-from Epidemiological Bulletin, Vol. 23 No. 3, September 2002-

Demographic and Mortality Trends
in the Region of the Americas, 1980-2000

This year, the Pan American Health Organization (PAHO) celebrates a century of work towards coordinating efforts of the countries to improve health in the most vulnerable populations of the Americas. In carrying out this effort, one of the essential functions of the Organization during this period has been the collection, analysis, and dissemination of information on health among the Member States. As part of its constitutional mandates, PAHO prepares since 1954 a quadrennial report on the health situation and trends in the Americas. Since 1998, this report is published under the title of “Health in the Americas.”1 Its 2002 edition was presented in the previous issue of this Bulletin. This publication contains PAHO’s analysis of different public health aspects of the population and the organized responses of the health sector. It accounts for the advances in the health conditions of the countries, and documents existing inequalities in the state of health and the access and use of health resources.

Beginning with this issue, a series of articles will be published in the Bulletin, presenting a summary of the most relevant aspects of the health situation contained in “Health in the Americas.” The present article summarizes the situation and trends of the demographic changes, life expectancy at birth, and mortality in the Americas in recent years.

Introduction
“Demographic transition” in a population refers to a process involving the trends of mortality and fertility rates over time.2 As mortality starts to decline and social and economic development occur, fertility is expected to drop. In the last decades, reductions in the overall mortality and fertility rates and population growth have been observed in the Americas, intensifying the on-going demographic transition. The consequent aging of the population in the presence of other important socio-demographic processes, such as migration and urbanization, has generated specific and complex demands for social and health goods and services. In addition, the majority of countries in the Americas have experienced what has been called “epidemiological polarization.”3 This process is characterized by simultaneous and substantial impacts on the population’s mortality profile by both communicable and non-communicable diseases and external causes. It is especially evident in the more susceptible population groups such as the poor or elderly. The resulting pattern of mortality magnifies the presence of significant health gaps between different social groups and geographic areas within countries.4 Considering the complex dynamics of the Region’s demographic and health conditions in the Region, the aim of the present article is to describe important markers of the “demographic transition” process within the Americas, singling out the changes in relevant indicators in recent years.

Data sources: This analysis is based on PAHO’s core health data, using countries from the American Region as geographic units. The countries were grouped into eight sub-regions including North America, Mexico, Brazil, the Latin Caribbean, Central America, the Andean Area, the Southern Cone and the non-Latin Caribbean.4 Demographic data come from the United Nations Population Division5, 6 and the US Census Bureau’s International Program Center7. Mortality data come from PAHO/WHO’s regional database on mortality. The data analysis includes the 19 countries for which data is available for 1980-2000. These countries account for 91.3% of the entire population of the Americas in 2001 and include Argentina, Barbados, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, the Dominican Republic, Ecuador, El Salvador, Jamaica, Mexico, Panama, Paraguay, Puerto Rico, Trinidad and Tobago, the United Sates, and Venezuela. Mortality rates were standardized by age and sex using the standard population proposed by the World Health Organization.8, 9

Demographic Situation
Population growth: The estimated population in the Americas in 2002 was 854 million (Table 1). The annual average population growth rate in the Region in 1996-2002 was 1.3%, with variations between 0.7% in the non-Latin Caribbean and 2.4% in Central America. In almost all the countries the rate is declining slowly. However, projections indicate that the population of the Americas will continue to grow and some 200 million people will be added between 2000 and 2020.

Urbanization: The population of the Americas is relatively highly urbanized, particularly in the more industrialized countries (Table 1). In 2002, it was estimated that 76.6% of the Region’s population lived in cities, compared to 41% in 1950. It should be noted, however, that currently the process of urbanization is occurring more rapidly in the less industrialized countries. The difference between the growth rate of the urban and the rural populations among the subregions was highest in Brazil with 3.4%, followed by the Andean Area with 2.3% and Latin Caribbean with 2.2%, indicating a faster urbanization process there than in other subregions. Approximately half of the largest cities in the Americas are in Latin America. Some 160 million people live in the 20 largest cities, 55 million of them in the largest metropolitan areas of Mexico City, Sao Paulo and New York.

