07392 Foundry_Eng 8/1/03 1:19 PM Page 1

Volume 8 No. 2 • 2003

The Magazine of the Pan American Health Organization Regional Office of the World Health Organization

in the www.paho.org VaccinationAmericas Week 07392 Foundry_Eng8/1/031:19PMPage2 Perspectives in Health • Volume 8 No. 2 • 2003 First Word think ofprimar to be—isastrategyfortransfor tive ofAlma-AtabyDavidT his fr the confer car ter ment, theyr as strangersbutwithmedicalhistoriesalr unpr ple, pr gr Or their peoples’healthasanissueofhumanrights.Itisourfor Ata, Kazakhstan,focusedworldwideattentiononther Alma-Ata andinthesubsequentquar Primar Fur Or health car we ar tar 50–80 per health car the deter in hospitals.Somealsorightlyemphasizedthatintersectorialactionwasneededtoaddr people intheirhomesandcommunities,of Impor posite ofhospitalcar accompanies themintheirdevelopment. an integratedhealthsystemthatr r tem. Theideaisthatthisshouldtakeplacenotatthehospitalandwhenapatiental to thefi Ata’ “Health forAll,”withlar to transfor on itssuccessandfailur health car gr health car sur in thehandsofhealthpr cialists ar quality thanhospitalcar ter eady ill,butbefor eat inter ound inthe1980s. 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Inthese25years,wehaveseenmajorincr e isallabout.Mor ence’ cent ofourcountries’healthbudgetsr est tomanyofourr m ourcountries’healthsystems.Infartoomanycases,wehave theoppositeof e, becausehospitalsar etur y healthcar y healthcar s goalof“HealthforAllbytheY y HealthCar AHO) willusetheoccasionof25thanniversar n totheircommunities,wher national Confer e andinor ecting CouncilmeetingthisSeptember e. Thisintur e impor efor e, whichisseenasmor es andtor ge sectorsofourpopulationsalmosttotallyexcluded.UntilAlma- e wasforitspr omoters andvolunteersratherthanmor e inasmuchneedoftransfor e assynonymouswithr . T m, peoplewer ticularly inhumanr e, thatis,people’ ence’ eover ely lost,however ejada, ar ejada, for tant workthatwascar der topr ming thehealthcar eaders, aswillhisanalysisofwhywehavenotfullyachieved y healthcar med ourhealthsystems,wewouldneverhavelostsomuch der topr ence onPrimar eaches outtoindividuals,familiesandcommunities s principalor n hasledtoaper e generallyfoundinurbanar eopen thedebateonprimar , technologicaldevelopmentsmakeitpossibletotake ural andurbanar ter centur e long-timepr event illness.Ef mer deputydir eady knowntothesystem.Aftertheyr oponents atAlma-Ata—andwhatitmustcontinue ogr r e leftonceagainwithoutser e begantodiminish,par y thisout.W e: APendingDebt fsetting thetendencytoconcentrater essively impr e thesystemcontinuestofollowup. s fi e sophisticatedandbetter , isthetransfor y ticipator y HealthCar . 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Hadprimar y healthcar y healthcar y car e andtheneed e in1978.But y healthcar e couldbeleft vices tor ed personnel. lled, wein y’ e isoflower e astheop orld Health s healthsys eceive tr e assumes etr esour y health rive not e r e shar ospec efl efers each eat ces ect ess ess es e. e y y y ------, Health Or “Reprinted fr Published bythePanAmericanHealthOr Reprints: Ar Or Ar continuing inter POSTMASTER: Sendaddr ganization, publishedinEnglishandSpanish.”Reprintsmustcar Its headquar ticles donotnecessarilyr Perspectives inHealth Ar Pan AmericanHealthOr ea ofPublicInfor ganization. Lettersandeditorialqueriesshouldbeaddr name andtwocopiesmustbesentto 525 T W ticles r om © 2003PanAmericanHealthOr ashington, D.C.20037.T Saint V Br Regional Of Perspectives inHealth wenty-thir P Perspectives inHealth W Ar Mir ters islocatedat525T eprinted withper AHO MemberStates W Gilles Collette,Ar yna Br Inter orld HealthOr mando W national publichealthagencyintheworldand Alex W Donna Eber olf Par ta RosesPeriago,Dir Associate Member Antigua andBarbuda T Saint KittsandNevis mation (PIN),PanAmericanHealthOr Dominican Republic net: http://www incent andtheGr fang Guzmán,Designer Obser rinidad andT d Str Fax: (202)974-3663 V United Kingdom The Netherlands epr ticipating States All rightsr ennan, ExecutiveEditor olume 8,No.2 (ISSN 1020-5551) United States ess changesto Puer fi El Salvador esent theof Saint Lucia Costa Rica Guatemala eet, N.W inder Nicaragua Honduras Ar ce fortheAmericasof V Colombia Dominica Suriname Barbados Paraguay Ur Bahamas Por Gr Ecuador Panama Jamaica Guyana (P Canada Mexico enezuela Bolivia France aak, Photographer Belize Brazil Spain Cuba Chile Haiti mission mustcar gentina ver States Per ganization (P AHO) , themagazineofPanAmericanHealth uguay enada to Rico ganization (WHO). tugal • • • • • , Pr wine, Editor ., W u eser fi cial viewpointofthePanAmerican ashington, D.C.20037. el: (202)974-3000 oduction Perspectives inHealth t Dir wenty-thir obago .paho.or ved Perspectives inHealth enadines AHO), theoldest r ector is publishedbythe ganization y thefollowingcr ector g/ d Str essed totheeditor ganization eet, N.W ganization, magazine, r . y author’ edit line: ., s . 07392 Foundry_Eng 8/1/03 1:19 PM Page 1

Features

2 Alma-Ata Revisited by David A. Tejada de Rivero

The first International Conference on Primary Health Care, held in 1978 in Alma-Ata, Kazakhstan, in the former USSR, pledged to achieve “Health for All by the Year 2000.” Now, a quarter-century later, a key participant looks back at the accomplishments of the historic conference...and at what went wrong. contents 8 Love, Tears, Betrayal...and Health Messages Columns by Paula Andaló First Word Latin American soap operas, known as telenovelas, are a wildly popular genre From the Director that has in recent decades crossed over into international markets. While captivating viewers with stories of impossible loves and personal tragedy, they 30 Last Word Lessons from SARS also have proven to be effective agents of social change, transmitting important social and health messages without sacrificing ratings. 32 Mailbox

14 An Act of Love: Vaccination Week in the Americas Text by Manuel Calvit, photos by Armando Waak

Health professionals and volunteers in 19 countries of Latin America and the Caribbean joined forces in early June for the first regionwide Vaccination Week in the Americas. The goal: to immunize children no matter where they live, no matter how hard to reach, leaving no child behind.

22 Cuba’s Jewel of Tropical Medicine by Annmarie Christensen

The Pedro Kourí Institute of Tropical Medicine, Cuba’s preeminent medical- scientific research center, has carved for itself an indispensable niche in the global fight against tropical and infectious diseases. Its 66-year history is partly a family affair. olume 8 No. 2 • 2003

Front cover: V The goal of “Health for All • by the Year 2000” seemed 26 Hasta la Vista, Paradise! attainable back in 1978, by Tony Deyal when the first International Conference on Primary Health Care met in Alma- The worldwide shortage of trained nurses has taken a particular toll on the Ata, Kazakhstan, in the for- Caribbean, where foreign recruiters have succeeded in creating a full-blown mer USSR. Yet 25 years nursing brain drain. Now the region is scrambling to find ways to keep nurses later, the goal remains in significant part unfulfilled. from deserting their tropical island homes for more rewarding careers abroad. Perspectives in Health’s cover story examines the

reasons why. Perspectives in Health

Photo by Cecilia Durand. Courtesy of the Noncommunicable Diseases 1 Unit of the Pan American Health Organization. 07392 Foundry_Eng 8/1/03 1:20 PM Page 2 photo © Powys Dewhurst olume 7 No. 3 • 2002 V • Perspectives in Health ony Deyal

2 2 photo © T

Photos © PAHO/WHO 07392 Foundry_Eng 8/1/03 1:20 PM Page 3

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by David A. Tejada de Rivero

“Health for All by the Year

2000” was an ambitious

and worthy goal. But even

those who formulated it

back in 1978 did not fully

grasp its meaning. No o 3 • 2002

wonder that 25 years later olume 8 No. 2 • 2003 V olumen 7 Númer V • • we have yet to realize all

the dreams of the first

International Conference Perspectives in Health Perspectivas de Salud 33 on Primary Health Care. 07392 Foundry_Eng 8/1/03 1:20 PM Page 4 AHO P his year marks the 25th as a historically new form of confrontation. promote them around the world as the re- anniversary of the first The Cold War was based on extraordinary sponsibility of all countries, rich and poor. International Confer- technological development on the part of ence on Primary the competing parties, as part of an im- A call for action Health Care in Alma- placable economic war whose goal was the Ata, Kazakhstan, an elimination of one of the two superpowers For Mahler and others, “Health for All” event of major histori- (this would eventually happen with the fall was a social and political goal, but above all cal significance. Convened by the World of the Berlin Wall). But within the socialist a battle cry to incite people to action. Its THealth Organization (WHO) and the bloc, there was also a major rivalry between meaning, however, has been misunder- United Nations Children’s Fund the Soviet Union and China. This compe- stood, confused with a simple concept of (UNICEF), Alma-Ata drew representatives tition would prove decisive for the confer- programming that is technical rather than from 134 countries, 67 international orga- ence at Alma-Ata. social and more bureaucratic than political. nizations and many nongovernmental or- ganizations. China, unfortunately, was notably absent. By the end of the three-day event, nearly all of the world’s countries had signed on to an ambitious commitment. The meeting itself, the final Declaration of Alma-Ata and its Recommendations mobilized countries worldwide to embark on a process of slow but steady progress toward the social and political goal of “Health for All.” Since then, Alma-Ata and primary health care have become inseparable terms. A quarter century later, it is useful to look back on the event and its historical con- text—particularly on the theme of “Health for All” in its original sense. For one who was a direct witness to these events, it is clear that the concept has been repeatedly misinterpreted and distorted. It has fallen victim to oversimplification and voguishly facile interpretations, as well as to our men- tal and behavioral conditioning to an obso- lete world model that continues to confuse the concepts of health and integral care with curative medical treatment focused almost entirely on disease. Looking back At the same time, a number of develop- When Mahler proposed “Health for The 1970s saw the cresting of the scien- ing countries had been trying, for a number All” in 1975, he made it clear that he was tific and technological revolution that of years and in various ways, to tackle referring to the need to provide a level of began with the end of World War II, a rev- health problems with limited financial, health that would enable all people with- olution that produced, among other major technological and human resources. Their out exception to live socially and econom- changes, what is today known as globaliza- experiences became the subject of scholarly ically productive lives (today we would say tion. But there was also a recognition of studies in the 1960s and 1970s, with “a minimally dignified standard of living” growing inequality among vast sectors of China, India and some countries of Africa in a context of “truly human develop- olume 8 No. 2 • 2003 V the world’s population. This recognition and Latin America emerging as the most ment”). The reference to the year 2000 • provided the impetus during the 28th and often cited examples. Following the publi- meant that, as of that date, all the world’s 29th World Health Assemblies in 1975–76 cation of some of these studies, WHO— countries would have developed the ap- for the commitment to “Health for All in under the leadership of Director-General propriate political strategies and be carry- the Year 2000.” Halfdan Mahler (1973–88)—responded ing out concrete measures toward Politically, the world was in a state of ide- enthusiastically. Mahler saw clearly the achieving this social goal, albeit within dif-

ological and economic polarization, as well worth of these experiences and began to ferent time frames. ▼ U.S. Senator Edward Kennedy (left) made a surprise Perspectives in Health appearance at the 1978 Alma-Ata conference. At right is then WHO Director-General Halfdan Mahler. 4 07392 Foundry_Eng 8/1/03 1:20 PM Page 5

