Mortality and disease burden across the life course: noncommunicable diseases and external causes

2.1 An overview of mortality and disease burden from noncommunicable diseases and external causes

Deaths and disease burden from noncommunicable diseases and external causes (2000–2019)

Chapter 1 explored life expectancy and mortality in the Americas, comparing three major causes of death (CMPN conditions, NCDs, deaths from external causes) between WHO regions ³ and PAHO subregions. ⁴ By 2019, 90% of all deaths and 89% of all disability-adjusted life years (DALYs) in the Americas were a result of NCDs and external causes, and much of the burden from lost life and lost health due to these causes is amenable to prevention and treatment.

Chapter 2 presents additional detail on the main contributors to NCDs and external causes. The chapter focuses on six broad causes of death and disability: cardiovascular diseases, cancers, respiratory diseases, diabetes, mental health and neurological conditions, and external causes (also known as injuries from unintentional and intentional causes). After a general introduction to these leading causes of death and disability, the chapter focuses on each of these six groups in turn. Section 2.2 describes the leading cardiovascular diseases, section 2.3 describes the leading cancers, section 2.4 describes the respiratory diseases, section 2.5 describes diabetes, section 2.6 describes the mental and substance use disorders and neurological conditions, and section 2.7 describes unintentional and intentional injuries.

The change in the numbers of deaths and DALYs between 2000 and 2019 is presented in Figure 10 by grouped causes of death and disability, for women and men separately. The numbers of deaths in all groups increased in the 20 years from 2000. From the smallest to largest change, the percentage increase in deaths for cardiovascular diseases was 15%, for deaths from external causes it was 24%, for cancers 31%, for respiratory diseases 40%, for diabetes 59%, and for mental and substance use disorders and neurological conditions, 179%. For the entire 20-year period, deaths in the Americas have been dominated by cardiovascular diseases and cancers, which in 2019 collectively accounted for 47% of all regional deaths.

Figure 10: The number of deaths and disability-adjusted life years (DALYs) in the Americas from noncommunicable diseases or external causes between 2000 and 2019 among women and men separately

The numbers of DALYs – the years of healthy life lost – also increased in all disease groups, with the largest percentage increases again for mental and substance use disorders and neurological conditions (a 47% increase) and for diabetes (an 88% increase). So, the relative importance of diabetes and of mental health and substance use disorders and neurological conditions as regional causes of lost life and lost health increased in the Americas between 2000 and 2019.

Certain gender differences are striking, with men in 2019 experiencing substantially more death and disability due to external causes, and substantially more disability due to cardiovascular diseases. Each of these causes of death and disability groups are explored in more detail in sections 2.2 to 2.7.

Twenty leading causes of death and disability from noncommunicable diseases and external causes (2000 and 2019)

The 20 leading causes of death and disability from NCDs or external causes ⁵ in the Americas in 2000 and 2019 are presented in Figure 11 for women and men combined, using the age-standardized mortality and DALY rates per 100 000 people. (See also Box 2.)

Top 20 causes of death

Ischemic heart disease (IHD), strokes, and chronic obstructive pulmonary disease (COPD) have dominated regional deaths for the 20-year period since 2000. IHD (mortality rate of 73.6 per 100 000 in 2019) dominated the top three causes, with a rate that was 2.3 times higher than stroke (32.3 per 100 000) and 2.9 times larger than COPD (25.1 per 100 000). Alzheimer disease and dementias (mortality rate 22.3 per 100 000) and diabetes⁶ (20.9 per 100 000) made up the top five causes of regional deaths.

There have been important shifts in the relative importance of causes of death between 2000 and 2019. In particular, dementias rose from 11th to 4th most important cause of death (mortality rate increased from 11.8 to 22.3 per 100 000), drug use disorders rose from 27th to 14th (mortality rate increased from 2.7 to 8.0 per 100 000), and falls rose from 24th to 18th (mortality rate increased from 3.6 to 5.4 per 100 000).

