Introduction: Main Health Problems and Challenges
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The Region of the Americas is home to just over a billion persons. Significant health-related gains have been achieved in the Region during the past decade, including documented successes in the Millennium Development Goal (MDG) targets of reducing levels of extreme poverty and hunger, reducing infant and childhood mortality, and making substantial progress in environmental sustainability by 2015. However, it did not achieve the reduction in maternal mortality expected as part of MDG 5.
Main health problems and challenges is devoted to the analysis of overarching drivers (health problems and health determinants) that represent the greatest burden and challenges to the population of the Region. These challenges and problems are viewed in three different but converging topics: health problems that are considered critical because of their severity, high prevalence, associated costs, or impacts on population health; environmental and social drivers that are out of the direct or exclusive control of the health sector; and barriers associated with the unpreparedness of many health systems in the Region to cope with challenges posed by the health problems and their determinants, particularly by the rampant and pervading inequities. Health goals are no longer constrained to reducing prevalence or incidence or to improving health services. They also aim at reducing health inequities, by including health as part of all policies and understanding health both as a component of and as a critical factor for sustainable development.
Topic 1 discusses the advances of the Region in reducing the burden of communicable diseases in the past 5 years. In doing so, the topic addresses the persistent inequities within countries and the huge gaps between countries in overall health outcomes including maternal and child mortality and morbidity. While chronic diseases are increasing, the burden attributable to communicable diseases and maternal and child deaths, including nutritional deficiencies, is still high in some countries and cannot be underestimated in the transition to the 2030 Sustainable Development Agenda. The persistence, emergence, and reemergence of infectious diseases associated with poverty and with changes in the physical and social context point to the need for continuous surveillance activities to prevent the emergence of new pathogenic arboviruses. There has been a reemergence of cholera in the Region, as well as recent outbreaks of dengue. In addition to dengue, new arboviral epidemics have emerged, notably the chikungunya and Zika viral outbreaks. The Zika epidemic has caused a major public health crisis with its new clinical manifestations in infants related to developmental neurological syndromes and microcephaly, with long-term morbidity and disability. Along with surveillance, a focus on disparities is required in order to close the gaps that hinder the progress towards sustainable development.
Topic 2 addresses the unprecedented socioeconomic and demographic changes that have led to a surge in noncommunicable diseases (NCDs), mental disorders, disabilities, road traffic injuries, and domestic and interpersonal violence, which have become leading health problems requiring multisectoral policies to confront them. Two crucial approaches for tackling NCDs are social determinants and the life-course perspective, both of which are extensively dealt with in Health in the Americas+ 2017. The capacity and the scope of health systems must be improved not only to provide care for those at risk or those living with an NCD, but also to build health along the life course. Fostering the capacity for self-care is a crucial part of the necessary efforts to overcome the challenges posed by the epidemiologic and demographic transition and the by-products of uncontrolled development. Violence is one of those by-products associated with weak governance, deficient rule of law, increasing income inequality, and limited educational opportunities. The frequent victims of violence are women and children. Mental health problems, particularly depression, also lead to significant morbidity, and are exacerbated in natural disasters and conflict. High suicide rates in some countries are also a cause for concern.
Topic 3 analyzes the rapidly evolving threat from climate change, which particularly threatens the small island developing states of the Caribbean and coastal zones of Central America. The Region of the Americas is prone to natural disasters, including hurricanes, volcanic eruptions, earthquakes, and floods, often with high costs in terms of human lives, environmental damage, and infrastructural destruction. There are predictions for major loss of coastal territory by 2050 as a result of global warming, as well as the spread of vector-borne illness and threats to food security. This public health threat remains largely unrecognized and requires our urgent attention. Health policymakers need the best available information to assess the magnitude of the current and projected impacts of climate change and their implications for health and to formulate and implement a variety of responses to ensure adaptation and strengthen health systems. The topic ends with some policy recommendations to reduce the side effects of human activity on climate change, particularly those related to the health sector, and to minimize its effects thorough the action of different sectors.
Topic 4 addresses the unprecedented increases in the population aging, which has implications for social security systems, the structure of the work force, and health systems. The increasing proportion of people living into older age brings about an increase in dementia, disability, and frailty. The dynamics of living into older age have radically changed and require the urgent creation of supportive environments. There is a critical need to strengthen national capacities to formulate and implement evidence-based policies and programs in the Region. Providing universal access to care will first require expanded horizons of action along the life course and substantial efforts to finance and implement policies and programs to provide quality care.
Topic 5 addresses the high levels of migration existing in the Americas, with irregular and forced migration largely driven by economic factors, but also by war, conflicts, and violence. Many irregular migrants attempt to travel through Central America to the United States, and are at increased risk of violence, abuse and exploitation, injury, disease and mental disorders, coupled with limited access to health care and services. This situation constitutes a public health crisis and must be managed accordingly. The topic refers to the overarching framework for the health system’s actions to protect the health and well-being of all migrants as reflected in the strategic lines action defined within WHO Resolution WHA61.17 of 2008 and PAHO Resolution CD55.R13 of 2016 on the health of migrants. One of those lines recognizes the need to strengthen and promote intersectoral action and multicountry frameworks to address the social determinants of the health of migrants, to increase community resilience, and to develop migrant-sensitive social policies and programs.
Topic 6 analyzes the inequities present in the Americas. Latin America and the Caribbean remains the most inequitable region in the world, with nearly a third of the population living below the poverty line. This tremendous disparity underpins not only the increased risk of NCDs, infectious disease, malnutrition, and lower life expectancy for those in the lower quintiles of the socioeconomic distribution, but also is directly associated with reduced access to health services. As such, inequities serve as a major barrier to the attainment of universal access. Specific interventions and investments are required to transform health systems to comprehensive, integrated, and equitable services available for all.
The MDGs yielded useful lessons about the perils of converting imprecise goals into programs and policies. However, the focus on national aggregates masked growing inequities and led to health coverage policies that exacerbated disparities.
The adoption of the Sustainable Development Goals and the 2030 Agenda provides a call for the Region to ensure the end of poverty, and to strive for overall prosperity, along all its basic dimensions. These goals will have to be translated into measurable targets to guide government and partners towards universal health coverage and to reduce all disparities in health outcomes.