—from Epidemiological Bulletin, Vol. 21 No. 4, December 2000—

Health Situation Analysis in the Americas, 1999-2000

Dr. Carlos Castillo-Salgado
Chief, Special Program for Health Analysis
Pan American Health Organization

This article presents a summary of the health situation and trends in the Americas, supported by basic data provided through PAHO’s Regional Core Health Data and Country Profile Initiative and diverse national health analyses.

Demographic and Urbanization Trends
During the latter part of the twentieth century, an important demographic transition occurred in the Region of the Americas. The decline of mortality and fertility rates during the last 30 years, with an impact on population growth and structure, has led demographers to use the term “demographic transition”. In 1950, the population of the Americas was 331 million and in 1999, it was estimated at 823 million, representing nearly 14% of the world’s population. About one-third of that population resides in the United States, while another third can be found in two other countries: Mexico and Brazil. The remaining third is scattered among the 45 countries and territories in the Region.

The demographic transition in the Americas and, in particular, Latin America and the Caribbean, began with a decline in infant and child mortality. Between the periods 1980-1986 and 1990-1996, most of the countries halved their mortality rates from communicable diseases among children under 1 year of age.

The average life expectancy at birth in Latin America in the period 1995-1999 stood at 70 years, the target set by the “Strategy for Health For All by the year 2000” for the end of the century. In the Region, the range is from 54.1 to 79.2 years, a difference of more than 25 years between the region’s two extreme countries. In many countries, the internal sub-national rates vary with larger gaps, reflecting substantial differences in the relative and absolute risk of dying prematurely.

Between 1950-1955 and 1995-2000, the gap between male and female life expectancy grew from 3.3 to 5.7 years in Latin America, from 2.7 to 5.2 years in the Caribbean, and from 5.7 to 6.6 years in North America. This change in the population’s demographic profile has resulted in the aging of the general population with a concomitant increase in chronic and degenerative diseases and disabilities, which affects females more frequently.

The level of population growth resulting from the varied mortality and fertility rates characterizes the demographic transition in the Americas. Four typologies have been used to identify the level of this transition in the corresponding countries.

Group 1. Incipient transition (high birth rate; high mortality; moderate natural growth (2.5%)): Bolivia and Haiti.
Group 2. Moderate transition (high birth rate; moderate mortality; high natural growth (3.0%)): El Salvador, Guatemala, Honduras, Nicaragua, and Paraguay.
Group 3. Full transition (moderate birth rate; moderate or low mortality; moderate natural growth (2.0%)): Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Guyana, Mexico, Panama, Peru, Suriname, Trinidad and Tobago, and Venezuela.
Group 4. Advanced transition (moderate or low birth rate and mortality; low natural growth (1.0%)): Argentina, Bahamas, Barbados, Canada, Chile, Cuba, Jamaica, Martinique, Puerto Rico, United States, and Uruguay.

It has become clear that averages do not tell the whole story, therefore measures of distribution of mortality and morbidity indicators are becoming more common. Following is an example of work in this direction that involves the use of Gini coefficients (1).

Figures 1a-b present the Gini coefficients for two countries with different levels of demographic transition (moderate and advanced transition). The degree of inequality in infant mortality, as measured by the corresponding Gini coefficient, is more than two times higher in a country that is currently in a moderate demographic transition than one in a full demographic transition. It is also important to note marked differences in the magnitude of health inequalities between Latin American populations that share the same stage of demographic transition.

The regional average urban population for the year 2000 is estimated at 76.0%. However, the average is 85.3% for the Southern Cone and 48.3% for Central America. Figure 2 illustrates the distribution of urban population in some countries of the Region by geographic sub-national units ranging from 11% to 99%. The growth of urbanization in the Americas has had important health implications in the sense that it has increased the absolute risk of significant social problems, such as violence and accidents.

Health status and epidemiological polarization
Most of the health situation analyses of the countries of the Americas have highlighted the remarkable progress made during the twentieth century in postponement of death, and the increasing span of healthy life for some population groups. On the other hand, these analyses also have underscored the large disparities that still exist between the national average expected lifespan vis-a-vis that of the disadvantaged groups. Although major advances have been made in controlling infectious and parasitic diseases, these remain important causes of death with rates similar to those for non-communicable diseases.

