Perspectives for workplace health promotion in Latin America and the Caribbean

The Latin American and Caribbean region is witnessing the emergence of discussion on workplace health promotion (WHP). The authors propose WHP as an equitable collective action targeting primarily work hazards and their determinants. It has its economic-political "macro" level and a downstream "micro" level. On the macro level, neoliberalism, privatization, and deregulation threaten equitable health and labor issues. Effective labor and health legislation and a fair degree of social redistribution of resources support WHP. Micro-scale WHP is important for contextual reasons and social diffusion, and can literally save lives. Worker involvement, free association of workers, public health affiliation, the precautionary principle, sensitization and training, employer responsibility for healthy working conditions, coalitions between workers and health professionals, and preference for reduction of direct work hazards over modification of personal lifestyles are basic tenets of WHP.     

Agricultural occupational health and health education in Latin America and the Caribbean

Agricultural diseases and injuries are major sources of healthconcern in Latin America and the Caribbean. To help alleviatethis situation, health education programs directed at workersat risk have been implemented. This paper discusses the factorsinherent to agricultural work that need to be considered inthe design, planning, implementation, and evaluation of healtheducation activities, such as the characteristics of agriculturalwork and occupational health problems. In addition, it presentsa case study of health promotion for Argentine Hemorrhagic Feverdirected to agricultural workers in the endemic area of thisdisease.     

Quality and health care reform in Latin America and the Caribbean]

Improving the quality of basic health services, together with the search for equity, efficiency, sustainability, and social participation, has been one of the guiding principles of health sector reform initiatives ever since the I Summit of the Americas was held in 1994. This article addresses some basic concepts, examines the status of quality control within health systems and services in Latin America and the Caribbean, and analyzes the most important trends observed in the Region in the establishment of quality assurance programs. Finally, ways of improving and monitoring quality continuously and sustainable are recommended.     

Urban air pollution in Latin America and the Caribbean: health perspectives

In the last few years, air pollution has become a major issue in some countries of Latin America and the Caribbean because of urban development and growing industrialization. In addition to industrial processes often concentrated in the cities, vehicle emission and stationary-source fuel combustion are the primary sources of air pollution. Although air-quality standards have been established in some Latin American countries, these are frequently exceeded. Adverse health effects of air pollution have been mainly associated with the following pollutants: sulfur dioxide and particulate matter, photochemical oxidants, nitrogen dioxide and carbon monoxide, and lead. Short-term as well as long-term effects can be expected at levels exceeding WHO guidelines. The Latin American urban areas most affected by anthropogenic pollutant emissions are: the area of S?o Paulo (Brazil), the city of Santiago (Chile) and the metropolitan area of Mexico City. However, situations similar to those prevailing in these cities could well occur in other cities of Latin America and the Caribbean. The population exposed to air-pollutant levels exceeding WHO guidelines can be estimated to 81 million or 26.5% of the total urban population of Latin America and 19% of its total population. These estimates correspond to 30 million children (0-14), 47 million adults (15-59) and 4 million elderly people (60+). To date a very limited number of epidemiological studies have been carried out to determine the potential health effects of air pollutants in Latin America. To obtain a rough estimate, a scenario was hypothesized in which subjects living in cities would be exposed to a given level of air pollutant, using data from the international literature to extrapolate the expected number of events in different strata of the hypothetical population. The estimated health effects are considerable and warrant priority control intervention. This is true although epidemiological studies are needed to evaluate the health impact of specific pollutant compounds as well as their interactions in Latin American populations exposed to high levels of pollution.     

Rethinking social protection in health in Latin America and the Caribbean]

Despite what is written in the constitutions and other basic document mandates of the countries of the Region, exclusion from social protection in health (SPH) affects an important proportion of the population (at least 20%, which represents, in absolute figures, between 80 and 200 million people). These estimates are obtained through a series of theoretical (social security coverage) and practical indicators that encompass structural indicators (poverty, ethnicity, and geographical barriers) as well as process indicators (non-institutional births, compliance with vaccination schedules, and access to basic sanitation). Exclusion levels in a society are affected by the degree of segmentation of the health system. Traditionally, most countries of the Region have had a public, a social security and a private subsystem in health. Lack of attention to the problem has resulted in the formation of a community-based subsystem. The coexistence of many subsystems, along with poor regulation on the part of health authorities, has resulted in high levels of exclusion and inefficient resource allocation within the sector. The organization of social dialogue processes focusing on SPH within the context of health sector reform initiatives in each country is recommended. The process, which should be participatory, should include a full diagnosis of the situation (how many are excluded, who are they, and why, and what mechanisms are the most appropriate for tackling the issue in each country). It should also provide a political and technical feasibility analysis of the most suitable options for each society, and a determination of whether or not conventional subsystems have exhausted their potential. The process should culminate in a program for implementing the specific proposals made in each society, in an effort to maximize SPH.     

