Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Special Centennial Edition
Volume 7, Number 2, 2002

As it celebrates its 100th anniversary, the Pan American Health Organization can take a lesson from the game of cricket. Now is the time to take stock of the surroundings, reassess one's strengths and focus even more closely on the work at hand.

Many images and ideas are associated with the concept of a century. The most widely known and accepted is that a century refers to a period of 100 years, and here at the Pan American Health Organization (PAHO) at this time, the association is with the 100 years of our existence. We celebrate the 100 years of health in the Americas, and we celebrate the progress the countries of the Americas have made with PAHO's support.

But to many of us who grew up in the English-speaking Caribbean, steeped almost from birth in the intricacies of the arcane but beautiful game of cricket, a century also refers to 100 runs and it is a goal to which every batsman in every class of cricket aspires. It means that he has withstood the onslaught and wiles of the bowlers from the opposing team and has registered 100 runs. It is a time for celebration with one's teammates, and in the gentlemanly spirit in which the game is played, it implies being congratulated by the opposing team as well.

But the really great batsmen--those who are revered in circles where the game is really understood, those whose names and feats are the lore of national pride--are never content with scoring a single century. The really great batsmen are not satisfied with the applause and the congratulations. They settle down, take a new guard and try to score another 100 runs. They go for another century. When they take a new guard, they assess the surroundings, look at their position at the wicket, assess their strengths anew and try to focus their concentration even more closely on the business at hand.

So it is with PAHO. Having scored a century, we must accept with modesty the plaudits of all those who wish us well and now dedicate ourselves with the maximum concentration possible to the business of the next 100 years. It is reasonable to savor the moment, and it is appropriate for us to assess the strengths that allowed us to reach this stage and ponder whether the auguries are good for another 100 years. But we also must focus clearly on the work we are here to do.

PAHO is a creature of the health situation of the Americas. We did not spring full-blown from the head of some mythical Zeus. We started slowly and grew slowly, adapting as we went along to the health needs of the countries of the Americas. Or more correctly, we adapted to those health needs that required our technical cooperation. It is quite clear that no one can predict the future health situations that will call for our support, but we can try to divine in general terms some of the difficulties that may be faced and reflect on how we will have to adjust our style and strokes. We could suggest the unlikely appearance of an Armageddon-like situation in which famine and pestilence follow the collapse of the public health systems of the countries.

We could predict scenarios close to the real-life situations depicted by Laurie Garrett in her book Betrayal of Trust, which tells of governments betraying the trust of the people and not maintaining public health systems. No early warning systems would alert us to epidemics that might cause havoc with all aspects of people's lives. We could suggest that the dire predictions about the shortage of potable water might become fact, and countries would fight not for territory but for the water that would become a commodity more scarce than gold. We could think that extreme global warming would become a reality, with attendant increases in cancers and the invasion of ecological niches by agents and vectors that were alien to those places, with the consequent appearance of yet unknown diseases. Conflicts of varying types would dominate the international scene, leading to armies of displaced persons invading other lands and places. Poverty would deepen across the Americas and be the cause of a deterioration of the social fabric, with malnutrition becoming rife. The sum of all this would be a rapid and profound retrogression in all the health indicators.

But I do not see any possibility that this apocalyptic situation will ever occur. Even in the grimmest days of the economic crisis of the decade of the eighties, there was nothing even remotely approaching such a desolate state. It is far more likely that the trends we have observed in the recent past can be used as portents of a much rosier health future that will affect our technical cooperation with the countries.

The first trend that we must note is the demographic transition, which is very marked in the Americas. Mortality rates will continue to fall, partly as a result of improved economic conditions, but perhaps more important, as a result of the growth and spread of technology. We have seen how technologies for improving child health, such as immunization and the use of oral rehydration materials, have decreased child mortality. Newer vaccines will become available, and the combining of technologies into schemes such as the Integrated Management of Childhood Illness (IMCI) will become a standard part of the public health agenda. The fall in fertility that follows the decrease in mortality is a constant phenomenon. The rationale for the sequence is unclear, but the phenomenon has been universally observed. With this fall in fertility will come a decrease in the rate of population growth. In addition, we can predict that as infant and child health conditions improve, an increase in life expectancy will occur, and we can look forward to an increasing graying of the population. There are now about 100 million persons in the Americas over the age of 60; in 50 years we expect that figure to be 300 million, with the increase most marked in Latin America and the Caribbean.

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