PAHO’s ongoing technical cooperation with its Member States addresses a wide range of health and health-related issues that, as discussed in Chapter I, are both directly and indirectly related to human security. This chapter presents highlights of PAHO’s work in these different areas during 2009–10. Examples are grouped thematically according to the seven major components of human security: economic, food, environmental, personal, community, political, and health.

Health Security and the Global Economic Crisis

The global economic downturn has put significant pressure on social spending in PAHO member countries. This has made it difficult for countries to sustain their national health budgets or, for countries striving toward universal coverage, to increase their budgets. PAHO’s technical cooperation during 2009–10 addressed these concerns with a particular focus on the search for sustainable health financing solutions, the reorganization of health systems using the renewed primary health care approach, and increasing equity in the distribution of scarce health resources.

In Ecuador, PAHO supported the government’s efforts to comply progressively-despite the global economic crisis-with a constitutional mandate that calls for increasing financing for the National Health System by at least 0.5 percent of GDP each year until the financing reaches at least 4 percent of GDP. PAHO helped develop a set of guaranteed health services to be offered by the public health network under the Right to Health Regime, as well as a methodological framework for evaluating the impact of health investments during the past three years, which includes the formulation and publication of “national satellite accounts.”

PAHO promoted discussion among ministries of health of the Eastern Caribbean countries and territories-Anguilla, Antigua and Barbuda, Barbados, British Virgin Islands, Dominica, Montserrat, Grenada, Saint Lucia, St. Kitts and Nevis, and St. Vincent and the Grenadines-on sustainable collective financing options for improving health systems and social protection while safeguarding households against catastrophic health expenditures. Three countries conducted consultations on primary health care to guide this process. In addition, PAHO organized a high-level meeting with health authorities on the primary health care renewal strategy to exchange lessons learned and review the countries’ progress in this area. PAHO also provided technical cooperation to Grenada, Barbados, and Saint Lucia to strengthen their institutional capacity to improve the financing of national health systems, particularly through the use of national health accounts.

In Venezuela, PAHO supported a technical working group on national health accounts and contributed to the formulation of a novel matrix incorporating the social determinants of health approach. PAHO partnered with the Ministry of Health, the Central Bank of Venezuela, and the National Institute of Statistics.

In Cuba, PAHO provided analysis and documentation of lessons learned and best practices adopted during the economic crisis of the 1990s, to guide current and future efforts to respond to economic pressures. This included strategies for social protection, reductions in public spending, efficient management of health services, and the introduction of new healthcare technologies.

Colombia’s Ministry of Health applied PERC (Production, Efficiency, Resources, and Cost), a PAHO-developed tool for health systems assessment and management, to a new primary health care–based model of services for dispersed populations in difficult-to-reach areas. The use of PERC facilitated the reorganization of services to increase efficiencies in expenditures and demonstrated that the new model was efficient and sustainable using resources from Colombia’s General System of Social Security in Health (SGSSS). Colombia is now considering extending the model from the department of Chocó to other dispersed populations in geographically isolated areas throughout the country and in areas of the department of Nariño.

During 2009–10, PAHO worked with the Costa Rican Social Security Fund (CCSS) to strengthen its network of services based on the primary health care renewal approach, a process that is expected to lead to better allocation of financial and human resources and better management of services. This included the design and redefinition of networks by level of complexity using the structural and functional elements of primary health care as a basis. Expected outcomes include reduced demand for hospital care, increased ambulatory and home-based care, the incorporation of health promotion into all levels of care, and earlier detection and treatment of chronic diseases.

PAHO assisted Brazil with the development of policies to improve equity in the financing of the Unified Health System by transferring resources according to the needs of municipalities and by reducing the gaps between rich and poor regions.

Ensuring Food Security

According to the World Food Summit of 1996, “food security exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life.” PAHO’s technical cooperation reflects this view, seeing both nutrition and food safety-not just sufficient calories-as essential aspects of food security.

In 2009–10, PAHO’s technical cooperation in this area ranged from support for family and community projects aimed at advancing MDG-1 to assistance for food safety regulatory agencies. It included support for planning and policymaking, legislation and advocacy, human resources training, the adaptation and implementation of standards, and research on malnutrition and the burden of foodborne illness.

In Costa Rica, PAHO worked with the Nutrition Institute of Central America and Panama (INCAP) in priority communities along the country’s northern border, providing technical assistance to community organizations, primarily of poor rural women, to help them produce safe and nutritious foods. Also in collaboration with INCAP, PAHO provided technical and financial cooperation to improve nutrition for young children in public daycare centers in the Dominican Republic.

PAHO supported the development and implementation of a number of food security projects financed through the MDG Achievement Fund, sponsored by the Government of Spain. These included projects in Bolivia, Brazil, Colombia, El Salvador, Guatemala, Nicaragua, and Peru focused on children’s food and nutrition security, as well as 27 family projects in indigenous communities in Costa Rica. In Cuba, PAHO was in charge of more than US$1 million of a US$8.5 million project financed by the MDG Fund to fight anemia in pregnant women and children under 5. PAHO helped strengthen capacity in maternity homes and maternal-child health observatories and provided support for nutritional surveillance, information systems, and human resources training.

Nicaragua, like Guatemala, also experienced a drought during 2009–10, and in this context, PAHO successfully promoted the incorporation of specific nutritional interventions into the U.N Country Team’s disaster response plans. These included support for exclusive breastfeeding, micronutrient supplementation, provision of oral rehydration salts, growth monitoring for small children, and surveillance of mothers and children under 5 to detect changes in nutritional status following disasters and after the provision of food assistance.

PAHO also provided support for Belize’s National Food and Nutrition Security Commission and for El Salvador’s National Council on Food and Nutritional Security (CONASAN). The work included a review of Belize’s 2001 National Food and Nutrition Security Policy and 2005–10 action plan as well as strengthening of CONASAN’s ability to develop public policies, create healthy and protective environments, strengthen social participation, and reorient the health services to focus more on food and nutritional security, especially in municipalities with high prevalence of chronic malnutrition.

PAHO continued to support the work of the Pan American Alliance for Nutrition and Development, launched in 2008. As one of 14 members of an inter-agency technical team, PAHO helped develop and disseminate conceptual and operational principles for the alliance in various academic and political-technical forums at both the national and regional levels. In early 2010, action began on developing integrated intersectoral interventions to address the social determinants of nutrition in Guatemala, El Salvador, Nicaragua, and Paraguay. These interventions tackle issues ranging from clean water and sanitation to sexual and reproductive health, income and working conditions, and social participation and empowerment.

