Célia Landmann Szwarcwald, Maria do Carmo Leal, Wanessa da Silva de Almeida, Mauricio Lima Barreto, Paulo Germano de Frias, Mariza Miranda Theme Filha, Rosa Maria Soares Madeira Domingues, Elisabeth Barboza Franca, Silvana Granado Nogueira da Gama, Cristiano Sigueira Boccolini, and Cesar Victora
Child health has been placed at the forefront of international initiatives for development. The adoption of the Millennium Development Goals has propelled worldwide actions to improve maternal and child health. In the course of the year 2000, the Latin American (LA) countries made marked progress in implementing effective newborn and infant life-saving interventions. Under-five mortality in LA fell by a third between 1990 and 2015, with a sharp decline in diarrheal diseases and respiratory infections. Due to the successful immunization programs in the region, some vaccine-preventable diseases have been eliminated. Many of the LA countries have reached nearly universal coverage of childbirths attended by skilled personnel and >80% coverage for antenatal care. In 2015, 18 countries in the region reported the elimination of mother-to-child transmission for both HIV and syphilis.
Although the advances in the public agenda aimed at promoting child health and development in Latin American countries are undeniable, unresolved issues remain. While many stillbirths and neonatal deaths could be averted by improving access to antenatal, intra-partum, and postnatal interventions, Latin America has the highest cesarean rate among all regions of the world with an excessive number of such operations without medical indications. The simultaneous lack and excess of cesarean deliveries in LA countries reflects a model of care that excludes a considerable portion of the population and reveals the persistent gaps and inequalities in the region. One of the main challenges to be faced is the lack of sustainable financing mechanisms to provide integrated and high-quality health care to all children, equal education opportunities, and social services to support disadvantaged families. When planning interventions, equity should be restored as the guiding principle of actions to ensure inclusion and social justice. Children represent the future of society in Latin America and elsewhere. For this reason, social commitment to provide universal child health is the genesis of sustainable development and must be an absolute priority.
Amira M. Khan, Zohra S. Lassi, and Zulfiqar A. Bhutta
Nearly 80% of the world’s population lives in low- and middle-income countries (LMICs) and these regions bear the greatest burden of maternal, neonatal, and child mortality, with most of the deaths occurring at home. Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, making it imperative that maternal, newborn, and child health (MNCH) interventions focus on communities in tandem with facility-based strategies. There is widespread consensus that delivering effective primary health care (PHC) interventions through the continuum of care, starting from pregnancy to delivery and then to the newborn, infant, and the young child, is an integral component of health strategies in high-, middle- and low-income settings.
Despite gaps in research, several effective community-based PHC approaches have been proven to impact MNCH positively. Implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Further robust studies are needed to evaluate certain strategies of community-based PHC and their impact on maternal and child health outcomes, such as the use of mobile technology and social franchises. Recognition of community health workers (CHWs) as a formal cadre and the integration of community-based health services within PHC are vital in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, despite the importance of community-based PHC for MNCH in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions.
Yudit Namer and Oliver Razum
For decades, researchers have been puzzled by the finding that despite low socioeconomic status, fewer social mobility opportunities, and access barriers to health care, some migrant groups appear to experience lower mortality than the majority population of the respective host country (and possibly also of the country of origin). This phenomenon has been acknowledged as a paradox, and in turn, researchers attempted to explain this paradox through theoretical interpretations, innovative research designs, and methodological speculations.
Specific focus on the salmon effect/bias and the convergence theory may help characterize the past and current tendencies in migrant health research to explain the paradox of healthy migrants: the first examines whether the paradox reveals a real effect or is a reflection of methodological error, and the second suggests that even if migrants indeed have a mortality advantage, it may soon disappear due to acculturation. These discussions should encompass mental health in addition to physical health.
