Latin America

Not all Iberian settlement in the Americas took place in areas in which Indians or black slaves formed a servile labor force. Grassland sections of what became Argentina, Uruguay, and southern Bra­zil were without a sedentary indigenous agricultural population and did not attract extensive European immigration until the latter part of the nineteenth and the twentieth centuries.

Data on mortality are sparse until about the mid­nineteenth century. Some scattered estimates of crude mortality rates from the early years of the century are as follows: between 21.2 and 28.9 per 1,000 in Sao Paulo, Brazil, during the years 1777­1836; between 36 and 46 per 1,000 in Havana be­tween 1801 and 1830; 44 per 1,000 in the town of San Pedro in Guatemala in 1810-16 (the most valid of several estimates from a series of neighboring towns); and probably never fewer than 30 to 35 per 1,000 in Mexico City at any time until the mid­nineteenth century. In Sao Paulo at the end of the eighteenth century, infant mortality is estimated to have been 288 per 1,000 live births and life expec­tancy at birth about 38 years (Kunitz 1986).

Judging by population estimates and scattered es­timates of mortality as well as fertility, it was in the first half of the nineteenth century that births began to outnumber deaths with sufficient consistency for population to begin to grow. This presumed stabiliza­tion of mortality, albeit at a high level, coincides with the period when independence was achieved by most Latin American nations. The two are not unre­lated, for the result of independence was that the monopoly on trade long held by Spain and Portugal was broken, and the new nations began to trade openly with the industrial nations, particularly En­gland. Moreover, relative social stability character­ized most of the new nations during the nineteenth century. “In sum, in Latin America the colonial heri­tages reinforced by external and internal factors pro­duced economic growth without appreciable socio­political change during the nineteenth century” (Stein and Stein 1970). Thus, political and social stability and economic improvements - still within a neocolonial context characterized by an illiterate and servile labor force working on plantations and haciendas producing raw materials for export- seem to have resulted in a stabilization of mortality at levels that were high but nonetheless low enough for population to grow.

It appears that among the most important identifi­able endemic diseases or syndromes were the follow­ing: the pneumonia—diarrhea complex of infancy and childhood, the severity of which is exacerbated by protein-energy malnutrition; in some regions ma­laria; and tuberculosis, which was widespread. Among black troops serving in British West Indian regiments in the West Indies, for instance, the aver­age annual death rate from tuberculosis was 6 per 1,000 in the 1860s, 8.5 in the 1870s, 5 in the 1880s, 3 in the 1890s, and less than 1 in the 1900s. Diseases of the respiratory tract, including tuberculosis, were the leading cause of death. Over the same period black deaths from malaria ranged between 1 and 2.5 per 1,000 per year (Curtin 1987).

The differences in mortality among nations, as well as in the rate at which it declined in the latter half of the nineteenth century and the first several decades of the present century, were primarily reflec­tions of their economic development. These in turn were a reflection of the degree to which countries were dependent on a servile labor force or had, like Argentina and Uruguay, attracted a large European population. Starting in the 1930s, however, the ra­pidity with which mortality declined increased sub­stantially, particularly in the high-mortality coun­tries, and the rate at which improvement occurred became essentially the same among all of them. Eduardo Arriaga and Kingsley Davis (1969) attrib­ute this to the widespread availability of public health programs that were imported from the indus­trial nations beginning at about this time or some­what earlier. This interpretation is supported by the observation that among Latin American nations with the lowest crude mortality rates at the turn of the twentieth century were Cuba and Panama, both places in which the U.S. government had important interests and in which major public health activities had been established. (Kunitz 1986).

Thus, crisis mortality seems to have been reduced by the development of relatively stable societies with a slowly improving standard of living. But because living conditions did not improve dramatically due to the neocolonial structure of most of these nations, mortality rates remained high. Dramatic improve­ments began to occur in the twentieth century when public health measures were introduced.

Mortality continued to decline after World War II, although to the present there has been a strong positive association between life expectancy and per capita gross national product, along with adult liter­acy, and an inverse relationship with the proportion of the labor force involved in agriculture. These eco­logical data as well as individual-level studies (Kunitz 1986) suggest that in much of Latin Amer­ica, the relationships persist between agricultural production for the international market, low levels of economic development, and high mortality.

Between 1950-5 and 1980-5 there were substan­tial increases in life expectancy in most Latin Ameri­can nations, the rate of improvement being inversely associated with the life expectancy in 1950-5, which is to say, the greater the life expectancy at the begin­ning of the period, the less was the proportionate increase over the following 30 years (PAHO 1986). The reason for this seems to be that populations with greater life expectancy to begin with were those in the economically more developed nations, in which a relatively large proportion of deaths were due to noninfectious diseases. Low life expectancy was asso­ciated with high death rates, particularly at young ages, for those infectious diseases most responsive to public health interventions.

It appears that what differentiates the contempo­rary mortality experience of most Latin American nations is mortality rates among infants and young children rather than rates and patterns at older ages. That is to say, mortality at all ages beyond about age 5 is due primarily to violence, accidents, and noninfectious diseases such as cancers and car­diovascular diseases. It is the magnitude of the con­tribution of infectious diseases to deaths among chil­dren during the first 5 years of life that accounts for most of the international differences, and these rates are highest in the poorest countries. The explana­tion that has been offered for these observations by the United Nations (1982) is as follows:

The departure of Latin American countries from the Euro­pean experience is related to a disequilibrium between improvements in socio-economic conditions and health in­terventions. While the latter may have a significant influ­ence on adult mortality in the complete absence of the former, the connexions between one and the other are more subtle at the beginning of life. The longer the popula­tion is exposed to health interventions in the absence or under conditions of precarious improvements in standards of living the greater will be the disparity between child and adult mortality.

This is so, it is argued by some, because neither therapy (including oral rehydration) nor public health measures are likely to have a profound im­pact on infant and child mortality caused by the interaction of malnutrition, pneumonia, and diar­rhea in the absence of significant economic develop­ment.

In either case, to the degree that reductions in infant and child mortality are dependent on in­creased spending for health and social services, as well as on improving standards of living, the current economic crisis and international indebtedness may make such improvements difficult to achieve. The evidence for an association between international in­debtedness and a diminution in the rate of improve­ment of life expectancy has been suggestive but not overwhelmingly persuasive, however, largely be­cause changes in domestic policies may mitigate the worst effects of the economic crisis, at least in the short term (Musgrove 1987).

Thus, there are two observations about contempo­rary mortality changes in Latin America that, though not necessarily at odds with each other, place emphasis on different elements of the process. One emphasizes that continuing improvements in life ex­pectancy will result from continuing socioeconomic improvements, which will have their most profound impact on the health of infants and children. The other suggests that the pattern of causes of death now reflects the overwhelming significance of human-made and noninfectious conditions among adults and that behavioral change at the individual level is likely to contribute most to further signifi­cant declines in the future (Litvak et al. 1987).