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COMMENTARY |
George A. O. Alleyne is with the Pan American Health Organization, Washington, DC.
Correspondence: Requests for reprints should be sent to George A. O. Alleyne, Pan American Health Organization, 525 23rd St NW, Washington, DC 20037 (e-mail: alleyned{at}paho.org).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONReferences |
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The Pan American Health Organization (PAHO) has responded to changing political times and different health challenges and has played a significant role in some of the recent achievements in health in the region of the Americas. Some of the more remarkable health gains of the past 8 years owe their success to the broad principles of equity and Pan-Americanism that guide PAHO’s work. The production and use of scientific–technical information is the fundamental underpinning of the technical cooperation that has facilitated the health work of countries. The future is bright for PAHO’s next century.
THE HISTORY OF THE PAN American Health Organization (PAHO), the oldest international health organization in the world, has now been recorded in many places, including the excellent editorial in this issue by Fee and Brown.1 This will be a personal account of the advances of the past 8 years, and why the advances of those years, which have built on the achievements of the past 9 decades, augur well for the future of PAHO. I am sure that these achievements were largely due to the style of management and the focus of the organization under the stewardship of previous directors, including Abraham Horwitz, Hector Acuña, and Carlyle Guerra de Macedo.
Horwitz had an expansionary vision of health and the conviction that PAHO should grow physically to fulfill its hemispheric destiny. He noted and capitalized on the fervor with which the Americas embraced the Alliance for Progress and recognized that "a mutual relationship exists between health, economic development, living standards and well-being."2 The countries were encouraged under the alliance to use the technical advisory services of the Pan American Sanitary Bureau in the preparation and execution of 10-year health plans. Horwitz saw this as a mandate for PAHO, and he focused PAHO’s efforts on assisting countries in the resolution of the health problems that were set out in those plans.3 In a stirring editorial, he wrote,
In their momentous Declaration of Punta del Este, the Chiefs of State recognized the fundamental role of health in the economic and social development of Latin America. They thus emphasized that in every society health, as a social service, meets vital needs. Hence its importance to production and productivity, and also to the improvement of the physical infrastructure so that natural resources can be more readily exploited. This interpretation does not undermine the moral significance of individual and collective heath as value for each person and his social milieu; on the contrary, the spiritual connotation is strengthened when it is made clear how health furthers development by helping to improve life and functioning.4
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Acuña came to PAHO at the time that the world had been lit with the flame of the Health For All policy of the World Health Organization (WHO) and the idea that primary health care would be the key to improving human health. The Americas would formulate their own strategies and plans of action for achieving the goal of Health For All.5,6
My immediate predecessor was Guerra de Macedo, who wore his social conscience on his sleeve proudly and had a remarkable capacity for transmitting the zeal and enthusiasm he felt for improving health and other social conditions in the Americas. He saw health as a noncontentious issue that could unite peoples, and was the moving spirit behind the noble initiative Health As A Bridge For Peace, which facilitated understanding among the contestants in war-riven Central America.
There are few of his speeches that better capture his view of what PAHO should be about than one given at a conference in Rome in 1989, when he said,
But it is the words of Mazzini, his appeal for independence, for peace and for freedom which still echo in the Americas. His call for ‘humanity to be seen as a great army moving relentlessly forward against powerful and wary enemies to pursue the common good’ seems particularly powerful as we begin this conference. For we are concerned here today with the future of humanity, with our capacity to respond to the crises which threaten that future.7
He described with pellucid clarity the environmental, economic, political, and other challenges the region faced, and reflected on the role of PAHO in meeting these challenges through what he called "the management of knowledge." When cholera returned to the Americas in 1991 after an absence of almost a century,8 his bold approach to meeting the epidemic reminded me of the quotation by the famous nineteenth-century Chicago architect Daniel Burnham, who said, "Make no small plans: they have no magic to stir men’s souls."
