Three days earlier, on June 22^nd, the Inter-American Commission on Human Rights (IACHR) presented its report ‘Severe human rights violation in the context of social protests in Nicaragua’ to the permanent council of the Organization of American States. The report – shamelessly turned down by Ortega’s Minister of Foreign Affairs as “subjective, prejudiced and notoriously biased” – gives a detailed account of “the Nicaraguan government’s repressive response”, including “murders, likely extrajudicial executions, mistreatment, likely acts of torture and arbitrary detentions”. It adds one more concern – echoing what Amnesty International already highlighted in its May 29^th report ‘Shoot to kill – Nicaragua’s strategy to repress protest’: “the violation of the right to health and (…) the denial of medical attention”.

There have indeed been numerous testimonies of denial of medical attention to injured civilians in public hospitals. The Minister of Health herself, Dr. Sonia Castro, had threatened the medical staff with expulsion if treatment was provided to students and protesters. Once this became widely known, she of course denied so while still describing the care-seeking of the wounded as “attacks and forceful access to hospitals”, which would hamper medical attention to poor infants with diarrhea. Attacks around hospitals are indeed documented, but by paramilitary forces and against wounded protesters seeking care. The same government-loyal paramilitaries systematically hampered the humanitarian work of Red Cross staff, paramedics, firefighters, doctors, medical students and volunteers. When improvised health posts were set up in houses, schools and churches, volunteers were threatened, and some of them kidnapped. To make the picture of terror complete, Ministry of Health ambulances were used to mobilize shock troops and police forces to attack neighborhoods where roadblocks had been put up by the population for protection. Autopsies have been interfered and corpses with evident signs of torture have been categorized as ´death by natural causes´.

One of the most heartbreaking stories was that of Álvaro Conrado. On April 20^th while carrying water to protesting students, the 15-year old boy was shot in the throat. Bleeding to death – his last words were “It hurts to breathe” – he was denied access to the social security Cruz Azul hospital, administered by a government doctor-politician who is also president of the National Assembly. Then taken to the private Baptist hospital, the boy died while undergoing surgery.

While the death count and the denial of human rights get worse day by day, very little concern and condemnation has been shown by the international community. The Latin American and the Caribbean Medical Confederation (Confemel) and the World Medical Association (WMA) have been the exception. Confemel raised its concern for the “scandalous tolerance of the international community” and the WMA condemned “the collapse of the public health care system in Nicaragua and the breakdown of medical ethics and human rights in the country”.

Adding insult to injury, the Ortega-Murillo regime blatantly denies the on-going human rights violations and maintains its Orwellian discourse of “war is peace, freedom is slavery and ignorance is strength” to convince the handful of Nicaraguans still supporting them.

Our diaspora has started voicing indignation for the indifference of some international entities. Last Tuesday, a man interrupted a PAHO meeting to question its Director Dr. Carissa Etienne’s silence at the crisis that has affected adversely the Nicaraguan health system. But not much has changed. We understand many crises are going on in the world at this moment, but still. How many more deaths do we have to show?

So you, colleagues and friends, will you help us to restore at least our right to health? Or would you rather prefer an ‘I really don’t care’ jacket? Which side are you on?

The social security reforms were just the trigger of Nicaragua’s sudden uprising that took us all by surprise. Since Daniel Ortega took office again in 2007, he and his wife (and now vice-president) Rosario Murillo have been pretty proficient in making alliances with former enemies and the private sector. This allowed their Sandinista party to make significant institutional changes and to take control of virtually every branch of government, the Supreme Court and the National Assembly. They established a State-Party-Family regime that also controls the streets, not allowing dissidence nor opposition. At the same time, Ortega-Murillo’s sons and daughters hold important positions as presidential advisers and they own TV channels among other private enterprises. First lady and vice-president Murillo has lavishly spent US$ 3.3 million to build and install 134 ‘Trees of Life’ and an additional $1.1 million annually in electricity bills, all this in the second poorest country of the Americas. These ‘Trees of life’ are 9-ton, 17-mts tall metallic constructs that ‘decorate’ the capital city, but above all reflect the esoteric vision of Nicaragua’s most powerful woman. Now, they are felled by the protesters, who keep on demanding the ouster of the presidential couple.

You might have seen some images of the protests on tv, thinking you were watching (yet again) riots in Caracas, Venezuela. Wrongly so. Far less forgivable was the regime’s immediate and irrational response, dismissing the protesters as “minuscule groups”, “vampires”, “full of hatred”, allegedly supported by “ultra-right” opposition, funded by the US government to destabilize the country, manipulated by the MRS party – a small party of Sandinista dissidents. All wrong. Then, what actually happened?