In the area of food safety, PAHO worked in 2009–10 to promote the World Health Organization (WHO) Five Keys to Safer Food as a training and social communication tool to reduce food safety risks in countries throughout the Region. In Guatemala, for example, PAHO helped develop manuals based on the Five Keys for teachers and school administrators that were subsequently adapted and validated in 12 rural and urban primary schools in four departments. Using Guatemala’s experience as a model, PAHO worked with WFP, INCAP, and national health authorities to carry out similar projects in Belize, El Salvador, and Honduras. PAHO has also supported the implementation of the Five Keys in rural schools of Bolivia’s Altiplano and Chaco regions and in indigenous Amazonian communities in Venezuela. Manuals are now available in Spanish, English, and Portuguese.

PAHO provided technical cooperation in the development of food safety policies and plans in Antigua and Barbuda, Dominica, Grenada, St. Vincent and the Grenadines, and in the U.K. Overseas Territories. In addition, PAHO’s Caribbean Epidemiology Center (CAREC) provided technical cooperation to strengthen foodborne disease surveillance, outbreak investigation, and laboratory capacity in 11 Caribbean countries through training and updating of protocols on integrated laboratory-based surveillance; specimen collection, transport, and diagnosis; and reporting of foodborne pathogens.

Similarly, PAHO supported Cuba’s efforts to improve national management of foodborne disease outbreaks through better detection, diagnosis, and response, and to prevent outbreaks through sanitary inspections. PAHO also supported Cuba’s “productive municipalities” strategy, which seeks to increase production of foods of animal origin while strengthening prevention, surveillance, and control of zoonoses.

In the Dominican Republic, PAHO supported efforts to harmonize food safety legislation and regulation as well as inspection and control of food risks in the context of the United States–Dominican Republic–Central America Free Trade Agreement (CAFTA-DR). In Ecuador, PAHO helped develop guides and tools for surveillance and early warning of foodborne disease outbreaks, as part of the National Epidemiological Surveillance System (SIVE ALERTA).

Similarly, in Chile, PAHO helped the Chilean Agency for Food Safety (ACHIPIA) develop a new legal-regulatory framework, which is currently under discussion in the Chilean parliament. In addition, PAHO helped Chile address food safety concerns in areas affected areas by the February 2010 earthquake and tsunami. Work included training and promotion at the community level based on the WHO Five Keys.

In countries throughout the Region, PAHO is supporting research as part of the Global Burden of Foodborne Diseases initiative, a WHO effort to generate more complete information about the etiology and scope of foodborne disease outbreaks and risk factors associated with food handling, preparation, distribution, and consumption. The information is intended to help policymakers justify investments in this area, prioritize problems, and design better food safety interventions. In 2009–10, studies were begun or completed in Dominica, Guyana, Grenada, Jamaica, Saint Lucia, and Trinidad and Tobago as well as in Argentina and Chile, in collaboration with the Pan American Foot and Mouth Disease Center (Panaftosa). Final results from Cuba were published in June 2010. As part of these efforts, CAREC organized a subregional Burden of Illness Analysis workshop in November 2009, in which 18 participants from nine Caribbean countries and territories-Barbados, Belize, Dominica, Grenada, Guyana, Jamaica, Saint Lucia, Trinidad, and Turks and Caicos-were trained to use survey data from their own countries to calculate the burden of illness due to acute gastroenteritis.

In 2009–10, PAHO supported and promoted “healthy food markets” in Bolivia, the Dominican Republic, Guyana, and Paraguay. PAHO’s assistance combined training in food safety with technical cooperation in basic sanitation, including disposal of solid and liquid wastes. In Bolivia, the initiative has proved so successful that it has been extended to several departments.

Building Secure Environments

Environmental security is a longstanding focus of PAHO’s technical cooperation, which recognizes and addresses a wide range of environmental risks to health. These include contaminated water and untreated waste, infestations of mosquitoes and other disease vectors, exposures to industrial and agricultural chemicals, and vulnerabilities to natural and manmade disasters. During 2009–10, PAHO’s efforts in this area ranged from risk reduction and disaster preparedness to primary environmental care, the promotion of “healthy spaces,” and efforts to protect children and workers from exposure to environmental risks.

Children’s and Workers’ Health

PAHO and other UN agencies supported Argentina in developing the Atlas of Childhood Environmental Risks, published in 2009, which documents the incidence, distribution, and sources of environmental contaminants that impact children’s health. According to the atlas, 58 percent of children living in Argentina (more than 5 million) are at risk from environmental contaminants; the majority live in poor areas that lack access to basic water and sanitation services and are exposed to agricultural or industrial chemicals and waste products. In follow-up to the atlas, PAHO is helping develop a manual of procedures and processes to combat environmental contamination, along with tools for detecting and responding to related health problems at the local level. The methodology will be made available for other countries to develop their own atlases of environmental risks.

Also in the area of children’s environmental health, PAHO supported a horizontal technical cooperation project for Argentina and Chile that led to the creation of new pediatric environmental units in two hospitals in Chile and to the joint publication of manuals, guides, and other support materials for training in this area.

During 2009–10, PAHO facilitated the creation of a binational academic technical advisory group to support the United States–Mexico Environmental Program: Border 2012, coordinated by the US Environmental Protection Agency (EPA) and Mexico’s Secretariat for the Environment and Natural Resources. With PAHO support, the group developed and began implementing an action plan to strengthen the technical capacity of the Border Environmental Cooperation Commission in the area of environmental health. The plan included the development of a binational multidisciplinary and inter-institutional research project to assess the vulnerability of children in the El Paso del Norte region to health risks associated with climate change, the development of a risk communication strategy in children’s environmental health, and training for graduate and undergraduate students in the US–Mexico border region in interdisciplinary team approaches to addressing children’s environmental health.

In Colombia, PAHO supported intersectoral working groups led by the National University of Colombia and the Secretary of Health of the Department of Cundinamarca in efforts to develop a departmental policy on workers’ health and local policies for 11 municipalities. PAHO also collaborated with the U.S. National Institute for Occupational Safety and Health (NIOSH) and Colombia’s Ministry of Social Protection to organize the Regional Meeting on Health Protection for Health Sector Workers, held in March 2010.

In Guyana, PAHO collaborated with the Fuddie Hospital, West Demarara Regional Hospital, and Georgetown Public Hospital to establish occupational health and safety committees that will address workers’ health in the context of hospital operations, including needle safety and infectious waste management. PAHO also helped develop new policies on the health and safety of health workers in the Dominican Republic.

In late 2009, PAHO mobilized experts from NIOSH to visit a major public hospital in the Bahamas and conduct a detailed assessment of a mold infestation. The visit produced extensive recommendations for resolving the problem and provided an opportunity for capacity-building on health and safety issues for the hospital’s management and employees, trade union members, and the staff of the Department of Environmental Health of the Bahamas’ Ministry of the Environment. The consultation resulted in the Bahamas’ Hospital Authority implementing a series of corrective actions to prevent or remove mold and moisture and chemical and physical hazards, as well as to promote health and safety in general for hospital workers and patients.

