Public health in the 21st century: optimism in the midst of unprecedented challenges
Dr Margaret Chan
Director-General of the World Health Organization
Professor Shih, ministers, friends, and colleagues,
This is a campus I know well from the past. These grounds bring back fond memories of a good educational experience. The time I spent at this university, earning a degree in public health, helped equip me to move on in my career and to assume higher responsibilities.
The job I hold now is a great honour, but it is not an easy job.
The landscape of public health has become increasingly complex in just the past ten years. The landscape is crowded, with multiple partners and actors implementing programmes in countries, sometimes overlapping, sometimes fragmenting overall care.
It is also crowded with health problems – both new problems and older problems that are getting bigger or appearing in unexpected places.
The boundaries of public health have become blurred, extending into other sectors that influence health opportunities and health outcomes. The importance of economic, social, environmental, and political determinants of health has grown.
Responsibilities, too, are blurred. The health sector regulates the quality and safety of food and pharmaceutical products. But who regulates the marketing, by satellite TV, of unhealthy lifestyles, including diets? What sector in what country is responsible when the earth’s depleted ozone layer increases the risk of skin cancer?
Globalization and urbanization play increasingly influential roles. Demographic and epidemiological transitions now combine with nutritional and behavioural transitions to create ominous new trends in health.
Chronic diseases, long considered the companions of affluent societies, have shifted places. Low- and middle-income countries now bear the greatest burden from these diseases.
Skilled health workers, in vast numbers, leave the countries that invested in their training. Today, an estimated 4 million health care workers are urgently needed to provide the bare essentials of care in more than a quarter of the world’s countries.
Emerging diseases have become a much larger menace in a world characterized by high mobility and the close interdependence of economies. New diseases are emerging at an historically unprecedented rate. The magnitude of their impact on economies and financial markets is likewise unprecedented.
Health systems in most countries have proved inadequate to the task. Developing countries cannot manage chronic diseases alongside continuing high mortality from infectious diseases.
Affluent societies cannot cope with the growing epidemic of obesity, which increasingly starts in childhood.
More developing countries now have pockets of wealth that attract the lion’s share of spending on health. More wealthy countries have growing urban slums and shantytowns, often populated by immigrants, that drain health resources and strain the social welfare system.
On present trends, no country in the world will have adequate surge capacity to cope with the next influenza pandemic. By surge capacity, I mean adequate numbers of hospital beds, medical supplies, and measures for managing public panic. The same can be said for surge capacity should a bioterrorist attack occur.
Most biomedical research aimed at product development is driven by market forces, geared to the needs of populations that can pay. Health needs in populations left behind by socioeconomic progress are also left behind by the R&D agenda.
Here is just one example. Developing countries experience from 300 million to 500 million clinical episodes of malaria each year. Imagine the impact on economic productivity – not to mention the suffering and the yearly toll of more than 1 million deaths. Yet our arsenal of treatments for this disease is limited to a single class of broadly effective drugs.
Globalization creates wealth but has no rules that guarantee its fair distribution. Huge gaps in health outcomes are growing wider, and these gaps divide rather precisely along the lines of poverty and wealth.
In terms of fair access to care, the “inverse care law”, first described in 1971, prevails: the availability of good medical care tends to vary inversely with the need for it in the population served.
If we focus on these glaring gaps in health outcomes, we have to conclude that the landscape of public health is out of balance. It has no fairness. But if we look at the present situation in a different way, we see that the concerns of the international community are converging. We see growing signs of solidarity in health.
We see signs of a shared desire for a more equitable world for health opportunities and outcomes, and of shared responsibility in making this happen.
Despite the complex challenges we face, I believe these are optimistic times for health. Thanks to the work of my predecessors, health is now appreciated as a key driver of socioeconomic progress. Poverty contributes to poor health, and poor health anchors large populations in poverty. But better health allows communities to work their way out of poverty and spend household incomes on something other than illness.