First of all, some students had already taken the streets early April, to protest against the slackness of the government when a week-long fire destroyed more than 5,000 hectares of Central America’s biggest rainforest reserve, the Indio Maíz, located in the Nicaraguan south-east corner. Ever since, the protesting students refer to themselves as ‘autoconvocados’  ( self-convoked ). They embrace non-violence and want no existing political party to represent them, neither right nor left wing. They do not trust the government nor the political figures that had their share of power in previous neoliberal governments and under the Ortega-Murillo regime. Protests intensified and the group of students became bigger after social security reforms were announced which raised contributions but left institutional corruption untouched. When protesting students were taken to prison, beaten up, and shot dead by the police and paramilitary forces, the population started supporting the students. Journalists covering the protests were targeted by the party mobs and the police; one of them was shot dead while broadcasting.

Protests have taken place in all parts of the country, also in the historical Sandinista strongholds. The ‘minuscule groups’ turned into a march of hundreds of thousands of people in the streets of Managua on April 23^rd, right after the Ortega-Murillo regime decided to take a step back and withdraw the social security reform. One day later, Ortega accepted to start a dialogue, in which the Catholic bishops will act as guarantors. But who will be allowed at the table, when the dialogue will start and what will be discussed, all these vital issues are still in limbo. The ‘autoconvocados’, as well as other sectors of the population are demanding the establishment of a new governing body, not allowing the Ortega-Murillo couple to finish its current term. They also want justice for the victims of human rights violations, including 46 (confirmed) dead, more than two dozen missing and still uncounted incarcerated protesters, of which many were tortured.

As one of the protest’s banners signaled “We are not from the left, nor from the right, we are the ones at the bottom and we come for those who are above us”. Is this a real “Nicaraguan Spring”? Will this be the end of our caudillismo curse? Wherever our movement will lead to, eventually, I don’t know. One thing I know for sure is that it will be a bumpy journey, as Ortega clings to power ferociously.

In his lecture, Dr. Myers gave a succinct and very relevant summary of the steep biophysical changes that have taken place on our planet and their impact on nutrition, infectious disease, displacement and conflict, non-communicable disease and mental health. He emphasized the intergenerational debt and highlighted the issue of equity in the nascent science of Planetary Health. In the end, as he put it, “it is the poorest people with the least diverse diets who will be pushed into worsening nutrient deficiencies by CO₂ concentrations that are increasing in response to wealthy world carbon emissions. Future generations will suffer the consequences of today’s unsustainable consumption patterns.”  Damned right.

He also mentioned in his lecture that the Planetary Health Science is only now teaching us “that each person on the planet, those alive today and those coming in future generations, is connected to everyone else”. Nevertheless, this realization of interconnectedness is not exactly new. Now it’s (finally) also becoming mainstream in the hands of the W²EIRD (White, Western, Educated, Industrialized, Rich & Democratic) people. Even actor Jim Carrey now makes a living out of preaching this ‘discovery’ through his ‘path of enlightenment’ (Ayahuasca ritual included, I would assume).

From the First Nations People in North America, over Indian tribal communities and the Australian aboriginal population, to quite a few Buddhists, many communities have this view of interconnectedness of all beings, past, present and future, and the land they are part of (not the land that belongs to them). It is not by chance that Aboriginal people have some of the highest rates of substance abuse in Canada: there is reporting and evidence that this issue is rooted in historical and inter-generational effects of colonization. Complex multiple losses that include the loss of traditional lands and culture and forced removal from families constitute some of the elements that lead to increased substance use as coping mechanism, sadly.

As for the ways forward to provide solutions to the set of wicked problems defined by Planetary Health Science, Dr. Myers made a plea for paradigm changes at different levels, involving actors outside and within Public Health disciplines. Again, alternative paradigms or frameworks have already emerged, such as Buen Vivir (Living Well or Collective Well-Being) in Latin America or Degrowth (versus ‘Sustainable Development’), just to name a few. Maybe it is now time to take a look at what we already have outside of the knowledge system of the W²EIRD people. To his credit, Dr. Myers seemed to agree that “it might be that indigenous and aboriginal cultures and many faith traditions have an important role in reconnecting us with that other important way of knowing that is more consistent with stewardship of our natural systems.”

In the meantime, the world keeps spinning, with COP23 ending in Bonn, New Delhi residents, including a good friend of mine, being affected by toxic smog and the Mapuche communities still bravely resisting land grabbing by Benetton in Patagonia, Argentina.

Planetary health proponents have their work cut out.

Although I was a bit afraid this would be a “mini Davos-like” event, as described (arguably, by a biased observer)  in past editions, it was surprising and even encouraging to see a good demographic balance, with very young students and professionals, as well as senior high-profile researchers, decision-makers and CEOs from pharmaceutical companies, among other usual suspects. Even a royal member of the Kingdom of Jordan, Princess Dina Mired, actively participated as the President-Elect of the Union for International Cancer Control. Young Leaders in Global Health had their say in the opening ceremony, via an eloquent representative.

The WHS 2017 was aligned to the G20 summit held in the same city earlier this year, which had launched a call for action and for determined political leadership to thwart forces that counteract global health progress. At the G20 summit 2017, health was for the first time recognized as a focal area in order to attain the overall SDG agenda. It was also the first G20 summit in which a WHO Director-General participated, as you know. After the high-level meeting, Dr. Tedros remarked that political commitment is the key to UHC and progress towards the SDGs. During the WHS opening ceremony, Dr. Tedros addressed the participants in a video message, emphasizing again how indispensable political commitment is if global health is to make real progress.

