Public Health

Providing public health care has long been a special challenge for Latin America. Because much of the region lies in the tropics, Latin America is home to many microorganisms that can bring illness and death to human hosts. Economic underdevelopment has impeded governments' efforts to provide clean water, proper sewage disposal, vaccinations, and care for the sick. And because many people in Latin America are poor and malnourished, they have weak or compromised immune systems, depriving them of the best defense against illness. Only in the twentieth century have significant strides been made in improving public health care in Latin America, but this progress has been very uneven.

COLONIAL ERA

Until the arrival of the Europeans in the late fifteenth century, the Western Hemisphere had enjoyed complete isolation from some global disease pools. The conquerors and their African slaves introduced into the Americas many deadly epidemic diseases from which the natives had no natural immunities to protect them. Smallpox, measles, influenza, typhus, and many other afflictions ravaged the New World; its population fell by roughly 90 percent in the first 110 years after the Conquest. Almost nothing could have been done to halt this disaster, and certainly little was tried. At the time, about the only public health measure taken was sometimes to quarantine incoming ships and isolate their crews during the worst epidemics.

European notions about the origin and spread of disease generally focused on miasmas (Greek for "pollution" or "stain"), which were believed to be foul, disease-bearing airs that arose from putrefying organic waste. Traditional medicine stressed the need to rid the body of poisons and recommended frequent bleedings, induced vomiting, sweating, and repeated enemas. One stood a better chance of recuperating if a doctor's ministrations could be avoided. During the era of the Spanish Bourbon Reforms, especially under King Charles III (1759–1788), enlightened colonial officials began to take more aggressive public sanitation measures to rid communities of the sources of miasmas. The clean-up campaigns served to make urban settings less foul but could do little to prevent or halt most epidemics.

THE NINETEENTH AND TWENTIETH CENTURIES

Beginning in the closing decades of the nineteenth century, several critical advances led to the rise of the modern era of public health in Latin America. The economy of Latin America rose swiftly in these years on the strength of increased primary product exports to the developed world. In the cities that served as the focal points for this expanding trade, control of epidemics became an urgent business concern, for quarantines halted commerce. Fortunately, these socioeconomic developments coincided with some stunning scientific breakthroughs in the field of medicine. In Europe the work of Robert Koch, Louis Pasteur, and others established the germ theory of disease. Their work, along with that of many others—including Latin Americans Oswaldo Cruz, Carlos Chagas, and Carlos J. Finlay—provided a sound theoretical basis for attacking the spread of infectious diseases.

Accordingly, by the late nineteenth and early twentieth centuries Latin American cities underwent significant sanitary reforms, including the construction of their first mass potable water systems and underground sewers (greatly reducing the risk of cholera, typhoid fever, and other water-borne diseases). They established vaccination programs against smallpox (which was quite effective) and bubonic plague (less so); developed mosquito abatement programs (greatly reducing the risk of yellow fever and malaria); began to inspect and regulate the sale of food, especially milk and meat; and opened modern laboratories to test foods and drugs for purity. They also built many new hospital facilities, incorporating modern medical methods developed in Western Europe and the United States, in particular better diagnostic and surgical techniques (including anesthesia and asepsis) and more specialized training of physicians. Doctors typically received their advanced training in France, although some good schools were established in the leading Latin American cities. National health departments were also formed across Latin America, beginning in Argentina and Uruguay.

These advances in medical treatment and urban sanitation contributed to an overall lowering of death rates in Latin America, which followed from a reduced incidence of infectious diseases such as yellow fever, cholera, typhoid fever, bubonic plague, smallpox, typhus, and tetanus. But other factors may actually have played a larger role. Scholars disagree as to what best explains the transition from lower overall death rates to rapid population growth. Some believe that microorganisms were gradually changing, becoming less deadly. Certainly there would be an evolutionary tendency for microorganisms to move in that direction: if they killed their hosts, they, too, died. Another possible factor for Latin America may have been the end to the African slave trade by the 1860s, which halted the steady importation of people from other disease environments. Perhaps most important of all was a general improvement in diet and housing conditions, although measuring such progress is difficult.

