Health in Brazil 6 Health conditions and health-policy innovations in Brazil: the way forward

Brazil is a large complex country that is undergoing rapid economic, social, and environmental change In this Series of six articles, we have reported important improvements in health status and life expectancy, which can be ascribed largely to progress in social determinants of health and to implementation of a comprehensive national health system with strong social participation. Many challenges remain, however. Socioeconomic and regional disparities are still unacceptably large, reflecting the fact that much progress is still needed to improve basic living conditions for a large proportion of the population. New health problems arise as a result of urbanisation and social and environmental change, and some old health issues remain unabated. Administration of a complex, decentralised public-health system, in which a large share of services is contracted out to the private sector, together with many private insurance providers, inevitably causes conflict and contradiction. The challenge is ultimately political, and we conclude with a call for action that requires continuous engagement by Brazilian society as a whole in securing the right to health for all Brazilian people.

A Brief History of the Research and Its Ideas

This article is an introduction to the special issue of Sexuality Research & Social Policy, where we share some of the research of our project, ""Relations among 'race,' sexuality and gender in different local and national contexts."" The goal of this project was to develop broad comparative research on race, sexuality, and gender in Brazil, South Africa, and the USA. New signs of identity and contestation were noted during our research. Given the numerous and important changes which are currently in progress in these interlinked fields, we identified important connections between transformations in the symbolic order and social gains, which cannot necessarily be converted into more widespread decreases in social inequality or which can break apart forms of hierarchization and exclusion. The results of our studies in South Africa and Brazil are the focus of this special issue, given that these two contexts are less well known by the American public.

Desire, Hierarchy, and Agency: Youth, Homosexuality, and Difference Markers in Sao Paulo

In this article, we present the results of ethnographic research undertaken in areas with concentrated recreational venues frequented by diverse youth groups in the city of Sao Paulo, Brazil. This material is part of the larger ""Relationships between race, gender and sexuality in different national and local contexts"" research initiative. Here, we focus upon data collected through ethnographic observation and interviews conducted in various locales where young men meet to engage in homoerotic sociability, demonstrating different degrees of conviviality among groups of different socioeconomic profiles and distinct esthetic preferences, consumer habits, and body types. We explore the production of styles and body presentations that link markers of color/race, gender, and sexuality, as well as the relationships that these maintain with opening or restricting possibilities for the establishment of erotic and affective partnerships involving these boys.

Transforming Youth Identities: Interactions Across ""Races/Colors/Ethnicities,"" Gender, Class, and Sexualities in Johannesburg, South Africa

In South Africa, and especially in Johannesburg, apartheid's ""racial"" paradigms are being transformed. Fifteen years after the end of apartheid and the elimination of all forms of inequity based on notion of ""race,"" including the abolition of the Immorality Act of 1949 that prohibited mixed marriages, the discourses of youth challenge preestablished boundaries. Today, the South African Constitution gives people the right to proclaim their sexual orientation and to shape their own identities. Through ethnographic observations carried out in Johannesburg and in-depth interviews with young people, this paper explores transforming notions of identity based on ""race/color/ethnicity,"" gender, class, and sexuality. The dynamics and challenges faced by young people with regards to mixed interactions in post-apartheid Johannesburg are analyzed and the paper looks at how "" race,"" gender, and sexuality interact in the various spaces in Johannesburg and how they affect young people's lives, particularly their perceptions of risk, violence, and HIV/AIDS vulnerability.

Living Our Lives on the Edge: Power, Space and Sexual Orientation in Cape Town Townships, South Africa

Much of social science literature about South African cities fails to represent its complex spectrum of sexual practices and associated identities. The unintended effects of such representations are that a compulsory heterosexuality is naturalised in, and reiterative with, dominant constructions of blackness in townships. In this paper, we argue that the assertion of discreet lesbian and gay identities in black townships of a South African city such as Cape Town is influenced by the historical racial and socio-economic divides that have marked urban landscape. In their efforts to recoup a positive sense of gendered personhood, residents have constructed a moral economy anchored in reproductive heterosexuality. We draw upon ethnographic data to show how sexual minorities live their lives vicariously in spaces they have prised open within the extant sex/gender binary. They are able to assert the identities of moffie and man-vrou (mannish woman) without threatening the dominant ideology of heterosexuality.

