Interview: Dr. Mirta Roses Periago, Director of the Pan American Health Organization
IFPRI Forum talks with Dr. Mirta Roses Periago about the relationships between health, agriculture, and poverty in Latin America.
FORUM: What do you see as some of the major challenges facing regional health organizations, such as the Pan American Health Organization, and the people they serve?
Roses Periago: The Latin America and Caribbean (LAC) region contends with four major challenges in public health, namely:
- Changes in health profiles and cumulative lags in health. Health profiles have changed as a result of demographic, epidemiologic, and technological changes that have both required and allowed for new benefits and treatments over increasingly longer human lifetimes, thereby increasing the cost of health services and healthcare expenditures. Cumulative lags in health reveal historical deficiencies and as well as the accrued social debt in terms of access to timely and quality healthcare services. Because it has extremely inequitable income distribution and a high level of exclusion, the LAC region experiences an “epidemiology gap”: non-communicable diseases are sharply rising, while communicable diseases and maternal and child ailments have yet to be satisfactorily resolved and are disproportionately affecting the poor.
- Inequity in, or lack of, access to health services. This deficiency aggravates the burden that exists from geographic, ethnic, and gender-based inequities that are hidden behind regional and national averages and aggregate figures.
- Insufficient and inadequate distribution of public spending on health. A level of public spending on health of between 5 and 6 percent of GDP is needed to achieve universal access to health care services, yet the percentage of public spending on health has essentially remained flat during the past 10 years, at 3.6 percent of GDP for 2004–2005. This problem is aggravated by the absence of mechanisms to ensure that public spending on health benefits the most disadvantaged groups in society. As a result, families endure extremely high out-of-pocket spending on health. Since this expenditure represents a higher proportion of the total income of poor families, health spending—including outlays for medications—ends up being an important cause of the impoverishment of families when chronic or life-threatening diseases quickly turn into catastrophic situations.
- Health threats that arise in the context of globalization or from climate change, with the influenza virus AH1N1 being the latest example of a new and rapidly spreading disease that is linked to globalization. We have already witnessed SARS and avian flu, as well as more frequent and more devastating natural phenomena related to climate change.
FORUM: In a recent declaration, the G8 called for promoting access to healthcare and education in rural areas in order to contribute to productivity and economic growth. In your view, what initiatives and investments are needed to achieve this in Latin America? Would strengthening partnerships between the health and agricultural arenas also help and, if so, how?
Roses Periago: This was one of the main subjects addressed in June 2008, in Brazil, by the Inter-American Meeting at the Ministerial Level on Health and Agriculture (RIMSA 15), convened periodically by the Pan American Health Organization and the Inter-American Institute for Cooperation on Agriculture as a common platform to facilitate dialogue and coordination of intersectoral public policies on food, agriculture, animal and human health, and rural development.
Successful approaches for fighting poverty, neglected diseases, and social inequities—such as regional, national, and local intersectoral strategies designed to reduce poverty and promote local development of health, as well as to create opportunities for rural enterprise (including access to land), particularly among the most neglected and excluded social groups—are presented and analyzed at these meetings. RIMSA 15 endorsed regional initiatives such as “Faces, Voices, and Places,” “Healthy and Productive Communities,” “Rural Microcredit for Women,” and rural agricultural and ecotourism enterprises. It also called for preserving and promoting biodiversity and the agricultural practices of native peoples; rediscovering traditional, local, and indigenous knowledge; and embracing that knowledge and its potential to inform the new practices and lessons learned about food and nutrition security and environmental protection. Improving water and basic sanitation, closing the energy and connectivity gap in rural and border areas, and addressing the uneven distribution of health human resources and the fragmentation of health services, particularly in rural areas, were also highlighted.
The meeting itself is an example of the benefits that partnerships between the health and agricultural sectors can bring to the peoples in the region. With 41 years of intersectoral–interprogramatic cooperation, RIMSA has allowed us to better respond to old and new challenges in the interactions between human health, food security, food safety, and animal health. Examples of common interest policies include the social protection and occupational health of rural workers (pesticides, venomous animals, accidents, and zoonoses) as well as transportation, connectivity, and education which are essential to promote rural development.
FORUM: There is strong evidence that health shocks prevent the extremely poor from escaping poverty. What are some ways in which PAHO is helping to mitigate these shocks?
Roses Periago: We are emphasizing the crucial role of social-protection mechanisms to prevent and/or mitigate these shocks and help to break the poverty cycle. The current crisis has highlighted the relevance of having safety nets and of promoting countercyclical measures to protect and increase social expenditures in order to ensure that the crisis’s negative effects do not permanently thwart the potential for growth. Many studies have shown that policies to provide free care for mothers and children and to establish conditional cash transfers linked to education and health goals are economically and socially sound. Instruments designed to cover catastrophic health expenditures faced by the poorest and unemployed, ensure access to essential medicines packages, and reduce or eliminate financial barriers to school nutrition and healthcare are also very valuable.
FORUM: While the full impacts of the food and financial crises may not be known for years, has PAHO been able to gauge any of the effects on public health?
Roses Periago: This is the first time in a decade that per capita income is declining in Latin America and the Caribbean—by around 3 percent in 2009, and it is likely to remain stagnant for 2010. We are also seeing a reduction in government expenditures for healthcare services as a result of policies seeking to temper the impact of the financial crisis by focusing on temporary job creation rather than on social sectors. Cuts in government expenditures for healthcare services are already being reported in some countries, while others face declines in formal employment (and, consequently, in the number of people affiliated to social security), thus leading to a loss of healthcare protection. Some countries are counteracting these effects by extending healthcare benefits for six months.
Previous economic crises have led to a shift from private out-of pocket expenditures toward increased use of public healthcare services. We do not have final data yet, but this shift will most likely be repeated. Remittance flows, which traditionally help to cover health expenditures, are also declining, by at least 11 percent according to the most recent data.
This is a tough scenario, but much like the ongoing efforts of the financial sector to incorporate fundamental change in the system, we are approaching this crisis as a window of opportunity to reorient public policies toward protecting public health gains, and promoting the idea that measures adopted at this time should pave the road for a more equitable design of public expenditures.
FORUM: Another hot topic is climate change and its impact on the environment. Any thoughts about its impact on health?
Roses Periago: The effects of climate change on health are already here, and they relate to major public health problems. Some of our biggest killers such as malaria, diarrhea, and risk conditions such as undernutrition—the single largest contributor to the global burden of disease—are among diseases that are sensitive to climate. These are also diseases of children and diseases of poverty.
In the Americas, the ever-extended impact of dengue fever and outbreaks of yellow fever have been directly related to climate change, which has widened the reach of vectors to zones that were previously out of bounds to those diseases. The fast expansion of the West Nile virus in the United States and Canada is but another example of this problem —winter is no longer harsh enough to kill the vectors. Indirect effects of climate change on health are clearly present in the destruction and deaths caused by extreme weather events throughout the region.
These effects are bound to intensify over time. Clearly, we need concerted actions at the national and regional levels, and advocating for this has been a constant of PAHO’s technical cooperation, as has been working with our Member States in the emergency and disaster preparedness field, with initiatives such as the Regional Disaster Information Center, the Safe Hospitals Program, and the creation of an Emergency Operations Center and a Regional Disaster Response Team.
At the same time, we are working to increase public awareness about this subject, since support and understanding from the citizenry will be crucial to the success of these endeavors. Fighting the effects of climate change on health will require the participation of each and every one of us, and of society as a whole as opposed to just the public health authorities. The sooner we start doing it, the better.