The Threefold Way

A Proposal for the Pan American Health Organization in Latin America

 

 

Prepared by

The Committee for the Analysis of PAHO Mission and Planning

University of California at Berkeley

Michele Barocchi

Cindy Caffery

Kacey Claudine

Aura De Trinidad

Les Folio

Phillip Michaels

Lily Panyacosit

Jamie Pehling

Arun Pramanik

Vishavjit Singh

Allan Taylor

Thao Phuong Vu

Ephraim Woldeselassie

Ojig Yeretsian

Consultant: Len Duhl, MD

 

 

 

 

 

 

 

Ó December 1998

Table of Contents

Table of Contents *

Abstract *

Annotated Table of Contents *

1. Introduction to the Threefold Way *

2. A History of PAHO in Latin America *

3. The Paho Mission: A Right To Health *

4. The Infectious Disease Challenge *

5. Urbanization and Environment *

6. Economics *

7. Corruption and Collaboration *

8. Food and Nutrition *

9. Health Education *

10. Health Care System Reform *

11. The Sustainable Frontier *

12. Conclusions and Recommendations *

13. Chapter References *

14. Biography *

 

Abstract

 

Health is an intricate web made up of complex factors that involve social, cultural, political, and economic issues. A change in one part of the web will have unintended consequences throughout the delicately linked pieces. In this report, the Threefold Way attempts to address these issues as a process of change within the context of the Pan American Health Organization's mission: "to cooperate technically with 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 peoples of the Americas may achieve Health for All by All" this process will rely on a foundation, one which includes community, human rights, and sustainability. Health for all is only possible in the context in which it is understood by all that there is a right to health, involving a minimal set of nine rights as a basis to which the member states can agree. This will lay the foundation allowing for the process to begin. Rapid urbanization, demographic, and ecological changes have an effect on transmission of infectious diseases, which pose a major threat to the health of Latin American communities. Economic factors also play a key role in the health of Latin America. PAHO has a responsibility to influence key members of the international lending and business community to ensure sustainable business ventures, and facilitate the infusion information and empowerment of local communities. Corruption is another issue in health, the antidote being one of collaboration. PAHO should work against corruption by facilitating collaboration between agencies in multiple sectors and levels of government, from local to international. The Pan American Health Organization enjoys an exemplary history of improving health in Latin America. It must now turn innovatively and boldly to new approaches on the future's uncharted waters of building environment, economy, and community building, and indeed to work aggressively against the universe of causes that impinge on health.

Annotated Table of Contents

 

1. Introduction to The Threefold Way

2. A History of PAHO in Latin America

3. The PAHO Mission: A Right to Health

4. The Infectious Disease Challenge

5. Urbanization and Environment

6. Economics

7. Corruption and Collaboration

8. Food and Nutrition

9. Health Education

10. Health Care System Reform

11. The Sustainable Frontier

12. Conclusions and Recommendations

13. REFERENCES

14. BIOGRAPHY

1. Introduction to the Threefold Way

There is a wise story of a person who loses his keys at the end of a dark alley. A passerby happens upon this unfortunate individual, not at the end of the alley, but near the street, on his hands and knees under a brilliant streetlight, scrutinizing the pavement. The passerby asks the person,

 

"What are you looking for?" "My keys," replies the man on the ground. "Did you lose them here?" asks the passerby. "No, at the end of the alley." "Then why are you looking for them out here?" the passerby asks, bemused. "Because out here I can see."

We sometimes behave as the person under the streetlight. We know what we seek, and perhaps even where it might be found. But our techniques for actually finding it, however impressive they might be for other tasks, are inadequate for the task at hand. Nevertheless, we continue to employ the tools we know, because we have difficulty conceiving of others.

In its Strategic and Programmatic Orientations, 1995-1998, the Pan American Health Organization boldly reached beyond the traditional confines of international health policy. It affirmed critical factors, not typically reckoned as part of public health practice, to be profoundly influential health determinants. Among these critical factors are inequity, lack of community power and unsustainability.

Efforts to ameliorate negative socioeconomic and ecological influences on health bedevil nearly all institutions. Perhaps one reason is that such large and diffuse influences are not amenable to the technical and procedural tools available to us, tools that have proved immensely successful in other spheres. If we are to achieve the health we take to be our human right, organizations such as PAHO must make socioeconomic and ecological afflictions a central part of the domain of international health. Indeed, to challenge structural factors of this magnitude will require not merely their identification, nor solely a reorientation of strategy, but a reconceptualization of how we strive for health.

Social inequity represents the absence of the keystone of the arch of good health. It leads to the weakening of communities and individuals, which exacerbates their vulnerability to health harming factors of both human and natural origin. Among the vulnerable there is tremendous exposure to isolation, violence, ignorance, hunger and environmental damage. So malignant are the effects of inequity on health, they may be considered human rights abuses on par with those customarily regarded as such. We often decry the imprisonment of an individual for exercising internationally recognized political rights, but are communities any less imprisoned by their lack of clean water, adequate shelter and nutritious food?

Our tools must match the task. The socioeconomic and ecological diseases at the root of ill health are curable only by interventions that operate in the socioeconomic and ecological spheres. In what follows, we endorse a triangular method of approaching this tremendous challenge and opportunity. We must direct our efforts toward the establishment and maintenance of a minimal, shared vision of human rights that will be accessible to all people everywhere. We must potentiate the capacity of local communities and avail ourselves of their particular wisdom by letting them define, plan and implement programs. Finally, we must guarantee that our projects work within an ecological framework of all things being connected, and no thing being permanent if it is not born in sustainability. Human rights, community and sustainability are the threefold way, a path that any campaign addressing the root causes of poor health must walk.

Basis of Universal Human Rights

Throughout history, movements with the finest of intentions often have failed to realize their aims or resulted in catastrophic harm. While the roads to hell are many, one of the most common is that by which an ideal or method is elevated to the status of an ultimate end, eclipsing the people whose lives it was intended to benefit. From such philosophical simplicity, at best failure, and at worst brutality, results.

An antidote to this human tragedy is to build new initiatives on the bedrock of human rights. Whatever follows would then be evaluated by how it enhances human rights. Human rights, however, is not a concept defined uniformly at the global, regional, or national level. By endorsing a small cluster of fundamental human rights, however, PAHO may develop just such a touchstone of quality for its goals, methods and results. A shared performance standard of human rights could be used enthusiastically by communities in all the member states.

Some may claim that a focus on human rights is inappropriate for a regional health organization, or that while such a vision is laudable, it is seriously out of step with social reality in the Americas. To the first concern, we reiterate the holistic vision of health that incorporates the totality of institutions, practices, and behaviors that affect health. If our responses to ill health are to be commensurate to its causes, the responses must be as broad as the causes. To the second concern, it is important that whatever the reality, beautiful or bleak, our efforts be informed by a vision of our ideals. Our vision should be a statement of our future reach, not necessarily our present grasp.

Community Wisdom and Democracy

Decentralization is a mantra of international planning. PAHO has endorsed decentralization of programs to the level of member states. It is important to realize, however, that while national initiatives have a large role in health, the diversity of worlds represented by the member states is mirrored by the diversity within the member states.

Programs that originate at the national level may not address the health issues defined by the communities. This procrustean neglect of local community realities results immediately from lack of community participation at the national level. More fundamentally, perhaps, such neglect is caused by a disregard for the peculiar wisdom of the individual community about its particular resources and needs.

Community control, and not merely input, is critical for project design and definition. The community should be the basic unit of democratic planning, so that interventions address the needs of the people they aim to benefit. To achieve this goal, PAHO must seek ties to, and facilitate the work of, organizations that connect to individual communities, where PAHO cannot arrange to do so itself.

Elevation of the local community to this role is not meant to deny the importance of national programs, but rather to ground national programs in community needs that are national in scope.

Holism, Ecology and Sustainability

In contemplating the many interrelated determinants of health, it becomes apparent that each determinant represents a system in itself. Each of these systems is at the same time a subsystem of the larger system of the health of the human community. The intimate integration of these many separate wholes into a larger, deeply connected whole, is the essence of the ecology of health.