Good health provides the very foundation for a productive life, and thus increasingly figures as a goal in poverty-reduction strategies.
This central place of health in the development agenda has its strongest affirmation in the Millennium Declaration and its goals. These goals aim to reduce poverty by attacking its root causes. These causes are complex and interrelated.
Health-related goals reflect the reality. In all countries, poverty is expressed as high rates of maternal and childhood mortality and large numbers of deaths from infectious diseases, most notably HIV/AIDS, tuberculosis, and malaria.
Commitment to the time-bound Millennium Development Goals takes place at a time of unprecedented interest in health. Our cause is supported by a growing number of health initiatives, implementing agencies, public-private partnerships, foundations, funding agencies, and rock stars.
The attention and resources being devoted to health are unprecedented. This, too, is part of the public health landscape. But attention means close scrutiny, and resources come with an expectation of results. The stakes are high and the responsibility to deliver is great.
As the agency responsible for guiding and directing international health work, much of this responsibility rests with WHO. As I said, this is not an easy job.
Let us step back and try to get some clarity.
At WHO, we use a six-item agenda as a simplified way of viewing these complex challenges. The first two items address fundamental health needs: for development and for security. The second two items are strategic: building health systems and generating the evidence needed to define strategies and measure results.
The remaining two items are operational: managing partnerships to get the best results in countries, and improving the performance of WHO.
As I said, this is a simplified way of looking at a very complex task. To do our job in the best way possible, we must look at some complex issues.
Why did the governments of 189 countries sign on to the Millennium Declaration as a shared responsibility? Why has poverty reduction, along with its health-related causes and consequences, become the principal focus of this commitment? Why have so many partners joined this effort?
What about corporate social responsibility, the new philanthropy? Or public-private partnerships that are donating first-rate drugs to eliminate ancient diseases of poverty? These are diseases foreign to the affluent world, where they are almost never seen. Why should anyone care?
What about the innovative new funding mechanisms created to redistribute some of global wealth to meet health needs of the poor? Like the Bill and Melinda Gates Foundation, the GAVI Alliance, the Global Fund, and the newest, UNITAID, which draws substantial new funds from a tax on airline tickets. I believe there are two main explanations for these trends. First, conditions following the end of the Cold War paved the way for looking at health as an issue of broad international concern. Second, the forces of globalization swept across this newly paved way, and changed things even more.
Both have something to do with international health security – the theme for this year’s World Health Day.
The end of the Cold War altered the way nations had been interacting for half a century. It also altered the meaning of security. In its traditional sense, security has long been a strictly national pursuit aimed at defending territorial integrity and ensuring state survival.
National security is intrinsically self-centered, focused on shielding citizens from external risks and dangers. Traditional approaches to the defence of national security are military functions: protecting borders, waging wars, and deterring aggressors.
The end of the Cold War meant an end to security issues polarized by the ideological conflict and geopolitical interests of the superpowers. It ended a tension kept on edge by the nuclear arms race and the threat of mutual destruction.
As these threats subsided, more attention focused on threats arising from civil unrest, internal conflicts, mass migration of refugees, and localized wars between neighbours. Concern was greatest when these events threatened to cause social, economic, or political instability.
As a result, security issues became broader and more complex. Attention began to focus on ensuring the internal stability of states by addressing the root causes of unrest, conflict, and mass population movement.
Space was created to start thinking about poverty and health as issues important to international security.
Particular attention was given to the threat arising from outbreaks of emerging and epidemic-prone diseases. An event whereby a foreign microbial agent invades sovereign territory, evades detection, kills civilians, and disrupts the economy fits well with many definitions of a security threat.
In a second event, the forces of globalization demonstrated the porous nature of national borders and eroded traditional notions of state sovereignty.
In a closely interconnected and interdependent world, the repercussions of adverse events abroad easily cross borders. They intrude on internal state affairs in ways that cannot be averted through traditional military defences.
