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The second half of the 20th century saw the development of social thought in health in Latin America and the Caribbean in which the social sciences had a central role. Such an innovative development was based on the understanding that health and disease are social processes that require the understanding of different health contexts. The origins of this development dates back to the renewal of medical teaching in Latin America, which had important support from the Pan-American Health Organization. The so-called field of social sciences in health then took shape, especially beginning in the 1970s and 1980s. The social sciences became part of teaching and assistance activities in social medicine and public health in many countries and contributed to consolidating postgraduate programs and networks of professors, researchers, professionals, and government agents who were active in public health actions and policies. Regarding Latin American realities, the issues of inequality in incidences of sickness and death and in the healthcare delivered to populations became relevant during this time. In close dialogue with relevant social groups, these actors have been significant in constructing responses to health problems in the region. Given the profound political, social, economic, environmental, and sanitary changes that took place in the transition from the 20th to the 21st century, social thought has attempted to meet the new empirical as well as theoretical and conceptual challenges to social sciences as applied to health. The analysis of the trajectory of this regional development, its details, advancements, and limits, is an important endeavor that should help to encourage suggestions toward bettering public health as well as fairness in these times of uncertainties and of new risks for humanity, as evidenced in an unprecedented way in the handling of the Covid-19 pandemic.

The relationship between environment and health is part of the history of medicine and has always been important to any study of human health and to public-health interventions. In Latin America many health improvements are related to environmental interventions, such as the provision of better water and sanitation services. Latin America’s development, industrialization, and sweeping urbanization have brought many improvements to the well-being of its populations; they have also inaugurated new societies, with new patterns of consumption. The region’s basic environmental-health interventions have needed to be updated and upgraded to include disciplines such as toxicology, environmental epidemiology, environmental engineering, and many others. Multidisciplinary and inter-sector approaches are paramount to understanding new profiles of health and well-being, and to promoting effective public-health interventions. The new social, economic, labor, and consumption aspects of modern Latin American society have become more and more relevant to understanding the complex interactions in the region’s social, biological, and physical environment, which are essential to explaining some of the emerging and re-emerging public-health problems. Environmental health, as concept and as intervention, is simple and easily understood, but no longer sufficient to achieve the levels of health and well-being expected and required by these new realities. Many global changes such as climate change, biodiversity loss, and mass migrations has been identified as main cause of ill health and are at the center of the sustainable development challenges in general, and many are critical and specific public health. To face this development, other frameworks have emerged, such as planetary health and environmental and social determinants of health. Public health remains central to some, such as the improved environmental-health agenda, while others assign public health a relative position in a variety of overarching frameworks.

