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Mirta Roses Periago Delivers 2013 Pitt Public Health Convocation Address


Shaping Public Health Through 2050

Mirta Roses Periago

First of all, I would like to thank Dean Burke for his introduction and kind words. Except for the age,I have a lot in common with all of you.

We are both at the starting line in our careers and either unemployed or looking for a new job. This is not necessarily a bad thing, since it also means that many roads are open and fantastic opportunities could be around the corner.

I have recently retired from the Pan American Health Organization (PAHO) and you are just graduating and full of expectations. I graduated from the school of public health in Argentina in 1973. Maybe that is why Dean Burke invited me to address you on this occasion.

There may be some other reasons: I was the first woman to be elected Director of PAHO exactly when it was celebrating its 100 years of existence. It took them sometime to trust a woman! Also, the first Dean of this School, Dr. Thomas Parran, was invited to succeed Dr. Cummings when he became Director of PAHO in 1920. Dr. Parran became the sixth Surgeon General of the USA and many years later he chaired the first International Conference called to set up the World Health organization in 1948.

At the time of my graduation,40 years ago, we were shaping public health through the year 2000; the new Millennium was a blurry horizon! Universities around the world were in protest; students were tearing down the last lines of colonialism and racism –just remember 1968: Woodstock, the University of Paris revolt, Martin Luther King’s speech on Vietnam, and my own University of Cordoba’s fight against a dictatorship in 1969. Everywhere there was a claim for participation, peace, equality and democracy.

The driver for public health demands was equal access to the fantastic discoveries in science and technology for the prevention and treatment of diseases. Smallpox was eradicated globally in 1971 and an International Conference on Primary Health Care held in 1977 declared “Health for all by the year 2000" as the world's goal.

But suddenly, the whole world was shocked by the surge of AIDS and all our assumptions were turned upside down. For the first time, health and human rights were put together at the highest level and stigma and discrimination were revealed as the toughest factors to modify in our quest for better health. HIV was discovered in 1983 and new antiretroviral drugs started to pop up. The illusion that infectious diseases were going to disappear vanished rapidly as new pathogens and pandemics became regular news.

So we thought that we had failed and that “Health for All” had been merely a romantic aspiration. But no! In 2000, the Millennium Conference set up, for the first time ever, a common agenda for the world, “The Millennium Development Goals by 2015”, and health was at its core. Health became a visible demand and was one of the poverty reduction strategies and an indicator of fair and sustainable development.

Key areas like maternal and child health, eradication of hunger and malnutrition, access to essential medicines, elimination of major diseases such as malaria, tuberculosis and AIDS, access to water and education, decent work, gender equality, were all listed in the 7 goals and defined objectives. An eighth goal called for new partnerships and for additional resources to finance the successful interventions and scale up the best practices.

The Global Health concept was born. New funding mechanisms were created like GAVI (Global Alliance for vaccines and Immunization), the Global Fund, PEPFAR (President’s Emergency Fund for AIDS relief). New philanthropists like Gates started to invest heavily in health.

Right now, we are coming close to 2015. What have been the impact and results of these goals? Have they come true for billions of people?

Many indicators have changed dramatically from their defined baseline of 1990. Life expectancy in the Latinamerica, for instance, has gained in average almost 20 years in just a quarter of the last century and infant mortality has dropped sharply. Substantial progress has been achieved everywhere, but unacceptable disparities persist among and within countries. The United Nations Secretary General has issued a passionate call to redouble the efforts in these last 1,000 days –especially in regards to maternal and children’s health and to hunger and malnutrition.

So graduates! Jump into the boat and try to row hard during this last lap. Make your contribution in lives saved and get the energy and experience required to influence the post 2015 development agenda.

As it happened in my generation with AIDS, yours is being shaken up by the tsunami of non-communicable chronic diseases (NCDs). Pushed by demographic factors like aging and population growth; sedentary habits derived from urbanization and automation; food industrial processes with increased salt, sugar, fat; larger food portions; and harmful addictions like tobacco, alcohol and drugs, the iceberg of NCDs is showing its real scary dimension.

In the future, the second cause of death and the first of premature death will be external causes such as lesions, traffic accidents, occupational and environmental accidents, and all expressions of violence, including homicides, suicides, and war and terrorism civil casualties.

This is the scenario you are going to dance on. Where are you going to leave your mark?

Life expectancy is projected to reach 100 years by 2050 with a world total population of 9 billion. Three quarters of the people of the world will be living in urban areas, including 70 megacities with over 10 million inhabitants –from the current 20, and only 3 in 1975. A dozen of these will be located in the Americas with half of them in the U.S.: New York, Los Angeles, Chicago, Washington DC, Boston and San Francisco, and half in Latin America (Mexico City, Sao Paulo, Buenos Aires, Rio de Janeiro, Lima and Bogota). Europe will have just 4 megacities, but Asia will account for half of all (34) and Africa will have 20 megacities, six times the current number of 3.

No wonder that just a few days ago the World Bank and the International Monetary Fund devoted the Global Monitoring Report 2013 to the rural-urban dynamics calling the developing countries to properly harness the urbanization process in order to achieve the MDGs.

Urbanization brings benefits on many fields, including better salaries and access to services, since poverty is significantly higher in rural settings. But it also comes with complex challenges: 800 million people worldwide live in urban slums. Our current pattern of production/consumption/destruction aggravate environmental degradation and ecological imbalances, increasing social tension and psychological and biological stress.

So, public health is at the crossroads and during your professional lifespan, you will shape it. Your generation may be able to jump into longevity as a result of the social contract established since 1900 (industrial revolution-microbial world)and into the 21st century (digital revolution-nano world), or we may witness the first ever shortening of life expectancy due to NCDs, violence and external causes.

