Mental, neurological, and substance use (MNS) disorders are major contributors to morbidity, disability, injury, and premature mortality, and increase the risk for other health conditions. The estimated 12-month prevalence for the Americas for MNS disorders ranges from 18.7% to 24.2%; anxiety disorders range from 9.3% to 16.1%; affective disorders 7.0% to 8.7%; and substance use disorders 3.6% to 5.3%. Though mental health is acknowledged as an essential component of overall health, evidence from the Region shows critical treatment gaps among people suffering from MNS disorders of up to 73.5% among adults with severe/moderate disorders and 82.2% among children and adolescents. Historical analyses find minimal change in the treatment gap in the Americas as a whole during the past 10 years and a possible increase for Latin America (). Table 1 shows the lifetime and 12-month estimated prevalence rates for specific mental disorders in the Americas and their corresponding percentage of treatment gaps.
Table 1. Prevalence and treatment gap of mental disorders in the Americas, 2013
Posttraumatic stress disorder
Source: Adapted from PAHO, Treatment gap in the Americas, technical document(). Note: Lifetime and 12-month prevalence correspond to population-based weighted rates. Treatment gap corresponds to the mean percentage of identified people with mental disorders not receiving any mental health service. Results are given as percentages.
Dementia is a growing concern in Latin America and the Caribbean (LAC), which has the highest rates worldwide with a 12-month prevalence of 8.5% among persons aged 60 and over (). Moreover, with more people reaching an advanced age, a significant rise in dementia is projected particularly in LAC, with an increase of 47% in the prevalence of severe disabilities in the group aged 60 and over. Figure 1 shows estimations of the populations suffering dementia in the Americas and worldwide.
Figure 1. Projected estimation of population with dementia in the Americas, 2010, 2030, and 2050
Note: Estimations based on the population 60 years and older in 2010. Source: Adapted from WHO, Dementia: a public health priority().
Suicide is an important possible outcome of mental illness with a mortality rate of 7.3 per 100,000 in the Americas. More than 90% of suicidal victims have a diagnosable chronic mental disorder such as depression as well as substance use disorders. There is a clear gender imbalance in suicide attempts, with females more likely to attempt suicide and males more likely to complete suicide. The highest rates were found in the over-70 group, while in North America and the Non-Latin Caribbean, females aged 45–59 were at highest risk (). Figure 2 shows the suicide rates and the contribution of suicide among the other causes of death by age group in the Americas.
Figure 2. Suicide rates and the contribution of suicide among causes of death in the Americas, 2014
Source: Adapted from PAHO, Suicide mortality in the Americas().Note: A. Suicide rates per 100,000 population by age groups. B. Contribution of suicide in percentage among other causes of death by age groups.
A detailed analysis of the disease burden of mental illness in the Americas is underway, partially correcting the known sources of bias that traditionally lead to an underestimation of the mental illness burden, which in turn results in underfunded mental health services, poorly prepared health systems, and worse general health outcomes (). Preliminary results show that MNS disorders are by far the largest source of disability in the Region. If we consider disability plus mortality, other groups of illnesses gain relevance due to their lethality, but despite this relative increase in other disease groupings, mental illness accounts for 19% of disability-adjusted life years (DALYs), ranging from 9% in Haiti to 23% in Canada, and it is responsible for 34% of years lived with disability (YLDs), ranging from 23% in Haiti to 36% in Brazil, Chile, and Paraguay. Moreover, depression is the leading factor, responsible for 8% of YLDs, among all conditions in the Americas (). Figure 3 shows the burden of disease attributed to MNS disorders as a percentage of DALYs and YLDs for selected countries in the Americas, and compared with other noncommunicable diseases, as well as communicable, maternal, child, and nutritional diseases and injuries.
Figure 3. Burden of disease attributed to MNS disorders in selected countries of the Americas, 2015
Note: A. Percentage of years lost to disability (YLDs) per country in the Americas. B. Percentage of disability-adjusted life years (DALYs) per country in the Americas. Mental, neuropsychiatric, and substance use disorders include psychotic, mood, anxiety, eating, drug use, alcohol use, autism spectrum, conduct, and attention deficit disorders; intellectual disability; dementia; epilepsy; tension-type headache; migraine; self-harm; and an estimation for psychiatric pain disorders, as per the model specified in Refs. (). Noncommunicable diseases (except mental illness) include the following groupings: cardiovascular and circulatory disorders; chronic respiratory disorders; neoplasms; digestive disorders; cirrhosis; diabetes, urinary, blood, and endocrine disorders; other neurological disorders; musculoskeletal disorders; and other NCDs. Source: Adapted from Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015 () and Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015 ().
Service delivery tends to be fragmented and there is poor coordination between health care levels. Mental institutions are emphasized at the expense of the development of community-based services. The material and human resources allocated are scarce, inequitable, and inefficiently distributed (). Figure 4 shows the distribution of budget allocations to mental health. The social and economic cost that MNS disorders represent for individuals and communities can be overcome with more investment and a shift in paradigms and models placing people and not illness in the center of the system and focusing on recovery rather than cure.
Figure 4. Distribution of mental health (MH) budget among psychiatric hospitals and other MH facilities in Latin America and the Caribbean, 2013
Source: Adapted from WHO-AIMS: Report on mental health systems in Latin America and the Caribbean Americas().Note: MH = mental health. MH budget indicated as the median percentage of total health budget allocated to MH; psychiatric hospitals and other MH facilities budget indicated as the median percentage of MH budget allocated; other MH facilities includes outpatient facilities, day hospitals, psychiatric units in general hospitals, and residential facilities.
1. Pan American Health Organization. Treatment gap in the Americas, technical document. Washington, D.C.: PAHO; 2013.
2. World Health Organization. Dementia: a public health priority. Geneva: WHO; 2012.
3. Pan American Health Organization. Suicide mortality in the Americas. Washington, D.C.: PAHO; 2014.
4. Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. The Lancet Psychiatry 2016;3(2):171–178.
5. GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet 2016;388(10053):1603–1658.
6. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet 2016;388(10053):1545–1602.
7. Pan American Health Organization. WHO-AIMS Regional report on mental health systems in Latin America and the Caribbean. Washington, D.C.: PAHO; 2013.
Health is a component of and a key resource for human development. It results from a cumulative process of continuous interaction between exposures and experiences, which have an impact at both the individual and population levels, not only episodically but over time, and with trans-generational effects (). The increase in human life expectancy by approximately 30 years over the last century provides a compelling reason to expand health-related goals beyond simple survival ().
In the Region of the Americas, the effort to increase life expectancy has been successful; however, the increase in healthy life expectancy has not kept pace. On average, 8 of every 10 people who are born in the Region will live beyond age 60, and more than 4 in 10 will live past 80 (). One-quarter of those who live past 80 will live with poor health () . According to estimates, people in the Region live on average 9 years with functional limitations or disability (). An increased lifespan, but with longer periods of illness and dependence on care provided by others, is a great burden for States, societies, and families, and a significant challenge for public health.
Halfon and colleagues define health throughout the life course as a dynamic process that begins before conception and continues for an entire lifetime (). This concept, even in evolution, is based on bio-psychosocial and post-genomic models, in which health is considered a process that is integral to complex systems ().
Acting upon that vision of health requires going beyond interventions targeted to specific diseases and their consequences and instead treating health as an essential resource in producing and maintaining capacities and reserves in individuals and populations, throughout the life course. Health is a dimension and a marker of sustainable development, since it reflects the combined effects of social, economic, and physical living conditions on the population. A healthy population displays greater labor and economic productivity, leading to more inclusive and sustainable growth ().
The life course approach
In the life course approach, the health of individuals and populations is conceived as the result of dynamic interaction between exposures and events throughout life, conditioned by mechanisms that embody the positive or negative influences that shape individual trajectories and the development of society as a whole. According to this conceptual framework, health is a fundamental dimension of human development and not merely an end in itself.
The life course comprises the succession of events that occur throughout the existence of individuals and populations. These events interact to influence health from preconception until death, and may extend even further to affect future generations. The life course perspective provides a basis on which to predict future scenarios in health. Trajectories, temporary conditions, transitions, critical periods, the interconnection of lives, and cumulative effects form a conceptual platform that, as part of the available scientific evidence, can be used to model scenarios in health ().
There are longstanding efforts to transcend the narrow vision of health as merely the absence of disease. However, these efforts have been limited to philosophical definitions, conceptualizations, and theoretical models of public health (). Clinical practice, the organization of services, indicators, and financing are key aspects of health that continue to revolve around disease, even though the “traditional model of disease” is less and less applicable to contemporary pathological disorders.
Building health means investing in the creation of a capacity or resource that enables individuals and populations to develop according to expectations and the demands of their environment (). It provides necessary tools not only for their development, but for their adaptation to unexpected situations such as natural disasters, infectious disease outbreaks, or violent events, or to challenges that can persist a long time, such as climate change, chronic diseases, disabilities, human rights violations, lack of job security, or violent situations ().
Under the leadership of the World Health Organization (WHO), during a 1986 conference in Ottawa, Canada, health promotion was defined as a process aimed at:
… enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living ().
Building health implies not only preventing disease, but also promoting the development and sustainability of physical, mental, and social capacity throughout life. This capacity, although it has a genetic component, is not innate, since one is not born with “maximum capacity” that is then gradually lost through an unhealthy lifestyle; rather, this capacity is actively created, subject to environmental and social determinants, enabling individuals to adapt to and modify the environmental demands in their present and future life ().
The life course concept includes the influence of the determinants of health on individuals and populations. According to this approach, these determinants not only can lead to disease and death, but also are decisive in building health. Understanding this can contribute to greater clarity about the influence of health on the model of life trajectories and on human development, and about the real impact of investments in health in the short, medium, and long term. Furthermore, it demonstrates that in health, both action and inaction have consequences. This vision of public health provides a more realistic view of the problems and sharpens the focus on the priorities and needs of the population.
In the Americas, health must be considered in an increasingly diverse population context. For the first time in history, five generations are alive at the same time (). These generations have had different life trajectories: the first was born without access to vaccines or antibiotics; another experienced the double burden of malnutrition (undernutrition along with overweight); still others started out with high levels of illiteracy and today must adapt to global connectivity and coexist with other generations that are growing up and becoming educated in this new world. Some people are born and move through their lives with certain health protections, only to lose them in later stages of life, which poses new challenges of adaptation. All this represents a challenge for public health, and any future design of universal health must take into account these generational differences. They are added to the amply documented, but largely unresolved, inequities associated with ethnicity and gender and with the different geographic and social contexts where people live.
Inequities in the Region of the Americas have been the main cause of failures related to health, and over the next decade will continue to be a barrier to progress. Efforts to reduce and eradicate inequities should be guided by a life course perspective and by a better understanding of the “inherited” nature of health as a resource and of its intergenerational transmission. Health inequities that affect some subgroups are not limited to a single health problem, nor confined to narrow, transitory environments, but exert pernicious and pervasive effects throughout the life course ().
The cycle of inequity
The health of mothers directly affects the health of their children, and this creates a cycle of inequities between the different generations. According to a study conducted in the Dominican Republic, a newborn whose mother has no formal education is 5.6 times more likely to not be registered at birth compared to the newborn of a mother with higher education. Social inequity in health continues when the child reaches adolescence and, in the case of women, childbearing age. The unmet need for family planning among women of childbearing age in the poorest quintile is almost double (1.9 times) the unmet need of women in the richest quintile. When they become pregnant, adolescents without formal education are 9.3 times more likely than adolescents from professional families to receive no prenatal care ().
The dynamic conception of health is grounded in solid theoretical and philosophical arguments. However, the aspiration to place people—and not diseases—at the center of health policies will not be realized until practical ways to carry out the life course approach are designed and implemented.
Building health is a continuous process, one in which interventions and results are not isolated but cumulative over time, with periods of stability and of transformation. This interaction shapes trajectories that may be regarded as health pathways, at both the individual and population levels.
Progress in health
A girl born in Chile in 1910 had a life expectancy of 30 years (); for the same child born today, this figure has almost tripled, to 84 years (). The probability of today’s child dying before her fifth birthday has declined from 36% to less than 2%. Moreover, she has less risk of dying in childbirth, contracting infections such as tuberculosis, or suffering from anemia or cancer in middle age. When she becomes an adult, she will have the opportunity to decide how many children she wishes to have; the fertility rate in the second half of the 20th century fell from 5.3 children to 2.3. If born today, that girl would likely be taller and stronger and have greater intellectual ability than if she were born a century ago. Her life would be not only longer, but healthier.
The analysis of this process reveals both the needs and the influence of protective factors, as well as their impact on the development and maintenance of the capacities of persons and populations. An understanding of trajectories is essential in order to identify and predict the “how and when” of health, making it possible to design and implement more efficient and better-organized health policies (). The health sciences, which for centuries have sought to understand the trajectories of diseases, will need to focus in the coming years on understanding life trajectories and, specifically, the health trajectories of individuals and populations.
It is important to emphasize that health is not innate; it is built over time. All individuals are born with a genetic capacity that underlies their personal potential and influences their health and longevity. However, we now know that genetic capacity accounts for only 30% of this influence, while the remaining 70% stems from the impact of positive and negative factors during the individual’s life trajectory (). Contemporary genomic medicine already has a knowledge base concerning the genetic capacity of individuals and how to influence or manipulate it. This has improved the ability to diagnose genetic errors and genetic diseases, making it possible to predict clinical symptoms long before they appear and physiological changes in individuals before they occur (). Modern genetics is capable of forecasting very early in life the diagnosis of diseases such as breast cancer or Alzheimer’s (). It is also possible to predict which patients will be sensitive, or not, to a given treatment. These discoveries and others associated with biotechnology, nanotechnology, and pharmacology are part of an important group of interventions known as precision medicine, which will influence clinical practice in the coming decade ().
Public health authorities in the countries of the Region should seek to understand the impact of these interventions and the ethical dilemmas they pose. For example, the decision of whether to intervene based on genetic risk () must take into account the high costs of such interventions and their potential effects on health coverage, as well as questions of access and financing ().
Advances in epigenetics explain how gene expression can be modulated in response to environmental signals and how these changes can persist across several generations (). A growing body of evidence makes clear that this plasticity is present not only in the early stages of life, but at other points during the life course, a finding that will have a great impact on medicine and public health (). In their adaptive response, human beings exhibit a high degree of plasticity (the capacity to modify developmental biology in response to environmental stimuli) that enables them to cope with the changes and different circumstances that they face ().
However, the greatest advances in increasing life expectancy and improving health indicators are due to interventions that influence the life trajectories of individuals. The vast majority of the actions implemented in the Americas to date that have proved highly effective and efficient are related to health promotion. They include immunization, proper nutrition, physical activity, and the crusade against tobacco use, among others. There is great scope for increasing actions aimed at promotion and prevention. The barriers imposed by poverty and, especially, inequality, as well as the high costs associated with technology, will continue to limit access to new advances in public health and medicine for the vast majority of the population. This chapter and others in this report highlight this reality and its influence on the health situation in the Americas.
The impact of events on the life course is not uniform. A single stimulus—negative or positive—can have different impacts, depending upon the time of life when it occurs (). During particularly sensitive periods, such as the prenatal stage, childhood, and adolescence, these stimuli can trigger adaptive responses in the individual and in populations, with long-term effects that extend to other stages of life. A reduced growth rate in utero and after birth has been associated with an increased risk of cardiovascular diseases and diabetes (). In recent decades, greater knowledge of such time-linked effects, known since the mid-20th century as the “fetal origins of adult disease,” has increased the body of evidence regarding specific and critical moments of greatest susceptibility, the mechanisms involved, and the results ().
Pregnancy and maternal health. With adolescent pregnancies in the Region at alarmingly high rates already, there is evidence of a new and troubling phenomenon: the increase in pregnancies among girls 14 years of age or younger in some countries (). There has also been a relative increase in pregnancies among women 35 years of age or older, with a consequent rise in complications and mortality associated with assisted reproductive technology practices. The current functional relationship between maternal mortality and age results in a U-shaped curve, whose upper ends correspond to girls under 15 and women over 35 (). The Region of the Americas is experiencing an obstetric transition that recalls the classical epidemiological models of demographic and epidemiological transitions. Although some less-developed countries and territories still have high rates of births and of direct maternal mortality, the predominant situation across the Region is a smaller number of births, a reduction of maternal mortality, and greater life expectancy for women. In this context, maternal mortality is linked to indirect obstetric causes and to the increased number of pregnancies that occur in complex circumstances, such as in women with noncommunicable diseases, transplants, and similar health problems. These different scenarios, shaped by economic, social, and cultural factors, will need an appropriate response from the health sector in the coming years. The goals and strategies for ending preventable maternal mortality require a specific and realistic framework to guide strategic planning. Furthermore, they should be sufficiently flexible so they can be interpreted and adapted effectively in various national contexts, and especially in the local contexts where they are applied.
Ample evidence exists that an inappropriate intergenesic space has an unfavorable effect on both the woman and her offspring. To ensure that a woman begins her pregnancy in the best circumstances, it is key to intervene with accurate information, while strictly respecting her self-determination (). This perspective, which is not yet widespread in the Region, is linked to a focus on preconception, which in the coming years should be accorded the importance it deserves, just as occurred with prenatal care in last century (). The impact of adverse conditions during pregnancy can be reduced through preconception care that is based on the provision of biomedical interventions and on the promotion of favorable habits and socio-environmental conditions, directed both to women and to their partners. The evidence suggests that births in disadvantageous conditions are often due to poor health behaviors, exposure to harmful environmental factors, and lack of access to health care ().
Newborn health. Health at birth is a factor that helps to predict long-term results, such as education, income, and disability. In the Region of the Americas, even today, 8% of all newborns have low birthweight (less than 2,500 g) and 8.6% are premature. Both low birthweight and prematurity require prenatal care, which is provided to 88.2% of pregnancies in the Americas. Regionwide, 94.1% of deliveries take place in hospitals, although these figures obscure inequalities both within and between countries ().
There is steadily increasing knowledge available about the protective effect on fetal health of various interventions, including expanded coverage of influenza vaccination—which helps prevent premature birth—as well as expansion of complementary nutrition, improvements in environmental health, reduction of violence against women, increased use of conditional cash transfers, and better understanding of maternal and fetal health (). The association between the height of the child and of the mother, or between low birthweight in girls and the body composition and intrauterine growth of their eventual offspring, demonstrates the intergenerational effect of these influences ().
High-quality care at the time of birth means achieving adequate coverage of the interventions with proven effectiveness, those that have a positive effect on maternal and newborn health. Examples of these interventions are timely clamping of the umbilical cord, early skin-to-skin contact, immediate initiation of breastfeeding, neonatal screening tests, and maternal-infant bonding to promote early development.
Breastfeeding and early childhood development
In the 21st century, breastfeeding is more relevant than ever, whether in a high- or low-income country or in a rich or poor family. The physical and emotional bond between a mother and her child is strengthened and influences epigenetic programming (). Adequate nutrition and a safe and nurturing environment favor early brain development and are essential in promoting better cognitive development, minimizing the risk of overweight, and protecting against certain chronic diseases ().
A good beginning means that the woman is attended by skilled personnel and that her delivery takes place in an appropriate institution and surroundings. Later, balancing the requirements of breastfeeding with the mother’s need to work implies extending maternity protection to provide mothers with a time, a private space, and an appropriate place to store breast milk and breastfeed safely. Society still does not provide a favorable and enabling environment to the majority of women who wish to breastfeed. Successful breastfeeding should be regarded as a collective social responsibility, involving health systems, families, communities, and workplaces. Rates of breastfeeding and indicators of adequate complementary feeding can be improved considerably in a very short time. Policies and programs to support nursing mothers in health centers, homes, and workplaces have a greater effect if they are designed and implemented as part of a package of interventions, but they require financing and political will ().
The life course approach clearly identifies the most critical or sensitive periods of life, which are “windows of time” characterized by heightened susceptibility, when exposure to certain factors can change the direction of a person’s life trajectory and modify the biological programming or social trajectory of individuals and populations, with short-term and long-term effects (). According to the United Nations Convention on the Rights of the Child, all children have the right to achieve their full development potential and enjoy maximum health (). Healthy children have greater opportunity to grow and develop into adults who are healthy and productive. The child population has particular characteristics and health needs that require specific responses and actions. The recognition of factors that promote their health and growth requires an understanding of the demographic, socioeconomic, and equity conditions that shape their lives, as well as factors related to family and social cohesion, health promotion policies, nutrition, the environment, and access to and utilization of services, among others ().
Preventing disease and death is not sufficient to ensure a healthy childhood. In 2015, WHO presented the Global Strategy for Women’s, Children’s and Adolescents’ Health (), one objective of which is to enable children to achieve their full development, which in turn yields high returns throughout the life course. It has been recognized that early childhood development provides a solid basis for the formation of human capital (). Today it is known that the foundations of brain architecture are laid and consolidated in the first years of life, through a dynamic interaction of genetic, biological, psychosocial, and environmental influences. The child’s brain begins developing at conception, and during the first two or three years of life this process advances more rapidly than at any other time ().
In 2016, Britto and colleagues () proposed three packages of effective measures aimed at creating opportunities for every child to achieve his or her maximum development potential: (a) a package of measures to support and strengthen families; (b) a package of multigenerational nurturing care measures; and (c) a package of early protection and learning measures (Figure 1). The challenge is to ensure that families and children benefit from these interventions, particularly children affected by multiple disadvantages.
Figure 1. Domains of nurturing care necessary for children to reach their developmental potential
(Reprinted with permission from The Lancet)
The child’s environment can modify his or her genetic map, especially during a critical period of life. The environment does not change DNA, but it produces chemical changes that affect the development and neurocognitive-motor performance of the child. Moreover, these chemical signals can be transmitted from one generation to the next. The dynamic interactions between the environment and genetics place children on different trajectories that affect their health throughout life, along with their cognitive abilities, behavior, and social functioning, and those of future generations (). The current literature on early childhood development emphasizes the need to adopt a broader approach to the physical, emotional, cognitive, and social development of children (). This is a topic with intersectoral implications, encompassing health, education, nutrition, well-being, and social protection, among other areas (). The interactions between children, their parents, and other caregivers—including those who provide health and social services—constitute the most important external influence, together with the exposure to environmental risks in the home and community. Parents and caregivers, both women and men, can help offset the negative effects of possible disadvantages by providing health care, nutrition, nurturing, security, and early learning-if they receive support to help them provide an appropriate upbringing to children.
In the Region of the Americas today, we have the necessary knowledge to eliminate infant mortality due to preventable causes, as well as to greatly improve the health and well-being of children and carry out the transformations needed to ensure a more prosperous and sustainable future ().
Transitions and critical moments of life: adolescence as a model
As discussed, the life trajectories of individuals and populations contain transitions that are milestones in themselves and that constitute moments of change. These transitions can be biological, psychological, social, economic, political, or even geographic in origin, and they are not necessarily predetermined nor always foreseeable: examples include retirement, menarche, menopause, school entry, the beginning of working life, and migration. Other changes that can be mentioned include changes in social roles or, from the biological perspective, the acquisition or loss of functions that accompanies the beginning or end of physiological processes ().
Adolescence represents the most documented example of the life course concept. It is one of the life stages with the most complex transitions and also one of the most sensitive periods of human development, during which behaviors are modeled and habits and lifestyles are adopted. The development of the human brain continues throughout life through a process known as neuroplasticity. Research suggests that the brain transformations taking place in adolescence are quite different from those that occur in childhood. During childhood, the focus is on dendritic outgrowth and synaptogenesis or synaptic growth, which permits the brain to increase substantially in size and weight. The evolution of the brain during the second decade of life and into early adulthood seems to concentrate on synaptic pruning, in which the process of eliminating weak or irrelevant synapses is necessary in order to obtain greater brain efficiency. Synaptic pruning is believed to depend on the responses of neurons to environmental factors and external stimuli. As a result, this stage is regarded as a critical period in which the individual is highly receptive to environmental stimuli, which in turn has enormous consequences for the neurological development of adolescents. This explains the adaptive form of learning and the rapid acquisition of interpersonal and emotional skills during adolescence ().
An analysis of this process points to the importance of ensuring a secure and stable social environment for adolescents in order to support optimal development of the brain functions that are essential for longevity and for social and emotional well-being in adulthood () (Figure 2). Although the family can provide the primary structure of protection and security during this period, adolescents by nature are exposed to and sensitive to many other influences, such as friends, school, communications media, the community, and the world of work. This sensitivity that is so characteristic of adolescence implies that the communications media can influence the attitudes, values, and behavior of the individual more than during any other stage of life. The digital revolution has facilitated exposure to new ideas and contacts with like-minded people, but it also carries new risks, such as the marketing of unhealthy products and the promotion of fixed consumption habits.
Figure 2.Ideal model to promote healthy development in adolescence
Young people leave the educational system and enter the world of work, where they assume steadily increasing responsibility for their own decisions, including those that influence their health. This is the time of life when the human body acquires the capacity to reproduce, and it is also the stage when young people typically encounter tobacco, alcohol, and other possible health hazards for the first time (). For this reason, parental monitoring and supervision of adolescents’ activities is indispensable in reducing health risks to adolescents. The effects of this relationship are documented: for example, the scientific evidence, although limited, suggests that communication between parents and adolescents-especially between mothers and daughters-on sexual subjects helps delay the beginning of sexual relations and promotes the use of contraceptive methods ().
Giving birth at a young age is associated with greater risks to health. Unwanted early conception contributes to unsafe abortion, to mortality, and to health problems in the short and long term. Pregnancy in adolescence affects the life trajectories of the mothers and of their offspring, and has biological, social, and economic consequences. Young maternal age is associated with shorter gestation periods, low birthweight, poor nutrition, and lower educational attainment in children. Girls who become pregnant are more likely to interrupt their education, thus reducing their capacity to earn income throughout life and to support themselves and their children (). The prevention of adolescent pregnancy and the provision of support to help adolescents control their own fertility not only helps save their lives, but also allows them to complete their reproductive development, increases their chances to acquire education and income, and improves the development prospects of future generations.
Health in middle age and beyond: a vision limited to disease?
In the next decade, efforts to provide comprehensive care to people in midlife should be reoriented to the health needs of people, rather than to diseases. The health issues of men and women in the post-reproductive stage of life have not received the necessary attention. These middle generations are subject to major social and family pressures related to caregiving, extension of the retirement age, and the implications of being viewed by health providers as bearers of diseases or risk factors. It is urgent to evolve toward a holistic vision of the person, using a life course approach.
Mental health is the result of interaction between protective factors and risk factors throughout the life course, including the prenatal period and intergenerational transmission. Failure to achieve key physical, cognitive, and socioemotional competencies leads to insufficient mental health development and can cause diseases (). Cumulative exposure to stressors can have a negative effect, increasing the likelihood of the deterioration in mental health (). Being a victim of child abuse can have effects that persist into adolescence and adulthood (). Psychosis, depression, and anxiety are disorders that originate in critical periods of early development ().
A life course approach to the analysis of these trajectories and transitions provides strategic opportunities to design programs for disease prevention and promotion of mental health (). Mental health policies should treat the long-term combined effects of the biological, psychological, and environmental vulnerabilities of specific groups. By mediating or moderating the effects of exposure to risk, protective factors can have a cumulative effect on the life course (). Cumulative risk indices make it possible to more accurately evaluate mental health and estimate the probability of suffering from mental illness; this in turn can lead to greater efficacy and efficiency in prevention and treatment, as well as a reduction in the equity gap determined by the accumulation of risks and disadvantages in certain populations ().
The WHO mhGAP intervention guide is an evidence-based model with a life course perspective, geared to the prevention and treatment of mental, neurological, and substance use disorders in non-specialized health contexts (). It offers strategies tailored specifically to pregnant and lactating women, children, adolescents, and older persons. The guide also provides tools for comprehensive care of priority disorders through the use of optimized and simplified algorithms for clinical assessment, decision making, and monitoring, as well as a new module on implementation to support the proposed interventions with the necessary infrastructure and resources ().
Intersections between violence against women and violence against children from the life course perspective
Violence against children and violence against women represent a global public health problem and are serious violations of human rights. The Sustainable Development Agenda recognizes both forms of injury as barriers to countries’ progress. An increasing body of scientific evidence points to the various intersections throughout the life course between these two forms of abuse (). Violence against women during pregnancy is associated with negative outcomes for the health of women and their children (). The consequences of child abuse often persist into adulthood, leading to long-term changes in brain structure, causing physical and mental health problems, predisposing the individual to engage in risky behaviors, and even reducing life expectancy at birth (). All this suggests that violence experienced during critical periods of development—whether directly experienced or witnessed—has harmful and lasting effects on the risk factors for health.
Building health in old age: functional capacity as the focus of care
Every 25 years, the global population of adults aged 60 or older doubles, and it is expected that by 2050 the Region will have approximately 400 million older people (). In the Americas, a person who lives to age 60 will live on average 20 years more, and a person who turns 80 can expect to live another 7 years (). In this demographic transition, healthy aging has been defined as a process that promotes and maintains the functional capacity required to permit well-being in old age (). This functional capacity, which has various health-related dimensions, enables people to live and act according to their beliefs and values. Although this is true throughout the life course, old age is the stage where it is essential to boost efforts to prevent a deterioration in functional capacity, thus preserving a healthy life expectancy, or at the very least, freedom from disability. The overarching goal is to enable older people to lead active and independent lives and to prevent an unnecessary increase in the burden of long-term care.
The situation of older persons and patients is perhaps the clearest expression of the new needs in health, which in turn call for a substantial transformation in the model of health care at both the individual and population levels. Because of its importance for the Region, this topic is further explored in section 2.4 Aging and health.
Many health services are organized around the care of diseases and consider the person as a secondary priority (). The appropriate treatment of chronic diseases is impossible without the participation of the individuals who suffer from them and the support of the community. A person who suffers from a chronic disease has a continuous relationship with that disease and must make decisions every day about his or her activities, diet, and prescribed medications. Meanwhile, that person’s contact with the health services is episodic and is limited to a number of hours or minutes every year. Hence, health systems should adopt programs of self-care that facilitate active autonomy, so that each person takes care of his or her own health. Such programs must help people properly monitor their own symptoms and comply with treatments in a responsible way. The goal is to promote well-being and the most active life possible, whether or not a person is living with disease (). There is a great deal of evidence on the efficacy of self-care programs, not only in terms of their effectiveness and impact on individuals, but also because they help reduce demand for and unnecessary costs of health services ().
Health is at the center of social development and economic growth. Healthy people and populations are more productive; children who enjoy good health develop better, growing into productive adults. An expanded response over the next few decades should include not only increases in financing directed to specific stages of life, but a commitment by all relevant sectors to carry out activities aimed at reducing health inequalities and inequities throughout life. To this end, it will be important to evaluate the long-term impact of investments and interventions in health, using the life course perspective.
Nutrition. Nutrition is one of the key factors that influences human health and longevity. More than for any other factor, theoretical arguments and empirical evidence support the role of nutrition in shaping the life trajectory and building health from preconception to death. Good nutrition in the first two years of life is associated with greater height and better cognitive and school performance. It has also been associated with greater economic productivity and its corresponding impact on personal income (). Nutrition and its mediating circumstances influence the socioeconomic status of women and the birthweight of children in the next generation (). However, the mechanism that links a woman’s early nutritional experiences with the nutrients transferred to her fetus is still unknown (). Malnutrition during the first years of life can negatively influence fetal and child growth in the next generation, whether through genetic, epigenetic, or physiological mechanisms. At present, obesity is one of the principal risks to longevity in the Region. Many population groups suffer from a double burden of nutritional problems, that is, undernutrition along with overweight ().
