Chronic conditions and diseases due to external causes

Summary

Noncommunicable diseases (NCDs), which comprise cardiovascular diseases, diabetes, cancer, and chronic respiratory diseases, are the leading causes of ill health, death, and disability in the Americas. Because of their high cost of care and economic impact, NCDs have a significant impact on development. Thus, tackling the common risk factors of NCDs (tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diet) is an urgent priority. In addition, mental and substance use disorders are highly prevalent, and together with road traffic injuries and interpersonal violence, are also major causes of disability.

These conditions are driven by demographic changes, economic growth, negative effects of globalization, rapid and unplanned urbanization, and the epidemiological transition from infectious diseases to chronic conditions. Populations living in vulnerable conditions are more affected by these changes, and together with structural factors such as education, occupation, income, gender, and ethnicity, lead to a disproportionate impact of underlying social determinants on this population.

Prevention is the cornerstone of a response to these chronic conditions. Policy, regulatory, and health promotion interventions are recommended to reduce NCD risk factors, and all policies should be centered on public health interests. For mental health, the first steps are early prevention, correct identification, and treatment of emotional or behavioral problems. Prevention practices for road traffic injuries and disabilities include laws that prohibit speeding and drunk driving and that require the use of motorcycle helmets and seat belts.

Universal health coverage for equitable access to quality care for persons living with chronic conditions, and in many cases multiple chronic conditions, is necessary to improve health outcomes. For those at risk for or living with one or more NCDs, a chronic care approach is recommended. This includes organizing services for continuous and quality care, evidence-based guidelines, support for self-management, clinical information systems, coordinating care among providers, and community resources to support patients. People living with disabilities require special attention as they often seek more health care but have greater unmet needs. Barriers to care include physical barriers, financial barriers, and lack of appropriate services. The treatment gap for mental health and other conditions is significant and is expected to worsen with an aging population. Service delivery tends to be fragmented, with poor coordination between the primary, secondary, and tertiary levels, and there is a heavy emphasis on mental institutions. The Mental Health Gap Action
Program (mhGAP) of the World Health Organization (WHO) offers a model of care, with psychosocial assistance and medication, to improve mental health.

As the Region continues to develop, the focus shifts to the Sustainable Development Goals (SDGs); they include specific targets for NCDs, mental health, and road safety, among other issues. Achieving these goals will require governments to intensify their response to chronic conditions, as well as increased technical assistance from the global health community.

Throughout the text, the terminology of chronic conditions is used to encompass conditions that are recurrent or that manifest throughout the life course, and not necessarily related to disease or illness. From the perspective of a socially organized response, chronic conditions are expressed in more expanded time trajectories and in cycles of critical periods that trap health systems in ongoing health interventions. This perspective is aligned with the life-course approach and with the social determinants approach, both of which are discussed in separate chapters.

Introduction

Noncommunicable diseases (NCDs)—including cardiovascular diseases, cancer, diabetes, chronic respiratory diseases—are the leading cause of morbidity, mortality, and premature death in the Americas, accounting for 79% of all deaths in 2012 (). A significant proportion of these deaths is preventable by tackling the four common risk factors: tobacco use, harmful use of alcohol, unhealthy diet, and physical inactivity (). In addition, mental, neurological, and substance use (MNS) disorders are among the leading causes of the global burden of disease, responsible for 19% of the overall loss in disability-adjusted life years (DALYs) in the Region (). Recurrent depression, anxiety disorders, schizophrenia, bipolar affective disorder, suicide, dementia, and alcohol-use disorders are among the most common MNS disorders, for which significant treatment gaps exist in the Region ().

The number of people with disabilities in the Americas, estimated at 140 million people, is increasing due to the population aging, increasing prevalence rates of NCDs, and changes in lifestyles (). People with disabilities generally have poorer health, fewer economic opportunities, and higher rates of poverty, owing to the barriers of everyday living ().

Road traffic injuries continue to be a significant public health problem in the Americas, with a death rate of 15.9 per 100,000 population (). The situation is worsening with greater population growth, urbanization, economic development, and weak public transportation systems (). The Americas is also one of the regions with the highest levels of violence of all types (). This situation is strongly associated with the poor rule of law; weakening governance; cultural, social, and gender norms; increasing unemployment and income inequality; and limited educational opportunities.

In this section, we describe the situation for this group of NCDs and health issues, while highlighting effective public health interventions to address these conditions.

Discussion

Overview of noncommunicable diseases

NCDs are the leading causes of death in the Americas, causing an estimated 4.8 million deaths in 2012 (). Premature mortality is a major concern, given that 35% of NCD deaths occur in persons under 70 years of age. Cardiovascular diseases (CVDs) account for 37% of all NCD deaths, while cancer accounts for 25%, diabetes for 8%, and chronic respiratory diseases for 6% (). CVD mortality rates have declined steadily in most countries in the Americas, with an overall reduction of 19% from 2000 to 2010 (20% in women and 18% in men) (), while cancer mortality rates have remained relatively stable for both men and women over the past 15 years ().

NCDs are impeding economic growth and development in the Region, as countries face important lost output due to early deaths, disability, and costs of ill health (). The economic burden of NCDs (including mental health) in low- and middle-income countries has been estimated at US$ 21.3 trillion for 2011-2030 (). This is in contrast to the estimated cost of US$ 2 billion annually, equivalent to less than US$ 0.20 per person, to implement a set of cost-effective interventions to address NCD risk factors in low- and middle-income countries ().

NCDs disproportionately affect people living in vulnerable situations because of the complex interplay between social, behavioral, biological, and environmental factors, along with the accumulation of positive and negative influences over the life course (). For example, NCD mortality tends to be higher in populations with less education, lower income, less social support, and racial discrimination ().

NCDs and their risk factors manifest differently among men and women. For example, insufficient physical activity is more common among women than men (37.8% vs. 26.7%), and more women are obese compared to men (27.4% vs. 21.7%) (). More men smoke than women (24.1% vs. 14.2%) and also drink alcohol heavily (21.0% vs. 7.2% among women) (). Hypertension affects men and women equally; however, women show greater awareness of their hypertensive status and have higher rates of treatment and control than men (). As a result, CVD mortality rates are higher in men in all countries of the Americas, and premature mortality from CVD during 2000–2010 dropped more in women (average annual rate of 2.7%, vs. 2.3% among men) ().

Underlying NCD risk factors

NCDs are driven largely by forces that include demographic changes, epidemiological transition, economic development, rapid and unplanned urbanization, and negative effects of globalization, among other factors. These dynamics have had an impact on the four key risk factors that account for the majority of preventable deaths and disability from NCDs: harmful use of alcohol, unhealthy diet, physical inactivity, and tobacco use ().

Most of these are associated with the consumption of commodities, such as tobacco, alcohol, and ultra-processed products (UPPs) including sugar-sweetened beverages (SSBs). UPPs are a result of modern industrial food science; their nutritional quality is very low although they may be palatable and quasi-addictive (). Alcohol and tobacco are psychoactive substances with reinforcing and known addictive properties. As a consequence of globalization and market changes, alcohol, tobacco, UPPs, and SSBs are widely available, inexpensive, and heavily promoted through advertising, promotions, and corporate sponsorships. In the case of alcohol, the negative impact goes beyond NCDs and includes mental and neurological disorders, injuries, and associated diseases.

The consumption of these commodities is influenced by industries that massively produce, distribute, sell, and promote their products without adequate regulatory frameworks. In addition, favorable trends in economic development that increase people’s income can also increase the affordability of these products, but only if not combined with sound regulatory measures, including trade, fiscal, and investment policies that limit their consumption. This is shown in the relationship between foreign investment and the increase in tobacco consumption (); market deregulation and fiscal incentives and the increase in sales and consumption of UPPs (); and trade liberalization and harmful use of alcohol (). In addition, physical inactivity is reinforced by rapid urbanization, automation of many activities, an increase in violence and insecurity, and inadequate or expensive public transportation.

