'Baptism of fire': Tested Caribbean trailblazer leads COVID response in the Americas

Mar. 16—She navigated the chikungunya and Zika fever epidemics across Latin America and the Caribbean, tackled a deadly yellow fever outbreak in Brazil, and mobilized a regional response against the threat of Ebola.

A medical doctor by training, Carissa Etienne's leadership during public health outbreaks as head of the World Health Organization's Americas office is rooted in years of handling crises, starting with the trailblazing reconstruction of her hurricane-battered Caribbean nation's health care system more than four decades ago.

But it is COVID-19, the virus first recorded in multiple Latin America and Caribbean countries a year ago this month, that is testing her resolve as it ravages economies, overwhelms health systems and disproportionately affects countries in the Americas.

"it's difficult to ever imagine a pandemic of this magnitude," said Etienne, whose day begins before dawn with a morning prayer that is followed by a long succession of back-to-back meetings.

For the past year, Etienne has been the public face of the regional response to the worst public health crisis in recent history in the Americas, home to some of the world's most unequal and hardest hit nations. She has done so with poise and calm, always remembering her Caribbean roots as the Pan American Health Organization worked behind the scenes to get laboratory testing kits, shore up the response of health ministries, while keeping an eye on other pressing health issues in the region that haven't gone away.

"Long days, late nights, early morning meetings with Geneva. Briefings of health ministers. Internal working groups. Grueling schedule," said Daniel Epstein, who works closely with her. "The only time I've seen her take time off is to go get vaccinated— with her mother —against Covid-19."

Even before the pandemic, the Americas region saw an estimated 1.7 million deaths a year due to barriers in accessing health care. The crisis has put those inequities into sharp relief, as hospitals in many countries struggled to provide enough beds, ventilators and oxygen to treat the sick.

"We are home to more than half of all the global COVID-19 cases," said Etienne, who began her career in her native Dominica, where for more than 20 years she served as the national disaster coordinator, in addition to other high-level public health posts. "And when we think about it, this is driven in no small part by the lasting inequities, the persisting inequities, in income, employment, access to health and other social determinants."

'Baptism of fire'

Week after week, Etienne sits in front of a video camera, sometimes from her home, other times from PAHO's Washington, D.C., headquarters, walking journalists through the latest information on the coronavirus, its tragic consequences for the region's health care facilities, indigenous and migrant communities, and others living on the margins with little to no health care access.

"The COVID pandemic is the worst public health crisis of our lifetime," she said during a recent press conference. "No country is out of the woods when it comes to the COVID-19 pandemic. We all remain vulnerable to getting infected."

Usually sporting a brightly colored blazer while relaying what is typically a grim outlook, Etienne exudes confidence while calmly sharing the latest infection and death numbers, urging governments and suppliers to speed up vaccine deliveries and warning that COVID-19 is not over.

"We need to bring this pandemic rapidly under control," she said in a Miami Herald interview. "We must do all that is in our power to reduce transmissions with public health measures."

Etienne first caught the attention of regional and international public health experts 42 years ago when Hurricane David, one of the deadliest storms to hit the Caribbean at the time, tore through tiny Dominica in August 1979 before pummeling the Dominican Republic.

David's 150 miles-per-hour winds and destructive rains wiped out banana crops, stripped trees from the island's lush mountaintops, disrupted health services and destroyed most of Dominica's healthcare facilities while leaving more than three dozen dead and 60,000 homeless.

Six weeks into her internal medicine postgraduate studies in Jamaica, Etienne, who holds degrees in medicine and surgery from the University of the West Indies at Mona in Jamaica, decided that rather than join the exodus of those fleeing the eastern Caribbean island, she would return.

"I felt the necessity to return home, return to serve my people," she said.

That decision would propel her into a leadership position that had the world watching. A year before, governments from around the globe had gathered for a U.N. health conference in Alma-Ata, Kazakhstan, in which dignitaries set a goal of "health for all by the year 2000." Building on the event, foreign donors, including PAHO, pushed Dominica to not just rebuild brick-and-mortar clinics but create a new primary health care system from scratch.

"We were the story that was waiting to be told. We were the example for the rest of the world," said Etienne, who also holds a master's degree in community health in developing countries from the London School of Hygiene and Tropical Medicine at the University of London. "So I also was catapulted into an international scene. And I guess, hard work and the grace of God helped as well."

Etienne's humility is her trademark, said Jennifer Tavernier Astaphan, a longtime friend and member of Dominica's primary care planning team. She described the one-time medical director at Dominica's Princess Margaret Hospital as "a humble person" who approaches challenges "with a lot of confidence in her knowledge and a lot of reliance on her experts that are around her."

"She chartered the course of primary health care in Dominica," said Astaphan, 72, who as permanent secretary in the Ministry of Health was also Etienne's boss at one point. "Even if we were a team, that is where her leadership stood out. She was always very convinced and forthright about what needed to be done to make it work. She's a pragmatist."

The married mother of three's reputation as a primary health care crusader and her uncompromising belief that public health is a critical element to the development of countries around the globe has helped drive her success at PAHO, where she served as assistant director between 2003 and 2008, and later at the WHO in Geneva, said Astaphan.

