Assistant Administrator Atul Gawande Remarks at Looking Forward Together to Improve Health in the Americas: A Dialogue with PAHO

Ms. Luciana Viegas, Session Moderator, Advisor in Public Affairs, Communications Department, PAHO/WHO: I'll start with the question to Dr. Barbosa, as our host, Dr. Jarbas as we reflect on what the region did or fared during the pandemic, at some point, accounting for the highest numbers of cases and deaths, we recognize the many challenges that our countries face in the region of the Americas, including unequal access to services, fragile health systems. What you believe were the most important lessons from the COVID-19 pandemic, and how can we use this to move forward?

Dr. Jarbas Barbosa da Silva, Jr., Director, PAHO/WHO: Thank you. Thank you, Luciana. And good morning. I think that it's really a pleasure to be here with our colleague from USAID, Dr. Gawande.

Luciana, I think that the first important lesson that the pandemic told us is that nobody was really prepared to face a pandemic like we experienced with COVID-19. So I think that is important first to recognize that you need to always think how to have the country better prepared to develop a stronger health surveillance system, how they can be more prepared to face the new public health threats that maybe will not be as severe as COVID-19, but it's not predictable, so it is really best to be prepared for the worst case scenario. This means that we need better global governance. I think that was very important to achieve an agreement during the World Health Assembly, to have the many improvements in the international health regulation that will provide a better platform to exchange information, to make assessments about the risks, to guarantee transparency, and also the discussion on the new threat for the pandemic, that will be completed until next year. I think that, of course, it's a totally member state decision process, but this accord needs to respond to one of the biggest challenges that you had during the pandemic: how to guarantee equitable access during a public health emergency. It's not only for vaccines, but for medicines, for ventilators, for masks and gloves from the beginning of the pandemic. So I think that these are very important parts.

The other one is to address the problem in the gap that we identified in each country of the region, of course, that in Latin America we had a huge problem that it's not easy to implement the stay at home policy. That was the only public health measures that you had at the beginning, in terms of that 50% of the economies are informal economies that the you cannot say, "Don't go to crowded space" for a person who lives in isolation where we see thousands of people around him that is like crowded, this permanent situation that they have with wash your hands for people that don't have access to our intervention. So I think that we had this social economic background that explains a lot why Latin America was the center of the pandemic for many months. But we really need to take the opportunity to improve the assessment of the capacities in each one of the countries. We need to build on some important achievements that we have now. For instance, now we have 30 countries in the region that have the genomic surveillance capacity. Before the pandemic, five years ago, we talked about genomic surveillance in the region was a kind of a dream, but now in Paraguay, they have capacity. They are not even monitoring the SARS - COVID too- but they are also analyzing viruses that have a public health importance for the region like Zika, chikungunya, and others. So I think that we had the capacity to adapt and to implement important things that now we need to build on that and to use more assessments, external assessments, of the capacities, and also to prepare better proposals for the pandemic fund, and all the financial mechanisms that can strengthen the capacity, providing training, ensuring better laboratory capacity, more integration with health services, risks, communication, vaccination. So I think all the things that are around a better response. I think that this is important because the pandemic told us that if we don't have more resilient health systems, if the primary health care cannot continue providing care during a public health emergency, we can't have good information systems. Clearly, we experience an excess mortality for all causes in the region, cancer, cardiovascular disease, and also, I think that this is a kind of comprehensive package of solutions, of alternatives that you need to implement to this big challenge.

Viegas: Thank you. Dr Barbosa, sounds like we have some opportunities too, from the lessons from COVID. Dr Gawande, what would you say, in your perspective, is the biggest lesson.

Dr. Atul Gawande: So I don't want to repeat what Dr. Barbosa is saying, except to say I completely agree with it, and I want to build on that. But first, I just want to thank you for being here in this building. This place has a very special place in my heart.

