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Amy Booth spoke with the candidates about their priorities and their vision for the future of the Pan American Health Organization. The Pan American Health Organization (PAHO) will elect a new Director at the Pan American Sanitary Conference in late September. Speaking to The Lancet, the six nominees expressed a common desire for equitable access to health care, especially COVID-19 vaccines, action on the growing burden of non-communicable diseases, and a PAHO that is more attentive to the needs of smaller member states. Regional health security and equity, especially regarding access to COVID-19 vaccines, are top priorities for many candidates. They felt that the worldwide focus on health systems in the context of COVID-19 offered a chance to push for crucial investment. Many of these concerns were echoed at the Summit of the Americas, where heads of state signed up to the “Action Plan on Health and Resilience in the Americas”, on June 9. The plan included a series of health targets for 2030 such as expanding equitable health-care access, boosting health education and financing, improving pandemic preparedness, and reducing premature deaths in the region.

heads of state signed up to the “Action Plan on Health and Resilience in the Americas”, on June 9. The plan included a series of health targets for 2030 such as expanding equitable health-care access, boosting health education and financing, improving pandemic preparedness, and reducing premature deaths in the region. “We're in a historic post-pandemic moment that has to make us see that health...is central for development and sustainability. There has never been a better opportunity to bring public health to the centre of international debate”, said Mexico's PAHO nominee, Nadine Gasman Zylbermann, who is the president of Mexico's National Women's Institute. “We’re at a point where there are still countries in the region that don’t even have 10% of their population vaccinated [against COVID-19].” By February, 2022, Latin America accounted for 28% of globally registered deaths from COVID-19, despite being home to only 8·4% of the world's population, according to WHO. A report by Amnesty International and the Center for Economic and Social Rights published in April found that countries with greatest inequality and lowest spending on health and social protection had the highest COVID-19 deaths per million people and overall excess deaths.

of the world's population, according to WHO. A report by Amnesty International and the Center for Economic and Social Rights published in April found that countries with greatest inequality and lowest spending on health and social protection had the highest COVID-19 deaths per million people and overall excess deaths. Jarbas Barbosa da Silva Jr (nominated by Brazil) is currently PAHO's Assistant Director. He wants PAHO to work with member states to develop equitable mechanisms to guarantee supplies of vaccines, medicines, and medical devices. Developing Latin America's capacity to produce mRNA vaccines is key, he said. “mRNA vaccines can be used if a new coronavirus emerges in the next few years, can be used for a pandemic influenza virus, or other viruses in the region, so I think this is very important”, he said. In September, 2021, PAHO announced that it had selected two laboratories in Argentina and Brazil to develop mRNA vaccines as part of a technology transfer programme promoted together with WHO. The candidates also said that PAHO would need to ramp up support to member states in dealing with mental health in the wake of the pandemic. Gasman described violence against women as “the other pandemic”, emphasising the need for a gender perspective in health care. For PAHO to stay at the “vanguard” as a technical institution, she says it needs to focus on parity and inclusion of women, indigenous people, and people of African descent, backed up by a zero-tolerance policy against abuse.

t women as “the other pandemic”, emphasising the need for a gender perspective in health care. For PAHO to stay at the “vanguard” as a technical institution, she says it needs to focus on parity and inclusion of women, indigenous people, and people of African descent, backed up by a zero-tolerance policy against abuse. Fernando Ruiz Gómez (nominated by Colombia, where he is the outgoing Minister for Health and Social Protection), will focus on the need to improve health-care coverage. “There are some countries where 80% of health expenditure comes from people's pockets”, he said. Daniel Salinas Grecco, Uruguayan Minister of Public Health and the country's nominee to lead PAHO, said that PAHO should focus on supporting countries to advance universal health coverage. PAHO will need to take countries’ widely varying socioeconomic circumstances into account, he said: while member states with high rates of formal employment may be able to expand coverage through social security and insurance, this is more challenging for countries with large informal labour markets. “In those countries that have...just 18–20% of the population contributing to their social security system, you can’t think of [social security] for 100% of the population”, he said. In such cases, he says that PAHO should formulate guidelines on social coverage and help the country strengthen its public health system, while respecting its culture and the principle of non-interference.

