Dr. Nelson Arboleda is the Director of the Office of the Americas at the U.S. Department of Health and Human Services. With previous roles at the Centers for Disease Control (CDC) as country director in the Dominican Republic and regional director in Central America, based in Guatemala City, he has a wealth of experience on vector-borne and emerging infectious diseases, outbreaks, and emergency preparations.

He came to Buenos Aires for the Pan-American Health Organization’s (PAHO) Vaccination Week in the Americas, a drive to strengthen inoculation rates in Latin America. Managing Editor Amy Booth spoke to him about vaccinations, dengue, and the effect of climate change on health. It has been lightly edited for length and clarity.

AJB: What are the US’s priorities for health in Latin America and the southern cone at the moment?

NA: Well, we have several long-term collaborations with not only the ministries of health of the region, but of course strengthening the PAHO’s efforts. After the pandemic, we are focused on rebuilding capacities that we probably weren’t able to focus on too much at that time. One of those could be increasing vaccination rates in the region. And of course this week is the Americas Week for Vaccination, which the PAHO and the US government is really promoting in the region.

AJB: Do you think we’re still in an era of vaccine geopolitics?

NA: It’s something that we need to consider, but what we’re probably most concerned with is that in the last decade in the Americas, we truly have seen a decrease in rates of vaccination. Not only as they relate to covid and the covid vaccines, but other vaccines, such as measles and mumps and rubeola, have decreased and we have seen even outbreaks, because we have decreased the rates unfortunately, and there’s a campaign to promote the safety of the vaccines, the confidence of those vaccines.

AJB: With regard to what you were saying about confidence in vaccines, how can medicine take the needs of marginalized groups such as Indigenous peoples into account? 

NA: Yeah, there are a number of strategies on which we’re working with different ministries of health to ensure that we reach all populations, you know, Indigenous as you mentioned, but also maybe Afrodescendants, really really truly marginalized populations, ensuring that all walks of life, all aspects, all individuals are able to get their needed not only health services, but of course medications, and their vaccines.

AJB: So Argentina is currently experiencing a record dengue outbreak with 40 deaths and over 60,000 cases, especially in the poorer provinces in the north of the country. I understand this issue with dengue has been a problem across the region. What can we do to better tackle this disease?

NA: Yes. It really is concerning what we have been seeing in the region, not only with dengue but also chikungunya. So we need to ensure that we continue to get the messaging out there, how do we control this sort of outbreak? But one of the first things we could also do is make sure that we have adequate surveillance, adequate laboratories. And that’s what the US government and the CDC and the FDA [U.S. Food and Drug Administration] and the NIH [U.S. National Institutes of Health], how do we really partner with the Argentine Ministry of Health to improve their capacities, to share best practices across the board? We understand, looking at some of the data, we have begun to reach a plateau, and are now trying to get that outbreak under control. But these are changes that happen in these viruses. These are also things we need to consider with climate change, the record heat that we’ve been seeing, that’s also been concerning, and contributing to the situation.

We’ve seen some changes in terms of, how can we truly assess and make that correlation, what we’re seeing between climate change, not only in this region with dengue and chikungunya, but we are seeing in other regions, where we may have seen a displacement or a change in the patterns that we would see traditionally with certain diseases.

AJB: Tell me a bit more about what that means in terms of both Buenos Aires and the northern provinces. We’re talking provinces that are sometimes the hottest places in the world according to meteorological surveys. So, this is a space of crossover between climate change and marginalization, because these are provinces that are often very poor, where there are situations of a lack of access to drinking water and so drinking water is sometimes being stored in open barrels. Is this effectively a problem of climate change and poverty that we need to address?

NA: We need to address it from many angles. Our support and collaboration with the Ministry of Health, for example, is ensuring best practices, one, but two, ensuring that they have the appropriate workforce. So, that they have epidemiologists, or they have adequate communication staff in terms of health that could actually reach all the different regions in the country. The Ministry of Health does tell us that they are improving, they’re working on enhancing the number of professionals that they will be able to send throughout the country, and that’ll be critical.

AJB: What can we do when it’s hard to get professionals to go and stay in regions of the country that are often very poor? It’s not the same living in a town in the Chaco in Salta as it is living in central Buenos Aires. 

NA: This is one of the challenges that we do indeed have. We even have it in the US where it is difficult to get health professionals to go into maybe rural areas, where they’re probably all in the major cities. We’ve done some strategies, actually, in Central America and the Caribbean, to work with medical schools to ensure that they’re having better coverage in the rural areas. But the topic of the health workforce is something that it’s really concerning, because we do have a gap of nearly three million health professionals throughout the Americas.

