The Burgeoning Bureau
A Regional Call to Arms
The Right To Health
Toward Health for All
The seeds of what became the Pan American Health Organization were planted in the 19th century, when serious health concerns brought political leaders from throughout the world together at four international sanitary conferences. The first and second held in Paris in 1851 and 1859, the third in Constantinople in 1866, and the fourth in Vienna in 1874. However for the countries of the Americas, these conferences proved disappointing. Since the venues and participants were for the most part European, matters of European concern dominated the agenda. While cholera was a problem on both sides of the Atlantic, the other main scourge affecting the Americas at that time -yellow fever- was of no interest at all in the Old World.
In the 1870s, an epidemic of yellow fever spread from Brazil to Paraguay, Uruguay and Argentina causing more than 15,000 deaths in Buenos Aires alone. In 1878 it reached the United States through maritime contacts, triggering a major outbreak up and down the Mississippi River that resulted in more than 100,000 cases and 20,000 deaths.
It was clear that something had to be done at the international level to combat this disease, and arrangements were made to hold in the Fifth International Conference, this time in the Americas "for the purpose of securing an international system of notification as to the actual sanitary situation of ports and places...." Participants in the Conference, which convened in Washington, DC, in early 1881 included 10 delegates from the Western Hemisphere - mostly diplomats stationed in the United States and "special delegates" experts in medical matters, from four countries.
Among the participants at that conference was Carlos J. Finlay, the special delegate for Spain representing Cuba and Puerto Rico. Finlay brought distinction to an otherwise administrative affair with the announcement, on 18 February 1881, of a major scientific theory: transmission of yellow fever required and intermediate agent. Shortly thereafter he single out the mosquito Aedes aegypti (then called Stegomyia fasciata) as the insect vector of the disease.
Around this time, the movement toward Inter American cooperation was beginning to take shape. In 1890 the First International Conference of American States, held in Washington, DC., had established the International Union of American Republics ( today the Organization of American States) for the initial purpose of collecting and disseminating commercial information. The Second Conference held in Mexico City in October 1901, recommended that the International Union call a "general convention of representatives of the health organizations of the different American republics" to formulate "sanitary agreements and regulations" and to periodically hold health conventions. The general convention should also "designate a permanent executive board of not less than five members" to be know as the "International Sanitary Bureau" with headquarters at Washington, DC.
It followed that the First General International Sanitary Convention of the American Republics whose purpose was to assure effective cooperation in promoting health in the Americas was held in Washington, DC, from 2 to 5 December 1902 with representatives of 11 countries present. To organize a united front against the spread of pestilence and disease that engulfed the Region at the turn of the century. Their determination -both visionary and pragmatic- gave birth to what was to become the oldest, continuously functioning international health agency in the world, The Pan American Sanitary Bureau (PASB). The first Chairman was Dr. Walter Wyman
The Second International Sanitary Convention, which took place in October 1905 again at the New Willard Hotel in Washington, DC., continued to stress the importance of yellow fever, noting the success of control campaigns in Cuba, the Panama Canal Zone and Mexico. Setting and important precedent, the convention resolved that, in event of epidemics, national health authorities would be responsible for quarantine and disease control campaigns
The Third International Sanitary Convention was held in Mexico City in December 1907. They authorized the Pan American Sanitary Bureau to establish relations with the Office International d"HygiŠne Publique and with a touch of New World self-importance "explicitly suggested that European countries adopt the Washington Sanitary Convention of 1905, so that their colonies in the Western Hemisphere would comply with resolutions adopted by the American republics for the control of yellow fever.
The Third Convention also urged that each of the countries set up a committee composed by three medical or health authorities to constitute, under the International Sanitary Bureau in Washington DC "Sanitary Information Committee" whose purpose will be to collect and communicate data related to public health.
At the Fourth International Sanitary Convention, held in San Jose, Costa Rica, from December 1909 to January 1910, the "Convention" in the Governing Body"s name was changed to Conference. From this point on, one notes a marked shift in the nature of those meetings: no longer solely or even primarily interested in quarantine issues, they begin to consider the promotion of health as a whole, including such other health matters as a smallpox vaccine, malaria and tuberculosis campaigns, national health legislation, scientific study of tropical diseases, with emphasis on parasitology and pathologic anatomy, laboratory research into tropical medicine, and general pathology.
The Fifth International Sanitary Conference meeting in Santiago, Chile, in November 1911, recommended that "delegates shall be sanitary authorities in their own countries". The Sixth International Sanitary Conference , scheduled for 1915 was postponed until 1920 due to the outbreak of World War I.
By the time the war ended, the stage has been set for a new era of cooperative progress in health in the Americas Scientific knowledge about the cause and spread of many infectious diseases had advance enough to begin to control them, and governments were aware of the urgency of setting up services to protect the public health.