It is impossible to forecast the future trajectories of migration patterns and equally impossible to always accurately predict the physical and mental health outcomes migrants/refugees who cannot return to the country of origin in times of war, political conflict, and severe climate change. However, following individuals on their path to becoming acculturated to new societies will not only enrich our understanding of the relationship between migration and health but also contribute to the acculturation process by generating advocacy for inclusive health care.
Catherine A. O'Donnell
Migration is a reality of today’s world, with over one billion migrants worldwide. While many choose to move voluntarily, others are forced to migrate due to economic reasons or to flee war, conflict, or persecution. Such migrants often find themselves in precarious and marginalized situations—particularly asylum seekers, refugees, and undocumented or irregular migrants. While often viewed as a single group, the legal status and entitlements of these three groups are different. This has implications for their ability to access health care; in addition, rights and entitlements vary across the 28 countries of the European Union and across different parts of national health systems. The lack of entitlement to receive care, including primary and secondary care, is a significant barrier for many asylum seekers and refugees and an even greater barrier for undocumented migrants. Other barriers include different health profiles and awareness of chronic disease risk amongst migrants; awareness of the organization of health systems in host countries; and language and communication. The use of professional interpreters can help to overcome communication barriers, but entitlement to free interpreting services is highly variable. Host countries need to consider how to ensure their health systems are “migrant-friendly”: solutions include provision of professional interpreters; ensuring that health care staff are aware of migrants’ rights to access health care; and increasing knowledge of migrants in relation to the organization of the health care system in their host country and how to access care, for example through the use of patient navigators. However, perhaps one of the greatest facilitators for migrants will be a more favorable political situation, which stops demonizing people who are forced to migrate due to situations out of their control.
Paulo Buss and Sebastián Tobar
The construction of the concepts of diplomacy and health diplomacy must consider their conceptions and practices, at both the global and regional levels. Health diplomacy is vitally important in a global context, where health problems cross national borders and more new stakeholders appear every day, both within and outside the health sector. On the other hand, regional integration processes provide excellent opportunities for collective actions and solutions to many of the health challenges at the global level. In the current global context, the best conditions for dealing with many health challenges are found at the global level, but the regional and subregional spheres also play essential roles.
The region of Latin America and the Caribbean (LAC) consists of 26 countries or territories that occupy a territory of 7,412,000 square miles—almost 13% of the Earth’s land surface area; it extends from Mexico to Patagonia, where about 621 million people live (as of 2015), distributed among different ethnic groups. Geographically, it is divided into Mexico and Central America, the Caribbean, and South America, but it presents subregions with populations and cultures that are a little more homogenous, like the subregions of the Andes and the English Caribbean. By its characteristics, LAC has acquired increasing global political and economic importance.
In the 1960s, integration processes began in the region, including the creation of the Union of South American Nations (UNASUR), Mercosur, the Andean Community, the Caribbean Community (CARICOM), the Central American System, the Bolivarian Alliance for the Peoples of Our America (ALBA), the Amazon Cooperation Treaty Organization (ACTO), the Sistema Económico Latinoamericano y del Caribe (SELA), the Asociación Latinoamericana de Integración (ALADI), and finally, since 2010, the Community of Latin American and Caribbean States (Comunidad de Estados Latinoamericanos y Caribeños, or CELAC), which is the most comprehensive integrative organization.
While originally a mechanism for political and economic integration, health is now an important component of all the abovementioned integration processes, with growing social, political, and economic importance in each country and in the region, currently integrating the most important regional and global negotiations.
Joint protection against endemic diseases and epidemics, as well as noncommunicable diseases, coordination of border health care, joint action on the international scene (particularly in multilateral organizations such as the United Nations and its main agencies), and the sectoral economic importance of health are among the main situations and initiatives related to health diplomacy in these integration processes.
The effectiveness of integration actions—and health within those actions—varies according to the political orientations of the national governments in each conjuncture, amplifying or reducing the spectrum of activities performed. The complexity of both the present and future of this rich political process of regional health diplomacy is also very important for global health governance (GHG).
