Will the Pan American Health Organization (PAHO), the continent's highest health authority, suspend its operations? Or will it be forced to drastically reduce its operations? PAHO's future will be decided very soon. During the last meeting of the Executive Committee on June 23, Dr. Clarissa Etienne expressed her concern about the unprecedented financial crisis the organization is facing.

According to its financial states, the member countries have an accumulated debt of US$ 162 million, corresponding to the contributions that 15 of them have failed to make for several consecutive years, led by the United States with 67% of the debt, followed by Brazil, Venezuela, Mexico, Argentina, Colombia and Chile.

Added to this are the attacks by U.S. President Donald Trump and his Brazilian counterpart Jair Bolsonaro, who have questioned the legitimacy of the World Health Organization (WHO), represented in the Americas by PAHO, to intervene in the management of the Covid-19 pandemic in their countries. This tension was formalized with the official withdrawal of the United States from the WHO on July 7, which it accuses of having an ideological bias in favor of China's geopolitical interests.

The uncertainty about PAHO's future is worrying and happens exactly when the Americas, at the time of writing, records more than 10.1 million cases and 376,000 deaths from Covid-19, making it the world's most affected region. But in addition to public health management, the PAHO crisis has serious implications for the future of cooperation between governments in the region.

What is PAHO and what does it do?

PAHO is a unique organization in the international system because it is both the health entity of the Inter-American System, led by the Organization of American States (OAS), and the regional office for the Americas of the United Nations health agency, WHO.

Created in 1902, PAHO is the world's oldest international health agency, and was founded at the same time as the Pan-American Union, today the OAS, the oldest functioning multilateral agency. From its headquarters in Washington, PAHO coordinates the work of 27 offices and three specialized centers spread across the region, and is responsible for 185 of the 813 centers that collaborate with WHO worldwide.

Its mission is "to promote equity in health, to combat disease, and to improve the quality of, and lengthen, the lives of the peoples of the Americas". To do that, it leads collaboration between governments, universities, civil society organizations, investigation centers, private enterprises and other international agencies.

PAHO's functions are many and include disease prevention, attention to health emergencies and environmental disasters, the strengthening of health systems, scientific research, technical cooperation, and promotion of healthy lifestyles, among many others. It also intervenes in public health issues such as road safety, smoking, citizen safety, and gender equity, among others.

Its current director, Dr. Etienne, has held the position since 2013 (she was re-elected for a second five-year term in 2018) and works hand in hand with the Executive Committee, whose members rotate every three years and currently includes representatives from Barbados, Belize, Canada, Costa Rica, Ecuador, Haiti, Mexico, Peru and the United States.

The Pan American Sanitary Conference, the organization's supreme authority, is attended by the 52 countries and territories of the Americas, including Puerto Rico, Aruba, Curacao and Sint Maarten, which, because they are not independent countries, are not members of the UN or the OAS. The United Kingdom, France and the Netherlands also participate as associate members, due to the territories they still have in the Americas and the Caribbean. This is why PAHO represents, like no other organization, the spirit of inter-American collaboration.

Public Health, the seed of Pan American multilateralism

PAHO's origins date back to a yellow fever outbreak that began in Brazil in 1870 and spread all the way to the southern United States. Its effects were felt for many years and largely motivated the creation of the International Sanitary Bureau, the precursor of today's PAHO, during the First International Sanitary Convention of the American Republics, held in Washington, D.C. in December 1902.

Its founding was led by then U.S. President Theodore Roosevelt, who already had ambitions to finish the construction of the Panama Canal, a project that had been paid for by France after more than 20,000 workers died from yellow fever and malaria. Cooperation among the governments of the region to control these diseases was a necessary condition for the success of this infrastructure project, and to prevent the increase in international trade from leading to the spread of new epidemic outbreaks.

This is why in its first years, the Office's main mission was to collect and share information on the health status of seaports. However, its scope of action was quickly broadened to focus also on the study, monitoring and eradication of tropical diseases, and it was legally strengthened with the signing of the Pan American Sanitary Code in 1924, which is still in effect.

After entering World War II, the United States increased its resources to exponentially strengthen public health, including its contributions to the International Health Office. This allowed the latter to have a permanent staff of 17 professionals, four divisions, three sections and two regional offices in Guatemala and Peru in 1946.