The Burgeoning Bureau 1920-1946
The Americas experienced a period of accelerated economic growth during the 1920"s, as a result of a dramatic expansion of agriculture and industry. Acknowledgment that labor was the indispensable tool for development prompted countries to become increasingly concerned with assuring the health of their work force. In the cultural vacuum left by a crippled Europe, the United States increasingly gained importance in the Region. That country"s permanent role in collaborative efforts to improve people"s health was evidence by the Rockefeller Foundation"s stepped up biomedical research in Latin America. At the start of the decade and during the entire interval between the two world wars, three international health entities coexisted: the Office International d"HygiŠne Publique, the health Section of the League of Nations established in London in 1929, and the Pan American Sanitary Bureau. As time would prove, only the Bureau would survive and grow.
The Sixth International Sanitary Conference of the American republics met in Montevideo, Uruguay, from 12 to 20 December 1920, and elected the U.S. Surgeon General, Dr. Hugh S. Cumming, to head the Bureau, changing the title of his office from Chairman to Director. The Conference then set out to reorganize the Bureau, creating the First Executive Committee. The fundamental role of the Bureau in information exchange with the countries of the Regions explain the importance given to what was at first called the Boletˇn Panamericano de Sanidad, whose maiden issue appeared in May 1922.
The first issue of the Boletin included contributions by authors from throughout the Hemisphere, primarily North Americans, but also Mexicans, Colombians, and Brazilians, among which figured the famous Brazilian scientist, Carlos Chagas. The articles reveal from the outset the wide net that the Bureau cast: leprosy, hookworm, the importance of a good set of teeth, advance in sanitary engineering, diphtheria, water disinfection, yellow fever, syphilis, tuberculosis, industrial hygiene, malaria and goiter. A regular feature was the summary of infectious diseases. And, beginning in 1924, the Boletin published resolutions of the Pan American Sanitary Conference. When the names of the institution"s official organs were change in 1923 from International Sanitary Conference and International Sanitary Bureau to Pan American Sanitary Conference and Pan American Sanitary Bureau, the name of the monthly journal likewise changed to its current title Boletin de la Oficina Sanitaria Panamericana.
During the Bureau first two decades , its resources had been as scant as its scope of operation was narrow. In keeping with the Bureau"s quintessential role as clearinghouse of health information, the Director beginning with his annual report in 1924, summarized the known health conditions in the countries. Two years later, his report informed the Governments of the Bureau"s efforts to set up a statistics service and promote the naming of epidemiologic assistants in the countries, so that they could collaborate with that service.. It is hoped that all countries submit to the Pan American Sanitary Bureau reports on diseases and mortality and that those reports be broad and detailed so as to be of real worth to the activities of the Bureau.
It followed that the Eight Conference, convening in Lima in 1927, established a Directing Council to meet every year to 18 months and to consist of officer and members of the Pan American Sanitary Conference. The first Directing Council of the Bureau (actually a "Meeting of the Officers and members of the Pan American Sanitary Bureau" met from 27 May to 9 June. It drafted the "Constitution and Status of the Pan American Sanitary Bureau" which were approved in 1934 by the Ninth Pan American Sanitary Conference
Health conditions at the outset of the decade, according to the report of the Director for 1930-1931, included plague in Ecuador, Peru, Argentina and Chile; yellow fever, mostly in Brazil; typhus in Bolivia, Brazil, Chile, Mexico, and the United States; undulant fever in the United States; onchocerciasis in Guatemala and Mexico; malaria in many of the countries; tuberculosis and smallpox in practically all of them; measles and whooping cough in all the countries; and an increasing cancer rate death throughout the Region. At their Third Pan American Conference, meeting in Washington DC, in April 1936, the National Directors of Health debated a subject that was to have increasing importance in later years: local health system.
During the early 1940"s the Bureau continued to adapt to changing health conditions in the countries and to the growing public health needs of their populations.. The decrease in incidence of cases and deaths due to quarantinable diseases continued; however, poliomyelitis was on the increase in practically all the countries; typhus and other rickettsial diseases were important problems in the Andean countries and Mexico; outbreaks of smallpox were reported in Argentina, Colombia, Mexico, and Paraguay; Chagas"disease was a problem in most of the countries; two serious outbreaks of cerebrospinal meningitis had occurred in Chile and the United States in 1942; other problems include encephalomyelitis in Colombia, tick-borne relapsing fever in Bolivia, yaws in Ecuador, and measles in El Salvador and Nicaragua.
The emergence of other international agencies dealing with health prompted the Third Meeting of the Ministers of Foreign Affairs of the American Republics, held in Rio de Janeiro, Brazil, in January 1942, to adopt two telling resolutions. First, the Governments of the American Republics should take individually, or by complementary agreements between two or more of them, appropriate steps to deal with problems of public health and sanitation, by providing - in accordance with ability - raw materials, services, and funds. Second, to those ends, they should use the technical aid and advice of the national health service of each country in cooperation with the Pan American Sanitary Bureau. This hemispheric recognition of the accomplishments of the Bureau presage the zeal, shown some years later when the World Health Organization was being created, with which the Governments of the Americas would defend the independence of the Bureau.