Overweight/obesity, physical inactivity, and unhealthy diet are strongly associated with type 2 diabetes, and more than half of these cases can be prevented by reducing these risk factors (). Furthermore, an estimated 30% to 40% of cancers can be prevented by reducing the main NCD risk factors. Tobacco control can significantly reduce chronic respiratory diseases, notably chronic obstructive pulmonary disease. Tobacco control and minimizing salt consumption can reduce population-level CVD risk. Control of elevated blood pressure (hypertension) is also a cost-effective intervention () to reduce cardiovascular risk, and secondary prevention can prevent and delay up to 75% of new cardiovascular events ().

More information on individual NCD risk factors is provided below.

Unhealthy diet and obesity. Hunger and nutritional deficits coexist with an increase in overweight and obesity; they share common determinants of poverty, inequities, and lack of healthy, nutritious food (). Changes in dietary patterns have emerged from globalization, urbanization, the incorporation of more women into the work force, and increased consumption of food outside the home concomitantly with the increase in marketing and availability of SSBs and UPPs (). The fastest increase in UPP sales, and in overweight and obesity, are found in Latin America and the Caribbean (). This is the result of food industry mass-marketing campaigns, foreign investments, and the takeover of domestic food companies (). Global producers are driving the “nutrition transition” from traditional, simple diets to highly processed foods, and the pace is accelerating ().

To address obesity in the Region and as part of the Plan of Action for Prevention of Obesity in Children and Adolescents (), PAHO commissioned an expert consultation group to develop a nutrient profile model (). The model has been used as a basis for legislation of front-of-package labeling in countries such as Chile and Ecuador.

Tobacco. Tobacco continues to be one of the main causes of preventable death (). In the Region, tobacco-related deaths account for 14% of all deaths in adults 30 to 70 years old. The average prevalence of tobacco smoking in the Region is decreasing, but this is not the case in all countries (). Research has shown that achieving the target of 30% reduction in tobacco use is fundamental to reaching the overall goal of 25% reduction in premature mortality from NCDs (). Despite the progress made in several countries by implementing the WHO Framework Convention on Tobacco Control (FCTC) and the growing engagement of civil society and Member States, a large proportion of the Region’s population is still not covered by even a single FCTC measure at the highest level of achievement (). Finally, the influence and interference of the tobacco industry has been, and continues to be, a severe obstacle to progress in tobacco control in the Region, as it is in the rest of the world ().

Harmful use of alcohol. Alcohol consumption is responsible for a host of often devastating consequences for the drinker, the family, and the community, including but not limited to death and disability (). Alcohol is the most common underlying risk factor associated with death in people 15–49 years of age and can cause significant disability throughout the life course. Alcohol use can lead to alcohol dependence, liver cirrhosis, traffic injuries, and over 200 illnesses, including cancers, cardiovascular disease, infectious diseases, and fetal alcohol spectrum disorders ().

The average per capita consumption among those aged 15 years and older in the Region of the Americas is higher than the global average (). The prevalence of heavy episodic drinking in adults and adolescents is also high (see Chapter 3) and appears to be increasing, consistent with initiation of drinking before the age of 14 (). The prevalence of alcohol-use disorders in women in the Region is the highest in the world, at 3.9% ().

Globally, alcohol consumption is responsible for 10% of DALYs lost due to NCDs (). Alcohol-attributable health conditions strike more men than women in every country, although, for the same amount of alcohol consumed, the risk for negative consequences is higher among women (). For some of these conditions, there is no known safe level of drinking (). Acute heavy episodic drinking is related to violence, injuries, and poisoning, while chronic disease is primarily associated with patterns of chronic or repeated episodic heavy consumption ().

Physical inactivity. The recommended physical activity levels are at least 60 minutes of moderate or vigorous physical activity every day for children and adolescents, and at least 150 minutes of moderate or 75 minutes of vigorous aerobic activity every week for adults of all ages (). Yet in the Americas, 50% of people do not meet this recommendation, raising the mortality risk by 20% to 30% ().

Physical inactivity leads to excess weight and obesity. Physical activity improves muscular and cardiovascular functions, improves bone health, and reduces depression and the overall risk of developing an NCD. Greater physical fitness also improves academic performance in children ().

The design of communities and cities and the ability of people to move about safely on foot, by bicycle, or using public transportation (all called “active transportation”) appear to have a major influence on levels of physical activity and obesity ().

Tackling the Major NCD Risk Factors

The global health community has adopted a set of nine targets to tackle major NCD risk factors and reduce NCDs (). This effort is reinforced by the Sustainable Development Goals, which include NCDs as a target within the health goal (Goal 3), with the aim of reducing premature mortality from NCDs 30% by 2030 ().

There is global consensus on the achievable, cost-effective measures to reduce NCD risk factors as described in Table 1 (). For tobacco, the interventions are defined by the WHO FCTC, the first international treaty negotiated under the auspices of WHO. The demand-side measures are summarized in the WHO MPOWER tool and include tax policies, health warnings, smoke-free environments, and a ban on advertisement, promotions, and sponsorship. Even though the Region has advanced in the implementation of smoke-free environments and health warnings, tax measures and marketing bans are well behind ().

Table 1. WHO Cost-effective interventions for NCD risk factors*

NCD risk factor	Intervention
Tobacco use	Strengthen the implementation of tax policy and administrative measures to reduce the demand for tobacco products. Implement comprehensive ban of tobacco advertising, promotion, and sponsorship, including cross-border advertising and on modern means of communication. Implement plain/standard packaging and/or large graphic and legislated health warnings on all tobacco packages. Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places, public transport, and all places of outdoor mass gatherings. Other interventions: Provide cost-covered, effective, and population-wide support (including brief advice, national toll-free quit line services, and mCessation) to everyone who wants to quit smoking tobacco. Implement measures to minimize illicit trade in tobacco products.
Harmful use of alcohol	Increase excise taxes on alcoholic beverages. Enforce bans or comprehensive restrictions on alcohol advertising (across multiple types of media). Enforce restrictions on the physical availability of retail alcohol (by reducing the density of retail outlets and limiting hours of sale). Other interventions: Enforce drunk-driving laws and blood-alcohol concentration limits via sobriety checkpoints. Provide brief psychosocial intervention for persons with hazardous and harmful alcohol use.
Unhealthy diet	Reduce salt intake by engaging the industry in a voluntary reformulation process. Reduce salt intake by establishing a supportive environment in public institutions, such as hospitals, schools, and nursing homes, that encourages low-sodium meals to be provided. Reduce salt intake through a mass-media, behavioral-change communication campaign. Reduce salt intake through implementing front-of-package labeling. Other interventions: Completely eliminate industrial trans fats by developing legislation that bans their use in foods. Promote breast-feeding and support exclusive breast-feeding for the first six months of life. Implement subsidies to encourage people to eat more fruits and vegetables. Replace trans-fats and saturated fats with unsaturated fats through reformulation, labeling, and fiscal and agricultural policies. Reduce sugar consumption by taxing sugar-sweetened beverages. Encourage limits on portion size to reduce energy intake and the risk of childhood overweight/obesity. Implement nutrition education and counseling in different settings (e.g., schools, workplaces, hospitals, etc.) to increase the intake of fruits and vegetables. Implement nutrition labeling to show better macronutrient information and total energy of foods (kcal). Institute nutrition labeling in educational settings to improve dietary intake. Implement mass media campaign on healthy diets, including social marketing to reduce the intake of total fat, fiber, and salt, and to promote the consumption of more fruits and vegetables.
Physical activity	Make counseling about physical activity a routine part of primary health care services. Other interventions: Ensure macro-level urban design that incorporates the core elements of residential density, connected street networks, and easy access to public transportation and to a variety of destinations. Implement public awareness and motivational programs for physical activity, including mass media campaigns to encourage a change in levels of physical activity. Ensure that adequate facilities are available on school premises to encourage recreational physical activity for all children. Provide safe and adequate infrastructure to enable walking and cycling. Implement multicomponent physical activity programs at workplaces.

