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Figure聽26 summarizes the mortality rate change between 2000 and 2019 for 29 of 33 leading causes of death with associated mortality.¹³ Mortality rates for 20 out of 29 causes improved,contributing to the regional improvement in life expectancy. This progress reflects important healthcare advances across the Region, along with public health communication successes.

Particularly large reductions in the mortality rates of ischemic heart disease and stroke led this 20-year mortality rate reduction. The success in reducing CVD mortality rates can be partly ascribed to reductions in smoking rates, improvements in the capacity to control high cholesterol and blood pressure, and in particular, greater access to effective care in the event of a heart attack or stroke (22).

These successes lead to regional aging, which generates new challenges, including more healthcare demand. The complexity of health聽care is also set to increase, with multimorbidity likely to become a key challenge for healthcare providers. In the face of increasing and increasingly complex healthcare demand, the move toward universal health coverage (UHC) 鈥� with an ultimate goal of maintaining health and avoiding risk factors for all 鈥� is an aspirational target for most regional governments. The definition of UHC includes three related dimensions: unfettered access to health services, financial protection when faced with health聽care, and quality healthcare provision that is also cost-effective and sustainable. This UHC goal remains a work in progress across the region, with a recent World Bank report highlighting limited progress toward UHC in many countries, regional variation in that progress, and key vulnerabilities that must be addressed (22). for example, there are recognized bottlenecks of key human and physical resources (doctors, nurses, hospital beds, medical technologies) that limit an effective healthcare response. The level of government healthcare spending in 2017 stood at 3.8% of GDP across Latin American and the Caribbean, compared to 6.6% among the Organization for Economic Co-operation and Development (OECD) countries (23). Data on quality of care and healthcare inequalities 鈥� critical UHC components 鈥� remain unavailable for many countries in the Americas.

Theme 2. Population growth and rapid aging have fueled a rise in the number of deaths

Future population growth and aging are inevitable demographic features that governments can use to anticipate future healthcare demands. Age-specific mortality rates reflect the health and healthcare environment of individual nations, and over time these rates can be influenced with appropriate national strategies. Across the Americas, improvements in age-specific mortality rates have offset the mortality increase due to population growth and aging by as much as 63% (in Trinidad and Tobago). In the Americas as a whole, a mortality rate improvement of 26% offset the mortality increase due to population growth and aging. The use of mortality rate improvement to control the healthcare implications of population growth and aging will continue to be a key measure in the coming decades.

Figure 28: Contribution of changes in population growth, population aging, and rates of age-specific deaths to the percentage change in deaths due to noncommunicable diseases and injuries, 2000鈥�2019

^{COPD: chronic obstructive pulmonary disease; HHD: hypertensive heart disease; IHD: ischemic heart disease; RHD: rheumatic heart disease.Data source: World Health Organization. Mortality and global health estimates. Available from: https://www.who.int/data/gho/data/themes/mortality-and-global-health estimates.}

A high regional inequality was sometimes driven by particularly high rates in a small number of countries. This was the case for drug use disorders 鈥� the associated mortality rate in the United States in 2019 was 21.3 deaths per 100聽000, almost three times higher than the next highest national rate (Canada, 8.7 deaths per 100聽000), and for asthma 鈥� where the mortality rate in Haiti (13 deaths per 100聽000) was almost three times higher than the next highest rate (Honduras, 5 deaths per 100聽000).

Large regional inequalities mean that some countries have reported far lower mortality rates for a condition, relative to other countries in the region. Countries reporting lower rates for a particular condition might offer practical examples of successful strategies for a particular disease, suggesting a pathway for regional cooperation and mutual learning. This cooperative dialogue could be key to reducing regional health inequalities.

Figure聽30 presents the DALY gender rate ratio (men:women) for 30 conditions affecting women and men. Three cancers primarily affected either women or men alone and were not considered in this section (prostate cancer, cervical cancer, breast cancer). The graphic provides a simple assessment of the relative disease burden among men compared to women in 2019. Values above 1 mean a greater burden among men. Values below 1 mean a greater disease burden among women.

^{Note: Bars to the right mean a higher DALY rate in men; bars to the left mean a higher rate among women.}

^{Data source:}

There was a particularly high male burden due to interpersonal violence, with the DALY gender rate ratio in 2019 of 6.51 and a mortality gender rate ratio of 7.16. This excess has been consistent in the 20聽years since 2000 鈥� always 7聽deaths among men for every female death. Although this male excess is unequivocal, interpersonal violence is a broad categorization, and further information is needed to tease out the complex and disparate patterns of violence across the region. Globally, men are more likely to die from violence (especially community violence), while women are more likely to experience non-fatal violence with severe and often long-term consequences for their mental, physical, sexual, and reproductive health and well-being. Further classification, for example, introduces a typology that identifies the perpetrator (such as family, partner, acquaintance or stranger) and the nature of the violence (physical, sexual, psychological, deprivation or neglect) (25). Within this broad classification there will be interpersonal violence types 鈥� such as domestic violence 鈥� where women suffer greater victimization. Improved injury surveillance and targeted research are urgently needed.

Mental health and substance use disorders present a complex picture, with a greater male burden of alcohol and drug use disorders, and a greater female burden of anxiety and depressive disorders. Many mental health disorders can be diagnosed and treated cost-effectively, and there is a growing recognition of the need for comprehensive mental health services to be offered as part of a universal health coverage (UHC) package (26). The Caracas Declaration in 1990 laid the foundation for community mental health services for the Americas, but progress across the region has been uneven (27).