A Regional Call to Arms 1946-1958
Once again, but this time more convincingly than ever, the sobering reality of war"s death and destruction convinced the countries of the world that they should seek the means to ensure peace and build a better world. Toward that end, the delegates of 50 nations gathered in San Francisco in 1945 to set up the United Nations. At that United Nations Conference on International organizations, delegates from Brazil and China recommended that "a General Conference be convened within the next few months for the purpose of establishing an international health organization [and that] full consideration should be given to the relationship of such an organization and methods of associating it with other institutions, national as well international, which already exist in the field of health.
In February 1946, the United Nations Economic and Social Council made arrangements for convening a Technical Preparatory Committee for the International Health Conference, the purpose of which would be to create the international health organization. That Committee, meeting in Paris 1946 in March-April 1946, consisted of 16 public health experts - distinguished private citizens rather than official representatives of any particular country - and representatives of four international health organizations.. Participants discussed views concerning the future constitution of a single international health organization and proposed a definitive conference for June. They recommended that instead of "International Health Organization" the name unofficially used until then to refer to the new agency, that "World Health Organization" be adopted. The Technical Committee recommended that the other three organizations represented at the meeting - The Office International d"Hygiene Publique, the Health Organization of the League of Nations, and the Health Division of the United Nations Relief and Rehabilitation Administration - be absorbed into the World health Organization. The Technical Committee deliberated at length as to whether "regional organizations should be integral parts of the central organization" or "amore flexible system" should be sought, allowing for "related autonomous [regional organizations}, established by multilateral intergovernmental agreement and brought into relationship with the World Health Organization. The sole present example of this type of regional health agency is the Pan American Sanitary Bureau. The United States during the International Health Conference convened on June 1946 submitted a resolution advocating the principle of "dual allegiance" in the sense that the Pan American Sanitary Bureau should not only promote regional health programs and undertaking among the American Republics in harmony with the general policies of WHO, but also serve when necessary as its regional committee in the Western Hemisphere.
On 22 July 1946, 61 states signed the Constitution of the World Health Organization. Encompassing a preamble and 19 chapters, with 82 articles, this basic charter of the Organization set forth its overall objective, enumerated its functions, established its central and regional structure, defined its legal status and provided for cooperative relationships between it and the United Nations and other organizations, both government and private, concerned with health matters.
Within months, delegates of 21 American republics met to celebrate the XII Pan American Sanitary Conference, held in Caracas, Venezuela, in January 1947. Although all of them had signed the WHO Constitution, they assertively drew attention to the fact that they want to cooperate with and participate in the World Health Organization, they were not interested in "integrating" the Bureau into WHO - if that meant absorption - and much less in abandoning it altogether. The XII Conference decided to consolidate the Bureau"s separate identity, reorganizing it as the Pan American Sanitary Organization (PASO), with four organs: the Pan American Sanitary Conference, as the supreme governing body of the Organization; the Directing Council with one representative from each Member Countries; the Executive Committee, with seven members elected by the Directing Council and serving for overlapping terms of three years; and the Pan American Sanitary Bureau, the Director and his staff, whose purpose would be to carry out the programs In addition, the XII Conference unanimously elected Dr. Fred L. Soper to be the next Director of the PASO.
The Conference instructed the newly formed Executive Committee to draft a Constitution for the Pan American Sanitary Organization. These instructions were followed, the first meeting of the newly constituted Directing Council being held in Buenos Aires, Argentina in September-October 1947. Comprised of representatives of all Member Countries, the Council adopted a Constitution for the Pan American Sanitary Organization that reflected the situation in the Americas at this historical juncture.
To establish a relationship between the regional and global health bodies, the First Directing Council authorized the Executive Committee to act "as Negotiator with the Negotiating Sub-Committee of the World Health Organization" on the conditions that the Pan American Sanitary Organization should continue to function as an independent identity for the solution of problems of a continental character"
The Council drafted a proposal agreement with WHO that was submitted to the First World Health Assembly in Geneva in 1948, which approved it. On 24 May 1949, the first Director-General of WHO Dr. Brock Chisholm, and the Director of the Bureau, Dr. Soper, signed an agreement formally establishing the relationships between the two organizations. It was approved on 30 June and became effective on 1 July during the Second World Health Assembly. As a result the Bureau was converted into the Regional Office of the World Health Organization, while at the same time maintaining its identity as the Pan American Sanitary Bureau
Yet another relationship, this time within the Inter American system, was due for an overhaul. To clarify their respective roles, the Pan American Health Organization and the Organization of American States signed an agreement in 1950 that established PAHO as a specialized inter-American organization; reaffirmed its autonomy; and defined the principles for mutual relationships, representation, and exchange of information - including commitment by PAHO to take into account recommendations by the OAS Council.
