other Latin American countries as well, particularly Argentina, Chile, Colombia, Costa Rica, and Mexico. Diverse studies related to the prevalence of mental problems have been performed, and mental syndromes peculiar to one region or one country have been described. Other studies have focused on the aspects of traditional- ism and modernism; the problem of machismo; and the development of at- titudes in the face of change in indigenous communities, in rural populations, marginal groups in the cities, and among students. The prevalence of certain mental disorders among the same groups has also been investigated. Although numerous sociological studies of migrant populations, new rural settlements, and health in city slums have been made, mental health-related issues have been treated only in passing; rarely have in-depth studies been conducted. Latin American psychiatrists have demonstrated great interest in the study of folk healing and shamanism and in the beliefs and attitudes of the com- munity in the face of those practices; the expression “folklore psychiatry” has been created to indicate this field of study [7]. Biological Psychiatry Investigations Kraepelin and the German psychiatric school in Latin America were very in- fluential until World War II. Clinical investigations were conducted in accor- dance with the precepts of this school. Arrival of the psychopharmacologic era during the 1950s marked a resurgence in biologic psychiatry that persists today. Indeed, clinical tests with psychopharmacologic products are now by far the most numerous investigations of mental health in Latin America. This is a consequence of the relative lack of legal restrictions on psychopharmacologic experimentation in many countries, of promotion by pharmaceutical com- panies, and of supposed ease in carrying out these tests. While some of these studies are methodologically faulty, most of them are sound and produce valid results. On various occasions, proposals to study the effects of living at high al- titudes and the effects of race on the action of psychopharmaceuticals have been made. However, it is not known whether such studies have actually been initiated. Various investigators have dedicated themselves to the task of searching through the abundant Latin American flora for species that produce psycho- tropic substances, and observing their effects on humans. René Gonzalez 183 Some centers, especially in Argentina, Brazil, Mexico, Cuba, and Venezuela, carry out neurophysiologic investigations. However, because few investigators are involved, the volume of publications in this field is still small. Studies of malnutrition and its effects on psychophysical development have occupied the attention of numerous investigators on the continent, especially in Colombia, Chile, Mexico, and Venezuela, and the Institute for Nutrition of Central America and Panama (INCAP) group in Guatemala [8]. Results have not been so conclusive as investigators had initially suggested, primarily be- cause of the large number of variables involved; therefore whether malnutrition during the first years of life permanently impairs certain mental functions is still debatable. Psychotherapy Studies Psychoanalytic contributions to the study of mental health in Latin America are being made by important groups in Argentina, Brazil, Chile, Colombia, Mexico, and Uruguay. Investigative works appear in numerous publications, of which the most significant is the Revista de Psicoanalisis, published by the Psychoanalytic Association of Argentina. Research articles in this journal have dealt with such subjects as machismo, violence, therapeutic procedures, and clinical observations. Child Psychiatry Studies Although children under 15 years of age constitute 50 percent of the popula- tion of Latin America, there is little research on child psychiatry. One reason for this is the scarcity of child psychiatrists and psychologists. Moreover, high rates of infant mortality in many countries and the high prevalence of communicable diseases during infancy and childhood tend to draw the atten- tion of investigators to somatic illnesses and conditions. Mental retardation is the condition that has been studied most, partly be- cause of the interest of associations of parents of exceptional children. These associations, as well as the Inter-American Child Institute (IACI) and PAHO, have facilitated meetings and backed investigations in this field. Recently research concerning the harmful effects of lack of psychosocial stimulation and the need to develop early intervention programs has come to the fore. Work in this area by the section for mental retardation of IACI and the section for mental health of the National Health Service of Chile has been particularly significant. The number of children abandoned or semiabandoned in the principal Latin American cities is alarmingly high, although the exact figure is unknown. In some cities, particularly Bogota, the mental health of such children has been studied; but otherwise the topic has scarcely been explored. 184 Biomedical Research in Latin America Alcoholism and Drug Dependence Studies Since the beginning of the century, alcoholism has preoccupied doctors, attorneys, and educators in Latin America. They have written articles pro- moting control of production, distribution, and consumption of alcoholic beverages, especially of the diverse fermented drinks consumed by the in- digenous population. Investigations of alcoholism in the region became even more important after 1940. The visit of E.M. Jellinek to Chile gave a great impetus to studies of alcoholism that were being carried out there, and had significant repercussions in other Latin American countries. Without a doubt, leadership in this area belongs to Chile, which has contributed substantially to the study of the biochemical aspects of alcoholism and to the design of ex- perimental studies of alcoholism in animals. Equally important are the contri- butions Chile has made to epidemiologic studies. These have served as a guide to numerous Latin American investigators, including Costa Ricans, who have emphasized the sociologic aspects of alcoholism. In addition, epidemiologic studies of alcoholism have been performed in Argentina, Brazil, Colombia, Costa Rica, Mexico, Peru, and the Dominican Republic. PAHO is currently coordinating an epidemiological study that in- cludes five cities in five different countries. Indeed, studies of drug dependence and alcoholism have been carried out in most Latin American countries, but unfortunately, politicans play down the extent of the problem. As a result, funding for research, treatment, and rehabil- itation is at a low level. On various occasions, representatives of Latin American countries have met to consider the drug problem and the need for research, especially epidemio- logic studies [9]. The report of the Second Latin American Seminar on Na- tional Programs of Investigation in Drug Dependence held in Cuernavaca, Mexico, in 1975, pointed out that seven countries were in the process of carrying out epidemiologic studies. In addition, two investigations of migration and drug dependence in Mexico and Puerto Rico were mentioned [10]. The chewing of coca leaves by the indigenous population constitutes a social, economic, and public health problem in various countries in the Andes. Between 1940 and 1950, a Peruvian investigator, Dr. Carlos Gutiérrez-Noriega, published numerous articles on the physiologic effects of the mastication of coca leaves. Since then, with the exception of an unpublished study conducted by the ministry of health in Peru in 1968 [11], there have been few studies of this phenomenon, despite the fact that it affects several million individuals. Dependence on opiates and their derivatives is very rare in Latin America, and the few studies that have been published in the region report on investiga- tions made in the United States by Latin Americans. On the other hand, dependence on central nervous system stimulants and barbiturates is an impor- tant problem, but the number of studies published on this topic is small. There René Gonzalez 185 are also very few studies devoted to inhalants, a problem that has been partic- ularly notable among young people in some of the large cities. After alcohol, marihuana is the most commonly abused substance in Latin America. In restricted population groups of the Atlantic and Pacific coasts and in the Caribbean, the habit is relatively old. In the last few years, use of the substance has extended to the cities, thereby mobilizing public opinion and stimulating scientists to make investigations. In two countries, Colombia and Costa Rica, the consequences of chronic use of this substance have been studied. In the majority of these countries studies of its prevalence have been conducted, especially among secondary and university students, utilizing diverse methodologies of varying scientific quality. Education and Training The number of centers of excellence with the capacity to train professionals in specific fields of mental health research is still small. However, the existence of important institutes for brain research in Argentina, Brazil, Cuba, Mexico, Uruguay, and Venezuela must be noted. These are relatively well equipped and are characterized by full-time staff of high competence. Perhaps the medical nature of neurophysiologic investigations accounts for the significance of this field. Research in social psychiatry has been carried out in departments of psychiatry in medical schools, as well as by isolated investigators. Among the research centers of this type, the most important for both research and training are the department of psychiatry of the Universidad del Valle, Cali, Colombia; the Center of Psychological Investigations of the University of Costa Rica; the departments of psychiatry of the Universities of San Marcos and Cayetano Heredia in Lima, Peru; and diverse scientific groups in Argentina, Brazil, and Mexico. In addition, studies of psychiatry and social psychology have been conducted by departments of psychiatry in other cities and by numerous hos- pitals and social services throughout Latin America. In spite of the numerous studies of psychopharmacology that have been carried out, few centers are systematically dedicated to this type of investiga- tion. Those in Buenos Aires, Mexico City, and Sdo Paulo are the most widely known. As noted above, Chile is the country that has produced the largest number of investigations into alcoholism. Professionals in this field are trained at various centers in Santiago, most of which are connected with the universities. Most professionals who do research also engage in clinical activities and in teaching. They typically derive most of their income from private practice. These circumstances militate against the development of high-quality research; however, the tendency to hire full-time professors and allow some of them to dedicate themselves completely to research is growing. 186 Biomedical Research in Latin America Professionals who are sent abroad constitute a special case since they have the opportunity to spend all their time on research. But as has been indicated, the training they receive is more directly related to the needs and interests of the institution that educates them than to the needs and interests of their country of origin. Administration of Services Psychiatric services in Latin America are typically provided in anachronistic establishments with installations that are almost always deteriorating; they are usually filled above capacity and understaffed by inadequately trained per- sonnel. This situation has concerned practically all Latin American mental health workers, who have denounced it in the scientific press, in numerous congresses, and in reports to governments and professional associations. In spite of sustained interest, there have been very few investigations related to provision of services. Services have been evaluated unsystematically, rarely in a continuous fashion or at regular intervals. Most publications and reports, including those of numerous consultants of PAHO and of technical missions under bilateral agreements, are descriptive. All of them, however, attempt a preliminary analysis of provision of services, and all of them make recom- mendations for improvement. During the last few years, some countries have undertaken to rationalize administration of mental health services by basing them on field investigations and on estimates of cost-effectiveness. PAHO has encouraged the adoption of these techniques and consolidated them in a seminar on the administration of psychiatric and mental health services in Vifia del Mar, Chile, in 1969 [12]. Conclusions Numerous mental health problems in Latin America call for attention. Many of these problems are peculiar to the region and exist within an economically and socially adverse context. In total they have great human, social, and economic importance, which makes imperative the in-depth study of causal relations in an attempt to improve conditions for the mentally ill. There is serious interest in more accurate assessment of the magnitude of mental health problems affecting these countries, the circumstances that cause them, their nature, and possible means for their correction. Yet the number of individuals who dedicate a substantial part of their time to research in this area is still small. Most mental health studies have been done by physicians, but recently pro- fessionals from other disciplines—especially sociology, psychology, and an- thropology—have been participating. A tendency to work in teams has also René Gonzalez 187 been observed, so that the solitary investigator who carries out work in his free time is seen with less and less frequency. Centers that give increasing importance to research have been created. These centers depend primarily on universities or health ministries and are rarely private. In relation to the tremendous size of the region, there are few. In addition to clinical investigations, the most frequently performed studies refer to aspects of social psychiatry, epidemiology, psychopharmacology, neurophysiology, alcoholism, and drug dependence. The number of studies re- lated to problems of childhood and adolescence is relatively small; the same is true with regard to problems of the elderly. Financial support for research is generally insufficient, which obliges investi- gators to divide their time among other activities, thereby adversely affecting the quality of research. The number of journals and other periodicals that appear regularly is small and their circulation is restricted. Consequently, dissemination of findings and communication between investigators in various countries is impeded, and Latin American investigators have even less access to the studies that are pub- lished occasionally in North American or European journals. Nevertheless, the facts that Latin American countries have a common cultural heritage, that only two languages are spoken in the majority of the countries, and that psychia- trists and psychologists belong to professional organizations of “Latin American character” go a long way toward solving the communication prob- lem. There is a certain degree of collaboration among the various countries, but large distances hamper development of closer relationships. This has encour- aged formation of subregions of cooperation, where interchange is more extensive ; the Central American countries, the nations of the so-called southern cone, those in the area of the Andes, and those along the Caribbean. The existence of common problems and similar situations has stimulated Latin American professionals to act together in their search for solutions. Re- search in mental health is one of the arms being used in that battle. References! 1. Seguin, C.A., and J. Mariategui. Perspectivas de la investigacién psiquiatrica en América Latina. Acta Psiquiatr Psicol Am Lat 21:175-184, 1975. 2. American Psychiatric Association. Mental Health in the Americas. Report of the First Working Conference on Mental Health in the Americas. 1969. With the cooperation of other professionals in the field, Dr. Gonzalez has compiled an extensive bibliography of mental health studies published in the principal Latin American health journals during the past 15 years. He will supply copies on request. 188 10. 11. 12. Biomedical Research in Latin America Mariategui, J., and G. Adis Castro (eds). Epidemiologia Psiquiatrica en América Latina. Buenos Aires, Argentina: Acta, 1970. Horwitz, J., J. Marconi, and G. Adis Castro. Epidemiologia del Alconholismo en América Latina. Buenos Aires, Argentina: Acta, 1967. World Health Organization. Report of the International Pilot Study of Schizophre- nia. Geneva: WHO, 1963. Caravedo, G., H. Rotondo, and J. Mariategui (eds). Estudios de Psiquiatria Social en el Pert. Lima, Peru: Ediciones del Sol, 1963. Seguin, C.A. Psiquiatria folklorica. In Psiquiatria Peruana, O. Valdivia and A. Pen- dola (eds). Lima, Pert: Editorial Amauta, 1970. Kallen, D. (ed). Nutrition, the Nervous System, and Behavior. Conference on the assessment of tests of behavior from studies of nutrition in the Western Hemis- phere. DHEW Publication No. (NIH) 73-242. Washington, D.C.: U.S. Government Printing Office, 1973. Psiquiatria en América Latina. Proceedings of the Vth Latin American Congress of Psychiatry. Bogota, Colombia: Tercer Mundo, 1968. Latin American Seminars I, II, and III on National Programs of Investigation of Drug Dependence, Mexico, 1974, 1975, 1976. Ministry of Health, Lima, Peru. Report on the chewing of the coca leaf in Peru (mimeographed), 1968. Pan American Health Organization. Servicios Psiquiatricos y de Salud Mental. Scientific Publication No. 210. Washington, D.C.: PAHO, 1970. 