A Better Health Agenda for the Americas


In June 2007 the Ministers of Health of all Latin American nations
issued a Health Agenda for the Americas: 2008-2015, (the "Agenda") a
supposedly comprehensive plan for improving the health of the people of
the Americas that was anything but comprehensive. It managed to leave
out many proven recommendations for improving the sexual and
reproductive health of the citizens of Latin America.

Infant and Maternal Mortality

If
the moral soundness of a society is measured by how it treats its
children, then Latin America, while better than Africa, does not
measure up. Infant mortality in Latin America is stubbornly high — averaging 23 per 1000 live births (versus 7 in the U.S.) — though an improvement
from 81 per 1,000 live births in the years 1970-1975. Maternal
mortality is far too high, with Bolivia and Peru leading at rates of
420 and 410 per 100,000 births respectively, as opposed to 17 in the
U.S. Uruguay has the low at 27. The major causes of high infant and
maternal mortality are well known: poverty, lack of skilled birth
attendants and deficiencies in emergency medical care. There are
underlying causes as well that lead to these medical emergencies, and
they all fall under the rubric of sexual and reproductive health.
Health experts, and mothers, know that contraception which enables
intended pregnancy can improve outcomes by 1) delaying first birth
until a woman has fully matured, 2) birth spacing, permitting a mother
to regain her health and to fully nurture the child she has before
giving birth to the next, and 3) reduction in absolute number of
births, allowing the mother to give more care to the children she has.
The Agenda, to its credit, called access to contraceptives
"indispensable," and called for continuous care to mothers before,
during and after pregnancy, for increased efforts to prevent
transmission of STI’s and for stronger men’s roles in all these.

While a good start, this is insufficient.

Contraceptive and Fertility Rates

The
issue in Latin America is not contraceptive use; it is getting the
contraceptives to those at risk for unintended pregnancy. Contraceptive
prevalence in Latin America is the highest in the developing world, on
average, with 75 percent of women in South America and 66 percent in
Central America having access to a method (the corresponding figure in
Africa is 27 percent and in the U.S. 73 percent). These rates are far
less in rural and poorer areas, and thus the rate of unintended
pregnancy there is higher. Increase in contraceptive prevalence (the
rate was 60 percent for Latin America and the Caribbean in 1998) though
has not translated into birth rate or abortion rate declines. The
reason is a combination of lack of contraceptive access in vulnerable
populations, along with higher intended childbearing desires. In some
Latin countries overall birth rates, including teen birth rates,
increased during the 1990’s, while in the rest of the world they
declined. On average, 20 percent of teens give birth in Latin America.
The fertility rate for ages 15-19 is currently 78 in South America. In
1996, the South American rate was 75, indicating a 4 percent rise since
then. A comparison with the U.S. is instructive. The fertility rate for
Hispanic teens in the U.S. is about 82 for 2005, or slightly higher
than the overall fertility rate for teens in Latin America (about 76).
The U.S. figure disguises ethnic variations among immigrant
populations, with the fertility rate for teens of Mexican origin in the
U.S. being 93. However, interestingly, the teen fertility rate in
Mexico is 63, about a third less than for Mexican teens in the U.S.
Hispanic teens in the U.S. in general have a higher fertility rate than
Hispanic teens in their country of origin. The reasons could include
lack of access in the U.S. to contraception or more teen sexual
activity. Also Hispanic culture meeting with more prosperity in the
U.S. (as well as in those Latin countries that have prospered) could
have led to increased teen birth rates. There are no figures, though,
that I have seen as to the intentionality of these teen pregnancies.
Though adolescents especially were recognized in the Agenda as needing
special attention, there was, however, no specific call for renewed
sexuality education efforts and increased availability of
contraceptives for adolescents. This is not dissimilar to the silence
in official circles in the U.S. Government around teen sexual activity,
except for calls for abstinence education.

One sure way to
decrease unintended pregnancy for teens and adults alike is emergency
contraception. In many Latin countries there are battles over the
legality of emergency contraception, which is characterized,
mistakenly, as an abortifacient. In Chile and Ecuador, cases
challenging distribution of emergency contraception recently went up to
their respective Supreme Courts where, alas, EC opponents prevailed.
The Agenda makes no mention of emergency contraception.