For alcohol, the most cost-effective interventions are an increase in alcohol taxes, legislative measures to control alcohol marketing, and restrictions on the physical availability of alcohol. However, only four countries (Colombia, Costa Rica, Panama, and Venezuela) have tax policies that can limit alcohol consumption, only two have comprehensive marketing bans, and no country has comprehensive controls on the physical availability of alcoholic beverages (). Despite adopting the WHO Global Strategy for Reducing Harmful Use of Alcohol in 2010, then adopting a Regional Plan of Action in 2011, the Region has not made progress on any of the alcohol indicators of the PAHO Strategic Plan 2014-2019 ().

A “Health in All Policies” approach, as illustrated in Box 1, is needed to reduce NCD risk factors. Such an approach calls for all relevant sectors to consider the impact of their policies on NCDs and to utilize policy, legislative, regulatory, and fiscal measures to better prevent and control NCDs. The sectors include economic, trade, education, and agriculture, among others. Promising interventions for NCD prevention that can also address broader social determinants of health are urban planning, taxation (incentives or disincentives), pricing and subsidies (incentives or disincentives), production and marketing of goods, health-promotion financing, and legislative mandates ().

Box 1. Examples of multisectoral policies for NCD prevention and control

Agriculture: subsidize healthy food production, substitute other crops for tobacco, maintain adequate land for agriculture and local food system development, encourage farmers markets, promote local food availability and sales.
Environment: improve mass public transportation systems; design and plan roads to facilitate walking and cycling; develop green spaces, facilities, and spaces for physical activity; enforce environmental pollution standards.
Education: develop school-based nutritious meal programs, curriculum on healthy lifestyles, and policies on sales of healthy foods and beverages; restrict marketing of foods and beverages to children in schools; increase time for physical education.
Trade: increase import taxes on unhealthy products such as tobacco, alcohol, sugar-sweetened beverages, and ultra-processed foods; reduce import taxes on health-promoting products.
Social-protection policies: consider a single-payer system that equitably funds treatment and care for persons with NCDs, mental health conditions, and disabilities.
Law enforcement: promote crime reduction and safe communities to encourage physical activity; establish and enforce penalties for violating smoke-free environment laws and for excessive drinking and occupational and environmental pollution.
Labor: provide incentives for worksite health-promotion programs.
Media: ban smoking and alcohol use in TV and films; enforce bans on advertising tobacco and alcohol in the media, and on marketing foods and beverages to children.

Source: Lin V, Jones C, Shiyong W, Baris N. Health in All Policies as a strategic policy response to NCDs. Health, Nutrition, and Population (HNP) discussion paper [Internet]. Washington, D.C.: World Bank; 2014. Available from: The World Bank.

Role of the private sector in tackling NCD risk factors

Given that many of the products associated with NCD risk factors are produced by the private sector, that sector has the potential to play a significant role in preventing NCDs. The private sector has acknowledged the need to create healthier products for consumers, as well as to create healthier workplaces. Moreover, the international community has called on the private sector to contribute to NCD prevention, as described in Box 2 ().

However, the interests of some private entities may be opposed to the interests of health protection/promotion, particularly when there may be a negative impact on profits. For example, in tobacco there is a long history of deceptive strategies to undermine regulatory action; much of it was confirmed by the industry’s own internal documents that were made public and clearly exposed as a consequence of tobacco litigation in the state of Minnesota (United States). Article 5.3 of the FCTC states that “in setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law” (). The guidelines for implementing this article detail how countries should interact with the tobacco industry (). Similar strategies are observed with food and alcohol industries, as well ().

Box 2. How the private sector can contribute to NCD prevention

Take measures to implement the WHO recommendations to reduce the impact of marketing unhealthy foods and nonalcoholic beverages to children, while taking into account existing national legislation and policies.
Consider producing and promoting more food products consistent with a healthy diet, including reformulating products to provide healthier options that are affordable and accessible and that follow relevant nutritional facts and labeling standards (information on sugars, salt, fats and, where appropriate, trans fat content).
Promote and create an environment for healthy behaviors among workers by establishing tobacco-free workplaces and safe and healthy working environments that adhere to occupational safety and health measures, including good corporate practices, workplace wellness programs, and health insurance plans.
Work towards reducing the use of salt in the food industry, to lower sodium consumption.
Contribute to efforts to improve access to and affordability of medicines and technologies that help prevent and control noncommunicable diseases.

Source: United Nations. Political declaration of the high-level meeting on the prevention and control of noncommunicable diseases. New York: UN; 2011.

Strengthening regulatory capacity and the use of health law

Regulatory processes refer broadly to both legislative and executive action. Many of these measures require the correction of market failures or the modification of widespread social practices—changes that can only be achieved through the effective use of legislation or regulation, often in areas outside the traditional scope of health systems. These measures require the health authority to effectively work with other sectors of government to ensure that all policies take into account the impact on health. PAHO launched the REGULA initiative in 2014 to strengthen the regulatory capacity of the Region’s health authorities to reduce NCD risk factors (). Laws related to each risk factor in every Latin American country have been collected, and in selected countries an in-depth analysis of the regulatory capacity has been conducted. In addition, Member States adopted a Strategy on Health-related Law in 2015 to strengthen legal and regulatory frameworks that promote health based on the perspective of the right to health. It aims to protect health by strengthening coordination between health authorities and legislative branches ().

Management of Noncommunicable Diseases

The challenge for managing NCDs is to implement universal, financially and physically accessible, high-quality primary care services while also enhancing early diagnosis, timely treatment, and improvements in the quality of care, particularly in disadvantaged communities (). Box 3 summarizes why a focus on NCD management is such an important aspect of the response to the NCD problem.

Box 3. Why focus on NCD management?

It has been estimated that:

Out of 100% of people who have an NCD, only 50% are diagnosed;
Of those diagnosed, only 50% are treated;
Of those treated, only 50% have their NCD under control;
Of those under control, only 50% are successfully controlled;

Therefore, among those who live with an NCD, fewer than 10% have it successfully controlled.

Poor NCD control leads to poor health outcomes.

Source: Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Effective Clinical Practice 1998;1(1):2-4.

Cardiovascular disease (CVD), the leading cause of death, requires intensified and specific health system interventions to reduce risk, control hypertension, manage acute episodic events, and prevent premature death (Table 2). Type 2 diabetes, a common comorbidity of hypertension, is a chronic metabolic disease that also requires specific primary care interventions (Table 2). However, a chronic care approach for integrated management of diabetes, CVD, and other NCDs has been proposed by PAHO (). This approach includes organizing health services to reduce barriers and promote prevention; self-management support to empower people to effectively manage their conditions; evidence-based guidelines and support for decision-making; coordinated care among the health team; a clinical information system to monitor patients; and community resources to support patient care.