11 HIGH-ALTITUDE RESEARCH Carlos Monge C. Introduction Mountains have imposed special ecological and socioeconomic conditions on our planet. In many mountainous territories animals and humans find their lives restricted or even impeded. Sometimes this is solely because of the exces- sive height; at other times the cold factor must be added. The dryness of the surroundings also restricts vegetable life and, consequently, the lives of animals and humans. The Andes play a decisive role in the way of life and the economy of many South American countries. Ecological conditions are such that sizable human populations exist at considerable altitudes. For example, the Altiplano of Bolivia and Peru, with its immense Lake Titicaca, contains millions of inhabi- tants at altitudes around 4,000 meters. The mineral riches of the Andean Cordillera, at altitudes above 4,000 meters, have drawn large populations to places very different from the agricultural habitat that was traditional prior to the Spanish Conquest. Forced settlement has brought the exigencies of modern life, and populations such as that of Cerro de Pasco (4,300 meters) and that of Morococha (4,500 meters) have attracted the attention of investigators from many countries who have been interested from the standpoint of physio- logy or economics. Spanish historians pointed out the difficulties of living at high altitudes in their earliest writings. For example, Father Acosta refers to them in his Natural and Moral History of the Indies in 1608. Therefore, it is not surprising that in 1921 Professor Joseph Barcroft of the University of Cambridge in England organized an expedition to Cerro de Pasco to study the effects of altitude on human physiology. This expedition was des- cribed in a classic book that attracted worldwide attention because of Barcroft’s reputation and because of his conclusions. In the final pages Barcroft concluded that the acclimatized man does not exist and that the man who lives at high altitudes is physically and mentally inferior to the man who lives at sea level. Reaction to this statement was not long in coming, and it was 189 190 Biomedical Research in Latin America natural that it should come from Peru. Professor Carlos Monge M. of the San Marcos National University in Lima organized his own expedition to the city of Cerro de Pasco in 1927. In a monograph presenting the results of his investigations, he concluded that the native inhabitant of high-altitude regions is perfectly acclimatized and, moreover, is capable of competing with more physically developed people at sea level. In this same report he described cases of chronic mountain sickness—an entity he had discovered years before—as a loss of acclimatization to altitude that can occur even in native inhabitants of the high regions of the Andes. These two expeditions mark the beginning of international interest in the problems of people living in regions of high altitude; and for many years Peru has been the most active research center in Latin America with regard to the study of human and animal biology and medicine at high altitudes. Scientific curiosity, military operations, mountain climbing, athletic con- tests, civil and military aviation, acclimatization of economically important animals—all of these concerns and more have turned the mountainous regions of the world into places of permanent challenge and occasional investigation. It would be impossible to compile all this information, even for Latin America. Therefore this chapter includes only information directly related to the public health of inhabitants of the Andes. Even so, we have limited ourselves to those fields that contribute to a general interpretation of the problem, omitting numerous important findings, which for the time being cannot be integrated into a general framework of high-altitude biomedicine. The bibliography cites those sources that can be of help to nonspecialists. Each entry has been annotated in order to give a more informal, more suitable description for general readers. Sites for High-Altitude Research Traditionally, Peru has been the country in which specialized high-altitude physiological and medical studies have been carried out on a continuous basis. Starting with Barcroft’s expedition in 1921 and continuing to the present, a large number of studies in the area of human physiology, medicine, animal physiology, etc., have been published locally or in the international literature. In 1963, Bolivia initiated systematic studies on the topic of high-altitude re- search and, along with Peru, became a country that supplies valuable data in this field. Other countries of the Andes region have also served as places of research, especially regarding the physiology of acclimatization. Research centers in Chile and Argentina, though not operating continuously, have contributed to know- ledge of the effects of environmental hypoxia. In recent years, occasional studies in Ecuador and Colombia have been added to the long list of Latin American articles in this field. In a way, the case of Mexico is unique since the Carlos Monge C. 191 majority of medical researchers there do not consider the altitude of Mexico City to be sufficient to cause important medicophysiological changes. Never- theless, during the 1968 Olympic games, athletic contests and sports activities revealed the necessity for including so-called moderate altitudes in physiologi- cal and medical studies of athletic activities. Latin American capitals at elevations of interest from the standpoint of physiology and medicine can be listed in the following order of altitude: La Paz, Bolivia 3,700 m Quito, Ecuador 2,800 m Bogota, Colombia 2,700 m Mexico City, Mexico 2,200 m. Cities of industrial mining importance at elevations above 4,000 meters exist only in Bolivia, Peru, and Chile. Populations at these elevations are not nu- merous, but from the economic standpoint they form the most productive populations in Bolivia and Peru. Specialized Institutes and Centers for High-Altitude Research The oldest institute in Latin America is the Institute of Andean Biology of the National University of San Marcos in Lima, Peru, which has been in continuous operation ever since its founding in 1931. It has one laboratory in Lima 150 meters above sea level and another in Morococha at an elevation of 4,500 meters. The automobile trip from Lima to Morococha takes approximately 3 hours by way of the Central Highway of Peru, which is the main access route from Lima to the Andes and the forest in the center of the country. The laboratory in Lima has facilities for hematological, respiratory, circulatory, biochemical, anatomopathological, nutritional, and other studies. The Moro- cocha laboratory has adequate space and facilities for accommodating several investigators and for carrying out various laboratory studies; it also has a “bioterrium” for small animals. The Institute of Andean Biology is the most widely known and best utilized in the world by Peruvian investigators and others interested in environmental hypoxia. The existence of laboratories both at sea level and at high altitude a small distance apart permits acute exposure studies and makes it possible for investigators living in Lima to do their experiments in Morococha during the day and return to Lima in the evening. The Institute for High-Altitude Research of the Universidad Peruana Cayetano Heredia was founded in 1961. It has laboratories in Lima (150 m) located in the Hospital General Base Cayetano Heredia and in Cerro de Pasco (4,300 meters). The Lima laboratories have facilities for research in hema- tology, physiology, biochemistry, and anatomopathology. The laboratory for circulatory research and that for pathological anatomy are in the Arch- bishop Loayza Hospital. The laboratory in Cerro de Pasco, 6-8 hours from 192 Biomedical Research in Latin America Lima, can accommodate six investigators and has adequate laboratory facili- ties for various studies. It, too, has a bioterrium for small animals. Cerro de Pasco, the most important mining city of Peru, has three hospitals where medical investigators can study regional pathology. A new hospital, under cons- truction near the institute, will make it possible to carry out high-altitude clinical research in connection with laboratories of the institute. In recent years a partnership has been established between the Institute of Andean Biology of the University of San Marcos and the Institute for High- Altitude Research of Cayetano Heredia University of Peru. This partnership is based on cooperation at the academic level that makes possible the use of resources and offers training programs utilizing the facilities of both institutes. Collaboration is administered by a committee that is alternately headed by each institute. This association of institutes offers unique facilities for studying high-altitude physiology and pathology. The Bolivian Institute of High-Altitude Biology was founded in 1963 in La Paz, Bolivia (3,700 m). This state institute has adequate facilities for bio- medical research in such areas as hematology, respiration, circulation, bio- chemistry, and hemotypology. Its director is a Bolivian and its codirector is a Frenchman representing the Institut Pasteur of Paris. Support by the Bolivian and French Governments has given this institute a special position. La Paz is the highest capital in the world. Because of its geographical location and its political importance, the city has become an outstanding center for human population studies and environmental pathology studies in the Andes. The nearby Altiplano of Bolivia (elevation approximately 4,000 meters) makes it possible to study aboriginal populations in high-altitude regions. In other regions, factors such as intermarriage, modern life, and environmental pollu- tion preclude separation of physiological changes produced by high-altitude acclimatization from those corresponding to conventional pathology aggra- vated by living at high altitudes. Comparative studies with sea-level popula- tions can be carried out in Santa Cruz, Bolivia, close to sea level. Chile has large mining populations at elevations similar to those of Bolivia and Peru. As in the neighboring countries, these populations, although small, are important to the economy of the country. Although Chile does not have a high-altitude research institute, individual investigators have drawn attention to the public health of miners and of native inhabitants of Chile’s high-altitude regions. Dr. Raymundo Santolaya B., a Chilean scientist involved in high- altitude research, is the director of a newly created center for high-altitude medical research. Studies were initiated in the hospital for the mines of Chu- quicamata (3,000 meters) with possibilities for using sites at 3,800 meters and 4,500 meters. According to Dr. Santolaya, the existence of isolated native populations in the Chilean Altiplano allows comparative studies with those mestizo populations that are usually studied from the biomedical standpoint. Through the efforts of Dr. Ricardo Cruz-Coke, of the J.J. Aguirre Hospital of Carlos Monge C. 193 the University of Chile in Santiago, since 1964 it has been possible to study human genetics in the region of the so-called slope of Arica. This geographical zone, which contains small populations of Aymaran origin, rises from sea level to an elevation of 4,500 meters within a distance of only 80 kilometers. For years the well-known Argentine physiologist Hugo Chiodi carried out basic respiratory research in the mining regions of the high Andes of Argentina. Although this chapter is devoted to high-altitude research in Latin America, it seems important to mention high-altitude studies performed in the United States by the cardiovascular pulmonary research laboratory of the University of Colorado Medical Center in Denver, Colorado. The director, Dr. Robert Grover, is studying the native high-altitude population in Leadville, Colorado (3,100 meters), and the workers in the Climax molybdenum mine (3,400 meters). The laboratory is located in Saint Vincent General Hospital in Lead- ville. Pike’s Peak laboratory (4,300 meters) is also used for acute adaptation studies. This laboratory belongs to the U.S. Army Institute of Environmental Medicine in Natick, Massachusetts. These laboratories are mentioned because of the close relationship between their investigators and those of Latin Ameri- ca, especially Peru. It is interesting, for example, to point out that this labora- tory and others of the University of Colorado have contributed substantially to knowledge of the physiology of oxygen transport in the llama. On the other hand, all 8,000 inhabitants of Leadville originally came from sea-level regions. This fact allows comparative studies with Andean populations that have lived for generations at high altitudes. In the same context, it is important to mention an interdisciplinary study being carried out in high-altitude regions of Peru by a North American group under the direction of scientists from Pennsylvania State University led by Paul T. Baker. This group, which has been working with environmental problems in the Peruvian Andes since 1960, in 1968 incorporated its multidisciplinary studies into the program on human adaptability that is part of the Interna- tional Biological Program. These studies—conducted in Nufioa (4,000 meters)— can make a permanent contribution to knowledge on the problem of adapta- tion in the Andes. The high-altitude adaptation study of this population of Quechuan origin was carried out with the collaboration of 17 scientists, most of whom were North Americans. The group also included Peruvian experts in the field of high-altitude adaptation. This exceptional field study, which may be beyond the economic reach of most Latin American countries, shows what can be done in terms of international cooperation for the study of environ- mental problems in this geographical area of the world. Research Areas Worldwide interest in the problems of living at high altitudes falls into two categories: physiological and clinical changes experienced by (1) those who 194 Biomedical Research in Latin America climb high mountains and (2) native inhabitants or permanent residents of high-altitude regions. In Latin America, interest has been focused on the permanent population of the Andes, and very little attention has been devoted to acute mountain sickness, probably for socioeconomic and cultural reasons. Latin American investigators are more interested in the health of miners or peasants devoted to farming or work with livestock. Investigators in more developed countries are interested in medicine as it relates to sports such as mountain climbing. Nevertheless, with improved transportation, thousands of Latin Americans move daily through various altitudes for reasons of work, travel, sports, recreation, and so forth. Accordingly, it seems that the field of acute mountain sickness will, of necessity, be intensively studied in Latin America in the near future. A problem of worldwide interest is pulmonary edema, which has been described by Dr. Alberto Hurtado of Peru. This prob- lem occurs not only in sea-level residents who quickly climb to high altitudes, but also in native inhabitants of high-altitude regions who descend for a few days to sea level and then return rapidly to high altitudes. Pulmonary edema has been found in La Paz and, more surprisingly, in Quito (2,800 meters). This problem was important from a military standpoint in India, where there are many high-altitude regions. Native inhabitants and immigrants to high-altitude regions have been exten- sively studied by investigators of the Andean region, particularly in Peru and more recently in Bolivia. Biomedical study of Andean inhabitants is so wide- spread that it seems advisable to divide this field into various sections of interest. : Normal Man After the publication of the monograph by Dr. Carlos Monge M. and his collaborators, it was universally accepted that native inhabitants of high- altitude regions are well acclimated and as physically and mentally fit for their environment as are sea-level inhabitants for theirs. The majority of Latin American investigators have concentrated on des- cribing the functional anatomy of native inhabitants of the Andes, so there have been many publications by Latin American and foreign authors who have worked there. Various aspects of health have been explored in humans and in experimental and domesticated animals, including respiration, circulation, hematology, endocrinology, renal function, digestion, neurology, nutrition, pharmacology, and biochemistry. The dominant tendency has been to apply biomedical methodology learned at sea level to persons living in high-altitude regions, thereby arriving at a description of these persons acclimated to high altitudes. Much less attention has been devoted to research on mechanisms of acclimatization. This taxonomical tendency has involved descriptions of data Carlos Monge C. 195 peculiar to natives of high-altitude regions, i.e., data related to polycythemia, hyperventilation, physiological emphysema, pulmonary arterial hypertension, predominance of the right ventricle, reduced filtration through the renal glomerular membrane with a high filtration fraction, hypertrophia of the carotid bodies, tendency towards dolicho-megacolon, low level of glucose in the blood without hypoglycemic symptoms, reduced production of lactic acid during exercise, vagotonia, tolerance to atropine, intolerance to sulfon- amides, and many other details. These data constitute perhaps the greatest Latin American contribution to knowledge of health at high altitudes. Monge’s Sickness Chronic mountain sickness, described by Dr. Carlos Monge M. in 1928, has been identified as Monge’s sickness by medical dictionaries of North America and Europe. In modern literature there is a growing tendency to accept Monge’s sickness as a specific clinical entity characterized by cerebral conges- tion and, at times, by cardiac insufficiency of the right ventricle. This is ac- companied by excessive polycythemia as a result of long stays at high altitudes and in connection with primary hypoventilation, which disappears when the patient descends to elevations near sea level. Study of this clinical entity in relation to the environment has stimulated international interest because it helps to explain physiological phenomena related to control of cardiopul- monary function. The relationship between high-altitude acclimatization and Monge’s sickness has been reinterpreted recently in Peru by Whittembury and Monge, and in England by