Between 2010 and 2014, new reported cases of leprosy in Latin America and the Caribbean declined from 37,571 to 33,789 (), a 10.1% reduction. Brazil reported 31,064 new cases in 2014, accounting for 91.9% of the new cases reported in the Region. In the same time period, the prevalence lowered from 0.38 per 10,000 inhabitants in 2010 to 0.33 in 2014, a 13.2% reduction. By 2014, all countries of the Region had reached the national goal of elimination of leprosy as a public health problem (<1 case per 10,000 inhabitants), with the exception of Brazil (1.27), while at the first subnational administrative level, seven countries had yet to reach the goal (Argentina, Bolivia, Dominican Republic, Guyana, Paraguay, Suriname, and Venezuela). During the same 5-year period, 18 countries and territories did not report any cases of leprosy, 17 countries and territories reported less than 100 new cases, and 10 countries reported 100 or more new cases.
In 2014, the rate of new cases with grade 2 disability at diagnosis in Latin America and the Caribbean was 3.59 per million population. WHO has established a global target of less than 1 per million population to be reached by 2020 (). Thus, efforts must continue by focusing on achieving leprosy elimination at the national level in Brazil, and at the first subnational administrative level in the seven countries where this goal has yet to be achieved. Preventing disability, through early case detection and treatment, and eliminating stigma and discrimination of patients and families affected by leprosy are also regional targets in line with the goals of WHO’s Global Leprosy Strategy 2016-2020 () to further reduce the burden of leprosy at the global and local level.
Tuberculosis in the Americas
The Region of the Americas was the first of the WHO regions to meet the Millennium Development Goal (MDG) targets related to tuberculosis (TB)—namely, reduction of incidence and reduction of prevalence and mortality by 50% between 1990 and 2015 (). However, progress in the detection and reporting of new TB cases, multidrug-resistant TB (MDR-TB), and TB/HIV coinfection has been slow. As a result, tuberculosis remains a serious public health problem in the Americas.
WHO estimated 268,500 new TB cases in the Americas in 2015, corresponding to an incidence rate of 27.1 cases per 100,000 population. Of the total estimated cases, 92% were concentrated in 12 countries (Table 1). TB cases actually diagnosed and reported that year came to 218,700, for an incidence rate of 22.1 cases per 100,000 (Figure 1). Between 2000 and 2015, TB incidence declined at a rate of 1.8% a year. In 2015, case detection reached 81.5% of the estimated total, up from 76.6% in 2000. However, these results show that 50,000 new patients failed to be diagnosed or reported. This gap may be largely attributed to shortcomings that have affected the response capacity of national TB control programs and health systems. Nevertheless, mortality during the same period, according to WHO estimates, fell from 4.3 to 2.5 deaths per 100,000 population, for a case-fatality rate of 9% in 2015 ().
Table 1. Countries accounting for more than 90% of incident cases of tuberculosis, Region of the Americas, 2015 (estimated figures)
Source: World Health Organization. Global tuberculosis report 2016().
Figure 1. Estimated and reported incidence of all forms of tuberculosis, Region of the Americas, 2000-2015
Source: World Health Organization. Global tuberculosis report 2016().
In the Americas, one of the greatest risk factors for the development of TB and death from the disease continues to be HIV infection; 82% of the incident TB cases were subjected to an HIV test in 2015. Of these patients, 12% were coinfected. According to WHO estimates, 9,700 TB/HIV cases were not detected. The coverage of antiretroviral therapy (ART) was 55%. These gaps may be attributed to insufficient implementation of TB/HIV collaborative activities in most of the countries, and to the continuing integration of TB and HIV care into the different levels of health systems.
Detection and early treatment of MDR-TB cases has improved. However, in 2015, surveillance of drug resistance to first-line drugs in notified cases only reached 29% among new TB cases and 45% among previously treated cases. That same year, 4,508 cases of MDR-TB were reported, representing 55.6% of the estimated pulmonary TB cases. This is due to the limited capacity and equipment of laboratories to provide timely and quality diagnosis. The slow implementation of new diagnostic molecular tests such as Xpert®/MTB/Rif and line probe assays (LPAs) contributes to the low resistance diagnosis ().
Differential analyses of cohorts of new TB cases of all forms and of new TB/HIV cases reported in 2014 showed treatment success rates of 76% and 56%, respectively (Figure 2). The treatment success rate for MDR-TB reported in 2013 was 55%. These results denote shortcomings in the application of patient-centered treatment, coupled with a low supply of ART for HIV-infected cases, which explains 19% of deaths in this cohort.
Figure 2. Treatment cohorts: new cases of all forms of tuberculosis and new cases of TB/HIV coinfection, Region of the Americas, 2005, 2010, and 2014
Note: New cases: previously untreated patients and patients with relapses. Source: World Health Organization. Global tuberculosis report 2016 ().
Tuberculosis control in the Americas faces new challenges from () the demographic changes taking place in the Region, including rapid urban growth, aging of the population, and migration (especially between countries in Latin America) (), and () the epidemiological transition, with an increase in noncommunicable diseases such as diabetes mellitus, smoking, alcoholism, and consumption of drugs and illicit substances (). All these factors increase the likelihood of M. tuberculosis transmission in the community and development of the disease in previously infected individuals.
It is well known that tuberculosis is closely associated with the socioeconomic factors that contribute to increased inequity and inequalities (). For example, TB prevalence is high among poor populations of ethnic minorities (e.g., African descendants, indigenous people, and migrants), prisoners, people living in the street, and others that live in low-income and marginalized areas of large cities in the Region of the Americas. Settlements of this kind in cities like Lima and Montevideo may account for as much as 60% of TB cases in the entire country.
The age distribution of TB (Figure 3) shows the persistence of active M. tuberculosis transmission in the younger age brackets. It also shows an increase in TB incidence among older adults, probably due to past TB infections and the increased life expectancy of the population.
Figure 3. TB incidence by age group and sex, Region of the Americas, 2015
Source: World Health Organization. Global tuberculosis report 2016().
Noncommunicable diseases, such as diabetes mellitus, are also a significant challenge for TB control, now and in the future. A study of the TB disease burden attributable to diabetes in the adult population of the Region showed that this disease accounted for 16.8% of TB incidence in the Region in 2013 (). Therefore, TB control should include interprogrammatic collaboration with diabetes control and other public health programs, depending on the predominant risk factors in the countries.
To control TB effectively, countries must have adequate financial resources for the purpose. In 2016, WHO received financial information for the period 2012–2016 from 26 low- and medium-income countries in the Region. They estimated that the total funding needed to control TB in the 26 countries in 2016 was US$ 496 million. Of this amount, 37% could be expected to come from domestic resources and 42% from international cooperation, leaving a funding gap of 21%, or US$ 104 million (). This assessment shows that a number of countries still depend on external resources and have large funding gaps. It is therefore essential to call for increased national political commitment that translates into financial resources for the prevention and control of this disease.
In light of these current challenges and the ongoing process of implementing the current End TB strategy initiated in 2016 (), PAHO, working jointly with national TB control programs, intends to step up its actions to support: () timely and rapid diagnosis of TB, MDR-TB, and TB/HIV coinfection; () patient-centered treatment; and () introduction of new initiatives, such as TB control in large cities (), elimination of TB as a public health problem, and TB control in migrant populations and ethnic minorities.
The framework for TB control in large cities has the following eight components: strengthening of national/local political commitment; epidemiological mapping of the TB situation; surveying and mapping of the health system and existing health care providers; adapting health care to the needs of at-risk populations; incorporating an interprogrammatic approach to TB control; having an intersectoral approach and including TB in social protection programs; promoting the engagement of civil society; and establishing systems for monitoring and evaluation. Implementation began in 2013 in three pilot cities in Brazil, Colombia, and Peru, and since 2014, the initiative has expanded to include more cities in other countries.
3. World Health Organization, Regional Office for South-East Asia. Global leprosy strategy 2016–2020: accelerating towards a leprosy-free world. New Delhi: WHO; 2016. Available from: http://apps.searo.who.int/PDS_DOCS/B5233.pdf.
8. Toru M, Chi Chiu L. Tuberculosis in the global aging population. Infectious Disease Clinics of North America 2010;24(3):751–768.
9. Creswell J, Raviglione M, Ottmani S, Migliori GB, Uplekar M, Blanc L, et al. Tuberculosis and noncommunicable diseases: neglected links and missed opportunities. European Respiratory Journal 2011;37(5):1269–1282.
10. Rasanathan K, Sivasankara Kurup A, Jaramillo E, Lönnroth K. The social determinants of health: key to global tuberculosis control. International Journal of Tuberculosis and Lung Diseases 2011;15(Suppl 2):S30–S36.
11. Munayco CV, Mújica O, León FX, del Granado M, Espinal MA. Social determinants and inequalities in tuberculosis incidence in Latin America and the Caribbean. Revista Panamericana de Salud Pública 2015;38(3):177–185.
12. Munayco CV, Mujica O, del Granado M, Barceló A. Carga de enfermedad tuberculosa atribuible a diabetes en población adulta de las Américas. Revista Panamericana de Salud Pública. In press.
14. United Nations General Assembly. Transforming our world: the 2030 Agenda for Sustainable Development, 21 October 2015. Resolution adopted by the General Assembly on 25 September 2015 (70/1). Available from: http://www.ipu.org/splz-e/unga16/2030-e.pdf.
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) ().