Nutrition has been shown to have a determining effect on the maintenance of muscle mass and on the intrinsic and functional capacity of older persons, which in turn has an important impact on the ability to maintain a healthy and active lifestyle for the longest period possible ().
Physical activity. The role of physical activity in building health throughout the life course must inform health strategies in the coming years. Sedentary lifestyles have favored an increase in chronic diseases associated with physical inactivity (). Individuals with less mobility suffer greater morbidity, disability, and mortality (). Several studies demonstrate that 25% of all people who engage in some type of physical activity spend less time with disability or with some type of injury, in comparison with people who do not perform any regular physical activity (). According to one study, participation in a physical activity program of moderate intensity for approximately 2.6 years can reduce mobility impairment in older persons ().
Immunization. The success of immunization strategies is perhaps one of the best arguments in favor of the life course approach. Vaccines have a lasting impact on the economy through their mediating effect on health. Bloom and Canning propose a causal chain to explain this link between health and income (). The following points illustrate these links between health and income:
Education: Immunization has a significant, long-term effect on intellectual performance and on health, which is manifested in an increase in cognitive capacity.
Productivity: Workers in healthy communities are less prone to absenteeism related to their own illness or the need to care for an ill family member. Bloom and Canning estimate that a one-year increase in life expectancy improves productivity by 4% ().
Saving and investment: Healthy people can expect to live longer, and as a result, they are more prone to save for their retirement. They also are capable of working productively for a longer time, thereby increasing their savings. The economic consequences of immunization are not limited to the direct effects associated with the costs of health services or disease prevention, but extend much further to include indirect effects mediated by cognitive development, level of education, labor productivity, income, savings, and investment.
Sensory health. In 2015, disorders of the sensory organs were the second-ranking cause of years lived with disability (), accounting for more than 68 million disability-adjusted life years (DALYs) (). Unoperated cataracts continue to be the main cause of blindness, and uncorrected refractive errors are the main cause of visual impairment (). Retinopathy of prematurity affects newborns in low- and middle-income countries due to deficient neonatal care (). A reduction in DALYs caused by visual impairment is a feasible and high-impact strategy for the years ahead. The high effectiveness of the interventions (glasses to correct refractive errors, and curative surgery for cataracts) in relation to their costs justifies greater attention to the burden associated with vision loss ().
The Global Burden of Disease Hearing Loss Expert Group estimates that in Latin America in 2008, the prevalence of auditory disability was 1.1% in children 5 to 14 years of age and 9.6% and 12% in girls and boys over 15 years of age, respectively (). Early identification and intervention in cases of hearing loss has a significant association with better language development in children (). The early detection of auditory disability in children, the timely use of antibiotics for treatment of otitis media and meningitis, as well as the provision of hearing aids for conductive hearing loss can reduce this burden ().
Evidence supports the importance of oral health in the different stages of life, as well as its intergenerational scope. According to a prospective cohort study, the presence of caries in adults 32 years of age is related to the oral health of the mother (), and in a low-income Hispanic population an association was found between levels of cariogenic bacteria in the saliva of mothers and their children in early infancy ().
In the near future, public health, the organization of health services, and clinical practice will all be affected by changes in traditional patterns. The contemporary patient will have high life expectancy but also chronic illnesses that may persist for many years, increasing functional limitations, and a need to interact with the health services over a long period of time. Such patients, in spite of their diseases, can enjoy well-being and feel healthy ().
Today, we can already glimpse the beginning of the evolution toward an approach in which individuals are no longer the “objects of health interventions” but instead become increasingly active subjects in building their own health and managing their diseases. Despite profound inequalities, people tend to be more—although not necessarily better—informed, and they are making autonomous decisions earlier and more frequently, often without the involvement of the health services. Contemporary public health cannot ignore the participation of people and other actors in health promotion. Developing strategies that take account of the bidirectional influence between these new actors and health professionals in building health will pose a great challenge in the next decade.
From the standpoint of measurement and indicators, the life course approach should be integrated into health care systems as a dynamic process. Toward this end, information systems will need to be revamped, modernized, and strengthened to upgrade their coverage, quality, and analytical capacity. Impact assessment of the life course model should be enriched by reliable sources of information from multiple sectors (education, transportation, environment, finances, employment, and the legal system, among others), as well as from elements of the private sector. Information systems should be reoriented to prioritize indicators of well-being, functioning, and quality of life, as well as environmental indicators, and will need interoperability with the databases of other sectors. It will be up to regional agencies and national governments to advocate the adoption of the life course approach in order to achieve a broader understanding of population health and the delivery of health services.
18. Dominican Republic, Oficina Nacional de Estadística; United Nations Children’s Fund. Encuesta nacional de hogares de propósitos múltiples: encuesta de indicadores múltiples por conglomerados, 2014. Informe final. Santo Domingo: Oficina Nacional de Estadística, UNICEF; 2016.
19. Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al. eds. Disease control priorities in developing countries. 2nd ed. Washington, D.C.: International Bank for Reconstruction and Development, World Bank; 2006.
20. Smith GD. Life course epidemiology of disease: a tractable problem? International Journal of Epidemiology 2007;36(3):479–480.
21. Christensen K, Johnson TE, Vaupel JW. The quest for genetic determinants of human longevity: challenges and insights. Nature Reviews Genetics 2006;7(6):436–448.
22. Black MM, Walker SP, Fernald LCH, DiGirolamo AM, Lu C, McCoy DC, et al. Early childhood development coming of age: science through the life course. The Lancet 2016;389(10064):77–90.
23. Chatterjee P, Roy D. Insight into the epigenetics of Alzheimer’s disease: a computational study from human interactome. Current Alzheimer Research 2016:13(12):1385–1396.
24. Huston C. The impact of emerging technology on nursing care: warp speed ahead. Online Journal of Issues in Nursing 2013;18(2):1.
25. Hall WD, Morley KI, Lucke JC. The prediction of disease risk in genomic medicine. EMBO Rep. 2004;5(S1):S22–S26.
26. Djalalov D, Musa Z, Mendelson M, Siminovitch K, Hoch J. A review of economic evaluations of genetic testing services and interventions (2004-2009). Genetics in Medicine 2011;13(2):89–94.
27. Dudley KJ, Li X, Kobor MS, Kippin TE, Bredy TW. Epigenetic mechanisms mediating vulnerability and resilience to psychiatric disorders. Neuroscience & Behavioral Reviews 2011;35(7):1544-1551.
28. Addo OY, Stein AD, Fall CHD, Gigante DP, Guntupalli AM, Horta BL, et al. Parental childhood growth and offspring birthweight: pooled analyses from four birth cohorts in low and middle income countries. American Journal of Human Biology 2015;27(1):99–105.
29. Kuzawa CW, Thayer ZM. Timescales of human adaptation: the role of epigenetics processes. Epigenetics 2011;3(2):221–234.
30. Elder GH, Giele J, eds. The craft of life course research. New York: Guilford Press; 2009.
31. Leicht I. Growth and health. International Journal of Epidemiology 2001;30:212–216.
32. Gómez PI, Molina R, Zamberlin N. Factores relacionados con el embarazo y la maternidad en menores de 15 años. Lima: Federación Latinoamericana de Sociedades de Obstetricia y Ginecología, Comité de Derechos Sexuales y Reproductivos; 2011. Available from: http://www.unal.edu.co/bioetica/documentos/2011/Maternidad.pdf.
37. McCann JC, Ames BN. An overview of evidence for a causal relation between iron deficiency during development and deficits in cognitive or behavioral function. American Journal of Clinical Nutrition 2007;85(4):931–945.
38. Mortensen EL, Michaelsen KF, Sanders SA, Reinisch JM. The association between duration of breastfeeding and adult intelligence. Journal of the American Medical Association 2002;287(22):2365–2371.
39. Angelsen NK, Vik T, Jacobsen G, Bakketeig LS. Breastfeeding and cognitive development at age 1 and 5 years. Archives of Disease in Childhood 2001;85:183–188.
40. Kretchmer N, Beard JL, Carlson S. The role of nutrition in the development of normal cognition. American Journal of Clinical Nutrition 1996;63(6):997S–1001S.
41. Rolland-Cachera MF, Maillot M, Deheeger M, Souberbielle JC, Péneau C, Hercberg S. Association of nutrition in early life with body fat and serum leptin at adult age. International Journal of Obesity 2013;37:1117–1122.
45. Pichora-Fuller K, Mick P, Reed M. Hearing, cognition, and healthy aging: social and public health implications of the links between age-related declines in hearing and cognition. Seminars in Hearing 2015;36(3):122–139.
47. Richter LM, Daelmans B, Lombardi J, Heymann J, López-Boo F, Behrman J, et al. Investing in the foundation of sustainable development: pathways to scale up for early childhood development. The Lancet 2016;389(10064):103–118.
48. Bacallao J, Alerm A, Ferrer M. Paradigma del curso de la vida: implicaciones en la clínica, la epidemiologia y la salud pública. Havana: Editorial Ciencias Médicas; 2016.
49. Britto PR, Lye SJ, Proulx K, Yousafzai AK, Matthews SG, Vaivada T, et al. Nurturing care: promoting early childhood development. The Lancet 2016;389(100064):91–102.
56. Patton GC, Coffey C, Cappa C, Currie D, Riley L, Gore F, et al. Health of the world’s adolescents: a synthesis of internationally comparable data. The Lancet 2012;389(9826):1665–1675.
57. Diiorio C, Kelley M, Hockenberry E. Communication about sexual issues: mothers, fathers, and friends. Journal of Adolescent Health 1999;24(3):181–189.
58. Fall C, Osmond C, Haazen D, Sachdev HS, Victora C, Martorell R, et al. Disadvantages of having an adolescent mother. The Lancet 2016;4(11):e787–e788.
59. Pillas D, Naicker K, Colman I, Hertzman C. Public health, policy, and practice: implications of life course approaches to mental illness. In: Koenen KC, Rudenstine S, Susser ES, Galea S, eds. A life course approach to mental disorders. New York: Oxford University Press; 2013.
60. Horwitz AV, Widom CS, McLaughlin J, White HR. The impact of childhood abuse and neglect on adult mental health: a prospective study. Journal of Health and Social Behavior 2001;42(2):184–201.
61. Pearlin L, Schieman S, Fazio EM, Meersman SC. Stress, health, and the life course: some conceptual perspectives. Journal of Health and Social Behavior 2005;46(2):205–219.
62. Arseneault L, Bowes L, Shakoor S. Bullying victimization in youths and mental health problems: much ado about nothing? Psychological Medicine 2010;40(5):717–729.
63. Clarke MC, Tanskanen A, Huttunen M, León DA, Murray RM, Jones PB, et al. Increased risk of schizophrenia from additive interaction between infant motor developmental delay and obstetric complications: evidence from a population based longitudinal study. American Journal of Psychiatry 2011;168(12):1295-1302.
64. Colman I, Ploubidis GB, Wadsworth ME, Jones PB, Croudace TJ. A longitudinal typology of symptoms of depression and anxiety over the life course. Biological Psychiatry 2007;62(11):1265–1271.
65. Weich S, Patterson J, Shaw R, Stewart-Brown S. Family relationships in childhood and common psychiatric disorders in later life: systematic review of prospective studies. British Journal of Psychiatry 2009;194(5):392–398.
66. Vinokur AD, Schul Y, Vuori J, Price RH. Two years after a job loss: long-term impact of the JOBS program on reemployment and mental health. Journal of Occupational Health Psychology 2000;5(1):32–47.
67. Wolchik SA, Sandler IN, Millsap RE, Plumer BA, Green SM, Anderson ER, et al. Six-year follow-up of preventive interventions for children of divorce: a randomized controlled trial. Journal of the American Medical Association 2002;288(15):1874–1881.
68. Brackenreed D. Resilience and risk. International Education Studies 2010;3(3):111-122.
69. Shaffer A, Yates TM. Identifying and understanding risk factors and protective factors in clinical practice. In: Compton M, ed. Clinical manual of prevention principles in mental health. Arlington: American Psychiatric Publishing; 2010:29–48.
70. Singh-Manoux A, Ferrie JE, Chandola T, Marmot M. Socioeconomic trajectories across the life course and health outcomes in midlife: evidence for the accumulation hypothesis? International Journal of Epidemiology 2004;33(5):1072–1079.
71. World Health Organization. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings, Version 2.0. Geneva: WHO; 2016.
72. Guedes A, Bott S, García-Moreno C, Colombini M. Bridging the gaps: a global review of intersections of violence against women and violence against children. Global Health Action 2016;9:31516.
73. World Health Organization. WHO guidelines on preventing early pregnancy and poor reproductive outcomes. Geneva: WHO; 2011.
74. Han A, Stewart DE. Maternal and fetal outcomes of intimate partner violence associated with pregnancy in the Latin American and Caribbean region. International Journal of Gynaecology & Obstetrics 2014;124(1):6-11.
75. MacMillan HL, Wathen CN, Varcoe CM. Intimate partner violence in the family: considerations for children’s safety. Child Abuse & Neglect 2013;37(12):1186–1191.
76. Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. The Lancet 2009;373(9657):68–81.
77. Pan American Health Organization. Strategy and plan of action on dementias in older persons. 54th Directing Council, 67th Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2015 Sept. 28-Oct. 2 (CD54/8).
78. Abramsky T, Watts CH, García-Moreno C, Devries K, Kiss L, Ellsberg M, et al. What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health 2011;11:109.
79. Rutherford JN. Fetal signaling through placental structure and endocrine function: illustrations and implications from a non-human primate model. American Journal of Human Biology 2009;21(6):745–753.
80. Behrman JR. Early life nutrition and subsequent education, health, wage, and intergenerational effects. Chapter 6. In: Spence M, Lewis M, eds. Health and growth. Washington, D.C.: World Bank; 2009:167-183. Available from: http://siteresources.worldbank.org/.
81. Peña M, Bacallao J. Obesity among the poor: an emerging problem in Latin America and the Caribbean. In: Peña M, Bacallao J, eds. Obesity and poverty: a new public health challenge. Washington, D.C.: PAHO; 2000.
82. Dale H, Brassington L, King K. The impact of healthy lifestyle interventions on mental health and wellbeing: a systematic review. Mental Health Review Journal 2014;19(1):1–26.
83. Shumway-Cook A, Patla AE, Stewart A, Ferrucci L, Ciol MA, Guralnik JM. Environmental demands associated with community mobility in older adults with and without mobility disabilities. Physical Therapy 2002;82(7):670–681.
85. Tremblay MS, LeBlanc AG, Kho ME, Saunders TJ, Larouche R, Colley RC, et al. Systematic review of sedentary behavior and health indicators in school-aged children and youth. International Journal of Behavioral Nutrition and Physical Activity 2011;8(1):98.
86. Costigan SA, Barnett L, Plotnikoff RC, Lubans DR. The health indicators associated with screen-based sedentary behavior among adolescent girls: a systematic review. Journal of Adolescent Health 2013;52(4):382–392.
87. Gill T, Guralnik J, Pahor M, Church T, Fielding R, King A, et al. Effect of structured physical activity on overall burden and transitions between states of major mobility disability in older persons: secondary analysis of a randomized, controlled trial. Annals of Internal Medicine 2016;165(12):833–840.
88. Vos T. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990—2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet 2015;388(10053):1545–1602.
89. Kassebaum N. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet 2015;388(10053):1603–1658.
90. Battle JF, Lansingh VC, Silva JC, Eckert KA, Resnikoff S. The cataract situation in Latin America: barriers to cataract surgery. American Journal of Ophthalmology 2014;158(2):242–250.
91. Carrión JZ, Fortes Filho JB, Tartarella MB, Zin A, Jornada ID Jr. Prevalence of retinopathy of prematurity in Latin America. Clinical Ophthalmology 2011;5:1687–1695.
92. Zin A, Gole GA. Retinopathy of prematurity-incidence today. Clinics in Perinatology 2013;40(2):185-200.
93. Stevens G, Flaxman S, Brunskill E, Mascarenhas M, Mathers CD, Finucane M. Global and regional hearing impairment prevalence: an analysis of 42 studies in 29 countries. European Journal of Public Health 2011;23(1):146–152.
94. Yoshinaga-Itano C, Sedey AL, Coulter DK, Mehl AL. Language of early- and later-identified children with hearing loss. Pediatrics 1998;102(5):1161–1171.
95. Chaffee BW, Gansky SA, Weintraub JA, Featherstone JDB, Ramos-Gómez FJ. Maternal oral bacterial levels predict early childhood caries development. Journal of Dental Research 2014;93(3):238–244.
In 2000, the United Nations (UN) General Assembly laid out the Millennium Development Goals (MDGs), an ambitious vision for global development with a groundbreaking approach to collaborative international action (). In the Americas, an unprecedented regional response allowed many countries to reach or surpass health-related goals to reduce child mortality, control infectious diseases, reduce poverty, and increase access to improved water and sanitation.
Figure 1. The “five Ps” (people, planet, prosperity, peace, and partnership) representing the broad scope of the 2030 Agenda for Sustainable Development, 2016-2030 Source: United Nations.
Nonetheless, persistent challenges present during the MDG era remain unresolved, and new challenges in the health landscape have since emerged. As a result, in September 2015, the UN General Assembly adopted Resolution A/RES/70/1, “Transforming our world: the 2030 Agenda for Sustainable Development” (). The product of numerous consultations and deliberations, the 2030 Agenda is an aspirational plan of action for people, planet, prosperity, peace, and partnership—the “five Ps” (Figure 1)—that shifts the world onto a sustainable and resilient path for global development over the next 15 years.Through an equity-based approach that emphasizes the needs and experiences of traditionally disadvantaged groups, the Agenda has the potential to transform the public health landscape in the Region of the Americas. By recognizing the interconnectedness of factors and interventions that influence human development outcomes, the 2030 Agenda and its Sustainable Development Goals (SDGs) outline a paradigm shift in policy-making, prioritizing actions that target the complex and intersecting structural determinants of social and economic development.
The SDGs contain just one explicitly health-oriented goal—SDG 3—out of a total of 17 (Figure 2), in contrast to the MDGs, which have three out of eight. However, many, if not all, of the SDGs include targets related to health, such as poverty, hunger, education, access to sanitation, and exposure to physical violence. While not explicitly included in SDG 3, these themes are among the most immediate determinants of health and well-being. The shift in focus between the two sets of global development goals represents a more nuanced understanding of the factors that affect health, and lays the groundwork for action across different sectors whose activities have significant effects on health but fall outside the purview of the health sector. Governments, the private sector, and civil society will need to innovate and adapt to meet the challenges laid out in the 2030 Agenda, which incorporates a broader and more multifaceted vision for health and development than ever before. A strong evidence base already exists to support this approach, and this chapter topic will extend the effort by highlighting useful strategies, mechanisms, and major global agreements to ensure that countries are prepared to achieve these global goals ().
Figure 2. Breakdown of the 2030 Agenda for Sustainable Development by goal (1–17), 2016–2030 Source: United Nations.
Equity: a renewed focus for sustainable development
The MDGs galvanized broad government action to achieve national targets related to specific diseases, maternal health, and child health, but in doing so frequently focused on the “low-hanging fruit” of populations already well served by services, leaving many behind. Despite many successes in reducing population averages of disease-specific incidence and maternal and child mortality, progress was not achieved equally within or between countries. As discussed extensively in “Social determinants of health in the Americas,” health outcomes in the Region are heavily influenced by income, gender, ethnicity, cultural identification, geographic location, and education, as well as access to services and infrastructure. The 2030 Agenda has the potential to address these gaps through the promotion of multisectoral programming that seeks to address the inequalities that persistently produce poor health outcomes, with particular attention paid to the social, economic, and environmental conditions in which people are born, live, work, learn, and age. This approach has profound implications for equity, a core principle of the 2030 Agenda.
In addition to the need to develop programs and interventions that promote health for vulnerable populations, monitoring their impact through data collection and analysis is crucial to ensure that the 2030 Agenda will achieve its promise of reducing health inequalities. Country capacity to measure Regional and national progress toward the SDG targets should be developed in the earliest phases of engagement with the 2030 Agenda in order for governments and policymakers to gain greater insight into which SDG-oriented activities are realizing their goal of reducing health inequalities. It will be especially important to establish equity-sensitive monitoring tools that show which populations are experiencing improvements and increased access to services while highlighting gaps that impede progress in addressing the needs of the most vulnerable and marginalized communities.
While the 2030 Agenda builds on the successes of the MDGs, it also articulates a critical political and conceptual shift in the development paradigm. The 2030 Agenda recognizes many of the lessons learned from the MDGs, which includes the need to explicitly address inequalities, requiring interventions designed to address the unequal distribution of health, disease, and resources. While the MDGs provided both a focal point and framework for government policy-making, a growing evidence base developed over the past 15 years has shown the need for a broader and more holistic understanding of health and human development (). Therefore, the 2030 Agenda encourages innovative multisectoral initiatives in which the health sector partners with actors from other areas of governance to address the key determinants of health affected by actions from systems and institutions outside the traditional scope of the health sector.
Figure 3. Breakdown of the Millennium Development Goal (MDG) agenda by goal (1–8), 2000&ndash2015 Source: United Nations.
The MDGs were focused on improving the health and living conditions of those in low-income countries (Figure 3 and Table 1), whereas the SDGs recognize that inequity and gaps in services, opportunities, and outcomes are present at all levels of economic development. Recognizing the limitations of the relationship between the traditional donor (high-income country) and recipient (low- or middle-income country), particularly in today’s globalized “market” of expertise, commerce, skills, and resources, the 2030 Agenda promotes innovative models for development governance, collaboration, and financing that encourage countries to engage creatively with the process of sustainable development. In this way, the SDGs are truly global in that they represent a shared commitment to address mutual challenges across the spectrum of economic development.
Beyond these key shifts, the 2030 Agenda places the 193 signatory countries at the center of SDG implementation. From the earliest stages of consultation, national and regional input has been key to defining goals, targets, and indicators. A case in point is the inclusion of noncommunicable diseases (NCDs) and universal health coverage (UHC) in the 2030 Agenda. Neither was included in the MDGs, but both were identified as major challenges for sustainable development, and ultimately became targets with associated indicators, in the final Agenda. This was an important achievement, particularly for the Region of the Americas, where UHC has long been a priority of policymakers and public health advocates.
As countries move from the MDGs to the 2030 Agenda, it is important to review progress made through 2015. As a whole, the Region achieved health-specific targets related to child mortality, the spread of HIV/AIDS, the incidence of tuberculosis and malaria, drinking water, and sanitation (Table 1). Much progress was made on several targets that were not strictly identified as part of the “health” MDGs, but have substantial implications for health, such as reducing the proportion of people living in poverty. However, some of this progress is under threat by political instability and the ongoing effects of the financial crisis of 2008. Moreover, progress achieved has tended to mask persistent inequalities while gains remain unequally distributed within and between countries.
Table 1. Outcomes for selected Millennium Development Goal (MDG) targets, 2000–2015
MDG and targets
MDG 1: Eradicate extreme poverty and hunger
1.C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger
This target was achieved
MDG 4: Reduce child mortality
4.A: Reduce by two-thirds, between 1990 and 2015, the under-5 mortality rate
This target was achieved
MDG 5: Improve maternal health
5.A: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio
This target was not achieved
5.B: Achieve, by 2015, universal access to reproductive health
This target was not achieved
MDG 6: Combat HIV/AIDS, malaria and other diseases
6.A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS
This target was achieved
6.B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it
This target was not achieved
6.C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases
This target was achieved for TB and malaria
MDG 7: Ensure environmental sustainability
7.C: Halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation
This target was achieved in terms of safe drinking water, and virtually achieved in terms of sanitation (the proportion was reduced by 48.5%)
Source: Adapted from PAHO, Millennium Development Goals and health targets: final report().
While the progress during the MDG era should be celebrated, the underlying inequalities driving poor health and limiting sustainable development remain. Furthermore, not all health-related targets were achieved by 2015, specifically those related to maternal mortality, access to reproductive health, and access to antiretroviral treatment for eligible persons who are HIV-positive. Persistent inequalities and the unmet health targets of the MDG agenda are key challenges to achieving health for all in the Americas, and will need to form the basis of action within the post-2015 development agenda.
As the most inequitable region in the world, the Region of the Americas is faced with unique challenges as it works toward promoting health for all and achieving sustainable development. Building on the achievements of the past 15 years, the 2030 Agenda encourages governments and societies to collaborate in new and innovative ways, while acknowledging that equity is central to sustainable global progress. It also presents a challenge to the global public health community’s responsiveness to policy action, given that the 2030 Agenda should be implemented in full alignment with national priorities, national action plans, and existing global agreements, such as the World Health Organization (WHO) Framework Convention on Tobacco Control (). To do so, identifying areas where the various agendas are harmonized will be of utmost importance so that countries are equipped to tackle these challenges efficiently and coherently.
SDG 3: “Ensure healthy lives and promote well-being for all at all ages”
Health, as a key input to sustainable development and healthy populations, is fundamental to the spirit and pursuit of the 2030 Agenda. In addition to traditional health development priorities targeted by the MDGs, particularly HIV/AIDS and maternal, newborn, and child health, the new agenda identifies a broader range of health objectives. Although SDG 3 is the only explicitly health-based goal, it calls for ambitious progress by 2030 (“Ensure healthy lives and promote well-being for all at all ages”). The first three targets for SDG 3 reflect the recognition of unfinished business under MDGs 4, 5, and 6, including commitments to reduce premature mortality due to maternal complications and to end preventable deaths due to the epidemics of AIDS, tuberculosis, malaria, and other communicable diseases (Table 2). The remaining targets address issues that were not addressed in the MDGs, including NCDs; mental health; alcohol, and other substance abuse; road traffic injuries; reproductive health services; UHC; and access to safe and effective medicines and vaccines for all.
Table 2. Sustainable Development Goal (SDG) 3: targets and means of implementation, 2016–2030
SDG 3 targets
3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births
3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases, and combat hepatitis, water-borne diseases, and other communicable diseases
3.4 By 2030, reduce by one-third premature mortality from noncommunicable diseases through prevention and treatment, and promote mental health and well-being
3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol
3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents
3.7 By 2030, ensure universal access to sexual and reproductive health care services, including for family planning, information, and education, and the integration of reproductive health into national strategies and programs
3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all
3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination
SDG 3 Means of implementation
3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate
3.b Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all
3.c Substantially increase health financing and the recruitment, development, training, and retention of the health workforce in developing countries, especially in least developed countries and small island developing States
3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks
Source: Adapted from United Nations, Transforming our world: the 2030 Agenda for Sustainable Development ().
By widening and diversifying the global health agenda, a shift that reflects a greater understanding of the breadth and complexity of global health challenges, SDG 3 targets have the potential to significantly improve global health outcomes. The redefinition of global priorities has profound implications for health governance. The 2030 Agenda and health-related SDGs not only lay out new principles, targets, and measurements for combating global health challenges; they also reinforce the role of the state as the primary actor in global health governance, while promoting partnership with non-State partners. Along with the emphasis on engaging civil society and mobilizing domestic political leadership and financial resources, there is an overall recognition of the state’s responsibility for setting public health agendas and implementing health-related interventions.
To achieve the nine technical targets and operationalize the four key means of their implementation under SDG 3, the health sector will need to assume a leadership role at the national level. The health sector’s pivotal position will be important in promoting actions, often implemented across sectors, which target the determinants of health and support overall well-being. At the same time, SDG 3 reflects the need for an integrated approach to addressing the cross-cutting elements of the SDG framework. Thus, the health sector will need to provide support to other sectors and institutions outside their purview to ensure progress and avoid inequitable health outcomes. While this approach will need to be adapted to differing country contexts, examining successful approaches employed at the national level can facilitate interventions that other countries in the Region may find useful.
While each of the SDG 3 targets and indicators are applicable to all signatories, countries have the flexibility to decide which ones to specifically pursue as part of their commitment to the wider Agenda, according to their own priorities and sovereign interests. Nonetheless, much of the Region of the Americas shares common priorities, particularly with regard to NCDs, UHC, and the elimination agenda for infectious diseases, which are discussed in further detail below. In fact, PAHO/WHO Member States had adopted several resolutions concerning these topics, and other SDG 3 targets, before the 2030 Agenda. Moving forward, these areas will serve as opportunities to not only produce further success at the national level but also generate shared achievements through joint collaborations at the Regional level.
NCDs represent a large and growing burden in the Region of the Americas, posing a threat to both regional and national development. Driven by the negative effects of unhealthy and unsustainable patterns of consumption, rapid unplanned urbanization, and longer life expectancy, these diseases have a direct impact on well-being, productivity, income, and health system costs (). The negative effects of chronic disease are exacerbated by an unequal distribution of the burden of disease predicated on socioeconomic inequality and unequal access to education, health services, and healthy living conditions. Knowledge about the impact of these diseases and the factors that lead to their development is limited by underreporting and underdeveloped monitoring systems.
Whereas the MDGs did not address NCDs, the inclusion of Target 3.4 in the 2030 Agenda clearly acknowledges the growing health burden of NCDs, a category that comprises 7 of the 10 leading causes of death in the world (). The explicit delineation of two separate targets to address communicable and noncommunicable diseases, both equally integral to the sustainability of human health and development, signifies that resources may need to be reallocated. Interventions that can most efficiently and effectively reduce the burden of diseases that pose the greatest threat to national and Regional well-being should be prioritized.
NCDs represent a whole-of-government issue, accompanied by a shift in discourse from the problem of individuals to a collective challenge requiring political action. These complex health challenges will require multisectoral collaborations and innovative solutions from heads of state. Approaches like the one used in the WHO Health in All Policies Framework for Country Action () that promote integrated, multilevel, and participatory health interventions have been identified as key to decreasing NCD prevalence in the Americas by acting on the relevant social and environmental determinants of health. Much can be learned from Mexico’s strategy to reduce obesity through its National Agreement for Healthy Eating (), Suriname’s enactment of antitobacco legislation aligned with the Framework Convention on Tobacco Control (), and Costa Rica’s executive order mandating schools to sell only fresh produce and foods and beverages that meet specific nutritional criteria ().
Target 3.4 goes further than just NCDs, however. Mental, neurological, and substance use disorders, including alcohol, are among the leading causes of the global burden of disease, and are the leading cause of global disability across all disorders worldwide and in the Americas. Like NCDs, mental health and well-being are precursors to family and community wellness, as well as the broader goals of the 2030 Agenda, which foresees “a world with equitable and universal access to quality education at all levels, to health care and social protection, where physical, mental and social wellbeing are assured” ().
Mental health can be linked with 8 of the 17 SDGs, including those related to health, poverty, hunger, gender equality, sanitation, employment, inequality, and inclusiveness. Given the important role of mental health, countries may consider measuring key markers of mental health and availability of mental health services, namely, avoidance of premature deaths, including those from suicide (), and achievement of parity in access to mental and physical health services (). In addition, Goals 4, 8, 10, and 11 highlight the inclusion of people with disabilities, essential for the promotion and protection of the rights of people with mental, neurological, and substance abuse disorders, a population that has historically comprised the most marginalized, vulnerable, and neglected in society (). Despite the significant overlap between mental health and substance abuse, each issue presents unique challenges. As such, a different target is dedicated to the prevention and treatment of substance abuse, though action on either will likely have implications for both.
