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. The areas in which there were sedentary agricultural populations attracted the most attention and as a result suffered devastating pandemics. The magnitude of the result ing population collapse is a matter of debate, but that it was catastrophic is beyond question. Though crisis mortality caused by pandemics and famines receded over the three centuries following first European contact, mortality remained high enough that there was essentially no population growth during the eighteenth century (McGovern-Bowen 1983). Indeed, significant growth did not begin until the early decades of the nineteenth century (McEvedy and Jones 1978). The increase resulted partially from the importation of African slaves (particularly to Brazil and the Caribbean) and European immigration from Mediterranean countries (particularly to Brazil and Argentina) and partly from changes in mortality patterns.

Data on mortality are sparse until about the mid-nineteenth 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 1777-1836; 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 mid-nineteenth 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). Life table estimates are available from the middle of the nineteenth century for all of Latin America, except Argentina, Uruguay, and Cuba. From 1860 to 1900, life expectancy at birth increased from 24.4 to 27.2 years. These average figures mask differences among countries. The Dominican Republic, Guatemala, and Nicaragua had a lower life expectancy in 1900 than Brazil, Chile, Colombia, Costa Rica, Mexico, and Panama had had in 1860 (Kunitz 1986). Diversity within some of the large nations, such as Mexico, was probably every bit as great as it was among nations.

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. These measures were aimed primarily at controlling the vectors of the most lethal and most prevalent infectious diseases, most notably perhaps malaria and yellow fever (Mandle 1970; Soper 1970; Giglioli 1972), and were not especially concerned with changing either the living conditions or the socioeconomic status of the bulk of the population. Thus, up to a point, technical interventions could play the same role in reducing mortality that economic and social development played in western Europe and North America. The question remains, where is that point? In other words, at what point can technical interventions no longer take the place of socioeconomic development?

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. Thus, the diminution in the rate at which life expectancy has improved over the past two decades has been associated with a shift in the proportionate contribution to mortality of infectious and noninfectious diseases. Noninfectious diseases are accounting for an increasing share of mortality, and they have continued to be less responsive to public health and medical measures than the infectious diseases (Arriaga 1981).

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 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. Others disagree, claiming that, rather than economic development, relatively simple interventions such as equitable distribution of food, increased literacy, and a few simple primary health care measures are all that are required (Halstead, Walsh, and "Warren 1985). How easily achieved even such "minor" measures are is a question that will undoubtedly engender debate.

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).

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