Sin Remedio.

Domingo, 18 de septiembre de 2011

A la pildorita
Por Cristian Carrillo
pagina12.com.ar/diario/suplementos/cash

“Hoy existen desarrollos científicos que permiten salvarle la vida a un enfermo de sida. El paquete cuesta 12 mil dólares por año en los países desarrollados. La Fundación Clinton, la Fundación Gates y la Organización Mundial de la Salud (OMS) firmaron un acuerdo de producción masiva con ocho laboratorios de la India y lograron bajar el precio a 300 dólares. Esos son los márgenes que maneja la industria.” Con este ejemplo, el economista y asesor de la OMS, Bernardo Kliksberg, sintetizó a Cash la problemática de índole ética y económica que existe detrás del negocio de los grandes laboratorios. En el mundo, sólo diez empresas controlan casi el 60 por ciento del mercado de medicamentos, estableciendo precios monopólicos con el argumento de la propiedad intelectual.

La Argentina le ganó una batalla a esa concentración a partir de la ley de genéricos y la condición impuesta a los laboratorios de producir en el país aquellos medicamentos sobre los que pretendan una patente. Sin embargo, todavía quedan otras por librar. El trabajo para una mayor concientización en el uso de estas herramientas y la necesidad de seguir profundizando la sustitución de importaciones son algunas de éstas, para que se establezca el medicamento como “un bien social”, como se dispuso en la denominada ley Oñativia, de 1964.

La noción de monopolio intelectual deviene de la antigua Grecia, pero no fue utilizada hasta la Revolución Industrial británica, cuando los inventores de la máquina textil demandaron “protección”. Actualmente, las patentes alcanzan desde genes hasta fragmentos de ADN y líneas celulares humanas. “Como en otras áreas del sistema económico mundial contemporáneo, existe un lobby feroz que lucha a brazo partido para que las patentes duren el mayor tiempo posible, e incluso para que haya restricciones posteriores de algún tipo cuando se liberen”, señala Kliksberg.

En los países que cuentan con un sistema de patentes, las firmas farmacéuticas que descubren nuevos productos los ingresan en el mercado bajo un determinado nombre comercial o marca. Durante este período, las marcas originales son posicionadas fuertemente en el mercado y tanto médicos como farmacéuticos y consumidores se acostumbran a su utilización, dificultando el acceso de otros medicamentos similares, aun después de expirada la vigencia de las patentes.

El poder de mercado de las marcas se refleja en los precios. Los productos de marca son 11,5 veces más caros que los genéricos. En algunos casos excepcionales, la diferencia llega hasta 50 o 100 veces. Esto explica por qué las firmas farmacéuticas gastan mucho dinero en marketing y publicidad, y menos en desarrollo. Los recursos destinados a venta son de alrededor del 25 por ciento del costo total de los laboratorios, mientras que en desarrollo sólo los líderes mundiales alcanzan la mitad de ese guarismo.

Un estudio realizado por la Comisión Nacional de Programas de Investigación Sanitaria, el Estudio Multicéntrico, la Universidad Maimónides y el Instituto de Investigación de Ciencias Sociales de la Universidad del Salvador demostró que la utilización del nombre genérico involucra un ahorro de 660 millones de pesos al año. “Esta realidad debilita el argumento que los patentistas a ‘ultranza’ utilizan para justificar el monopolio de la explotación y los altos precios”, señala el ex ministro de Salud, Ginés González García, y las economistas Catalina de la Puente y Sonia Tarragona en el libro Medicamentos, Salud, Política y Economía.

La imposición por conservar esta modalidad de negocios proviene de los grandes laboratorios multinacionales, que a pesar de la crisis financiera internacional mantienen una tasa de ganancia superior al 20 por ciento, siendo la industria más rentable de Wall Street. Paradójicamente, Estados Unidos fue uno de los principales países en establecer un mercado integral de genéricos. “Las drogas genéricas hacen que la salud americana sea mucho más accesible”, aseguraba en octubre de 2002 el entonces presidente estadounidense George W. Bush. Sin embargo, como toda la política de ese país, mantiene estándares internos y externos bien diferentes. Centroamérica es un ejemplo de ello: los medicamentos genéricos no pueden penetrar en esos países porque las condiciones de firma de tratados comerciales bilaterales con los Estados Unidos se lo impiden.
Nuevas recetas

“En la Argentina, durante la administración de Ginés González García en Salud, se libró una dura batalla, y se ganó. Hoy los medicamentos genéricos son obligatorios en las recetas médicas. Los médicos tienen que prescribirlos de esa forma”, indica Kliksberg, aunque muchos profesionales no lo cumplen. La Argentina junto con Brasil y Uruguay son los únicos países donde existe esa obligatoriedad. El programa de distribución gratuita de medicamentos Remediar es, además, uno de los más importantes del mundo en cuanto a volumen de entrega. Por su parte, en los primeros meses de la presidencia de Néstor Kirchner se avanzó sobre otro punto neurálgico de esta industria: las patentes se otorgan al laboratorio bajo la condición de que produzcan el medicamento en el país. “Fue un lobby tremendo. Recibimos muchos ataques por parte de las industria extranjera y local”, recuerda el ex ministro Ginés González García en diálogo con Cash.

Durante la década del ’90 se inició una primera instancia del debate que enfrentó a los laboratorios nacionales con las multinacionales. La disputa giró en torno de la cláusula de fabricación local –que no aparecería hasta diciembre de 2003–, los riesgos de las licencias compulsivas y la posibilidad de una suba en los precios. Hasta ese momento, las empresas locales se habían limitado a copiar y comercializar innovaciones producidas en los países centrales. “Los laboratorios plagian las fórmulas de los medicamentos y los comercializan al mismo precio, siendo sus ganancias mayores que las de los inventores, por el hecho de no haber invertido recursos en investigación y desarrollo”, fue la defensa que esbozó Pablo Challú, ex directivo de Cilfa (cámara de los laboratorios nacionales), y actual secretario de la Unión Industrial de la provincia de Buenos Aires.

Con la Ley de Patentes –que fue aprobada en 1995 y entró en vigencia en octubre de 2000– se les aseguró a las corporaciones transnacionales ampliar su cuota de mercado, vendiendo medicamentos en exclusividad o cobrando royalties a empresas locales. Esa norma sólo amplió el diferencial de precios, mientras que los grandes laboratorios se dedicaban a importar los medicamentos. De las 40 compañías extranjeras que operaban en el país hasta 2002, quince se dedicaban exclusivamente a importar productos. Las compras externas pasaron de un 12 por ciento en 1992 a 43 por ciento diez años después. La ley generó así una sustitución de los productos locales por más importaciones.