Cancers were treated as 23 separate groups of conditions in this regional ranking, and they collectively dominated the causes of death, with 8 cancer groups in the top 20 causes in 2019, and with the top 5 cancers being trachea, bronchus, and lung cancers (7th position, mortality rate in 2019 of 18.7 per 100 000), breast cancer (8th position, 15.5 per 100 000 women), prostate cancer (9th position, 15.2 per 100 000 men), colorectal cancer (12th position, 9.8 per 100 000), and cervical cancer (15th position, 6.1 per 100 000 women).

Figure 11: The 20 leading causes of death (using mortality rate per 100 000) and disability (using disability-adjusted life years [DALY] rate per 100 000) in 2000 and in 2019 in the Americas

^{Note: These are leading causes from the six broad causes of death and disability: cardiovascular diseases, cancers, respiratory diseases, diabetes, mental health and neurological conditions, and external causes.}

^{Data source:World Health Organization. Mortality and global health estimates.}

Top 20 causes of disease burden

Disease burden, measured using the DALY rate, was also dominated by IHD, with a rate of 1515 lost years of health per 100 000 in 2019, down from 2291 per 100 000 in 2000. Some illnesses did not feature as a cause of death but were important causes of disease burden, notably depressive disorders (7th most important cause of disease burden, DALY rate in 2019 of 658 per 100 000), anxiety disorders (9th position, DALY rate 534 per 100 000), alcohol use disorders (14th position, 388 per 100 000), and migraines (15th position, 379 per 100 000). Other illnesses did feature in the top 20 causes of death, and were even more important as causes of lost health, notably interpersonal violence (6th most important cause of death, 2nd most important cause of lost health), road injuries (10th position, 4th position), drug use disorders (14th position, 6th position), and falls (18th position, 13th position). Five illnesses gained importance as causes of lost health in the 20 years since 2000: Alzheimer disease and dementias (rising from 20th to 16th most important cause of lost health), self-harm (16th to 11th), drug use disorders (12th to 6th), diabetes (5th to 3rd), and interpersonal violence (3rd to 2nd).

Unconditional probability of dying between 30 and 70 years of age (2015 and 2019)

The Sustainable Development Goal (SDG) target 3.4 is to reduce premature mortality from NCDs by a third by 2030 relative to 2015 levels, and to promote mental health and well-being. Premature mortality for this target is defined as mortality between 30 and 70 years of age, and NCDs include four of the six grouped causes considered in this report: CVD, cancers, respiratory diseases, and diabetes. Progress toward target 3.4 is being monitored by a consortium including WHO (3). Progress in the Americas by 2019 is summarized in Figure 12.

The baseline probability of dying between 30 and 70 years of age (30q70) in 2015 ranged from 3.1% in the Andean subregion to 5.9% in the Latin Caribbean (Figure 12, right-hand panel). By 2019, this probability had fallen in all subregions, with reductions above 6% in the Southern Cone and Andean subregions, reductions between 4% and 6% in Brazil, Central America, and Latin Caribbean, reductions between 2% and 4% in North America and non-Latin Caribbean, and a reduction of less than 1% in Mexico. In the four years from 2015, these reductions translate to annual percentage reductions of between 0.13% in Mexico and 1.72% in the Southern Cone subregion. An annual reduction over 2% will eventually be required to achieve a 33% reduction in NCD premature mortality over 15 years.

2.2 Cardiovascular diseases

Cardiovascular diseases (CVD) is a general term for conditions affecting the heart or blood vessels. The risk of certain CVDs may be increased by high blood pressure or cholesterol, smoking, unhealthy diet, lack of exercise, obesity, excessive alcohol consumption, or poor sleep. Diabetes, itself a major cause of disability and death, is also a recognized CVD risk factor. These risk factors have been reliably linked to lifestyle, which in turn is influenced by a person's social circumstances. Because of the association of CVD with lifestyle, a large proportion of CVD deaths are assumed to be preventable or delayable through interventions, for example, to promote healthy eating, to help avoid tobacco smoke, and to limit alcohol intake. Cost-effective treatments to lower blood pressure and lipids or to control diabetes are also widely implemented.

