Clinician, Researcher, Epidemiologist, and Primary Care ‘Rock Star’ in Brazil
Bruce Duncan is a physician and epidemiologist, born and trained in the U.S. Being of a contrarian mindset, he became the counterflux – while the life path of thousands of scientists was to immigrate to North America or Europe, his, in 1983, was to move to Brazil. He has always believed that if you are interested in global health, why not work close to where the challenges to health arise? In so doing, together with his wife and professional partner, Maria Inês Schmidt, Bruce has championed clinical epidemiology, playing a pivotal role in establishing a solid foundation for evidence-based medical practice in his adopted country. Together, Maria Inês and Bruce co-founded a master´s and doctoral program in Epidemiology and mentored many leaders of the next generation of Brazilian investigators, produced five editions of what has been for 30 years Brazil´s leading primary care textbook, and influenced patient care and policy decisions through their publications on diabetes and related non-communicable diseases.
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“We moved down here, but we weren’t really sure what to do. Brazil was in recession. It was considered the lost decade. …There was absolutely no money for research, and the universities were really in a shambles.”
“Ambulatory Medicine – Evidence-based Primary Care” was elected as the Classic Academic Book of 2024.
The Jabuti Academic Award, held by the Brazilian Chamber of Book Publishers with the support of the Brazilian Society for the Progress of Science (SBPC) and the Brazilian Academy of Sciences (ABC), is an unprecedented annual distinction aimed at academic works published in Portuguese in Brazil .
A road less travelled…Let’s start at the beginning. Tell us where it all began.
Bruce Duncan: That’s a good question. I went to law school and then decided that I didn’t want to be a lawyer, or at least initially, I was uncertain whether I wanted to be a lawyer or not. I had a friend who had been in the Peace Corps, and he stimulated me to, not exactly drop out, but to take time off and travel. This was in Berkeley, California. I spent three months working in Washington DC, at the U.S. Senate as an intern, and then put a backpack on my back and travelled around the world for nine months, spending some time in Europe, but mostly in sub-Saharan Africa, Asia, South Asia, a little bit of East Asia.
And when I came back, I really didn’t know what I wanted to do. I thought for a while that maybe I wanted to be a Buddhist monk, but a little experience trying showed me that it was not where my strengths were. I went to law school for another three months or so and decided that if I stayed there I would, just by inertia, end up in a career that perhaps I wasn’t interested in. So I quit. I was really uncertain about what I wanted to do, but I’d had a few experiences while traveling that showed me that there was an awful lot that could be done in medicine and public health in what was then called the Third World and now less developed or low- and middle-income countries, and that interested me.
I talked to my dad who was a physician, and told him that I was interested in public health, and he said, ‘Well, you know, if you want to do public health, you probably want to be a physician because, when all is said and done, most of the important positions are held by physicians.” I did all the pre-medical courses, which I hadn’t done in college as an economics major, and studied really hard and managed to get into Johns Hopkins Medical School. I ended up doing four years of medical school plus public health, an MPH, and in that process I met my wife, who is a Brazilian and who was doing a fellowship there in diabetes.
We decided to get married. She was already a university professor here in Porto Alegre so the deal was that we would stay in the States while I was doing my residency, and then we’d go to Brazil for an equal period of time and then decide what we wanted to do with our lives. She stayed and got a doctorate in epidemiology at the University of North Carolina. I did my residency, but then she wasn’t ready to go because she hadn’t finished her doctorate. I ended up on the faculty for a while at the University of North Carolina in the Epidemiology Department. And then we came down to Port Alegre, Brazil, in 1983. At that time, it was like dropping off the world. This was pre-Internet.
I’d worked in a research organization, the Lipid Research Clinics, in Chapel Hill, doing cardiovascular epidemiology research. In those days in Brazil, you’d type your paper, and then you’d send it by mail for your co-authors to review or whatever. And then you’d get it back, retype it, and send it to a journal overseas and cross your fingers. Several months later you’d hear whether it had been sent out to a review or not.