In Trinidad and Tobago, PAHO mobilized human and financial resources from the Government of Canada to support efforts to protect the health and safety of healthcare workers and the public during two large international meetings in 2009: the Fifth Summit of the Americas and the Commonwealth Heads of Government Meeting. PAHO helped mobilize a team from Canada’s University of British Columbia and Vancouver Coastal Health to carry out a rapid assessment and provide training on the surveillance and control of respiratory pathogens. PAHO also facilitated the acquisition of personal protective equipment for healthcare workers as well as biosafety cabinets for three laboratories. In addition, financial resources were provided to each of the country’s regional health authorities to develop and implement projects to enhance local capacity for occupational health and infection prevention and control.

During 2009–10, PAHO’s Virtual Campus of Public Health offered the second edition of its Virtual Course on Work and Health, developed in conjunction with the School of Public Health at the National University of Cordoba in Argentina. The course is aimed primarily at public health educators and officials from the human resources units in ministries of health. PAHO also supported workshops and seminars for methodological and technical updating on workers’ health in Cuba, as well as training and guides for evaluating and controlling occupational risks in Ecuador and El Salvador.

Primary Environmental Care

In the area of primary environmental care, PAHO’s technical cooperation ranged from support for the development and implementation of water safety plans and programs to community participation in building healthy environments.

PAHO, working with other UN agencies, supported several projects financed through the MDG Achievement Fund aimed at strengthening policies on and management of water and sanitation services and environmental risks, with an emphasis on citizen participation. In Paraguay, PAHO helped mobilize the participation of eight indigenous communities in the Chaco region to carry out community diagnostics on environmental and housing risks. In Ecuador, PAHO supported the design and implementation of a plan for surveillance of water quality and also provided capacity-building for the country’s Administrative Water Boards. In Nicaragua, PAHO helped advocate new legislation to promote safe drinking water, in conjunction with youth-based environmental groups.

Similarly, in El Salvador, PAHO provided technical cooperation in the planning and management of water supply, sanitation, solid waste disposal, and protection of water sources.

Healthy Settings

PAHO continued to support healthy settings initiatives throughout the Region, including healthy communities, healthy workplaces, healthy schools, and the youth-based Ecoclubs movement.

In Colombia, PAHO worked with UNDP, UNICEF, and FAO on a project financed by the MDG Achievement Fund aimed at reducing vulnerabilities due to environmental degradation and climate change in the country’s poorest and most affected areas and populations. PAHO helped introduce “healthy environment” interventions as measures to adapt to climate change in the Colombian Massif ecosystem and also contributed to the recommendations of Colombia’s National Council on Economic and Social Policy (CONPES) on climate change.

PAHO helped strengthen the national healthy schools networks in countries including Chile, Cuba, and Ecuador. In Chile, PAHO’s country office organized a contest to identify the best examples of health promotion in schools. In Cuba and Ecuador, PAHO helped strengthen and expand membership in the national healthy schools networks. By the end of 2009, Ecuador’s network counted 2,700 members, representing 20 percent of the country’s public schools.

In Suriname, PAHO supported a school-based hygiene project launched on the Second Global Handwashing Day, October 15, 2009. The goal was to raise awareness of the importance of hand hygiene among school children, teachers, and their communities to reduce acute respiratory infections and diarrheal diseases. PAHO helped mobilize the private sector-including soap distributors, water supply companies, and private laboratories-to provide financial and in-kind support, helped develop educational materials, facilitated training for 31 school teams, and helped document the project.

In Panama, PAHO helped mobilize some 3,000 youths from more than 20 Ecoclubs throughout Panama to undertake studies on the social determinants of health and to carry out community-based projects and activities to protect and improve the environment.

PAHO’s efforts to promote healthy environments included support for preparations and activities leading up to World Health Day 2010, whose theme was urbanism and healthy living. Among the most notable of these activities was the First World Fair on Municipalities and Health, organized by PAHO and Argentina’s Ministry of Health in Buenos Aires in August 2009. The four-day conference attracted some 5,000 participants and provided a high-visibility forum for promoting sustainable, participatory local development and the importance of “health in all policies.”

Also during 2009–10, PAHO headquarters in Washington, D.C., adopted a PAHO Green and Healthy Initiative to reduce the Organization’s environmental impact. The effort is being overseen by PAHO’s Health, Safety and Well-being Committee and contributes to the Sustainable United Nations (SUN) initiative.

Tobacco Control

During 2009-10, PAHO provided technical cooperation to help its member countries implement tobacco control measures recommended in the WHO Framework Convention on Tobacco Control (FCTC). In Venezuela, for example, PAHO supported the consolidation of the country’s National Plans and Programs for Prevention and Control of Tobacco as a legal framework in accordance with the terms of the FCTC. PAHO provided support for Venezuela’s implementation of Article 11 of the FCTC, on packaging and labeling of tobacco, through the publication of 10 new graphic health warnings in 2010. PAHO also provided evidence to support increased taxes on tobacco and supported the development of proposed legislation that would require all enclosed public and work places to be smoke free, as called for in Article 8 of the FCTC.

During 2009 and 2010, three countries-Trinidad and Tobago, Paraguay, and Peru-became 100 percent smoke-free, joining the Region’s five other smoke-free countries: Canada, Colombia, Guatemala, Panama, and Uruguay.

In the Bahamas, PAHO organized a train-the-trainer workshop to pilot a newly developed WHO training package on treatment for tobacco dependence. Forty-three participants were trained in the “5A” (Ask, Advise, Assess, Assist, and Arrange) and “5R” (Relevance, Risks, Rewards, Roadblocks, and Repeat) models and in identification of evidence-based tobacco dependence treatments, assessment of nicotine dependence, pharmacological treatment, and prescribing of nicotine-replacement products. At the end of the workshops, the participants recommended that the Bahamas implement population-level tobacco control measures such as smoke-free work and public places and incorporate treatment for tobacco dependence into the curricula of health professionals’ on-the-job-training.

Disaster Response

PAHO’s ongoing technical cooperation in disaster preparedness and risk reduction have paid off in recent years as more and more member countries in Latin America and the Caribbean are able to respond to emergencies and disasters with their own resources, without seeking aid from the international community. In 2009, this was the case in the aftermath of several natural disasters. However, the earthquakes in Haiti and Chile in early 2010 proved an exception. In events of such magnitude, no amount of preparedness would have allowed the countries to respond effectively without international support.