buting to their social security system, you can’t think of [social security] for 100% of the population”, he said. In such cases, he says that PAHO should formulate guidelines on social coverage and help the country strengthen its public health system, while respecting its culture and the principle of non-interference. Most candidates are calling for modernisation and better technology for national health systems and PAHO alike. Barbosa advocated for the potential of existing technology such as smartphones to make procedures faster: “This is stuff we already have“, he said. Camilo Alleyne (a gynaecologist and former health minister, nominated by Panama) said that he wants PAHO to lead greater use of digital systems to streamline and standardise processes to improve transparency and efficiency. Modernisation would involve “putting all the accounts and funds online…sharing inventories and public health policies, healthcare materials, vaccines…an exchange online that all the countries can consult”, Alleyne said. With the growth of non-communicable diseases across the Americas, most candidates agreed that PAHO should focus on strengthening health education, but Salinas and Alleyne also emphasised the role of regulating industries. “We have to work on labelling, we have to make more consumer information laws about the effects of tobacco on lung, larynx, trachea and throat cancer”, Salinas said.

ost candidates agreed that PAHO should focus on strengthening health education, but Salinas and Alleyne also emphasised the role of regulating industries. “We have to work on labelling, we have to make more consumer information laws about the effects of tobacco on lung, larynx, trachea and throat cancer”, Salinas said. However, he pointed out, labelling legislation requires careful negotiation with industry: industry groups voiced concerns when Argentina passed a food labelling law in October, 2021. Tobacco multinational Philip Morris attempted to sue Uruguay over its anti-smoking policies, which included warning labels on packets, although an international investment court ruled in Uruguay's favour in 2016. Alleyne also voiced support for restrictions on tobacco products and the sale of unhealthy foods in schools.

obacco multinational Philip Morris attempted to sue Uruguay over its anti-smoking policies, which included warning labels on packets, although an international investment court ruled in Uruguay's favour in 2016. Alleyne also voiced support for restrictions on tobacco products and the sale of unhealthy foods in schools. Financial stability will probably be in the spotlight for the incoming director following a 2020 funding crisis. PAHO is funded through a combination of quotas from member states, WHO allocations, and voluntary contributions from governments, international organisations, and private and public organisations. In May, 2020, the organisation warned that it could become insolvent after several member states failed to pay their fees and the Trump administration in the USA froze contributions to WHO. Although the crisis has been mitigated by factors such as the USA rejoining WHO under the Biden presidency and WHO adopting a new financing mechanism, several PAHO director candidates felt that problems with member states paying quotas late reflected underlying problems with how PAHO relates to its member states.

WHO. Although the crisis has been mitigated by factors such as the USA rejoining WHO under the Biden presidency and WHO adopting a new financing mechanism, several PAHO director candidates felt that problems with member states paying quotas late reflected underlying problems with how PAHO relates to its member states. According to Ruiz, while the organisation requires more participation and funding from its members, it will also be necessary to examine how it is spending its budget. “It has a pretty heavy structure, a structure with significant associated costs”, he said. Alleyne expressed similar concerns, stating that many members don’t feel “satisfied” with PAHO's support and that “it spends a lot on consulting, but you don’t see the effectiveness”. He suggested that putting PAHO's accounts online would improve transparency.

e, a structure with significant associated costs”, he said. Alleyne expressed similar concerns, stating that many members don’t feel “satisfied” with PAHO's support and that “it spends a lot on consulting, but you don’t see the effectiveness”. He suggested that putting PAHO's accounts online would improve transparency. Florence Duperval Guillaume, nominated by Haiti, where she was once Minister of Public Health and Population, said it was important for the organisation to listen to the needs of smaller member states, a view echoed by several nominees. “They believe in the PAHO but they’re frustrated because they don’t have the support that they’re supposed to have”, she said. Private donors stipulating that their money can only be spent on specific areas constitutes a further obstacle, she added. She criticised the tendency of wealthier member states to view regional cooperation as a target for cost-cutting that ultimately endangers regional public health. Inclusion of smaller states should also promote research into traditional plant medicines, Guillaume said. “We need to try to work with traditional healers, botanical healers, because everything is in our plants…We need to have some research.”

a target for cost-cutting that ultimately endangers regional public health. Inclusion of smaller states should also promote research into traditional plant medicines, Guillaume said. “We need to try to work with traditional healers, botanical healers, because everything is in our plants…We need to have some research.” Barbosa, Guillaume, Alleyne, and Salinas all said they would address the growing threat that climate change poses to health. Natural disasters and access to water are likely to pose increasing problems to health systems, according to Alleyne. “In five years, I would like to have created a school of natural disasters, focused on climate change”, he said. Barbosa wants to pay particular attention to Caribbean countries, where hospitals are often unable to cope with surges in demand during disasters such as hurricanes. He also wishes to raise the profile of the environmental health threats of soil contamination and air pollution, which he said remains a “hidden problem” despite its role in millions of deaths worldwide. Salinas said that PAHO will need to consider how the effects of a changing climate vary between regions of the Americas. “In South America, we don’t have hurricanes with the same frequency as the Caribbean”, he said. “In the Caribbean, we would have a strong focus on a tactical health response group that could be deployed rapidly, and that would involve all the healthcare personnel, mobile surgical hospitals, and immediately available drinking water, at the country's request…In South America, meanwhile, flooding, landslides, that's an issue.”