Abortion

An
abortion rate about 50 percent higher than the North American level
predominates throughout Latin America, along with attendant maternal
mortality and morbidity. This would indicate pregnancy rates are higher
than the desired childbearing rates. Still, women in Latin America have about one more child than they say they want.

Abortion is proscribed virtually everywhere in Latin America, except
Cuba, Guyana and Mexico City. Four of the five countries of the world
which prohibit abortion in all cases, even to save the mother’s life,
are in Latin America: Honduras, Chile, Nicaragua and El Salvador. There
are about 4 million illegal abortions a year, 95 percent of which are
unsafe. About 5,000 women die a year, resulting in 20 percent of all maternal deaths being from unsafe abortion.

There
has been progress during the last year in decriminalization. Colombia’s
Constitutional Court decriminalized abortion in three cases: rape, for
the life or health of the woman and for fetal deformity. The Mexico
City legislature also decriminalized abortion, by a vote of 46 votes in
favor and 19 against, despite a threat of excommunication.

The Agenda made no mention of de-criminalizing abortion or providing post-abortion care.

STD’s and HIV/AIDS

While
HIV/AIDS levels are below those of sub-Saharan Africa, HIV is still at
serious levels. The prevalence rate is at or below 1 percent in every
South American country, similar to most Asian countries, compared to
rates of 25 percent in southern Africa. Condom use
in Latin America is low — just 4 percent of women in Brazil and Mexico
report using condoms, compared with 13 percent in the U.S. according to
PAHO (other sources show a higher rate of condom use of 18 percent in
the U.S.).

Approximately one-third of Latin women have never
had a Pap smear. In the U.S. about 84 percent of women had a Pap smear
within the last three years (including 81 percent of Hispanics),
indicating that Hispanic women are not disproportionately marginalized
from the U.S. health care system. The Agenda made no specific
recommendations for increasing condom use and the availability of Pap
smears.

Violence Against Women

Violence
against women is apparently more prevalent in Latin America than in the
United States, though comparable and accurate statistics are hard to
come by. In the U.S. there has been a steady decline in what the U.S.
Department of Justice calls "intimate partner non-fatal victimization"
(a gender neutral term) which had declined from 6 per 1000 persons to
about 2 per 1000 from 1993 to 2005. The rate of violence
against both Hispanic and non-Hispanic females in the U.S. declined as
well and averaged about 4.2 per 1000 annually during the period 2001-5.

In
Latin America, the few surveys that have been done show, for example,
that over 40 percent of women ages 15 to 49, who have ever been in a
union in Peru (42 percent) and Colombia (44 percent), have been victims
of partner violence. This is a cumulative figure, but it would appear
that violence against women is higher in Latin America than among
Hispanics in the U.S. DHS surveys in Latin America reveal that, for
instance, in Nicaragua 11.9 percent of women experienced domestic violence in the year preceding the survey.

There was not a single mention of violence against women or domestic violence in Health Agenda for the Americas: 2008-2015.

The Americas’ Health Ministers’ Recommendations … and Omissions

So,
the Latin American Health Ministers made a less than sterling start in
addressing the sexual and reproductive health needs on their citizens,
leaving out sexuality education, teen access, condoms, safe abortion,
emergency contraception and measures to combat domestic violence.

Not
unexpectedly, they did call for increased spending on health. The
region spends 6.8 percent of its GDP on health care, or about $500 per
person (the U.S. figures are 16 percent and $7,600, respectively).

How
to pay for increased sexual and reproductive health care? First,
decriminalizing abortion will save health care dollars. So will
providing preventive health care, including family planning, emergency
contraception and condoms. Passing and enforcing domestic violence laws
too will reduce health care expenditures.

If funds are needed,
countries might consider increasing tax revenues. Latin American taxes
average 18 percent of GDP (in the U.S. it is about 25 percent and about
36 percent in Western Europe.

Finally,
the U.S. and other donor nations could also increase their ODA to the
agreed-upon level of 0.7 percent of GDP. The U.S. ODA in 2006 was at
0.17 percent. Only three Scandinavian nations, the Netherlands and Luxembourg exceeded 0.7 percent. Having healthy neighbors is in our national interest.

This article was first posted at Alternet.

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