What we’re seeing currently is that there are specific needs in certain regions of our continent where there might be a need for epidemiologists, a shortage of nurses in another country, or a need for geriatric health professionals in other parts of our region. So we really need to find ways to entice, or to ensure that we have better coverage, with our health professionals.

AJB: You get situations where young residents might go for a few months, but then they head back to the city. One strategy I have heard local doctors expressing is the need for Indigenous and local medics and an investment in health. What other strategies do you see?

NA: There are several initiatives that we’re analyzing currently with the PAHO to see how we could, at least during an outbreak, ensure that we’re able to mobilize staff properly to a specific region. For more long-term capability, I mean, I think it’s an initiative that needs a more holistic approach. You have better services, you have better capabilities for those health professionals to be attracted to that region.  Maybe it’s financial, maybe it is sort of an opportunity for them to be interested in a specific area and that will entice them to go to that region.

AJB: How big a threat is chikungunya in the region? This is a disease that we haven’t heard much about in Argentina. 

NA: Yes, so chikungunya was actually an emerging disease in our hemisphere. We’ve been really exposed in the Western Hemisphere to chikungunya for the first time I would say in the last 10 or 15 years. For the first time ever. The virus was traditionally circulating more rapidly in Africa. So there is a lot of sometimes what we call competition between these viruses, and they’re able to move around our region, and now because of what we touched on earlier, we are seeing that maybe they’ve re-adapted or because of the changes in climate change or the heat that we’re seeing currently, we’re seeing patterns that are quite concerning. 

I was recently in Paraguay and was able to witness the more concerning signs and symptoms of chikungunya, and unfortunately even had some deaths. Some pediatric deaths through chikungunya. So we were able to send the CDC team promptly, to work jointly with the Ministry of Health to address the situation and put measures to control that outbreak.

AJB: So in other words, we’re seeing children dying of this disease in neighboring countries?

NA: We have seen children, it’s not at a point that we’re really really concerned overall, and we’ve been able to control the situation. But the most crucial thing is to continue to ensure that there’s messaging to control what we know are appropriate measures to control diseases such as chikungunya and dengue.

AJB: Are there other emerging diseases that we should be watching in the Southern Cone? We’ve heard that situations where humans and animals are in very close contact, especially wild animals, and where there’s an advance of the deforestation frontier, are a prime risk. For example Chapare virus in Bolivia, there was a very small and bloody outbreak and then it disappeared again, but it was taken as a warning sign.

NA: We’re really focused on, currently through our US Government efforts, working with our colleagues here at the Ministry of Health. Yesterday I was at the Malbran Institute, which is an institute that we’ve been able to support. Maybe an equivalent to our CDC. So they will have the capabilities to promptly diagnose to properly identify any new sort of virus. We will continue to see viruses, or bacteria, or mycotic diseases. But I think the important thing is to be able to respond to those properly and be able to contain any sort of disease before it gets out of control. And that’s our great collaboration that we’re currently establishing with the Ministry of Health of Argentina.

AJB: Does the economic crisis that Argentina is currently facing present a risk in your view?

NA: I mean, I don’t know the details of the investments that are currently being awarded to the Ministry of Health. Argentina continues to be a leader in the region and they get resources or they get collaboration from the PAHO, because they do a lot of training, not only on health, not only in Argentina, but for the region, even the Caribbean.

AJB: So you’re in Argentina for the PAHO’s Vaccination Week in the Americas. Argentina stood out as a country that achieved very high levels of COVID-19 vaccine coverage compared with some other countries in the region. Do you think there’s more to be done? 

NA: Argentina did a really marvelous job at ensuring to rapidly get the vaccination during the pandemic. We know it’s a different time [from the pandemic] I think. Individuals, or the general public, were more concerned and were probably called to vaccination easier than what we have with regular scheduled vaccines. Nevertheless, we do need to do more. We do need to improve our general schedules because we’re seeing that falling to what we had not seen in 30 years.

AJB: Which specific illnesses?

NA: General vaccines: measles, mumps, rubeola, even polio. Diseases that we’ve been able to control and to really not have any more outbreaks in the region and in our hemisphere overall, we have unfortunately seen come back because we don’t have adequate levels of vaccination.

AJB: Why don’t we have those levels these days?

NA: I think folks have not maybe seen the risks of some of these diseases, and there are probably also some concerns with the safety. One major angle that we are addressing is the current misinformation and disinformation out there about vaccines, and this is something that we’re looking for strategies for what may be the best mechanism to reach the population. We’re working with several regional, what we call trusted voices. Maybe we do need to get the Messis and the Neymars and those sorts of individuals, to have those better health communicators or better health messaging to ensure that our children are getting their vaccines.