GEORGE A.O. ALLEYNE, M.C., DOCTOR EN MEDICINA.(1)
All anniversaries are moments for reflection and repositioning. I am certain that the National Institute of Public Health will be reviewing its achievements over the past 10 years and this review will no doubt be informed by similar activities of the School of Public Health of Mexico as it celebrates its 75th anniversary. It will be fascinating to read how these prestigious institutions have separately or together kept faith with the ideals and ideas that were set out for them when they were founded. The Pan American Health Organization (PAHO) celebrates its 95 years of continuous existence this year as well and it is perhaps even more important for older organizations to undergo self-examination as part of a process of constantly adjusting to shifting realities. I propose to reflect here on some aspects of international health, the challenges that have to be faced and the prize to be won if the challenges are recognized and overcome.
The first issue to be addressed is what really are the major challenges that have to be faced in international public health with special emphasis on the Americas. I use the term international health here as describing those aspects of the publics health that are of concern to the countries as a group and not only the traditional health or disease problems of the public of one nation.
I would propose that the major problems are rooted in inequity and many of the specific categorical health or disease problems stem from this.1 Governments have not been able to fulfill entirely their responsibility in the sense that the World Health Organization (WHO) Constitution requires them to ensure the health of their people by the provision of adequate health and social measures.2 This is almost a restatement of the American Declaration on the Rights and Duties of Man that speaks to individuals having the right to the protection of their health through the provision of "sanitary and social measures". The great challenge of public health of our time is to provide those measures and do so in such a way that there is equity such that the distribution is not unequal in an unfair and unjust way.
The traditional approach is to see this inequity only in terms of health services, but the real challenge is to work for equity in all the sanitary and social measures. If this is put so that the determinants of health are coterminous with these measures, then we must consider the challenge of how to seek equity as regards those physical and social ecological factors that impact on health.3 In addition, within the services themselves, equity must apply not only to the provision of personal care curative services, but also to the preventive and promotive services that are necessary for the protection and preservation of health. I pose this issue of equity as relating to countries as a group and it also has consonance with the Constitution of WHO that says that «the achievement of any state in the promotion and protection of health is of value to all".2 Equity must be sought both within and among countries.
It is possible to take a different approach and describe problems or classes of problems that derive from the important trends and movements of our time.4 Thus, globalization, the major revolutions in communication and the mass movements of people all do affect health. But at the root of some or most of these, or as a mechanism through which ill health results, we may find inequity as a major factor conditioning that ill health. The mass migration of people and much of the basis of the ethnic conflicts that cause them are based on actual or perceived inequity. The deleterious changes in environmental conditions will certainly affect health, but we can be almost sure that the poor will suffer much more.
There are obviously several aspects of health that form the basis for opining on equity, but I would single out here the one related to gender. The health problems of women related to their biology are reasonably well understood and have for many years been a crucial part of programs in public health.5 What is less well appreciated is that those problems of womens health that derive from gender based discrimination are not well documented and only recently are coming to the fore as problems of public health. The issue of violence against women stands out here as a clear example of a problem of immense magnitude.
I will depart somewhat from the analysis of international health organizations that is currently fashionable. In discussions of this nature, international is often attached exclusively to either health or organizations. For this analysis I will deal both with organizations that are concerned with international health as well as those that are international and have health as their major field of activity. Both sets of organizations derive their legitimacy from the nature of their purpose and mission and both should be considered when the health of the regions public is being discussed.
The organizations involved in international health are not homogeneous and I will refer to only two groups of them. There are organizations that are essentially domestic but seek to call attention to the international nature of dominant health issues. Examples of such institutions in the Americas with which I am familiar are the National Council for International Health of the USA (NCIH) and the Canadian Society for International Health (CSIH). The critical challenge for these organizations is the mobilization of national interest in the global or international as opposed to the purely domestic aspects of health. The stated mission of NCIH for example, is "to improve global health by providing vigorous leadership and advocacy to increase private and public sector commitment to international health issues." These organizations seek to identify potential national change agents so as to influence domestic policy. They try to overcome the increasingly worrying tendency of their countries towards inward-looking policies and at a basic level try to exert influence not only on policy but also on funding for international public health. Essentially, the central aspect of their ethos is the appreciation that health problems are indeed becoming inter or transnational and extranational health problems can most definitely exert major impact on national interests. The argument is most commonly put by emphasizing such issues as the international spread of the communicable diseases. However, it can be and has been argued that these and other health concerns that are international can even affect national or domestic security.6
These two organizations with which I am familiar exercise their mission in part by promoting international intercourse, and as a policy, setting out for close examination by multinational of groups participants issues that can be shown to be of direct local relevance. Such issues have included womens health, violence, population, health reform and the environment.