La crisis socioeconómica de 2001 produjo un fuerte cimbronazo en toda la estructura productiva del país, arrastrando también al sistema sanitario al borde del colapso. La gente con escasos recursos no podía acceder a los medicamentos. En ese momento se lanza la Ley de Genéricos y el plan Remediar, que lograron estabilizar el mercado, permitiendo a los laboratorios locales recuperar parte del terreno perdido en los ’90. Ambas medidas dieron cobertura a 54 presentaciones, que representaban el 80 por ciento de las consultas médicas. “La ley de prescripción por nombre genérico mejoró el acceso porque hizo bajar los precios. Pero es una batalla permanente de concientización”, señaló González García. En cuanto al plan Remediar, el ex ministro y actual embajador argentino en Chile aseguró que no existe otro ejemplo de “esa envergadura”. “Alcanza a unos 15 millones de personas y su costo anual para el Estado nacional es de 2 dólares por habitante”, apuntó.
Made in Argentina

El mercado de fármacos argentino es uno de los más importantes del mundo en cuanto a abastecimiento interno y consumo. Es el cuarto país a nivel mundial en consumo de medicamentos por habitante, con un promedio de 186 dólares anuales. También es uno de los cuatro que mantienen más de la mitad de la demanda local abastecida por laboratorios locales. Sin embargo, la recuperación sostenida de la industria nacional no se dio hasta la modificación de la Ley de Patentes, que se produjo en diciembre de 2003. Esta norma dispuso que para extender una patente por veinte años, los laboratorios deben producir ese nuevo producto en el país. La modificación contempla desde una carga de prueba hasta el patentamiento de microorganismos, patentes transitorias y la protección de datos de pruebas contra un uso comercial ilegal u otras variantes. En la práctica, este cambio, que sólo figura en la legislación de Brasil y Uruguay, impidió que los laboratorios extranjeros desplacen sus plantas a países con menor costo de producción.

“Brasil sacó la Ley de Patentes dos años después que la nuestra (1995) y allí obliga a producir todo lo que se consume dentro de su territorio. Esto condujo a una fuerte migración al país vecino”, señaló a este suplemento un directivo de Cilfa. Actualmente, la tendencia se revirtió. Incluso se informó en las últimas semanas que un laboratorio estadounidense se radicará en la Argentina para producir medicamentos que luego venderá en su país de origen. También hubo intenciones de compra de firmas locales. La multinacional Roche llegó a ofrecer 2400 millones de dólares por Roemmers. Antes, Roemmers había adquirido las plantas de Roche en el año 2000. Este laboratorio nacional no tiene invento patentado, pero sí una enorme fuerza de venta doméstica. Rechazó la propuesta, en tanto que adquiría las instalaciones de Brystol Myers Squibb (2005) y las de Valeant (2008).

La industria logró desde 2003 una fuerte recuperación. Las exportaciones muestran una tendencia creciente y las empresas están diversificando destinos. Existen 230 laboratorios registrados y 110 plantas industriales. Los diez primeros laboratorios explican el 42 por ciento de las ventas. La actividad registra un importante déficit estructural. La producción nacional fue de 3466 millones de dólares en 2010, de los cuales se exportaron 691 millones. El consumo interno es de 4341 millones de dólares y las importaciones ascendieron a 1566 millones. De esta manera, el 58 por ciento del mercado doméstico se abastece de laboratorios nacionales. La industria farmacológica local tiene una estructura transformadora moderna, siendo importados los principios activos, principalmente de China e India. En los últimos años, la industria pudo aumentar 116 por ciento los envíos de estas materias primas, aunque crecieron en un 229 por ciento las importaciones de medicamentos.

Los laboratorios de capitales nacionales mantuvieron su participación a través de estrategias de concentración y de alianza con multinacionales. Esto mantiene una estructura de poder de las grandes compañías que, en su mayoría, prefieren importar los productos antes que producirlos en el país. A esta situación se suma además el impacto en los consumidores de la imposición mediática de sus marcas. Esta batalla es librada en el campo de la publicidad. Numerosos trabajos han demostrado los efectos de la publicidad sobre las prescripciones y los consumidores, generando un patrón de comportamiento de la demanda bastante alejado de las necesidades reales. Además de la pelea cultural para sortear el bombardeo mediático, también deben llevarse a cabo medidas tendientes a desconcentrar el sector y fomentar la producción local. “El Estado generó un mercado interno del orden de 4400 millones de dólares, por lo que ese mismo Estado va a exigir ahora producción en territorio”, sostuvo la ministra de Industria, Débora Giorgi. En esa línea, en julio último, el Congreso promulgó una ley que declara de interés nacional la investigación y producción pública de medicamentos, vacunas y productos médicos. El objetivo es promover el acceso a medicamentos y propiciar el desarrollo científico y tecnológico. La medida se encuentra en análisis del Ministerio de Salud para su reglamentación. “No puede ser que el mercado sea el único motor para la invención y el conocimiento porque, de ser así, no habrá investigación en enfermedades de pobres”, sentenció González García

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60 % de las muertes por ECNT

