Dr Brundtland's speech to the International Conference on Public Health
Ladies and Gentlemen,
Let us start by thinking back 400 years.
In 1603, Villads Nielsen was hired by the Crown to protect this city against the threat of epidemics, after the suffering that had been caused by the attacks of plague. Here we see the real roots of public health: the state asserting its authority, and taking responsibility for the health and safety of its citizens.
Norway is one of the fortunate countries around the world where gains in the length and quality of human life have been profound. Four hundred years ago, infectious diseases and nutritional deficiencies were the dominant cause of premature death. Over time, better sanitation and hygiene helped to reduce infection, particularly in children, and, together with more nutritious food, these measures contributed to steady improvements in the health of the nation.
Two hundred years ago we were already vaccinating people against smallpox. Over the last century, the rate at which new scientific knowledge has been translated into preventive programmes has increased substantially.
We now take so much for granted: routine immunizations; safe water and food supplies; healthier housing and safer roads; effective laws to control tobacco use and alcohol abuse. And we have linked prevention and health promotion to family policy to ensure safe motherhood and healthy child development.
As we think about the challenges for the future, I would like to reflect on some of the lessons we have learnt from recent developments in different parts of the world, including what we have learnt from the history of public health in Norway.
I recently reread Henrik Ibsens’s “An Enemy of the People”. Written 120 years ago, its central message is a powerful reminder of one of our key challenges today. In the play, Dr Stockmann wanted to shut down financially successful public baths because they were contaminated, and constituted in his words “the gravest threat to public health”. Recall the response of his brother, the Mayor, who warned: “The matter is not simply a scientific one: it is a complicated matter and has its economic and its technical side”.
Good science is the basis of good public health, but the challenge we face is to translate the best science into public policy. This is my first lesson. And as Ibsen realized: science, economics, and I should add, politics, do not always go hand in hand.
Rarely are the issues clear cut. We have had to examine the evidence carefully before issuing travel advisory notices for areas affected by SARS, knowing the potential economic impact. And yet, we know that the economic consequences would have been more severe if WHO measures to contain the spread of the disease were not implemented.
Public health must play a greater role in policy decisions in other sectors of the economy. But we have to be prepared for being told, like Dr Stockmann, that these are complicated matters and that we need to consider “economic realities” lest we become the enemy of many people and countries.
This was certainly the case when we decided to tackle tobacco. But here the arguments against us were completely spurious – tobacco control is plainly good economics. Nevertheless, for decades we tolerated tobacco use as normal, and the fight against it has been long and thorny. It will be no less difficult as we continue to work to promote more healthy diets: for reducing sugar intake, we still have a group of lobbyists who close their eyes to both science and economics.
These experiences point to my second important lesson: no success story in public health ever results from the action of one single person: it is the commitments and alliances we are able to create that make the difference.
Let us look at another piece of recent public health history. Five years ago, it was considered defensible in public health circles to suggest that life-saving drugs for those living with AIDS in poor countries should be available only to those who could afford them. Aid agencies would not spend on treatment on the grounds of cost-effectiveness. As I said to the WHO Executive Board in January 2000 – the drugs are in the north and the disease is in the south – and this is unacceptable.
Look at what has happened. Initially we faced opposition. But attitudes have been radically transformed. We now are confident of reaching three million people living with AIDS in developing countries with affordable treatment by the end of 2005. What accounts for this change? In part the answer is better science and economics. But the greater part of this transformation has been due to powerful alliances involving civil society, that have maintained pressure on industry, governments and, indeed, on international organizations.
The journey has been rocky at times, but we are far closer to the destination than would have been possible had we acted alone.
As we celebrate 400 years of public health action here in Bergen, the very first global public health treaty is being signed in Geneva, one that will save millions and millions of lives in poor and rich countries alike.
The work on the Framework Convention on Tobacco Control reaffirms the power of partnership. This process has fostered and strengthened alliances – in their calls for smoke-free public places, for tobacco-free sports and tobacco-free film. It has united voices raised in a call for an end to advertising and promotion of a global epidemic. It has created an arena where civil society, the public health community, and United Nations organizations can learn from each other how to work together to reach common goals.
The FCTC process had clear direction. It also had magnitude. As we struggled with death rates and disease, Health Ministers around the world reached out to Prime Ministers and Presidents, Finance and Foreign Ministers in search of solutions. When we said that tobacco should not be advertised, glamorized or subsidized, we were in effect telling the world that viable health solutions, by definition, are multi-sectoral, and require several arms of governments to synchronize their actions. I believe this has happened and an important start has been made.
The Tobacco Convention also illustrates a third important lesson. In an era of globalization that calls for international collaboration across borders we need to look more carefully, and creatively, at how we can use the instruments of international law.