Birth and fertility: There were an estimated 15.7 million births in the Americas in 2002, about 74% from Latin America and the Caribbean (Table 1). Birth rates are expected to continue declining in the Region, as has already occurred over the past 40 years. In the 1960s, the birth rate in the Americas was 32.5 per 1,000 population, while in 2002 it was estimated to be 18.4 per 1,000. Similarly, a reduction in the fertility rates was also observed, with a decline from 3.1 children per woman in 1980-1985 to 2.3 in 2002. In this period, total fertility rates declined in all sub-regions, but more markedly in Brazil, Central America, the Andean Area and Mexico.

Aging and life expectancy at birth: Between 1996 and 2002, the ratio of persons in the 15-64 year-old age group to the population aged 65 and over decreased in the Americas and in all sub-regions, except in North America and the non-Latin Caribbean. However, this indicator remains high in several areas, especially in Central America, the Andean Area, Mexico and Brazil, with values higher than 12:1 (Table 1). Life expectancy at birth (LEB) in the Americas was estimated to be 73.2 years in 2002. This figure is increasing at different rates in all the subregions. Within the Region, the LEB estimate was 77.7 years for North America, with all the other sub-regions lagging 3.6 to 10 years behind. On average, this indicator for women in the Region is approximately 6.3 years longer than for men, with this difference varying from a low of 5.5 years in the Caribbean to a high of 8 years in Brazil.

Mortality indicators
Overall mortality: It was estimated that the mortality rate in 2002 in the Americas will be 7.2 per 1.000 population (Table 1). In the last two decades of the 20th century, the Region has seen a reduction of about 25% in the mortality rate. This indicator varies little between sub-regions, with rates ranging from 5.1 in Mexico to 8.7 in the Latin Caribbean.

Infant mortality: The infant mortality rate (IMR) in the Americas is estimated to be around 25.3 deaths per 1,000 live births in 2002, which indicates that a total of 400,000 children in the Region will die before their first birthday (Table 1). However, in 10 years the IMR decreased by almost one-third, from 36.9 deaths per 1,000 live births in 1980-1985. The greatest improvement occurred in Central America, Brazil, and the Latin Caribbean, with reductions of 45%, 34%, and 30% respectively. Since the expected rate of decline is similar in all countries, the subregions that have higher IMR are expected to experience greater absolute declines. The IMR continued to decrease from 1996 to 2002 in all American sub-regions (Table 1). The vast majority of the countries have lowered their IMR for both sexes.

Mortality by broad groups of causes:
Communicable diseases: Among the countries selected for analysis, the greatest decline in cause-specific mortality occurred in communicable diseases, from 95 per 100,000 population in 1980 to 57 per 100,000 in 2000. In the early 1980s, the mortality rate for communicable diseases varied from 12.9 per 100,000 population for females in Canada to 282.4 per 100,000 for males in Ecuador. By the end of the 1990s, the variation in this data ranged from 12.6 per 100,000 for females in Canada to 151.7 per 100,000 for males in El Salvador (Table 2). Marked reductions in mortality from communicable diseases occurred in almost all countries analyzed, except in Barbados, Canada, the United States, and Puerto Rico where rates were lowest (Graph 1). This increase was more likely the result of AIDS among young adults, particularly in males.

Chronic diseases and external causes of deaths:
Neoplasms: Between the early 1980’s and the end of the 1990’s, there was an overall decrease in the mortality rates due to neoplasms in most of the countries analyzed, except for Barbados, Ecuador, Mexico, and Trinidad and Tobago for both sexes, and Canada, Cuba, Dominican Republic, Jamaica, and Paraguay for males only. Among the countries analyzed, at the end of 1990s mortality rates due to neoplasms ranged between 69.2 for females in Puerto Rico to 171.6 for males in Barbados (Table 2).

Diseases of the circulatory system: In the Region, the greatest risk of dying continues to be due to diseases of the circulatory system with 214 deaths per 100,000 population, a rate almost twice as high as for neoplasms and 4 times greater than external causes. However, at the end of 1990s mortality rates from this group of diseases also decreased in all countries for both sexes, ranging between 94.7 for females in Canada to 375.2 for males in Brazil (Table 2). In addition, the magnitude of reduction varied from a low of 0.2% for men in Paraguay to a high of 52.8% for men in El Salvador.