“It took over seven years to get the first edition out…It became a bestseller among students who were taking their examinations to get into residency…Readership expanded over time along with Brazil´s expanding primary care network, and the book is now in its fifth edition. Its heyday was probably the third edition when 30,000 copies were purchased by the Ministry of Health and distributed to primary care clinics around the country.”
Fior the link to the textbook on ambulatory care, see https://loja.grupoa.com.br/medicina-ambulatorial-5ed-2vols-p1018412
For a link to the ELSA cohort study, see http://elsabrasil.org/
We moved down here, but we weren’t really sure what to do. Brazil was in recession. It was considered the lost decade. Brazil had accepted all this money from major international banks, as many other less developed countries had done, and then, when it couldn’t pay, times got tough. There was absolutely no money for research, and the universities were really in a shambles. In the US, my wife had had an opportunity for a position and I could have gotten a position there on a faculty somewhere, but that really wasn’t what we’d planned to do. We had worked with the Fletchers, of clinical epidemiology fame, in Chapel Hill. But here we were, unsure of what to do.
The decision as to when to come to Brazil was made when we found out that the folks from Clinical Epidemiology in McMaster were coming to Brazil as part of a Rockefeller initiative to spread clinical epidemiology around the world, and specifically to a national course for coordinators of Brazilian master’s and doctoral programs in medicine, in Brasilia, for them to learn about clinical epidemiology from Dave Sackett, Brian Haynes, Peter Tugwell, and others. We decided we were going to go to Brazil to be monitors of the course Afterwards, when we arrived in Port Alegre, we decided that maybe we ought to teach clinical epidemiology since you don’t need much funds to do that. We developed a clinical epidemiology course, which we gave at our university, and a few folks from other states who came were very interested and they invited us to go to their universities to teach there. And over the next ten years, more or less, we developed this.
We were able to teach clinical epidemiology at universities and travel around Brazil. It was a wonderful experience. We got to know a lot of places, made some great friends, and taught a lot of clinical epidemiology, mainly at several of the major universities in Brazil. Years ago, when I tried to count, we had given, one way or another, clinical epidemiology courses to something like 5000 master’s and doctoral students, many of them at our university but at many other places, and also, to 5000 or so undergraduates, mostly medical students at our university, over the 20 – 25 years. So that’s how I got here and what we initially started on.
There’s one other thing that’s worth mentioning. Before we ‘dropped off the world’, which was my perspective at the time, I wondered what I was going to do when we got to Brazil. My wife had a teaching position here, but I had nothing. I had worked on a book by Bob Fletcher on ambulatory medicine. It was an internal medicine book. I had trained in internal medicine in Chapel Hill so, why not do a book in Brazil? When we got here, we met some university professors who considered the idea interesting, and one, Aloyzio Achutti, embraced us and put together a team of local expert consultants. We had a meeting to discuss the book, and all of them universally said no, it can’t be internal medicine; it has to be across-the-board Primary Care. I said, okay, and my wife was in this with me. But I’m not a paediatrician, I’m not a gynaecologist, so how are we going to do this? The answer was – over a very long period of time. It took over seven years to get the first edition out. We found a paediatrician who was interested in primary care to come on board with my wife and me as the editors of the book, and we put the first edition out in 1991.
It became a bestseller among students who were taking their examinations to get into residency. For residency selection in our State, the people in charge felt that primary care was important so they filled the written exam full of primary care questions, many of which came from the book. So, if you wanted to do well on the test, it would be good to read the book. Readership expanded over time along with Brazil´s expanding primary care network, and the book is now in its fifth edition. Its heyday was probably the third edition when 30,000 copies were purchased by the Ministry of Health and distributed to primary care clinics around the country. It was high times for a while. I’d go to a meeting and physicians would come up and ask to take pictures with me, like a mini rock star, although that’s long come and gone.