People-Centered Security

PAHO’s technical cooperation has been growing in a number of areas that impact on health but that fall outside the core areas of disease control and prevention. These include efforts to address the social determinants of health, as described in some of the examples above, but also programs and interventions addressing issues such as intra-family and gender-based violence, stigma and homophobia, and mental health. All these issues directly affect people’s sense of and status with regard to human security, and PAHO and its member countries have developed and applied effective public health interventions to address them.

Gender-Based Violence

Gender-based violence is a major public health problem in the Americas and a significant obstacle to personal security. While data are not comprehensive, existing studies suggest that nearly half of all women in Latin America have been victimized by or threatened with violence. During 2009–10, PAHO created a new position of Regional Advisor on Intra-Family Violence and continued supporting member countries’ efforts to reduce gender-based and intra-family violence. Activities included national and subregional workshops in Guatemala, Mexico, and Jamaica on prevention of intimate partner and sexual violence and on monitoring and evaluation of programs that address violence against women.

In addition, PAHO published several reports on intimate partner and sexual violence in the Region. These included the Spanish translation of Unhappy Hours: Alcohol and Partner Aggression in the Americas; the second edition of Improving the Health Sector Response to Gender-Based Violence: A Resource Manual for Health Care Professionals in Developing Countries (June 2010), published in partnership with International Planned Parenthood Federation; and Sexual Violence in Latin America and the Caribbean (June 2010), a desk review published in partnership with the Sexual Violence Research Initiative, UNFPA, and Ipas.

In Barbados, PAHO supported the efforts of gender bureaus in Eastern Caribbean countries and territories-Anguilla, Antigua and Barbuda, Barbados, British Virgin Islands, Dominica, Montserrat, Grenada, Saint Lucia, St. Kitts and Nevis, and St. Vincent and the Grenadines-to mainstream gender issues and to involve men as part of the solution to gender inequalities, and particularly violence.

In El Salvador, PAHO supported the implementation of a national Plan for Prevention and Care of Intra-family Violence, which includes a comprehensive approach involving the health, education, and judicial sectors as well as civil society. Key achievements during 2009–10 included the strengthening of four special treatment centers in different parts of the country, a research project on intra-family violence and HIV, the incorporation of norms for addressing violence against women and sexual violence into the Ministry of Health’s Family Health Program, and strengthening of an action network against gender-based violence.

Similarly, in Ecuador, PAHO worked with UNIFEM on the development and dissemination of new norms and protocols for integrated treatment and care for victims of gender-based, family, and sexual violence as part of the National Plan to Eradicate Violence against Women and Children in Ecuador.

PAHO also supported the joint UN program “Consolidating Peace in Guatemala through Violence Prevention and Conflict Management,” a three-year project financed through the MDG Achievement Fund and also supported by UNDP, UNICEF, UN-HABITAT, UNESCO, UNFPA and national authorities. During 2009–10, PAHO began updating protocols for care and handling of victims of violence and worked with law enforcement, judicial, and health personnel on the appropriate application of legal frameworks, particularly regarding gender-based violence. This work was also supported by Sweden (through SIDA).

In Haiti, PAHO carried out a needs assessment of the health sector response to survivors of violence, outlining key areas for intervention to guide technical cooperation in this area.

With support from Norway (through NORAD), PAHO assisted women’s organizations in Nicaragua with efforts to prevent and respond to intra-family violence, which claimed the lives of 79 Nicaraguan women during 2009. PAHO also worked with Nicaragua’s Ministry of Health to strengthen its capacity to respond to violence through the adoption and application of norms and through joint efforts with women’s and community organizations. PAHO is also supporting efforts to improve access to justice for Nicaraguan women who are victims of violence.

In Paraguay, PAHO is a member of an interagency team charged with developing plans of action to incorporate violence prevention and treatment into emergency health care in six referral hospitals specializing in maternal-child care. The team has developed and helped implement protocols to improve the treatment of victims of sexual and intra-family violence in the country’s health services.

Similarly, in Cuba, PAHO collaborated with the Ministry of Health’s mental health team to provide training to health professionals on the diagnosis, referral, and treatment of violence and to promote changes in attitudes, practices, and knowledge in providing care for families that suffer from such violence.

Homophobia and Stigma

The problem of homophobia and stigma against sexually diverse individuals is a significant threat to personal security as well as a contributor to the spread of HIV and other sexually transmitted infections. Discrimination against these individuals has declined in the Region but remains a problem. During 2009–10, PAHO provided technical assistance and advocacy to promote the human rights of lesbian, gay, bisexual, and transgender (LGBT) people and people living with HIV in both in the health sector and in society at large.

PAHO supported efforts by Eastern Caribbean countries and territories-Anguilla, Antigua and Barbuda, Barbados, British Virgin Islands, Dominica, Montserrat, Grenada, Saint Lucia, St. Kitts and Nevis, and St. Vincent and the Grenadines-to address HIV-related stigma in the health services, to reduce barriers to access to services, and to scale up access to HIV testing.

PAHO helped Argentina’s Ministry of Health develop a new guide to providing health care for transgender people, Health, HIV/AIDS and Transsexuality. PAHO also worked with the Argentine Association of Transvestites, Transsexuals, and Transgender People (ATTA) on HIV prevention and helped them disseminate the video Translatina, which depicts the lives of transgender people in Latin America.

In Guatemala, PAHO supported efforts to reduce homophobia and helped promote sexual diversity issues on the country’s health and human rights agendas. PAHO provided technical and financial assistance to nongovernmental organizations working in this area, including training in administration and project management, and supported a campaign carried out by Guatemala’s National Sexual Diversity and HIV Network, which included public service messages aimed at raising awareness of these issues. PAHO also helped improve clinical treatment of people with HIV and sexually diverse groups through upgrades of clinic infrastructure and equipment and through the validation of models of care that address their special needs.

In Belize, PAHO provided support and guidance to a newly developed support group for people with HIV and helped the United Belize Advocacy Movement (UNIBAM), which promotes LGBT issues, to develop its institutional capacity and a draft strategic plan.

In Costa Rica, PAHO worked with UNAIDS to provide training and other support for civil society organizations that promote issues of concern to sexually diverse populations. PAHO also organized events to raise awareness among public officials of these issues and to promote respect for gender diversity. Similarly, in Cuba, PAHO collaborated with other UN and national agencies to develop strategies to fight homophobia as well as gender-based and intra-family violence through courses and workshops, cultural activities, social communication campaigns, and dissemination of best practices.

With support from Norway (through NORAD), PAHO promoted the harmonization of policies, plans, and legislation related to adolescent and sexual health with international human rights treaties ratified by PAHO Member States. Activities included training workshops on sexual health and human rights in Bolivia, El Salvador, the Dominican Republic, Guatemala, Honduras, Nicaragua, and Panama as well as support for reforming Guatemala’s national HIV law to be consistent with UN and OAS human rights treaties and standards. In addition, PAHO collaborated with ministries of health, national parliaments, and courts in Argentina, Honduras, and Peru, providing technical information on emergency contraception in a manner consistent with the observations of the UN Committee on the Elimination of all Forms of Discrimination against Women and the UN Committee on the Rights of the Child.