Toward the end of the twentieth century, mortality rates have declined in virtually every country of the Americas. The average life span has increased in Latin America by 18 years in four decades. However, a unique pattern of mortality has emerged in the Region that reflects an epidemiological polarization. This epidemiological polarization is characterized by a prolonged coexistence of two mortality patterns, one typical of the developed societies (chronic and degenerative), and the other of poor societal living conditions (infectious and parasitic) combined with high mortality from accidents and violence. The relative contribution of chronic diseases to the mortality pattern is as important as that of communicable diseases. This polarization is reflected in the structure of causes of death presented in Figure 3. This profile indicates the persistence of large health gaps between different social groups and areas within countries. Not all population subgroups have achieved full access to health and adequate living conditions that are needed to sustain marked shifts in the causes of death. Increasing gaps in income and social inequalities still raise concerns because of their effect on the widening of mortality differentials in the Region.

Using national averages, between 1980 and 1999, we observe a decrease in the number of years of potential life lost (YPLL) throughout the Region. While part of this change can be attributed to the aging of the population, the principal cause was the decline in mortality in the first years of life. However, the intensity and speed of this decline was not the same in all the countries or even in different areas of the same country.

Inequalities in the risk of becoming ill and dying prematurely correlate with inequalities in the distribution of resources. For example, the infant mortality rates vary from country to country and within a given country. In several countries with a relatively high income level, this indicator ranges from 13.4 to 109.8 per 1,000 live births at the subnational level. The inclusion of a subnational disaggregation of information becomes, then, very important and quite relevant, since as indicated previously, national averages of health indicators do not reflect the heterogeneity that exists in the frequency distribution of health indicators within a given country. The observed regional and national inequalities in health are replicated with greater intensity at the subnational and local levels.

Non-communicable diseases accounted for 49.7% of the mortality of adult population in the Americas while external causes accounted for 13.8 % of deaths. In the period 1990-1995, 89% of homicide victims were males as reported in a substantial number of countries. This represented a 65% increase over the 1980-1985 level for males; for females, the increase was 30%. In all the subregions, nearly three times as many males as females died from motor vehicle accidents between 1980 and 1996.

Information from different population groups and not only national averages should be used to formulate health policies. In addition, sustained impetus is needed for local disaggregation of information for health analysis. There is pressing need for improving empirical public health information that facilitates the periodic assessment of the health situation and trend analysis of all population groups and geographic levels and not only the national averages.

PAHO’s response
One of the basic responsibilities of the Organization is to facilitate the collection and dissemination of health information and there is a long and fruitful history of PAHO’s involvement in this area in the member countries. In 1995 PAHO launched its Regional Core Data/Country profile Initiative which sought to use modern technology to systematize the collection, analysis and dissemination of essential health data. The availability of geographically disaggregated national data is essential for detecting disparities and directing resources to close those gaps that may be described as inequitable. Under the impulse of this initiative, twenty Ministries of Health have established systems for collecting, analyzing and publishing core data in a fairly uniform format.

It is now important to continue improving the comparability, validity, and reliability of health information to identify and quantify the inequalities that disproportionately affect certain segments of societies, while giving recognition to the main factors that determine health inequalities. PAHO is collaborating with national health authorities, academic institutions, and civil society groups to continue refining the methodological and operational instruments for subnational and local health assessments, as well as for the selection of appropriate and useful indicators and indices. Emphasis is being placed on useful, practical basic instruments and indices that can be applied and generated at the national level.

The Organization is committed to working toward the consolidation of health information systems and communication platforms in the member countries. This strategy will help to document the impact of health interventions on reducing the health disparities that are so much a feature of the health landscape of this Region.

This document was presented during the Pan American Health Organization's 42nd Directing Council (52nd Session of the Regional Committee). Document No. CD42/6 (Eng.)

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Epidemiological Bulletin , Vol. 21 No. 4, December 2000