In the journey ahead, it will be seen that all things are connected. Lack of economic opportunity drives small farmers from the land to the cities, increasing urbanization. Excessive urbanization overtaxes environmental resources, such as land for dwellings and clean water, and consigns people to live in crowded conditions leaving them vulnerable to a variety of infectious diseases. A part of this squalor is malnutrition, which is aggravated by decreased food production and enhanced by urbanization. International lending agencies further decrease food production by demanding export agriculture. The lack of protection for basic human rights allows these dire circumstances to take hold, and prevents local community action to disentangle this vicious web of destructive cause and more destructive effect. Each whole unto itself, or holon, takes its place in the larger holon of ill health.

The interconnectedness of our efforts must reflect that of the obstacles. The holons of physical medicine, mental health and preventive medicine are already united in the holon of community oriented primary care. Now this holon must be joined to those of environmental restoration, small farmer credits and women’s education to create a holon of community development. The holon of one community’s development must be fused to those of other communities to become the holon of the nation’s development.

We must approach the realization of the fullest human health possible in a holistic, ecological manner, because the barriers to health are diverse and related. Our efforts must also be made in light of the whole, lest they fail to address important realities or even exacerbate existing problems. Programs must be designed ecologically to be sustainable. PAHO has shown an exemplary recognition of the importance of ecology, in the environmental sense, in human health. To address the root causes of poor health in the Americas, our understanding of ecology must expand to include, in essence, all things.

The struggle to address the health needs of the Americas is unlikely to be won in a day or a lifetime. PAHO must join a commitment of practice to its innovative theoretical commitment to these ideals. By following the threefold way of human rights, community and sustainability, PAHO will accomplish the dream of health for all.

 

2. A History of PAHO in Latin America

Introduction

Since its inception in 1902, the Pan American Health Organization (PAHO) has been improving the health of Latin American people. Throughout its history it has maintained a strong commitment to its mission: to promote and coordinate the efforts of the countries of the Region of the Americas to combat disease, lengthen life and promote the physical and mental health of their people. It is to be commended for its various efforts and, more importantly, for its ability to grow, both strategically and ideologically from past experiences.

According to the Strategic and Programmatic Orientations 1995-1998 ( PAHO, 1995), experience has shown that health be recognized in the formulation of both social policy and in the development process. This has strong implications for the promotion of health in the international scene. In this context, improving health will entail a deep understanding of the political, social and cultural forces that shape the complex reality of Latin American society. This represents the acknowledgment that health is affected by numerous interrelated elements that may or may not be related to a diagnostic approach to healthcare.

The Role of PAHO as a Regional and International Organization

PAHO’s range of action is concentrated in three levels: international, regional and local (via its country offices). The diverse, multinational scope that PAHO faces, requires effective management at all three levels. This implies a largely facilitative role in order to insure that the interest at various levels do not conflict. Also, it suggests that PAHO is in a unique position to promote at all three levels simultaneously.

The strength of these relationships will continue to be critical for the success of PAHO’s mission. This includes working with non-governmental organizations (NGOs), community-based organizations and international groups – e.g., the World Bank, IMF, and others. The present difficulties involving coordination between major players highlights a major obstacle for the goal of improving the health of Latin American people.

The Future for Health Planning in Latin America

PAHO’s broad set goals will continue to provide the initial framework for all planning. The purpose is to create a common vision of health that PAHO, its country offices and associated NGOs can subscribe to as a basis for their actions. At the heart of the concept are the specific regional goals listed in the Strategic and Programmatic Orientations (PAHO, 1995) for the next quadrennium:

• to increase the span of healthy life for all people in such a way that disparities between social groups are reduced
• ensure universal access to an agreed upon set of basic health services
• ensure survival and healthy development of children and adolescents
• to improve the health and wellbeing of target priority population groups
• to ensure healthy population development
• to eradicate, eliminate, or control major diseases constituting regional health problems
• to enable universal access to safe and healthy environments and living conditions
• to enable all people to adopt and maintain healthy lifestyles and behaviors

There is an implied recognition that health problems cannot be approached in a vacuum, but must be addressed simultaneously from a variety of perspectives. In this context, the hope is to envision and promote a basic level of health that should be available to the entire population.

Progress Toward a Healthy Latin America

According to the latest Quadrennial Report (PAHO, 1998), significant gains have been made in the Region:

• Vital statistics have improved as follows: the infant mortality rate was 91 per 1,000 live births in the period 1965-1970 and has now been estimated at 47 per 1,000 for 1990-1995. In addition, the life expectancy is 68 years in Latin America and 76.1 in the United States and Canada.

• Education: levels of schooling continue to rise as a result of substantial and sustained increases in enrollment rates. Enrollment rates of the primary-school-age population are now between 80% and 100%. For secondary school population it is between 40% and 80%.

• Immunization for children: Polio has been interrupted in the area and there has been a marked decline in the frequency of measles, diphtheria and whooping cough.

Regional Issues, Patterns and Trends: the Latin American Reality

In spite of the substantial gains, there are many aspects of health and health care in the Region that have not been addressed. This is partly due to globalization and interrelatedness of the world and its systems requiring that health planning be done within the context of the increasingly complex myriad of socioeconomic and political factors that shape the Latin American reality. Sustainable health is no longer determined in a laboratory, but is the result of community-oriented, multi-disciplinary approaches.

According to the Quadrennial Report (PAHO, 1998) and ECLAC’s report, Social Panorama, 1997 (ECLAC, 1997), the region has experienced many changes in recent history. The analysis of these complexities may represent opportunities that PAHO could exploit as major points of leverage. In addition, any and every program of health promotion must have these aspects as the foundation for any scenario that is developed.

Political Trends

A majority of the countries have adopted a form of democratic civilian-based government, which has increased political stability in the region. This has created a positive environment in which the leadership, no longer preoccupied with political struggles, can focus on long-term strategies that enhance the well-being of the population. This opens the door for PAHO and the individual ministries to be more pro active, rather than reactive, in their health planning. In addition, this environment could make local governments more receptive to innovative suggestions regarding the health of their individual countries.

Economic Issues

The increasing globalization of the world economy has led to substantial economic growth in various areas of the Region (Chile, Argentina, Brazil, etc.). Between 1991-1993, the Region’s overall GDP experienced growth of 4.3% per year. While this is indeed positive, it must be weighed against the fact that the Region faces an accumulated debt of over US$500 billion. As a result, much of the annual revenue is predetermined monies.

Unfortunately, the health of the Region has been adversely affected by economic growth. The proliferation of free-trade agreements such as the North American Free Trade Agreement (NAFTA) and the Southern Common Market (MERCOSUR) have increased intercontinental migration. This has put pressure on local governments to provide healthcare and public health facilities to a growing population including migrants from neighboring regions. These factors are putting additional pressure on an already fragile socioeconomic structure. It does not seem likely that these governments are presently equipped to handle the consequences of rapid economic change.

Demographic Pattern

The changing age-structure of the population also has direct implications for promoting health in the region. By 1995, it was projected that 47.7% of the population will be between 15 and 44 years of age. Also, the life expectancy has increased to 68.1. This increase in population will have a significant impact in the provision and accessibility of health care and on the economic structure as unemployment continues to soar.

It is estimated that an average of 74.2% of the population will live in cities in 2000 and that 91% of the population increase will take place in the cities. This will put great strain in the infrastructure of cities including the availability of sewage and water systems. This places pressure on an already unstable economic foundation. Again, the question remains, how will these nations provide for their growing populations?

Social Issues

The major challenge in Latin America is extreme poverty. This is related to the inequitable income distribution in which 20% of the population controls 67% of the wealth and another 20% earns no more than 7.5%. Here, economic growth does not favor the entire population but rather, perpetuates the polarization of society. Other issues include violence, drug abuse and the violation of human rights in what can be characterized as a largely racist society.

