A nonmedical paradigm for public health.

In the last decades, Latin America and the Caribbean have achieved measurable gains in some important health indicators, such as life expectancy, infant mortality, reduction in the prevalence of several infectious diseases, and the eradication of poliomyelitis.

At the beginning of the last century, for every one thousand live births more than one hundred infants died in the first year. Today, that number has been reduced to about thirty as a regional average, with keen differences: in Haiti, the rate is still higher than eighty per thousand, while in both Cuba and Costa Rica the rate is about ten per thousand live births. This improvement in health indicators has been, to a large extent, the result of better living conditions: better nutrition, higher education levels, improved sanitation, successful public health policies, and better quality of health services.

But now these critical gains are at risk of being rolled back because of government economic policies that are widening the gap between rich and poor, and by health-sector policy reforms that in several cases appear to be driven mainly by financial and/or political considerations.

In theory, health-sector reform aims at improving the health status of populations by improving access, quality, and efficiency of health services. It is part of a political transformation process that redefines the role of government and the public and private sectors. In many countries, a central feature of this process is the transfer of state responsibilities for health to the private sector. Often, however, the state's role is undermined and the most vulnerable sectors of the population receive even less access to health services.

In some cases, rather than reducing inequities, the health-sector reforms have increased them. This has happened because these reforms, strongly advocated for and supported by international financial institutions, have put greater emphasis on privatizing services rather than on improving the outcomes of health interventions.

Despite progress, the countries of Latin America and the Caribbean still face daunting challenges due to sprawling urbanization and environmental problems that affect citizens of all ages, but have a particularly negative impact on children. At the same time, some countries are experiencing an unrelenting increase of HIV/AIDS, malaria, dengue, tobacco and substance abuse, noncommunicable diseases, and physical and mental disabilities. Increasingly, violence and accidents are responsible for an important percentage of deaths, mainly among young men.

Maternal mortality is an important health indicator. A high level of maternal mortality is usually due to insufficient health coverage and inadequate health services. Maternal morbidity is also a considerable problem, since it has been shown that for every maternal death sixteen women become ill during pregnancy, child birth, or postpartum up to six weeks after delivery.

While maternal mortality rates have experienced very little improvement in the last decade, the gap between the Latin American and Caribbean countries and the United States and Canada has increased: The risk of dying during pregnancy, childbirth, and postpartum is over forty times greater in developing countries than in those industrialized countries. The risk is particularly great among young women from indigenous and poor sectors of the population, reflecting a glaring inequity, particularly when one considers that these deaths are preventable through simple, cost-effective measures.

To improve the situation it is important to increase public investment in infrastructure and basic equipment and supplies, adopt policies that increase access to essential medicines, make widely available safe blood supplies, and improve epidemiological surveillance. It is also important to address more effectively issues such as violence, which is claiming a growing number of victims, and demanding a political as well as a public health solution.

This is a critical moment for implementing a new paradigm that promotes health and disease prevention and addresses the nonmedical determinants of health. Increasing health expenditures will not, by themselves, lead to improvements in public health, as successful health policies in Cuba and Costa Rica have shown. What is necessary is to have more equitable health policies with emphasis on the most vulnerable sectors of our populations.

It is crucial to strengthen the role of the state through stronger alliances between the public-health sector with the education, agriculture, labor, housing, and water and sanitation sectors. At the same time, it is important to increase the cooperation between governmental and nongovernmental organizations, and to improve the exchange of health information among countries. These actions will effectively reduce the burden of disease, and will translate into better health and quality of life for all citizens of the hemisphere.