Cost risk benefit analysis to support chemoprophylaxis policy for travellers to malaria endemic countries

Background: In a number of malaria endemic regions, tourists and travellers face a declining risk of travel associated malaria, in part due to successful malaria control. Many millions of visitors to these regions are recommended, via national and international policy, to use chemoprophylaxis which has a well recognized morbidity profile. To evaluate whether current malaria chemo-prophylactic policy for travellers is cost effective when adjusted for endemic transmission risk and duration of exposure. a framework, based on partial cost-benefit analysis was used Methods: Using a three component model combining a probability component, a cost component and a malaria risk component, the study estimated health costs avoided through use of chemoprophylaxis and costs of disease prevention (including adverse events and pre-travel advice for visits to five popular high and low malaria endemic regions) and malaria transmission risk using imported malaria cases and numbers of travellers to malarious countries. By calculating the minimal threshold malaria risk below which the economic costs of chemoprophylaxis are greater than the avoided health costs we were able to identify the point at which chemoprophylaxis would be economically rational. Results: The threshold incidence at which malaria chemoprophylaxis policy becomes cost effective for UK travellers is an accumulated risk of 1.13% assuming a given set of cost parameters. The period a travellers need to remain exposed to achieve this accumulated risk varied from 30 to more than 365 days, depending on the regions intensity of malaria transmission. Conclusions: The cost-benefit analysis identified that chemoprophylaxis use was not a cost-effective policy for travellers to Thailand or the Amazon region of Brazil, but was cost-effective for travel to West Africa and for those staying longer than 45 days in India and Indonesia.

Forest Policy Reform in Brazil

Rapid deforestation in the Brazilian Amazon, caused by economic, social, and policy factors, has focused global and national attention on protecting this valuable forest resource. In response, Brazil reformed its federal forest laws in 2006, creating new regulatory, development, and incentive policy instruments and institutions. Federal forestry responsibilities are maintained within the ministry of the environment; its regulatory agency responsibilities are divided among three different branches of the agency; many powers are delegated to states and municipalities; and a new private concession system is being developed. These reforms offer promise to improve forest protection and management in Brazil but must overcome significant institutional and social resistance for success.

THE POLICY AGENDA OF ISPRM

This paper suggests a comprehensive policy agenda and first steps to be undertaken by the International Society of Physical and Rehabilitation Medicine (ISPRM) in order to realize its humanitarian, professional and scientific mandates. The general aims of ISPRM, as formulated in its guiding documents, the relations with the World Health Organization (WHO) and the United Nations system, and demands of ISPRM`s constituency herein form the basis of this policy agenda Agenda items encompass contributions to the establishment of rehabilitation services worldwide and the development of PRM societies ISPRM`s possible input in general curricula in disability and rehabilitation, and in fighting discrimination against people experiencing disability are discuss. Moreover, the implementation of the International Classification of Functioning. Disability and Health (ICF) in medicine, contributions to WHO guidelines relevant to disability and rehabilitation the provision of a conceptual description of the rehabilitation strategy and the outline of a rehabilitation services matrix are seen as important agenda items of ISPRM`s external policy. With regard to its constituency and internal policy, a definition of the field of competence and a conceptual description of PRM, as well as the development of a consistent and comprehensive congress topic list and congress structure appear to be crucial items. The proposed agenda items serve as a basis for future discussions.

DEVELOPING THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE (ISPRM): FOLLOWING THROUGH

In 2008 the International Society of Physical and Rehabilitation Medicine (ISPRM) started an initiative to systematically develop its capacity and its internal and external policy agenda. This paper sums up achievements that have been made with this ISPRM initiative as well as pending issues and strategies to address them. The paper treats the following: ISPRM`s policy agenda in collaboration with the World Health Organization (WHO), research capacity in functioning and rehabilitation, ISPRM world conferences, relationships with regional societies of Physical and Rehabilitation Medicine (PRM), and ISPRM`s membership and governance structure.