Universal health coverage
In a Region that has historically maintained a public-private health system, UHC is considered an essential pillar for development. It is key to achieving health-related SDGs and critical to minimizing health system fragmentation, preventing disease, achieving better health outcomes, and, ultimately, promoting well-being for all. UHC also signifies a shift from disease-specific interventions to ensuring that communities have access to well-resourced health systems that offer comprehensive health services. Although the socioeconomic and political context of each country requires flexibility when developing strategies to achieve UHC, the need for health coverage for all is truly universal. Ensuring access to comprehensive, timely, and good-quality health care without discrimination requires a society-wide commitment to expand equitable access to health services and supplies, strengthen governance, increase financing, improve information systems, invest in human resources, and support multisectoral coordination.
To make meaningful progress toward fulfilling the promise of UHC, a human rights framework must be used to support the progressive and equitable implementation of the right to health as an obligation of the state. Doing so opens the door to an array of policies to increase the scope and equity of health programs. For example, national health systems have grown increasingly more responsive in delivering affordable care for all without causing financial hardship. Public spending, population coverage, and access to health services are increasing in the Region, while out-of-pocket payments are declining ().
A long-term challenge to UHC is the development of fiscally sustainable approaches to improve revenue generation. For any health system to become sustainable, countries must balance actual revenue generation and current expenditures. Increasing revenues through taxes is only one means of doing so and can be more or less equitable depending on which taxes are raised and in what ways they are raised (). Other ways to increase revenue include anchoring inputs or expenditures, such as limiting waste, reducing administrative inefficiencies, and reducing the adoption, intensity, and volume of services that are not cost-effective. The resulting level and quality of available health care resources is a trade-off between service coverage, the public service portfolio, and costs. Middle-income countries might struggle to adapt to steep health expenditures outpacing economic growth, whereas low-income countries often face other, unique, and possibly more limiting, obstacles. In addition to sustained investments in health, an evidence base, informed by continuous progress assessments and formal mechanisms for dialogue, should be prioritized to inform policies at the national level.
The call for UHC by the 2030 Agenda also leads to increased demand for qualified health workers, which must be matched with redoubled government efforts to produce and retain the health workforce. Strategies include coping mechanisms and self-sufficiency policies to address gaps in distribution of health workers. Countries can also offer higher salary levels and financial incentives to health providers, or introduce health worker safety policies to reduce occupational diseases and work-related accidents. Though ensuring a sufficient health workforce accounts for a significant portion of health service costs in low- and middle-income countries, strategic planning and management will better prepare countries to meet international health regulations and promote global health security (). It will also trigger broader socioeconomic development in line with SDG attainment, such as gender equality and decent employment opportunities.
The explicit inclusion of UHC and the promotion of both physical and mental health is evidence that the 2030 Agenda considers access to health and overall well-being as essential not only to human health but also to sustainable development.
Elimination agenda for infectious diseases
Countries in the Americas are increasingly aware that the control and elimination of infectious diseases have far-reaching implications for health and well-being, social and economic outcomes, and the achievement of SDG 3 and broader development goals. Over the last decades, the Region has undergone a changing environment marked by an increasingly aging population (demographic transition) and socioeconomic development including successful vaccination and vector control efforts, leading to a decrease in the overall burden of communicable diseases (epidemiologic transition). For example, there has been a 30% decrease in disability-adjusted life years (DALYs) due to communicable diseases since the year 2000. This significant progress in the control of many infectious diseases has prompted the next steps in infectious disease control, namely disease elimination.
The Region set targets for the elimination of many infectious diseases, and has already achieved many of these goals. Historically, the Americas has been a global pioneer in elimination efforts. Many endemic diseases such as smallpox (1971), polio (1994), rubella (2015), and measles (2016) were eliminated through the widespread use of vaccines. Regional elimination of mother-to-child transmission of HIV, malaria, tuberculosis, viral hepatitis B and C, syphilis (including congenital syphilis), and neglected tropical diseases (onchocerciasis, schistosomiasis, Chagas disease, leprosy, and trachoma) represents a more ambitious step forward.
Disease elimination has evolved from being based on interventions relying on effective vaccines to include those cases where no vaccine or cure (in the case of HIV) exists. In this regard, the WHO has coined the term “elimination as a public health problem,” wherein the elimination threshold is a minimum value that is achievable using all current evidence-based interventions, and where continued actions will be necessary (Box 1). Strategies for the elimination of communicable diseases now comprise a wide spectrum of interventions focusing on vaccination, use of vector control strategies, diagnostics, and medications, acknowledging the need for broad multisectoral interventions for success. Currently, there is no absolute common definition of elimination for all diseases. The various criteria used for disease elimination make having one single conceptual framework and definition a pending task that experts are working to build.
Box 1. Basic definitions related to the control and elimination of infectious diseases.
Control: Reduction of disease incidence, prevalence, morbidity, or mortality to a locally acceptable level as a result of deliberate efforts. Continued intervention measures are required to maintain the reduction.
Elimination as a public health problem: A term related to both infection and disease. It is defined by achievement of measurable global targets set by WHO in relation to a specific disease. When reached, continued actions are required to maintain the targets and/or to advance to the interruptions of transmission. The process of documenting elimination as a public health problem is called “validation.”
Elimination of transmission: Reduction to zero of the incidence of infection caused by a specific pathogen in a defined geographic area, with minimal risk of reintroduction, as a result of deliberate efforts; continued actions to prevent reestablishment of transmission are required. The process of documenting elimination of transmission is called “verification.”
Eradication: Permanent reduction to zero of a specific pathogen as a result of deliberate efforts with no risk of reintroduction. Intervention measures are no longer needed. The process of documenting eradication is called “certification.”
Sources: Dowdle WR. The principles of disease elimination and eradication. Bulleting of the World Health Organization 1998;76(S2):23-25.
Pan American Health Organization. Report on the Regional consultation on disease elimination in the Americas. Washington, D.C.: PAHO; 2015.
The current major components of the elimination agenda include the vaccine-preventable disease agenda, including HBV infection; the neglected tropical diseases; the big epidemics of tuberculosis, HIV, and malaria; and lastly, sexually transmitted diseases and chronic HCV infection. The decreasing burden of disease and efficacy of technology will dictate new possibilities for elimination defining the thresholds for elimination from a public health perspective. As new drugs and new technologies develop, the elimination agenda will surely broaden to include other infectious disease and may expand into NCDs, such as for cervical cancer in relation to vaccine-preventable HPV.
Past experience shows that continuing current prevention and control efforts alone are not sufficient for elimination. In addition to strong political will, adapting strategies to local contexts, capitalizing on new technologies, and accelerating translation of science into policy and implementation are required. Combining intensified traditional approaches with innovative approaches can generate new synergies and enhance the effectiveness of elimination efforts.
Current threats to the elimination agenda include the emerging drug resistance, an increasingly aging population, antivaccination movements, and shifting political priorities. High initial costs in the path towards elimination might also be deterrents, but as the health system becomes more effective, unit costs will decrease. There are also high costs to monitor its success.
The Region is moving towards a comprehensive elimination agenda that ranges from disease control to eradication, with quantifiable goals for each step along the way. Countries are striving towards greater integration of disease elimination efforts and capitalizing on synergies. This agenda symbolizes how the Region continues to work on health, human rights, and tackling inequities. To achieve these ambitious targets, along with the other targets of SDG 3, countries must exercise strong leadership to collaborate and create synergies with other sectors and ministries.
Unlike the disease-specific focus of health sector priorities outlined by the MDGs, the 2030 Agenda establishes numerous health-related targets that would traditionally fall under the coordination of other sectors. The interdependent framing of the SDGs creates opportunities for health programming and activities across the entire 2030 Agenda, allowing countries to tailor their national plans and policies to their own needs. While all SDGs create opportunities for the health sector, or have some effect on them, WHO has identified specific SDG targets and indicators that countries should prioritize in policy-making and resource allocation for the best return on health. These include Target 2.2 (child stunting, and child wasting and overweight); Target 6.1 (drinking water); Target 6.2 (sanitation); Target 7.1 (clean household energy); Target 11.6 (ambient air pollution); Target 13.1 (natural disaster); and Target 16.1 (homicide and conflicts) (Table 3).
Table 3. Sustainable Development Goal (SDG) targets identified by the World Health Organization for policy-making/resource allocation prioritization, 2016&ndash2030
SDG health targets
3.1 Maternal mortality and births attended by skilled health personnel
3.9 Mortality due to air pollution; unsafe water, unsafe sanitation and lack of hygiene; and unintentional poisoning
3.a Tobacco use
3.b Essential medicines and vaccines
3.c Health workforce
3.d National and global health risks
SDG health-related targets
2.2 Child stunting, and child wasting and overweight
6.1 Drinking water
7.1 Clean household energy
11.6 Ambient air pollution
13.1 Natural disaster
16.1 Homicide and conflicts
Source: Adapted from World health statistics 2016: monitoring health for the SDGs().
Like the SDG 3 targets, the quantity and breadth of these health concerns have far-reaching implications for funding and policy implementation, particularly in low- and middle-income countries. The systemic and multifactorial interventions needed to achieve these targets have the potential to strain the human, financial, and technological resources of health sectors and health systems. For example, “achieving universal and equitable access to safe and affordable drinking water for all” and “significantly reducing all forms of violence and related death rates everywhere” pose more complex challenges than the disease-specific MDGs.
Historically, policymakers and political leaders tend to prioritize the most feasible goals and activities with the potential to produce rapid results. As countries move forward with the 2030 Agenda, the criteria for prioritizing targets should instead focus on selecting those that utilize the most appropriate principles, assumptions, and methods to maximize health outcomes per unit of resources available.
While SDG 3 offers four essential means of implementation, they must be complemented by other actions to fully achieve the 2030 Agenda’s health and health-related targets. SDG 16 and 17 fill many of those gaps. SDG 16 articulates the importance of effective and equitable governance as an essential and enabling feature of the 2030 Agenda, and sets the stage for international cooperative action and partnerships among governments, civil society, and the private sector. SDG 17 supplements each of the goal-specific approaches with cross-cutting means of implementation for the entire agenda. Framed as a revised global partnership for sustainable development, SDG 17 covers a wide range of targets for finance, technology, capacity building, trade, policy, and institutional coherence.
National budgetary constraints demand a thorough analysis to strategically select which targets will be emphasized and how they will be financed. Public-private partnerships and investments in other sectors should be considered to ensure that all are viable and can operate efficiently. Internally, countries can mobilize domestic resources by improving tax collection, reducing external debt, and tackling tax evasion. A financially feasible development agenda will require domestic public resources and traditional sources of financing for development, such as official development assistance, as well as private investment, innovative mechanisms for funding to address structural threats to health, and the use of regulations to ensure compliance with national priorities and legislation.
The UN Addis Ababa Action Agenda, adopted in July 2015, was the first step toward developing a new and innovative financing framework (). It proposes an array of mechanisms for countries and stakeholders to effectively mobilize financial resources for the achievement of the SDGs, taking into particular consideration the challenges of middle-income countries like many of those in the Americas. The first Regional consultation on financing for development took place in Santiago, Chile, in March 2015, allowing the Region’s perspective and priorities to be fully reflected in the process ().
Measurement, monitoring, and evaluation
The importance of highlighting and tackling inequalities between subpopulations is central to the 2030 Agenda and requires indicators that incorporate data disaggregated for drivers of inequality. As the most inequitable region in the world, average improvements may mask growing inequalities between population groups, particularly the most vulnerable, disadvantaged, and marginalized. As such, there is a need to refine, adapt, and scale up the measurement, monitoring, and evaluation capacity of countries, especially those with less developed or poorly equipped health information systems. The explicit goal to develop indicators that are disaggregated by income level, education, gender, and ethnicity, as well as other important determinants of health and social inclusion within the SDG agenda, represents an important shift from the MDG agenda and reflects a growing appreciation for the negative impact of inequalities on health and development.
Mobilization of stakeholders
Achieving the health-related targets will require contributions, engagement, and leadership from beyond the health sector and greater coordination between public and private stakeholders. The term “stakeholder” should be considered broadly and adapted at the country level to expand the participation of relevant actors, including sectors such as finance, trade, environment, and labor, along with government institutions, local authorities, international organizations, civil society organizations, and the private sector. The negotiation process of the 2030 Agenda is a key example of how Regional leadership is both evolving and redefining traditional approaches to health and development. There is no doubt that the changing landscape of these players will continue to have important implications for the Region through 2030.
Because the most marginalized populations often suffer most from the negative effects of unsustainable growth and development, locally led civil society organizations are an essential element to fulfill the 2030 Agenda. A people-centered, inclusive, participatory approach will strengthen mechanisms designed to advance the 2030 Agenda. Moreover, as the front line of engaging with citizens to achieve the SDGs, civil society plays a critical role in widening access to different populations, fostering advocacy, identifying development priorities, proposing practical solutions, and even providing feedback on problematic or unrealistic policies (). Often, governments and civil societies share common goals; a good example of this is the Region’s adoption and implementation of tobacco control policies, a process in which civil society has actively promoted and monitored the enforcement of new policies ().
Although Regional bodies and organizations have long been involved in health issues in differing roles and to varying degrees, their increasing influence on global health policy-making will make them key players in the implementation of the SDGs. Because of their familiarity with Regional challenges, barriers, and opportunities, these organizations have the ability to mediate between the global and national levels. They also have the unique capability to unite specific countries and harmonize specific goals and data at the regional or subregional level. Ultimately, Regional organizations can generate new opportunities for information exchange at the global level.
Think tanks and academic institutions can also help accelerate the SDG process through their engagement in policy development, identification of determinants of success, measurement of policy outcomes, and role in ensuring that the knowledge that is generated, translated, and disseminated reaches marginalized populations more quickly (). In turn, these institutions can provide direct input to high-level processes and support more effective implementation of the overall 2030 Agenda as well as specific actions, thereby ensuring greater political accountability.
Finally, business has a critical role to play in achieving the SDGs. The private sector has traditionally been the driver of scientific and technological development and strategies. Involving the private sector has immense potential to tap into that innovative capacity and deliver solutions to the barriers outlined in the 2030 Agenda (). Mobilization of the private sector will be critical to provide capital, jobs, technology, and infrastructure. Governments should coordinate with the private sector from the earliest stages of planning and implementation to ensure that businesses contribute to, and do not undermine, inclusive and sustainable development.
Table 4. Examples of Regional stakeholders in the 2030 Agenda for Sustainable Development
Type of stakeholder
Southern Common Market (Mercosur), Economic Commission for Latin America and the Caribbean (ECLAC), Central American Integration System (SICA), Council of Ministers of Health of Central America (COMISCA), Organization of American States (OAS), Pan American Health Organization (PAHO), Community of Latin American and Caribbean States (CELAC), Union of South American Nations (UNASUR), Andean Health Organization (ORAS-CONHU)
The 2030 Agenda is a timely reminder of the complexity of human health and the systems designed to protect it. It is also an opportune moment to strategize, coordinate, and plan for a future in which many of the Region’s greatest health concerns will originate outside the health sector. In light of this, health experts will be required to strengthen health systems and break down artificial boundaries across sectors to address key trends in the Americas that have direct and indirect implications on the Region’s health and well-being.
Health in All Policies (HiAP) is a useful framework for policymakers and government officials to address the SDGs at the national level (). Before the Health in All Policies approach was explicitly defined, it had already been adopted and applied throughout the Region of the Americas to place health at the center of development. Specifically, the HiAP framework is designed to identify and develop common ground between the health sector and other sectors in order to build shared agendas and strong partnerships, ultimately leading to mechanisms for participation, accountability, collaboration, and dialogue among various social actors ().
HiAP is frequently seen as a country approach to tackle NCDs and the social determinants of health, including tobacco use, obesity, housing, and transportation. Focused action and alliances between the health sector and sectors involved in clean energy, chemical safety, standards for employment opportunities in the health industry, and safe food production and distribution have also proven to be win-win situations (). While the HiAP framework has been successful in these areas, it can also be effective in “hard” politics (the use of traditional political systems and mechanisms), bringing together various stakeholders in health security, foreign policy, and finance to negotiate for health among competing interests. Given that the HiAP approach requires firm, long-term political commitments from national authorities responsible for formulating policies within and beyond the health sector, the 2030 Agenda provides an effective platform for building intersectoral health-oriented policies.
Likewise, innovative health promotion strategies can result in greater capacity and empowerment to both prevent and respond to public health concerns. A robust Healthy Municipalities and Communities Network() (Red de Municipios y Comunidades Saludables) is already in place throughout much of the Region (). In line with the 2030 Agenda, health promotion and the Healthy Settings approach() provide practical models of integrated, multilevel interventions based on enabling healthy environments, engaging local governments, reorienting health services, and promoting well-being and healthy choices through political commitment, public policies, community involvement, and strengthened individual capacity to improve health.
Both of these approaches complement the biomedical services already in place, but they also foment a Regional shift from response to preparation and prevention of negative health outcomes, and from a medicalization of society to a true public health approach to solve complex challenges. In addition, they emphasize the fact that all people and all levels of government bear responsibility for controlling diseases and managing health. The approaches and principles of the health promotion and HiAP strategies mirror those of the SDGs, thus ensuring synergy with the 2030 Agenda. More specifically, the Agenda’s call for an inclusive and participatory approach, expanded resources and participation, and collaboration across sectors presents a historic opportunity to mobilize relevant sectors, local and national governments, civil society organizations, and communities in an effort to promote health and achieve HiAP goals. Both strategies will be increasingly important at the global level, for achieving the goals of the 2030 Agenda, and at the Regional level, with regard to managing the effects of mega-trends and addressing inequalities that have become so large that they contribute to instability and poor health outcomes.
Poverty reduction is inextricably linked to health and sustainable development. It is a multifaceted phenomenon that threatens the health outcomes of affected individuals and communities, denying them full enjoyment of their human rights, including the right to health. As shown in Table 1, poverty and extreme poverty rates have decreased in the Americas since 1990, culminating in the Region’s achievement of the first target of the MDGs. Thanks to improvements in employment opportunities and income levels, income inequality also fell during this period ().
Nonetheless, since the start of the economic slowdown in 2008, the downward trends for poverty and extreme poverty have slowed; in fact, the rates are projected to increase slightly in coming years, which will affect the creation of jobs and the quality and level of the available work (). Moreover, the Region remains the most unequal in the world, leaving a high proportion of the population in a highly vulnerable position defined by volatile incomes near the poverty line (). In this way, poverty eradication signifies more than the elimination of extreme poverty; it also involves efforts to close these gaps and minimize individuals’ and communities’ vulnerability to poverty.
Approaches that prioritize concerted efforts toward poverty reduction will benefit from potential synergies with other priority areas of sustainable development, including sustainable cities, employment, energy, water, and education. Previous Regional experience has demonstrated that progress toward poverty reduction will remain fragile and reversible until countries embrace the multisectoral approach presented by the 2030 Agenda. Cross-sectoral collaboration must be accompanied by concrete commitments to ensure UHC, universal access to health, and social protection mechanisms that sustainably mitigate vulnerability and eradicate poverty in all its forms.
Sustainable consumption and production
Controlling production and consumption patterns are prerequisites for achieving the 2030 Agenda objectives of true equity, inclusion, and sustainability. As the Region’s population continues to grow, so does the importance of maintaining the productivity and capacity of the planet to meet human needs and sustain economic activities. At the same time, Regional patterns of consumption are being altered by lower fertility rates and an aging population ().
In order to reduce the risks to health and the environment associated with overarching demographic dynamics, this two-pronged issue depends on the sustainable, clean, and efficient production of goods and services, as well as more efficient and responsible consumption. Natural resources key to human survival, such as water, food, energy, and habitable land, must be protected; pollution associated with human and economic activity, including greenhouse gases, toxic chemicals, emissions, and excess nutrient release, must be reduced; and current consumption patterns, as drivers of unsustainable development, poor health outcomes, and resource degradation, must be significantly altered.
Food loss, waste, and overconsumption represent part of the unsustainability of the Region’s production and consumption patterns. The overconsumption of food has led to sharp increases in obesity and detrimental effects on the environment, primarily through greenhouse gas production, overuse of arable land, and deforestation. In spite of this, growing consensus in recent years shows that the Region has not only an adequate food supply but also a network of economic and social policies that could eradicate hunger, combat malnutrition, and address obesity in the short to medium term ().
To achieve the goals of the 2030 Agenda, the Region will need to promote a combination of multisectoral policies and economic and social activities. These should serve as enablers, empowering countries, producers, and consumers to become owners and successful users of technologies and processes that will ensure resource efficiency, sustainable consumption, and, ultimately, healthier livelihoods and lifestyles.
Since the start of the global financial crisis, the Region has been undergoing an economic slowdown. The Americas will confront the challenges of the 2030 Agenda in the midst of persistent external vulnerability, long-run low growth rates, smaller financial inflows, weaker external demand, and declines in investment growth rates. The slowdown has led to consistently increasing urban unemployment rates and poor employment quality, factors that partially explain why Regional inequality reduction has slowed. These patterns of economic activity represent one of the most significant challenges for the Region in building the capacity, infrastructure, and innovation necessary to achieve the 2030 Agenda ().
Moreover, these economic trends have the potential to reverse development progress achieved over the last decade, particularly with regard to shared prosperity and poverty reduction (). Sustaining these advances and realizing the SDGs, despite the deceleration of activity and sometimes contracting economy, means the Region must change its way of doing business under conditions less favorable than those experienced during the MDG era. This will require a stronger Regional commitment to governance and regulation of the ways institutions are shaped, legitimized, and equipped. Governance structures affect growth, equity, and well-being, each of which is pivotal for realizing sustainable development.
Accountability and responsiveness are two key pillars underlying the effectiveness of government institutions and their ability to deliver on the SDGs. Neglect of these pillars can lead to social and political instability, reduced investment, poor economic performance, and direct and indirect effects on the well-being of citizens. They can be overcome by reforms that prioritize transformative leadership, citizen participation, transparency, and innovative interventions. In order to manage this transition and mitigate the associated risks, it is vital that the Region continue to bring together high-level decision-makers, researchers, experts, and civil society to engage in strategic policy discussions, build alliances, and explore innovative approaches and mechanisms for use by governments and citizens to effect positive, sustainable change.
The Region of the Americas is the most urbanized region in the world, with nearly 80% of the population living in urban centers, a proportion expected to increase to an estimated 85% by 2030 (). These urban areas are often hubs of innovation and economic production, with populations that tend to have greater access to social and health services than their rural counterparts. While opportunities, jobs, and services are concentrated in these areas, so are health risks and hazards. The adverse effects of these conditions are increasingly concentrated among the urban poor, generating notable health inequities between the richest and poorest urban populations. Aggravated by poor strategic planning, the ability of urban centers to meet the needs of their entire population has become a persistent challenge that will inhibit truly sustainable development.
For example, unhealthy lifestyles resulting from diets that prioritize cost savings and convenience over health; sedentary behaviors; and the harmful use of alcohol, tobacco, and drugs could heighten risks related to obesity and the increase in chronic NCDs, including diabetes, heart disease, and cancer (). In addition, the potential for communicable disease outbreaks is amplified due to large numbers of people living in close proximity, oftentimes in conditions with compromised standards for sanitation and water provision. Substance abuse, poor housing conditions, road safety concerns, and a plethora of environmental hazards associated with urban centers can also have a harmful effect on the ways in which people grow, work, live, and age.
If the 2030 Agenda is to effectively foster health and well-being in a way that advances equity, the importance of urban centers to human lives and livelihoods must be fully considered. Although an increasingly urbanized world has the potential for a multitude of adverse consequences for health and well-being, it also creates opportunities. Because the trends of urbanization are highly interdependent and multilevel, a greater focus on the ways in which cities are planned, designed, developed, and managed can help policymakers recognize systemic relationships and opportunities for strategies that will generate co-benefits and long-term synergies for health. Strategies from multiple sectors must be applied to reduce inequities and influence the determinants of health associated with rapid urbanization.
Widespread urbanization, population growth, and industrial development continue to directly affect human health and broader development goals in the Americas. The effects of these trends include increased exposure to both traditional environmental hazards, like indoor air pollution and drinking-water contamination, and newer hazards, such as toxic chemicals, pesticides, electronic waste, and phenomena related to climate change, including natural disasters and irreversible changes to ecosystems. In terms of climate change, shifting temperatures alter disease patterns and vector distributions, ambient air quality has negative effects on respiratory health, and extreme climate events increase the vulnerability of populations to morbidity and mortality. At the same time, higher population concentrations require increased reliable access to resources that are already in high demand, namely water, sanitation, infrastructure, and energy.
While the assortment of risks varies across and within countries, they all reflect potential effects of environmental shifts on the Region’s vulnerability. Moreover, they are evidence that sustainable development, environmental health, and climate change are deeply intertwined, and that improving environmental conditions is a prerequisite for achieving SDG 3. This interconnectedness is apparent in both SDG 13 of the 2030 Agenda and the Paris Agreement of the United Nations Framework Convention on Climate Change (). In the Paris Agreement, several Regional signatories have committed to strengthening responses to the threat of climate change and developing plans to urgently reduce greenhouse gases to help meet part of the Framework’s broader goals to “allow ecosystems to adapt naturally to climate change, to ensure that food production is not threatened, and to enable economic development to proceed in a sustainable manner” (). In other words, the planet and the people that inhabit it are intrinsically interdependent. Because they cannot be separated, the harms inflicted on the planet are a threat to peoples’ health and ability to thrive.
The Region’s unequal distribution of income and the fact that those in the highest income brackets make a disproportionate contribution to emissions will require considerable improvements in the diversification of renewable energies; preservation measures in agriculture; and coverage of public services, such as mass transit and waste management (). In this way, multisectoral approaches to protecting the environment and protecting people from the consequences of its degradation are increasingly accepted as key aspects of strategies for overcoming health inequities and achieving the broader 2030 Agenda.
The health and well-being of the Region, as well at its ability to achieve these global agendas, is dependent on scaled-up actions, both immediate and long-term, to address the rapidly changing nature and scope of challenges related to the environment and climate change. Those actions are also needed to ensure that all national development plans consider environmental concerns and include rigorous safeguards and sustainability measures that also benefit and synchronize with the aims of the health sector, such as actions related to chemical safety (). Throughout this process, the greatest challenge will be to reconcile the demands of growth with the need to protect and manage natural habitats and resources and the importance of ensuring that environmental policies do not generate additional burdens for the poor. Nonetheless, the Region has many opportunities to address the topic of health and many facets of environmental sustainability in national and regional policies, which can subsequently contribute to an enabling environment for achieving many of the SDGs.
Building resilience and improving adaptive capacity is critical to continued development and achievement of the 2030 Agenda across the Americas. Adaptive efforts include increasing engagement with other sectors to improve environmental consciousness; reducing carbon footprints; and developing innovative solutions in renewable energy, transportation, water supply, forestry, agriculture, and urban development. In addition, countries must improve the reliable production of environmental statistics, promote research, build regional capacity, and develop platforms for dialogue and shared learning among relevant stakeholders. This will support the development of evidence-based prevention policies; generate income opportunities; mainstream environmental health and climate change in broader development initiatives; and ultimately strengthen the Region’s capacity to adapt to an ever-changing world.
The world has entered a new era of sustainable development, building on the successes of the MDGs. To continue advancing on social, economic, and environmental fronts, the Region must advocate, implement, and practice innovative public policies that close persistent inequities and address the increasing complexity and interconnectedness of health and development. Although only one of the 17 SDGs explicitly names health as a priority, many SDGs and their targets are related to health and thus highlight the health sector as one that not only is inherent to achieving the overall 2030 Agenda but also provides many opportunities for cooperation. In this way, health is central to the development of an equitable and sustainable future.
In the midst of rapid urbanization, threats to the climate and environment, and the emergence of new challenges, such as the growing burden of NCDs, it is crucial to adopt the 2030 Agenda core principles of equity and multesectoriality to harness complementary efforts and deliver shared gains. National plans and global agreements that are already in place, such as the WHO Framework Convention on Tobacco Control, the Minamata Convention, and the Paris Agreement, are prime examples of how the 2030 Agenda can be used to integrate priorities, innovations, and inputs from a variety of partners and stakeholders (). The public, private, and civil society sectors all have a role to play in strengthening the implementation of these policies and ensuring that new policies and interventions are not only equitable but also efficient.
Health is politicized at all levels of governance—locally, regionally, and globally—in governments, international institutions, the private sector, and civil society organizations. In addition, health itself is inherently political, because it is unevenly distributed, with many determinants that are dependent on political action, and inherently related to human rights (). Thus, only when the political nature of health is explicitly acknowledged will countries be enabled to develop more realistic, evidence-based public health strategy and policy.
Given the central importance of equity to the 2030 Agenda, it is clear that persistent inequities are not likely to dissipate unless health-related issues are discussed and addressed at the highest political levels. Because health affects economic and social conditions, and thus also has an impact on political legitimacy, the consequences of not embracing this strategic shift may be significant. At the same time, the effective use of politics in public health is already generating positive outcomes in areas such as NCDs and climate change. In order to gain political influence, countries and public health organizations must be equipped to analyze political contexts and complexities, frame arguments, and act effectively in the political arena ().
The 2030 Agenda has redefined public health in a fundamental way by demonstrating that public health challenges can no longer be addressed merely through technical actions but must be accompanied by political action within and beyond the health sector. The implementation of such an ambitious agenda simultaneously () creates opportunities to apply an ecological perspective, and systems thinking, and () requires that health be considered in government policies. Regional bodies, civil society groups, and global health institutions will be essential in accelerating the 2030 Agenda at all levels of governance, and the Region of the Americas must be prepared to embrace a more political approach to health in the context of sustainable human development and the SDGs.
The 2030 Agenda represents a fascinating point in public health history in which health is a driving force for a new quality of life and well-being, and challenges in the health sector extend beyond traditional health boundaries. The health sector thus becomes intertwined not only with development but also with politics and political processes. Health challenges require complex solutions and should thus have policy potential to take advantage of windows of opportunity and produce mutual gain across different sectors. Moreover, the co-production and co-benefits of health must be shared across society as a whole. The 2030 Agenda establishes a framework in which successful outcomes in health can have a positive impact on other aspects of development-advances that will in turn reciprocally benefit health.
Despite the complex interplay of the SDGs, the 2030 Agenda’s call is straightforward: in order to create a more equitable world for future generations, countries must identify their most vulnerable populations, develop innovative strategies to reach those populations, and monitor progress toward that end. Achieving these objectives should not be solely the responsibility of government, however. The aspirational goals and targets of the 2030 Agenda must be translated into relatable, practical, and implementable actions that individuals, families, and communities can take. These everyday actions will make sustainable development tangible, enhance effectiveness, involve new actors, and foster ownership of the Agenda across and within borders. Now, more than ever, it is of paramount importance to collectively transform the 2030 Agenda into a reality for the benefit of all.
