Annual Report of the Director 1996

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The Health Situation

HEALTHY PEOPLE AS A FUNCTION OF HEALTH STATUS

A population's health status is a complex, multidimensional process that refers to the set of health conditions that are present in a given space/population and that enhance or hinder the level of physical, mental, and social well-being of its residents. In practical terms, identifying healthy people requires the observation of their health status, as measured by a set of basic indicators in a defined, dynamic space/population. Using available data, this chapter seeks to provide an analytical description of the health status of the Region's countries in terms of four basic indicators: infant mortality, life expectancy at birth, total fertility rate, and the ratio of physicians to inhabitants.

Infant mortality, expressed as a rate per 1,000 live births, is a meaningful indicator of health status, and the 48 countries and territories reporting data show broad disparities in this regard. Although the median for the Region is 19.0, a newborn in a Group I country such as Canada or the United States lives in an environment that offers him or her a probability of survival past the first year of life that is 10 times greater than that for a child born in a Group V country, such as Bolivia or Haiti. The maximum and minimum values for this indicator are 7.0 for Group I and 74.0 for Group V.

Map 1 and Table 2 show these disparities more clearly. Throughout the Region, only seven countries reported infant mortality rates lower than 12.0 (quintile 1, least inequity); these countries are home to approximately 305 million persons, or 39.5% of the Region's total population. Nine countries have infant mortality rates that are higher than 43.1 (quintile 5, greatest inequity); these countries are home to 233 million persons, or 30.2% of the population of the Americas. Map 1 shows that infant mortality within each country shows the same patterns of inequality as the regional analysis. In Argentina, a Group II country, 6 out of 24 provinces have infant mortality rates between 12.0 and 17.9 per 1,000 live births; 7 million persons, or 20.1% of the country's total population, live in this area. However, in 12 provinces, with 59.8% of the population (20.8 million), the rates are between 21.4 and 43.1 per 1,000 live births. Similarly, in Ecuador, a Group IV country, only 1 of the 21 reporting departments has a rate between 12.0 and 18.0 (11,500 persons, or 0.1% of the national population); 10 departments (with 6.5 million inhabitants, or 56.6% of the population) showed infant mortality rates higher than 43.1 per 1,000 live births. Table 2 shows the percentage distribution by level of inequity in infant mortality for the countries depicted in Map 1.

Given the importance of the level of health at the local level, an analysis was conducted to give further geopolitical disaggregation of infant mortality data, as presented in Map 2 and Table 3. This map again shows the pattern of inequalities in health. For instance, the Argentine province of Entre Ríos is located in the third quintile of inequity for this indicator (Map 1); however, 5 of its 16 departments fall in the fourth quintile (337,000 persons, or 31.3% of the population), thus bespeaking inequalities within the province. Similarly, in Costa Rica, the province of San José, where the capital is located, is ranked in the second quintile of inequity for infant mortality, but 7 of the province's 20 cantons fall in the bottom two quintiles (175,000 persons, or 14.6% of the province's population). Map 2 and Table 3 use the provinces of Catamarca (Argentina) and Cartago (Costa Rica) to exemplify this situation of inequality in health.

Lastly, the apparent homogeneity of countries such as Peru and Bolivia, as observed in Map 1, which shows all the departments in these two countries to be in the last quintile of inequity for infant mortality, reflects the yawning gap that separates them from this indicator's regional trends. In order to examine the level of inequity within each of these two countries, a further analysis was done on the bottom quintile (greatest inequity). The resulting categories were visibly higher than the regional counterparts, but they pointed up, once again, the enormous differences in the health status of the respective space/population units. Map 3 and Table 4 show that in Peru, Huancavelica is to Lima what Potosí is to Santa Cruz in Bolivia: in these geographical environments, the highest rate is 150 per 1,000 live births and the lowest is 50 per 1,000, which suggests that the risk of dying during the first year of life is three times greater in Huancavelica and Potosí than in Lima or La Paz.