Certain political circumstances made government action in the field of public health more likely. Health care reforms came fastest in those nations where the urban middle class and the trade union movement first grew strong. As they pushed for incorporation into the political system, they also advanced a social agenda that included health concerns. Where skilled export workers occupied a strategic bottleneck position in the economy, they could sometimes join with privileged middle-class employees and press effectively for reforms. The elites responded by co-opting these groups with the creation of health programs to serve them, even as the health needs of those with less political leverage were ignored. Social programs to provide medical insurance for the middle class and favored sectors of the urban working class were enacted in Argentina, Brazil, Chile, Cuba, and Uruguay as early as the 1910s and 1920s.

In some circumstances, imperialism led directly to sanitation and public health reform. The United States occupation of Cuba, Haiti, the Dominican Republic, and Panama and, likewise, British control of Jamaica, meant stationing officials and troops in unhealthy tropical zones. Responding to this threat to their own citizens, the United States and Great Britain carried out massive public works projects in their colonial holdings, including effective mosquito abatement measures and the construction of hospitals, potable water systems, and underground sewers, thereby greatly reducing public health risks for all.

TWENTIETH-CENTURY PROGRESS

During the twentieth century international organizations played an important role in the advancement of Latin American public health care. Based in the United States, the Rockefeller Foundation's International Health Division (created in 1913) took an active role, launching campaigns against malaria, yellow fever, and hookworm. The programs against yellow fever and malaria proved quite effective, even if the hookworm campaign did not. Overall, however, the foundation's usual practice of retaining direct control over policies and funding often rankled public officials in host nations.

The Pan American Health Organization (PAHO) also played a key role in Latin American public health progress in the twentieth century. The first Pan American Sanitary Conference met in 1902, under the aegis of the Pan American Union (now the Organization of American States). This small organization was actually run and staffed through the Surgeon General's Office of the U.S. Public Health Service. By 1924 the organization had drawn up the Pan American Sanitary Code, adopted everywhere in the Americas by 1936. In 1947 the Pan American Sanitary Bureau (PAHO since 1958) finally obtained its own building in Washington, D.C., and added more personnel. In 1949 this bureau became a Latin American regional organization under the newly created World Health Organization. PAHO came to play an important role in the eradication of infectious diseases such as smallpox, malaria, and yellow fever.

Over the course of the twentieth century life expectancy doubled in Latin America, with most of the gain coming from the lowering of infant mortality rates (the number of deaths ages 0-1 per 1,000 live births). (The infant mortality rate for Latin America fell from 125 in the five years from 1950 to 1955 to 36 in the five years from 1995 to 2000.) But whereas prior to 1930 most Latin American public health care advances could be linked to the improved economic circumstances, after 1930 the gains stemmed principally from the importation of new sanitation and medical technologies from the United States and the rest of the developed world.

One key development was the mass spraying of the insecticide DDT. In the late 1950s PAHO undertook massive effort to wipe out the mosquitoes that serve as vectors for yellow fever, malaria, and dengue (or "breakbone") fever. The program was an enormous success, and illness and death from most mosquito-vectored diseases were all but eliminated. However, the overuse of DDT, especially in commercial agriculture, in time reduced its effectiveness against mosquitoes. Concerns in the 1960s over the possible harmful implications of introducing massive amounts of DDT into the environment brought an end to the program.

Other public health efforts included the chlorination of potable water; better sewage disposal and treatment; expanded vaccination; and the widespread introduction of new antibiotics (which proved especially effective in reducing the number of deaths due to pneumonia and tuberculosis). These steps, in the words of Nicolás Sánchez-Albornoz, were "grafts from other civilizations" (The Population of Latin America, p. 5). Through them, the risk from nearly all major infectious illnesses in Latin America was eliminated or greatly reduced, at least for a time.

POVERTY, EQUITY, AND HEALTH

In the largest sense, the economic context most determines success in providing for public health. Two macro-measures are most significant: per capita gross domestic product (GDP) and distribution of income. As a rule, the more advanced the economy, the better the overall public health situation. Because economic growth usually brings a reduction of poverty, it usually results in improvement in the public health situation.