The Region of the Americas has made substantial progress over the past decade in achieving health-specific goals related to maternal and child mortality, reproductive health, infectious diseases, and undernutrition. Socioeconomic development, environmental factors, the relative strength and resilience of health systems, and improved access to health services have been instrumental in these achievements (). However, advances at the national level continue to obscure disparities among certain subpopulations. The slow progress in closing gaps resulting from avoidable inequalities continues to negatively affect the balanced distribution of those advances (). For example, scaling up evidence-based interventions to fight communicable diseases (CDs) and improving maternal and child health is necessary but not sufficient to resolve health disparities across different populations. Progress, while ongoing, has been nonlinear, and potential social, economic, environmental, and public health crises threaten to reverse the fragile gains.
The Region also faces new challenges from emerging and reemerging infectious diseases that adversely affect communities, families, economies, and health systems and services. Lessons learned from past emergencies (i.e., the 2009 influenza pandemic) have resulted in greater preparedness and increased awareness of the need to strengthen surveillance (). Yet, in other cases, such as the dengue, Zika, and chikungunya epidemics, important challenges remain that will require a coordinated, multisectoral, integrated response.
Achieving the goals of the 2030 Sustainable Development Agenda requires more integrated and collaborative approaches to address inequities in the Region across the social, environmental, and economic dimensions of development, including a clear intergenerational vision. Health systems must adopt a more decisive role in efforts to increase equity and sustainable development, ensuring effective coverage and quality of health services and interventions, and, most importantly, contributing to build coherence and synergy of actions across different sectors, both nationally and locally.
In recent decades, the patterns of disease in the Region of the Americas have shifted, with an overall decrease in both the communicable disease (CD) burden and maternal and child deaths linked mainly to disease control, an aging population, increased political will, and improvements in socioeconomic conditions (). Over the past two decades, in all countries in the Region, CDs and maternal, neonatal, and nutritional diseases have dropped below noncommunicable diseases (NCDs) and injuries as causes of years of healthy life lost (disability-adjusted life years). Progress in decreasing mortality over the past decade has been greatest in Latin America and the Caribbean (LAC), with reductions of more than 30% in the Dominican Republic, Guatemala, Haiti, Honduras, Mexico, and Nicaragua (). However, significant disease burdens persist in some countries, such as Bolivia, Haiti, Guatemala, Guyana, and Peru, where more than 20% of deaths are estimated to be related to CDs and maternal, neonatal, and nutritional diseases ().
Sustained long-term economic development with improvements in public sanitation, housing, nutrition, and health care over the past decade has driven a transition in health outcomes (). Despite this progress, the persistence of specific CDs as well as preventable maternal and child illnesses hinders the well-being, social cohesion, and development of some populations in the Region. These conditions are markers of inequities related to gaps in socioeconomic development.
The Millennium Development Goals (MDGs) for 2000–2015 helped mobilize political will and address health development and equity challenges, and the Sustainable Development Goals (SDGs) (2016–2030) are building on that momentum (). This section covers health-related goals of the MDG agenda—maternal and child mortality, reproductive health, infectious diseases, and undernutrition—focusing on current challenges in public health policy and action, including control and/or elimination of CDs within the context of changing health outcomes, persisting inequities, and a re-strategized approach to sustaining gains while leaving no one behind.
Diseases are not limited by geopolitical boundaries and thus can spread quickly across borders through international travel and trade, with a single health crisis in one country potentially affecting the economies and livelihoods of the entire international community. In the Americas, there are a wide variety of settings and unique scenarios that may contribute to the emergence of infectious hazards events such as populated urban centers affected by multiple natural disasters, and remote rural areas lacking access to drinking water and sanitation, where close contact between humans and animals is common. Risk of CDs in the Region is also affected by environmental pressures associated with, among other events, rapid urbanization and climate change. For example, the emergence and spread of arboviruses depends on the presence and abundance of vectors, which is in turn related to various social, economic, and environmental factors (). The macrodeterminants that influence the onset of these diseases are compounded by climate change effects, which impact the intensity and duration of rainy seasons and hurricanes, give rise to intense droughts, and alter biodiversity (). Persisting poverty and social inequities also impede sustainable, equitable progress in the control of CDs.
Of all human pathogens worldwide, 61% are classified as zoonoses and account for 75% of all emerging pathogens in the past decade (). A study analyzing the importance of zoonoses and CDs common to man and animals as potential public health emergencies of international concern (PHEIC) reported that 70% of recorded PHEIC in the Region were within the animal/human health interface. Of these, 25% were food safety events (). These results underscore the importance of the animal/human health interface and intersectoral collaboration. Several zoonotic diseases, such as influenza and leptospirosis, are listed as top 10 infectious hazards in the Americas in the WHO Event Management System (EMS) (). Plague, another zoonotic disease, is one of the few diseases requiring notification under IHR 2005, even though there are no current plague outbreaks in the Region ().
Other challenges in controlling CDs in the Region are related to changes in demographics and lifestyle and issues such as availability of treatments and drug resistance. For example, multiple chronic infectious diseases have increased with aging populations. Antimicrobial, antifungal, antiparasitic, and antiviral drug resistance has emerged as a factor with high economic impact in the annual global gross domestic product (GDP), which could fall between 1.1% to 3.8% in 2050 (depending on estimated levels of antimicrobial resistance), according to a World Bank report (). Drug resistance may jeopardize efforts to eliminate malaria, tuberculosis (TB), and HIV and would thus have a direct impact on the lethality of these diseases (). Preventing the spread of resistant infections and slowing the emergence of resistance overall is critical in the Region.
Among the groups at highest risk of contracting infectious diseases are people with inadequate access to water and sanitation and those who live below the global poverty line (), particularly pregnant women, children, and immunosuppressed patients. Some populations may also face barriers in access to prevention and control services due to stigma and discrimination based on their behaviors, sexual orientation, or ethnicity that can be compounded by legal frameworks and cultural and religious beliefs.
While the circulation of many established pathogens in the Americas has decreased, both new and traditional infectious diseases, such as Zika virus (ZIKV), chikungunya virus (CHIKV), dengue virus (DENV), plague, cholera, yellow fever virus (YFV), and leptospirosis, periodically emerge or reemerge. This poses challenges to health systems that lead, in some cases, to competing political, social, and technical perspectives, the absence of an organized and efficient public health strategy.
Disease emergence or reemergence is related to social, political, and economic factors that have resulted in increased movement among the population, increased pressure on the environment, and environmental changes, as well as disparities across different social groups related to a lack of health service capacity in disease detection, prevention, and control (). Prevention and management of emerging diseases is a major health concern in the Region. Acute outbreaks of DENV, CHIKV, and ZIKV have increased the pressure on health systems, highlighting their structural weaknesses and the shortcomings of fragmented approaches to public health emergencies. In addition, the Region faces outbreaks of reemerging diseases such as yellow fever, cholera, and plague, which can cause devastating epidemics. These outbreaks pose a threat to public health security and can undermine socioeconomic progress.
Some of the more important Regional challenges in communicable disease control—foodborne diseases (FBDs), health care–associated infections (HAIs), arboviruses, influenza, plague, leptospirosis, and cholera—are described below.
Foodborne diseases (infections and intoxications)
Foodborne diseases can be defined as conditions commonly transmitted through ingested food and comprise a broad group of illnesses caused by enteric pathogens, parasites, chemical contaminants, and biotoxins. FBDs reduce societal productivity, impose substantial stress on the health care system, and reduce economic output by adversely affecting tourism, food production, and access to domestic and export markets. In the Caribbean, acute gastrointestinal illness associated with contaminated food (which has an annual incidence of 0.65–1.4 cases/person) has an estimated cost of US$ 700,000–US$ 19 million per year (). The U.S. Centers for Disease Control and Prevention (CDC) estimates that each year about 1 in 6 people in the United States gets sick, 128,000 are hospitalized, and 3,000 die of FBDs, at a total cost of US$ 77.7 billion ().
Socioeconomic determinants lead to different levels of exposure and vulnerability to FBDs (). Poverty, education, ethnicity, gender, demographic factors, living and working conditions, and trade are structural determinants of food safety and different modes of food production, handling, and consumption. For example, ethnicity is often structurally linked to inequity, leading to conditions prejudicial to food security and safety. Brucellosis due to the consumption of raw milk or raw milk products such as cheese occurs more frequently among indigenous populations (). Female literacy rates and education are also important factors in access to food and food safety ().
Health care–associated infections
Health care–associated infections (HAIs) are linked to significant morbidity and mortality and pose a major problem for hospitals and other health care delivery settings throughout the world. Estimating HAI incidence Region-wide is challenging, but some countries have national surveillance systems that include hospital-acquired infections (). In 2014, the United States reported more than 700,000 HAIs and 75,000 deaths in patients with HAIs ().
The economic impact of HAIs is substantial. The costs of treating a bloodstream infection in the United States can be high as US$ 45,000 (). Data from Latin American countries indicate that treatment of HAIs accounts for 15%–35% of operational costs for critical care units ().
Implementing infection prevention and control programs, which include surveillance and targeted strategies at the hospital level, can prevent 55%–70% of HAIs (). Although the main prevention strategies are not resource-intensive, many countries do not have HAI control programs at the national and hospital level (), and implementation of the programs in countries where they do exist remains a challenge. For example, hand-hygiene campaigns at health care facilities showed implementation rates of about 50% ().
In the Americas, the changing population demographics, increasing number of patients with comorbidities and chronic treatments, development of antimicrobial resistance, and more complex medical care aggravate the challenge posed by HAIs.
Despite vector control efforts, in recent years the prevalence of viral infections transmitted by arthropods has increased worldwide (). Emerging epidemics in the Americas from new arboviruses such as CHIKV and ZIKV and already endemic viruses such as DENV and the reemergence of YFV reflect important changes in patterns of disease (, ). A recent example was the PHEIC declared in February 2016 in response to the increasing numbers of ZIKV-associated neurological syndromes ().