Improved access to safe and reliable water, sanitation, and hygiene (WASH) services in the developing world has many positive health and economic impacts. Two of the key channels through which such impacts manifest are (a) the reduced time burden for the household members, usually women, who are responsible for water collection and transportation, and (b) time saved from not having to defecate in the open, far away from living areas. WASH interventions can produce time savings for low-income households via several specific pathways—for example, through access to closer, more convenient, better quality water and sanitation sources; reduced cost of water delivery to the home; direct conveyance of water via reliable piped supply; or improvements that reduce the time costs of coping with unreliable supply. In existing studies, time savings arising from WASH interventions have primarily been elicited using one of three methods. The first is the time diary approach, which aims to reconstruct an individual’s time use on a recent or typical day. A second approach is direct questioning, where the time spent on a specific activity in a recent (or typical) time period—in this case water collection and WASH management—is recorded. Finally, researchers have begun to use the Global Positioning System and smartphones to track information related to individuals’ movements throughout the day and to determine how those locations map to community water and sanitation facilities. The time savings estimated in published works vary greatly, which may be due to differences in intervention evaluation methods, time elicitation strategies, geographical context, households’ baseline water situation, and the type of improved technology considered. Then, the value of time saved by individuals from use of improved WASH services depends on the opportunity cost of time—that is, the value of the next best use of that time. From a development perspective, alternative time uses for education or income generation may be of particular interest, but other time use (e.g., for leisure, other domestic work, or rest) may also contribute to enhanced household and individual welfare. Unfortunately, in contrast to a fairly robust time valuation literature, especially regarding transportation choices, there is relatively sparse literature on the reallocation of time savings, and its value, from WASH interventions. Many economic analyses therefore fall back on “rule-of-thumb” methods that assume that time savings are worth some fraction, typically approximately 50%, of the prevailing market wage rate. Two methods for time valuation could be used more extensively for valuing WASH-related time savings and burdens in middle- and low-income countries: (a) revealed preference methods based on choices made by individuals between time and other burdens and (b) structured stated preference trade-offs that yield time values based on respondents choices in hypothetical games. Given the shortcomings of the literature, researchers working in this domain should devote greater attention to reporting the nature of the pre-intervention WASH situation in their study setting, describing and validating time use elicitation methods, including, when possible, with objective measures, and more thoroughly considering how time savings are reallocated or contribute to household well-being and reduced poverty. Finally, when conducting cost–benefit analysis of WASH interventions, analysts should use their judgment and knowledge about the specifics of a particular water project when specifying time savings; however, 60% of baseline time spent appears to be a reasonable base case estimate for water supply improvements. For sanitation improvements, the evidence base is thin, but per person time savings of 5–10 minutes per day appears reasonable as a starting point. In each case, sensitivity analysis is recommended around these base case values. Specifically, the value of that time is unlikely to be worth 100% of the household after-tax wage in the policy site, so the analyst should test whether the outcome of a project appraisal would change if time is valued between 25% and 75% of the average after-tax wage rate or, absent that data, the local unskilled wage rate. If the project recommendation changes within this range, the analyst should consider investing in primary research in the policy site, most likely using a stated preference approach. Primary research may also be warranted if distributional consequences of the project (e.g., on women or on the poor) are a central focus of the intervention.

There is one common health objective among all nations, as stated in the constitution of the World Health Organization in 1947: progress towards the best feasible level of health for all people. This goal captures the concept of health equity: fair distribution of unequal health. However, 70 years later, this common global objective has never been measured. Most of the available literature focuses on measuring health inequalities, not inequities, and compare health indicators (mainly access to health services) among population subgroups. A method is hereby proposed to identify standards for the best feasible levels of health through criteria of healthy, replicable, and sustainable (HRS) models. Once the HRS model countries were identified, adjusted mortality rates were applied to age- and sex-specific populations from 1950 to 2015, by calculating the net difference between the observed and expected mortality, using the HRS countries as the standard. This difference in mortality represents the net burden of health inequity (NBHiE), measured in avoidable deaths. This burden is due to global health inequity, that is, unfair inequality, due to social injustice. We then calculated the relative burden of health inequity (RBHiE), which is the proportion of NBHiE compared with all deaths. The analysis identified some 17 million avoidable deaths annually, representing around one-third of all deaths during the 2010–2015 period. This avoidable death toll (NBHiE) and proportion (RBHiE) have not changed much since the 1970s. Younger age groups and women are affected the most. When data were analyzed using smaller sample units (such as provinces, states, counties, or municipalities) in some countries, the sensitivity was increased and could detect higher levels of burden of health inequity. Most of the burden of health inequity takes place in countries with levels of income per capita below the average of the HRS countries, which we call the “dignity threshold.” Based on this threshold, a distribution of the world’s resources compatible with the universal right to health—the “equity curve”—is estimated. The equity curve would hypothetically be between this dignity threshold and a symmetric upper threshold around the world’s average per capita GDP. Such excess income prevents equitable distribution is correlated with a carbon footprint leading to >1.5º global warming (thus undermining the health of coming generations), and does not translate to better health or well-being. This upper threshold is defined as the “excess accumulation threshold.” The international redistribution required to enable all nations to have at least an average per capita income above the dignity threshold would be around 8% of the global GDP, much higher than the present levels of international cooperation. At subnational levels, the burden of health inequity can be the most sensitive barometer of socioeconomic justice between territories and their populations, informing and directing fiscal and territorial equity schemes and enabling all people within and between nations to enjoy the universal right to health. HRS models can also inspire lifestyles, and political and economic frameworks of ethical well-being, without undermining the rights of others in present and future generations.