We felt that the book had to be based on evidence. Working in clinical epidemiology and seeing the evidence-based medicine movement, we quickly embraced it and tried to spread it at our institution and around Brazil. We decided that all of the treatments, either treating disease or preventive treatments, presented in our book needed to have a little icon that indicated the level of evidence behind the treatment. This, in a 2000 page book, is not a trivial task, and almost did us in! In the 4th edition we decided to do GRADE tables for all treatments. But, in the 5th edition, we abandoned the idea – it was really just too much. So, the textbook was about ambulatory care, or better, primary care, based on evidence.
So, we’d been involved in three major activities: One of them was teaching clinical epidemiology. One of them was this book. And the third was doing research. We had been researchers before we came to Brazil and we think of it as our bottom line. In the beginning, there was no money for research, but around the year 2000 money became available. In the early 2000s, if you remember, Brazil began taking off. Commodities were high, things were looking good, and there was a lot of money for research. We got involved in putting together a cohort study, the result of which is a 15,000 member cohort which we’ve been following for about 20 years now. (http://elsabrasil.org/)
So that’s how I got here and what I’ve done over the period of time.
“We’d been involved in three major activities: One of them was teaching clinical epidemiology. One of them was this book. And the third was doing research. We had been researchers before we came to Brazil and we think of it as our bottom line.”
The ELSA team at work and at play!
DMacA: I’ve been looking at the various cohort studies, and you’ve published an enormous number of papers from those cohort studies. You have done a lot of work on diabetes, on chronic disease, tell us about that work.
BD: My wife’s main interest, since she was a resident, is diabetes, and the bug bit me also. There was a camp for kids with diabetes in North Carolina that we went to and there I learned about taking care of diabetes. These were kids with Type One diabetes, and it was a very interesting and stimulating experience. And then my wife’s interest shifted from Type One to Type Two disease studies. She did her doctorate through a clinical trial looking at shifting insulin dosage from the morning to the evening in diabetes and got very much involved in that. And we’ve been diabetes epidemiologists from then to now.
We’ve been in Brazil since 1983, but we went back for two sabbaticals in Chapel Hill in the 90s. We worked on diabetes in the ARIC study, which is a large cardiovascular disease epidemiology study that is still ongoing.
When we thought of research here, we thought of doing research in diabetes, and we put together, with many other people a Brazilian cohort. We made sure that it had the information that was necessary to look at diabetes. And, another research focus which appeared in the midst of all this is the Global Burden of Disease (GBD) study.
Around ten years ago, we got involved in the GBD, and we’ve been very active as collaborators, particularly looking at diabetes. We put out an article a couple of years ago on diabetes in the Americas, trying to summarize where we are.
Our time now is basically spent researching, principally on diabetes and non-communicable diseases. One of the things that the GBD has been very good for is showing that in less developed countries, low- and middle-income countries, times have changed. It’s important, of course, to deal with malaria and diarrhoea and maternal and child health problems. But if you look at the GBD, if you believe in the GBD assumptions, nearly everywhere you go, chronic disease is the main burden these days. And it’s really true about Brazil. Looking at Brazil, 80% of morbidity is due to chronic diseases and 65% of the overall burden results from chronic disease. Many public health people in Brazil and around the world hadn’t woken up to that. We’ve spent a lot of our time in recent years trying to emphasize the importance of chronic disease and especially the importance of trying to get chronic disease risk factors under control because that’s something that the world’s done very poorly.
DMacA: The public health message in Brazil is very interesting and I know you’ve done quite a lot of work on obesity and the prevalence of obesity, but there seems to be an awareness in Brazil of the importance of public health, encouraging physical activity and encouraging universal health care.
