-Have you been vaccinated against dengue?
-No. I have no indication to do so. I live in CABA, an area in which there is no endemic circulation and there is still not much evidence on whether in areas like this the indication is warranted. What is decided in terms of public policies for jurisdictions with dengue all year round is different, where particular decisions must be made, beyond the fact that it is under debate whether it makes sense to immunize in the midst of the outbreak.
-This week the Government said that PAHO did not recommend the vaccine, even though the organization did not really say so. What do you think?
-PAHO does not reject the vaccine at all and I do not think it should be rejected. There is evidence of its safety and effectiveness for endemic areas. The issue is that there is great confusion. On the one hand, most social and prepaid insurance plans do not cover the vaccine or do so partially. And many people are applying it without clear indication, based on discretionary decisions.
-What do you think that the Ministry has not decided to vaccinate in endemic areas where the outbreak is very strong?
-In the case of provinces like Salta, Misiones or Corrientes, for example, that began vaccinating, the national State should take charge. I mean, in this brutal outbreak and in areas with high circulation and high mortality where the virus is affecting very vulnerable populations. I think the state should support these provinces.
-In a recent interview with
TN
, Minister Mario Russo raised what he called “an uncomfortable truth”: he said that the Ministry of Health is not a supermarket that should send products to the provinces. What does he think?
-To a large extent you are right. Provinces usually expect the national State to provide them with goods and services, such as vaccines, ambulances, medicines, insecticides and other critical supplies, without any conditionality. It's a mistake. One of the things we did was reinforce the so-called “transfers against results.” For example, financing is transferred to the extent that the province meets the agreed goals. Thus, financing is tied to objectives linked to indicators that improve public health. The opposite is a distorted idea of federalism. We must revalue intelligent federalism, compared to the stupid federalism that predominates here.
"The relationship between dengue and poverty is very clear," says Rubinstein. Photo: Guillermo Rodríguez Adami
-How would you describe this intelligent federalism?
-Faced with the claim that the Nation solves everything without anything in return, intelligent federalism implies that the provinces take charge of what they have to do and that the State, for its part, defines national policies to achieve certain objectives. For example, reducing health disparities by allocating resources equitably.
-We are going through the worst epidemiological outbreak of dengue in Argentine history. How do we get here?
-The relationship between dengue and poverty is very clear. In the 70s, except in South Asian countries, dengue did not exist. It is now in more than 100 countries and increasingly descends to the subtropical and temperate zones. He arrives before and leaves later. There is clearly a relationship that is seen inside the cities, in settlements and villages, which today are bursting with cases. There is an ecosystem that shows a very linear relationship between poverty and exposure. This is what in public health is usually called “social determinants.” That is, “the causes of the causes.” They are, from water treatment and availability of running water to waste collection and overcrowding. All factors that influence beyond the big factors, such as climate change and accelerated urbanization.
-Did politics have nothing to do with it?
-Argentina began to re-emerge in terms of dengue in the late 90s, a virus that was more common in Brazil and Paraguay. The great epidemic was in 2009 and in part caused the resignation of (
the former Minister of Health and current Buenos Aires legislator Graciela
) Ocaña. The second large outbreak, when there was still a cycle, was in 2016, at the beginning of Jorge Lemus' Health management. During my administration there were no major outbreaks, although we had threats of Chikungunya, Zika and yellow fever. Now, how much of this could have been avoided? I don't know. There are climatic, geographical and social determinants. Government management can hardly avoid them. I say so as not to assign absurd blame, although it is true that in 2022-2023 there was a major dengue outbreak and very little mobilization of resources to focus on endemic areas, block vector bases, selectively fumigate, scrap...
-How much influence did the electoral campaign have?
-And... partly it was the electoral campaign. Or, rather, after the pandemic a period of certain paralysis of the Ministry of Health began and last year nothing was done. Now, to what extent could this outbreak, which is exceeding last year's by 50%, have been stopped? Hard to say.
-What is your assessment of the current management in the face of the dengue health crisis?