Leading causes of death and disease burden

The absolute number of CVD deaths in the Americas increased from 1.76 million in 2000 to 2.02 million in 2019. Total deaths in the Region also increased, from 5.46 million in 2000 to 7.16 million in 2019, so that the share of deaths due to CVD decreased slightly, from 32.3% in 2000 to 28.3% in 2019. The five leading causes of CVD deaths in the Americas in 2019 are summarized in Table 4.

General cardiovascular disease trends

For four of the five leading causes of CVD (hypertensive heart disease is the exception), there have been important reductions in death and DALY rates. For women and men combined, the reductions have ranged from 35% to 45% for death rates, and from 31% to 34% for DALY rates. These death and DALY rate improvements are a critical and welcomed step on the pathway to improved population health, and point to the importance of healthcare interventions across the Region. The rate reductions, however, were not large enough to offset the region's increasing population, and its rapid aging, so that overall the number of CVD deaths and years of life lost have continued to increase. There have been exceptions, with the number of IHD deaths decreasing slightly among women; cardiomyopathy, myocarditis, and endocarditis deaths and DALYs decreasing slightly among women; and rheumatic heart disease deaths and DALYs decreasing among women and men.

The region's population size has been discussed in Chapter 1 (section 1.2, Table 2), and the health challenges associated with population growth and population aging are discussed in Chapter 3.

^{Notes: a Mortality is described using the age-standardized mortality rate. Disease burden is described using the age-standardized DALY rate. Both rates presented per 100 000 population. b Ischemic heart disease. c Hypertensive heart disease. d Cardiomyopathy, myocarditis, endocarditis. e Rheumatic heart disease. f All CVD includes “other” circulatory diseases (All CVD ICD-10 codes: I00–I99. Other CVD ICD-10 codes: I00, I26–I28, I34–I37, I44–I51, I70–I99).}

^{Data source:World Health Organization. Mortality and global health estimates.}

Again, for four of the five leading causes of CVD (rheumatic heart disease is now the exception), men were disproportionately affected, with a higher burden of deaths and DALYs. In 2019 the ratio of male to female death rates ranged from 1.18 to 1.80, and the range for DALY rates was 1.14 to 2.03. There were 1.04 million deaths and 23.0 million years of lost health in 2019 among men, compared to 981 000 and 17.9 million among women.

Ischemic heart disease since 2000

Coronary artery disease (narrow or blocked coronary arteries) can lead to ischemic heart disease (IHD), which in 2019 accounted for 15% of all deaths, and over half (54%) of all CVD deaths in the Americas. The IHD mortality rate has improved considerably since 2000, down by 37% to 74 IHD deaths per 100 000 people. This 20-year improvement has been similar in women and men, with the mortality rate among men improving from 149 in 2000 to 96 in 2019 (a 36% improvement), and the rate in women improving from 92 in 2000 to 55 in 2019 (a 41% improvement). Nonetheless, many more men continue to die from IHD, with the mortality rate ratio rising gently from 1.61 in 2000 to 1.75 in 2019, and over 600 000 men dying of IHD in 2019, 110 000 more deaths than among women. Similar improvements were seen in the IHD DALY rate, with the rate among men down from 3074 per 100 000 people in 2000 to 2071 per 100 000 in 2019 (a 33% improvement), and the rate among women down from 1614 per 100 000 in 2000 to 1021 per 100 000 in 2019 (a 37% improvement). So, in 2019 the DALY rate among men remained at twice the level for women (DALY rate ratio 2.03). There were 12.3 million years of lost health among men in 2019, compared to 7.7 million lost years among women.