Table 2. NCD management interventions

NCD	Disease management objectives	Primary health care interventions
NCD	Disease management objectives	Counseling, patient education, and prevention	Screening and early detection	Treatment
Cardiovascular diseases (CVDs)	Assess risk and reduce risks for developing CVD Diagnose CVD early and accurately Control high blood pressure Prevent acute events and complications Improve self-care for CVD	Assess risk for CVD Educate about risk factor reduction Educate about healthy lifestyle	Measure and monitor blood pressure, body mass index (BMI), and blood lipid profile	Drug therapy for those who have had or are at risk for heart attack and stroke Hypertension medication Treatment of new cases of acute myocardial infarction with either: acetylsalicylic acid, or acetylsalicylic acid and clopidogrel, or thrombolysis, or primary percutaneous coronary interventions Treatment of congestive cardiac failure with ACE inhibitor, beta-blocker, and diuretic
Diabetes type 2	Prevent diabetes, including gestational diabetes Assess risk for developing diabetes Improve quality of care and outcome in people with type 2 diabetes Reduce and maintain a healthy body weight Control blood sugar levels Reduce complications from poor diabetes management Improve self-care for diabetes	Lifestyle education to prevent type 2 diabetes Prenatal care and intensive glucose management among pregnant women to prevent gestational diabetes Advice to overweight people to reduce weight by reducing food intake and increasing physical activity Education on diabetes self-management, including foot care and eye care	Measure blood sugar Screen for diabetic retinopathy	Drug therapy to control blood sugar Drug therapy to prevent progression of renal disease
Cancer	Prevent cancer Detect cancer at early stages Screen men and women for cancers amenable to early detection (cervix, breast, colorectal cancers) Ensure prompt diagnosis, treatment, and supportive and palliative care	Health education on cancer prevention and healthy lifestyles Hepatitis B vaccination for the prevention of liver cancer HPV vaccination for the prevention of cervical cancer	Examinations for early signs and symptoms of common cancers (lung, prostate, colorectal, breast, cervix, stomach, leukemia, etc.) Breast cancer clinical breast exam and/or mammogram, according to national guidelines Cervical cancer – pap test, HPV, DNA test, visual inspection with acetic acid (VIA), cryotherapy for treatment of precancerous lesions, according to national guidelines Oral cancer – screen in high-risk groups such as tobacco smokers Colorectal cancer – fecal occult blood test or colonoscopy, according to national guidelines	Refer to secondary level care for diagnosis and treatment, including surgery, chemotherapy, and radiotherapy. Provide post treatment follow up care Offer supportive care and palliative care
Chronic respiratory diseases	Control asthma and COPD Improve quality of care for persons living with asthma and COPD	Health education on self- management for persons with asthma and COPD	Assess asthma control using severity and frequency of symptoms	Drug therapy to manage stable asthma and COPD, as well as exacerbated asthma and COPD.

PAHO has disseminated this approach through the Evidence-Based Chronic Illness Care (EBCIC) course attended by over 1,000 primary health care providers. As a result, a total of 81 chronic care projects in 27 countries have been implemented, some of which have shown impact. For example, in Argentina, the REDES program increased the proportion of people with hypertension who were taking medication and decreased mortality due to stroke (personal communication, Sebastian Laspiur, Argentina Ministry of Health). In Cuba, after applying a chronic care approach, 62% of people achieved good glycemic control, according to international norms (). In Porto Alegre, Brazil, a chronic care program decreased hospitalization due to CVD and diabetes and improved hypertension control from 60% to 77% ().

Two other examples of a chronic care approach applied to improve hypertension control include the Canadian Hypertension Education Program () and the Kaiser Permanente model in northern California (). These models include a simple, standardized, and evidence-based treatment algorithm; the availability of and access to a set of core, high-quality medications; a clinical registry for monitoring patients and evaluating performance; and teamwork, with shared responsibilities, patient empowerment, and community participation. This approach was tested in Barbados with promising results, including improvement in hypertension control, development of a clinical registry, and improvement of prescription practices (). Similar hypertension control interventions are in place in Chile, Colombia, and Cuba.

An initiative of broader scope for CVD, the Global Hearts Initiative, has been launched that aims to reduce heart attacks and strokes by improving management of CVD in primary health care. Global Hearts is led by WHO in collaboration with the Centers for Disease Control and Prevention of the United States, PAHO, the World Heart Federation, the World Stroke Organization, the International Society of Hypertension, the World Hypertension League, and other partners ().

While these are illustrative examples of NCD management, most countries in the Region continue to have important gaps in the implementation of clinical NCD preventive services, secondary CVD prevention, and cardiac rehabilitation management (). For example, data from Argentina, Brazil, Colombia, and Chile show that only 18% of people with hypertension had blood pressure controlled (<140/90 mmHg) (), and only 12% of those with coronary heart disease or stroke were under treatment with three or more drugs of proven efficacy in preventing recurrence ().

Additionally, most countries report a lack of progress in health system response to managing CVD acute events. Public awareness is low, capacity and resources for early reperfusion therapy are insufficient, and infrastructure (such as stroke units) is inadequate (). Five priority interventions are recommended to improve this situation: (1) public communication and education to recognize symptoms and warning signs and seek emergency care; (2) equitable availability of emergency medical services; (3) broadened access to early reperfusion therapy, including availability of basic technologies; (4) coronary and stroke units within the health system that give priority to patients at highest risk of complications and death; and (5) rehabilitation programs for social reintegration of patients ().

Cancer includes a group of diseases with multiple causes that require specific health system interventions at all levels of care (Table 2). To effectively control cancer, PAHO/WHO promotes the development and implementation of national cancer control plans (Table 3), with public health and health service interventions that provide primary and secondary prevention, accurate and timely diagnosis and treatment, and palliative care (). More than half the countries in the Region (23 of 34 countries, 67%) report having a national cancer control plan, strategy, or policy in place (). Peru’s national cancer plan, Plan Esperanza, is an example of how a cancer plan can have an impact. Since it was launched in 2013, over 16 million Peruvians have received free cancer prevention services; 2.5 million have been screened for cervical, breast, stomach, colon, or prostate cancer; and the proportion of patients who paid out-of-pocket expenses for cancer treatment decreased from 58% to 7% ().

Table 3.National cancer control plan

Primary prevention	Screening and early detection	Diagnosis and treatment	Palliative care
Policies for tobacco, alcohol, healthy diets, physical activity Vaccination for hepatitis B and HPV Policies to reduce exposure to carcinogens in the workplace and the environment	Organized screening program, with quality assurance, for: Cervical cancer (HPV test, Pap test, or VIA test) Breast cancer (mammography) Colorectal cancer (fecal occult blood test or colonoscopy) Knowledge of early signs and symptoms of cancer, with prompt referral for diagnosis	Pathology services Chemotherapy, surgery, radiotherapy	Palliative care Regulations and education for access to opioids

Primary prevention

Screening and early detection

Diagnosis and treatment

Palliative care

Policies for tobacco, alcohol, healthy diets, physical activity
Vaccination for hepatitis B and HPV
Policies to reduce exposure to carcinogens in the workplace and the environment

Organized screening program, with quality assurance, for:

Cervical cancer (HPV test, Pap test, or VIA test)
Breast cancer (mammography)
Colorectal cancer (fecal occult blood test or colonoscopy)

Knowledge of early signs and symptoms of cancer, with prompt referral for diagnosis

Pathology services
Chemotherapy, surgery, radiotherapy

Palliative care
Regulations and education for access to opioids

Notable progress is being made in cervical cancer prevention, in which mortality has declined in 11 countries: Brazil, Canada, Chile, Colombia, Costa Rica, El Salvador, Mexico, Nicaragua, Panama, Venezuela, and the United States (). To date, 23 countries in the Region (58%) report introducing human papillomavirus (HPV) vaccines and 33 countries (87%) report available cervical cancer screening services, although only 5 of those countries report having adequate screening coverage of 70% or higher. Despite that breast cancer is the most common cancer in women, only 16 countries (42%) report that mammography is available, and only 3 countries report a screening coverage likely to have an impact (70% coverage or greater) ().

Prostate cancer continues to be the leading cause of cancer in men and is increasing in some countries in the Region (). Black men of African descent, specifically Jamaican men, are at greater risk of prostate cancer; the explanations for this are inconclusive (). Prostate cancer screening has not decreased mortality, and harm (impotence and incontinence) associated with prostate-specific antigen (PSA)-based screenings is frequent (). The current approach is, therefore, to strengthen cancer diagnosis and treatment ().

