Social vulnerability and its possible relation to the principal causes of morbidity and mortality in the Mexican state of Oaxaca

Vulnerability is defined as the susceptibility to be harmed, or as the degree to which a system is susceptible and cannot withstand adverse effects [1]. It is marked by different factors: biological, cultural, social, economic, political, geographic, as well as diseases, educational level, age, gender, social status, behaviour and housing, which make certain groups more sensitive to premature and excessive morbidity and mortality. Moreover, these factors are not mutually exclusive [2]. Consequently, the same groups can present these vulnerabilities or disadvantage factors in a cumulative way; hence, those groups that tend to accumulate a greater number of factors are more likely to suffer injury or have a specific priority need in comparison to the rest of the population [2].

The state of Oaxaca, like every state within the Mexican Republic, has access to priority health programs; however, it ranks among the last places in health indicators in the national health surveys. Why does this state present such disparity? A possible answer could be found by analysing different social and economic factors related to vulnerability in order to clarify the main issues that may affect this phenomenon, so that the major health needs of the people of Oaxaca would be considered.

To carry out the social study of living conditions we analysed reports of the National Institute of Statistics and Geography (INEGI) [3], Ministry of Health (SESA) [4] and the National Survey of Health and Nutrition (ENSANUT 2012) [5], as well as citizen reports of access to health care in Oaxaca. Once the social data were obtained, health conditions were compared between the states ranked from 1 to 32, with the lowest and highest degrees of social vulnerability [6] The ranking of the principal factors associated with diabetes and hypertension, living conditions and principal causes of mortality were obtained by dividing the rank occupied by the state by the total number of states (32) Mexico has 32 states, so the highest value implies the worst conditions. World Health Organization (WHO) [7] reports and published scientific articles were consulted for biological studies associated with social conditions. Finally, the work data was analysed for morbidity and mortality related to living conditions in Oaxaca.

Urinary tract infections are associated with kidney failure and ischemic heart disease and cerebrovascular accidents are associated with high cholesterol, high triglycerides or obesity (64.6% of the population) and arterial hypertension. Ischemic heart disease, in the case of Oaxaca, cannot be attributed solely to the presence of high levels of serum carbohydrates, in view of the high level of physical activity of the population. With 90% of the population active, Oaxaca is positioned as the state with less physical inactivity, shown by the few hours that people spend in front of the television. This is probably a function of poverty, as people have to walk everywhere, cannot afford television, and live in areas without access to television or Internet signals.

Hence, it is necessary to consider that breathing contaminated air inside the home is a social factor that may be associated with the three main causes of mortality in Oaxaca, especially in women, since they are the most exposed to polluted air due to cooking and time spent within the home. When biological factors are not enough to explain causality, the answer is surely related to social factors.

To reduce morbidity and mortality in Oaxaca, in addition to complying with the vaccination programs and recommendations issued by WHO, it is necessary to analyse the possibility of environmental interventions that are closely related to health.

In 2015 the United Nations proposed that with the implementation of 17 global goals, life could be improved for people around the world. To achieve these objectives the united efforts of government, business and civil society is necessary. The goal of Sustainable Development Goals 3 (SDG3) is to ensure healthy lives and promote well-being for all. Additionally, there are health related SDGs, such as SDG6, that focus on ensuring availability and sustainable management of water and sanitation for all, and SDG 7, dedicated to ensure access to affordable, reliable, sustainable and modern energy for all [25]. SDG6 is directly related to SDG3, as providing good quality water reduces tropical diseases like malaria and water-borne diseases. The SDG reports mention that in Mexico, mortality attributed to household air pollution is 15.2%, but in Oaxaca it is much greater, at 23.5%, and unsafe water, unsafe sanitation and lack of hygiene is 1.1 per 100,000 population [25]. Although worldwide access to water sources and waste disposal has improved, the situation of different regions or states of a country may be far from the national averages [26] and local problems may be underestimated.

The lack of access to appropriate sources of water and the use of fuels other than gas or electricity are not problems that poor people can solve on their own in order to prevent the deterioration of their health. In some cases the solution may be unknown, their living situation places them at a disadvantage and they lack the resources to modify their environment.

The reduction of use of solid fuel for heating and cooking, and improved sanitation, is not a key objective in some countries because it is not directly related to non-communicable diseases. As Krieger points out, the disadvantages in social epidemiology are not mutually exclusive, [27] and in this case they are associated with the prevailing conditions in Oaxaca. Oaxaca displays a biological expression of social inequality, since people are incorporating pollutant particles into their bodies by inhaling them during their daily activities and thus, the population expresses biologically the experiences of economic inequality due to the impoverished conditions in which they live, leading to an untimely death [27]. The difference in health conditions with the rest of the country is not a matter of race or ethnicity, but of the living conditions of these ethnic groups. Women and children being the most affected, biological affectation has a lifelong trajectory development, which could be considered as “biological programming” in which the harm that has occurred during childhood has repercussions throughout the rest of life.

Although there has been an increase in health expenditures in the state of Oaxaca, it is quite obvious that there is still a lot more to be done. Despite the fact that a large part of the population has government health insurance (Seguro Popular) 15.9% do not have access to health services, and 83.8% do not have access to social security [4, 10]. Moreover, within the population that has access to health services, ENSANUT reports that in 2012 the rate of these services was 66.8%, lower than the 77% national rate [5] . Nevertheless, being affiliated with the health system does not necessarily indicate that access to the services is full and effective. Additionally, user reports on quality and effective access to health services in Oaxaca indicated that the people who were attended either did not receive their full medication prescriptions or had to pay for laboratory studies or medications during surgical treatment [28]. The actions of the SDGs related to health can reduce the main causes of morbidity and mortality in Oaxaca and places Mexico as one of the countries that improves the life of the population through the application and fulfilment of the SDG goals.

As can be deduced, opening more clinics is not the solution, as there will probably be no doctors, not enough medicines and the location will be inaccessible to the population. If Oaxacans have the same rights to health services as the rest of the country, then the causes of social disadvantage are the immediate problem and the causes of morbidity and mortality which do not present risk factors such as lack of physical activity and/or diabetes, will require multifaceted action for health improvement, specifically in the construction of healthy environmental conditions.

Therefore, if actions were to be implemented to reduce the two factors of contaminated air and water that have been established as global objectives, as in the millennium development goals of SDGs 3, 6 and 7, Oaxaca’s morbidity and mortality would be reduced. WHO has suggested a plan called Water, Sanitation and Hygiene, with the objective of accelerating and sustaining progress in respect to unattended tropical diseases (WASH) and thus to control and eliminate them [29]. An excellent example is improving health by clearing the air to reduce premature mortality from non-communicable diseases. Policies implemented to reduce the exposure to dangerous particles have reduced cardiovascular mortality from 17.8% in 2000 to 10.3% in 2015 [30].

Additionally it has been observed that changing fuel material, ventilating homes or increasing the quantity of multivitamin tablets, increases the function of the immune system and thus reduces respiratory infections. These measures have been taken by other countries to reduce the production of pollutants within the home [31, 32]. And, as with any measure, it must go hand in hand with national health programs.