Diabetes affected men more than women in 2019, but this was not always the case, with the DALY gender ratio at parity in 2000. The worsening outcomes among men relative to women come against a backdrop of a near stationary diabetes mortality rate (a 5% drop in the regional rate between 2000 and 2019) and a rising disability rate (the regional DALY rate rose by 17% between 2000 and 2019). The comprehensive care required for people living with diabetes involves daily self-management and regular contact with primary care, and the tendency of men to seek health聽care less regularly than women may contribute to this evolving gender inequality (28).

Figure聽31 presents the distribution of DALY rates for 33 countries of the Americas grouped into two broad subregions: the Caribbean (Latin Caribbean and non-Latin Caribbean combined) and the rest of the Americas. The distributions are provided for three groups of conditions (CVD, cancers, and diabetes), with the median DALY rate (white line) provided for each region. The two Caribbean subregions in 2019 reported noticeably higher rates of mortality and disease burden for these three groups of conditions. for CVD, 9 out of the 10 highest disability (DALY) rates were among Caribbean countries. For cancers, 8 out of the 10 highest disability rates were among Caribbean countries. For diabetes, 8 out of the 10 highest disability rates were among Caribbean countries.

CVD, diabetes, and many cancers are influenced by a similar group of lifestyle risk factors, including lack of physical activity, poor nutrition, tobacco use, and excessive alcohol use. Over time, these behaviors can lead to overweight and obesity, high blood pressure, and high cholesterol. The Global Burden of Disease (GBD) has quantified estimated health loss (DALYs) from hundreds of diseases and injuries for all regions of the world. In a recent publication, the GBD study highlighted risk factors contributing to disease burden across the world (29). There were eight leading risk factors common to all subregions of the Americas (for the GBD Study, the Americas was subdivided into five subregions: Caribbean, Central America, High-income North聽America, Southern Latin America, Tropical Latin America). Each of these eight risk factors influences the NCD burden, and they are shown in figure聽32, ranked by order of importance¹⁶ in each subregion (1 to 8). Between subregions, the same risk factor is joined by a gray line. From these eight risk factors, high fasting plasma glucose, high systolic blood pressure, and high body mass index were in the top four contributors for every subregion. Risk factors that increased markedly in importance between 2010 and 2019 (an annual increase in attributable risk above 1.6%)聽are highlighted as red circles. The Caribbean and Central America subregions each had six of eight risk factors with a marked increase in importance, including the same leading three factors: high fasting plasma glucose, high systolic blood pressure, and high body mass index.

In the face of increasing numbers of deaths and DALYs (see Theme 2) and an increasingly prevalent risk factor burden, public health interventions offer critical pathways for NCD control. WHO in 2020 published a report on progress toward implementing a set of public health 鈥渂est buy鈥� interventions to prevent and control NCDs (30), with progress tracked using 19 indicators (31). figure聽33 presents the progress of each country in the Americas toward implementing these best聽buy interventions (not implemented, partially implemented, fully implemented). The countries in the chart are ordered using an informal policy progress summary score (0 points for not implemented, 1聽point for partially implemented, 2 points for fully implemented, for a total score between 0 and 38 points). National scores ranged from 30 (Chile) to 3 (Haiti). Of the 33 included countries, the top 17 countries (progress scores from 33 to 17) included just 1 Caribbean nation (Guyana). The bottom 16 countries (progress scores from 16聽to 2) included 12 Caribbean nations.

A note on COVID-19

The Americas was severely affected by COVID-19, with profound implications for future health. This report has drawn primarily on the 2019 edition of the WHO Global Health Estimates (GHE), which presents comprehensive and comparable health-related indicators from 2000 to 2019. The 2019 edition was released before the COVID-19 pandemic took hold across the world, and before its far-reaching social and economic consequences could have been imagined.

The pandemic was a health crisis, but it affected all aspects of our societies. Businesses were hit hard, losing working hours that amounted to 255聽million full-time jobs in 2020 (32). Working hour losses were particularly high in Latin America and the Caribbean, reflecting the stringent lockdown measures across the region. Economically, women and young adults were hardest hit because of the sectors most affected by the pandemic: food, hospitality and tourism, health, and social care. School closures shifted care responsibilities to the home, with this additional burden more regularly falling on women. Whether through job losses or school closures, the pandemic reversed real progress on gender equality (33).

All economies were affected, and the wealthiest countries provided extensive social support to workers and the general population, injecting USD聽9.8聽trillion into their economies (from a global total of USD聽11.7 trillion)聽(34). These support mechanisms were not possible among most low- and middle-income countries, which had fewer resources to counteract the health and economic burden of the pandemic. Health system frailties were laid bare, with shortages of health workers, hospital beds, and medical technologies.

The absolute numbers of deaths across the region exceeded 2.7聽million by April 2022 (the first confirmed death in the Americas was in the United States on 29 February 2020), against a backdrop of 7.61聽million deaths from all-causes in 2019. The effect of COVID-19 on future mortality and disease burden estimates will be profound, but to arrive at comparable estimates of mortality and disease burden for different countries and over time will inevitably require estimation for the many locations without detailed information, for example on excess mortality ¹⁷ related to the pandemic. The next Global Health Estimates update will include an assessment of the direct and indirect impact of the COVID-19 pandemic on mortality and morbidity.