De acuerdo con un estudio de la Organización Mundial de la Salud, las enfermedades no transmisibles, como las cardiovasculares o respiratorias, se han convertido en la principal causa de mortandad en todo el mundo.
Para la OMS, el causante de esta situación no es más que el estilo de vida que lleva la mayoría de las personas en el mundo, hábitos como el sedentarismo y el consumo de comida insana.
Según el informe presentado, las enfermedades no transmisibles son las causantes de más del 60 por ciento de las 57 millones de muertes que hubo en el mundo durante 2008.
El porcentaje de muertes por enfermedades no transmisibles quedó de la siguiente manera, según datos presentados por la OMS: Enfermedades cardiovasculares, 48%; Problemas respiratorios, 12%; Cáncer, 12%; Diabetes, 3%.
Para la OMS, la dieta es un factor muy importante para el alza de estas enfermedades, ya que ahora se consume más azúcar que antes, además de grasas saturadas y sal, que en grandes cantidades son generadoras de problemas como el alza de los niveles de azúcar y colesterol en la sangre, además de enfermedades como hipertensión arterial.
Además, el índice de masa corporal se ha duplicado en los últimos treinta años, además de que los índices de sobrepeso han aumentado dramáticamente en muchos países del mundo. De tal manera que los decesos por estas enfermedades ocurrieron en personas menores de 60 años, y un 90 por ciento de éstas ocurrieron en países de bajos ingresos.
Una de las razones para el aumento de muertes prematuras en países en desarrollo es que con dichas economías es más difícil llevar una dieta sana y resulta más barato comer comida saturada en grasas, sales y azúcares, indica la OMS.
Por su parte, Douglas Betcher, director de la Iniciativa anti-tabaco de la OMS, indicó que este tipo de enfermedades colapsan los servicios médicos de los gobiernos, ya que su atención significa un gasto de millones de dólares, así que consideró urgente apurar el avance en la prevención de estas enfermedades.
Los sistemas de salud luchan por reducir el impacto de las patologías cardiovasculares, el cáncer, las enfermedades respiratorias crónicas y la diabetes. La ONU realizará una cumbre en Nueva York con especialistas de todo el mundo.
De la Redacción de El Litoral
area@ellitoral.com
Las cuatro enfermedades no transmisibles principales —cardiovasculares, cáncer, enfermedades pulmonares crónicas y diabetes— matan a tres de cada cinco personas en el mundo, y causan un gran daño socioeconómico, en especial en los países en desarrollo. Por eso, el 19 y 20 de septiembre se realizará en Nueva York la Cumbre de las Naciones Unidas sobre las Enfermedades No Transmisibles (ENT).
En la Argentina, la mala noticia es que empeoraron los indicadores de los factores de riesgo de las ENT, según la Encuesta Nacional de Factores de Riesgo que realizó el Ministerio de Salud de la Nación en el 2009.
Las cifras preocupan. El 53,4% de la población adulta tiene exceso de peso, el 54,9% realiza actividad física insuficiente y sólo el 4,8% de la población consume la cantidad de frutas y verduras diarias recomendada por la OMS.
El consumo de tabaco, aunque disminuyó, sigue siendo uno de los más alto de América, con un 30% de la población adulta fumadora. Y el consumo de sal promedio es de 12 gramos por día, cuando se recomienda 5 gramos, como máximo. Esta es una de las causas de que un tercio de los argentinos sean hipertensos (se estima que esta es la causa de muerte de 50.000 argentinos por año).
A nivel global, las enfermedades no transmisibles son la principal causa de mortalidad y discapacidad. Representan alrededor del 60% de todas las causas de muerte y son responsables del 44% de los fallecimientos prematuros en el mundo (alrededor de 35 millones de muertes anuales, de las cuales el 80% se producen en países de bajos y medianos ingresos).
La OMS estima que las muertes debidas a las ENT aumentarán un 17% en los próximos diez años en todo el mundo. En 2008, sólo el cáncer fue la causa de 7,6 millones de muertes, esta cifra es más que el VIH/Sida, la malaria y la tuberculosis juntos. A pesar de esta situación, las ENT sólo reciben el 0,5% de los fondos destinados a la asistencia global al desarrollo.
La prevención es clave
Los cuatro factores de riesgo más importantes de las ENT son el uso de tabaco, los hábitos alimentarios inadecuados, el sedentarismo y el abuso de alcohol, todos ellos determinantes sociales evitables y prevenibles.
- En el caso del cigarrillo, se calcula que aproximadamente 6 millones de personas mueren como consecuencia del consumo de tabaco y la exposición al humo de tabaco ajeno. Hay estudios que estiman que fumar causa el 71% del total de los casos de cáncer al pulmón, el 42% de las enfermedades crónicas respiratorias y casi el 10% de las enfermedades cardiovasculares.
- La falta de actividad física es otro problema grave. Las personas que no realizan actividad física tienen entre un 20% y un 30% de mayor riesgo de mortalidad, especialmente por aumento del riesgo de hipertensión arterial, enfermedades cardiovasculares, diabetes, cáncer de mama y colon y depresión.
- La mala alimentación aumenta la prevalencia de ENT por mecanismos tales como el aumento de la presión arterial, la glucemia, las alteraciones del perfil de lípidos sanguíneos, el sobrepeso y la obesidad. Aunque las muertes por ENT se dan principalmente en la edad adulta, los riesgos asociados a las dietas malsanas comienzan en la niñez y se acumulan a lo largo de toda la vida.
- Unas 2,7 millones de muertes anuales son atribuibles a una ingesta insuficiente de frutas y verduras, según la Organización Mundial de la Salud. Asimismo, el alto consumo de grasas saturadas y trans está relacionado con enfermedades cardiovasculares.

Tabaco. En la Argentina, el 30% de los adultos fuma. Es uno de los más altos del continente y un grave problema de salud pública. Foto: Archivo/Mauricio Garín 54,9 por ciento de los argentinos no realiza suficiente actividad física. El 53,4 de la población adulta tiene exceso de peso.
12 gramos diarios. Ésa es la cantidad de sal promedio que se consume en el país por habitante. Es más del doble de lo que recomienda la OMS.

Determinantes sociales en enfermedad cardiovascular

Determinantes políticos de los determinantes sociales de salud

Epi + demos + cracy: Linking Political Systems and Priorities to the Magnitude of Health Inequities—Evidence, Gaps, and a Research Agenda
Jason Beckfield and Nancy Krieger
Epidemiologic Reviews. Oxford Journals
http://epirev.oxfordjournals.org/content/31/1/152.full
Abstract

A new focus within both social epidemiology and political sociology investigates how political systems and priorities shape health inequities. To advance—and better integrate—research on political determinants of health inequities, the authors conducted a systematic search of the ISI Web of Knowledge and PubMed databases and identified 45 studies, commencing in 1992, that explicitly and empirically tested, in relation to an a priori political hypothesis, for either 1) changes in the magnitude of health inequities or 2) significant cross-national differences in the magnitude of health inequities. Overall, 84% of the studies focused on the global North, and all clustered around 4 political factors: 1) the transition to a capitalist economy; 2) neoliberal restructuring; 3) welfare states; and 4) political incorporation of subordinated racial/ethnic, indigenous, and gender groups. The evidence suggested that the first 2 factors probably increase health inequities, the third is inconsistently related, and the fourth helps reduce them. In this review, the authors critically summarize these studies’ findings, consider methodological limitations, and propose a research agenda—with careful attention to spatiotemporal scale, level, time frame (e.g., life course, historical generation), choice of health outcomes, inclusion of polities, and specification of political mechanisms—to address the enormous gaps in knowledge that were identified.

Key words
democracy epidemiology health status health status disparities politics public health social class socioeconomic factors
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INTRODUCTION

Epi + demos + cracy
The terms “epi + demos + cracy” together lend themselves to the study of how political systems and priorities shape population health and the magnitude of health inequities. After all, epi (“upon”) + demos (“the people”) are the roots of “epidemic” (i.e., a disease outbreak that falls upon everyone) (1, 2) and demos (“the people”) + -cracy (“politically who rules”) (2) refers to a particular kind of political system. That links existed between these 2 concepts was apparent even in the 5th century BCE in ancient Greece, when these terms were coined (1–5). The classic Hippocratic treatise on “Airs, Waters, Places,” for example, famously asserted that the Europeans—and especially Greeks—were healthier and more vigorous than the inhabitants of Asia, with 1 “contributory cause” stated to be that, for Asia, “the greater part is under monarchical rule,” whereas in Europe, the people “are not subject races but rule themselves and labour on their own behalf” (1, p. 160). Moreover, within the context of Greek democracy (which, by contemporary standards, was not particularly democratic, since only free male citizens (less than 10% of the population) could vote; free women, metics (foreign residents), and slaves were not enfranchised (3–5)), the Hippocratic writings likewise recognized that those with power, property, freedom, and leisure had better health than “the mass of people who are obliged to work,” who “drink and eat what they happen to get” and so “cannot, neglecting all, take care of their health” (5, p. 240). In other words, awareness that political systems and social position affect health is an ancient, not new, idea.

