Address to the Regional Committee for South-East Asia
Dr Margaret Chan
Director-General of the World Health Organization
Minister Lyanpo Thinley Gyamtsho, Chairperson of the sixtieth session of the Regional Committee, Honourable Ministers, distinguished delegates, Regional Director Dr Plianbangchang, colleagues of the UN family, ladies and gentlemen,
I am well aware that I am appearing before a group of ministers and other leaders responsible for health in some of the most densely populated countries in the world.
Worldwide, public health is engaged in basically the same struggles on three main fronts.
We struggle to hold the microbial world at bay. We struggle to change human behaviours. And we struggle to gain attention and resources. But the challenges in South-East Asia have distinct dimensions.
I am aware of the heavy responsibility on your shoulders. Routine health functions take on monumental dimensions because of the sheer numbers of people you must reach.
This part of the world has the largest number of children missed by immunization services.
It has the highest number of deaths from measles, and the highest number of deaths from complications of pregnancy and childbirth.
South-East Asia has the highest number of unsafe abortions.
Problems like malnutrition in children, and anaemia in pregnant women, persist. You have so many mouths to feed, so many babies to deliver safely.
You have my full appreciation for the magnitude of challenges you face.
You also have my full admiration.
At a time when social justice and fairness are driving the development agenda, I believe you have three golden assets at the policy level.
I am referring to your commitment to poverty reduction, your commitment to universal access, and your responsiveness to the desires of your citizens, right down to the grassroots level.
I see these policy commitments, time and time again, in your national health plans and long-term objectives. Many of these objectives are visionary.
It is not surprising that this region has pioneered the adoption of rational approaches to the provision of essential care, on a massive scale.
You have shown the world how to maximize population-wide protection from preventable threats.
Above all, your efforts are lessons in how to stretch resources so that benefits reach the largest possible number of people.
This region leads the world in the use of lists of essential medicines as part of national drug policies.
Use of the WHO Model List goes hand-in-hand with policies promoting rational drug use.
To protect health, you use health legislation to great strategic advantage.
Health-promoting regulations in this region range from mandated latrines in households, to child protection legislation, to control of the safety and quality of medicinal products, including blood safety.
Your legislation also provides a model for using a natural resource to extend access to essential care.
I am referring here to the region’s rich heritage of traditional medicine and the wealth of knowledge and wisdom preserved by its practitioners.
Traditional medicine is especially well-regulated in this region. In many countries, modern and traditional systems co-exist in harmony, and benefit from mutual referral.
This is, once again, a rational way to use existing resources to reach more people.
Health leaders in South-East Asia take advantage of regional and global strategies, especially those that increase operational efficiency.
For childhood illness, many countries have adopted the WHO strategy for the Integrated Management of Childhood Illness.
This approach recognizes that most childhood deaths result from a handful of causes that can be prevented by a handful of cost-effective interventions.
It attacks these causes, including malnutrition, in an integrated way, using standardized treatment protocols.
For the Stop TB strategy, experts agree: progress in this region is driving progress globally and I commend you for this.
As another example, you have on your agenda a proposed regional framework for the prevention and control of chronic diseases.
Again, a population-wide collaborative approach is the most rational way to counter this growing threat.
As we all know, South-East Asia is the ancestral home for some of humanity’s oldest diseases, including leprosy and cholera.
Today, these and other neglected tropical diseases are closely associated with extreme poverty. Their control is clearly a poverty-reduction strategy.
The tremendous progress in controlling these diseases is another sign of your commitment to tackle the diseases of poverty, even when the people affected are largely hidden in remote areas and have little political voice.
As just one example, nine countries in this region have reached the target for elimination of leprosy as a public health problem.
Apart from being the ancestral home of some ancient diseases, this region is also the birthplace for some newer and better things.
I am referring here to microfinancing schemes that are helping to lift millions of people out of poverty.
These schemes are now being used worldwide. They show, in particular, that income opportunities for women give them a chance to realize their potential as agents of change.
As mounting evidence tells us: the benefits for the health of households and communities are immense.
As I have said, women are not just a vulnerable group, and not just a free source for health care. They are agents of change, and a tremendous resource for poverty reduction and sustainable development.
Allow me to put some of these challenges and achievements in perspective.
As I mentioned, all of us working in public health are engaged in common struggles on three fronts.
First, we struggle against the constantly changing microbial world. We have some rare victories, when we eradicate or eliminate a disease.
But for the most part, we struggle to hold these diseases at bay, to maintain the fragile detente between microbes and their human hosts.
And the struggle is, indeed, constant. Research develops drugs. Microbes develop resistance.