To place the Bureau"s resources closer to their sphere of action, six decentralized zones were set up. Zone I with Headquarters in Washington, DC covered the United States, Canada and the non-self governing territories and had field offices in Jamaica and El Paso; Zone II, in Mexico City, covered Cuba, the Dominican Republic, Haiti and Mexico; Zone III, in Guatemala City, covered the British Honduras (today Belize), Costa Rica, El Salvador, Guatemala, Honduras, Guatemala, Nicaragua and Panama; Zone IV, in Lima, Peru, covered Bolivia, Colombia, Ecuador, Peru and Venezuela; Zone V, in Rio de Janeiro, covered Brazil; and Zone VI, in Buenos Aires, Argentina, covered Argentina, Chile, Paraguay and Uruguay. Each Zone office was a miniature of what the Headquarters was before decentralization - had a medical officer with a degree in Public Health, in some cases more medical officers, a sanitary engineer, a public health nurse, and other staff as programs requirements indicated.
The Organization created several Pan American Centers during this period. The Institute of Nutrition of Central America and Panama (INCAP) was set up in Guatemala in 1946. The Pan American Foot -and- Mouth Disease Center (PANAFTOSA) was established in Rio de Janeiro in 1951 as an hemispheric entity for cooperation in the fight against foot - and - mouth disease. The Pan American Zoonoses Center (CEPANZO) began operations in Buenos Aires in 1956 to promote and strengthen activities against zoonoses in the Americas.
At this time the population of the Americas showed the highest rate of increase in the world, an increase that implied an urgent need for expanded health services, which in turn meant a demand for more trained health workers. To help overcome the countries" shortage of trained personnel, the Bureau organized seminars and special training courses and workshops, awarded fellowships, and helped schools expand their courses.
Whereas in the period from 1902 to 1946, the Bureau and the countries had sought to strike a balance between the threat of spread of infectious diseases and the interruption of international commerce, their focus was now no longer on preventing the passing the diseases from one country to another or on merely controlling them, but on eradicating diseases at their very source.
The Right to Health 1958-1975
Pan Americanism in health developed from the late 1950s to the mids-1970 against an international backdrop of sweeping political, technological, and social change. Politically, competing Soviet Union and U.S. commitments to world revolution and containment played out as a cold war between two blocks - Communist and Western - that for decades threatened to become a hot, nuclear one. The Third World for the most part resisted alignment with either bloc, asserting increasingly greater independence from bipolar balance power. The West Indies Federation came into force, a number of Caribbean islands gained their independence, and the countries of the Americas sought strength in unity by forging greater solidarity through institutions of the inter-American and United Nations systems.
Technologically, the period boasted countless innovations: man orbited space and landed on the moon, invented artificial heart and transplanted a human one, deciphered the DNA double helix, and discover new galaxies.
Socially an era of the "hot line" "hippies" and "minis" students rose up world wide to protest social injustices; environmentalists warned of a "silent spring" wrought by the misused tool of agricultural development; guerrillas waged wars; computers unleashed an electronic revolution; and cigarettes were proven once and for all hazardous to health.
The Region experienced a general economic boom in the late 1950s and during the 1960s. The good times, however, eventually ran their course, and by the mid 1970s worldwide inflation triggered dramatic increases in the cost of food, fuel and materials, bringing a halt to economic growth and widening the breach between rich and poor nations..
The first Latin American Director of the Pan American Sanitary Bureau, Dr. Abraham Horwitz of Chile, elected to office in 1958 by the XV Pan American Sanitary Conference, drew attention to the mounting evidence of the relationship between health and wealth and, conversely, between sickness and poverty. The great challenge to public health today lies in the social environment of most developing countries, where large number of people barely exist, their labor is unproductive; their food always scarce; their house inadequate; their life expectancy short; and their physical, mental, and social health poor and precarious.
At the outset of the 1960s, the Governments of the Americas were gaining a clearer understanding that the problems of economic development was essentially one of rapidly assimilating that vast resources of modern technology to raise the living standards of the broad masses. In signing the Act of Bogot in 1960 the member countries of the Organization of American States fixed the concepts of health policies and programs, set up a Special Fund for Social Development, and agreed to cooperate in promoting accelerated economic and social development and in improving their people"s living conditions.
These commitments were the basis for the Charter of Punta del Este. The Charter affirmed the close interrelationship between natural and human resources on the one hand and progress and social and cultural changes on the other.. The Charter set two general objectives: to increase life expectancy and to enhance the capacity to learn and produce by improving individual and collective health. Its specific objectives included water supply and sanitation, reduction of infant mortality, control of communicable diseases, improvements in nutrition, training and development of health personnel, strengthening of basic services, and intensification of scientific research, with knowledge being used to prevent and cure diseases. The Charter was coupled with the Ten Year Public Health Program of the Alliance for Progress - a juridical instrument that was to serve as framework for national development policies that intimately related health objectives and programs, goals, and action.