Stroke since 2000

A stroke is a serious and often life-threatening condition that happens when the blood supply is cut off to part of the brain. An ischemic stroke is more common and is caused by a blood clot. A hemorrhagic stroke occurs when a weakened blood vessel supplying the brain bursts. Rapid diagnosis and treatment is crucial to limit the damage. After IHD, stroke is the second most common cause of CVD death and disability. In 2019, the regional stroke burden was roughly half that of IHD, with 478 000 deaths and 10.3 million years of lost health. Like IHD, rates have improved consistently since 2000, with the death rate down from 49.9 to 32.3 per 100 000 (a drop of 35%) and the DALY rate down from 1172 to 797 per 100 000 (a drop of 32%). The gender difference again favored women but was less pronounced than for IHD (mortality rate ratio 1.18, DALY rate ratio 1.14). Although rates of stroke were a little lower among women, the larger number of women alive in the older age groups mean that more women died from stroke in 2019 (257 000 deaths among women, 220 000 deaths among men), and there were more years of lost health among women (5.31 million years among women, 5.02 million years among men).

Hypertensive heart disease since 2000

Over time, untreated hypertension can lead to a thickening of the heart wall, and this is an important step in the pathway toward heart failure and other less common outcomes, collectively known as hypertensive heart disease (HHD). Hypertensive heart disease is the only major CVD with mortality rates and DALY rates that have increased in the past 20 years. Deaths increased from 81 000 in 2000 to 157 000 in 2019, and mortality rates in women and men combined from 9.5 per 100 000 to 10.6 per 100 000 (a 12% increase). Similarly, years of healthy life lost increased from 1.70 million in 2000 to 3.02 million in 2019, with a DALY rate increase of 212 to 232 per 100 000 (a 9% increase).

Cardiomyopathy, myocarditis, and endocarditis since 2000

A group of conditions affecting the heart muscle, including stretching, thickening, or stiffening of the heart chambers that is mostly inherited (cardiomyopathy), inflammation of the heart muscle often caused by a viral infection (myocarditis), or inflammation of the inner lining of the heart's chambers and valves often caused by a bacterial infection (endocarditis).

The burden from this group of conditions is less than one-tenth that of IHD, and there have been similar 20-year reductions in burden since 2000. The mortality rate for women and men combined dropped from 7.9 to 5.1 per 100 000 (a 36% decrease), and the DALY rate dropped from 232 to 155 per 100 000 (a 33% decrease). Men were again disproportionately affected (mortality gender rate ratio 1.80 in 2019); there were 39 000 deaths and 1.1 million DALYs among men in 2019, compared to 29 000 deaths and 680 000 DALYs among women.

Rheumatic heart disease since 2000

Rheumatic heart disease is a condition in which the heart valves have been permanently damaged by rheumatic fever. Rheumatic fever is a disease of poverty and has been mostly eliminated in high-income countries. Although still problematic in the Americas, the mortality rate dropped from 1.3 to 0.7 per 100 000 (a fall of 45%) and almost two-thirds of all deaths occurred in just two countries: Brazil (2192 deaths), where rheumatic fever remains endemic; and the United States (3645 deaths), where rheumatic fever is uncommon and cases of rheumatic heart disease are likely to be among immigrant communities.

Deaths across the life course

Figure 13 presents the proportion of deaths and DALYs in each of five age groups: under 5s, 5–19, 20–39, 40–64, 65+. For IHD, stroke, and HHD, just over three-quarters of all deaths were among adults aged 65+. Among the remaining two conditions – cardiomyopathy, myocarditis, and endocarditis, and rheumatic heart disease – around two-thirds of all deaths were among adults aged 65+, with the remaining one-third split between young adults (20–39 years) and adults aged 40–64 years. For IHD, stroke, and HHD the full disease burden measured by DALYs was roughly split between adults aged 40–64 (one-third of the entire burden) and adults aged 65+ (two-thirds). Among the remaining two conditions – cardiomyopathy, myocarditis, and endocarditis, and particularly rheumatic heart disease – the full disease burden was split more evenly across the age groups, with older children (aged 5–19) and all adults affected.

Regional inequalities

Regional and subregional averages can mask important inequalities between countries. Figure 14 presents 2019 mortality rates for each of the five leading causes of CVD. Each bar represents the mortality rate for one country, the bars are ordered from high to low mortality rates, and the black bar represents the mortality rate for the entire Region of the Americas. Countries with the highest five and lowest five mortality rates are listed on the chart. The index of disparity (IoD) is presented on the chart and is an overall measure of inequality between countries – the larger the value the higher the regional inequality for that cause of death.