In Paraguay, PAHO supported the incorporation of human rights, gender, and nondiscrimination perspectives into the country’s schools of public health through the project “Public Policies for Education in Sexuality in the Paraguayan Educational System.”

Mental Security

Just as mental health is an integral part of human health-as enshrined in the WHO Constitution-it is a critical component of personal security. This is reflected in PAHO’s inclusion of mental health concerns in its emergency and disaster response efforts and in its programs addressing intra-family and gender-based violence.

Mental health problems are a major public health concern in Latin America and the Caribbean. Over 125 million people suffer from some form of mental disorder but fewer than half have access to treatment. The challenge in this area is to improve access to adequate services in all of the Region’s countries. Progress toward this end came in 2009, when PAHO’s Directing Council approved the Strategy and Plan of Action on Mental Health. In endorsing the plan, countries pledged to integrate mental health into their health policies and programs and to promote reforms and other changes reflecting a new approach to psychosocial problems.

In support of these efforts, PAHO worked closely with its Member States throughout 2009–10 to develop policies on mental health within national health plans and to strengthen the community-based model of care to replace the traditional curative model. An example of this work is a PAHO Technical Cooperation among Countries (TCC) project involving Cuba, El Salvador, and Guatemala aimed at decentralizing mental health services from hospital settings to community-level primary care.

PAHO also provided support for legislative changes to advance mental health reform. In Argentina, PAHO supported legislators in drafting a new National Mental Health Law and provided support for its presentation to congressional health committees and during subsequent debates and discussions. Similarly, in Belize PAHO helped develop a national mental health policy and supporting legislation as well as a National Plan for Mental Health and Psychosocial Support in Emergencies. PAHO also worked with Trinidad and Tobago’s Ministry of Health to update and improve mental health legislation, encouraging the adoption of a human rights approach. PAHO also helped the ministry implement a new integrated approach to mental health service delivery and advocated with both the Ministry of Education and the private-sector Employers Consultative Confederation for the adoption of strategies to promote mental health in the workplace.

PAHO collaborated with the health secretariats of Mexico and Chihuahua state to organize a workshop in Ciudad Juárez on mental health care for people affected by violence. With an average of 139 homicides per 100,000 population per year, Ciudad Juárez has one of the highest murder rates in the world. The workshop, supported with funds from the United States (through USAID), focused on comprehensive mental health care based on community and primary care models incorporating gender-sensitive and human rights approaches.

Also during 2009–10, PAHO mobilized mental health experts in support of Mexico’s response to the H1N1 outbreak and as part of its disaster response team following the earthquakes in Chile and Haiti.

In addition, PAHO worked with the School of Public Health at the University of Chile to develop a new diploma program in management of mental health services, offered via PAHO’s Virtual Campus of Public Health, and continued to provide technical support for comprehensive audits of mental health systems, which have been completed in 20 member countries (reports are available on www1.paho.org).

Community Security

Violence and injuries are major contributors to human insecurity in Latin America and the Caribbean. The increase in violence in many countries during recent years has had a negative impact on human development as well as on democratic governance. At the same time, the Region of the Americas has proved to be fertile ground for policies, strategies, and interventions that seek to prevent violence and injuries by addressing their risk factors. PAHO provided support for a number of initiatives in these areas during 2009–10.

In Jamaica, PAHO joined forces with the Violence Prevention Alliance to celebrate the International Day for Peace 2009 with activities focused on young males, the group most seriously affected by violence in Jamaica, both as perpetrators and victims. The celebration encouraged young men to break down barriers and focus on their commonalities rather than what they see as differences. PAHO sponsored a sports event for young men as well as the production of educational materials distributed at the event. Also in Jamaica, PAHO partnered with the Council of Voluntary Social Services to provide training in conflict resolution among youths for nongovernmental organizations involved in violence prevention services at the community level.

In the Bahamas, a participant in PAHO’s Leaders in International Health Program began a study on the epidemiology of violence among the country’s youth. The study is a response to the increasing incidence of violence-related injuries, which disproportionately affect youths ages 15 to 24. The results will shed light on the determinants of violence, their impact, and how they interact at the national, regional, and international levels, with the goal of providing evidence for policymaking and programs.

PAHO also provided support for Brazil’s “Rede VIVA” injury surveillance system that collects information on violence through sentinel sites in the health services and through annual surveys.

Road Safety

PAHO’s work promoting road safety during 2009–10 included two publications, Advocating for Safe and Healthy Public Transportation and the Regional Status Report on Road Safety, as well as the dissemination of the Global Status Report on Road Safety in major road safety meetings held in Argentina, Brazil, Colombia, and Panama. These reports show that traffic injuries are a leading cause of death in the Region, especially among 5- to 44-year-olds, claiming some 142,252 lives each year and injuring over 5 million people. Highlights of PAHO’s technical cooperation in this area during 2009–10 include:

In Costa Rica-the country with the highest per-capita spending on road safety in the Region-PAHO supported efforts by the Road Safety Council (COSEVI) to prevent traffic accidents, particularly among youth. PAHO also worked with COSEVI and the Institute on Alcoholism and Drug Dependency (IAFA) to promote passage of a law to reduce blood alcohol limits for drivers, to develop a new national policy on alcoholic beverages, and to prevent consumption of alcohol by minors.

In El Salvador, PAHO supported the implementation of a new National Road Safety Plan in collaboration with members of the National Commission on Road Safety (CONASEVI), including the National Civil Police, the Ministry of Government, the Ministry of Health, and municipal governments. Efforts included the establishment of a surveillance system for traffic accidents, strengthening of enforcement of speed limits and other traffic norms, the development of a technical guide on emergency care for victims of both road crashes and violence, and traffic safety education for children and youths at 11 critical safety points. The activities were supported in part by the UN Trust Fund for Human Security (see also above).

In Cuba, PAHO worked with the Ministry of Transport and the National Institute of Sports, Physical Education and Recreation to promote road safety through community activities targeting children and adolescents.

PAHO also supported a project of Brazil’s Ministry of Health aimed at reducing deaths and injuries due to traffic accidents by providing financing to municipalities to plan activities in these areas. In addition, PAHO is supporting Brazil’s participation in the global Road Safety in 10 Countries (RS10) project, funded by the Bloomberg Family Foundation. Brazil’s activities will focus on drunk-driving reduction and speed management and will be implemented in the cities of Palmas, Teresina, Belo Horizonte, Curitiba, and Campo Grande.

