Dr. Jarbas Barbosa

Jarbas Barbosa da Silva, Jr., was named PAHO area manager for Health Surveillance and Disease Management in 2007. A Brazilian national, Barbosa received his medical degree from the Federal University of Pernambuco and studied public health and epidemiology at the Oswaldo Cruz Foundation (FIOCRUZ). He holds a master's degree in medical sciences and a doctorate in public health from the State University of Campinas in São Paulo state. His 25-year career in Brazil's public health sector includes posts at the municipal, state, and federal levels. He has served as coordinator of Pernambuco's HIV/AIDS program, secretary of health of the municipality of Olinda, secretary of health of the state of Pernambuco, director of the National Center for Epidemiology, secretary of public health surveillance at the federal level, and executive secretary of the Ministry of Health of Brazil.
 

How did you become involved in public health?
My grandfather was a doctor. He worked in the Ministry of Health in the 1940s as a pneumologist, working in tuberculosis control. He died young, but my father was also a doctor, a clinician. In medical school, I started out interested in psychiatry, but then I switched to surgery, and during my last two years, I was interested in pediatrics. That was before I took my first course in public health and realized that was what I wanted to do. At the National School of Public Health, FIOCRUZ, I was fascinated by epidemiological techniques, outbreak investigation, and the collective treatment of health problems. My first job was in the epidemiology unit at the Health Secretariat of Pernambuco, but two or three months later, I was asked to coordinate and basically create a program on AIDS and sexually transmitted diseases. Later I was a district chief of epidemiology in São Paulo for a short period. In 1993, I was named secretary of health of Olinda, a municipality of about 400,000 people, and later I was secretary of health of the state of Pernambuco. Then in 1997, I was invited to head the National Center for Epidemiology, where I was asked to stay under four consecutive ministers of health.

What has it been like joining PAHO at this time?
It's been very interesting, because since I arrived, we've been working on the Health Agenda for the Americas and the Strategic Plan. They've given me a very clear vision of all of PAHO's objectives, our areas of work, and the commitments we need to fulfill. I think [PAHO Director] Dr. Roses is very clear about how she sees the organization and its priorities. She's very direct in her ideas and observations, and that also helps. Change is good, and even though as humans, we might feel anxious about it, we have to be open to it. I think this is a good time to think about whether what we are doing is what we should be doing. And I hope I can contribute with my experience in a country that has so much diversity, so many projects, and so many problems, but which has also built something worth emulating.

What lessons can be learned from Brazil's experience?
Brazil underwent a very interesting political process, in which democratization included the participation of society in health. Every four years we have a national health conference. In 2003, the director-general of WHO at the time, Jong-wook Lee, was there and was impressed to see 5,000 people in the audience. Before the national conference, there are conferences in municipalities and states. This provides a very important political base for the health sector.And in Congress, there is a health caucus that is very active in supporting health. It has members coming all the way from the far left to the right.Also, academia was a major force in the formulation of Brazil's new health system and is very involved in the health services today.

How has Brazil's health system evolved?
The health sector today is far better off than it was. If you look at the Ministry of Health in the early 1990s, it was very fragile. There's been a big change because the budget has grown and because decentralization has created a stronger structure. The health departments at the municipal level, which had no role in the 1970s, are now the main actors. The mayors hold the purse strings, and that public dimension is very important. So is community participation, from associations, trade unions, and so forth. And as I said, you have close involvement of academia, which underwent a renewal and became technically very strong. Now, just in epidemiology, we have more than 30 doctoral programs. Brazil's Congress of Public Health draws some 9,000 to 10,000 people, including not just graduate students but technical teams from the municipal and state levels. So academia in Brazil has very high technical standards but also is very involved in maintaining the quality of health services.

What are the challenges facing Brazil's health system?
There's still more to do.We still need more resources. For all the budgetary growth there's been, Brazil still spends less as a percentage of GDP than you need to finance a universal system like Canada's or the U.K.'s. A system that covers everything from vaccines to heart transplants to chemotherapy needs more financing as it grows. But I think there is an understanding and a consensus in Brazil that we need a universal system, that it needs to be taken to that level. Every attempt so far in the other direction has been rejected by society. Brazilians today are proud, for example, of our vaccination program, which has been very successful, and our AIDS program. Our transplant program is the second-largest in the world, and 98 percent of transplants are financed by the health system—private insurers don't pay for heart or liver transplants. But even in England and Canada, people have to wait for nonemergency surgery. Another problem is that our cities have grown so fast, it's very hard for the health infrastructure to keep up. And decentralization creates certain problems, because the Ministry of Health has its projects, and the states have their projects, and the municipalities have projects, and it's only possible to function well if the three levels work together.

What would you like to see happen in the region in the next five years?
I think in five years, we need to have all the countries in the region complying with the International Health Regulations. We need all the countries to be able to rapidly detect and contain any major health threat. This is a big challenge both for the region and for the world. We also need to be close to fulfilling the unfinished agenda in the area of communicable diseases, such as malaria and tuberculosis, and diseases of poor and neglected people, like leprosy. Noncommunicable diseases is another major challenge because of the high burden of mortality and morbidity. People still think noncommunicable diseases are a natural part of aging, but that's not true; there is a major excess of premature deaths. This requires better health services, more health promotion to address the determinants, and better surveillance on the risk factors.

What do you see as PAHO's strengths?
I think PAHO's traditional role of providing leadership with technical quality is a very important one. PAHO is not alone, but it's different from other organizations because of its tradition and the high technical quality of its staff. It's a decentralized agency with a presence in almost all the countries. And I think it's important what PAHO has done in recent years in terms of trying to meet new challenges, providing for countries' needs for technical cooperation but also fulfilling the mandates of the Directing Council. Today it's not enough to keep doing what one did well in the past 40 or 50 years. We have to keep doing that well, but we also have to meet new challenges so that the countries will continue to see PAHO as their principal reference for health in the Americas.