Global health diplomacy: negotiating health in the 21st century
Dr Margaret Chan
Director-General of the World Health Organization
President Couchepin, excellencies, distinguished guests, colleagues in public health, ladies and gentlemen,
We are meeting at a time of crisis. We face a fuel crisis, a food crisis, a severe financial crisis, and a climate that has begun to change in ominous ways. All of these crises have global causes and global consequences. All have profound, and profoundly unfair, consequences for health.
Let me be very clear at the start. The health sector had no say when the policies responsible for these crises were made. But health bears the brunt.
For climate change, all the experts tell us: developing countries will be the first and hardest hit. The warming of the planet will be gradual, but the effects of more frequent extreme weather events will be abrupt and acutely felt.
We can already measure the costs to health of floods, tropical storms, drought, water scarcity, heat waves and air pollution in cities. We can already measure the costs when the international community is called upon to provide humanitarian assistance.
Climate change is by its very nature a global event. These calls for international assistance will become more frequent, and more intense, at a time when all countries are stressed by the pressures of climate change and the costs of adaptation.
According to the latest projections, Africa will be severely affected as early as 2020. This is just a dozen years away. By that date, increased water stress is expected to affect from 75 million to 250 million Africans. A dozen years from now, crop yields in some African countries are expected to drop by 50%. Imagine the impact on food security and malnutrition.
In many African countries, agriculture remains the principal economic activity, and agricultural products are the principal source of export trade. Vast rural populations survive, hand-to-mouth, on subsistence farming. There is no surplus. There is no coping capacity.
Imagine what the current crisis of soaring food prices means in developing countries, where the average household spends as much as 80% of disposable income on food. Again, there is no surplus, no coping capacity to absorb the shocks. More money for food means less money for health.
And there are other consequences. Food choices are highly sensitive to price increases. The first things to drop out of the diet are the healthy foods, which are nearly always the most expensive – like fruits and vegetables, and high quality sources of protein. The result: processed foods, full of fat and sugar and low in essential nutrients, become the cheapest way to fill a hungry stomach.
Have you ever watched a news report on malnutrition and noticed that the babies and children, with their vacant eyes and swollen bellies, are often attended by overweight adults? Well, here is the answer. The cheap foods that make adults fat starve children of absolutely essential nutrients. Children who do not receive protein and other nutrients during early development are damaged for the rest of their lives.
When the policies that govern the international production, trade, and distribution of food are driven by greed instead of by human nutrition needs, then we should not be surprised when the system generates a crisis of soaring food prices and a crisis of diet-related chronic diseases.
When something so fundamental to life as food is priced beyond the reach of the poor, we know that something in our world has gone terribly wrong.
No one can predict how the financial crisis will evolve. Will funding for health development run dry? Will our hard-won progress in health development be set back, as happened in some parts of the world following the emergence and spread of HIV/AIDS?
Ladies and gentlemen,
Last week, WHO issued its 2008 World Health Report. The report critically assessed the way that health care is organized, financed, and delivered in rich and poor countries around the world. It documents a number of failures and shortcomings that have left the health status of different populations, both within and between countries, dangerously out of balance.
The report found striking inequalities in health outcomes, in access to care, and in what people have to pay for care. Let me give some examples. Differences in life expectancy between the richest and poorest countries are now greater than 40 years.
Of the estimated 136 million women who will give birth this year, around 58 million will receive no medical assistance whatsoever during childbirth and the postpartum period, endangering their lives and that of their infants. Globally, annual government expenditure on health varies from as little as US$ 20 per person to well over US$ 6000.
For 5.6 billion people in low- and middle-income countries, more than half of all health care expenditure is through out-of-pocket payments. This is an extremely inefficient situation for health care. When people have to pay for care, they tend to wait until a condition is so far advanced that treatment is difficult, if not impossible, and the costs are much higher.
With the costs of health care rising and systems for financial protection in disarray, personal expenditures on health now push more than 100 million people below the poverty line each year.
This is a very bitter irony. At a time when the international community supports health as a key driver of economic progress and a route to poverty reduction, the costs of health care are themselves a cause of poverty for many millions of people.
Like the global crises we are experiencing, this reality flies in the face of steady progress and promising trends experienced since the start of this century. These trends and realities show us the two sides of globalization, a bright side and a very dark one.
Ladies and gentlemen,
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?
This is the bright side of globalization: a sense of solidarity and shared responsibility for health.
What about corporate social responsibility, the new philanthropy, the new trend of treating health as a foreign policy issue? What about the US$ 3 billion being made available by wealthy nations for the control of malaria, a disease they never see within their own borders?
What about the innovative new funding mechanisms, like the Global Fund, the GAVI Alliance, the Bill and Melinda Gates Foundation, or UNITAID, which uses funds from a levy on airline tickets to buy drugs for the poor?
This is the bright side of globalization: a deliberate effort to redistribute global wealth to meet the health needs of the poor.
But will this momentum and these commitments survive the current financial crisis? This is the dark side. And there are other shadows.
Under the influence of globalization, the landscape of public health has changed in profound and almost universal ways. All around the world, health problems are being shaped by the same powerful forces.
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.
The boundaries of sovereign nations are blurred. New diseases, like SARS, like avian influenza, are emerging at an historically unprecedented rate. No country acting alone can defend itself against a microscopic agent that invades by stealth, evades detection, kills civilians, and disrupts the economy.