Jump to the 21st century CE, and a new round of critical epidemiologic research, concerned with the societal determinants of health, is exploring links between bodily health and the body politic, drawing on a rich body of recent literature that has theorized about connections between political rule and population health (6–21). At issue is how societal conditions—and especially social inequality—become embodied, thereby shaping population distributions of health: both overall rates of disease, disability, and death and the patterning and extent of health inequities (7). To date, much of this research has been concerned with associations—and ultimately causal connections and biologic pathways—between individual-level data on 1) social position (especially in relation to social class, race/ethnicity, and gender) and 2) health status. Within the past decade, however, new work, partly informed by recent developments in multilevel frameworks and methods (22, 23), has begun to consider how contextual factors such as political systems and government policies drive population health and health inequities (6, 8–13, 15–17, 21, 24–33).

However, epidemiologists are not alone in asking these questions. In the social sciences, a new and growing body of work is investigating links between political systems, policies, and population health (25–27, 29, 30, 34–44). Building on an enormous and well-developed body of social science literature regarding different types of political systems, social processes, and (especially) social inequalities (34, 45–57), along with older and more general theoretical work that considered a narrower range of political determinants and health outcomes and paid less attention to health inequities, 1 line of this work has called for greater attention to the societal policies, relations, and processes that are behind the social categories used to study health inequities in epidemiologic research (e.g., socioeconomic position, race/ethnicity, gender, sexuality). Its orientation is in contrast to the more conventional epidemiologic approach of treating these categories and social relations as static “risk factors” construed as properties of individuals (58). Another line, concerned with the political economy of health, focuses on how different types of state structures and political and economic systems and institutions affect population well-being, including health inequities (38, 42, 43, 59, 60), albeit with relatively little direct attention to biologic pathways of embodiment.

To date, these 2 bodies of literature, despite common interest in population health and health inequities, have rarely engaged directly. To advance—and better integrate—the work, we accordingly have prepared a critical review of empirical research linking political systems and priorities to the magnitude of health inequities, drawing on our respective fields of political sociology and social epidemiology. In this paper, we focus on the conceptual frameworks informing this research, the substantive findings to date, and the next steps needed for developing a research agenda to address extant gaps in knowledge, so as to provide a better basis for redressing health inequities between and within polities.

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FROM THEORY TO HYPOTHESIS: FRAMEWORKS FOR ANALYZING LINKS BETWEEN POLITICAL ECONOMY AND HEALTH INEQUITIES

To situate our review of the empirical literature, we start by briefly summarizing the relevant theories that informed our approach. Because we believe that readers of Epidemiologic Reviews are likely to be more familiar with the social epidemiology theories than the political sociology theories, we devote less attention to the former and more to the latter.

Social epidemiology
As reviewed in recent publications (61, 62), social epidemiology offers a wealth of frameworks and models to guide empirical research on the societal determinants of health and of health inequities—often including, in a very broad manner, the impact of political systems and priorities. In particular, the ecosocial theory of disease distribution, introduced by Krieger in 1994 (63) and elaborated upon since (7, 62, 64), has provided a means for conceptualizing the myriad ways social inequality, including class, racial, and gender inequality, becomes biologically embodied, thereby creating health inequities. At issue are the cumulative interplay of exposure, susceptibility, and resistance, at multiple levels, across the life course. The specific forms of these pathways of embodiment are filtered via the prevailing political economy and political ecology. Two corollaries are that 1) population health and health inequities must be analyzed in societal, historical, and ecologic context, and 2) neither the forms of social inequality nor their associations with health status are “fixed” but instead are historically contingent. Moreover, recognizing the interplay between the embodied facts of health inequities and how they are conceptualized, ecosocial theory also calls attention to accountability and agency, both for social inequalities in health and for ways they are—or are not—monitored, analyzed, and addressed.

A model recently prepared by the World Health Organization Commission on the Social Determinants of Health (65) is similarly concerned with how population health is shaped by what it terms the “socioeconomic political context.” This context is posited to generate the structural determinants of health, defined as including “governance,” “macroeconomic policies,” “social policies (labor, housing, land),” “public policies (health, education, social protection),” and “cultural and societal values.” These structural determinants are held to work through and along with socioeconomic position (involving not only education, occupation, and income but also class and access to resources, power in relation to political context, prestige, and discrimination), gender, and “ethnicity (racism)” to affect intermediary determinants (e.g., material circumstances, behaviors and biologic factors, psychosocial factors), which in turn “impact on equity in health and well-being” (65, p. 48).

Thus, common to the social epidemiologic perspectives are concerns with 1) political context, 2) health inequity, and 3) the biologic pathways by which societal conditions become embodied, in relation to time, place, and history, including life course and age-period-cohort effects. At issue is how power and material resources, operating at different levels and in diverse domains, affect population distributions of health. Social epidemiologic frameworks accordingly set the basis for hypothesizing that different types of polities would have different health profiles, including different magnitudes of health inequities.

Political sociology
At the intersection of sociology and political science, political sociology has developed conceptual and analytical tools for understanding the “political context” that regularly appears in frameworks drawn from social epidemiology. At issue are various intersections of the state and civil society (66, 67), including the “welfare state” or the set of “social rights of citizenship” (68), such as family benefits, health insurance, pension provisions, unemployment insurance, housing allowances, and welfare payments; engagement with other formal political institutions; and social movements.

Below and in Table 1 we briefly describe key features of 4 predominant theoretical frameworks used in political sociology that address social inequality directly: 1) “welfare regimes,” 2) “power constellations,” 3) “varieties of capitalism,” and 4) “political-institutionalism of inequality.” While each of these theories views welfare states as systems of stratification, they differ in their analysis of the causal processes that generate social inequality. In Table 1, we provide examples of the types of hypotheses each of these theories (and related theories pertaining to social movements) could propose regarding links between political systems and health inequities.

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Table 1.
Political Sociology Theoretical Frameworks for Analyzing Political Determinants of Health Inequities: Tenets, Hypotheses, and Data Needs

One influential political-sociologic approach is the “welfare regime” framework developed by Esping-Andersen (69) in 1990, which posits the existence of “3 worlds of welfare capitalism”: liberal, social democratic, and conservative. Distinctions pertain to the degree to which each regime decommodifies labor by making it possible to maintain a socially acceptable standard of living without reliance on the market. The fundamental insight of this approach is that social inequalities do not emerge “naturally” from the market but are instead politically constructed. According to this framework, liberal welfare states (where the “liberty” in “liberal” refers to the political prioritizing of “free markets”), such as the United States, do little to reduce poverty or inequality, while social democratic welfare states, such as Sweden, reduce poverty and inequality dramatically by providing a wide range of social services, and conservative welfare states, such as Germany, provide relatively generous social services and welfare benefits but deliver them in ways that reinforce existing patterns of social inequality (e.g., gender roles in the family). New research has updated and revised Esping-Andersen's regime scheme, contrasting “social market economies” (combining generous social provisions with coordinated business-interest representation and strong labor unions) with “liberal market economies,” with the former outperforming the latter in reducing inequality, without sacrificing economic growth and jobs (51, 56). For definitions of many of the central terms in the welfare-regimes literature, see the recent glossary by Eikemo and Bambra (12).