Kira Fortune, Francisco Becerra, Paulo Buss, Orielle Solar, Patricia Ribeiro, and Gabriela E. Keahon
There is a broad consensus that the health of an individual or population is not influenced solely by the efforts of the formal health sector; rather, it is also defined by the conditions of daily life as well as the inputs, intentional or not, of various stakeholders and policies. The recognition that health outcomes and inequity in health extend beyond the health sector across many social and government sectors has led to the emergence of a comprehensive policy perspective known as Health in All Policies (HiAP). Building on earlier concepts and principles outlined in the Alma-Ata Declaration (1978) and the Ottawa Charter for Health Promotion (1986), HiAP is a collaborative approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. Health in All Policies has become particularly relevant in light of the adoption of the 2030 Agenda for Sustainable Development and the 17 Sustainable Development Goals (SDGs), as achieving the goals of the agenda requires policy coherence and collaboration across sectors. Given that local governments are ideally positioned to encourage and galvanize partnerships between a diversity of local stakeholders, the implementation of HiAP at the local level is seen as a powerful approach to advancing health and achieving the SDGs through scaled-up initiatives. As there is no single model for the development and implementation of HiAP, it is critical to examine the different experiences across countries that have garnered success in order to identify best practices. The Region of the Americas has made much progress in advancing the HiAP approach, and as such much can be learned from analyzing implementation at country level thus far. Specific initiatives of the Americas may highlight key examples of local action for HiAP and should be taken into consideration for future implementation. Moving forward, it will be important to consider bottom up approaches that directly address the wider determinants of health and health equity.
Rachel Humphris and Hannah Bradby
The health status of refugees and asylum seekers varies significantly across the European region. Differences are attributed to the political nature of the legal categories of “asylum seeker” and “refugee”; the wide disparities in national health services; and the diversity in individual characteristics of this population including age, gender, socioeconomic background, country of origin, ethnicity, language proficiency, migration trajectory, and legal status. Refugees are considered to be at risk of being or becoming relatively “unhealthy migrants” compared to those migrating on the basis of economic motives, who are characterized by the “healthy migrant effect.” Refugees and asylum seekers are at risk to the drivers of declining health associated with settlement such as poor diet and housing. Restricted access to health care whether from legal, economic, cultural, or language barriers is another likely cause of declining health status. There is also evidence to suggest that the “embodiment” of the experience of exclusion and marginalization that refugee and asylum seekers face in countries of resettlement significantly drives decrements in the health status of this population.
Ralph J. DiClemente and Nihari Patel
At the end of 2016, there were approximately 36.7 million people living with HIV worldwide with 1.6 million people being newly infected. In the same year, 1 million people died from HIV-related causes globally. The vast prevalence of HIV calls for an urgent need to develop and implement prevention programs aimed at reducing risk behaviors. Bronfenbrenner’s socio-ecological model provides an organizing framework to discuss HIV prevention interventions implemented at the individual, relational, community, and societal level. Historically, many interventions in the field of public health have targeted the individual level. Individual-level interventions promote behavior change by enhancing HIV knowledge, attitudes, and beliefs and by motivating the adoption of preventative behaviors. Relational-level interventions focus on behavior change by using peers, partners, or family members to encourage HIV-preventative practices. At the community-level, prevention interventions aim to reduce HIV vulnerability by changing HIV-risk behaviors within schools, workplaces, or neighborhoods. Lastly, societal interventions attempt to change policies and laws to enable HIV-preventative practices.
While previous interventions implemented in each of these domains have proven to be effective, a multipronged approach to HIV prevention is needed such that it tackles the complex interplay between the individual and their social and physical environment. Ideally, a multipronged intervention strategy would consist of interventions at different levels that complement each other to synergistically reinforce risk reduction while simultaneously creating an environment that promotes behavior change. Multilevel interventions provide a promising avenue for researchers and program developers to consider all levels of influences on an individual’s behavior and design a comprehensive HIV risk-reduction program.