This vulnerability is most apparent in financial markets and business systems. In today’s world economy, markets are interdependent, stock prices interact, banking networks are interconnected, and cross-border cash flows continue to expand. A disturbance in one market segment or one country rapidly ricochets throughout the global financial system.
Concerning business systems, trends such as global sourcing and just-in-time production have made manufacturing in a broad range of businesses – from cars to clothes to computers – highly sensitive to distant disruptions in multiple places.
A minor disturbance from a single supplier can disrupt the entire production chain, rapidly halting delivery of the finished product.
In this context, locally disruptive events, such as an outbreak, have the power to disrupt the entire global system in ways that cannot be controlled by one nation acting alone. For outbreaks of emerging and epidemic-prone disease, recognition of this universal vulnerability – especially to economic shocks – called for global solidarity and collective defence.
Globalization, accompanied by changing perceptions of national and international security, has had some profound implications for health. Let us look at some of these implications, and then see how they influence the six-item agenda being pursued by WHO.
First, globalization has helped spread a costly epidemic of chronic diseases to the developing world. Consumer behaviours the world over are being shaped by global forces of production, trade, marketing, and distribution. In the developing world, a strong national asset – the healthy diets and physical activity associated with rural farming – is being lost.
As a result, chronic diseases, strongly linked to diet, physical activity, and tobacco and alcohol consumption, have increased dramatically. The burden of diseases such as heart disease, stroke, cancer, diabetes, and asthma is now heaviest in low- and middle-income countries.
In these countries, the age of onset is usually younger, health systems are ill-equipped to cope with the demands of chronic care, and the costs to households can be catastrophic.
These diseases are also an impediment to poverty reduction. The costs of long-term care can push an already impoverished household below the poverty line. In countries experiencing rapid economic growth, heart disease, stroke, and diabetes alone have been shown to hold back economic growth by an estimated 1% to 5% per year.
As a second implication, the forces of globalization have changed the epidemiology of emerging and epidemic-prone diseases. From 1973 through 2003, when SARS appeared, 39 pathogenic agents capable of causing human disease were newly identified.
You will recognize the names of some: Ebola, HIV/AIDS, and the organisms responsible for toxic shock syndrome and legionnaire’s disease. Others include new forms of epidemic cholera and meningitis, Hanta virus, Hendra virus, Nipah virus, H5N1 avian influenza and, of course, SARS. All of this within 30 years.
This is an historically unprecedented trend. For example, when Ebola emerged in 1976, this was the first potentially explosive new viral disease seen in the world for more than three decades.
This is an ominous trend and it is certain to continue. It arises from fundamental changes in the way humanity inhabits the planet. Constant evolution is the survival mechanism of the microbial world. An organism that can replicate more than a million times a day is well-equipped to take advantage of every opportunity to mutate, adapt, invade, and evade. These opportunities are multiple.
Demographic pressures cause people to encroach on previously uninhabited areas, disrupting centuries-old relationships between pathogens and their natural reservoirs. Intensive farming practices exert additional pressures.
Population growth crowds humans together with domestic animals. Of the emerging pathogens capable of infecting humans, around 75% originated as diseases of animals.
Urbanization is another force that has swept through the world. In sub-Saharan Africa, for example, around 37% of the population lives in cities. Of these city dwellers, 72% live in slums. Human crowding under unsanitary conditions creates an ideal opportunity for pathogens and their insect vectors to exploit.
The mosquito vector of dengue and yellow fever has adapted to breed and thrive in the litter and filth of urban slums. A discarded yogurt cup is sufficient – no need for puddles or ponds.
Climate change also has a health impact. We all recall the large numbers of elderly people who perished during the heat wave in Europe in 2003. Last year, we saw huge outbreaks of cholera in several countries, and the first outbreak of Rift Valley fever in humans in six years, both linked to unusual patterns of rainfall.