-The Minister of Health took over with this explosion. In mid-December they sat down to see how the hand was coming and I don't think the previous management made it easy for them. Added to this is that it took them a while to name many officials and there are still several to be named. Beyond that, one cannot blame them so much. Yes, it is true that there are a couple of functions that depend on the Ministry and that cannot be delegated. One is that you have to go out and talk. An indelegable responsibility of the public function is to go out and communicate, to reassure people. It has to be done. I think of the example of (
the Buenos Aires Minister of Health
) Fernán Quirós in the pandemic.
"The Ministry has a fundamental responsibility in national policies." Photo: Guillermo Rodríguez Adami
-The former Minister of Health Carla Vizzoti also did it...
-Yes, and it's what has to be done. The second issue, which is not really understood, is the stock of repellent. It was reported that there were no more at the beginning of January. Months passed and it was not resolved. It is not understood why the importation of repellents was not opened before, something that draws attention since this is a Government that speaks of "freedom and market" and allocates resources according to "supply and demand." The same in terms of the national laboratories that could produce repellent not basic supplies, such as packaging. In Brazil and Paraguay the epidemic is much greater and they do not lack repellent.
-Some of these laboratories are publicly managed, which recalls the problem that the Government has made abrupt cuts to scientific research and universities. Could these decisions impact the health system? If yes, how?
-Obviously. Of course. Although it is true that in Argentina the public health system is decentralized and depends on the provinces or municipalities, the reality is that the Ministry has a fundamental responsibility in national policies. It cannot be ignored from the promotion of development in terms of technological and scientific innovation. It is a key function. The ministry must not only provide goods and services but also facilitate policies so that technological innovation reaches everyone equally. In practice, this means ensuring that in the Northern provinces the frequency of cervical cancer, breast cancer or cardiovascular disease is not eight or ten times higher than in the richest provinces. The function of the Ministry of Health of the Nation cannot be delegated.
-He seems angry...
-Yes absolutely. It is not a useful speech. One can find inefficiencies, but we cannot question the role of Conicet in science and technology. Houssay (
doctor Bernardo
) already said it
when he won the Nobel Prize: “
Rich countries are rich because they dedicate money to scientific-technological development and poor countries continue to be poor because they do not do so. Science is not expensive; “Ignorance is expensive
.”
-Milei made it clear in many ways that he would go for a shrinking of the social and scientific areas. Today, the Health budget is the same as in 2023, except for 38 billion pesos (14% of last year's budget) that have just been added. You experienced the demotion from Ministry to Secretary of Health when they wanted to give a signal of austerity. To what extent can the Ministry function with the resources it has today?
-The issue is that when Health was moved from Ministry to Secretariat during the Macri administration, the budget was not touched. It was a bad decision because it was decorative. Nothing changed. If there was a goal, it was not met. Now, having the same nominal budget is obviously a serious problem when you had more than 200% inflation. You can have a crisis and say there is no way, but you have to ask yourself what you are going to prioritize. In health there are things that you cannot cut back. And, in others, the trimming exercise must be meticulous. You cannot make a “tabula rasa”, as is happening.
-An example of a “crushed” budget is the DADSE, a national directorate that for months has not been able to guarantee high-cost treatments for chronic patients without coverage. The conflict dates back to a complaint from the Minister of Human Capital, Sandra Pettovello, who froze the activity of the area, after they reviewed a couple of unheard audits, which at the time denounced corruption during Kirchnerism and in your management. What responsibility does the political class of the last 20 years have in the bitter drinks of these days?
-The DADSE was in Social Development and during my administration it moved to Health because it was a corruption fund. We clean it absolutely. However, the first thing Ginés did was return it to Social Development. We had transformed it into a technical area and had eliminated many niches of corruption.
-But like many officials of these years, you were also denounced for overpricing...
-No. What there was was a redetermination of prices. You put out a tender to purchase medicines and one who charges 100 pesos wins, but everything is settled a year later, devaluation through. Who gives it to you when you say “oh no, it's 100 pesos.” They prefer not to turn you in and pay the fine. We had to make price redeterminations to guarantee supplies deliveries. Now, with respect to the political class of recent decades, I answer it with another question: What is the reason why Milei had 56% support? The crisis and anguish brought tolerance to very high levels. The responsibility of the political class is total and at all levels, not only in Health. What's more, I would say that it is a totally systemic phenomenon.
