Public Policies for Health Promotion in Brazil: A Look at Dengue Control

Editorial

In 2024, Brazil recorded more than a thousand deaths from dengue in the first thirteen weeks of the year, the third highest number since the beginning of the historical series in 2000. On the same date, eleven Brazilian states declared an emergency because of dengue fever [1]. Brazil’s socio-environmental conditions are highly favourable to the expansion of the Aedes aegypti mosquito, making it possible for the vector to spread since its reintroduction into the country in 1976, and since then, the mosquito has shown a high capacity to adapt to the environment created by accelerated urbanization and the new habits of the population. Dengue is vector-borne, i.e. transmitted by mosquitoes, which is why it has been perceived as a socio-environmental disease, since the high concentration of garbage in areas of urban expansion and the climatic conditions in Brazil have favored the development of the mosquito. The Aedes aegypti mosquito, which transmits the dengue virus, lays its eggs in standing water, whether it is clean or not. When the temperature is high, the eggs hatch, and in this water, the larvae develop into mosquitoes [2].

It is estimated that the origin of the mosquito is Egypt and in the 17th century, the period of the Great Navigations, the mosquito spread around the world via slave ships, since the mosquito’s eggs can resist for up to a year without contact with water [3]. In Brazil, the presence of four serotypes at the same time (DENV-1, DENV-2, DENV-3 and DENV-4) is an atypical situation, because when an individual is infected once, they become immune to that specific serotype, but remain susceptible to the others. In this way, the more serotypes in circulation, the greater the chances of those who have already been infected becoming ill again [4]. In this context, the complexity involved in an outbreak like this means that health professionals alone are unable to resolve the factors that favor the proliferation of the dengue vector, requiring broader strategies. Even more so if we consider that one in 20 people can develop the severe form, also called dengue hemorrhagic fever, which occurs after changes in blood clotting. The condition usually occurs after the second infection, when the immune system overreacts, leading to hemorrhagic complications [3].

Health emergencies, such as epidemics like dengue, Zika, yellow fever and Chikungunya, make it clear that there are problems that affect a very large number of people and are impossible to solve through individual action. In this sense, considering all the social inequalities that exist, especially in Brazil due to the plurality of social groups, the territorial extension and geographical diversity, there is a wide range of health problems that require political solutions. As such, public authorities play a role in promoting, protecting and recovering the health of individuals and the community. Public health policies are state actions aimed at improving the health conditions of the population and the environments that surround them. Public Health Policies comprise a varied agenda of issues, involving government activities carried out directly by the state apparatus and government actions that regulate and organize the state’s public functions in the area of health.

As such, public policy formulation is a process that comprises the definition of two main elements: agenda and alternatives. While the agenda involves directing attention around specific issues or problems that are considered important at a given time, as a result of political action by various actors; the focus on possible alternatives explores and draws up a possible plan for action. Both the agenda and the alternatives are determined in terms of their distinctive characteristics, in a complex combination of institutions and actors, involving technical and political elements. The definition of a problem is a fundamental element in the formation of the agenda, however, it should be considered that problems are not purely objective conditions and many are defined in politics to tension conflicts, shaped by personal and institutional interests [5].

In Brazil, due to strong pressure from the sanitarist movement, a broad social and political movement to reform the health sector, and based on the expanded concept of health adopted in the 1988 Constitution (known as the Citizen Constitution), the role of the state was established to guarantee economic and social policies aimed at reducing the risk of disease and other illnesses [6]. Since then, these public policies have been guided by the principles of universal and equitable access to actions and services and by the guidelines of decentralized management, comprehensive care and community participation, in the organization of a single health system in Brazil. With the publication of the National Health Promotion Policy (PNPS) on March 30, 2006, guidelines and actions for Health Promotion were implemented in line with the principles of the Unified Health System (SUS).

According to the Charter of the 1st International Conference on Health Promotion, better known as the Ottawa Charter, health promotion is the name given to the process of empowering the community to act to improve their quality of life and health, including greater participation in controlling this process. Health promotion is one of the strategies for producing health, that is, as a way of conceiving and operating, articulated with the other policies and technologies developed in the Brazilian single health system, contributing to the construction of actions that make it possible to respond to social health needs. The focus of health promotion is on the Social Determinants of Health (SDH), which aim to overcome inequalities and inequities in health [7].