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The process of conceptual development that involves horizontal, symmetrical and Repeatedly, while I was deputy director- surrounding just what health is was also im- participatory relationships. Atención, in general of WHO, I was forced to keep a portant. In 1946, the new WHO constitu- contrast, is vertical, asymmetrical and never prudent silence when high-level officials tion incorporated a definition of health participatory in a social sense. El cuidado is from a given government would tell me proposed by the Croatian public health pi- intersectorial, while la atención is the work with pride that they had a specific “office” oneer Andrija Stampar. It said health was of a single sector, an institution, isolated or a “national program” for primary care, “a state of complete physical, mental and programs or specific services. or that they had primary care activities only social well-being and not merely the ab- The term “primary” has linguistically di- in the most peripheral health centers. sence of disease or infirmity.” This was a verse and even contradictory meanings. In qualitative leap from earlier concepts, but it Spanish, in particular, some of these are A Soviet proposal was difficult for many government experts nearly opposites. Primario can mean of the time to fully grasp its meaning. “primitive and uncivilized” or “principal or It was at the 28th World Health The Declaration of Alma-Ata repeats this first in order or degree.” As a result of the Assembly, held in 1975, that the urgent definition, adding that health is “a funda- simplistic and biased perceptions of the ex- need for new approaches to health care for mental human right and that the attain- periences on which the concept was based, everyone and by everyone was finally rec- ment of the highest possible level of health it was easier, more comfortable and safer to ognized. This is how the notion of primary is a most important worldwide social goal accept the former meaning, while the spirit health care emerged, and it was a victory whose realization requires the action of of Alma-Ata clearly embraced the latter. for the developing world. Western powers many other social and economic sectors in The Declaration states that primary health accepted this notion, but the Soviet Union addition to the health sector.” opposed it, considering it a step backward Perhaps because of what might be called in scientific and technological progress. professional deformation, it was not really The concept of primary health care has been This showed that the “Flexnerian” model understood that health is a social phenom- had crossed the ideological frontiers of the enon whose determinants cannot be neatly repeatedly misinterpreted and misunderstood. Cold War. separated from other social and economic No one thought about an international determinants. Nor can it be assigned solely For many, it has become synonymous with conference on the subject, however, during to one bureaucratic-administrative sector the 28th assembly; the prevailing wisdom of the state. Nor was it understood suffi- marginal, low-cost treatment for the poor. was that new experiences were needed in ciently—though it was spelled out clearly— this area. that health is, above all, a complex social Then in January 1976, a day before the and political process that requires political meeting of WHO’s Executive Board (prior decision-making not only at the sectorial care “forms an integral part both of the to the 29th World Health Assembly in May level but also by the state, so that these de- country’s health system, of which it is the of that year), Dimitri Venediktov, the pow- cisions are binding upon all sectors without central function and main focus, and of the erful Soviet vice-minister for international exception. overall social and economic development affairs in the Ministry of Health, came to Something else that was quite explicit, of the community.” It was never seen as an see me at my home in Geneva. He pro- but that remains misunderstood, is that isolated part of the health care system, nor posed holding a major international con- health is the responsibility of everyone— was it limited to marginal, low-cost treat- ference on primary health care and offered individuals, social groups and civil society ment for the poor. $2 million as an extraordinary contribution as a whole. In practice, people continued to There is a fundamental difference be- by the Soviet Union. He explained to me be viewed as passive recipients of health ser- tween integral health care for everyone and that the leading socialist power could not vices that emphasize curative medical treat- by everyone—care that is multisectorial allow China a victory within the Third ment of specific illnesses. and multidisciplinary, health-promoting World. His proposal came as a great sur- and preventive, participatory and decen- prise, and my argument that such a confer- he conceptualization of “primary tralized—and low-cost (and lower quality) ence would be premature—and that it health care” was based on erro- curative treatment that is aimed at the should not take place in Moscow—did not Tneous and biased perceptions of the poorest and most marginalized segments of seem to convince him. experiences of Third World countries in the population and, what is worse, pro- Venediktov presented his proposal at the providing health care with limited vided through programs that are parallel to start of the WHO Executive Board meet- olume 8 No. 2 • 2003

resources. In particular, the Chinese exper- the rest of the health-care system without ing and, under considerable pressure, con- V ience with “barefoot doctors” was inter- the direct, active and effective participation ceded that such a conference should take • preted simplistically and superficially. of the population. place in a developing country rather than in As for the concept of “care,” the original In my academic activities I have repeat- the Soviet capital. The idea was formally ac- term in English was translated into Spanish edly stressed this issue, attempting to point cepted four months later at the World as atención rather than cuidado. In Spanish, out what primary health care is not (re- Health Assembly, and the conference was cuidado has a much broader connotation gardless of its name, which can lead to mis- scheduled for 1978. I was designated by than atención, implying something integral taken assumptions), and what it indeed is. the director-general as general coordinator Perspectives in Health

5 07392 Foundry_Eng 8/1/03 1:21 PM Page 6 AHO P Key conclusions in charge of the technical, logistical and po- litical aspects. The task would take me 29 The final Declaration of Alma-Ata contained 10 principal points, which are summarized below. months and several trips to the Soviet The full text of the document can be viewed at http://www.who.int/hpr/archive/docs/almaata.html. Union and other countries. I must acknowledge today that holding a I. Health is a state of complete physical, mental and social well-being and is a fundamental human major international conference was the right. Attaining the highest possible level of health is a worldwide social goal that requires the right thing to do, since it might well have action of many sectors. provided an effective way of promoting a II. The existing gross inequality in people’s health status is unacceptable and is of common concern to much-needed change. In this respect, there all countries and people. III. Economic and social development is essential to attaining health for all, and health is essential to sustained development and world peace. IV. People have the right and duty to participate in planning and implementing health care. V. A main goal of governments and the inter- national community should be the attain- ment by all peoples by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this goal. VI. Primary health care is based on practical, sci- entifically sound and socially acceptable methods and technology made universally accessible through people’s full participation and at a cost that the community and coun- try can afford. It is the central function of the health system and its first level of contact, bringing health care as close as possible to where people live and work. VII. Primary health care evolves from a country’s own conditions and addresses the main health problems in the community. It should lead to progressive improvement of health care for all while giving priority to those most in need. VIII. Governments should formulate policies and plans of action to make primary health care part of a comprehensive national health sys- tem, in coordination with other sectors. This requires political will to mobilize domestic and external resources. is no doubt that my friend Venediktov was IX. The attainment of health in any one country directly concerns and benefits every other country. All a consummate politician. The distortions countries should cooperate in the development and operation of primary health care throughout of the concepts surrounding this subject the world. were not a result of the conference; they X. An acceptable level of health for all people by 2000 can be attained through better use of the must be attributed to a lack of promotion world's resources, much of which is spent on military conflict. and follow-up on the part of the govern- ments and international organizations that olume 8 No. 2 • 2003

V “The International Conference on Primary Health Care calls for urgent and effective national and convened it. • international action to develop and implement primary health care throughout the world and particu- Once Moscow was ruled out, the search larly in developing countries in a spirit of technical cooperation and in keeping with a New International was on for another location in the Third Economic Order. It urges governments, WHO and UNICEF, and other international organizations, as well World to host the conference. It was a dif- as multilateral and bilateral agencies, nongovernmental organizations, funding agencies, all health ficult task, given the economic and logisti- workers and the whole world community…to collaborate in introducing, developing and maintaining cal implications of such an undertaking. primary health care in accordance with the spirit and content of this Declaration.” There was an additional cost of slightly

more than $1 million over the original ▼ Delegates take a break outside Alma-Ata’s monumental Lenin Perspectives in Health Convention Center, with its seating capacity for 3,000 people. 6 www.paho.org 07392 Foundry_Eng 8/1/03 1:21 PM Page 7

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$2 million offered by the Soviets. San José, Working documents were prepared one as GOBI and GOBI-FFF (growth moni- Costa Rica, was discarded when U.S. sup- year ahead of the conference. Following toring, oral rehydration, breastfeeding, im- port could not be secured. Cairo was also consultations with governments and other munization; female education, family rejected when the oil-producing countries organizations, these became official docu- spacing, food supplements), as well as from the region failed to provide the re- ments for the conference’s review and ap- other variations contradicted and distorted quired support. I traveled to Iran to see if proval. The Declaration and Recom- the spirit and concepts of Alma-Ata. Teheran might host the event, but I only mendations went through 18 drafts revised managed to interest the Shah’s sister, in meetings in the six WHO regions, in the A new era Princess Ashraf Pahlavi (she later became Special Meeting of Ministers of Health of one of six vice-presidents of the the Americas in 1977 and in meetings of The conditions that led to the social and conference). Finally, there was no other special country groupings and certain indi- political goal of “Health for All” and to the practical solution than to select a city in the vidual countries as well. The conference strategy of primary health care still exist Soviet Union other than Moscow. was prepared as an open, decentralized, and are, indeed, even more pronounced. Venediktov and I discussed possible democratic and participatory process, There remain gaping inequities and social venues and traveled together to Baku, though this was never formally declared. injustice that leave large segments of the Tajikistan and Alma-Ata. The decision had The draft that was officially presented population without integral health care. to be made by the Soviet government, and contained a few changes that, in hindsight, Poverty is on the rise, and the few resources I only made a detailed chart of the mini- that societies have for education and health mum physical and logistical requirements. are invested and spent in misguided and But once again my friend Venediktov There are still gaping inequities and social unfair ways. The confusion between health taught me a lesson in political management. and curative medical treatment that is fo- At all three sites he introduced me as the injustice that leave many without integral cused on a few diseases inexplicably still person who would make the final decision. prevails. Health systems have not been de- The choice of Alma-Ata was due to two health care. Perhaps it is time for an centralized effectively, and both “citi- fundamental considerations: the dynamism zen participation” and “social control” in and leadership of Kazakhstan’s minister of Alma-Ata II, to reexamine the original health remain distorted concepts. health, and the feasibility of having the re- In today’s globalized, unipolar world, quired physical infrastructure ready on concepts behind the call for “Health for All.” where national sovereignty is increasingly short notice. Alma-Ata, which means threatened, one of the few ways in which “father of the apples,” was in the republic countries can still control their own destiny where the Soviet Union had its Cold War contributed to the later distortion of the is through the development of genuine, space programs. It was also next to China. original concepts. Many delegations and decentralized and participatory democra- The work undertaken by the govern- individual delegates fought to include de- cies. Nowadays it is essential to transfer, or ment and the Ministry of Health of tails that had more to do with medical spe- rather, to return political power for social Kazakhstan was truly extraordinary. In the cialties than with health. decision-making to its point of origin, that space of a year, they built, among other It was important that the conference was is, the citizenry. Integral health care for all things, a hotel with 1,000 beds. The mag- cohosted and jointly organized with and by all—perhaps the best way to phrase nificent Lenin Convention Center, with its UNICEF. This was difficult at the begin- Alma-Ata’s call for genuine primary health auditorium for 3,000 people, had a simul- ning, but the work done by two key care—is a necessity not only for health but taneous interpretation system and ear- UNICEF representatives, Richard also for the future of countries that aspire phones at each seat. However, the Hayward and Newton Bowles, was instru- to remain sovereign nation states in an in- communications system was one-way— mental in winning over Henry R. creasingly unjust world. that is, from the podium to the delegates Labouisse, then executive director, and se- There have been major global changes and not vice versa—so another system had curing the active participation of the and many important new experiences in to be brought in from Italy. agency. I still consider it a privilege to have the world during the 25 years since the first Other problems were solved in the worked so closely with UNICEF and to International Conference on Primary course of several trips. To facilitate immi- have continued that close collaboration Health Care. Perhaps it is time now to con- gration and customs procedures in until my departure from WHO. vene an Alma-Ata II, to set forth again, Moscow and Alma-Ata, we flew in the en- It is regrettable that afterward the impa- without distortions, the original concepts olume 8 No. 2 • 2003