The characteristics that make these epidemics complex issues for prevention and control include the following: (1) vectors’ adaptation to new habitats, use of unusual breeding sites (e.g., sewers and septic tanks), and expansion to new geographic areas or areas where they had been eliminated (e.g., the reinfestation of Aedes aegypti in continental Chile); (2) virus spread in densely populated areas in the Region; and (3) the simultaneous circulation of closely related pathogens and new clinical manifestations. All of these factors contribute to the increase in virulence and pathogenicity of arboviruses in the Americas.
The association between congenital ZIKV infection and birth defects, including microcephaly, has prompted concern among health officials and the public, highlighting the need to address the issue from both a human rights and reproductive health perspective. The report of congenital syndromes has demonstrated gaps in the proportion and number of cases reported by each country, mostly due to differences in surveillance systems. Therefore, standardized methodologies should be implemented.
The epidemiologic status of arboviruses in the Region is complex. DENV control efforts have decreased fatality rates, but incidence and morbidity are on the rise. For example, in 2015, DENV case fatality decreased by 23% compared to 2012, but incidence increased by 44% over the same period (). In December 2013, after autochthonous transmission of CHIKV in Saint Martin (French territory) was confirmed, the virus spread rapidly from that focal point to the northern coast of South and Central America. In 2015, transmission of CHIKV was documented in 44 countries and territories in the Region. Similarly, the dissemination of ZIKV has rapidly disseminated following the first detection of the virus in northeast Brazil in May 2015 (). By 2016, the virus had been confirmed in 40 countries and territories in the Region (). The new patterns of arboviral disease, including the emergence of ZIKV and its cocirculation with other arboviruses in areas where only DENV had been documented, highlight the need for more research on the pathogenesis and clinical and epidemiological behavior of these viruses in new habitats.
Emerging and reemerging epidemics are causing an overload on health systems, affecting families and communities. Challenges include difficulties in clinical and laboratory diagnosis as well as surveillance (). These epidemics also increase the pressure on social infrastructures in affected countries and territories. Chronic disease manifestations or sequels can affect the productivity of the population as well as individual and national incomes. Congenital health problems in newborns related to virus infections can result in the need for long-term care and family and community support. Although some research has been conducted (, ), the economic and social impact of arbovirus infections has not been fully estimated.
The response to arbovirus epidemics requires a multisectoral approach. Responses limited to the health sector increase the risk of higher-cost outcomes with less social impact and more inequity. The promotion of an integrated approach for arboviral disease surveillance, prevention, and control should therefore be a priority.
Influenza is estimated to cause about 80,000 deaths annually in the Americas (). In 2013–2015, there were tremendous gains in the Region related to the surveillance of influenza. There are currently more than 100 hospitals in the Americas conducting influenza surveillance according to global standards and 28 national laboratories carrying out virologic surveillance. These hospitals and laboratories, working with their ministries of health, international partners, and PAHO/WHO, developed a Regional influenza network, SARInet, which was formally established in 2014. This type of Regional collaboration allows for the sharing of experiences, lessons learned, and resources and has created a structure to respond to questions of public health importance, such as the burden of influenza-associated hospitalizations.
Groups at higher risk for adverse outcomes from influenza infection include children, the elderly, pregnant women, and persons with specific coexisting conditions. It is recommended that these groups receive the influenza vaccine and early antiviral therapy (e.g., oseltamivir) in order to decrease their risk of prolonged hospitalization and death (). Trends in the early use of antiviral therapy are difficult to monitor due to untraceable purchases of antiviral products without a prescription, but increased use of the influenza vaccine in the last 5 years has been reported. In 2014, 40 countries and territories in the Americas used the vaccine, and 12 of them (29%) targeted pregnant women in their coverage (compared to seven countries/territories in 2008). Among the 23 countries reporting coverage data, on average, 75% of adults ≥60 years, 45% of children aged 6–23 months, 32% of children aged 2–5 years, 59% of pregnant women, 78% of health care workers, and 90% of individuals with chronic conditions were vaccinated during the 2013–2014 vaccination campaigns (). Estimates based on 2013 surveillance data from LAC suggest that the vaccine was 52% effective in preventing medically attended severe influenza infection ().
There is much more to be done, especially in strengthening influenza surveillance at the human-animal interface, developing estimates of the burden of influenza-associated hospitalizations, strengthening the rapid response capacity, and gaining a better understanding of the barriers to access to vaccination among various population groups. Targeting these aspects of the work plan requires a multisectoral approach and open communication and data sharing among partners.
Plague persists in the Americas, with endemic foci in Bolivia, Brazil, Ecuador, Peru, and the United States (). Since 2009, small outbreaks and occasional human deaths have occurred, including in hospital settings. Notification of pneumonic plague is mandatory under the IHR (). Plague’s epidemiology is highly entangled with the ecology of its vectors and reservoirs, which are influenced by climatic, ecological, and social changes that have contributed to its resurgence.
The Andean region population has the highest risk of ecological and climatic changes derived from the El Niño Southern Oscillation (ENSO). The effects of ENSO have been associated with plague reemergence in the past (1992 and 1998). High-risk populations include those living in semiarid areas surrounded by a rural agricultural (intensive or extensive/traditional) landscape, where interface with the sylvatic cycle of the plague reservoir may be ubiquitous. Local housing conditions can also increase the risk of plague; isolated households in maize or sugarcane production areas, with adobe homes that have soil floors, high intrahousehold human density, and store agricultural products inadequately, are most at risk.
Estimates suggest that in the Americas, over the last decade there have been more than 100,000 cases of leptospirosis, causing 5,000 deaths annually. Consequently, leptospirosis has garnered more attention, mostly during outbreaks (). However, the disease remains under-reported due to nonspecific symptoms that mimic those of DENV, malaria, and influenza, and because it requires laboratory confirmation (). The diversity of leptospirosis’ animal carriers creates additional challenges for prevention and control.
Studies have identified environmental drivers of leptospirosis, such as heavy rains or floods, frequently related to outbreaks with a higher number of cases (). Alkaline and neutral soil types facilitate the survival and persistence of the bacteria (). Socioeconomic drivers include living in dense urban or peri-urban areas with inadequate waste collection and sanitation, lack of potable water, and poor housing conditions (). As an occupational disease, leptospirosis affects rice workers, animal handlers, sewer workers, and gold miners (). Rural workers who acquire leptospirosis in areas with limited access to health services may not be able to return to their jobs and some may even die. Severe leptospirosis cases may lead to renal failure that requires hemodialysis (). If this complex and costly procedure is not available, the chances of patient recovery are low.
Cholera is still present in the Americas. In 2010–2016, cholera was reported in Cuba, the Dominican Republic, Haiti, and Mexico. In Haiti, Vibrio cholerae O1 has persisted since 2010 and epidemiological peaks have been observed during rainy periods due to the increased water runoff feeding the endemic transmission, which is maintained through movement of the population and inadequate hygiene practices. The oral cholera vaccine was introduced in Haiti in 2015, and approximately 373,000 persons were vaccinated. However, on 4 October 2016, Hurricane Matthew struck the departments of Grand Anse and Sud, generating more cases than normally expected for the season. Water and sanitation infrastructure is limited in the country and was destroyed in the southern peninsula by the hurricane. Total sanitation coverage in Haiti remains low (28% in 2015); in 2012, in the poorest population quintile, 90% were still practicing open-air defecation (). Drinking water coverage in Haiti declined in urban settings over the period 1990–2015, despite a national increase of 2%; in 2012, in the poorest population quintile, only 1% had access to improved water sources. Water treatment centers in urban settings in Haiti need to improve their performance in water chlorination and routinely measure fecal coliforms and residual chlorine in drinking water. In rural settings, sustainable local water chlorination strategies still need to be devised. Without adequate investment in sewage discharge infrastructure, improvements in the current endemic cholera situation in Haiti will be slow. The Dominican Republic and Cuba reported cholera cases related to Haiti’s outbreaks. Differences in health service infrastructure, sanitation conditions, and access to safe water help explain patterns in cholera spread across the three countries. Mexico also suffered a cholera outbreak related to the Haitian strain between 2012 and 2014 ().
Disease elimination and eradication are the ultimate goals of public health. The successful eradication and/or elimination of diseases such as smallpox (1971), polio (1994), rubella (2015), and measles (2016) and significant progress in the control of many infectious diseases have prompted global and Regional target-setting, collective decision-making, and action towards elimination of goals with regard to many diseases.
Nevertheless, the costly up-front investments required to eliminate diseases and the risk of failure are cause for concern. The benefits of disease elimination include the positive return on the investment in most cases, ending important causes of disability and death, improved results in health service delivery, and closing the equity gap (). Lessons learned from previous elimination successes show that the societal and political commitment of countries is key to maintaining efforts to achieve elimination (). To support the elimination agenda, countries need to move beyond a perspective based solely on cost-effectiveness. Disease elimination requires political commitment, a human-rights- and gender-based approach, and a strategy that addresses structural and social determinants, focusing on the most excluded and vulnerable populations.
With regard to HIV, 2016 was a turning point. The Americas, which has an estimated 3.4 million people living with HIV, is moving toward ending the AIDS epidemic by 2030, as marked by the 2016 United Nations General Assembly (UNGA) High-Level Meeting on Ending AIDS, held in New York, where heads of state from member countries endorsed the Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track strategy to end the AIDS epidemic by 2030 (). This is an important challenge given that an estimated 25% of people with HIV in LAC do not know their serostatus and a 55% were receiving antiretroviral treatment (ART) in 2015 ().