Although historically this general relationship among economic performance, reduction of poverty, and improvement in public health has held true in Latin America, since the 1990s it has no longer been the case. When the region's economy grew in the 1960s and 1970s, the number of families living in poverty fell; the deep economic decline of the 1980s brought a sharp increase in poverty levels. (During the 1980s, workers' real wages across Latin America fell by about one-quarter.) However, when economic growth eventually returned in the 1990s, albeit at a much slower pace than in the 1960s and 1970s, the percentage of those living in poverty did not decrease. Indeed, in the late 1990s the percentage of Latin Americans living in extreme poverty (earning less than a dollar a day) began to grow again. In the twenty-first century, in Nicaragua and Haiti over half of the population lives on less than a dollar a day. More than half of the population of Bolivia, Colombia, Ecuador, Guatemala, and Paraguay live in poverty (less than two dollars a day). In Haiti, Nicaragua, and Honduras more than seven out of ten people live in poverty. In Latin America as a whole, six of every ten children live in poverty.

The problem is that Latin America has the most unequal distribution of income of any region in the world, a situation that has significantly worsened since the 1990s. From 1990 to 1995, a time of economic recovery and growth, the income share received by to the bottom 10 percent of the population fell 15 percent. If Latin America's income were only as unevenly distributed as that of Eastern Europe or South Asia, its economic growth since the 1990s would have all but eliminated poverty (reducing poverty to around 3 percent of the population). In Latin America income is so unequally distributed that economic growth cannot reduce poverty. This has enormous implications for Latin America's public health.

The poor are more likely to become ill, less likely to receive medical attention when they become ill, and more likely to suffer premature death. Infant mortality is especially associated with poverty. In Peru, for example, the infant mortality rates for the poorest one-fifth of the population is five times higher than that of the wealthiest one-fifth. In Bolivia the infant mortality rate of the poorest one-fifth of the population is 107 while that of the wealthiest one fifth is 26. Moreover, in Latin America racial and ethnic minorities are more likely to live in poverty, and these groups suffer worse public health conditions as a result. In Brazil, for example, the infant mortality rate for whites is 37, but for people of color it is 62. In Mexico, childhood mortality (ages 5 or younger) is two and a half times higher for indigenous than nonindigenous people.

Improvement in public health is much more strongly linked to income equity than to economic growth: the more even the distribution of income, the better the overall public health situation. To illustrate, the per capita GNPs of Haiti and Cuba are roughly equal (ranking at the bottom of all Latin American nations), but in Haiti income is very unevenly distributed whereas in Cuba it is very evenly distributed. As a result, by almost any measure Haiti has the worst public health situation in Latin America and Cuba has the best. Life expectancy in Haiti is 60 years; in Cuba it is 82. Most contemporary public health experts therefore regard social inequality as the leading source of deficiencies in public health care in contemporary Latin America.

HEALTH INSURANCE

Beginning in the 1930s, many Latin American nations developed national health insurance programs, although these systems tended to cover only salaried employees. Consequently, even by the late 1960s only one of six Latin Americans was covered by a social health insurance program. In the early 1980s Chile, as part of its conversion to free market (or neoliberal) economic policies under the Augusto Pinochet dictatorship (1973–1990) privatized its public health care system. Soon many other Latin American nations followed, establishing private, for-profit health insurance systems. This policy direction continues to be actively supported by the United States, acting through the Inter-American Development Bank and the World Bank. The reforms are patterned after the U.S. health care system, even though it is the most expensive per capita in the world and ranks behind most developed nations in nearly all leading public health indicators.

A key concern with the privatization of public health care in Latin America is that for-profit health insurance companies seek naturally to enroll those individuals who are both in excellent health and can afford to pay high premiums. Moreover, providing health care through private insurance systems works best in urban areas among workers employed in the formal sector, but works far less well for peasants and urban informal sector workers. For Latin America the difficulty is that these latter two categories make up the bulk of the economically active population. During the 1990s and to 2005 at least seven of every ten new jobs created was in poorly paid informal sector. In Latin America today more than three-quarters of the population has no health insurance of any kind.