tire staff of the WHO secretariat; it took tience of some international agencies, both that led to that conference in 1978. V two airplanes. But in the end, everything U.N. and private, and their emphasis on • proceeded without delay. U.S. Senator achieving tangible results instead of pro- Edward Kennedy, who arrived at the last moting change—something that is always David A. Tejada de Rivero was minute and not as an official member of difficult—led to major distortions of the deputy director-general of the World Health Organization from the U.S. delegation, was well received. His original concept of primary health care. So- 1974 to 1985 and twice served as presence demonstrated the political impor- called “selective primary health care” and minister of health of Peru. tance the conference had achieved. packages of “low-cost interventions,” such Perspectives in Health

7 07392 Foundry_Eng 8/1/03 1:21 PM Page 8 olume 8 No. 2 • 2003 V •

▼ Tony Dominguez tells his fiancée, Kristen Forrester, that he has tested positive for the AIDS virus, on the CBS daytime drama The Bold and the Beautiful. The two later marry and travel to Africa to adopt an AIDS orphan. Like U.S. soap operas, Latin America’s telenovelas are increasingly tackling health and social themes along with more traditional fare. Perspectives in Health

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Latin America’s telenovelas have long captivated TV audiences with their overwrought stories of love and betrayal, sin and punishment, and triumph over adversity. But for public health advocates, they also are an ideal medium for transmitting positive messages about healthier living.

by Paula Andaló

osé Alfredo, a handsome young Mexican, has been confined to a wheelchair since an accident two years ago. But he hasn’t let it get him down. He still plays basketball, he runs his own shoe store, and he recently married a beautiful woman. His motto is: “You’re only defeated when you feel defeated.” Julia, an Argentine housewife, is fed up with her husband’s physical abuse. After 15 years, she summons the courage to report him to the police and demand a di- vorce, completely changing her life. Capitú, a young Brazilian woman, holds a condom in front of her partner and with a single gesture makes it clear that Jthey’ll make love using protection—or not at all. They are all fictional characters, appearing in scenes from the Latin American soap op- eras Entre el amor y el odio (Between Love and Hate), Sin marido (Husbandless) and Lazos de Sangre (Blood Ties). Their stories, however, mirror the lives of real men and women and thus provide a powerful medium for transmitting positive messages on important issues of public health. Soap operas, and their Latin American counterparts, known as telenovelas, are among television’s most widely watched genres worldwide. “There are data from a number of countries on their impact, not just in commercial terms but also in terms of their cultural olume 8 No. 2 • 2003 and social importance,” says Nora Mazziotti, professor of communication sciences at the V • University of Buenos Aires and author of The Telenovela Industry. Photo courtesy John Paschal International The first telenovelas—which differ from U.S. soap operas in that each begins and ends within about a year’s time—appeared in the 1960s, when a group of Cuban screenwriters led by Delia Fiallo began adapting radio theater stories for use on television. From the out- set these stories, with themes taken from classical tragedy—betrayal, forbidden love, pun- ishment—captivated television audiences throughout Latin America. Perspectives in Health

9 07392 Foundry_Eng 8/1/03 1:21 PM Page 10 AHO P In the late 1980s, these Latin soap operas toward deeper social themes, providing a began to cross over beyond Spanish-speak- subtle but effective guide for public opin- Brazilians give ing audiences in North and South America ion on sometimes controversial matters of to viewers overseas. In China, for example, public health while promoting a healthier for life some 450 million viewers followed the and more ethical society. Brazil’s TV Globo network has been incorpora- Brazilian telenovela La esclava Isaura ting social themes into its telenovelas since 1990. (Isaura, the Slave). Seven out of 10 The power According to the most recent edition of its annual Russians tuned in regularly to Mexico’s Los of fiction report Social Marketing: Entertainment Serving ricos también lloran (The Rich Also Cry), Social Good, in 2002 more than a thousand epi- and the Venezuelan series, Cristal—about An early indication of telenovelas’ enor- sodes of telenovelas included social themes, rang- a young small-town woman in the big mous potential came in 1986, when a ing from condom use and organ donation to city—ran seven seasons, with the final character on Venezuela’s Cristal was diag- caring for the environment. episode drawing some 11 million fans. nosed with breast cancer. The episode led To demonstrate telenovelas’ potential for pro- Telenovelas’ larger-than-life story lines to an avalanche of female patients getting moting social change, TV Globo producers carried may be exaggerated renditions of real-life check-ups in Venezuela and in Spain, out a study in which they tracked changes in dramas, but many viewers see their own where the series also aired. But there were health services during the airing of Lazos de lives reflected in those of their favorite even earlier experiences. In Entertainment Sangre (Blood Ties), whose protagonist, Camila, stars. They identify themselves and others Education: A Communication Strategy for was diagnosed with leukemia. The study, titled they know with various characters and are Social Change, Everett Rogers and Arvind “The Camila Effect,” found that in November 2000, drawn in by the compelling twists and Singhal analyze the success of Simplemente during the show’s early episodes, Brazil’s National turns of overwrought plots. Thus, model- María (Simply Maria), the story of a Registry of Bone Marrow Donors reported an ing a behavior they see on screen is almost Peruvian country woman who moves to average of 20 new registrations per month. In natural. the city, becomes pregnant, is betrayed and January 2001, when the leukemia plot had be- No wonder then that beginning in the must carry and give birth to her baby come more established, there were 900 new regis- 1970s professional health communicators alone. After the show aired in Peru in trations. Similarly, “Disque Salud,” a Ministry of in Latin America decided to insert positive 1969 (it was readapted later in several Health call-in service that provides information health and life-skills messages among the other countries), there was a marked in- and referrals for organ and blood donation, re- tears, betrayals and star-crossed love affairs. crease in enrollment in classes for literacy ceived 67 calls in November 2000 but 458 by At first, the messages were basic, almost in- and sewing—the two things that helped January 2001. The Hematology Institute of Rio de tuitive, such as “smoking is bad” or “you Maria overcome her obstacles and move Janeiro registered 10 blood donors in November need an education to make something of on in life. Unintentionally, Simply Maria 2000 but 154 the following January. yourself.” Over time they have evolved had produced social change. During the airing of El Clon (The Clon), which dealt with drug addiction, calls to the National Anti-Drug Society of Brazil increased from 900 in January 2002 to 6,000 in May of the same year. Other organizations working on drug dependency observed increases of up to 120 percent in calls requesting information and help. Responding to such success, producers, writers and public health advocates have been working together to reinforce health themes through week-long public awareness campaigns aired in conjunction with the telenovelas. El Beso del Vampiro (Kiss of the Vampire), for example, was aired the same week as International Blood Donation Day. tesy Miguel Sabido Photo cour olume 8 No. 2 • 2003 V •

Los hijos de nadie (Nobody’s Children) was among Mexico’s “telenovelas for development.“ The show sparked a national debate about abandoned children. Perspectives in Health

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Observing these successes, Miguel De cuerpo y alma (Of Body and Spirit) Southern California (USC) is working Sabido, former vice-president of the about the need for a heart donation. with the Centers for Disease Control and Mexican network Televisa and a pioneer in Perez notes that while telenovelas can- Prevention (CDC) to train screenwriters “edutainment,” produced a series of seven not singlehandedly solve social problems, and producers on health issues. Recently, programs between 1975 and 1978, so- they can make a significant contribution. the Pan American Health Organization called “telenovelas for development,” that “When telenovelas spark national interest, (PAHO) helped Suriname import the combined education and entertainment. organizations working on the same issues South African soap Soul City, whose plots One, titled Caminemos (Let’s Go), pro- should take advantage of the heightened cover such issues as AIDS, teenage preg- moted sexual responsibility among adoles- interest and carry out public-awareness nancy and drug addiction. (See sidebar cents. Nosotras las mujeres (We Women) campaigns,” she says. page 12.) promoted the notion of gender equality in Currently, the Hollywood, Health and Mexican society and Ven Conmigo (Come Society program at the University of Breaking the with Me) encouraged adult education. pattern “My intention was to have commercial television produce social benefits through As health themes have gained ground on telenovelas, which are viewed by the very As Camila, of Blood Ties, battled leukemia, the soap scene, two types of programs have people who most need to become better Brazil saw a dramatic increase in blood and emerged: telenovelas produced specifically informed,” says Sabido. “I wanted to pro- to promote a particular message and those vide those viewers with the tools they need bone marrow donor registrations. that include health themes in the context to improve their own lives. I set up study of a larger plot. Both types have been groups to analyze behaviors and ways of growing in number as well as shifting their incorporating positive messages without focus as awareness of social and public betraying the rules of the genre. I capital- health issues has increased. Many early ized on the shows’ capacity for moral re- telenovelas followed a “good vs. bad” flection about good and evil and showed model: the bad guys were the ones in- how all this could be done without hurt- fected with HIV (for example, in the ing their ratings.” Argentine program Celeste, starring In 1994, Colombia’s Ministry of Health Andrea del Boca), and unwanted preg- coproduced Santa María del Olvido (Saint nancy was punishment for a night of sex Mary the Forgotten), a telenovela about so- out of wedlock—an error the heroine paid cial and health issues aimed at a female au- for over the course of the next 300 dience. Last year, officials from Brazil’s episodes. Ministry of Health acknowledged that the A new generation of screenwriters is now theme of drug addiction in TV Globo’s El producing what they call “breaking-the- clon (The Clone) in 2001 had done more pattern telenovelas.” Pushing the message- for the prevention and treatment of drug placement envelope, they have tackled such dependency than many government cam- high-impact issues as urban violence, politi- paigns. As the troubled young Mel cal corruption, AIDS and even trafficking in watched his life fall apart because of drug human organs in series such as Colombia’s abuse, the show’s screenwriters inserted La mujer del presidente (The President’s snippets of testimony from real-life drug Wife) in 1998 and Amores perros (Love’s a addicts between the dramatized scenes. Bitch) in 1999, Brazil’s Nada personal “It occurred to me that testimony from (Nothing Personal) in 1997 and Argentina’s people who were really suffering from Resistiré (I Will Resist) in 2003. drug problems would be more effective Telenovelas still have their retrograde and less moralistic than psychologists bab- moments, with lines such as: “Look how bling about how bad drugs are,” says you treat your husband; no wonder he screenwriter Gloria Perez. More than 45 beats you,” spoken by a female character in million viewers watched the telenovela’s Venezuela’s Telefutura production Angé- olume 8 No. 2 • 2003

final episode. lica pecado (Angelica Sin). But positive V In Brazil’s Blood Ties (2000), Camila, treatments of these issues are now much • the star, needed blood and bone marrow more the rule. For example, Brazil’s donations to help her fight leukemia. In Mujeres apasionadas (Passionate Women) the days following the leukemia episode, deals with the issue of domestic violence in interest in real-life donations increased a very different way: It is no longer stigma- dramatically. (See sidebar opposite page.) tized, and its treatment mirrors real life. A similar result followed a 1992 episode of This, coupled with evening airing hours, Perspectives in Health

tesy TV Globo 11 Photos cour 07392 Foundry_Eng 8/1/03 1:21 PM Page 12 AHO P From Mexico to India, using telenovelas for social education