Organization of the public health services in Latin America and the Caribbean]

The organisation of veterinary public health (VPH) services in countries of Latin America and the Caribbean has resulted from an historical process which has consolidated the structure of these services and the concept of VPH. This concept comprises five principal plans of action: promotion of animal health in order to increase the production of protein of animal origin; protection of foods for human consumption; vigilance, prevention, control and eradication of zoonoses; promotion of environmental protection, together with the development of biomedical models. These plans of action serve the purpose of improving human health and well-being, which is essential for the socioeconomic development of populations. Within this context, the authors describe the organisation of VPH services for health and agriculture, which have a part to play in intersectorial collaboration and in social participation. Finally, an account is given of progress in the control of rabies, brucellosis and tuberculosis, and the organisation of integrated programmes for food protection and also the control and eradication of foot and mouth disease. Technical cooperation with the Pan American Health Organisation (PAHO) assists these activities and intersectorial coordination, principally between health and agriculture.     

Environmental health conditions and cholera vulnerability in Latin America and the Caribbean.

Epidemic cholera reached South America in January 1991 and later spread to Central America and the United States. It afflicted 312,000 people and claimed 3200 lives. Since cholera had not been in Latin America for almost 70 years, health authorities allowed environmental health barriers to cholera collapse. For example, the Governments of the Region agreed in 1961 to abide by the Charter of Punta del Este to provide water and sewerage to 70% of the urban population and 50% f the rural population by 1971. They did not achieve their goals for the rural population. In fact, at the end of 1988, water was piped to 79% of the urban households and an additional 11% of the urban population had access to a public water source. Sewerage services served 49% of the urban population and, with other methods of excreta disposal, 80% of the population had adequate excreta disposal. On the other hand, only 55% of rural inhabitants had access to either piped water or public standpipes. Further sanitary excreta disposal services only covered 32%. Besides the water quality of existing water supply systems was poor. Since feces of infected people have as many as 1 billion Vibrio cholerae and , in some of Vibrio, up to 80% of carriers exhibit only mild symptoms or no symptoms at all, it is easy to understand how cholera took hold in Latin America. Researchers identified the points of contamination responsible for the cholera outbreak in Piura and Trujillo, Peru to be wells, distribution systems, and house. Annual population growth in Latin America at 2.6% poses specific problems to providing enough water and sanitation services to all in need, especially those in marginal areas around the cities (who will make up 40% of the population by 2000).     

Occupational risks in Latin America and the Caribbean: economic and health dimensions

This study analyzes health and economic aspects of occupational safety in Latin America and the Caribbean. Work-related injuries and illnesses represent a primary health risk in the region. Specific factors negatively affect work safety in the region: the structure of the labour market, the lack of adequate resources for enforcement, prevention and research, the hazard profile, as well as the presence of vulnerable groups in the workforce. This study estimates that between 27,270 and 73,500 occupational fatal accidents occur in the region each year. It also calculates that the economic costs of these hazards represent between 2 and 4% of regional Gross Domestic Product. The paper concludes by discussing public policies that could address this problem and improve compliance with appropriate safety standards in the region.     

Regional initiative on health care reform in Latin America and the Caribbean]

Many countries throughout Latin America and the Caribbean are introducing reforms that can profoundly influence how health services are provided and who receives them. Governments in the region identified the need for a network to support health reform by building capacity in analysis and training, both at the Summit of the Americas in 1994 and at the Special Meeting on Health Sector Reform, which was convened in 1995 by an interagency committee of the Pan American Health Organization/World Health Organization, the Inter-American Development Bank, the World Bank, and other multilateral and bilateral agencies. In response, in 1997 the Pan American Health Organization and the United States Agency for the International Development launched the Latin America and Caribbean Regional Health Sector Reform Initiative. The Initiative has approximately US$ 10 million in funding through the year 2002 to support activities in Bolivia, Brazil, the Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Paraguay, and Peru. Now in its third year of implementation, the Initiative supports regional activities seeking to promote more equitable and effective delivery of basic health services.     

