Lecture at the Academy of Medical Science

Beijing, People's Republic of China
20 April 2004

Good morning everyone.

It is a pleasure to be with you today. Some of you are veteran health workers, and others have not yet begun. I would like to help the young and the old to learn from each other by talking about the past, the present and the future of international health work. Then I would be happy to hear about your ideas and questions. Historical background

In the 1930s many westerners went to China to support the struggle for justice and stability. Those international supporters included doctors such as Norman Bethune and George Hatem, known here as Ma Haide, who contributed their medical skills to building health systems in China. To some of you, that part of China's history must seem a long time ago, but for others it is still recent and living memory. I am very happy that Ma Haide's widow, Su Fei, could be with us here today for this occasion, to help us see our work in its historical perspective. Those foreign doctors who came to work in China were making a kind of individual and unofficial response to the need for international cooperation in health.

After the Second World War, in 1945, there was a United Nations Conference on International Organization. At that conference it was the Chinese and Brazilian delegations which put forward the idea of setting up a World Health Organization. The proposal was welcomed, and WHO's Constitution was drafted and adopted the following year. WHO came into existence officially on April 7 1948, when 26 of the 51 Member States of the United Nations had ratified the Constitution. China and the United Kingdom had been the first two states to ratify, in July 1946.

The Constitution reflects an ambitious and optimistic view of what health services can achieve in the world if they are supported by a system of international cooperation. It proclaimed that the highest attainable standard of health was "one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." It defined health as "a state of complete physical, social and mental well-being and not merely the absence of disease or infirmity".

By this very broad definition, health can be seen as central to the effort of building a just global society after the war. Indeed, it is hard to think of a more worthwhile objective for any human activity than "complete well-being". The Constitution goes on to state that no country or community or individual should be denied access to the health care they need.

Like many others in the late 1940s and early 1950s, the first Director-General of WHO believed that health technology was now so advanced that it could prevent or cure the major diseases of the world, and the main remaining problem was human behaviour. He supported mass campaigns against malaria, tuberculosis and yaws.

Yaws, with the effectiveness of penicillin, was brought quickly under control, but the fight against malaria and tuberculosis ran into difficulties. One reason for these difficulties was the failure in the early days to make a large enough investment in controlling these diseases. WHO's first biennial budget was only $ 5 million instead of the 7 million recommended by the Interim Commission to the World Health Assembly. Unfortunately, both malaria and TB continue to cause a huge burden of death and disease, and are demanding major efforts to control them.

Attention shifted in the 1970s to the eradication of smallpox, an easier disease to stop, by means of vaccination. A worldwide immunization campaign met with strong support from governments, and it succeeded. The last known natural case of smallpox was reported in Somalia in 1977.

The health-for-all movement was launched in 1978. Morale was high in health work in the early 1980s.

But by the end of that decade the clouds were gathering. Most countries began to face major health financing problems, and were attempting in the 1990s to solve them with market-based approaches which tended to exclude the poor. Communicable disease control was undermined by failing health systems and rising drug resistance. Even as the infectious diseases of poverty were making their comeback, noncommunicable diseases such as cancer and cardiovascular conditions were also increasing rapidly, in all societies, as a result of changes in lifestyle.

Overshadowing all of these problems was AIDS, first named in 1982, and a worldwide public health disaster by 1990. Today 40 million people are living with HIV infection, and 30 million have died from AIDS. There is still no vaccine and no cure for it, but antiretroviral therapy, discovered in the 1990s, enables patients to recover their strength and lead a normal life. Until very recently, however, this treatment has been unaffordable to most of those who need it in developing countries.

Current agenda

An estimated 6 million people are in need of treatment and will die during the next two years unless they obtain it. Their need for treatment and society's obligation to provide it is unquestionable. The only question is how to get it to them as quickly as possible.

As a first step towards universal access, WHO and its partners launched an initiative last December to get the necessary antiretroviral drugs to 3 million people by the end of 2005. The initiative involves training staff in 60 countries to carry out the necessary diagnostic and treatment activities, building up a central system for the procurement and distribution of drugs, and strengthening national health systems.

The immediate aim is to save lives, but the initiative is also designed to catalyse the construction of health systems that can do this on a permanent basis, by meeting the challenges of the twenty-first century.

Health challenges can also arise much more suddenly, without warning, like the SARS emergency last year, which had such a profound impact on this country. I visited the health authorities here last year before I took office as Director-General, and was impressed by China's determination to contain the outbreak.

Prevention, a well-prepared response, and a strong health system are the three requirements for effectively dealing with emergencies. We are refocusing our work to support countries more effectively in meeting them. This means increasing the channels for direct communication, and increasing the proportion of our staff working in countries with the national and local health authorities.

Another important means of improving cooperation, especially in emergencies, will be our Strategic Health Information Centre in Geneva. Informally known as "the situation room", it brings together the latest communication technology, visual display systems and coordination software to facilitate quick and accurate decision-making.

But by far the most effective and economical approach to emergencies is to prevent them. To this end, the International Health Regulations, which have been in force since 1971, are being revised to cover the current known health risks. In addition to disease control, they include provisions for food and water safety, and the prevention of disasters. Regional consultation meetings on these regulations are in progress. The recommendations will then be reviewed by an Intergovernmental Working Group in Geneva in November of this year.

