Speeches from the Director

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Annual Report of the Director, 1998
The Director's Message

Information for Health

The Pan American Sanitary Bureau shall be the central coordinating sanitary agency of the various member republics of the Pan American Union, and the general collection and distribution center of sanitary informaion to and from said republics.

­Article 55,
Pan American Sanitary Code

This basic mandate has been a source of continuous discussion ever since the Code was signed in 1924. Questions often have revolved around what constitutes necessary sanitary information and what are the proper ways to collect and distribute it.

In the 75 years since the Code was signed, the ways information is treated and viewed have drastically changed. Although information has always been one of the fundamental bases for the organization of societies and the maintenance and distribution of power, it is only recently that it has come to be regarded as a basic resource for economic growth­almost as another form of capital. Unfortunately, we have yet to appreciate fully the fundamental difference between this form of capital and more traditional ones. Unlike human and physical capital, information is almost infinitely expandable, and it does not depreciate in the same way. Moreover, our concept of the value and use of information has been confounded in recent times by the availability of technology that makes for the facile accumulation and communication of information. This new age is driven by the vertiginous development of technology that links computers and communications, and the ever falling cost of transmitting data.

I continue to claim that it is not merely an epistemological quirk to distinguish among data, information, and knowledge, and hold that this distinction has implications for our Organization. The sanitary information that we transmit represents data collected from primary sources that is subsequently organized in such a way as to have added value. Eugene Garfield, the doyen of health information scientists, puts it very clearly: "The former [i.e., data] has no 'shape' that is relevant to a particular viewpoint. It must be given relevance, arrangement, coherence, usefulness within a definite framework of meaning intent or interest. Then data or facts become information, they do inform the mind, or going back to the basics concepts, cast light upon a subject." The dedicated staff of PAHO are indeed knowledge-workers, because their basic tool is knowledge that is derived from the internalization and contextual processing of information that can be carried out by­and so far only by­individuals.

I still hold to my original view of the Secretariat's major responsibilities in managing information. We need to produce information about the health status of the population and about the systems that the countries adopt to protect that status. Of no less importance is our responsibility to produce and disseminate scientific-technical information about health. We also owe it to our various interested publics to share with them information about the workings of the Bureau and the extent to which our efforts help to reduce the burden of ill health in our Region. And, of course, we need information for our corporate functions.

Over the years I have written and spoken often about the critical importance of information for PAHO and have used various metaphorical allusions to emphasize its value for everything we do. Most recently, in my quadrennial report, I described information as "the loom upon which we weave the Pan American shawl that embraces all our countries and facilitates the description and reduction of inequities in health that must be our constant concern.".

Our main task is to so structure our operations so that the sanitary information with which we work does cast light upon the health situation of the Americas. In conceptualizing and refining what the Bureau would do, it has been difficult for me to avoid becoming enmeshed in the endless discussion about the possibility of perfecting health information systems in the countries. How could one avoid paying an inordinate amount of attention to the collection of data that mainly deal with the systems' inputs, and often has little connection to health outcomes? How could one avoid becoming enmeshed in the minutiae of infinitely sophisticated diagnostic systems of personal medical care that offered a level of precision at a cost that was often prohibitive for many of our countries? Would our efforts be better expended if we made a distinction between the various and many systems needed for the health services and the technology that should be developed to support such systems? I have often been amused and sometimes comforted by what is known as Finagle's Law of Information: "the information you have is not the information you want; the information you want is not what you need, and the information you need is not the information you can get."

Over the past year I have made minor modifications to the Secretariat's structure in order to sharpen our work in the area of information. In this report we give prominence to some recent approaches in the use of the sanitary information for casting light upon one of the important value principles that continues to guide our work­the search for equity! As has been pointed out on numerous occasions, the search for equity must begin with a demonstration of the inequalities that exist, and this can only be done on the basis of information. While we do not ignore the importance of the ill health of those who are disadvantaged, economically or otherwise, we give some priority to the gaps or differences, and to the possibility of reducing those gaps through already tried and available interventions.

The first section of the report uses the measures of inequality that have been developed in economics, where the distribution of income is routinely measured by derivation of the Gini coefficient. This is a first step to relating these inequalities to other variables beside economic status. We know already that inequality of income distribution is strongly related to health status. It will be of interest to relate the inequalities of health and economic status, and also the inequalities in health to the other determinants of health status. The inequality across various disease categories compared across income and other groups will produce interesting data, as most believe that the inequalities in health and those that can justly be called inequities cut deeply into the fabric of society and cannot have any single simple cause.

This report's technical sections emphasize the use of available data to determine existing gaps. This has to be a first step in defining the nature and scope of our technical cooperation. A critical step within our programming system is the definition of a given project's purpose: in other words, establishing what it is that merits change. It is only through an analysis of the pertinent information that such a situation can be properly identified, and we have begun to make even greater efforts to see that this approach informs all of our programs.

I believe that we must get beyond the standard approach of national averages as the baseline for our comparisons, and have recently made presentations to our Governing Bodies to show the direction of this work. We are increasingly encouraging countries to disaggregate their data at least geographically, and many of the basic data sets of the larger countries now show these geographical differences.

This push of ours to develop and produce ever more disaggregated data is in line with the strong political movement in the Americas towards decentralization. But it also has a philosophical underpinning. The egalitarian posture to which I am inclined makes it necessary to identify the neediest groups, so that special attention can be given to them. National averages hide these groups, and it is critical that there be measures of distribution in addition to the aggregate figures. I have mentioned geographical distribution, but distribution according to sex and ethnicity also will be important. Our technical cooperation must measure its results not only by how much national averages improve, but also by the extent to which the gaps between and within countries are reduced. It would be ingenuous to believe that our efforts could ever remove the differences that make some persons and groups healthier than others, but we are convinced that we can close some of the gaps. Our success, then, would lie in how far we move toward equity, rather than whether we attain it completely. The light that we wish to cast is, therefore, not only upon the situation in our countries and the contributions to policy there, it is also a guide to our own technical cooperation.

I continue to be proud of the quality of the scientific and technical information we produce and publish. Our emphasis is not only on the production of information, but also on innovative mechanisms for disseminating it. This insistence on quality is in no way inimical to the possibility of recovering some of the production costs through a well designed marketing system. During the course of this year the Secretariat continued to widen the number and nature of the public that we consider to be our legitimate audiences, and we have done this because we feel that it is part of a public organization's responsibility to inform the public about what it does.

We do not detail every aspect of our corporate information systems here, but give some idea of their scope and particularly what we consider to be innovative approaches. Although these systems are support systems by nature, they are of value in and of themselves, and they show the focus on efficiency that can never be far from our minds. The report ends with a synopsis of some of the major accomplishments of technical cooperation in each of our countries. These country-by-country summaries are brief because the intention has been to focus on the use of information in technical cooperation, rather than give a detailed account of everything that has transpired. I am pleased to note that more detailed information is appearing in reports published in the individual countries themselves.

This concern for information must be a continuing quest for the Pan American Sanitary Bureau. Much in our basic documents speaks to this, but it is fitting to recall here one of the objects of our Sanitary Code: "The stimulation of the mutual interchange of information which may be of value in improving the public health and combating the diseases of man.

So it was in the beginning. So it should be forever.