Mental disorders in Latin America and the Caribbean: a public health priority]

OBJECTIVE: The growing burden of mental disorders in Latin America and the Caribbean has become too large to ignore. There is a need to know more about the prevalence of mental disorders and the gap between the number of individuals with psychiatric disorders and the number of those persons who remain untreated even though effective treatments exist. Having that knowledge would make it possible to improve advocacy, adopt better policies, formulate innovative intervention programs, and apportion resources commensurate with needs. METHODS: Data were extracted from community-based psychiatric epidemiological studies published in Latin America and the Caribbean from 1980 through 2004 that used structured diagnostic instruments and provided prevalence rates. Estimates of the crude rates in Latin America and the Caribbean for the various disorders were determined by calculating the mean and median rates across the studies, by gender. In addition, data on service utilization were reviewed in order to calculate the treatment gap for specific disorders. RESULTS: Nonaffective psychosis (including schizophrenia) had an estimated mean one-year prevalence rate of 1.0%; major depression, 4.9%; and alcohol use abuse or dependence, 5.7%. Over one-third of individuals with nonaffective psychosis, over half of those with an anxiety disorder, and some three-fourths of those with alcohol use abuse or dependence did not receive mental health care from either specialized or general health services. CONCLUSIONS: The current treatment gap in mental health care in Latin America and the Caribbean remains wide. Further, current data likely greatly underestimate the number of untreated individuals. The epidemiological transition and changes in the population structure will further widen the treatment gap in Latin America and the Caribbean unless mental health policies are formulated or updated and programs and services are expanded.     

Gender equity in health sector reform policies in Latin America and the Caribbean]

Gender equity is increasingly being acknowledged as an essential aspect of sustainable development and more specifically, of health development. The Pan American Health Organization's Program for Women, Health, and Development has been piloting for a year now a project known as Equidad de género en las políticas de reforma del sector de salud, whose objective is to promote gender equity in the health sector reform efforts in the Region. The first stage of the project is being conducted in Chile and Peru, along with some activities throughout the Region. The core of the project is the production and use of information as a tool for introducing changes geared toward achieving greater gender equity in health, particularly in connection with malefemale disparities that are unnecessary, avoidable, and unfair in health status, access to health care, and participation in decision-making within the health system. We expect that in three years the project will have brought about changes in the production of information and knowledge, advocacy, and information dissemination, as well as in the development, appropriation, and identification of intersectoral mechanisms that will make it possible for key figures in government and civil society to work together in setting and surveying policy on gender equity in health.     

The economic crisis and its impact on health and health care in Latin America and the Caribbean

The economic crisis that struck most Latin American and Caribbean countries beginning in 1982 has caused sharp reductions in domestic investment and in imports; domestic consumption has been less affected, while public sector spending has responded in different degrees in different countries. In general, public spending on health decreased, sometimes quite dramatically, but some countries were able to maintain the real value of noninvestment spending for health by central governments. It is much harder to tell what may have happened to output of health services, and still harder to know how health status has been affected. Scattered evidence suggests two conclusions. First, worsened economic conditions can seriously damage health status, with effects on infant mortality and on the patterns of disease and death, especially for children. Second, these repercussions do not have to occur, and public programs designed specifically to maintain basic health services and to assure adequate nutrition are effective in offsetting the worst consequences of economic hardship.     

Social scenarios in Latin America and the Caribbean]

A wide range of sources have pointed out the magnitude and depth of the social problems that trouble Latin America and the Caribbean and the risks that these problems pose for democracy. Although there are other issues that merit consideration, this article briefly outlines nine key social problems: 1) the increase in poverty, 2) the impact of poverty, 3) unemployment and informal employment, 4) deficiencies in public health, 5) problems in education, 6) the newly poor, 7) the erosion of the family, 8) increasing crime, and 9) the perverse cycle of socioeconomic exclusion. Solving these problems must not be delayed. It is urgent to move to a comprehensive view of development that achieves a different balance between economic and social policies, and that recognizes the indispensable role of these policies in achieving truly sustainable development. At stake are problems that not only concern resources, but also priorities, levels of equity, and the organization of society. Facing up to this poverty and inequity requires an in-depth assessment of these economic policies' social consequences, of the crucial subject of Latin American inequity--the greatest in the world--and of the role of social and public policies.     