Like the “welfare regimes” approach, the “power constellations” approach theorizes about the causes and effects of the welfare state, but here political parties are the central determinant of social welfare policies (55, 70, 71). Power constellations theory views social democratic parties, Christian democratic parties, and social movements as engines of distinct welfare-state trajectories, with research demonstrating that party incumbency directly and indirectly affects a country's level and type of social inequality. While the key causal mechanism in the power constellations approach is the political party, social movements (e.g., labor, feminist, tax-revolt) also play a role in party formation and formal political participation. A key contribution of social movements theory is identification of the conditions for societal impacts of movements (72–74).

In sharp contrast to both the regimes and constellations frameworks is the “varieties of capitalism” institutionalist tradition (54, 75), which focuses on the role of employers and employees in welfare politics and policy within the context of international market competition. The key taxonomic distinction is between “coordinated market economies” like Germany and Sweden and “liberal market economies” like the United States and the United Kingdom, where the former is more likely to protect employees’ and employers’ investments in specific skills, a priority that involves coordinated wage bargaining and which simultaneously produces less wage inequality but also (usually) more occupational gender segregation (76, 77).

An emergent political-institutional approach in turn considers how policy domains not typically considered in welfare-state analyses, such as the penal system and the education system, also have implications for inequality (78, 79). Research motivated by this framework, for instance, has investigated how increasingly punitive prison policy in the United States has led to increased antiblack discrimination in the labor market (80), felon disenfranchisement and decreased political participation among blacks (81), and increased black-white wage inequality (82).

Common to all 4 theories is recognition that, as Lundberg (6) and others (83–86) have noted, the state is not a unitary actor, such that it is dangerous to assume a perfect correspondence between, for instance, a welfare regime on the one hand and health policy on the other (43). Even so, all 4 theories, combined with those of social epidemiology, provide good grounds for theorizing that types of states and their political priorities should be causally linked to the magnitude of health inequities. To consider whether these predictions actually hold, we next consider the empirical evidence.

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METHODS

Our review objective was to locate articles that empirically investigated and tested hypotheses regarding within- and between-country comparisons of health inequities in relation to political systems, political economy, and changes in politics and policies. To locate articles for inclusion in this review, we searched the ISI Web of Knowledge database, version 4.3, with “all databases” (Thomson Reuters, New York, New York; http://apps.isiknowledge.com.ezp1.harvard.edu/) and the PubMed database (US National Library of Medicine, Bethesda, Maryland; http://www.ncbi.nlm.nih.gov/sites/entrez) between May 27 and June 7, 2008. The ISI Web of Knowledge database includes works published since 1900; the PubMed database includes works published since 1948. Topic keywords common to all searches were 1) “epidemiology” and 2) “[health and (inequalities or inequality or inequities or inequity or disparities or disparity)].” Additional terms included “welfare and state,” “political and economy,” “social and policy,” “structural,” “trends,” “political and change,” “democratization,” “democracy,” “globalization,” “policy,” “politics,” “neoliberalism,” “retrenchment,” “stratification,” “class and differences,” “international,” “cross-national,” “cross-country,” and “human and rights.”

Searching on these keyword permutations yielded a total of 12,237 records (not mutually exclusive; the original searches were conducted by N. K. and replicated exactly by J. B.). The majority of these focused on socioeconomic health inequities, overall and sometimes by gender or race/ethnicity (especially studies from the United States and New Zealand). Initial review of abstracts by N. K. yielded 1,730 articles that potentially were relevant. N. K. and J. B. then together reviewed these 1,730 abstracts and identified 45 that met 1 or both of the inclusion criteria; that is, they either:

explicitly and empirically tested for changing trends in the magnitude of health inequities in relation to an a priori hypothesis relating these to political changes, or

explicitly and empirically tested for significant cross-national differences (cross-sectional or over time) in the magnitude of health inequities in relation to an a priori political hypothesis.

In accord with our inclusion criteria, we excluded 2 types of studies also concerned with political systems and population health, as summarized in the Web Table (which is posted on the Epidemiologic Reviews Web site (http://epirev.oxfordjournals.org/)): 1) descriptive studies that did not explicitly test political system hypotheses and 2) descriptive and analytic studies focused on overall population health (as opposed to the magnitude of health inequities). We did, however, draw on these studies and other relevant literature (24–33, 38, 41–44, 59, 62, 65, 87–90) to inform our analysis of the selected articles.

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RESULTS

Tellingly, the 45 studies included in Table 2 were all published between only 1992 and 2008, despite our search of databases extending back to 1900. This new, small body of literature clusters around 4 central political factors: 1) the transition from a command economy to a capitalist economy; 2) neoliberal restructuring of economic regulations; 3) welfare states and welfare regimes; and 4) the political incorporation of subordinated racial/ethnic and indigenous groups and women. None explicitly tested hypotheses pertaining to the impact of social movements on the magnitude of health inequities.

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Table 2.
Results From Quantitative Studies (n = 45) Analyzing Whether Variation in the Magnitude of Health Inequities Is Associated With Variation in Political Systems or Priorities, 1992–2008

Before summarizing the key findings of each of these 4 emerging lines of research, we first note that, with regard to outcomes, 25 of the 45 studies (56%) focused on all-cause or cause-specific mortality, 3 (7%) on life expectancy, 14 (31%) on self-rated health or long-standing limiting illness, 2 (4%) on health behaviors, and 8 (18%) on other health status outcomes (with some studies including more than 1 type of outcome). Additionally, as is summarized in the last set of columns in Table 2, 21 (47%) considered multiple dimensions of inequality (“MDI”) in relation to either determinants or outcomes, 19 (42%) investigated the possibility of contradictory effects (“CE”) on health inequities, 10 (22%) employed a life-course (“LC”) approach or tested for lagged effects, 6 (13%) included measures of the mechanisms (“MM”) hypothesized to connect political input to health inequities, 26 (58%) assessed both relative and absolute (“RA”) health inequities (with the remainder typically focusing only on relative inequities), and 17 (38%) employed a multilevel (“ML”) framework or analysis. Only 1 study addressed birth cohort effects. Moreover, 38 of the 45 articles (84%) focused on countries in the “global North”—that is, European nations (Western, Northern, Southern, and Eastern), North American nations (United States and Canada), New Zealand, Australia, and Japan.