By 1960, progress in health had translated into an average five year increase in life expectancy over the preceding decade in five countries: Argentina, Chile, El Salvador, Mexico and Venezuela. Death rates for infectious diseases were 41% lower in 1963 as compared to 1956; those for diseases of the digestive system, mainly gastroenteritis, decreased 35%; and those resulting from ill-defined causes dropped 35%. Because a system of collection and analysis of basic data was critical to determining the magnitude of health problems, their frequency, relative priority, and resources and manpower available to solve them, the Organization stressed the importance of setting up services for vital and health statistics
The Organization stressed efforts to prevent, control, and eradicate both those diseases preventable by vaccines as well as those requiring other methods of prevention and control. While strides had been made in eliminating malaria - deaths caused by the disease had dropped from an annual average of 43,368 in the period 1950 - 1952 to 2,285 in 1964.
Dr. Horwitz convinced as early as 1960 that smallpox can be eradicated from the Americas, orchestrated stepped up activities in the production of vaccine, training of technicians, provision of essential supplies, and organization of eradication programs in the countries. The Region"s last autochthonous case was reported in April 1971 and in 1973 the XII PAHO Directing Council declared the disease eradicated from the Hemisphere.
PAHO continued its efforts to eradicate Aedes Aegypti vector of both yellow fever and dengue. No case of urban yellow fever had been reported since 1954, but the Caribbean was experiencing outbreaks of Dengue. To combat poliomyelitis PAHO collaborated in trials of live attenuated poliovirus vaccine; sponsored two international conferences in 1959 and 1960 for exchange experiences among researchers from throughout the world on biological, immunologic, and epidemiologic aspects of the disease; and assisted in organizing programs and making arrangements for the supply of vaccines and equipment. By the early 1970s, a marked decline in cases of poliomyelitis was being registered.
The Organization also prepared a continental plan to combat tuberculosis, based on the training of specialists, particularly epidemiologists, to program the incorporation of tuberculosis control into local health services; formulation of standards for application of curative and preventive measures; and collection and analysis of information.. In Latin America mortality from tuberculosis by 1973 dropped to one-tenth of what it had been in 1953.
Another cause for concern, leprosy, prompted PAHO to work with countries to intensify case detection and to hold courses in diagnosis and epidemiology of the diseases. Also targets of the PAHO advisory services during these years were other diseases preventable by immunization: measles, whooping cough, tetanus, diphtheria, and typhoid fever; the lingering problem of plague; and such parasitic afflictions as Chagas. Disease and schistosomiasis. Providing abundant water for 11 million people was the major accomplishment of the 1960s. Increases in the countries" populations were outstripping the capacity of hospitals and health centers to provide services. The Organization stressed in the existence in every country of services having the widest possible coverage and the training of professionals and auxiliaries to carry out aims of individual programs and of the health plan as a whole.. The most begging problems continued to be the imbalance between needs and resources, poor utilization of services, and use of inappropriate technology. Moreover, the costs of services were rising; by the end of the 1960s, infrastructure costs represented over 80% of countries" health budgets. A major feature of the Organization"s thrust in the area of health services during this period was its rural strategy targeting some 40% of the population - based on the combined efforts of the motivated and active community; the empirical health worker trained to use simple scientific techniques, and the health auxiliary properly trained to prevent and treat and above all refer to his superiors that which he cannot or should not.
Inherent to the focus on health and development in the 1960s was recognition that the best possible use of available resources a critical factor in development depended on the preparation of professionals and the training of auxiliaries. Dr. Horwitz, calling education an training the most important long term investment for protecting and promoting health.. In support of human resources development, PAHO promoted nurse education in both medical care and in health protection and promotion; increased substantially the number of fellowships awarded with nearly 5,000 awarded in 1970-1973; emphasized preventive medicine in medical education; carried out projects to raise the standards of medical education; launched a study in Colombia aimed at devising a method for determining how many and what kind of personnel a country would need at a given moment and in the future
With the aim of adapting educational technology to the health policy and health system in each country, the Organization helped to establish a Latin American Center for Educational Technology in Rio de Janeiro in 1972 an another in Mexico city in 1973 to develop self teaching and self evaluation instruction methods for training physicians, dentists and nurses.
The PAHO textbook Program placed dozen of clinical textbooks, in Spanish and Portuguese, at the disposal of students of the health professions in the Region, at much lower than commercial prices. A parallel program made diagnostic instruments available to students of the health sciences.
To provide a forum on manpower development issues, in 1966 the Organization launched a quarterly journal for health professionals in the Americas, Educaci˘n m‚dica y salud The focus on information dissemination led to establishment in Sao Paulo in 1967 of the Regional Library of Medicine and Health Sciences (BIREME), which developed a Pan American Network of biomedical and health information that incorporated the US National Library of Medicine data banks.
By the early 1970s, women of childbearing age and children made up two thirds of the population of Latin America and the Caribbean. In support of maternal and child health, immunization programs were stepped up, breast feeding stressed, education of mothers promoted, safe water supply in or near the home urged, and prenatal and perinatal health services emphasized. The Latin American Center for Perinatology and Human Development was established in 1970 in Montevideo with a focus on investigation and application of new methods of pregnancy, delivery and the purpuerium, and in the first 30 days of life.