In the mid-2000s, among my roles was directing a WHO program for patient safety, and we were working on a program that designed and then implemented the safe childbirth, safe surgery checklist, one of my first major global projects. And we tested in eight cities around the world, including in the Americas, and in 2009 we unveiled the results and came out with the publication in the New England Journal showing that the use of a team checklist in the operating room cut deaths by 47% where they were used. It is now in 80% of operating rooms in the world, and the introduction with PAHO was critical to the success, came out of work we did with Ariadne Labs, but then formed a nonprofit called Lifebox with leaders across Latin America who continue this day as anesthesiologists, nurses, and surgeons to be bringing safety and quality in surgery throughout the region, and it's been an exemplary body of work. And I just want to say my thanks to this organization for the breadth of commitment in public health in the Americas as a whole.

Second, I want to say that our partnership together in COVID highlighted some of the most important investments that we have in addition to the ones that Dr. Barbosa mentioned, I want to zero in on the last thing you began to talk about, which is the role of primary health care in this work. What we saw in the region proved to be true across the world, where you had strong primary health care systems, they became the backbone of having a response before vaccines were available and then after vaccines were available. They have been the backbone for the success of virtually every public health program that we have executed since the 1960s when USAID was founded.

This was critical to the maternal child health and nutrition programs that we started with, especially in Central America. There were major gains that came out of investing in infrastructure that brought community based primary health care teams that could manage at that time, you know, very specific programs in maternal child health, malaria soon, and other programs we demonstrated that we could move smallpox vaccines out so that this entire region, the Americas as a whole, became the first success in eradicating smallpox and all of that came, still, we would have had found it hard to imagine we've come to where we've come now in the Americas, where in Latin America as a whole has been leading the world as a region in matching equity in healthcare and life expectancy, in how long people survive. We now have the United States at a 78 year life expectancy. We have at least half a dozen Latin American countries that now match or exceed that with Chile and Costa Rica, leading the pack and having higher life expectancy than in the United States. And those places that have succeeded have done it by investing in primary health care as their top priority, and it's very specific things in primary health care that you are achieving universal coverage of primary health care at low or free cost.

Those countries that are doing it by assigning everyone in the community to a default Primary Health Care Center that they can belong to, and then that there are community health workers who provide outreach to touch every household in the community and be able to offer access when COVID came to vaccines, for example, and be able to indicate you are scheduled now for having your COVID vaccines. In the United States, we had to hire 150,000 or more community health workers in order to reach people who were not accessing the vaccine, in order to make sure people were able to have access. We couldn't get to 95% elderly vaccination without it. And the countries that throughout Latin America had those systems got there faster, got public health information out, and so on. And so I would say that there is an opportunity we have together to really build on the lessons of the countries that have been able to, at low cost, achieve higher survival, higher life expectancy than we would have expected, 25 to 30 years ago.

Some of those lessons are this concept of empanelment, that everybody belongs to a system, that there are low costs, that there is outreach, and not just good clinicians waiting for you to show up, and that allows our work. I will say that we are very proud of our partnership together working to implement some of the lessons Dr. Barbosa talked about, including launching a couple years ago, America's Health Corps as a joint effort to improve the quality and availability of the health workforce in the region by training 500,000 healthcare workers and public health and primary health care over the course of five years, as the plan we under a PAHO umbrella grant with USAID, 115,000 health workers have received training through the virtual campus for public health and that's approximately half of the total 260,000 in health workers trained across U.S. government supported efforts to meet the goals of the America's health core. I'll finally just say, we'll get to it. But I think some of our lessons out of COVID also apply to our global health security strategy, where we're working to build that capability that has multiple important elements to make us better at preventing future outbreaks and then responding far more effectively and far more quickly when the next major epidemic comes.

Viegas: Thank you. Dr. Gawande. I want to come back to the U.S. Global Health Strategy, but before that, I just wanted to ask a follow up question, Dr. Barbosa on primary health care. Dr. Gawande mentioned a low cost entry point to become accessible for all people. But you have also spoken before about a revitalized, differentiated role of primary care, or expanded perhaps, if you want to add on that.