LAC countries have the highest level of ART coverage of all low- and middle-income countries (LMICs) and have achieved a remarkable reduction in new infections in children (a 55% decrease since 2010). However, challenges remain in curtailing new infections, and an effective response is complex given the nature of the epidemic. In 2015, LAC experienced a decreasing trend in HIV deaths and new infections compared to 2005 (a 32% versus 10% decrease respectively). However, the rate of reduction in new infections slowed after 2010, and has begun to increase in the past 2 years. The burden of HIV is not equally distributed and key populations in the Americas, such as gay men and other men who have sex with men (MSM), transgender women, and sex workers, are disproportionately affected compared to the general population. Key populations also include prison inmates, certain ethnic groups (e.g., the Honduran Garifuna population and Canadian Aboriginal people), the homeless, non-injecting drug users, and young women in the Caribbean. These high-risk groups are increasingly vulnerable and often driven underground due to various factors including stigma and discrimination in their communities and at health service facilities (). Stigma and discrimination can lead to delayed care-seeking. In 2015, almost one-third of newly diagnosed HIV cases accessed care with a highly compromised immune system ().
The HIV epidemic uncovers social inequities, stigma and discrimination and poses challenges to health systems. Stigmatization of same-sex relationships and sex work hinders access to HIV prevention services and leads to an increase in risky behaviors (). Homophobia drives MSM away from HIV testing and prevention activities and is associated with lower adherence to treatment. Women in key populations face stigma and discrimination in various forms, including violence and violations of their human rights ().
Ending AIDS by 2030, to meet the goals of the Sustainable Development Agenda, will require increased financial investment to expand services and improve the prevention response. UNAIDS has estimated that US$ 3.05 billion was allocated to finance the response to HIV in 2014 in LMICs in the Region, with 87% of that amount coming from domestic (in-country) resources. The Americas region is a global leader in terms of supporting the HIV response with domestic funds, although one-third of countries depend on external donors for much (more than 40%) of their response (particularly Haiti, Bolivia, and the Dominican Republic). Other requirements for meeting Agenda goals include (1) the decentralization of services, to support the expansion of HIV testing and treatment for all; (2) the implementation of models for delivery of prevention services, with a focus on the most vulnerable populations, and those at highest risk; and (3) the elimination of stigma and discrimination, including the elimination of punitive laws and policies that create barriers to the receipt of health care and the protection of human rights.
Box 1. Elimination of mother-to-child transmission (MTCT) of HIV and congenital syphilis (CS) in LAC
In 2015, Cuba became the first country credited by WHO for eliminating MTCT of HIV and syphilis. Other countries and territories, such as the United Kingdom Overseas Territories (OKOTs) and Eastern Caribbean countries, have applied to WHO for accreditation for HIV elimination. As of 2015, 19 countries and territories in the Region had reached CS rates compatible with the elimination of MTCT of syphilis ().
Data suggest that testing for HIV and syphilis has been integrated into antenatal care (ANC) services, and the goals of eliminating MTCT of HIV and syphilis are seen as indicators of good quality in maternal and child health services. Despite the high rates of testing and treatment coverage (in 2014, 75% and 79% for HIV and syphilis testing, respectively, and 81% and 85% for treatment of pregnant women for HIV and syphilis, respectively), the neediest and most vulnerable populations are underserved ().
Health service barriers for the elimination of CS in LAC countries include late access to ANC; the need to attend health centers multiple times (for diagnosis and treatment of syphilis), often resulting in a lack of follow-up care for syphilis-positive pregnant women; penicillin shortages and stock-outs; uncommitted budgets; and lack of partner treatment, resulting in syphilis reinfection in pregnant women (). To eliminate CS, it is necessary to address sexual health and syphilis prevention as well as diagnosis and treatment among women of reproductive age and the general population. Therefore, effective responses must address HIV and sexually transmitted infection (STI) prevention in the community, satisfy the need for family planning, and rapidly identify and treat early infections, including in sexual partners ().
Sexually transmitted infections
STIs have often been neglected in favor of the HIV response, but the socioeconomic costs of these infections and their complications are substantial. For example, they rank among the top 10 reasons for health care visits in most developing countries (). Annually, 64 million new cases of four curable STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, syphilis, and Trichomonas vaginalis) are reported among people 15–49 years old in the Americas (2012 data) (). High levels of STIs among key populations such as gay men and other MSM, sex workers, transgender populations, and specific indigenous and ethnic groups in LAC have been reported (). Reported data for 2008 and 2012 show a small decrease or stagnation in the incidence and prevalence of the four curable STIs among men and women 15–49 years old (). However, in recent years, some countries, such as Brazil and the United States, are reporting increases in rates of curable STIs (). Stigma regarding STIs is prevalent in the Region () and community attributes such as poverty, substance abuse, sex roles, gender-based violence, and norms for sexual behavior affect the risks associated with individual behaviors and impede the adoption of preventive behaviors ().
The decision to move toward the elimination of STIs was agreed upon by WHO Member States in 2016 (). Most STI prevention tools and interventions have been available for years (STI case management, counseling and behavioral interventions, diagnostic tests, treatment and vaccines, etc.). However, the extent of their use varies and the adoption of innovations such as point-of-care tests, multipurpose technologies, and HPV vaccine is slow (). These interventions require targeted approaches for vulnerable populations, including youth (). The time has come to address the broader framework for sexual health to end STI epidemics. This will require interventions at not only the individual level but also the community and public infrastructure levels to address the root causes and social contexts.
In 2015, an estimated 268,500 people in the Region contracted TB, and 25,000 died (). Between 1996 and 2015, with the implementation of Directly Observed Treatment Short Course (DOTS) and the WHO Stop TB Strategy, and improved socioeconomic conditions in the countries of the Region, TB incidence dropped from 46 to 27 cases per 100,000 population (), thus meeting the TB-related MDG indicators for 2015 for the Region and the majority of its countries. This rate of decline has slowed since 2007 due to the persistence of factors linked to poverty, social inequity and exclusion, and rising urbanization, which generate living conditions and circumstances favorable to TB transmission. These difficult conditions also influence adherence to treatment among groups with poor socioeconomic status and education, regardless of disease control measures ().
Countries are committed to ending the TB epidemic (<10 cases per 100,000 population) by 2030 and eliminating TB as a public health problem (<1 case per 1,000,000 population) by 2050 (). Challenges to achieving elimination include social inequalities; demographic changes such as rapid urbanization, migration, and aging of the population; the epidemiological transition, with an increase in NCDs; and the persistence of multidrug TB and HIV transmission (), all of which increase the risk of falling ill with TB (, ). TB is concentrated in the most disadvantaged populations within the social gradient (, ), including those living in city slums, where poor housing and limited access to basic health services generate greater transmission and vulnerability (, ); ethnic minorities; migrants, prisoners; people with HIV; and those affected by NCDs (). Countries are applying different prevention and control initiatives adapted to the needs of each population. One example is the initiative for TB control in large cities () using a cross-sectoral and inter-programmatic approach, incorporating community participation and health care services adapted to the needs of the poorest.
Eighteen of the 21 countries in the Americas endemic for malaria have committed to eliminating the disease in the next 5 to 15 years (). Argentina and Paraguay have formally requested certification of malaria-free status from WHO. Costa Rica reported zero autochthonous cases since 2013 and El Salvador and Belize reported, respectively, 6 and 19 autochthonous cases in 2014. The Dominican Republic, Ecuador, and Mexico are also considered close to malaria elimination ().
As the Anopheles vector exists in almost all of the 30 non-endemic countries in the Americas, it is imperative to have surveillance and emergency response systems in place Region-wide to prevent the reestablishment of malaria transmission. Between 2000 and 2014, non-endemic countries reported an annual average of about 2,000 imported cases, mostly originating among travelers from endemic countries. Control measures in the non-endemic countries are based on travel and include preparedness for outbreaks.
In the 21 endemic countries, malaria risk depends on interactions with the epidemiologic factors (host, vector, parasite, and environment). The most important drivers of the disease in these countries are related to social determinants, occupation, geography, and the environment. Social determinants stemming from race, ethnicity, and cultural distinctions are major issues to consider in malaria elimination in key malaria-endemic areas. Many ethnic groups live in poverty, lack access to health care, and face cultural barriers inhibiting proper diagnosis and treatment. Cases from ethnic/indigenous populations were only reported by 8 of the 21 endemic countries in 2014. In Guyana, Amerindians have a fivefold higher risk of malaria than the rest of the population. Unfortunately, most other countries do not report similar types of information, making it difficult to measure risks by ethnicity, track disease trends, implement proper interventions, and make sound cases for policy change. Additional risks are related to specific occupational exposures, particularly in mining, logging, and agriculture. Miners in all countries making up the Guiana Shield are at risk of malaria with limited intervention or control methods available to them (). The approach to malaria elimination needs to be tailored to the local situation and needs to consider the social determinants in contexts where available interventions may be highly effective if implemented appropriately ().
An increasing trend of domestic funds remains the primary source of support for malaria efforts in the Region (approximately US$ 189 million in 2013) (). There are also a number of ongoing malaria initiatives in the Americas focusing on malaria elimination, including the U.S. Agency for International Development (USAID) investment to support technical cooperation on malaria control and elimination throughout the Region; the Elimination of Malaria in Mesoamerica and the Island of Hispaniola (EMMIE) initiative, funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Geneva); and Malaria Zero (Atlanta, Georgia, United States), funded by the Bill & Melinda Gates Foundation (Seattle, Washington, United States). These and other initiatives, along with in-country resources, financial support from key partners, and technical collaboration from international agencies, provide a platform for eliminating malaria in the short to medium term.
