The authors have declared that no competing interests exist.
Conceived and designed the experiments: IRH SJ AH. Analyzed the data: IRH. Wrote the paper: IRH SJ CH MMM. Read and approved the final manuscript: IRH SJ CH MMM AH RW ENH MM LS. Obtained funding: AH RW ENH MM LS.
¶ Members of the U.S. Caribbean Alliance for Health Disparities Research Group can be found in the Acknowledgments.
We describe trends in life expectancy at birth (LE) and between-country LE disparities since 1965, in Latin America and the Caribbean.
LE trends since 1965 are described for three geographical sub-regions: the Caribbean, Central America, and South America. LE disparities are explored using a suite of absolute and relative disparity metrics, with measurement consensus providing confidence to observed differences. LE has increased throughout Latin America and the Caribbean. Compared to the Caribbean, LE has increased by an additional 6.6 years in Central America and 4.1 years in South America. Since 1965, average reductions in between-country LE disparities were 14% (absolute disparity) and 23% (relative disparity) in the Caribbean, 55% and 51% in Central America, 55% and 52% in South America.
LE in Latin America and the Caribbean is exceeding ‘minimum standard’ international targets, and is improving relative to the world region with the highest human longevity. The Caribbean, which had the highest LE and the lowest between-country LE disparities in Latin America and the Caribbean in 1965-70, had the lowest LE and the highest LE disparities by 2005-10. Caribbean Governments have championed a collaborative solution to the growing burden of non-communicable disease, with 15 territories signing on to the Declaration of Port of Spain, signalling regional commitment to a coordinated public-health response. The persistent LE inequity between Caribbean countries suggests that public health interventions should be tailored to individual countries to be most effective. Between- and within-country disparity monitoring for a range of health metrics should be a priority, first to guide country-level policy initiatives, then to contribute to the assessment of policy success.
Two cornerstones of public health policy—improving the average health of a population and reducing disparities in health [
To facilitate the public health goal of monitoring and reducing disparities, the US has developed infrastructure including the Health Disparities Act (2000), which in turn allowed the creation of the National Institute on Minority Health and Health Disparities (NIMHD). The NIMHD has funded a 5-year program (NIH number: U24MD006959) to explore and compare for the first time health disparities among African-descent populations in the Caribbean and the US. This partnership between the Sullivan Alliance [
This article focuses on life expectancy at birth (LE), a basic health indicator adopted, among others, by the United Nations, the World Health Organisation, and the Organisation for Economic Co-operation and Development [
Every two years the United Nations Department of Economic and Social Affairs updates its population size projections for all member countries, and includes a number of country-level demographic summaries, including LE. The World Population Projections (WPP) 2012 revision was released in June 2013 and is the source for all data used in this article [
In Latin America and the Caribbean, the sub-regions of Central and South America are based on well-accepted geographical boundaries. A definition for the Caribbean is less clear, and depends on historical and socio-political factors as well as geography [
There are many potential measures of health disparity, and the properties of some of these measures have been summarized in recent reviews [