Health Conditions

While improvements have been made in the area of health status and promotion, there have been some drawbacks:

• Mortality rates have decreased at a slower rate in most countries.
• In many of these cases, reducible gaps in mortality have not decreased, but remained constant.
• The gaps are as big as 45% in some areas. Interestingly, these gaps are the highest in the countries with the highest social inequity. Poverty levels are also related: in the poorest countries 70% of all preventable deaths happen within the under 15 age group.
• In some rural areas 8.3% of a country’s entire population accounts for 30% of all total mortality in the under 1 age group. Again, this reflects the inequitable income distribution and poverty stricken areas. It is evident that the vulnerable groups in the Region must be a priority for any health program.
• Infectious diseases continue to cause high mortality and morbidity rates. The most important ones are diarrheal diseases, tuberculosis, vector borne diseases and AIDS.
• Unsuitable living conditions in marginalized areas contribute to the proliferation of diseases such as malaria, typhoid and tuberculosis, among others.
• The decrease in mortality due to communicable disease has been counteracted by the proportional increase in chronic and degenerative diseases. Cancer accounts for 10% of deaths in some of the countries.
• The incidence of mental health problems increases every year due to lack of hope for a healthy and meaningful life among large segments of the population in Latin America, compounded by an increase in drug and alcohol abuse.
• Malnutrition throughout Latin America limits the health, creative and occupational potential.

These complications in the health conditions of the Region exemplify the extent to which indirect factors—economic, political, social—are having an increased effect on the health status of the population. Urbanization, disparities in vital health statistics and the proliferation of mental health problems can be viewed as the result of a modernization of the Region. This is problematic because Latin America still faces many of the public health threats that are often associated with less developed areas of the world such as the spread of infectious diseases. In this context, intervention and planning must account for all the forces that drive health and health care in Latin America.

Health Sector Development

The health care infrastructure has, in average, not expanded and there are some signs that it has, in fact, deteriorated in some areas. This is mainly due to the reductions in public spending undertaken in order to reach fiscal solvency required for economic development via International Monetary Fund/World Bank loans.

In the public health sector, decentralization has been emphasized in recent years. This opens the door for innovative health planning methods at various levels from regional to local and community - all of which are pivotal to the success of PAHO’s mission. The system is now more open to reform via the modernization of the management and development of health care systems.

Coverage of social security systems has not expanded. This, coupled with the erratic age distribution of the population could signal problems in both the short and long term.

The decentralization of the health sector and the democratization of government could create opportunities for rebuilding of the health sector. In this case, an appropriate, multi-disciplinary approach could result in a health sector infrastructure that is more suitable to the needs of the Region and thus, the future promotion of health in the Region.

Conclusions

It is evident that the dire health conditions of Latin America are inextricably linked to the political, economic and social issues that form the complex realities of the Region. While the interrelatedness of the different elements admittedly complicates PAHO’s mission, it does also create opportunities for improvement and reform. Viewing health in the context of these variables allows PAHO to broaden its scope of action. In this manner, health development and promotion can be approached from both direct and indirect channels; furthermore, this multi-disciplinary perspective will maximize PAHO’s ability to influence health care in the Region.

The movement is towards a vision of universal health rights: a basic level of health that all people of the region must have access to in an equitable manner. The major challenges towards achieving health in Latin America are poverty, inequitable income distribution, violation of human rights and fluctuations in world and regional economies. While these issues are not directly medical aspects of health, they do eventually lead to problematic situations that undermine the health status of the Region. The recognition of these connections and the corresponding attempts to address them in the same holistic manner can be PAHO’s strongest tool for fulfilling its mission of improving the well-being of the entire population of the Americas. In this manner, the solutions to a multi-dimensional problem will be matched by equally multi-faceted solutions.

3. The PAHO Mission: A Right To Health

Introduction

Health for all is only possible in a context in which it is understood by all that there is a right to health. In such a context it is possible for those working in the two major paradigms of health, medicine and public health, to be working in concert, to be working with common goals. This effort toward health can only be successful if the social, political and ethical value of a community dominates the visions and attitudes of the people and nations. The effort can only be successful if the economic value of sustainability is endogenous to the vision and its implementation.

PAHO has made considerable progress in the promotion of health and the promotion of the value of a right to health. Continuing this effort is imperative. It must be continued in the social arena, the economic arena and, most particularly, the political arena. By identifying some basic rights to health—we present nine—which can be accepted as universal and widely dispersed, learned and adhered to by the society and by political and governmental structures. Specifically, we can begin the movement to a social, political and economic system that develops a strong middle class and eliminates or minimizes the numbers of the impoverished. Such success will be instrumental in bringing health to the masses of the underserved. Support and coordination among the political, health and business leadership of the nations will be instrumental. A healthier Latin America will require changes in the laws of nations to guarantee and enforce the right to health. It will require courage. It will bring notable success.

Health: Rights, Community and Sustainability

Health for the peoples of the Pan American region is inextricably linked to the attitudes which all peoples have regarding their neighbors. Attitudes of compassion, care and concern–attitudes of strong community–will carry much benefit for all, providing a basis for the economically, politically and ecologically sustainable development of programs and resources that will bring health benefits to all.

There is no doubt at this point in time, that increased education brings significant health benefits. There is no doubt that increases in public health resources can bring substantial increases in health to those who have access to so little of the world’s wealth. There is no doubt that even minor increases in access to basic healthcare resources and medicines also improves the health status of these same populations. There has likely never been much doubt that an adequate diet brings an improvement in health. Yet these are all lacking in sufficient quantity among the poor of Latin America.

It is not that little is known about the causes of poverty and its ill effects on health. It is that little is known about how to make everyone care about poverty and its ill effects on health. There needs to be an understanding of the interconnectedness between ourselves and our neighbors–that everyone is a member of a singular community. It needs to be understood that poverty is not part of a win-lose proposition. It is part of a lose-lose proposition until the collective community has the will to overcome it. A lack of communal concern about one's neighbor’s health is quite likely to show up as a very ugly blight at our own doorstep. Ill health spreads ill health, and lost productivity, and social, cultural, and class upheaval, and even political revolution. That is an undesirable kind of sustainability.

Sustainability of one form or another will be with us. A choice has to be made to sustain the good, the economically productive, the socially communal, the health of all, or to neglect such a choice and the negatives will be sustained. Good health brings externalities of positive benefit. Good health reduces the potential for disease to spread to others. It provides the capacity for productive labor to fuel the engines of economies. It provides the strength for nations to be strong and resilient in the face of potential aggressors.

So what prevents greater progress against the national threat that poverty imposes? Attitude. Individuals, members of the community, have not yet developed an adequate sense of what they owe in their community to their brothers and sisters. An adequate sense has not been developed that they should not be subjected to live lives that one would find appalling for oneself and one's children. A sufficient sense has not been developed that they should have health and the physical and psychological things necessary for health. This attitude can be developed throughout nations. Some nations so far have done better than others and lessons can be learnt from their successes.

Political and business leaders in Latin America are no less capable of learning the significant issues related to social, political and economic struggle than are others throughout the world. They, in fact, have a degree of sophistication and learning that far surpasses that of leaders of many other nations. Political and business leaders in Latin America will be able to see that it is to their advantage to promote the well-being of the poor. Political and business leaders in Latin America will be able to see that it is the countries with a strong middle class and a minimal number of indigent people that have provided the most security for their nation, for their lifestyle and for their families. Examples of war that started over issues of inadequate access to economic, civil and political resources and that disrupt nations of the world today are seemingly omnipresent.

Nine Basic Rights to Health

These ideas are sometimes referred to as the concept of human rights. But the term ‘human rights’ comes with some baggage. There are over fifty different declarations and conventions proclaiming human rights. None of them are in complete agreement. Some of them make proclamations for rights that others find too extreme, even ridiculous. What we propose is a minimal definition of human rights for PAHO. Not as a total solution. Not as a final goal. But as a starting point. One upon which most of the people of Latin America, and the world, can be expected to agree. One by which we likely will not be accused of imposing colonial and imperialistic western ideologies. We start with nine basics:

the right to survival and healthy development of children and adolescents; the right to adequate and sanitary food and water; the right to shelter; the right to adequate sanitary and waste disposal; the right to freedom from slavery and indentured servitude; the right to freedom from torture and political and unlawful imprisonment; the right to primary education; the right to protection of the environment from would-be polluters and profiteers; the right to believe as one chooses.