Women have been especially disadvantaged by the changes to the health care system. The new private health insurance systems are tied to employment in the formal sector, with payment coming in the form of paycheck withholding. Women who do not work for pay (half of the working age population of females in Latin America) or work in the informal sector and are paid less than men (Latin American women earn on average three-quarters of what men earn) are extremely unlikely to be able to afford the cost of private health insurance. Compounding this are the special health care needs of women. Beyond the health burdens of childbirth (a woman's risk of dying from maternal causes was 1 in 160 in Latin America, but 1 in 3,500 in the United States and Canada), women tend to live longer and suffer higher rates of morbidity and disability than do men. Reflecting this reality, health insurance premiums are higher for women than for men. In Chile, for example, health insurance premiums cost on average two and a half times more for women than men.

TRENDS IN SCHOLARSHIP

Public health care officials have long recognized the link between poverty and problems in public health, but historically most treated poverty as a given, focusing their efforts instead on measures that seek to ameliorate the social conditions that stem from poverty. But by the 1930s an influential minority of Latin American public health researchers and physicians began to push beyond just noting the health implications of poverty, taking a more activist political stance. These "social medicine" critics sought to diagnose the etiology of poverty itself, offering socioeconomic and political prescriptions: government-provided food, clothing, and shelter, and above all, income redistribution. The writings of Salvador Allende Gossens, especially La realidad médico-social chilena (The Chilean medico-social reality, published in 1939, when he was Chile's minister of health), stimulated increasing interest in the "social medicine" approach. Elected to the presidency in 1970, Allende sought to put in place some of the leading precepts of social medicine. Since the late twentieth century, a host of new studies and specialized journals have come to focus on research into the relationship between social inequities and health care problems in Latin America.

PRESENT CHALLENGES

There has been some heartening progress in public health care in Latin America, most notably in the area of vaccination coverage. Routine childhood vaccinations against diphtheria, whooping cough, and tetanus have dramatically reduced the incidence of these afflictions across Latin America. Vaccination programs have also succeeded in eradicating both polio and measles in Latin America, even as these diseases continue to disable and kill people, especially children, elsewhere in the developing world.

Yet in several key areas Latin America has failed to progress in the provisioning of public health. Whereas life expectancy in Latin America was five years longer than in East Asia in the mid-1960s, by the mid-1990s Latin America had fallen behind by 1.2 years. Contemporary neoliberal economic policy has stressed the need to reduce the role of government, favoring instead free market solutions to social concerns. However, reductions in public spending on both potable water and sewers has had serious public health implications. Beginning in 1991 contaminated water supplies led to a widespread Latin American outbreak of cholera, a disease that had been unseen in the region for nearly a hundred years. Nevertheless, today roughly two-thirds of Latin American cities make no attempt to treat their raw sewage before dumping it into nearby rivers or the sea. In several nations only half of the population has in-home potable water, and its purity is by no means guaranteed. Across Latin America, only about a quarter of piped water is routinely checked for contaminants. These deficiencies represent a substantial failure in the provisioning of public health needs in Latin America, for with each percentage point increase in potable water coverage for the population, the infant mortality rate drops 1 person per 1,000 births.

Another serious concern is rising antibiotic resistance, a result of massive overuse and/or inappropriate use of antibiotics. Fully two-thirds of all pharmaceutical drugs used in Latin America are purchased without a doctor's prescription. Today a wide array of antibiotics have been rendered partly or completely ineffective, and lethal strains of multi-drug-resistant tuberculosis have appeared in Peru and Haiti. Their spread to the rest of the world is but a plane ride away.

Although maternal mortality is rare in the developed world, in Latin America it remains the main cause of death for women aged 20 to 34. A leading cause of maternal mortality in Latin America is complications from abortions. Abortion is generally illegal in Latin America, except in Cuba. (In Cuba the number of abortions has dropped sharply because of widespread availability and use of contraception.) Nevertheless, about half of all pregnancies in Latin America end in abortion. Another leading cause of female mortality is cervical cancer, especially in poorer nations where women are unlikely to undergo periodic Pap smears.