One other subset of this group of organizations are the academic institutions and professional organizations that develop programs in "international health".7,8 In general these programs can most appropriately be called extranational since they are often focused on extranational projects and services that provide models to be examined and problems to be investigated. The challenge to these organizations lies in the nature of the exercises themselves. It is essentially how to attract and maintain interest in problems that often seem distant. The prize for most of these institutions and associations lies in the development of new knowledge that has a value in and of itself as well as success in seeding in those who participate a new appreciation of the reality of health in other settings.
It is interesting to note how these entities involved in international public health have been virtually ignored in the debate on how international or global public health problems might be addressed. As far as I am aware, little systematic attention has been given to the possibility of having this kind of institution become international or multinational in the sense of being replicated in several countries of the world.
The second group of organizations are those that derive their legitimacy not only from the nature of their mission but from a constitutional basis that is genuinely international. The premier organization of this type is of course the World Health Organization, and given the plethora of critiques of its functions and structure,9-11 it is redundant to describe here in any detail the challenges it faces and the possible prize that awaits it. In my view the basic challenge is to make its constitutional mandate effective. In much of the debate that swirls around this Organization, sight is sometimes lost of the nobility of the principles on which it was founded and the degree of success it has had so far in making those principles live. I will deliberately not comment further on the many and varied proposals that are addressed to the reform of this Organization, some based on the premise that reform in a major institution is an ictal episode with a sharply defined beginning and end. There are of course other organizations that have a global focus and can be called international such as UNICEF, UNFPA, but they will not be discussed here.
Instead, I will devote the rest of this article to the PAHO and the problems of international public health that must be faced by the countries of the Americas. The dominant challenge to PAHO is similarly to respond to its constitutional purpose and maintain its compass fixed on the charge with which it has been legally entrusted. The constitutional purpose of the Organization speaks to its responsibility to "promote and coordinate efforts of the countries of the Western Hemisphere to combat disease, lengthen life and promote the physical and mental health of the people".12
Over its 95 years of existence there have been major changes in the Americas to which the Organization has had to adapt and it is perhaps this capacity to see the new circumstances and change to meet them that have ensured its continuity and relevance. The overall principles may be timeless but the form of work to fulfill these principles has obviously had to change. It is therefore relevant to examine the current environment that determines to a large extent how PAHO can and will meet the challenges that determine whether it can fulfill its pristine purposes and assist the countries of the Americas in reducing inequity in health. I will use one taxonomy that I have employed previously although there have been significant changes in the interim.13 It is not too simplistic to describe our major current challenges as the 4 Ps and say that they relate to developments with regard to politics, poverty, pollution and population.
The political environment must not be seen only in the context of the web of connections between actors who wield political power in the conventional sense. The nature of the political governance of PAHO and its origins are also of relevance to PAHOs ability to meet the challenges.
The current political climate in the Americas is marked by the firm establishment of participatory democracy as the preferred form of government. There may be variations in the extent to which all sectors participate equally, but the evidence is clear that the countries are willing to use more than words to ensure that their democratic regimes remain. The formation of blocs that are principally economic also has political implications. Some of the groupings such as those of the CARICOM countries and Central America have political and foreign policy coordination as major parts of their policies. The frequency of the summit meetings of heads of state is a relatively new phenomenon that can have implications for the possibility of achieving a Region wide higher level political imprimatur for health action. The Presidential Summit held in Miami in 1994 dealt with the issue of health sector reform for example and assigned specific responsibility to PAHO.
But perhaps the major political trend to be noted is the redefinition of the role of the state14-16 and the extent to which elected governments are the sole custodians of the responsibility of that state. There is no doubt about the tendency towards a state that is less widely flung in terms of functions, and towards one that has predominantly a regulatory role and one of guaranteeing the balance between individual and societal goals. It is becoming clearer that the most potent unit of societal organization may not be the nation as a whole, but more local entities that are closer and more responsive to local needs.
One challenge for PAHO is to find the appropriate point or points of entry into the political system and thinking. If the Organization is to be optimally effective in advocating for the appropriate ways to meet the overall challenges of health internationally, it must be able to gain access to and mobilize the appropriate political resources. It has developed a structured approach to decision makers across the political spectrum in order to advocate for public health both nationally and in its international dimension.
