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Child Health in Latin America  

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.


Disability and Rural Health  

Rayna Sage, Genna Mashinchi, and Craig Ravesloot

The ways in which disability impacts people and their health in rural places are a result of the interaction between the person and the rural environment in which they live. Disability is defined as ongoing difficulties engaging in daily activities and social roles due to physical or mental conditions. The United Nations Convention on the Rights of People with Disabilities (UN-CRPD) implemented policy in 2008 that recognized that disabled people are worthy of autonomy and dignity. The social and physical environment are constructed in ableist ways that make it difficult for people with disabilities to realize their independence and this is particularly true in many rural places. Person–environment fit and urbanormativity (the favoring of urban spaces at the expense of rural ones) are important concepts in understanding the experiences of rural disabled people. There is little existing research regarding the epidemiology of disability and rural health, but rural people report higher and earlier rates of disability than urban people and rural places have higher rates of older adults with higher rates of disability. Furthermore, rural people with disabilities experience various secondary health conditions and higher rates of mortality compared to urban people with disabilties. The lack of access to health care and advocacy help explain some of the differences in health outcomes when comparing rural and urban people. The disability rights movement led to the creation of different types of advocacy and service organizations across the globe to address these disparities. An important way to improve the experiences and health of rural people with disabilities is to ensure they have access to quality and dependable in-home services and community-based rehabilitation, which currently tend to be under-funded with dramatic worker shortages in many rural places. A final promising approach to improving the health of rural disabled people is through evidence-based health promotion programming that targets early indicators of health problemsand recovery and health-sustaining efforts following a health problem.


Ensuring the Public Value of Long-Term Care Services  

Joseph E. Ibrahim

Many seniors needing social and clinical care come from vulnerable populations that have difficulty accessing services, a great need for those services, and/or potentially impaired decision-making skills. At the same time, when seniors use services on a routine basis, they become increasingly dependent on the individual service provider. The aged care sector has a duty to provide “public value”—that is, to provide a valuable contribution to society within existing resource constraints. This requires more than simply addressing the basic individual needs of care recipients. Ethical factors must be considered in policies around services to vulnerable seniors and potential issues in addressing suboptimal quality of care, neglect, and abuse of seniors, as demonstrated by continuing public news of poor care provided to seniors in nursing homes, social care, and residential care settings.


Health Care Access for Migrants in Europe  

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.


Health Diplomacy in the Political Process of Integration in Latin America and the Caribbean  

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).


Health in All Policies: Perspectives From the Region of the Americas  

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.


Health of Indigenous Peoples in Brazil: Inequities and the Uneven Trajectory of Public Policies  

Ricardo Ventura Santos, James R. Welch, Ana Lucia Pontes, Luiza Garnelo, Andrey Moreira Cardoso, and Carlos E. A Coimbra Jr.

Victims of epidemics, slavery, genocide, and countless other episodes of violence during the colonial enterprise in Brazil, which continues decades into the 21st century in some regions, Indigenous peoples face health inequities resulting from a five-century history of social marginalization and vulnerability. Since the late 1990s, the health and well-being of Indigenous peoples in the country have benefited from progressive legislation that values sociocultural diversity within a public primary healthcare subsystem attending to Indigenous peoples living in federal Indigenous lands. However, these transcultural ideals remain elusive in practice. The Indigenous Healthcare Subsystem continues to suffer from numerous systemic problems, including low quality of local services, lack of health professional training for work in intercultural contexts, and unpreparedness for attending to health emergencies involving Indigenous peoples living in voluntary isolation. Being Indigenous in Brazil in the 2020s implies greater chances of higher infant mortality, lower life expectancy, suffering from undernutrition and anemia during childhood, living with a high burden of infectious and parasitic diseases, being exposed to a swift process of nutritional transition, and experiencing a surge in chronic violence. Community case studies have shown the importance of close patient follow-up over long periods of time, the heavy burden of disease due to nutrition transition since the mid-1980s, the relevance of international reference curves for evaluating Indigenous child undernutrition, and failures of primary healthcare provided to Indigenous populations. Improvements in national health information systems in Brazil beginning in the early 2000s have shown external causes, perinatal diseases, infectious and parasitic diseases, and respiratory diseases to be the leading causes of death among the country’s Indigenous population.