Leading causes of death and disease burden

The absolute number of cancer deaths in the Americas increased from 1.04 million in 2000 to 1.36 million in 2019. This 20-year increase broadly tracked the increase in total regional deaths, so that the percentage of regional deaths due to cancer remained static at around 19%. The 10 leading causes of cancer deaths in the Americas in 2019 are summarized in Table 5.

^{Notes: a Mortality is described using the age-standardized mortality rate. Disease burden is described using the age-standardized DALY rate. Both rates presented per 100 000 population. b Lung cancer also includes the relatively rare cancers of the windpipe (trachea) and the glands and ducts of the lung airways (bronchi). c Breast cancer is presented for women only. There were a small number of breast cancer deaths among men: 813 deaths in 2000, rising to 1050 deaths in 2019. d Colorectal cancer is known as colon cancer or rectal cancer depending on where it starts. e Cervical cancer is also known as cervix uteri cancer. f “All cancers” include “other” cancers (All cancers ICD-10 codes: C00–C97. Other cancers ICD-10 codes: C17, C26–C31, C37–C41, C46–C49, C51, C52, C57–C60, C63, C68, C69, C74–C75, C77–C79).}

^{Data source:World Health Organization. Mortality and global health estimates.}

General cancer trends

For 9 of the 10 leading causes of cancer deaths (liver cancer is the exception) mortality rates and rates of disability have dropped in the 20 years from 2000. Overall, the cancer mortality rate fell by 21% (down from 128 per 100 000 in 2000 to 101 per 100 000 in 2019). As with the cardiovascular diseases, these improvements reflect the important public health and healthcare initiatives ongoing across the region. The gains are large, but do not fully offset regional population growth and aging, so that the absolute numbers of cancer deaths and years living with cancer disability have increased since 2000.

Three of the 10 cancers are sex-specific (prostate cancer in men, cervical cancer in women, and breast cancer mostly in women). For the remaining seven cancers, men are disproportionately affected, with higher mortality rates and higher rates of disability. In 2019, the ratio of male to female death rates ranged from 1.27 to 1.79, and the range for DALY rates was 1.31 to 1.80. In 2019, there were 707 000 deaths and 16.7 million years of lost health among men, compared to 654 000 and 16.1 million among women.

Trachea, bronchus, and lung cancers since 2000

This group of cancers is dominated by lung cancer. Although people who have never smoked can develop lung cancer, smoking is the most common cause, accounting for around 70% of cases (4, 5). Lung cancer does not cause noticeable symptoms until it has spread through the lungs or to other parts of the body, and for this reason the outlook for people with lung cancer is not as good as for other cancers. Despite a consistent annual improvement in mortality rate, lung cancer has been the leading cause of cancer death and disability in the Americas since 2000.⁷ In 2019 lung cancer ccounted for 4% of all deaths in the Americas, and 19% of all cancer deaths. It caused 56 000 deaths and 5.5 million years of lost health. The 20-year improvement in lung cancer mortality rates has been greater in men than in women, with the mortality rate among men improving from 39 per 100 000 in 2000 to 23 per 100 000 in 2019 (a 40% improvement), and the rate in women improving from 20 per 100 000 in 2000 to 15 per 100 000 in 2019 (a 23% improvement). Although more men continue to die from lung cancer (143 000 men died of lung cancer in 2019, 30 000 more deaths than among women), the mortality gender rate ratio dropped from 2.0 in 2000 to 1.5 in 2019, highlighting a narrowing of this gender difference.

