High ambitions for health equity in the Americas
Authors: None The Lancet Public Health
Journal: The Lancet Public Health (2019)

On Oct 1, 2019, the Pan American Health Organization (PAHO) published Just Societies: Health Equity and Dignified Lives, the report of the Commission on Equity and Health Inequalities in the Americas—a Commission established by PAHO, chaired by Sir Michael Marmot, and tasked to analyse the effect of drivers influencing health, while proposing actions to address health inequalities in the region. The report finds that, although there have been substantial health improvements in the region over the past 20–30 years, these have not been shared across its diverse countries and individuals. The PAHO Commission advocates for far-reaching policy changes that address a colonial legacy of power imbalance, structural racism, and current wealth inequalities to achieve a more equitable health future. The region of the Americas as a whole has seen average life expectancy increase over the past decade, but at the country level average life expectancy ranges widely—from 66 years for women and 60 years for men in Haiti to 85 years for women in Bermuda and 80 years for Canadian men. This disparity between countries is repeated across a multitude of health outcomes, including a difference of up to 18 years in average years of healthy life, an under-5-year-old mortality that ranges from less than ten up to 70 per 1000 livebirths, adult mortality due to tuberculosis ranging from 0 up to 25 per 100 000 population, and a homicide rate that ranges from less than five per 100 000 population in Canada and Chile up to a staggering 70 per 100 000 population in El Salvador. These figures highlight the huge differences in life outcomes between the countries of the Americas, but most striking are the within-country disparities between people of different economic and demographic backgrounds. Within many of the region's countries, opportunities and outcomes are appreciably worse for poorer people, indigenous people, black people, disabled people, older people, sexual and gender minorities, and more often for women than for men. In 2010, infant mortality was highest among people of African descent across seven Latin American countries and infant mortality in 2010 was higher in indigenous versus non-indigenous populations in 11 Latin American countries, the USA, and Canada. Across many countries black and indigenous people are more likely to grow up in poverty, have less education, and be underemployed. Disabled people across the region struggle to access education and employment and, along with the older population, face barriers to social interaction. LGBT individuals face high levels of discrimination, which in turn disproportionately impacts on their mental wellbeing. Women in many of these countries have more years of life in ill health than men and typically spend more time out of paid employment, which leads to pension poverty later in life. The report argues that disparities in health and life outcomes are intimately tied to inequality in wealth and income in the region. Eight out of the ten most inequal countries—according to share of income of the top 1% of earners—are in the Americas and includes the USA. The region also has some of the world's highest levels of tax evasion, and high levels of corruption. Relative poverty is an important driver of people's health and wellbeing and yet, although Latin America made great strides in cutting poverty rates by more than 10% in the early 2000s, rates have been static at around 30% of population since 2008. Reducing wealth inequality through progressive and redistributive taxation and social spending policies is a cornerstone of the report's recommendations. This would include universal health coverage, increasing social protection through guaranteed welfare payments, and providing state pension to ensure a dignified older age for all. Governments should recognise the long shadow of colonial discrimination and promote equality of access to education, employment, services, and political inclusion. Health equity as a human right should be integrated across the whole of law and government. All of the recommended actions are designed to align with the Sustainable Development Goals—protecting the environment while improving health and equality. The PAHO Commission report is ambitious and its proposals are likely to meet with considerable political resistance. Progress towards health equity is fragile and political. Even in the face of a difficult political landscape, public health researchers must reinforce the evidence and continually make the case for an equitable society. Dietary carbohydrate intake and mortality: reflections and reactionsThere are several problematic issues in the Article by Seidelmann and colleagues.1 First, the quality of the dietary data is weak, since they are based only on two samples. The food frequency questionnaire that they used appears not to have been independently validated, and it contained only 66 questions and excluded several popular items, such as pizza.1 Food was clearly underreported, as evidenced by a reported average energy intake of roughly 1500 kcal per day. Full-Text PDF Open AccessDietary carbohydrate intake and mortality: reflections and reactionsIn their Article in The Lancet Public Health (September 2018), Sara Seidelmann and colleagues1 use data from a long-term prospective cohort study and do a meta-analysis of other related cohorts to assess the association between carbohydrate intake and mortality. Our main problem with this Article1 was regarding the confounders that are related to an individual's consumption of carbohydrates and to that individual's associated mortality. Some of these confounders were included as control variables, but since it is impossible to account for all possible confounders, some confounders necessarily went unobserved. Full-Text PDF Open AccessDietary carbohydrate intake and mortality: reflections and reactionsI read Sara Seidelmann and colleagues study1 with interest, and there are several shortcomings that deserve attention. Although, the authors appropriately acknowledge the limitations of data collection by questionnaire, in their study, participants were expected to recall their food intake over 25 years, in detail, over two sessions. Full-Text PDF Open AccessDietary carbohydrate intake and mortality: reflections and reactionsThe Article by Sara Seidelmann and colleagues1 presents the analysis from the Atherosclerosis Risk in Communities study of adults aged 45–64 years over a median duration of 25 years, at six timepoints. The mean caloric intake by each adult was 1558–1655 kcal per day. I have several issues with this study. First, this analysis seems to ignore the fact that, after 25 years, participants are aged 70–89 years, which is older than the 2016 estimate of life expectancy by the US Centers for Disease Control and Prevention: 78·6 years. Full-Text PDF Open AccessDietary carbohydrate intake and mortality: reflections and reactionsEven if the Food Frequency Questionnaire had been robust and accurately reflective of what people had eaten during the whole 25-year study, a mean calorie intake of 1560–1660 kcal per day had been explained, and people had been allocated correctly to groups that reflected their actual carbohydrate consumption after a health diagnosis. Full-Text PDF Open Access