 

WHO and PAHO Rights History

WHO and PAHO have a strong and proud history of support for human rights. Examples of both WHO and PAHO support for human rights include the opening speech at the European Conference of the International Medical Parliamentarians Organization (IMPO) in 1995. The former Director-General of the World Health Organization (WHO), Dr. Hiroshi Nakajima, devoted that speech to "the issues of scientific advances, professional ethics and human rights within the context of global change."¹ Another example was their Diabetes and Human Rights theme for World Diabetes Day 1998, which commemorated the "50th anniversary of the Universal Declaration of Human Rights adopted in 1948."²

Just between July and September, 1998, WHO sponsored several human rights focused meetings: the WHO/EHA Consultative Meeting on Management Support of Relief Workers, the WHO/UNICEF/UNFPA Coordinating Committee on Health Policy, Technical Consultation on the Global Eradication of Poliomyelitis, Informal Consultation on Monitoring of Drug Efficacy in the Control of Schistosomiasis and Intestinal Nematodes, Visit of MIKI Groups, the Advanced WHO Course on Immunology, Vaccinology and Biotechnology Applied to Infectious Diseases, and the WHO/ICD Cooperation in the Field of Food Safety.³

PAHO has identified its stance on human rights and bioethics in several of its own publications, including Ethics and Law in the Study of AIDS, The Right to Health in the Americas: A Comparative Constitutional Study, and Bioethics: Issues and Perspectives.⁴ Therefore, it is in keeping with WHO and PAHO policy to make human rights a centerpiece of activity in their own work, and to strive for a similar focus in the political work of the Latin American nations. Hence, the following is a scenario of a possible world, a world possible in Latin America.

A Scenario: A World Infused with Human Rights

The world is one of relative peace, having achieved much of the dream of economists, psychologists, sociologists, political scientists, political and religious leaders, health practitioners and activists dedicated to improving the condition of the world and its peoples. With the trends of rampant globalization, corporatization and colonization subsiding, the middle classes—which were once disappearing with the increasing polarization of rich and poor–are re-emerging to become the political and economic power that they were in the middle of the twentieth century in the modern industrialized nations. Social scientists, as well as social, political and economic analysts and politicians are attributing this outcome to the change in the attitude of the world’s populations regarding human rights and their intolerance of human rights abuses.

Some see this modern change beginning with the Nuremberg Trial of the perpetrators of the Nazi Holocaust, and gradually building over the next several decades as perpetrators of other atrocities were held accountable for their evil deeds of misery-making upon others. The process began slowly, with most of those responsible not being held accountable, but with more and more at least being identified as responsible, even if they continued to live unfettered lives. But as human rights organizations proliferated, and as organizations like WHO, PAHO and the United Nations began to take an enlightened stance, strongly espousing the necessity of ongoing human rights dialogues as a matter of concern for every issue to cross their plate, of the necessity for a human rights orientation to all their work and to the work of all leaders of every stripe, a new ethic began to slowly emerge. This new ethic was one in which the dignity of every human being was accepted as a mandatory condition for any kind of reasonable existence for the masses of people on the earth.

It was seen as necessary to eliminate poverty within the world. It was a challenge leveled by WHO and PAHO to all countries to eliminate poverty within their own boundaries—recognizing the human rights of all people to a viable and healthy existence. This was recognized and reaffirmed continuously throughout the world in the meetings of nearly every national, state and local government. A human rights ethic had become a vision for all governments and all aspiring and enduring leaders of governments.

It was also recognized that it is powerless people, marginalized people, who become the target for oppression. It was WHO and PAHO that gave life and sustenance to the new vision of giving strength to all by creating a world comprised in vast majority of a powerful middle class. This middle class understood the necessity for each and every human being to be treated with dignity, respect, care and compassion. This middle class understood the need for everyone to be acknowledged as intrinsically deserving and thus inherently granted–as a function of their mere existence among the human community–all the basic needs for a quality life lived in an aura of good health. Thus, all could be protected from the ravages of the occasional demagogue who treads upon the scene.

What has brought this vastly improved state of affairs to the world after a century in which hundreds of millions were murdered in wars and genocidal madness, was the fact that PAHO leadership, with strong support from its mother organization, WHO, initiated an evolution of human rights concepts. First, was the formulation of a list of nine basic human rights related to the right to health. Then, as these became increasingly accepted, other rights became also to be seen as basic. Because of these efforts, there was an increasing acceptability to Western nations of the concept of economic rights. Thus, there was a resulting rapprochement between nations who had historically been counterpoised because of their conflicting defense of either economic rights or civil rights in preference to the other. Hence came a new synthesis of the world’s nations.

Then, PAHO and WHO leadership decided to initiate a major review of the Universal Declaration of Human Rights during the year of the Declaration’s 60^th anniversary in 2008. This review resulted in the revision and incorporation into the Declaration of numerous human rights principles from over twenty-five other charters, conventions and declarations of human rights that had been proposed by various organizations during the latter half of the 20th Century. This newly strengthened Declaration was then proposed to the world as the new standard for human rights by which peoples of all nations would adhere and support. Not initially received with great enthusiasm, nor immediately adopted, the document was increasingly seen as a viable and necessary approach to achieving a comprehensive change in national and individual attitudes that could lead to economic prosperity and peace for all the world and its children.

 

4. The Infectious Disease Challenge

Introduction

Infectious disease will continue to be a major challenge for the communities of Latin America. The following table and chapter is an introduction to some of the infectious disease in Latin America and a few strategies in their prevention and control.

 

Disease Agent	Factors In Emergence	Statistics	Current Prevention Strategies
Bacteria:
Tuberculosis Mycobacterium tuberculosis	Human demographics/behavior, industry and technology, international commerce and travel, microbial adaptations, breakdown of public health infrastructure.	TB is the leading cause of morbidity and mortality in the world. Brazil has 100,000 new cases/year. In Peru it is the number one killer of young adolescents and women of child-bearing years.	Direct Observed Treatment Short-course (DOTS). Combines five elements: -Political commitment -case detection through sputum microscopy -DOTS short course -regular drug supplies, -monitoring systems (WHO World Health Forum)
Diarrheal Diseases (Vibrio cholera, Salmonella, E. coli, Rotavirus, E. histolytica)	Limited access to clean water, lack of public health infrastructure, industry and technology, and migration.	Diarrheal diseases are a major cause of infant mortality, typically in children <1 year. Peru and Ecuador have the highest incidence of Vibrio with 34,629 and 2,728 cases respectively. (WHO 1998)	Oral Rehydration Therapy (ORT), Provision of clean water.
Viruses:
Dengue/Dengue Hemorrhagic Fever Vector: Aedes aegypti	Expanding distribution of Dengue viruses, transportation, migration, rise in urban population. Poor sanitation and lack of clean water, storage, and waste disposal provides more opportunity for vector breeding areas. There is a need for Containment/eradication of the vector Aedes aegypti, which breeds primarily in man-made containers.	Currently there are an estimated >300,000 cases of Dengue in the Americas. 7,715 are DHF. A large proportion of infections occur in children.	Need for greater surveillance, sustainable vector control (community based clean-up control of breeding sites), assessment of social economic, environmental factors that lead to increase in transmission, research in vector control, and collaboration with other health sectors.
Respiratory infections	Human demographics, migration, lack of vaccine and access to immunizations.	One of the leading causes of infant mortality in children between 1-4 years.	Health education, immunizations. Improved surveillance and prevention efforts are needed.
Parasites:
Malaria Plasmodium spp. Vector: Anopheles spp.	Favorable conditions for mosquito vector, deforestation of land, economic development, and pesticide use.	Malarial deaths occur mainly among non-immune newcomers to endemic areas. Bolivia's incidence is on the rise with 40% of the population living in Anopheles territory. 42.9% of Brazilians live in areas at risk for Malaria, with over 600,000cases.	Goals are to provide early diagnosis and prompt treatment, preventative measures, detection and containment of the Anopheles spp. vector, strengthen local capabilities in basic and applied research.
American Trypanosoma (Chagas Disease) Trypanosoma cruzi Vector: Triatoma infestans Rhodnius prolixus	Vector breeding sites, human demographics, and migration.	T. cruzi infection in the Americas is estimated at 16-18m cases. 25% of the population of this Region is at risk for contracting the infection. Chagas disease is the most important endemic parasitic disease in Argentina. Bolivia has 1.2m cases. Territories in Paraguay and Uruguay see an infestation rate of >14%.	Control is primarily based on the interruption of transmission by the vector, and recently systematic screening of blood donors. Most are insecticide -based control methods, housing improvements, health education, and the strengthening of health service infrastructure for multiple blood screening.
Leishmaniasis Leishmania spp. Vector: Phlebotomus spp.	Population displacement, economic development, new irrigation systems, construction of dams, habitat changes favorable to the insect vector, increase in immunocompromised host.	Leishmania is a major problem in many rural areas in Brazil Columbia, Venezuela, and Nicaragua. In 1993 there were 9,000 cases of CL in Brazil alone. Leishmania/HIV is considered the new "emerging" disease. IV drug users are the largest population at risk for this co-infection.	Insecticide impregnated bed nets and increased surveillance methods.

