Address to the Regional Committee for the Eastern Mediterranean
Dr Margaret Chan
Director-General of the World Health Organization
Mr Chairman, his royal highness Abdulaziz Bin Ahmed Al Saud, honourable ministers, distinguished delegates, Dr Gezairy, ladies and gentlemen,
This is the sixth Regional Committee I have attended. I have been in office for almost ten months.
In my visits to countries, in my discussions with health ministers, I have been impressed by the commonality of health problems in all regions.
Public health around the world is engaged in basically the same struggles on three fronts.
First, we struggle against the constantly evolving microbial world.
Second, we struggle to change human behaviour.
Third, we struggle for attention and resources.
This is nothing new, of course. But events in just the past decade have made each of these struggles far more complex and challenging.
All around the world, health is being shaped by the same powerful forces. Some of these forces create new threats or make existing problems more ominous.
Others are causing present gaps in health outcomes to grow even wider, both within countries and between them.
No one questions the close links between income levels and health.
We all know the problem. Globalization creates wealth, and this is good. But globalization has no rules that guarantee fair distribution of this wealth.
I believe that, in matters of health, the world is out of balance as never before. Life expectancy can differ by as much as 40 years between the richest and the poorest countries.
Never before has medicine possessed such a sophisticated arsenal of tools and technologies for curing diseases and prolonging life.
Yet each year, more than 10 million young children and pregnant women continue to have their lives cut short by conditions that are largely preventable.
In the midst of our collective wealth, it should not be so difficult for a pregnant women to stay alive. It should not be so difficult for a baby to survive.
As we all know, this world will not become a fair place for human development all by itself. I believe there is no sector better placed than health to insist on greater equity and social justice.
The argument is easily expressed. No one should be denied access to life-saving or health-promoting interventions for unfair reasons, including those with economic or social causes.
For health, inequalities really are a matter of life and death.
This is one reason why I am such a strong supporter of this region’s initiative for meeting basic development needs.
This is a poverty alleviation strategy closely aligned with the values, principles, and approaches of primary health care.
Since 1988, experiences in this region have shown how community-based initiatives, supported by a multisectoral approach, can tackle the fundamental determinants of health on multiple fronts.
Evidence further demonstrates that, when women are given an opportunity to develop their potential, health indicators rapidly improve for households and communities.
Let me quote from a recent paper, published last year in the British Medial journal and authored by staff from this Regional Office.
“Women are often the key to improving a population’s health, and this is especially true in the Eastern Mediterranean region. Projects that empower women and provide basic needs are transforming poor communities.”
I could not agree more. I have seen the results first-hand during a visit earlier this year to Afghanistan and Pakistan.
I was greatly encouraged to learn that these programmes are now reaching close to 3 million people in more than 250 communities.
Abundant evidence shows that health policies that promote equitable access to services, and equitable health outcomes, bring economic and social benefits.
Health is a foundation for prosperity. Pro-poor health policies contribute to stability. A prosperous and stable region serves the interests of all countries.
Ladies and gentlemen,
Let us look more closely at these three struggles, and at the factors that have increased the complexity of challenges facing public health.
Changes in the way humanity inhabits the planet have disrupted the delicate equilibrium of the microbial world. As a result, new diseases are emerging at an historically unprecedented rate.
Old diseases are resurging or moving to new continents, as seen in this region with Rift Valley fever.
SARS taught us many lessons. Here is one. The unique conditions of the 21st century have amplified the invasive and disruptive power of new diseases, and increased their economic costs.
Any city with an international airport is at risk. The world has lived under the looming threat of an influenza pandemic for four years. This region has experienced recurring outbreaks of H5N1 avian influenza in poultry and some human cases.
Despite heroic efforts on several continents, we have not been able to eliminate this virus from bird populations.
We do not know if the next influenza pandemic will be caused by H5N1 or another virus. But we do know that influenza pandemics are recurring events. We dare not let down our guard.
Our struggle to change human behaviours has also become more difficult. Global communications, through satellite television and the internet, contribute to lifestyle changes, and these speed the rise of chronic diseases.
Urbanization is a global trend. The move of workers from agriculture to the service sector is a global trend. Lifestyles are increasingly sedentary.
The food supply is globalized, as are its distribution channels. Energy-dense foods are cheap, convenient, and increasingly available, especially in urban settings. They are also extensively advertised.
These trends have had ominous results for health.
Chronic diseases, long considered the companions of affluent countries, have changed places. These diseases now impose their greatest burden on low- and middle-income countries.
This region is rightly concerned.
In our struggle for attention and resources, we have great reason for optimism. In just the past decade, health has received unprecedented attention as a poverty-reduction strategy and a fruitful arena for foreign diplomacy.
The number of innovative funding mechanisms continues to grow, as does the size of resources they command.
But here, too, we see added complexity. The proliferation of partnerships has created problems. Partnerships can impose enormous demands on recipient countries. Efforts may be duplicated.
