Primary healthcare is conceived as a set of integrated activities which, although emphasizing the primary level, forms part of the national health system and, as such, must be coordinated with the other levels of that system, as well as with the other sectors that contribute to the strategy for comprehensive development.
The following section analyzes, at the regional level, the evolution of child mortality from causes specifically related to primary care activities. Available data will be considered for those highly specific actions that involve an almost direct relationship between technology and disease, such as vaccination and measles, or oral rehydration and diarrhea.
The evolution and effects of other primary care interventions will not be analyzed, either because of insufficient data, lack of specificity, or because they have already been studied by other authors. Among these are family planning actions, whose influence on infant mortality in Latin America has been studied by Érica Taucher.
Through basic activities for which simple and effective technologies exist, a considerable percentage of infant mortality caused by vaccine-preventable diseases, acute respiratory infections, diarrheal diseases and malnutrition can be reduced.
Vaccine-preventable diseases
Diseases that can be prevented through vaccination and that are included in the Expanded Program on Immunization (EPI) continue to be a priority health problem in the Region. Although between approximately 1970 and 1979 the proportion of deaths due to diphtheria, tetanus, whooping cough, measles and poliomyelitis decreased, a high proportion of unnecessary deaths still occurred every year in the Region.
As recently as 1979, 24% of all deaths caused by infectious and parasitic diseases in the 1-to-4-year age group in Latin America were due to causes preventable by vaccination. In North America, during the same period, the proportion did not exceed 1%.
Much remains to be done for the countries of the Region to reach the goals of the EPI in particular, and those of health for all by the year 2000 in general. It should be noted that immunization programs constitute the starting point of the primary care strategy, whose impact on the reduction of diseases will measure progress toward achieving those goals.
Between 1970 and 1979, Latin America and the Caribbean substantially reduced the number of deaths from the five diseases mentioned. The total number of deaths from these causes in the 0-to-5-year age group fell from 42,677 in 1970 to 19,796 in 1976, meaning an absolute reduction of 22,881 deaths and a percentage reduction of 53.6%.
In North America, these deaths did not reach two dozen in 1979. It cannot be denied that the application of the technologies proposed by the EPI has contributed to reducing the number of deaths, but much remains to be done. Moreover, these figures reflect only a portion of Latin American reality, and because of the previously mentioned problems of registration and certification, the remaining burden of vaccine-preventable mortality is greater than that recorded.
Acute respiratory infections
This group of causes includes a set of pathologies with diverse etiologies, and there is no doubt that their reduction is related to the expansion of coverage and the effectiveness of vaccinations, the application of simplified early treatments and, especially, the improvement of maternal and child nutrition.
Around 1979, deaths from acute respiratory infections in children under five ranked first in one country of the Region, second in nine countries and third in eight. During the 1970s, mortality among children decreased considerably, despite the absence of a specific technology as certain as vaccination or oral rehydration salts.
It is probable that greater access by the Latin American population to health services influenced the reduction of several of the diseases included in this group. Between 1970 and 1979, the number of deaths fell from 116,504 to 70,998, representing an absolute decrease of 45,506 deaths and a percentage reduction of 39.0%.
Diarrheal diseases
The control of diarrheal diseases is related to basic sanitation and timely oral rehydration. In most of the Region, these diseases still constitute a leading cause of mortality in infancy and childhood, even though their certification remains incomplete and does not reveal the true magnitude of the problem.
Table 9 shows that diarrheal diseases were among the three leading causes of death in children under five in 15 of the 18 countries that reported data around 1970 and 1979. In both years, their order of importance remained the same.
Table 9 also shows that around 1970 there were 103,027 deaths from diarrhea in children under five. In 1979, the figure fell to 75,829, representing an absolute reduction of 27,298 deaths, or 26.5%.
For children under one year of age, the corresponding absolute values were 66,362 and 52,422, with a reduction of 13,940 deaths, or 21%. In the 1-to-4-year age group, the corresponding figures for 1970 and 1979 were 36,665 and 23,307, with a decrease of 13,358 deaths, or 36.4%.
In terms of rates per 100,000 inhabitants, the reductions are similar, indicating that deaths due to diarrheal diseases are decreasing in the Region, although not at the pace needed to achieve the goals of the Ten-Year Health Plan for the Americas.
Despite the progress noted, the difference with developed countries remains great. The rate for North America is 21.9 per 100,000 among children under one year of age, while in Latin America and the Caribbean it still reaches 903.8, that is, 41 times higher.
Although Costa Rica, Cuba and Chile reduced their rates to one fifth during the 1970s, progress in controlling diarrheal diseases should be more significant, given that effective, low-cost instruments with easy cultural acceptability are available.
Finally, it is probable that the persistence of the poverty-malnutrition-diarrhea cycle is a sociobiological constant and that these diseases require deeper socioeconomic transformations for their reduction and control.