Cancer treatment in the form of radiotherapy and chemotherapy is generally available in the public sector in the majority of countries in the Americas (), but most cancer cases are diagnosed at an advanced stage, when treatment is less effective (). Palliative care is necessary to improve the quality of life of patients and their families by managing pain and providing physical, psychosocial, and spiritual support. Yet access to opioid medications, such as oral morphine for pain management, continues to be a challenge; availability is reported in only 50% of the countries ().

A set of cancer-control priorities, suitable for all resource levels, have been recommended as follows:
– primary prevention through tobacco control, alcohol reduction, healthy diet, and physical activity
– prevention of liver cancer through hepatitis B vaccination
– prevention of cervical cancer through HPV vaccination (two doses) for girls 9–13 years old; and through screening for women aged 30–49, either through visual inspection with acetic acid (VIA), Pap smear (cervical cytology) every three to five years, or HPV test every five years; linked with timely treatment of precancerous lesions
– early detection of breast cancer through screening with mammography (once every 2 years for women aged 50–69 years), linked with timely diagnosis and treatment
– population-based colorectal cancer screening through a fecal occult blood test starting at age 50 years, linked with timely treatment
– home-based and hospital-based palliative care with a multidisciplinary team and access to opiates and essential supportive medicine;

However, implementing these interventions will require strengthening health care systems, as follows:
– increase financial resources for cancer control, including access to high-cost drugs and procedures
– develop social protection policies against catastrophic health expenditure for poor individuals towards equitable services and coverage
– reduce long waiting times for diagnosis and treatment, especially in rural and remote regions and
– address the shortages of cancer specialists through use of telemedicine, and retraining of specialists ();

While they share the main cancer risk factors associated with other NCDs, cancers attributable to occupational exposures and environmental pollution have additional important sources of risk. The most common types of occupational cancer are lung, bladder, mesothelioma, leukemia, and skin. In general, the most common agents in the Region include solar radiation, environmental tobacco smoke, crystalline silica, pesticides, and asbestos (). The WHO global plan of action on workers’ health calls on governments to strengthen legislation and regulations to eliminate carcinogenic exposures in the workplace, to protect and safeguard workers’ health ().

A population-based cancer registry (PBCR) is recommended by WHO to inform cancer programs (). However, this requires significant resources, and in the Americas only 11 countries have high-quality PBCRs: Argentina, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Ecuador, Puerto Rico, Uruguay, and the United States (). Convened by the International Agency for Research on Cancer, the Global Initiative for Cancer Registry Development (GICR) is using regional expertise to establish hubs in Latin America and in the Caribbean in order to expand the coverage and quality of data from PBCRs.

Chronic respiratory disease (CRD)—principally chronic obstructive pulmonary disease, asthma, and occupational lung diseases—is responsible for approximately 372,000 deaths annually in the Americas (). Tobacco use, air pollution, and occupational chemicals and dusts are the most important risk factors for these diseases, which cannot be cured but for which effective treatment is available. Treatment is reported as generally available in the primary care facilities of the public health sector in the Region: 28 countries (74%) report availability of steroid inhalers and 33 countries (87%) report availability of bronchodilators. Guidelines on the management of CRD, however, are only implemented in 9 countries (24%), and only 8 countries (21%) indicate that they have an operational policy, strategy, or action plan specific for CRD. Better surveillance to establish the magnitude of CRD, and primary prevention to reduce risk factors and improve health care for people with CRD, are urgently needed to improve quality of life for those affected by CRD.

Mental Health

No health without mental health

It is widely acknowledged that mental health is a fundamental component of health (). Member States adopted the Plan of Action on Mental Health 2015–2020 (), committing to “a region in which mental health is valued, promoted, and protected, mental and substance-related disorders are prevented, and persons with these disorders are able to exercise their human rights and to access both health and social care.” The plan includes four strategic lines of action on mental health policies: community-based services, promotion and prevention, information systems, and evidence and research. Mental, neurological, and substance-use (MNS) disorders were recognized in the global scenario as health priorities and ratified in the international development agenda ().

Burden of MNS disorders

Mental disorders represent an alarming public health concern. Ten percent of the world’s population and 20% of children and adolescents suffer from some mental or neuropsychiatric disorder, and this doubles among populations facing humanitarian emergencies (). MNS disorders are responsible for 12.35% of disability-adjusted life years (DALYs) and 35.9% of years lived with disability (YLDs), making them the leading cause of global disability. In the Americas, MNS disorders are the leading cause of disease burden, accounting for 19% of DALYs, and they are the largest source of disability, responsible for 34% of YLDs. Depression is the leading factor, or 8% of YLDs, while anxiety and substance use disorders (including alcohol) are responsible for 5% and 3% of YLDs, respectively ().

Socioeconomic impact

The global cost of MNS disorders has increased to US$ 8.5 trillion and is projected to double by 2030 (). Although scaling-up services for depression and anxiety might cost only US$ 1.50 annually per person, the resources gap is significant due to the existing low coverage levels. The disparity between burden of disease and available resources results in treatment gaps of 73.5% among adults with severe/moderate disorders, 82.2% among children and adolescents (), and bigger gaps among indigenous and African-American descendants (). Nevertheless, such investment could represent a return value of US$ 709 billion and benefit-to-cost ratios of up to 3:1 (). For the Region, not taking action represents a gross domestic product (GDP) annual loss of 0.82% in Costa Rica, 0.58% in Jamaica, and 1.42% in Peru (). Costs are higher if also considering mid- to long-term effects of maternal depression and poor care practices on early child development, burden of substance use disorders (), and dementia as growing Regional concerns ().

Emergencies

Mental health preparedness and response are critical components of any emergency (); the relationship between mental and physical health becomes closer and bidirectional following emergencies (), and exposure to extreme stressors is a main risk factor for mental illness (). Community-based services constitute an important intervention level during emergencies, with communities engaging in nonspecialized activities across sectors aiming for a return to normal living conditions (). Indeed, emergency settings became opportunities to improve regular sustainable mental health systems ().

Human rights

Multiple treaties and conventions () require countries to adopt a paradigm shift to an approach firmly rooted in the promotion and protection of human rights (). People with mental disorders experience a wide range of violations of human rights (). Children with psychosocial disabilities are neglected in particular when living in institutional settings, a harmful but still a common practice; mental institutions are associated with human rights infringements (); and in low-income countries, people with severe mental illness die up to 30 years younger than their peers ().

Main MNS conditions

Most common mental disorders

Depression results from a complex interaction of social, psychological, and biological factors; it can develop after exposure to adverse life events that become chronic stressors, and at moderate or severe intensity it can lead to suicide (). Anxiety disorders include acute problems and chronic conditions involving significant stress-related symptoms; recurrent, excessive, sudden, or progressive displays of anxiety or worry; and impaired daily functioning (). Depression and anxiety account for 13% of YLDs and 5.5% of DALYs in the Americas.

Severe mental disorders

Schizophrenia results from an interaction of genetic, environmental, and psychosocial factors. People with schizophrenia are 2.5 times more likely to die early; they also experience stigma and neglect when treated in traditional psychiatric hospitals (). Bipolar affective disorder is a severe type of depression consisting of manic and depressive episodes separated by periods of normal mood (). Schizophrenia and bipolar disorder account for 3.4% of YLDs and 1.5% of DALYs in the Americas ().

Children and adolescents

Developmental and behavioral disorders are specific conditions affecting children and adolescents; they usually have an early onset and a regular sustained development, and they can persist into adulthood. These disorders are characterized by impairment or delay in functions related to maturation of the central nervous system, diminished ability to adapt to the daily demands of life, and increased vulnerability to physical illness and to other mental and neurological conditions (). Developmental and behavioral disorders account for 2.2% of YLDs and 0.9% of DALYs in the Americas ().