Just as ratings confirm the success of telenovela In Kenya in 1987, the telenovela Tushauriane that audiences are likely to identify with. Produced in story lines, the impact of social messages in telenove- (Let’s Talk About It) and the radio program Ushik- both English and Zulu, the program has proven to be las can be demonstrated quantitatively. Following wapo Shikamana (If Assisted, Assist Yourself) were a useful public health tool in countries throughout the nine months of episodes developing the theme of aired with the aim of getting men to be more open- continent. family planning in the 1977 Mexican telenovela minded about their wives’ practicing family planning. In view of this success, in 2002 the Pan American Acompáñame (Accompany Me), the country’s They became two of the most popular shows on Health Organization (PAHO), through its country National Council on Population (CONAPO) reported Voice of Kenya. By their conclusions, contraceptive office in Suriname, decided to import a children’s ver- the following results: use had increased some 58 percent in the country, sion of the show, titled Soul Buddyz. According to • The average number of telephone callers and the average family size considered as ideal Carol Vlassoff, then PAHO representative in Suriname, requesting information on family planning among Kenyans had declined from six children to the program is directed at children between the ages rose from a handful to 500 per month. Many of the callers referred directly to Accompany Me. • More than 2,000 women volunteered to work in a national family planning program, appar-

ently in response to the show’s promotion of tesy Fonovideo social work. • Sales of birth control pills rose 23 percent in Photo cour one year, compared with a 7 percent increase the previous year. • More than 560,000 women signed up to participate in family planning programs in clinics, a 33 percent increase over sign-ups before the show. The “Sabido model” has been successfully applied outside Latin America as well. The Mexican experi- ence was adapted for use first by Population Com- munications International (PCI) and later by the Popu- lation Media Center (PMC), organizations that work at the global level to promote education in family planning, prevention of sexually transmitted dis- eases, reproductive health and gender equity. PMC has used “telenovelas for development” in India, Ethiopia, Kenya, Côte d’Ivoire, Malawi, Burkina Faso, Nigeria, Rwanda, Sudan and Swaziland. During In Gata Salvaje (Wildcat), the character Adriana loses her baby. The Fonovideo production preproduction, experts analyze the cultural norms of each country and then adapt the stories to local cul- incorporates a number of medical situations that illustrate how hospitals function. tures, increasing the messages’ chances for success. PMC president William Ryerson believes telenove- four. In addition, a study of rural health centers by of 8 and 12. Studies done after the show aired found las are an excellent way to promote positive health the University of Nairobi’s School of Journalism a significant impact on children’s knowledge and atti- messages, “much better than single-episode shows, found that women were more likely to seek birth tudes about such topics as empowerment of girls and since their extension through time allows the audi- control after hearing and seeing the programs. In discrimination against children with disabilities. ence to forge bonds with the characters and get Côte d’Ivoire, the show Sida dans la cité (AIDS in the Today Soul City is airing in Suriname as part of a involved with their thoughts and actions, creating City) was watched by 75 percent of the population in joint edutainment project involving Suriname and strong emotional ties.” 1988—perhaps not surprising in a country where South Africa. PAHO has sponsored meetings in Para- Studies in Mexico, India and several African 640,000 people are HIV-positive. maribo and Johannesburg to gather lessons from

olume 8 No. 2 • 2003 nations also confirm the genre’s potential. One study, The Soul City Institute for Health and Develop- the South African experience and to provide guid- V

• headed by PMC president Ryerson and funded by the ment Communication was launched in South Africa in ance for the show’s African producers on gender Rockefeller Foundation, looked at Humraachi (Come 1992 to effect social change through mass media issues. As part of the same initiative, PAHO is spon- Along With Me), an Indian telenovela that aired in “edutainment” projects. Its flagship production is the soring surveys among Surinamese youth for use in 1992. The study found that people who watched the soap opera Soul City, which features public health developing a local pilot show titled Sabana Pasi show regularly changed their attitudes about the themes such as prevention of sexually transmitted (Savannah Road), which will incorporate health pro- ideal marrying age and the acceptability of women in diseases and HIV. The show’s preproduction team ana- motion and disease prevention topics of particular the work force, two central themes of the story. lyzes societal attitudes and interests and designs plots interest in Suriname. Perspectives in Health

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has helped the show capture a growing health issues that can be included in future their rights and responsibilities to become male audience along with the usual females. episodes. To encourage the practice, the a healthier population. The key to success for health messages CDC awards an annual Sentinel for Health Nearly 35 years have passed since the in telenovelas is to preserve the centrality Award to daily soap operas that “inform, heroine of Simply Maria arrived alone in of the fictional narrative, according to educate and motivate viewers to make the big city with little more than her own Argentine expert Nora Mazziotti. choices for healthier and safer lives.” hopes. She gave birth to unwanted chil- “When the story gets lost and the mes- In April in Miami, the First World dren, was betrayed by lovers, turned out to sage is not interwoven with the narrative, Summit of the Telenovela Industry, spon- have a rich biological father, became an people don’t like it,” she says. “The mes- sored by TV Más magazine, included heiress and lived the life of a lover, wife, sage has to be attractive and easy to under- health message placement in its agenda. mother and perpetual victim of those who stand.” She favors an unobtrusive approach (Since 1995, annual Soap Summits have envied her goodness and beauty. Thirty- akin to for-profit product placement. been held to encourage social and health five years ago, Maria dared to get an edu- “Episodes involving health issues always messages in the U.S. daytime shows.) cation to improve her lot. Today’s

“Telenovelas are viewed by the people who

tesy TV Globo most need to be better informed. With their

Photo cour capacity for moral reflection about good and evil, they can provide the tools people need to improve their own lives. And all this can be done within the rules of the genre and without bringing ratings down.”

—Miguel Sabido

TV Globo’s Mujeres apasionadas (Passionate Women) tackled the themes of alcoholism and telenovela heroines fight for gender equal- gender equity in Brazilian society in ways that appealed to television audiences. ity, for the right to use birth control and to overcome addiction or stigma. While te- lenovelas’ tried-and-true formula may not attract audiences,” Mazziotti continues. “What is really new and positive is the in- have changed in more than three decades, “Telenovelas definitely educate without terest that big writers, producers and distrib- their messages about health and life have trying to, and it’s important to take advan- utors have in working with health changed—and continue to change for tage of this potential.” specialists,” says Amanda Ospina, editor of the better. For Vicki Beck, director of USC’s TV Más and organizer of the summit. “For Hollywood, Health and Society program, these messages to achieve their goal, you the value of telenovelas as a vehicle for have to have joint efforts between all those Paula Andaló is a journalist in the public health messages has been demon- involved in a show’s creation.” Public Information Area of the Pan American Health Organization in olume 8 No. 2 • 2003

strated at the global level. She notes that in Participants in the gathering, which Washington, D.C. V Kenya, a 1987 television series that pro- included producers, screenwriters, actors • moted family planning “became the most and researchers, were enthusiastic about popular TV show in the country’s history.” incorporating salient social themes into The program Beck heads, which is sup- their shows. Televisa’s Miguel Sabido ported by the CDC, provides information noted that the number of Hispanics in the and consultants to television screenwriters U.S. viewing audience is growing and said and producers and suggests important that they must be better informed about Perspectives in Health

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Vaccination Week in the Americas

Text by Manuel Calvit • Photos by Armando Waak

The whistle of a teakettle pierces the morning silence, and the clock strikes six. It is June 1, 2003. Today and throughout this week, children in 19 Latin American and Caribbean countries will be the focus of attention for doctors, community leaders, politicians, volunteers, mothers and fathers. Together they will vaccinate millions of children wherever they are, no matter how remote their villages, no matter how difficult to reach.

It is a historic effort, a gesture of love for all the region’s children, an investment of hope in their present and future.

easles is one of hu- better surveillance, targeted immunization The campaign also helped reinforce key manity’s most conta- and improved laboratory capacity. concepts of international public health: gious diseases and The sheer magnitude of the problem has that joint efforts can lead to great achieve- continues to be the meant delays; new outbreaks occurred in ments; that health is a bridge to solidarity, Mmain cause of vaccine- the 1960s in Argentina, Bolivia and Brazil, understanding and hope; and that vaccina- preventable death in the world, claiming and in 2000–01 in Haiti and the Domini- tion is an individual right as well as an im- the lives of some 770,000 children under can Republic. But vaccination efforts con- portant tool of public health. In this spirit, the age of 5 each year. tinued, and between November 2002 and countries mobilized their own resources Before a vaccine became available in July 2003 there was no indigenous trans- and won support from agencies such as the 1963, nearly all children got measles. Then mission of measles anywhere in the U.S. Centers for Disease Control and in 1994, two historic achievements were Americas. Keeping the region measles- Prevention, the United Nations Children’s announced at the Pan American Sanitary free, however, requires maintaining high Fund and PAHO. Conference in Washington, D.C. Latin levels of childhood vaccination. Finally, Argentina, Bahamas, Bolivia, America was declared free of polio (Luis Andean ministers of health meeting last Brazil, Chile, Colombia, Costa Rica, Fermín Tenorio, a young boy from April proposed an Andean vaccination Ecuador, El Salvador, Guatemala, Hon- Pichanaquí, Peru, was the last known week. The idea was soon expanded to in- duras, Jamaica, Mexico, Nicaragua, case). Second, all the region’s countries clude South America and later Mexico, Paraguay, Peru, Suriname, Uruguay and olume 8 No. 2 • 2003 united in an effort to interrupt indigenous Central America and the Caribbean. Venezuela signed on to the historic initia- V • transmission of measles. Eventually 19 countries joined together for tive. Officials and health workers at all Since then, the region’s countries have the first Vaccination Week in the Americas. levels—ministerial, local and community— focused impressive efforts and resources The focus was on children who had never met daily through May 30, 2003, to make on this goal. The Pan American Health been vaccinated: those in hard-to-reach sure that the required personnel, equip- Organization (PAHO) developed a rural areas or marginal urban zones whom ment, vehicles and vaccines would all be in measles eradication strategy based on earlier campaigns had left behind. place for the week-long campaign. Perspectives in Health

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Mothers and fathers line up with their children in tow, many dressed as if for a party. Enthusiasm fills the air, disturbed only momentarily by the shriek of a child who has just realized he’s going to be vaccinated. olume 8 No. 2 • 2003 V • Perspectives in Health

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Guayaquil, June 1 June 2003

After a quick breakfast of fresh-baked bread with butter and guava jam, black coffee and slices of fresh papaya, we leave our hotel in Guayaquil’s Simón Bolivar waterfront along the Guayas River. We head for our first destination, a small health center on the outskirts of town.