Heath and Williams. The former consider the sickness to be a natural concomitant of permanent stays at high altitudes and increasing age. The latter think that it is probably due to minute pathological changes in the lungs that become manifest at high altitudes. The implications of these inter- pretations for the public health of Andean populations will be discussed later. High-Altitude Pathology Apart from the physiological and clinical studies related to acclimatization or the loss of acclimatization produced by Monge’s sickness, it is necessary to stress the fact that there are special differences between sea-level pathology and high-altitude pathology and, moreover, that the incidence of illness can vary significantly with the clinical picture. Thus in the high-altitude region of the Andes there is low incidence of arterial sclerosis and arterial hypertension, but high incidence of bronchopulmonary illnesses. The frequency of dolicho- megacolon is higher, due to the greater volume occupied by intestinal gases because of low barometric pressure; a secondary cause of this phenomenon is the high frequency of intestinal volvulus. Other differences include the greater 196 Biomedical Research in Latin America incidence of patent ductus arteriosus, which requires surgical correction; acute thrombosis, which occurs in some patients who have asymptomatic sickle- cell anemia at sea level; and the diseases such as chronic bronchitis, pneumo- coniosis, xyloscoliosis, and other entities that affect respiratory function and whose seriousness is alleviated by descending to sea level. These and other clinical pictures have been described by Peruvian physicians and have been studied on a basic level in Peru and Bolivia. Basic Studies In the area of basic research, the Institute of Andean Biology of the University of San Marcos of Lima, the Institute of High-Altitude Research of Cayetano Heredia University of Peru, and the Institute of Andean Biology of Bolivia have high-level investigators in the fields of biochemistry and physiology. On an independent basis, the laboratories of biochemistry, biophysics, and physi- ology of Cayetano Heredia University of Peru are developing intense activity in the field of high-altitude acclimatization, both in the Cerro de Pasco labora- tory and in the biophysics laboratory, where an experimental model of inter- mittent hypobaric hypoxia has been developed. A recent contribution from the biochemistry laboratory indicates that coldness appears to be more important than hypoxia in adaptation of cells to climate at high altitudes. In fact, removal of the cold factor nullifies many of the findings described previously in the international literature as attributable to the hypoxic factor. Interdisciplinary Studies Human adaptation must be studied primarily from a physiological standpoint, as it has in the majority of biomedical investigations of persons living at high elevations. Nevertheless, it is also evident that such factors as the way of life and social stucture interact with the biological substrate and the interrela- tionships need to be better understood. The findings of Baker, mentioned earlier, are of significance to the Andean countries. R. Brooke Thomas, a member of Baker’s team, concluded : -..it is the obligation of community leaders, politicians, and scientists who are committed to change in the highlands to carefully weigh the long-term effects of their programs on basic Andean adaptations. To neglect and to seriously disrupt these adaptations will most likely result in a final blow to the Andean way of life—a way of life that 500 years ago flourished as a major civilization. Another interdisciplinary team of great importance for the advancement of Andean adaptation studies is the French group associated with the Bolivian Institute of Andean Biology in La Paz. The French Government, under the leadership of Professor Jacques Ruffié, has provided a continuous flow of investigators who collaborate in the areas of hemotypology, physiology, and biochemistry, for example. The significant contribution of this group is its Carlos Monge C. 197 identification of anthropologically well-defined Andean populations in which physiological studies can be carried out in comparison to those conducted with mestizo populations. The Problem of Human Acclimatization at High Altitudes Any discussion of public health in the high Andean regions should be pre- ceded by an analysis of the capacity of humans to adapt to high altitudes. The following points should be considered: whether satisfactory acclimatiza- tion exists; whether there is biological adaptation in the form of genetic changes that distinguish natives of high elevations; whether acclimatization occurs in persons born at sea level who become residents of high-altitude regions; and whether it is essential to be born in a region of high altitude in order to be considered a high-altitude person. These questions have been partially answered. For example, the Peruvian anthropologist A. R. Frisancho, of the University of Pennsylvania, has pointed out that children brought to high-altitude regions before reaching puberty attain the same indexes of respiratory function as do high-altitude natives. This does not occur in young people brought to these altitudes at a later age. Nevertheless, there is no agreement on the adaptive capacity of native inhabit- ants of high-altitude regions, and studies on this point remain inadequate. For the most part, Latin American investigators have followed the original line of Dr. Carlos Monge M. in considering high-altitude residents as com- pletely acclimatized. Although there is no evidence of genetic changes by which high-altitude persons could produce a high-altitude race, investigators assume that the residents are so acclimatized that they have the characteris- tics of athletes, as pointed out by Monge in 1928 and by Dr. Alberto Hurtado in 1964. This statement is based on the capacity of natives of Morococha (4,500 meters) to perform physical exercise on a competitive basis with sea- level persons and to have a lower concentration of lactic acid in the plasma after comparable exercise at both altitudes. Bolivian and French investigators at the Bolivian Institute of Andean Biology concur with this position, as do the majority of international investigators who have worked in high-altitude regions of the Andes. With respect to Monge’s sickness, Monge himself, like most of the investi- gators who have studied this disease, thinks that it is the result of hypoven- tilation with accentuation of hypoxemia, which in turn causes excessive polycythemia. Although Monge thought this sickness was a specific entity that can affect high-altitude persons and is caused by a loss of acclimatization, neither he nor other investigators intended to associate it with the process of acclimatization itself. On the other hand, Donald Heath, a British pathologist, and his colleague David Reid Wiliiams assert that many changes produced by long stays at high 198 Biomedical Research in Latin America altitudes can be considered pathological rather than physiological. As it has not been possible to make anatamopathological studies of typical cases of chronic mountain sickness, the possibility remains—for these authors—that cases of Monge’s sickness are the result of minor pulmonary pathological conditions that become serious in inhabitants of high-altitude regions. However, we question the absoluteness of acclimatization in natives of high-altitude regions and those who have always lived in the central Andes of Peru, where Monge’s sickness was first described. On the basis of evolutionary biological analysis, comparative physiology in the animal chain, and the fact that the hematocrit has been described as increasing with age and with al- titude, we postulate that human acclimatization does not exist in these regions, that Monge’s sickness is the result of the natural aging process in the high Andes. Francisco Simé, Carlos Monge C., and José Whittembury later demon- strated that the decrease in pulmonary ventilation with age at the elevation of Cerro de Pasco (4,300 meters) explained the increasing hematocrit. According to them, the determining factor in Monge’s sickness is polycythemia, which increases with age and causes loss of acclimatization in residents of high- altitude regions when it reaches symptomatic levels. To avoid risky generalizations, we wish to make it clear that our opinions refer to acclimatization and loss of acclimatization in the regions of the central Andes of Peru where the mining population is found. Even if it is true that the “normal” population and those with Monge’s sickness do not suffer from evi- dent respiratory diseases and do not work inside the mines, it is also true that their standard of life corresponds to the industrial one. Slight environmental pollution, a different nutritional standard from that of ancestral times, a work regimen organized by industry, and other factors may constitute sufficient cause for loss of the delicate balance called high-altitude acclimatization. Unfortunately, no similar studies exist on the agricultural aboriginal popula- tions at altitudes comparable to those of Cerro de Pasco (4,300 meters) or Morococha (4,500 meters). How can we relate the two findings of Carlos Monge M.? His first discovery was that the physical output of persons living in the central Andes of Peru was equal to that of athletes. His second finding, taking into account the fact that the same persons showed no pathological symptoms, was that they could lose their acclimatization. We believe that the explanation lies in the fact that environmental hypoxia in effect causes them to develop increased aerobic capacity in comparison with persons living at sea level. Yet this capacity develops more and more at the expense of polycythemia, which eventually leads to a congestive picture of cerebral predominance that is the cause of the dominant symptomatology in Monge’s sickness. Carlos Monge C. 199 The Problem of Public Health in the High Andes Region The great emphasis by the Latin American scientific community on testing the adaptive capacity of natives in high-altitude areas necessitates study of the environment as well. In light of the increase of interbreeding in the mining regions of the high Andes, it is not valid to speak of aboriginal high-altitude races. With regard to the problem of public health, the following factors must also be considered - Rapid shifts in altitude resulting from modern transport can cause changes in adaptive capacity; A slight degree of environmental pollution is serious at high altitudes; Normal decline in respiratory function at sea level could cause ex- cessive polycythemia at high altitudes; The danger of acute pulmonary edema requires inhabitants of high- altitude regions to take special precautions when they spend a few days at sea level and then return to high elevations; Blacks with sickle cell anemia, which is asymptomatic at sea level, may suffer a serious crisis of vascular thrombosis when ascending to high altitudes; and Athletic performance decreases with changes in altitude. In addition, the fact that pulmonary pathology at sea level is aggravated at high altitudes means that the problem of public health is an immense one in the Andes region. We are convinced that it is possible to live satisfactorily in the high regions of the world and that adequate knowledge of high-altitude physiology and pathology will enable scientists to identify those who are at risk of high- altitude sickness. Scientists should also be able to devise tests to predict which sea-level inhabitants can move to high-altitude regions; such tests may also determine which age groups can live most satisfactorily at what elevations. On the other hand, it is likely that the climate of high-altitude regions prevents the appearance of arterial sclerosis, arterial hypertension, and certain other diseases. Furthermore, it is known to be advantageous for asthmatic patients and perhaps for patients exhibiting other clinical entities. Thus it is obvious that there is a great need for research. The Future of High-Altitude Health Research In the past, human health research in high mountainous regions of Latin America has focused on adaptive human physiology and clinical observations. Within the area of physiology the taxonomical tendency has predominated, i.e., collection of laboratory data and functional tests performed on residents 200 Biomedical Research in Latin America of high-altitude regions, which—in turn—are compared with control data ob- tained at sea level. With rare exceptions, there has been little inclination to explore intimate mechanisms of adaptive changes. For the most part it has been foreign investigators, with a large amount of experience in their own fields, who have made theoretical advances or have applied original techniques to the problem of high-altitude research—probably because of the weakness in basic science in those countries where high-altitude problems exist. For ex- ample, it is interesting to note that in the 1968 Olympics in Mexico, the main studies on the physiologies of exercise designed to predict the result of athletic performance were done in Great Britain. However, in recent years there appears to be a clear tendency among some high-altitude researchers of Andean countries, mainly in Peru, to develop their own theories, design their own experimental methods, and arrive at conclusions that do not necessarily reflect the findings of other international investigators. In the field of clinicopathological observation of persons living at high elevations, large contributions have been made, mainly in Peru. Monge’s sickness, acute pulmonary edema at high altitudes, pulmonary arterial hyper- tension, hypertrophia of the carotid bodies, hypoglycemia, decrease in the glomerular filtration of the kidneys along with a high filtration fraction, endocrinological picture with specific modifications, dolicho-megacolon, hyperactivity of the vagus nerve, tolerance to acute and chronic anemia—all are typical of studies in countries of the Andes region. The main difficulties facing human health research in Latin America have been intellectual and economic. Latin Americans are not yet conscious oi the important role played by altitude in the health and economy of their countries. Frequently, they have been passive witnesses while foreign investi- gators, using basic resources in the country under study, conducted research of major significance for public health. As for the economic aspect, the Govern- ments and politicians of countries with inhabited mountainous regions have been inclined to consider high-altitude research as something foreign and, to a certain extent, a luxury. They have not given the same attention to this prob- lem as they have to contagious infectious diseases, parasitic diseases, and nu- tritional diseases, for example. A Developmental Plan for High-Altitude Research In the area of basic research, it is advisable for investigators to explore the field of environmental hypoxia in the fullest biological sense. Information obtained from the study of ecology, comparative animal physiology, and the theory of evolution should be an impetus to systematic investigation. The development of experimental models already initiated at Cayetano Heredia University of Peru will enable investigators interested in environmental Carlos Monge C. 201 hypoxia—whatever their location—to do research without having to wait for opportunities to travel to high altitudes. Using experimental models and natural resources in the form of indigenous high-altitude animals, scientists should start now to study the mechanisms of environmental adaptation at high elevations, thereby conceivably enabling future investigators to avoid unnecessary expenses and wasted efforts. For instance, studies at Cayetano Heredia and abroad suggest that the major adaptive response to high-altitude areas may be extracellular. This impression, in conjunction with the finding of no substantial changes in some enzymes of the respiratory chain, has precluded other costly experiments. Human health research in high-altitude regions should be interdisciplinary, like that conducted by Baker’s group. It should include ecological factors, such as altitude and cold, and socioeconomic factors, such as the necessity for mining populations to work above the ecological altitude, the necessity for indicating tolerable limits of environmental pollution, and the effect of age at high altitudes. Findings utilizing these factors should then be combined with physiological and clinical knowledge. It is necessary to create interdisciplinary groups, at least in Bolivia, Chile, and Peru, where rich mineral deposits are found at high altitudes. Governments and their ministries of health would be obligated, in conjunction with large mining concerns, to finance the inter- national infrastructure for high-altitude research; thus national funds would be supplemented with foreign aid. The efforts of the French multidisciplinary group working in cooperation with the Bolivian Institute of Scientific Research once again should be empha- sized. Professor Jacques Ruffié has directed his endeavors in accordance with the Franco-Bolivian group, and as a result of his personal interest has obtained the economic support of the French Government for research in Bolivia. This aid is not limited to research; it is also for training Bolivian professional and paraprofessional personnel in France. The results of such collaboration have been mutually beneficial. Bibliography These publications give a general idea of high-altitude research carried out in Latin Amer- ica by local and foreign investigators. In these works the reader will find information on specific topics that are beyond the scope of this review. Barcroft, J. The Respiratory Functions of the Blood. Lessons from High Altitude. Cambridge: Cambridge University Press, 1925. This book opened the doors to international scientific interest in the problems of high-altitude adaptation. Professor Barcroft, one of the pioneers of this century in respiratory physiology, pointed out that there is no such thing as a person acclimatized to high altitude, and that inhabitants of high-altitude regions are physically and mentally inferior to those living at sea level. As we indicated in the introduction to this chapter, this book challenged Dr. Carlos Monge M. to initiate the Peruvian Institute of High-Altitude Research. 