Noncommunicable diseases: more things in heaven and earth than are dreamt of?

Macinko & Mullachery 1 analyzed data from Brazil's first two Brazilian National Health Surveys (PNS), conducted in 2013 and 2019 and coordinated by the Oswaldo Cruz Foundation (Fiocruz), in partnership with the Brazilian Institute of Geography and Statistics (IBGE).The authors sought to test two relevant socio-epidemiological hypotheses.The first hypothesis was that over the six years between the two surveys, economic recession, deteriorating socioeconomic conditions, and weakened social policies increased the prevalence of noncommunicable diseases (NCDs) in Brazil.The second was that this increase mostly affected the poorer population, thus widening social inequalities for these diseases and risk factors.Although they are not comparable regarding data sources and analyses, previous work 2 had shown mixed results for an earlier period (1998-2013), when economic and social indicators were improving in Brazil: a decrease of educational disparities in the prevalence of hypertension and heart disease, but an increase in those prevalence disparities for diabetes.For a defined group of physician-diagnosed NCDs that were self-reported by survey participants at in-person interviews (with body mass index calculated based on measured weight and height), the authors observed an increase in prevalence rates from 8% (arthritis) to 24% (obesity) between 2013 and 2019.However, health inequality indexes (slope index of inequality -SII, relative index of inequality -RII, population attributable fraction -PAF, all of which are still underused with Brazilian data) showed no meaningful increase in social gradients for those diseases and risk factors.The authors acknowledged several limitations of their analyses, including the self-reported nature of most data, their cross-sectional nature, the restricted number of outcomes, and the use of education as the single marker of social position.They speculated about possible causes for the absence of growing health inequalities for the analyzed NCDs, such as detection or survival bias.However, both PNS datasets do not seem to indicate those biases.Further analyses might clarify this important issue if they explore already available data from the PNS regarding the inclusion of additional NCDs, sex-specific trends, health care details, and case stratification by clinical severity and age at diagnosis.If perhaps the next PNS is conducted 10 years after the 2013 PNS, it may give more time for the induction and latency periods needed for several NCDs to develop.Sadly, consequences of the current COVID-19 pandemic in Brazil -where, as in most countries, incidence and case fatality are higher among the poor -will most likely increase health inequalities as they will for NCDs, with sev-