In light of the experience with SARS and the potential for new and existing diseases to threaten global health, the revision of the International Health Regulations is a top priority. But, as we consider whether international law is keeping up with our rapidly changing world, we are faced with many questions. What should sovereign states’ legal obligations be with regard to reporting sensitive health information? How can we best combine human rights obligations and the need to restrict individual liberty to prevent the spread of disease? How should countries handle immigration in ways that safeguard fundamental freedoms as well as public health?
The reality is that public health is, as never before, a priority on the global agenda. This is for the simple reason that so many of the challenges we now face have a global impact, requiring global solutions and a global response. In short, my fourth lesson is that globalization of disease and threats to health mean globalization of the fight against them.
Our task is to build trust and solidarity.
In an interconnected and interdependent world, bacteria and viruses travel almost as fast as email messages. There are no health sanctuaries. No impregnable walls between the world that is healthy, well-fed, and well-off, and another world which is sick, malnourished and impoverished. Globalization has shrunk distances, broken down old barriers, and linked people together.
It has also made problems halfway around the world everyone’s problem – the tenacity of the SARS virus, the public health and economic uncertainty it brings, underscores this too well.
Surveillance and effective response is an important expression of solidarity in public health. It saves lives, protects economies and is an essential pillar of both national and international security.
If the world can unite against SARS, we should be able to address other health scourges, especially those which affect not thousands, but millions of people.
The Global Fund to Fight AIDS, TB and Malaria is an important expression of solidarity. But, if it is to succeed, those with the resources need to back their commitment with real money – not just on a one-off basis – but regularly and reliably.
Where trust is absent, positions become easily entrenched. The impasse on access to drugs in the WTO discussions on the Doha Declaration benefits no-one. Not the cause of health, not the cause of trade, not the cause of intellectual property rights.
Stalemate in crucial negotiations allows the problems that we are most concerned about to continue unabated. They hurt the world economy. Failure to find a resolution undermines the institutions involved. Building trust, forging a sense of solidarity – are critical elements of a political solution.
Our world is also interdependent in less direct – but no less important – ways. Countries that are impoverished, in crisis, in conflict - that are failing and weak - can have a crucial influence on the prosperity, security, and ultimately the health of the rest of the planet.
In many parts of Africa, some parts of the Middle East and some countries in South America, people have seen decades – in some places more than a generation – of stagnation. They are not progressing; sometimes they are even moving backwards. It is not a small number. Between 1990 and 2000, the human development index declined in nearly 30 countries. Well over a billion people – more than one fifth of the world’s population – are unable to meet their daily minimum needs. Almost one-third of children are undernourished. Although the UN last year stated that access to clean water is a human right, 1.1 billion people still go without it.
Populations in many of the poorest countries have also become much harder to reach. As the iron hand of the cold war loosened its grip, some countries enjoyed new freedoms, but, in other areas, paradoxically, the result was conflict, marginalization, and collapsing states.
In these “disappearing” countries, the work of donors, NGOs, and international agencies can be almost impossible. Of course, this trend is not universal: Cambodia, Mozambique and Uganda are only three examples that have seen relative peace, stability and functional government appear out of the ashes of war. But we don’t need to look far to find the areas where insecurity is hampering the best efforts to provide crucial health services as in, Afghanistan, the Democratic Republic of the Congo, Iraq, Liberia.
And there are many other countries where too many people cannot meet even their basic daily needs for food, water and shelter. They cannot access the services they need for survival, including essential health care and personal protection. They are vulnerable and insecure. Worse, trapped in ethnic conflict or civil strife – but beyond the media spotlight – they also risk being forgotten by an international aid community stretched to breaking point.
We started out by looking at the success of public health in Norway. What has happened here could be the basis for good health everywhere. But, sadly, this is far from being the case.
In many countries there is movement in the right direction in increasing access to health care. But, at the same time, never have so many been denied access to even the most basic levels of health service. One-fifth of humanity has no access to modern health care and one-half lacks regular access to essential drugs. The developing world still carries 90 per cent of the disease burden, yet poorer countries benefit from only 10 per cent of the resources that go to health.
Absolute poverty is spreading. About 600 million children in the world live in families who are unable to afford the very basic necessities of life - food, clothing and shelter. Women – so critical in all communities to securing development – continue to be disproportionately vulnerable. 70 percent of the absolute poor are women.
Equity in health outcomes and the pursuit of more equitable access to the fruits of development remains at the heart of the public health agenda. This is lesson six. I give it particular emphasis for several reasons. First, as I have said, the gap between the richest and poorest nations is increasing. And international solidarity is an almost inevitable casualty. We have seen at one international negotiation after another, how hard it is to forge a sense of trust in an atmosphere increasingly dominated by a burning sense of injustice.