We go slowly. The street lights gradually turn off, and street vendors start to take up their positions. Some of them are children.

Before long the sun breaks out. By 7 o’clock the heat is already unbearable, as is the traffic. Our driver, Don Rafael, weaves expertly through a sea of cars, buses and pedestrians who cross the street wherever they feel like it. This is a city of both old and new, changing from block to block. We pass the cathedral and Las Iguanas Park and begin to see small repair shops, kiosks and sidewalk stands selling fruit and vegetables.

After a sharp turn to the right, we leave pavement behind and enter a narrow dirt road full of potholes. From our jeep we peer out at rickety shacks, hapha- zard electrical wires and residents looking hesitantly out their windows into the scorching sun.

7:15 a.m.

- We arrive at the Fertisa Health Center. A sign an nouncing Vaccination Week in the Americas hangs prominently over the entrance. Mothers and fathers , many are already lining up with their children in tow lls the air, dis- dressed as if for a party. Enthusiasm fi olume 8 No. 2 • 2003 V

turbed only momentarily by the shriek of a child • who’s just realized he’s about to be vaccinated. The y- health workers are eager to show and explain ever e thing to us. We ask about their colleagues who ar viewing resi- going house to house to vaccinate, inter e’re told dents and reviewing vaccination records. W nd they have already left but also where we might fi eturn. them. We say a quick goodbye and promise to r Perspectives in Health

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A voice from a distant megaphone at first sounds like someone hawking oranges or pine- apples. We see a red truck turn the corner and head in our direction. The megaphone is on its roof. The voice becomes louder and clearer: “Vaccination Week in the Americas....Protect your children....It’s free.…Health workers will come to your house or you can take your chil- dren to the health center.” The message is repeated over and over. We signal to the truck, and it stops next to our jeep. The campaign poster is affixed to each of its doors. A young nurse tells us, without our asking, “Marita, Lourdes and Joaquín are vaccinating on the next street. Go straight ahead and turn left at the green house on the corner.”

We find them there, unmistakable in their white coats, each with an ice chest in one hand and a notebook in the other. We get out of the jeep and walk toward them. We meet as they are knocking on the door of a small wood-frame house. A young woman opens the door timidly. Without hesitation, the nurses get right to the point: “Good morning. We are carry- ing out a vaccination campaign. Are there children in this home? Are you a mother? May we come in?”

Seconds later we’re all in the tiny living room of the modest home. Everything is tidy and clean. While Lourdes reviews the child’s vaccination card, Marita vaccinates the mother. She explains that they are also giving tetanus vaccines to mothers and women of childbearing age. From outside the house, we hear the sounds of a gathering crowd. “Where is that kid? Has anyone seen Chinto?”

He finally appears, sweating and surprised to see so many people in his house. Chinto is 4 years old, with alert eyes, cinnamon-colored skin and jet-black hair. It doesn’t take long for him to figure out what’s happening. He glances at the door, planning his escape, but it’s too late. His mother holds him gently but firmly in her arms.

Now Lourdes explains to the young woman what the pentavalent vaccine is. Chinto fixes his eyes on his mother’s face as she gently strokes him. He stops resisting and takes his shot with dignity. Joaquín, a community volunteer, rewards the brave boy with a sticker on his T- shirt, confirming that he has been vaccinated. As we say goodbye, we leave a mark on the frame of the outside door, with the owner’s permission. Now the next campaign workers will know the children in this house have already been vaccinated.

The three health workers continue their door-to-door mission beneath the hot sun. We fol- low them for several hours, until Don Rafael reminds us that we had promised to return to the health center.

Huaquillas, June 2

At Huaquillas, a bridge over an invisible borderline links Ecuador and Peru. As at any bor- der crossing, vendors sell their wares from stands on both sides. The two nationalities mix noisily, buying and selling, sharing news and gossip, coming and going with boxes and bags full of fruit and vegetables, CDs and tape recorders, shirts and sandals. olume 8 No. 2 • 2003 olume 8 No. 2 • 2003 On both sides of the border children are being vaccinated. Señora Aminta, a vendor, asks V V • • me if I will watch her vegetable stand while she takes her daughter to be vaccinated. She asks me shyly, calling me “doctor,” which I am not. Her 3-year-old clings to her skirt. “Of course,” I say. “With pleasure. What do I do?” But my question gets lost in the bustle. I sit on some old coffee sacks and contemplate for a moment the symbolism of this campaign: two sister countries, joining forces, have become for this occasion a single community. Perspectives in Health Perspectives in Health

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As of this week, children will no longer be mere statistics in reports or fodder for public speeches. They will be honored by people who truly care for them through olume 8 No. 2 • 2003 row olume 8 No. 2 • 2003 V actions that will help them g V • • up strong and healthy. Perspectives in Health Perspectives in Health

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Quito, June 3

For an entire day, we visit some of the capital city’s most marginal areas: La Magdalena, Cotocollao, San Golquí and San Rafael. In each of the health centers we visit the pace of activity and efficiency are impressive. Mothers, fathers, boys and girls are everywhere, and health workers tire- lessly perform each critical task, vaccinating, reviewing records, taking notes. Others screen visitors to speed up the work: “If you’re not here for a vaccination, please come this way.” After the vacci- nations comes the parent survey: “How was the experience? How long did you have to wait? How did you learn about the vaccine campaign? How can we improve our services?” Some answer quickly as they head back to their offices, shops and construction sites after taking time off to dedicate to their children’s health. A father kisses his wife and daughter goodbye and jumps on a passing mi- crobus, which heads down the narrow streets leading to the city center.

We visit health centers of all sizes. Enthusiastic health workers show us the iceboxes where the vac- cines are kept, the examination rooms, vehicles with megaphones, detailed maps. But they also show us something else: their dedication and love for their work, their joy at being able to provide a lit- tle hope for their fellow citizens. olume 8 No. 2 • 2003 olume 8 No. 2 • 2003 V V • • Perspectives in Health Perspectives in Health

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Cusubamba, June 4

t and are buoyed The official launching ceremony for the campaign begins at midday. We get an early star by cloudless blue skies and a light breeze. A detour in the road delays us, but coming out of it we soon ent deforestation, which allows for begin a serpentine upward climb toward Cusubamba. We notice appar clearer views of the mountainous, arid landscape. We drive on in silence. e, many of them in indigenous When we arrive, a band is playing live music, and people are everywher en run noisily dress. The plaza, with its church and small shops, is decorated as if for a festival. Bands of childr ficial ceremony. after ice cream and candy vendors while adults gather solemnly and attentively for the of - Between songs, people give speeches thanking all those whose efforts have gone into the vaccination cam om the music and speeches, paign. It’s like a festival—a celebration of health. And just a few meters away fr children are being vaccinated. It is a spectacle of color, goodwill and dedication.

Río Daule, June 6

, whose Slowly the late afternoon sun begins to fade. We drive along a road that parallels the Daule River green waters blend in with the vegetation along its shore. We leave the car behind and continue on foot along a narrow dirt path until we reach a clearing. We hear children laughing and playing, crickets chirping rounded by silence. Someone and the sound of a radio. In the midst of it all, I suddenly feel myself sur e health workers whose face I never see says, “Do you see over there on the river, in the distance? Those ar - going by boat up the river. During the rest of the week, they’ll visit all the villages along the river to vacci ough the murky waters, nate children who can’t come all the way down here.” Three boats move gently thr each in a different direction: upriver, downriver, onto a tributary—but each with the same goal.

During an entire week, every day from sunrise to sunset, an army of 200,000 health workers will give en, this week marks a turning their best so that 15 million children can receive their vaccines. For the childr tunity to point in their lives. Instead of becoming victims of preventable diseases, they will have the oppor grow up healthy and strong. Instead of becoming mere statistics or fodder for public speeches, they will be vivors, they will be honored by the actions of people who truly care for them. Instead of being simple sur . able to wake up each day to the morning sun and do what all children do: go to school, play and be happy olume 8 No. 2 • 2003 V •

Manuel Calvit is a radio producer, video editor and scriptwriter in the Public Information Area of the Pan American Health Organization (PAHO) in Washington, D.C. Perspectives in Health Armando Waak is PAHO’s staff photographer. 2121 07392 Foundry_Eng 8/1/03 1:26 PM Page 22

Cuba’s Jewel of Tropical Medicine by Annmarie Christensen tesy IPK Photos cour

The Pedro Kourí Institute, founded in 1937, has evolved into a world-class player in the global fight against tropical and infectious diseases.

turnoff at kilometer 6 of Havana’s Novia del Mediodía (“Noontime Bride”) highway leads through the gates of the Pedro Kourí Institute of Tropical Medicine (IPK), one of Cuba’s institutional crown jewels. Inside the modern 10-building complex, the island’s top medical scien- tists carry out research in more than a dozen fields, from biotechnology to treatment of HIV/AIDS. AIn his office, the institute’s director, Gustavo P. Kourí, receives a visitor with a smile that brightens his chiseled face. On the wall behind him are myriad international and national commendations received by him and his institute over the years, including his most recent olume 8 No. 2 • 2003

V prized possession, a medal from the Vatican. • Kourí wears his white lab jacket like a family coat of arms. Continuing the work of his father, the late Pedro Kourí, he has transformed the 66-year-old institute into not only Cuba’s leading research and treatment center in tropical medicine and infectious diseases, but also a leading player in these fields worldwide. In the process, Kourí has acquired his own impressive international credentials. He is di- rector of the Pan American Health Organization (PAHO)/World Health Organization (WHO) Collaborating Center for Research and Training in Medical Malacology and Perspectives in Health