The politics of governance at the national level may also impact on PAHO in the not too distant future. To the extent that the other actors of civil society are clamoring for and ensuring that their voices are heard when decisions are made nationally, it is highly probable that such actors may also claim a place in organizations like ours that have hitherto been governed by the designated representatives of the elected governments.17,18 This is likely to be one of the most profound transformational changes in how PAHO and similar organizations called international are directed and governed. The non governmental organizations and the private sector are those groupings that are most likely to make their case for inclusion in the decision making of these organizations which will increasingly work with them.
Poverty is no new factor for us in the Americas, but it has taken on new dimensions recently. The decade of the 80s was catastrophic in economic terms for the Americas, and almost every country went through some process of stabilization and economic restructuring that did not leave the health sector unscathed. All the evidence shows that the 90s are seeing a slow but steady economic recovery. Between 1991 and 1994 the GDP expanded at an annual rate of 3.6%; even the shocks of 1995 were withstood and the majority of countries continue to show significant economic growth.19 However, it is abundantly clear that this rate of growth is not enough to eliminate the poverty that existed before and was exacerbated by the economic crises of the 80s. The numbers of the poor are increasing.
The problem is not only the decrease in the quantum of resources, but their distribution is of equal or even greater significance. There is evidence that as a general phenomenon, the gap between the rich and the poor is increasing and the income inequality that is rising20 and is itself inhibiting economic growth.21
There are health effects of both poverty and income inequality.22 The data show that among the poorer countries there is a correlation between national wealth and health, although the linearity of this relationship disappears or is blunted in the richer countries. It is significant however, that when groups of countries are analyzed, there is a clear correlation between income inequality and measures of health such as life expectancy and infant mortality. The greater the degree of income inequality, the worse the health indicators. These relationships that have been observed in developed countries can be equally well demonstrated from our data for Latin America and the Caribbean. Health status is better in economically more egalitarian societies.
The challenges for PAHO in this field are many. It is incumbent on the Organization to produce and refine data on the relationship between poverty and health, not so much to repeat what is known in terms of the poor having poorer health, but to investigate the possibility that investment in health may indeed reduce poverty. Data are appearing on the impact of investment in health on national economic growth.23 It is important to point out here that there is no contradiction between investing in actions to protect and promote health for moral ethical reasons, and doing so for essentially economic purposes. It is claimed however, that the health status of the Region is not commensurate with the resources invested in health and there is a "health gap." The Region should be healthier for the money spent.24
The problems attendant on population issues are pressing ones in the Americas. The population of Latin America and the Caribbean was 460 million in 1992 and is expected to be about 690 million in 2025. The increase in population is due both to the continuous fall in mortality rates coupled with a high fecundity. In the decade of the 80s the average annual population growth was 2.1% and is expected to be around 1.7% at the turn of the century.25 The demographic changes have led to a change in the population structure, with an increase in the adult population. This, and the consequent shift in disease profiles has meant that many of the countries struggle simultaneously with the infectious diseases and those that go along with extended life spans, and the treatment of these latter so called chronic diseases imposes a tremendous burden on the health services and increases their costs. Reforms in the services are needed to increase coverage for reasons of equity, but also to contain costs26,27 and the need for the societal involvement to define the limits of public spending on individual care is recognized.
The demographic projections will produce a change in the dependency ratios. The ratio of persons less than 5 years to those greater than 65 years is decreasing steadily over time. In 1950, with the exception of Uruguay, which had a ratio of 1.07, all the countries of Latin America had ratios of over 2.5. The projections are that all ratios will fall steadily and by the year 2025 only 7 countries will have ratios greater than 1.0. and in Uruguay it will have fallen to 0.53.*
The trend towards urbanization will bring in its train massive concentrations of poverty and more income inequality. The predictions are that this movement which is global is probably irreversible, and will result in major shocks to the established social order and the appearance of social pathologies such as family disintegration, crime and violence.28
A major challenge for PAHO lies in its capacity to assist governments in the reforms of their services to address these problems.26 The three aspects on which we concentrate are the form and organization of the services, their financing and the role of government through the Ministry of Health in directing the process. This regulatory function is often ignored in the discussion on reform, but the kinds of decisions to be made on regulatory norms, the content of the basic package of services and those services that must be provided by the state can only come from a ministry that is conscious and capable of discharging this role. The services to be delivered will be conditioned by the disease patterns as well as by the spatial and age distribution of the population and the problems these engender.
