Health diplomacy in the 21st century
Dr Margaret Chan
Director-General of the World Health Organization
Address to Directorate for Health and Social Affairs, Norway
Distinguished ministers, colleagues in health and other sectors,
As I begin my sixth week in office, I value this opportunity to speak with you and hear your views. We face many challenges. But thanks to my predecessors, we are in a strong position to meet these challenges.
This is an appropriate occasion for me to pay tribute to Dr Brundtland’s leadership. She wanted to raise the profile of health in the debate about development. She succeeded. Health is at the centre of the Millennium Development Goals.
With her Commission on Macroeconomics and Health, she defined the links between poor health and poverty, and good health and socioeconomic progress. Health problems of the developing world are now talked about at levels ranging from political summits to interviews with rock stars. Health has never received such attention.
Funding agencies and foundations have never given health such wealth. And this wealth is earmarked for the world’s sickest and poorest people. These are optimistic times for public health.
I thank Dr Brundtland, too, for recognizing that health issues are inherently political, and then tackling them at the political level. She forged head-on into battle with big tobacco, and won.
In a politically more delicate move, she engaged with the pharmaceutical industry. She sought common ground on such difficult issues as tiered pricing, intellectual property rights, and innovation, especially for neglected diseases.
She understood the importance of infectious diseases as killers in their own right. But she also understood the special features of outbreaks and, under her watch, of SARS. For reasons I will discuss, outbreaks attract political attention at levels far higher – and more powerful – than ministries of health.
She skilfully used the spotlight of public, press, and political concern about SARS to profile the power of public health – and of WHO at the helm. All of public health has benefited.
I have been asked to speak about current issues of high importance for WHO. I use a six-point agenda as a simple way of looking at a very complex task.
The first two items address fundamental health needs: for health development and for health security. I include chronic diseases under health development, together with the Millennium Development Goals, the neglected tropical diseases, the health of women, and the health of the African people. I will speak about health security at length.
The next two items are strategic: building the capacity of health systems, and gathering the evidence we need to set priorities and measure progress. As I have said, what gets measured gets done.
The remaining two items are operational: building and managing partnerships to get the best results in countries, and ensuring that WHO – and its partners – perform well.
The three presentations scheduled for today address issues of central importance to this agenda. I thank the Norwegian government for its engagement in today’s big health issues, especially as many of these issues do not directly affect the health of the Norwegian people.
Health systems and health personnel are fundamental challenges throughout the developing world. Although we are making spectacular progress in some areas, such as childhood immunization, we are falling short in other ways. We are not reaching impoverished populations with essential care on a scale big enough to make a difference.
We face three main problems. For some diseases, we have no tools or only imperfect ones. In other cases, we have excellent tools, but high cost puts them beyond the reach of the poor who need them most. Third, we often have powerful interventions that are cheap or even free, but fail because we lack the systems and personnel for their delivery.
These are life-and-death failures, and I find them unacceptable.
There is much talk these days about building the right “architecture” for global public health. Let me remind you: architecture rests on a foundation. All of our well-intended efforts will fall short unless they are firmly rooted in the capacities and infrastructures of recipient countries and driven by their priorities. Decades of experience have taught us this lesson.
We face many difficult dilemmas. Should we act now, with imperfect strategies and tools? Should we wait – first get the infrastructures and capacities in place? How many lives are at stake? Can we do the two together – deliver and build capacity?
In Africa, for example, we need to tackle the high-mortality infectious diseases as a matter of urgency. Yet the infrastructures for doing so are weak or non-existent.
Here is a second dilemma. We have a multiplicity of health initiatives focused on delivering outcomes. The ability to deliver these outcomes requires a functional health system. Yet strengthening health systems is not the core purpose of these initiatives.
We need a common approach to service delivery. This is why I have called for a return to integrated primary health care as an approach to strengthening health systems.
I will turn now to one area where the Norwegian government has taken a leadership role: health security and foreign diplomacy. There are many areas where foreign diplomacy can further the interests of international health.
The engagement of multinational industries is one challenge. Dr Brundtland made WHO the number one enemy of big tobacco. Good. This is one industry where we want no engagement.
But we need to engage the food industry if we want population-wide approaches that make healthy food choices the easy choices. We know that chronic diseases are a problem in every part of the world. Unless we engage the generic and research-based pharmaceutical industry, we will not solve the problem of poor access to existing interventions or see the development of badly needed new tools.
Issues of international trade impinge on health, often in significant ways. This is an especially challenging area for foreign diplomacy.
Another area arises from the behaviour of emerging and epidemic-prone diseases. As they have no respect for borders, epidemics have long been a subject of diplomatic importance.
International health diplomacy dates back to at least 1851, when European diplomats and physicians met in Paris to seek collaborative ways to secure their populations and commercial interests against repeated visitations of pestilence. The focus of concern was the so-called “quarantinable” diseases: cholera, plague and yellow fever.
The situation today is dramatically different. In the last decades of the previous century, new diseases began emerging at the unprecedented rate of one per year. This trend will continue.
I mentioned before that outbreaks have special features. They provide a straightforward example of a health event that can take on political dimensions at the international level.
I will look first at unique features of outbreaks that give them this potential. I will then show how these features have operated in reality by looking at 3 watershed events of the 21st century. This also allows us to appreciate how much our highly mobile, interconnected, and interdependent world has changed in terms of its vulnerability to transnational threats.