The Region's median life expectancy at birth is 72.7 years. However, a person from a Group I country, such as Canada, has nearly 21 more years of life expectancy than does someone from a Group V country, such as Haiti (77.4 and 56.6 years, respectively). In the Region, the median life expectancy for women is five years higher than for men (75.0 and 70.0 years, respectively). However, the range between the maximum and minimum values is broader for women: the difference between the maximum and minimum life-expectancy-at-birth values for men is 20.1 years, while for women it is 22.4 years. In the Region, nearly 300 million persons in nine countries live in areas where the life expectancy at birth is 75.6 years or more; 222 million live in nine other countries in areas where the life expectancy at birth is less than 67.5 years. Map 4 and Table 5 show life expectancy at birth by geographical location in the Region and in some countries and their political subdivisions. For instance, although Argentina as a whole is in the third regional quintile for inequity in terms of life expectancy at birth, 11 million persons (31.7% of its population) in 19 provinces are situated in the bottom quintile (greatest inequity). Peru, on the other hand, which as a country is situated in the bottom quintile, has 7.6 million persons who live in areas where life expectancy at birth is over 73.3 years (top two quintiles).

The median total fertility rate for the Americas is 2.6 children per woman. The maximum and minimum values for this indicator across the Region show that, for example, the rate in Guatemala is nearly four times higher than in the Cayman Islands (5.4 and 1.4, respectively). Map 5 and Table 6 show the geographical distribution of this indicator by quintile for the Region and for selected countries. In the Americas, 41.7 million people live in areas where the total fertility rate is below two children per woman, while 46.3 million live in environments where the rate is over 3.5. In Argentina, the average value is 2.6; however, 26.6% of the country's population (9.2 million) lives in 17 provinces where the rate is higher than 2.8. In Peru, 31.9% of the population (7.6 million) lives in two departments where the rate is between 2.4 and 2.7 children per woman; 11.9 million (49.9% of the population), however, live in 17 departments where the rate is over 3.5. Table 6 shows the percentage distribution of the population by total fertility rate for the countries depicted in Map 5.

In the Region of the Americas, the median number of physicians per 10,000 population is 10.8, although this indicator varies considerably. Cuba, for example, has 32 times more physicians per 10,000 population than Haiti (51.8 and 1.6, respectively). Indeed, 100 million people (13.0% of the total population) live in 19 countries of the Region in environments where there are fewer than 8.6 physicians per 10,000 population. To illustrate the inequalities in this area, Map 6 and Table 7 show the status of this indicator for the Region and for four countries. In Mexico, 11 million people (12.1% of the population) live in four states that have more than 16.5 physicians per 10,000 population, but 24 million (26.3%) live in four states with fewer than 8.6 physicians per 10,000 population. In Peru, 8 million people (35% of the population) live in 4 departments with more than 11.4 physicians per 10,000 population, while 12.8 million (53.8%) live in 17 departments where the figure is below 4.9.

HEALTHY SPACES AS A FUNCTION OF LIVING CONDITIONS

Living conditions can be viewed as a set of determining factors that interact to either protect or undermine social and human development; they also reflect society's ability to satisfactorily fulfill the population's needs. In broad terms, living conditions entail two major considerations: poverty--as an economic and political abstraction--and social inequality, which is a consequence of social differentiation and involves such structural concepts as equity and citizen participation. Identifying healthy environments implies observing living conditions as expressed in defined, dynamic space/population units. The present section analyzes living conditions in the Region by means of four basic indicators: access to drinking water supply services, access to sewerage and excreta disposal services, urban population, and literacy.

Access to drinking water supply services is measured as the percentage of the population having service coverage. Since this indicator includes information on the population's access to basic services and on investments in health infrastructure, it is a good gauge of living conditions. Based on data provided by 33 countries, the total population with access to drinking water was calculated, producing a regional median of 81.2% and a range of 35.9% to 100.0%. However, significant inequalities were observed between urban and rural environments. While 95% of urban residents in the Americas have access to drinking water, only 67% of the rural population has such access. The maximum and minimum values for this indicator in the Region's rural areas show that the rural population in a Group I country, such as Canada, has 100% coverage; accordingly, the likelihood of living in an environment with access to drinking water is 10 times greater in Canada than it is for residents of a Group IV country, such as Paraguay, where only 11% of the population has access to this basic service. For urban environments, national figures do not present such marked inequalities--a fact that is not unrelated to the high percentage of urban population in the countries of the Region.