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Biological Control of Vectors and tering medical school and graduating in stitute [in Cuba],” Kourí says. Eager to Intermediate Hosts, one of three 1962. He was trained in surgery and hone his research skills, he joined a team of PAHO/WHO collaborating centers that pathology and did his medical internship a dozen colleagues who got the center up are housed at IPK. He is a member of the in parasitology. He also spent a year at and going. Joint Coordinating Board of the Special Minas del Frio in the Sierra Maestra for his “We called ourselves the 12 crazy doc- Program for Research and Training in clinical rural practice in general medicine. tors,” he recalls. They spent two years Tropical Diseases and a member of the It was in the mountains that he met studying basic sciences, including physics Council of the International Society of Castro, two years after the revolution. and math, to prepare themselves for re- Infectious Diseases. He also served on Kourí was stationed at a school for primary search. Kourí was named vice-director of PAHO’s Centennial Advisory Board in and secondary teachers. During the con- the center in 1968. Twelve years and three 2002, the year the organization celebrated flict, the site had served as a military base posts later he landed at Cuba’s Ministry of its 100th anniversary. under the command of the legendary Che Higher Education as national director for What motivates him? “My country, my Guevara, and it had a 20-bed hospital used research and postgraduate studies. institute, my family, my people,” he says. by the revolutionaries. Castro, now presi- dent as well as comandante, showed up An institute A family affair one evening and spent four hours talking reborn with Kourí and the other medical staff-in- The Kourís’ battle against tropical dis- training. They discussed the merits of Meanwhile, the small but impressive in- eases began in 1937 when Pedro Kourí Cuba’s rural hospital program, and Castro stitute Pedro Kourí had founded went into created the Institute of Tropical Medicine left the young doctors and nurses with the decline after his death in 1964. For more at the University of Havana. For 20 years, feeling that he had complete confidence in than a decade, it carried on with just 14 the institute’s work focused on Cuba’s their work. staff working in a 1,000-square-meter most worrisome parasitic diseases: malaria, After his stint in the mountains, Kourí facility. Gustavo recalls that it suffered Bancroftian filariasis, hepatic fascioliasis, decided to relicense in microbiology, but from a “lack of leadership” and the fact amoebiasis and other intestinal parasites. in 1965 Castro announced the formation that Cuba’s public health system was dete- Students from the United States, Latin of the National Center for Scientific riorating and “resources were being di- America and other regions came for train- Research. “It was the first big scientific in- rected to more serious problems.” ing in tropical medicine and research. In 1979, however, the Cuban govern- Pedro Kourí represented Cuba at various ment decided to support the institute’s national and international congresses, in- activities, incorporating it into the Min- cluding the Third World Congress on Following in his father’s footsteps, Gustavo istry of Health and recruiting the younger Microbiology, held in New York in 1939, Kourí as director. where he announced his discovery of a Kourí has cultivated international ties while “We started a second phase with full new parasite, Inermicapsifer cubensis. He support from our government and decided developed new methods for diagnosing helping his own country conquer its most to bring the institute to the highest scien- and treating parasitic diseases, presenting tific level in the shortest possible time,” these in his four-volume publication, threatening infectious diseases. says Kourí, adding proudly: “This task was Lessons on Parasitology and Tropical given to me directly by our President.” Medicine. The new Kourí Institute cultivated sci- Gustavo was an admiring witness to entific relationships with countries and in- such accomplishments. “I was very close ternational organizations around the to my father,” he says. “Even as a boy, I world, including in the United States. worked with my father. As a teenager, I Support from the Special Program for continued and worked with him at the Research and Training in Tropical Diseases institute.” (TDR), of the United Nations Develop- When Fidel Castro’s revolution tri- ment Program (UNDP), the World Bank umphed, the elder Kourí took the sweep- and WHO, was critical to the institute’s re- ing changes in stride, according to his son. tooling. TDR provided training, research “There was no contradiction with the rev- and project grants and helped the institute olume 8 No. 2 • 2003

olution,” recalls Gustavo. “My father and establish exchange relationships with other V most of his colleagues reacted very favor- scientific centers around the world. • ably. He was of very poor origin and was al- Today the Pedro Kourí Institute for ways focused on the diseases of the poor, so Tropical Medicine comprises 52,000 he had a very advanced feeling in relation square meters and 700 employees and is to socialism.” Cuba’s leading research and training It seemed natural that Gustavo Kourí center in infectious diseases, as well as a would follow in his father’s footsteps, en- major player in international efforts to Photo by Annemarie Christensen Perspectives in Health

23 07392 Foundry_Eng 8/1/03 1:26 PM Page 24 AHO P In addition, the institute has a medical residency program and master’s and Ph.D. programs in virology, bacteriology, para- sitology, vector control, epidemiology and infectious diseases. Kourí takes equal pride in—if not explicit credit for—Cuba’s overall health achieve- ments, many of which could not have oc- curred without his institute’s contributions. They roll off his tongue like the names of his children: “Cuba was the first country in the Americas to eliminate polio. Vaccines against 13 infectious diseases have been de- veloped, and so the incidence is very low. Typhoid is 0.1 percent, TB is 7.8 percent, tetanus is zero, and bacterial meningitis is 0.3 percent. Malaria is completely eradi- cated, and dengue outbreaks have all stopped. And AIDS is under control.” Having largely conquered its own most threatening infectious diseases—thanks in significant part to the work of IPK—Cuba Among the Kourí Institute’s current projects are a recombinant dengue vaccine and one for has more recently taken on the role of pro- viding assistance in this area to other de- HIV/AIDS. The Institute conducts evaluation and clinical trials for all Cuban vaccines and is veloping countries. As with other national health pursuits, Kourí’s institute is deeply in charge of control and evaluation of antiretroviral treatment for HIV/AIDS. involved in this. Continuing in the tradition of his father, Kourí says he is especially proud of the in- stitute’s teaching function. Since 1980, it control tropical diseases. Many of the the European Union and the Wellcome has trained more than 20,000 students, national laboratories of Cuba are housed at Trust, among others. some 1,800 of them foreigners from 72 the institute, along with the island’s only While the institute originally limited its countries. tertiary AIDS clinic and research center. It work to parasitology and tropical medi- “IPK is respected throughout Latin continues to receive support from TDR as cine, it now addresses infectious diseases in America and beyond,” says Paul Farmer, well as Canada, France, Spain, Belgium, general, with projects in more than a professor of medical anthropology at dozen research fields. These range from Harvard Medical School. “With a compar- sexually transmitted diseases and infections atively tiny budget—less than the budget, in immunodepressed patients to strategies say, of a single large research hospital at for the control of the disease-bearing mos- Harvard—IPK has conducted important quito Aedes aegypti. basic science research, helped develop IPK is in charge of evaluation and clin- novel vaccines, trained thousands of re- ical trials for all Cuban vaccines, “which is searchers from Cuba and from around the very relevant work for our biotechnology world, and developed ties with researchers industry because we determine the in the United States, too. Gustavo Kourí effectiveness of our products,” Kourí says. has provided the leadership for all of this.” Among the vaccines the institute is devel- oping or preparing to test are a recombi- nant dengue vaccine and a vaccine for International ties

olume 8 No. 2 • 2003 HIV/AIDS. IPK is also in charge of the V

• control and evaluation of antiretroviral The Kourí Institute has developed re- treatment for HIV/AIDS, which the search and educational exchange ties with a government provides free of charge to number of academic institutions in the those who are infected. (As part of Cuba’s United States, including Cornell, Harvard, public health system, the Kourí Institute North Carolina, Princeton and Yale univer- provides its services free of charge to sities. The most significant of these is with Cuban nationals.) the David Rockefeller Center for Latin Perspectives in Health

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American Studies at Harvard. Since the within a year we started having scientists course—currently coming up on the center’s inception in 1994, one of its prior- from there come to the Harvard School of eighth one—we have 14 to 16 years of ef- ities has been to reestablish and expand ties Public Health,” David says. Harvard stu- forts to bring researchers together. About with Cuban scholars and institutions. dents and faculty have also traveled to 50, 75 people come [to] do special labora- Through its Cuba Program, the center has Cuba, and the two institutions have jointly tories…. It’s an opportunity to meet peo- fostered collaboration between Cuban sponsored conferences and workshops on ple with the same interests.” counterpart institutions and the Harvard dengue, immunology and health reform, Harvard’s Farmer observes that much Medical School, the Harvard School of among other topics. more than “pure research” is at stake in Public Health, the John F. Kennedy School David adds: “Our relationships have these collaborations: “The IPK has sin- of Government and even the Graduate been quite separate from dissidents. gled out a number of ranking infectious School of Design. The autocracy has not affected our rela- threats, including TB, dengue, malaria Harvard Medical School had strong ties tionships.” and HIV. Comparatively speaking, these to the Kourí Institute even before the rev- The Kourí Institute has even developed are not ranking threats within Cuba. But olution. That relationship dissipated fol- relationships within U.S. government cir- these diseases constitute huge problems lowing Castro’s rise to power and the cles. Gary Clark, chief of the Dengue for the poor world.” There is no effective institute’s decline. But in 1998, John Branch of the U.S. Centers for Disease vaccine for any of them, and they are the David, professor emeritus of tropical med- Control and Prevention, has known Kourí leading infectious diseases in the world icine in the Department of Immunology for more than a decade and participates in today, he says. and Infectious Diseases at the Harvard IPK courses on dengue fever. He notes Kourí also views his mission in these School of Public Health, wrote to Gustavo that such collaborative ventures are impor- larger terms. “Considering the risk of in- Kourí suggesting ways of strengthening re- tant to researchers in Cuba and the United troduction of exotic diseases in Cuba, our search ties between the two institutions. States, as well as other countries. government decided to strengthen the in- Kourí replied with an invitation. “It’s an opportunity to meet people stitute and increase our surveillance. But at “I went there to see if we could have ex- with the same interests,” says Clark. the same time, our president declared that changes between faculty and students, and “Through Dr. Kourí’s leadership and the this center was not only for Cuba, but also for humanity.” For Farmer, IPK represents an opportu- nity not to be missed. After playing a key role in the fight against Cuba’s most threatening diseases, the Kourí “Harvard Medical School and the Harvard School of Public Health may well Institute has more recently directed its energies toward infectious diseases such as TB, constitute the world’s largest university- based medical research complex,” he ex- dengue and malaria—those that most threaten the world’s poor. plains. “If we were to join forces with one of the developing world’s premier research institutions to develop new tools to con- trol or treat these plagues, it would be, as Shakespeare put it, ‘a consummation de- voutly to be wish’d.’”

Annmarie Christensen is director of publications at the Global Health Council in Vermont, USA. She reported this story while visit- ing Cuba for the council in April. olume 8 No. 2 • 2003 V • Perspectives in Health

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More and more, nurses in the Caribbean have been packing their bags and head- ing for countries with less-than-perfect climates to get better pay and more respect. Now the region is looking for ways to keep them from leaving—and even to lure those abroad back home. by Tony Deyal

ack in the 1980s, Moreover, others are following in their vices policymakers, planners, educators, Glenda Caesar worked footsteps, emigrating to the Middle East, employers, managers and employees. as a staff nurse in a hos- Europe, Canada and the United States. As Experts are studying the impact of the pital on the island of fast as you can sing “Working for the global nursing shortage on world health Trinidad. She earned the Yankee Dollar,” nurses from throughout status and the quality of health care.” Bequivalent of about the Caribbean have been packing their The fact that these trends are not con- $250 per month. Given bags and saying, “Farewell, paradise!” fined to the Caribbean provides little con- the cost of living, it left her with virtually As early as the 1970s, the World Future solation to the region. In certain ways, its no disposable income. To make matters Society was predicting that the global de- problem is worse. Because English is the worse, she says her working conditions mand for nurses would be virtually infinite. native language of most Caribbean coun- were “deplorable,” with extreme patient Today, the shortage of trained nurses has tries, their nurses are highly desirable to overcrowding and serious shortages of become one of the most serious crises fac- North American and British recruiters. medicines and equipment. ing the health care industry worldwide. This exacerbates the region’s homegrown So in 1990, along with three other The World Health Organization (WHO) shortage. nurses from Trinidad, Caesar accepted a reports a shortage of nursing personnel in Noel says recruitment agencies from job offer in Saudi Arabia that paid her each of the six regions of the world it rep- these and other countries send representa- more than four times her Trinidad salary. resents. If the trend is not reversed, “the tives who in some cases try to lure nurses Leaving behind her tropical island home, ability of many health systems to function right off hospital floors. She finds it “inter- she traveled to the harsh desert climate of will be seriously jeopardized,” says a 2000 esting” that “a country with the highest Riyadh, where she enjoyed perks such as a WHO report. ratio of nurses, the United States, which “rest and recreation” allowance, had much Gloria Noel, a health systems manage- has 97.2 nurses per 10,000 people, is re- olume 8 No. 2• 2003 V better working conditions and earned ment consultant and former nurse advisor cruiting nurses from Jamaica, where the • enough to live comfortably and still send to the Pan American Health Organization ratio is just 11.3 nurses per 10,000, and money back to her family in Trinidad. (PAHO), says three labor trends are feed- from Guyana, with 8.6 nurses per Eventually homesickness compelled ing the problem: “Nurses are not entering 10,000.” She cites U.S. Bureau of Labor Caesar to give it all up and return home. the profession, those who are there are not Statistics projections that estimate U.S. de- But her fellow Trinidadians and other staying, and those remaining are not mand at an additional 800,000 registered nurses from the Caribbean are still there. happy. This crisis preoccupies health ser- nurses by the year 2005. Perspectives in Health