202 Biomedical Research in Latin America 2. Monge, C. La Enfermedad de los Andes. Anales de la Facultad de Medicina. Lima: Universidad Nacional Mayor de San Marcos, 1928. 3. Monge, C., E. Encinss, C. Heraud, A. Hurtado, T. Escajadillo, M. Cervelli, O. Fosalba, J. Lopez, A. Morey, V. Nuiiez, E. Rondén, and E. Rosa Medina. La Enfermedad de los Andes. Estudios Fisiologicos. Anales de la Facultad de Medi- cina. Lima: Universidad Nacional Mayor de San Marcos, 1928. These articles, which appeared in a single volume of the Revista Médica de la Universidad de San Marcos de Lima, form a classic work in which C. Monge des- cribes chronic mountain sickness and the adaptive capacity of the native inhabitant of high-altitude regions. 4. Monge, C. Les Erythémes de L’Altitude. Paris: Masson, 1929. This book is an analysis of previous articles. In the prologue, Prof. G.H. Roger, Dean of the Faculty of Medicine of Paris, proposes that chronic mountain sickness be called Monge’s sickness. 5. Monge, C. Acclimatization in the Andes. Historical Confirmation of ‘Climatic Aggression” in the Development of Andean Man. Baltimore: Johns Hopkins Press, 1948. This is the classic most often cited in the international literature on high- altitude adaptation. Its prologue was written by the well-known geographer, Isaiah Bowman, who was president of Johns Hopkins University. The book has been re- edited at the request of Paul T. Baker, an expert in high-altitude human adaptation, who has written a preface for the new edition, published by Blaine Ethridge Books, Detroit, 1973. 6. Hurtado, A. Animals in High Altitudes. Resident Man. /n Handbook of Physiology, Section 4: Adaptation to the Environment, D.B. Dill, E.F. Adolph, and C.G. Wilber (eds), pp. 843-860. Washington, D.C.: American Physiological Society, 1964. This frequently cited chapter summarizes the work of Alberto Hurtado and his collaborators on persons with Monge’s sickness and on normal persons living at high altitudes. 7. Monge M., C., and C. Monge C. High Altitude Disease. Mechanism and Management. Springfield, Illinois: Charles C. Thomas, 1966. This small book presents the general problem of high-altitude adaptation and reviews concepts on Monge’s sickness some 40 years after its original description. 8. Monge, C., Sr., and C. Monge, Jr. Adaptation to High Altitude. In Adaptation of Domestic Animals, E. S. E. Hafez (ed), pp. 194-201. Philadelphia: Lea and Febiger, 1968. The authors compare the adaptive physiology of domestic animals brought to the South American Andes by the Spanish during the Conquest with that of animals native to the high Andes. 9. Porter, R., and J. Knight (eds). High Altitude Physiology : Cardiac and Respiratory Aspects. Ciba Foundation Symposium. Edinburgh: Churchill Livingstone, 1971. This symposium, organized in London in honor of Professor Alberto Hurtado, is an excellent source of references, not only in the field of high-altitude cardio- respiratory physiology but also for studies on Monge’s sickness. 10. Bonilla, H. El Minero de los Andes. Lima: Instituto de Estudios Peruanos, 1974. This small book by a Peruvian social scientist is an excellent analysis of the socioeconomic reality of the mineworker of Morococha (4,500 m). This type of research can be used as a starting point for interdisciplinary studies that will make it possible to integrate biological and socioeconomic knowledge, a process which, in our opinion, will ultimately serve as a basis for solving the difficult problem of health of the Andean mineworker. 11. Ward, M. Mountain Medicine. A Clinical Study of Cold and High Altitude. London: Crosby Lockwood Staples, 1975. The author discusses basic problems related to the physiology of high-altitude acclimatization, with special attention to acute mountain sickness and its clinical forms. It includes a chapter on Monge’s sickness and an extensive bibliography. Carlos Monge C. 203 12. 13. 14. 15. Baker, P. T., and M. A. Little (eds). Man in the Andes. A Multidisciplinary Study of High-Altitude Quecha. Stroudsburg, Pennsylvania: Dowden, Hutchinson, and Ross, 1976. This book presents an extensive interdisciplinary study of high-altitude adap- tation in aboriginal populations of the Andes. Two well-known Peruvian investi- gators, Tulio Veldsquez and Emilio Picon, collaborated in this work. Monge C., C., and J. Whittembury. High Altitude Adaptations in the Whole Animal. In Environmental Physiology of Animals, J. Bligh, J. L. Cloudsley-Thompson and A. G. McDonald (eds), pp. 289-308. Oxford: Blackwell, 1976. This chapter reviews adaptation to hypoxic environments in the scale of ani- mals. The authors point out that the evolution of mammals has taken place at sea level, where oxygen is at its highest natural concentration. They consider the environment of the high mountains as a recent and severe biological challenge to attempts at acclimatization by humans and animals. Heath, D., and R. Williams. Man at High Altitude. The Pathophysiology of Accli- matization and Adaptation. Edinburgh: Churchill Livingstone, 1977. This book is a complete compilation of information on physiology, clinical studies, and pathology of high altitude. Although the authors disagree with the majority of other investigators on the concept of human acclimatization at high altitudes, they discuss the prevailing opinion of the remaining investigators. Ruffiée, J., J. C. Quilicy, and M. C. Lacoste (eds). Colloque Anthropologie des Populations Andines. Paris: INSERM, 1976. This colloquium presents the experience of French investigators in multidis- ciplinary studies of the high Andes. The collaborators are well-known researchers from Andean countries. This publication offers information on works that are in full progress in this region. Chg. SE op ser 12 MEDICAL AND HUMAN GENETICS Heber Villalobos C. Definitions Human genetics includes the study of mechanisms of transmission of traits from parents to children and of individual variations. In other words, it is the study of the nature and functions of genes and their influence on the develop- ment and functioning of human beings. Medical genetics, on the other hand, is basically concerned with abnormal genes and their role in the abnormal development and functioning of human beings. The concept of human genetics is thus broader and more comprehensive than that of medical genetics, since the former is concerned with both normal and pathological hereditary traits. It is not always easy to establish a precise boundary between health and sickness since man, as a biopsychosocial being, is very complex and the sub- jective factor plays an important role in defining the condition of health or sickness. For the same reasons, it is extremely difficult to differentiate between human genetics and medical genetics, both of which are often in- volved in challenging problems. Scientific Developments As a medical discipline, genetics is undergoing an extraordinary development. Success in the fight against infectious and contagious diseases has prolonged the average life span considerably, thus making it possible to intensify medical assistance to patients with diseases of genetic origin [1]. For instance, better knowledge of blood groups has permitted resolution of many problems of transfusion and fetal-maternal incompatibility. In addition, advances in mo- lecular biochemistry have led to development of analytical techniques appli- cable to research on the structure and function of genes, pinpointing biochem- ical changes characteristic of many hereditary diseases. Immunological ad- vances applied to genetics have been valuable in understanding rejection phenomena in the case of organ and tissue transplants. Finally, development of 205 206 Biomedical Research in Latin America chromosomal analytic techniques has made it possible to establish that many pathological conditions are the result of chromosomal changes. In developed countries, the burden imposed on society by diseases of genetic etiology is considerable, from both an absolute and a relative stand- point [2]. In these countries, control of environmental or exogenic causes of diseases has inevitably resulted in a proportional increase in genetically deter- mined diseases as a cause of death [3]. In the developing nations of Latin America and the Caribbean, however, the situation is different. Communicable diseases and malnutrition, particularly in childhood, are the main causes of mortality and morbidity. Therefore, these problems constitute first priorities of action and research at the moment. Nonetheless, once communicable diseases and nutritional problems are con- trolled, hereditary problems will become relatively more important. Although it is not yet possible to modify the genetic makeup of persons suffering from hereditary disease, by changing the environment in certain cases we can alter the phenotype in a beneficial manner and thus eliminate the undesirable expression of an abnormal genotype. Moreover, it is possible to prevent the appearance of undesirable genotypes, both during the preconception period and prenatally. Most Latin American and Caribbean countries are more or less ethnically homogeneous, although each has certain characteristic features. The native aborigines mixed with Latin Europeans, mainly Spanish, following discovery and colonization. Large contingents of African peoples were subsequently brought over and distributed among most American countries. These two ethnic groups, together with American aboriginal groups, are mainly respon- sible for current Latin American communities. Of course, throughout the continent’s postcolonial history, other ethnic groups in various areas and at different times have contributed to defining current communities; the mi- grations of the last two centuries, from Italy, Portugal, Japan, India, Near- Eastern countries, etc., are especially important. For many years, however, some Latin American communities remained truly isolated from a genetic standpoint; and for reasons noted below, the genetics of these groups should be studied intensively and promptly. Human genetics research in Latin America dates from the time of Teoddsius Dobzhansky, a Brazilian pioneer in the field, who raised that country to one of the foremost in the world in the area of drosophila population genetics [4]. Brazil now has a well-developed organization comprising all types of geneticists and reflecting the progress achieved by this country in all areas of genetics. Indeed, Brazil is the pioneering Latin American country in human genetics research. It has established a school of genetics supported by various institutes and centers in which medical and human genetics research is per- formed; and it has many highly qualified professors for its graduate and post- graduate courses. Heber Villalobos C. 207 Centers for Genetics Research Human genetics has existed as a discipline only since the 1950’s, when mo- lecular biochemistry and chromosomal analysis were first applied to human genetics. Following its inception in Brazil, both this discipline and medical genetics developed systematically in other Latin American countries. Before the sixties there was only sporadic and isolated activity in human genetics research. The World Health Organization (WHO) Committee of Experts in Human Genetics published its first technical report in 1962, Genetics Instruction in Medical Schools and in Advanced Training Courses [1], and its second in 1964, Human Genetics and Public Health [2]. These reports pointed out the need to establish human genetics centers for teaching and research. Since then, medical and human genetics centers have been organized in various countries of Latin America and the Caribbean. Most of these centers have been formed under the auspices of medical schools. In a few cases, secretariats or ministries of health and social security institutes have been responsible. In Venezuela, for example, of the 10 existing medical and human genetics centers, 6 were established under the auspices of medical schools, 1 under the Ministry of Health and Social Welfare, 1 under the Venezuelan Institute for Scientific Research (IVIC), 1 under the Red Cross, and 1 under the Ministry of Defense. However, some health au- thorities have opposed establishment of this type of service because hereditary diseases are not serious public health problems in Latin America and the Caribbean at the moment. They maintain that clear priority must be given to problems of malnutrition and infectious/contagious diseases. As an example of the spirit of cooperation among various organizations, establishment of the Medical Genetics Center in the city of Buenos Aires, Argentina, in 1967 is noteworthy. The office of the Secretary of Health, the Argentine Association of Medical Schools and the Pan American Health Organi- zation all participated in its establishment. Genetics societies in some Latin American countries are increasingly being called on to play an important role in establishing and strengthening medical and human genetics centers. On some occasions, they have been the decisive factor for governments having chosen to establish such services through their health institutions or universities. In 1978, seven national genetics societies were affiliated with the Latin American Association of Genetics, and all of them stated, in statutory objectives, their intention to promote research in various areas of genetics. As in other parts of the world, medical and human genetics research in Latin America and the Caribbean was initially limited to scientists (mainly doctors, biologists, and anthropologists) in the field of hematology. As pioneers in the study of problems of human heredity in these latitudes, these men made 208 Biomedical Research in Latin America important contributions to the knowledge of human genetics, for example, discoveries of the variety of hemoglobin known as Porto Alegre and the Diego immunohematologic factor. As has been true for most developed countries, contributions in this first phase of research were mainly in population genetics—genetic polymorphism and hereditary pathology—basically in immunologic and hematologic pathology [5]. With the establishment of medical and human genetics centers, research was planned and conducted by scientists specifically trained in human genetics. This does not mean that the first researchers did not have outstanding qualifi- cations. On the contrary, they performed and continued to perform outstand- ing work, but the majority of them were not geneticists in the strict sense. Since then, research has become considerably diversified, involving prac- tically all of the 26 different areas listed in the National Foundation-March of Dimes International Directory [6]. The areas in which work has been most intense and successful have been morphological cytogenetics, clinical genetics and genetic counseling, dermatoglyphics, congenital malformations, immuno- hematology, and population genetics. To a lesser degree, biochemical genetics, the twin study, psychiatric genetics, immunogenetics, and physical anthrop- ology may be noted [3, 4, 6-13]. Areas that have been investigated include congenital malformations, which have already been reported, some inborn errors of metabolism (e.g., G-6 PD deficiency, pseudocholinesterase deficiency, congenital metabolic changes of amino acids and organic acids, intestinal lactase deficiency and other disaccharidases), chromosomal aberrations, and polymorphisms. In the remaining fields, research has been somewhat sporadic. The Latin American Cooperative Study on Congenital Deformities (ECLAMC), a cooperative research study among various Latin American countries, deserves special mention. The study began in 1967 in various maternity hospitals in Argentina; it currently includes more than 20 maternity hospitals in seven Latin American countries—Brazil, Chile, Ecuador, Peru, Uruguay, and Venezuela, in addition to Argentina. ECLAMC is an epidemiol- ogic study of the case-control type and is therefore long-range, with both descriptive and analytical objectives. It is based on the voluntary participation of professionals who have decided to pool data on congenital deformities. Investigators have combined in a multinational research program and have agreed to conform to a precise, uniform operational plan that is described in the study’s operational manual. The study is fundamentally a low-cost program that functions by using the established capacity of health, educational, and research organizations. It could not be otherwise in countries where congenital malformations do not occupy a position of priority among causes of death and disease. The program requires no complex observation of newborn infants; it can be carried out by pediatricians as they see fit. A final characteristic is the detailed and standardized description of congenital malformations, making Heber Villalobos C. 209 the program a clinical epidemiological study that endeavors to combine the informational qualities of individual and multi-institutional studies. Valuable material, accumulated during 10 continuous years of research on congenital deformities, with more than 500,000 births examined, has been published in accredited international journals and has been used to prepare de- gree dissertations. Eventually, all of this material will be published | 14]. Priorities for Research: Recommendations The following ideas are proposed as possible priorities for medical and human genetics research. Genetics of Aboriginal People Aboriginal people (isolated genetic islands) may disappear in the near future. Among them are the Guayakis of eastern Paraguay, the Sirionos of Bolivia, the Guaharibos of Venezuela and Colombia [15], the Aicuna in Argentina, and the Colonia Tovar and Bobures in Venezuela. The cultural assimilation that these groups have undergone (or the reduction in their numbers) hinders research on them, but studying them with cooperation from