BD: Brazil is an independent country. It’s sufficiently big that it can have its own vision about things and move them forward. And, certainly, Primary Care is the perfect example of that. When the high-income world was telling low- and middle-income countries that you need to privatize your health care, that you can’t do it all, that you should emphasize the basic things and let the market take care of the rest, Brazil decided, No, we need a universal health care system. And shortly thereafter, that we need a strong primary care element. And it’s a fascinating story. And, where did this start? It started in a drought in Ceará, which is one of the northeastern states, where they decided they needed lay community workers, what later became community health workers. They needed lay people to deal with the problems caused by the drought. And, that worked. And then, they thought maybe we need community health workers to deal with other problems so they had non-physician, non-nurse, laypeople, minimally trained, but well supervised, to make the connection between the people and the health care system, and that worked. This was in 1994 or so, and that gradually expanded and became Brazil’s primary health care system. Then physicians were added to it and it expanded dramatically. It went from zero teams in 1994 to, now more than 40,000 teams, which in general have a physician, a couple of nurses, and six or eight community workers that care for the population of a geographically defined area. It’s had its ups and downs, but it has really expanded. And there are many studies now that show that it has had many positive effects.
DMacA: The physical infrastructure also. There was a huge investment in primary health care centers.
BD: My son is a primary health care physician. For years he worked in Rocinha, the largest slum in Brazil, located in the southern part of the city of Rio de Janeiro. And he worked at this fancy, recently constructed health post with electronic health records and whatever. So, Brazil really invested. Things rise and fall, and the conservatives got into power and then things, to a certain extent, got stuck. There are real problems. There have always been problems with the continued under-financing of the national health system in Brazil. But it’s there; it’s working. It’s not perfect, but then what is perfect?
“Looking at Brazil, 80% of morbidity is due to chronic diseases and 65% of the overall burden results from chronic disease. Many public health people in Brazil and around the world hadn’t woken up to that. We’ve spent a lot of our time in recent years trying to emphasize the importance of chronic disease and especially the importance of trying to get chronic disease risk factors under control because that’s something that the world’s done very poorly.”
DMacA: Finally, let me ask you, because I’m so impressed with your work in clinical epidemiology, in creating this textbook so widely spread around Brazil, your research, the infrastructure, and the development of primary care in Brazil, where is it going for the future? What would you take from Brazil to the rest of the world?
BD: I think it’s going in the wrong direction, to tell you the truth. I think the social media folks, fake news, and the Alt-Right have been taking over, and public health is obviously not one of their big issues. I worry that science is increasingly discredited.
In fact, in many ways, the world is not going in the right direction. We’re currently in the midst of this huge flood here, with half a million people in my state, Rio Grande do Sul, currently out of their homes. So, climate change, the response to climate change, planetary health, all these are really important issues that, we need to see acceptance of and movement on. And frequently what we see, instead, are culture wars and people with other secondary interests diverting the population’s attention from the real problems which face us now, which are enormous. Hopefully, Brazil will continue its primary care. No one in Brazil questions the legitimacy, the importance, the necessity of a strong primary care system. Hopefully other countries can look and see what they have and what they don’t have and what Brazil has.
I had the opportunity, in a research consortium, to travel to Mexico, India, and South Africa. Mexico has a national health system. It’s not as strong as Brazil’s, but it’s there and it can be stimulated to do the right thing. In Brazil, and I imagine it’s common in other countries, there are a large number of physicians. Brazil may now have more medical schools than the United States. Left on their own, many physicians will go in the wrong direction. You need to make money somehow, so maybe many will take up prescribing alternative therapies, such as ones taking those spike proteins out of your blood. There’s a lot of that stuff around. A National Health System manages to guide medical care, at least that prescribed by those who work in the health system, to be evidence based, which is fundamental. Seeing how people with diabetes get their care in South Africa or in India, it’s worth crying about. In Brazil, that’s not the case. If you need insulin, you can get insulin. You cannot get SGLT2 inhibitors or GLP-1 agonists, but you can get the basic medicines. The system provides that, and it’s impressive. You can treat hypertension for $1.50 a year or something ridiculously inexpensive like that. So, it makes a lot of sense to have a national health system.
A lot of what I would like to do is to continue to stimulate that, continue to emphasize, not just treating disease but preventing disease because there’s so much that can be done. It makes so much sense to do that.
DMacA: Bruce, thank you very much for sharing so much of your life and your career and for your tremendous leadership. And what you have done, not just in Brazil, but in your leadership in medicine worldwide. It’s just been a pleasure talking to you. Thank you very much indeed.