Map 7 and Table 8 show that, for the Region as a whole, drinking water supply coverage is less than 62.4% in 6 of the 33 countries for which information is available; this corresponds to a population of at least 25.5 million. Focusing on the two bottom quintiles (greatest inequity), this figure rises to a total of 132.5 million people in 13 countries of the Region whose environments have drinking water coverage of less than 70.2%. An analysis of this indicator within each country showed even higher levels of inequality. For example, in the regional analysis, Argentina fell in the second-to-last quintile (greater inequity) and only 8.6% of the country's population was in the top quintile (least inequity) with regard to drinking water access. This is owed to the fact that some 3 million people live in Buenos Aires, the capital, while 17 million people (49.4% of the population) live in six provinces that are ranked in the bottom quintile (greatest inequity). A similar situation is observed in Nicaragua, which is in the bottom quintile in the regional analysis, while only 10% of its population lives in areas classified in the quintile of least inequity (downtown Managua). Roughly 70% of Nicaragua's population--approximately 3 million people--lives in environments ranked in the bottom quintile. Table 8 shows the percentage distribution of the population by degree of inequity in selected countries depicted in Map 7.

A deeper analysis based on further geopolitical disaggregation of the data, i.e., within the political subdivisions of each country, shows even greater inequalities in drinking water access. Map 8 and Table 9 show the spatial distribution of this indicator in the 110 municipalities of the state of Chiapas, Mexico, and the 11 cantons of the province of Guanacaste, Costa Rica, based on an ad hoc classification of five categories of inequity. According to this classification, Chiapas is one of the Mexican states ranked in the category of greatest inequity, with drinking water coverage of 55% or less. And, within the state, the values for this indicator show considerably greater disparities. From Table 9, it can be seen that of the 110 municipalities in Chiapas for which information is available, 51 of them--with 1.4 million inhabitants (38.7% of the state's population)--are located in the category of greatest inequity. Only three municipios--Chiapilla, Nicolás Ruiz, and Osumacinta, which have 11,000 residents (0.3% of the state's population)--have drinking water coverage of more than 85%.

Of Costa Rica's seven provinces, Guanacaste is ranked in the third category for the drinking water supply indicator. However, one of its cantons (Tilarán), which has a population of 16,000 (7.3% of the province's population), is in the first category, and two cantons (La Cruz and Nicoya), which have a combined population of 52,000 (23.9% of the province's population), fall into the category of greatest inequity.

Access to sewerage and excreta disposal services is another basic indicator that suffers from unequal distribution among the population of the Americas, as can be seen in Map 9 and Table 10. Although the regional median is 75.2%, 293.5 million people in four countries live in environments where sewerage service coverage is 98.0% or higher; 110 million live in areas where coverage is 64.7% or lower. Within the countries, the inequalities are significantly greater. For instance, Brazil has a national average coverage level equivalent to 77.5%; however, 32.2 million Brazilians living in six states have coverage below 64.8%. In Colombia, where an average of 80.4% of the population has access to sewerage services, 7.6 million people live in 11 departments that are ranked in the quintile of greatest inequity (coverage below 49.8%).

The percentage of urban population is a basic indicator that in recent decades has shown a drastic increase in the Region, reflecting the dynamics of migration, centralization, and urban development that affect living conditions in the Region's space/population units. The median percentage of urban population in the Americas is 63.0%. Of the 43 countries reporting data, 7--with a total of 61 million residents--have 84.0% or more urban population; in 10 countries, home to 30 million people, the urban population is less than 45.0%. The country-by-country analysis mirrors these differences. In Mexico, for example, the average proportion of urban population is 75.0%, although 15.0 million people live in six states where the urban population accounts for less than 53% of the total. In Costa Rica, 63.2% of the population (2.2 million) live in six provinces having urban population levels of less than 45.0%. In Peru, six departments (with a total of 9.6 million inhabitants) have urban population levels of 84.0% or higher, while seven departments (with 5 million inhabitants) have urban populations of less than 45.0% (see Map 10 and Table 11).