Sub-regional life expectancies were calculated as the weighted average of country life expectancies, with the weight being each country’s population size. LE was then plotted between 1965 and 2010 for the world, and for sub-regions of the Americas. For each year, the difference in LE was calculated compared to the world average (the LE gap) and compared to the highest sub-regional LE in each year, using 22 UN-defined world sub-regions (the LE shortfall). Next, using 5-year time periods between 1965–70 and 2005–10, the suite of six health disparity metrics were calculated: three absolute measures (LED, MD, BGV) and three relative measures (LER, ID, STI). Between-country LE disparities are the main subject of this analysis and are reported separately for women and men. All analyses were performed using Stata statistical software [
Globally, LE rose 15.7 years to 69.4 years in the 45-years from 1965, an average annual rise of 4.2 months of life per calendar year. This consistent and striking improvement in global LE between 1965 and 2010 is repeated for each major world region and all sub-regions of the Americas. Against this positive global message, important variations exist in the region of the Americas. In 1965, LE was 57.8 years in Central America (CA), 58.2 years in SA (SA), and 60.8 years in the Caribbean, and rose during the next 45-years by 18.1 years in CA, by 15.5 years in SA, and by 11.5 years in the Caribbean (Fig
Compared to the Caribbean, LE has increased by an additional 6.6 years in CA, by an additional 4.1 years in SA, and by an additional 4.2 years globally (Fig
Considering women and men separately, the 45-year reduction in LE shortfall was generally greater in women than men, and greater in Central and South America than in the Caribbean. Among women this shortfall was reduced from 14.6 to 5.6 years in CA (a 9-year reduction), from 14.1 to 6.8 years in SA (a 7.3-year reduction), and from 11.8 to 9.1 in the Caribbean (a 2.7-year reduction). In men, it was reduced from 12.7 to 6.5 years in CA (a 6.2-year reduction), from 12.4 to 9.3 years in SA (a 3.1 year reduction), and increased from 9.5 to 9.9 in the Caribbean (a 0.4 year increase) (Fig
The global gender disparity in LE between men and women in 1965–70 was 2.9 years (4.9% difference), rising to 4.5 years (6.3% difference) in 2005–10. In Latin America and the Caribbean, women lived longer than men, with the gender difference in 2005–10 being 5.2 years (6.9% difference) in the Caribbean, 5.3 years (6.8% difference) in CA, and 6.8 years (8.9% difference) in SA (
Region | Year | LE (overall) | LE (women) | LE (men) | F:M Difference | % Difference | F:M Ratio |
---|---|---|---|---|---|---|---|
1965–70 | 62.08 | 63.95 | 60.34 | 3.62 | 5.65 | 1.06 | |
2005–10 | 71.79 | 74.42 | 69.26 | 5.16 | 6.93 | 1.07 | |
1965–70 | 58.83 | 60.95 | 56.79 | 4.16 | 6.83 | 1.07 | |
2005–10 | 75.31 | 77.91 | 72.59 | 5.31 | 6.82 | 1.07 | |
1965–70 | 59.15 | 61.39 | 57.04 | 4.35 | 7.09 | 1.08 | |
2005–10 | 73.14 | 76.6 | 69.77 | 6.83 | 8.92 | 1.1 | |
1965–70 | 70.49 | 74.28 | 66.95 | 7.33 | 9.87 | 1.11 | |
2005–10 | 78.36 | 80.81 | 75.83 | 4.99 | 6.17 | 1.07 | |
1965–70 | 58.91 | 61.14 | 56.8 | 4.34 | 7.1 | 1.08 | |
2005–10 | 73.45 | 76.7 | 70.22 | 6.48 | 8.45 | 1.09 | |
1965–70 | 64.52 | 67.49 | 61.75 | 5.74 | 8.5 | 1.09 | |
2005–10 | 75.37 | 78.28 | 72.45 | 5.83 | 7.45 | 1.08 | |
1965–70 | 56.52 | 57.92 | 55.07 | 2.85 | 4.91 | 1.05 | |
2005–10 | 68.72 | 71 | 66.52 | 4.48 | 6.31 | 1.07 |
Between-country LE disparities in 1965–70 and in 2005–10 are presented in
Disparity measures using best and worst country LE | Disparity measures using LE from all countries | ||||||
---|---|---|---|---|---|---|---|
Region | Year | LE ratio | LE difference | Mean Absolute Deviation | Index of Disparity | Symmetric Theil Index | Between Group Variation |
1965–70 | 1.55 | 26.22 | 8.31 | 11.26 | 33.19 | 26.23 | |
2005–10 | 1.33 | 20.81 | 7.10 | 8.53 | 20.86 | 23.46 | |
% change | -14.19 | -20.63 | -14.56 | -24.25 | -37.15 | -10.56 | |
1965–70 | 1.32 | 16.16 | 10.01 | 14.84 | 52.41 | 36.38 | |