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27 07392 Foundry_Eng 8/1/03 1:27 PM Page 28 AHO P The growing demand “It is not only for the money. For the is due to several com- most part, it is a matter of improving Year of the plementary factors. themselves and their families. Many of us nurse People are living longer have children at university. We have mort- than before, increasing the gage payments. We have the car, food, As part of their stepped-up efforts to numbers of infirm and chroni- phones and a salary that can barely feed us keep trained nurses from leaving home, the cally ill. Improved lifestyles and greater and pay off the bank. Our colleagues countries of the Caribbean recently declared health promotion reduce premature death abroad have enough money to pay their a “Year of the Caribbean Nurse” from May and illness but add to the health care bur- mortgages and still have something left 2003 to August 2004. The 16-month-long den of an aging population. So, too, do for the rainy day. This is why so many of “celebration of nursing and nurses” is aimed seemingly endless medical-scientific dis- my colleagues think, ‘maybe I should get at increasing recruitment and retention, coveries and technological advances in out too.’ strengthening nursing and midwifery ser- health care. “When you look at the hospital where I vices and “recognizing the best of nursing And that’s the good news. was trained and worked, there is severe and nurses in the region.” On the downside, Noel points to in- overcrowding. There used to be a staff “I cannot overstate the significance or creases in antibiotic-resistant infections ratio of five nurses to 109 patients in the potential that the Year of the Caribbean and “cost-cutting pressures of managed medical wards, and that is low by interna- Nurse holds for all people in the region,” care.” There is also HIV/AIDS. While an- tional standards. Now you get three nurses says Marjorie Parkes, chairperson of the tiretroviral therapy increases the numbers to one ward, if you’re lucky.” Regional Nursing Body. of people living with HIV/AIDS, it also Contrast that with conditions in recruit- The year was kicked off at a gala event increases their need for trained caregivers. ing countries such as Saudi Arabia. “All the in May in St. Kitts, with Prime Minister Den- The Caribbean is second only to sub- support facilities are available—the equip- zil Douglas presiding. Each month through- Saharan Africa in terms of HIV rates, with ment, the staff, are all there,” she says. out the year, two different countries will an estimated 2.2 percent of Caribbean na- “The linens and packs are changed regu- host special events showcasing nurses’ con- tionals living with the virus, according to larly. This is the big difference.” Asked tributions. Among the highlights will be spe- the Joint United Nations Program for about language and cultural differences, cial welcoming ceremonies—complete with HIV/AIDS (UNAIDS). she says, “Patients are patients everywhere. media coverage—for nurses returning to the Whatever the language, their needs are the Caribbean from abroad, whether for vaca- tudies have identified other factors same.” tions or for good. In return, they will be underlying the nursing crisis. In the asked to contribute “a few days to a week” SCaribbean, these include inadequate Nursing brain of mentoring activities to pass their skills on workplace environments, with facilities drain to more junior nurses. that are in disrepair and lacking essential With the theme of “Nurses Lighting the equipment. The problem is compounded The impact of the nursing crisis is being Way to Professional Excellence,” organiz- by inadequate compensation and benefits. felt throughout the Caribbean region. ers have produced a special Caribbean Most Caribbean countries have suffered Many of the most experienced, skilled and nursing symbol featuring a lighted lamp severe economic downturns and have im- specialized nurses have left for greener and against a backdrop of the flags of all the plemented structural adjustment programs more professionally rewarding pastures. region’s countries. It will be passed from that have brought major reductions in Many of those remaining are nurses near one country to the next until the celebra- health-care budgets. retirement (mandatory at age 55 in most tion culminates in Curaçao in August 2004 Nurses also complain of a lack of recog- Caribbean countries), and the number of at a meeting of an estimated 400 nurses nition and professional power, which leads new nursing graduates is declining. About from throughout the region. to unsatisfactory social relations at work. 35 percent of nursing posts in the region’s The main organizers of the year are the “There is no respect for nurses who stay health sector are currently vacant. Many Caribbean Nurses Organization and the and who make the sacrifices,” says Caesar. patient care units have had to be merged Regional Nursing Body, also lead actors in Under such conditions, even family com- and elective surgery often cancelled in the region’s Managed Migration program. mitment, patriotism and the opportunity many hospitals. “Sick outs” by nurses de- Supporters include the Pan American to contribute to national development are manding better pay and working condi- Health Organization, Johnson and Johnson, insufficient motivators for trained nurses tions have cost governments almost $3 the Lillian Carter Centre for International

olume 8 No. 2 • 2003 Nursing and the Department of Advanced

V to remain in the national health service. million. • Caesar has been a nurse for 26 years As a result of the nursing brain drain, the Nursing Education at the University of the and is now an assistant secretary with the loss in public investment in training nurses West Indies. Public Services Association of Trinidad at the basic level is estimated at nearly $17 and Tobago, the industrial relations rep- million. One senior nurse in Trinidad, who resentative of most local nurses. She says prefers that her name not be used, says that she understands well why many nurses many young nurse trainees make no effort want to leave. to disguise their intention of using the pro- Perspectives in Health

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fession as a means of getting a “green strategy for retaining adequate numbers of the Caribbean and other regions with this card” to work in the United States. competent nursing personnel to deliver problem, such as Africa, need to imple- “It makes me upset,” she says, noting health programs and services to Caribbean ment sound long-range human resources that this further reduces the standard and nationals at the highest level of quality.” It planning; improve the image of nursing; quality of nursing care. addresses the recruitment, retention, de- increase enrollment of male and female In the larger sense, the nursing crisis feeds ployment and succession-planning issues students and marginal groups in nursing widespread fears among the taxpaying pub- inherent in the exodus of nurses from the schools; redesign curricula to make nurs- lic about the availability, safety and quality Caribbean. A newly established “imple- ing education programs more exciting and of health care. “It has, and will continue to mention team” is coordinating efforts in challenging, including adding mentoring have, a profound impact on nursing services several priority areas, including the terms programs; enhance opportunities for pro- both quantitatively and qualitatively,” says and conditions of work; use and deploy- fessional development and career progres- Noel. “This shortage is unlike those of the ment of nurses; recruitment, education and sion; improve working conditions; match past and requires bold action and innovative training; management practices and the clinical practice opportunities and respon- and creative solutions.” value of nursing. sibilities with nurses’ knowledge and skills; Carl Browne, recognize nurses as equal partners with former permanent physicians in the health team; and com- secretary in the pensate nurses commensurately with their Ministry of Health education, experience, responsibilities and of St. Vincent and contributions to health care. the Grenadines “These reforms require commitment, and now project cooperation, mutual trust, respect and sus- manager for a tained action on the part of all stake- European Com- holders,” says Noel. “These include policy- munity HIV/AIDS makers, health systems planners, and the project in the re- nursing profession, with input from con- gion, supports the sumers of health care.” initiative but is Whether sheer necessity will prompt ess adamant that at these needed interventions remains to be the base of the seen, but whatever happens, the role of rinidad Expr problem is the nurses in the development of health care tesy T need for more will continue to be pivotal. They are the training institu- wheel and hub of health services. Photo cour tions for nursing. As Noel told nurses at a recent confer- He says, “We ence on the future of nursing in Guyana: Nursing “sick-outs” for better wages and working conditions have cost need to produce “It takes a special person to be a nurse. more nurses. You are the unsung heroes, the unseen an- the Caribbean nearly $3 million. Now nurses are getting more respect. Nursing should be gels. Be the best that you can be. Celebrate on the curriculum each other, be strong, view the many frus- of our community trations as challenges, take care of your- With the problem gaining attention, a colleges and other tertiary institutions. We selves, as you are the fabric and future of Caribbean response to the challenge has should also establish some kind of com- health care in this country and the world.” now emerged. At the national level, min- pensation arrangement with organizations istries of health, with support from PAHO, that recruit our nurses and use the funds are partnering with local nursing associa- from this to train more nurses. Tony Deyal is a former advisor to tions and other stakeholders to address the “We have to recognize that the de- the Pan American Health Organi- zation and currently an underpaid roots of the problem. At the regional level, mand for trained nurses in the developed newspaper columnist in Trinidad. the Regional Nursing Body, the Caribbean countries will continue indefinitely. He was last seen trying to find the Nurses Organization, other professional Instead of viewing the situation as a cri- help-wanted ads in Arab News. associations and teaching institutions are sis, we must analyze it for the opportuni- olume 8 No. 2 • 2003

similarly involved. Also participating are ties that it undoubtedly contains. There V the ministries of health and nursing and are benefits that we can exploit for our • health organizations in recruiting coun- countries and for our nurses. Most of tries, as well as private companies and those who leave remit money to relations foundations. here and buy property, intending to re- A central focus of these efforts has been turn home when they retire.” the development of a new Managed Gloria Noel believes the solution must Migration program, defined as “a regional be as multifaceted as the problem. She says Perspectives in Health