scientists and institutions of other countries (Brazil and Venezuela) would be useful. Such research, applying population genetics to the human species, would constitute a valuable contribution to the knowledge of the biochemical anthropology of these ethnic groups [15]. Registers of Congenital Malformations A continuous record of congenital deformities, among the first five causes of infant mortality in practically every country of the area, should be established. A large amount of knowledge in this area has already been accumulated by ECLAMC, with its low-cost program in which research organizations volunteer their participation. Registers of Hereditary Diseases A register of hereditary diseases, which could be kept in centers with programs of clinical genetics and genetic counseling, would provide information on the burden of abnormal genes in communities. (On the basis of the preceding two studies a longitudinal study could be designed to follow the development of the prevalence of hereditary diseases. This would undoubtedly be linked to migration on one hand and on the other hand to mutation factors, health education programs, and means of preventing and treating hereditary diseases, etc.) 210 - Biomedical Research in Latin America Metabolic Program A screening program particularly oriented to those metabolic disorders that can be treated with possibility of relative success should be established. Dis- orders of this type generally coincide with mental retardation, which has heavy economic and medical-social costs. Immunodeficiencies A research program on immunodeficiencies of a hereditary nature would also be complex and expensive. However, it is essential to distinguish between hereditary and nonhereditary immunodeficiencies. Cvtogenetics This research program, which would be very expensive and would require a large number of qualified personnel, should include: e® From the medical genetics point of view, evaluation of the burden represented by chromosomal abnormalities in relation to spontaneous abortions and of the extent to which observed clinical syndromes are due to chromoso- mal alterations. ® From the human genetics point of view, study of chromosomal poly- morphisms of communities in this geographic area, principally of isolated genetic groups. Environmental Mutagenic Factors A separate area of study could be designed to determine physical, chemical, or biological environmental factors that might have mutagenic effects in Latin American and Caribbean communities. The ultimate purpose of such research would be to prevent exposure to mutagens. Human beings in industrialized societies are constantly exposed to chemical compounds and ionizing agents, many of which act directly or indirectly on the human genetic heritage. In the Latin American and Caribbean area, some countries are already industrialized or are in the process of becoming so (e.g., Brazil, Argentina, Mexico, Vene- zuela, and Cuba) and must deal increasingly with ignorance of mutagenic factors, in addition to lack of health education and of laws and regulations for environmental and personal protection of workers in specific industries and the population in general. The list of chemical substances is virtually endless; insecticides, pesticides, fertilizers, food preservatives, and chemical contraceptives are only a few. The situation is further complicated by the fact that structural chromosomal abnormalities of somatic cells are observed more frequently with advanced Heber Villalobos C. . “, 211 protein-calorie malnutrition and these abnormalities persist with the same frequency even after children have recovered from the malnutrition [3]. One of the few criteria available for judging whether a substance or agent is mutagenic or harmful to genetic material is its ability to cause chromosomal changes [16]. However, this method is not completely satisfactory because we do not know the biological importance of acquired chromosomal changes. Nevertheless, such a study should be carried out on the maximum feasible scale, reinforced with a well-designed health education program in genetics [17] and with promulgation and enforcement of laws and regulations for control of environmental pollutants. Social Genetics Finally, there is the area of social genetics. This includes matters related to amendment of existing laws and promulgation of new laws and regulations. These social controls deal with legal, ethical, religious, and technical factors involved in research and clinical applications of genetics. To cite an example, prenatal diagnosis of hereditary defects offers more prospects of beneficial results with every passing day, as the complex methodology is accepted and applied almost universally. However, technical, ethical, and legal problems are involved because the procedure can lead to voluntary termination of preg- nancy. Identification and Removal of Obstacles: Recommendations The following recommendations are suggested as possible means for over- coming difficulties currently confronting Latin American and Caribbean countries. Establish Research Policies In the course of their development, Latin American and Caribbean countries will soon be facing hereditary diseases as a major public health problem. Actually, in some countries, congenital malformations (a heterogeneous group of nosologic conditions whose origin is partially genetic) have become one of the first five causes of infant mortality and 1 of the first 10 causes of general mortality [18]. There is great ignorance concerning the effects of genetically determined diseases on Latin American communities, and the impact is in- tensified by factors such as malnutrition, ignorance, and lack of health educa- tion programs, that exaggerate the effects of genetic diseases. For these rea- sons, further development of medical and human genetics research in Latin American and Caribbean countries is urgent. 212 Biomedical Research in Latin America In addition, policies for development of national and multinational research programs in human and medical genetics should be established by each nation. Organization of research on congenital malformations by the ECLAMC group is a good example of what can be done when efforts and interests are com- bined. This program is currently operating at a high scientific level and at low cost. Develop Human Resources Lack of qualified personnel at all levels for carrying out specific tasks, both in community service and in teaching and research, is well known in all parts of the world. The WHO Committee of Experts on Human Genetics therefore recommended in its first technical report [1] that personnel be trained in order to make available the teachers and researchers so desperately needed. Brazil is one of the few Latin American countries that have taken on the task of training human resources for medical and human genetics research. Various Brazilian universities grant degrees in human genetics at the master’s or doctor’s level; furthermore, very shortly after its establishment in 1967 the Buenos Aires Medical Genetics Center began training personnel through a cooperative program with the Pan American Health Organization. Another exception is Mexico, where—as of 1975—a single course in human genetics was offered at the National Autonomous University; it was a specialized 2-year course in medical genetics, with emphasis almost exclusively on clinical aspects [9]. A formal 2-year course in human genetics at the master’s level was begun in 1975 at the Venezuelan Institute of Scientific Research in Caracas. With the possible exception of Brazil, most of the scientists and technicians of Latin American and Caribbean countries have been trained in developed countries, mainly the United States and Canada and some European countries. While technical training has been excellent, well-known problems—such as expectations of elaborate equipment—are often generated. Moreover, many scientists must hold two or more jobs because academic salaries are low. Teaching must often be given priority. As a result, complete dedication to research and associated graduate teaching is rarely possible. Any national policy of human genetics research must include development of human resources at both postgraduate and intermediate levels. Existing programs would have to be strengthened and new programs for developing human resources established, but it is equally important to train laboratory personnel and qualified assistants. Establish New Research Centers and Strengthen Existing Ones Research work is hampered by lack of resources. Since problems of human genetics are not considered public health problems and are consequently not Heber Villalobos C. 213 one of the first priorities, official government institutions skimp on funds for genetics research. Few genetics centers in Latin American and Caribbean coun- tries have resources adequate for high-level research. Some years will still be required before individuals with decision-making authority are fully conscious of the urgent need to allocate resources necessary for development of human genetics research. Another problem is the bureaucratic procedures that researchers must go through not only to obtain, but also to manage, funds. These come either from the institution to which the researcher belongs or from other national organizations such as foundations and national councils on scientific and tech- nological development; and both sources have complicated rules and pro- cedures. New human and medical genetics centers should be established and existing ones reinforced. Moreover, they should be managed in a way that facilitates rather than hampers the conduct of research. This would have to be under- taken by the governments of the Latin American and Caribbean countries through their health institutions and their universities, as part of the overall genetics research policy. Establishment of these centers means providing them with a physical plant, equipment, and other material resources, as well as human resources, that will permit them to conduct research without being subject to the vicissitudes presently confronting them. In developing this policy, it would be wise to use experience acquired by existing Latin American and Caribbean centers, some of which operate at a very good scientific level. Improve Communication and Understanding Legislation bearing upon research and clinical applications of genetics should be carefully reviewed and appropriately amended, or new laws should be enacted. Religious and ethical concepts related to genetics are changing quick- ly. Technology is advancing so rapidly that new opportunities to improve human health, and new dangers to human health, appear in great numbers. On the one hand, biomedical experts should be able to study and apply the most advanced techniques for the benefit of mankind while attempting to control environmental genetic threats. On the other hand, limits must be set on both application of genetic techniques and on attempts to control the environment in a manner consistent with the values of the community. These recommendations could be carried out more effectively if govern- ments and health authorities had adequate knowledge of the problem and if both the general public and members of the health establishment were better educated. Therefore it is necessary to implement a full health education program in the area of genetics [17]. This would involve education of poli- ticians and public officials by competent professionals. It would include pro- grams in human genetics instruction for all health establishment professionals, 214 Biomedical Research in Latin America in both undergraduate programs and advanced training courses [2, 8]. Finally, it would encompass a broad program of public instruction on genetics. References 1. Organizacién Mundial de la Salud. La Ensefianza de la Genética en las Facultades de Medicina y en los Cursos de Perfeccionamiento. Serie de Informes Técnicos 238. Ginebra: OMS, 1962. 2. Organizacion Mundial de la Salud. Genética Humana y Salud Publica. Serie de Informes Técnicos 282. Ginebra: OMS, 1964. 3. Lisker, R., y S. Armendares. Prioridades de investigacion en genética en Latino- américa. (Editorial). Gac Med Mex 104:87-92, 1972. 4. Beiguelman, B., N. Freire-Maia, O. Frota-Pessoa, y F.M. Salzano. Prioridades de pesquisa en genética humana no Brasil. Ciéncia e Cultura 26:642-647, 1974. 5. Schull, W.J. Oportunidades de investigacion en Genética de Poblaciones en Sud- america. Organizacion Mundial de la Salud. Seminario Viajero sobre Genética Hu- mana y Salud Piblica. América Latina, 16 Noviembre-5 Diciembre 1969. 6. The National Foundation March of Dimes. International Directory: Birth Defects, Genetic Services, Sth ed. New York: The National Foundation, May 1977. 7. Beiguelman, B. Polimorfismos Genéticos de Importancia Clinica no Brasil. Ciencia e Cultura 29:876-887, 19717. 8. Congreso Venezolano de Salud Publica (V). Caracas, Octubre 9-16, 1976. Ponencia Salud Materno-Infantil y Bienestar Familiar: Genética y Salud Materno-Infantil. Ministerio de Sanidad y Asistencia Social, Caracas, Diciembre 1976. SCVSP-P2, pp. 1-31. 9. Velazquez, A. Desarrollo de recursos humanos a nivel de post-grado en genética humana. Rev Invest Clin 28:103-108, 1976. 10. Cruz-Coke, R., y R. Iglesias. Frecuencia de los alelos T y t en la poblacion de la Isla de Pascua. Arch Biol Med Exp 1:29-37, 1964. 11. Cruz-Coke, R., and R. Barrera. Color blindness among Aymara in Chile. Am J Phys Anthropol 31:229-230, 1969. 12. Cruz-Coke, R. Anthropologie physique des populations Andines, génétique et altitude. INSERM 63:145-152, 1976. 13. Englert, P.S., y R. Cruz-Coke. Estructura genealogica de la poolacion tribal de la Isla de Pascua. Rev Med Chil 103:340-343, 1975. 14. Castilla, E.E., y H. Villalobos (eds). Malformaciones Congénitas. Grafilux, S.R.L. Maracaibo, Vol. 1, 1977. 15. Organizacion Mundial de la Salud. Investigaciones Genéticas en Poblaciones Primi- tivas. Serie de Informes Técnicos 279. Ginebra: OMS, 1964. 16. Buckton, R.E., and H.J. Evans (eds). Methods for the Analysis of Human Chromo- some Aberrations. Geneva: World Health Organization, 1973. 17. Villalobos, C.H. Nuevos desafios en la educacion para la salud—Genética médica. Educ Med Salud 11:119-126, 1977. 18. Organizacion Panamericana de la Salud. Las Condiciones de Salud en Las Américas 1969-1972. Publicacion Cientifica 287. Geneva, OPS, 1973. 13 THE HEALTH IMPACT OF EARTHQUAKES Claude de Ville de Goyet Definition of the Problem A natural disaster has been defined as an ecological disruption exceeding the adjustment capacity of the community and requiring outside assistance [1]. Of all natural disasters in Latin America and the Caribbean in the past 10 years, earthquakes inflicted the greatest loss of life and property. Etiology According to the plate tectonics or continental drift theory, earthquakes are caused by the movement of large areas or “plates” of the earth’s surface. These plates are thought to interact in one of three ways: spreading, where new crust is formed; subduction, where one plate plunges under another; or fault action, where two plates rub. The movements of the plates create forces that can exceed rock strength and cause sudden slip and rock fractures that con- stitute an earthquake. The most seismically active areas of Latin America lie along the boundary between the Pacific plate, which includes most of the floor of the Pacific Ocean, and the American continent (North American plate, Caribbean plate, and South American plate) [2]. Several indicators are used to measure earthquakes: ® Richter scale of magnitude. This measures the energy released. The zero of the scale is fixed arbitrarily to fit small earthquakes, and the scale is open- ended, with the largest known magnitudes near 8.75. Every step of one mag- nitude unit means a 32-fold increase in energy release. ® Modified Mercalli intensity scale. Intensity is a measure of physical effects at a given place as contrasted with magnitude, a measure of total energy. ® Mortality data. The number of deaths attributed to an earthquake is a measure of its immediate impact on human communities. The death toll 215 216 Biomedical Research in Latin America depends on many variables: physical characteristics of the earthquake, time and place, density of the population, type of human settlements, extent of mitigation or preparedness measures, etc. Data are often fairly accurate. ® Morbidity data. The number of persons injured is an additional measure of the impact of an earthquake, but the usefulness of this term is limited by the lack of consistency and standardization of criteria. Mortality and mor- bidity data are closely related. As a rule of thumb, it is estimated that for 10 deaths 30-35 persons will require some medical attention (slightly injured) and 1 or 2 will require hospitalization [3, 4]. ® Property damage. The cost of replacement or repair of damaged private or government property or utilities is a measure of the long-term impact of an earthquake on the socioeconomic development of a country. Earthquakes as a Public Health Problem It has been estimated that 10-15 million people have lost their lives in earthquakes during recorded history, i.e., the last 4,000-6,000 years [3]. Between 1970 and 1976, earthquakes caused almost 100,000 deaths on the Latin American continent (see table 1). Table 2 compares various mortality causes: earthquakes, communicable diseases, gastroenteritis, and accidents. Data on earthquakes as a cause of mortality in the last 10 years may not be impressive, even in countries that experience major earthquakes; but what makes earthquakes important is not so much the number of deaths as the fact that they happen suddenly, are TABLE 1. Deaths and Damage From Earthquakes, Latin America, 1970-76 Damage Year Country Deaths Injured (x $1,000) 1970 (May) Peru 66,794 143,331 530,000 1970 Ecuador 29 N/A 4,000 1970 (Dec) Peru 29 N/A 2,000 1971 Chile 85 N/A 236,400 1972 Nicaragua 6,000* 20,000 845,000 1973 Costa Rica 21 N/A 200 1973 (Jan) Mexico 17 N/A - 1973 (Aug) Mexico 500 N/A - 1974 Peru 78 N/A 10,000 1976 Guatemala 22,778 70,000 1,000,000 N/A, not available *Estimates range from 6,000 to 10,000 deaths. TABLE 2. Estimated Number of