The Americas was the first Region in the world to eradicate smallpox, poliomyelitis, rubella, congenital rubella syndrome (CRS), and measles. With the technical support from the Pan American Sanitary Bureau and its associated Revolving Fund for Vaccine Procurement, the Region has been at the forefront of sustainable and equitable introduction of new vaccines ().
An analysis of return on investment associated with achieving projected coverage levels for vaccinations to prevent diseases related to 10 antigens in 94 LMICs during 2011–2020, based on the costs of illnesses averted, and using costs of vaccines, supply chains, and service delivery and their associated economic benefits, estimated that immunizations will yield a net return about 16 times greater than costs over the decade. Using a full-income approach, which quantifies the value that people place on living longer and healthier lives, net returns amounted to 44 times the costs. Across all antigens, net returns were greater than costs ().
As with other indicators, high national vaccine coverage levels often mask inequalities within a country. There is a clear gradient in the proportion of the population under 1 year old living in municipalities of the Americas with suboptimal coverage of DTP3 (i.e., less than 80%) along the social hierarchy defined by per capita income. Countries in the lower income quartile have an excess of almost 20% of the population under 1 year living in municipalities with suboptimal DPT3 coverage compared to countries in the highest quartile. Such excess risk of exposure is attributable to the prevailing economic inequality among countries ().
The main priorities for the Americas are (1) to ensure universal access to vaccines with emphasis on the most disadvantaged, (2) to manage the risk of reintroduction of diseases that could be brought into the Region by people traveling from other regions where the disease circulates, (3) to respond to increasing pressure from “antivaccine” groups, (4) to manage the high cost of new vaccines, and (5) to maintain immunization as a political priority, as reflected in the sustained allocation of national resources.
Neglected infectious diseases
The neglected infectious diseases (NIDs) rank with HIV/AIDS, malaria, and tuberculosis among the most common serious infections globally and in the Americas (). They are associated with poverty and marginality and have failed to receive attention, nor sufficient resources to address them, and have not historically been a priority on the public health or research agendas. They disproportionately affect populations that have been historically neglected including certain indigenous populations, Afro-descendants, and poor populations in rural and peri-urban areas. Their social determinants of health include poor housing conditions; lack of access to proper drinking water, basic sanitation, and hygiene; low income; poor education; and other barriers to access health services.
NIDs create a significant social and financial burden on poor and marginalized groups because they contribute to the cycle of poverty (). The adverse effects on the individuals include growth retardation, stunting, and impairment of cognitive development caused by soil-transmitted helminths in children, leading to decreased productivity and income in adulthood; chronic, disabling morbidity, such as chronic heart failure due to Chagas disease; disability and disfigurement caused by leprosy, lymphatic filariasis, and leishmaniasis; and visual impairment and blindness resulting from trachoma and onchocerciasis. In many cases, the chronic sequelae caused by NIDs lead to additional stigmatization and discrimination.
Many NIDs are on the path toward elimination (lymphatic filariasis, onchocerciasis, schistosomiasis, Chagas disease, leprosy, and trachoma). Others can be prevented or controlled with the appropriate tools and resources from health systems as well as government commitment and support from partners, and donors. The main challenges for elimination and control of NIDs can be grouped into two areas: (1) political and financial and (2) technical.
Political and financial challenges
NIDs are usually given a low priority in the national public health agendas due to competition with other public health-related problems, including public health emergencies, and because they affect mostly groups of people with a low political voice and their chronic nature. This diminishes the resources needed to tackle this group of diseases. This is particularly concerning because only with sustained interventions across several years can the elimination goals be reached.
Technical complexity of interventions
NIDs can be prevented, controlled, and in some cases even eliminated when health services use the proper tools and resources and have both commitment from their governments and support from partners and donors. While in some cases adequate implementation, monitoring, and evaluation of public health interventions have contributed to the successful elimination of some NIDs (e.g., preventive chemotherapy for onchocerciasis, lymphatic filariasis, and trachoma), intersectoral action in tackling the social determinants of NIDs is essential for achieving a faster, greater, and longer-lasting impact. The effective implementation of intersectoral coordination and collaboration poses a great challenge. The most cost-effective public health intervention for the control of schistosomiasis is the large-scale distribution of praziquantel, but access to healthy water, improved basic sanitation, snail control, and environmental enhancements are key to moving towards elimination. Transmission of soil-transmitted helminths and of trachoma is also closely linked to lack of access to proper sanitation, hygiene, safe water, and to lack of education on good hygiene practices such as hand and face washing and personal cleanliness. The use of proper shoes is also vital to keep children from being infected with soil-transmitted helminths.
The weakness of health systems affects the care and treatment of many persons affected by NID. Only an estimated 1% of persons with Chagas disease annually receive appropriate and timely diagnosis and treatment (). Young and middle-aged women are most likely to develop irreversible visual disabilities from ocular trachoma because of their limited access to health services, and weak health systems also contribute to delayed diagnosis of leprosy cases, with a higher risk of developing disabilities and deformities.
Changes in the environment also affect the distribution and incidence of some NIDs as occurs with visceral leishmaniasis in the Southern Cone, which is expanding due to population displacement, environmental changes, and adaptation of vectors to different environments ().
A major shift worldwide has occurred in the significance given to viral hepatitis as a public health concern. Considered “silent” epidemics, they are now on the global health agenda with a goal of elimination as a public health threat by 2030. Of the different hepatitis virus types, the greatest burden of disease in the Americas is caused by hepatitis B and C, which contribute to more than 95% of the Regional mortality from viral hepatitis (). While the burden of other CDs has declined in the past decade, the burden of viral hepatitis has increased. National strategies for the prevention, care, and control of viral hepatitis are in place in fewer than half of countries in the Americas. The greatest strides in the Region have been in vaccination for HBV: Every country and territory has included HB vaccine in its immunization schedule for children and 69% of countries/territories have included an HB birth dose in their immunization policies. While the Region of the Americas is making gains in reducing chronic HBV prevalence, particularly from decades-long universal HBV vaccination and catch-up campaigns (), the time has come to accelerate access to care and treatment for people living with chronic viral hepatitis, particularly from HCV.
With a focus on health systems strengthening, strategies based on integrating packages of services in primary health care, including maternal and child health services, and strengthening infection control policies and practices in healthcare institutions, are key components of a sustainable and efficient public health response to viral hepatitis. Major challenges for countries include the financial investment related to prices of viral hepatitis treatment, and improving the planning, organization and delivery of services for viral hepatitis prevention, diagnosis and treatment. Price negotiation, use of generics and joint procurement strategies are solutions underway to address these issues.
Challenges for Women, Children, and Adolescent Health, including Nutritional Deficiencies
Sexual and reproductive health, newborn and child health, and nutrition in the Americas progressed in the last decade, with improvements in the national indicators and reduced inequalities among economic and educational subgroups (). Increased contraceptive use, ANC coverage and births attended by skilled personnel, decreased unmet need for family planning, decreased stunting, and decreased maternal mortality (despite not meeting the MDGs for maternal health) show a pattern of slow national improvements and a small reduction in absolute inequities in most indicators. Nevertheless, inequalities in reproductive, maternal, and child health continue and the most disadvantaged populations groups present values that the advantaged groups presented 5 to 10 years ago ().
The lessons learned from these efforts and progress are (1) the effort to assure child survival needs to be accompanied with a focus in child development; (2) achieving goals for maternal, child, and adolescent health requires addressing health sector issues, for example, those related directly to safe blood and obstetric services, and also a wider array of strategies addressing sexual health for women and adolescents, nutrition, gender, human rights, poverty and exclusion; (3) further gains will require specific approaches toward the needs of most vulnerable populations; and (4) greater attention needs to be focused on adolescent health.
Maternal health, measured by maternal mortality, remains a crucial indicator for measuring human and social development. In LAC, countries have made tremendous efforts to improve outcomes in maternal health. Between 1990 and 2015, the maternal mortality ratio (MMR) decreased by 52% in Latin America (from 124 to 69 per 100,000 live births) and by 37% in the Caribbean (from 276 to 175 per 100,000 live births) (). This decrease in MMR, however, was not enough to achieve MDG 5 (75% reduction compared to the 1990 baseline) ().
In 2015, an estimated 7,800 women died of maternal causes throughout the Region (). Most of these maternal deaths were due to complications of pregnancy and childbirth, such as bleeding, sepsis, unsafe abortions and hypertension, and the majority were preventable with quality obstetric care during pregnancy, delivery, and postpartum (). These deaths are concentrated within certain disadvantaged populations of women who face inequity in access to adequate reproductive and maternal health care services (). The link between social determinants, such as place of residence, race, occupation, gender, religion, education, and socioeconomic status, and maternal mortality is clear. In Peru, the estimate for the poorest group presented a sixfold excess maternal deaths per 100,000 live births compared with the richest quintile (). In Guatemala, the maternal mortality rate among indigenous women was more than double that of nonindigenous women (163 versus 77 deaths per 100,000 live births) ().
By looking closely at the causes of maternal mortality and morbidity, it is evident that there are economic, social and gender health inequalities that persist throughout LAC (). Women with lower socioeconomic status are less likely to have contact with the health system during pregnancy and childbirth, which are known to be periods of extreme vulnerability. On average, 90% of women in LAC have at least four ANC visits. Yet, large inequalities exist, for example, in Haiti and Nicaragua, where there is a gap of more than 30 percentage points between the poorest and wealthiest women having at least four ANC visits; for Bolivia and Panama, the gap is about 20 percentage points (2).