Another concern is HIV/AIDS, which now infects at least 2.4 million people in Latin America. The Caribbean region has been especially hard hit, and prevalence there is higher than any other region in the world except sub-Sahara Africa. In the Caribbean HIV/AIDS is the leading cause of death for people aged 15 to 49. All told, at least half a million people have died from AIDS in Latin America. Education remains a problem: a third of Latin American adolescents do not understand how to protect themselves from the disease.

Several mosquito-borne diseases, once thought to be eradicated, have now either come back or are on the verge of doing so. Lapses in mosquito control have led to the reemergence of dengue fever (a debilitating and painful affliction) and dengue hemorrhagic fever (a less frequently occurring but lethal counterpart) across much of the Caribbean. There is no vaccine, no cure, and no effective treatment for dengue. Urban yellow fever, driven from all Latin American cities in the early twentieth century, now appears poised to return. The reinfestation of the mosquito vector, aedes aegypti, and the advance of human settlements into the Amazon where jungle yellow fever is endemic among some species of monkeys, raises the risk of reintroduction of yellow fever into urban areas.

Despite continuing and serious public health concerns, today most spending on health in Latin America goes for modern, expensive, curative measures and for private physicians serving the more privileged in society, while less-expensive, mass preventive measures are not usually well funded. Critics argue that the existing system misallocates scarce public health spending, for preventive programs could help attack the health concerns of poorer, especially rural regions, and diseases that especially affect children. To critics, Latin America's pattern of spending on health represents a massive shift of resources from the poor to the rich and from the young to the old.

See alsoAcquired Immune Deficiency Syndrome (AIDS); Cities and Urbanization; Diseases; Medicine: Colonial Spanish America; Medicine: The Modern Era; Population: Brazil; Population: Spanish America.

BIBLIOGRAPHY

Abel, Christopher. Health, Hygiene and Sanitation in Latin America c. 1870 to c. 1950. London: Institute of Latin American Studies, 1996. Provides a historical sketch of public health care history in Latin America.

Barrientos, Armando, and Peter Lloyd-Sherlock, "Health Insurance Reforms in Latin America: Cream Skimming, Equity and Cost-Containment," in Social Policy Reform and Market Governance in Latin America, edited by Louise Haagh and Camilla T. Helg?. New York: Palgrave Macmillan, 2002.

Casas, Juan Antonio, J. Norberto W. Dachs, and Alexandra Bambas. "Health Disparities in Latin America and the Caribbean: The Role of Social and Economic Determinants." In Equity and Health: Views from the Pan American Sanitary Bureau. Washington, DC: Pan American Health Organization, 2001. Provides a summary of equity issues.

Pineo, Ronn. "Misery and Death in the Pearl of the Pacific: Health Care in Guayaquil, Ecuador, 1870–1925," in Hispanic American Historical Review 70, no. 4 (1990): 609-637. Discusses public health care at the turn of the twentieth century.

Kiple, Kenneth F., ed. Cambridge World History of Human Disease. Cambridge, U.K., and New York: Cambridge University Press, 1993. The best place to begin a study of the history of Latin American public health.

Londoño, Juan Luis, and Miguel Székely. "Persistent Poverty and Excess Inequality: Latin America, 1970–1995," Journal of Applied Economic, 3, no. 1 (2000): 93-134, Supplies numbers on economic growth and inequality.

Pan American Health Organization. Health in the Americas, vols. 1 and 2. Washington, DC: Pan American Health Organization, 2002.

Sánchez-Albornoz, Nicolás. The Population of Latin America: A History, translated by W. A. R. Richardson. Berkeley: University of California Press, 1974. Demography and public health.

United Nations. The Millennium Development Goals: A Latin American and Caribbean Perspective. Santiago, Chile: United Nations, 2005. Provides a full overview of existing conditions.

                                       Ronn Pineo