Since the early 1990s, health policy in Latin America has focused on reform in most countries with the explicit purpose to increase access, decrease inequity, and provide financial protection. Basically, two different and opposed models of reform have been implemented: the Universal Health Coverage (UHC) model and the Single Universal Health System model. The essential characteristics of Latin American UHC are that health care is commodified by the introduction of competition that depends, in turn, on the payer/provider split, free choice, and pre-priced health service plans. In this framework, insurance, be it public or private, is crucial to assuring market solvency, because health needs not backed by purchasing power do not constitute a market that is particularly important in the Latin American region, the most unequal in the world. The Single Universal Health System (in Spanish, Sistema Universal de Salud, SUS) model is a model inspired by the principles of social justice and egalitarian, universal social rights. Characteristically funded by tax revenues, it makes provision of health services to the whole population a responsibility of the State and a universal citizens’ entitlement, independent of individual ability to pay or prior contributions. It considers health to be a public good that, for reasons of efficiency and equity, the market cannot provide. Everyone is entitled, as a right, to free care financed by the State. Given that health system reform occurs in specific historical contexts, these models have had different results in each country. In order to highlight the concrete reform outcomes, the following issues need be addressed: the political scenario and the stakeholders involved; the previous health system and the relative strength of the public and private sectors; coverage achieved by public institutions or insurance, public or private; the different health packages existing within each country; the institutional (re)organization; and the relative importance of public health actions. An analysis is needed of the UHC reforms in Chile, Colombia, and Mexico, on the one hand; and the Single Universal Health System in Brazil, Venezuela, and Cuba on the other. The UHC model in practice tends to increase inequity in access, create new bureaucratic barriers to timely care, fail to provide financial protection, and leads to deteriorated public health measures. It has also created new powerful private sector stakeholders, particularly in Chile and Colombia, while in Mexico the predominance of a strong public sector has “crowed-out” the private one. The Single Universal Health System has significantly increased access for millions that before reform had almost no access and has also strengthened public health actions. However, the strong preexisting private sector providers have profited from the public-sector purchases of complex medical services. Private health insurance has also increased among the upper middle class and workers belonging to strong labor unions.

More than 50 million Americans are currently 65 and older, with current projections estimating that there will be nearly 100 million by 2060. While there is great variability among the older population, many older adults will be disproportionately affected by negative health and well-being consequences associated with chronic diseases, increased fall risk, and physical inactivity. The implementation and dissemination of evidence-based programs can play a major role in the prevention and management of these conditions, thus improving quality of life for the growing number of older adults worldwide. These goals are consistent with the World Health Organization Declaration of the Decade of Healthy Ageing. Research and practice around evidence-based programs for chronic illness management and related conditions in older adults have spearheaded many new opportunities to promote healthy aging as well as revealing challenges in getting effective programs and policies implemented and widely disseminated. For example, most evidence-based programs are not readily scalable or sustainable. Reasons for this may include delay in implementing programs as a result of contextual barriers or the lack of infrastructure for dissemination. These challenges emphasize the need for strategies to ensure the successful implementation and dissemination of evidence-based programs for older adults. Dissemination and implementation science (DIS) provides a broad framework to design interventions and identify implementation strategies that work in diverse real-world clinical and community settings to meet the need of diverse populations. Advancements in research and practice require a basic understanding of (a) principles of DIS; (b) relevant theories, frameworks, and conceptual models; (c) awareness of national and international case examples of chronic disease, falls, and physical activity initiatives for better management of health and functioning in older adults; and (d) shared lessons from research and practice. This lens helps underscore the importance of the evidence-based program movement to the aging services network.

Many utilities, including water, electricity, and gas, use nonlinear pricing schedules which replace a single uniform unit price, with multiple elements such as access charges and consumption blocks with different prices. Whereas consumers are typically assumed to be utility maximizers with nonlinear budget constraints, it is more likely that consumer behavior shows limited-rationality features such as reference dependence. Recent studies of water demand have explored consumer reactions to social comparison nudges, which can moderate consumption and might be a useful tool given low demand-price elasticities. Other authors have noted the difficulties of correct price perception when tariff schedules are complex, and attributed those low elasticities to a lack of information. Nonetheless, it is also possible that consumers form reference prices, relative to which the actual price paid is compared, in a way that affects consumption choices. Faced with a nonlinear price schedule, such as increasing block tariffs, consumers could evaluate their actual marginal price as a loss or a gain relative to a particular reference price that is derived from the schedule. Introducing gain/loss terms into the utility function, in the discrete/continuous model of consumer choice that has been widely used for water demand analysis, leads to consumption decisions that vary when a higher-than-reference price is seen as a loss and a lower-than-reference price as a gain. Utilities might wish to explore these reference-price effects according to their strategic goals. For example, if there are capacity constraints or water scarcity problems, potential water savings can be achieved from highlighting the first-block price as a reference and framing higher-block prices as losses, inducing conservation even without raising overall prices. Furthermore, if higher-block prices are subsequently raised the demand response could be stronger.

