Promoting & Protecting People s

Health

Promoting & Protecting People s

Health

T h e C o m m i t m e n tIn 1994, the Pan American Sanitary Conference instructed theBureau to orient its technical cooperation with the countries to:

• foster social development based on the principles of equityand the right of all people to health and well-being throughthe formulation and application of health-oriented public policy relating to food and nutrition, drug addiction andsmoking, and prevention and control of violence;

• encourage the development of a culture of health founded ona healthy environment and the adoption of lifestyles thatpromote health through the development of strategicinterventions designed to create healthy options for thepopulation;

• support the development of the health sector’s capacity toidentify and lead intersectoral processes that will promoteand protect physical and mental health, recognizing that it isat the local level that health promotion and protectionactivities must be implemented, and supporting local effortsto mobilize resources and improve health and well-being;

• support the generation, evaluation, dissemination, and use ofinformation relating to health in general and health promotionand protection in particular;

• promote the development of policies and programs relating topopulation issues, reproductive health, fertility regulation,and the health concerns of adolescents and children, andenhance the coordination of health promotion activities andreproductive health services;

• seek continued improvements in the nutritional status of allpopulation groups, promoting breastfeeding as an importantstrategy for ensuring good childhood nutrition.

52

Tapping Social Capital for Community HealthSocial capital—a force comprising an intricate web of relationships, norms of behavior,values, obligations, and information channels—can provide the ties that lead to acommunity’s well-being and prosperity. More specifically, community bonds can serveas a powerful agent of change in health. paho has therefore fostered a healthy settingsmovement—encompassing municipalities, cities, communities, schools, andworkplaces—in all the countries of the Americas. Networks of healthy municipalitiesand health-promoting schools have evolved, providing important vehicles forpractitioners, researchers, and teachers in the countries to share their experiences andidentify good practices. Each municipality prepares a plan of action, based on prioritiesidentified by the people, that demonstrates political commitment, allocates resources forinclusion of health promotion and human welfare in local development, and assures fullinvolvement of the community in efforts to improve environmental and socialconditions. Sharing experiences and information has been the objective of paho-sponsored international meetings of municipal health secretaries (Fortaleza, Brazil, 1995,and Havana, Cuba, 1997) and of mayors (Campinas, Brazil, 1996, and Boca del Río,Mexico, 1997). paho has also supported the founding of the Latin American Networkof Health-promoting Schools, which first convened health and education sectorrepresentatives from 14 countries in San José, Costa Rica in 1996 and which broughttogether representatives from 22 countries at its latest meeting in Mexico in 1998.

T h e R e s u l t s

Health-pr omoting schoolscontribute to social and economicdevelopment, incr easedproductivity, and a better qualityof life for all by pr omoting thehealthy development of youth.

Chile

The national plan of action for healthy communesset up a planning committee of public and privatesector repr esentatives committed to community

involvement in delivering primary health care. The communes ofViña and Quillota have established healthy hospitals, and severalothers have adopted a primary envir onmental care strategy to dealwith solid waste and industrial pollution.

53

Promoting & Protecting People s Health

Among the healthy settings projects in which PAHO is cooperating...

Trinidad and T obago

Each r egion of the country has developed healthycommunities based on their members’identifi cation of priority needs: to control pests

(rats, cockr oaches, fl ies, and mosquitoes), the Don Miguel W omen'sGroup sought training as litter war dens; to compensate for lack ofland for home gar dening, the La Beta Self Health Gr oup in BeethamGardens lear ned container gardening; and to addr ess the pr oblemof neglected childr en, the Capildeo Lands Settlement CommunityGroup gave training in par enting skills to a cadre of mothers, who inturn are teaching those skills to mothers of families at risk.

Colombia

“Healthy communities for peace” targetprevention of violence, with communitymembers—political, civil, military and religious

leaders, private and public entities, business executives and workers,individuals and families—dedicating their efforts to improving livingconditions, fostering healthy envir onments, and str engtheningcommunity well-being.

Costa Rica

In 1996 the PA H OCountry Office instituted anannual award for the best proposals to cr eatehealthy “cantones,” with fi rst and second

place prizes of US$6,000 and $2,000 to be used forimpr ovements in local health and envir onment. Granted by acommittee of public sector and PA H Orepresentatives, the awardserves to stimulate sound health and envir onmental planningand pr ogramming. Canton pr ojects submitted for the awardrange from sanitary landfi lls, to waste r ecycling and anti-littering campaigns, to pr evention of drug abuse.

