Pan American Health Organization: 'We Can't Be the Last in Line Again During a Pandemic'

When he took the helm at the Pan American Health Organization (PAHO) at the end of January, Jarbas Barbosa, MD, MPH, PhD, was intent on reshaping the image that the health sector developed during the COVID-19 pandemic. His aim was to leverage the revamp as a way of strengthening the health system "to address ongoing problems and shortfalls and secure the right to health for all people in our region."

While the magnitude of the challenges has often eclipsed the progress made, Barbosa hasn't given up; rather, he has doubled down. He discussed several pressing health issues in an exclusive interview with Medscape Spanish Edition in Berlin, Germany, where he was participating in the World Health Summit 2023.

There, he had presented his agency's strategy to eliminate more than 30 communicable diseases in the Americas by 2030. The issues discussed included the decrease in vaccination coverage, the proliferation of false information, lessons learned and preparation for future pandemics, late cancer diagnosis, training human resources in health, and the mental health crisis, "which was amplified by COVID-19, but was already a problem."

Barbosa graduated from the Federal University of Pernambuco (UFPE) in Recife, Brazil, and received his master's degree in medical science and PhD in public health from the State University of Campinas (UNICAMP).

Communicable Diseases

Medscape: Let's start with the initiative to eliminate more than 30 communicable diseases and related conditions by 2030. Which of these do you consider to be the most important or the most challenging? Is this goal too ambitious, given the state we're in after the pandemic?

Barbosa: The initiative was approved in 2019 by the countries of the region, but the pandemic hit just a few months later. Since then, we've acquired some new technologies and strategies, so we relaunched the initiative at our board meeting 2 weeks ago. At that event, we invited several countries to present their experiences. For example, Argentina presented on the elimination of hepatitis C. Brazil presented on the new inter-ministerial mechanism that brings together nine ministers for the elimination of diseases linked to social determinants [of health]. Antigua described their cervical cancer elimination program that uses a combination of vaccination against the human papillomavirus, new tests for detecting human papillomavirus lesions, and simpler treatments.

I think it's an ambitious undertaking, but we already have the technology to eliminate all of these diseases. The biggest challenge is working with countries to identify the status of these diseases in each country, set down national goals, and adapt strategies to national realities, leveraging the best practices and experiences in the region. For example, there are countries that are very close to completely eradicating malaria, while others are still just trying to reduce it.

I think we're going to achieve a lot by 2030 because the goals are different for each one of these diseases. For example, for HIV and for tuberculosis, we need to make clear that eliminating them does not mean having zero cases, but rather means reducing mortality and the number of cases to a level that's no longer a major public health problem. For others, like hepatitis B, we're already very close to the indicator that ensures elimination thanks to mass vaccination started by the countries a few years ago.

For hepatitis C, if we make an effort to increase access to diagnosis and treatment, we can also get very close. Just to give an example: 5 years ago, treating hepatitis C with sofosbuvir cost $1500. Now, if countries that do not have the patent for that drug buy it through PAHO's strategic fund (pooled procurement mechanism), it costs less than $200.

So, in summary, I do think it's an ambitious initiative. But with political commitment, and by accelerating access to new technologies, new treatments, and new interventions, we can hit a lot of the targets.

Medscape: One disease on this list is Chagas disease, which remains neglected in the region and has high morbidity and mortality. Another, trypanosomiasis, or "sleeping sickness," in Africa, seems to be much closer to being eliminated. Are we truly able to imagine a scenario where that story could be rewritten?

Barbosa: For Chagas disease, the problem lies with people's living conditions and also vertical transmission. That's why it's one of the four diseases included in the PAHO initiative for the elimination of mother-to-child transmission. The other three diseases are HIV, syphilis, and hepatitis B. This way we can move away from a silo approach to the disease by grouping it with a more comprehensive collection of diseases. This will be coordinated with prenatal care, lowering barriers, and facilitating access of pregnant women to tests that are already available. I also think it's possible to achieve many goals with that broader approach.

Vaccines and the Pandemic

Medscape: Countries in the region, like Argentina and Brazil, have approved a new [quadrivalent] dengue vaccine this year, which also got the green light from the European Union at the end of December. What is PAHO's view on the need for that vaccine and how is it complementing, rather than replacing or robbing momentum from, other vector control strategies?

Barbosa: In addition to the vaccine, we're supporting several studies in the region on new vector control technologies, like Wolbachia, the bacteria that infects mosquitos. We're supporting countries like Brazil, Colombia, and Mexico to do research. We also have a new strategy to make vector control smarter because, when we analyze a city, epicenters of vector population growth are always in the same places. Maybe by using smart maps we could guide and fine-tune control interventions.