The relationship between malnutrition and excessive child mortality and mental retardation underlay the Organization"s expanded efforts in the area of nutrition during this period. The institute of Nutrition for Central America and Panama was becoming one of the most outstanding centers in the world for nutrition studies. INCAP research targeted development of a vegetable protein mixture that would be high in nutritive value and inexpensive, The result was INCAPARINA a nutritious as milk but costing one fourth less which began to be mass produced in Central America in the 1960s.
Towards the end of the decade, a consensus among the Governments of the Region urged the formulation of a food and nutrition policy principally concerned with feeding the population. The activities of the Organizations were strengthened by the establishment of the Caribbean Food and Nutrition Institute (CFNI) in Kingston, Jamaica, in 1967 At the begging of the following decade, the Ten-Year Health Plan set targets aimed at substantially reducing malnutrition and totally eliminating it in its severe form.
In 1961, the Director recognized that it is now evident that a long-range research program coordinated by PAHO is needed. That same year the US Public Health Service gave PAHO a grant to set up an Office for Research Coordination, whose charge it would be to carry out projects that investigated medical and social problems characteristic of the Americas.
The PAHO Advisory Committee on Medical Research indicated that the immediate purpose of the Organization"s support of scientific research in Latin America should be the solution of problems with a view to promoting human welfare.
Throughout the 1960 and early 1970, the Organization developed a growing and varied program of research projects in biology, medicine, and the social sciences. Those projects spanned a full range of public health concerns: acute infectious, nutritional states, and sanitation as factors conditioning infant mortality; trial on new drugs for treatment of malaria; use of a live attenuated poliovirus vaccine., etc.
In describing the Organization"s role and, by implication, his own during this period, Dr. Horwitz summarized: "We have given priority throughout our work in the Americas to assuring coverage for all of those who are now without access to minimum health services. We do not accept any discrimination or any compassion in health, of we regard it as a right" That work, in effect, heralded the end of acceptance of a reality best characterized as "health for some" and the beginning of a commitment, the length and breadth of the Hemisphere, to what would soon come to be known as "health for all"
Toward Health for All 1975 - 1983
Health and health care services in the Americas developed in the midst of vertiginous political, economical, and social change from the mid - 1970s to the early 1980s. The course of political progress in Latin America proved tortuous. One country after another suffered military coups that thwarted the cause of democracy. Yet a number of countries in the Region: Dominica, Saint Lucia, Saint Vincent and the Grenadines, Belize, Antigua and Barbuda gained their independence and joined the community of nations, as well as the Pan American Health Organization. The oil crisis that began in 1973 triggered continuing inflation and affected economies throughout the world. Social changes during this period were wide ranging. New environmental concerns about ozone damage and acid rain emerged.
The XIX Pan American Sanitary Conference, meeting in September 1974, elected Dr. Hector R. Acu¤a, of Mexico, to serve as Director of the Organization.
Eight years after the Americas had wiped out smallpox, the World Health Organization announced the global eradication of the disease in 1979. No sooner had one disease been vanquished, however, than another one that would prove devastating beyond calculation appeared: in 1981, scientist identified a new threat to human health -Acquired Immunodeficiency Syndrome (AIDS).
In 1977 the World Health Organization resolved that the main social target of Governments and the Organization for the remainder of the century would be "the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life" .
Toward the close of the decade, an evaluation of the Ten -Year Health Plan pointed out a number of shortcomings in the areas of immunization services, epidemiologic surveillance systems, maternal and child health care, food and nutrition policies, rural water supply, and solid waste disposal. The main problem was that the population was growing at a faster pace than services could be extended. It was deemed that, to close the gap, the health sector would have to both strengthen relations within the sector and broach new ones outside it.
As they had at the beginning of the 1960s and the 1970s, the Governments of the Americas, at the outset of the 1980s, charted the future course of collective health action, this time in pursuit of health for all by formulating national and regional strategies. Together two documents, Health for All by the Year 2000: Strategies (1980) and the Plan of Action for Health for All by the Year 2000 (1980) served as a framework for the Organization"s and the countries" health program for the remainder of the century.
To achieve the extension of services, regional health leaders stressed the importance of formulating and adjusting health policies, improving planning and administration to strengthen the health system, and developing human resources. The Organization designed methods for analyzing, on one hand, sources of financing health programs as well as, on the other, the cost-effectiveness of existing programs. The Organization stressed the development of information systems, so that national health programs could have timely and reliable data to plan, program, administer, and evaluate their programs and projects, as well as management systems to achieve greater equity in access to health services by efficiently administering resources. The Organization continued to provide technical cooperation aimed at diminishing the sickness, death, and disability produced by diseases that could be prevented or controlled, promoting the inclusion of disease control activities into general health and especially primary health care services.
The development in earlier decades of vaccines that prevented the more common and destructive communicable diseases had led to vigorous mass vaccination campaigns. Those campaigns withered, however, as complacency set in when it appeared that the disease had been overcome. By the mid 1970s, a number of those communicable diseases were in fact resurging in many places. In response to this situation, the World Health Organization launched the Expanded Program of Immunization (EPI) in 1977 to provide immunization services for all children in the world by 1990 against diphtheria, tetanus, whooping cough, poliomyelitis, measles, and tuberculosis. The program was directed toward high-risk infants and pregnant women and rested on integrating immunization activities in general health services.