 

Primary Factors in the spread of Infectious Diseases

It becomes apparent from the above table that infectious disease are, and will continue to pose a challenge in Latin America for the new millenium. In order to engage in the dialogue for infectious disease prevention, we must consider human dynamics and the complexity of their interactions in the complex web of infectious disease causation. It is clear from past experience that social, economic, political, and climactic factors shape the emergence of infectious diseases and allow for their transmission across borders.

How do we sustain prevention efforts for Latin American communities, which will provide the basic conditions of communal and individual health? Continuing PAHO's commitment to community involvement of health promotion, local communities involving public health investigators as well as local citizens will have to be active participants in efforts to create new solutions for the above mentioned factors.

In light of the complexity surrounding the emergence and continuing prevalence of infectious diseases, solutions that address these issues need to be flexible, dynamic and appropriate to the Region. To address increased cases of morbidity and mortality due to infectious diseases, and the eventual integrated approach to their control and prevention, collaborations must be formed to include all levels of a country's health and scientific infrastructure. The Sustainable Sciences Institute, a new US based non-profit organization, has arisen to fill this need and exemplifies such efforts. This newly formed institute grew out of 10 years of experience as the AMB/ATT Program. In July of 1995, as part of a long term collaboration, this organization introduced a molecular biology technique known as reverse transcriptase polymerase chain reaction (RT-PCR) to the Nicaraguan Ministry of Health. This allowed the Ministry to detect and type dengue virus during the current epidemics.

Soon after, in October of 1995, Nicaraguan scientists used this technique to investigate an outbreak of hemorrhagic fever in the Northen area of the country. Initially, this outbreak was thought to have been caused by dengue virus, but scientific analysis and experienced investigators proved this was not the case. Questions about the outbreaks' etiologic agent sparked international interest. Teams of scientists from CDC and the Cuban Instituto de Medicina "Pedro Kouri", collaborated with Nicaraguan scientists in an effort which lead to the discovery that a Leptospira was the causative agent of the infections (Harris 1996, 1998). SSI aims to increase the educational, financial, material, and informational resources available to biomedical scientists engaging in public health research in less developed countries.

Since 1988, members of AMB/ATT, now known as SSI, have organized on-site courses to educate Central and South American scientists in molecular biology, epidemiology, and technical writing, with the goal of addressing local public health needs. These regional workshops have spurred this scientific community to:

At a time when infectious diseases and epidemiological problems often reach across geopolitical borders, SSI directors and scientific advisors feel it is of utmost importance to help local scientists in underserved communities to put in place effective scientific research structures specific to their environment, in order to help fight the spread of diseases.

Sustainable Sciences Institute will co-sponsor two workshops in the appropriate application of scientific technologies in Bolivia (October 1998) and Guatemala (March 1999), and will initiate new courses within Latin America in the year 2000. will organize and secure funding for the regional workshops, which will take place in local research laboratories. The goal of the training offered by the Institute is to enhance the capacity of local public health researchers to:

In addition, the Institute provides follow-up support to its trainees in the form of funding, consulting, material aid, and networking opportunities. This support is critical for local scientific and public health workers to investigate and prevent infectious diseases specific to their region. The outcome will be measured by the progress of local researchers towards investigating communicable diseases in their regions, efforts which will have an impact on the incidence of infectious diseases.

Ecologic sustainability

In the South, because of the critical environmental role played by tropical forest, it is important to establish "tree-farms" on lands already deforested rather than harvest the natural forest. Fuelwood plantations are also urgently required in the Americas to relieve pressure on natural forests. We need to increase five-fold the number of fuelwood trees planted per year, especially around farms and in village woodlots, at an annual cost estimated at $1 billion. The difficulties, are however not financial. Community forestry relies on the involvement of local people. If everybody's ideas are sought from the start, hopefully everybody will plant trees and everybody will ensure that the harvesting system produces a regular supply of fuelwood.

Migration to urban areas and the provision of clean water are essential factors to be taken into account for the control of infectious diseases. Medical interventions have been very successful in treating many of the ailments resulting from infectious contagions, but with rapid demographic, migratory and ecological changes in Latin America the need for preventive approaches has become very important.

 

5. Urbanization and Environment

Introduction

Poverty is technically defined as subsisting on US$1 per day or less. In essence, however, poverty consists of more than this paltry definition. Poverty, as the UNDP defines it, is also the denial of basic human rights, e.g. the right to good health, adequate nutrition, literacy and employment, and goes on to encompass a lack of political freedom, an inability to participate in decision making, a lack of personal security, an inability to participate in the life of a community, and a threat to sustainability and intergenerational equity(UNDP). In Latin America, where poverty is prevalent (46% of the Latin American population currently lives in poverty), it is the greatest motivating factor for the migration of people from rural to urban areas. The dream is to escape poverty and create a happier and healthier life for oneself and one's family, but the odds of achieving this dream are minimal since the reality of urban poverty is tied to the urbanization movement. Economic growth and development have brought about an intense, rapid rate of urbanization, environmental degradation and an almost over-centralization. Latin American communities continue, however, to lure migrating rural populations, even though they cannot readily absorb the growing population due to a lack of infrastructure and a lack of city planning.

Ecological issues that emerge as the most urgent and challenging as a result of rapid urbanization are water supply, sanitation, water resource management, solid waste management and air pollution (World Resource Institute). These issues subsequently force us to recognize the link between population, development, environment and health (WHO). Doctors and health workers have become so focused on the prevention and treatment of diseases and their consequences, that the totality of human life in communities are too easily overlooked. Ultimately health policy has to be redefined as being more influenced by social policy and ethical concerns, rather than confining itself solely to the conventional health sector (WHO).

Urbanization

As of 1995, more than 300 million of Latin America and the Caribbean’s 481 million-person population lived in urban areas, most of them on the coast. Much of the economic activity and growth in Latin America has occurred on the coast, thus the migration towards the coast and the urban areas. United Nation’s demographers predict that by the year 1999, approximately three-quarters of the Latin American population will be urbanized, mostly in the coastal cities. Nearly forty percent of Venezuela’s population is crammed together on only two percent of its land area, the north-central coastal zone around Caracas, an area that accounts for three-quarters of the country’s industries, 61 percent of GNP and 40 percent of all fixed investments (Hinrichsen).

Urbanization, stimulated by huge economic growth in cities, propels internal migration from rural areas to urban areas to take advantage of opportunities for employment, and thus a better life. Most Latin American cities have lacked the infrastructure needed to absorb the intense urbanization, resulting in over-congestion, overcrowding and a lack of affordable housing. These factors have driven the migrating population outward to the urban periphery, to squat on unoccupied land, land which may be privately or publicly owned, and unoccupied for a myriad of reasons, including being environmentally unstable, i.e. vulnerable to mudslides and floods (floodplains) or environmentally or ecologically sensitive, e.g. wetlands.