Barbosa: Thank you. Here at PAHO we do believe that primary health care is the backbone of a resilient health system and what we have been working on is how we can strengthen and renew primary health care. Because when we read the Alma-Ata Declaration, and it was a revolution at that time, but the epidemiological scenario when Alma-Ata happened is totally different than what we have now. So this renewing strength in primary health care needs to be able to deploy health promotion surveillance.

I think that you mentioned some very good examples that we had in Latin America that primary health care and community work is able to monitor, to provide support, to guarantee the isolation of patients at home, to deploy good information for the houses. So for this part, they are also very important, but also to respond to this very complex environment that you have nowadays with this huge dengue fever outbreak, millions of cases. If the primary health care is not ready to respond, we will have preventable deaths related to them. But also, let's remember that nowadays, no communicable diseases are responsible for 71% to 72% of the deaths in the region, and the 34% of these deaths could be prevented if a very efficient primary health care system - and we are talking about the access to training for the health care workers, access to medicines, to diagnosis - we could prevent the around one-third of these deaths.

But when we look to the field, we have many challenges talking about noncommunicable diseases. For 100 persons that have hypertension in Latin America and the Caribbean, only 50 are aware that they have hypertension, and only 25 have their hypertension under control. So if you don't have disease, is strong primary health care working? What we are doing, we are wasting resources because we are treating diabetes and inpatient second orientation levels and at the same time, we have not been able to offer to these people the care that they need at the proper time. So I think that we are also missing a very important opportunity. So I do believe that this is the way that we are working with the councils in the region to have this very strong primary health care system.

Viegas: Thank you, Dr. Barbosa. Dr. Gawande, coming back to the U.S. global health security strategy, we see now a growing recognition that health security, economic security, also climate security, are interrelated and are equally important. Could you tell us a little bit more about the strategy and USAID's contribution to it?

Gawande: Yes. Earlier this year, the United States launched our Global Health Security Strategy, which represents our strategy across our entire interagency of work. It's the work of CDC, USAID, Department of Defense, State Department, everybody, and the critical components of it is recognizing that speed is of the essence in our ability to successfully manage and control outbreaks.

Prevention is, of course, key, and a One Health approach that recognizes that most of the dangerous outbreaks originate in animals. Means that, you know, work that we strongly are aligned on, with PAHO to strengthen our surveillance in the animal sector, along with the disease outbreaks in human beings is critical. We see that in avian influenza and so on and so that starts with that core element, but the second part is to recognize that we need rapid response in order to make both components work. We have had to recognize that we need to have cooperation at the country level in a network of countries across the world that can ensure we shrink our blind spots to the outbreaks of disease.

The International Health Regulations are supremely important because the modifications did two things. Number one is they affirmed the standards that countries have to be able to have the capacity for surveillance and the capacity for response that would allow us to drive better prevention and detection. Second, it recognized that there is a need for investment and external donor support to help countries that aren't meeting those goals and don't have the resources to meet those goals. And third, there is an expectation that countries will report far more quickly than occurred in COVID when there are outbreaks, and that information, specimens, tissue would be shared so that there can be quicker response.

In the U.S. strategy, USAID's role has been that we are backing more than 50 countries where we are providing supportive investments in increasing the laboratory capacity, the training and infection prevention and control, the local health worker, knowledge and strengthening, and some of the work I described earlier with PAHO is an essential part of that. There are five countries in Latin America, where there are investments in the PAHO system, including in the workforce development system to make it possible. And those come from partnerships in Brazil, Colombia, Peru, Jamaica, and the Dominican Republic. And all of them are with an aim that we're lifting more and more spaces where we avoid blind spots to disease. We have faster, stronger recognition by primary health care workers when there are outbreaks. And third, that you then are able to mount an emergency response, bring international support where that's needed, and get the right technical assistance and guidance to bring things under control. I'll say one last thing, which is that an important part of this is recognizing how much context matters. Diseases that will break out are different from place to place. We see how deforestation in parts of the Americas is leading to more contact between wild animals and human beings. We see how there are very specific diseases, such as arena viruses and filoviruses that we don't hear much about, but must be monitoring carefully, like the machupo and chapare virus, which have produced high hemorrhagic fever outbreaks in Bolivia. We don't hear about these until they are a serious problem. Training at the frontline has to be specific to the needs and the risks in these areas. And we're proud of the partnership that has been implementing these approaches already to become more rapid in what we're doing.

