First, let me thank you for the opportunity to participate in this lecture series, and I feel honored to be following the distinguished persons who have addressed you in this forum. I believe that these addresses must be relevant to the work and mandates of the Organization of American State (OAS) and therefore I will try to put health of the American people in the context of those issues with which I think the modern OAS must deal.

I have taken the inauguration address of the Secretary General as a point of departure, as it gives a clear idea of his vision for the Organization and the mission it should embrace. He referred to the challenges for the Hemisphere as encompassing:
“consolidating our democracies and strengthening democratic governance; protecting human rights; advancing the consensus that integral development is more than just economic growth and must also take into account the principles of inclusion and equity; and carving out a policy of multidimensional security that effectively addresses the main security problems affecting the people of the Hemisphere”.
In his further elaboration of the concept of integral development, he pointed out that “progress in this sphere is unsustainable without objective dissemination of social rights, of high quality education and health, in short, the social and material conditions our citizen need to achieve their aspirations”.

The burden of this lecture is to demonstrate the role of health in the realization of the aspirations of our people in these various spheres that constitute genuine human development or as the Secretary General would say-integral development. The concept of what constitutes this development and the role of health in it has fascinated me for the past twenty-five years, and I have been influenced by the thinking of Caribbean scholars such as Sir Arthur Lewis on the true role of wealth in facilitating human choice and by Dr. Eric Williams who said simply that development is the face of man. But I have come to embrace the more recent concepts of Mabub Ul Haq and Amartya Sen in defining human development as the possibility of human beings expressing and fulfilling their capabilities. For that fulfillment, it was essential to focus on health, education, economic growth, a safe environment and a set of people freedoms that embraced such things as democracy and human security. These are all interrelated and for example, health is as much a driver as a consequence of economic growth and the people freedoms to which I referred. People value health. In the Millennium Poll which is one of, if not the largest public opinion poll ever conducted, health appeared as the thing that people valued most. It is not fortuitous that every aspirant to political office and every election manifesto make proposals for improving health.

But first, what is the state of health of the Americas? All the evidence shows that by the conventional measures of population health, there has been steady improvement over the years. In the past two decades, life expectancy at birth has increased by about five years and is now 70.4 years for men and 76.7 years for women. Our people are living longer and indeed the percentage of people over the age of 65 has increased steadily. Infant mortality rate which is a fairly good indicator of the basic public health services has fallen over that time by about half, and is now 20.1 deaths per 1000 live births. Malnutrition is no longer the problem it used to be. Female fertility is falling and the rate is now 2.3 children per woman. The Americas has been singularly successful in the control of the infectious diseases. The dreaded diseases of poliomyelitis and measles no longer pose problems and the childhood illnesses that are preventable by immunization are disappearing. The regional childhood vaccination days represent an example of international cooperation that is an envy of other parts of the world. Chagas disease which is seen only in our Region is slowly but surely coming under control.

There is genuine cause for some satisfaction, although not hubris, as there are still major problems to be addressed. The most important of these are the chronic noncommunicable diseases such as hypertension and diabetes which are increasing in the Americas. We must confront the scourge of HIV/AIDS, the ravages of mental illness and the growing problem of injuries and violence. Behind much of the increase in chronic diseases is the increasing prevalence of obesity in our populations and this is seen in both the developed as well as in the developing countries. In some of the Caribbean countries from which we have data as many as 60% of the females and 40% of the males are overweight or obese. Our Region has been fortunate so far compared with others in that HIV/AIDS has not wreaked the havoc that we see in regions such as sub-Saharan Africa and only in few countries, mainly in the Caribbean and Central America do we see prevalence rates greater than 2%. And the good news is that in some of those countries, such as Haiti the infection rate is on the decline, and countries such as the Bahamas and Barbados have been cited as good examples of how we should deal with the epidemic.

But these data refer to the averages for the Americas as a whole and hide one of the major problems we have to face. The human or integral development to which the Secretary General refers as one of the legitimate aspirations of the Hemisphere as a whole will not be achieved when there are such marked disparities and gross inequalities between countries and within countries.

If we examine the various regions of the Americas for example, we note that infant mortality rates are four times higher in the Andean region than in North America and fifty percent higher than in the Caribbean. This inequality is seen even more starkly when one looks at individual countries, comparing the poor with the better off. Infant mortality rates are ten times higher in Haiti than in Canada and maternal mortality rates are fifty times higher. I have sometimes referred to this as one of the scandals of our time that a mother in Haiti is fifty times more likely to die performing the natural function of giving birth than is her sister in Canada. We see the same differences in most of the indicators of population health when we examine the situation between groups within a country, most often with the rural areas being most disadvantaged. The major determinant of the differential is poverty. The poor countries have worse indicators that the rich ones and the poor within a country have worse indicators than the rich.