These are issues much more complex than infectious diseases, but the microbial and vector worlds are not quiet. New pathogens and strains are constantly emerging, mixing, mutating and developing strategies to survive through antimicrobial resistance and their expansion due to climate change, mobility and transportation.

The progress provided by hygiene, energy, science and technology, agricultural and industrial revolution may come short now. The innovation you will be responsible for will be stemming from social sciences and ethics, recovering the ancestral universal principles known as "The 3Ps": PROTECT, PRESERVE, PREVENT. Learning to live in harmony with all other living creatures and within our means and natural resources, with a spirit of continuous renovation, will truly make the difference.

A new public health will accompany a new vision for development in which health is considered the leading indicator of a well-functioning society.

We need a public health paradigm that goes well beyond the “repair and maintenance shop” medical mentality and becomes an indicator of human development more precise and powerful than the GDP (Gross Domestic Product) and wealth creation. You are called to build a new public health movement, one where the global and the local, the individual and the collective solidarity and responsibility interplay and lead to individual, social and environmental actions for longer, healthier lives.

You are called to lead a multidisciplinary endeavor, involving broad and multiple knowledge from fields as diverse as sociology and journalism, urban planning and information technologies, economics and politics, meteorology, and even arts and entertainment.

The good news is that we have no shortage of tools to confront the public health problems ahead like NCDs, and to eradicate once and for all old scourges such as the neglected diseases that will be keeping me busy the next few years. The real question is: will all that knowledge and tools be enough? Are they going to be used to benefit all human beings? Einstein once remarked, “Without ethics there is no salvation for humanity”. An ethical imperative must be at the center of the new public health paradigm, one that prioritizes access to quality health services for all.

So we have come back under a renewed framework to the utopian “Health for all”. We must continue the quest: the vision is not failed; the world has failed the vision. Progress toward universal access to health is encouraging as seen recently in the U.S. and in many countries in LAC and other parts of the world. But there are threats to cut back on many also. We must keep pressing on this subject until nobody slips through the cracks and the protective net of public health covers everyone, every family.

Universal Access to Health Services and Action on the Social Determinants of Health are the two main strategies of the new paradigm and they have to be inspiring and included in the post 2015 development agenda.

But do not forget the behavioral aspects. NCDs, mental health, violence, discrimination, not only demand a “whole of society” and a “whole of government” approach but are also intimate to individual and group behavior. There is much to learn from those who market bad habits and create unnecessary and harmful “needs”. A very significant part of a successful response must come from “within” –from each and every one.

Due partially to the “repair and maintenance shop” model, we tend to look for a quick and easy fix instead of braving the painful, slow process of reflection and change from the inside. We want a surgery or a pill, instead of exercising, changing our diet, or quitting alcohol or tobacco.

How can we get people to change and choose what is healthier, while avoiding real or alleged trampling of individual liberty? How do we make the healthy choices the easy choices? This will demand additional research, inspired message crafting, copious amounts of industry-oriented persuasion efforts, carefully calibrated regulations, and highly committed leadership. Public Health is not only working for the people but mainly with the people.

You have the advantage of bringing to this battle a set of skills that is uniquely well-fitted, including being contemporary to the social networks and new technologies. But the most important individual assets you need are what I like to call “The 3Ps”: perseverance, patience and passion.

Perseverance: to overcome the obstacles, the ignorance, the complacency, and the defeats that will mine your professional journey.

Patience: to prepare the conditions and to pursue your goals until they become a reality, to listen and to learn from others, from history and the elders, from your own failures.

Passion: for your chosen cause and the wellbeing of your fellow human beings and for Mother Earth. Passion that comes from love and fun combined, from the joy of a work well done; this is a force that can move mountains and rally hundreds behind your dreams.

Now, in closing, allow me to mention a lesson learnt during my 30 years career at PAHO, and particularly during the last 10 years as Director: you have to choose your battles given the limited time we know we have. I chose three big battles that may useful to you in the future.

First, to shape a vision for the health of this continent relevant to every country, overcoming their diversity and allowing for the creation of a common framework and a joint commitment. This led to the Health Agenda for the Americas 2007-2017 with 8 areas of joint work and mutual collaboration and support.

Second, to bring everyone on board recognizing that public health is a network of networks and a web of partnerships. This led to powerful social movements like Vaccination Week in the Americas, which evolved –continent by continent- into the first World Immunization Week launched last year; the Forum on Action on NCDs; the Wellness Revolution and the Wellness Week including health fairs and health days; a revitalization of health promotion mobilizing media networks, volunteers and the youth, faith-based and non-governmental organizations, the public/private partnerships, majors, the academia and professional associations, celebrities, teachers, you name it.

Third, to make a public health institution fit for purpose using advanced management techniques. By adopting results-based management, a transparency and accountability framework, updated human and financial resources policies and establishing a code of ethics, the organization became truly owned by the Member States. It helped them go beyond their boundaries, enabling them to think big and in solidarity, to reach out and embrace all partners, and to rally everyone to work for health.

In short, wherever you go, whatever road you choose to pursue in the rich realm of public health: evidence-based policies, results-based management, and teamwork for health will empower you to be authentic change makers. You have in front of you the marvelous opportunity of being key players in shaping public health through 2050.

Go ahead, my fellow colleagues, take the baton, pursue your dreams and remember always to be patient, to be passionate, to persevere through the last mile, because you have embraced a noble profession, one that has the power to influence the future of many generations for a better world for all.

Mirta Roses Periago
Pittsburgh, 28th April, 2013

4/28/2013
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