The M8 Alliance’s WHS 2017  Declaration, titled ‘health is a political choice’, highlights the need for action in the following areas of global health: 1) commitment to strong and reliable governance, 2) commitment to ensure global health security, 3) commitment to healthy and resilient cities, 4) commitment to responsible approaches to big data, 5) commitment to research, innovation and development, and 6) commitment to innovation and health systems strengthening in Africa.

The M8 Alliance and German authorities also called upon the countries that will hold the next G7 and G20 presidencies to make the political choices required to ensure the implementation of the 2030 SDG agenda. As for the G20, German’s presidency ends next month. Argentina will then become the first Latin American country to host the G20 summit. However, the bar has been set (too) high for the South American country, it seems – recently, the (right-wing) Argentina government implemented austerity measures which cut, among others, the science ministry budget by a whopping 36%. The current government clearly treats science and research innovation with disdain, in the name of attracting (more) foreign investment (or at least that is what they hope for, the logic isn’t entirely clear to us).

Nevertheless, on the other side of the world, academics and other stakeholders made a strong plea for “investments in science and innovation as well as in public health institutions and capacity”, (rightly) stating that this is critical to progress in Global Health. Emphasis was put on the development of vaccines, new antibiotics to address the challenge of antimicrobial resistance and efforts to prioritize the digital potential of health systems.

In many sessions, it was agreed that an inter-sectorial approach is much needed to tackle many of the challenges in achieving the SDGs. The new mindset and humble attitude of public and private actors to come together for the common good were part of the diplomatic discussions.

´Innovation´ and ´social participation´ were some of the buzzwords in Berlin. The latter was briefly addressed, starting from a rather abstract definition given by the WHO, during the workshop ‘Equitable Access to Universal Health Coverage & Care´. How and when will social participation be ensured? It is still not very clear to which extent private-for-profit and public entities are willing to let people participate in the decision-making processes and implementation of strategies to ensure equity and access to affordable and quality care. Even less clear is how social &/or community participation will be measured and assessed.

I was very glad that Elhadj As Sy, Secretary General of the International Federation of the Red Cross (IFRC) claimed that if we are really serious about ´leaving no one behind´, there is a need to involve the communities. Investing in communities, building local leadership and strengthening communities is the way forward. When it comes to preparedness and response to global threats, he highlighted that partnerships cannot be built in the middle of a crisis. Joanne Liu, International President of Médecins Sans Frontieres addressed the issue during her keynote speech at the opening ceremony, urging the world to overcome its current ‘selective humanitarianism’ and to stop “reacting to an epidemic (only) when it comes knocking on your door” (rich countries’ doors, that is).

Shouldn’t epidemic preparedness, tackling NTDs and NCDs and ensuring UHC involve the communities? Can innovations not also rise from local needs and responses, within the communities? I bet few people will disagree with this. Community participation should be as important as political commitment from heads of states. If that’s the case – and we believe it is-, then it seems also necessary to engage them in global health fora too. Perhaps an idea for the 10^th anniversary of the WHS in 2018?

Of course, we welcome the fact that this year’s theme is related to a “social determinant of health” rather than a particular mental illness. This opens the door to prevention of work-related mental health issues from a non-health perspective, and to a broader public policy perspective. Such a shift from an individual’s illness focus to a psychosocial approach is long overdue.

WHO’s proposal to boost mental health in the workplace suggests a three-pronged approach consisting of: (1) reducing work-related risk factors for health; (2) creating a healthy workplace; and (3) supporting people with mental disorders at work. The second one overlaps with the agenda from the World Economic Forum. Nevertheless, even WHO’s broader three-pronged approach falls short of what is needed to improve mental health in the workplace, basically, because it remains firmly grounded in the capitalist model, which by definition is incompatible with “healthy lives, a healthy planet and social equity”.

There is no magic bullet or “one-size-fits-all” response to the issue of the workplace as a potential generator of suffering and illness. In addition, we need to acknowledge that work “as we know it” is constantly changing. We can look at the mental health impact of the workplace from various angles, whether it’s the rise of the ‘gig’ economy in the North; the high unemployment rates around the world that are expected to rise even further this year (as compared to 2016); the more than 40 million people across the world that are victims of modern slavery (with almost 25 million of these in forced labour), according to a recent report by the International Labour Organization (ILO) and the International Organization for Migration (IOM); or job dismissal, overwork & burn-out, common phenomena now in many “developed” and other countries. Just recently, we heard of one of the many cases of ‘death from overwork’ or karoshi, in Japan, and students forced to work long hours in China.