12. Pan American Health Organization. Chapter 2: Technical cooperation and achievements. In: PAHO. Annual Report of the Director 2013: building on the past and moving into the future with confidence. Washington, D.C.: PAHO; 2013. Available from: https://www.paho.org/annual-report-d-2013/Chapter2.html.
13. Norheim OF, Jha P, Admasu K, Godal T, Hum RJ, Kruk ME, et al. Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN sustainable development goal for health. The Lancet 2015;385(9964):239–252.
14. Thornicroft G, Patel V. Including mental health among the new sustainable development goals. BMJ 2014;349:g5189.
15. Izutsu T, Tsutsumi A, Minas H, Thornicroft G, Patel V, Ito A. Mental health and wellbeing in the Sustainable Development Goals. The Lancet Psychiatry 2015;2(12):1052–1054.
20. United Nations. Addis Ababa Action Agenda of the Third International Conference on Financing for Development. Final text of the outcome document adopted at the Third International Conference on Financing for Development (Addis Ababa, Ethiopia, 13–16 July 2015) and endorsed by the General Assembly in its resolution 69/313 of 27 July 2015. New York: UN; 2015. Available from: http://www.un.org/esa/ffd/wp-content/uploads/2015/08/AAAA_Outcome.pdf.
21. Economic Commission for Latin America and the Caribbean. Committee of High-level Government Experts (CEGAN) Twentieth Session. Regional Consultation on Financing for Development in Latin America and the Caribbean, Santiago, 12–13 March 2015. Draft report. Santiago: ECLAC; 2015. Available from: http://www.regionalcommissions.org/ECLACffdreport.pdf.
22. Economic Commission for Latin America and the Caribbean. Ten key messages of the Latin American and Caribbean Regional Consultation on Financing for Development. Economic Commission for Latin America and the Caribbean (ECLAC), Santiago, 12–13 March 2015. Santiago: ECLAC; 2015. Available from: http://www.regionalcommissions.org/ECLACffd10key.pdf.
24. Sebrié EM, Schoj V, Travers MJ, McGaw B, Glantz SA. Smokefree policies in Latin America and the Caribbean: making progress. International Journal of Environmental Research and Public Health 2012;9(5):1954–1970.
25. Jha A, Kickbusch I, Taylor P, Abbasi K, SDGs Working Group. Accelerating achievement of the Sustainable Development Goals. BMJ 2016;352:i409.
27. Pan American Health Organization, Task Force and Working Group on Health in All Policies and the Sustainable Development Goals. Health in All Policies and the Sustainable Development Goals: reference note. Washington, D.C.: PAHO; 2015.
28. Buss PM, Fonseca LE, Galvão LA, Fortune K, Cook C. Health in All Policies in the partnership for sustainable development. Revista Panamericana de Salud Publica 2016;40(3):186–191.
29. Galvão LA, Haby MM, Chapman E, Clark R, Câmara VM, Luiz RR, et al. The new United Nations approach to sustainable development post-2015: findings from four overviews of systematic reviews on interventions for sustainable development and health. Revista Panamericana de Salud Publica 2016;39(3):157–165.
The settings-based approach to health promotion involves holistic and multidisciplinary action across risk factors to maximize disease prevention via a “whole system” approach. More information is available at http://www.who.int/healthy_settings/en/.
According to the International Organization for Migration (IOM), a migrant is a “person who is moving or has moved across an international border or within a State away from his/her habitual place of residence, regardless of (a) the person’s legal status; (b) whether the movement is voluntary or involuntary; (c) what the causes for the movement are; or (d) what the length of the stay is” (). The term encompasses a wide array of categories. This chapter is oriented to present the health challenges faced by migrants and their host communities, emphasizing the special challenges faced by irregular and forced migrants who, because of their situation, are in conditions of high vulnerability ().
Migrations are often prompted by, and in turn can lead to, many situations of insecurity. Economic deprivation, disease outbreaks, food insecurity, environmental hazards, political and religious persecution, family separation, and gender, sex, and ethnic discrimination constitute several of the factors that may give rise to massive migration flows and affect the health of migrants during their migration path. These factors often place migrants at higher risk for occupational injuries, violence (including sexual violence), drug abuse, mental health disorders, tuberculosis, HIV/AIDS, and other infectious diseases (). In addition, there may be barriers to accessing health services, including restrictive policies and laws, high costs, language and cultural differences, stigma, and discrimination.
The social, economic, environmental, and political context within which migration takes place in the Americas is dynamic, presenting new challenges and opportunities in the health field that can help facilitate a dignified and safe migration process. This section examines health determinants and conditions of migration and health matters associated with migration in the Americas. It also examines global, regional, and national policy responses and proposes a path for the future to ensure the health of migrants and their host communities in the Americas.
Migration is not a new phenomenon, despite its seemingly sudden rise to global attention. The movement of people, whether within country borders or across international borders, has been occurring for centuries and has recently become a major feature of globalization.
Figure 1. Total male and female international migrant stock in Latin America and the Caribbean (LAC) and Northern America in 2015 ()
In the Americas, the number of people who migrated across international borders surged by 36% in the last 15 years, to reach 63.7 million in 2015; of those, 808,000 were defined as refugees (see Figure 1). About 15.2% of the population of Northern America (Canada and the United States) and 1.5% of the population of Latin America and the Caribbean (LAC) are international migrants. Approximately 39% of this population in LAC and 26% in Northern America are 29 years old or younger and about 51% are females (see population pyramids in Figure 2). Forced migrants within country borders account for an estimated 7.1 million people, of whom 6.9 million are in Colombia (). Most LAC members are primary sources of emigration to northern high-income countries in America and Europe. Table 1 lists the top 10 emigration countries in LAC. Despite these flows from lower- to higher-income countries, migration between low- and medium-income countries and from higher- to lower-income countries has increased recently (). In addition, LAC has been experiencing a significant increase in extraregional irregular migrants. For example, according to IOM, Costa Rica experienced an inflow of over 5,600 irregular migrants between April and August 2016, primarily from Haiti and African and Asian countries ().
Table 1. Top 10 LAC countries for emigration in 2015 ()
Number of people that emigrated
Proportion of people that emigrated from the total home country population
According to IOM (), the Americas are characterized by four migration-related trends: a steady flow of returnees due to economic crises and inhospitable social settings in high-income countries; the receipt of remittances from migrants in high-income countries as an important source of income for several LAC countries; the trafficking in persons and smuggling of migrants; and the contribution of LAC communities in the United States, Canada, and Europe to the development of cultural, economic, and social ties with their countries and communities of origin.
Figure 2. International migrant stock by age and sex in LAC and Northern America in 2015 ()
The right to health of migrants and other related human rights in the Americas
The Universal Declaration of Human Rights proclaims that “all human beings are born free and equal in dignity and rights,” that every person is entitled to all human rights and fundamental freedoms, and that all persons “have the right to freedom of movement and residence within the borders of each State [and] the right to leave any country, including his own, and to return to his country” (). The Constitution of the World Health Organization (WHO) also clearly supports the right to health: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” (). This right applies to all persons, wherever they are and regardless of their migration status.
According to the Office of the United Nations High Commissioner for Human Rights, there are 27 international legal instruments relevant to migration and human rights (). In particular, the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families of 1990 () has been increasingly recognized and prominently reflected in the international agenda. As States Parties of the Convention, 18 governments of the Americas have acknowledged the need to integrate health needs and the vulnerability of migrant workers into their national plans, policies, and strategies. Accordingly, these governments have demonstrated a heightened appreciation for the development of health programs and policies that address health inequities and improve access to health facilities, goods, and services. It is important to note that migrant destination countries such as Brazil, Canada, the Dominican Republic, and the United States have yet to take action on the Convention.
In the Americas, the 59th Session of the Executive Committee of PAHO in 1968 began to discuss the relationship between health and international human rights instruments in the context of the technical cooperation that PAHO provides to its Member States (). In 2007, ministers and secretaries of health of the Americas underscored their commitment to the aforementioned international principle in the Health Agenda for the Americas (2008–2017). In doing so, they placed human rights among this instrument’s principles and values and reconfirmed the importance of ensuring the highest attainable standard of health by stating, “In order to make this right a reality, the countries should work toward achieving universality, access, integrity, quality and inclusion in health systems that are available for individuals, families, and communities” (). In 2010, the 50th Directing Council of PAHO agreed to work to improve access to health care for groups in conditions of vulnerability, including migrants, by promoting and monitoring compliance with international human rights treaties and standards ().
Social determinants of health of migrants in the Americas
Migration is regarded as a social determinant of health since the health of migrants is determined primarily by the conditions along the migration path. As illustrated in Figure 3, the health of migrants can vary according to personal characteristics, individual and relational factors, social and community influences, living conditions, and general socioeconomic, cultural, and environmental conditions (). In particular, irregular and forced migrants may travel to destination communities in precarious conditions. For example, many irregular migrants from Central America ride atop moving cargo trains colloquially known as La Bestia, or the beast, on their journey across Mexico to the United States. Along the trip they face physical dangers including amputation and death. In addition, they are subject to extortion and violence at the hands of gangs and organized-crime groups ().
Figure 3. Risk factors associated with migration at the individual, relational, community, and social levels of the ecological model ()
Migrants work in some of the riskiest industries in their destination communities, including agriculture, forestry, fishing, and construction. These types of work have higher rates of injury and fatality compared with other sectors. Migrant farmworkers are also more exposed to pesticides and their associated health risks. Moreover, their housing is associated with unsafe drinking water; crowding; substandard and unsafe heating, cooking, and electrical systems; inadequate sanitation; dilapidated structures; and food insecurity. For example, it is estimated that more than half of the migrant farmworker households in the United States suffer from food insecurity due to their limited access to transportation, food storage, and cooking facilities ().
Migration can also affect the health and well-being of family members who stay in the communities of origin by impacting on remittances and “brain drain” (i.e., the migration of educated workers to higher paying countries). On the one hand, remittances can improve the economic conditions of remittance-receiving households in communities of origin and can have a positive effect on their health and well-being. Households receiving remittances have improved human development outcomes including better access to health services, less crime, and better education. For example, a study in Nicaragua showed that about 48% of remittances are used to pay for health services, 27% for home improvement, 15% for education, and 10% for savings (). In 2014, there was an inward remittance flow of US$ 63.6 billion into LAC countries, with the top remittance recipients being Haiti (22.7% of gross domestic product, or GDP), Honduras (17.4% of GDP), EI Salvador (16.8% of GDP), and Jamaica (16.3% of GDP). On the other hand, family separation may lead to negative effects regarding health and well-being, including psychological trauma, material hardship, residential instability, and family dissolution. Moreover, remittances may generate tensions and inequalities between remittance-receiving households and households that do not receive them (). In addition, communities of origin can find themselves at risk of a “brain drain” of talent, depriving them of trained workers in key sectors of their economy ().
Migrants’ access to health services
Migrants, and in particular irregular and forced migrants, often have limited access to appropriate health services and financial protection for health. WHO reports that globally, migrant health needs are not addressed consistently and access to health services in recipient countries remains highly variable ().
Factors associated with health policies and the organization of health systems can constitute formal barriers to accessing health services. These include legal restrictions on entitlements to health services and financial barriers to irregular and forced migrants. In several countries in the Americas, only emergency and limited private charity health services are available to these migrants. For example, exclusionary policies and treatment resulted in limited health care service accessibility for male Latino migrant workers in North Carolina, U.S.A. (). User fees can also be seen as a formal barrier, creating inequality in access due to migrants’ limited financial means.
Inadequate health literacy, language differences, sociocultural factors, stigma, and perceptions of the health system may constitute informal barriers to access to health services (). Health beliefs and health-seeking behavior of migrant groups may be different from the host communities because of their needs and differences in social norms, culture, and organization of health systems in communities of origin. For example, a study of a shelter in Monterrey, Mexico, with migrants primarily from Central America, shows that migrants avoided public health services due to the need to work in order to survive and the constant fear of being traced (). In these situations, health education is often regarded as a solution that can improve health literacy and help migrants acquire the skills they need to maneuver in their new health system. Health education programs for migrant groups need to be appropriately targeted to reach them more effectively (). Limited proficiency in the host community language can also present a significant obstacle to accessing health services. For example, an analysis of U.S. Behavioral Risk Factor Surveillance System data from 2003 and 2005 showed that Spanish-speaking Hispanics reported far worse access to care than English-speaking Hispanics (). To the extent possible, patient information on health issues should be provided in whatever languages are necessary to reach potential users of health care services. In addition, health service providers should be trained on cultural sensitivity and appropriateness. Furthermore, limited understanding of the patient’s social norms and culture may also present an obstacle. For this reason, the role of the translator should include cultural mediation. Migrants may also be reluctant to make use of services because of stigma or anxieties about reactions within their own community. Mental health, for instance, is often stigmatized in migrant communities. For example, the perceived discrimination and the experience of humiliation have contributed to poor mental health and limited access to health services among Haitian migrants in the Dominican Republic (). Reproductive health, sexuality, pregnancy, and childbirth are sensitive topics that people may find difficult to discuss with a stranger. Often, one of the elements that helps overcome informal barriers to accessing health services is trust. Clients need to be confident that they will be treated with respect and receive appropriate and relevant services.
International border areas are geographical spaces in which residents, regardless of which country they live in, share risks and protective factors that generate a health profile that is often different from that of populations in the rest of their country’s national territory (). Border communities can also be impacted by forced migratory movements including people displaced by war, sudden environmental events, violence, and political or financial crises (). Border population groups in conditions of vulnerability may also include indigenous groups whose conception of the land may give them a different recognition of country borders from that of the dominant population (). In other cases, border areas are poles of economic development that generate disorganized urban growth where basic services are limited (). Moreover, border communities tend to be distant from the national political center of the country and therefore have little influence on decision-making and the allocation of resources ().
The nature of cross-border political cooperation that exists can influence the health situation of the border population, and at the same time, it can determine how the countries and their respective border populations organize themselves to respond jointly to their health needs. For border areas in which the relationship is one of merely coexistence or even confrontation between countries, looking after health issues may foster understanding between them. For example, in 2012 Paraguay was politically suspended from regional country integration systems but continued participating in health projects. This shows that joint work on health activities can overcome political barriers, serving to tie neighboring nations together (). For border areas in which the relationship is one of interdependence between countries, there is a mutual interest in improving health conditions. However, in several cases, such interdependence may be asymmetrical. For example, there has been a financial asymmetry in environmental health collaboration between the United States and Mexico along the border. Most funds available for border programs have been provided by the U.S. Environmental Protection Agency, enabling this agency to have more control over the program agenda (). For borders where relationships are more integrated, the countries and their border communities make maximum use of existing resources (); examples include portable health insurance for border communities between Uruguay and Brazil (), health services shared between Ecuador and Peru (), and joint delivery of emergency health services between Chile and Argentina ().
Health interventions in border areas may create tensions between the national government and its border communities. On the one hand, border communities feel a need to resolve concrete issues in a space that is influenced by—and to some degree shared with—another country (). On the other hand, national governments have a constitutional mandate to safeguard national sovereignty (). Therefore, striking a balance between national and local interests is crucial when designing and implementing health interventions in border communities ().
Defining health priorities is one of the greatest challenges of cross-border cooperation since it must respond to the needs and assets of two or more countries. One criterion may be tackling health issues that are causing or may cause conflict between neighboring countries, such as the origin of an infectious disease in one country that could affect people, productivity, or trade in a neighboring country, or the use of the health services by residents of one country in a neighboring country, incurring additional costs to the latter’s health system (). Another criterion may be managing health issues that cannot be resolved without a binational approach. This frequently applies to vector-borne diseases and environmental contamination. A third criterion may be the interest of academic researchers, since border populations can become unique public health laboratories ().
Structures and mechanisms to address border health issues may be official or unofficial. For the former, the predominant actors are national and subnational governments including local governments in the countries that share the border (). Generally, the higher the public institutional level of participation, the better organized the structures or mechanisms, and the more long-term oriented their objectives are (, , ). However, they may also be more political, be slower to act, be less sensitive to the perceived needs and assets of border communities, and have more problems addressing issues on which the countries do not agree (). The opposite is seen when unofficial structures and mechanisms such as academic, private, or community-based institutions play the central role (, ). They often are more technical and have a more limited sphere of work and a shorter-term vision. They also tend to be transient or with limited sustainability. Many border areas address health issues through both mechanisms. For example, health issues in the United States—Mexico border area are addressed through formal national and state-level structures through the United States—Mexico Border Health Commission or more informal structures through binational health councils that are part of sister city arrangements ().
Depending on their objectives, the structures and mechanisms can be temporary or permanent. Countries in the Americas have developed structures and mechanisms to attend to border health issues that encompass the types mentioned, from short-term specific projects, to medium-scope programs, to permanent binational commissions (). The latter have been developed primarily for cases in which the needs of border communities have been made a national priority and placed at the highest level of the political agenda.
Humanitarian health assistance
Globally, about 201 million people were affected by disasters and conflicts in 2014, of which 141 million endured sudden environmental events and 60 million were forcibly displaced by violence (). In the Americas, the Inter-Agency Standing Committee (IASC) () estimates indicate that Haiti, Colombia, and Guatemala have the highest risks for humanitarian crises and disasters. According to the Office of the United Nations High Commissioner for Refugees (UNHCR) (), there was a five-fold increase in asylum-seekers from El Salvador, Guatemala, and Honduras, primarily of unaccompanied children, from 2012 through 2015. In addition, even as it strives to resolve decades of conflict, Colombia reported about 6.9 million internally displaced people.
In 2016, PAHO reported giving critical support to several Member States that have faced unexpected migrant flows, including 171,000 Venezuelan migrants in Colombia between October 2015 and May 2016; over 5,000 Cuban nationals who traveled through Ecuador, apparently intending to continue northward towards the United States but instead found themselves stranded in Central America in late 2015; and approximately 100,000 Haitians who were repatriated in 2015 from the Dominican Republic ().
A special concern during humanitarian crises is the need for adequate basic health services and sanitation in shelters and settlements. For example, in Colombia, even though 75% of the internally displaced people were affiliated with the national social security program in 2014, only 32% had access to health services. (Of those, 38% were males and 62% were females.) Barriers to health services include limited infrastructure, technology, and human resources in rural areas (). The low vaccination rate among Venezuelan migrants in Colombia also caused concern about a potential change in the host population’s health profile. Another major health concern was the increased risk of cholera outbreaks among deported migrants in the Haiti–Dominican Republic border area ().
Finally, the impacts of climate change—primarily on Small Island Developing States such as the ones in the Caribbean, and on indigenous communities–have led to discussions about decision-making regarding the potential need to migrate (). Climate-induced migration may cause forced displacement from rural to urban areas and from one country to another. The range and extent of health risks associated with future climaterelated population movements cannot be clearly foreseen. However, the evidence of movements of people due to similar situations indicates that health risks will predominate over health benefits ().
Migrant workers’ health
Current levels of human mobility have created serious challenges for migrant workers, becoming a political priority at national and supranational levels. Despite several migrant-specific instruments adopted by the International Labour Organization (ILO) during the past seven decades (Conventions No. 97, 86, and 143, and Recommendation No. 151) (), the dignity and rights of migrant workers are threatened because of limited national labor protection regulations and enforcement.
In 2014, the Fair Migration Agenda was adopted after the UN General Assembly High-Level Dialogue on International Migration and Development (). The Agenda seeks to make migration a choice and not a need by pursuing decent work opportunities in the countries of origin. It also aims to ensure fair recruitment and equal treatment of migrant workers by promoting bilateral agreements for well-regulated and fair migration between countries, countering unacceptable situations, and contributing to a strengthening of the multilateral rights-based agenda on migration.
According to the ILO (), in 2013 there were 150.3 million migrant workers worldwide (55.7% males and 44.3% females). They represented 4.4% of the global work force. The majority of international migrant workers were in high-income countries, about 24.7% in North America and only 2.9% in LAC, accounting for 20.2% and 1.4% of the work force in North America and LAC, respectively. They were concentrated in certain economic sectors, primarily in services (71.1%), industries including manufacturing and construction (17.8%), and agriculture (11.1%). Domestic service migrant workers represented 7.7% of all international migrant workers (with 73.4% of domestic service migrant workers being females) and were concentrated in high-income countries.
ILO estimates that in 2015 migrant workers sent US$ 601 billion in remittances to their home countries, evidence that their work is a driver for economic development in the countries of origin. At the same time, migrant workers fill labor gaps in countries of destination. Nonetheless, the unequal distribution of types of work, income, benefits, and job opportunities has raised questions of social justice, sustainable development, and health equity ().
Based on the impetus created by the adoption of the 2030 Agenda for Sustainable Development, ILO has developed several instruments for addressing migrant workers’ health rights and equity. For example, the gender equality in labor migration law, policy, and management tool kit () was created to support fair immigration and respect for fundamental rights of women migrant workers, seeking to offer them real opportunities for decent and healthy work.
It is vital that the international community acknowledges the shared global responsibility of developing collective and inclusive action, particularly in the context of the 2030 Agenda for Sustainable Development. Effective actions may include creating more productive and decent work in countries of origin; establishing more dignified, regular, and safer migration processes that meet real labor market needs and facilitate preservation of family units; and placing human rights, including health and labor rights, at the core of all interventions.
Communicable diseases can significantly affect the health and well-being of migrants, and have public health implications due to the potential importation of transmissible pathogens. In the Americas, the spectrum of communicable diseases in migrants may range from diseases that require acute recognition and management (such as malaria) to chronic illnesses with significant public health concerns (such as tuberculosis and HIV/AIDS). The recognition and timely management of infectious diseases in migrants requires knowledge of the geographic context, modes of transmission, and clinical presentation of a wide variety of infectious agents. Many of these infections may be unfamiliar to health care providers in destination communities.
In South America, small-scale gold mining draws people to the Guiana Shield from different countries, known in Brazil as garimpeiros. The Guiana Shield comprises Guyana, Suriname, French Guiana, and parts of Colombia, Brazil, and Venezuela. In 2014, miners in this region represented at least 13% of all malaria cases in the Americas. It is highly likely that the number is even higher due to underreporting, since many miners live solitary lives and try to avoid health facilities. Mining also prompts related movements within country borders, leading to malaria outbreaks. For example, malaria increased from around 21,000 cases in 2010 to over 52,000 in 2014 in the Sifontes municipality of Bolivar State in Venezuela due to an increase in the mining population coming from other parts of the country ().
The importation of cases is a major factor that can inhibit progress being made in the control of outbreaks and can defer elimination of the disease. For example, the district of Candelaria in Campeche State, Mexico, near the Guatemalan border, reported an outbreak of malaria in 2014 although it had had no cases in previous years. A change in migratory patterns was suggested as a possible reason for this outbreak. Malaria in Dajabon in the northwest corner of the Dominican Republic has also been attributed to mobility across the international border between the Dominican Republic and Haiti. This location is known for its binational market that attracts residents from both countries. Since 2005, approximately 2,000 Haitians have entered the Dominican Republic twice weekly to buy and sell their goods. The number of malaria cases reported subsequently increased from approximately 100 in 2005 to about 1,000 in 2007. This number has decreased in recent years (17 cases in 2014) due to focused interventions ().
While the preceding examples highlight how migration has increased the risk of malaria in the Americas, success stories are also present in the region. For example, Suriname’s Ministry of Health has succeeded in reducing the number of malaria cases by improving diagnosis and treatment to miners through trained individuals working in mining areas. Another example is the success story of Costa Rica. Since 2000, the Ministry of Health, in coordination with the private sector and the national health services network, has prevented the introduction of imported cases of malaria in Huetar Atlantica and Huetar Norte despite agricultural developments in these areas that led to an increased risk of malaria due to vector habitat changes and an inflow of migrants seeking work.
Migrants’ risk for becoming infected with or developing active tuberculosis (TB) depends on the TB incidence in their community of origin; living and working conditions in their communities of destination, including their access to health services; whether they have been in contact with an infectious case (including the level of infectiousness and how long they breathed the same air); and the way they travel to the destination countries (with the risk of infection being higher in poorly ventilated spaces). People who live in communities characterized by low levels of education, poor nutrition, inadequate or overcrowded housing, and with poor access to preventive and curative medical services are the most vulnerable to infection. Specifically, recently arrived migrants from endemic countries who often congregate in deprived communities within wealthy cities constitute high-risk groups. Fears of deportation and having contacts traced could prevent individuals from seeking medical assistance. Once in treatment, family support and migrant-sensitive health providers can become key factors facilitating adherence ().
In the Americas, migrant groups are associated with an increase in TB prevalence in low-risk countries. For example, the increase in TB incidence in Costa Rica between 2009 and 2011 was associated, among other factors, with the influx of Nicaraguan migrants. The increase in TB incidence in Chile was also associated with migrants from endemic countries ().
At the national level, migration has also influenced the incidence of TB in destination countries outside of the Americas. For example, Spain has one of the highest incidence rates of TB in Europe with approximately 20 cases annually per 100,000 persons, primarily international migrants. In particular, in Barcelona, the percentage of foreigners with TB increased from 5% to 32% with an incidence rate greater than 100 cases per 100,000 persons per year between 1999 and 2000 (). Studies conducted between 1998 and 2013 revealed that multidrug- resistant TB was 2.5 to 4.0 times more frequent in immigrant populations from Latin America, Eastern Europe, Africa, and Asia than in the native Spanish population. Multidrug resistant TB was diagnosed in 7.8% of immigrant population cases but in only 3.8% of native cases (). Moreover, studies using Spanish national surveillance data between 2004 and 2009 reported that TB was often diagnosed in later stages in migrant populations due to their limited access to quality, migrant-sensitive health services (). About 60% of TB cases in migrants were diagnosed in hospitals and not in primary health care facilities.
Migration can disrupt migrants’ access to HIV services. Barriers include lower and late access to testing and care and fear of discrimination and deportation (). For example, there are documented cases of Central American migrants having their HIV services disrupted when they travel through Mexico to the United States (). According to a cross-sectional study by Leyva-Flores et al. (), the prevalence of HIV among Central American migrants traveling through Mexico was 0.71% between 2009 and 2013 and peaked at 3.45% in the transvestite, transgender, and transsexual community, reflecting the concentrated epidemic in their countries of origin. In addition, it appears that there is a modest positive association between population mobility, measured by the net migration rate, and HIV prevalence in Central America and Mexico when socioeconomic cofactors are included by country (education, health, and income) (). Moreover, male migrants who stayed in border areas were more likely to engage in sex, and have unprotected sex, with female sex workers during their recent stay on the border compared with those in other contexts ().
The mental health of migrants is frequently affected by changes in their lives that result from the process of migration itself, and varies according to how their experience in the new situation and cultural context evolves (). In particular, uncertainty about the future and the process of moving from one cultural setting to another can be stressful, with potentially negative impacts on mental health outcomes ().
The conditions that create forced migration increase psychosocial stress on the individuals and families affected (). Migrants may be exposed to various stress factors in each phase of the migration path, and they experience different challenges during and after migration. These challenges could become risk factors for mental illness. For example, the reasons that cause or promote migration, such as a difficult economic and employment situation in the country of origin, the breakdown of social support, or possible trauma, as well as uncertainty about whether one will be accepted by the new host community or not and about the process of migration itself all have an impact on one’s mental health (). In the post-migration phase, other risk factors have been associated with mental disorders, such as the uncertainty about legal status, employment opportunities or lack thereof, loss of any preexisting social role, uncertainties about family and social support, and the difficulties of learning a new language and culture and adapting to these new norms ().
Many studies have reported that the process of migration can lead to a whole spectrum of mental health disorders, for example, psychoses (), posttraumatic stress disorders (), depression (), and suicidal acts (). Multiple factors and complex interactions will determine post-migration adjustment and the outcome of migration. The evidence of mental health disorders among populations who migrate between or within LAC countries is limited. Only a few studies report an association between natural disasters and mental disorders in the subregion (). Other studies show an increase in psychological issues in migrant children and adults due to political repression in their countries of origin (). On the other hand, there is significant evidence of mental health disorders in people who migrated from LAC to North America ().
While the aforementioned elements can have an impact on all migrants, some social groups may be exposed to additional risk factors that must be taken into account when considering possible psychosocial or mental disorders, in particular for women; children and adolescents; the elderly; lesbian, gay, bisexual, and transsexual (LGBT) people seeking asylum; indigenous populations; and people with mental disorders prior to migrating (). Preexisting mental health conditions can be intensified due to the same requirements of adaptation in short periods of time that many migrants without preexisting conditions experience ().
The assessment of risk for mental health problems includes consideration of pre-migration exposures, stresses, and uncertainty during migration, and post-migration resettlement experiences that influence adaptation and health outcomes. It is important that cultural elements are taken into consideration when assessing physical health and more clearly when dealing with mental health issues by the health system in the host community (). Furthermore, the right to receive pharmacological or psychotherapeutic treatments has to be preserved. Some evidence has been reported of satisfaction of the mental health services among immigrants (), but more research on the effectiveness of these services in immigrant populations is needed. Clinicians need to be aware of the mental health needs of immigrants and the challenges of delivering appropriate care to them ().
Violence is an increasingly important driver of migration in LAC (). According to 2012 estimates (the most recent available), 18 of the 20 countries with the highest homicide rates in the world were located in LAC (see Figure 4 for the top 10). Also, the rate of 23 homicides per 100,000 population for the Region of the Americas was nearly four times the world average (6.2 per 100,000)—higher than the average for the “fragile and conflict-affected” countries as defined by the UN (). Preliminary 2015 data suggest that after the end of a gang truce in 2012, El Salvador may have surpassed Honduras as the most dangerous peacetime country in the world ().
Figure 4. Countries with the highest homicide rates per 100,000 population, 2012 ()
Violence associated with transnational organized crime and gang activity in the Central American “Northern Triangle” (El Salvador, Guatemala, and Honduras) and Mexico has created what the UNHCR calls a “protection crisis,” forcing thousands of women, men, and children to leave their home (). Asylum applications by Northern Triangle migrants in Belize, Costa Rica, Mexico, Nicaragua, and Panama rose by almost 1,200% between 2008 and 2014, and the number of families and unaccompanied minors migrating north from Central America through Mexico towards the United States has risen sharply (). Meanwhile, civil war in Colombia has created the largest internal forced migration in the world (an estimated 6.9 million) (), as well as a large diaspora of refugees in surrounding countries such as Ecuador ().
Violence plays a particularly important role in female migration. A 2015 UNHCR study found that a majority of women interviewed after migrating north out of Central America and Mexico cited violence, including rape, assault, extortion, and death threats, as a primary motivation for leaving their communities; much of this violence was perpetrated by intimate partners, many of whom were involved in gang activity (). Often, women left after local authorities refused or were unable to provide protection. Conflict-related sexual violence has been a persistent feature of the armed conflict in Colombia, and an important reason why many women have been forced to leave their communities ().
While many migrants leave home to escape violence, they often face heightened risk of physical and sexual violence during the journey itself and within destination communities. Women and families migrating north from Central America and Mexico report high levels of extortion, kidnapping, rape, death threats, and abandonment in life-threatening situations along the migratory travel route (). Research in Colombia has documented “pervasive exposure to violence” and vulnerability to physical harm in forced migrant settlements (). In the United States, migrant populations report high levels of certain types of violence, including sexual harassment and assault among women migrant farm workers (). In sum, violence not only drives much migration in the Region but is an important human rights and public health problem during all stages of migration and displacement, including within communities where migrants and displaced populations settle.