Emergency contraception in Latin America and the Caribbean]

Introducing the post-coital birth control method in the family-planning services of Latin American countries has not been an easy task. Catholic and other conservative groups with great influence in the political arena have time and again stopped it from being adopted as an alternative method and have even succeeded in having it removed from official directives after formal acceptance by health authorities. The main objections are triggered by the erroneous supposition that "emergency contraception" pills are abortifacients. However, a large dose of cultural discrimination against women seems also to be involved. It has been extremely difficult to register dedicated products and make them available in drug-stores and even more difficult to distribute them without charge at public health centers. They are hard to find, expensive, and unavailable to adolescents at risk for unwanted pregnancies and to most low-income women, especially in rural areas. Dissemination of appropriate information has been scarce and slow and there are still great numbers of people that do not understand how or why the method works. Brazil has been the only exception, as its open society has readily accepted this method of contraception. The Latin American Consortium on Emergency Contraception founded in the year 2000 and its regional conference two years later had an important impact on the situation, as they encouraged the coordination of efforts by governmental and nongovernmental entities with those of women's groups to fight for sexual and reproductive rights. A number of studies have shown that the more people learn about emergency contraception, the more they find it acceptable and necessary, and radio spots and other media techniques have begun to educate the public about this matter. In spite of the many difficulties encountered, in the last few years several countries have made strides to include this method in their public health guidelines. However, because of the powerful forces against it, accessibility and distribution of the emergency pills are not always implemented as planned and there are still many areas that require work. Details are given on the situation in Argentina, Bolivia, Chile, Colombia, Ecuador, Honduras, Mexico, Paraguay, and Peru.     

Quality assessment activities in Latin America and the Caribbean

The Pan American Health Organization (PAHO) supports performance evaluation programs in clinical chemistry, Caribbean. Much more work remains to be done before many labs in this part of the world can be certified as providing accurate results, but PAHO has taken an important first step toward establishing benchmarks and rallying for labs to improve test quality.     

Perspectives for Workplace Health Promotion in Latin America and the Caribbean

Abstract

The Latin American and Caribbean region is witnessing the emergence of discussion on workplace health promotion (WHP). The authors propose WHP as an equitable collective action targeting primarily work hazards and their determinants. It has its economic-political “macro” level and a downstream “micro” level. On the macro level, neoliberalism, privatization, and deregulation threaten equitable health and labor issues. Effective labor and health legislation and a fair degree of social redistribution of resources support WHP. Micro-scale WHP is important for contextual reasons and social diffusion, and can literally save lives. Worker involvement, free association of workers, public health affiliation, the precautionary principle, sensitization and training, employer responsibility for healthy working conditions, coalitions between workers and health professionals, and preference for reduction of direct work hazards over modification of personal lifestyles are basic tenets of WHP.     

Breast cancer in Latin America and the Caribbean.

As recently as two decades ago breast cancer was not a significant public health concern in Latin America and the Caribbean (LAC). However, mortality rates from breast cancer have been increasing for at least 40 years in most LAC countries. Socioeconomic development and consequent changes in reproductive behaviors over the past 50 years are thought to have contributed to the increased risk of breast cancer. Socioeconomic development has also increased women's health awareness and therefore the demand for quality services. In industrialized countries, screening and widely available, high-quality treatment protocols are being implemented as the main strategy for breast cancer control. Studies show that out of three available screening methods (mammography, clinical breast examination, and breast self-examination), only mammography for women 50-69 years of age has been effective at reducing mortality, and has done so by an estimated 23%. While there is much controversy about the benefits and cost-effectiveness of mammography screening for women aged 40-49, some countries, including Australia, the United States of America, and four European nations, recommend that physicians assess the need for it on an individual basis. A survey that we conducted of LAC countries shows that most of their breast cancer screening policies are not justified by available scientific evidence. Moreover, as seen by relatively high mortality/incidence ratios, breast cancer cases are not being adequately managed in many LAC countries. Before further developing screening programs, these countries need to evaluate the feasibility of designing and implementing appropriate treatment guidelines and providing wide access to diagnostic and treatment services. Given the relevance of breast cancer in Latin America and the Caribbean today, it is crucial that both women and health care providers have access to up-to-date information on which to base their decisions.