Transition to capitalism
Among the 9 studies testing the hypothesis that (class-based) health inequities would grow during the period immediately following a transition to capitalism (a variant of hypothesis 1.3 in Table 1), 8 found supportive evidence pertaining to growing relative or absolute education-related health inequities (Table 2). Outcomes for these 8 studies included: for Russia, overall and cause-specific mortality (91), with 1 study finding evidence against the hypothesis that this was driven by growing inequality in alcohol consumption (92); and, for Poland, East Germany, Estonia, the Czech Republic, and Lithuania, premature mortality (93), unhealthy housing conditions for children (94), life expectancy (95, 96), birth weight and preterm delivery (97), and all-cause mortality (96, 98). The 1 study with negative findings focused on self-rated health in Estonia, Latvia, and Lithuania, with Finland serving as a control (99).

Neoliberal restructuring
Eight studies listed in Table 2 tested hypotheses regarding the health inequities impact of the neoliberal (market-oriented) political and economic reforms of the 1980s and 1990s (per hypotheses 1.3, 2.1, and 2.2 in Table 1). Four of these focused on mortality—of which 3 found that neoliberal reforms were associated with increased health inequities, including 2 New Zealand studies on education- and income-based relative disparities in adult mortality rates (100) and child mortality (101) and a US study on relative and absolute income and racial/ethnic inequities in premature mortality and infant mortality (102). By contrast, 1 study found that, at least for premature mortality, relative health inequity in New Zealand during its period of neoliberal reform did not increase more than it did in Denmark, Finland, and Norway (103). Among the 4 studies that focused on nonmortality outcomes, 1 in New Zealand found evidence of post-neoliberal reform increases in Maori-European relative and absolute inequality in the dental caries experience of children (104), whereas the 3 studies with self-rated health as the outcome, all Scandinavian, found stable education- and gender-based relative and absolute inequalities during the period of neoliberal reforms, as evident in Sweden (105), Norway (106), and Finland (107).

Welfare state
Investigations concerned with the implications of the welfare state for health inequity comprised the bulk of the studies in Table 2 (23 of 45; 51%) and offered deeply divergent findings. Underscoring the possibility of different effects of “welfare state” arrangements (i.e., social rights conferred on the basis of citizenship rather than market position) on health inequities, we categorized these 23 studies according to 3 themes: 1) the effect of the health system itself on health inequities (9 studies); 2) the effect of welfare-state policy domains that lie outside health insurance, the medical system, and public health (11 studies; 10 as listed under this subheading, plus the study by Krieger et al. (102)); and 3) the effect of welfare regime type on health inequities (3 studies).

Among the 9 studies on the effect of the health-policy dimension of the welfare state, 5 provided evidence that enhancement of welfare-state provisions reduced relative health inequities: 1) 2 studies using Canadian data linking establishment of Canada's national health insurance plan to decreased income-based relative inequities in mortality due to conditions amenable to medical treatment (108, 109); 2) an investigation showing that increased public health spending in poor countries was associated with decreasing relative wealth inequality in child mortality (110); and 3) 2 Brazilian studies documenting that expansion of health-related infrastructure investments brought down relative and absolute economic inequality in infant and child mortality (111, 112). A sixth study, however, found that establishment of the Australian national health care system was simultaneously associated with increased relative—but decreased absolute—socioeconomic inequalities in avoidable mortality (113), while a seventh study observed that education-based inequality in acquired immunodeficiency syndrome mortality remained stable after highly active antiretroviral therapy was made freely available in Barcelona, Spain (114). Additionally, 2 studies that focused on Western Europe, where the welfare state has seen its most advanced expression, reported that enhancement of welfare-state health systems did not translate to reduced health inequities: 1 in Norway, on postneonatal mortality (115), and 1 comparing class inequality in infant mortality in the United Kingdom and Sweden (116).

Conversely, among the 11 European and US studies concerned with whether welfare-state policies outside the health domain counteract the effects of the market and other social forces in producing health inequality (Table 2), 5 investigations offered suggestive evidence that strong welfare states and generous social policies can dampen social inequities in health. First, a US study found that relative and absolute socioeconomic inequities in premature mortality and infant mortality, especially among populations of color, were at their lowest following the 1960s “War on Poverty,” the enactment of civil rights legislation, and the growth of the US welfare state, with these gains being reversed by subsequent neoliberal reforms (102). Second, in a cross-national comparative study, Olafsdottir (42) reported that current relative socioeconomic inequalities in self-rated health are lower in social democratic Iceland than in the United States. A third study documented that relative education- and income-based health inequalities grew less in Nordic countries than elsewhere in Europe (117). Finally, 2 Swedish studies found protective effects of the welfare state on infant and maternal health (118, 119). Even so, 2 European studies found that countries with different degrees of welfare-state provisions nevertheless had similar patterns of health inequities: 1 investigation compared 11 European countries on 4 measures of morbidity and observed that the Nordic countries did not have less relative education-based health inequality than the remaining non-social-democratic states (120), while in another, investigators reported that the magnitudes of health inequities for single mothers versus married mothers were similar for self-assessed health and limiting long-standing illness in Finland and Britain, despite the 2 countries’ different policy provisions for single mothers (121, 122). Additionally, investigators in 3 studies reported increases in health inequities following expansion of the welfare state in Spain (123), Finland (124), and Norway (125).

Only 3 studies, all based in the global North, explicitly tested hypotheses regarding the impact of welfare regime type on health inequality (per hypotheses 1.1–1.4 in Table 1). All 3 focused on education- and class-based relative or absolute inequities in self-rated health, limiting long-standing illness, or self-reports of physical functioning. In 1 study, investigators reported that associations between affluence and health were greater in liberal welfare states (e.g., the United States and the United Kingdom) than in social democratic (e.g., Sweden) and conservative (e.g., Germany) welfare states (126); in another, by contrast, researchers found that relative education-based health inequities were highest in both Southern Europe and, surprisingly, Scandinavia (29); and in the third, investigators reported that the observed relative class-based health inequities were more similar across regimes for men than for women (127).

Political incorporation of subordinated groups
Finally, only 7 studies examined whether political incorporation was associated with the magnitude of health inequities (per hypotheses 2.4 and 5.1–5.4 of Table 1), of which 6 found that—assuming use of an appropriately long time frame—increased political incorporation was associated with reductions in relative and in some cases absolute health inequities. With regard to racial/ethnic inequities, the previously mentioned US study found sharp reductions following the 1960s “War on Poverty” and enactment of civil rights legislation (102). By contrast, investigators in 2 studies reported that the dismantling of apartheid in South Africa in the post-1990 period was not associated with reductions in racial/ethnic inequities in physical growth in infancy or infant mortality (128, 129); in a third study, expanding the time frame back to 1970 showed that racial/ethnic disparities in South African infant and child mortality have declined (130). In the case of indigenous populations, research in New Zealand found that Maori-European relative and absolute health inequities widened following neoliberal reforms (104) and also that Aboriginal health disparities in Australia grew during a period of policy inattention (131). Additionally, in the case of gender, 1 recent analysis of 61 countries found that gains in women’s political representation (e.g., election of women to the national parliament) were associated with lower rates of femicide (conceptualized as an extreme form of patriarchal repression) (132), and a separate analysis of 51 countries reported that increases in female autonomy and maternal education reduced socioeconomic inequalities in child mortality (133).