Cuba

A network of 57 healthy settings comprisesschools, markets, cooperatives, communities,universities, workplaces, and clinics. Schools

promote students’ understanding of diet, personal hygiene, andsexually transmitted diseases as well as better lighting, ventilation,and equipment. High-risk pr egnant women cared for in maternalcooperatives are nourished by wholesome food from far mers’associations, r esulting in the lowest rate of perinatal deaths in 1997ever r ecorded in the country. Popular councils foster better nutrition,water supplies, sanitary latrines, and healthy living conditions .

Panama

A network of “municipios for the 21st century”has str engthened community health committees’role in local health pr omotion and local

development. A pr oject to develop health-pr omoting schools hasbrought together the health and education sectors to analyzestudents’ needs and how best to addr ess them, r esulting in astudent health pr ogram emphasizinghealth pr omotion.

Paraguay

A committee to pr omote healthy communitiesidentified national and inter national institutionsoperating at the local level, elaborated a “basket

of available technical r esour ces” to support local needs—especiallyelimination of measles and Chagas’ disease—and disseminatedinfor mation in support of the movement, leading to organization of13 municipios and a proposal to develop health-promoting schools.

Peru

Local authorities and neighborhood leaders in themunicipality of T acna pr epared a strategic planfor envir onmental management and health

impr ovement that r esulted in construction of a sanitary landfil l,creation of gr een ar eas i rrigated with tr eated wastewater, andattention to air and land pollution.

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Health of AdolescentsPA H Ohas pioneered an appr oach toadolescent health based on a planof action, adopted by the DirectingCouncil in 1997, that advocatesplacing the issue on the politicalagenda; impr oving countries’ abilityto satisfy adolescents’ needs byadopting public policies andpreparing human r esour ces;strengthening adolescent healthplans, pr ograms, and ser vices;developing networks ofprofessionals and institutionsworking in adolescent health; andpromoting adolescents’participation in their and theircommunities’ health. As a r esult ofthe plan and PA H O’s technicalcooperation in this ar ea: Ar gentina,Brazil, and Mexico have developednational and state pr ograms for theintegral health of adolescents withhealth services, counseling, andeducation components; the English-speaking Caribbean countries havetaken the lead in health-pr omotingschools where students are taughtlifestyle changes, development ofhealthy eating habits, andprevention of pr oblems caused bysmoking, drug abuse, and sexualpromiscuity; and adolescents inmany countries are acting as agentsof social change, as exemplified byAY U D A—American Y outhUnderstanding Diabetes Abr oad—agroup of adolescents in the UnitedStates that supports the cause ofdiabetic adolescents in Ecuador.

Mass mediacampaignssuppor ted by thegover nment andoften the FirstLady aimed atreducingmaternalmortality havebeen launched inBolivia, Ecuador,Mexico, and Peru .

CanadaUnited States

BarbadosPanama

Costa RicaChile

UruguayTrinidad &T obago

CubaBahamas

ArgentinaColombia

Dominican RepublicMexico

JamaicaVenezuela

EcuadorNicaraguaParaguay

GuatemalaBrazil

HondurasPeru

El SalvadorBolivia

Haiti

Making Motherhood SafeEach year around 26,000 women in theAmericas lose their lives as a directconsequence of being pregnant. The vastmajority die for want of timely,accessible, and competent care—tragicdeaths made all the more so because ofthe loss they represent to the women’sfamilies. To make death in childbirth athing of the past, paho promotespregnant women’s access to qualityprenatal care and delivery, obstetricemergency services, sex and reproductivehealth education, and family planning.Progress to date in this area includes: 13countries with national health plans toreduce maternal mortality; a regionalproject sponsored by paho, usaid, andMother Care and Quality Assurance toimprove emergency obstetric care in 11countries; another paho project withunfpa to prevent adolescent pregnancies

0 200 400 600 800 1000

in 14 countries; and the leadership ofFirst Ladies in the countries in support ofsafe motherhood. The emphasis is onimproving the quality of care through bettermanagement and participative approaches;one such approach in Bolivia resulted in adoubling of the national hospital occupancyrate in a two-year period.