I use pollution to cover all the environmental problems that may affect health. The range of these is impressive and alarming. We are now aware of the actual and potential effects of climate change29 and already there is speculation that the heat waves that are occurring are one manifestation of that change. But the trend towards urbanization that was mentioned above will expose the deficiencies in basic sanitation and provision of adequate water supplies. The appearance of cholera and the recurrent epidemics of dengue are indicative of the environmental deficiencies. We do not know the full extent of the effects of exposure to physical and chemical hazards. Pesticides are widely used and must produce health damage, although the magnitude of the problem has not been adequately documented. Many of these issues and the possible solutions were addressed in the Pan American Conference on Health and Environment in Sustainable Human Development convened in 1995 by PAHO as a follow up to the Miami Presidential Summit of 1994.
PAHO has to organize its technical cooperation to cover an almost impossibly wide range of issues. While advice is given on the broad mega issues, there is greater concentration on environmental health promotion and management of the very real local issues. The risk approach makes for differentiating between the actions to identify the risk and those to provide and test the interventions that may correct it.
But the challenges to be faced by PAHO as an organization relate not only to how to cope with the external environment and assist countries to face the problems that arise from that environment. PAHO has had and continues to grapple with the challenges of adapting its own internal environment.
The structure of the Organization bears examining. One kind of structure relates to the locus of activity and there is a central office as well as offices in almost all of the countries of the Americas. As in every organization so structured, there will be tension between the center and the periphery, but appreciation of the elements of due process from a managerial perspective30 seek to make that tension creative. Without entering into detail, this has involved making the Organization flatter administratively, promoting open communication, transparency of decision making and involvement of the several levels in the development of policy.
Another form of organization relates to division along thematic lines and the Strategic and Programmatic Orientations agreed upon by the Pan American Sanitary Conference form the basis for the Organizations five technical divisions. These are: Health and Human Development, Health Systems Services, Health Promotion and Protection, Environmental Protection and Disease Prevention and Control. There is a Special Program of Vaccines and Immunizations.
Perhaps the biggest internal challenge relates to the Organizations human resources and it calls for some managerial dexterity to effect changes, given the nature of the international personnel system which makes planning difficult. Thus, it has been possible as a matter of policy to incorporate more women into the professional ranks of PAHO and there is gender equality in the recent recruitment. There is a recurrent cry and a need to include more social scientists in health organizations. This is certainly valid, but not because such organizations are dominated by thinking that derives from a biomedical approach to health. This view completely ignores the fact that the days have long past when the reductionist Newtonian approach to health represented the sole or dominant thinking. The essence of public health lies in its systemic approach.
Another major problem in our Organization in this area is in the training of professional staff to cooperate technically with countries. I contend that this represents a skill in itself and must not be confused with the particular disciplinary orientation or capacity of the individual. PAHO has embarked on a program of preparing new professionals adequately for their essential technical cooperation functions which include inter alia a deep appreciation of the content and practice of technical cooperation itself as well as the environment in which it must take place.
Having presented the broad major challenge for international health with emphasis on our Region, the institutions and organizations that concern themselves with international health and sketched out the environment that conditions the challenges to be faced, it remains to outline the essence of the prize to be won.
There is no single glittering prize for an international organization like PAHO. Clearly, the immediate or proximate prize is the recognition by its constituents of its usefulness, and therefore be supported to function efficiently and discharge its pristine purpose and its mission. That mission as currently conceived and crafted by the members of the Bureau states:
The Pan American Sanitary Bureau is the Secretariat of the Pan American Health Organization (PAHO), an international agency specializing in health. Its mission is to cooperate technically with the Member Countries and to stimulate cooperation among them in order that, while maintaining a healthy environment and charting a course to sustainable human development, the people of the Americas may achieve Health for All and by All.
But the ultimate prize is that every American does have his health protected and preserved and that the glaring inequities be eliminated. This is no more and no less than a restatement of the values inherent in the call for Health for All. We can point to achievements in the technical field to demonstrate that parts of this prize are within our grasp. There is clear evidence that in the field of disease control the countries have made enormous strides there is no more smallpox, or poliomyelitis, measles is disappearing, the old scourge of Chagas disease is disappearing and the classic indicators of health are steadily improving. These achievements are a testimony to the Panamerican approach that we have established as a major principle of our work.
But more significant and rapid gains will be made by clearer appreciation at the public and political level of the nature and value of health and what must be done. In the same manner that there is understanding of the value of economic growth as a means to achieving some worthwhile good, there must be more than passive understanding of the value of health as a resource. When the international discourse and practice at the highest political level in the Americas encompasses health as a value, then there will be greater possibility of achieving that ultimate prize. Organizations like PAHO will assist in this if they are daring enough to complement their solid technical work by deliberately engaging that wider public that dictates or effects real change in our societies.