A while ago, we had the chance to interview Cecilia Ros and Miriam Wlosko, two researchers who have been working on the Lanus National University’s Health, Subjectivity and Work programme for over 20 years in Argentina. An interesting finding from their research concerns the impact of neoliberal policy reforms – aka “adjustments” – on people who are fired, the unemployed and their families and communities. In many cases, they found job dismissals not only to have an impact on those directly affected but also on the people who continue to work in the same place. The so-called ‘survivors’ (or those that are “left behind”, if you want it in inclusive SDG jargon) more often than not have to endure conditions that are not acceptable, or downright precarious. According to Ros and Wlosko, dismissals and precarious working conditions have the purpose of disciplining workers; the threat of being fired has become a managerial strategy in quite a few workplaces around the globe, not just in Argentina – any resemblance with the situation of academics toiling in neoliberal environments is of course purely coincidental .

SDG 8 aims to “promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all”. The International Labour Organization has defined decent work as work that “is productive and delivers a fair income, security in the workplace and social protection for families, better prospects for personal development and social integration, freedom for people to express their concerns, organize and participate in the decisions that affect their lives and equality of opportunity and treatment for all women and men”. Seems like a nice definition, if you ask us; still, many questions can be asked, such as: What is “a fair income”? How much participation should be promoted? How  “decent enough” is work before it can be considered as ’decent work’? And, perhaps even more importantly, is a ‘decent work’ agenda really compatible with a predatory globalized capitalist economy?

Whatever actions are taken to promote and create awareness of mental health in the workplace, we should perhaps get rid of the (somewhat naïve) belief that having a job will always be a guarantee of stability. We need to focus on improved well-being in the workplace, and not just zoom in on specific pathologies such as depression and anxiety. Last but not least, if we are to talk about mental health in the workplace, one needs to have a “workplace” first. As you know, not everybody is that lucky. And that’s even before the robots and other AI tools are going to take over.

Well, at least they won’t need Prozac. 

Photo credit: Inti Ocón

The theme this year was ‘Ethics and transparency in access to medicines’, a hot topic across the globe now, including in Latin America.  The agenda featured 2 main panels on the first  day: the first panel focused on transparency in the negotiation process and access to medicine information and medical supplies, the second one zoomed in on ethics and conflicts of interest in the management of medicines and medical supplies.

This was an opportunity to discuss the many barriers that hamper equitable access to medicines in these Latin American countries. One of the main barriers is related to the rising cost of high-cost medicines (such as antiretrovirals, orphan drugs and biologics, … ), a global trend as you know, which in turn jeopardizes the sustainability of health care systems. A well-documented case is that of cancer drugs. For instance, it has been reported that the median annual price of cancer drugs has increased from US$ 12,000 before 2000 to more than US$ 120,000 by 2015, much higher than the per capita gross domestic product (GDP/capita) of any Latin American country. Even more disturbing is the fact that many new cancer medications do not always offer meaningful clinical benefits or therapeutic value to patients despite their elevated cost. Additionally, in some cases (cancer) treatment drugs are costlier in LMICs than in high-income countries. Drug prices are usually set at whatever “the market” will put up with.

We think it is important for governments to do their own (internal) analysis on the transparency of the pharmaceutical sector. Regulating entities play a vital role, trying to strike a balance between the practical guidelines, supplies and technologies and the ethical practices. Therefore, disciplinary strategies should be implemented to prevent corruption in the negotiation process of purchasing medicines. An example of this is the Ricarte Soto Law in Chile, which states that technical commissions in charge of making recommendations on which treatments should be financed, cannot comprise professionals who have had financial links with the pharmaceutical industry in the previous 24 months; these professionals are also forbidden to have any link till up to 24 months after playing a role in such commission.

The strengthening of national regulatory agencies, with a view on increasing their regulatory competencies and control over health technologies is urgent and necessary. These efforts should reach beyond local action by governments and also involve regional action, allowing the implementation of strategies to improve access to medicines, supplies and technologies. An important regional initiative is DIME (Informed Decisions over Medicines), a platform that has been built through Communities of Practice, coordinated by consultants and health authorities from the 8 participating countries. The platform will soon be open to the public.

Another example of how to mitigate the burden of public spending on high-cost medicines was the joint bargaining effort & purchase of high-cost medicine by countries from the intergovernmental regional organizations UNASUR and MERCOSUR, in 2015. This smart move resulted in collective cost savings of approximately US $ 20 million for the involved countries in the joint purchase of darunavir—an antiretroviral treatment for HIV and AIDS. Hopefully we can see more of this in the years to come, despite the political changes (and challenges) in the region.

Scarce knowledge and expertise, weak institutional structures vulnerable to pressure from suppliers, lobbyists and other unwanted influences are among the other obstacles to be overcome by most of the fragmented health care systems of the Latin American region. The development of entities that can detect, analyze and penalize anticompetitive and corrupt activities should be another aim. For instance, the former Minister of Health in Guatemala, Lucrecia Hernández Mack, had signed an anti-corruption and transparency agreement. She recently resigned, however, in protest of the presidential decision to expel the International Commissioner Against Impunity in Guatemala – a major setback to the efforts made to curb corruption in the country, obviously.  Even when there are legal mechanisms to improve the access to generic medicines, these have not always been used due to the lobbying of private stakeholders of the pharmaceutical industry and the lack of knowledge of the technical, political and judiciary authorities on the topic. Making use of the existing legal mechanisms requires capacity and technical expertise of national authorities along with a strong political commitment to take on market forces. PAHO and other expert agencies (including non-governmental ones) should support the member states in this respect—as is the case with the Salud Derecho Initiative.

