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OPS Directora Public health is a powerful tool to build a safer and durable world for all.
"That is why I have devoted my entire career to public health; that is why pursuing a career in global health is so rich in personal fulfillment in spite of the occasional disappointments and all the limitations to be found; that is why more attention should be given to it both in policy and in politics." [ Director's Speech at Georgetown University, WDC. ]

*Dr. Mirta Roses, Director, Pan American Health Organization

 Georgetown University.
Washington, D.C.
 7 April 2010.

First of all, allow me to express my gratitude to Women in Politics for this opportunity to have an exchange with all of you in such a highly respected University as Georgetown is. This is a very commendable undertaking showing how seriously you take, as students, the opportunities you are having. 

To reciprocate your nicety, I will try to adhere to the piece of advice of a sage Spanish writer, Baltasar Gracian, that no doubt you will appreciate very much: “Good and short, twice the good”, he used to say. I cannot guarantee this will be good, but at least I will try to keep it short!

There is no shorter summary than this: Public health is a powerful tool to build a safer and durable world for all.
That says it all: that is why I have devoted my entire career to public health; that is why pursuing a career in global health is so rich in personal fulfillment in spite of the occasional disappointments and all the limitations to be found; that is why more attention should be given to it both in policy and in politics.

For me it all started in a way that must be familiar to many of you: by volunteering. I was a Red Cross volunteer in elementary school; we had a nice little nurse white dress with cap, apron, and all that.  In high school I was most into group - and team - organizer and leader. In medical school I volunteered as a house-to-house vaccinator and also in the polio rehab ward. My residence was in infectious diseases and postgraduate training in tropical medicine, then came public health and finally a specialization in epidemiology. In between I was an assistant researcher in the team that developed the Argentinean hemorrhagic fever vaccine

A second crucial element came from the cross-pollination entailed by the opportunity of learning from different cultures and ways of pursuing common objectives:

  • Started at PAHO working in the English-speaking Caribbean with CAREC;
  • Then represented it in the Spanish-speaking Caribbean, in Dominican Republic;
  • Later in the Andean Bolivia;
  • I moved to Washington in 1995 as Assistant Director for PAHO, and there I had the opportunity to work closely with representatives from 34 Member States, including some from outside the Hemisphere, such as France, England and The Netherlands; but also to build strong working ties with colleagues from other continents and with the WHO headquarters in Geneva.
  • As PAHO Director since 2003, I have kept learning from all those people but also from my peers at other UN Agencies working in different but interconnected fields, and from worldwide donors and partners in many endeavors.

A third, vital, element has been the fact that international public health is in essence a “network of networks” that puts together the isolated actions of millions of individuals to create a common good, a protective net that covers each and everyone – think about the protection you create not only for yourself but also for others by the mere act of getting a vaccine. No one – no individual, country or organization - is too big or too small to not contribute to, or affect the, well-being of others.

All these experiences, plus the sound ethics and moral principles learned from teachers and elders, have been essential for helping me in my career, especially by providing me with competencies that are pivotal for managing an international public health organization like PAHO, such as:

  • The analytical methods,
  • The value of sound information for decision making,
  • The awareness about the interaction of host/agent/environment and the multi-causality of diseases,
  • The need to be a good listener and observer before jumping to conclusions,
  • To keep always open to innovation,
  • And the patience to define a good strategy to address problems based on trends and best practices that produce successful results.

International public health 

Those experiences have also molded the advice I could give to those interested in pursuing a career in international public health:

  • Be sure you feel a deep commitment with the well-being of others, not just to your own professional and personal interests,
  • Look for as much intercultural experiences as possible, hands-on and real sharing
  • Learn to extract lessons from others’ experiences and approaches,
  • Interdisciplinary and interprogrammatic approaches will take you places, both professionally and personally,
  • Strengthen your advocacy skills –you will need them,

Always remember the values of equity, inclusiveness and solidarity, and the commitment to the needed that are now fueling you – they are vital to succeed in public health endeavors.
Now, do not be afraid to push the envelope a little bit, and be ready to break some ceiling glasses you will find. I had the chance to break a particular ceiling glass, that of gender, and become the first woman to ever lead PAHO in its 100 years history. To be able to advance the cause of public health you will also need to break some other barriers. Otherwise, things will keep being the same and that is not why you got into public health to begin with.

Major challenges in global health in the Americas

When examining the current state of global health, with a special emphasis on the Americas, I would say there are four major challenges.

*  Changes in health profiles and cumulative lags in health.
Health profiles have changed as a result of demographic, epidemiologic, and technological changes that have both required and allowed for new benefits and treatments over increasingly longer human lifetimes, thereby increasing the cost of health services and healthcare expenditures.