When Etienne decided to mount a campaign for the top post at PAHO in 2012 with the backing of Dominica Prime Minister Roosevelt Skerrit, who helped secure the Caribbean Community's 15 votes in her favor, Astaphan's response, was "You go, girl."

Dr. James Hospedales, who has closely followed Etienne's career, says her early experience responding to Hurricane David set the groundwork for her ability to tackle the coronavirus.

"For anybody who is leading an international health organization at this time in the last year, it has been tough, because you face a massive, socially and economically devastating situation in COVID-19; you face anger and fear, desperate pain and need, civil unrest from affected groups; you face sudden, crippling loss of funding," said Hospedales, 65, the former head of the Trinidad-based Caribbean Public Health Agency during the chikungunya and Zika virus outbreaks.

"She has led PAHO extremely well through this COVID period, and her ability to do that is rooted in her strong faith, and life experiences, above all, that baptism of fire in David, where she emerged as the leader of the health sector transformation," Hospedales added.

Describing Etienne as "a Caribbean champion," Hospedales also credited her team of experts, which consists of seasoned public health professionals who are respected regionally and globally, in supporting her and allowing her to "deliver in very, very difficult circumstances."

If the coronavirus pandemic has laid bare the deficiencies in the region's health systems as countries wrestle with lockdowns, curfews, and surging hospitalizations, it has also reinforced something else, Etienne said: The policies she has long promoted, including reducing health inequities and universal health coverage, are needed now more than ever.

"Access to health remains really an overlooked right," she said.

'We have to work'

Seven years ago, as the threat of Ebola hung over the region, Etienne mobilized PAHO teams to assess the readiness of 28 countries and help them identify the gaps. Ebola didn't become a realistic threat, but the exercise provided insight into how unready the region was to deal with any deadly pandemic.

In November of 2019, Etienne said that for a still inexplicable reason, she convened PAHO's pandemic influenza planning committee. Soon word spread about about a mysterious pneumonia-like illness in Wuhan, China. Etienne immediately placed governments in the region on alert.

"That was January 16, long before a public health emergency was declared on January 30th of last year. Immediately, I summoned my team and said, 'We have to work,'" said Etienne, who started her second five-year term as director in 2018.

"When I called them, we were ready to go. I said, 'I need a team to go to every country to do the assessments on the ground, to help address health systems needs going forward, etc,'" she said. "They told me, 'Well, this will take us until April.' I said, 'Never. I need this done and completed by February.'"

But Etienne, who herself hasn't flown since January of last year, and her staff, had never contemplated that so many countries would close their borders, which presented more challenges in getting in.

Since then, she has had to confront not just COVID-19's spread and the emergence of new variants, but political complications, like the Trump administration's decision to terminate the U.S.'s relationship with the WHO, which led to non-payments and a loss of funding for some projects regionally.

There also has been criticism over the slow roll-out of vaccines in Latin America and the Caribbean from the United Nations-backed COVAX Facility, which PAHO is leading. Some of the most vocal critics have been the same governments in the Caribbean who supported her rise.

Even still, she always makes certain to mention the Caribbean, from the smallest country geographically to the tiniest population-wise.

"We make it a point of duty of also reminding the world, reminding our region, that there are issues in the Caribbean that need to be looked at but also there are lessons to be learned from the Caribbean as well," said Etienne.

Early on in the pandemic, the Caribbean Community, also known as CARICOM, came together to confront COVID-19 in unison as the tourism-dependent governments recognized their joint challenges and established common positions they could all implement. Almost all closed their borders to international air traffic and cruise ships and imposed strict lockdowns.

"I think that took courage and leadership, because they depend on tourism, and they were virtually closing the doors to tourism," Etienne said. "But beyond all of this really, the Caribbean has always been an interest for PAHO. And for me personally, obviously. And so we are always asking ourselves, 'What is it that we can learn from the Caribbean?'"

Under Etienne's guidance, PAHO has achieved a number of noteworthy milestones. Among them, the Americas became the first WHO region to successfully eliminate the endemic transmission of measles, rubella and congenital rubella syndrome. In addition to leading response efforts for regional chikungunya and Zika viruses, it improved responses to all declared emergencies and disasters in the region to within 48 hours.

Beyond COVID-19

Today, Etienne said, her biggest challenge is getting countries to plan beyond COVID-19.

"COVID-19 will end and we have to ensure that our region is well placed; one, to stop the pandemic, but at the same time, to plan ...for the future," she said.

The deficiencies in the region's health systems like inequity and the lack of investment still need to be addressed.

"You cannot grow your economy if you don't have a strong health system," she said. "If you can't ensure that, you can't lift people out of poverty."

As for the lessons learned during the pandemic, she has personally learned several.

"You have to be decisive," Etienne said. "You have to be timely in your decision-making. You need to engage across the organization, you need to engage member states early and to support them to get to where they need to be."

Thinking of the lives lost and forever changed by the pandemic, Etienne noted the pandemic has hit hard, especially in communities that were already vulnerable.

"It is really my hope that our governments, the national authorities, that they heed this warning, and pay attention to the lessons that have come out of the experience of the pandemic," she said. "That could help them fulfill a promise that they've made to their communities: that everyone has a right to health."

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