In Trinidad and Tobago, PAHO supported the launch in 2010 of the national EVIPNet (Evidence-informed Policy Network) and hosted a training workshop on the development of policy briefs for the prevention of violence and injuries.

PAHO also supported a study on the economic impact of traffic injuries in Belize and helped analyze data on deaths and injuries due to road incidents in major cities of Ecuador.

Participation and Social Protection

Social protection schemes are the most established broad-reaching mechanism for ensuring human security in the Americas, and health protection is an integral part of these schemes. During 2009–10, PAHO supported countries’ efforts to strengthen social protection schemes by developing and implementing policies, laws, and programs that seek to eliminate exclusion; guarantee equitable access to goods, services, and technologies in health; and establish health as a universal human right. Much of PAHO’s work in the area of social protection in health was supported by Sweden (through SIDA).

In Guatemala, PAHO helped health authorities develop a proposed law on universal coverage and financing for comprehensive health care. The law would establish a coordinated national health system, legal framework, and budget to finance universal coverage and provide explicit guarantees to ensure access for all Guatemalans, without discrimination, to free and comprehensive health care. The proposed legislation was presented to the Health Commission of the Guatemalan Congress in May 2010.

In a similar vein, Bolivia, with PAHO support, developed legislation to create a Unified Health System that would ensure that all public health facilities-including those in the social security system-offer the same quality and services and provide access to free health care for all Bolivians. The law was expected to be approved by the Bolivian Congress in 2010 and to begin functioning in January 2011.

PAHO also supported Uruguay’s efforts to incorporate additional population groups into the National Health Fund (FONASA). As a result of this work, spouses, retirees, and professionals who do not contribute to Uruguay’s Social Security Bank are scheduled to be incorporated into FONASA during 2010.

In Colombia, PAHO supported a project funded through the UN Trust Fund for Human Security to develop an integrated and sustainable social protection system. PAHO is helping design a primary health care model that is consistent with Colombia’s National Health Policy and is using a “healthy housing” strategy to empower 500 families to improve their housing conditions. Other UN agencies working on the project are FAO, OCHA, UNHCR, UNICEF, UNIFEM, UNODC, and WFP.

Also during 2009–10, PAHO collaborated with other U.N. agencies to promote and document existing integrated social protection systems in the Region. An example was a study begun in September 2009 on the Nutritional Dimension of Social Protection Networks in Central America and the Dominican Republic, led by WFP with the participation of PAHO, INCAP, ECLAC, UNAIDS, UNICEF, and the OAS. The final report on the study was released in April 2010.

In the Dominican Republic, PAHO is supporting a conditional cash transfer initiative known as the “Solidarity” program, in which low-income families receive money in exchange for complying with a series of health and education requirements. These include getting vaccines and micronutrient supplementation for children under 3, Pap smears and pre- and postnatal care for women, and annual check-ups for family members over 65, as well as participation by adolescents in activities aimed at reducing risk factors. The program currently covers more than 750,000 households.

Access to Services

PAHO continued in 2009–10 to support its member countries’ efforts to expand access to health services for their populations. Technical cooperation in this area ranged from support for legislation guaranteeing access to health care to initiatives aimed at improving the coordination and delivery of health services.

In Guatemala, PAHO worked with the Health Commission of the Guatemalan Congress, the Ministry of Health, the University of San Carlos, and the Guatemalan Social Security Institute (IGSS) to design and advocate a proposed new law based on the human right to health, with provisions on financing of universal care. PAHO also helped develop new legislation creating a public service career in the health sector, which seeks to guarantee the availability of human resources in health in poor and remote rural areas. It includes personnel incentives designed to promote patient-centered care and respect for patients’ rights and to improve the productivity and quality of care in the country’s health system.

In Venezuela, PAHO provided support for the development of “community health houses” as part of the National Plan for Reducing Maternal and Infant Mortality. The community health houses operate out of private homes and are headed by a volunteer member of the household, typically mothers, who provide care for pregnant women and children under 5, based on the Integrated Management of Childhood Illnesses (IMCI) strategy. Begun as a way to expand access to health services, the community health houses have become an integral part of local health networks and have had a positive impact on reducing child and maternal deaths.

PAHO supported efforts by the Eastern Caribbean countries and territories-Anguilla, Antigua and Barbuda, Barbados, British Virgin Islands, Dominica, Montserrat, Grenada, Saint Lucia, St. Kitts and Nevis, and St. Vincent and the Grenadines-to reorganize their health delivery networks based on the primary health care strategy and to upgrade their health infrastructure. PAHO’s technical cooperation included support for the development of comprehensive models of care and for the design and assessment of integrated healthcare networks. As part of this process, PAHO engaged UNOPS, whose staff worked with health ministry officials for the first time in the English Caribbean to present reliable and cost-effective options for hospital infrastructural development in Barbados, Saint Lucia and Grenada.

In El Salvador, PAHO is helping to implement integrated health service delivery networks (IHSDN) in seven municipalities in the country’s western region. The process includes community participation and intersectoral cooperation, coordination between hospitals and health units, improvements in infrastructure and quality of care at different levels, referral systems, improvements in the management of clinical laboratories, and implementation of a system for effective pre-hospital emergency care.

With support from Sweden (through SIDA), PAHO organized a multicenter study on the impact of exclusion from health services on access to essential medicines. Country studies for Guatemala and Nicaragua were finalized during 2009–10, and PAHO organized workshops to discuss and disseminate the results and lessons learned. In addition, a comparative analysis of those results and results from Honduras was completed in 2009.

Other PAHO-supported efforts in this area during 2009–10 included a seminar on the right to health and improved access to basic services, co-hosted with Belize’s Ministry of Health in December 2009, and the Third Congress of Social Security Regulators, held in Santiago, Chile, in November 2009. PAHO also supported a report based on that meeting comparing social security systems in nine PAHO member countries and detailing the major obstacles facing these systems in the Region today.

Health Security and Disease Control

Among PAHO’s most direct contributions to human security in the Region of the Americas during 2009–10 was its work in the area of control and prevention of diseases. PAHO’s ongoing efforts in this area address all the major contributors to the burden of disease in the Americas, with emphasis on diseases that disproportionately affect the poorest and most marginalized population groups and those that are most effectively addressed through regional efforts.

IHR and Regional Health Security

The International Health Regulations 2005 (IHR) require countries to have the ability, by 2012, to detect, evaluate, confirm, report, and implement control measures for any health event that has the potential to cause an international public health emergency.