Anyhow, the issue of access to medicines is here to stay. It will definitely also be a hot topic at the upcoming G20, hosted by Argentina in 2018.

And yet, even fear and shock can ignite a fire of hope and sense of agency. Take tuberculosis: the re-emergence of TB as top-ten global killer led to combined efforts of nations across the continent to curb the disease.

The latest Global Tuberculosis Report counted 10.4 million new cases and 1.4 million TB deaths in 2015 (global figures), with 0.4 million deaths resulting from TB among people living with HIV. Over 95% of cases and deaths happen in developing countries, many of which also suffer from weak health systems and adverse social determinants of health. To compound matters, TB has a complex cause-effect relationship with poverty, marginalization and discrimination. In the Americas, the Pan American Health Organization (PAHO) estimates  there were approximately 23,000 deaths due to the disease in 2014, 280,000 cases reported and an estimated 65,000 cases undiagnosed.

In November 2016, Mexico City hosted a 3-day workshop on ‘Political TB Advocacy for Focal Agencies of the TB Parliamentary Front against TB in the Americas’. The aim was to consolidate and officially launch the TB Coalition of the Americas, which includes the vast majority of countries in the region, including Canada and the United States. We hope the US commitment and participation will not be compromised by the major policy changes happening in “TrumpLand” today.

Prior to this workshop, a  Regional Parliamentary Front against TB in the Americas was created in early 2016, which brought together parliament members from Brazil, Mexico, Peru, Bolivia, Uruguay and Nicaragua. One of its main goals is to work alongside governments and civil society to ensure the allocation of enough funds to finance cost-effective interventions to halt the spread of TB. The Regional Parliamentary Front is committed to establish national parliamentary groups that will demand  accountability, monitor expenditure and joint work of the governments with civil society organizations or focal agencies in each country. These interventions include those beyond the health sector, ensuring financial and social protection that are necessary to prevent TB as a poverty-related illness. Groups will be in charge of positioning TB as a transversal topic across national policies, promoting human rights of those affected by the disease and informing the ministries (annually) about the advances and/or setbacks in the fight against the epidemic.

The Belgian NGO Damien Foundation is one of the focal agencies working on this issue in Nicaragua and Guatemala. The NGO provides technical support to the TB Control National Programs in these two countries. In Nicaragua the Foundation plays a key role in strengthening the community network to take measures against TB.

These efforts could not come at better moment given that the United Nations General Assembly has announced that it will hold a high-level meeting dedicated solely to TB in 2018. Similar meetings have  taken place to address other major global health issues over the last decade and a half, respectively on HIV/AIDS in 2001, NCDs in 2011, the Ebola crisis in 2014 and the antimicrobial resistance threat in 2015. Moreover, the International Organization for Migration (IOM) has just launched the world’s first TB and Migration Portal: The Knowledge Platform on Tuberculosis and Migration.

It may seem like “many small people, in small places, doing small things that can change the world”, in Eduardo Galeano’s words, but we are also building the much needed resilience and taking action to demonstrate the real greatness of America, the Americas, plural.

Post scriptum: Before you get blinded by the light, I recognize that we still have some darkness too. As the Guttmacher Institute reminded us nearly a year ago, more than 97% of women of childbearing age in Latin America and the Caribbean live in countries where abortion is restricted or banned altogether. And that was before the Global Gag Rule…

Community health workers planning intervenyions to takle TB in their communities. Nindirí, Masaya, Nicaragua.

There is little support for health system researchers in the region. Curiously, the same countries that provide more support for their athletes also tend to be the ones that have prioritized health systems research. What do they have in common? Well, they have policies and good financial mechanisms to fund initiatives that lead to success in sports as well as to the development of more equitable health systems.

In the Latin American and Caribbean region, the countries that have won the most medals in the past are Cuba (over 200!), Brazil, Argentina, Mexico and Colombia. Up to date, over half of the region’s gold medals (72 to be precise) come from Cuba, where the government has allocated large amounts of state resources to pursuing (and achieving) international sporting success. You might say that’s perhaps not what a relatively poor country should focus on, but Cuba is also one of the countries that have put a great deal of effort on supporting health systems research. The Ministry of Public Health in Cuba has under its direction an initiative called The Research Program on Health Systems and Services Cuba. The program has a proven impact on health systems in terms of more equity, quality and efficiency in health services. And let’s not forget how Cuba became the first country to halt HIV mother-to-child transmission about a year ago.