The Latin American Center forPerinatology and Human Development(clap) focuses its efforts on improvingthe perinatal health of mothers andnewborns. The Center has developed acommon data registry system for theRegion that makes it possible to establishregional priorities; has produced a seriesof evidence-based norms, procedures, andtechnologies; and has trained thousandsof health workers in perinatology.

Estimates of mater nal deaths per 100,000 live bir ths inselected countries of the Americas.

Avoidable mater nal deaths are anoutrage. PA H Ois putting maternalmortality on the public agenda,enlisting the support of Heads ofState, First Ladies, and agencies inother sectors.

PA H Ohas r evamped the concept of dietaryguidelines as practical indications to help peopleselect and consume better food and ther eby attaintheir nutritional goals, taking into account theirdietary habits and social, economic, and culturalfactors; 13 countries—Ar gentina, Brazil, Costa Rica,Chile, Cuba, El Salvador, Guatemala, Honduras, Mexico,Nicaragua, Panama, the United States, andVenezuela—have implemented or are in the pr ocessof validating these guidelines. Shown clockwisefrom top right, are the guideline icons of Canada,Chile, and Guatemala.

Promoting Healthy Diets and Good NutritionWith the aim of improving people’snutritional status, paho and the countriesare targeting three micronutrients: iron,iodine, and vitamin A. As part of theirnational food and nutrition plans, 18countries—Argentina, Barbados, Belize,Bolivia, Chile, Colombia, Costa Rica,Dominican Republic, Ecuador, ElSalvador, Guatemala, Honduras, Jamaica,Nicaragua, Panama, Peru, Trinidad andTobago, and Venezuela—have put inplace low-cost programs to fortify foodwith iron and, in some cases, folic acid inorder to reduce the high prevalence ofiron-deficiency anemia and neural tubedefects, respectively, targeting youngchildren and pregnant women inparticular. Another major advance is thefortification of salt with iodine, resultingin three countries—Bolivia, Colombia,and Ecuador—having been declared freeof iodine-deficiency disorders, principalamong which is endemic goiter.Fortification of sugar with vitamin A hasbeen carried out in countries with a highprevalence of vitamin A deficiency.

Promoting & Protecting People s Health

55

Protein-energy malnutrition in children under 5 is onthe decline due to a number of specific inter ventions,among them the pr omotion of br eastfeeding.

6 0 %

5 0 %

4 0 %

3 0 %

2 0 %

1 0 %

0 %

Cuba

Peru

Bolivia

Brazil

Colombia

Ecuador

El Salvador

Guatemala

Panama

English Caribbean

Costa Rica

Argentina

Mexico

Chile

Brazil

El Salvador

Nicaragua

Peru

Dominican Republic

Mexico

Guatemala

Colombia

Ecuador

Honduras

Bolivia

Argentina

Belize

Venezuela

Panama

El Salvador

Guatemala

Peru

Venezuela

Panama

Colombia

Bolivia

Nicaragua

Costa Rica

Vitamin A defi ciencyin children under 5Endemic goiter

Anemia in pregnant women

Nutrition-r elated pr oblems PA H Oand the countries are deter mined to solve(bars show percentage of the population af fected in selected countries).

*Estimates based on par tial, not national, studies.

Gua

tem

ala

Hon

dura

s

Peru

Haiti

Bolivia

Ecu

ador

Nicar

agua

El S

alvad

or

Mex

ico

Dom

inican

Rep

ublic

Par

agua

y

Braz

il

Col

ombi

a

Uru

guay

Ven

ezue

la

Jam

aica

Arg

entin

a

Cuba

Chile

At the same time, the Organization is researching the currentsituation of obesity in the Region and advocating its designationas an emerging health problem. paho’s two centers—theCaribbean Food and Nutrition Institute (cfni) and the Instituteof Nutrition of Central America and Panama (incap)—workwith the countries in their regions to deal with protein-energymalnutrition, micronutrient deficiencies, and obesity.