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 or Internet, of unhealthy lifestyles, including diets, tobacco products and pharmaceuticals of questionable quality?
Rapid unplanned urbanization, the spread of unhealthy lifestyles, and the ageing of populations are now universal trends. Chronic diseases, long considered the companions of affluent societies, have changed places. Low- and middle-income countries now bear the greatest burden from these diseases.
Chronic diseases, like heart disease, cancer, diabetes, and mental disorders, raise concerns about the burden of long-term care on health systems and budgets. They raise concerns about the costs that drive households below the poverty line, and the need for prevention in a situation in which most risk factors lie outside the direct control of the health sector.
Differences between rich and poor countries are no longer so clear. 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 that drain health resources and strain the social welfare systems.
In terms of fair access to care, the “inverse care law”, first described in 1971, prevails. Well-off populations, who tend to be healthier, have the best access to the best care, while the poor are left to fend for themselves.
Inequities in access to health care and in health outcomes are usually the greatest in cases where health is treated as a commodity and care is driven by profits. The results are predictable: unnecessary tests and procedures, more frequent and longer hospital stays, higher overall costs, and exclusion of people who cannot pay.
And there is another serious problem: an almost total neglect of prevention. This comes at a time when WHO estimates that use of existing measures could prevent around 70% of the global disease burden.
Something is wrong.
Ladies and gentlemen, In August of this year, the WHO Commission on Social Determinants of Health issued its final report. The striking gaps in health outcomes are its main concern, and greater equity is the objective.
The report challenges governments to make equity an explicit policy objective in all government sectors. Political decisions ultimately determine how economies are managed, how societies are structured, and whether vulnerable and deprived groups receive social protection.
Gaps in health outcomes are not matters of fate. They are markers of policy failure.
The report contains a particularly striking statement that raised some eyebrows and caused some scepticism back in August. Let me quote. “Implementation of the Commission’s recommendations depends on changes in the functioning of the global economy.”
Since when has the health sector ever had the power to change the global economy? On the contrary, health has traditionally been at the mercy of the global economy, a sector where budgets can be cut when the money gets tight.
Shortly after the commission published its report, the Economist news magazine ran a review which praised the significance of the report’s arguments and recommendations. But, as the Economist observed, the report was largely “howling at the moon” when it attacked global imbalances in the distribution of power and money.
But let me ask you, how does this statement sound right now, with the global financial system on the verge of collapse? Is it not right for health and multiple other sectors to ask for some changes in the functioning of the global economy?
As I have mentioned, globalization has its bright and its dark sides. It brings benefits. It can increase wealth. And it inspires a sense of solidarity and shared responsibility for health.
But here is the problem: globalization has no rules that guarantee the fair or balanced distribution of benefits. As the commission noted, the economic benefits of globalization tend to go to countries and populations that are already well off, leaving others further and further behind.
Ladies and gentlemen,
I believe that our world is out of balance in matters of health as never before. This should not be the case. Health is the very foundation of economic productivity and prosperity. Balanced health status within a population contributes to social cohesion and stability. A prosperous and stable population is an asset in every country.
A world that is greatly out of balance in matters of health is neither stable nor secure. This world will not become a fair place for health all by itself. Economic developments within a country will not automatically protect the poor or guarantee universal access to health care.
Health systems will not automatically gravitate towards greater fairness and efficiency. International trade and economic agreements will not automatically consider the impact on health. Nor will globalization self regulate in ways that favour fairness in the distribution of benefits. Deliberate policy decisions are needed in all these areas.
I believe there is no sector better placed than health to insist on equity and social justice. Let me use just one example. The AIDS epidemic demonstrated the relevance of equity and universal access in an especially vivid way. With the advent of antiretroviral therapy, an ability to access medicines and services became equivalent to an ability to survive for many millions of people. AIDS helped make one point crystal clear: equity in health really is a matter of life or death.
No one should be denied access to life-saving or health-promoting interventions for unfair reasons, including those with economic or social causes. Equity in access to health care comes to the fore as a way of holding globalization accountable, of channelling globalization in ways that ensure a more fair distribution of benefits, a more balanced and healthy world.
Ladies and gentlemen,
Some things need to be said. The policies governing the international systems that link us all so closely together need to be more foresighted. They need to look beyond financial gains, benefits for trade, and economic growth for its own sake.
They need to be put to the true test. What impact do they have on poverty, misery, and ill health – in other words, the progress of a civilized world? Do they contribute to greater fairness in the distribution of benefits? Or are they leaving this world more and more out of balance, especially in matters of health?
Thirty years ago, the Declaration of Alma-Ata launched primary health care as the route to greater fairness in health. This year’s World Health Report calls for a renewal of primary health care.
The visionary thinkers in 1978 could not have foreseen subsequent world events: an oil crisis, a global recession, and the emergence of a world-transforming disease like HIV/AIDS.
In the recession that followed the launch of the Alma-Ata Declaration 30 years ago, huge mistakes were made in the restructuring of national budgets. Health throughout sub-Saharan Africa and in large parts of Latin America and Asia has still not recovered from these mistakes.
If history tends to repeat itself, can we not at least learn from the past and avoid repeating mistakes? There is too much at stake, right now, in our turbulent and tottering world, to make the same mistakes yet again.