2005–10 | 1.10 | 7.47 | 4.85 | 5.98 | 5.43 | 6.48 | |
% change | -16.67 | -53.77 | -51.55 | -59.70 | -89.64 | -82.19 | |
1965–70 | 1.52 | 24.65 | 11.20 | 15.58 | 70.30 | 51.36 | |
2005–10 | 1.20 | 13.83 | 5.54 | 6.79 | 11.44 | 13.02 | |
% change | -21.05 | -43.89 | -50.54 | -56.42 | -83.73 | -74.65 | |
1965–70 | 1.02 | 1.45 | 1.45 | 1.92 | 0.47 | 0.53 | |
2005–10 | 1.03 | 2.21 | 2.21 | 2.67 | 0.91 | 1.22 | |
% change | 0.98 | 52.41 | 52.41 | 39.06 | 93.62 | 130.19 | |
1965–70 | 1.60 | 28.33 | 11.77 | 15.57 | 60.04 | 46.62 | |
2005–10 | 1.33 | 20.81 | 6.53 | 7.84 | 15.85 | 18.06 | |
% change | -16.88 | -26.54 | -44.52 | -49.65 | -73.60 | -61.26 | |
1965–70 | 2.42 | 45.05 | 17.44 | 22.72 | 220.01 | 144.85 | |
2005–10 | 1.95 | 41.90 | 14.42 | 16.76 | 115.02 | 108.25 | |
% change | -19.42 | -6.99 | -17.32 | -26.23 | -47.72 | -25.27 | |
1965–70 | 1.51 | 22.75 | 6.41 | 9.47 | 34.45 | 24.02 | |
2005–10 | 1.30 | 17.75 | 6.28 | 8.19 | 19.43 | 18.78 | |
% change | -13.91 | -21.98 | -2.03 | -13.52 | -43.60 | -21.82 | |
1965–70 | 1.30 | 14.91 | 10.15 | 15.88 | 57.95 | 35.92 | |
2005–10 | 1.15 | 10.00 | 6.44 | 8.42 | 12.12 | 12.22 | |
% change | -11.54 | -32.93 | -36.55 | -46.98 | -79.09 | -65.98 | |
1965–70 | 1.53 | 22.55 | 9.10 | 13.90 | 66.96 | 41.28 | |
2005–10 | 1.19 | 12.06 | 5.60 | 7.42 | 9.12 | 8.88 | |
% change | -22.22 | -46.52 | -38.46 | -46.62 | -86.38 | -78.49 | |
1965–70 | 1.03 | 2.19 | 2.19 | 3.18 | 1.30 | 1.20 | |
2005–10 | 1.03 | 2.60 | 2.60 | 3.33 | 1.43 | 1.69 | |
% change | 0.00 | 18.72 | 18.72 | 4.72 | 10.00 | 40.83 | |
1965–70 | 1.61 | 25.99 | 9.47 | 13.73 | 58.71 | 39.40 | |
2005–10 | 1.33 | 19.22 | 7.36 | 9.41 | 16.41 | 16.15 | |
% change | -17.39 | -26.05 | -22.28 | -31.46 | -72.05 | -59.01 | |
1965–70 | 2.40 | 41.84 | 16.53 | 23.03 | 202.39 | 115.50 | |
2005–10 | 1.82 | 35.75 | 12.73 | 16.00 | 97.35 | 81.56 | |
% change | -24.17 | -14.56 | -22.99 | -30.53 | -51.90 | -29.39 | |
1965–70 | 1.53 | 24.47 | 7.31 | 10.33 | 33.41 | 24.78 | |
2005–10 | 1.32 | 19.43 | 6.87 | 8.58 | 20.16 | 21.04 | |
% change | -13.73 | -20.6 | -6.02 | -16.94 | -39.66 | -15.09 | |
1965–70 | 1.31 | 15.49 | 10.05 | 15.32 | 54.3 | 35.6 | |
2005–10 | 1.12 | 8.52 | 5.58 | 7.09 | 7.79 | 8.57 | |
% change | -14.5 | -45 | -44.48 | -53.72 | -85.65 | -75.93 | |
1965–70 | 1.52 | 23.5 | 10.06 | 14.67 | 67.85 | 45.47 | |
2005–10 | 1.2 | 13 | 5.64 | 7.18 | 10.18 | 10.73 | |
% change | -21.05 | -44.68 | -43.94 | -51.06 | -85 | -76.4 | |
1965–70 | 1.02 | 1.74 | 1.74 | 2.41 | 0.74 | 0.76 | |
2005–10 | 1.03 | 2.41 | 2.41 | 2.99 | 1.15 | 1.45 | |
% change | 0.98 | 38.51 | 38.51 | 24.07 | 55.41 | 90.79 | |
1965–70 | 1.6 | 27.02 | 10.44 | 14.48 | 58.87 | 42.46 | |
2005–10 | 1.33 | 19.86 | 6.8 | 8.45 | 15.92 | 16.88 | |
% change | -16.87 | -26.5 | -34.87 | -41.64 | -72.96 | -60.24 | |
1965–70 | 2.4 | 43.26 | 16.78 | 22.66 | 210.91 | 129.39 | |
2005–10 | 1.88 | 38.7 | 13.48 | 16.3 | 104.9 | 93.15 | |
% change | -21.67 | -10.54 | -19.67 | -28.07 | -50.26 | -28.01 |
Average between-country LE disparities reduced consistently between 1965–70 and 2005–10 in each sub-region of Latin America and the Caribbean, with Latin American reductions substantially greater than those in the Caribbean. In Central America, absolute disparities reduced by 55% and relative disparities by 51%. In SA the reductions were 55% and 52%, and in the Caribbean they were 14% and 23%. Reductions were broadly similar in women and men in each sub-region. Among women, absolute and relative disparity reductions were 63% and 55% in CA, 56% and 54% in SA and 15% and 25% in the Caribbean. Equivalent disparity reductions among males were 45% and 46% in CA, 54% and 52% in SA, 15% and 24% in the Caribbean.
LE disparity trends between 1965–70 and 2005–10 are plotted in