Deaths Caused by Earthquakes and Other Factors, 1967-76 Communicable Accidents; Country All Causes Earthquakes Diseases Gastroenteritis All External Causes Peru 1,200,000 66,901 275,400 N/A 55,300 Nicaragua 145,000 6-10,000 49,000 27,600 ? Guatemala 810,000 22,778 282,000 165,000 ? N/A, not available. Sources: U.N. Population and Vital Statistics Reports (1967-73); PAHO Health Statistics (1967-72) 10K09) 3p JIA 2p APNE) LIZ 218 Biomedical Research in Latin America localized, and affect large numbers of people. In other words, they are time- and place-clustered events. In a matter of seconds, as many people were killed by the Guatemalan earthquake of February 1976 as are expected to die from all other causes in 3% months or from communicable diseases in 10 months. In addition, most earthquake deaths could be prevented by using simple available building techniques to improve existing housing. In Peru, 66,794 lives were lost in a single province, compared to the corres- ponding annual mortality of 160,000 deaths for the whole country. Perhaps more significant is the impact of this loss on the development of a country or a region. Progress may be halted or postponed for several years. To assess the importance of earthquakes by taking lives lost as a numerator and the whole population as a denominator and averaging over long periods of time is an epidemiological fallacy because this understates the significance of the problem. This fallacious calculation may at times justify the low-rank prior- ity given to natural disasters by planners, administrators, and researchers; but mobilization of world interest in terms of outpouring of considerable resources of all kinds, often on a spontaneous and noncoordinated basis, is a better indication of the true impact of these disasters. Three main epidemiological features of natural disasters in general, and especially earthquakes, explain why the world at large is so concerned: (1) They are sudden and occur without prior notice; (2) they affect a large number of people simultaneously; and (3) they are believed to affect equally all categories of individuals. Everyone's life is threatened during an earthquake, although the wealthy urban dweller stands a far greater chance of surviving [3]. Problems Following an Earthquake Problems facing the authorities and population of the affected country are manifold. Disruption of essential services, including transportation and com- munication, generally exercises a determining influence on the health situation. Health problems, though the most pressing, are not necessarily the most critical problems after the first few days when political and economic issues dominate public life. Health Problems Morbidity-mortality data alone do not reflect adequately the effect of an earthquake on public health in a developing country. Public health problems range from management of mass casualties (usually completed within the first 3-5 days) to control of communicable diseases, prevention of long-term mental health disturbances, and reestablishment of basic health services in the affected region. Health problems and their solutions are dependent upon socioeconomic factors that emerge after the disaster. Claude de Ville de Goyet 219 Epidemiological studies in Guatemala suggest that “the major health con- sequences of earthquake in Latin America consist not of the epidemics or famines that are often overpopularized and relatively unimportant, but of the trauma that occurs within moments of the major quake” [5]. Trauma is usually caused by deficient manmade structures. Landslides, a major cause of fatality, result in few injuries. In Peru, landslides following the 1970 earth- quake buried two cities, leaving a few hundred unharmed survivors out of over 30,000 inhabitants. Fire, a major cause of death in Japan (Tokyo in 1923: 143,000 deaths), has been shown to be of little health significance in Latin America. Tsunamis (seismic tidal waves) are not uncommon, but have been a relatively minor source of immediate health concern. Management of Mass Casualties [4, 6-10] In developing countries, management of mass casualties is the first priority. However, treatment of mass casualties is an extremely acute, short-term problem. Within a few days, critically injured victims have been taken care of or are on the way to spontaneous recovery if still alive. Within 5 days following the urban earthquake in Nicaragua [6, 7] and 8-10 days following the rural quake in Peru and Guatemala [4], the types of patients attending or admitted to hospitals and temporary facilities closely paralleled those found in any general hospital during normal times—as opposed to acute disaster situations. During the first 24 hours, the burden of rescue/relief remains for the most part with the affected community. After this time, medical personnel and material resources mobilized at national and international levels are not only sufficient but often exceed the capacity of absorption of the affected region. The major problem is mainly coordinating needs and availability of beds within the country and controlling the vast amount of medical personnel and supplies entering the country. Environmental Sanitation and Communicable Disease Control [11-16] Outbreaks of communicable diseases are of major concern to the population and authorities in the aftermath of an earthquake. In the last decade, however, no dramatic increase in incidence of waterborne or insect-borne diseases was documented or reported following an earthquake in Latin America or other parts of the world. Epidemiological surveillance or periodic investigations carried out by the World Health Organization (WHO), the Center for Disease Control, or other institutions failed to demonstrate an abnormal incidence of gastroenteritis, typhoid fever, or other environmental diseases. This suggests that the risk is either grossly exaggerated or the effectiveness of the emergency sanitation measures immediately carried out by the authorities is underes- timated. 220 Biomedical Research in Latin America Mass immunization generally is not regarded as an appropriate method of disease control in the emergency stage for the following reasons [11]: ® Mass campaigns are rarely necessary, since the potential for transmission is not significantly altered by the earthquake. ® Mass campaigns drain off valuable manpower and resources. ® Mass campaign logistics often pose insurmountable problems after a disaster. Proper recording generally is not possible under the pressure of events nor is the required followup for subsequent injections. ® Groups at greatest risk are usually missed. ® Vaccines against typhoid fever and cholera, the most feared diseases following earthquakes, afford a low level of short-lived individual protection that plays little if any role in reducing disease transmission. The nature of diseases regarded as potentially epidemic following earth- quakes often bears little relevance to the country’s epidemiologic situation. Cholera and smallpox are widely quoted as imminent threats in spite of being nonexistent in Latin America. Higher priority should be given to restoration of water supply, waste dis- posal, and food sanitation. Burial of the dead is required more on sociocultural and psychological grounds than for prevention of outbreaks of communicable diseases. Food Supplies Earthquakes usually have no direct immediate impact on food production in rural areas [4, 5]. They specifically affect manmade constructions and so disrupt normal food processing and distribution facilities in urban areas. Al- though staple food grains may be available or salvaged from the debris of shelters, mass feeding and food distribution generally should be included in the relief program for humanitarian and practical reasons. Provision of Temporary Shelters [13, 16, 17] Provision of temporary or permanent housing following an earthquake is a critical issue that provokes much scientific research and political controversy. Health implications, especially in refugee camps, are important. In Latin America, the extended family system has contributed to limiting the problem to semipermanent settlements of unemployed urban victims. Water supply and hygienic facilities are usually of a low standard. Lack of environmental sanitation in overcrowded refugee camps is another major problem. Claude de Ville de Goyet 221 Social Behavior and Mental Health [18-25] Earthquakes and natural disasters in general do not create a new pattern of social behavior; rather, they heighten or exacerbate social problems existing prior to the event. Panic is uncommon and looting is rare in rural areas. Emotional disturbances are frequent and may persist for several months or years. Depressive reactions and anxiety are common in young children. Few new cases of psychosis are detected, although individuals with psychotic antecedents are prone to relapse or deteriorate. Disruption of Control Programs Essential health services can be profoundly disrupted by the physical impact and, more significantly, by the relief effort itself. For example, routine control programs may be hampered by an unduly overextended response to the emer- gency. Operational Problems Operational problems usually preclude orderly use of existing health resources and impede optimal management of health problems during the first weeks following a major earthquake. Transportation Partial or total disruption of the road network is caused by landslides or damaged public works. Lack of communications bears directly on rescue activities, emergency medical attention, and flow of relief supplies toward outlying areas. Communications and Data Collection The most significant cause of poor disaster management in most instances is lack of information on the geographical extent of the impact. Telecommuni- cation facilities are too limited to meet the needs of national health author- ities; the approximate number of dead and injured cannot be ascertained in the first week after the catastrophe. Figures and lists of affected localities have to be revised regularly. Misleading rumors and unsubstantiated information on the need for medical care or outbreaks of communicable diseases contribute to confusion and waste of resources. Chaos is often made greater by lack of coordination of the various sources providing assistance. Objective assessment of needs, using simple techniques, is probably the most useful contribution epidemiologists can offer to manage- ment of postearthquake situations. 222 Biomedical Research in Latin America Logistic Problems During relief operations, large quantities of donated medical supplies need to be identified, sorted, and distributed. In some cases, warehouse keepers and pharmacists may be able to render greater services than physicians. Relatively few of the drugs donated by foreign countries arrive already sorted—that is, in packing cases holding a single type of drug or in drug containers, properly identified and marked. Furthermore, only a very small proportion of the sorted drugs are needed at once; vitamins, antacids, and nasal sprays are by no means “emergency drugs” worth rushing in by air. The timing also needs to be appro- priate. A similar problem is created by the humanitarian appeal of earthquakes: Volunteers frequently arrive on the scene with inappropriate qualifications or skills and in some cases without a basic understanding of or familiarity with the health problems, language, and customs of the affected community. National human resources supplemented by organized, efficient assistance from neighboring countries may often suffice to deal adequately with the situation. Unprepared individuals contribute to the problems and increase the work of national coordinators. Political Problems National Failure to acknowledge promptly the existence of a disaster is a common political problem in most disaster-prone countries in the world. However, it is not likely to occur in the instance of a major earthquake because of the un- questionable evidence recorded by the world seismological network. Problems are more frequent during the relief and rehabilitation phases when perceived success or failure may be used to serve the political objectives of ruling parties or their opponents. In addition, coordination and cooperation among armed forces and ci- vilian health services are often insufficient. Working together closely is essen- tial because armed forces have operational capability and emergency authority, while civilian health services have the necessary technical public health ex- pertise. International [26-28] Recipients and donors occasionally present conflicting views of their res- pective responsibilities and duties. The demand of the affected country for respect of its national sovereignty and the political or “public relation” moti- vations of donating countries and institutions, along with their need for ob- jective international assessment, are sources of potential problems. Claude de Ville de Goyet 223 Approaches to Solutions Natural hazards, especially earthquakes, have been considered acts of God, to be accepted. Such a belief is still largely prevalent in most of the populations. Analytical review and active steps toward understanding earthquakes have been initiated only recently. Records of past earthquakes and of their impact on health and life have been available for an extremely short period in geolog- ical terms, since monitoring of seismic activity first became systematized during the final decade of the 19th century. The following features are suggested by existing information: e There is no evidence of increasing frequency or severity of earthquakes. ® Health effects and threats to life increase in relation to more intensive settlement in earthquake-prone areas. e® Management of natural disasters—e.g., earthquakes—has improved con- siderably in the last decade with increased preparedness of disaster-prone countries as reflected by establishment of specialized institutions (emergency committees, civil defense, etc.) at national and international levels. Earthquake Prediction [29, 30] Since there is no prospect of preventing earthquakes in the foreseeable future, attention must be centered on earthquake prediction. It is not seismic forces themselves that cause disasters, but their effects on human populations. These effects could be prevented by timely warning of an impending earthquake. Reliable prediction may result in the near future from close monitoring of a complex set of data, including changes in ground tilt and uplift, water-level variations, geomagnetic and electric variations, time- space variations of seismic activity, and anomalous animal behavior. Prediction is becoming technologically possible. It is likely to be economically feasible only in a few high-risk areas where economic interest and population density will justify the efforts and investments required. The social, economic, and political implications of issuing earthquake predictions and warnings are enor- mous and have never been fully assessed in Latin American or Caribbean countries. The most basic problems in the field of earthquake disasters (that is, con- sequences of a natural physical process) are those related to planning and development of human settlements and earthquake-resistant constructions [31-36]. Planning and Development of Human Settlements The first step is to evaluate carefully existing seismic conditions. Geologic mapping is not a general practice in Latin America and the Caribbean. For 224 Biomedical Research in Latin America example, the location and likely activity of existing surface faults could be predicted if detailed geologic maps and seismic data were available and were augmented by field studies in critical localities. Landslides such as those that killed over 30,000 inhabitants in Peru (1970) are caused by lack of ground stability, a feature that can be determined to some extent by careful studies. The second step is to define areas of different degrees of potential risk; this is called seismic zoning. The third step is to determine land use patterns, selecting the lowest-risk areas for location of the most important components of the city (residential and industrial areas) and promoting less vulnerable activities or construction in higher-risk areas (recreational activities and open spaces). Clearly, the third step has economic and political implications that may pre- clude making a decision on purely technical grounds. Earthquake-Resistant Construction: Building Codes A building code must determine the required safety factor for different types of structures and assess seismic risks; in addition, it should provide techniques for earthquake-resistant construction using local materials. The safety factor is based on the principle that during the strongest earthquake, none of the structural components should fail to an extent that endangers human life. The requirements for a seismic design are the following: ® Constructions should be as light as possible. ® The center of gravity should be as low as possible. ® Building materials should be ductile and absorb energy e.g., steel, rein- forced concrete, wood, or plastic. ® Design should be simple, with symmetrical floor plans. ® Parts of buildings differing in design (height, disposition of bearing elements) should be physically separated. ® Important buildings should be established on firm soil, with sufficiently deep foundations. The principles for building practices differ for concrete urban constructions and low-cost, predominantly rural, housing. In Latin America, over 90 percent of all earthquake victims perish in low-cost, one-floor houses. Heavy tile or adobe roofs often fall, killing many people sleeping or resting in the houses. The failure of roofs is caused by deflection of outside bearing adobe walls. They are not able to follow the vibrations caused by the earthquake because of their brittleness. Houses built according to the “Taquazal” system, con- sisting of vertical wooden studs connected by nailing on horizontal wooden laths filled with clay and stones, behave similarly. This system is widely used in Central and South America and caused many deaths during the Nicaraguan earthquake of 1972. A complete change of