PAHO supported its member countries in their efforts to fully comply with the IHR’s requirements by helping to evaluate their capacities for surveillance and response and with training to improve capacities in these areas. To date, 28 of 33 countries in Latin American and the Caribbean have prepared national plans for strengthening their IHR capacities, and 26 have established National IHR Focal Points (NFP), which operate 24 hours per day, seven days per week. For 11 priority countries, PAHO mobilized $1.1 million to strengthen NFPs through training, guidelines, and tools for health surveillance and NFP operations. PAHO also organized the First Regional Meeting on the Implementation of the International Health Regulations in Quito, Ecuador, in May 2010, for officials responsible for IHR implementation in their countries. In addition, PAHO prepared and disseminated a “Framework for the Normative Implementation of the IHR (2005),” which includes recommendations on regulations and best practices for implementing the IHR from a legal standpoint.

To strengthen response capacities, PAHO supported training for rapid response teams in Bolivia, Costa Rica, Chile, and Ecuador; participated in the preparation of a proposal for a new Field Epidemiology Program in Paraguay; and is supporting similar efforts in Peru and Argentina. This work has included the provision of tools for field investigations (including personal protective equipment) as well as training in infection control strategies, safe handling of clinical samples, management of mass casualties, and risk and outbreak communication.

In addition, PAHO has helped 18 Member States evaluate their capacities for detection and reporting of health events at ports of entry; 10 countries have now prepared corresponding action plans. PAHO’s advisor on this subject has carried out technical cooperation missions to Argentina, the Dominican Republic, Ecuador, El Salvador, Nicaragua, and Uruguay, and the Organization hosted a meeting in El Paso, Texas, where countries shared knowledge and experiences on border crossings. Participants included representatives from Brazil, Guatemala, Mexico, Peru, the United States, and Uruguay.

During 2009, as the IHR Regional Focal Point, PAHO registered 166 events of importance to international public health, 39 of them related to the 2009 (H1N1) pandemic. Thirty-four percent were notified by NFPs in the countries, 14 percent were reported by other governmental institutions, and 52 percent were captured through routine surveillance. PAHO’s regional event management site (EMS) provided 539 updates on 49 public health events that were analyzed at daily event evaluation meetings.

Other capacity-building efforts in the area of surveillance and response have included the PAHO-CDC Generic Protocol for Influenza Surveillance, aimed at creating a surveillance system that will allow assessment of influenza activity throughout the Region and facilitate comparisons across regions and subregions of circulating influenza strains and cases of infectious respiratory disease.

In related efforts, PAHO has worked with Member States to improve laboratory capacity through training in laboratory techniques and the procurement of equipment, reagents, and other materials. As a result of this work, five new National Influenza Centers in the Region were designated by WHO in the past five years (three-in Bolivia, Guatemala, and Nicaragua-during 2009–10) for their abilities to safely and effectively diagnose influenza viruses.

The 2009 (H1N1) Pandemic

The 2009 (H1N1) influenza pandemic provided an important test case for the new International Health Regulations (IHR) and for several years’ worth of preparedness efforts carried out in the Region with PAHO support. Six months into the pandemic, at a September 2009 meeting in Miami, representatives of PAHO Member States agreed that recent efforts to improve countries’ abilities to comply with the IHR as well as specific pandemic preparedness efforts had been instrumental in strengthening the Region’s response to the 2009 pandemic.

The emergence and spread of the novel (H1N1) virus beginning in April 2009 produced an overwhelming demand for technical cooperation from PAHO. The Organization responded quickly by mobilizing interdisciplinary teams of experts through WHO’s Global Outbreak Alert and Response Network (GOARN). They provided assistance to affected countries in surveillance of respiratory diseases, infection control, laboratory diagnosis of influenza, and outbreak and risk communication.

One of the most important areas of PAHO support was for training in the use of polymerase chain reaction (PCR), one of the few reliable methods to detect the pandemic (H1N1) 2009 virus. PAHO also coordinated the purchase of equipment, materials, and reagents for laboratories. As a result of these efforts, every country of the Region now is in a position to diagnose the pandemic (H1N1) 2009 virus.

PAHO also helped its member countries intensify their surveillance of acute respiratory infections, providing guidelines and training. In addition, PAHO coordinated purchases and donations of materials and equipment, including more than 589,000 doses of oseltamivir and 50,000 kits of personal protective equipment. In collaboration with the Pan American Association of Infectious Diseases, PAHO convened a group of experts to develop clinical guidelines for management of cases of suspected or confirmed pandemic (H1N1) 2009. Other forms of information support included the translation of multiple guides into Spanish and the publication of a weekly bulletin summarizing the latest epidemiological and virological information on the pandemic.

To assure access to the new pandemic (H1N1) 2009 vaccine for its member countries, and following a request from heads of state of the Union of South American Nations (UNASUR), PAHO’s Revolving Fund for Vaccine Procurement opened a bid solicitation on behalf of the countries and territories of the Region. By mid-2010, 23 countries had acquired more than 20 million doses through the fund. In addition, Bolivia, Chile (after its earthquake), Cuba, El Salvador, Guatemala, Guyana, Honduras, Nicaragua, Paraguay, and Suriname-received donated vaccines through WHO.

Support for these activities was provided by Canada (through CIDA), Spain (through AECID), the United States (through USAID and CDC), the Inter-American Development Bank (IDB), and WHO.

Immunization

As one the most effective interventions in the public health arsenal, immunization is a critical contributor to health and human security and has long been one of PAHO’s most important areas of technical cooperation. During 2009–10, PAHO’s immunization program played a critical role in two major areas: the 8th annual Vaccination Week in the Americas and the regional rollout of the pandemic (H1N1) vaccine.

Vaccination Week in the Americas 2010 was celebrated on 24 April to 1 May in countries throughout the Americas. The slogan for the event, “Reaching Everyone,” reflected the initiative’s objective of reaching out to adults and children, males and females, the very young and the elderly, with the overall goal of reaching some 42 million people regionwide. Countries and territories throughout the Region carried out a wide variety of activities to promote vaccination and other preventive interventions, including Vitamin A supplementation.

The launching events for the 2010 Vaccination Week took place in Nicaragua, on the United States–Mexico border (in conjunction with the US National Infant Immunization Week), on the border between Haiti and the Dominican Republic, and on the border between French Guiana and Suriname. The latter marked the first bi-regional launch of Vaccination Week in the Americas, since French Guiana is a French department. Health workers from both sides of the border participated in a series of workshops to share immunization practices and address issues related to border populations, such as the challenges of tracking immunization of children who have been vaccinated in more than one country. As a result of these efforts, the two countries have pledged to strengthen their reporting and sharing of epidemiological information and data on vaccination coverage.

This year also saw further geographical expansion of the Vaccination Week initiative. Observers from WHO’s Africa Region (AFRO) participated in VWA activities in Haiti and the Dominican Republic, while the European Region (EURO) celebrated its 5th European Immunization Week on 24 April to 1 May. In addition, the first Vaccination Week in the Eastern Mediterranean Region (EMRO) was held on 24–30 April, with launching events in Lebanon, Afghanistan, Iraq, Pakistan, and Sudan, among others. If progress continues as planned, the goal of a global immunization week will be closer than ever.