The Caribbean-wide (N = 21 countries) life expectancy for women and men combined was 62.1 years in 1965–70 and 71.8 years in 2005–10, an absolute increase of 9.7 years and a percentage increase of 15.7%. We removed 1 Caribbean country at a time to create twenty-one different 20-country groupings. The results of this sensitivity analysis are presented in a Supplement to this article (
Cuba and Haiti, as the largest countries in the Caribbean region, might have been expected to heavily influence results. We paid particular attention to these two countries during this sensitivity work. Haiti had a population of approximately 9.3 million in 2005–10, about 22% of the 21 country Caribbean population. It had a LE of 60.7 years in 2005–10, 19.4 years below Martinique as the best performing Caribbean country. Excluding Haiti increased the regional LE average by 3.2 years, to be 1.8 years higher than South America and 0.3 years lower than Central America in 2005–10. Its removal had little impact on the percentage increase in LE since 1965–70 (15.6% increase with Haiti, 14.5% increase without Haiti), and had little impact on the percentage decrease in regional disparities (Index of disparity: 17.0% decrease with Haiti, 14.4% decrease without Haiti). So although the removal of Haiti from a definition of the Caribbean pushed up regional average life expectancy, it did not materially affect LE change or LE disparity change over time. Since 1965–70, the Caribbean has underperformed compared to its regional neighbours, with or without Haiti. Cuba had a population of approximately 11.3 million in 2005–10, about 27% of the 21 country Caribbean population. It had a LE of 78.3 years in 2005–10, 1.8 years below Martinique as the best performing Caribbean country. Conversely, excluding Cuba decreased the regional LE average by 2.4 years, to be 3.8 years lower than South America and 5.9 years lower than Central America in 2005–10. Again, its removal had little impact on the percentage increase in LE since 1965–70 (15.6% increase with Cuba, 17.8% increase without Cuba), and had little impact on the percentage decrease in regional disparities (Index of disparity: 17.0% decrease with Cuba, 16.8% decrease without Cuba). So removing Cuba from a definition of the Caribbean pushed down regional average life expectancy, but again did not materially affect LE change or LE disparity change over time. Since 1965–70, the Caribbean has underperformed compared to its regional neighbours, with or without Cuba.
In the Americas, LE has increased consistently since 1965 and 33/38 countries (87%) now report a LE above 70 years: all countries in Central America, 9/10 in South America and 17/21 in the Caribbean. These improvements are a fundamental public health success. However, reviewing the data with a focus on regional disparities in LE presents a more nuanced picture, with Latin America able to claim greater relative success compared to the Caribbean. In Latin America and the Caribbean, 45-year gains in LE ranged from 4.9 to 18.0 years among Caribbean countries, from 7.2 to 23.7 years in South America, and from 13.7 to 23.5 years in Central America, so that the Caribbean, which had the highest LE in Latin America and the Caribbean in 1965, had the lowest LE by 1987. This Caribbean-Latin American LE difference has continued to widen thereafter. The Latin American sub-regions have reduced their LE shortfall compared to the best performing sub-region, whereas the Caribbean has not. Reductions in between-country disparities in LE at birth have also been enjoyed throughout the Americas, with larger reductions seen in Central and South America compared to the Caribbean. Average reductions in absolute and relative disparities in the Caribbean between 1965–70 and 2005–10 were 14% and 23%, in CA the reductions were 55% and 51%, and in SA they were 55% and 52%. These larger Latin American reductions have left the Caribbean as the sub region with the largest between-country disparities in LE, irrespective of the disparity metric used.