1. Pan American Health Organization. The search for equity. Annual Report of the Director. Official Document num. 277. Washington, D.C.: PAHO, 1995.
2. World Health Organization. Basic Documents. 39a. edición. Ginebra: WHO; 1992:1-8.
3. Evans RG, Barer ML, Marmor TR. Why are some people healthy and others not? The determinants of health of populations. Nueva York: Aldine de Gruyter, 1994.
4. Frenk J, Sepúlveda J, Gómez-Dantés O, McGuiness MJ, Knaul F. The new world order and international health. Br Med J 1997;314:1404-1406.
5. Pan American Health Organization. Health conditions in the Americas. PAHO, 1994. Scientific Publications num. 549:100-101.
6. Alleyne GAO. Health and National Security. Bull Pan Am Health Organ 1996;30:158-163.
7. Stuck C, Bickley LS, Wallace N, Velji AM. International health medical education consortium: Its history philosophy and role in medical education and health development. Infect Dis Clin North Am 1995;9:419-424.
8. Prist RE, Moher SP, Medical education for international health: The Arizona experience. Infect Dis Clin North Am 1995;9:445-452.
9. Sterky G, Forss K, Stenson B. Tomorrows global health organization: Ideas and options. Estocolmo: Ministry of Foreign Affairs, 1996.
10. Godlee F. WHO in crisis. Br Med J 1994;309:1424-1428.
11. Godlee F. WHO reforms and global health. Br Med J 1997;314:1359.
12. Pan American Health Organization. Basic Documents. 15a. edición. Washington, D.C.: PAHO 1991;240:23-41.
13. Alleyne GAO. Prospects and challenges for health in the Americas. Bull Pan Am Health Organ 1995;29:264-271.
14. Naim M. Latin America: Post adjustment blues. Foreign Policy 1993;92: 133-150.
15. Haggard S. The reform of the State in Latin America. Paper prepared for World Bank Annual Conference in Development in Latin America and the Caribbean; 1995; Rio de Janeiro, Brazil.
16. The Economist. The nation state is dead. Long live the nation state. December 23 1995-January 5 1996 vol. 337(7946):15-18.
17. Matthews JT. Power Shift. Foreign Affairs 1997;76:51-55.
18. The Report of the Commission on Global Governance: Our Global Neighborhood. Londres: Oxford University Press, 1995.
19. United Nation Economic Commission for Latin America and the Caribbean. The economic Experience of the last fifteen years. Latin America and the Caribbean 1980-1995. Santiago, Chile, 1996.
20. United Nations Economic Commission for Latin America and the Caribbean. The Equity Gap, Latin America, the Caribbean and the Social Summit. Sao Paulo, Brazil, 1997.
21. Birdsall N, Ross D, Sabot R. Inequality as a constraint on growth in Latin America. En: Turnham D, Foy C, Larrair G, ed. Social tensions, job creation and economic policy in Latin America. París: Organization for Economic Cooperation and Development; 1995:175-207.
22. Wilkinson RG. Unhealthy societies. The afflictions of inequality. Londres: Routledge, 1996.
23. Behrman JR. Investing in human resources in economic and social progress in Latin American 1993 report. Washington, D.C.: Interamerican Development Bank, 1993.
24. Londoño JL. Is there a health gap in Latin America? The World Bank, Technical Department for Latin America, Working Paper, April 1996.
25. Salud, equidad y transformación productiva en América Latina y el Caribe. Organización Panamericana de la Salud, Comisión Económica para América Latina y el Caribe. Cuaderno Técnico núm. 46. Washington, D.C.: Pan American Health Organization, 1997.
26. Alleyne GAO. The faces of health reform. Presentation at the 2a. Canadian Conference on International Health. 1995; Ottawa, Canada.
27. Berman P(ed). Health Sector Reform in Developing Countries. Making health development sustainable. Boston: Harvard University Press, 1995.
28. Massey DS. The age of extremities: Concentrated affluence and poverty in the twenty first century. Demography 1996;33:395-412.
29. Conference on Human Health and Global Climate Change. National Science and Technology Council and the Institute of Medicine/National Academy of Sciences. Washington, D.C.: National Academy Press, 1996.
30. Chankim W, Mauborgne RA. Making global strategies work. Sloan Management Rev 1993;34:11-27.
* Migliónico, personal communication.
(1) Director, Pan American Health Organization, USA.
Reprint requests to: Dr. George A. O. Alleyne. Director, Pan American Health Organization. 525 Twenty Third Street N.W. Washington, D.C. 20037-2895, USA.