29 07392 Foundry_Eng8/1/031:28PMPage30 30 Perspectives in Health • Volume 8 No. 2 • 2003 Last Word how local,r dracunculiasis—all ar anthrax, plague,RiftV Marbur ef cer to diseaseoutbr deter scene andcoor and r por r and pr entifi and tracedittoitsorigins,pr painstakingly plottedanepidemic’ “shoe-leather” epidemiologist,who cholera. Snowwasthequintessential br visit thesceneofapar risked theirownhealthandwell-beingto mitted physiciansandmedicalexper ar a lar water pumpwasr endar emer wor I emedy fective andhonestpublichealthaction: e r eak andobser At thecor Fast-for I wouldstar Har tain principlesthatser t theirfi d ofastrangenewillnessbeganto ge numberofLondonr eplete withstoriesoftalented,com ge, butinthe1850s,whenleg c documentationofhisconclusions mine thecauseandpossiblesolutions esour y JohnSnowshowedthatasingle oducing dramaticr . g andW war ces havebeenmobilizedatthe ndings. Hanta,Ebola,Lassa, e ofallsuchinvestigationsar egional andglobalexper d tothepast20years,which d-Lear t, notlastNovember dinated atdistantpointsto est Nilevir eaks. ve, r n mi O “ n S a esponsible forinfecting s r h at t e s r ou o ecor e r g io p a alley fever ticularly nastyout o d-J ped d ecent examplesof n l n ve asthebasisfor d itbe me o d andrapidlyr i a uses, alongwith z esults withhis un l p at esidents with io oviding sci ea e f t u , g n (WH , dengue, bl d initst wh in s h ned Lessonsfr , when ic h ts who s path e l en ou p tise e r s e ea ea e s - - - - - o O) a lt d n r tgo h c a in s weh cks g ag respond tointernationalepidemicswill in nnoun o • • • come inhandytheeventofanew , m fi science becompr Under nocir nation onhowtocontr fur g D ” SARS outbreakorsimilarepidemic. of thosetheyr in theinvestigationbecausehealth Gover scientifi and shar All datashouldbegather But equallyimportantwillbeeach ndings willunderpinafi a m pe a ther diseasespr in—o ve l WHO’ affected country’ un ir o c pl nments shouldcooperatefully e ed t c manner c it ea e a ed inaquick,intelligentand t y be o r sh voluntary response r r h s expandedauthorityto -G r n oun at se cumstances shouldthe ed fr ou epr l ie en . ead. esent isatstake. ve itisun l d t omised, sincethe d s er ver o a m t h o l Gr ol andpr e a e wo me o ed, collected nal deter h cu e fi s immediate o H rl t t h e r r om SARS d si l er t s event i t ou k a mi e e rl g s l hr - pir y t h em B . b t ed w eat b y R at PAHO h r ea cials inChina(atthepr and economicdamageavoidedhadof late howmanylivesmighthavebeensaved r In mid-1997,rightar of opennessandinter to lookthanHongKongseethemerits for even mor ality demandsclearinfor English versionofthe News Kong r of thecountr on theepidemic.Acknowledginger Communist Par suspect untilearlyApril,whenthe China’ measur Kong’ demic ofavianfl r Disease Contr with helpfr the W or health aswellthemayorofBeijingand at S o en equests forassistance.Theyhadnofar esponded swiftlyandef run r obert J In thecaseofSARS,wecanonlyspecu der By contrast,of it False fi k? thcoming earlierwithinfor y s in h r ed gr A g n obser orld HealthOr s healthof dt yn s SARSepidemicwassparseand es tostopthedisease’ e ever R l l e thanatthenationallevel)been e ie a dr S h . eater transpar w d ved inaneditorial:“Harshr n f ted toChineser . H o d o om theU.S.Centersfor Y me (S ol andPr owa as r e isease emer y’ ty fi t m u br f t s initialr fi cials r fi rst steps r ea ed China’ r h cial infor national cooperation. a ound thetimeHong d A oke out.ButHong ganization (WHO), e n l l y int R W y go fi ency inr evention (CDC), eached out,and mation fr cial ovincial per S) h o fectively with esponse, the rl s spr China Daily g ule, anepi s ministerof n mation and mation on d H e—wh h e a a e in ead. epor d be om the ea wa t haps ther ting er lt en r at or y fi e h - . - - - - 07392 Foundry_Eng 8/1/03 1:28 PM Page 31

authorities, so the public can be fully in- SARS is unlikely to be the last public and effective use of information are critical formed of the situation and take appropri- to gaining the public trust needed for ef- ate measures.” A subsequent article in The fective contagion control. Asian Wall Street Journal also criticized health threat of its kind. It has never government officials, saying they “thought The next time first not of the public’s health, but of the been more important for governments economic and social harm that might be There is still much to learn about SARS, caused by a panic.” whether its cause is indeed a single virus It is important to note that China’s re- to cooperate fully with the international and what kinds of treatments and vaccines sponse did not violate any international might be effective against it. There is no agreements. Like all WHO member coun- better way to tackle these challenges than tries, China is a signatory to its Inter- scientific and health community in combined through a multitude of talented scientific national Health Regulations (IHR), but minds evaluating both the epidemiology these require compulsory reporting on efforts to battle diseases of this kind. and the laboratory aspects of this illness as only a small number of diseases. At the we move toward definitive findings. Just most recent World Health Assembly—in such work is now taking place in labs and Geneva in May, as SARS was dominating public health offices around the world, and world headlines—WHO’s member coun- continuing openness and information tries expanded the organization’s authority sharing are essential to its success. to respond to such international epi- Our planet grows smaller every day as a demics. It is now authorized to consult un- result of global travel, commerce and ex- official sources of outbreak information, ploding populations. SARS is unlikely to and it no longer needs permission from be the last public health threat of its kind. member governments to conduct on-site It has never been more important for investigations (though it must inform gov- elected and appointed officials to cooper- ernments and let them know of its teams’ ate fully with their international col- whereabouts). leagues, scientific bodies and global health These changes, part of an ongoing organizations in combined efforts to battle process of revamping the IHR, will come such diseases. We must work together, in handy should a new SARS or other dan- with skill, speed, openness and dedica- gerous international outbreak occur. But tion—all elements of the best tradition of equally important is each affected coun- public health. try’s immediate voluntary response. Openness is not always easy, even more so when the stakes are as high as they are in Robert J. Howard heads a health communications consulting firm olume 8 No. 2 • 2003 the case of SARS. Affected countries know V in Duluth, Georgia, USA, and • that if their epidemic appears to interna- teaches at Harvard University, tional observers to be out of control, they the University of South Florida and six National Public Health risk serious economic loss. At the domestic Leadership institutes. level, health officials must alert health workers and the public to be vigilant, but without causing undue panic. Openness Perspectives in Health

31 07392 Foundry_Eng8/1/031:28PMPage32 32 Perspectives in Health • Volume 8 No. 2 • 2003 Mailbox ✒ dr 8, No.1)drawsattentiontothemanyhazar in developingcountries.Butther alone, coal-fi and exposur exposur in developedcountriesasthedevelopingworld. tant envir 100 tonsofmer to pr often accumulateinfi str into methylmer (EP mer of child-bearingageintheUnitedStateshaveblood- mer dose of5.8par seen incr between 1980and1995,manyr Rates ofasthmaintheUnitedStatesdoubled tr after thefact. “the envir and oceansbutever r quality issopoorthatchildr to pr First, nonecanbeaddr American youth. childr including pesticideexposur tions ofchildr work, playandgr Mailb ecommended nottogooutside.Cer ✒ envir Kids andthe y todealwiththeirenor en facefr eams. Theseandotherpollutants,suchasPCBs, A) datashowthatmor cur cur Y egnant womenandtheunbor These includeairqualitypr Recent U.S.Envir event exposur What doallthesepr en andleadpoisoningamongAfrican- our excellentar y concentrationsgr y advisoriesinef e, mer easing ratesofcode-r onmental hazar onment” isnotjustfor om envir e toindoormold.IntheUnitedStates r onment ed powerplantscontributemor en fr cur ts permillion.In2001,44stateshad cur cur y exposur ow equently facegr y eachyear es inthefi y bybacteriainlakesand ywher onmental exposur . Second,thepr ticle “FortheKids’Sake”(V onmental Pr sh, r essed untilwer fect fornoncommer oblems haveincommon? o ds foundjustasfr e than8per esulting inpar eater thanther mous healthconsequences e childr e, exposur e amongfar en andtheelderlyar rst placeratherthanto , whichistransfor ed days,whenair x oblems, pesticide ests, beaches,rivers e ar otection Agency en lear eater hazar n. oper r e otherimpor egions have tain subpopula e toleadpaint cent ofwomen es, par ecognize that m worker ticular risks n, live, efer esponse is equently Latin America,nowexposedfr r documents. tackling smuggling,implementingbansonpr public health.Keyissuesintheconventioninclude used aninter clearly thanthetobaccoindustr pened inAsia.Nothingcoulddemonstratemor and youhaveavir and ParaguaytoChina,GuamthePhilippines, the W pr the waytheyr behave thesame,andsimilaritiesar the pr its histor vention onT demic isalsothesame.EnterFrameworkCon gover r and discussedsmugglingduty-not-paidciga cial fi ds chil ead yourexcellentar ettes. T USA W Childr Executive Dir ✒ dir ticularly e than ograms, handedoutfr ence ds, ashington, D.C. obacco’ med It waswithapr Change thenamesfr The obviousconclusionisthattheaction ol. e sh. en’ nments mustimplementtocur oduct isthesame,tobaccocompanies orld HealthAssemblyinMay - - s Envir ty tricks - y thattheW ector onmental HealthNetwork obacco Contr nationally bindingtr tz ecr enough toensur Rabbi DanielSwar within ourgrasp. r like. W par know howtor technological know-howthanofsocietalwill.W ected towar uited scientists,intr tual identikitofwhatalsohap ticulate levels,eliminateleadpoisoningandthe ofound senseofdéjàvuthatI Addr s orld HealthOr ticle onthetobaccoindustr e justhavetobelieveinthewor eebie tourstojour ol, whichwasappr om CostaRica,Guatemala essing thesepr d applyingsolutionsthatar om theindustr educe mer y’ e thatadequater s ownwor eaty tofur , thefi ganization has tail theepi oduced youth www e uncannyin oblems islessaquestionof .paho.or rst timein cur nalists, This isapr on aglobalscaleandbyalltheworld’ ther and specializedagencies,becausewithouthealth Nelson Simatovich gopolistic inter that ofdr Dr ds that ther oved by y emissions,impr ✒ dr Essential Hong Kong Asian ConsultancyonT Dir Ur Montevideo Latinoamericano (ICDLA) Instituto deCooperaciónparaelDesar General Coor omo y’ ugs,” byMar uguay g e s own ector - e cannotbedevelopment,muchlesspr - Y - y in - our ar - ugs esour ug patentsandlicensesinthehandsofoli oblem thatmustbetackledbycivilsociety dinator ofPr th ofchildr ces ar ticle “Don’ e alr photographs. Pleasequer unsolicited manuscriptsand/or eber at 202-974-3143orbye-mailto W Guidelines ar Health 525 T Pan AmericanHealthOr Health the issuestheyraise.W ar W Send totheEditor Please includeyournameandaddr issue. Somemaybeeditedforspace. sampling oflettersr ticles in national phar ashington, D.C.20037,orviafax e encourager tin For r tion, cr Judith Mackay us thattheneedforsuchactionisclearlyglobal. taxes topr ettes. Thetobaccoindustr [email protected] eady e di obacco Contr wenty-thir ove , Ar cannot ber ograms e - eman, dealswithavitalissue, Perspectives inHealth ea ofPublicInfor t LetTRIPST en eation ofsmoke-fr e availableuponr event youngpeoplefr d Str ol eaders’ commentson maceutical laboratories. r , ollo esponsible for g. Perspectives in eceived ineach eet, N.W Perspectives in e willr rip upEssential ganization, y fi mation, s gover rst. ., un a equest. ee ar and on y’ ogr s owndocumentsshow ess. nments

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om buyingciga - easing - 07392 Foundry_Eng 8/1/03 1:28 PM Page 33

P AN AMERICAN HEALTH ORGANIZATION

December 1, 2003

W orld AIDS Day

Eliminating Stigma and Discrimination Live & Let Live

33 http://www.paho.org/ 07392 Foundry_Eng 8/1/03 1:28 PM Page 34

A child pauses between chores near his family’s farm in Ibarra, Ecuador, near the Colombian border. Pan American Health Organization (PAHO) staff photographer Armando Waak captured the image as part of a PAHO audiovisual team that chronicled the first regional Vaccination Week in the Americas, held June 1–8.

The 19-country initiative made a special effort to reach children in remote areas and marginal urban zones who had never been vaccinated before. By the end of the week, more than 15 million children in Latin America and the Caribbean had received vaccines. (See article page 14.)

www.paho.org