The new Takeda vaccine is already authorized by the European Medicines Agency (EMA), and since the EMA is on the WHO's list of stringent regulatory authorities, it's easier to get prequalification for it. We've already started a conversation with the producer to reduce the price. It was initially very expensive, and I don't know if it would have been within reach of any countries in Latin America. On the other hand, production capacity is also very limited for that vaccine. So when we speak with the producer in November, there will be a meeting of the technical advisory group on vaccines and immunization in the Americas Region, because we wish to slightly revise the way we adapt the general recommendation for our region. I think it's going to be a vaccine that is very likely to be included in the region's vaccination programs in the future.

There is also a vaccine developed by the National Institutes of Health in the United States whose technology has been transferred to the Butantan Institute in São Paulo, Brazil. They're wrapping up phase 3. Unfortunately, I don't think we'll get a vaccine that's completely effective and that will eliminate the need for control, because Aedes aegypti is also the vector for Zika and chikungunya. We need to take the broader view.

Medscape: How much has progress in the region been delayed in terms of regular immunization programs? What can be done about this?

Barbosa: Coverage levels had been decreasing in the region since 2015 for several reasons, one being a decreased perception of risk by families and even by healthcare professionals regarding diseases like poliomyelitis, which hasn't existed in the region for many decades. In view of this, people wonder: "Why should I keep vaccinating?" The same is true for measles, which has been eliminated on a regional level.

But I think some invisible barriers are also to blame. For example, in some poor communities in the region's big cities, like São Paulo, Buenos Aires, Lima, Bogotá, or Mexico City, health centers where vaccinations are given are only open Monday through Friday, 8:00 AM to 5:00 PM. This constitutes a barrier because women work and can't be gone from work 10 times a year to take their kids to get vaccinated. And [I mention] women, because half of the poor families in Latin America only have one adult with some kind of income, and it's a woman, but the same applies to men too. That's why we need to develop new strategies to ensure that people get access. PAHO encourages countries to offer vaccination over the weekends, at fairs, at markets, and in homes where, for example, there may be older adults who are unable to get out and get their flu shot. In Córdoba, Argentina, we got together with the authorities of the province and held a very interesting initiative — The Night of Vaccines — that included cultural activities. We have to work on that.

On the other hand, COVID-19 made the situation worse for several reasons. First, we estimate that 23% of children in the Americas stopped receiving vaccinations during the pandemic because centers were closed, the family was afraid of going to a clinic, and so on.

Second, the false information that was leveled against vaccines during the pandemic was also pitted against routine vaccines. We have some data from last year and from the first half of this year that suggest that we've turned the corner, and that vaccine coverage has started to rise again, but it's positive data that we need to analyze with caution. We're not yet where we need to be, so we need to develop new communication strategies. We need to understand that some families want to know more about vaccines. It's not a question of them being hesitant toward vaccination; they just want more information: "Why do I need to vaccinate my child? What's the process that ensures that vaccines are safe and effective?"

We need a different communication strategy. We need more participation from all healthcare professionals because we have surveys demonstrating that they are the most reliable source for families making decisions. If a family asks a doctor or nurse if they should vaccinate for this or that, and they don't have an answer, the family will come away with some reservations. Political, religious, community, and scientific leaders must also get involved. We need to try to translate the knowledge of why we need to vaccinate into clear language, [and we need to inform] about vaccine quality and safety. That's the most important thing.

Medscape: You've mentioned the misinformation that is thought to have jeopardized some vaccination programs that were considered examples to follow, such as for polio in Brazil. While PAHO has launched campaigns and publications, is that enough? Is there anything else that could be done at the highest level to counter health misinformation?

Barbosa: We need a very strong political commitment from the countries to back the subject of vaccination, as if it were a social pact, and not only from the governments but also from society. On the other hand, we need to change our communication strategy. If there's fake news on social media every day and the ministry only does one campaign a year, that's not enough. We need to adapt our strategy.

We had a good experience during the pandemic with an agreement with Meta to re-evaluate fake news on the social media networks managed by Meta (Instagram and Facebook). Four weeks ago, I met with Meta executives in New York during the United Nations General Assembly, and we're working on continuing to strengthen that type of agreement. But we need to do a lot more. We're supporting countries so that they can develop a broader communication strategy. Not just publish one message a year about vaccines, but to listen to people who are hesitant about vaccination and understand what questions they need answers to. Our goal is that vaccination coverage will continue to grow and reach the right level.

Medscape: We analyzed 10 speeches you've given since January of this year. You mentioned "health," "COVID-19," and "pandemic" the most. What has been the greatest strength and the greatest weakness in the region's response to the pandemic, and what lessons should be learned for addressing future health crises?

Barbosa: No country, and no organization, was prepared to face a pandemic like COVID-19. We need to take a close look at what happened so that we can implement all the lessons we learned. I'll mention two that I think are very important.