Viegas: Thank you, Dr. Gawande. I want to stay with the current epidemiological threats that we see in the region of the Americas. Dr. Barbosa, my question was to you now. Avian flu, we see more and more has spread to mammals. We have seen cases in birds and wildlife for the past couple of years. We see it now in farm animals, and this outbreak, of course, with the COVID experience, shows the importance of the One Health approach Dr. Gawande mentioned. How is PAHO integrating this approach in its work with countries in the region, and how can it contribute more to global health security?

Barbosa: Thank you. Avian flu is a public health issue that we really need to improve the response of when we are talking about the public health threats. We can have a surprise, but the usual suspects for a pandemic is a coronavirus or a flu virus. In general when you look to the last 10 years or so all of them came from the animal sector. So when we are talking about One Health, we really need to see how to adapt and to implement this concept in better coordination among the animal sector, the environmental sector, and the human sector. Our member states approved a resolution two years ago that was asking power to be more active, to work better with the other sectors. We have implemented in the region what we call quadripartite plus, because we have not only the global institution, but also the regional institution. And we have some challenges, because sometimes the private sector is not very friendly when we are talking about the strengthening and sharing information, because, unfortunately, this can be used for competitors in the global markets. So we really need to think about how to bring the private sector to the table. But we already have, I think with very good experiences. Here we have this multi-department working group that will bring together the human sector, animal sector, food safety, antimicrobial resistance, and environmental sectors. I think that this is the kind of integration that we really need and to have some projects. I went to Paraguay, I don't know when, two months ago, and we could see in the same room all the sectors working together on how to implement a project that we worked on with the Ministry of Health. But it's not only the Ministry of Health. The agricultural sector was there. The environmental sector was there, the international agencies were there. So that's kind of how we move from the concept to a very concrete action at the country level. So I think that this is the future, and this leads to strategy, building trust, and having transparency, exchange of information, and capacity to analyze the information, and then for this kind of thing, having laboratory capacity at the same time, very well-trained people in the system. I think that is crucial.

Gawande: Can I build on that slightly? Just to say influenza is so hard. This outbreak of H1N1 started more than 25 years ago. I think it was 1996 when it originated and it has been circulating in birds. What's changed now is that we've had these die-offs in a variety of different mammals, which makes us much more worried about it making the jump into human beings. But I think we've had a strategy that has been logical and constantly has to be revisited. But we are continuing to observe that the best way to monitor this is to continue to have surveillance in birds and poultry in particular, we, you know, have you know, part of what makes it hard for an industry is when we find it, you need to cull the animals, which means safely disposing of those animals, not putting those birds or the lead into circulation, but that has been a critical way to both address and see how the virus is evolving and control it. And then we have our influenza like illness global surveillance program, where we pick up when human influenza arises. And then there's a real debate and set of decisions where experts are of different opinions on how to monitor mammals, because which mammals it's been self contained. You know, there was sea lions, and then there was baby seals, and then there's alpacas, and each time it's been more contained, and so where to have the appropriate surveillance at the next level of animals is an opportunity for close collaboration, as we have experts trying to come together around where the monitoring in those populations would be most successful.

Viegas: Thank you very much. I'm conscious of the time, so I would like to open the floor for any questions from the audience to give everyone an opportunity to pose a question.

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