International cooperation beyond ideology

The formation of the UN in 1945 shaped a new landscape for international bodies. In this context, the Health Office signed an agreement in 1949 with the newly founded WHO, through which it became its regional office for the Americas. However, the Office was not integrated into the United Nations System and maintained its autonomy from the UN.

In theory, this implied a certain distance from the Pan American Union, which had decided to join the United Nations System through the 1948 Treaty of Bogotá, in which it also adopted its current name, the Organization of American States (OAS). But in practice, its ties persisted through collaboration agreements between the agencies of the Inter-American System and the Pan American Health Organization, the name adopted by the International Health Office in 1958.

In the 1960s, PAHO was in charge of the public health projects of the Alliance for Progress, promoted by the United States through the OAS to stem the spread of communism in the region. However, despite Cuba's expulsion from the latter organization in 1962, PAHO has maintained close relations with the island and is virtually the only regional forum in which the United States and Cuba participate.

Indeed, PAHO has been a key ally in the development of Cuba's health system and its soft power strategy through medical missions around the world. The most illustrative example was the triangular cooperation program for polio eradication in Angola in 2005, from which both the island and the Organization benefited.

In the 1980s and 1990s, PAHO expanded rapidly and positioned itself as a key player in UN agencies' humanitarian and sustainable development programs. In 2002, the year of its first centenary, PAHO had made significant achievements, such as increasing life expectancy by 35 years, eradicating smallpox and polio, significantly reducing infant mortality, and placing Latin America and the Caribbean at the forefront of the fight against HIV and AIDS in the Global South.

Reserved diagnosis

However, PAHO's work has also been subject to criticism, which has intensified in recent years. In 2010, PAHO was widely questioned for its inability to contain a cholera outbreak in Haiti just eight months after the devastating earthquake that struck the country. Five years later, WHO and PAHO were singled out for their late response to the Zika outbreak in Brazil, which put the 2016 Olympic Games in Rio de Janeiro at risk.

In 2018, PAHO became embroiled in a scandal following the hasty departure of 8,000 Cuban doctors who had arrived in Brazil as part of the Mais Médicos program, launched by the government of Dilma Rousseff in 2013. PAHO was sued in a Miami court by a group of Cuban doctors who had left the program, which has been accused of labour exploitation and even human trafficking, due to the low salaries and precarious conditions to which the Cuban doctors were subjected in Brazil.

This case was echoed again in the recent claims of U.S. Secretary of State Mike Pompeo and Brazilian President Jair Bolsonaro, who have conditioned the payment of the debt and the continuity of their countries' contributions to PAHO until their participation in the Mais Médicos program is clarified and their actions are guaranteed to be in line with the "democratic ideals" of their governments.

PAHO, an indispensable organization today and tomorrow

Much of this criticism is legitimate and reflects structural deficiencies that, as several analysts have pointed out, need to be reformed within both WHO and PAHO. COVID-19 has once again highlighted the difficulties of international health agencies in responding quickly and effectively to increasingly numerous and complex threats to public health, and in coordinating the action of national and local health authorities in the face of such threats.

However, it is also important to point out that many of these criticisms, especially those of leaders such as Trump and Bolsonaro, are more motivated by their desire to fuel nationalist discourses than by a real concern for improving public health in their countries and in the region.

The health and quality of life of the peoples of the American continent and the Caribbean depend to a large extent on the outcome of the crisis that PAHO is currently experiencing, for three main reasons. First, because of PAHO's capacity for dialogue with Cuba, Venezuela and Nicaragua, despite the political differences between their governments and the other countries of the region, which is essential for responding to health threats that know no borders or political colors.

Second, because of the dependence of many small, low-income countries, especially in Central America and the Caribbean, on the PAHO Revolving Fund for the purchase of vaccines to protect their populations from some of the most serious diseases on the planet. Through this mechanism of equity and solidarity, PAHO buys vaccines in bulk from pharmaceutical companies to distribute them at more accessible prices among its members according to their financial capacities.

And finally, because PAHO has positioned itself as a key player in guaranteeing human rights in the region, framing threats to public health as human rights violations. In this way, PAHO has become an example for other international health agencies in the world and has set an important precedent for cross-cutting work for global governance. When the pandemic is hitting the entire region particularly hard and its true evolution is still unpredictable, it is clear that multilateral coordination and PAHO's expertise are more necessary than ever