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3.The stroke problem in Brazil (by Dr. Octávio Marques Pontes Neto)

Stroke, cerebral ischemia, faint, thrombosis, congestion, whatever. None of the 28 different denominations utilized in Brazil referring to stroke could reflect the impact of this disastrous disease in our country. Stroke is the leading cause of death in Brazil! And for at least 20 years. Every 5 minutes, one person dies of a stroke in Brazil, totalizing more than 100.000 deaths every year. The disease is also the leading cause of disability in adults. Each year, it removes thousands of Brazilians from work leading them restricted to a bed, incapable of walk, take a shower or eat without help and, therefore, without dignity. But it couldn"t be that way...

Caused in its majority of cases because of the obstruction of an artery that irrigates the brain, stroke could present itself acutely with a variety of symptoms: weakness or numbness at one side of the body; trouble speaking or to comprehend; loss of vision; coordination difficulty; explosive headache. Similar to an earthquake that precede a Tsunami, these initial symptoms should be understood as a warning for a tragedy. The stroke patient that do not seek medical attention quickly has the serious risk of dying or to become highly disabled forever. Unfortunately, these warning signs are ignored by the general population, that only seek medical attention in the next day, when there is very little to be done.

Stroke already has treatment and is a medical emergency. There are specific medications that if administered at the first hours of symptoms onset are able to open the obstructed artery restoring the blood flow to the affected brain area. Therefore, the blood returns to flow to the brain, bringing oxygen and essential nutrients to its normal functioning. These treatment called thrombolysis (-throm = clot; -lysis = break) was cientific approved in the United States of America 14 years ago and changed the way we treat stroke worldwide. Thrombolytics are also used to treat myocardial infarction for almost 20 years. Different studies from a lot of countries has shown that it is cost effective, decreases disability and mortality rates, saving great amount of  funds that are been used today to treat stroke related illnesses and disability. That is the reason why in developed countries, where stroke is the second or third cause of mortality, stroke is been faced with great importance by national authorities, with great investments towards its prevention and treatment. However, the reality in Brazil is still very different.

In our country stroke is systematically forgotten by the public health managers. Even though the thrombolytic therapy (rt-PA) for stroke is available in Brazil since 2001, it is not funded by the public health system and just a minority of patients is treated with rt-PA. While some private hospitals in the south and southeast of Brazil 30% of patients are treated with thrombolytic therapy, less than 1% of patients depending on the public health system receive adequate thrombolytic treatment, usually at university hospitals that could relocate funds from another secttors. Besides, there is not sufficient stroke units, each means specific units with interdisciplinary professionals trained and qualified to stroke management. Stroke units had demonstrated to be effective to reduce mortality and disability in developed countries.

This is one fact that demonstrates the enormous social disparity in Brazil. Stroke affects more dramatically Afro-Americans and people with poor income. Patients with stroke accumulate on overcrowded emergency departments of the public health system, without treatment, with deficits and sequel that could be prevented if the disease was faced with seriousness by the government. Actually Brazil has more in common with the BRIC emergent countries (Brazil, Russia, India and China) than just the will to increases its share of the international commerce. The alarming burden of stroke in those countries is not a coincidence. It is not by chance that these countries are included between the 10 countries with the highest stroke mortality in the world. The combination of increased life expectancy, aging population and cerebrovascular disease neglect has caused increasing mortality by those diseases on emergent countries.

Aiming to modify the great social and economical impact of stroke in Brazil the Health Ministry Emergency and Urgency General Coordination began in July of 2008 , under coordination of Dr. Cloer Véscia Alves, at that time Emergency and Urgency General Coordinator, to implement the Stroke Treatment National Network. The objective was to develop a program of stroke treatment aiming to contemplate all the levels of treatment: general population awareness, pre-hospital care, hospital care, rehabilitation and prevention. The final fase of the project is the organization of the urgency network, improving hospital capacitation all over the country and linked with the SAMU (pre-hospital care) enabling stroke treatment under international patterns of care and offering thrombolysis to specific patients. The organization, capacitation, tecnical advise and monitorization of the system is supported by the greatest vascular neurologists in the country. (members of the ABN/SBDCV), forming the Brazilian Stroke Network (REDE BRASIL AVC), with the main objective to improve stroke care, education and research. All the project is been organized with cooperation of the state and municipal health departments, public and private hospitals already showing improvements in stroke care and minimizing stroke disability. After 18 months evaluating the national picture with more than 15 states visitated and more than 50 hospitals included in the project, with different levels of organization, in September 2009 the national project was interrupted by the goverment.  The  Brazilian Academy of Neurology/Brazilian Cerebrovascular Diseases Society view is that the organization and structuration of stroke care network should be prioritized involving all levels of patient care: general population education, primary and secondary prevention, pre-hospital care, rehabilitation and social reintegration, with implementation of a better care supported by the scientific evidences, like it"s been done in the National Stroke Treatment Project, although canceled by the government the project shall continue by the Brazilian Stroke Network supported by Brazilian Academy of Neurology and Brazilian Cerebrovascular Diseases Society.

Stroke is responsible by 100.000 deaths annually but is only cited by the general media when it does famous victims like the deceased deputade Clodovil. Enough with stroke neglect... Next Outober 29, world stroke day, the Brazil should awake up. Stroke should be interpreted as an epidemic and public health emergency. It is essential to change the way this disease is faced in Brazil. Continue under penalty of being swept away by this announced tsunami.

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