In the meantime we have to keep maintaining and renewing our traditional agenda of communicable disease control. For polio eradication that means massive immunization campaigns in the remaining handful of polio-endemic areas, particularly in Nigeria, India and Pakistan. For tuberculosis it means a major drive to increase case-finding and coverage with treatment to meet our target for 2005. For malaria it means maintaining the full range of prevention and treatment options while intensifying research on vaccines and drugs.

For noncommunicable disease control an important achievement was the adoption last year by the World Health Assembly of the Framework Convention on Tobacco Control. This has now been signed by 102 countries and ratified by 10. When 40 countries have ratified it, it will come into force and help to save millions of lives. China has signed and I hope will soon ratify the Convention.

An important part of WHO's current agenda was set by the international community in the year 2000. In September of that year the largest ever gathering of heads of state agreed to make a firm commitment to improving the lives of the billions of people by adopting the Millennium Declaration. The Declaration was endorsed by 189 countries and formulated as improvements that must be achieved by 2015.

The section on development and poverty eradication contains eight goals known as the Millennium Development Goals. These represent a commitment to tackle poverty and hunger; lack of education; gender inequality; child mortality; maternal mortality; HIV/AIDS and other lethal epidemics; environmental dangers; and the need for global partnership in development.

Partnership also refers to the spirit in which these goals were set. They were seen as a kind of pact: developing countries would make them priorities on their domestic agenda, while the industrialized ones would support them by respecting the rules of fair trade, and providing development assistance, debt relief, access to essential medicines, and technology transfer. In this way the Millennium Development Goals may come to be seen as a step towards renewing the commitments of the United Nations for the twenty-first century.

As you see, health is central to achieving these goals. Three of them are about health, and all of the other five are directly linked to health. For instance, improved health reduces poverty by making it possible to work, look after one's children and avoid catastrophic health care costs. Education and health contribute to each other. Women are able to protect their own health and that of their families when they have equal rights. Clean air and water are major health concerns. Partnerships are essential for the health systems of tomorrow.

Some countries are making much better progress than others towards achieving the targets set for 2015. Thanks mainly to China and India, for instance, the targets of halving poverty and improving access to safe water are likely to be met. In 14 countries of Africa, on the other hand, the mortality rate for children under five years old has actually been rising.

Major changes will have to take place if the Millennium Development Goals are to be achieved. The targets are valuable as a reference point for national and international efforts, and as a stimulus for health system development.

Public health issues in China

China has made remarkable progress in health improvement over the last 50 years. Life expectancy in China has now reached 71 years, which is similar to that of many much more economically developed countries. These improvements are impressive, and additional progress will be achieved with further investment in health and social services, in order to meet the challenges ahead.

Overall, China is achieving its health targets for the Millennium Development Goals. But there are two important exceptions in disease control: tuberculosis, and HIV/AIDS.

Since the Ministerial Conference on TB in Amsterdam in 2000, China has greatly increased its investment in TB control activities, but like most other countries it is still having difficulty in meeting the target case detection rate of 70%. By the end of 2003 this was still only 39% for China. Related to this is China's very high rate of drug-resistant TB, affecting 40% of people with TB in this country. The main cause is inadequate or inappropriate treatment of TB patients. This is a problem in urgent need of attention.

For HIV/AIDS, the number of people infected is increasing rapidly. The current estimate is 840 000 people living with HIV/AIDS in China at present. This number could become 10 million by 2010 unless decisive action is taken now. I believe the action has already started with the recent National Conference on AIDS sponsored by the State Council. This is a very welcome development, as is China's strong support for the "3 by 5" initiative. The five-year grant of $97 million from the Global Fund presents a real opportunity to change this situation by scaling up prevention, treatment and care activities.

SARS and avian influenza remain a major issue. Both WHO and China are eager to see SARS eliminated as a public health threat. Unfinished tasks include clarifying the origin and epidemiology of the infection, and finding an effective treatment and vaccine. We also both want to perfect our joint ability to facilitate emergency response efforts.

With increased life expectancy comes the health transition, in which communicable diseases are replaced by noncommunicable ones as the dominant cause of death. In 2002 there were 10 million deaths in China. Of these, 7 million were due to chronic noncommunicable diseases, particularly stroke and cancer, and 1 million were due to injuries. Reducing road traffic accidents is the theme of this year's World Health Day, and I know this is a major priority for China.

This disease pattern reflects the major risk factors for chronic diseases, which include tobacco consumption, unhealthy diets, and physical inactivity. These and other risk factors for chronic diseases are still in an early stage of development in China. Investment in preventing these diseases will be less costly if it is done now rather than left till later, and will reap significant social, economic and health benefits for the country.


Much more can be said about the world's health situation and that of China, but I would like to conclude my remarks here, by mentioning the principles of primary health care. They were defined in the Alma-Ata Declaration in 1978, and I believe they point the way to the future.

In particular these principles call for equity; a needs-based approach; intersectoral health activities; community participation; and prevention and treatment as complementary functions.

China has played a leading role in upholding these values in the past and I'm sure it will continue to do so in the future. Not only because of its size but because of its strength and leadership, China has always been a key Member State of WHO. We look forward to continuing our cooperation for many years to come, for the well-being of all people everywhere.