construction practice for low-cost housing is a difficult economic problem. Initially, a program should include incorporation of lightweight roofs and reinforcing outside bearing walls by Claude de Ville de Goyet 225 increasing the strength of adobe with cement and constructing horizontal and vertical tie bands. Emergency Preparedness [37-42] Emergency preparedness consists of establishing an ad hoc agency and disaster plans with the necessary legal and technical support to meet anticipated needs following the impact. The first priority is generally development of a law or decree that will outline areas of responsibility and authority of government agencies, private enterprise, and voluntary organizations. Disaster plans are simply procedures previously agreed upon between various ministries or de- partments or between institutions and various private and voluntary organi- zations that will assist during a disaster. In the health sector, planning should be performed at the national, regional, and institutional (hospital) levels, thereby minimizing the chaos that usually accompanies national and international relief operations. The main objective is to maintain and possibly expand essential services. Health disaster planning should not be limited to contingency plans for hospitals, although official and scientific interest have generally focused on the latter. As a matter of fact, emergency preparedness has attracted little interest among scientists and health administrators. As a consequence, the role of the health sector in emergencies has too often been limited to mere implementa- tion of health measures originating outside the Ministry of Health and scien- tific health institutions. Primary Research Areas and Trends Geoscience Many scientific institutions in Latin America and the Caribbean have con- tributed greatly to the study of physical events, making it possible to predict earthquakes with sufficient accuracy in the foreseeable future. Some studies have been carried out in almost every earthquake-prone country. Most of the investigations seem to consist of case studies of local earthquakes or geologic mapping of vulnerable areas. Lack of specialized personnel and a sophisticated network of equipment has limited the impact of this research. Most studies on Latin American and Caribbean earthquakes are undertaken by foreign teams from disaster-prone developed countries and published exclusively in English in prestigious international journals. The major deficiencies in present knowledge, as noted by the Earthquake Engineering Research Institute [26], are concerned with: ® lack of physical scientific background on the pre-earthquake situation; e inadequacy in pre-earthquake planning of investigations that should be conducted immediately after a major earthquake occurs; 226 Biomedical Research in Latin America ® lack of previous field experience of the great majority of investigators; and ® lack of communication among scientists from various disciplines and origins studying the same earthquake. Present priority is placed on development of reasonably accurate earthquake predictions, the most promising research area. Survey of premonitory signs of earthquakes in the continent, including the Caribbean, is essential in this regard. However, benefits for the least-developed countries of the continent, particularly the rural areas where most of the casualties occur, may be limited by the anticipated high-cost installation of a network of measuring devices and the managerial skill to supervise the professional and voluntary personnel required to collect data. Public pressure will probably guarantee rapid appli- cation of research findings in major urban areas. Engineering and Architecture [46-47] Extensive studies have been carried out on the performance of engineered works during earthquakes in Latin America and the Caribbean. The behavior of modern buildings and community lifelines (transportation, communications, water, sewage systems, energy) has attracted much interest among scientists. Knowledge in this area is far ahead of that in other areas, such as earthquake- resistant, low-cost housing. The general comments on geoscience research are also applicable to this discipline. It is indeed striking to note the bulk of docu- ments, reports, and publications issued on seismic behavior of urban structures compared to the relative scarcity of scientific studies on rural dwellings, the collapse of which is responsible for most deaths. It strongly suggests that the relevance of the investigation of the industrialized countries or the edu- cated elite of the affected community is the decisive criterion in formulating research projects. Inexpensive improvement of rural adobe housing has been studied in the Andean region and simple techniques have been made available. Nonetheless, their diffusion to large sectors of the population, after a major earthquake unfortunately causes considerable problems and delays. Rebuilding with tra- ditional materials and unsafe techniques is a grim consequence of the failure to disseminate applied research findings from other countries into rural isolated areas. Social Sciences Social behavior is culturally specific. Advanced research carried out for over 10 years in the United States (for example, at the Disaster Research Center, Ohio State University, and the Natural Hazards Research Center, University of Colorado) has limited relevance to Latin American or Caribbean rural com- Claude de Ville de Goyet 227 munities. Among the few investigations in Latin America, the in-depth analysis of the impact on humans of a disruptive urban earthquake (Managua, 1973) represents an important step toward better understanding the response of local communities to a major stress [48]. Questionnaire surveys often lack adequate planning and clearly defined long-term objectives, and their scope is limited to medical and paramedical professionals. Research areas of substantial importance include spontaneous local response to the disaster during the isolation period (until the first relief assistance reaches the community), behavioral patterns and interrelationships of private and official organizations, profiles and roles of national and foreign volunteers, cultural impact of donated relief supplies, and social long-term impact of the earthquake and—perhaps more significantly—of the relief effort itself. Effectiveness of information systems under stress and tracing of rumors have hardly been investigated by researchers, nor have local political scientists thus far applied their skills and knowledge to earthquake situations. Health Sciences Scientific knowledge of health problems following natural disasters—in par- ticular, earthquakes—is surprisingly limited and fragmentary. After the 1970 earthquake in Peru, health research on earthquakes attracted the attention and interest of some scientists, especially epidemiologists; but for the most part, biomedical research on earthquakes has remained limited in Latin America and the Caribbean. Very few scientific articles or reports are published in Latin America and the Caribbean. Extensive searches of literature either through available index- ing services or through regional libraries in Latin America failed to demonstrate a significant level of activity. In a comprehensive review of biomedical docu- ments published in 1973 in Mexico [49], 2,164 articles or documents were identified. A single three-page article briefly reviewed the principles of mass treatment and triage in a hospital, even though Mexico experienced several flash floods and earthquakes in 1972 and 1973. Obstacles to Research ® The need for reliable scientific knowledge is not generally perceived. Traditional and completely unfounded cliches are still widely accepted by the public, including health professionals. Among these false impressions are explosive outbreaks of communicable diseases, mass hunger and social unrest, mass casualties neglected for days, and lack of medical supplies. e The emotional impact of earthquakes calls for immediate relief, not for research. Strong personal involvement and commitment during the emergency 228 Biomedical Research in Latin America preclude the necessary scientific detachment and impartiality. During the acute emergency, observers and scientists may not be readily tolerated. ® Proper planning of research projects on health situations following an earthquake is complicated by the unpredictability of the natural event. Time and place of investigation remain unknown until the last moment. ® Most investigators lack previous field experience. Stability and conti- nuity are difficult to achieve in this line of research because of the relative scarcity of major earthquakes and fluctuating funding sources. In the world, only two research groups have succeeded in achieving continuity over the last 5 years in the study of the health impact of natural disasters in developing countries. These are the London Technical Group (London, England) and the Research Center on Disaster Epidemiology (Brussels, Belgium). ® The relevance of research to funding agencies or countries may be one of the most basic causes of the present situation. It is striking to note the keen interest of industrialized countries in the study of seismic vulnerability of urban structures and public works, their moderate concern for investigating earthquake behavior of rural low-cost housing, and their reluctance to support social or health research, which is less likely to bear relevance and provide useful knowledge outside the affected Latin American or Caribbean country. ® On the part of the scientists themselves, greater concern for the short- term usefulness of their investigations should be developed. Health research following earthquakes cannot ethically be justified for the sake of “science” alone. Health scientists are partially responsible for the lack of dialogue and the mutual distrust between action-minded relief officials and investigators. Research Priorities for the Future Priority research areas must be dictated by gaps in our existing knowledge and their relevance to problems encountered in preparing disaster plans and pro- viding humanitarian assistance. Current knowledge and understanding of health problems in earthquakes is based on descriptive observations, fragmentary data of questionable reliability, and partial case studies of essentially complicated and volatile situations. The following research areas need attention: Epidemiologic analysis of risk factors. In the two major earthquakes in Latin America 90,000 persons were killed. Besides the fact that most have lived and died in non-earthquake-resistant, low-cost housing, little is known about the risk factors. Some data would suggest that children under 5 and adults over 50 are at much higher risk. If this is confirmed, this factor has direct implications on the rescue/relief activities and the medical supplies that will be required. Type of housing and time and place of the quake are additional variables to be investigated. In Guatemala, mortality caused by the earthquake ranged from virtually nil to 21.5 percent in different villages, Claude de Ville de Goyet 229 apparently with similar rates of material damage. Provided there are no gross errors in the recorded number of deaths, the lack of adequate explanation of those statistically significant differences underlines the gap in our understand- ing of earthquakes. Type of pathology. Basic knowledge of types of trauma and injury caused by earthquakes is essential to determine the appropriate relief supplies, equip- ment, and personnel needed in such situations. Although some experienced surgeons may have developed a personal intuitive opinion on the matter, systematic and objective observations are totally missing. For instance, a high rate of crush syndromes is usually expected. From partial observations, it seems that almost no such cases have been detected following the Managuan and Guatemalan earthquakes. There are several hypotheses: ® Prolonged compression of soft tissue is improbable with that type of housing; e Patients with crush syndrome died before receiving medical attention; and ® Training of physicians did not prepare them to diagnose this peculiar traumatic syndrome. Rescue activities. Most valuable scientific research on rescue of persons trapped under debris (e.g., techniques, survival type, composition of rescue teams) was carried out during World War II. Further research is required now in the Latin American environment. Management of casualties. Present concepts result from military medicine; their applicability to civilian natural disasters remains to be determined. Research might focus on how various hospitals handle the influx of patients, allocation of resources, operation of temporary facilities, recordkeeping, and arrival and integration of foreign medical personnel and supplies [46]. The period of time between field rescue, evacuation, medical diagnosis, and treat- ment are decisive factors, the study of which can deeply influence future relief operations. Field hospitals, either fully staffed military hospitals or packaged disaster hospitals, are routinely requested, sent, and gratefully acknowledged by the affected country. Their appropriateness (i.e., timing, site of operation, nature of services, actual cost, country) should be regarded as an important topic for research. Medical supplies. Operational research is needed to determine what medical supplies are actually needed (based on number and nature of injuries and standard acceptable treatments); requested at local and national levels; or provided by national or international communities. The three categories are likely to differ significantly. Analysis of the time factor and techniques applied in inventorying, sorting, and distributing relief supplies may confirm the ob- servation that incoming medical supplies rapidly exceed the local capacity to absorb them. 230 Biomedical Research in Latin America Environmental sanitation and control of communicable diseases. Outbreaks of infectious diseases appear to be a major issue following earthquakes. How- ever, the problem has never been scientifically analyzed. Field investigations are required. Expensive and sophisticated emergency measures are taken to distribute drinking water in affected rural areas. However, scientists have made no syste- matic attempt to estimate the vulnerability of water supply systems to con- tamination caused by the quake or to determine the significant factors. Results of chemical and bacteriological analysis of water samples performed before and after the earthquakes in Managua and Guatemala City are a valuable untapped source of research material. Roles played by other factors (unburied bodies, rodents, insects, etc.) remain to be documented. Information. Research on the dynamics of rumors will assist public health officials in dealing with this sensitive issue. Techniques and methodology for epidemiologic surveillance need to be developed by scientists. International relief [46]. The benefits and problems associated with the influx of large quantities of relief supplies and relief personnel need to be studied thoroughly and the results disseminated. Research should be under- taken in the affected countries, as well as in the countries providing assistance. The mechanism and motivation of the often burdensome response of the general public of developed countries (especially the medical community) are not fully understood. Research must be done on the problem of unacceptable or useless supplies so that organizational alternatives can be identified. Multi- disciplinary studies of the role of foreign medical volunteers following earth- quakes in Latin America should settle the controversy about their usefulness and provide public health authorities and medical associations with guidelines and criteria for a constructive approach. Investigation of coordination among relief organizations and governmental agencies is likely to be more compli- cated. Authoritative studies and constructive suggestions from the scientific community are, however, essential to improve coordination, the key factor to efficient relief activities. Role of International Organizations International organizations could be instrumental in promoting, supporting, and facilitating operational research at national and regional levels. Active involvement of international organizations will ensure a multidisciplinary and multinational approach to health research following earthquakes and con- tribute to minimizing loss of life and suffering. Definition of priority research areas. International organizations such as the World Health Organization could assist in defining priority research areas of immediate concern and feasibility for public health management of earth- quakes. A review of the situation by a committee of international scientists Claude de Ville de Goyet 231 experienced in this field and public health officials of disaster-prone countries would avoid the pitfall of research relevant only to the researcher’s scientific interest. Provision of research grants. Research grants constitute a powerful tool to stimulate applied research in Latin America or the Caribbean. Detailed research protocols can be prepared and reviewed ; contracts or grants can be approved in advance. On the occurrence of a major earthquake, research activities could be initiated without delay provided approval of the health authorities of the affected countries had been secured beforehand. Such a procedure is time- consuming but would guarantee sufficient planning of the project relevant to the interest of the country. International organizations such as the Pan American Health Organization may review proposed research projects and assist research grantees in contact- ing health authorities and academic institutions in disaster-prone areas. References 1. Lechat, M.F. Disaster epidemiology (editorial). Int J Epidemiol 4:5-6, 1975. 2. Plafker, G. Tectonic aspects of the Guatemala earthquake of 4 February 1976. Science 193(4259):1201-1208, 1976. 3. Lechat, M. F. An epidemiologist’s view of earthquakes., (Publisher not available.) 