Lancet Global Health
Nov 2016 Volume 4 Number 11 e761-e871
http://www.thelancet.com/journals/langlo/issue/current

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Editorial
Disease, conflict, and the challenge of elimination in the Americas
The Lancet Global Health
Good news from the Americas illuminated the global health scene in September. As the Ministers of Health from the western hemisphere gathered in Washington, DC, USA, for PAHO’s 55th Directing Council, a series of announcements confirmed the New World’s role as a pioneer of sorts in disease prevention and control. Repeating the pattern that began with smallpox in 1971, polio in 1994, and rubella in 2015, the region of the Americas was declared the first in the world to be free of endemic measles on Sept 27. This feat was achieved through 14 years of unrelenting efforts to reach the farthest pockets of unvaccinated populations and document the end of transmission of a virus that still caused over 110 000 deaths worldwide in 2014, mostly in children under 5 years of age. It is a laudable achievement and a testament to the success of yearly national immunisation campaigns and efforts to educate the populations of the region on the innocuity and efficacy of vaccines. The confidence in this essential global health tool in the countries of the Americas is highlighted in a recent article published in EBioMedicine, which shows that countries of the region reported low levels of scepticism on the dimensions surveyed, including the importance of vaccination and the safety and effectiveness of vaccines. The fact that other countries or regions do not show the same confidence, and the related impact on vaccination coverage, underscore the fragility of the elimination status and the importance of persistently promoting the value of vaccines at the global level.

Achievements such as these educate us on the feasibility of reaching elimination goals. They perhaps also provide additional thrust for efforts towards harder to reach, more uncertain milestones. The Ministers of Health concluded their gathering at PAHO with a set of agreements on the prevention, control, and elimination of diseases in the Americas, including a plan of action for malaria elimination with ambitious goals for the next 4 years. Elimination, if reached, would be a first step in a major global health quest: the eradication of malaria, a disease that currently threatens half of the world’s population, and in 2015 killed almost 500 000 people worldwide. Perhaps the Americas can show us once again how it is done.

While the region celebrated the elimination of one scourge, another—namely the devastating 52-year civil war in Colombia—was also on the brink of history. Over the years, and within the confines of Colombia’s borders, the conflict has touched on many issues that are now at the forefront of global health and development. Rapid urbanisation, fuelled in large part by the displacement of millions fleeing violence, led to the creation of slums and all their related health issues. Those who stayed in conflict zones, many of them of indigenous and African descent, were left in a health services vacuum and now suffer the consequences, on maternal and child health in particular, and in terms of inequalities. A historic peace agreement between the Colombian Government and the Revolutionary Armed Forces of Colombia (FARC) was signed in Cartagena on Sept 26. Yet on Oct 2, the Colombian people narrowly rejected this agreement in a national referendum, sending back to the negotiation table a document considered by some as too lenient towards the FARC.

So the promise of stronger social cohesion and human rights is not to be delivered just yet in Colombia, but the implications of the peace process and their potential impact on health must not be overlooked. Nobody denies the radical impact peace could have on these populations, and the now defunct agreement, negotiated with the active participation of women’s and minority groups in a process deemed by some as a model, had the consideration of health and inequalities threaded throughout its terms. So wherever the process goes in Colombia from this point forward, that experience and the point reached on the way to peace remain a much needed sign of hope in a world where violence is on the rise. War and violence, or the absence thereof, are now integral building blocks of the development agenda since their inclusion in SDG16. In Colombia and elsewhere, peace—just like health—is a delicate balancing act that requires constant work, but we must remain convinced that it is attainable.