Suicide

Suicide is determined by the interaction between psychosocial, biological, and psychiatric factors. A systematic review from 2003 showed that up to 90% of suicidal victims have a diagnosable mental disorder (). Attempted suicide is 10-20 times more common than completed suicide (), and while suicidal ideation is a predictor of suicidal acts (), the strongest risk factor is a previous suicide attempt. In the Americas, according to estimates from 2005–2009, suicide has a mortality rate of 7.3 per 100,000 and is responsible for 1.6% of total DALYs. Chile, Uruguay, and Trinidad and Tobago have rates of more than 10 per 100,000. Suriname and Guyana have the highest rates of the Region, with 23.3 and 26.2 per 100,000 population, respectively (). Significant efforts in suicide prevention are being conducted. Guyana, for instance, has launched a National Mental Action Plan for 2015–2020 and a National Suicide Prevention Plan.

Dementia

Dementia is a syndrome in which there is deterioration in memory, thinking, behavior, and the ability to perform everyday activities beyond what might be expected from normal aging. With more people reaching an advanced age, dementia constitutes a big concern for Latin America and the Caribbean (LAC), with a projected increase of 47% by 2030 in the prevalence of severe disabilities affecting people aged 60 and older (). Dementia accounts for 1.2% of YLDs and 2% of DALYs in the Americas ().

Epilepsy

Epilepsy can be caused by genetic and congenital abnormalities, brain damage, tumors, and infections such as meningitis, encephalitis, neurocysticercosis, and cerebral malaria (). In the Americas, epilepsy is one of the most frequent chronic neurological disorders; it affects 5 million people and accounts for an annual death rate of 1.04 per 100,000 population. Although epilepsy responds to treatment 70% of the time and the cost of medication is as low as US$ 5 per patient per year, more than 50% of persons in LAC with epilepsy do not receive treatment (). Epilepsy accounts for 0.8% of YLDs and 0.5% of DALYs in the Americas ().

Substance use disorders

Some 85 million people use illicit substances each year in the Americas; their use is associated with adverse health and social consequences, particularly for young people (). A public health approach to reduce substance use includes prevention, treatment services, monitoring, and surveillance. Substance-use disorders account for 1.8% of YLDs and 1.5% of DALYs in the Americas ().

Conditions of disability

In the Americas, 140 million people live with some form of disability, and rates are increasing due to the aging population and their chronic conditions. Those living in psychiatric institutions experience higher levels of disability. Among persons with disabilities, only 3% have access to rehabilitation. MNS disorders are the biggest contributors to the burden of disabilities. Their treatment cannot be limited to the physical domain, but should also include the psychosocial axis, addressing the needs of, and impact on, relatives and communities ().

Strategies and interventions

Insufficient treatment coverage and inadequate and outdated models of care need to be addressed. The service structure is fragmented and there is insufficient coordination between primary, secondary, and tertiary levels. There exists a heavy emphasis on mental institutions at the expense of delivering mental health care in primary- and secondary-care settings and at the expense of developing community-based models (). Allocated resources are scarce and are distributed inequitably and inefficiently. While LAC countries assign 1%-5% of the total public health budget to mental health, 88% of funds are allocated to psychiatric hospitals that serve 10% of those requiring mental health services. Psychiatric hospitals persist as a result of tradition and the absence of comprehensive models of care. People living in mental institutions do not receive individualized care based on their needs and rights (). Mental health should be integrated into existing care delivery channels as a key strategy to close the treatment gap in the Region. That effort targeted prevention and promotion programs; services through primary health care; rational cost-effective roles for secondary and tertiary levels of care; comprehensive community-based services; and synergetic interactions with key areas, stakeholders, and actors within and beyond the health sector ().

Prevention and promotion

The first step in reducing the burden of mental illness is tackling its onset with evidence-based interventions to help prevent MNS disorders and protect mental well-being, particularly in the early stages of life. Because up to 50% of adult mental disorders begin before the age of 14, fundamental action lines include early prevention, identification, and treatment of emotional or behavioral problems in childhood and adolescence. Powerful models of mental health promotion and prevention provide strong evidence about their effectiveness and represent promising starting points in reducing mental health illness and its consequences. Because suicide is a potential outcome of MNS disorders, suicide prevention is an essential component of any strategy ().

Care levels and community-based services

To integrate basic mental health services into primary health care (PHC), it is extremely important to adopt task-sharing approaches (also known as task shifting), especially in countries with limited specialized human resources (). With proper care from PHC professionals, psychosocial assistance, and medication, tens of millions could be treated for MNS disorders, prevented from suicide, and begin to live normal lives even where resources are scarce ().

Developing a community-based model with new services and alternatives is a key element in offering comprehensive, specialized, and continuous mental health services (). The recommended strategy is to shift resources allocated to mental hospitals into development of service networks that cover persons with MNS disorders and other potential users. This model allows progressive replacement of mental institutions and offers a higher quality of secondary-level care to people who need acute, mid- and long-term specialized care. The objective is recovery rather than cure; the services include psychosocial rehabilitation and they combine psychosocial and pharmacological interventions. Recommended services to develop include: (a) community mental health centers with specialized professionals in charge of the mental health needs in specific catchment areas; (b) coordination with facilities that provide acute care and support from health workers at the PHC level; (c) community-based residential facilities that provide overnight residence for people with relatively stable and long-term mental disorders; (d) psychiatric services in general hospitals to take care of patients’ needs during acute phases and the needs of nonpsychiatric patients in the hospital (interconsultation); and (d) day hospitals that provide more intense treatment and structured support for users who have failed to respond to outpatient care or have been discharged from inpatient care ().

Opportunities for integration and challenges

Community-based interventions are an opportunity for integrating referrals and coordinating interventions between sectors, sharing material and human resources, and innovation and sustainability. Key areas for collaboration include maternal and child health and nutrition; children and adolescents; gender, aging, and disability; noncommunicable diseases such as cancer, diabetes, and cardiovascular disease; and communicable diseases such as HIV/AIDS and tuberculosis; and substance-use problems and disorders ().

Barriers to introducing this model and implementing the required reforms include the complexity of decentralizing mental health services; resistance from authorities and health professionals; the low number of workers trained and supervised in mental health care; and a scarcity of public health perspectives in mental health leadership (). Although 81% of countries in the Region have a stand-alone mental health policy/plan, 50% do not have laws or regulation frameworks. Just 34% have mental health legislation that is partially or fully implemented and in satisfactory compliance with human rights standards ().

In addition to national authorities, civil society also typically tries to create conditions that encourage successful community integration and participation (). Together, government institutions and civil society share responsibilities to build tools and promote and monitor effective implementation. The Region is making serious efforts to overcome the challenge of shifting from services at traditional psychiatric hospitals to a community-based model that results in better care and rehabilitation of people with MNS disorders and other types of disabilities ().

Road Traffic Injuries

Road transportation is considered the most complex and dangerous essential human activity (). In the Americas, road crashes kill 154,089 people each year, or 12% of road traffic deaths worldwide (). The regional death rate is 15.9 per 100,000 people, marginally lower than the global rate of 17.4 per 100,000 (). However, there are variations between countries, with national rates ranging from a low of 6.0 per 100,000 population in Canada to a high of 29.3 per 100,000 population in the Dominican Republic (). Nearly half the world’s road traffic deaths occur among pedestrians (22%), motorcyclists (20%), and cyclists (3%), all of whom are considered vulnerable road users ().

A combination of economic changes, unmet need for public transportation, traffic congestion, and a number of other factors associated with motorcycle use (their comfort, low cost, readily available financing, ease of maintenance, and the appeal of urban mobility) have resulted in motorcycle sales outpacing economic development. The results is that the number of motorcycles on the roads has increased by more than six-fold ().