I assumed the directorship of PAHO in 1995 and could instinctively relate to the philosophy behind the goal of Health For All as being in keeping with my understanding of the principles of Rawlsian justice.9 I proposed that the overarching values that would guide our work would be equity and the ideal of Pan-Americanism, and that they would permeate our work. Over the course of 8 years we have seen the notion of equity come to center stage. There is almost universal acceptance of Whitehead’s concept of inequity as representing unfairness.10 Disparities represent inequity when they are avoidable and unnecessary, when they are nonvolitional, and when, therefore, there must be a responsible agent. PAHO is producing work that inserts this thinking into our technical programs.11–14 But beyond inequities in health outcomes, we have looked even more carefully at disparities in the determinants of health that lead to health inequities.15
When I was elected in 1994, I spoke of my vision of a world in which there was no otherness in health: "[F]or that vision to be realized we will have to use well that most powerful of modern instruments, information—perhaps the only instrument that can close the gap between the world that is and the world that might be, the only instrument that can relieve the ignorance of many of our people, who pay the cost of that ignorance in the coin of ill health and suffering."16
I am particularly proud of our Regional Core Health Data Initiative, which now has 5 components: the Basic Indicators brochure, a Web-based table generator system, an indicators glossary, a collection of country health profiles, and a geographic information system. The highly successful Basic Indicators brochure tabulates 58 basic indicators for the 48 countries and territories in the Americas and also produces analyses by geographical subregion.17 But perhaps the most interesting advance has been in the stimulation of the production of disaggregated data by most countries of the region.18 Averages for countries hide the disparities; it is not enough to reduce the averages—we must reduce the gaps between the various groups of persons.
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Work on the determinants of health disparities, such as sex and ethnicity, has grown. Disaggregation of data by sex is a fairly standard part of health data analysis, but only recently have the ethnic differences in health status that occur in so many of the countries of the Americas been emphasized.19 This emphasis on data collection and analysis does not occur only at the central regional level—an increasing number of countries, with the assistance of PAHO, have established and now use health "situation rooms" in which they track and display trends in health indicators. PAHO has a long tradition of producing scientific–technical information, and its bulletin has an unbroken history of 80 years. In keeping with the broadening of its scope, it is now published as Revista panamericana de salud pública (Pan American Journal of Public Health). Not only has PAHO continued its production of quality health information, but there has been a more systematic attempt at marketing the information produced, resulting not only in the capture of a wider audience, but also in increased sales of our publications.
The regional library in medicine at the Latin American and Caribbean Center on Health Sciences Information in São Paulo, Brazil, has been transformed and reoriented, spurring another significant advance in the production and dissemination of health information. This center has spearheaded the establishment of the Virtual Health Library, which is the ultimate network of scientific–technical information in health in the Americas. This library, which provides access to key public health journals, has the capacity to revolutionize the connectivity that makes health information resources widely and readily available.20 The Virtual Health Library has drawn praise for innovation in the field of making relevant literature widely available in the developing world.21
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PAHO has also continued its technical cooperation in various programmatic areas. We have developed a taxonomy of technical cooperation that clarifies what we do.22 In addition, we have continued to develop and refine a system of planning, programming, and evaluation known as the Regional Office of the Americas (AMRO) Planning and Evaluation System to facilitate better and more relevant monitoring and evaluation of programs. This has allowed us to define the areas that are the responsibility of the PAHO Secretariat and the extent to which the expected results in a particular project have been achieved.
A few areas of PAHO’s technical cooperation particularly demonstrate the approach to cooperation with countries and the virtues of equity and Pan-Americanism. The region of the Americas has been justly proud of its advances in the field of immunization. This region was the first to eliminate both smallpox and poliomyelitis. The success of the latter and the strategies that were adopted have been described extensively elsewhere,23,24 but I would emphasize the critical nature of the intercountry cooperation that is the practical hallmark of the Pan-American ideal. A great part of the success was due to the commitment of the countries, which was manifest in the resources assigned to immunization, in their support of the PAHO Revolving Fund For Vaccines, and in their willingness to coordinate the vital local interagency committees. The Americas launched the more difficult initiative of eliminating measles in 1994, and the results have been more than heartening. In 2001, there were some 30 million cases of measles worldwide and some 800 000 deaths, but only 537 cases in the whole of the Americas.
We have seen advances in environmental health programs, community management of noncommunicable diseases, adolescent health, efforts to reduce maternal mortality, an approach to mental health that stresses noninstitutional care, the provision of essential drugs, and promotion of nutrition and physical activity to halt the silent epidemic of obesity. Violence as a public health issue occupies our attention, and essential strategies of health promotion are being applied to many programs that traditionally were excluded from this focus. The program on women’s health and development is elucidating the many subtle ways in which sex discrimination affects health in the Americas. PAHO has been alive to the political climate and in recent times has been a keen supporter of the Summit of the Americas process, as well as following the mandates of the Ibero-American Summits.