Inequalities and Inequities in the Health of People With Intellectual Disabilities  

Eric Emerson

Children and adults with intellectual disabilities have poorer health and are more likely to die sooner than their non–intellectually disabled peers. There is growing evidence that some of these inequalities in health are avoidable, unjust, and unfair, given that they are driven by the higher rates of exposure of people with intellectual disabilities to well-established social determinants of poor health. People with intellectual disabilities are more likely than their peers to: live in poverty, not be employed (or if employed to work under precarious conditions), be exposed to discrimination and violence, face significant barriers in accessing effective health care, and be less resilient when exposed to adversities. In other words, they are examples of health inequities that arise from “the societal conditions in which people are born, grow, live, work and age, referred to as social determinants of health. These include early years’ experiences, education, economic status, employment and decent work, housing and environment, and effective systems of preventing and treating ill health” (World Health Organization). Future research needs to address three key issues. First, most of the existing evidence is based on the experiences of people with intellectual disabilities in the world’s high-income countries. In contrast, the vast majority of the world’s population live in middle- and low-income countries. The limited evidence available suggests that children with intellectual disabilities growing up in middle- and low-income countries are much more likely than their peers to be growing up in poverty and to be exposed to specific social determinants of poorer health associated with poverty such as undernutrition, poor sanitation, low levels of parental stimulation, violent parental discipline, and hazardous forms of child labor. Second, little research has focused on health inequalities and inequities among two important groups of people with intellectual disabilities: people with intellectual disabilities from minority ethnic communities and people with mild intellectual disabilities. Third, very little research has attempted to test the proposition that people with intellectual disabilities may be more or less resilient than their peers when exposed to social determinants of health. While much remains to be learned about the inequalities and inequities faced by people with intellectual disabilities, the existing knowledge is sufficient to guide and drive changes in policy and practice that could reduce the health inequities faced by people with intellectual disabilities. These include: improving the visibility of people with intellectual disabilities in local, national, and international health surveillance systems; making “reasonable accommodations” to the operation of health care systems (e.g., introducing annual health checks into primary care services, making “easy read” materials available, employing intellectual disabilities liaison nurses in acute hospitals) to ensure that people with intellectual disabilities are not exposed to systemic discrimination; and ensuring that people with intellectual disabilities (along with all other people with disabilities) are included in and benefit equally from local and national strategies to reduce population levels of exposure to well-established social determinants of poor health.


Intervention Approaches for Osteoarthritis  

Susan Hughes, Cheryl Der Ananian, and Andrew DeMott

Osteoarthritis (OA) currently affects 32.5 million people in the United States at a cost of $136.8 billion. The available literature on the epidemiology of OA shows that the number of people affected will increase exponentially by the year 2040, affecting 78.4 million people. There is an abundance of evidence that self-management and physical activity (PA) approaches improve multiple outcomes for individuals with arthritis. However, these programs are not widely accessible to the population that can benefit from them across the United States. Two national organizations—the arthritis program of the Centers for Disease Control and Prevention (CDC) and the Administration on Community Living (ACL)—have established similar, but distinct, criteria for the review of evidence-based programs and seek to promote their dissemination. The CDC arthritis program has reviewed the evidence bases of arthritis-appropriate, evidence-based intervention programs and classified them as self-management or PA approaches. These “recognized” programs are recommended for national dissemination by the CDC. The ACL has also recognized several of the same programs by using its own criteria and classified them as Self-Management or Falls Prevention approaches. The different review criteria used by these two national public organizations present significant challenges for investigators who design interventions. The situation is further compounded by an investment in funding that hugely supports the discovery of interventions as opposed to the dissemination of interventions that have demonstrated efficacy. The National Public Health Agenda for Osteoarthritis: 2020 Update presents a blueprint that includes nine strategies for improving public health outcomes among persons with OA. These recommendations should be considered by interventionists in the future when developing programs. Other areas that can substantially benefit from further research include weight management and weight loss, injury prevention, technology-based interventions, addressing comorbid conditions, and understanding program mechanisms of action. Finally, underscoring all of these approaches and common to them is the need to enroll underserved populations to improve health equity. Underserved populations disproportionately include African Americans, Hispanics, persons with low socioeconomic status, and persons who live in rural areas of the United States. Policy recommendations to render future approaches to improving health outcomes for persons with OA are (a) to increase funding for the dissemination of programs that demonstrated efficacy and effectiveness, (b) to increase the transparency of the review and funding processes across public agencies, and (c) to nurture, broker, and provide sustainable funding streams to maintain evidence-based programming for all persons with OA across the United States.