We triumphed over smallpox in 1979. Just a few years later, HIV/AIDS was on the scene.
We failed to stop this new disease from spreading internationally and becoming endemic. We will pay the enormous price of this failure for decades to come.
We stopped SARS dead in its tracks in July 2003. Five months later, human deaths from H5N1 avian influenza were confirmed. And we have lived under the looming threat of an influenza pandemic all the long years since.
We struggle on a second front: to change human behaviour.
On the surface, it sounds so easy. Use a condom. Sleep under a bednet. Don't smoke. Eat a healthy diet. Get plenty of exercise. And finish the course of TB pills.
As we all know, behavioural change has tremendous preventive power, but it is one of the hardest tasks we face.
Prospects for behavioural change improve in an overall environment that makes healthy choices the easy choices.
National policies and legislation can provide critical support, especially when they shape activities in other sectors – like agriculture or environmental sanitation – with an impact on health.
This brings me to the third struggle. Public health is constantly fighting to gain attention and resources.
Many of the mechanisms and infrastructures that safeguard public health on a daily basis go unnoticed until something dramatic goes wrong.
The need to invest may come into view only when the food or water supply is contaminated, hospital beds are full, substandard or counterfeit drugs enter the market, or surveillance misses the start of an outbreak.
Although the consequences of such failures are costly and disruptive, public health still struggles to persuade governments to invest in basic infrastructures and services – before something dramatic goes wrong.
None of this is new, of course. Public health has struggled on these three fronts virtually since the beginning. But the struggles have become much more complex, sometimes ominously so.
Changes over just the past few decades have reshaped the landscape of public health, introducing a host of new challenges.
First, that fragile detente with the microbial world is increasingly tense.
Changes in the way humanity inhabits the planet have disrupted the natural equilibrium of the microbial world.
Population growth, urbanization, intensive farming practices, the misuse of antibiotics, environmental degradation, and incursion into previously uninhabited areas have exerted enormous pressure on pathogens.
As a result, new diseases are emerging at an historically unprecedented rate. Old diseases are resurging, or spreading to new areas.
Resistance to mainstay antimicrobials is occurring at a rate that outpaces the development of replacement drugs.
Simultaneously, emerging and epidemic-prone diseases have become a much larger menace under the unique conditions of the 21st century.
The international spread of disease, and the disruption it causes, have been greatly amplified in our highly mobile, interdependent, and interconnected world.
As just one obvious example, World Bank estimates of global economic losses during the first year of an influenza pandemic have ranged from US$800 billion to more than US$2 trillion, depending on the virulence of the virus.
After almost four years of intensive control efforts, the H5N1 avian influenza virus remains stubbornly present in birds in large parts of the world, including some countries in this region.
We do not know whether this virus will cause the next pandemic or not. But influenza pandemics are recurring events, and we are long overdue. We dare not let down our guard.
The struggle to promote healthy behaviours has also become more complex. The forces of globalization have democratized several lifestyle factors.
The food and beverage supply is globalized. Advertising and marketing, also for tobacco products, have a global reach.
Confronted by these trends, developing countries are losing two of their most important natural assets: healthy traditional diets, and healthy lifestyles.
In this part of the world, lifestyle changes join demographic trends to cause a dramatic rise in chronic diseases.
This new burden comes at a time when most countries are still struggling to bring infectious diseases under control
Health systems can often manage the intermittent emergencies caused by infectious diseases. The patient either survives or dies.
Health systems have a much more difficult time managing chronic conditions. For households, the costs of chronic care can be catastrophic.
Faced with this trend, the best strategy for public health is population-wide prevention.
Fortunately, chronic diseases are largely caused by a small number of shared risk factors: improper diet, inadequate physical activity, tobacco use, and excessive alcohol consumption.
We return, again, to that difficult struggle to change human behaviour.
On the third front – the struggle for attention and resources – the situation looks far more optimistic, especially at the international level.
Ladies and gentlemen,
In just the past decade, health has received unprecedented support from a growing number of partnerships, implementing agencies, foundations, and funding mechanisms.
Although there will always be unmet needs, health has never before received such attention, or enjoyed such wealth.
The Millennium Declaration and its Goals represent the most ambitious commitment ever made by the international community.
They tackle one of the biggest problems facing health development in this region: poverty.
The goals recognize that poverty has multiple, interacting causes, and they tackle these causes at their roots.
They champion the role of health as a key driver of socioeconomic progress.
The health sector has been arguing for this kind of recognition and intersectoral action since the Declaration of Alma-Ata, almost 30 years ago.
Like the Health for All movement, the Millennium Development Goals are all about social justice and fairness.
