Margarida Tavares attributes her “being in the right place at the right time” simply to good luck. More likely, it’s a combination of her fascination with emerging infectious diseases, her tangible concern for protecting the health of the population and her love of planning.
Portugal’s Secretary of State for Health Promotion first encountered a serious infectious disease outbreak in São Paulo, Brazil, where she lived during her teenage years. A sudden outbreak of yellow fever in a local district prompted her, along with family and friends, to volunteer in a prevention campaign, advocating for control measures to tackle breeding mosquitos, and encouraging the affected community to get vaccinated.
Even as a young person and outsider, or non-local, she was not intimidated by the prospect of going into marginalized communities to share public health messages. She has since trained as an infectious disease specialist and here we discuss her passion for public health, her work on prison health, and what she believes countries need to get right, ahead of the next pandemic.
Listen to the patients
Dr Tavares speaks plainly and directly, and with a strong sense of pride when discussing those she has cared for.
“I know the names of all my patients, and I know about their children, about their travels and their work. I always ask something because I really want to know.”
Her genuine interest in her patients’ lives is not just social. Her experience shows that the information patients provide is a vital component of being able to provide good care. She recalls a nugget of wisdom imparted by an older doctor in her department.
“He told me once that you just need to listen to them; listen to the patients. They will tell you everything you need to know to treat them. Ever since, I have put my time into listening.”
This simple piece of advice may seem at odds with rapid advances in medical science and technology. However, Dr Tavares illustrates her point with a recent example drawn from her experience coordinating Portugal’s response to the monkeypox (Mpox) outbreak in 2022. Listening is exactly what she did.
“I’m really proud about what we did at that time, and it was so easy because they [people at risk of Mpox] told us how to do everything. We found unexpected stakeholders, including one owner of a sauna, who had a clear vision about how to control this disease and what to tell people. Who normally listens to the owner of a sauna in the middle of a crisis?! Yet, he knew exactly what to do. People can teach us health care professionals. We need to see them as stakeholders. They can tell us the best solutions. We don’t need to do the thinking for them, most of the time.”
Protecting populations
Dr Tavares’s human touch extends beyond the individual patients she treats. Her natural sympathy for, and sense of solidarity with underserved populations is particularly evident. Speaking about people who are incarcerated, she points to the reality of their circumstances:
“People in prisons, usually before being in prison, they were disadvantaged. To lose your freedom when you are in prison shouldn’t mean losing your right to health; that should be guaranteed, especially for people who lose their freedom. We need to give more to people who started out with less. There are so many difficulties and such disadvantage in prisons; we need to go there.”
Tavares says she learned these principles studying public health. They are not simply values she believes in, however – her research and experience of managing infectious disease outbreaks underlines and strengthens them.
“I saw the need for equity most clearly in my infectious disease specialty. To really prepare, look to the most vulnerable. That’s the starting point. Health emergencies always disproportionally affect the most fragile, the poorest, the most vulnerable in our society. This is really important for the next infectious disease pandemic or threat. We want to alleviate suffering and we want our policies to protect the whole population. Everyone benefits from prevention.”
Care for prisoners
Dr Tavares chose to specialize in infectious diseases at a time when it was not a popular choice among medical graduates. In the mid-1990s, countries were still getting to grips with the devastating HIV/AIDS epidemic. Effective treatments were emerging but many people, including health-care professionals, were still fearful of caring for infected patients. During her first years as a practising physician, most of her patients were HIV-positive. She became, and has remained, a steadfast ally and advocate of people living with HIV, including those in prison.
The prevalence of HIV in Portugal’s prisons is estimated to be just under 4%. The majority of prisoners have access to medical care during their incarceration. Many prisons – although not all – screen for infectious diseases such as HIV and hepatitis C (HCV) so that treatment can commence. A study of one prison in the Secretary of State’s hometown of Porto shows that the diagnosis of HCV infection was made in prison for a significant number of patients, and that after a 12-week treatment course, the virus was no longer detectable in their blood. Improving HIV and HCV care for people in prison will be part of a new national plan to improve prison health.
Equity is possible
In 2003 Dr Tavares was working in São João University Hospital in Porto. While attending a short training course in infectious diseases at Harvard University, Boston, WHO made its first announcement about severe acute respiratory syndrome (SARS), a new viral respiratory disease emerging in China.
“It was amazing to be there at that time because, suddenly, the entire course programme shifted focus to this new emergency. It was an opportunity for me to be closely linked into what was happening from the outset.”
Since her involvement in her region’s SARS preparedness response, Dr Tavares has progressed to lead Portugal’s national programme for HIV and other sexually transmitted diseases. She has also held key roles in planning for pandemic influenza, Ebola virus, and coronavirus disease (COVID-19). Not short of practical experience, she now finds herself at the policy-making table.
“Equity is possible. If we, here in the Ministry of Health, don’t try, who will? People in prisons, minorities, migrants, vulnerable and fragile people, old people – they don’t have voice.” What then is her message to policy-makers in terms of building resilience and getting ready for the next pandemic?
“Make sure your highest risk and most vulnerable population is being looked after, including people in prison. Invest in public health; prepare public health workforce and agencies; and bring ‘public’ to public health by engaging with people and with communities. Don’t get carried away with questions of security like we did in the last pandemic, which led to the closure of borders. More than safety, I prefer solidarity.”
Public health, at its core, is about the safety of the collective, and for Dr Tavares, it is solidarity through policies and actions that will deliver that.
A national plan for prison health
In February 2023, Portugal hosted the launch of WHO’s “Status report on prison health in the WHO European Region 2022”. As Secretary of State, Dr Tavares used the occasion to initiate a policy dialogue on prison health in Portugal with people released from prison, prison security and health staff, nongovernmental organizations, academics, WHO and policy-makers. The report of this policy dialogue is available online.
Arising from this process, the Ministry of Health announced the establishment of a working group tasked with developing a national plan for improving health-care provision in prisons. The group will draw on the data from the WHO Health in Prisons European Database (HIPED) to identify priority areas for action. Ministries of health, justice, and education and science will all be involved in the decision-making process, alongside civil society organizations. WHO/Europe will monitor and support the work of this group, through its Collaborating Centre at the University of Porto’s Institute of Public Health (ISPUP).
The national plan is expected to be published by the end of 2023, with implementation commencing in 2024. Few countries have publicly available strategic plans for prisons. Alongside Ireland, Portugal’s progress in this area presents a potential roadmap for other countries.