Breast cancer since 2000

In countries that collect data, breast cancer is regularly the most common cancer among women. In the United States, for example, about one in eight women will develop invasive breast cancer during their lifetime (6). When detected early there is a good chance of recovery, and campaigns to encourage regular breast examinations or screening are a feature of many countries. Although rare, breast cancer can also occur in men. Among women in 2019, breast cancer was the leading cause of cancer deaths (jointly with lung cancer) and was the leading cause of cancer disability in the Americas. In 2019, the breast cancer mortality rate was 16 deaths per 100 000 (lung cancer in women was 15 deaths per 100 000), and the DALY rate was 490 per 100 000 (lung cancer in women was 349 lost years of healthy life per 100 000). Breast cancer rates have improved consistently since 2000, with the mortality rate down from 19 per 100 000 (a drop of 19%) and DALY rate down from 597 per 100 000 (a drop of 18%).

Prostate cancer since 2000

In countries that collect data, prostate cancer is regularly the most common cancer among men. In the United States, for example, about one in eight men will develop prostate cancer during their lifetime (6). Prostate cancer mostly occurs in later life, generally in men over 50 years of age. It usually progresses slowly, so that a man with prostate cancer may live for decades without symptoms or needing treatment. Prostate cancer is the second most common cause of cancer deaths and disability among men in the Americas. In 2019, the prostate cancer mortality rate was 15 deaths per 100 000 (the lung cancer mortality rate in men was 23 deaths per 100 000), and the DALY rate was 296 per 100 000 (the lung cancer DALY rate in men was 512 lost years of healthy life per 100 000). Prostate cancer rates have improved consistently since 2000, with the mortality rate down from 21 per 100 000 (a drop of 26%) and DALY rate down from 384 per 100 000 (a drop of 23%).

Colon and rectum cancers since 2000

Colorectal cancer is also known as colon cancer or rectal cancer depending on where it starts. Most people with colorectal cancer are aged 60 years or older. Although specific causes are not known, the common lifestyle risk factors for NCDs (such as physical inactivity, obesity, alcohol consumption) are thought to play a part. A diet low in fiber and high in processed meat can increase risk, as can a family history of early onset colorectal cancer. Colorectal cancer in 2019 in the Americas caused 134 000 deaths (68 000 deaths among men, 65 000 among women), and 3.1 million years of lost healthy life (1.6 million years among men, 1.4 million among women). Mortality rates improved gently between 2000 and 2019, down from 15 to 11 deaths per 100 000 among men (a 23% improvement) and from 11 to 9 per 100 000 among women (a 21% improvement).

Cervical cancer since 2000

Cervical cancer originates in the cervix – the neck of the womb. Nearly all cervical cancers are caused by human papillomavirus (HPV), and for this reason cervical screening programs are a feature of cancer prevention in many countries. HPV vaccination is available across the region, making cervical cancer largely preventable. Although mortality rates have fallen by 24% since 2000, across the Americas almost 39 000 women died from cervical cancer in 2019, up from 33 000 twenty years ago. This increase partly reflects the growing population of the Americas and also points to the need for continued communication campaigns highlighting the importance of vaccination and screening. HPV vaccination coverage has a target of 90% of girls by age 15, but falls short of this in many countries (7).

Other top 10 cancers since 2000

Five more cancer sites make up the top 10 causes of cancer deaths in the Americas: pancreatic cancer, lymphomas and myelomas, stomach cancer, liver cancer, and leukemia. Mortality rates for these cancers in 2019 ranged from 4 to 6 per 100 000, and rates of disability ranged from around 123 to 153 years of lost health per 100 000. Mortality rates for three of the five cancers (the lymphomas and myelomas, stomach cancer, leukemia) have dropped noticeably since 2000, falling by between 20% and 30%. The mortality rate for pancreatic cancer has remained roughly unchanged, dropping by just 2% over 20 years, and liver cancer is the only condition to see a mortality rate increase, rising 11% since 2000.

Deaths across the life course

Cancers occur with increasing frequency as we age, most likely due to the accumulation of risk over time and the reduced ability of the aging body to effectively make cellular repairs. Figure 15 presents the proportion of deaths and DALYs in each of five age groups: under 5s, 5–19, 20–39, 40–64, 65+.