Squatting

Squatters, by definition, are people who occupy land illegally. As a result, they are often forced to live without adequate access to clean water, sanitation, lack satisfactory disposal methods of solid and hazardous wastes and in constant fear of eviction. Without proper solid and hazardous waste disposal methods, waste is disposed of inappropriately furthering environmental degradation. Water supply is often found in too close proximity to sanitation facilities, generating an environment in which communicable diseases flourish. In addition, the lack of secure land tenure oftentimes imparts a sense of impermanence, diminishing any desire to conserve and improve the environment they live in. Squatters have also unwittingly been placed in a position most vulnerable to ecological disasters, consequences being lost homes, lost possessions and broken dreams.

The issues surrounding squatting directly or indirectly contribute to equity issues as they relate to differences in quality of health and life of urban rich vs. the urban poor, the possible reduction of efficiency and productivity of cities, and permanent damage to local or regional ecosystems. Social inequalities, in infrastructure and access to jobs, are only accentuated by dispersed urban areas (World Resource Institute).

Effects of Urbanization

Problems of the urban poor can in fact turn out to be quite costly. For example, in Bogota, about 2,500 tons of solid waste, is left uncollected every day. Some is recycled informally while the rest is left to rot in small clumps or in canals, sewers or streets. In Mexico City, an average of 2.4 workdays per person is lost, and 6,400 deaths are caused every year by abnormally high levels of suspended particulates. Annual health costs from air pollution are estimated to exceed $1.5 billion (Cohen).

Children’s Health Effects

Not only does urban poverty suppress a growing economy, it can turn quite deadly as well. Children are the most vulnerable to the detrimental effects of poverty as they lack the strength and the resources needed to ward off malnutrition and diseases that result from contaminated water, lack of adequate sanitation and air pollution. There are more than 4 million deaths per year from acute respiratory infection in the developing world, a quarter of which are linked to malnutrition (an indicator of poverty, no less), a quarter associated with pulmonary complications of measles, pertussis, malaria and HIV/AIDS. Incidence of ARI resulting from pneumonia, in developing countries, range from 10-20%, and are associated with risk factors such as malnutrition, low birth weight and indoor air pollution, all risk factors associated with poverty. Diarrheal diseases are responsible for some 3 million-childhood deaths in developing countries all around the world, where 80% of these deaths occur in the first two years of life. Diarrheal diseases are associated with unsafe water, poor sanitation, coupled with poor food-handling practices, a telling example of the coupling of poverty and lack of education (WHO).

Portrait of Infant Mortality in Latin America

Infant Mortality Data

From a global perspective, infant-mortality is lowest in Sweden, Finland, Singapore, Japan (ranking from 3.7 to 4.3 per 1000 live births); it is 5.6 in Spain and 7.6 in the United States. In Latin America it ranges from 19 to 85 per 1000 live births.

During 1965-1970, Latin America’s overall infant mortality was 91 per 1000 live births, decreasing to 47 per 1000 live births for 1990-1995. The range of mortality differences within some countries are extremely large, possibly reflecting substantial socioeconomic differences correlated with geography. In Mexico City, for example, infant mortality ranges from 13.4 per 1000 live births in the affluent districts to 109.8 in the poorest areas. In Venezuela the infant mortality rate in the poorest areas of in the country (31 per 1000 live births) is twice the rate in areas with better living conditions. In Peru, the infant mortality rate in urbanized Lima is 50 per 1000 live births, while in some rural areas it is over 140.

The rates also vary considerably by ethnic origin. In Panama, the risk of dying for an indigenous child under the age of 1 year is 3.5 times higher than for a non-indigenous child, and although the indigenous make up only around 8.3 % of the country’s population, they account for close to 30% of total mortality in this age group. Thus in order to reduce avoidable mortality at the same rate as in the past, the huge social inequities and living conditions in the countries of the Region must be recognized and addressed.

Infectious diseases continue to be a significant cause of morbidity and mortality in most of these countries. The major ones are acute diarrheal diseases, respiratory infections and tuberculosis, vector borne diseases and AIDS. AIDS has spread to all the countries of the Region, primarily due to heterosexual transmission, and has been estimated to have affected at least 3 million people. Perinatal transmission of AIDS has also increased significantly, particularly among the poor, who do not have access to counseling and treatment.

Migration and Infant Mortality

Argentina and Venezuela are the two Latin American countries with the largest number of immigrants and skew the infant mortality data. Migration from rural to urban areas has accounted for up to 60% of urban growth in Argentina, Chile, Paraguay and Uruguay. One large study concluded that many disadvantaged urban children would probably have been better-off had their mothers remained in village. There are an estimated 42 million indigenous people living in 400 towns and villages in these regions, with one out of four living in rural areas. In a recent report, data compiled from 15 demographic and health surveys showed high levels of residential segregation of migrant women, and their children had a higher mortality compared to the non-immigrant urban children.

Population Trends

A high infant mortality rate will drain precious and limited resources of a country. On the other hand, a sudden decrease in infant mortality by instituting simple public health measures, such as sanitation, clean water supply, immunizations may lead to unforeseen population growth if fertility rates are not controlled, which may have a negative impact on the country’s economy, ecology, and human rights. As we head into the new millenium, most Latin American countries have undergone political, economic and demographic changes, which have resulted in, among other things, transitions from closed, state-run economies to open economies in competition with the rest of the world.

Most countries will have to make adjustments to accommodate a population that is growing larger with each passing year. The population of the Americas is estimated at 800 million, representing 14% of the world’s population. About one-third of that population resides in the United States, while another third can be found in two other countries: Mexico and Brazil. The remaining third is scattered among the other 45 countries and territories in the Region. The number of births has increased in some subregions, Guatemala being the highest with 36 per 1000 (average 19.2). This subregion also leads in mortality, with a rate of 8.7 deaths per 100 population in 1998.

Health Perspective And Infant Mortality

The overall health situation in Latin America has improved over the past decade, reflecting numerous social, environmental, cultural and technological factors, as well a greater availability of health services and public health programs. In contrast, basic amenities such as drinking water, sewage and waste water disposal varies from country to country. In Costa Rica, for example, every household has access to water. This is not so in Haiti and Paraguay, where only four 10 households do. A similar situation prevails with respect to the Bahamas, Costa Rica and Trinidad, where access to sewer and sanitation services is available to nearly every household. In Haiti and Paraguay, less than one out of three households has such access. Natural disasters, such as flooding, earthquakes and hurricanes also may have a devastating impact on infant mortality, and various countries have different coping abilities.

Nutrition And Infant Mortality

Protein-calorie malnutrition, iron deficiency, iodine and vitamin A deficiencies are the most prevalent nutrition problems, especially among infants, preschool children and women of childbearing age. These nutritional deficiencies may significantly contribute to morbidity and mortality in the disadvantaged groups.

 

International Drinking Water and Sanitation Decade of the 1980s

The World Bank concluded in 1992, that improving access to clean water and sanitation would be the single most effective means of alleviating human distress (World Bank, 1992). The International Drinking Water and Sanitation Decade of the 1980s goal was to provide clean water and sanitation for all. And despite nearly $100 billion in investments, it fell short of meeting its goal. The World Resources Institute has defined four key lessons that have emerged from the International Drinking Water and Sanitation Decade of the 1980s :

• systems should respond to local demands and should be as simply, sturdy and inexpensive as possible;
• the involvement of the community and households – particularly women – in system design and maintenance is a crucial component to a project’s success;
• governments need to improve the efficiency and sustainability of system operation and maintenance;
• water should be treated as an economic commodity paid for by users.

Lessons Implemented?

The lessons learned, as stated by the WRI, embody much of a bottom up approach. But what really characterizes any type of bottom up approach is the presence of a dialogue between the actors, i.e. the squatter settlements, PAHO, NGOs, or any other mediating body and the government. The movement towards becoming a healthy city is one that cannot go forward if the dialogue between the actors does not exist.