Maternal and child health
The Americas is home to 6.3 million migrant children, about one-fifth of the global total. Approximately 80% of them reside in three countries: the United States, Mexico, and Canada, with the United States hosting the largest number in the world, an estimated 3.7 million. An alarming concern is the percentage of children who migrated from Central America, where almost half of all migrants are younger than 18 years of age, compared with an estimated 8%, 15%, and 15% from North America, South America, and the Caribbean, respectively ().
A distinct pattern in the Region is the number of children who have migrated on their own, many of them fleeing violence in their homes and communities, primarily from Colombia, El Salvador, Guatemala, Mexico, and Honduras (), and wanting to reunite with their families, many of whom are located in the United States ().
Migrating children and adolescents face barriers to accessing adequate health services during the migration path (). Studies have shown that children residing in households with noncitizen parents have trouble accessing health care and thus experience worse health outcomes (). A study in Argentina reported that migrant women had poor prenatal care and newborns required more medical care compared with newborns born to native-born mothers (). Similar challenges have been cited for children of internal migrants. In a study examining child mortality associated with maternal migration in Haiti, researchers reported that children born to migrants moving from rural to urban areas or vice versa experienced higher mortality (). Other situations faced by child migrants include being detained at borders, being left behind by migrating parents, and being forcibly returned to their countries of origin ().
Several countries are trying to improve access to health services for migrant children. For example, Guatemala is working with IOM on capacity- building for government officials to assist child migrants in transit, especially those who are unaccompanied or have been separated from their families (). In Brazil, policies have recently been adopted to assure equal access to coverage for all migrants including irregular migrants (). The increase in the number of unaccompanied and separated children who have been detained at the southern border of the United States () has led to increased cooperation between the United States and several Central American countries—led by El Salvador, Guatemala, and Honduras—in programs to reduce extreme violence and increase economic opportunities in countries of origin (). In order to make further improvements to health services for migrant children, it is necessary to better understand their specific health needs by collecting data disaggregated by socioeconomic status, geographic location, and migration status during the entire migration path ().
Adolescents face unique challenges during their migration path because adolescence is a time of rapid physical, mental, emotional, and social development, during which the influence of parents, peers, the media, and school plays an important role in their life. This is also when they first develop the capacity to reproduce and when they begin to take progressive responsibility for their own health and development. Adolescents may be forced to move with their families, forced to migrate without their families to seek a better future somewhere else, or left behind by migrating parents to take care of younger siblings.
On the one hand, migration can have positive results for adolescents, including increased opportunities for education and income. On the other hand, the potential increased health risks associated with separation from family, peers, school, and community requires careful consideration and response. There is growing evidence that the health and development of adolescents are profoundly affected by their relationships with these social settings. For example, studies in the English Caribbean countries and territories have documented associations between low levels of connectedness or emotional attachment with parents, peers, school, and community and increased risk of negative health outcomes and behaviors such as anxiety, depression, suicide ideation and attempts, unsafe sex, unplanned pregnancy, and substance use (). Studies also document the protective effect of high levels of connectedness on the emotional and physical well-being of adolescents (). With the interruption and separation from these social settings that comes with migration, it is critical that programs and services attempt to fill the gap and offer opportunities for adolescents to build meaningful relationships with peers, adults, and social institutions along their migration path.
A number of studies have shown differences in the risk for noncommunicable diseases among different population groups of recent LAC migrants to the United States and between recent international migrants and populations born in the United States. For example, recent migrants from South America to the United States have a lower prevalence of diabetes and being overweight than the average United States–born population and a lower prevalence than recent migrants from Mexico, Central America, and the Caribbean, too. Moreover, there appears to be an increased morbidity and mortality burden among Latinos born in the United States compared with Latinos born elsewhere. The decline in health status of subsequent generations of Latinos can be attributed to negative acculturation and to adopting unhealthy behaviors (poor diet, smoking, alcohol consumption, substance abuse, and physical inactivity) that are more prevalent in the receiving communities to which the migrants moved (). Furthermore, conditions related to communities of origin appear to have a protective effect on cancers but not on obesity and diabetes. However, over time, the rates of most cancers tend to converge towards the rates seen in locally born residents ().
Rural to urban mobility in low- and middle-income countries, such as the Andean countries, can also be detrimental to the health of migrants due to changes in dietary and physical activity patterns, enhancing the risks for cardiovascular diseases such as hypertension and obesity (). However, it appears that the impact of rural-to-urban migration on the cardiovascular risk profile is not uniform across different risk factors and can be further influenced by the age at which migration occurs (). Moreover, rural-to-urban migrants may have better access to health services than the populations who stay in rural areas ().
The situation of migrants has gained recognition in and prominence on global agendas. In October 2013, the UN General Assembly adopted the Declaration of the High-Level Dialogue on International Migration and Development, which recognizes that human mobility is a key contributor to sustainable development. In September 2015, the UN General Assembly adopted the 2030 Agenda for Sustainable Development, recognizing “the positive contribution of migrants for inclusive growth and sustainable development.” A central reference to migration is made under Goal 10 (reduce inequality within and among countries), under which target 10.7 is a commitment to “facilitate orderly, safe, regular, and responsible migration and mobility of people, including through the implementation of planned and well-managed migration policies” (). Finally, in May 2016, the UN Secretary General presented his report, “In Safety and Dignity: Addressing Large Movements of Refugees and Migrants” (). The report focuses on ensuring at all times the human rights, safety, and dignity of refugees and migrants. It calls for the development of national inclusive policies (including health policies), seeking to bring migrants into the receiving society and to provide access to basic services, including health services. As a follow-up to the UN Secretary General’s report, the General Assembly held a high-level plenary meeting in September 2016 to address the topic of large movements of refugees and migrants. At the meeting, Member States adopted the New York Declaration for Refugees and Migrants (). The Declaration endorsed a set of commitments related to refugees and migrants including women at risk; children, especially those who are unaccompanied or separated from their families; members of ethnic and religious minorities; victims of violence; older persons; persons with disabilities; persons who are discriminated against on any basis; indigenous peoples; victims of human trafficking; and victims of exploitation and abuse in the context of the smuggling of migrants. Specifically, the Declaration endorsed among other commitments, the need to address the vulnerability to HIV and specific health care needs experienced by migrant populations.
Specifically in health, the new WHO’s International Health Regulations of 2005 () were adopted “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.” As of 2016, the status of all core capacities established in the International Health Regulations across PAHO Member States continues to be heterogeneous, with the lowest scores consistently registered in the Caribbean (). In 2008, the 61st World Health Assembly endorsed the WHO Resolution on the “Health of Migrants” (), and in 2016, the 69th World Health Assembly endorsed a report promoting the health of migrants () in support of migrant-sensitive health policies, information programs, and services.
Heads of State in the Americas agreed to establish an inter-American program within the Organization of American States (OAS) at the Third Summit of the Americas held in April 2001 (), for promoting and protecting the human rights of all migrants, regardless of their immigration status. The OAS recognizes that, given the scope, prevalence, and significance of the current migratory phenomenon, virtually every state in the Americas has become a country of origin, transit, destination, or return for migrants, and as a direct result of this, migration has become a priority in the Region (). Specifically regarding the health of migrants, the 55th Directing Council of PAHO in 2016 () adopted the Regional Strategy for Universal Access to Health and Universal Health Coverage () as the overarching framework for health system actions to protect the health and well-being of migrants.
At the national level, there are wide differences in the extent to which countries in the Americas have considered and implemented national migrant policies that include the health dimension. They range from free access to health services in the formal public system for all people in precarious economic conditions, including migrants, like in Argentina (), Brazil (), and El Salvador (), to ensuring health insurance coverage or health services in the public system only to migrants with legal residential status, like in the United States () and Canada (). The overall political climate in a country is an important factor that can help or hinder health systems in becoming more responsive to the needs of migrants (). The range of areas that need to be addressed by migrant-sensitive health policies should go beyond improving health services to encompass actions addressing the social exclusion of migrants and their employment, education, and housing conditions (see Figure 5).
Figure 5. Policy measures tackling the social determinants of health for migrants ()
By adopting a resolution on health and human rights in 2010 (), agreeing on a Regional Strategy for Universal Access to Health and Universal Health Coverage () and Plan of Action for the Coordination of Humanitarian Assistance () in 2014, and adopting the global 2030 Agenda for Sustainable Development in 2015, the countries of the Americas have shown their commitment to protecting the rights of all people, including migrants. Thus, everyone can achieve the highest attainable standards of physical and mental health and commit to the development of health policies and programs to address health inequities and improve access to health services.
At the national and supranational levels, the strategic lines of action defined within WHO Resolution WHA61.17 of 2008 and PAHO Resolution CD55.R13 of 2016 on the health of migrants constitute the overarching framework for the health system’s actions to protect the health and well-being of all migrants. The agreed strategic lines of action on these resolutions are well aligned with the 2030 Agenda for Sustainable Development, and comprise the following:
Ensuring inclusive health services responsive to the needs of migrants and readily accessible to migrants by eliminating geographical, economic, and cultural barriers;
Improving mechanisms to provide financial protection in health for migrants with equity and efficiency;
Adopting inclusive policy and legal frameworks that provide access to comprehensive, high-quality, and people-centered health services to migrants that are consistent with international human rights legal instruments;
Ensuring the standardization and comparability of data among countries on migrant health; supporting appropriate aggregation and assembling of migrant health information and mapping of good practices; and
Strengthening intersectoral action and development of partnerships, networks, and multicountry frameworks to address the social determinants of health of migrants; these should aim at shaping individual and community resilience and advocating for migrant-sensitive social policies and programs.
Furthermore, the countries of the Americas, in coordination with international entities, have shown a continuous commitment to ensuring that all people, including migrants, are able to access life-saving and essential health care during health emergencies such as internal and international massive force displacement due to sudden environmental events, violence, or other reasons. This includes HIV prevention, protection, and treatment; reproductive health services; food security and nutrition; and water, sanitation, and hygiene services. Key to the success of humanitarian health assistance is coordination with existing national disaster risk management authorities, promotion of mechanisms for coordination with other sectors, participation in regional and global health networks for emergencies, and implementation of a flexible mechanism for registry of qualified foreign medical teams and multidisciplinary health teams and for emergency response procedures (). In addition, the countries of the Americas should continue working toward attaining and strengthening core capacities required by the International Health Regulations, including migrant-sensitive surveillance, response, preparedness, risk communication, human resources, and points of entry ().
At the local and community levels, there is a need for a sustainable, equity-driven process that can bridge short-term humanitarian assistance during health emergencies with long-term universal access to health and universal health coverage for all migrants. Mainstreaming human security in country health plans can play this bridging role. In the Americas, PAHO’s Member States have demonstrated a heightened appreciation for considering the incorporation of human security into their country health plans by adopting the 2010 Resolution “Health, Human Security, and Well-being” (). A human security approach can help overcome challenges of national health systems with regards to the health care of marginalized communities such as migrants and their families. It would seek to address health threats in communities of origin, transit, destination, and return following a balance of individual and community-based interventions that are people-centered, context-specific, prevention- and promotion-oriented, comprehensive, and multisectoral within an integrated protection-empowerment framework. Human security can effectively guide health systems to be better prepared and to promote resilience in communities with migrants so that they move beyond a focus on survival to a focus on livelihood and dignity (). For example, the integration of the human security approach in health emergency plans would prevent, monitor, and anticipate acute migrant health-related threats by developing early warning and response mechanisms, as well as strengthen community ownership, resilience, and preparedness to identify and control these threats. Incorporating the human security approach in local health service models would provide migrant-sensitive services, as well as strengthen the health knowledge, mobilization, and decision-making power of migrants and of communities of origin, transit, destination, and return. Mainstreaming human security in country health plans requires a substantial capacity-enhancement program that is focused on research, training, and consolidation of multidisciplinary expertise. It calls for a multisectoral, multistakeholder strategy that articulates collective interests, establishes rights and obligations, and mediates differences using good governance principles such as promotion of equity, participation, pluralism, transparency, co-responsibility, and the rule of law ().
4. United Nations. International convention on the protection of the rights of all migrant workers and members of their families. Adopted by the United Nations General Assembly, New York, 1990 Dec 18 (Resolution A/RES/45/158). Available from: http://www.ohchr.org/EN/ProfessionalInterest/Pages/CMW.aspx.
6. Urquia ML, Glazier RH, Blondel B, Zeitlin J, Gissler M, Macfarlane A, et al. International migration and adverse birth outcomes: role of ethnicity, region of origin and destination. Journal of Epidemiology and Community Health 2010;64(3):243–251.
15. Pan American Health Organization, Executive Committee. Relaciones entre la salud y el derecho. Washington, D.C.: PAHO; 1968 July 11 (Document CE59/16).
16. Pan American Health Organization. Health Agenda for the Americas 2008-2017. Presented by the Ministries of Health of the Americas in Panama City at the XXXVII General Assembly of the Organization of American States, Washington, D.C.; June 2007.
17. Pan American Health Organization. Health and human rights. Concept paper prepared by the 50th Directing Council, 62nd Session of the Regional Committee, Washington, D.C., 2010 Sept. 27-Oct. 1 (CD50/12; 2010 Aug 31). Available from: https://www.paho.org/hq/dmdocuments/2010/CD50-12-e.pdf.
25. Fleming P, Villa-Torres P, Taboada A, Richards C, Barrington C. Marginalisation, discrimination and the health of Latino immigrant day labourers in a central North Carolina community. Health and Social Care in the Community 2017;52(2):527–537.
26. Kuruvilla R, Raghavan R. Health care for undocumented immigrants in Texas: past, present, and future. Texas Medicine 2014;110(7):e1.
27. Pottie K, Batista R, Mayhew M, Mota L, Grant K. Improving delivery of primary care for vulnerable migrants: Delphi consensus to prioritize innovative practice strategies. Canadian Family Physician 2014;60(1):e32–e40.
28. González-Vázquez T, Torres-Robles C, Pelcastre-Villafuerte B. Transnational health service utilization by Mexican immigrants in the United States. Salud Pública de México 2013;55(4):477–484.
29. Stoesslé P, González-Salazar F, Santos-Guzmán J, Sánchez-González N. Risk factors and current health-seeking patterns of migrants in northeastern Mexico: healthcare needs for a socially vulnerable population. Frontiers in Public Health 2015;3:191.
30. Netto G, Bhopal R, Lederle N, Khatoon J, Jackson A. How can health promotion interventions be adapted for minority ethnic communities? Five principles for guiding the development of behavioural interventions. Health Promotion International 2010;25(2):248–257.
31. DuBard CA, Gizlice Z. Language spoken and differences in health status, access to care, and receipt of preventive services among US Hispanics. American Journal of Public Health 2008;98(11):2021–2028.
32. Keys H, Kaiser B, Foster J, Burgos Minaya RY, Kohrt BA. Perceived discrimination, humiliation, and mental health: a mixed-methods study among Haitian migrants in the Dominican Republic. Ethnicity & Health 2015;20(3):219–240.
33. Rhi-Sausi JL, Conato D. Cooperación transfronteriza e integración en América Latina: la experiencia del proyecto fronteras abiertas. Proyecto Iila-Cespi: fronteras abiertas. Rome: Biblioteca Virtual de Derecho, Economía y Ciencias Sociales; 2009.
35. Pan American Health Organization. Proyecto de prevención y control de la diabetes en la frontera México-Estados Unidos: Estudio de prevalencia de la diabetes tipo 2 y sus factores de riesgo. Washington, D.C.: PAHO; 2010. Available from: http://iris.paho.org/xmlui/handle/123456789/4330.
36. República Dominicana, Ministerio de Salud Pública, Dirección General de Epidemiología (DIGEPI). Situación epidemiológica de las enfermedades transmisibles sujetas a vigilancia 2009. Epidemiología 2010;18(1):1–16.
37. República Dominicana, Ministerio de Salud Pública, Dirección General de Epidemiología (DIGEPI). Perfil de la salud materna. Santo Domingo: DIGEPI; 2013.
38. Colectiva Mujer y Salud, Mujeres del Mundo, Observatorio Migrantes del Caribe (CIES-UNIBE). Fanmnanfwontyè, Fanmtoupatou: una mirada a la violencia contra las mujeres migrantes haitianas, en tránsito y desplazadas en la frontera dominico-haitiana (Elías Piña/Belladère). Santo Domingo: CIES-UNIBE; 2011.
47. Boccara GB. Etnogubernamentalidad. La formación del campo de la salud intercultural en Chile. Revista de Antropología Chilena 2007;39(2):185–207.
48. Organization of American States. Comisión Mixta de Cooperación Amazónica Peruano-Brasileña. Programa de Desarrollo Integrado de las Comunidades Fronterizas Peruano-Brasileñas [online]. Diagnostico Regional Integrado. Washington, D.C.: Secretaria General de la Organización de Los Estados Americanos. Secretaria Ejecutiva para Asuntos Económicos y Sociales Departamento de Desarrollo Regional y Medio Ambiente; 1992. Available from: https://www.oas.org/dsd/publications/Unit/oea09s/oea09s.pdf.
49. Secretaría Permanente del SELA. Cooperación Regional en el ámbito de la Integración Fronteriza. XXIV Reunión de Directores de Cooperación Internacional de América Latina y el Caribe, 2013 May 30–31 (SP/XXIV-RDCIALC/DT No. 2-13). Available from: http://www10.iadb.org/intal/intalcdi/PE/2013/11724a05.pdf.
56. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto No. 7.239, 2010 julho 26. Promulga o Ajuste Complementar ao Acordo para Permissão de Residência, Estudo e Trabalho a Nacionais Fronteiriços Brasileiros e Uruguaios, para Prestação de Serviços de Saúde, firmado no Rio de Janeiro; 2008. Available from: http://www.planalto.gov.br/ccivil_03/_Ato2007-2010/2010/Decreto/D7239.htm.
58. Ministerio de Relaciones Exteriores, Ministerio de Salud Pública. Ley 18546: Nacionales fronterizos uruguayos y brasileños. Prestación de servicios de salud. Ajuste complementario del Acuerdo sobre permiso de residencia, estudio y trabajo. Sala de Sesiones de la Cámara de Representantes, Montevideo: Poder Legislativo; 2009. Available from: http://uruguay.justia.com/nacionales/leyes/ley-18546-sep-2-2009/gdoc/.
59. República Oriental del Uruguay. Acuerdo entre el Gobierno de la República Oriental del Uruguay y el Gobierno de la República federativa de Brasil sobre permiso de residencia, estudio y trabajo para los nacionales fronterizos uruguayos y brasileños y su anexo. Carpeta n° 1033 de 2003. Repartido No. 639, 2003 June. Available from: http://www.parlamento.gub.uy/htmlstat/pl/pdfs/repartidos/senado/S2003060639-00.pdf.
66. Oddone N. La construcción de una matriz relacional para la cooperación transfronteriza. El caso de la triple frontera de Monte Caseros, Bella Unión y Barra do Quaraí [Internet]. Buenos Aires, Argentina; 2012. Available from: http://www.global-local-forum.com.
68. 68. Organization of American States. Período ciento doce de sesiones ordinarias de la Comisión Andina, del 13 al 19 de diciembre de 2013. Decisión 93. Por la que se aprueban medidas relativas a la prevención, control y erradicación de la fiebre aftosa. Lima: OAS; 2013. Available from: http://www.sice.oas.org/trade/junac/Decisiones/DEC793s.pdf.
69. Palerm JV, Borrego SA, Anderson DW, Fernández de la Garza G, Letey J, Matsumoto M, Orlob GT. Alternative futures for the Salton Sea. UC MEXUS Border Water Project: Issue paper No. 1. Riverside: University of California Institute for Mexico and the United States (UC MEXUS); 1999.
72. Ortiz Gómez Y, Trujillo E, Guzmán JM. Cooperación técnica en salud entre Colombia y sus países fronterizos. Revista Panamericana de Salud Publica 2011;30(2):153–159.
73. The Government of the United States of America and the Government of the United Mexican States. Agreement between the government of the United States of America and the government of the United Mexican States to establish a United States-Mexico Border Health Commission [Internet]. Washington, D.C.: U.S. Department of State; 2000. Available from: http://www.state.gov/documents/organization/126990.pdf.
79. Mendoza G. Salud fronteriza: tema y objeto de estudio. Revista de la Facultad de Salud Pública y Nutrición 2004;5(3):1–2.
80. Rótulo D, Damiani O. Documento de Investigación. El caso de la integración fronteriza Uruguay Brasil: dimensiones analíticas e hipótesis de trabajo preliminares. Documento de Investigación No. 61 Facultad de Administración y Ciencias Sociales Universidad ORT Uruguay; 2010. Available from: http://www.ort.edu.uy/facs/pdf/documentodeinvestigacion61.pdf.
86. United Nations Office for the Coordination of Humanitarian Affairs. Humanitarian data exchange. INFORM country risk profiles 2016 [Internet]; 2016. Available from: http://www.inform-index.org/Results/Global.
98. Elbadry MA, Al-Khedery B, Tagliamonte MS, Yowell CA, Raccurt CP, Existe A, et al. High prevalence of asymptomatic malaria infections: a cross-sectional study in rural areas in six departments in Haiti. Malaria Journal 2015;14:510.
99. Abarca Tomás B, Pell C, Bueno Cavanillas A, Guillén Solvas J, Pool R, Roura M. Tuberculosis in migrant populations. a systematic review of the qualitative literature. PLoS ONE 2013;8(12):e82440.
100. Herrera T. VI Reunión de países de baja prevalencia de tuberculosis en las Américas. Revista chilena de enfermedades respiratorias 2013;29(2):108–117.
101. Vallés X, Sánchez F, Panella H, García de Olalla P, Jansá JM, Caylá JA. Tuberculosis importada: una enfermedad emergente en países industrializados. Medicina Clínica 2002;118(10):376–378.
102. Galán JC, Moreno A, Baquero F. Impacto de los movimientos migratorios en la resistencia bacteriana a los antibióticos. Revista Española de Salud Pública 2014;88(6):829–837.
103. Casals R, Camprubi E, Orcau A, Caylá JA. Tuberculosis e immigracion en España. Revisión bibliográfica. Revista Española de Salud Pública 2014:88(6):803–9.
104. Molina-Salas Y, Lomas-Campos M, Romera-Guirado FJ, Romera-Guirado MJ. Influencia del fenómeno migratorio sobre la tuberculosis en una zona semiurbana. Archivos de Bronconeumología 2014;50(8):325–331.
105. Fakoya I, Reynolds R, Caswell G, Shiripinda I. Barriers to HIV testing for migrant black Africans in Western Europe. HIV Medicine 2008;9(S2):23–25.
106. Goldenberg SM, Strathdee SA, Perez-Rosales MD, Sued O. Mobility and HIV in Central America and Mexico: a critical review. Journal of Immigrant and Minority Health 2012;14(1):48–64.
107. Leyva-Flores R, Infante C, Servan-Mori E, Quintino-Perez F, Silverman-Retana O. HIV prevalence among Central American migrants in transit through Mexico to the USA, 2009-2013. Journal of Immigrant and Minority Health 2016;18(6):1482–1488.
108. Leyva-Flores R, Aracena-Genao B, Servan-Mori E. Population mobility and HIV/AIDS in Central America and Mexico. Pan American Journal of Public Health 2014;36(3):143–149.
109. Zhang X, Martinez-Donate A, Simon N-JE, Hovell MF, Rangel MG, et al. Risk behaviours for HIV infection among travelling Mexican migrants: the Mexico-US border as a contextual risk factor. Global Public Health 2016;12(1):65–83.
110. Bhugra D. Cultural identities and cultural congruency: a new model for evaluating mental distress in immigrants. Acta Psychiatrica Scandinavica 2005;111(2):84–93.
111. Bhugra D, Jones P. Migration and mental illness. Advances in Psychiatric Treatment 2001;7(3):216–223.
112. Torres JM, Wallace SP. Migration circumstances, psychological distress, and self-rated physical health for Latino immigrants in the United States. American Journal of Public Health 2013;103(9):1619–1627.
113. Alderete E, Vega WA, Kolody B, Aguilar Gaxiola S. Lifetime prevalence of and risk factors for psychiatric disorders among Mexican migrant farmworkers in California. American Journal of Public Health 2000;90(4):608–614.
114. Carswell K. The relationship between trauma, post-migration problems and the psychological well-being of refugees and asylum seekers. International Journal of Social Psychiatry 2011;57(2):107–119.
115. Veling W, Susser E. Migration and psychotic disorders. Expert Review of Neurotherapeutics 2011;11(1):65–76.
116. Salgado-de Snyder VN, Cervantes RC, Padilla AM. Migración y estrés postraumático: el caso de los mexicanos y centroamericanos en los Estados Unidos. Acta psiquiátrica y psicológica de América Latina 1990;36(3-4):137–145.
117. Rasmussen A, Rosenfeld B, Reeves K, Keller A. The subjective experience of trauma and subsequent PTSD in a sample of undocumented immigrants. Journal of Nervous and Mental Disease 2007;195(2):137–143.
118. Bhugra D, Ayonrinde O. Depression in migrants and ethnic minorities. Advances in Psychiatric Treatment 2003;10(1):13–17.
119. Bhugra D. Migration and depression. Acta Psychiatrica Scandinavica Supplementum 2003;418:67–73.
120. Ratkowska KA, De Leo D. Suicide in immigrants: an overview. Open Journal of Medical Psychology 2013;2:124–133.
121. Gargurevich R. Posttraumatic stress disorder and disasters in Peru: the role of personality and social support. Leuven: Katholieke Universiteit Leuven; 2006.
122. Norris FH, Weisshaar DL, Conrad ML, Diaz EM, Murphy AD, Ibañez GE. A qualitative analysis of posttraumatic, stress among Mexican victims of disaster. Journal of Traumatic Stress 2001;14(4):741–756.
123. Escobar JI, Canino G, Rubio-Stipec M, Bravo M. Somatic symptoms after a natural disaster: a prospective study. American Journal of Psychiatry 1992;149(7):965–967.
124. Quiroga J. Torture in children. Torture 2009;19(2):66–87.
125. Summerfield D, Toser L. Low intensity war and mental trauma in Nicaragua: a study in a rural community. Medicine and War 1991;7:84–99.
126. Rojas-Flores L, Herrera S, Currier JM, Lin YE, Kulzer R. We are raising our children in fear: war, community violence, and parenting practices in El Salvador. International Perspective in Psychology, Research, Practice, Consultation 2013;2(4):269–285.
127. Allodi F, Rojas A. The health and adaptation of victims of political violence in Latin America (Psychiatric effects of torture and disappearance). In: Pichot P, Berner P, Wolf R, Theau K, eds. Psychiatry: the state of the art. New York: Plenum; 1985;243–248.
128. Takeuchi DT, Alegría M, Jackson JS, Williams DR. Immigration and mental health: diverse findings in Asian, Black, and Latino populations. American Journal of Public Health 2007;97(1):11–12.
129. Pumariega A, Rothe E, Pumariega JB. Mental health of immigrants and refugees. Community Mental Health Journal 2005;41(5):581–597.
130. Bhugra D, Gupta S, Bhui K, Craig T, Dogra N, Ingleby JD, et al. WPA guidance on mental health and mental health care in migrants. World Psychiatry 2011;10(1):2–10.
131. Hickling F, Rodgers-Johnson P. The incidence of first contact schizophrenia in Jamaica. British Journal of Psychiatry 1995;167(2):193–196.
132. World Health Organization. Policy brief on migration and health: mental health care for refugees. Geneva: WHO; 2015.
133. Jackson SJ, Neighbors HW, Torres M, Martin LA, Williams DR, Baser R, et al. Use of mental health services and subjective satisfaction with treatment among black Caribbean Immigrants: results from the National Survey of American Life. American Journal of Public Health 2007;97(1):60–67.
134. Bacon L, Bourne R, Oakley C, Humphreys M. Immigration policy: implications for mental health services. Advances in Psychiatric Treatment 2010;16(2):124–132.
137. Katz CM, Hedberg E, Amaya LE. Gang truce for violence prevention, El Salvador. Bulletin of the World Health Organization 2016;94:660.
138. Office of the United Nations High Commissioner for Refugees. Children on the run: unaccompanied children leaving Central America and Mexico and the need for international protection [Internet]. Washington, D.C.: UNHCR, Regional Office for the United States and the Caribbean. Available from: http://www.unhcr.org/en-us/children-on-the-run.html.
140. Office of the United Nations High Commissioner for Refugees. Women on the run: firsthand accounts of refugees fleeing El Salvador, Guatemala, Honduras, and Mexico. Geneva: UNHCR; 2015. Available from: http://www.unhcr.org/5630f24c6.html.
142. ABColombia. Colombia: mujeres, violencia sexual en el conflicto y el proceso de paz. London: ABColombia; 2013.
143. Valdez ES, Valdez LA, Sabo S. Structural vulnerability among migrating women and children fleeing Central America and Mexico: the public health impact of “humanitarian parole.” Frontiers in Public Health 2015;3:163.
144. Simmons WP, Menjivar C, Tellez M. Violence and vulnerability of female migrants in drop houses in Arizona: the predictable outcome of a chain reaction of violence. Violence Against Women 2015;21(5):551–570.
145. Servan-Mori E, Leyva-Flores R, Infante Xibille C, Torres-Pereda P, Garcia-Cerde R. Migrants suffering violence while in transit through Mexico: factors associated with the decision to continue or turn back. Journal of Immigrant and Minority Health 2014;16(1):53–59.
146. Infante C, Silvan R, Caballero M, Campero L. Central American migrants’ sexual experiences and rights in their transit to the USA. Salud Pública de México 2013;55(S1):S58–S64.
147. Shultz JM, Garfin DR, Espinel Z, Araya R, Oquendo MA, Wainberg ML, et al. Internally displaced “victims of armed conflict” in Colombia: the trajectory and trauma signature of forced migration. Current Psychiatry Reports 2014;16(10):475.
148. Murphy J, Samples J, Morales M, Shadbeh N. “They talk like that, but we keep working”: sexual harassment and sexual assault experiences among Mexican indigenous farmworker women in Oregon. Journal of Immigrant and Minority Health 2015;17(6):1834–1839.
149. Waugh IM. Examining the sexual harassment experiences of Mexican immigrant farm working women. Violence Against Women 2010;16(3):237–261.
150. Kim NJ, Vasquez VB, Torres E, Nicola RM, Karr C. Breaking the silence: sexual harassment of Mexican women farmworkers. Journal of Agromedicine 2016;21(2):154–162.
152. Center for Gender & Refugee Studies. Childhood and migration in Central and North America: causes, policies, practices and challenges. Lanus: Universidad Nacional de Lanus; 2015.
153. Congressional Research Service. Unaccompanied children from Central America: foreign policy considerations. Washington, D.C.: Congressional Research Service; 2016.
154. Ziol-Guest K, Kalil A. Health and medical care among the children of immigrants. Child Development 2012;83(5):1494–1500.
155. Raimondi D, Rey C, Testa MV, Camoia ED, Torreguitar A, Meritano J. Migrant population and perinatal health. Archivos Argentinos de Pediatría 2013;111(3):213–217.