Barry S. Levy and Cora Roelofs
Climate change has increased the risk to workers’ health and safety. Workers, especially those who work outdoors or in hot indoor environments, are at increased risk of heat stress and other heat-related disorders, occupational injuries, and reduced productivity at work. A variety of approaches have been developed to measure and assess workers’ occupational heat exposure and the risk of heat-related disorders. In addition, increased ambient temperature may increase workers’ exposure to hazardous chemicals and the adverse effects of chemicals on their health. Global warming will influence the distribution of weeds, insect pests, and pathogens, and will introduce new pests, all of which could change the types and amounts of pesticides used, thereby affecting the health of agricultural workers and others. Increased ambient temperatures may contribute to chronic kidney disease of unknown etiology among workers. Global warming is increasing ground-level ozone concentrations with adverse effects on outdoor workers and others. Extreme weather events related to climate change pose injury risks to rescue and recovery workers. Reducing the risks of work-related illnesses and injuries from climate change requires a three-pronged approach: (1) mitigating the production of greenhouse gases, the primary cause of climate change; (2) implementing adaptation measures to address the overall consequences of climate change; and (3) implementing improved measures for occupational health and safety.
Saida M. Abdi
The psychosocial well-being of migrant children has become an urgent issue facing many Western countries as the number of migrant children in the population increases rapidly and health-care systems struggle to support them. Often, these children arrive with extensive exposure to trauma and loss before facing additional stressors in the host country. Yet, these children do not access mental health support even when available due to multiple barriers. These barriers include cultural and linguistic barriers, the primacy of resettlement needs, and the stigma attached to mental health illness. In order to improve mental health services for migrant children, there is a need to move away from focusing on trauma and mental health symptoms and to look instead at migrant children’s well-being across multiple domains, including activities that can promote or diminish psychological well-being. Trauma Systems Therapy for Refugees (TST-R) is an example of an approach that has succeeded in overcoming these barriers by adopting a culturally relevant and comprehensive approach to mental health care.
People who are forcibly displaced are forced to flee by serious threats to fundamental human rights, caused by factors such as persecution, armed conflict, and indiscriminate violence. Contemporary drivers of forced displacement are increasingly complex and interrelated. They include population growth, food insecurity, and water scarcity, at times compounded and multiplied by the effects of climate change. A refugee is someone who fled his or her home and country owing to “a well-founded fear of persecution because of his/her race, religion, nationality, membership in a particular social group, or political opinion,” according to the United Nations 1951 Refugee Convention. Internally displaced persons (IDPs) are people who have not crossed an international border but were forced to move to a different region than the one they call home within their own country. People who cannot return home without serious risk to their human rights have specific needs.
Forced displacement, both within a country and to other countries, is a major life event that abruptly changes environmental living conditions, such as social networks, language, and cultural environment of the displaced populations. The changes in environmental living conditions and disruptions in life challenge both the individual and the families of the displaced persons. Both types of forced displacement challenge adaptational mechanisms of individuals and families. Accordingly, the challenges can contribute to changes in mental health and mental disorders. However, estimates of mental health, mental disorders, and mental health determinants vary across and between forcibly displaced persons. This heterogeneity in estimates is associated with differences between refugee groups and with methodological difficulties in assessing refugees’ mental health. Instruments to assess mental health need to be culture-grounded and gender-sensitive to capture the scope and extent of refugees’ mental health and mental disorders. Based on reliable and valid instrument needs for assessing mental health and mental disorders, determinants can be identified and intervention can be developed and evaluated.