0 % 2 0 % 4 0 % 6 0 % 0 % 1 0 % 2 0 % 3 0 % 0% 2 0 % 4 0 %

*

*

*

*

*

*

*

*

*

*

Overall under nutritionStuntingW asting

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Mental HealthDemographic and social changesunder way in the Americas areincr easing people’s mental healthcare needs. In support of countries’efforts to addr ess those needs,PA H O/W H O, the World Federation forMental Health, the Car ter Center,and Harvard University amongothers convened an inter nationalmeeting of women leaders—manyof them First Ladies—for mentalhealth ( PA H OHeadquar ters, 1996)with repr esentation of 20 countriesin the Region. Par ticipants signed adeclaration that committed thempersonally to pr omote mentalhealth in the Americas. Since thenthe First Ladies have participatedactively every year in W orld MentalHealth Days on 10 October andpresided over national advisorycommittees on mental health. In1997, PA H O’s Directing Councilreviewed the Bur eau’s activities inthis area and ur ged that countriescarry out mental health pr ograms asan integral component of nationalhealth plans and that they reorientmental health ser vices from aninstitutional to a communityappr oach. The Council’s initiativehas ser ved as a model for otherregions in the world.

Fighting Tobacco, Drugs, and AlcoholIn countries throughout the Region, paho is working with the Organization ofAmerican States to boost the efforts of national commissions to control and prevent theabuse of harmful substances—efforts aimed at developing national programs, enactinglegislation and regulations, and accrediting treatment centers. In support of the Region’sinteragency tobacco and health action plan, paho provides training and information,conducts baseline and epidemiological studies, and mobilizes funds to promote anti-tobacco legislation, smoking cessation programs, and smoke-free environments. paho isalso working with three collaborating centers in Canada, Costa Rica, and Mexico todevelop knowledge and standards for monitoring public drinking and designing publicpolicies on alcohol-related health issues.

In Trinidad and T obago, with PA H O’ssupport, the gover nment declaredall public offi ces “smoke-fr ee” onW orld No T obacco Day and theMinister of Health announced that,thenceforth, smoking would bebanned at all institutions under theministry and a national no-smokingpolicy would be developed.

First Ladies and other leaders from thr oughout the Americas havecommitted to pr omote mental health in the Region.

Health, Well-being, and AgingHow healthy are people 60 and older?What illnesses, handicaps, and pains dothey suffer? Do gender, income, andeducation make a difference in theirhealth? What makes for a healthy oldage? What kind of relationships doolder adults have with younger membersof their families? How does the aging ofa population affect the operation ofhealth insurance systems? The answersto these and many other questions arethe focus of a regional study on health,well-being, and aging that paho iscoordinating among universities,collaborating centers, and ministries ofhealth in Barbados, Brazil, Chile, CostaRica, Cuba, Mexico, Uruguay, and theUnited States that will collect, compare,and analyze data in metropolitan areasof the selected countries. paho and theLatin American Parliament sponsoredan international forum on aging(Montevideo, 1997), with 115 delegatesfrom 21 countries throughout theRegion issuing a declaration thatrecommends changes in attitudes aboutaging, promotes actions aimed ateliminating age discrimination and bias,and proposes a comprehensive healthyaging policy that encompasses socialsecurity and medical care services,health promotion and social well-being,housing and community services,intergenerational relations, and activeaging. In Chile, the Ministry of Healthhas developed national guidelines forthe health care of older persons;Uruguay has created theNational Institute of Aging; andGuatemala has developed anational plan on aging. ■

In Panama, as part of thehealthy municipalitiesinitiative, a situationanalysis in two healthregions pointed up theimpor tance of involvingthe elderly in communitiesin deter mining theirhealth needs and r esultedin local action plans forthe r egions’ health ser vices.

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Promoting & Protecting People s Health

Canada

United States

Uruguay

Cuba

Puerto Rico

Argentina

Chile

Trinidad & T obago

Jamaica

Panama

Brazil

Costa Rica

Colombia

El Salvador

Venezuela

Peru

DominicanRepublicEcuador

Mexico

Paraguay

Bolivia

Haiti

Guatemala

Honduras

Nicaragua

An easily understood indicator of thechanges in age structure is the agingindex—the ratio of the number ofpersons aged 60 and over per 100youths under age 15. Among selectedcountries in the Americas in 1997, thisratio ranged from a high of 82 inCanada to a low of 9 in Nicaragua.Over the next three decades, the agingindex is expected to double or triple inmost countries. By 2025, several nationswill have a smaller youth populationthan they have persons in the 60 andover category. In both r elative andabsolute ter ms, notably high ratios willbe observed in Canada, the UnitedStates, Cuba, Puerto Rico, Chile, andTrinidad and T obago.

Aging index in selected countries of the Americas.

0 20 40 60 80 100 120 140 160 180

1997

2025