156. Smith-Greenaway E, Thomas KJA. Exploring child mortality risks associated with diverse patterns of maternal migration in Haiti. Population Research and Policy Review 2014;33(6):873-895.
158. Catalano RF, Berglund ML, Ryan JAM, Lonczak HS, Hawkins JD. Positive youth development in the United States: research findings on evaluation of positive youth development programs. Prevention Treatment 2002;5:15.
159. McBride D.C., Freier MC, Hopkins GL, Babikian T, Richardson L, Helm H, et al. Quality of parent-child relationship and adolescent HIV risk behaviour in St. Maarten. AIDS Care 2005;17(S1):S45–S54.
160. Markham CM, Lormand D, Gloppen KM, Peskin MF, Flores B, Low B, et al. Connectedness as a predictor of sexual and reproductive health outcomes for youth. Journal of Adolescent Health 2010;46(3):S23–S41.
161. Blum R, Halcon L, Beuhring T, Pate E, Campbell-Forrester S, Venema A. Adolescent health in the Caribbean: risk and protective factors. American Journal of Public Health 2003;93(3):456–60.
162. Pilgrim N, Blum RW. Protective and risk factors associated with adolescent sexual and reproductive health in the English-speaking Caribbean: a literature review. Journal of Adolescent Health 2012;50(1):5–23.
163. Montesi L, Turchese Caletti M, Marchesini G. Diabetes in migrants and ethnic minorities in a changing world. World Journal of Diabetes 2016;7(3):34–44.
164. Vega WA, Rodriguez MA, Gruskin E. Health disparities in the Latino population. Epidemiological Reviews 2009;31(1):99–112.
171. United Nations. New York Declaration for Refugees and Migrants. Outcome document of the high-level plenary meeting of the General Assembly on addressing large movements of refugees and migrants. New York: United Nations; 2016. Available from: http://www.un.org/ga/search/view_doc.asp?symbol=A/71/L.1.
177. Organization of American States, Inter-American Council for Integral Development, Committee on Migration Issues. Draft review of the inter-American program for the promotion and protection of the human rights of migrants, including migrant workers and their families. Washington, D.C.: OAS; 2016 (Document CIDI/CAM/doc.19/15 Rev.9).
181. International Organization for Migration. Informe final. Estudio exploratorio sobre la condición de salud, acceso a los servicios e identificación de riesgos y vulnerabilidades específicos a la migración en El Salvador, 2014. San Salvador: IOM; 2014.
183. Campbell RM, Klei AG, Hodges BD, Fisman D, Kitto S. A comparison of health access between permanent residents, undocumented immigrants, and refugee claimants in Toronto, Canada. Journal of Immigrant and Minority Health 2014;16(1):165–176.
186. Pan American Health Organization. Health, human security, and well-being. 50rd Directing Council, 62th Session of the Regional Committee of WHO for the Americas; Washington, D.C., 2010 Sep. 27-Oct. 1 (Document CD50/17). Available from: https://www.paho.org/hq/dmdocuments/2010/CD50-17-e.pdf.
1. According to IOM, irregular migration refers to the “movement that takes place outside the regulatory norms of the sending, transit and receiving countries. There is no clear or universally accepted definition of irregular migration. From the perspective of destination countries, it [means to enter], stay, or work in a country without the necessary authorization or documents required under immigration regulations. From the perspective of the sending country, the irregularity is, for example, seen in cases in which a person crosses an international boundary without a valid passport or travel document or does not fulfil the administrative requirements for leaving the country. There is, however, a tendency to restrict the use of the term ‘illegal migration’ to cases of smuggling of migrants and trafficking in persons” ().
2. According to IOM, forced migration refers to “a migratory movement in which an element of coercion exists, including threats to life and livelihood, whether arising from natural or man-made causes (e.g. movements of refugees and internally displaced persons as well as people displaced by natural or environmental disasters, chemical or nuclear disasters, famine, or development projects)” ().
3. According to IOM, a refugee is a person who “owing to a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinions, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country” (Art. 1(A)(), Convention relating to the Status of Refugees, Art. 1A(), 1951 as modified by the 1967 Protocol). In addition to the refugee definition in the 1951 Refugee Convention, Art 1(), the 1969 Organization of African Unity (OAU) Convention defines a refugee as any person compelled to leave his or her country “owing to external aggression, occupation, foreign domination or events seriously disturbing public order in either part or the whole of his country or origin or nationality.” Similarly, the 1984 Cartagena Declaration states that refugees also include persons who flee their country “because their lives, security or freedom have been threatened by generalized violence, foreign aggression, internal conflicts, massive violations of human rights or other circumstances which have seriously disturbed public order” ().
4. According to IOM, internally displaced persons are “persons or groups of persons who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized State border” (Guiding Principles on Internal Displacement, UN Doc E/CN.4/1998/53/Add.2) ().
Between 2000 and 2050, the proportion of the world’s population aged 60 years and older will double, from about 11% to 22%. The absolute number of people 60 years and older is projected to increase from 900 million in 2015 to 1.4 billion by 2030, to 2.1 billion by 2050, and to 3.2 billion in 2100 (). Between 2025 and 2030, life expectancy in Latin America and the Caribbean (LAC) will increase to a projected 80.7 years for women and 74.9 years for men; in Canada and the United States of America, those numbers are projected to be even higher: 83.3 years for women and 79.3 years for men ().
The increase in life expectancy is due to several factors, including a decline in fertility rates and success in reducing fatal childhood diseases, maternal mortality, and mortality in older ages (). However, longer life expectancy is also a source of concern for policymakers; income growth may become harder to realize in countries with large populations of older people, and meeting the needs of a large elderly population will be especially difficult in low- and middle-income countries. It will be necessary to create economic and social institutions that provide income security, adequate health care, and other needs for the aging population (). An additional issue that policymakers are facing today is how to best define an older person. Terms used to define an older people include “the aged,” “the elderly,” “the third age,” and, in some cultures, “the fourth age” (). However, being “old” comes at different times to different people (). How to define older persons will remain a challenge because “the elderly, despite being a class, consist of individuals with unique life experiences, goals, and needs,” and because becoming older involves a change in capacity, social involvement, and physical and mental health ().
In response to these demographic transitions and concerns, the the Pan American Health Organization (PAHO) and the World Health Organization (WHO) have approved strategies and guidelines related to aging and health. In 2002, for the first time, PAHO Member States approved a resolution on health and aging (CSP26.R20). The Region of the Americas was the first WHO region to approve a strategy and plan of action on aging and health, in 2009(). In June 2016, the Organization of American States, with the technical support of PAHO and the Economic Commission for Latin America and the Caribbean (ECLAC), approved the Inter-American Convention on Protecting the Human Rights of Older People (). These instruments, which have been developed in the international context of health and aging, highlight the need for an innovative approach in the care of older persons. However, most of the countries in the Region still lack a holistic view of the demographic transition and do not provide an integrated approach to the care of older persons. The challenge posed by this change is viewed in a fragmented way, addressing the increased prevalence of chronic diseases, disability, and care dependency, or the consequent impact of these problems on health services, medication use, and long-term care. Therefore, it will be necessary to continue developing an integrated approach and working on comprehensive public health actions “to ensure healthy lives and promote well-being for all ages through universal health coverage including financial risk protection” ().
In the next decade, both population aging and individual aging will be major factors in modulating health needs, social security, and social protection, as well as the way in which these demands will be met. Despite the tangible implications of this aging trend for social security and public health, the Region still lacks a comprehensive vision of health for older persons. Knowledge about their health needs and care is not uniform, and most health systems lack indicators to monitor and analyze the impact of health measures. Coverage, continuity of care, and geographical, physical, economic, and cultural access to health services are inadequate, and the few persons who who do have access still do not receive services to meet their needs (). In this context, most experts agree that it is necessary to foster integrated health interventions () and to develop strategies that enable health systems to adapt to the new demographic and epidemiological realities ().
WHO’s Global Strategy and Plan of Action on Ageing and Health highlights the importance of demographic changes and how the changes will drive new challenges for public health and offer opportunities and a window for action created by the “demographic dividend” to be experienced during this decade (). The term demographic dividend refers to the dependency ratio in the population (i.e., the proportion of children aged less than 15 and adults over 59 years, compared with persons aged 15–59 years). The demographic dividend occurs when the dependency ratio drops substantially (Figure 1) due to the large pool of adult workers with low fertility combined with a relatively small group of dependent older people. Such a situation offers a “window of opportunity” to make investments in strengthening the country’s education, pension, and health systems (). The demographic dividend will span a much shorter period of time in countries with large pools of older persons than for those countries in the Region whose populations are still younger (). In the next decade, the extended work life of older people and their active participation in productive activities will require a review of the point at which they might be considered a “dependent” segment of the population.
Figure 1. Total child and old-age dependency ratios under different projection variants in LAC, 2010–2050
By international standards, Canada and the United States, in which some 20.7% of their population is at least 60 years of age, are already “old.” The aging of this population has taken place gradually over a period of 50 years. In contrast, in LAC, the number of persons 60 and older is expected to climb from 59 million to 196 million between 2010 and 2050. As shown in Figure 2, in LAC, the growth of the aging population will occur in a severely contracted interval of 20 to 30 years ().
Figure 2. Percentage change in the proportion of adults aged 60 or older in the Americas, for North American and for Latin America and the Caribbean (LAC), 2000–2015 and 2015–2030
Data Source: United Nations. World population prospects: the 2015 revision. New York: UN, Department of Economic and Social Affairs, Population Division; 2015.
Currently, people over 60 comprise about 13% of the population in the Caribbean, 12% of the population in South America, and 9% of the population in Central America. In contrast, by 2050, approximately 25% of the population of LAC will be 60 years and older (). These demographic trends will continue in the Region in the next 25 years and will be associated with a decrease in the proportion of children (aged 0–14) in the population, leading to drastic changes in the aging index (i.e., the ratio of older people to people under the age of 15) ().
In 2010, there were approximately 36 older persons for every 100 children in LAC. The projections indicate that this trend will reverse as of 2036, and by 2040, there will be 116 older persons for every 100 children younger than 15. With regards to the Caribbean, by 2040, the aging index could reach 142 older persons for every 100 children ().
Figure 3. Young children and older persons as a percentage of the population of the Americas: 1950–2050
Source: He W, Goodkind D, Kowal P. U.S Census Bureau, International Population Reports, P95/16-1, An Aging World: 2015. Washington, D.C.: U.S. Government Publishing Office; 2016.
Life expectancy in the Region has increased by 21.6 years, on average, over the last 60 years and will continue to increase during the rest of the century. The octogenarians of the second half of this century have already been born, highlighting the importance of substantial investment in population health throughout the life course (this topic is discussed further the section “Building health throughout the life course“) (Figure 4).
Figure 4. Probabilities of survival to ages 60 and 80 among the 1950–1955 and 2000–2005 birth cohorts, by sex, for Latin America and the Caribbean (LAC) and for North America
Data Source: United Nations. World population prospects: the 2015 revision. New York: UN, Department of Economic and Social Affairs, Population Division; 2015.
While investment throughout the life course is imperative, the reality is that LAC will have to adapt much more quickly to the growth of the aging population at much lower levels of national income compared to the experience of higher-income countries in North America (). Unless there is unprecedented economic expansion, countries in LAC will generally experience rapid aging combined with increasing pressure for pension coverage that is already deficient for older people (). It is therefore essential that the Region develops a new paradigm of aging that views longevity as a period that continues to be productive and is characterized by self-care and involvement with family and community (). It is increasingly recognized that many countries in the Region will need to increase social security funds for older people, such as contributive and noncontributive public pensions. Additionally, removing the stigma of old age is essential for developing different approaches and ensuring not only the financial security but also the health and social protection of older people in a broad and equitable fashion ().
Not only can individuals expect to live much longer than previously, but families and communities are changing, too. Traditionally, the well-being of older people relied on support provided by younger relatives. Culturally, it was considered the responsibility of adult children to protect and care for parents. However, a significant shift has occurred in this norm due to changes caused by urbanization, migration, changes in living arrangements, increased life expectancy, and a rapid decline in fertility. These changes mean there will be fewer older people living with, or in proximity to, adult children who are able to provide support and care for them (). In countries with a younger population, the majority of older persons still live in multigenerational households; however, as populations age, the percentage of older persons living alone increases. In Central American countries, for example, only 10% to 23% of older adults live alone, while in Uruguay and Argentina over 50% live alone. By definition, as populations become older, fertility declines and life expectancy increases (). Only about one-third of adults in LAC receive income from pensions; as a result, material support for old age is still dependent on the extended family. Furthermore, rapid aging is occurring in a fragile institutional environment, i.e., in which the bulk of sources that guarantee minimum levels of social and economic support (such as old-age pensions) are being reformed or, in some cases, eliminated (). As families become smaller, it is conceivable that adult children will have to ration available resources in support of three and even four generations (). Thus, in LAC, a highly compressed aging process will take place in the midst of rapidly changing intergenerational relations and fragile public social protection structures, affecting pensions and access to health ().
Healthy aging in the Region will be determined by the availability of age-friendly policies and programs that create sustainable environments to allow older persons and their families to live with dignity and a high quality of life. The time to act is now, while most countries still have a window of opportunity (). The stage is set: the current older population in the Region grew up with a wide range of privileges and disadvantages that have resulted in sharp differences in life expectancy, longevity, and health. Therefore, the current policy challenge is to invest in necessary interventions to reduce health inequities in adults who are older, and to improve conditions that promote healthy aging and equity by building the infrastructure that is needed to address the continued expansion of the older adult population that will occur during the next decade ().
“When we are old, it is hard to do things; age takes over and we are no longer able to work like before… [I] don’t have the strength to do the things I used to do, my children are all gone; what can I do? Perhaps it is time for me to die.” (An indigenous older person in the qualitative study on aging in Ecuador)
The impact of aging extends to practically all spheres of life. It is especially evident in its economic, social, and public health spheres, and in family and personal life. The Political Declaration and Madrid International Plan of Action on Ageing () approved in Madrid in 2002, defined three priority areas: integrating older people into development strategies; providing enabling environments for aging and older people; and promoting the health of older people. These three priorities are now very much in force in the Region. The pursuit of equity through the life course is imperative for healthy aging (see “Building health throughout the life course“). Almost 50% of the older people interviewed for the Salud, Bienestar y Envejecimiento (SABE) study said that they did not have the financial means to meet their daily needs, and one-third did not have a pension or a paying job (). In developed countries, approximately 75% of the older population receives some pension; in LAC, only 40% of older people do. There is a significant difference between the genders, too; 11% of older men and 25% of older women have no income of their own (). The level of schooling among older people is lower than that of the general population, and they have very high illiteracy rates. Ill health in old age is not inevitable, and there is a demonstrable association between ill health and social and health conditions. In the United States, 77% of people over the age of 65 report they are in good health. In LAC, however, less than 50% of people over 60 describe their health as good. Furthermore, women in LAC say that they are in poorer health than men.
Inequality and indigenous populations
Studies in Ecuador and Peru offer a window into the experience of aging among indigenous populations in rural areas, which have high rates of extreme poverty. In Peru, in a sample of low-income “younger olds,” defined as the beginning of old age (), 61% reported that they had good or very good health, with no significant difference between rural and urban areas. However, among people 75 or older who lived in rural areas that percentage dropped to 48%. In contrast, in urban areas, 61% of those 75 and older reported they were in good health (). This difference is consistent with the number of self-reported chronic conditions untreated or unmanaged in rural versus urban areas and in the percentage of individuals who report difficulties with instrumental activities of daily living (). In a qualitative study of an indigenous population in Ecuador, aging is most frequently associated with the loss of capacity to do physical work and with dependence on others to meet basic needs ().
Figure 5. Percentage of older persons reporting good or very good health by age, and rural/urban residence
Source: ESBAM 2012. Ministry of Development Social Inclusion –General Department of Monitoring and Evaluation.
With time, and especially after having reached a peak of development, humans experience important biological changes at the cellular and molecular level that lead to a decrease in the capacity of organs and systems. This is reflected primarily in a loss of reserve capacity, but eventually the changes also lead to a loss of functional capacity, exponentially increasing the risk of becoming ill or disabled, or dying. However, it is clear that all people do not age in the same way; although genetics is involved, aging is also determined by many positive and negative influences during the life course (). The development of geriatrics and gerontology in the last decades has allowed for a better understanding of the processes of health and aging and their relation to disease ().
The World Report on Ageing and Health defines healthy aging as “the process of developing and maintaining functional abilities that enable well-being in older age. Functional abilities are the health-related attributes that enable people to be and to do what they have reason to value; it is made up of the intrinsic capacity of the individual, relevant environmental characteristics and the interactions between the individual and these characteristics” ().
Ensuring healthy population aging begins before birth and continues throughout the life course. The challenge for policymakers today is to address increases in chronic conditions and frailty among older persons, as well as continuing to improve health along the life course. But addressing longevity requires systemic changes in health care systems; what works when the health care system focuses on primary prevention of noncommunicable diseases and on curing acute conditions does not necessarily work when the aim is to maintain health and functional capacity in adults and older adults with chronic conditions. These changes need to be informed by the diversity of health, disease, and functional trajectories that occur during the last four decades of life ().
In LAC, birth cohorts that reached 70 after the year 2000 are unique in that they are largely the product of public health interventions that increased childhood survival. This cohort was exposed to infectious diseases and early malnutrition that may contribute to the late onset of chronic conditions and frailty. Evidence that early childhood conditions affect adult health is mounting fast (). Empirical data as well as theoretical arguments () highlight four factors in early childhood that may influence later health: () conditions that developed in utero or shortly after birth may remain latent for long periods and may be expressed in late adulthood as chronic conditions (); () illnesses during early childhood may directly cause the late onset of some chronic diseases such as heart disease and rheumatic fever; () recurrent bouts of infectious diseases during early childhood and the processes of sustained inflammation in later life may cause the early onset of coronary heart disease; and () socioeconomic conditions in early childhood could have harmful health effects in a person’s later years (see Building health throughout the life course ).
Achieving the goals of healthy aging is “not simply a case of doing more of what is already being done or doing it better. Systemic change is needed” (). Aging is and will continue to be a driver in public health for decades to come. Population aging in the Region is not only a matter of increased number of people 60 and older, but the increased combination of multiple chronic conditions, recurrent infectious diseases, and geriatric conditions that include diminishing muscle mass, changes in sensory and cognitive functions, and a decline in immune functions. However, the current public health and health care systems were developed around a different set of demographic and epidemiological imperatives and are seriously unprepared to address the needs and priorities of a fast-growing older population (). Regardless of socioeconomic conditions in the Region, life expectancy at the age of 60 may now mean another 18 to 23 years of life can be expected. People aged 80 and older are the fastest growing population group in the Region (). This is an unprecedented reality, and their presence will affect existing paradigms of public health and health services.
About two in three older persons have a chronic condition, including arthritis, asthma, chronic respiratory conditions, diabetes, heart disease, and hypertension (). The prevalence of two or more concurrent chronic conditions increases with age (). As the number of chronic conditions in an individual increases, so do the risks of poor functional status and otherwise unnecessary hospitalizations.
The resource implications of addressing multiple chronic conditions are immense. In the United States, 66% of total health care spending is directed toward care for the approximately 27% of Americans with multiple chronic conditions (). The 2015 World report on ageing and health describes a systematic review of studies in seven high-income countries, which concluded that more than half of all older people are affected by multimorbidity for which the prevalence increases sharply in very old age (). Even though we lack information in LAC about the prevalence and impact of multiple chronic conditions, the increasing life expectancy and the aging LAC population will dramatically increase the need for health systems to change from a “young” system of care to a mature system that deals in large part with the effect of multiple chronic conditions in an older population.
The aging population will experience greater functional loss, dependence, and demand for care, and despite the visible implications that this phenomenon will have for social security and public health in the next 10 years, the Region still lacks a plan for long-term care. This scenario also requires that health care confront new prevention and treatment challenges. Health systems and services should prepare in a timely way to respond to the growing health care needs caused by those conditions and should not be focused only on cures or avoiding death. By 2020, the prevalence of severe disabilities affecting this population group in LAC will increase by 47%. In the year 2010, dementias were responsible for an estimated global cost of US$ 604 billion; in the Americas alone, the total estimated cost was US$ 235.8 billion ().
Preventing blindness in older persons
The aging process is frequently associated with declines in sensory functions that can have important implications for the well-being of older people and their families. Much of this dependence can be completely prevented with health interventions. Untreated sensory changes affect not only quality of life but also the level of dependency and disability, with the associated costs of caring for someone who becomes disabled in old age. In order to achieve universal access to health, health systems must develop simple interventions aligned to the health needs of older persons, including improved access to intraocular lenses used in cataract surgery. These lenses can make the difference between healthy aging and premature dependency on others. Cataracts that are not corrected by surgery continue to be the most common cause of blindness for three million people in the Americas. In Latin America, cataract surgery performed by the public sector or by NGOs costs about US$ 300; cataracts that go uncorrected cause 58.0% of blindness in Peru and 66.4% in Panama. In the United States, the 13-year societal cost perspective for the financial return on investment (ROI) for first-eye cataract surgery was US$ 121,198, a 4,567% gain over 13 years. The direct ophthalmic medical cost for unilateral cataract surgery in 2012 was US$ 2,653 ().
Poor health is not inevitable in old age, but a long life of good health is not a given. Older people have accumulated a lifetime of risk factors associated with multiple chronic conditions in addition to the physiological changes of old age. Faced with a long-lived population, it is necessary for public health systems to develop an approach focused on functional capacity and health, in addition to disease management.
Whether or not we are able to promote healthy aging and support the intrinsic capacity of older adults to maintain functional capacity will depend on how well we achieve systemic changes in the health care system. In turn, how well we promote healthy aging, in spite of multiple chronic conditions, will determine the cost of population aging and the capacity of the health system to respond to the health needs of the entire population.
The World report on ageing and health provides three key reasons to act. The first reason is the rights of older persons: an approach to health based on human rights means that health “embraces a wide range of socioeconomic factors that promote conditions in which people can lead a healthy life and extends to the underlying determinants of health, such as food and nutrition, housing, access to safe and potable water and adequate sanitation, safe and healthy working conditions, and a healthy environment” (). In addition, this approach recognizes that older persons’ autonomy, participation, and integration into the community are central to their well-being (). The second reason is to foster sustainable development: promoting older persons’ contribution to development promises to lead to a more equitable society. Healthy older adults contribute to the community in numerous ways. Conversely, lack of access to health care may lead to avoidable hospitalizations and loss of functional capacity, which in turn requires the care and resources of family members. The third reason is the economic imperative: based on the continuous contribution older people make to individuals, family, and the community, WHO presents a new paradigm.
The World report on ageing and health takes a novel approach to the economic implications of older populations. It states that “rather than portraying expenditures on older persons as a cost, these are considered as investments” (). These investments include expenditures in an integrated health system aligned to the needs of older persons, long-term care, and age-friendly environments. As with any other investment, doing what is known to work to improve and maintain functional capacity will yield a sustainable return on the investment. The public health response will suggest how some of these investments may be prioritized.
The Multisectoral Action for a Life Course Approach to Healthy Ageing: Draft Global Strategy and Plan of Action on Ageing and Health () defines five priority areas to concentrate the public health response to aging. One of the first steps in implementing the plan includes developing indicators with core baseline data to be used in monitoring progress in each of the priority areas and to document progress towards planning for a decade of healthy aging during 2020–2030 (). The identified priorities represent an important road map for the public heath institutions in America.
Commitment to action on healthy aging in every country
The WHO strategy recognizes that fostering healthy aging requires leadership and commitment. To enable all people to live a long and healthy life calls for a multisectoral approach with strong engagement from diverse sectors and different levels of government. Collaboration is also needed between government and nongovernmental actors, including service providers, product developers, academics, and older people themselves. A key step to fostering action must therefore be to build local, regional, and international coalitions to develop a shared understanding of the issues involved.
Much of the investment to foster healthy aging will also have direct benefits to other population groups and will tend to strengthen a country’s commitment to the Sustainable Development Goals. For example, multisectoral leadership will ensure that all actions to improve healthy aging foster the ability of the elderly to make multiple contributions in an environment that respects their dignity and human rights, free from gender- and age-based discrimination, and it promotes the social, political, and economic inclusion of all, irrespective of age. Within this framework, the rights of older persons become an important driver for meeting regional goals for sustainable development, human rights, and universal access to health. The Inter-American Convention on Protecting the Human Rights of Older Persons, adopted at the 45th regular session of the Organization of American States General Assembly (), recognizes the need to address matters of old age and aging from a human rights perspective, provides a framework to address and ensure those rights, and highlights the need to eliminate all forms of age discrimination in the Americas.
Several countries in the Region have developed at least one public policy tool (law, national plan, specific policy, or program) to address aging and/or specifically aging and health. The task ahead is to ensure that all public policy instruments develop indicators and core data for monitoring implementation and evaluating effectiveness. Therefore, a priority must be to strengthen Member States’ capacity to develop, monitor, and evaluate public policies for healthy aging.
Developing elder-friendly environments
Environments that are elder-friendly help to foster healthy aging in two ways: by supporting the building and maintenance of intrinsic capacity across the life course and by enabling greater functional ability so that people with varying levels of capacity can do the things they value ().
Whether or not individuals are able to function depends not only on the person’s intrinsic capacity, such as strength, musculoskeletal function, and other conditions that induce physiological limitations, but also on the individual’s environment and access to supportive services and devices. For example, a person who has difficulty walking one block due to osteoarthritis may be able to function independently with a combination of (a) appropriate assistive devices, such as a cane or walker, that compensate for decreased intrinsic capacity, and (b) a proven regimen of physical activities that supports and improves intrinsic capacity. Thus, healthy aging is framed in a way that focuses both on strengthening or maintaining intrinsic capacity and creating supportive environments and technologies.
In this context, multisectoral leadership, commitment, and resources at the local level are essential. A WHO global network of age-friendly cities and communities in the Region of the Americas would provide numerous examples of how coordinated action among municipalities and various public and private sectors can improve life for older people. The goal of age-friendly communities is to foster the autonomy and engagement of older people as well as to ensure access to transportation, housing, outdoor spaces, communication and information sources, employment, community support and health services, and encourage social and civic participation, respect, and social inclusion (). No sector can be solely responsible for promoting and supporting the ability of older persons to function and continue to contribute to society. Member States should collect and use age and socioeconomic disaggregated information on older people’s functional abilities and should assess the effectiveness of and identify gaps in existing policies, systems, and services in meeting the needs and rights of the older persons ().
Prevention of falls
Extensive evidence indicates that falls and the risk of falls can be reduced through systematically identifying risks and taking actions that include a combination of clinical and community-based interventions. Engaging older adults in strategies that help prevent falls is cost-effective (). Interventions that strengthen intrinsic capacity and technologies and environmental changes that compensate for decreasing intrinsic capacity can prevent many risks that result in falls (). Public health interventions to prevent falls should be evidence-based. Interventions are grouped into three categories: exercise-based, home modification, and multifaceted interventions that address a combination of risk factors ().
Table 1. Seven risk factors of effective fall interventions
Lower body weakness
Targeted strengthening exercises
Vitamin D deficiency
Vitamin D supplementation
Difficulties with walking and balance
Physical therapy intervention and mobility-assisted devices
Vision problems such as cataracts
Timely cataract surgery and vision aids, as needed
Foot pain or poor footwear
Home and environmental hazards
Home and environment are made age-friendly
Adapted from: Centers for Diseases Control and Prevention. Preventing falls: a guide to implementing effective community-based fall prevention program. Atlanta: CDC; 2015 ().
Aligning health systems to the needs of older populations
In order to ensure that older people have universal access to health, systemic changes are needed because old age does not mean simply living more years. It is a new phase in human development (). A health care system that is aligned to the health needs of older adults has policies, plans, and programs to improve or maintain functional capacity, manage multiple chronic conditions, and provide services and support for long-term care ().
With the longevity of the population, new challenges will appear as health systems address the health needs of adults in their 60s, and older adults present different problems related to health and frailty that have significant impact on the capacity of health systems across the Region. A system aligned to the needs of older people has the capacity to address the problems that matter to them: chronic pain; difficulties with hearing, seeing, walking, or performing daily or social activities; and depressive symptoms. Primary care services are still focused on diagnosis and treatment of diseases, but most problems that older people bring to the clinics are not necessarily identified as “diseases” in the traditional sense. Primary care personnel are not trained in nor do they receive much guidance in recognizing and managing health problems identified by older people. Nor are they able to identify community resources and the extended-care team needed to respond to the health issues of older persons. A focus on prevention requires that the health team better understand the intimate relationship that exists between intrinsic capacity, environment, and the technologies used to compensate for the normal losses that occur as part of the aging process.
Primary prevention focuses on four risk factors: harmful use of alcohol, unhealthy diet, physical inactivity, and tobacco use. These factors are important throughout the life course not only to prevent but also to manage noncommunicable diseases. Epidemiological data in the Region show that a significant number of adults and older adults will live with a chronic disease such as diabetes, lung and heart diseases, arthritis, and cancers for an average of 30 to 40 years (). Teaching older people how to be healthy, and how to live healthy lives even with these chronic diseases, is essential.
A WHO framework of integrated, people-centered health services sets forth a vision in which “all people have equal access to quality health services that are co-produced in a way that meets their life course needs…” (). The framework defines the concept of “co-production of health” as “care that…implies a long-term relationship between people, providers, and health systems where information, decision-making, and service delivery become shared” (). A health service aligned to the needs of older persons has the necessary human resources, technologies, and community partners to be able to assess risks and symptoms. Unlike acute care, where treatment is usually short and definitive, ongoing treatment and monitoring chronic conditions require productive interactions between health professionals and the individual with the chronic conditions. Person-centered care requires active participation in self-care management and promotes a partnership in improving and maintaining health. In the life of a typical person living with a chronic condition, health care system interventions take no more than a few hours a year. The rest of the time the patient is responsible for self-care management. Outcomes are determined not by the short time in the doctor’s office but by the daily behaviors of the individual. To achieve the goals of person-centered care, the health system needs to support the self-care management (for more information see the box Self-care programs) of individuals living with chronic conditions. Evidence-based programs are those that have been rigorously tested in controlled settings, proven effective, and translated into practical models that can be implemented at community sites. Primary health care services should seek to adopt evidence-based programs that provide skills and practice to older adults in the co-production of health ().
Self-care or self-management requires processes that are designed to assist with behavioral changes and empowerment. Research has shown that patients can learn and change behaviors at any age. Programs specifically designed to improve patients’ self-efficacy, such as the Stanford University Chronic Disease Self-Management Program, have been used with adults of all ages and have proven effective in changing patients into proactive self-care managers. In a meta-analysis of 25 years of research findings, the Centers for Disease Control and Prevention concludes that, “At the population level, these interventions could have a considerable public health effect due to the potential scalability of the interventions, the relative cost to implement them, wide application across various settings and audiences, and the capacity to reach large numbers of people” ().