External causes: Similarly, in many countries there was also a reduction in mortality rates from external causes for both sexes. The exceptions were for men in Brazil with 5.7% , Colombia with 9.4%, Costa Rica with 3.2%, and Puerto Rico with 4.3% and for women in Costa Rica at 2.1%, Paraguay at 17.7%, and Puerto Rico at 4.3%, where rates increased. The mortality rates from external causes at the end of the 1990’s ranged from 4.2 for females in Jamaica to 207.3 for males in Colombia among the countries analyzed (Table 2).

Concluding remarks
During the latter part of the 20th century, advances in the demographic transition occurred in the Americas, particularly in Latin America and the Caribbean. This process began with an important decline in infant mortality rates and in mortality rates due to communicable diseases. Since 1980, most of the countries have halved their mortality rates from communicable diseases among children under 1 year of age. In addition, besides reductions of mortality rates, especially among younger age groups, for most of the countries of the Americas several factors might have moved this demographic transition forward. These factors include contraception policies, increase of education level, accelerated urbanization, and economic modernization, among others. In particular, the growth of urbanization in the Americas – three quarters of the total population now live in cities – has had important health implications associated on the one hand with the risk factors related to urban settings, and on the other hand with the possible increase in the access to goods and services.

A decline in fertility rates followed and modified these events. An estimated average fertility rate of 3.1 children per woman in 1980-1985 decreased to an estimate of 2.3 children per woman in 2002. These changes in the population’s demographic and mortality profiles, especially the declining fertility rates, have changed the overall age composition of the Region’s population, contributing to a longer life expectancy at birth and to the aging of the general population. As the population ages, a new pattern of health services needs and use presents a challenge for the health system.

Although the overall trends of demographic and mortality indicators are described in this article, different degrees of demographic transition can be seen in the American Region. There are countries or territories in more advanced stages of demographic transition, such as Canada, Martinique, Aruba, Montserrat, Bermuda, Barbados, the United States, Cuba and Anguilla, where life expectancies at birth are higher than 76.0 years and fertility rates are lower than 2.0 children per woman. At the same time, there are countries with high fertility rates (>3.5 children per woman) in the presence of low life expectancy at birth (<66.0 years), such as Haiti, Bolivia and Guatemala. To understand the several “demographic transitions” that take place within each sub-region in the America, detailed heath analysis is necessary, including the study of cause-specific mortality rates and trends as well as age, gender and social group differences. Some of these approaches will be the subject of additional reports.

References:
(1) Pan American Health Organization. Health in the Americas: 2002 Edition. Volume 1. Washington, DC:PAHO, 2002.
(2) Pan American Health Organization. Assessment of the 1980-1998 Health Situation and Trends in the Americas, por Subregión. Epidemiological Bulletin 20(1):2-10; 1999.
(3) Pan American Health Organization. Health Situation Analysis in the Americas, 1999-2000. Epidemiological Bulletin 21(4):1-3; 2000.
(4) Pan American Health Organization, Special Program for Health Analysis. Health Situation in the Americas. Basic Indicators 2000. Washington, DC: PAHO; 2000. (PAHO/SHA/00.01).
(5) United Nations. World population prospects: the 2000 revision. New York: UN Population Division; 2001.
(6) United Nations. World population prospects: the 1999 revision. New York: UN Population Division; 2000.
(7) US Census Bureau, International Program Center. International Data Base (IDB). Washington, DC: US Census Bureau; 2000.
(8) Waterhouse J, et al. [eds]. Cancer incidence in five continents. International Agency for Research on Cancer (IARC); Lyon, 1976 (Vol. 3, p.456). In: World Health Organization. World Health Statistics Annual 1995. Geneva: WHO; 1996.
(9) Xunta de Galicia, Consellería de Sanidade e Servicios Sociais. Pan American Health Organization, Special Program for Health Analysis. Análisis Epidemiológico de Datos Tabulados (Epidat), Version 2.1 [Computer software for Windows]; 1998

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Epidemiological Bulletin, Vol. 23 No. 3, September 2002