Curitiba, Brazil, is without a doubt one of the oldest and best known "Healthy Cities" found in Latin America. The success of Curitiba as a healthy city can be characterized by the idea that integrative planning could help solve urban-growth related problems. The Curitiba planning process consisted of two very distinct phases: 1) the pre-implementation phase, in which a master plan responded to social demands, voiced by representatives of the citizens of Curitiba was developed as basic guidance for the future growth of the city, and 2) an implementation phase characterized by the political will and the commitment of the public administration to getting things done (Rabinovitch).

The urban poor, however, are not without the knowledge and resources needed to create a better life for themselves, given the opportunity. For example, people living in these squatter settlements often buy water at three to four times the cost of people who have piped water. Without secure land tenure, there is simply no motivation for them to conserve and protect their environment, or to come together as a community and make demands on the government as a whole to help them to create and improve infrastructure. The problems that ail the urban poor are the same ones that are at the basis of an "unhealthy city" and economic inefficiency. Solutions must be created which address the problems plaguing the urban poor to achieve a sustainable economic infrastructure and to create a healthy city.

PAHO will be instrumental in fostering the creation of a dialogue of human rights, community and sustainability among the essential actors, the governments, NGOs and communities. The image of the urban poor needs to be reconstructed as citizens of the city, citizens that are indispensable towards the achievement of sustainable economic development and a "healthy city". PAHO can facilitate this movement, by promoting improved infrastructure, water and sanitation facilities, and proper methods of waste disposal. PAHO can encourage the move towards recognition of land-use rights or the development of conscientious resettlement plans on the part of the government, motivating factors for communities to start organizing themselves or with the aid of either the government or other non-governmental organizations (NGO) to plan a better life for themselves.

 

6. Economics

Introduction

Economics play a key role in the health of Latin America. Recently, this region has seen average annual growth rates of 3.4%, and a steady increase is expected. However, economic gains must be considered in light of their sustainability and contribution to the health of the population. "Economic factors are just one measure for evaluating the success or failure of economic reform programs," (Peabody). "Social factors, such as agricultural development, education, infrastructure and political factors… are also critical in evaluating success and failure." Health, a natural outcome of these factors, is inevitably tied to economic policy. Because of this interaction, PAHO’s role must extend into the economic domain.

Latin America is an important player in the international arena as an investment opportunity and as a market source. Recent agreements have widened trade with these countries, posing both potential opportunities and potential dangers for the region. With an influx of corporations looking for cheap labor for mass production, the health of workers and the surrounding communities should be monitored. First, there is potential for increased human rights abuses, such as child labor. Helping to establish unions and local means of power provides one way that PAHO might facilitate the protection of these populations. Second, through international agreement, multinational corporations should be made responsible, through taxes or other safeguards, for the environmental and health effects on the community.

Sustainable agriculture, rather than quick, cash crops must be encouraged. Currently, crops may be grown, underpriced and sold internationally, to the ecological and economic detriment of the local communities. Both from long-range ecologic and short-range economic viewpoints, agricultural policies should be addressed according to the needs of the communities.

The Impact of Economics on Latin America

Loan policies at the international, national and community levels also show potential for reform. Policies such as the structural adjustment programs implemented by the World Bank in the 1980’s dramatically cut social services spending in many Latin American countries and the population’s health has suffered. As a result, loan policies have tightened at the national level. Presently, the average national savings rate is 20%. An estimated 25-28% is needed to expand internal loan opportunities. This calls for further inflation control on the part of these governments, to encourage savings.

Loan policies at the community level also offer promise. Examples such as the Grameen Bank in Bangladesh, have shown that micro-loans provide benefits far beyond the capital invested. As a means of stimulating entrepreneurship and promoting self-sufficiency, these loans should be organized, distributed and reinvested in the communities. PAHO should provide models for adaptation, based on world successes in this field.

Unemployment is a growing problem within the Latin American region, due to its increasingly large youth population and present economic instability. Approximately 7.7% of Latin America’s 560 million inhabitants are now without employment. As state regulation of the economy gives way to private enterprise, more jobs may be lost. There are two areas in which national and community governance can aid in the transition. First, there is a need for strengthening social services for the unemployed. Second, education which is a fundamental human right, must be a prime focus for communities and nations. New education programs need to be created to provide training in emerging fields, such as the growing field of information technology.

Improved economic conditions can feed directly into the public health arena. As loan policies are reformulated and the general economy rises, attention to public health concerns is also expected to increase. In many communities, this will mean simply developing infrastructure that will contribute basic health measures such as sanitation. Investment in nutrition and related agricultural reform, will benefit the population as well as the productivity in the region. Support for low-technology treatments of disease and funding for scientific research at the local level can strengthen the public health base in the region. As the global community develops, regulation standards, such as for water supply and air pollution, will also be an expectation. Community health workers should be introduced as a more far reaching and cost-effective approach to health care. Also, strengthening health information systems offers a pivotal new advance for the health of Latin America. It is goal for Latin America to begin community initiatives based on the experiences of other countries in these cost-effective approaches to health, modified for individual national needs. PAHO should play a key role in facilitating this information transfer. As an information broker, PAHO can introduce ideas without ossifying the health programs of these communities.

Finally, there is a demonstrable need for community social support. Evidence points to the importance of social inclusion for health. As the economy of Latin American countries continues to grow, the disparity between rich and poor continues to widen, and access to education and health care is becoming correspondingly stratified. Results of this division are demonstrated in the rising crimes and violence in segments of the population without the means to change their situations. Through local action, a sense of identity with and responsibility to the community must be fostered. Further, an identification with the larger world community and human rights must take place for healthy change.

PAHO has a responsibility to influence key members of the international lending and business community to ensure sustainable business ventures and protection of human rights, coordinate with national governments to enhance social services and, perhaps most importantly, facilitate the empowerment and informing of local communities. It is through these actions in the economic arena that PAHO will effect change for the health of Latin America.

 

 

7. Corruption and Collaboration

Introduction

As the world becomes increasingly globalized, economic and social development and health for any country is becoming contingent on international efforts and relations. PAHO can encourage and facilitate relationships between external, internal and multilateral agencies internationally and among member states. These collaborations should be monitored by PAHO to increase efficiency, avoid duplication of effort, analyze progress and reduce corruption. Monitoring joint external and internal collaboration would help member countries and PAHO evaluate existing policies in development and health, set regional priorities and direct resources to best achieve PAHO’s goals in Latin America.

The Problem of Corruption

PAHO can facilitate the development of relations between agencies to attain a common goal - A PAHO objective. The network model created will combat corruption in the health sector via an integral system of monitoring by each member of the network. Each member, having a vested interest in attaining the goals, will encourage diffusion of responsibility and discourage corruption.

Corruption is often a manifestation of exclusion and isolation. Development of a multilateral network model can allow an alternative means for empowerment to those who turn towards corruption. PAHO should become concerned with character of development institutions. When these institutions fail to maintain fairness and transparency in their operations and programs, they become more prone to corruption (using their power for something other than their stated purpose).

• Corruption disrupts the balance of power necessary for the legitimacy of institutions. As more members contribute toward a goal, the more accountable the members become, thus preserving the equal distribution of power.
• Corruption undermines PAHO’s mission by limiting participation. Extending collaboration networks to local levels and smaller agencies will provide access to resources at the grassroots level. This model of collaboration opens up channels to better implement programs of all levels. It will facilitate a more efficient utilization of the allotted resources, leading to greater effectiveness.
• By supporting the proposed networks, PAHO will be opening channels of communication through an integration of agencies in all sectors.

International support in combination with the efforts of the member countries and all concerned organizations is crucial to achieving PAHO’s goals in Latin America. International cooperation should be based on needs assessed from an analysis of external cooperation requirements which supplement the programs and resources existing within the countries. The role of external aid should be supportive toward developing internal systems within the member countries to perpetuate and facilitate self management in health for the population of each country.