Some of the main barriers affecting maternal health in LAC countries in obtaining skilled birth attendance (SBA) include the lack of medical personnel in rural and low-income areas, difficult and long distances to the nearest health facilities, cost of care, and the low quality of medical treatment. As a result, a significant number of women in rural areas are less likely to deliver with SBA. In Haiti, there is a 35% gap between women living in rural and urban areas, while in Guatemala and Bolivia there are gaps of 41% and 26%, respectively (). The SDGs present a renewed opportunity to meet the challenges of maternal health and reduce the maternal health inequalities (), offering a new scenario aligning the strategy to end preventable maternal deaths ().
Neonatal, child, and adolescent health
The traditional way of describing the health situation of children () has been to present the mortality trends and the disease prevalence of the main causes of deaths for three age groups: under 5 years old, under 1 year old, and 10–19 years old. While the MDGs promoted a more integrated approach to health, the emphasis remained on mortality and on a limited set of diseases. Neonates and adolescents were barely visible, and equity was a missing component.
The region achieved MDG 4 due to the 67% decline in the under-5 mortality rate between 1990 and 2015 (). Diarrhea, pneumonia, undernutrition, and vaccine-preventable diseases as causes of mortality have decreased significantly (). However, the risk of dying shows a clear gradient: the lower in the social position the higher the risk of dying. This is the case for newborns, children, and adolescents. Most child deaths in the Region are currently either neonatal or stillbirths.
A more detailed analysis shows that the speed of mortality reduction varied by age. The annual rate of reduction was largest in the post-neonatal group, followed by the 1–5 year age group, and lower in the neonates and stillbirth (). The mortality rate of adolescents for all causes has remained stable, but the mortality rates are consistently three to four times higher among male adolescents compared with females ().
Despite international calls to address the health and social needs of adolescents, adolescent health has been overlooked. Sexual and reproductive health among adolescents is an area of political sensitivity and tension. Latin America and the Caribbean shows some decline in adolescent fertility (from 70 in 2008 to 65 births per 1,000 women 15-19 in 2014), but remains significantly higher than the global average of 45 (). Adolescent pregnancy is recognized as having profound effects on the health and well-being of young women and their children, especially for those living in disadvantage. Access to contraceptives in LAC is limited due to various legal and religious restrictions and the increasing influence of conservative groups. Child marriage is still a concern in various countries in the Region. Finally, groups such as ethnic minorities, LGBT (lesbian, gay, bisexual, or transgender) youth, those with disabilities, or who are homeless or in juvenile detention have the greatest health needs that remain invisible and unmet.
Ensuring the survival of children, their mothers, and adolescents is crucial when aiming for zero preventable deaths. Even so, country efforts to save lives are incomplete if the life prospects of those who survive remain constrained by factors that could be effectively addressed (). The process of growth and development are by nature inter-related, interdependent, and mutually reinforcing. Therefore, efforts and resources must simultaneously promote survival and development (intellectual, emotional, and social).
Globally, an estimated 7.1% of preterm babies who survive have some level of long-term neurodevelopmental impairment (). In the LAC region, an estimated 4.1 million children 3–4 years old (18.7% of the population for that cohort) experienced low cognitive and/or socio-emotional development (). The economic consequences of these and other delays are significant. Developing countries lose an estimated US$ 616.5 billion per cohort due to early life growth faltering, which is just one factor affecting child development. The losses for Latin America are estimated at US$ 44.7 billion ().
The foundations of brain architecture are laid down early in life (). Social inequities in early life contribute to inequities in health later in life (). Gender inequalities have roots in early childhood through gender socialization, gender biases, and the day-to-day experiences of a child’s early years, especially among girls.
The emphasis on early child development (ECD) is growing in the Region. The main factors driving the expansion of ECD programs are recognition of the importance of ECD and the need to increase female participation in the labor market, especially among women living in poverty. The programs vary widely in terms of their organizational structure, governance, and level of financing ().
The investment of countries in ECD services is significant. Countries such as Brazil and Chile spend annually US$ 882 and US$ 641 per child 0–5 years old, respectively (). While public spending on children 0–5 years old is estimated at 0.4% of GDP, it is two or three times higher for children 6–12 years old, in countries in Latin America and the Caribbean. In addition to lower levels of investment for younger children, it is necessary to improve the overall quality of these services. The few available studies show that full-time day care services in the Region are generally of low quality.
The health care system has an important role to play in ensuring that children and adolescents have the opportunities to thrive (). Mothers and young children seek health care more frequently than in any other period of their lives. For them, health services can serve as a platform for information, as well as a source of support and linkages with other social resources. Adolescents have the poorest level of health coverage of any age group. This fact makes the visit of an adolescent to a healthcare service a unique opportunity to address the nutritional, sexual, mental health and social changes of this age period. More than in the case of maternal and child health, progress in adolescent health will only be possible if a whole of society approach is at the center of country efforts.
The nutrition landscape in the Americas is undergoing change in all countries and in most population groups as a result of changes in the food environment that affect diet and eating practices. The Americas met the MDG 1 target related to underweight prevalence in children under 5, but undernutrition in the form of stunting in young children continues to be highly prevalent in many countries, particularly in Central America and the Andes (). There are large differences within and among countries, with indigenous and Afro-descendant children and those living in rural areas especially affected. Stunting is a predictor of lower educational outcomes and adult productivity and a risk factor for subsequent overweight and associated metabolic disorders. Wasting is far less prevalent and focused in specific high-poverty communities. Overweight and obesity are similar in women and adolescents and among all income and ethnic groups. In some households, child stunting and maternal overweight coexist ().
Between 1990 and 2014, the prevalence of stunting among children less than 5 years of age in the Region decreased from 14.9% to 7.1%. However, it remains above 25% in two countries and above 15% in six more. A traditional approach to reduce stunting has been to provide complementary foods, which has met with limited success. A more innovative approach is to provide conditional cash transfers/or comprehensive and integrated programs to address its root causes of poverty and other social determinants. Brazil and Mexico have been particularly successful with this approach and have significantly reduced not only the prevalence of stunting but also inequities among the affected population subgroups. At the same time, such programs have led to increases in overweight in women and need to be carefully monitored and adjusted to not reduce one nutrition problem while exacerbating another ().
Micronutrient deficiencies, particularly iron deficiency, continue to be a problem among women, children, and adolescents, and rates are especially high among children under 2 years of age and pregnant women. Staple food fortification, such as salt iodization and fortification of sugar with Vitamin A has proven effective in reducing deficiencies of these micronutrients. However, the reduction of iron deficiency and deficiency of other key micronutrients through supplements and food-based approaches is challenging. As the reduction in the consumption of salt and sugar to prevent obesity and/or NCDs becomes increasingly important, adjustments to staple food fortification programs will be needed ().
Given the rapid changes in the nutrition landscape in which undernutrition coexists with overweight and obesity, the increases in child, adolescent, and maternal overweight and obesity, and persistent micronutrient deficiencies, efforts to improve food and nutrition security must be addressed through comprehensive multisectoral actions that simultaneously address malnutrition in all its forms. While alleviating poverty and other social determinants, actions are also needed in the agricultural sector to improve access to nutritious foods. Regulatory actions are necessary to improve the food environment to promote the consumption of minimally processed foods such as fiscal policies, regulation of food marketing and front-of-package labeling ().
In all countries of the Americas, maternal and child mortality and the burden of CDs have decreased in the past 5 years. Nevertheless, inequities persist in the Region, and LMICs experience worse health outcomes, including higher mortality and morbidity related to CDs and other diseases and conditions that affect mothers and children. Re-strategizing the approach to sustain the gains in MDGs 4, 5, and 6 and address complex issues of this unfinished agenda will be part of the transition to the 2030 Agenda. Countries and development partners need to acknowledge that while chronic diseases are increasing, the burden of CDs and maternal and child deaths including those related to nutritional deficiencies is still considerable.
The Region of the Americas has moved into a period of emergent infectious diseases due to changes in environment, lifestyle, and travel. These conditions can lead to the evolution of new pathogenic arboviruses and others, meaning that timely notification of public health events with potential international impact and future disease control strategies must recognize this context and plan accordingly. Vaccine development, innovative technologies, new drugs, and research programs are some of the areas recommended for collaboration among different sectors, including public sector partners such government health, education, agriculture, and urban development departments and private sector partners such as industry, academia, and civil society.
A focus on health, education, and socioeconomic disparities is needed in order to close the gaps and leave no one behind in working to achieve the SDGs—particularly in the elimination of HIV, malaria, NIDs, STIs, TB, and viral hepatitis and the improvement of maternal, child, and adolescent health.
1. De Andrade LO, Pellegrini Filho A, Solar O, Rigoli F, Malagon L, Castell-Florit Serrate P, et al. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries. The Lancet 2015;4(385):1343-1351.
2. A Promise Renewed for the Americas, United Nations Children’s Fund, Tulane University. Health equity report 2016: analysis of reproductive, maternal, newborn, child and adolescent health inequities in Latin America and the Caribbean to inform policymaking. Summary report. Panama City: UNICEF; 2016. Available from: https://www.unicef.org/lac/20160906_UNICEF_APR_HealthEquityReport_SUMMARY.pdf.
3. Mújica OJ, Haeberer M, Teague J, Santos-Burgoa C, Galvão LAC. Health inequalities by gradients of access to water and sanitation between countries in the Americas, 1990 and 2010. Pan American Journal of Public Health 2015;38(5):347-354.
4. Restrepo-Méndez MC, Barros AJD, Requejo J, Durán P, Serpa LAF, França GVA, et al. Progress in reducing inequalities in reproductive, maternal, newborn, and child health in Latin America and the Caribbean: an unfinished agenda. Pan American Journal of Public Health 2015;38(1):9-16.
5. MacDonald G, Moen AC, St Louis ME. The national inventory of core capabilities for pandemic influenza preparedness and response: an instrument for planning and evaluation. Influenza and Other Respiratory Viruses 2014;8(2):189-193.