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.

Research in diverse fields has examined how social and gender norms, broadly defined as informal rules of acceptable behavior in a given group or society, may influence sexual and reproductive health outcomes. One set of conceptual and empirical approaches has focused on perceptions of how commonly others perform a behavior and the extent to which others support or approve of the behavior. Another set of approaches has focused on how social norms emerge from structures of gender and power that characterize the social institutions within which individuals are embedded. Interventions intended to improve sexual and reproductive health outcomes by shifting social and gender norms have been applied across a wide range of populations and settings and to a diverse set of behaviors, including female genital mutilation/cutting, the use of modern contraceptive methods, and behavioral risk reduction for HIV. Norms-based intervention strategies have been implemented at multiple socioecological levels and have taken a variety of forms, including leveraging the influence of prominent individuals, using community activities or mass media to shift attitudes, and introducing legislation or policies that facilitate the changing of social norms. Recent advances in social and gender norms scholarship include the integration of previously disparate conceptual and empirical approaches into a unified multilevel framework. Although challenges remain in measuring social and gender norms and studying their impacts on sexual and reproductive health-related behaviors across cultures, the research will continue to shape policies and programs that impact sexual and reproductive health globally.

The development of public health in Latin America during the 20th century combined, early on, the social medicine framework on the social, political, and environmental origins of disease with the contributions of medical anthropological fieldwork. Despite the hegemony of the medical model, the surge of the preventive medicine framework further legitimized the involvement of social scientists in the study of the multicausality of disease. However, the limitations brought by the preventive medicine model’s lack of historical and political contextualization gave way to the Latin American social medicine movement, which was grounded in historical materialism, and the development of both critical epidemiology and critical medical anthropology.

Street science is the processes used by community residents to understand, document, and take action to address the environmental health issues they are experiencing. Street science is an increasingly essential process in global urban health, as more and more people live in complex environments where physical and social inequalities create cumulative disease burdens. Street science builds on a long tradition of critical public health that values local knowledge, participatory action research, and community-driven science, sometimes referred to as “citizen science.” Street scientists often partner with professional scientists, but science from the street does not necessarily fit into professional models, variables or other standards of positivist data. Street science is not one method, but rather an approach where residents are equally expert as professional scientists, and together they co-produce evidence for action. In this way, street science challenges conventional notions in global health and urban planning, which tend to divorce technical issues from their social setting and discourage a plurality of participants from engaging in everything from problem setting to decision-making. Street science does not romanticize local or community knowledge as always more accurate or superior to other ways of knowing and doing, but it also recognizes that local knowledge acts as an oppositional discourse that gives voice to the often silent suffering of disadvantaged people. At its best, street science can offer a framework for a new urban health science that incorporates community knowledge and expertise to ensure our cities and communities promote what is already working, confront the inequities experienced by the poor and vulnerable, and use this evidence to transform the physical and social conditions where people live, learn, work, and play.

In many countries, Traditional Chinese Medicine has acquired a status similar to other historical healthcare systems that are not at all or only partially legitimated by modern science, such as Ayurveda and homeopathy. They all contribute in one way or another to the health of the public. And yet, Chinese medicine eludes inclusion in modern, global public health concepts. Its focus on the individual patient-healer relationship, its diverse non-Chinese terminologies, often developed by individuals regardless of the historical meaning of the original Chinese terms, and an increasingly uncoordinated development of TCM in China and the rest of the world, with heterogenous educational standards resulting in very different skill levels of practitioners, make it impossible to draw far-reaching conclusions and contribute generalizable suggestions for the continued improvement of global public health.