Cumulative lags in health reveal historical deficiencies and as well as the accrued social debt in terms of access to timely and quality healthcare services and essential conditions of hygienic and decent living.

Because it has extremely inequitable income distribution and a high level of exclusion, the LAC region experiences an “epidemiology gap”: non-communicable diseases are sharply rising, while communicable diseases and maternal and child ailments have yet to be satisfactorily resolved and are disproportionately affecting the poor. But other regions around the globe are also experiencing this challenge.

*  Inequity in, or lack of, access to health services.
This deficiency aggravates the burden that exists from geographic, ethnic, and gender-based inequities that are hidden behind regional and national averages and aggregate figures.

Insufficient and inadequate distribution of public spending on health.

Most countries do not reach the level of public spending on health needed to achieve universal access to health care services (5-6% of GDP).

This problem is aggravated by the absence of mechanisms to ensure that public spending on health benefits the most disadvantaged groups in society.

As a result, families endure extremely high out-of-pocket spending on health. Since this expenditure represents a higher proportion of the total income of poor families, health spending—mostly for medications—ends up being an important cause of the impoverishment of families when chronic or life-threatening diseases quickly turn into catastrophic situations.

And even those countries which spend enough of their GDP on health, have problems ensuring that their spending is adequately distributed and return the highest level of health for every dollar spent.
*  Health threats that arise in the context of globalization or from climate change.
The influenza virus AH1N1 has been the latest example of a new and rapidly spreading disease that is linked to globalization.

But we have already witnessed SARS and avian flu and HIV/AIDS and multi-resistant TB.

More frequent and more devastating natural phenomena related to climate change, have also been experiences over the last few years. 

On the other hand, there has never been a commitment of all leaders at the highest level to fight against inequity and poverty as eloquent as the Millennium Declaration with its Development Goals. We have still 5 years to go up to 2015 and the UN Conference this September will make us all accountable for the situation after the first decade.

It is clear that the financial crisis has hindered the advances we were having in this regard. It has been estimated it will throw about 100 million people worldwide into poverty, reversing hard-fought gains. But the crisis could also provide an opportunity to re-think and redesign the way we do things, as to ensure that we develop more inclusive and equitable societies. A good example of this can be found very close to home: the health reform process in the U.S.

To fight inequity we need to expose them. It is normally hidden in plain sight, behind “average” numbers and national aggregates that tend to veil the big disparities suffered by many in our societies. Lack of data and data quality to produce necessary evidence at local levels regarding financial and geographic barriers to access for disadvantaged groups, intercultural competencies of health workers and institutional practices, health needs of the population, disparities in public health care spending among the rich and the poor, among others, continue to be a problem for many countries, usually the poorest ones. While national health indicators such as maternal and infant mortality can give us some idea, disaggregated data that can discriminate the real situation within the country and lead to actionable information, are still lacking.

We need to bring those inequities out and advocate for the adoption of measures to correct them, in order to achieve health for all. This is the purpose of the primary health care approach that we have been promoting at PAHO.

The PHC approach would allow us to have in place well-functioning health systems that are:

  • Able to protect the population under any circumstances;
  • Resistant and resilient in the face of crises;
  • Capable of reacting rapidly and developing urgent strategies;
  • Skilled at rebuilding themselves as necessary to respond to current and future challenges arising from demographic and epidemiological changes.

Only such health systems will lead us to achieve health gains that are sustainable and have reasonable costs, while ensuring equitable access to health care. Because of that, the PHC approach is a crucial instrument to help all countries achieve the goal of providing Health for All, no matter their economic development stage.

Having said that, we must be aware that there is no single way to apply the PHC approach and all what it implies. Each country historical, political, epidemiological and socioeconomic factors could and should influence its specific policy mix, as long as it responds to the values and core principles that inform the PCH strategy.

A very encouraging development in the fight for equity in health has been the incorporation of new actors to our network of networks. The role of philanthropic and advocacy efforts like those of the Gates Foundation and the Clinton Initiative, the impact of alliances like GAVI or the Partnership for Maternal, Newborn and Child Health to cite just two, and the increased prominence of public health issues for the public and on the political agendas worldwide, have been very significant factors to increase the scope of what is achievable today in terms of public health.

Any professional battleground is good to fight for Health for All if we truly care for people. I have had opportunities. You are having opportunities. We must strive to ensure that other people, in particular the poorest and neediest, also get opportunities to improve their lives.

So, come and join the good fight, the quest for Health for All.
You will be effectively helping to build a better, safer, happier world.

For more information, contact Diaz, Katia (WDC), Pan American Health Organization, Office of the Director (WDC) 



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