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DISCUSSION

Our central finding is that while there is no simple or single relation between type of state, political priorities, and the magnitude of health inequities, there nevertheless are common threads. Among these are: 1) the transition to capitalism (as observed in the 1980s and 1990s in Central and Eastern Europe) has probably expanded relative education-based health inequities; 2) neoliberal (market-oriented) reforms have either exacerbated or entrenched existing relative and absolute health inequities, and certainly have not reduced them; 3) within wealthy nations, the association between the type of welfare state and the magnitude of health inequities appears to be weak, especially for education-based inequity; and 4) democratic incorporation, if considered in relation to a long time frame, can lead to reduced relative and absolute health inequities.

Considered together, these modest results from this new literature imply that major changes to the status quo (and cross-polity differences in the status quo) can affect the magnitude of health inequities, for bad and for good. They also hint that determinants of the magnitude of health inequities may differ for rich societies versus poor societies, with the caveat that research comparing a large number of poorer and richer societies is just beginning (39).

Of course, any inferences based on the 45 studies we reviewed are constrained by important limitations in the extant research. In addition to most of the studies’ being focused only on the global North, relatively few of the investigations explored multiple dimensions of social inequality, allowed for contradictory effects of politics and policy on health inequities, attended to life-course processes and lagged effects, incorporated measures of political mechanisms, assessed both relative and absolute inequalities, or employed multilevel techniques in the empirical analysis; only 1 considered birth cohort effects. The implication is that understanding of relations between political systems and health inequities would be improved by development and implementation of a systematic research agenda. We view the literature we reviewed as a promising point of departure.

Research agenda
The first task is theorizing: Before we can progress much further toward generating actionable and theoretically sound knowledge, we need to get the questions right. Here, we propose a theoretically informed research agenda—drawing on the social epidemiology and political sociology theories we have described, coupled with careful attention to: 1) spatiotemporal scale, level, and time frame (e.g., life course, historical generation), 2) choice of health outcomes, and 3) inclusion of polities, political determinants, and specification of political mechanisms—to address the enormous gaps in knowledge we identified. Although this agenda carries methodological implications, we focus our discussion below on the sorts of questions that should be addressed to fill the gaps in the literature we identified.

Spatiotemporal scale, level, and time frame.

In conceptualizing the processes that translate politics to health inequities, ranging from macro-level political context to lived experiences and qualitative meanings (58, 134), we start by urging more rigorous theorizing about relevant spatiotemporal scales and levels (64). Embodiment takes time (7, 135, 136), yet very few of the 45 studies we reviewed took into account etiologic period, cumulative exposures, or lagged effects. Additional aspects of the “when” questions also needing more careful theorizing include birth cohort effects, life-course implications of the timing of exposures, and possible period effects, including such issues as radical disjunctures and tipping points. With regard to levels, theorizing needs to consider not only within- but also between-country processes, including those operating at the global level of the health distribution, since so much of “total world health inequality” is driven by growing international inequality in health (39, 137). Recognizing that the political factors that matter for international health inequities may or may not be the same ones that drive health inequity within nations (123, 138), research is needed on the role of inequality in access to and participation in global institutions (52, 139, 140) in generating and perpetuating the patterns of global health inequality. Complicating this task is the scarcity of cross-nationally and longitudinally comparable data, such that part of the research agenda we are advocating includes investment in data collection and dissemination for monitoring health inequities, especially outside the set of rich countries typically featured in this research.

Choice of health outcomes.

Existing research has also been relatively restricted in the range of health outcomes that have been analyzed. All-cause, premature, and less frequently cause-specific mortality, along with self-assessed health, dominate the empirical literature. In the case of mortality, more attention to etiologic period is warranted: Whereas deaths due to injuries, violence, and some causes of preventable death can probably be linked to temporally proximate or even concurrent conditions, others are likely to require consideration of longer lag times, as also shaped by birth cohort (89, 108, 141). Population-based data on somatic disease occurrence and health behaviors would be helpful for refining the picture (142), as would data on mental health (44, 143–145); as Sydenstricker (146) noted over 75 years ago, in answer to critics who claimed that the health consequences of the Great Depression were small because mortality rates barely budged, the first place to detect an association is not mortality but morbidity—which he and his colleagues found (147). Additionally, the limitations of relying exclusively on self-reported health status need greater emphasis, given concerns about both potentially incommensurable meanings and differential correlations with measured health status across social groups (148–150), despite the predictive power of self-reported health in some contexts (151, 152). Greater consideration also needs to be given to the selected outcome’s baseline rate and to secular trends within social strata (e.g., rising or falling, including potentially even reversing, associations with social position, as has occurred with smoking and smoking-related diseases (58))—since all can affect the likelihood of detecting both cross-sectional differences and temporal changes in the magnitude of health inequities. In other words, more attention to theorizing about the diverse pathways of embodiment whereby politics translates into health inequities is needed, so that the partial patterns revealed by any 1 outcome in any given age group and birth cohort can be interpreted in context.

Inclusion of polities, political determinants, and specification of political mechanisms.

As our review of the nascent literature on the political production of health inequities makes clear, future work should include more polities from the global South. Doing so is critical in order to evaluate the generality of findings from the global North, evaluate untested hypotheses from Table 1, and fill in the empirical gaps, on both cross-sectional comparisons and historical trends, as identified by our review of the existing research.

Also striking is how the empirical literature to date has focused on a relatively narrow range of political determinants of health inequities, with most studies pursuing only a small handful of the admittedly small number of plausible hypotheses we sketch in Table 1. To expand the repertoire, researchers could take advantage of the progress made by political sociologists and others in measuring various aspects of the transition to capitalism, neoliberalism, the welfare state, and incorporation of subordinated groups (45, 56, 71, 153–155) and include these measures in quantitative models. Examples of more familiar welfare-state determinants that could be studied include: corporatist economic regulation (56), employment policy (especially the move toward part-time employment in many European countries (156, 157)), changes in pension policy, private social provisions, and shifts in the monetary regime (158), and decommodification and recommodification of labor (45, 69). Additional, less-considered determinants include: construction of regional political-economic structures like the European Union (53), trade liberalization (159, 160), war (161), human rights (162, 163), citizenship and migration policy and racialization of the state (164), and corporate regulation (165). Many of these policy changes can be connected to health through their impact on economic, racial/ethnic, gender, and sexuality-based inequality (166)—as well as other intersections of institutional arrangements and social inequalities (41). Use of political contextual analysis (167) could likewise inform richer choices of political determinants selected for inclusion in quantitative analyses.