People should not be denied the opportunity to realize their human potential for unfair reasons, including those with economic or social causes. Again, we see the importance of this region’s commitment to poverty reduction, social justice, and universal access to essential care.
Ladies and gentlemen,
Returning to the situation in South-East Asia, I want to draw your attention to what I believe are three major concerns.
The first is financial protection for the poor.
Out-of-pocket expenditure is the main financing mechanism in most countries of this region. This region has some of the highest levels of out-of-pocket spending in the world.
The concern is obvious. If we want better health to work as a poverty reduction strategy, we cannot let the costs of health care drive impoverished households even deeper into poverty.
I know the need for more equitable health financing is fully recognized in your national health strategies.
This need is also increasingly recognized by the international aid community.
A country’s decision to abolish user fees, in the interest of equitable access, needs to be matched by a guarantee of long-term, predictable compensatory funds.
A second concern pertains to unfinished business. I am referring here to polio eradication.
The past 12 months have seen a revolution in the tools and tactics being used to finish the job of eradicating polio, once and for all, from South-East Asia.
The global eradication effort is already reaping the benefits of your re-invigorated efforts.
In Myanmar, the very rapid response to a new outbreak is saving hundreds of children from paralysis.
In India, western Uttar Pradesh has been the most entrenched reservoir of polio in history. In this area, no child has been paralysed by type 1 poliovirus for more than six months.
This progress has put us in the homestretch for polio eradication.
As a final area of concern, we are near the midpoint in the countdown to 2015, the year given so much significance by the Millennium Development Goals.
Malaria is a major problem in this part of the world, but you have good control strategies, and many countries are on track to meet the target.
South-East Asia has seen remarkable progress in improving detection and cure rates for tuberculosis.
The recent emergence of extensively drug-resistant tuberculosis is of great concern, as it could render this disease, once again, virtually untreatable.
Again, we must never let down our guard.
In many countries in this region, the HIV/AIDS epidemic remains largely confined to groups with high-risk behaviours. It would be extremely unwise to assume that this situation will remain stable.
The stakes are too high for such a gamble.
Countries in South-East Asia must get the upper hand on this disease, before it gets out of hand.
This region has long been considered a potential powder keg for explosive spread, partly because of high population density, but also because of the high prevalence of sexually transmitted diseases.
Worldwide, we are still running far behind this deadly, devastating epidemic. For every person placed on antiretroviral therapy, another six people will become newly infected within a year.
We must do a better job of prevention, and a better job of expanding access to treatment. Above all, we must do a better job in that age-old struggle to change human behaviours.
For this region, indicators suggest that achieving the goals for maternal and child health will be a major challenge.
Expanded childhood immunization, and implementation of the strategy for integrated management of childhood illness hold great promise for accelerated progress.
But too many babies are still dying within their first few weeks of life.
Globally, the numbers of maternal deaths have remained stubbornly high despite two decades of efforts.
To address this problem, the need for better health systems and service delivery is absolute.
We will not see a substantial reduction in maternal deaths until skilled birth attendants are present at more deliveries, and more women have access to emergency obstetric care.
Improved access to sexual and reproductive health services is a vital preventive strategy.
As I conclude, let me return, briefly, to those three classic struggles.
The conditions of this 21st century increasingly call for shared responsibility and global solidarity, especially when vulnerability to a threat is universal.
In our collective struggle to hold the microbial world at bay, we now have the greatly strengthened International Health Regulations, which came into force in June of this year.
The revised Regulations move away from the previous focus on passive barriers at national borders, to a strategy of pro-active risk management.
This strategy aims to detect an event early and stop it at source, before it has an opportunity to become an international threat.
The strategy greatly strengthens our collective security, and raises the preventive power of these Regulations to new heights.
We must never again allow a disease such as HIV/AIDS to slip through our surveillance and control networks.
In our struggle to change human behaviour, we have the Framework Convention for Tobacco Control. This Convention has become one of the most widely embraced treaties in the history of the United Nations.
This is preventive medicine, on a global scale, at its best.
Next year, the Commission on Social Determinants of Health will issue its report. This will be another powerful tool as we seek to address the complex social factors that influence health.
In our struggle for attention and resources, we have the Millennium Development Goals.
We have unprecedented momentum, political commitment, new partnerships, global initiatives, and funds from innovative sources.
This, in turn, has increased the responsibility on the health sector to use these resources and enthusiasm wisely, and in ways that have a maximum impact on health outcomes.
While the challenges in this most densely populated region are great, your leadership has the qualities that count the most: a commitment to fairness and social justice, and a determination to see that progress in health development reaches all segments of your vast populations.
I commend your courage, and wish you every success in this noble endeavour.