PAHO also worked in 2009–10 to strengthen health regulation and regulatory systems in its member countries to improve access to medicines, vaccines, and other biologicals, including biotechnology products and antivenoms. At the regional level, these efforts were carried out through the Pan American Network for Drug Regulatory Harmonization (PANDRH). PAHO also began developing and implementing a process for evaluating the capacities of national regulatory authorities to carry out basic functions established by WHO for this area.

Neglected Diseases

In 2009, PAHO’s Directing Council, through Resolution CD49.R19, agreed to work together to eliminate or reduce neglected and poverty-related diseases such that they are no longer public health problems by the year 2015. To advance this goal, PAHO joined forces in 2009 with the IDB and the Global Network for Neglected Tropical Diseases/Sabin Institute to create a trust fund to support the elimination of these diseases in PAHO Member States. The fund’s first initiatives included two pilot projects: in Recife, Brazil, to eliminate lymphatic filariasis, and in Chiapas, Mexico, to eliminate onchocerciasis and trachoma.

PAHO continued its longstanding efforts to eliminate Chagas’ disease, which affects an estimated 8–9 million people in the Region, with signs of transmission in 21 countries. During 2008–09, four countries-Chile, Guyana, Panama, and Peru-joined 14 other countries with universal screening for Chagas in their blood banks and there was an increase in preventive prenatal diagnosis of maternal infections with Chagas to facilitate early diagnosis and treatment of newborns. In addition, PAHO produced new guides and training resources to address foodborne outbreaks of the disease.

More than 9 million people continue to be at risk of lymphatic filariasis in the Region, the largest proportion of them in Haiti. The January 2010 earthquake complicated the timely delivery of drugs to treat the disease, but a meeting convened by PAHO in February 2010 mobilized international partners to continue working toward the disease’s elimination.

PAHO also supported efforts to expand antiparasitic treatment to cover an increasing proportion of the estimated 46 million children in Latin America and the Caribbean who are at risk of geohelminths, or soil-transmitted intestinal parasites. PAHO data show that in 2009, 4,805,522 preschool-age children and 37,430,165 school-age children received deworming medication at least once a year.

Schistosomiasis-a chronic parasitic disease that can damage internal organs and impair growth and development in children-continued to be transmitted in four countries of the Region: Brazil, Saint Lucia, Suriname, and Venezuela, with 25 million people at risk, most of them in Brazil. In 2009, PAHO helped design a study of the prevalence and intensity of schistosomiasis as well as geohelminth infections in Suriname. The study is expected to be completed in 2010.

PAHO continued to promote surveillance of leprosy, also known as Hansen’s disease. In 2009, 48,432, cases were reported in 27 countries of the Americas. In all countries except Brazil, cases have been reduced to less than 1 per 10,000 population.

During 2009–10, PAHO supported the mapping of cases of trachoma at the municipal and community levels in Brazil, Guatemala, and Mexico, and helped develop comprehensive plans for implementing the SAFE (Surgery, Antibiotics, Facial cleanliness, and Environmental improvement) strategy for its elimination. PAHO also worked to forge strategic partnerships with institutions, universities, NGOs, and donors to support comprehensive trachoma elimination plans in Guatemala and Brazil.

PAHO continued in 2009–10 to support and promote the prevention and control of malaria. Since 2000, 18 of the Region’s 21 endemic countries have reported a steady decline in the number of cases, and the elimination of malaria transmission is considered feasible in Mexico and Central America, Haiti and the Dominican Republic, and Argentina and Paraguay. PAHO has supported the expansion of the Amazon Malaria Initiative, which now includes Brazil and eight neighboring countries. PAHO is also supporting the extension of efforts of the Amazon Network for the Surveillance of Anti-malarial Drug Resistance (RAVREDA) to other subregions, including Mesoamerica, with funding from the United States (through USAID).

Neonatal tetanus has been eliminated as a public health program in all countries of the Region except Haiti, which reported more than half all cases during the last five years. PAHO supported vaccination of Haitian women of childbearing age carried out in 2009 and following the earthquake in 2010.

With PAHO’s support, countries continued efforts in 2009–10 to eliminate human rabies transmitted by dogs. Haiti succeeded in vaccinating 400,000 dogs and cats in a campaign that began before the earthquake and was completed afterward, using vaccine donated by Brazil. In its first mass rabies campaign in recent decades, the Dominican Republic vaccinated more than 1 million animals, also using vaccines donated by Brazil. PAHO also provided support to Bolivia’s national rabies program, which has cut human rabies cases in half. In the Region as a whole, cases of human rabies have been reduced from 268 in 1983 to 17 in 2009, 10 of these transmitted by dogs.

Sexual and Reproductive Security

Sexual and reproductive health impacts heavily on human security and human development, with life-and-death consequences as well as lasting effects on individuals’ psychological, physical, and socio-economic well-being. During 2009–10, PAHO continued to provide technical cooperation addressing key sexual and reproductive health issues, including safe motherhood and newborn survival, sexually transmitted infections, and the prevention, detection, and treatment of cervical cancer.

In Bolivia and El Salvador, PAHO supported the implementation of new national strategic plans for sexual and reproductive health and provided technical cooperation on care of women in pregnancy, childbirth, and postpartum; newborn care; family planning; prevention and treatment for sexually transmitted infections; prevention of cervical cancer; and prevention and care for adolescents.

Also in Bolivia, PAHO helped develop new protocols for cervical cancer detection and control and helped implement control and monitoring of cervical cancer in health units where such services were formerly unavailable. PAHO’s support included providing laboratory equipment for cytopathology and colposcopy and providing training for doctors and nurses in screening using both the Pap smear and visual inspection with acetic acid.

In Ecuador, PAHO supported efforts to implement a paradigm change in the health services from “maternal-infant care” to a broader focus on sexual and reproductive health. In addition PAHO worked with CLAP, WHO, and the Partnership for Maternal, Neonatal and Child Health (PMNCH) to support a horizontal technical cooperation project to promote maternal, newborn, and child health in Bolivia, Chile, Ecuador, and Paraguay through the development of joint proposals, training, and the exchange of information and experiences.

In Costa Rica, PAHO collaborated with the Ministry of Health, UNFPA, the Costa Rican Social Security Fund (CCSS), and civil society institutions to organize the 2010 National Survey on Sexual and Reproductive Health. The survey will focus on women and men ages 15 to 80 and will collect data on such issues as sources of information on sexual and reproductive health, knowledge about contraception and family planning, and sexual behavior, including age at initiation, types of partners, types of relations and levels of satisfaction, maternal health, fertility, and attitudes toward pregnancy. The last such survey in Costa Rica was carried in 1996.