Migrant Health in Refugee Camps: A Neglected Public Health Issue  

Manuela Valenti

There are 1 billion migrants in the world today, which means that one in seven of the world’s population are migrants. Of these, 272 million are international migrants and 763 million are internal migrants. It is estimated that around 70 million of the world’s migrants, both internal and international, have been forcibly displaced. Many things force people to leave their homes in search of a better future: war, poverty, persecution, climate change, desertification, urbanization, globalization, inequality, and lack of job prospects. Migrants remain among the most vulnerable members of society even when their living conditions improve after migration. Migrant women and children are a particularly vulnerable group and have a great need for basic and preventive health care. Many refugees and migrants are young and in good health, but hard living conditions and difficulty accessing basic health care can affect their state of health. Many of them face inhuman journeys during migration and live in refugee camps with very low standards of hygiene; when they find a job, they are often exploited. All these things can also affect their mental health. Migrants struggle with similar challenges as other marginalized groups when it comes to access to health care, but they face the additional barriers of mobility, language barriers, cultural differences, lack of familiarity with local health care services, and limited eligibility for publicly and privately funded health care. Governments should provide affordable preventive and basic health care to refugees and migrants not only because it is a human right but also because in the long term it can lower the costs of the whole health care system.


Migration, Migrants, and Health in Latin America and the Caribbean  

Deisy Ventura, Jameson Martins da Silva, Leticia Calderón, and Itzel Eguiluz

The World Health Organization has recognized health as a right of migrants and refugees, who are entitled to responsive healthcare policies, due to their particular social determinants of health. Migrants’ and refugees’ health is not only related to transmissible diseases but also to mental health, sexual and reproductive health, and non-communicable diseases, such as diabetes. Historically, however, migration has been linked to the spread of diseases and has often artificially served as a scapegoat to local shortcomings, feeding on the xenophobic rhetoric of extremist groups and political leaders. This approach fosters the criminalization of migrants, which has led to unacceptable violations of human rights, as demonstrated by the massive incarceration and deportation policies in developed countries, for example, the United States under the Trump administration. In Latin America and the Caribbean, in particular, there have been legal developments, such as pioneering national legislation in Argentina in 2004 and Brazil in 2017, which suggest some progress in the direction of human rights, although in practice drawbacks abound in the form of countless barriers for migrants to access and benefit from healthcare services in the context of political turmoil and severe socioeconomic inequality. The COVID-19 pandemic has exposed and enhanced the effects of such inequality in the already frail health conditions of the most disenfranchised, including low-income migrants and refugees; it has both caused governments in Latin America to handle the crisis in a fragmented and unilateral fashion, ignoring opportunities to cooperate and shield the livelihoods of the most vulnerable, and served as a pretext to sharpen the restrictions to cross-border movement and, ultimately, undermine the obligation to protect the dignity of migrants, as the cases of Venezuela and the U.S.-Mexico border illustrate. Still, it could represent an opportunity to integrate the health of migrants to the public health agenda as well as restore cooperation mechanisms building on previous experiences and the existing framework of human rights organizations.


Prevention of Suicide  

Danuta Wasserman

Around 700,000 people take their lives each year worldwide. Suicide accounts for approximately 1.3% of all deaths and therefore represents a major public health problem. The global age-standardized suicide rate is 9 per 100,000 population, yet there are large variations among genders, ages, countries, and world regions. The stress–vulnerability model of suicidal behaviors has been proposed to explain how a diathesis, developed through the influence of genetic and neurodevelopmental factors in relation to perinatal, postnatal, and life experiences, interacts with different risk and protective factors that either decrease or enhance the individual’s level of resilience to stress and suicidal risk. Public health suicide prevention strategies include suicide means restriction, reducing harmful substance use, promoting responsible media reporting, public-awareness campaigns, gatekeeper trainings, school-based interventions, crisis helplines, and postvention. Mental health strategies comprise identification, treatment, and rehabilitation of persons in distress and at risk for suicide. Multicomponent strategies that use a combination of evidence-based methods from public and mental health sectors are recommended. Future work should aim at enhancing the quality of epidemiological data, improving the research on protective and ideation-to-action factors, expanding the quantity and quality of data coming from low- and middle-income countries, and evaluating the cost-effectiveness of different suicide prevention strategies.