6. Johnson LEA, Clará W, Gambhir M, Chacon Fuentes R, Marín-Correa C, Jara J, et al. Improvements in pandemic preparedness in 8 Central American countries, 2008-2012. BMC Health Services Research 2014;14:209.
7. GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet 2016;388(10053):1459-1544.
8. Ceschia A, Horton R. Maternal health: time for a radical reappraisal. The Lancet 2016;388(10056):2064-2066.
10. San Martín JL, Brathwaite-Dick O. La estrategia de gestión integrada para la prevención y el control del dengue en la Región de las Américas. Revista Panamericana de Salud Pública 2007;21(1):55-63.
11. Dick OB, San Martin JL, Montoya RH, del Diego J, Zambrano B, Dayan GH. The history of dengue outbreaks. American Journal of Tropical Medicine and Hygiene 2012;87(4):584-593.
12. Patz JA, Epstein PR, Burke TA, Balbus JM. Global climate change and emerging infectious diseases. Journal of the American Medical Association 1996;275(3):217-223.
13. Khasnis AA, Nettleman MD. Global warming and infectious disease. Archives of Medical Research 2005;36(6):689-696.
14. Taylor LH, Latham SM, Woolhouse ME. Risk factors for human disease emergence. Philosophical Transactions of the Royal Society of London Series B 2001;356(1411):983-989.
15. Schneider MC, Aguilera XP, Smith RM, Moynihan MJ, Barbosa da Silva Jr. J, Aldighieri S, et al. Importance of animal/human health interface in potential Public Health Emergencies of International Concern in the Americas. Pan American Journal of Public Health 2011;29(5):371-379.
16. Schneider MC, Jancloes M, Buss DF, Aldighieri S, Bertherat E, Najera P, et al. Leptospirosis: a silent epidemic disease. International Journal of Environmental Research and Public Health 2013;10(12):7229-7234.
17. Schneider MC, Najera P, Aldighieri S, Galan DI, Bertherat E, Ruiz A, et al. Where does human plague still persist in Latin America? PLoS Neglected Tropical Diseases 2014;8(2):e2680.
18. World Health Organization. International health regulations. 2nd ed. Geneva: WHO; 2008.
19. World Bank. Drug-resistant infections. A threat to our economic future. Washington, D.C.: International Bank for Reconstruction and Development/World Bank; 2016.
20. Review on Antimicrobial Resistance. Tackling drug-resistant infections globally: final report and recommendations. London: AMR; 2016.
21. Etienne CF. Foreword: Caribbean burden of illness study. Journal of Health, Population and Nutrition 2013;31(4):S1-S2.
22. Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson M-A, Roy SL, et al. Foodborne illness acquired in the United States-major pathogens. Emerging Infectious Diseases 2011;17(1):7-15.
31. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Internal Medicine 2013;173(22):2039-2046.
32. Gordillo A, Mejia C, Mogdazi C, Guerrero F, Schmunis GA, Falconí G, et al. Costo de la infección nosocomial en unidades de cuidados intensivos de cinco países de América Latina: llamada de atención para el personal de salud. Revista Panamericana de Infectología 2008;10(4):70-77.
33. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infection Control & Hospital Epidemiology 2011;32(2):101-114.
34. Campos AC, Albiero J, Ecker AB, Kuroda CM, Meirelles LEF, Polato A, et al. Outbreak of Klebsiella pneumoniae carbapenemase-producing K pneumoniae: a systematic review. American Journal of Infection Control 2016;44(11):1374-1380.
35. World Health Organization. Ten years of clean care is safer care 2005-2015. Geneva: WHO; 2015.
36. Nantasit Luangasanatip N, Hongsuwan M, Limmathurotsakul D, Lubell Y, Lee AS, Harbarth S, et al. Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis. BMJ 2015;351:h3728.
37. Weaver SC, Reisen WK. Present and future arboviral threats. Antiviral Research 2010;85(2):328-345.
47. Shepard DS, Undurraga EA, Halasa YA, Stanaway JD. The global economic burden of dengue: a systematic analysis. The Lancet Infectious Diseases 2016;16(8):935-941.
48. Tiga D, Undurraga E, Ramos-Castaneda J, Martinez-Vega R, Tschampl C, Shepard D. Persistent symptoms of dengue: estimates of the incremental disease and economic burden in Mexico. American Journal of Tropical Medicine and Hygiene 2016;94(5):1085-1089.
49. Cheng P, Palekar R, Azziz-Baumgartner E, Luliano D, Alencar AP, Bresee J, et al. Burden of influenza-associated deaths in the Americas, 2002-2008. Influenza and Other Respiratory Viruses 2015;9(S1):13-21.
51. Ropero AM, El Omeiri N, Kurtis HJ, Danovaro C, Ruiz Matus C. Influenza vaccination in the Americas: progress and challenges after the 2009 A(H1N1) influenza pandemic. Human Vaccines & Immunotherapeutics 2016;12(8):2206-2214.
52. El Omeiri N, Azziz-Baumgartner E, Clará W, Guzmán-Saborío G, Elas M, Mejía H, et al. Pilot to evaluate the feasibility of measuring seasonal influenza vaccine effectiveness using surveillance platforms in Central-America, 2012. BMC Public Health 2015;15:673.
53. Costa FE, Hagan JC, Kane M, Torgerson P, Martinez-Silveira M, Stein C, et al. Global morbidity and mortality of leptospirosis: a systematic review. PLoS Neglected Tropical Diseases 2015;9(9):e0003898.
54. World Health Organization. Report of the second meeting of the Leptospirosis Burden Epidemiology Reference Group. Geneva: WHO; 2011:1-37.
55. Felzemburgh RDM, Ribeiro GS, Costa F, Reis RB, Hagan JE, Melendez AXTO, et al. Prospective study of leptospirosis transmission in an urban slum community: role of poor environment in repeated exposures to the Leptospira agent. PLoS Neglected Tropical Diseases 2014;8(5):e2927.
56. Liverpool J, Francis S, Liverpool CE, Dean GT, Mendez DD. Leptospirosis: case reports of an outbreak in Guyana. Annals of Tropical Medicine & Parasitology 2008;102(3):239-245.
57. Schneider MC, Nájera P, Aldighieri S, Bacallao J, Soto A, Marquiño W, et al. Leptospirosis outbreaks in Nicaragua: identifying critical areas and exploring drivers for evidence-based planning. International Journal of Environmental Research and Public Health 2012;9(11):3883-3910.
58. Schneider MC, Nájera P, Pereira MM, Machado G, dos Anjos CB, Rodrigues R, et al. Leptospirosis in Rio Grande do Sul, Brazil: an ecosystem approach in the animal-human interface. PLoS Neglected Tropical Diseases 2015;9(11):e0004095.
59. Maciel EAP, de Carvalho ALF, Nascimento SF, de Matos RB, Gouveia EL, et al. Household transmission of Leptospira infection in urban slum communities. PLoS Neglected Tropical Diseases 2008;2(1):e154.
60. Bacallao J, Schneider MC, Najera P, Aldighieri S, Soto A, Marquiño W, et al. Socioeconomic factors and vulnerability to outbreaks of leptospirosis in Nicaragua. International Journal of Environmental Research and Public Health 2014;11(8):8301-8318.
61. World Health Organization. Human leptospirosis: guidance for diagnosis, surveillance and control. Geneva: WHO; 2003.
62. United Nations International Children’s Emergency Fund. Call for action for WASH investment. New York: UNICEF; 2012.
64. Sicuri E, Evans DB, Tediosi F. Can economic analysis contribute to disease elimination and eradication? A systematic review. PLoS ONE 2015;10(6):e0130603.
65. Aylward RB, Hull HF, Coche SL, Sutter RW, Olivé JM, Melgaard B. Disease eradication as a public health strategy: a case study of poliomyelitis eradication. Bulletin of the World Health Organization 2000;78(3):285-297.
66. UNAIDS. Fast-track: ending the AIDS epidemic by 2030. Geneva: UNAIDS; 2014.
67. UNAIDS/WHO. Global AIDS response progress reporting. Geneva: WHO; 2015.
68. UNAIDS. The gap report. Geneva: WHO; 2014.
69. Pan American Health Organization. Improving access of key populations to comprehensive HIV health services towards a Caribbean consensus. Washington, D.C.: PAHO; 2011.
70. Shannon K, Strathdee SA, Goldenberg SM, Duff P, Mwangi P, Rusakova M, et al. Global epidemiology of HIV among female sex workers: influence of structural determinants. The Lancet 2015;385(9962):55-71.
73. Pan American Health Organization. Elimination of mother to child transmission of HIV and syphilis in the Americas. Washington, D.C.: PAHO; 2015.
74. Luu M, Ham C, Kamb ML, Caffe S, Hoover KW, Perez F. Syphilis testing in antenatal care: Policies and practices among laboratories in the Americas. International Journal of Gynaecology and Obstetrics 2015;130(S1):S37-S42.
75. Fenton K. Sexual health: expanding our frame for action. In: Kumar B, Gupta S, eds. Sexually transmitted infections. 2nd ed. New Delhi: Elsevier; 2012:3-9.
76. Newman L, Rowley J, Vander Hoorn S, Wijesooriya NS, Unemo M, Low N, et al. Global estimates of the prevalence and incidence of four curable sexually transmitted infections in 2012 based on systematic review and global reporting. PLoS ONE 2015;10(12):e0143304.
77. Zoni AC, González MA, Sjögren HW. Syphilis in the most at-risk populations in Latin America and the Caribbean: a systematic review. International Journal of Infectious Disease 2013;17(2):e84-e92.