Brazil invests the most in research and development as a percentage of its GDP (1.18%) – compare with the regional average of 0.69%. Together with the investments of Mexico and Argentina, the three countries represent 89.7% of all R&D spending in the region.  Other countries like Costa Rica, Ecuador, Guatemala, Paraguay and Peru have a specific agenda of national priorities for research for health. On the other hand, Honduras, Panama, Mexico, Uruguay and Nicaragua have not established any national priorities for research for health. In Mexico, however, the Council of Science and Technology issues calls for proposals based on a lists of topics from where research topics are selected.

Admittedly, in 2009, the approval by all member states of PAHO’s Policy on research for health was a breakthrough towards supporting health research in the region. Progress has been made since then, but it has been uneven across the region. Efforts need to go beyond a few conferences aiming to bring academics together to share their experience (even if that’s a favourite pastime of academics around the globe ). There is an urgent need to bridge the gap between academics, policy makers and activists. For the latter, see for example a movement like ALAMES (Asociación Latinoamericana de Medicina Social/Latin American Association for Social Medicine), whose presence is significant across Latin American countries. As for policies, a cornerstone for structuring some sort of national initiative for health systems research, some countries still need to add this to their national agenda. We also hope more and more Latin American health systems researchers will find their way to global health systems research symposia (like the one coming up in Vancouver). The Latin American delegation last time, in Cape Town (’14), wasn’t exactly of Olympic proportions. (Do you read this, Health Systems Global?   )

For now, we’ll keep celebrating our athletes’ triumphs who, defying the odds and in spite of scarce support, continue to let Latin American people dream. For example, the gold medal of Oscar Figueroa, a Colombian weightlifter, just a few days ago.

What receives far too little attention is the fact that the Zika crisis – and the response to it – generates fear, confusion and uncertainty for the poor actually living through it, especially women. Little justice is done to gender, sexual and reproductive health issues, major inequities in the living and sanitary conditions of the poorest and criticism towards mainstream control strategies.

Delaying pregnancies is one containment measure. Several Latin American countries have asked women to delay pregnancies until there is a better understanding of Zika and its relation to microcephaly, and the transmission of the virus in utero. It is good to realise that Latin America is the same region that saw abortion banned in Chile, Surinam, El Salvador, Haiti, Nicaragua and the Dominican Republic, where access to contraceptive methods is generally inadequate, and which already has the highest proportion of unintended pregnancies (56%) in the world. It’s also the region where ‘Christian’ beliefs are most influential in policymaking, and pope Francis’ comment that in times of Zika “avoiding pregnancy is not an absolute evil” caused panic among local church officials .

With Zika being the latest addition to Aedes-spread infections in Latin America (yellow fever, dengue, chikungunya), vector control is key to the public health response. Ever since the construction of the Panamá Canal, chemicals have occupied a central role, either through spatial fumigation or adding them to drinking and non-drinking water storage containers. Most commonly used in the region were organophosphates like Temefos and Malathion, and they keep being used despite well-known harmful effects on humans and ecosystems, and increasing resistance of the mischievous Aedes. A pesticide of more recent use in chemical vector control is pyriproxyfen. In Brazil, where pyriproxyfen was introduced in drinking water in 2014, Abrasco (Associação Brasileira de Saúde Coletiva) made a case for paying more attention to the association between poverty, intensity of chemical disease control and incidence of microcephaly (in a February 2016 Technical Note ). Abrasco’s thoughtful questioning of mainstream disease control was dismissed as a complot theory, the suggestion that pyriproxyfen could be part of the problem debunked as a myth. While indeed the case for a causal link between the Zika virus and microcephaly is getting stronger, defenders of pyriproxyfen have weak arguments. The WHO, in its emergency update ‘No evidence that pyriproxyfen insecticide causes microcephaly’ , bases its claim on 2008 ‘Guidelines for Drinking Water Quality’ . Those guidelines however extrapolated the safety of pyriproxyfen from tests in rats and rabbits only, and clearly state that “this guideline value is not intended to be used when considering the use of pyriproxyfen as a vector control agent”. From a scientific point of view, it is a pity that the mounting evidence against culprit Zika eclipses critical attention for the impact of pesticides. From an ethical point of view, it is a shame.

What is common to most Zika control measures so far  – vector control and others – is a total neglect of the people involved. Women are told to postpone childbearing, but denied family planning. Favela shacks are sprayed without consent, while their inhabitants are denied a life worthwhile living. This is of course nothing new in disease control; it is rather a déjà vu. Nearly 100 years ago, Juan Bautista Justo was one of the first to criticize Rockefeller public health in Latin America for turning a blind eye to the people. What was needed, Justo argued with strong political arguments, was social change for improved health. He was laughed away.

We should be wiser today. On top of the arguments Justo already had, we have a century of failed disease control, including old and new emergencies, and know much more of social and environmental impact than was the case then. For public health to be effective, it should be with the people, not against them.

On the heels of the next major health systems event in a country that feels refreshingly “new” since yesterday, the Emerging Voices for Global Health team is also gearing up for a shift.