In the Americas, 73% of road traffic deaths occur in middle-income countries, whereas 26% take place in high-income countries. The motorcycle fleet in the Region has increased by 45%, while the automobile fleet has grown by 11%. The rapid and massive introduction of motorcycles in countries of the Americas—used for activities varying from urban delivery services to cattle driving in rural regions—is a relatively recent phenomenon, and has not yet been absorbed into the culture of local road traffic.

Although motorcycles have provided unprecedented mobility for many, the rapid rise in their use has led to large increases in motorcycle injuries and death. Mortality among motorcyclists increased from 15% to 20% in 2013, and in some countries of the Americas, the proportion of motorcycle users involved in road fatalities has exceeded pedestrian fatalities. Furthermore, poorer countries in the Region have higher motorcycle fatality rates than richer countries ().

In the early 2000s, after the United Nations requested that WHO coordinate global efforts to tackle road traffic injuries (RTIs), PAHO/WHO emphasized their importance as a public health concern. This launched a multisector response involving the health sector, law enforcement, traffic/transport engineering, and road safety education. The effort has faced challenges, particularly in defining the role the health sector can play and what impact it can have in improving road safety.

PAHO has provided direct technical support to ministries of health, with plans, programs, projects, legislative improvements, publications, and road safety policies. It has monitored road safety indicators through regular reports, encouraged the collection and analysis of national data, and built local capacity for integration and technical cooperation between countries. Also, it has advocated designating road safety as a public health issue in national policies, and for strengthening the health sector’s response on road safety initiatives.

The Vida no Trânsito (“Life in Traffic”) project, implemented in Brazil in 2010, is illustrative of the health sector’s approach to road safety. The project, led by PAHO and Brazil’s Ministry of Health, was based on the need for good data and multisectoral coordination. It was initially implemented in five state capitals and was later extended to other cities. The strategy consists of national and local multisectoral road safety commissions that are firmly backed by program directors and authorities such as mayors.

Local commissions gather data from multiple sources (health, police, and traffic/transport) and generate information on the crashes (type, nature, time, days, places, etc.), victims’ profiles, and the risk factors involved. This resulted in focused interventions with measurable goals to build capacity, raise awareness, and implement best practices for road safety. The initiative’s visible results include increased speed control and alcohol checkpoints and sobriety tests (with fewer drivers testing positive). As a result, the mortality rate declined in most of the cities that enacted the project.

In 2011, PAHO adopted the Plan of Action for Road Safety (), which was approved during the 51st Directing Council. This plan is consistent with the UN Decade of Action for Road Safety 2011&ndash2020, which acts as a call to action for Member States to adopt road safety policies. More recently, the 2nd Global High-Level Conference on Road Safety, held in Brazil in 2015, provided further opportunities for countries to strengthen their road safety response. There, Member States adopted the Brazilian Declaration on Road Safety (), developed through a long intergovernmental process involving consultation with different stakeholders. The Brazilian Declaration highlights road safety measures coupled with equity/inclusion issues that are highly relevant in the Region. Furthermore, it extends the health sector’s role beyond RTI prevention and addresses issues such as mobility and active, sustainable modes of transportation—walking, cycling, and public transportation.

The Brazilian Declaration, endorsed by the 58th United Nations General Assembly (), reinforces the Sustainable Development Goals (SDGs), to reduce road traffic deaths and injuries by 50% by 2020, and it consolidates the linkage of road traffic safety and sustainable mobility policies. This is reflected in the SDG 11.2 target, which aims to provide access to safe, affordable, accessible, and sustainable transport systems for all. Its objective is to improve road safety, notably by expanding public transportation, with special attention to the needs of those in vulnerable situations, e.g., women, children, persons with disabilities, and older persons.

Interpersonal Violence Prevention

Interpersonal violence takes many forms, including multiple manifestations of violence against children, youth, and women, as well as the elderly. All forms of interpersonal violence lead to negative health outcomes, threaten development, undermine quality of life, and erode communities’ social fabric. Recognizing the impact that violence has on development, the 2030 Agenda for Sustainable Development includes multiple targets relating directly to violence under Goal 5 for achieving gender equality and empowering women and girls (targets 5.2 and 5.3) and under Goal 16 for promoting just, peaceful, and inclusive societies (targets 16.1 and 16.2).

The Americas is one of the regions with the highest levels of violence, a phenomenon that has had a significant negative impact, particularly in the countries where it is most common. The 2014 Global Status Report on Violence Prevention (GSRVP) () shows that there were an estimated 185,235 deaths from homicide in the Region in 2012 (the last year for which data are available). The average homicide rate was 19.4 per 100,000 (35.1 for males and 4.1 for females). Young male adults (aged 15–44 years) bear much of this burden, accounting for about 72% of the deaths. Over the period 2000–2012, homicide rates were estimated to have increased by about 20% in the Americas as a whole; nearly all of the increase was in low- and middle-income countries, while high-income countries reported negligible changes ().

Women, children, and older persons bear the brunt of nonfatal physical, sexual, and psychological abuse. Such violence can contribute to lifelong ill health—particularly for women and children—and early death. For example, one in three women in the Americas has experienced violence from an intimate partner or sexual violence by a nonpartner during her lifetime () and over 99 million children report experiencing some form of child maltreatment in the last 12 months ().

Interpersonal violence can be effectively prevented and its far-reaching consequences can be mitigated, although different types of violence may require different strategies. According to the GSRVP (), several countries in the Americas have begun to implement prevention programs and victim services and to develop national action plans, policies, and laws to prevent and respond to violence. However, planning efforts have been undermined by severe lack of data to guide actions, and by lack of funding for national plans and policies on violence prevention. As for the lack of data, most instances of nonfatal violence against women, children, and older persons do not even come to the attention of authorities or service providers. In addition, while countries are investing in violence prevention programs that include the seven WHO strategies for violence prevention (Box 4 (159)), their investment is not on a level commensurate with the scale and severity of the problem. Moreover, since evidence regarding “best buy” violence prevention strategies is limited and biased in favor of high-income countries, it may be challenging for governments in low- and middle-income countries to decide where to invest.

Box 4. “Best buy” violence prevention strategies

Develop safe, stable, and nurturing relationships between children and their parents and caregivers.
Develop life skills in children and adolescents.
Reduce the availability and harmful use of alcohol.
Reduce access to guns and knives.
Promote gender equality to reduce violence against women.
Change cultural and social norms that encourage violence.
Identify victims and provide them with care and support programs.

Source: Pan American Health Organization. Status report on violence prevention in the Region of the Americas. Washington, D.C.: PAHO; 2014.

The GSRVP also shows that countries of the Americas have addressed key risk factors for violence through policy and other measures, such as ones on the harmful use of alcohol or the accessibility to firearms. However, fewer than half of the 22 countries surveyed have implemented social and educational policies that would help mitigate these risk factors—such as incentives for youth who are at risk of violence to complete secondary schooling, or housing policies explicitly aimed at reducing violence by reducing the concentration of poverty in urban areas.

Moreover, the GSRVP reported that although laws to prevent violence are largely in place, enforcement is often inadequate. The biggest gaps between the existence of laws and their enforcement were laws pertaining to rape, to sexual violence involving contact but without rape, and to noncontact sexual violence. Finally, the report indicated that the availability of high-quality care and support services to identify, refer, protect, and support victims of violence is highly variable. For example, the medical-legal services most widely reported to exist on a large scale are services pertaining to sexual violence and child protection; services least likely to exist are those pertaining to elder abuse. (The quality of these services and their accessibility were not ascertained.)

To realize the full potential of violence prevention, policies, plans, and programs should be adequately funded; data collection and management should be strengthened; research regarding effective violence prevention strategies should be promoted; national violence prevention action plans should be developed and should be people-centered, context-specific, comprehensive, evidence-informed, and integrated into other health and nonhealth platforms; laws should be enforced; and care services for victims should be comprehensive and informed by evidence ().