78. U.S. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2015. Atlanta: U.S. Department of Health and Human Services; 2016.
79. Ministério da Saúde – Secretaria de Vigilância em Saúde. Boletim epidemiológico – sífilis 2015. Brasilia: Departamento de DST, Aids e Hepatites Virais; 2015.
80. Morris JL, Lippman S, Philip S, Bernstein K, Neilands TB, Lightfoot M. Sexually transmitted infection related stigma and shame among African American male youth: implications for testing practices, partner notification, and treatment. AIDS Patient Care STDS 2014;28(9):499-506.
82. U.S. Centers for Disease Control and Prevention. Addressing social determinants of health: accelerating the prevention and control of HIV/AIDS, viral hepatitis, STD and TB. External consultation meeting report. Atlanta: CDC; 2009.
83. World Health Organization. Global health sector strategy on sexually transmitted infections 2016-2021. Toward ending STIs. Geneva: WHO; 2016.
84. Kalamar AM, Bayer AM, Hindin MJ. Interventions to prevent sexually transmitted infections, including HIV, among young people in low- and middle-income countries: a systematic review of the published and gray literature. Journal of Adolescent Health 2016(S3):S22-S31.
85. Dillon JA, Trecker MA, Thakur SD, Fiorito S, Galarza P, Carvallo ME, et al. Two decades of the gonococcal antimicrobial surveillance program in South America and the Caribbean: challenges and opportunities. Sexually Transmitted Infections 2013;89(S4):36-41.
86. Herbst de Cortina S, Bristow CC, Joseph Davey D, Klausner JD. A systematic review of point of care testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Infectious Diseases in Obstetrics and Gynecology 2016;2016:4386127.
87. Bychkovsky BL, Ferreyra ME, Strasser-Weippl K, Herold CI, de Lima Lopes Jr. G, Dizon DS, et al. Cervical cancer control in Latin America: a call to action. Cancer 2016;122(4):502-514.
89. Dye C, Lonnroth K, Jaramillo E, Williams BG, Raviglione M. Trends in tuberculosis incidence and their determinants in 134 countries. Bulletin of the World Health Organization 2009;87(9):683-691.
90. Pan American Health Organization. Tuberculosis in the Region of the Americas. Regional report 2014 epidemiology, control and financing. Washington, D.C.: PAHO; 2014.
91. Munayco CV, Mújica OJ, León FX, del Granado M, Espinal MA. Social determinants and inequalities in tuberculosis incidence in Latin America and the Caribbean. Revista Panamericana de Salud Pública 2015;38(3):177-185.
92. Pan American Health Organization. Plan of action for prevention and control of tuberculosis. 54th Directing Council of PAHO, 67th Session of the Regional Committee of WHO for the Americas, Washington, D.C., 2015 Sept. 28 to Oct. 2 (CD54/11).
94. Rasanathan K, Sivasankara Kurup A, Jaramillo E, Lönnroth K. The social determinants of health: key to global tuberculosis control. International Journal of Tuberculosis and Lung Disease 2011;15(S2):S30-S36.
95. Andrews JR, Basu S, Dowdy DW, Murray MB. The epidemiological advantage of preferential targeting of tuberculosis control at the poor. International Journal of Tuberculosis and Lung Disease 2014;19(4):375-380.
96. Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Social Science & Medicine 2009;68(12):2240-2246.
98. Creswell J, Raviglione M, Ottmani S, Migiliori GB, Uplekar M, Blanc L, Sotgiu G, Lonnorth K. Tuberculosis and noncommunicable diseases: neglected links and missed opportunities. European Respiratory Journal 2011;37(5):1269-1282.
104. Andrus JK, Crouch AA, Fitzsimmons J, Vicari A, Tambini G. Immunization and the Millennium Development Goals: progress and challenges in Latin America and the Caribbean. Health Affairs 2008;27(2):487-493.
105. Ozawa S, Clark S, Portnoy A, Grewal S, Brenzel L, Walker D. Return on investment from childhood immunization in LMIC, 2011-2020. Health Affairs 2016;35(2):199-207.
106. Becerra F, Mujica O. Equidad en salud para el desarrollo sostenible. Revista de Salud Pública y Nutrición 2016;15(1):16-26.
108. Hotez PJ, Bottazzi ME, Franco-Paredes C, Ault SK, Roses Periago M. The neglected tropical diseases of Latin America and the Caribbean: a review of disease burden and distribution and a roadmap for control and elimination. PLoS Neglected Tropical Diseases 2008;2(9):e300.
109. Oberhelman RA, Guerrero ES, Fernández ML, Silio M, Mercado D, Comiskey N, et al. Correlations between intestinal parasitosis, physical growth, and psychomotor development among infants and children from rural Nicaragua. American Journal of Tropical Medicine & Hygiene 1998;58(4):470-475.
110. Guyatt H. Do intestinal nematodes affect productivity in adulthood? Parasitology Today 2000;16(4):153-158.
111. Ault SK, Roses Periago M. Regional approaches to neglected tropical diseases control in Latin America and the Caribbean. In: Institute of Medicine (US) Forum on Microbial Threats. The causes and impacts of neglected tropical and zoonotic diseases: opportunities for integrated intervention strategies. Washington, D.C.: National Academies Press; 2011:115-131.
114. Stanaway JD, Flaxman AD, Naghavi M, Fitzmaurice C, Vos T, Abubakar I, et al. The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study. The Lancet 2016;388(10049):1081-1088.
115. Pan American Health Organization. Hepatitis B and C under the spotlight: a public health response in the Americas, 2016. Washington, D.C.: PAHO; 2016.
116. Restrepo-Méndez MC, Barros AJD, Requejo J, Durán P, Serpa LAF, França GVA, et al. Progress in reducing inequalities in reproductive, maternal, newborn, and child health in Latin America and the Caribbean: an unfinished agenda. Revista Panamericana de Salud Pública 2015;38(1):9-16.
119. Economic Commission for Latin America and the Caribbean. Review of the implementation of the Beijing Declaration and platform for action and the outcome of the Twenty-Third Special Session of the General Assembly in Latin American and Caribbean countries, Santiago, 2009 (LC/L 3175). Available from: http://www.cepal.org/mujer/noticias/paginas/8/36338/eclacbeijing15.pdf.
120. Ronsmans C, Graham W. Maternal mortality: who, when, where, and why. The Lancet 2006;30;368(9542):1189-1200.
126. United Nations Inter-agency Group for Child Mortality Estimation. Levels and trends in child mortality report 2015. New York: UN; 2015.
127. Liu L, Hill K, Oza S, Hogan D, Chu Y, Cousens S, et al. Levels and causes of mortality under age five years. In: International Bank for Reconstruction and Development, World Bank. Reproductive, maternal, newborn, and child health: disease control priorities. 3rd ed. Vol. 2. Washington, D.C.: World Bank; 2016:71-83.
128. GBD 2013 Collaboration. Global and national burden of diseases and injuries among children and adolescents between 1990 and 2013: findings from the Global Burden of Disease 2013 Study. JAMA Pediatrics 2016;170(3):267-287.
130. Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics 2012;129(1):e232-e246.
131. Lawn JE, Blencowe H, Oza S, You D, Lee ACC, Waiswa P, et al. Every newborn: progress, priorities, and potential beyond survival. The Lancet 2014;384(9938):189-205.
132. Lu C, Black M, Richter L. Risk of poor development in young children in low-income and middle-income countries: an estimation and analysis at the global, regional, and country level. The Lancet Global Health 2016;4(12):e916-e922.
133. Fink G, Peet E, Danaei G, Andrews K, McCoy DC, Sudfeld CR, et al. Schooling and wage income losses due to early-childhood growth faltering in developing countries: national, regional, and global estimates. American Journal of Clinical Nutrition 2016;104(1):104-112.
135. Grantham-McGregor S, Cheung Y, Cueto S, Glewwe P, Richter L, Strupp B, et al. Developmental potential in the first 5 years for children in developing countries. The Lancet 2007;369(9555):60-70.
136. Inter-American Development Bank. The early years: child well-being and the role of public policy. Washington, D.C.: IADB; 2015.
137. Lancet Series. Advancing Early Childhood Development: from Science to Scale. October 2016. The Lancet.
138. Galicia L, Grajeda R, López de Romaña D. Nutrition situation in Latin America and the Caribbean: current scenario, past trends, and data gaps. Revista Panamericana de Salud Pública 2016;40(2):104-113.
139. Tzioumis E, Adair LS. Childhood dual burden of under- and over nutrition in low- and middle-income countries: a critical review. Food and Nutrition Bulletin 2014;35(2):230-243.
140. Uauy R, Garmendia ML, Corvalán C. Addressing the double burden of malnutrition with a common agenda. Nestle Nutrition Instructional Workshop Series 2014;78:39-52.
1 Health events that endanger international public health, as defined by the International Health Regulations (IHR) (2005), an agreement between 196 countries including all WHO Member States.
2 An online WHO application tool designed to provide timely information for event monitoring and iterative risk assessment and support decisions about response operations during outbreaks and other acute public health events in accordance with the IHR [http://apps.who.int/iris/handle/10665/206496?locale=zh&null].
3 While elimination is based on interruption of transmission to zero or very low levels, the specific definitions of elimination vary depending on each disease and its control measures.
4 Key populations refer to both vulnerable and most-at-risk populations for HIV infection. They are important to the dynamics of HIV transmission in a given setting and are essential partners in an effective response to the epidemic (WHO. 2013. HIV/AIDS: definition of key terms. Available from: http://www.who.int/hiv/pub/guidelines/arv2013/intro/keyterms/en/).