Projects may not align with country priorities and capacities. Single-disease initiatives can draw staff away from the provision of comprehensive care.
Transaction costs are high. Lines of accountability are blurred. Aid can be fragmented, unpredictable and even fickle, shifting as donor interests change.
Ladies and gentlemen,
Increasingly, health has international dimensions.
Increasingly, countries are vulnerable to the same shared threats that cannot be addressed by any single country acting on its own.
Increasingly, the protection of public health benefits from international instruments and commitments, especially when these promote greater fairness in access to essential care, or protect populations from universal threats.
Within countries, the underlying causes of ill health increasingly lie outside the direct responsibility of the health sector. This demands that multiple sectors work together, giving priority to health concerns.
I doubt that anyone in this room would question the need to give health issues priority at the highest level of government.
Here is another problem. More attention to health means closer scrutiny. More resources come with an expectation of results.
We are at the midpoint in the countdown to 2015, the year given so much significance by the Millennium Declaration and its goals.
Here is the reality. Off all the goals, those pertaining to health are least likely to be met.
Globally, the goals set for reducing maternal and child mortality pose the greatest challenge. This should come as no great surprise, given the many determinants of these deaths in multiple sectors.
Almost 99% of these deaths occur in low and middle-income countries. To reduce these deaths, broad social determinants must be addressed.
To reduce these deaths, the need for a well-functioning health system, able to reach the poor, is absolute.
Ladies and gentlemen,
Let us use this international perspective to look at some of the problems facing this region and, more specifically, at some of the items before this committee.
In the midst of all this complexity, we see some opportunities to simplify.
Neglected tropical diseases, so strongly associated with extreme poverty, frequently overlap geographically, opening opportunities for integrated approaches.
The vast majority of deaths in young children can be attributed to just four diseases, amplified by malnutrition. Again, this opens the opportunity for an integrated approach.
Most chronic diseases are caused by a limited number of shared risk factors linked to human behaviours. This opens opportunities for comprehensive preventive policies.
As set out in documentation before this committee, regional health policy is taking advantage of each of these opportunities to improve operational efficiency.
The technical paper on the neglected tropical diseases makes it clear. Integration of control interventions for several related diseases is technically feasible, operationally efficient, and economically rewarding.
These diseases affect the poorest of the poor, usually hidden in remote areas and with little political voice. I want to commend countries in this region for tackling these diseases with such commitment.
In particular, great strides have been made in the elimination of lymphatic filariasis in some countries, and in the provision of de-worming tablets to schoolchildren.
Because of the huge numbers of people affected, efforts to eliminate or control these diseases are a poverty-reduction strategy on a grand scale.
On a second front, this region has adopted the strategy for integrated management of childhood illness as primary health care for children. Some 17 countries are at various stages of implementing the strategy.
Rigorous evaluation, conducted in the region, has clearly shown an improvement in the quality of health services being delivered to children when this approach is implemented.
Evidence has great strategic and persuasive power, especially when it comes to moving an initiative to national scale.
The Islamic Republic of Iran, Egypt, and Djibouti are approaching national coverage, using trained personnel to deliver the packaged interventions.
The region has a strong foundation for expanding the scope of this strategy to address newborn survival and healthy growth and development.
You have a paper before you on neonatal mortality, which also rightly addresses the health needs of mothers.
Regional rates of exclusive breastfeeding are unacceptably low. More than 40% of pregnant women are anaemic. Only around half of deliveries benefit from a skilled birth attendant.
Many countries in this region have made great strides forward in improving female literacy. Similar improvements are needed for female health literacy.
Women need better nutrition, skilled attendants at birth, and access to emergency clinical care for themselves and their infants.
But they also need better information about the numerous things that can be done, in households and communities, to protect themselves and their babies.
This brings me back to my enthusiasm for this region’s efforts to meet basic development needs.
On a third front, several countries in this region are experiencing a dramatic rise in chronic diseases, including diabetes and other conditions linked to obesity.
You have before you a paper on food marketing to children and adolescents. It draws attention to the scale and complexity of the problem, and the urgent need for strong preventive measures at the highest policy level.
The document is clear. Public health has a leadership role to play when advocating for comprehensive preventive actions. Public health must be an explicit objective when food marketing policies are set.
As countries experience a rise in chronic diseases, it is extremely important that they also find ways to make essential medicines more affordable and accessible.
You have before you another excellent paper outlining options for the procurement of drugs that are safe and effective, but also more affordable.
Ladies and gentlemen,
We cannot address health conditions in this region without looking at another set of factors that challenge public health. I am referring to natural disasters, civil strife, and complex emergencies. Such events can stop the development process, disrupt basic services, and concentrate efforts on emergency responses. Extended crises have the power to set back development gains achieved during decades of hard work.
WHO remains constantly attentive to health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan.