Key Areas for International Collaboration

• Financial and technological resources to develop and maintain the orientation of internal systems toward goals for health in each country
• Joint efforts to disseminate education and information
• International exchange programs for health and technical education
• Training internal human resources to use, teach and maintain technical equipment and programs
• Education focusing on development of information systems, research facilities, medical machinery, health administration and education, and safety and sanitation development

Inter-country collaboration is another crucial component in achieving PAHO’s goals in Latin America. Health concerns and problems are common to many of the member countries. Combined efforts of several countries would increase efficiency and facilitate programs monetarily, by cost sharing. Joint efforts should involve the development of human resources, shared research and technological development, shared research facilities and equipment, and cooperation among the countries in the dissemination of knowledge.

Reducing corruption will forge a path for progress in the challenges for improving health mentioned in this report. The most efficient combative method against corruption is the development of a strong network through collaboration. PAHO should support network development between NGOs, private enterprises, non-profit organizations, and governmental and international agencies at local, national and international levels. These agencies should include development agencies from all sectors, including human rights, economic development, social development and environmental preservation, and other organizations which would complement and support efforts toward creating a strong network, a network which would serve as a foundation for achieving the goals shared by PAHO and many of these agencies.

8. Food and Nutrition

Introduction

Food and nutrition is a broad public health problem throughout Latin America, intimately related to poverty, urbanization, environmental conditions and many other factors. The current Regional Plan of Action on Food and Nutrition established by PAHO aims to bring down the high prevalence of malnutrition in the region through technical cooperation in the design and execution of interventions targeting food security and the prevention and control of malnutrition problems. The plan includes projects attempting to promote healthy eating behaviors, provide information about food safety and availability and alleviate specific macro- and micro nutrient deficiencies. PAHO is also working to establish an epidemiological surveillance system for monitoring the food and nutrition situation and is committed to supporting human resources training and development and improving communication through an electronic information system. The current program is a necessity and will no doubt have a beneficial impact on the nutritional status of much of the Latin American population. Many issues that are also necessary for improving the nutritional status of the Latin American population, however, remain unacknowledged in the current plan.

Factors Affecting Nutrition

Nutrients alone do not ensure a population safe from malnutrition. Instead, factors leading up to the availability of food and nutrients need to be secure in order for good nutrition to result. Top priority issues in the nutritional status of Latin America need to be rural and community development, connecting farmers to the marketplace, equity of land-ownership and development of a sustainable agriculture system to help the region become more independent of external forces. Together these issues not only improve the nutritional status of the people, but will have the potential to improve environmental and economic conditions, strengthen rural communities, and address human rights in the context of food security, gender issues and land rights.

• Rural Development and Agricultural Sustainability

• Land Ownership

• Opportunity for Small Farmers

• Community Building

• Equity of Food Distribution

• Communication and Information Systems

PAHO’s Role In Improving Nutritional Status In Latin America

The current Food and Nutrition Program initiated by PAHO is handling many of the macro- and micronutrient deficiencies experienced throughout the Region. PAHO should also have a role in improving the agricultural conditions of the Region as well as supporting equity in land ownership and gender issues. In support of the regional plan of action, PAHO should, to the extent of its resources:

• Help countries of the region, when requested, in formulating detailed national agriculture and rural development strategies, policies and plans of action. It should also provide technical assistance, information and advice on policy and planning
• Cooperate with countries to assess the possible harmful impacts of agricultural reform on food security, agricultural production and trade, rural areas and people, and in formulating programs and projects to counter potential adverse effects
• Help mobilize external resources for agriculture from the international community
• Help countries fully integrate environmental resource considerations into agricultural formulation and planning
• Reinforce cooperation with regional intergovernmental organizations working in the sectors of food and agriculture
• Facilitate activities by other subregional, regional and international bodies and help promote technical and economic cooperation among the countries of the region

 

9. Health Education

Introduction

Education has been one of the hallmarks of all nations and societies which have achieved improved health status. Education is one of those human rights necessary for a healthy community. With disparities in education, a community cannot function at its most efficient level thereby leading to problems of physical as well as social ill-health. All societies maintaining high education rates have sustained improved health status for the entire community. Latin American countries have to provide this basic right to their communities before they can hope to envision a healthy society.

 

Opportunities for Prevention by Education

By looking at the problems the current health education system is facing (if there is an existing system) it is possible for PAHO to implement a new health education system. First we have to assess all problems, and people’s beliefs concerning the problems, including the social and cultural aspects. We will also look at different shortcomings and defects that prevent us from implementing a health education system as follows:

• Lack of money: Latin America’s shortage of resources is the main obstacle of implementing a strong health education system. In order to overcome this problem Latin American countries should search for low cost measures to provide health education.
• Lack of respect for local traditions: Most Latin American countries have adopted modern science as the complete answer to health problems. They should strive to incorporate modern and traditional means for low cost and less conflicting ways of changing the old systems.
• Lack of understanding of, and respect for, the environment: In most of Latin America, environmental conditions are rapidly deteriorating. >From standard air and water pollution to all kinds of highly toxic substances, the air and water, the basic needs of life, are becoming increasingly poisonous and unhealthy.
• Lack of innovations: There is frequently a dearth of professionals in the field of science and technology.
• Lack of people’s empowerment: Political systems in Latin America often lack strong democratic traditions and the political will to deal with the problems of the poor is often missing. People, therefore, cannot manage their national resources base or the health and education services offered to them by the state.
• Lack of respect for women: Women and children suffer a range of diseases and health problems, which are not just conditioned by the ecological and economic conditions of women but also by their cultural conditions. Their low status in society may even preclude them from obtaining adequate services from the state even if such services are made available.
• Literacy: Literacy is the main problem striking Latin Americans today. People’s inability to read and write deprive them of knowing and even using the innovation that exists about common diseases and their control mechanisms.

Solutions

Local community workers must be trained as health promoters. By means of this training, sanitation knowledge and actions (vector control, etc.) are multiplied. This idea of "multiplier" and the image of the "exponential" diffusion of knowledge can be used in massive literacy campaigns (see below). The principle of literacy campaigns is that if someone reads and writes sufficiently well, she can offer her knowledge and experience to other people. It is important to note that in the case of literacy projects seeking aims as diverse as education or improved health, the differing objectives affect the reading materials with which one must work.

The health promoters must undergo a highly complex training process because they are not only expected to transmit a series of specific techniques and routines, but to change people’s way of life, which implies changing the way of life of the future promoter herself. It is hard to convince people to quit a habit. When we ask them to stop doing something which seems so simple as a medically defined health risk, actually what we are asking them is to relinquish a highly complex part of their lives. In their view, health education is an attempt to take something away from them, without offering a replacement or appropriate compensation. The health educator must therefore avoid a confrontation between the norms of the knowledge recipient and the demands that the health promoter herself represents. In an effort to encourage people to adopt our suggestion, we often sprinkle liberal quantities of ‘fear-arousal’ as a kind of motivational seasoning of our message. This generates considerable concern but little subsequent behavior change.

Another challenge to be met by the health educators searching for community participation and multiplication of knowledge through the training of local community workers has to do with the search for greater horizontal and dialogue in the relationship between professional personnel and the community. The educator should not propose active methodologies but should help the group to acquire the knowledge by themselves. The education system should be dialogue-based, participatory and integral, in which participants can offer critical opinions and yet avoid unnecessary confrontation with each other. The system should also handle alternative techniques of implementing an effective health education that is particularly suitable for a certain area.

Communication Technologies

In this part we asses what kind of means are available or should be available in order to implement the health education system, and how traditional communication technologies, can be used as a means of health education:

• Mail can be used to send documents and data to near and distant locations, to survey a population or to communicate with individuals or groups. Mass mailing is effective in reaching large populations.
• Telephones represent an instantaneous and relatively inexpensive means of communication. They can be used for individual and group conferences as well as for individual contact or small-groups.
• Fax communication is very effective for the immediate transmission of documents and data via phone line. Documents reach their destination in a matter of minutes or seconds.
• Radio, television and newspaper are very important for mass communication and can be used to get a great deal of information to large groups of people
• Film, videos and slides can be used to communicate to large audiences or small group