4. de Ville de Goyet, C., E. del Cid, A. Romero, E. Jeannée, and M.F. Lechat. Earth- quake in Guatemala: Epidemiologic evaluation of the relief effort. Bull Pan Am Health Organ 10(2):95-109, 1976. 5. Glass, R., J. Urrutia, S. Sibony, H. Smith, B. Garcia, and L. Rizzo. Earthquake injuries related to housing in a Guatemalan village. Science 197(4304):638-643, 1977. 6. Coultrip, R.L. Medical aspects of U.S. disaster relief operations in Nicaragua. Milit Med 139:879-883, 1974. 7. Whittaker, R.D., D. Fareed, P. Green, P. Barry, A. Borge, and R. Fletes-Barrios. Earthquake disaster in Nicaragua. J Trauma 14:37-43, 1974. 8. Ministerio de Salud Publica, Managua, Nicaragua. Encuesta sobre efectos demogra- ficos y de salud del terremoto de Managua. September 1974 9. Kouchner, B. Coordinacion de voluntarios nacionales e internacionales. Presenta- tion at the PAHO/WHO Seminar on Public Health Administrative Aspects in Dis- aster Situations. Guatemala, November 1976. 10. Mendieta, E., and J. Moore. Pharmacists in a disaster: The Guatemalan earthquake. Paper presented at the 12th Annual Meeting of the USPHS commissioned officers association, San Francisco, California, April 1977. 11. Western, K. The Epidemiology of Natural and Man-made Disasters: The Present State of the Art. Thesis, London School of Hygiene and Tropical Medicine, 1972. 12. Spencer, H.C., C.C. Campbell, O. Zeissig, A. Romero, R.A. Feldman, E.R. Boos- strom, E. C. Long. Disease-surveillance and decision-making after the 1976 Guate- mala earthquake. Lancet 2(8030):181-184, 1977. 13. Assar, M. Guide to Sanitation in Natural Disasters. Geneva: World Health Organi- zation, 1971. 14. De Ycaza Bosh, M. Anilisis del comportamento de la planta de purificacion de agua de Santa Luisa antes y después del terremoto. Thesis, University of San Carlos, Guatemala, November 1976. 232 13. 16. 17. 18. 19. 20. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 33. 36. 37. 38. Biomedical Research in Latin America Garcia Ovalle, J.G. Estudio del saneamiento basico rural en la zona de desastre a través de un programa de emergencia. Thesis, University of San Carlos, Guate- mala November 1976. Morataya Jiminez, J.C. Saneamiento de campamentos de emergencia. Thesis, University of San Carlos, Guatemala, November 1976. Cuny, F. Refugee camps and camp planning. The state of the art. Disasters 1(2): 125-143, 19717. Sanchez Lépez, J.R. Actividades desarrolladas por el personal en 4 hospitales de Guatemala. Febrero de 1976. Bol Of Sanit Panam Lang, K., and G. Lang. Planning for emergency operations. Mass Emergencies 1: 107-117, 1976. Jeri, F., and F. Leon. Psycologia del panico. Rev Sanid Polic 24:69-84, 1964. Infantes, V., J. Véliz, J. Morales, Pardo-Figueroa, and F. Jeri. Observaciones psico- patologicas en el area del sismo (Ancash, 1970). Rev Neuro-psiquiatra 33:171-188, September 1970. Jeri, F. Problemas de conducta en los desastres. Acta Méd Peruana 3(1):3748, March 1974. Coordinacion Nacional de Salud Mental (Nicaragua). Consecuencias psicosociales de un terremoto. Ministerio de Salud Publica Managua, November 1976. Ahearn, F., and S. Rizo Castellon. Problemas de salud mental después de un terre- moto. Bol Of Sanit Panam Barrios Flores, J.R. Estudio psiquiatrico sobre efectos del terremoto del 4 de feb- rero de 1976 en Guatemala. Presentation at the XXVIIth Congreso Nacional de Medicina, Guatemala, November 17-20, 1976. Zapata, R. La ayuda internacional en casos de desastres naturales. Cuadernos Medi- cosociales, 15(3):20-22, 1974. Green, Stephen. International Disaster Relief Towards a Responsive System. 1980 Project/Council on Foreign Relations. New York: McGraw-Hill. United Nations Association. Acts of nature, acts of men: The global response to natural disasters (Report of policy-studies panel on international disaster relief). June 1977. U.S. Geological Survey. Earthquake prediction: Opportunity to avert disaster. Conference on earthquake warning and response, San Francisco, California, No- vember 7, 1975. USGC Circular 729. UNESCO. Conferencia intergubernamental sobre la evaluacién y la disminucion de los riesgos sismicos. Paris, February 10-19, 1976. UNDRO. Guidelines for disaster prevention. Vol. 1: Predisaster Physical Planning of Human Settlements; Vol. 2: Building Measures for Minimizing the Impact of Disasters; Vol. 3: Management of Settlements. UNDRO/10/76, May 1976. Ayarza, H. Asismicidad de vivienda econdmica. Presented at the U.N. interregional seminar on low-cost construction resistant to earthquakes and hurricances, Skopje, Yugoslavia, November 1971. Doc. ESA/HBP/AC.6/3 and ST/TAO/SER.C/147. Kuroiwa, J., E. Deza, and H. Jaén. Investigations on the Peruvian earthquake of 31 May, 1970. Presented at the Sth world conference on earthquake engineering, Rome, Italy, June 1973. Kuroiwa, J. Proteccion de Lima metropolitana ante sismos destructivos. Comite Nacional of Civil Defense, Peru, 1977. Gallo, R. Evaluacion de los principales hospitales de Lima metropolitana bajo la hipotesis de un sismo destructor de grado VII M.M. Thesis, Universidad Nacional de Ingenieria, Lima, Peru, 1977. U.S. Geological Survey. Seismic hazards and land use planning. Circ. 690, 1974. Saenz Jiménez, L. Planificacion de los servicios de salud en situaciones de emergen- cia. Bol Of Sanit Panam 82(2):98-110, February 1977. Villablanca, E. Efectos del terremoto de 1971 en el servicio de obstetricia y gine- cologia del Hospital San Camillo (San Felipe). Rev Chil Obstet Ginec 37(4):153-158, 1972. Claude de Ville de Goyet 233 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. Fajardo Ortiz, G. El hospital en los desastres. Prensa Med Mex 38(5-6): 175-177, May-June 1973. Perales Mogrovejo, A. El hospital frente a los desastres. Rev Med de la Caja Nacional de Seguro Social, Lima, Pera 22(2):161-257, June 1973. Mahler, K. Disaster planning for developing countries. PAHO seminar on public health administrative aspects during natural disasters. Guatemala, November 1976. Zapata Diaz, R. La atencion médica chilena en caso de catastrofe. Cuadernos Medicosociales 16(1): 23-31, 1975. Earthquake Engineering Research Institute. Learning from Earthquakes: 1977 Planning and Field Guide. U.S. Department of Housing and Urban Development. Directory of Disaster- Related Technology. HUD Report No. 401-FDA, 1975. Manning, D. Disaster Technology, An Annotated Bibliography, 2nd ed. Elmsford, N.Y.: Pergamon Press, 1976. Olson, R.A., and R.S. Olson. The Guatemala Earthquake of 4 February 1976: Social Science Observations and Research Suggestions. Davis, R. Report on housing strategy in Managua, December 23, 1972-December 1, 1973. Thesis, University of London, 1973. Kates, R., J. Haas, D. Amaral, R.A. Olson, R. Ramos, and R.S. Olson. Human impact of the Managua earthquake. Science 182:981-990, 1973. Finkelman, J., and J. Valdespino. La investigacion médica en México. Vol. 4: Publicaciones cientificas y de divulgacion. Inst Mex del Seguro Social, 1976. INDEX Acclimatization, 197-198 Africa, 72-73 Air pollution, 131-132 ALAD. See Latin American Diabetes Association Alcoholism, 184-185 Amebiasis, 129 Argentina, 19-20, 68-76, 80, 151-152, 158 Artigas Plan, 124 Autonomous University of Mexico (UNAM), 18, 34 Barbados, 77-78 Biochemistry, 25 Biomedical research Argentina, 19-20 Brazil, 16-18, 103 cancer, 139-163 Chile, 20 Colombia, 21-23 Costa Rica, 23-24 cultural influences, 8-9, 16-24 current status, 6-24 diabetes mellitus, 165-177 earthquakes, 215-233 economic influences, 10, 16-24 environmental health, 127-137, 189-203, 215-233 funding, 4-6, 11-24, 49-52, 54 genetics, 205-214 government support, 31-43 history, 1-3 Latin America (general), 3-16, 127-128 manpower problems, 67-96 Mexico, 18-19, 33-40 multinational support, 49-65 parasitic diseases, 99-109 Peru, 24 political influences, 9-10, 16-24 priorities, 15-16 Venezuela, 20-21 zoonotic diseases, 113-126 BIREME. See Regional Library of Medical and Health Sciences (Brazil) Bolivia, 69, 71, 73-74, 76, 150, 152, 158, 190 Bolivian Institute of High-Altitude Biology, 192, 196 Brazil, 16-18, 68-76, 91, 121-122, 150, 152-153, 158-159 235 Brucellosis, 114,117,118, 121, 122-123 Campomar Foundation, 20 Canada, 70, 72, 74-75, 78-79, 92-94 Cancer incidence, 145 Cancer Incidence in Five Continents, 143, 149 Cancer mortality, 144 Cancer research, 139-163 Argentina, 151-152, 158 Bolivia, 150, 152, 158 Brazil, 150, 152-153, 158-159 Chile, 151, 154, 160 Colombia, 148-149, 154,159 Costa Rica, 147, 160 Cuba, 154 Dominican Republic, 154 El Salvador, 148, 161 epidemiology, 141-145 Guatemala, 154 information exchange, 162-163 Mexico, 146-147, 155, 160 Nicaragua, 160 Panama, 161 Paraguay, 161 Peru, 149-150, 156, 161 Puerto Rico, 156 treatment centers, 152-157 Uruguay, 157 Venezuela, 149,157,161 Cancer treatment centers, 152-157 CANCERLINE, 63 CAREC. See Caribbean Epidemiology Center Caribbean Epidemiology Center (CAREC), 60, 115 Caribbean Food and Nutrition Institute, 58 Central American Institute of Investi- gation and Industrial Technology (Guatemala) (ICAITI), 8,132 CEPANZO. See Pan American Zoonoses Center CEPIS. See Pan American Center for Sanitary Engineering and Environ- mental Sciences CETESB. See Companhia Estadual de Technologia de Saneamiento Basico e de Defesa do Meio Ambiente (Brazil) Chagas’ disease, 13-14, 51, 133-134 236 Child psychiatry, 183 Chile, 20, 69, 74-76, 151, 154, 160, 192 Chronic diseases, 61-63 Colciencias. See Colombian Fund for Scientific Investigation Colombia, 21-23, 68-72, 74-76, 81, 90-91, 148-149, 154, 159 Colombian Fund for Scientific Investi- gation (Colciencias), 22 COMLURB. See Companhia Municipal de Limpieza Urbana (Brazil) Companhia Estadual de Technologia de Saneamiento Basico e de Defesa do Meio Ambiente (Brazil) (CETESB), 132 Companhia Municipal de Limpieza Urbana (Brazil) (COMLURB), 133 CONICYT. See National Council for Scientific and Technological Investi- gations (CONICYT) Costa Rica, 23-24, 69, 71-74, 147, 160 Cuba, 68, 74-76, 79, 154 Cysticercosis, 120 Diabetes mellitus research, 165-177 current status, 168-170 history, 165-167 Mexico, 170-172 organization, 167-168 DISCA. See Division of Investigations on Environmental Pollution (Venezuela) Distomatosis, 120 Division of Investigations on Environ- mental Pollution (Venezuela) (DISCA), 132 Dominican Republic, 68, 71, 74-76, 154 Drug dependence, 184-185 Dysentery, 129 Earthquakes, 215-233 construction for, 224 disease control following, 219-220 emergency preparedness, 225 mass casualty management, 219 measurement indicators, 215-216 political problems, 222 prediction, 223 public health effects, 216-220 relief operations, 219-222 research areas/trends, 225-231 ECLAMC. See Latin American Coopera- tive Study on Congenital Deformities Ecuador, 69, 71-72, 74-76, 190 EEE. See European equine encephalitis El Salvador, 69, 71, 74-75, 148, 161 Epidemiology, 3, 26, 60, 181 Biomedical Research in Latin America European equine encephalitis, 116, 117 Family Welfare Agency (Colombia), 21 FEEMA. See State Foundation of Engineering of the Environment (Brazil) Financial Agency for Studies and Proj- ects (Brazil), 16 Foot-and-mouth disease, 59-60 Ford Foundation, 12 Foreign medical graduates (FMG), 68-76 FINEP. See Financial Agency for Studies and Projects (Brazil) FIPEC. See Research Fund of the Bank of Brazil FMG. See Foreign medical graduates Foundations, 4-5, 11,12, 13 France, 75 FUNRURAL, 91 FUNTEC. See Research Fund of the National Development Bank (Brazil) Genetics research, 24, 205-214 communication in, 213-214 environmental mutagens, 210-211 personnel, 212 policies, 211 priorities, 209-211 registers, 209-210 research centers, 207-209, 212-213 Gorgas Memorial Institute of Tropical and Preventive Medicine, Inc. (Panama), 8, 134-135 Guatemala, 69, 74, 154 Guyana, 73-74, 77-78 Haiti, 68, 71, 73-76 High-altitude research, 189-203 acclimatization, 197-198 basic studies, 196 pathology, 195-196 public health, 199 research areas, 193-197 sites and centers, 190-193 trends, 199-201 HIPOLITO UNANUE, 91 Honduras, 69, 71-75 Hydatidosis, 115, 120, 121, 123-124 Hypoxia, 190-191, 197-198 ICAITI. See Central American Institute of Investigation and Industrial Tech- nology (Guatemala) ICBF. See Family Welfare Agency (Colombia) Index ICITEX. See Institute for Manpower Training and Education (Colombia) IDB. See Inter-American Development Bank Immunology, 25, 58 Immunology Research and Training Centers (Sao Paulo and Mexico City), 58 IMSS. See Mexican Institute of Social Security INAS. See National Institute of Health (Colombia) INCAP. See Institute of Nutrition of Central America and Panama Industrial hygiene, 132-133 INISI. See Institute for Health Research (Costa Rica) Institute for Health Research (Costa Rica) (INISI), 23 Institute for High-Altitude Research (Peru), 191-192, 196 Institute for Manpower Training and Education (Colombia) (ICITEX), 22 Institute of Andean Biology (Peru), 191, 196 Institute of Cardiology (Mexico), 18 Institute of Nutrition (Mexico), 18 Inter-American Child Institute, 183 Inter-American Council of Psychiatric Associations, 180-181 Inter-American Development Bank (IDB), 51, 118, 124 International Union Against Cancer, 162 Institute of Nutrition of Central America and Panama (INCAP), 8, 25, 53, 57-58, 183 IVIC. See Venezuelan Institute for Scientific Research Jamaica, 74, 77-78 Kellogg Foundation, 12 LACRIP. See Latin American Cancer Re- search Information Program Latin American Cancer Research Infor- mation Program (LACRIP), 62-63, 139, 162-163 Latin American Center for Perinatology and Human Development (Mantroedeo), 58 Latin American Cooperative Study on Congenital Deformities (ECLAMC), 208, 212 237 Latin American Diabetes Association (ALAD), 167-168 Latin American Diabetes Plan (PLAD), 62 Leptospirosis, 115-116, 118,120 Louisiana State University, 142 LSU. See Louisiana State University Manpower, 67-96 Medical education, 4, 14, 72-76, 85-88 MEDLINE, 42 Mental health research, 179-187 alcoholism, 184-185 child psychiatry, 183 drug dependence, 184-185 education/training, 185-186 epidemiology, 181 neurological investigations, 181 psychopharmacology, 182-183 psychotherapy, 183 social psychiatry, 182 Mexican Institute of Social Security (IMSS), 18, 33-40,4347, 146 Mexico, 18-19, 3340, 68-76, 79, 146-147, 155,160, 170-172,190 Migration, 67-96 age factors, 79-80 consequences of, 89-90 factors influencing, 81-88 policies, 90-94 type of practice, 80 Milbank Memorial Fund, 12 Monge’s sickness, 195 Mutagens, 210-211 National Cancer Institute (U.S.), 139, 141 National Council for Scientific and Technical Investigations (CONICYT), 20, 23,40,170 National Indicative Plan for Science and Technology (Mexico), 19 National Institute of Health (Colombia), 21 National Institutes of Health (U.S.), 12 National Polytechnic Institute (Mexico) Center for Research and Advanced Studies, 18 National Research Council (Brazil), 16-17 National Test for the Prevalence of Trypanosomic Infection, 103 NCI. See National Cancer Institute (U.S) Nicaragua, 69, 71, 73-76, 160 Nurses, 76-77, 79 238 OAS. See Organization of American States OMS. See World Health Organization Onchocerciasis, 134 OPS. See Pan American Health Organiza- tion Organization of American States (OAS), 51 Osvaldo Cruz Foundation, 13 PAHO. See Pan American Health Organization Pan American Center for Human Ecology and Health, 60 Pan American Center for Sanitary Engineering and Environmental Sciences (CEPIS), 59, 129-132 Pan American Foot-and-Mouth Disease Center (PANAFTOSA), 59-60 Pan American Health Organization, 26, 32,41-43,49-51, 52-65, 76,128, 135,139 Advisory Committee on Medical Research, 56 chronic disease research, 61-63 organization, 55-56 research centers, 57-60 research program, 53-55 scientific communication, 63-65 zoonotic diseases, 113-126 Pan American Sanitary Bureau (PASB), 52 Pan American Zoonoses Center (CEPANZO), 53,59,115-116 PANAFTOSA. See Pan American Foot- and-Mouth Disease Center Panama, 68, 73-76, 161 Paraguay, 69-75, 160 Parasitology, 25, 99-109 PASB. See Pan American Sanitary Bureau Peru, 24, 69, 73-76, 149-150, 155, 161, 190 Physicians, 68-72, 77-96 PLAD. See Latin American Diabetes Plan Psychopharmacology, 182-183 Psychotherapy, 183 Public health administration, 26 Publishing, 6-8, 38-39, 64 Puerto Rico, 156 Pulmonary edema, 194 Rabies, 114, 117-118, 120, 122,123 Red Panamericana de Muestra Normali- zado de la Contaminacion del Aire (REDPANAIRE), 132 Biomedical Research in Latin America REDPANAIRE. See Red Panamericana de Muestro Normalizado de la Con- taminacion del Aire. Regional Library of Medicine and Health Sciences (Brazil) (BIREME), 4243, 63, 64-65 Research and Reference Center for Vec- tor Biology and Control, 60 Research Fund of the Bank of Brazil, 16 Research Fund of the National Develop- ment Bank (Brazil), 16 Rockefeller Foundation, 11, 24 Sdo Paulo Research Fund, 16-17 Schistosomiasis, 134 Social genetics, 211 Social psychiatry, 182 Social security systems, 33-40, 91 Solid waste, 133 Spain, 75 State Foundation of Engineering of the Environment (Brazil) (FEEMA), 132 Tobago, 73-74, 77-78 Trinidad, 73-74, 77-78 Tuberculosis, bovine, 115,117,118, 121,124 Typhoid fever, 129 UICC. See International Unior Against Cancer UNAM. See Autonomous University of Mexico UNDP. See United Nations Development Program UNESCO. See United Nations Educa- tional, Scientific, and Cultural Organization UNITAR. See United Nations Institute for Training and Research United Kingdom, 70, 72, 77-79, 92-94 United Nations Development Program (UNDP), 49-52 United Nations Educational, Scientific, and Cultural Organization (UNESCO), 73 United Nations Institute for Training and Research (UNITAR), 89 United States, 68-70, 72-81, 92-94, 193 University of Chile, Institute of Nutri- tion and Food Technology, 20 University of the West Indies (UWI), 77-718 University of Valle (Colombia), 141-142 Uruguay, 68-72, 74-75, 156 UV. See University of Valle (Colombia) UWI. See University of the West Indies Index VEE. See Venezuelan equine encephalitis Venezuela, 20-21, 68-72, 74-76, 149, 157, 161 Venezuelan equine encephalitis, 117, 120, 121 Venezuelan Institute for Scientific Re- search (IVIC), 21, 149, 207 239 Water pollution, 129-131 West Indies, 69-71, 77-79, 81 WHO. See World Health Organization World Health Organization (WHO), 49-51, 68, 207 Zoonotic diseases, 113-126 # U. S. GOVERNMENT PRINTING OFFICE : 1980 623-966/1547 WAR