This period of time witnessed major advances in the control of diarrheal diseases, the principal cause of death among infants and children under 5 in more than half of the countries of Latin America and the Caribbean.
Acute respiratory infections continued to be responsible for high mortality in children and ranked among the top three causes of death in those under 1 year of age in 23 countries. To foster measures to prevent these infections, PAHO disseminated information, conducted epidemiologic and operations research, and sponsored meetings and training workshops.
Chronic diseases were causing growing health problems in both developing and developed countries as their population aged, lifestyles became more sedentary, eating habits changed (with the consumption of more fats and sugars) obesity became prevalent, and other risk factors conductive to cardiovascular and chronic respiratory disease increased. PAHO cooperate with the countries by promoting knowledge of noncommunicable diseases; designing programs to control and prevent them, taking into account local conditions, resources, and health care structures; providing training and current information; and arranging extrabudgetary financing to carry out multinational projects to standardized criteria and coordinate activities to control and prevent these diseases.
In an effort to extend urban, periurban, and rural water supply and sanitation services, the Organization helped in conducting feasibility studies and worked with national planners and financial institutions the Inter-American Development Bank, the World Bank, the Canadian International Development Agency, and the United Nations Development Agency. From 1974 to 1977, US$ 1.36 billion roughly half in the form of international loans and half from national funds was invested in water and sewerage systems.
In preparation for the International Drinking Water Supply and Sanitation Decade ( 1981-1990), PAHO stressed the operations and maintenance aimed at improving quality of water supplies, gave training courses, disseminated information, helped develop institutions and manpower, promoted appropriate technology, and support research.
Health in Development 1983 - 1992
Over the past decade, the international scene has witnessed an unending parade of profound and wide- ranging political economic, scientific, and social changes. Seemingly overnight, the cold war thawed and dissolved altogether, with a rapid succession of radical geopolitical events: "glasnost," perestroika" the fall of the Berlin wall, the independence of the erstwhile satellite countries of eastern Europe, the reunification of Germany, and the break-up of the Union of Soviet Socialist Republics into sovereign States. These changes enabled the transition from the largest peacetime arms build-up in history to a major disarmament among First World powers, and the hope that defense cuts worldwide would make possible greater investments in social sectors.
Worldwide scientific and technological progress during these 10 years was promising. Researchers created the first artificially made chromosome, grafting it onto yeast cells; the space shuttle made its maiden flight; and the first transatlantic optic fiber telephone cable entered service. Computer technology continued to advance at a dizzying pace, launching the compact disc, the microcomputer cum mouse, the silicon microchip, a "transputer" that enabled computers to parallel process information, and a portable computer weighing less than two pounds.
The health field likewise registered many firsts. United States and French teams independently discovered the AIDS virus; surgeons used laser to clean out clogged arteries; and medical researchers achieved the first triple heart, lung and liver transplant, implanted the first plutonium powered pacemaker, performed the first brain cell transplant, and administered the first gene therapy to a human being. But nature continued to mock the progress wrought by man, unleashing a succession of major disasters during these years.
The United Nations estimated in 1988 that the world population was growing by 220,000 a day and, in 1990 predicted that it would rise from 5 billion to 14.2 billion in 2100. The population of the Americas reached 735 million in 1991 and was estimated to top 835 million in the year 2000. Almost three fourths of the population is now living in urban areas, and the urbanization trend will continue: it is estimated that by the century"s close some 100 cities in Latin America will have more than 4 million. Migrations resulting from the quest for greater opportunity or, in the case of some Central American countries, the escape from armed conflict became an important demographic phenomenon. One aspect of migratory movements in the Region was refugees: between 1985 and 1990 their number grew from 360,000 to 1,200.000.
This rapid increase of the population and the massive growth of major cities created serious problems of infrastructure shortages, pollution, unemployment, violence, insecurity, and marginality bringing with them greater demands for health services. In general, health conditions reflected poverty related problems, including communicable diseases and malnutrition, accompanied by an increase in degenerative problems and in risks. Health services systems encountered serious operating capacity difficulties, which were compounded by waste in the utilization of resources. The work of multiplicity of health care delivery institutions was generally not well coordinated, trained personnel were short in supply and misused, and health care coverage was insufficient, 30 % to 40% of the population had no access to basic health services.
To cope with this situation the countries sought to adjust and strengthen planning and administration to improve the sector"s ability to mobilize, organize, and utilize resources in harmony with those of other development sectors.
In 1982, the XXI Pan American Sanitary Conference elected a new Director, Dr. Carlyle Guerra de Macedo, of Brazil, and in 1986 and 1990 the XXII and the XXIII Conferences reelected him.