Neither should we forget that relative success at national level can disguise inequities within countries. Social exclusion is important in Bergen and Barcelona, not only in Mogadishu or Mumbai.
Lastly, we have to be aware that the advances in science, such as the therapeutic agents that may result from developments in genomics, can also be the cause of an ever-widening gap between those have access to new technologies and those that do not.
Public health and development is a fast moving field. Even five years ago, when I first arrived at WHO, the development agenda was weighed down by old dogmas, long past their sell-by date. The most anachronistic was the notion that investments in health are essentially add-ons – luxuries which developing countries could only afford after having boosted economic growth and achieved higher income levels. “Soft” programmes aimed at promoting basic health, social welfare, even education were seen at best as a diversion from more pressing issues; at worst as a drain on scarce financial resources.
This approach was fundamentally flawed. It failed to recognize that a healthy population is as much a prerequisite for growth as a result of it. In 1999, the WHO asked leading economists and health experts from around the world to come together and consider the links between health and economic development. Two years later, under the guidance of Professor Jeffrey Sachs of Harvard University, the Commission on Macroeconomics and Health presented its report. It shows, quite simply, how disease is a drain on societies, and how investments in health can be a concrete input to economic development. It went further, stating that improving people's health may be the single most important determinant of development in many poorer regions, including Africa. One of my goals as Director-General of WHO has been to deliver this message at the highest political level – at international conferences and summits, in my many meetings with national governments, and in the WHO’s day-to-day contacts and collaboration with other international agencies. Three diseases - HIV/AIDS, tuberculosis and malaria – are crucially important. HIV/AIDS makes up just over half of the global burden these three diseases represent, both in terms of healthy life-years lost, and mortality. Malaria and tuberculosis share the rest on a roughly equal basis. It means that more than 90 million healthy life-years are lost to HIV/AIDS each year, 40 million to malaria and nearly 36 million to TB.
More than five and a half million people die every year worldwide from these three diseases. But these are certainly not the only health issues that need to be on the international community’s radar screens. Maternal and child conditions, reproductive ill-health, mental illness, violence, injuries, immunizing children against vaccine-preventable diseases, and the health consequences of tobacco – to name but a few - are also global health priorities. Any serious attempt to stimulate global economic and social development, and so to promote human security, must successfully address the burdens caused by these diseases.
What do we learn from this? Two lessons are apparent to me. First, with great respect to Henrik Ibsen, we have to recognize that health and economics are not always in competition. Indeed, quite the reverse is often true. As public health professionals we have to learn to state our case in terms that those who control the purse strings can appreciate. Secondly, we have to recognize that both ideas and contexts change. We need to keep learning, and be prepared to look a little over the horizon.
I think here, for example, of the shift towards an older population. In rich countries, the number of people over 65 who will require medical care, is expected to increase by between 50% and 120% from 1995 to 2025. Not only is the number of aged people increasing rapidly, but health expenditures per person per year increase with age. One survey found that people older than 75 accounted for nearly 30% of total health expenditures despite comprising only five per cent of the population.
Our challenge is to turn this shift into a full benefit for society. It will demand tremendous changes in the way we organize our work places, our living arrangements and our concept of care for those who cannot live on their own. We will have to reconsider the way we define how people contribute to society and how we measure productivity itself.
Ladies and gentlemen,
Perhaps the most important lesson of all from recent experience in public health, is that improving people’s lives remains the bottom line.
We have broad agreement on key poverty reduction and development targets such as the Millennium Development Goals. Despite the months of work they take, negotiating treaties and targets is the easy bit. Putting them into practice is the hard part.
Setting up new financing mechanisms is one thing, sustaining commitments to the additional financing they require is altogether something else.
Agreeing on what constitutes the right to health is an important step – but making sure that right is protected or realized is the step that makes the difference.
For all those countries that will achieve the development goals endorsed by the world community, there are many that will not. We have to ask ourselves why, and what can be done about it.
Let me end, then, with one simple message. The simple fact is there can be no real growth without healthy populations.
No sustainable development without tackling disease and malnutrition.
No international security without assisting crisis-ridden countries.
No hope for the spread of freedom and democracy unless we treat health as a basic human right.
Health must be at the centre of all of these agendas because what we are really talking about is the interdependence of people – not just markets and multinationals.
I am reminded of a survey taken in California some years ago. An opinion pollster asked a man on the street: 'Which is the greater problem facing the world today: Ignorance or apathy?' The man replies, "I don't know, and I don't care."
The fact is – we do know, and, we must care. We have all the evidence we need to know that investment in health is an investment in our common future. And, we are already seeing the consequences of not caring soon enough. The way that we, as an international community, work to address current crises and prevent future ones, will determine whether we succeed, or fail, in our shared efforts to advance global development, growth, and peace.