LE at birth is a measure of health and social development used widely by international agencies [
The ICPD-at-15 reviewed its wide-ranging goals and had this to say about Caribbean LE:
The NCD burden poses new governance challenges: the causes are multifactorial, the affected populations diffuse, and effective responses require sustained multi-sectorial cooperation. The relative contribution of lifestyle changes and medical intervention has been explored [
The Caribbean is dominated by Small Island Developing States (SIDS), and this fact may make the NCD response harder to sustain. The United Nations currently recognises 51 SIDS, with 22 of these in the Caribbean, and 17 in our 21-country Caribbean grouping [
Monitoring is needed to accompany these public health efforts, and lessons from the Millennium Development Goal (MDG) era must inform NCD data collection and reporting. MDG monitoring regularly suffered from data that was old, incomplete and of poor quality, with insufficient investment in the strengthening of national statistical capacity [
This NIH-funded project represents a new facet of the regional response to monitoring and improving health and reducing health disparities. We propose that LE as a ‘performance metric’ should be supplemented by measures of health variation at two levels of reporting.
First, between-country disparity measures could allow decision makers to assess national performance alongside their Caribbean neighbours, who will be subject to many of the same external international influences, but perhaps be pursuing different public health programmes. Between-country disparity monitoring of LE should include as a minimum the LE ‘shortfall’ comparing the region and each country to that world region or country with the highest LE. A suite of between-country disparity measures, as we have provided in this report, should be tracked through time, and free software is available to ease the analytical burden of these efforts [
Second, within-country disparity measures should allow decision makers to track disparities between key population subgroups through time, and so become core monitoring tools for the evaluation of sub-national public health interventions. Central to such monitoring is the acceptance that as a country achieves national health targets, vulnerable minority groups with poorer health outcomes will persist. A focus for within-country disparities monitoring should be the active reporting of socially determined population subgroups, stratified for example by gender, by socio-economic position, by geography, or by race/ethnicity. The WHO STEPS surveys, conducted throughout the Caribbean, is one possible data source for such within-country monitoring [
This article reports on two social determinants of health: place of residence and gender. They have been identified as two of eight key drivers of health inequity: place of residence, race or ethnicity, occupation, gender, religion, education, socioeconomic position, and social capital—the so-called “progress” acronym [
The completeness of mortality data collected by a country’s vital registration system is an important determinant of LE validity, and indicators of data quality are reported in the United Nations World Mortality Report [
The choice of disparity summary measure is important, and three considerations should help to guide this choice: whether to report relative or absolute disparity, how to examine departures from health equality (in other words what is an appropriate reference group), and whether to weight the disparity measure by the size of each population sub-group? A fourth consideration, that the concept of “health disparity” remains conceptually ambiguous, has fundamental importance for indicator choice. It has been recognised that if our understanding of disparity remains ambiguous, then an accurate measure of disparity should preserve this ambiguity [
Since 1965, against a backdrop of important LE improvements throughout the Americas, LE in the Caribbean has increased less quickly than in Latin America, with disparities in Caribbean LE barely changed. This relative performance has left the Caribbean as the sub-region of the Americas with the lowest LE, and the largest between-country disparities in LE, irrespective of the disparity metric used. Caribbean Governments have championed a collaborative solution to the growing burden of non-communicable disease, with 15 territories signing on to the Declaration of Port of Spain, signalling regional commitment to a coordinated public-health response [
(XLS)
(XLS)
The project described was supported by Grant Number U24MD006959 from the National Institute on Minority Health and Health Disparities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Minority Health and Health Disparities or the National Institutes of Health.