As a third implication, the interdependence of financial markets and businesses has made outbreaks a much larger menace. I need just one example to illustrate this point. SARS demonstrated how much our world has changed in terms of its vulnerability to economic and social disruptions far beyond the outbreak site and well out of proportion to the actual threat.
As a fourth implication, globalization of the labour market has contributed to an acute shortage of health workers. WHO estimates than 4 million health workers are urgently needed to maintain essential care in 57 countries. The crisis is most severe in sub-Saharan Africa. This part of the world accounts for 24% of the global burden of disease, but has only 3% of the health workforce.
Essential services in jeopardy include childhood immunization, care during pregnancy and childbirth, and access to treatment for HIV/AIDS, tuberculosis, and malaria. As you will recall, these are precisely the problems targeted by the MDGs.
The final impact of globalization that I want to discuss is a positive one. Globalization has returned the ethical principle of equity to its rightful place as the single most important guiding principle for health and development.
Equity drove the Health for All movement, and equity is now at the heart of international development goals. The principle is simple and straightforward. Populations should not be denied access to life-saving and health-promoting interventions for unfair reasons, including those that arise from economic or social causes.
Health development and the MDGs are all about fairness.
With this as a background, let me return briefly to my six-point agenda for WHO for the next five years.
We see the principle of equity at work in the first item, health development. Quite simply: if health improvement is to work as a poverty-reduction strategy, health services must reach the poor and underserved.
Here is a stark conclusion. For the first time, we have funds flowing in, powerful interventions, proof of their effectiveness, strong political commitment, and international determination.
What we don’t have is systems for delivering these interventions to the poor. We know this now. This is our biggest bottleneck to progress.
We face a dilemma. Abundant initiatives have formed to deliver a specific health outcome. Successful delivery depends on a functioning health system. Yet the strengthening of health systems is almost never a core component of these initiatives.
The second agenda item is health security. We have good international mechanisms, such as the Global Outbreak Alert and Response Network, for defending the world against the threat of emerging and epidemic-prone diseases. We have the greatly strengthened International Health Regulations coming into force in June.
But true health security depends on strong national capacities to detect and contain outbreaks at their source – before they have an opportunity to become international health emergencies. Again, we see the bottleneck.
Strengthening health systems is the third item, and it is one of my highest priorities. I have called for a return to integrated primary health care as an approach to strengthening health systems. When equity is our guiding principle, I believe this is the right way forward.
Decades of experience have taught us that primary health care is the surest route to universal access. We know, too, that sustainability increases when we follow the principles of local ownership, community participation, and the right mix of curative and preventive services.
Our job now is to convince partnerships, funding agencies, and donors. Most health ministers I have spoken with are already convinced. That is a good start.
We will convince the others through activities under the fourth item: evidence. We have started the process already. We need solid evidence that primary health care improves equitable access and health outcomes, meets priority needs, and brings sustainable results.
We also need data on costs. Primary health care is not second rate care for the Third World, and it is not cheap.
As I said, evidence is strategic. We need evidence to manage the large number of partnerships working in countries – the fifth agenda item. We must get their activities aligned with country priorities and capacities, particularly concerning service delivery.
We must get their activities aligned with overarching strategies that aim for sustainability. We must get them to follow best technical practices. We must use the persuasive power of WHO’s reputation for technical excellence and objectivity in its normative and standard-setting functions.
Finally, we must improve the performance of WHO. The Organization must continue to reform, to find synergies and ways of streamlining its work, to concentrate on those activities it is uniquely well suited to perform.
This is a responsibility on my shoulders. Much is expected of WHO, and much is at stake, measured in human lives and deaths, as well as socioeconomic progress.
The landscape of public health is complex and rapidly changing. The challenges are unprecedented.
But this landscape also reveals a spirit of global solidarity, and a strong desire for fairness in health. And this gives us an occasion for unprecedented optimism as well.
I thank you for your attention.