Solveig A. Cunningham and Hadewijch Vandenheede
There are over 230 million international migrants worldwide, and this number continues to grow. Migrants tend to have limited access to and knowledge about resources and preventative care in their communities of reception, but nonetheless they are often in better health by many measures compared with native-born people in their communities of reception and with the people they left behind at their place of origin. With time since arrival, however, immigrants’ health advantages often dissipate and they experience increases in health problems, especially obesity and diabetes, which are chronic diseases that are increasingly prevalent in the overall population as well and are associated with multiple co-morbidities and limitations. It may be that immigrants have specific health endowments leading to these health patterns, or that the processes involved in migration, including exposure to new environments, behavioral change, and stress of migration may also affect risks of obesity and other chronic conditions. Understanding the health patterns of migrants can be useful in identifying their specific health needs, as well as contributing to our understanding of how specific environments, changes in environments, and individual health endowments interplay to shape the long-term health of populations.
Emily Q. Ahonen
Occupational health and safety concerns classically encompass conditions and hazards in workplaces which, with sufficient exposure, can lead to injury, distress, illness, or death. The ways in which work is organized and the arrangements under which people are employed have also been linked to worker health. Migrants are people who cross borders away from their usual place of residence, and about one in seven people worldwide is a migrant. Terms like “immigrant” and “emigrant” refer to the direction of that movement relative to the stance of the speaker. Any person who might be classified as a migrant and who works or seeks to work is an immigrant worker and may face challenges to safety, health, and well-being related to the work he or she does. The economic, legal, and social circumstances of migrant workers can place them into employment and working conditions that endanger their safety, health, or well-being. While action in support of migrant worker health must be based on systematic understanding of these individuals’ needs, full understanding the possible dangers to migrant worker health is limited by conceptual and practical challenges to public health surveillance and research about migrant workers. Furthermore, intervention in support of migrant worker health must balance tensions between high-risk and population-based approaches and need to address the broader, structural circumstances that pattern the health-related experiences of migrant workers. Considering the relationships between work and health that include but go beyond workplace hazards and occupational injury, and engaging with the ways in which structural influences act on health through work, are complex endeavors. Without more critically engaging with these issues, however, there is a risk of undermining the effectiveness of efforts to improve the lot of migrant workers by “othering” the workers or by failing to focus on what is causing the occupational safety and health concern in the first place—the characteristics of the work people do. Action in support of migrant workers should therefore aim to ameliorate structural factors that place migrants into disadvantageous conditions while working to improve conditions for all workers.
There are an estimated 300 million indigenous peoples worldwide. Although there is ample evidence of worse health and social outcomes for the majority of indigenous peoples, compared to their non-indigenous counterparts, there has yet to be a review of racism as a determinant of indigenous health using global literature. Racism constitutes unfair and avoidable disparities in power, resources, capacities, or opportunities centered on ethnic, racial, religious, or cultural differences that can occur at three levels: internalized, interpersonal, or systemic. For indigenous peoples this is closely related to ongoing processes of colonization. Available research suggests that at least a third of indigenous adults experience racism at least once during their lives and that about a fifth of indigenous children experience racism. For indigenous peoples, racism has been associated with a considerable range of health outcomes, including psychological distress, anxiety, depression, suicide, posttraumatic stress disorder, asthma, physical illness, obesity, cardiovascular disease, increased blood pressure, excess body fat, poor sleep, reduced general physical and mental health, and poor oral health, as well as increased alcohol, tobacco, and marijuana use and underutilization of medical and mental healthcare services. Disparities in medical care experienced by indigenous patients compared to non-indigenous patients have also been found. Existing studies indicate that avoidant and passive coping tends to exacerbate the detrimental health impacts of racism for indigenous peoples, whereas active coping ameliorates the ill-health effects of racism. Reducing individual and interpersonal racism can be achieved by (a) providing accurate information and improving awareness of the nature of racism and racial bias; (b) activating values of fairness, reconciling incompatible beliefs, and developing antiracist motivation; (c) fostering empathy and perspective-taking and confidence in regulating emotional responses; (d) improving comfort with other groups and reducing anxiety; and (e) reinforcing antiracist social norms and highlighting personal accountability. There are five key areas for combating systemic racism in organizations and institutions: (a) institutional accountability; (b) diversity in human resources; (c) community partnership; (d) antiracism and cultural competence training; and (e) research and evaluation.