Passions and convictions of the rookie civil servant who gained fame as a rebel minister
“You have to be where the Minister is, eh? It's an electric chair. You have to be there. In this sense, I have the empathy with (
Mario
) Russo that I had with Ginés (
González García
) and with (
Carla
) Vizzotti. Because you have to be there.”
This turn of momentary brotherhood on the part of Adolfo Rubinstein, when he evaluated with analytical distance the challenges that his successors had to (and must) face in the national Health portfolio, shows a couple of very clear traits in his personality: a concessive measure that knows make coexist with a side, one could say, often “indignant”. He is that other Rubinstein who exposes himself and does not silence his criticism of the status quo, statements that he chews on based on his deepest convictions about how to conduct (and how not to conduct) public health in a fragmented and apparently irrecoverable country. Everything that he to some extent tried to implement during his brief time in Health management. And it is also that which, to a different extent, he failed to realize. As someone who wanted to but couldn't or was left wanting, there's a reason he often says that the entire Argentine health system requires “a profound reform.”
"You have to be where the Minister is, eh? It's an electric chair. You have to be there," says Rubinstein. Photo: Guillermo Rodríguez Adami
-But, with all this... would you return to politics?
-I don't know. I'm happy with what I'm doing. Developing health projects and being with young and proactive people is an incredible pleasure.
Then as now, as he enters his sixties, Rubinstein makes clear his profound rejection of
extremism
and the bombastic gestures of
populism
. Recognition must be based, not on mere declamation but on verifiable merits. He does not seek the prominence of the parachutist - who lands wherever he can - but rather that of the mountain climber, who with effort achieved a sought-after goal.
“I had never been a civil servant and I didn't expect it. I did not have a political career when I was called to the Ministry. The stars aligned. “I came from an important academic career and was more or less known in public health, to which I dedicated my entire life,” he says.
“I came in as Secretary of Health Prevention and nine months later I was promoted to Minister. I had to go through the management learning curve quite quickly, but I had a great advantage that this Health management does not have nor did the previous ones have. And I was able to name my team freely. There was no batching of charges. “It was quite unprecedented,” he adds later.
Although “he had always had an interest in politics, it had been a marginal participation,” he points out, before defining himself as a full supporter and admirer of former president Raúl Alfonsín, of whom his father, Juan Carlos Rubinstein, was an official. “I have a photo of Alfonsín on my desk. “His name moves me, but he really moves me, huh?” he shares proudly.
The goals and convictions may explain his disruptive departure from the Ministry of Health, when there were a couple of weeks left before former president Mauricio Macri handed over the command of the Government to Alberto Fernández. Rubinstein, then, launched to
approve the protocol
for the Care of People with the Right to Legal Interruption of Pregnancy, against the grain of the Executive.
In a context of harsh questions about his management in Health and when social unrest due to the economic crisis was gaining strength, that frontal gesture on the part of an official who in other ways seemed weak, gave him a different air. Rubinstein capitalized on it and managed to regain his current path in the world of health. But for a while he managed to be “the rebel minister.”
Itinerary
Adolfo Rubinstein
, former Minister of Health of the Nation (2017-2018), is a doctor and professor of Public Health at the UBA, researcher at Conicet and current director of the Center for Implementation and Innovation in Health Policies (CIIPS) of the Institute of Clinical and Health Effectiveness (IECS). Master in Clinical Epidemiology from Harvard University (USA) with a diploma in Health Economics (University of York, England) and another in Public Policy Implementation (Harvard School of Government), he has more than 140 publications in international magazines.
Right now
A leader:
Alfonsín, always.
A book:
“Life 3.0. Being human in the age of artificial intelligence”, by Max Tegmark.
A movie:
“The Godfather.”
A musician:
Charly García.
One meal:
Milanese with horse fries.
A sport:
Tennis, trekking and hiking in the mountains.
A team:
“El millo”. My heart is red and white.
A place:
Bariloche.
A memory:
My old man.
A passion:
River!
A wish:
That Argentines do well once and for all.
A challenge:
Never get tired of promoting the growth of young people.
P.S.