WHO remains alert to data indicating a deterioration in health status, and continues to provide support for the continuity of health services.
The Secretariat’s report to this year’s Health Assembly drew attention to several specific health concerns during a difficult year.
Iraq is experiencing a large cholera outbreak, with indications of limited spread to at least one neighbouring country. Fortunately, prompt emergency action by the ministry of health, with WHO support, has kept the case-fatality low.
Security concerns in some areas jeopardize the success of global health initiatives. This region is home to two of only four countries where polio remains endemic.
As I speak, Somalia has now been free of transmission for more than six months. This is a milestone. This region is now the first to have stopped all the outbreaks that followed international spread of the virus from 2003–2006.
This demonstrates the tremendous commitment of member states, under the Regional Director’s leadership.
In this region, the biggest remaining challenge is to reach children in the rugged and restive area along the Pakistani-Afghan border where the virus remains endemic.
Last month, the Taliban Shura announced the full participation of Taliban-controlled areas in polio immunization campaigns.
This gave the September polio campaign access to almost 100,000 children who had been missed for more than two years.
I also want to thank this region, and its Director, for technical support to Nigeria. You have also used prominent religious scholars to combat rumours about vaccination safety. I thank Dr Gezairy for this support.
Conflict and instability impair the achievement of a second international goal: the eradication of guinea worm disease.
During 2006, southern Sudan accounted for 82% of the total remaining cases of guinea worm disease. Most experts agree that the successful eradication of this disease will not be possible until lasting peace is achieved in southern Sudan.
The health consequences of civil strife in southern Sudan are, of course, much broader than a single disease.
WHO has responded with massive and sustained support, from this regional office and from staff at the country office and sub-offices.
This support aims to keep an already tragic situation from causing even more human misery.
To prevent outbreaks, an efficient early warning system, extending routine surveillance to more than two million people, is functioning well to guard against potentially explosive outbreaks in camps.
Early warning systems such as this one become all the more important as we move towards full implementation of the revised International Health Regulation.
Ladies and gentlemen,
Let us return again to the international level. As I have said, health increasingly has international dimensions. In each of our common struggles, we are now aided by powerful international instruments and commitments.
These are expressions of our shared vulnerability, our common humanity, and our mutual responsibility in matters of health. Each is a call for collective action.
The greatly strengthened International Health Regulations 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 event.
This 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 networks for surveillance and early containment.
In our struggle to change human behaviour, we also have a powerful international instrument.
The Framework Convention on Tobacco Control 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 Declaration and its Goals. They represent the most ambitious commitment ever made by the international community.
These goals have at least three major implications for health at the policy level.
First, they attack the root causes of poverty, and recognize that these causes – in multiple sectors – interact. Like the Declaration of Alma-Ata, they call for a multisectoral approach.
Second, they champion health as a key driver of socioeconomic development. This elevates the status of health.
Health is no longer a mere consumer of resources. It is also a producer of economic gains.
Third, by making health a poverty reduction strategy, they give clear direction to international policy.
For example, if we want health to reduce poverty, we cannot allow the costs of health care to drive impoverished families even deeper into poverty.
This has implications for health financing. In this region, as elsewhere, the rise of chronic diseases and the costs of continuing care can have catastrophic consequences for the poor.
As a second example, if we want health to work as a poverty-reduction strategy, we must reach the poor.
This is where we fail. The power of existing interventions is not matched by the power of delivery systems to reach those in greatest need, on an adequate scale, in time.
This is why I have called for a return to the values, principles, and approaches of primary health care.
This is why, once again, I am such a strong supporter of this region’s initiative for meeting basic development needs.
Ladies and gentlemen,
There is one additional trend at the global level with important consequences for health, and this trend may turn out to be the most challenging of them all.
I am referring to climate change.
The science is now overwhelming. The effects of climate change are already being felt.
Even if greenhouse gas emissions were to stop today, the changes we are already seeing will progress throughout this century.
The emphasis now is on the ability of our human species to adapt to changes that have now become inevitable.
The warming of the planet will be gradual, but the increasing frequency and severity of extreme weather events – intense storms, heat waves, droughts, and floods – will be abrupt and the consequences will be acutely felt.
Just as we fought so long to secure a high profile for health on the development agenda, we must now fight to place health issues at the centre of the climate agenda.
We have compelling reasons for doing so.
Climate change will affect, in profoundly adverse ways, some of the most fundamental determinants of health: food, air, water. Developing countries will be the first and hardest hit.
Several countries in this region already face severe shortages of fresh water. Predicted changes in rainfall patterns are expected to make this situation worse.
Scientists further tell us that certain areas, including the Nile Delta and the Gulf coast of the Arabian peninsula, are vulnerable to floods from rising sea levels. Those countries with strong health infrastructures will be best able to cope.
This is, I believe, one more compelling reason why we must reach the Millennium Development Goals, on time, and in full.