In light of the challenges posed by changing political, economic, and social conditions in the Region over this 10-year period, the Organization set out to reorient the thrust of its work. It adopted a series of policies aimed at improving people"s health, transforming health service infrastructures, and furthering the relationship between health and development
Overarching all other policy considerations during the course of these 10 years has been the focus on health in development In a world marked by deeply differences and beset by social, economic, and political conflicts, health as an area of human endeavor can and should be used as a bridge connecting all peoples in the common effort to attain peace, understanding, tolerance, and justice. It is recognized that, in order for health services to support those values, the way health is integrated into socioeconomic development has to be revised.
The Organization considered it indispensable that health services be organized and administered in accordance with the principles and values of health for all and primary care: equity, universal coverage, participation, and efficiency. Extreme poverty and the disparities in access to health services among different social groups had to be reduced. Health services should be reoriented to allow each individual to live a socially and economically productive life.
Comprehensive health care requires that the countries overhaul their health systems. In response to those systems excessive centralization, which hinders the expansion of health services delivery, the Governing Bodies endorsed the concept of decentralization through the development and strengthening of local health systems in an effort to establish authority, responsibility, and accountability at the local level, where health services can directly respond to people"s health needs.
A keystone to the transformation of health systems is the management of knowledge, and the Organization encouraged stimulation of the cycle of production, collection, critical analysis, and application of knowledge. At the same time social communication with health information provided though mass media, schools and community forums enables an informed public to seek individual and collective health and to support local health systems.
To enhance technical cooperation among countries, PAHO promoted a number of sub regional initiatives. A Plan for Priority Health Needs in central America and Panama was adopted by the Ministers of Health of that sub region in March 1984. A major regional meeting of epidemiologists, health administrators, and planners, held in Buenos Aires in 1983, reviewed the uses and prospects for the practices of epidemiology and concluded that countries continued to need encouragement to assess the population"s health status, its determinants, and trends and that national capabilities for evaluating the effectiveness and impact of health service systems and programs for health promotion and disease prevention still required urgent attention. In 1986 PAHO set up a new program, health situation and trend assessment, that promoted the use of epidemiology as an instrument in the planning and technical administrative management of services and as an essential element for understanding the factors that influence changes in the health profiles of populations, changes that would in turn influence the allocation of resources for health and decisions on health policies and programs. Countries progressed in the complex task to establishing epidemiologic profiles on which to base preventive interventions and develop local health systems.
Disease control area became progressively more proactive over these ten years, as the Organization committed to attacking the communicable diseases that threatened human health, with the aim of eradicating some and eliminating others. In 1985, in order to speed up measures for the eradication of poliomyelitis it was proposed by the PAHO a plan of action to halt the transmission of the wild poliomyelitis virus in the Americas. The Region"s last poliomyelitis case was reported in August 1991, and that progress prompted the PAHO Governing Bodies, in 1992 to request the Director to initiate a plan for certifying eradication of the disease from the Americas. The rapid decrease in the incidence of neonatal tetanus led the Governments of the Region to agree to a strategy for eliminating that disease during this decade, and a number of countries proposed eliminating measles as well by the end of the century.
Malaria continued to cause great and growing concern, as the number of new cases increased year by year, exceeding 1 million in 1990. PAHO promoted active case detection, epidemiologic mapping of relative incidence and risk factors on which to base malaria control activities, research and training. The Government Bodies reaffirmed the Aedes aegypti control policy and recommendations intensifying programs for the control of dengue and jungle yellow fever, in light of the fact that a number of countries continued to report cases of those disease.
In the mid 1980, the technology for preventing, diagnosing, and treating tuberculosis had reduced the problem by nearly 10% per year in some countries and 5% per year for the Region as a whole. By 1990, however, some countries were registering increases in incidence of the disease, which was complicated by its close relationship with HIV infection. The spread of the IADS epidemic in the Americas led to formal creation, in 1987, of a program to prevent and control the disease. By 1992 the situation was serious and worsening. Of the 430,000 cases of AIDS reported to WHO up through December 1991, 250,000 (58% of the total) were from the Americas. Conservative estimates were that more than 2 million people in the Region were infected with HIV"1 million in the United States, 750,000 in Brazil, and 370 in the rest of the countries.
Cooperation was based on establishing laboratory networks, supporting laboratory operation, and monitoring and improving national and regional case surveillance. PAHO provided the countries technical guidelines for AIDS prevention and helped emerging national prevention and control programs.
The Organization focused on an integrated approach to preventing and treating cancer, cardiovascular diseases, diabetes, and other noncommunicable diseases by promoting healthy lifestyles, strengthening health services for adults and the elderly, and identifying the most effective interaction. PAHO stressed the importance of linking hypertension control with general health services, gave cooperation to countries in the formulation of arterial hypertension control programs.
The Organization recognized that the societies of Latin America and the Caribbean face an enormous challenge if they want to approach the goals of health, rise their health standards and reduce inequities among and within countries. The health sector is not alone in confronting this challenge, particularly since many existing problems cannot be lessened, much less solved, without the combined efforts of most State"s sectors and the total support of all society.
In light of that recognition,
PAHO will work to effect changes directed toward achieving equity and eliminating
wide disparities in health care..