The fact that the poor have worse health is not new and the backward link between health and wealth is also not new. What is of interest to us today is whether health is a contributor to the wealth and economic growth of countries. The debate is more around the mechanisms, but the evidence for the health to wealth link is now firm. The Nobel laureate, Robert Fogel has shown that up to 30-50% of the economic growth of Europe during the nineteenth century was due to improvement in health and nutrition, and there have been similar findings for other groups of countries. We also have data from the Americas, showing that the health status of countries is reflected in their economic performance after a variable lag period and research from Guatemala shows that the nutritional intake of young children correlates with their earning capacities when they reach adulthood. The report of the Commission on Macro-economics and Health produced evidence that starting infant mortality rates in countries was inversely proportional to their future economic growth. An increase of life expectancy by one year is associated with around a 4% increase in GDP per person.

The mechanisms by which health contributes to wealth are many, and perhaps the most obvious is that healthy people are able to produce more, and indeed good data from several countries, including Brazil, show that height as a good indicator of health and previous nutrition is correlated with earning capacity and wages. Tall men earn more than short men. Essentially health increases the quantity and quality of human capital stock and slows its depreciation. Also, when populations are healthy and live longer, they save more and the accumulated savings clearly spur growth.

We have one of the classic examples of the impact of ill health on the economy in our own Region. The Panama Canal could not have been built unless the malaria and yellow fever were conquered principally by good public health measures of environmental engineering. There are classical studies in Paraguay of some 40 years ago showing the negative effect of malaria on the economy. The impact of illness can be catastrophic and large numbers of persons fall into a poverty trap from which they cannot escape because of the expenditure incurred in treating illness.

Thus the evidence is now unassailable that the health of a population contributes to its capacity to grow economically. Health is clearly not the sole determinant of` economic growth, but it is an important one and obviously complements the other determinants. There has been significant volatility of the economic performance of the Latin American and Caribbean economies over the last four decades which has been attributable to many factors such as technological progress or changes in total factor productivity. Population health status is not that volatile and effect on the economy is likely to be over a longer time period. But the point I wish to make as clearly as possible is that it is no longer necessary to justify the investment in health because of its welfare function or as I have said elsewhere because of its constitutive value, but also because it is instrumental in its own right in contributing to wealth and other aspects of human development.

In relation to health and wealth there is one important point I must make. Yes, it is true that the poor are less healthy and the richer countries have better health indicators. But it is abundantly clear that we do not have to wait until every one is rich for health to improve and there can be significant advances in health without the corresponding increase in income. There are choices even poor countries can make and interventions they can employ which will improve the health of their populations. Just to give one example, countries do not have to wait to be rich to raise their taxes on cigarettes and ban tobacco advertising, thereby reducing considerably their burden of heart disease and lung cancer.

Education is another one of the necessities for human development. As more of our people become knowledge workers and depend less on production from physical labor, the greater will be the need to ensure an educated work force and health is necessary for this. I will cite only a few of the multiple links between health and education. Children cannot learn if their cognitive ability is impaired because of ill health which has impaired brain development. Good health increases the returns to education. The longer the healthy life, the greater will be the returns to the investment made in education.

I will mention only briefly the relation between health and the environment. The effect of the physical environment on human health has been known from the days of Hippocrates. It is more difficult to demonstrate that the health of the people has a direct effect on the environment, although it is true that disease and poverty go hand in hand with poor environmental conditions.

The OAS has often been referred to as a political organization and the maintenance of security and democracy are some of the essential freedoms which are critical for development and occupy much of your time and energy. Does health impact on these concerns? Many years ago, I tried to convince the Minister of Foreign Affairs of Brazil that health was critical for national security and that Ministers of Foreign Affairs should become adjunct Ministers of Health. Three years ago the Pan American Health Organization contributed to the Hemispheric Conference on Security and outlined the role of health. Our concepts have been reinforced by the results of the report to the Secretary General of the United Nations on Human Security which showed clearly the importance of health to human security.

Everyone here would agree that the notion of a security that considered solely the protection of some defined territorial space is no longer tenable and that security of the person is of critical importance. Security can no longer be considered in terms of` armed conflict within or between states. It has to be seen in terms of those ingredients of human or integral development to which the Secretary General referred. The Declaration of Bridgetown at the 32nd General Assembly of the OAS states “the security of the hemisphere encompasses political, economic, social, health and environmental factors”. The UN Security Council declared in 2001 that the disease, HIV/AIDS posed a threat to global security.