A few months back, EV alumni organised themselves to come up with a new globally representative governance structure comprised of EV alumni from all regions:

* Prashanth Nuggehalli Srinivas (Institute of Public Health, Bangalore) (South-East Asian region)- Chair;

* Dorcus Kiwanuka Henrikson (Karolinska Institutet) (East/South African region)- co-chair;

* Jin Xu (Peking University) (Western Pacific region) – treasurer;

* Arsene Kpangon (University of Parakou) (West/Central African region);

* Vladimir Gordeev (London School Of Economics) (European region);

* Asmat Malik (AMZ Consulting, Pakistan) (Eastern Mediterranean region) – co-chair;

* Elena Vargas (Independent Researcher) (Region of the Americas) – Secretary.

Two liaison (and not elected) members complete the Governance team:  Kopano Mabaso (liaison with HS Global); Kristof Decoster (liaison with ITM).

Together, the new EV4GH governance hopes to improve the scope, reach and impact of the EV event in future editions. After the new governance team was put together, the EV4GH group has been closely interacting with the WHO Alliance for Health Policy and Systems Research as well as with Health Systems Global, both entities being important partners and well-wishers for us. Indeed, over the coming months, EV4GH hopes to pursue a systematic collaboration with Health Systems Global and eventually integrate in some way with the society.

This month, with the help of ITM’s EV team, a new secretariat is being established for the EV4GH at the Institute of Public Health Bangalore (IPH). IPH has been an early partner of the EV4GH having been involved since the first edition that was held in association with the first global symposium on health systems research in Montreux. For the coming year, the team at IPH (including Prashanth N S, the Chair of the EV governance group and Sophia Thomas, the secretary for the EV governance) hopes to take forward this new phase in the EV4GH evolution.

IPH is of course not alone in this. With the support of various EV partner institutions including the Institute of Tropical Medicine, Antwerp (ITM), Belgium;  the Public Health Foundation of India (PHFI); University of Cape Town (UCT), South Africa; University of the Western Cape (UWC), Cape Town, South Africa; Peking University Health Science Center (PUHSC), Beijing, China, the new secretariat at IPH is all set to launch a call for fresh EVs to participate in the 4th global symposium at Vancouver. We foresee a new and vibrant bunch of researchers, implementers and other health system actors to be selected in this edition to participate and constructively engage and challenge the global health discussions at the symposium. This year, the new EV2016’s will gather a few weeks before the symposium in Vancouver for a face-to-face training and will again try to enliven the discussions at the symposium. We look forward to welcoming a fresh batch of Emerging Voices for Global Health!

Stay tuned for the call details on the website of the 4th Global Symposium for Health Systems Research and on the EV4GH website.

The OAS emerged in 1948 from the previous ‘Union of American Republics’. As such, it claims heritage of liberator Simón Bolívar’s proposal from 1826 – incidentally, also in Panama – for a Treaty of Union, League, and Perpetual Confederation. The organization is in charge of promoting democracy, solidarity and peaceful resolution of conflicts on the continent. It largely failed to achieve these objectives, however, functioning instead as a tool for the United States to constantly interfere with democracy throughout Latin America and the Caribbean.

Counterbalancing the OAS, heavily influenced and dominated by Washington, a number of regional organizations have been created in Latin America over the last decade. The most outstanding ones are (1) the Community of Latin American and Caribbean States (CELAC, a Latin-American/Caribbean alternative to OAS for political dialogue; it exists since 2011 and comprises 33 member states), (2) the Bolivarian Alliance for the People of Our America (ALBA, taking up Bolívar’s dream of integration since 2004, with 11 member states), and (3) the Union of South American Nations (UNASUR, unifying Mercosur and the Andean Community of Nations since 2008, 12 member states). All are expressions of Latin America’s determination to handle its own affairs. However, the OAS still remains the chief political and diplomatic forum in the Americas, on top of a complex and complicated constellation of regional and international bodies (for a complete picture, see here).

The ambition of the 7^th Summit of the Americas is gigantic: to reach – in the most unequal region of the world – common ground on security, energy, education, migration, democratic governance, citizen participation, and health. Given the discrepancy between the U.S. and a rather important proportion of Latin American countries, can real solutions to the region’s collective problems be expected?

Nowadays, Latin America and the Caribbean (LAC) balances between the hope offered by social movements and progressive governments and the shadows of sectors that deepen neoliberal policies or even want military dictatorships back in the region.

Conservative LAC governments (Colombia, Peru) haven’t improved a single element of the social determinants of health, for example, while progressive ones (Ecuador, Bolivia, Venezuela) at least improved income, employment, social protection and education, even if much still remains to be done (and no progress is guaranteed forever). The latter also tried to improve the public part of their segmented health systems (Ecuador, Bolivia and Venezuela again). Conservative governments, as expected, continued on the road towards privatization of health services (Colombia, Peru), a road going to nowhere in our opinion.