In 2016, PAHO joined efforts with numerous UN and national government agencies to launch the INSPIRE project (), an initiative to help countries and communities achieve the SDGs 5 and 16. INSPIRE includes seven strategies (Table 4) that together provide a framework for ending violence against children and that may also prevent violence against women. These agencies stand together and urge countries and communities to intensify their efforts to prevent and respond to violence against children by implementing the strategies in this package.

Table 4. INSPIRE package for preventing and responding to violence against children aged 0–18 years ()

Strategy	Approach
Implementation and enforcement of laws	Laws banning violent punishment of children by parents, teachers, or other caregivers Laws criminalizing sexual abuse and exploitation of children Laws that prevent alcohol misuse Laws limiting youth access to firearms and other weapons
Norms and values	Changing adherence to restrictive and harmful gender and social norms Developing community mobilization programs Promoting bystander interventions
Safe environments	Reducing violence by addressing “hot spots” Interrupting the spread of violence Improving the built environment
Parent and caregiver support	Via home visits Via groups in community settings Via comprehensive programs
Income and economics	Cash transfers Group saving and loans combined with gender-equity training Microfinance combined with gender-norm training
Response and support services	Counseling and therapeutic approaches Screenings combined with interventions Treatment programs for juvenile offenders in the criminal justice system Foster care interventions involving social welfare services
Education and life skills	Increasing enrollment in preschool, primary, and secondary schools Establishing a safe and enabling school environment Improving children’s knowledge about sexual abuse and how to protect themselves from it Providing training in life skills/social skills Offering programs for adolescents focused on preventing violence between intimate partners

Disabilities

The number of people with disabilities in the Region of the Americas is growing due to the aging population, an increase in NCDs, and changes in lifestyles (). It is estimated that these disabilities represent 66.5% of DALYs in low- and middle-income countries (). Occupational injuries and those caused by traffic accidents, violence, and humanitarian crises are most common, with 1.7% of DALYs attributed to injuries caused by traffic accidents and another 1.4% to violence and conflict ().

The World Report on Disabilities shows that about 15% of the world population lives with some type of disability (). In the Region of the Americas, approximately 140 million people are living with disabilities; 2% to 3%, or 2.8 to 4.2 million people, have disabilities serious enough that they affect functioning. Only 3% of those with some type of disability have access to rehabilitation services, and 3% have a high level of dependency on another person to perform their vital activities ().

Disabilities disproportionately affect vulnerable populations: the highest prevalence is among the poorest quintile, as well as women and the elderly. People with low incomes, without work, or with little academic training have an increased risk of disability, as do ethnic minorities and indigenous groups. Compared to those without disabilities, people with disabilities have worse health outcomes, less education, higher poverty rates, and participate less in economic activity. This is due in part to the obstacles they face in accessing health services, education, employment, transport, and information ().

Estimating the prevalence of disabilities in the Region continues to present major challenges primarily because there is little consistency in the criteria for measuring them. However, the 2010 round of censuses provides an accurate estimate of the prevalence of disabilities and of country-to-country comparisons (Figure 1). Women have a higher rate of disability than men, especially women over 60, who are more likely to have health problems and often become disabled; this population also often lacks resources and access to affordable support services. They are among those who devote more time to caring for a family member with a disability, and are at greater risk for acquiring a disability themselves. Also, people living in rural areas are at greater risk of living with a disability compared to those in urban areas. Finally, the censuses show that compared to other groups, people of African heritage in Brazil, Colombia, Costa Rica, Ecuador, El Salvador, Panama, and Uruguay are more likely to be disabled, particularly men and children under the age of 18.

Visual impairments, hearing problems, and limitations in mobility associated with increasing age, as well as mental and neurological disorders and intellectual disabilities, are all very common in Latin America and the Caribbean ().

Although significant, the direct and indirect economic and social costs of disability are difficult to quantify. It is important to know the cost of disability in order to determine the investments that are needed and to design good public policies and implement services. However, even in the developed countries, information on the cost is scarce and fragmented, partly because neither definitions nor methods of measurement are standardized. Standardized definitions and methodologies are needed.

For people with disabilities, the greatest challenge is improving aspects that affect the quality of life—accessibility, social acceptability, educational opportunities, job opportunities, and the right to exercise citizenship. The WHO World Report on Disability () and ECLAC report on the Social Panorama of Latin America () found that people with disabilities have the poorest health outcomes and highest rates of poverty. They also have poorer educational performance, lower rates of participation in economic activity, more restricted opportunities, and are more likely to be dependent.

To meet the needs of people with disabilities, it is necessary to overcome social, environmental, and physical challenges—developing appropriate policies, addressing negative social views, improving accessibility and delivery of services, making reliable data more available, and involving people with disabilities in decision-making. To address these issues, PAHO/WHO is working with Member States to develop programs, strengthen rehabilitation services (including health and social services and access to devices for technical assistance), and improve data.

Figure 1. Prevalence of disabilities in the Americas (based on 2010 census data)

Source: PAHO/WHO elaboration according to publically available census data from 2010

Chronic Conditions, Life Course, and Social Stratification

Health disparities are closely linked to social, economic, and/or environmental disadvantage. Subgroups that have historically faced discrimination and exclusion encounter greater obstacles to health, and the disparities they face are caused by factors beyond any individual’s behavior or choices (). Individual behavior accounts for only approximately 30% to 50% of deaths and other health outcomes.

Over the course of a life, social stratification and social and economic conditions have a strong modifying effect on health of the population (). Even small initial differences in the conditions at birth and in early childhood widen with passing years and can lead to large health differences among adults (). Improvements in living conditions and health during the last decades of life invalidate the assumption that the elderly are more vulnerable simply because of their age. Due to increased life expectancies, growing proportions of people with limited resources are now reaching the age of retirement and a very old age. However, because of the social determinants of health, there are larger gaps in health outcomes in the older population, which are reflected mainly in indicators of morbidity and mortality associated to chronic diseases and conditions (). Also, social stratification and a life course perspective are closely interconnected. Family and social support can be significant resources, but they can also be sources of stress when responses are nonadaptive.

Conclusions

Unprecedented socioeconomic, demographic, and epidemiological changes in recent decades in the Americas have led to significant changes in the population’s health status. NCDs, mental disorders, disabilities, road traffic injuries, and interpersonal violence are, cumulatively, the leading health problems and urgently require strengthening of multisectoral policies and health systems.

NCDs are largely preventable by tackling their common risk factors; they can be better managed by improving health systems to provide chronic care for people at risk of or living with an NCD. There are global commitments and targets for reducing the burden of NCDs, as well as consensus on cost-effective and feasible health policies and health service interventions; it is now a matter of making greater investments, strengthening multisector collaboration, and building country capacity to implement the interventions. The treatment gap for mental disorders can be reduced by integrating mental health care in primary- and secondary-care settings and moving away from providing treatment in mental institutions. Road safety measures should be addressed through legislation and regulations, which are urgently needed to reduce speed, enforce the wearing of seat belts, and increase the use of motorcycle helmets. People with disabilities, both physical and mental, need better access to community-based rehabilitation services, health services, and more support services. Violence of all types, a significant problem in the Americas, is strongly associated with weakened governance; poor rule of law; cultural, social, and gender norms; increasing unemployment; income inequality; and limited educational opportunities. Stronger violence prevention measures are needed, with legislation and regulations that limit access to firearms and other weapons, reduce excessive alcohol use, and offer enhanced services for victims of violence.

Advances in science, technology, and knowledge, together with the Sustainable Development Goals and numerous public health commitments to tackle health issues, offer a promising future for improved health and well-being for the people of the Americas.

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1. Information and reference on the Vida no Trânsito project is located on the PAHO website: https://www.paho.org/bra/index.php?option=com_content&view=category&id=1249&layout=blog&Itemid=787.

There is a new version of Health in the Americas available in https://hia.paho.org/en