In this way, fronts were opened up for the transfer of financial incentives, the training of professionals, the production of technical and informational materials, national plans and indicators that contributed to the strengthening and recognition of health promotion in surveillance, assistance and health care actions, especially in Primary Health Care [6]. Despite its importance, the Brazilian National Health Promotion Policy faces many challenges, such as the plurality of local living and health conditions and the inequality of health situations in the federal units. It is necessary for the various devices used by Primary Health Care professionals to take into account the aspects that give people and families existential meaning, since the essence of comprehensive health care processes concerns them [8].

In the case of the fight against dengue fever, the Brazilian government had proposed the Aedes aegypti Eradication Program (PEAa) in 1996. However, during the process of implementing the program, it became technically impossible to eradicate the mosquito in the short and medium term, due to the socio-environmental conditions favorable to its expansion. Seeking to revise its strategy for combating the dengue mosquito, in 2002 the Brazilian Ministry of Health created the National Dengue Control Program (PNCD), which seeks to incorporate the lessons of national and international experiences in controlling the disease, outlining permanent strategies, since there is no technical evidence that eradicating the mosquito is possible in the short term. The program addresses the development of information campaigns and the mobilization of people, the strengthening of epidemiological and entomological surveillance to increase the capacity for prediction and early detection of outbreaks of the disease, and improving the quality of field work to combat the vector. One of the fundamental principles of the PNCD is the integration of dengue control actions in primary care, with the mobilization of the Community Health Agents Program (PACS) and the Family Health Strategy (ESF) so that the activities of Community Health Agents (ACS) and Endemic Disease Combat Agents (ACE) are carried out in an integrated and complementary way [9].

In February 2024, the Emergency Operations Center (COE) against dengue and other arboviruses began its activities, seeking greater agility in monitoring and analyzing the scenario to contain the spread of the disease in the country. The Center aims, among other things, to coordinate response actions with state and municipal SUS managers and other public institutions. In addition, Brazil is the first country to make dengue vaccines available in the public health system, having acquired the available production of the Qdenga vaccine. The Ministry of Health has purchased 6.5 million doses of the immunizer for 2024 and 9 million for 2025 [10].

However, the Center encounters many obstacles to the success of dengue control programs, such as pending issues, characterized by the existence of closed properties at the time of the agent’s visit, or those in which the owner does not allow the agent to carry out his work (refusals), because due to the great dispersive capacity of the mosquito vector and the need for total coverage of this type of activity, the entire control effort can be compromised if the field operators do not have access to the dwellings. Sanitary control presents this dilemma, since there is a constant tension, on the one hand, in the state’s duty to adopt effective and efficient actions to combat diseases and other health problems and, on the other hand, in the state’s duty to respect citizens’ rights to freedom. These issues lead to reflections on individual freedoms, but the awareness that there are problems that are essentially public, such as the maintenance of order and public health, indicates that the solution must be found by public means [11].

It’s important to note that Brazil, like almost all of America, had already eradicated Aedes aegypti in the 1950s and 1960s, when the problem was not dengue but urban yellow fever, also transmitted by Aedes. However, this vector has not been eradicated worldwide. Thus, the return of the mosquito in Brazil has been motivated by various factors, including globalization, which has made it difficult to control the entry of the vector into the country, as well as the favourable climate and the lack of urban sanitation [3]

The disease, which used to be a feature of summer in southern hemisphere countries, has now spread to the United States and Europe. And in Brazil, dengue has started to affect regions and periods of the year that were previously immune to the presence of the transmitting mosquito, due to disorganized and exclusionary development [12]. Given the importance that the Social Determinants of Health have for Health Promotion, it is clear that the search for equity and improvement in the quality of life and health of Brazilians cannot be achieved with non-integrative social policies. The structural challenges affecting Brazil, as well as most of Latin America, are complex and require the field of health promotion to formulate care strategies that are aligned with the imperative to combat the concrete injustices of everyday life.