One is having all countries in the region participate very actively in the global debate on the new WHO pandemic [prevention, preparedness, and response] instrument, which may be a convention or an agreement, but it will be approved in May 2024 along with changes to the International Health Regulations. Of the six regions comprising the WHO, we are the only one that has already held two in-person meetings (Geneva and Washington), in addition to many virtual meetings, with the participation of ministers of health and foreign affairs, and we'll be having the third meeting at the end of this month.

It is important that all countries have information and participate. When we see other pandemics that we had more recently, I think this is the window of opportunity to reach a consensus on some sensitive issues. For example: will we have a global mechanism for equitable access? If we don't reach a consensus by 2024, we'll unfortunately have to wait for the next pandemic.

On the other hand, the pandemic underscored some problems in a lot of countries: the need for more resilient health systems, the subject of having better-trained health professionals, with personal protective equipment, and so on. Regional production was also [considered to be] an important topic.

We're working with countries on realistic and actionable strategic projects to expand production capacity in the area of vaccines. We have two projects for messenger RNA technology: one in Argentina, with Sinergium Biotech, and one in Brazil, with Fiocruz. But we're also working on other initiatives. For example, in El Salvador, we established a testing hub for quality certification of personal protective equipment, like masks and gloves, to service producers in Central America and the Caribbean, so that production capacity can be ramped up in a sustainable manner. We can't be the last in line anymore to have access during a pandemic.

Medscape: What emerging or re-emerging disease are you most concerned about?

Barbosa: When it comes to re-emerging diseases, there's always a risk of those that are prevented by vaccines. We still have poliomyelitis in Pakistan and Afghanistan. They're the last cases. But there's always the possibility of exportation. We still have measles in Europe, Africa, and Asia, so surveillance and vaccination must continue.

As for emerging viruses for a new pandemic, of course we can't fully foresee the future, but if we look to the past, it will most likely be a new coronavirus or influenza virus that will give rise to a new public health emergency of international significance. So we really need to strengthen our surveillance capacity. That's the legacy from the pandemic.

Today we have 25 Latin American and Caribbean countries with capacity that are performing genomic sequencing and monitoring. That would have been unthinkable before the pandemic. For example, Paraguay uses genomic surveillance to monitor not only SARS-CoV-2 but Zika virus as well. So we have a much greater capacity in the region for more rapid identification if a new virus or a new variant of a known virus arises. We need to continue to strengthen these systems.

We've been somewhat disappointed by the Pandemic Fund because we were expecting a lot more resources. Nonetheless, there are still four approved projects in the region: one that we lead on a regional level, one in the Caribbean, one in Suriname, and one in Paraguay.

But whether it's countries using their own resources, or the next rounds from the Pandemic Fund, we want to continue to build up lab capacity, increase staff training, and promote integration with health services. This includes primary care, which is the first line for identifying whether there's an outbreak of, for example, a respiratory illness that's not influenza or isn't caused by a known pathogen, or if there's an outbreak of a febrile illness that we need to investigate. All of this is needed so that each country has a greater capacity for detection and response.

Cancer and Food

Medscape: On October 17, PAHO introduced a Latin American and Caribbean Code Against Cancer with 17 recommendations. How might healthcare providers at the primary care level actively reduce cancer's burden of disease and mortality? There are a lot of actions, but if you had to mention just one that a primary care physician should take to make an impact in this area, what would it be?

Barbosa: Incorporate screening for the most common cancers into primary care. Cervical cancer, for example, is the second [leading] cause of death in women in many countries in the region, but in poorer areas it's the primary cause. We've had a test for 50 years [cervical cytology], which requires women to go to a health center and have a sample taken, and then she has to come back three or four times. All that to say, it's a strategy that could be completely changed by including the PCR test, which is of much higher quality and for which women can collect samples by themselves. This eliminates the barrier of going to a specialized center to have it done. But we also have new technologies to treat lesions from the human papillomavirus in primary care.

That's an example of how well-integrated primary care could rapidly reduce mortality from cervical cancer and support screening for other common forms like skin, breast, or lung cancer. They could at least do the first screening to identify and refer people to a more specialized department so that cancers can be identified at earlier stages.

That's a problem we have in the region: we still identify many cancers like cervical, breast, and lung cancer at advanced stages. And that means we missed a lot of opportunities when that person went to a health center.

Medscape: Regarding factors that influence cancer and other chronic noncommunicable diseases related to diet, what's happening with the front-of-package food labeling model with warning seals? This has already been started in several countries in the region, including Chile, Mexico, Peru, Uruguay and, more recently, Colombia and Argentina. What about the other countries? And the ones using other labeling models, like the magnifying glass in Brazil or the traffic light in Ecuador — should they change their models?

