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A Century of Public Health in the Americas

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A Century of Public Health in the Americas Chapter 1 A Century of Public Health in the Americas Health is a powerful tool for making a safer and INTRODUCTION durable world for all. For those who really want to ‘‘talk the talk’’ and ‘‘walk the walk,’’ it is a moral The Region of the Americas is a geographically vast, imperative to make inequities visible. (1) historically rich, and ubiquitously beautiful land. It Mirta Roses Periago, also is a region of stark and contrasting realities—in Director, Pan American Health Organization its population’s health and human development and Health in the Americas, 2012 Edition: Regional Volume N ’ Pan American Health Organization, 2012 HEALTH IN THE AMERICAS, 2012 N REGIONAL VOLUME in the interplay of social, economic, environmental, predominantly rural to being predominantly urban and political determinants. These disparate traits (4, 5). have been increasingly scrutinized, documented, The Region of the Americas has made and targeted since the Pan American Health remarkable strides in population health. In the last Organization (PAHO) came into being in 1902. 110 years, the infant mortality rate decreased from Without question, in the intervening 110 years the 167.4 per 1,000 live births in 1900 (229.1 in Latin Region has made remarkable strides in improving America and the Caribbean; 145.0 in North the health of its people. But inequities persist, and America) to 15.2 in 2010 (20.3 in Latin America this fact will inspire and guide the Region’s collective and the Caribbean; 6.6 in North America): that is, effort to usher in a better future—a future that is on average, an astounding 11-fold reduction (22-fold healthier, wealthier, fairer, and more equitable. in North America) in the absolute risk of dying At the beginning of the 20th century, there before reaching age 1 (Figure 1.2, left scale). In were 194 million people living in the Region simpler terms, in 1900, one out of every four babies (102 million in North America and 92 million born in Latin America and the Caribbean and one in Latin America and the Caribbean). By 2010, out of every seven babies born in North America North America’s population had tripled, and the would not live to see their first birthday. A century population of Latin America and the Caribbean and a decade later, 99% of babies in North America had grown six-fold; the Region’s population is and 98% of babies in Latin America and the expected to reach one billion in seven years (2, 3). Caribbean have already survived beyond their first In 1900, the Region was beginning to confront the first wave of globalization that followed the great FIGURE 1.2. Historical trends in infant mortality level and inequality, Region of the Americas, industrial revolution of the late 1800s; in 2010, the 1900–2010. Region faced the second globalization wave that 200 -0.5 a Infant mortality level followed the great technological revolution of the Infant mortality inequality -0.4 late 20th century . Back in 1900, the median age was 150 -0.3 23 years and the ageing index was 14 (in other 100 words, there were 14 people aged 65 and older for -0.2 50 every 100 people younger than 15). By 2010, the -0.1 Infant mortality rate (per 1,000 population) median age was 31 years and the ageing index 0 0.0 Health concentration index 1900 1925 1950 1975 2000 2010 was 37. Moreover, in the intervening 110 years, Source: Reference (7). the population structure changed dramatically a Total population as proxy for live-birth population. (Figure 1.1) and massively shifted from being FIGURE 1.1. Population structure, by age and sex for main subregions, Region of the Americas, 1900 and 2010. 1900 2010 Latin America and the Caribbean/North America Latin America and the Caribbean/North America 80+ 80+ 75-80 Males Females 75-80 Males Females 70-74 70-74 65-69 65-69 60-64 60-64 55-59 55-59 50-54 50-54 45-49 45-49 40-44 40-44 35-39 35-39 30-34 30-34 Age (years) 25-29 Age (years) 25-29 20-24 20-24 15-19 15-19 10-14 10-14 5-9 5-9 0-4 0-4 8%6% 4%2% 0% 2% 4% 6% 8% 8%6% 4%2% 0% 2% 4% 6% 8% Population per 100 of both sexes Population per 100 of both sexes Source: United Nations Population Division. Pyramids generated by PAHO/WHO with Epidat 4.0H, 2012. $2 CHAPTER 1 N A CENTURY OF PUBLIC HEALTH IN THE AMERICAS year of life and have a very good chance of making it FIGURE 1.3. Historical trends in inter-country through childhood, adolescence, adulthood, and old income level and inequality, Region of the age. Americas, 1900–2010. a Life expectancy at birth rose from 40.9 years in ) $ 16,000 1.0 Income level 14,000 1900 (48.0 in North America; 29.2 in Latin America Income inequality 0.8 and the Caribbean) to 75.8 years in 2010 (78.6 in 12,000 10,000 0.6 North America; 74.2 in Latin America and the 8,000 0.4 Caribbean): that is, a solid absolute gain of 35 years 6,000 0.2 Gini coefficient in the expectation of life at birth (31 in North 4,000 2,000 0.0 America; 45 in Latin America and the Caribbean), GDP per capita (constant i 1900 1925 1950 1975 2000 2010 which is, on average, just 15% short of doubling it Source: Reference (7). from the previous century (6, 7, 8). In other words, a a In 1990 international Geary-Khamis dollars. baby born in the Americas in 1900 had only 41 years to live, learn, work, start a family, and contribute to society; a baby born this very day in our Region will These gains notwithstanding, the Americas live almost twice that long and will probably be able also experiences—simultaneously and contrastingly— to see his children and perhaps even his grand- persistent inequities both in its health and in its children grow and become parents themselves. social realms. In fact, there is plentiful evidence Thanks to the welcome availability of sound, currently available that points to the latter as being comparable, historical data series,1 it now can be determinants of the former: persistent social inequi- documented that those remarkable strides in the ties are determinants of persistent health inequities. Region extended beyond the health of its population, With this understanding, unambiguously advanced reaching its major determinants, as epitomized by by the WHO Commission on Social Determinants the trends in income and education (7, 9, 10). From of Health, comes the realization that the reduction 1900 to 2010, the income per capita (in purchasing and elimination of health inequities only can be power-comparable, inflation-controlled 1990 Geary- attained by acting on the social determinants of Khamis dollars) (11) rose, on average, fivefold, health across the whole spectrum of the social from GK$ 2,921 to 15,660 (from GK$ 4,012 to gradient. 30,596 in North America; from GK$ 1,196 to 6,973 An exploratory analysis of the available histor- in Latin America and the Caribbean) (Figure 1.3, ical country-level data (12) shows that, despite the left scale). In the same period, the national primary documented rise in income level, the inter-country education enrollment ratio of the population aged income inequality, as measured by the Gini coeffi- 5–14 went up, on average, from 61.1% (94.7% in cient, barely changed during the historical period North America; 18.7% in Latin America and the examined. In 1900, this Gini index was 0.40; in Caribbean) to 96.8% (97.9% in North America; 2010, it was 0.44 (Figure 1.3, right scale). Moreover, 96.2% in Latin America and the Caribbean), which in 1900, the income share for the countries in the speaks to the remarkable expansion—particularly poorest quintile of the population was 6.3%, and that in Latin America and the Caribbean—of human of the richest was 7.4 times greater (the so-called capital in the Region. Kuznets ratio). In 2010, the share of the poorest quintile was down to 5.3% and that of the richest quintile was now 9.6 times greater. 1 The reader is directed to the list of references at the end Consistent with the social determination of of this chapter, including Maddison’s, Benavot-Riddle’s, health approach, these historical inequalities in the Montevideo-Oxford’s, Sa´nchez-Albornoz’s, and Abouharb-Kimball’s databases, among others listed there. distribution of income (and wealth) in the Americas The numerical estimates and aggregates offered here may reproduce—determine—inequalities in the distribu- differ from others presented elsewhere in this publication. tion of health. In an analogous methodological $3 HEALTH IN THE AMERICAS, 2012 N REGIONAL VOLUME approach, the inequality in the absolute risk of dying different American republics’’ charged with creating before age 1, as measured by the concentration index agreements and regulations and convening periodic of the infant mortality rate, has not improved in the conferences on health. To this end, the First General last 110 years, again despite the remarkable success International Sanitary Convention of the American in reducing the average infant mortality rate high- Republics was held on 2 December 1902 in lighted above. In fact, the relative health inequality Washington, D.C. The convention established the seems to be worsening: back in 1900, the health International Sanitary Bureau, which was renamed concentration index was –0.15; in 2010 it was –0.29 the Pan American Sanitary Bureau in 1923 and (Figure 1.2, right scale).
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