Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Special Centennial Edition
Volume 7, Number 1, 2002
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Perspectives in Health Magazine |
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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.
For the past 30 years it has been fashionable to speak of the epidemiologic transition as if epidemiologic stages progressed steadily from one to another. Vivid accounts described the three stages of a transition: the age of pestilence and famine would be followed by the age of the receding pandemics, until finally we would reach the age of chronic diseases such as cancer and cardiovascular diseases. In fact, the health development of our countries shows more of a mosaic pattern. We now have to confront the mosaic of chronic diseases that are increasingly important, while at the same time we must cope with new and emerging infections. It has been a salutary lesson for us that microbes will never go away, and we have to learn to inhabit the earth with them.
We can expect that new discoveries in science will shed more light on the relation of life in utero to the future development of a wide range of diseases, thus introducing the possibility of genuine early intervention and prevention. But we must never lose sight of the possibility that new diseases or new forms of old diseases may come to haunt us.
I can see the improvement of the environmental conditions that impact on health. The past decade has brought an improvement in the availability of potable water to the population. I am cheered by the recent efforts at collaboration between ministers of health and ministers of the environment that are focused specifically on joint approaches to improving human health.
I can see the health sectors of our countries accepting the need for their efforts in health sector reform to result in a more equitable distribution of health goods, and the state accepting the responsibility for the discharge of essential public health functions. We will see a wider acceptance of the thesis that health is an important contributor to human development, and national as well as international development agencies will direct their attention even more to the health of the people and ways to improve it. Those of us who see gender inequality as a societal issue will take heart from the wider acceptance of the belief that gender diversity is essential for health development, and women will assume roles in health beyond their traditional ones.
Having surveyed the surroundings and taken a new guard, we can now ask, What are the characteristics of PAHO that will make for its continued existence and increase the possibility that it will score another century in fine style?
First, its hemispheric character is a strength. We are more fortunate than other regions in that we have a geographically defined limit, and the notion of pursuing a Pan American ideal has a long history. The importance of the hemispheric approach and the concept of health as a hemispheric venture has been emphasized repeatedly in various presidential summits that have also validated the usefulness of the inter-American institutions.
The focus of PAHO on information and the use of information as a tool of technical cooperation has been one of our Organization's strengths from its inception and will continue to be such. The growth in the importance of information as power, coupled with the ever expanding availability of technology, will further strengthen our capacity to assist countries in knowing what problems the people face and what measures must be taken to address those problems. Our use of information and the accompanying technologies will not merely be passive, but will also contribute to changes in the behaviors that account for so much of the morbidity and mortality from the diseases that appear within the epidemiologic mosaic.
Another strength must be the nature and caliber of human resources. Over the years we have seen a greater disciplinary diversity as the nature of the health problems we face has changed. We have a greater appreciation of what is meant by our technical cooperation and of the means by which such cooperation is played out not only between ourselves and our countries but also between our countries. The deployment of these human resources such that the Organization has a physical presence in the countries must be another one of our strengths. The countries see the face of PAHO and feel its presence beyond the cold documents that are the inevitable product of any bureaucracy.
Our presence in the countries enhances the capacity to respond to situations of disaster and emergency. Disasters are a normal part of our landscape, and our ability to see them as the result of lack of preparedness for the occurrence of natural hazards has been and must continue to be one of our strengths. Our focus on the continuum from preparedness through prevention, mitigation, succor and subsequent development has been and must continue to be one of our strengths into the next century. Natural hazards are by definition largely unpredictable, but we can limit the extent to which they become disasters.
Part of the landscape that will influence the guard we take will be the increasing number of actors who will be involved in health. It will be part of our strength to discern the nature of the partnerships that will be optimally productive and be complementary to our own actions. This will demand a flexibility and openness that can only come from a self-confidence born of having already scored a century and seen the value of partnerships in specific fields.
But in the final analysis, I believe that our ability to take a new guard and score another century will depend, more than anything else, on the power of the principles we espouse. In recent years I have promoted as vigorously as I could the concepts of equity and the pursuit of the Pan American ideal. The idea that we can help identify the inequalities in health that exist, and at the same time help to identify the inequality in the distribution of the determinants of that health, is a noble one. It is one that is worthy of an orga-nization that has been at the service of the Americas for 100 years. Abundant evidence shows that the countries of the Americas can perform great feats in health when they work together.
Undoubted benefits accrue to all countries from such joint efforts, but in addition I wish to see greater Pan American collaboration in support of countries in the Region that are less well endowed and have poorer health. My hope is that future generations of Americans will be seized, as we are, by the importance of the past century, and be as convinced of the nature of the challenges and the possibilities of PAHO addressing them based on some of the strengths I have outlined. If my hope is realized, then the prospects for at least another century of service are good.