It is also essential to examine how the political context matters for health inequity at various points in the distribution of social inequality. As Alderson et al. (50) noted, theories of the political (and economic) determinants of inequality imply change at different points of the (income) distribution, with some theories suggesting faster income growth among the rich and other theories predicting slower income growth among the poor. These ideas should be extended to understanding health inequity, because it is quite likely that the impact of politics and policy varies across the stratification structure of society. For example, welfare-state enhancements include not only universalistic programs, intended to be of benefit to all, but also programs directed toward those most harmed by social inequality—for example, community health centers placed in impoverished neighborhoods, which presumably would contribute to improving health status only among persons accessing those services. Conversely, welfare-state retrenchments could be hypothesized simultaneously to harm the health of persons with fewer resources while improving the health of those with more resources (38, 39). The implication is that political systems may shape the magnitude of health inequities via different factors acting within and across different economic and social strata, as opposed to these inequities’ being produced by 1 unitary “fundamental” “cause.” Yet, as our review makes clear (see Table 2), too few studies include measures of mechanisms in their empirical models.

Conclusion
In summary, our reading of the theoretical and empirical literature on the political production of health inequity tells us that new research which combines the strengths of political sociology and social epidemiology is practically feasible, theoretically valuable, and policy-relevant. We already have substantial evidence that health inequity is neither natural nor inevitable but significantly the product of politics. As our literature search also reveals, the political determinants of health inequities are alterable, since people have changed them, for bad and for good, both from the “top down” and from the “bottom up.” Consequently, to help promote health equity, the next step empirically is to refine the research questions and methods by specifying the “where,” “when,” “how,” and “who” of the complex political processes producing health inequities. Of course, these questions inevitably raise thorny ideological issues (168, 169), to which a useful response is to specify the kinds of empirical evidence on falsifiable hypotheses that can inform these debates.

The ultimate value of the proposed research is that knowledge about the political predictors of health inequity is actionable, in the sense that it shows which political systems, priorities, and policies are productive in reducing health inequities and which are implicated in expanding such inequities. If the former policies themselves result in part from the mobilization of disempowered groups (e.g., the labor movement, the feminist movement, and the civil rights movement in the United States) and the latter from the mobilization of persons with power, then identification of these political predictors about the balance of power can inform discussions of strategies for reducing health inequities. Power, after all, is the heart of the matter—and the science of health inequities (169) can no more shy away from this question than can physicists ignore gravity or physicians ignore pain. To understand and alter the afflictions that fall upon the people, epidemiology and political sociology need each other—hence epi + demos + cracy.

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Acknowledgments

Author affiliations: Department of Sociology, Harvard University, Cambridge, Massachusetts (Jason Beckfield); and Department of Society, Human Development, and Health, School of Public Health, Harvard University, Cambridge, Massachusetts (Nancy Krieger).

Los increíbles costos de la guerra, en vidas y en dólares,según premio Nobel de economía

Los increíbles costos de la guerra, en vidas y en dólares

La pérdida de poder, un efecto de los atentados

La pérdida de poder, un efecto de los atentados

Vacuna HPV: ¿eficaz y efectiva?

05/09/2011
por Alfredo Zurita

La prensa nacional comunica el inicio de la aplicación de la vacuna HPV, para prevención del cáncer de cuello de útero a la cohorte de niñas nacidas en 2000, aseverando la vacuna es segura y eficaz, y que representa una estrategia más prometedora que el examen periódico de Papanicolau para diagnóstico precoz, el cual aunque muy efectivo, no beneficia a todas las mujeres, por barreras de acceso y déficits de calidad del proceso de toma y lectura de las muestras, según reconocen los responsables de estos programas.

Efectivamente, las mujeres en mayor riesgo de cáncer de cuello de útero, las mujeres pobres, lo cual está muy asociado a sexo inseguro, (la forma de contagio), difícilmente acceden a un examen de Papanicolau regularmente y de buena calidad, pero es un error presentar a la vacuna como Eficaz, puesto que la evidencia disponible dice sólo prevendría 70 % de los canceres de cuello de útero, y una mujer vacunada de todos modos deberá hacerse periódicamente el examen de Papanicolau, para prevenir el restante 30 %. Esto me parece la consideración más importante, además de otras varias, que deben transmitirse al público, que son las siguientes

¿La vacuna es segura?
Es decir su uso no conlleva iatrogenia?. Difícilmente podría asegurarse esto al 100 %, y han existido algunos accidentes menores, pero en las condiciones habituales de uso de las vacunas podemos afirmar que es suficientemente segura. Señalo esto porque se extiende una onda antivacunas, en la que incluso participan médicos, y que se justifica en la potencial iatrogenia de las vacunas, y filosofías naturalistas varias, así como intereses industriales incentivando el uso, más alla de las evidencias.

¿La vacuna es efectiva?
Es decir estas niñas, adultas, tendrán una menor incidencia de cáncer de cuello de útero?. Esto no se sabe, aunque es razonable suponer que si, y recién se sabrá fehacientemente algunas décadas después del inicio de su uso en forma masiva. La evidencia que existe es que es eficaz, término que utilizamos para designar un cambio inmediato, inmunológico en este caso, que suponemos reducirá la incidencia de la enfermedad en el futuro, lo que llamamos efectividad. En el caso del examen de Papanicolau esta efectividad es del orden del 92 %.

Un ejemplo aclaratorio seria que uno sale vivo de una cirugía, hay 100 % de eficacia, pero si muere al mes siguiente por la misma enfermedad que motivó la cirugía, la efectividad es del 0 %.

Normalmente la efectividad de las vacunas se prueba en forma rápida, porque el periodo que transcurre entre el contagio y la aparición de la enfermedad es de pocos días, pero el caso del cáncer de cuello de útero es mas complejo, porque este periodo dura décadas, lo cual posibilita la detección precoz mediante la prueba de Papanicolau, pero dificulta ahora la prueba de efectividad.

Deberíamos esperar que la experiencia en otros países muestre efectividad para iniciar la vacunación aquí?

Como toda decisión medica se debe tomar en condiciones de incertidumbre. Tampoco había prueba de efectividad cuando se decidió generalizar la prueba de Papanicolau, que décadas después mostró ser efectiva.

Otra información errónea es también decir que la vacuna es gratis. No es así, se pagara con el presupuesto, por tanto con impuestos, y algo se dejara de hacer.

El elevado costo de la vacuna crea por tanto interrogantes sobre costo de oportunidad, es decir, es aplicar en forma masiva la vacuna HPV mas efectivo que mejorar la cobertura y calidad del examen de Papanicolau?.

Hace cinco años el ministerio nacional decidió no incorporar la vacuna por razones de costo efectividad, y ahora decide que si, las evidencias científicas no han variado, pero quizás si la disponibilidad de recursos, o quizás otras razones no ligadas a la ciencia.

Alfredo Zurita
Profesor Titular de Salud Pública
Facultad de Medicina
UNNE