Health contributes to security in several ways. It constitutes an area in which there is likely to be a commonality of value and is a platform on which people who differ radically in other areas can come together and agree. It is one of the few areas in which there is no essential human difference and as I have said before, “there are no others in health”.

One of PAHO’s shining moments was its promotion of the concept of Health as a Bridge for Peace in the Central American isthmus in the 1980’s, at a time when that area was riven by conflict. We believed that the understanding among the countries around the health needs and status of the populations went a long way towards creating a climate in which other negotiations could take place. And here I must give credit to my predecessor the gifted Brazilian, Carlyle Guerra de Macedo, who was the genius behind the creation and promotion of the concept. In those troubled times he said: “We believe that health transcends political divisions. We believe that not only can it, but many times it has been a key factor in promoting dialogue, in fomenting solidarity and in contributing to peace among people and among nations”

I am pleased when I see the concept being proposed and promoted in other parts of the world even though PAHO is not credited with authorship.

Conversely, ill health and perhaps, more importantly, the health inequities that are often seen within a country are major causes of social unrest and can threaten internal security. The perception of injustice that is seen when there are marked differentials in health status or access to health benefits can be a potent cause of social instability. Disease and its partner poverty foment mistrust and can destroy the social capital that is essential for a stable society. I believe that it is almost impossible for people who are disease ridden, who have constantly before them the manifestations of illness in forms such as the premature deaths of their children to take part meaningfully in the formal democratic process. I have sometimes asked myself how the rural poor in Haiti, with the burden of disease that is a result of the violence wrought upon them from all sides be concerned with the formalities of what we call democracy. I sometimes ask whether we pay as much attention to establishing democracy as to preventing mothers from dying in childbirth and children wasting from malnutrition and if we don’t, why not.

The recent concern with bioterrorism has put another face on the relation between disease and security. The infectious agents that may be used in a bioterrorism attack are such that the impact could well be regional or global and not restricted to one country. The interconnectedness that is a feature of the new globalized world means that human vectors could ensure the spread of an infectious agent to many countries simultaneously with consequent impact on global security. The experience of SARS and the scenarios being painted for the avian influenza, bring home to us very clearly the impact of` disease on the economic and social security of` all countries.

Is there a role for the OAS in achieving this human or integral development, or should it merely articulate the challenges and by thinking of itself as a political organization be concerned only with the political aspects of the hemisphere’s problems. I would cite an old saying, modified for the purpose. “He knows not politics who only politics knows.” I am not advocating that the OAS have the necessary technical capacity in all the aspects of human development, but I was more than enthusiastic to hear the Secretary General refer to the need to strengthen the inter-American system to address the American and inter-American development problems.

There are institutions of the system which can be mobilized in some coordinated way to address these problems. I know from experience that to a great extent the Regional institutions function very independently. I believe that there is commonality of concern for the human development in the Region and there could be a more coordinated approach to ensuring that the problems in the various areas are tackled together. There was a time when I persuaded the IDB and the World Bank to join with PAHO in developing a “Shared Agenda” for health in the Region.

It might add value to the work of all the institutions if the OAS took the lead, when addressing the development problems of a country to consider not only the political aspects in which it has unparalleled experience and expertise, but also involve the health agency, the financial agency, the agriculture agency which has been advancing so well the agenda for reducing rural poverty and perhaps others with whose work I am unfamiliar. I am not arrogant enough to suggest that all the problems of a country can be solved by attention to the health of its citizens or that the health sector is more essential than the others. But I am positing that health does have a fundamental role in all the aspects of human or integral development at the national level and the intersectoral cooperation which we know to be absolutely fundamental for progress be based on the notion of the importance of all sectors and that none are intrinsically more or less important. It is on the basis of this thesis that I express openly my enthusiasm for the proposal of the Secretary General to mobilize and attempt to seek some coordination of the resources and talents of the inter-American system.

Mr. Chairman, I, and sometimes my colleagues in health have been accused of entering fields for which we are not prepared and have no competence, such as politics and the requirements of democracy. I would reply to this by citing what Thucydides has Pericles say in his famous funeral oration. “Men accept responsibility both for their own affairs and for the state’s, and although different men are active in different fields, they are not lacking in understanding of the state’s concerns: we regard the man who refuses to take part in these not only as non-interfering, but as useless”.

That is a designation none of us here would wish.