For the least optimistic observers in the region, this summit will be less about achieving consensus to tackle regional problems and more about the presence and behavior of the attendants. Celebrity watchers hope that Barack Obama and Raúl Castro do their handshake at Nelson Mandela’s funeral all over again, more formally this time, now that the US has decided to re-establish diplomatic relations with Cuba. But the US also recently declared Venezuela a threat to its national security and foreign policy, which will certainly boost less diplomatic interactions at the summit. As for two of the other key players in the region, Brazil and Argentina, they both support the current Venezuelan president, Maduro (like most other Latin American countries). But it will be interesting to watch: on the one hand Obama will be lifting the Cuba embargo, on the other hand it is very likely that he makes a big declaration against Venezuela (to satisfy Republicans?) which might not go down too well in the region.

The results of the summit—if any, are yet to be seen. The summit’s real significance might be more existential: will it be a turning point from contested hegemony towards equitable cooperation, with or without the OAS?

One can almost see Bolívar smiling from behind the clouds…

According to the report, Nicaragua closed about 79% of the gender gap –  a figure based on a stunning 100% improvement in health and survival and 99% in educational attainment, followed by 54% in political empowerment. Nicaragua occupies the sixth position globally. This achievement was obviously celebrated by the Nicaraguan government and supporters of the Sandinista ruling party; they considered it a result of “the restitution of women´s rights by the Sandinista government”. While it can’t be denied that more women have made it into parliamentary and ministerial positions since the Sandinistas regained power in 2006, not all is rosy under the red and black flag.

Civil society organizations, human rights associations and feminist movements were less enthusiastic about the results. Criticisms were voiced over the methodology used and the reliability of the data.  Sofía Montenegro, journalist, social researcher and feminist activist from the Women´s Autonomous Movement put it this way (2):

“The report says that in Nicaragua men and women are on par in inequality and exclusion (gaps); this doesn’t mean that there is gender equity (justice) in the country.”

She added: “They valued outcomes, not processes (i.e. how many women are in the parliament, not how they got there).”

Behind the fancy scores in the report there is indeed a different reality on the ground. Critical areas of the gender gap may have been bridged, yet violence against women and women’s reproductive health continue to be challenges.

° Despite the improvements in financial accessibility to contraceptive methods (usually available at no cost in the public system), there is no sexual education in public schools. Important barriers to contraceptive use among adolescents haven´t been addressed at all. Nicaragua still has the highest adolescent pregnancy rate in Latin America and the Caribbean: 92 adolescent pregnant women per 1,000, with 27% of all pregnant women in the age group of 14-19 years (3). Adolescent pregnancy is not seen as an important issue by adolescent males; they are usually expected to have many children with different women (not needing to take responsibility for them) – it’s even considered an expression of masculinity (4).

° In the 1980s, on demand of feminist activists and AMNLAE – the Sandinista women’s organization, abortion had become a woman´s right. Yet in 2006, abortion was made totally illegal following an opportunistic move of the Sandinista party to get electoral support from the Catholic and Protestant groups. The impact of the resulting law on maternal mortality has not been measured in a country where most maternal deaths are deemed avoidable and related to deficient healthcare services.

° According to a recent study carried out by the National Autonomous University, approximately one million women (35%) suffer violence in Nicaragua. In 2012, Nicaragua passed Law 779 – ‘Comprehensive Law against Violence towards Women’ – along with reforms to the Penal Code. Religious and other conservative sectors of the population opposed the law because “it threatened the integrity of families and moral values of society at large”, leading to unconstitutional reforms introduced in 2014. One of the major changes involved the redefinition of the term ‘femicide’, which after the reform no longer includes deaths of women in private and public spheres, but is now limited to the death of a woman perpetrated by her partner (5). In cases of domestic violence, the woman is no longer able to file a complaint directly to the police if she hasn´t first attempted to solve or mediate the conflict with her aggressor “within the community”. This mediation process would involve religious leaders and “family promoters” (usually neighbors), who are members of a parastatal structure, namely the Family and Community Cabinets, and – by default – militants of the Sandinista party.

Urgent action is needed for a real “restitution of women’s rights” in Nicaragua and the government has a moral duty here. After all, the Sandinista movement of which the actual government claims to be the heir was the only revolution in the world with 30% women among the revolutionaries. They fought for freedom, but also for gender equality.

Pictures are from Inti Ocón (AFP photographer)

References

1. Hausmann R, Tyson L.D, Bekhouche Y, Zahidi S. (2014). The Global Gender Gap Index 2014. World Economic Forum, Geneva, Switzerland. 2014.
2. Montenegro S. (2014). Nicaragua el más equitativo en la desigualdad. Confidencial [online] 2014 Oct 29. Available from: http://www.confidencial.com.ni/articulo/19962/nicaragua-el-mas-equitativo-en-la-desigualdad.
3. INIDE. (2013). Informe preliminar de la Encuesta Nicaragüense de demografía y salud 2011-2012.
4. Quintanilla M. (2014). Por Ser Niña: Más allá de las adolescentes-otras dimensiones del embarazo adolescente en Nicaragua. Managua, Nicaragua. 2014.
5. Solís A. (2013). La Ley 779 tiene una larga historia de lucha y su reforma envía a la sociedad un mensaje muy negativo. Envío Digital [online] 2013 Nov. Available from: http://www.envio.org.ni/articulo/4770