It must be a priority to retool the health care work force to deliver care centered on older persons and to create and use evidence-based programs to best promote healthy aging. In a 2007 Regional meeting, an informal survey was conducted in which 85% of the focal points who participated acknowledged not having any formal training in either gerontology or geriatrics. A “geriatricized” work force is one that has been provided with training in healthy aging and has basic skills and tools to develop elder-centered plans and programs aligned to meet the health needs of older persons and their families. It is a work force that understands elder-care priorities, that focuses on functional capacity, and that can avoid preventable complications. To fill this training gap, PAHO’s Regional Program on Health and Aging, in collaboration with other academic partners in the Region, has developed a 420-hour certificate in “Management of Aging and Health Programs.” It combines 40 weeks of total immersion and online training in a flexible format that is rich in tools and promotes online group learning. Since 2007, more than 250 individuals from 25 countries in LAC have completed the program.
In 2000, with the support of PAHO, the Latin American Academy of Medicine of Older Persons (Academia Latinoamericana de Medicina del Adulto Mayor, ALMA) was established to create a network of faculty members in medical schools across the Region for teaching geriatrics and for training medical students and primary health care doctors in the specialty of geriatrics. ALMA provides ongoing education and now has 220 faculty members from 16 Latin American countries. In 2005, ALMA published a guide to teaching geriatrics in general medical education ().
Despite these advances in training, rethinking the primary care work force for the 21st century for extremely fast aging scenarios requires a different approach to the education and training of the existing work force and to the expanded role the care team will need to assume to ensure universal access to person-centered care. There will be a growing need for nurses, physical therapists, dietitians, community health workers, and health educators who are trained in population health with a focus on diverse populations from birth to age 100 ().
Developing sustainable and equitable systems for long-term care
Families are the main providers of unpaid care in LAC: in particular, women account for 90% of all unpaid care providers. Family caregivers cut back up to 20% on paid work to provide care to older persons (). About 43% of caregivers, mainly informal/family caregivers, show symptoms of depression and anxiety; it is estimated that compared to non-caregivers, caregivers have twice the risk of heart disease and injuries. In addition, when care is provided in conditions of poverty and when caregivers have no training, resources, or social or institutional support, elders are at increased risk of morbidity; furthermore, the elderly who are being cared for are at increased risk of neglect and abuse by their overwhelmed caregivers ().
In the next decade, health systems must integrate medical, social, and supportive care in a more efficient way. A health system aligned to the needs of older adults develops elder-driven care plans and is aligned with the goals of both the older person and his or her family. This means that they have alternatives to hospitalization and institutionalization, and access to long-term care support and services designed to maintain health and functional capacity for as long as possible during a life phase that is marked by frailty and dependence.
“System of activities undertaken by informal caregivers (family, friends, and/or neighbors) and/or professionals (health, social, and others) to ensure that a person who is not fully capable of self-care can maintain the highest possible quality of life, according to his or her individual preferences, with the greatest possible degree of independence, autonomy, participation, personal fulfillment, and human dignity” ().
For people who live into old age, maintaining health and avoiding crises requires a very different health care system than the existing model. Just one generation ago, people rarely survived into frail old age. For those who survived, someone in the family was always able to provide care. But for millions of families caring for a loved one, this is no longer a simple affair. Urban settings are not elder-friendly, fewer children are available and able to provide care, and long-distance caregiving have all changed the dynamics of living into old age with supportive environments. When there are no options for caregivers, caregiving crises result in otherwise preventable, long-term, costly hospitalizations.
In a young society, one becomes accustomed to people dying of a terminal illness with a relatively short period between the onset of the fatal disease and death. However, in an aging society, there is a new phase in the life course for those who live into old age: frailty. In this phase, no terminal illness is identified, and the decline of functional capacity, speech, and ambulation may be prolonged for as many as 6 to 8 years ().
Access to family care is no longer the norm. Almost half of older adults live alone or with a spouse, not in a multigenerational family (). Intergenerational living takes place not only within households but also among generations regardless of living arrangements. The many SABE surveys consistently report a lifetime bidirectional distribution of resources going one way or the other in critical periods of life, with family relations often strained by illness and disability ().
Long-term supportive services at home are essential during this phase of life. The transition from being a healthy, functioning older adult to a frail, dependent adult is not as clearly defined as transitions in other stages of life, such as the transition from childhood to adolescence. However, these transitions are real, and society has to recognize that at the onset of frailty, the individual will need services from health care providers, family, and friends that are distinctly different from services provided to non-frail persons. Although the majority of older people will enjoy active and healthy aging until near the end of life, a significant number will suffer from dementia and other conditions that lead to disability, frailty, and the need of long-term care (see Box “The case of dementia” for more information regarding dementias). About 20% of people 65 and older will require long-term care services and support in order to perform activities of daily living ().
The case of dementia
Dementias are the most important contributor to disability and dependence among older persons. It is estimated that in the Americas the prevalence of Alzheimer’s disease and other dementias will double every 20 years, increasing from 7.8 million in 2010 to 14.8 million in 2030. The countries of LAC will be the most affected, where the number of people with dementias will increase from 3.4 million in 2010 to 7.6 million in 2030, surpassing the projected 7.1 million people with dementias in the United States and Canada. In 2010, the estimated cost of dementias in the Americas was US$ 235.8 billion ().
Dementias cause the second largest burden of years lived with disability (11.9%) (). The proportion of people needing care for dementias rises with age, from 30% of people between the ages of 65–69 to 66% of people 90 years and older. And unlike with other chronic conditions, people with dementias may need care beginning in the early stages of the disease and be increasingly dependent on caregivers as their condition worsens (). At the 54th Directing Council, PAHO approved Resolution CD54.R11, the Strategy and Plan of Action on Dementias in Older Persons; it urges Member States to strengthen the capacity of their health systems and health services networks in order to increase access to resources, programs, and services for people with dementias and their families ().
Improving measurement, monitoring, and research for healthy aging
The primary driver of change in public health is data. Public health addresses perceived threats to health when those threats are quantified and localized, and the action taken to address them needs to be driven by evidence: evidence of the threat to healthy aging; evidence that there are policies, interventions, and programs proven to improve healthy aging; and evidence that there is local capacity to adopt the policies, interventions, and programs with fidelity.
The Regional capacity to study aging and health issues has improved during the past 15 years. What is missing is a substantial effort to collaborate regionally in order to provide infrastructure and build capacity for analyzing and utilizing findings that support policies, plans, and programs that address the needs of the Region’s diverse, aging population. Strengthening the scientific foundation for policy-making that meets the challenges of healthy aging must be a priority for the Region ().
The goal for the next 5 years is for health systems throughout the Region to develop core indicators of health and functional capacity across the life course, segregated by sex and age groups, and representative of the population from birth to old age. The aim is to prepare and then adopt systemic changes that are needed for an aging population. With the support of PAHO, Member States will need to create a database that can provide indicators on healthy aging and that is focused on access to health and functional capacity, segregated by age groups and geographic areas. Local knowledge can then drive local decision-making in support of national plans. PAHO’s appointed multidisciplinary work group on aging research has a 5-year goal of ensuring that at least 40% of the Region’s countries will develop the capacity to manage a database on aging and health indicators and will be able to translate that research and data into evidence that can inform decision-making and public health interventions. The long-term vision is to use evidence, information, and research to help reduce inequalities in health and improve healthy aging, with a special focus on those who are at greatest risk of disability or premature death.
The next 5 years will require a major commitment by various sectors of government and society, including older people, to respond to the five key priorities for healthy aging. Member States will have many opportunities to exchange information, coordinate actions, and share lessons learned to support the development of healthy aging. The Region will need to strengthen national capacity to formulate evidence-based policies and programs. If the policies and programs are well crafted and implemented with an evidence-based approach, their cost will be a solid investment, and the return on that investment will be healthier older adults as a key step toward universal health.
Orienting health systems around intrinsic capacity and functional ability will require sustainably financed services, collaboration between sectors, and health and social systems that are aligned to foster healthy aging. Providing access to care and supportive services for people who live into old age will require substantial efforts to finance, create, and implement mechanisms to provide quality care. In general, the next 5 years will require collaboration among Member States, international development organizations, the scientific community, and all sectors of society, which will need to test a variety of approaches to further health and functional capacity in a rapidly aging, diverse population.
1. World Health Organization. Multisectoral action for a life course approach to healthy ageing: draft global strategy and plan of action on ageing and health. 69th World Health Assembly, Geneva, 2016 April 22 (A69/17). Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_17-en.pdf.
6. Kite S. Palliative care for older people. Age and Ageing 2006;35(5):459–460.
7. Miller JM. International human rights and the elderly. Marquette Elder’s Advisor 2009;11(2):6.
8. Pan American Health Organization. Plan of action on the health of older persons, including active and healthy aging. 49th Directing Council, 61st Session of the Regional Committee, Washington, D.C., 2009 Sept. 28–Oct. 2 (CD49/8).
17. Schulz-Aellen MF. Ageing and human longevity. Boston:Springer; 1997.
18. He W, Goodkind D, Kowal P. U.S Census Bureau, International Population Reports, P95/16-1, An Aging World: 2015. Washington, D.C.: U.S Government Publishing Office; 2016.
19. Cruz M, Ahmed A. On the impact of demographic change on growth,savings, and poverty. Policy Research Working Papers, August 2016.Washington, D.C.: World Bank; 2016. Available from:http://dx.doi.org/10.1596/1813-9450-7805.
20. Verena HM, Means R, Keating N, Parkhurst G, Eales J. Conceptualizing age-friendly communities. Canadian Journal of Aging 2011;30(3):479–493.
21. European Centre for the Development of Vocational Training. Working and ageing: the benefits of investing in an ageing workforce. Luxemburg: Publication Office of the European Union; 2012.
22. Beard JR, Biggs S, Bloom DE, Fried LP, Hogan P, Kalache A, et al., eds. Global population ageing: peril or promise. Geneva: World EconomicForum; 2011.
24. Palloni A, Pelaez M, Alfonso JC, Ham-Chande R, Hennis A, Lebrao ML, etal. SABE – Survey on health, well-being, and aging in Latin America and the Caribbean[Internet]; 2000. Available from: https://doi.org/10.3886/ICPSR03546.v1.
25. Gorman M. Development and the rights of older people. In: Randel J,German T, Ewing D, eds. The ageing and development report: poverty, independence and the world’s older people. London: Earthscan Publications; 1999:3–21.
28. Romero Rizos L, Abizanda Soler P, Luengo Márquez C. El proceso deenfermar en el anciano: fundamentos de la necesidad de una atención sanitaria especializada. In: Abizanda Soler P, Rodríguez Mañas L, eds. Tratado de medicina geriatrica. Barcelona: Elsevier; 2015:9–16.
29. National Research Council Panel on a Research Agenda and New Data for an Aging World. Preparing for an aging world: the case for cross-national research. Washington, D.C.: National Academies Press; 2001.
35. Parekh A, Goodman R, Gordon C, Koh K. Multiple chronic conditions – a strategic framework: optimum health and quality of life for individuals with multiple chronic conditions. Washington, D.C.: U.S. Department of Health and Human Services; 2010.
38. Mexican Health and Aging Study. Data files and documentation [Internet]; 2007. Available from: http://www.mhasweb.org/.
39. U.S. Department of Health and Human Services. Multiple chronic conditions – a strategic framework: optimum health and quality of life for individuals with multiple chronic conditions. Washington, D.C.: U.S. Department of Health and Human Services; 2010.
40. Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimorbidity: a systematic review of the literature. Ageing Research Reviews 2011;10(4):430–439.
41. Brown GC, Brown MM, Menezes A, Busbee BG, Lieske HB, Lieske PA. Cataract surgery cost utility revisited in 2012: a new economic paradigm. Ophthalmology 2013;120(12):2367–2376.
50. Cano C, Gutiérrez LM, Marín PP, Morales Martínez F, Peláez M, Rodríguez Mañas L. Proposed minimum contents for medical school programs in geriatric medicine in Latin America. Pan American Journal of Public Health 2005;17(5–6):429–437.
54. Albala C, Lebrao ML, Leon Diaz EM, Ham-Chande R, Hennis AJ, Palloni A,et al. The health, well-being, and aging (“SABE”) survey: methodology applied and profile of the study population. Pan American Journal of Public Health 2005;17(5–6):307–322.
The social determinants of health (SDH) are defined by the World Health Organization as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (). These forces and systems include economic policies and systems, development agendas, social norms and policies, and political systems. These conditions can be highly inequitable and lead to differences in health outcomes. The experience of such conditions may simply be unavoidably different, in which case they are considered inequalities, or they may in fact be unnecessary and avoidable, in which case they are considered inequities and therefore appropriate targets for policies designed to increase equity.
In the Region of the Americas, evidence exists on how the SDH influence a wide range of health outcomes and efforts towards universal health, as reflected in both the development of the Millennium Development Goals (MDGs) and the ways in which they were pursued by countries. Analyzing these determinants is particularly relevant in the Americas, given that health inequity and health inequality continue to constitute the principle barriers to sustained development in the Region. Those living in the Region tend to be disproportionately affected by the poor conditions of daily life, which are shaped by structural and social factors (macroeconomics, ethnicity, cultural norms, income, education, occupation). These conditions and factors are responsible for pervasive and persistent health inequalities and inequities throughout the Americas.
The Pan American Health Organization’s Strategy for Universal Access to Health and Universal Health Coverage notes that recent improvements achieved in health throughout the Americas were due in part to advances in economic and social development of the countries, the consolidation of democratic processes, the strengthening of health systems, and the political commitment of countries to address the health needs of their populations (). The strategy recognizes that policies and interventions addressing the SDH and fostering the commitment of society as a whole to promote health and well-being, with an emphasis on groups in conditions of poverty and vulnerability, are essential requirements to advance toward universal access to health and universal health coverage. There is a clear need to continue efforts to overcome exclusion, inequity, and barriers to access and the timely use of comprehensive health services. Improved intersectoral action is required to impact policies, plans, legislation, regulations, and joint action beyond the health sector that address the SDH.
Conceptual foundation of the social determinants of health
The concept of the SDH incorporates a broad set of determinants extending beyond those that are only social in nature. The basic components of the SDH conceptual framework include (a) the socioeconomic and political context, (b) structural determinants, and (c) intermediary determinants (). Figure 1 outlines some of the key social, economic, cultural, and environmental aspects influencing health outcomes. Combined with individual behavior, genetic factors, and access to quality health care, these factors are thought to account for all, or virtually all, health outcomes (). It is critical to both distinguish between factors that mitigate risk concerning the extent to which they are modifiable–in other words, whether the differences in health outcomes they cause represent inequities or inequalities–and to consider the probable relationship between these factors and policies designed to influence them (). In considering the value, effectiveness, and appropriateness of policies in this regard, the SDHs offer the opportunity to position health as a public good, that is to say, having benefits for all of society that are not reduced by the marginal health gains of one individual but may in fact have exponentially positive effects on the health of other individuals ().
Figure 1.The social determinants of health conceptual framework
Source: Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Geneva: World Health Organization; 2007. ().
The SDH approach is widely regarded as a highly effective means of addressing health inequities that promotes action across a range of factors that affect individual and population health outcomes, many of which are beyond the reach of the health sector. The approach has developed substantially over the past number of years, punctuated by two core calls to action. In 2005, the World Health Organization launched a Commission on the Social Determinants of Health (CSDH) and charged it with the responsibility of gathering evidence on inequities, as a way to understand the SDH and their impact on health equity, and issue recommendations for action (). The CSDH’s final report (2008) issued three recommendations for action: to improve daily living conditions; to tackle the inequitable distribution of money, power, and resources; and to measure and understand the problem and assess the impact of action (). The Rio Political Declaration on Social Determinants of Health (2011) also had substantial implications for this agenda in the Region. The Declaration emphasizes the need for an SDH approach and served as a call to action on interrelated principles addressing the SDH approach as well as broader, related concepts including equity and human development.
Clear emphasis has been placed on the importance of multisectoral action in addressing the SDH, the unacceptability of stark health inequities, and health as a human right. Grounded in equity, action on the SDH in the Region of the Americas requires recognition of the complex and often long-term causes of ill health and health inequity, through research in both social science and epidemiological disciplines. A growing body of evidence has led to intensified action across the global health spectrum with notable national-level engagement in the Region of the Americas. By addressing the fundamental “causes of the causes” of good and ill health, the SDH approach has the potential to remove some of the fundamental barriers that impact health and address some of most intractable health issues in the Region that are closely associated with dimensions of inequity, supporting the progressive transition towards universal health.
The Region of the Americas has much to celebrate in terms of the progress in health over the past 5 years. As we reach the end of the era of the Millennium Development Goals (MDGs), it is valuable to briefly review progress made during this period in order to contextualize the current health landscape in the Region and address key areas where there is still much work to be done. Significant progress has been recorded in terms of reaching the health-related MDG, particularly in terms of overall levels of nutrition, life expectancy, poverty, under-5 mortality, HIV, malaria, and tuberculosis. Targeted efforts at the local, national, and regional levels in each of these areas have been facilitated by economic development, resulting, for example, in improved levels of nutrition and lower levels of associated child stunting.
At the same time, the review of progress made during this period combined with the assessment of the current health landscape in the Region highlights key areas where there is still much work to be done. Pursuit of the MDG contributed to improved outcomes in health for the Region; however, it also highlighted challenges with regard to equity of outcomes. While the achievements made during this time period can be lauded, other challenges have appeared in their place. In some areas, progress has stagnated. For example, despite reaching the MDG target of halving the rate of extreme poverty (), the reduction in rates in the Americas has slowed to a near halt in recent years (). This has severe implications for the Region as poverty has a direct impact on access to decent housing, services, education, transport, and other vital factors for overall health and well-being (). In fact, poverty is arguably the single largest determinant of health (). A recent publication from the World Bank Group on chronic poverty estimated that one in four people in Latin America and the Caribbean (LAC) are still living below the poverty line (). Compounding concerns over mobility, the United Nations Development Program (UNDP) estimates that over 200 million people in the Region subsist just above the poverty line of US$ 4 a day, outside of the middle classes not yet included in income classifications as poor (). These individuals are considered to be at high risk of falling into poverty should a financial crisis or natural disaster strike. This type of transient poverty (that is, poverty experienced as the result of a temporary fall in income or expenditure) generates variability and thus inequality in the poverty status of individuals ().
Additionally, the favorable trends that have been reflected in national and regional averages mask the gaps in progress that remain both within and between countries. A more nuanced look at the regional and national averages disaggregated by income and social strata reveals substantial gaps in equity between and within countries in the Region (). Most notably, in 2015, while the Region of the Americas had one of the highest reported average for life expectancy at birth (76.9) (), a closer look at country-specific data reveals that the difference in life expectancy at birth between countries was as great as 18 years (). The Region’s apparent success with regard to eradicating poverty also demonstrates the MDGs focus on national averages rather than on progress at subnational levels and across different population groups (). The Economic Commission for Latin America and the Caribbean (ECLAC) 2014 edition of Social Panorama of Latin America confirmed that not everyone in the Region has reaped the same benefits on this front as the downward trend in poverty over the last 15 years was greater among the wealthiest groups than among the most disadvantaged (). Many individuals categorized as chronically poor were unable to escape poverty during this time period. Labor income was a powerful driver behind the immense reduction in poverty over the last decade. The chronically poor face greater barriers to entering the labor force, reducing their opportunity for employment and exacerbating the cycle of chronic poverty. Poverty also continues to be concentrated within certain ethnic groups. In the Region of the Americas, indigenous peoples remain among the poorest and, in some areas, the income gap between them and other population groups has grown even wider ().
These findings highlight the concerns that programming to achieve the MDGs did not go far enough in terms of reaching less advantaged populations. Regional successes relate disproportionately to the “low-hanging fruit” of those already better served by public services. This paradox highlights the genuine limitations of the MDG-era achievements. While true success has been achieved in terms of global health indicators, many of these successes fall short when viewed through the equity lens.
Monitoring inequities and the factors that determine them is a challenge for existing information systems, requiring changes in the types of data the health sector collects. Information gathering entails choosing basic health indicators, stratifying criteria, and applying indices to measure both inequities and inequalities (). Conversely, it also offers the opportunity to measure multiple facets of health outcomes: who we are, how we live and die, and which events and circumstances play deciding or influential factors in determining these outcomes, at both the individual and population levels. Though numerous MDG targets were achieved, it must be noted that, almost universally, progress by wealthier, more privileged members of society exceeded that of the more disadvantaged. Furthermore, MDG targets that were not achieved indicate continuing Regional challenges in addressing health outcomes related to gender, sexual and reproductive health, communicable diseases, noncommunicable diseases, mental health, and access to care. This section examines the inequities and inequalities related to a sample of Region-specific issues in reproductive and maternal health, communicable and noncommunicable diseases, and mental health that will require more concerted action on the social determinants of health to improve health outcomes in these areas.
Reproductive and maternal health
The health of mothers can directly affect the health of their children. The cycle that is created from this dynamic potentially allows health inequalities to remain concentrated in certain populations for generations. While progress was made in terms of reducing the under-5 mortality rate during the MDGs era, on a global scale, maternal mortality remains incredibly high, reflecting the presence of inequities in access to health services, such as routine reproductive health care. A lack of access to basic services results in many unmet health care needs, such as contraceptive needs, unintended pregnancies, undiagnosed sexually transmitted infections, and undiagnosed cancers.
In order for barriers to be addressed and for progress to be made, it is imperative that social policies recognize the role of gender as a strong structural determinant of health. For example, women have higher health care costs than men due to their greater use of health care services. At the same time, women are more likely than men to be poor, unemployed, or engaged in work that does not provide health care benefits (). That said, gender alone does not account for all of the barriers women face in accessing care. Access to the necessary resources for health attainment is further restricted by the intersections between gender inequality and other important determinants of health such as income, education, age, ethnicity, and sexual orientation, leaving vulnerable populations at an especially high risk. For example, in Latin America and the Caribbean, women from the poorest quintile have greater unmet health needs, such as the need for contraception, compared to women from the wealthiest quintile (). Lower levels of income and ethnic background have been associated with early sexual initiation. Early sexual initiation is often associated with risks of both adolescent pregnancy among young women and adverse sexual health outcomes, such as sexually transmitted infections, thereby exposing less-advantaged populations to a double burden of infectious disease and barriers to women’s socioeconomic mobility (). Additionally, women in rural communities do not have equal access to convenient, affordable, or culturally appropriate reproductive health services and education. Women from racial/ethnic minorities frequently experience social and economic exclusion—yet another example of an unequal situation that produces health inequities at numerous moments throughout the life course, particularly during pregnancy and childbirth.
Within the Region of the Americas, reducing maternal mortality also remains a persistent challenge despite the fact that numerous Member States reported having adopted policies, programs, or plans for gender and health. This has troubling implications for the Region’s ability to meet the needs of women, despite the avowed political commitment. National and subnational inequalities in the maternal mortality rate are prominent (). Data from 2015 revealed stark differences between countries in the maternal mortality rate per 100,000 live births, with numerous countries reporting rates far below or far above the Regional average of 81 per 100,000 live births (Figure 2) (). These findings echo the point that has been made from a variety of Regional stakeholders, that the focus must remain on gaps in achievement of the MDGs, recognizing that however challenging the achievement of MDG targets was, there is still considerable work to be done to ensure that these targets are met on an equitable basis ().
Figure 2. Maternal mortality rate (per 100,000 live births), 2015
The incidence of major infectious diseases has declined globally since 2000. Regardless, communicable diseases remain a prominent global challenge. For many years, the “big three” of HIV, tuberculosis, and malaria have overshadowed others, leading to the emergence of the “neglected diseases” category, also referred to as “neglected tropical diseases” (NTD). The SDG recognize NTD as a major global threat, with an estimated 1.7 billion people across 185 countries requiring treatment for NTD in 2014 (). The pressing concern of NTD, as well as other vector- and water-borne diseases, led to the adoption of the target 3.3 within the SDG, “by 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.”
NTD encompass a group of pathologies that disproportionally impact resource-constrained areas of the world, subject to inadequate response systems, resources, and the ability to mitigate harm, in addition to the level of harmful environmental exposures. Numerous determinants affect the spread of communicable diseases. These determinants include, but are not limited to, water and sanitation, housing and population clustering, climate change, gender inequity, sociocultural factors, and poverty. The relationship between these determinants and health and equity is rather complex given that these determinants are often overlapping. For example, housing and population clustering can be viewed as an intermediary social determinant for NTD as it has direct links with poverty as a structural social determinant. It must be recognized that the spread of these diseases is often perpetuated by multiple environmental and social determinants coupled with a lack of resources for prevention and care, and due attention afforded to the issue by policymakers.
Noncommunicable diseases and mental health
Noncommunicable diseases (NCD) have been identified as a major challenge to sustainable development in the 21st century and are therefore central to the post-2015 development agenda (). The rise of NCD has been driven by primarily four major risk factors: tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets. Efforts to address these risk factors have been met with numerous challenges, many of which are attributed to the prioritization of wealth over health by other sectors. There has been substantial growth in the provision of processed foods and products that are linked to higher levels of obesity, diabetes, and other diet-related chronic diseases ().
NCD represent a substantial disease burden in the Americas in terms of both mortality share and impact upon disability-adjusted life year (DALY) rates (). Looking at the proportional mortality in the Americas, the burden of NCD appears staggering, with the overall proportion of deaths attributed to NCD ranging from 60% to 89% (Figure 3)(). Moreover, not all social groups are affected by NCD in the same way. NCD risk factors are much higher among poor populations. In fact, substantial differences in DALYs across income levels exist in the Americas (). There is also a strong correlation between low education levels and high rates of NCD in low-, middle-, and high-income countries. Given this, there has been a shift towards interventions focused on risk factors and their related environmental, economic, social, and behavioral determinants. Additionally, differing characteristics of inequity and inequality within and between countries require country-specific contexts to be taken into consideration when addressing NCD. Changing demographics give cause for concern, as does the impact of increasing economic prosperity on individual health once a particular threshold is passed. For example, a 2016 study on socioeconomic status and health in adolescents found a positive correlation between socioeconomic status and sedentary behavior, which is associated with risk of NCD, suggesting that this group may respond to interventions that target this behavior (). In these cases, health does not always follow wealth, highlighting the complex nature of inequalities and the social determinants of health ().
Figure 3. Proportional mortality in the Americas by subregion, 2012
Source: Escamilla-Cejudo JA, Sanhueza A, Legetic B. The burden of noncommunicable diseases in the Americas and the social determinants of health. In: DCP3 Disease Control Priorities. Section 2: socioeconomic dimensions of the impact of NCD. 3rd ed. Seattle: Disease Control Priorities Network; 2013:13–22. ().
Mental health also has been inextricably linked to NCD and their outcomes. The prevalence and social distribution of mental health disorders has been well documented in high-income countries, but there is a growing recognition of the issue in low- and middle-income countries. Evidence suggests that social risk factors for many common mental disorders are heavily associated with social inequalities, whereby the greater the inequality, the higher the risk (). Accordingly, mental health disorders can be shaped by various social, economic, and physical environments () operating at different stages of life—not only in early life when there is a higher predisposition to develop a mental health disorder, but also at older ages, and during working and family-building years (). The impact of these social determinants on mental health can be accumulated over the life course (hence the importance of employing the “life course perspective” in considering fundamental causes of health and morbidity), increasing the severity of mental health disorders and/or the incidence of new ones.
Studies have shown that the more relevant SDH associated with mental health disorders include income, education level, gender, age, ethnicity, and geographic area of residence. For example, increased rates of depression and substance use are systematically associated with lower income levels (). The poor and disadvantaged suffer disproportionately from common mental disorders (depression, anxiety, suicide, etc.) and their adverse consequences (). In addition to household income, low educational attainment, material disadvantage, and unemployment are other factors leading to common mental disorders (). Gender is another important social determinant: certain mental health disorders are more prevalent in women than in men (), and, in fact, women frequently experience the impact of social, economic, and environmental determinants in different ways than men (). For example, women report more suicide attempts while men commit more fatal suicides (). Regarding substance abuse, though men are more likely to engage in risky behavior and develop drug-related problems, women suffering from addiction are less likely to seek treatment for substance abuse due to societal barriers in place ().
In the Region of the Americas, there is increasing interest in the relationship between working conditions and mental disorders, particularly depression and anxiety. Mental health disorders affect many employees in the Region, a fact that in the past has been overlooked because these disorders have tended to be hidden in the workplace. As a consequence, mental health disorders often go unrecognized and untreated, not only damaging an individual’s health and career but also reducing productivity at work ().
The social determinants of health approach to core Regional challenges
Given the close links between health equity and the underlying determinants of health, an integrated and systematic approach to address the underlying determinants of health is essential for reducing health inequities. The idea that health is created in the context of everyday life as opposed to being limited to health service-oriented settings was articulated in the 1986 Ottawa Charter for Health Promotion (). The Ottawa Charter drew strong links between the principles of health promotion and the SDH, both of which consider health to be an ecological phenomenon, created and modified by the wider system of factors that influence how individuals, as well as population groups, experience daily life and long-term trends throughout the life course. Taking into account the contextual determinants of health and health behaviors, a vigorous health promotion response is another essential component to addressing health challenges ().
Recently, health promotion in the Region has focused on the creation of healthy and supportive municipalities, workplaces, housing, schools, and universities. As part of this strategy, there has been a reactivation of the various health-promoting networks at the Regional level, namely Healthy Cities, Municipalities and Communities; Health-Promoting Universities; and Health-Promoting Schools. For example, while both Mexico and Cuba have maintained full coverage of Healthy Cities for over 20 years, numerous cities in the Region of the Americans have joined this movement in recent years. Prominent cities include Medellín, Cali, and Bogotá in Colombia; Curitiba, Guarulhos, and São Paulo in Brazil; La Granja, Chile; Cienfuegos, Cuba; and Buenos Aires, Argentina.
Building on the Declaration of Alma-Ata, the Ottawa Charter also highlighted the need for all sectors to invest in health and the need for the expansion of the concept of health determinants in order to “build healthy public policies.” Currently, a strategic approach to harness action across all sectors, known as Health in All Policies (HiAP), is being implemented in countries. The Helsinki Statement on Health in All Policies (2013), articulated HiAP as “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve populations health and health equity” (). HiAP emerged from the increasing recognition that health outcomes and inequity in health extend beyond the health sector across many social and government sectors. HiAP is known as the “operational arm” of the SDH approach precisely because many of the health inequities outlined have root causes in social, economic, structural, and environmental causes that do fall under the purview of sectors outside of health. In order to truly achieve equity in health, the “one size fits all” approach must be avoided. The various policy interests involved in the conditions that produce healthy (or unhealthy) outcomes require coordination, stewardship at the highest level of government, mutual appreciation for distinct priorities and capacities of different sectors, and skills in communication and negotiation that have not traditionally been part of the public health sphere. HiAP establishes a strategic approach that provides advocates and policy makers with guidance to address the “causes of the causes” of ill health and to develop intersectoral effective action.
In line with the Helsinki Statement, the HiAP approach promotes sustained collaboration among sectors whose policies and practices have significant influence on health outcomes such as those discussed (). It sets out concrete priorities and practices to support positive action on the SDH (). The approach has been well received in the Region of the Americas, the first WHO Region to establish a Regional Plan of Action on Health in All Policies (2014) (). The Regional Plan of Action on HiAP marks a significant milestone in the global acceptance of the HiAP approach to encourage collective and coordinated action for health. Progress since then in the Americas includes a series of guiding documentation and activity designed to support Member States in implementation, largely under the rubric of the aforementioned HiAP initiative and including the Road Map for the Plan of Action on Health in All Policies (), the creation of a Health in All Policies in the Sustainable Development Goals Task Force and Working Group, and the Commission on Equity and Health Inequalities in the Region of the Americas. Additionally, countries including Brazil, Chile, Mexico, and Suriname (see Box), have recently embarked on consolidating actions in this area through capacity building and planning that will ensure that health is firmly placed at the crux of national policy development and planning. Such action is being complemented by PAHO through the work of Commission on Equity and Health Inequalities in the Region of the Americas.