Two other programs—oral health and blood banking—have made advances that are not often appreciated. In the 1980s, PAHO emphasized the formation of the necessary dental public health infrastructure, including the support of dental health in the Ministries of Health. In the 1990s, there was more stress on establishing good surveillance systems and focusing on dental caries in children as the most important dental public health problem in the Americas. Our data showed that the decayed/missing/filled-teeth index for 12-year-old children had an overall regional mean of about 4.4, with extremes of up to 8.0 in some countries—considerably above the WHO goal of 3.0 or less. PAHO embarked on an aggressive program of surveillance, fluoridation (predominantly through salt), and atraumatic restorative treatment. The costeffectiveness of salt fluoridation has been amply demonstrated, and almost every country has enthusiastically embraced the program. The results have been most gratifying. Every country has seen a decrease in dental caries, and the vast majority have now met the WHO goal. With the increasing use of atraumatic restorative treatment, there is the expectation that "healthy smiles for children" will be a reality, not merely a slogan.25,26
PAHO has intensified technical cooperation in the provision of safe blood, which has become even more critical with the advent of the HIV/AIDS epidemic. Current problems include the transfusion of unscreened blood, the low rate of voluntary nonremunerated blood donation, the inappropriate use of blood, and the low rate of blood collection. It is estimated that for a country to have an adequate blood supply, the annual collection of blood units should be equivalent to 5% of the population donating. This occurs in only 1 country in the Americas. PAHO has concentrated on ensuring that 100% of blood units are screened, promoting appropriate numbers of blood banks in countries and appropriate legislation, and stimulating the voluntary nonremunerated donor as the ideal for the region’s blood supply. We have seen improvement in the quality of transfusion medicine, greater participation in the External Evaluation of Performance on Serology for Transfusion-Transmitted Infections, and decreased risk of acquiring infections via transfusion.27,28
In the past 8 years, 2 other major, ambitious objectives have been accomplished. PAHO has joined with the Inter-American Development Bank and the World Bank in a shared agenda for health, in which the 3 institutions have identified critical areas in which there can be mutual benefit from a common approach.29 PAHO has also developed a core of essential public health functions, the investigation of which allows countries to see deficiencies in their systems and the corrective measures necessary. This has filled a gap in our knowledge, and the compiled data give a clear picture of the state of public health in the Americas and the extent to which our societies have organized their resources to address the issues critical to ensuring the health of the public.30
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The most critical factor in these advances has been the unswerving support of all the countries of the Americas for PAHO, and their eagerness to discourse with the PAHO Secretariat and arrive at a feasible, beneficial program of cooperation. The second most important factor is the PAHO staff. My visits to the countries and my discussions with those staff there and at PAHO headquarters have assured me that there is unity around what is conceived as a noble enterprise. A third factor has been the refinement of the systems that have allowed for the fiscal and programmatic transparency that are vital for a public intergovernmental organization.
I believe the future is bright for PAHO. There is increasing recognition of the need for organizations such as ours to deal with the threats to health that are truly transnational, and our history has shown our capacity to adapt to changes in the social environment. The culture of the production and use of information is firmly seeded in PAHO as a necessary and proper requirement for its search for equity in health in the Americas. But above all, as long as PAHO employs the kind of men and women that it has at present, it will continue to prosper and be useful to the countries that support it.
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Acknowledgments |
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Footnotes |
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Accepted for publication September 7, 2002.
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References |
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TOPABSTRACTINTRODUCTIONReferences |
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2. Alliance for Progress. Official documents emanating from the Special Meeting of the Inter-American Economic and Social Council at the Ministerial Level; August 1961; Punta del Este, Uruguay. Organization of American States Official Records. OEA/Ser H/X11.1. Rev 2 (English).
3. Pan American Health Organization. Ten-Year Health Plan for the Americas. Final Report of the III Special Meeting of Ministers of Health of the Americas. Washington, DC: Pan American Health Organization; 1973. Official Document 118.
4. Horwitz A. Health and the declaration of the presidents of America. Boletín de la Oficina Panamericana. V–X:selections from 1966.