Barbosa: We've done a very thorough review of what is most effective in front-of-package labeling. We've even set boundaries that we feel are the most appropriate. Argentina, for example, is implementing the PAHO model. We offer technical cooperation with the countries. The concept of the traffic light, which began 15 years ago in Chile, has not been shown to be very effective. Foods for children, for example, have lots of colors, so the traffic light is a little confusing and its interpretation is not as straightforward. What does it mean if a food has two green lights and a red light, or a green, a red, and a yellow light? Can I eat it or not?

The label proposed today, whether an octagon, triangle, or square, gets straight to the point and identifies that a food is high in sugar, salt, fat, and so on. There's a lot of pressure from the food industry, with threats of unemployment, which is an authoritative attitude. From our point of view, it's not like that. People have the freedom to eat what they want, but it's one way to ensure the consumer's right to know what they're buying so that they can make decisions. You don't need to be a specialist to know what's in it.

We think the advances in the region are very positive. Two weeks ago, I was in Argentina for the World Summit on Mental Health and held a bilateral meeting with the Minister of Health from Spain. He was very impressed with the advances in Latin America on the topic of front-of-package labeling. We took the opportunity to send him some technical notes on the progress we're making in the region. It would be a good example of North-South cooperation, or rather South-North cooperation.

Of course, that by itself isn't enough. We need to look at other initiatives so that people can have more access to healthy foods, because it's often not just a problem with individual decisions. People in the Caribbean pay 50% more than people in the United States to have access to fruits and vegetables. That is to say, families might have good information but may not have the financial wherewithal. This means expanding access to healthier foods to poorer families.

Medscape: For the countries using other labeling models, do you think they should be changed?

Barbosa: Each country makes their own decision because this often involves approving a law or, in others, changing regulations. We provide technical cooperation to all and give out the information, but the decision must be made by the countries themselves.

Medscape: At the beginning of the year, the WHO director defined 'trans fat' as "a toxic chemical that kills, and should have no place in food." However, its complete elimination will not be achieved by 2023, as was the goal. Do you have any idea when it might stop being consumed in the region?

Barbosa: I think there's a feasible approach. We already have the technology to eliminate the use of trans fats altogether, and many countries have approved laws and regulations that require them to be eliminated by 2025, 2027, or 2028, so I think by 2030 we're going to have trans fats practically eliminated from foods in the region, which is very good. But we need to see what else we can do. Like, for example, reducing the amount of salt in foods like bread that are consumed a lot. Perhaps a national process could be established to achieve this. There is good evidence that this has an effect on the entire community by reducing high blood pressure. I think trans fats are almost a thing of the past. The next step would be to reduce salt.

Mental Health and Health Education

Medscape: You referred to the World Summit on Mental Health, which is another pressing problem. The average state funding for mental health in the Americas accounted for only 3% of health expenditures. What fundamental change must be adopted in the region to address the mental health issues that so greatly affect the region and that were aggravated by the pandemic?

Barbosa: PAHO established a high-level commission with people from government, academic institutions, and individuals who have experience living with mental health problems in their families. That commission gave us its report in June with 10 very specific recommendations that we have already turned into a document approved by our board of directors in September to bolster mental health care and suicide prevention in the region.

I would say that the most relevant thing is to make a sustainable transition from the highly hospital-centric model that we had in the region to a model that is more centered around care in the community, that focuses on human rights and combats discrimination and stigma. Primary care itself may also form an important part of this response. Of course, more specialized care will be needed for some cases, but the problem was so focused on hospitals and locked institutions that it just contributed to the stigma. Many people with anxiety or depression were not seeking out services. In my opinion, this is the main change.

Budgets also need to be increased. We need to be training professionals and building more capacity to provide mental healthcare to the people who need it. The pandemic drew attention to the problem. Of course it made it worse, because in one way or another we all experienced a lot of distress, uncertainty, and worry about what was going on as we were losing people from our families and among our friends. That was terrible. But the problem was already there. The pandemic amplified it — underscored it — but at the same time drew attention to it. I think things are starting to move toward making mental health care an important part of national health plans.

Medscape: Is there any message you would like to leave with physicians and other healthcare professionals?

Barbosa: Medical education is also a priority topic. We just approved a resolution to support countries with human resource planning. In almost every country in the region we are struggling in terms of insufficient quantity, inadequate distribution, or lack of readiness to respond to current needs in the complex epidemiological landscape that exists. We want to work with countries to draw up plans and begin a process of transforming education models so that there are qualified professionals for primary and specialized care. There are a lot of shortfalls in the region.

And, as for a message for them, I just want to thank them. Many times healthcare professionals in the region work in unsatisfactory conditions without the recognition that they deserve. They worked tirelessly during the pandemic and continue to do so in the same way to bring health to the communities of the region.

Medscape German Edition was a media partner of the World Health Summit in which Barbosa participated.

This article was translated from the Medscape Spanish edition.

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Cite this: Pan American Health Organization: 'We Can't Be the Last in Line Again During a Pandemic' - Medscape - Nov 14, 2023.