Outbreaks are always urgent emergencies, and they are highly newsworthy. Official responses are closely scrutinized by the press. Authorities are expected to act decisively.
In reality, outbreaks are largely unpredictable. Urgent decisions with major consequences are often made in the midst of considerable scientific uncertainty.
This uncertainty fuels public anxiety. Anxiety and fear can produce economic and social disruption far out of proportion to the real threat and well beyond the outbreak zone.
Here is one example. Estimates of the costs of the next influenza pandemic vary greatly, depending on the presumed virulence of the virus. These estimates have ranged from 800 billion dollars within a year to well over 2 trillion dollars.
But all estimates agree: the highest costs will come from the uncoordinated efforts of the public to avoid infection.
This disruptive potential gives outbreaks a final characteristic: their high political profile. When public anxiety, social disruption, and economic losses accompany an outbreak, it demands attention at the highest level of government. With this high profile comes responsibility to the international community in an unwritten but agreed code of proper conduct. It is simple: authorities must not conceal an outbreak, especially if it has the potential to spread internationally.
Here is a clear limit to state sovereignty. When the world is collectively at risk, defence becomes a shared responsibility of all nations. I repeat: no nation has the right to conceal an outbreak within its territory. Nor can they afford to, given the force of public and political opinion.
For outbreaks, the first watershed event of this century occurred in October 2001, when anthrax spores were deliberately distributed through the US postal system. It was not the 22 cases and 5 deaths that made this a landmark event. It was the timing, coming as it did on the heels of the 11 September terrorist attacks.
This was the shocking new reality. If civilian aircraft could be piloted into landmark buildings, that same mentality was capable of conducting an attack using a biological agent. The previously unthinkable became distinctly more plausible.
As preparedness for such an event, exercises and studies were undertaken to predict how a deadly viral disease might spread and wreak havoc under the unique conditions of the 21st century. In the midst of these exercises, the SARS virus emerged to prove these theories right.
SARS spread rapidly along the routes of air travel. It cost Asian economies more than 30 billion dollars in less than four months. It placed any country with an international airport at risk of an imported case.
Not every country was concerned about a bioterrorist attack, but every country feared the arrival of a disease like SARS.
SARS redefined national responsibilities for outbreaks in at least two important ways. First, given the international repercussions, governments will be held accountable, by the international community as well as their citizens, for failures in outbreak management.
Second, it is now virtually impossible to hide an outbreak. Our world is electronically transparent. News will always leak out and spread – via text messages, chat rooms, or media reports.
During SARS, the experts told us: be prepared. This is bad, but the worst will come with the next influenza pandemic. That will be a far more contagious disease. Spread will be unstoppable.
In December 2003, just four months after WHO declared the SARS outbreak over, surveillance set up to guard against a return of the disease detected an unusual cluster of fatal respiratory disease at a paediatric hospital in Hanoi, Viet Nam. Multiple tests were conducted to no avail.
SARS was suspected, but not strongly. SARS was never a paediatric disease.
By early January 2004, the causative agent was known: the H5N1 strain of avian influenza virus. So began the threat of an influenza pandemic that still looms, with even greater menace, three years later.
From this experience, we have another important lesson in international health diplomacy. It concerns the principle of fairness.
Virtually every country affected by an outbreak behaved impeccably, with full recognition that the threat within their territory was hugely important for the world. In short: they accepted their duty to the international community.
Human cases were reported immediately and transparently. Samples were sent to WHO laboratories for analysis.
More than 220 million birds died or were slaughtered. And this took place in countries with economies largely dependent on subsistence farming. Poor rural households were asked to bury their livelihoods – their food, their protein for growing children.
Most received no compensation. The funds were not there. Elsewhere, affluent countries spent millions of dollars investing in antiviral drugs and vaccine development to protect their populations.
As you are probably aware, the question of fairness has now come to a head. One country is no longer willing to share viruses internationally. The fear is that viruses will be used by wealthy countries to produce pandemic vaccines that will not, in all likelihood, ever reach the developing world.
The issue can be summarized succinctly. Many impoverished countries did everything in their power to keep a local threat from becoming an international catastrophe. They showed solidarity. Should not wealthy countries reciprocate? Don’t poor countries also deserve protection during a pandemic?
The problem is perceived to be one of fairness. In reality it has much to do with capacity. Access to a pandemic vaccine is limited by finite manufacturing capacity.
On present capacity, with plants working 24-hours a day, we could produce 500 million doses per year. This is way too little for a world of more than 6 billion people, all of whom will be fully susceptible to infection with an H5N1-like pandemic virus.
Again, we face that classic divide where wealth – and not need – governs access.
Can we draw some lessons from these recent events that apply to other areas of health diplomacy?
I can make three suggestions.
First, we will have the best chance of winning support when we appeal to national self-interest. International solidarity to contain SARS had much to do with fear of the economic and social consequences should be fail.
Second, there must be some ground rules for good and poor performance on the international stage. I have mentioned just one: a country must not conceal an outbreak.
Third, there must be accountability. If we want to enforce the ground rules, we need to find ways of using the power of public and political opinion to exert pressure. We have seen this work well with outbreaks. And we have seen it work to get the prices down for antiretroviral drugs.
Public health always wants a peaceful way forward. This is diplomacy.
I will leave you with these thoughts.
In conclusion, I want to express my personal delight in the initiatives being supported by the Norwegian government. They are an expression of our shared responsibility and international solidarity in health. They reinforce my view that these are optimistic times for health.