The Suriname experience—implementing health in all policies to address the social determinants of health
After hosting the subregion’s first HiAP training in Paramaribo, the government of Suriname began immediately moving towards implementation of the HiAP approach to address the social determinants of health. Under the leadership of the Ministry of Health and with support from PAHO, the Government of Suriname implemented a Quick Assessment of the Social Determinants of Health to understand the underlying causes of major health problems and associated health inequities. Results from the assessment of available data found that, in Suriname, the social determinants that are predominately related to the major diseases contributing to DALYS are geographical location, socioeconomic status, population group, and gender. These findings were used to establish eight country-specific areas of action for the implementation of HiAP. Suriname’s experience demonstrates the success of taking on a multisectoral approach to health and highlights the strong links between the social determinants of health and HiAP.
Given the strong overlap of the goals, means, and priorities associated with the SDH approach, health promotion, and HiAP, progress made on one front has great potential to simultaneously advance the others. Additionally, the successful implementation of HiAP and health promotion throughout the Region demonstrates that the factors that affect health and well-being can be addressed through the establishment of sustainable public policies, the creation of intersectoral partnerships, the development of supportive environments, the active participation of local governments and communities, and the strengthening and sustainability of new and existing networks (). The focus on an inclusive and participatory approach and collaboration across sectors is echoed by the global community’s recent commitment to implement the 2030 Agenda and the Sustainable Development Goals (SDG).
Advances achieved in the key action areas identified by the Rio Declaration
Within the Americas, individual countries and Regional bodies have made considerable progress in implementing the SDH agenda. Practitioners, policymakers, and the public alike have been receptive to this equity-oriented approach, advancing a range of initiatives to address some of the gross health inequalities that feature nationally and regionally using SDH tools. The Rio Political Declaration on Social Determinants of Health continues to serve as a guiding principle for the successful implementation of the SDH approach. In line with the recommendations of the Commission on Social Determinants of Health (), the Rio Declaration established five key action areas on SDH at the global, national, and local levels (). These key areas optimize the potential of the approach to reduce inequities and achieve targets set by the Region and help build momentum within countries for the development of dedicated national action plans and strategies. Accordingly, a review of the advances and progress in addressing the SDH over the last 5 years, within the context of the Rio Declaration, is merited.
1. Key area: improve governance for health and development
Improving health means improving governance in health and development. The three main arguments supporting this assertion are as follows: (1) health is unevenly distributed, (2) many health determinants are dependent on political action, and (3) health is a critical dimension of human rights and citizenship (). Improved governance is therefore essential to advance human health and development. In this context, the term governance refers to the interaction between governments (including their different constituent sectors) and other social organizations, how governments and organizations relate to civil society, and how decisions are taken in a complex and globalized world ().
Improving governance for health and development and addressing the social determinants involves transparent and inclusive decision-making processes that give voice to all groups and sectors involved (). Actions within this area pertain to government structures and the development of social and environmental policies and programs that aim to reduce inequity in health. In order to provide guidance to countries, the following five principles of good governance have been identified to better address the SDH ():
Legitimacy: Processes focused on the implementation of policies that impact the SDH must ensure legitimacy by providing a voice to all stakeholders involved, including those affected by the decisions.
Direction: Work on the SDH requires a clear, strategic vision for promoting the SDH agenda.
Performance: The mechanisms for decision-making on the SDH must be responsive to all stakeholders and encourage participation.
Accountability: All actors must be held accountable for the decisions made in respect to the shared goals.
Fairness: Decision-making should be fair and aim to reduce inequalities in health.
These principles demonstrate that effective governance requires a range of conditions, including the creation of conducive policy frameworks; accountability and ongoing participation of civil society and nontraditional partners; and emphasis on shared values, interests, and objectives among partners. Successful implementation of an SDH approach to improve health and well-being requires the establishment of governance mechanisms that delineate the individual and joint responsibilities of different actors and sectors in the pursuit of health and well-being.
A lack of coordination among different actors and conflicting interests can constitute a significant barrier to advancing development. This touches on another important concept, namely the commercial determinants of health, defined as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health” (). Historically, there has been criticism from the public health sector regarding the influence of the corporate sector on health and well-being. There are four main channels through which corporate influence is exerted: (1) marketing, (2) lobbying, (3) corporate social responsibility strategies, and (4) extensive supply chains. The focus on lifestyle choices has been extensively analyzed, particularly in regards to tobacco marketing and the marketing of unhealthy commodities towards children (). There is now a growing body of evidence to suggest that the tobacco, food, drink, and alcohol industries have on occasion employed tactics and strategies to undermine public health, and policymakers have faced difficulties to effectively mitigate against the impact of such strategies.
Action across all sectors—Regional approach to reducing traffic-related injuries and deaths
The Region’s progress in reducing traffic-related injuries and deaths is an example of collaboration and intersectoral action in practice. Intersectoral strategies include improving road infrastructure, updating transportation legislation, and promoting vehicle inspections and safety standards. Numerous countries within the Region have created national policies promoting sustainable and safe public transportation. Specific countries implementing safe transportation practices include Argentina, Cuba, Guatemala, Jamaica, Panama, Peru, and Uruguay. Additionally, 27 countries created road safety agencies between October 2011 and December 2014. Fifteen countries passed laws setting the blood alcohol limit for drivers, 32 countries approved laws making seatbelt use compulsory for all passengers in vehicles, and 30 countries passed laws on compulsory helmet use for all motorcycle passengers.
Source: Pan American Health Organization. Progress report on plan of action on road safety. 54th Directing Council of PAHO; 67th
Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2015 September 28-October 2 (CD54/INF/5)
An example of intersectoral action for health at work is Mexico’s National Agreement for Healthy Food (). This agreement is an intersectoral initiative to address the determinants of obesity, by regulating access to food and beverages and providing supportive environments for healthy lifestyles. The agreement received political support from the highest levels of the federal government, and has been implemented through several federal government agencies including finance, social development, education, economics, agriculture, rural development, workplace safety, and health. The program focuses on reducing inequity by giving particular attention to the prevalence of overweight and obesity in children, low-income populations, and indigenous communities. Under the agreement, the food and beverage industries were held accountable for their role in health outcomes, particularly those of children. The objective here was to work with the food and beverage industries to contribute to health more positively by incorporating health-promoting principles into their campaigns while at the same time limiting the marketing of unhealthy foods and beverages towards children. Since the program was first implemented, much progress has been made, particularly in terms of the regulation of media advertisements and the sale and distribution of unhealthy foods and beverages in schools ().
2. Key area: promote participation in policy-making and implementation
Successful action on the SDH requires the participation of communities and civil society groups in the creation of policies, and the monitoring and evaluation of their implementation. Civil society has a critical role to play in identifying priority areas for action, generating evidence for work on the SDH, and by holding policymakers and program implementers accountable for the actions they undertake and the commitments they make. Governments can play an active role in promoting participation by offering incentives, subsidizing costs, and ensuring legitimacy and transparency. Improving transparency in policy-making on the determinants of health is critical for the adoption and implementation of successful and inclusive policies.
A recent report from the World Bank and PAHO, Toward universal health coverage and equity in Latin America and the Caribbean evidence from selected countries, noted that governments have made progress in supporting and promoting the participation of civil society in the policy-making process (). Bolivia, Ecuador, and Venezuela, among other countries, have have inscribed social participation in their constitutions as a means of reducing social and economic inequality (). Additionally, as of 2014, nine countries and territories reported having specific mechanisms in place to engage communities and civil society in the policy development process across sectors.
Case Study: Ecuador’s National Plan of Good Living
Ecuador’s Plan nacional para el buen vivir (National Plan for Good Living, or NPGL) is an example of the successful involvement of civil society in policy-making and implementation. Ecuador’s countrywide action plan incorporates an SDH approach to health and policy and is committed to developing and implementing social policies. The plan was developed through consultation with diverse actors and recognizes citizen participation as a basic right. In order to identify specific needs within the policy, forums for dialogue were created to enable the participation of different groups, including women and men from different social-cultural backgrounds, of different ages and sexual orientation, to provide their opinion on the achievements of the previous National Development Plan. The feedback given was incorporated into the new plan. The NPGL consists of specific sectoral work plans consistent with national strategy and priorities, with one specific work plan being dedicated to health. The health sector work plan adopts the SDH approach and its goals are set through multiple sectors including health, education, and housing, among others. Ecuador’s NPGL serves as a concrete example of the successful use of the SDH approach in the development of new policies with the input and participation of citizens and different social groups.
Throughout the Region, efforts have also been made to engage previously excluded populations. As of 2014, 10 countries and territories reported having specific strategies in place to involve marginalized groups in policy discussions at the local, subnational, and national levels (). Actions are ongoing to promote mental health and well-being in indigenous populations. Indigenous populations are disproportionately affected by an array of common mental disorders. These groups have different ways of conceptualizing their health issues and of organizing care, as determined by historical, geographic, and cultural factors. Argentina, Brazil, Canada, and Chile, among others, have promoted fora for dialogue with the participation of indigenous practitioners, clinical health, public health, anthropology, and mental health specialists, where each of the actors share their knowledge and best practices spanning different indigenous communities.
3. Key area: further guide the health sector towards reducing health inequalities
Reducing health inequities and inequalities through transformation of the health system is core to PAHO’s Strategy for Universal Access to Health and Universal Health Coverage, adopted in 2014 (). The strategy expresses the commitment of PAHO Member States to strengthen health systems, expand access to comprehensive quality health services, provide financial protection, and adopt integrated, comprehensive policies to address the SDH and health inequities. It argues that “universal access to health and universal health coverage require determining and implementing policies and actions with a multisectoral approach to address the social determinants of health and provide a society-wide commitment to fostering health and well-being” (). The strategy makes the case that gender, ethnicity, age, and economic and social status are social determinants that have a positive or negative impact on health inequities, the reduction of which is a core objective of universal health.
In the Region, Argentina, Brazil, Chile, Colombia, Costa Rica, Guatemala, Jamaica, Mexico, Peru, and Uruguay have implemented an array of policies to increase the scope and equity of health programs (). There has also been Regional progress in expanding health care services and resources to persons with disabilities. In October 2014, ministers of health throughout the Americas pledged to improve access to health and rehabilitation for people with disabilities and to safeguard their rights. To demonstrate this commitment, the Regional Plan of Action on Disabilities and Rehabilitation was approved by PAHO Member States in 2014. This plan calls for a stronger, more integrated health sector response in supporting persons with disabilities, their families, and caregivers. Countries that have demonstrated notable efforts towards a more integrated health sector response in supporting persons with disabilities, their families, and caregivers include Chile, Guyana, and Mexico ().
The strategies adopted by countries to transform the health system moving towards universal health are presented elsewhere in this chapter, specifically in the discussions relating to access to health services, improved health governance and stewardship, and health financing. Here, however, it is important to note that efforts to address health inequities, as they relate to the SDH, must vary depending on the context of the country, existing health inequities, and the structure of social and health systems. For example, in examining the health situation of women in La Paz, Bolivia, critical variations were found in several conditions: cancer (especially cervical-uterine cancer), maternal mortality, sexual and reproductive health, the impact of HIV/AIDS, and domestic and intrafamily violence. Women reported significantly lower health care coverage and minimal participation in the promotion and care of their own health. Evidence suggests that this was due to discrimination, mistreatment, and the lack of available services that address needs specific to women. The STAR Health Services initiative was developed by the health department in La Paz from 2004 to 2006 later focusing on the Pampahasi Bajo health services (). The initiative aimed to improve health conditions by strengthening the management of services, ensuring “quality with a focus on gender” and the development of processes that empower women in their community (primarily migrant Aymarans and those living in poor areas).
During the first phase of the initiative, gender considerations were successfully integrated into the primary health care framework. These adjustments included improvements in signs posted, the use of native language and curtains for privacy, easier scheduling,, more accessible and informative literature, the organization of health service teams, better treatment of patients, the monitoring of user satisfaction, and the development of a community education program that raised awareness and strengthened the respect for women’s health care rights. The initiative served to reestablish the role of the health team as an “agent of change” responsible for confronting gender-based issues and promoting gender sensitivity within the existing healthcare delivery system. It demonstrated the need for collaborative planning among health staff and community organizations to address differentiated needs and to respond appropriately to the inequities at hand.
4. Key area: strengthen global governance and collaboration
Ensuring political coherence requires action on the SDH both within countries and internationally. International collaboration towards the adoption of coherent policy approaches that are based on the right to the enjoyment of the highest attainable standard of health is an important component in advancing an SDH approach. Reforming global governance for health is a necessary component for achieving global health with justice, as this goal requires international and domestic responsibilities that are centered on human rights (). For example, the Framework, was developed in response to the globalization of the tobacco epidemic to demonstrate the commitment of all countries to combating this health crisis. Thirty countries in the Region of the Americas are State Parties to the Convention (). Brazil was one of the first signatories of the WHO Framework Convention on Tobacco Control, and created an intersectoral commission called the National Commission for the Implementation of the Framework Convention on Tobacco Control and its Protocols. Tasked with developing and implementing policies to reduce tobacco consumption, 18 different governmental sectors collaborated to produce the National Policy for Tobacco Control (). They also passed other legislative changes to regulate tobacco product costs and marketing, and even to provide technical and financial support for small-scale tobacco farmers to diversify their crop production.
Some more recent prominent international conferences that address health and development include the Third International Conference on Financing for Development, the 2015 UN Summit (during which the Sustainable Development Goals were adopted), the 2015 UN Climate Change Conference, and the Seventh World Urban Forum, to name a few. These conferences have considered including commitments for advancing global health and its determinants (). For example, the Paris Agreement for Climate Action, adopted at the 2015 UN Climate Change Convention, constitutes a global commitment to regulate emission levels and mitigate the adverse effects of climate change on health.
The Paris Agreement for Climate Action: a global commitment
The Paris Agreement for Climate Action, adopted at the 2015 UN Climate Change Convention, constitutes a global commitment to regulate emission levels and mitigate the adverse effects climate change has on health. The Paris Agreement is a global initiative to protect population health from harmful and unhealthy products and environments. In 2016, 31 PAHO Member States signed the Paris Agreement, including Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Bolivia, Canada, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, El Salvador, Granada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, the United States of America, Uruguay, and Venezuela.
5. Key area: monitor progress and increase accountability
It is imperative that the implementation of policies that address the SDH be informed by evidence. The availability of data, or lack thereof, adversely impacts decision-making in policy development and public health action, and in shaping what research can or will be done. Building the evidence base for intersectoral action that addresses the SDH will be necessary to improve our understanding of populations that experience the greatest levels of inequality, and the interventions that are required to address inequities and disparities. This is particularly relevant for many low- and middle-income countries where there are significant limitations in the available data, namely, disaggregated data for socioeconomic status, ethnicity, and education levels as well as other important health determinants ().
As a result of the priorities established in the MDG agenda, there is a greater preponderance of data related to reproductive, maternal, and child health, allowing for a more detailed analysis of socioeconomic inequalities in these areas. However, countries are now being tasked with meeting SDG 17, which specifically calls for the “availability of high-quality, timely and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location and other characteristics relevant in national contexts.” The need to address this challenge is of particular relevance when developing monitoring mechanisms for SDG 3, to ensure healthy lives and promote well-being for all at all ages. The limited data associated with NCD as well as measures for universal health coverage means that countries will need to build capacity in assessing health inequalities as they relate to the SDH and these health priority areas. The Health Inequality Monitoring Framework developed by the WHO along with the Health Equity Monitor, as part of the Global Health Observatory, provides a guide and resource to countries when building monitoring capacity. Ensuring the comparability of data is essential for sharing successes and challenges when addressing health inequalities at the national level. The Region of the Americas has already taken action on this front through the inclusion of indicators measuring inequality in the 2014–2019 Strategic Plan of the Pan American Health Organization. Countries are responding to the challenge of generating disaggregated data by establishing observatories for the measurement of inequalities and health inequities. Already, Uruguay and Colombia have established national observatories that use the WHO Framework for monitoring inequalities, and Mexico is in the process of establishing its own health inequity monitoring system.
Monitoring the progress made during the MDG era has played an important role in identifying key areas for future action as well as core health issues that still remain to be addressed. The Region of the Americas has shown a strong commitment to identifying these key areas. Throughout the Region, countries have begun establishing national/regional networks of multisectoral working groups and stakeholders to evaluate the impact of government policies on health and health equity. As of 2014, six countries reported having these networks in place. Additionally, in May 2016, ECLAC presented a document, Horizons 2030: equality at the centre of sustainable development, which takes an in-depth look at the key challenges and opportunities for implementation of this approach in the Region (). The Member States of ECLAC also recently adopted resolution 700(XXXVI) establishing the Forum of the Countries of Latin America and the Caribbean on Sustainable Development, a body responsible for monitoring and reporting on implementation of the wider 2030 Agenda. A series of priorities has been articulated by ECLAC to support this approach, which both strengthens and reinforces the connections between the SDH, equality, and sustainable development, namely, strengthening the regional institutional architecture, enhancing analysis of the means of implementation of the 2030 Agenda at the Regional level, supporting the integration of the SDG into national development plans and budgets, and promoting the integration of the measurement processes to build SDG indicators into national and regional strategies for the development of statistics and statistics capacity (). Several of these components—particularly strengthening statistics capacity at the country level, which facilitates examination of the population groups benefiting most and least from certain policies and interventions—have profound implications for achieving equity and improving health.
Additionally, monitoring and surveillance systems have been identified as key to guiding the adoption of new programs and policies. Given the varying national contexts within the Region, programming must be sensitive to the landscape of social determinants within each country. Therefore, country-specific programming is required as opposed to a broad-brush Regional approach. A number of new surveillance initiatives have been developed in order to better understand the arising health needs that vary within and between countries. In 2013, UN-Habitat introduced a measure for prosperity, the City Prosperity Index, with the intention of helping decision-makers design appropriate policy interventions (). Since its creation, the City Prosperity Index has been applied in numerous cities in the Region, including Buenos Aires, Ciudad Obregón, Fortaleza, Guadalajara, Guayaquil, Guatemala City, Lima, Medellín, Mexico City, Montreal, New York, Panama City, Quito, São Paulo, and Toronto. Moving forward, the relationships between health outcomes and social stratification variables must be clearly established, and developing accountability mechanisms in policy-making will be essential.
The 2030 Agenda for Sustainable Development named eradicating poverty, in all forms and dimensions, as one of the greatest challenges facing humanity as well as a core component to achieving sustainable development (). The 2030 Agenda and the 17 SDGs recognize that the eradication of poverty and inequality, the creation of inclusive economic growth, and the preservation of the planet are linked to each other and to the overall health and well-being of the population. Poverty is explicitly highlighted in Goal 1 of the SDGs, which calls for an end to poverty by 2030 (). Achieving this goal entails targeting the most vulnerable populations through poverty-reduction strategies. These strategies involve the development and use of cross-sectoral development frameworks that tackle the cause and effect of poverty in a country (). Based on the broad consensus of leading development agencies, successful poverty-reduction strategies must be results oriented, comprehensive, country specific, participatory, collaborative, and long term (). In the Region, a large number of countries have expanded coverage and noncontributory benefits to specific populations through poverty reduction strategies in the form of special plans and programs. In several countries, these programs have contributed to reducing poverty and extreme poverty, particularly in rural areas.
Conditional cash transfers (CCT), which are programs through which cash can be transferred to families in extreme poverty, have been recognized as evidence-based mechanisms for both reducing poverty and improving health. These programs also serve as important contributors to human development and social protection. CCT programs have a long-standing history throughout the Region. From the earliest transfer programs in the mid- to late 1990s in Mexico to the Federal District in Brazil, practically every country within the Region has deployed these types of programs. Positive outcomes are evident in significant, albeit modest, improvements in school enrollment, education outcomes, and overall early childhood development. Progress in health has been demonstrated across several indicators including infant mortality, maternal health, immunization, access to nutritious food, and quality of services accessed. As poverty often manifests itself in the form of hunger and malnutrition, the success of these interventions in regards to food and nutrition are particularly relevant for vulnerable groups and those living in extreme poverty. That said, contextual goals and benchmarks that respond appropriately to domestic priorities are critical to this process (). It is worth noting that the greatest advances in these trends have occurred in countries with modest welfare gaps such as Argentina, Brazil, Chile, Uruguay, and, to a lesser extent, Panama. However, Ecuador, Bolivia, El Salvador, and, to a lesser extent, Mexico, have positively escaped this generalization as these countries have enacted successful initiatives despite having very low fiscal commitment. As both poverty and growing inequality are detrimental to economic growth and undermine social cohesion, practical solutions such as these that pertain to the common challenges of human development will be crucial moving forward.
Conditional cash transfers: improving outcomes for the most vulnerable
The effects of poverty are particularly harmful in vulnerable populations such as infants and children. Many CCTs have therefore set their focus on maternal and child health. For example, Juntos (“Together”), a cash-transfer program in Peru, aims to lift children out of poverty and improve their education, health, and nutrition. While the program appeared to lead to modest improvements in school enrollment (a 4% increase), a recent evaluation found that Juntos has mitigated the problem of extreme chronic malnutrition among its child participants. The program has also successfully enhanced access to resources and services. Since 2012, Juntos has been managed by the Ministry of Social Development and Inclusion, in coordination with various ministries in charge of social affairs. This cooperation across sectors opened access to the variety of public services offered by each individual ministry.
The Uruguay Grows with You program outlines another platform for success, which runs highly focused activities targeting the most vulnerable citizens. The impact on those enrolled has been substantial thus far, reducing the level of depression in mothers and pregnant women from 31% to 16% since 2012. Other actions include the inclusion in social safety nets, such as family allowances and housing programs, and the construction of inclusive policies. The latter is especially important as the development of inclusive policies helps promote economic opportunities for the poor.
Both in Uruguay and Peru, contextual implementation was key, yet in each case, and elsewhere in the Region, integrating different institutional sectors into an overall strategy has allowed policymakers to create all-encompassing strategies to combat poverty in novel and effective manners.
As the Region transitions from the MDGs into the new 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs), addressing health inequities must be seen as priority. It is important to benefit from the lessons learned and address unfinished business through the new development agenda (). This new Agenda is the product of an unprecedented inclusive and collaborative process and is unique in that it integrates all three dimensions of sustainable development (economic, social, and environmental) around people, the planet, prosperity, peace, and partnership. The targets set by the SDGs seek to go beyond the scope of MDGs while addressing the most important social, economic, environmental, and governance challenges of our time. The SDGs recognize that the eradication of poverty and inequality, the creation of inclusive economic growth, and the preservation of the planet are linked to each other and to the overall health and well-being of the world’s population (). The implementation of the SDGs provides a unique opportunity to address the “causes of the causes” and shape health outcomes through a stronger focus on the differential distribution in access to health services. Whereas traditional approaches to public health and health promotion addressing risk factors centered around individual “risky” behavior remain relevant, increasingly (regionally and globally) attention is shifting to examine macroscale processes involving trade, global markets, and geopolitical relationships as determinants of health (). Surveillance systems will need to be enhanced for the wider social monitoring of the goals of SDH, the SDGs, and HiAP.
The Strategy for Universal Access to Health and Universal Health Coverage constitutes a call for action, for the health sector to progressively expand integrated quality health services, and beyond the health sector, in the implementation of health policies, plans, and programs that are equitable and efficient and that respect the differentiated needs of the population. Health is a key component of sustainable human development, and universal access to health and universal health coverage are essential for the achievement of better health outcomes in order to ensure healthy life and promote the well-being of all.
As countries continue to develop people-centered, robust, and resilient health systems, efforts must continue to intensify intersectoral action focusing on areas outside of the health sector to improve equity, health, and well-being, in accordance with the 2030 Agenda, for Sustainable Development and the Sustainable Development Goals and the SDGs. The breadth and ambition of the 2030 Agenda for Sustainable Development, and the interlinked nature of the 17 SDGs, require a national, regional, and global response that harnesses cooperative action across sectors. From the education of women and girls to taxation of nonnutritious foods, from healthy living spaces to health financing, universal health will only be achieved through a concerted effort to address the social determinants of health, and the development of key strategic partnerships involving actors well outside of the health sector.
21. Blas E, Ataguba JE, Huda TM, Bao GK, Rasella D, Gerecke M. The feasibility of measuring and monitoring social determinants of health and the relevance for policy and programme – a qualitative assessment of four countries. Global Health Action 2016;9:29002.
28. Kutluk T. The UN General Assembly (UNGA) High-Level Meeting on the Comprehensive Review and Assessment of the Progress Achieved in the Prevention and Control of Non-communicable Diseases: Mr Tezer Kutluk -opening remarks. Geneva: The NCD Alliance; 2014.
29. Moodie R, Stuckler D, Monteiro C, Sheron N, Neal B, Thamarangsi T, et al. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. The Lancet 2013;381(9867):670–679.
31. Escamilla-Cejudo JA, Sanhueza A, Legetic B. The burden of noncommunicable diseases in the Americas and the social determinants of health. In: DCP3 Disease Control Priorities. Section 2: socioeconomic dimensions of the impact of NCD. 3rd ed. Seattle: Disease Control Priorities Network; 2013:13–22.
32. Mielke G, Brown W, Nunes B, Silva I, Hallal P. Socioeconomic correlates of sedentary behavior in adolescents: systematic review and meta-analysis. Sports Medicine 2017;47(1):61–75.
33. Lang T, Rayner G. Beyond the golden era of public health: charting a path from sanitarianism to ecological public health. Public Health 2015;129(10):1369–1382.
34. Allen J, Balfour R, Bell R, Marmot M. Social determinants of mental health. International Review of Psychiatry 2014;26(4):392–407.
38. Patel V, Lund C, Hatheril S, Plagerson S, Corrigall J, Funk M, et al. Mental disorders: equity and social determinants. In: Blas E, Kurup AS, eds. Equity, social determinants and public health programmes. Geneva: WHO; 2010:115–134.
39. Lemstra M, Neudorf C, D’Arcy C, Kunst A, Warren LM, Bennett NR. A systematic review of depressed mood and anxiety by SES in youth aged 10–15 years. Canadian Journal of Public Health 2008;9:125–129.
40. Campion J, Bhugra D, Bailey S, Marmot M. Inequality and mental disorders: opportunities for action. The Lancet 2013;382(9888):183–184.
41. Melzer D, Fryers T, Jenkins R, Brugha T, McWilliams B. Social position and the common mental disorders with disability: estimates from the National Psychiatric Survey of Great Britain. Social Psychiatry and PsychiatricEpidemiology 2003;38(5):238–243.
42. Patel V, Kleinman A. Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization 2003;81(8):609–615.
43. Karsten IP, Klaus M. Unemployment impairs mental health: meta-analyses. Journal of Vocational Behavior 2009;74(3):264–282.
44. Fryers T, Melzer D, Jenkins R, Brugha T. The distribution of the common mental disorders: social inequalities in Europe. Journal of Public Mental Health 2005;1:14.
45. Seedat S, Scott KM, Angermeyer MC, Berglund P, Bromet EJ, Brugha TS, et al. Cross-national associations between gender and mental disorders in the WHO World Mental Health Surveys. Archives of General Psychiatry 2009;66(7):785–795.
46. Vlassof C. Gender differences in determinants and consequences of health and illness. Journal of Health Popular Nutrition 2007;25(1):47–61.
47. Crosby AE, Han B, Ortega LAG, Parks SE, Gfroerer J. Suicidal thoughts and behaviors among adults aged ≥18 years—United States, 2008–2009. Morbidity and Mortality Weekly Report Surveillance Summaries 2011;60(13):1–22.
48. Green CA. Gender and use of substance abuse treatment services. Alcohol Research and Health 2006;29(1):55–62.
49. Harris CR, Jenkins M. Gender differences in risk assessment: why do women take fewer risks than men? Judgment and Decision Making 2006;1:48–63.
50. Cánepa C, Briones J, Pérez C, Vera A, Juárez A. Desequilibrio esfuerzo-recompensa y estado de malestar mental en trabajadores de servicios de salud en Chile. Ciencia & Trabajo 2008;10(30):157–160.
51. Guic E, Mora P, Rey R, Robles A. Estrés organizacional y salud en funcionarios de centros de atención primaria de una comuna de Santiago. Revista Medica de Chile 2006;134(4):447–455.
52. Ansoleaga E, Garrido P, Lucero C, Martínez C, Tomicic A, Dominguez C, et al. Patología mental de origen laboral: guía de orientación para el reintegro al trabajo. Santiago de Chile: Universidad Diego Portales; 2013.
54. Pan American Health Organization. Regional strategy on health promotion and well-being, 2016–2019: renewed health promotion in the Americas, 30 years after the Ottawa Charter. Washington, D.C.: PAHO; 2016.
55. World Health Organization. The Helsinki Statement on Health in All Policies. 8th Global Conference on Health Promotion, 2013 June 10–14, Helsinki, Finland. Geneva: WHO; 2013.
56. Pan American Health Organization. Concept note: implementing the Pan American Health Organization’s Regional Plan of Action on Health in All Policies (HiAP). Washington, D.C.: PAHO; 2015.
58. Pan American Health Organization. Plan of action on Health in All Policies. 53rd Directing Council of PAHO, 66th Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2014 Sept. 29–Oct. 3 (Document CD53/10, Rev. 1 and Resolution CD53.R2). Available from: https://www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=26797&Itemid=270&lang=en and https://www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=27549&Itemid=270&lang=en.
63. Bambra C, Fox D, Scott-Samuel A. Towards a politics of health promotion. Health Promotion International 2005;20(2):187–193.
64. World Health Organization. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: WHO; 2008. Available from: whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf.
66. Kickbusch I, Allen L, Franz C. The commercial determinants of health. The Lancet Global Health 2016; 4(12):e895–e896.
67. Latinovic L, Rodriguez-Caberera L. Public health strategy against overweight and obesity in Mexico’s National Agreement for Nutritional Health. International Journal of Obesity Supplements 2013;3:S12–S14.
72. Gostin LO, Friedman EA, Buss P, Chowdhury M, Grover A, Heywood M, et al. The next WHO Director-General’s highest priority: a global treaty on the human right to health. The Lancet Global Health 2016;4(12):e890–e892.
75. Kickbusch I. Global health governance challenges 2016 – are we ready? International Journal Health Policy Management 2016;5(6):349–353.
76. Hosseinpoor AR, Bergen N, Kunst A, Guthold R, Rekve D, d’Espaignet ET, et al. Socioeconomic inequalities in risk factors for non-communicable diseases in low-income and middle-income countries: results from the World Health Survey. BMC Public Health 2012;12:912.
82. Organization for Economic Co-operation and Development. Paris declaration on aid effectiveness: ownership, harmonization, alignment, results and mutual accountability. Paris: OECD; 2005. Available from: http://www.oecd.org/dac/effectiveness/34428351.pdf.