The indigenous peoples of Europe and Russia comprise the Inuit in Greenland, the Sami in northern Norway, Sweden, Finland and Russia and forty officially recognized ethnic minority groups in northern Russia plus a few larger-population indigenous peoples in Russia. While the health of the Inuit and Sami has been well studied, information about the health of the indigenous peoples of Russia is considerably scarcer. The overall health of the Sami is in many aspects not very different from that of their non-indigenous neighbors in northern Scandinavia; the health of the Inuit is similar across Greenland and North America and far less favorable than that of Denmark, southern Canada and the lower 48 American states, respectively; the health of the indigenous peoples of the Russian north is poor, partly due to poverty and alcohol.
Gerard Bodeker and Kishan Kariippanon
An estimated 370 million Indigenous people reside in 90 countries and make up 5% of the global population. Three hundred million Indigenous people live in extremely disadvantaged rural locations. Indigenous people have suffered from historic injustices due to colonization and the dispossession of their lands, territories, and resources, thus preventing them from exercising their right to development according to their own needs and interests. Across the board, Indigenous people have poorer health outcomes when compared to their non-Indigenous fellow citizens.
Cancer, respiratory disease, endocrine, nutritional, and metabolic disorders, primarily diabetes, affect Indigenous people disproportionately. Newborns of Indigenous women are more than twice as likely to be of low birth weight as those born to non-Indigenous women. Indigenous rates of suicide are the highest in the world.
For public health to be effective, a social determinants approach, along with health interventions, is insufficient to create lasting health impact. Partnerships with Indigenous organizations, Indigenous researchers, and the professionalization of health workers is essential. Integration of traditional medicine and traditional health practitioners can enable the Western biomedical model to work in partnership with Indigenous knowledge systems and become more locally relevant and accountable.
The Indigenous health workforce is increasingly using evidence-based, innovative approaches to address the shortage of health professionals as they move toward universal health coverage. Internet, mobile, and communication technologies are enhancing the mobilization of Indigenous health efforts and the support for health workers in rural locations. Presented are country examples of integrated medicine and Indigenous partnerships that effectively implement health interventions.
In different countries and regions of the world—particularly in Latin America and the Caribbean—the term “workers’ health” may have different meanings. From a more traditional perspective, defined on economic and demographic bases, this term introduces a delimitation characterized by economically active people, usually over 10 years of age, of both sexes, and who are working, have worked at some point in their life, or are in search of work. This condition usually ceases in case of retirement or disability. Such a criterion, as can be imagined, is extremely imprecise, particularly in regions such as the ones analyzed here, since it includes great variability of situations, including work considered informal; the work of children and adolescents (prohibited or restricted in accordance with international labor standards); clandestine and illegal work; domestic work (sometimes not formally recognized); and slave and forced labor. It is not clear, either, when work activity actually ceases, especially when there are no social protection systems for elderly and disabled people. But even if this definition is adopted, it is already possible to foresee the complexity of the theme, both in the conceptual perspective and in the scope of health programs, as well as in the health and illness problems of this population.
However, in some countries, the term “workers’ health” (or “worker’s health”) goes beyond the economic or demographic delimitation, and includes a paradigm shift about the role of workers in the struggle for their health. This perspective, political and ideological, originates in the concepts and experience of the “Italian Labor Model”; brings in elements of the Marxist discourses and Liberation Theology; takes advantage of and improves the perspective of “Social Epidemiology” or “Social Medicine”; and, in our continent, can be considered as an unfolding of “Latin American Social Epidemiology.” This understanding of workers’ health also depends on social movements—such as unions and other forms of organizing workers—as well as on political leaders committed to the struggle of workers against precarious work, unemployment and the destruction of already established social rights, especially in the context of neoliberalism.
Therefore, workers’ health is a polysemic and complex concept, and its discussion is a living, dynamic, and extremely rich agenda.