The publication Basic Indicators, 1996 presents the regional distribution of literacy rates by sex.4 The regional median for male literacy is 94.0%, and for females, 93.0%. Both groups present wide variations, ranging from 33.0% to 99.0% for men and from 32.0% to 99.0% for women. Map 11 and Table 12 show the inequality of this indicator in the Americas. Of the total for the Region, 295 million people in five countries live in areas classified in the top quintile (literacy of 97.5% or higher). Some 41 million live in six countries in environments that are ranked in the bottom quintile (less than 82.8% literacy). These inequalities are even more marked within some countries. In Brazil, 4 out of every 10 persons live in 18 states where the literacy rate is ranked in the lowest quintile. In Belize, 70% of the population lives in five districts that have less than 82.8% literacy. In Peru, approximately 3 out of every 10 persons live in three environments that fall in the top quintile and another 3 in 10 live in eight environments ranked in the bottom quintile. In Bolivia, 70% of the population lives in six areas ranked in the lowest quintile for literacy.

The spatial approach to health inequalities can be enhanced by incorporating a broad set of indicators on living conditions and the health status of the Region's space/population units, including those related to the environ ment. For instance, it is possible to show the Region's health inequalities by means of indicators that are linked to the potential impact of humans on the environment, as can be seen in Map 12 and Table 13. The map presents the spatial distribution, by state, of access to waste collection services in Brazil; among the states, Bahia, Ceará, and Rio de Janeiro are broken down by municipality. Of the country's total population, 63% have access to waste collection services, which corresponds to approximately 98 million people. However, 15.5 million people live in states ranked in the quintile of greatest inequity, where coverage is below 35.5%. Map 12 and Table 13 show the increase in inequality in the geographical distribution of this indicator upon analyzing the situation of the municipalities in the states of Bahia, Ceará, and Rio de Janeiro.

It also has also been possible to conduct an analysis at a much more local level of spatial disaggregation; Map 13, for instance, depicts some characteristically urban environments. The map represents the Mexican city of Guadalajara (population of 2.8 million) in terms of basic geostatistical areas, which are the true spatial nuclei of urban composition. The map thus illustrates the descriptive capacity of spatial analysis and highlights the important interrelationships involved in analyzing living conditions in a local urban space. The first box is a thematic map of the distribution of drinking water coverage in the urban area. Clearly, the areas with greater coverage, i.e., with greater service supply, are grouped around the center of the city. The second thematic map shows the spatial distribution of overcrowding (defined in terms of the number of residents per dwelling), and indicates that the areas with less overcrowding also are focused in the center of the city. This contrasts with what can be seen in the third thematic map, i.e., that the most densely populated basic geostatistical areas lie at the periphery of the urban area. Such cartographic representations suggest that the supply of drinking water services in this city does not reach the most numerous and probably the most needy sector of the population. Access to services, in a literal but not exclusively geographical sense, is shown as spatially compromised. From this standpoint, an analysis of the local health situation could help to identify inequities in health and, in turn, identify healthy people in healthy environments.

The Group I countries, especially Canada and the United States, show high levels of health status and living conditions for their populations, according to the basic indicators. This notwithstanding, a geostatistical analysis shows that even in these countries there are inequalities in terms of scope and distribution. Map 14 is a composite of thematic maps depicting nine indicators of the health situation in the United States. From a descriptive standpoint, the spatial distribution of these indicators is very heterogeneous, and there appears to be a correspondence between individual states and lower rankings for each indicator. The states with lower health insurance coverage, for example, are the ones where people have lower per capita incomes and greater per capita spending on health. It is in these same areas that most of the Black and Latino populations live and that rates are highest for infant mortality and mortality from motor vehicle accidents.

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