5. Pan American Health Organization. Health for All by the Year 2000. Strategies. Washington, DC: Pan American Health Organization; 1980. Official Document 173.
6. Pan American Health Organization. Health for All by the Year 2000. Plan of Action for the Implementation of Regional Strategies. Washington, DC: Pan American Health Organization; 1982. Official Document 179.
7. Guerra de Macedo C. Cooperation in health among Italy, Latin America, and the Caribbean—a step toward solidarity and peace among people. Speech delivered at: Conference on Health, Environment, and Development; May 3, 1989; Rome, Italy.
8. El plan regional de inversión en ambiente y salud para América Latina y el Caribe. Boletín Oficina Sanitaria Panamericana. 1996;120:538–541.
9. Rawls J. A Theory of Justice. Cambridge, Mass: Harvard University Press; 1971.
10. Whitehead M. The concepts and principles of equity and health. Int J Health Serv. 1992;22:429–445.[Medline]
11. Pan American Health Organization. Equity and Health. Views from the Pan American Sanitary Bureau. Washington, DC: Pan American Health Organization; 2001. Occasional Publication 8.
12. Alleyne GAO, Casas JA, Castillo-Salgado C. Equity, equality: why bother? Bull World Health Organ. 2000;78: 76–77.[Medline]
13. Alleyne GAO. Equity and the goal of Health For All. Pan Am J Public Health. 2002;11:297–301.
14. Casas-Zamora JA, Gwatkin DR. The many dimensions of health equity. Pan Am J Public Health. 2002:11;III–IV.
15. Alleyne GAO. Equity and health. Pan Am J Public Health. 2000;7:1–7.
16. Alleyne GAO. Acceptance address delivered at: 24th Pan American Sanitary Conference; September 26–30, 1994; Washington, DC.
17. Pan American Health Organization. Health situation in the Americas. Basic indicators, 2002. Special program for health analysis [brochure]. Washington, DC: Pan American Health Organization; 2002.
18. Castillo-Salgado C. Health situation analysis in the Americas, 1999-2000. Boletín Epidemiológico. 2000;21:1–3.
19. Torres C. Descendientes de africanos en la Región de las Américas y equidad en materia de salud. Revista Panamericana de Salud Pública. 2002; 11:471–479.
20. Packer AL, de Castro E, eds. The Virtual Health Library. São Paulo, Brazil: Latin American and Caribbean Center on Health Sciences Information; 1998.
21. Godlee F, Horton R, Smith R. Global information flow. Lancet. 2000; 356:1129–1130.[Medline]
22. Alleyne GAO. Toward a taxonomy of technical cooperation in health. Bull Pan Am Health Organ.1991;25:356– 366.[Medline]
23. de Quadros CA, Tambini G, DiFabio JL, Brana M, Santos JI. State of immunization in the Americas. Infect Dis Clin North Am.2000;14:241–255.[Medline]
24. de Quadros CA, Andrus JK, Olive JM, Guerra de Macedo C, Henderson DA. Polio eradication from the Western Hemisphere. Annu Rev Public Health. 1992;13:239–252.[Medline]
25. Estupiñán-Day S. The success of salt fluoridation in the region of the Americas. In: Abstracts of the 128th Annual Meeting of the American Public Health Association; November 12–16, 2000; Boston, Mass. Abstract 52080.
26. Pan American Health Organization. Plan of operations: Project PRAT. Washington, DC: Pan American Health Organization, Inter-American Development Bank; 2000.
27. Schmunis G, Zicker F, Del Pozo A, Segura E. Transfusion-transmitted infectious diseases in Argentina, 1995 through 1997. Transfusion. 2000;40:1948–1953.
28. Schmunis G, Zicker F, Cruz JR, Cuchi P. Safety of blood supply for infectious diseases in Latin American countries, 1994–1997. Am J Trop Med Hyg.2001;65:924–930.[Abstract]
29. Pan American Health Organization. PAHO/IDB/World Bank Shared Agenda for Health in the Americas. Presented at: 42nd Directing Council CD42/17; September 25–29, 2000; Washington, DC.
30. Pan American Health Organization. Public Health in the Americas: Conceptual Renewal, Performance Assessment, and Bases for Action. Washington, DC: Pan American Health Organization; 2002. PAHO Scientific and Technical Publication No. 589.
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