For most cancers, between half and three-quarters of all deaths occurred among adults aged 65+. Cervical cancer was the notable exception, with more adults aged 40–64 (49%) dying than adults aged 65+ (39%). Breast cancer also had a younger age profile at death, with adults aged 40–64 contributing 40% of all deaths. Only prostate cancer reported deaths almost exclusively among adults aged 65+. Years of healthy life lost was also dominated by the older age groups, but the percentages reflected a sizable proportion of adults aged 40–64 also living with cancer. For breast, cervical, stomach, and liver cancers, more years of healthy life were lost among adults aged 40–64 than aged 65+. Overall, the years of healthy life lost among all cancers was roughly the same for adults aged 40–64 (14.3 million, 44% of all healthy years lost) and adults aged 65+ (15.2 million, 46% of all healthy years lost). Leukemia stood apart, with all age groups contributing to the years of healthy life lost.

Regional inequalities

Among the 10 leading causes of cancer, the largest between-country differences in mortality rates were seen for cervical (IoD 100) and prostate cancers (IoD 105) (Figure 16). For both cancers, variation in the coverage of screening (and for cervical cancer vaccination) is likely to contribute to these higher inequalities. The United States and Canada, with high screening and vaccination coverage, have rates among the lowest five countries. Caribbean countries have noticeably higher mortality rates for breast and prostate cancer, contributing to mortality rate inequalities in these two cancers. For prostate cancer, all 13 Caribbean countries (along with Belize in Central America) have higher mortality rates than the rest of the Americas. For breast cancer, 12 of the highest 15 mortality rates are in Caribbean countries. These cancer disparities reflect relationships among many factors, including social circumstances, behavior, biology, and genetics – all of which can have profound effects on health, including cancer risk and outcomes. There is reliable evidence, for example, that women of African descent have a higher prevalence of triple-negative breast cancer, with poorer rates of survival (8).

2.4 Respiratory diseases

Respiratory diseases (RD) are conditions affecting the lungs and airways. The most common of these are chronic obstructive pulmonary disease (COPD) and asthma, but there are many others, including pulmonary hypertension (high blood pressure in the blood vessels that supply the lungs), and a range of occupational lung diseases. Tobacco smoke is the main RD risk factor, and there are many others including indoor and outdoor air pollution, and occupational chemicals and dust. RDs are not curable, and treatment focuses on expanding the airways to relieve symptoms and improve the quality of life of people living with RD. The WHO Global Alliance against RDs (GARD) aims to improve diagnosis and treatment of RD, focusing in particular on the needs of people with RDs in low-income and middle-income countries (9).

Leading causes of death and disease burden

The absolute number of RD deaths in the Americas increased from 382 000 in 2000 to 534 000 in 2019. This 20-year proportional increase was larger than the increase in total regional deaths, so that the percentage of all deaths due to RD increased slightly, from 7.0% in 2000 to 7.5% in 2019. The leading causes of RD deaths in the Americas in 2019 are summarized in Table 6.

Deaths across the life course

Figure 20 presents the proportion of deaths and DALYs in each of five age groups: under 5s, 5–19, 20–39, 40–64, 65+. The age profile for diabetes highlights the increasing mortality in each age group, with over two-thirds (69%) of all diabetes deaths among adults aged 65 and older. The years of full health lost because of diabetes is split evenly between adults aged 40–64 (49% of all healthy years lost) and adults aged 65+ (46% of all healthy years lost).

Regional inequalities

In 2019, the country with the lowest diabetes mortality rate in the region was Canada (7 deaths per 100 000), and would see 14 fewer deaths per 100 000 people than the regional average for the Americas (21 per 100 000), and 75 fewer deaths per 100 000 than the country with the highest mortality rate (Guyana, 83 per 100 000) (Figure 21). The overall regional diabetes inequality (IoD 107) was similar to that seen in prostate cancer (which in 2019 had the highest inequality of the top 10 cancer sites, IoD 105). The higher diabetes mortality rates were dominated by Caribbean countries. Among the 10 countries with the highest mortality rates in 2019 (mortality rate range 54 to 83 deaths per 100 000), seven were in the Caribbean.⁹