International public health: between old and new paradigms
Cristianne Maria Famer RochaI; Rubén Darío Gómez-AriasII; Guillermo J. PadrónIII
IUniversidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
IIFacultad Nacional de Salud Pública, Medellín, Colombia
IIIConsultant, Pan American Health Organization, Washington, D.C., United States of America
In today's changing world, public health has had to adjust to new demands arising out of the intense activity of complex and dynamic cultural, social, and economic processes that transcend borders. The dizzying development of trade, modes of transport, and telecommunications, which has led to the nearly exponential growth of migration, has contributed to this phenomenon. Changes in the health status of populations have revealed that the old ways of thinking are incapable of explaining and dealing with health and have led to the creation of new paradigms. Thus, today it is accepted with little discussion that the public health of a country is not a strictly national issue that can be fully controlled with the domestic measures adopted by local government. The borders between countries have become highly permeable to market phenomena that bring resources and opportunities with them, as well as risks and diseases.
The complexity of the political and social processes experienced by the international community since the last century has generated a wealth of experiences that concretely represent the interaction of the countries on health issues, often inspired by opposing paradigms that reflect, in turn, the different interests of the stakeholders participating in the negotiations. The concepts of "international health," "health cooperation," "global health," "global fund," and "market for health commodities," as well as others, have been integrated into the political agenda as new paradigms.
This process, including its conceptualization and the practices that aim to consolidate it, are still in full development. An example of this can be found in the articles that the Revista Panamericana de Salud Pública/Pan American Journal of Public Health (RPSP/PAJPH) has included in this special issue. The publication of these articles, which describe experiences aimed at promoting greater interaction between countries to improve the health of the population, is intended to encourage discussion on the scope and limitations of international health vis-àvis the current situation of the countries of the Region.
The activities have not always met with the same success or been carried out in the same way, and the causes of their limitations can be linked to their conceptual and ideological foundations. This is the matter considered by Birn in her article Remaking international health: refreshing perspectives from Latin America.
The achievements and the limitations encountered throughout the more than 100 years of work of the Pan American Health Organization (PAHO) represent a repository of lessons learned of incalculable value. Since 1985, at the initiative of a group of prominent thinkers, PAHO began a systematic program for conceptualization and the education of professionals in the field of international health. The history of this experience is the main topic of the article The Pan American Health Organization and international health: a history of training, conceptualization, and collective development. Other relatively more recent initiatives are not yet sufficiently known or have not been fully evaluated. Two of them are described in the article Salud internacional y nuevas formas de asociación: el Diálogo Multipartito y el Foro de Socios [International health and new forms of association: the Multipartite Dialogue and the Partners Forum], which will certainly attract the attention of readers, as it makes it possible to anticipate the potential advantages and limitations of their application in other environments.
At times, the limitations of the efforts agreed on by the countries are directly related to the specific characteristics of their legal and regulatory contexts. This situation is especially important in the border areas, as seen in two articles on this topic published here. The first article, Cooperación técnica en salud entre Colombia y sus países fronterizos [Technical cooperation for health between Colombia and bordering countries], describes the perspective of the actors involved in the technical cooperation of that country with its four neighbors and highlights the need for binational technical groups. The other article, Armonización de la vigilancia sanitaria interfronteriza: una propuesta vinculante en salud internacional [An international health proposal to harmonize cross-border health surveillance], presents an analysis of the mechanisms required for the harmonization of health surveillance along the borders of the Brazil-Colombia-Peru Amazon region.
In the context of today's new paradigms, international aid is considered to be an urgent mechanism for overcoming health inequities, an area in which the international community has placed much of its hopes. In this regard, in the article El terremoto de 2010 en Chile: respuesta del sistema de salud y de la cooperación internacional [The 2010 earthquake in Chile: the response of the health system and international cooperation], this exceptional experience in the wake of the catastrophe is analyzed, and proposals for coping with other disasters are presented-all from the perspective of social determinants. In addition, the article El financiamiento internacional para la cooperación al desarrollo de la salud de América Latina y el Caribe [International financing for cooperation to develop health in Latin America and the Caribbean] analyzes the international aid for health development received by the countries of the Region. The analysis leads to the conclusion that bilateral aid has been characterized by instability, making its behavior hard to predict, showing the limitations of cooperation management based solely on geographical criteria.
Health policy-making based on financial decisions is one of the issues considered in the article Medicamentos de alto costo: análisis y propuestas para los países del Mercosur [Costly drugs: analysis and proposals for the Mercosur countries], which analyzes the way in which the countries in this subregional group access, regulate, and finance expensive medications for their population. This is complemented by the article Agenda regional da saúde no Mercosul: arquitetura e temas [Mercosur's regional health agenda: architecture and themes], which identifies the way in which Mercosur structures contribute to the construction of the regional health agenda and analyzes how integration can aid in the fight to reduce inequalities in the Region.
One of the topics directly related to regional integration is the migration of health workers, since it is a growing phenomenon and creates serious problems for operation of health systems in some countries. In the article La migración de médicos en Venezuela [The emigration of physicians in Venezuela], an exploratory analysis of the migration of Venezuelan physicians is presented, based on the perceptions of medical professionals and students.
By making this selection of articles available to readers, the RPSP/PAJPH supports one of PAHO's priority lines of action; that is, to strengthen national and subregional health systems. We hope in this way to have the Journal more closely address the interests of our readers and make a modest contribution to establishing validated concepts in international public health.
We would like to express our appreciation to the authors who put their confidence in us, as well as the coordinators and participants of the Leaders in International Health Program "Edmundo Granda Ugalde", who have made a significant contribution to the preparation of this issue.