ibbean, we would have a strong focus on a tactical health response group that could be deployed rapidly, and that would involve all the healthcare personnel, mobile surgical hospitals, and immediately available drinking water, at the country's request…In South America, meanwhile, flooding, landslides, that's an issue.” Abortion divides Latin America. It is banned under all circumstances in El Salvador, Dominican Republic, Nicaragua, Jamaica, Haiti, Suriname, and Honduras. However, Argentina, Mexico, and Colombia have legalised the procedure. Chile has included provisions for abortion and reproductive rights in the draft of a new constitution which will be put to referendum in September. Gasman stated that PAHO “has to work with countries to guarantee health and reproductive rights” and highlighted gender-based violence as a public health priority. Guillaume described abortion as an issue of education. “I cannot understand that you want to legalise abortion instead of educating a woman that if you cannot afford to have children, please take your contraceptives”, she said. Alleyne said that it was a question of “the human right to life” but added that the procedure might be necessary in cases of illness, infection, or risk to the lives of the pregnant person and the fetus. Barbosa emphasised that abortion legislation is determined nationally and PAHO works to support countries within the context of their laws. The next director of PAHO will be chosen by member states in a secret ballot, and will take office on Feb 1, 2023.

Gasman stated that PAHO “has to work with countries to guarantee health and reproductive rights” and highlighted gender-based violence as a public health priority. Guillaume described abortion as an issue of education. “I cannot understand that you want to legalise abortion instead of educating a woman that if you cannot afford to have children, please take your contraceptives”, she said. Alleyne said that it was a question of “the human right to life” but added that the procedure might be necessary in cases of illness, infection, or risk to the lives of the pregnant person and the fetus. Barbosa emphasised that abortion legislation is determined nationally and PAHO works to support countries within the context of their laws. The next director of PAHO will be chosen by member states in a secret ballot, and will take office on Feb 1, 2023. For more on the Summit of the Americas please see https://www.paho.org/en/news/14-6-2022-health-gains-ix-summit-americas For the Amnesty International report see https://www.amnesty.org/en/latest/news/2022/04/americas-disproportionate-deaths-covid-preexisting-inequalities/ For PAHO's vaccine announcement see https://www.paho.org/en/news/21-9-2021-paho-selects-centers-argentina-brazil-develop-covid-19-mrna-vaccines For PAHO's financial statement see https://www3.paho.org/hq/index.php?option=com_docman&view=download&alias=51989-cess1-2-e-financial-situation-paho&category_slug=ce166-en&Itemid=270&lang=en] For more on the USA rejoining WHO see https://eu.usatoday.com/story/news/health/2021/01/22/scientists-applaud-biden-decision-rejoin-world-health-organization/4243377001/ For more on WHO's new financing mechanism see https://www.paho.org/en/news/24-5-2022-world-health-assembly-agrees-historic-decision-sustainably-finance-who

ore on the USA rejoining WHO see https://eu.usatoday.com/story/news/health/2021/01/22/scientists-applaud-biden-decision-rejoin-world-health-organization/4243377001/ For more on WHO's new financing mechanism see https://www.paho.org/en/news/24-5-2022-world-health-assembly-agrees-historic-decision-sustainably-finance-who For more on the Summit of the Americas please see https://www.paho.org/en/news/14-6-2022-health-gains-ix-summit-americas For the Amnesty International report see https://www.amnesty.org/en/latest/news/2022/04/americas-disproportionate-deaths-covid-preexisting-inequalities/ For PAHO's vaccine announcement see https://www.paho.org/en/news/21-9-2021-paho-selects-centers-argentina-brazil-develop-covid-19-mrna-vaccines For PAHO's financial statement see https://www3.paho.org/hq/index.php?option=com_docman&view=download&alias=51989-cess1-2-e-financial-situation-paho&category_slug=ce166-en&Itemid=270&lang=en] For more on the USA rejoining WHO see https://eu.usatoday.com/story/news/health/2021/01/22/scientists-applaud-biden-decision-rejoin-world-health-organization/4243377001/ For more on WHO's new financing mechanism see https://www.paho.org/en/news/24-5-2022-world-health-assembly-agrees-historic-decision-sustainably-finance-who