Power of public health lies in strong health systems

Dr Margaret Chan
Director-General of the World Health Organization

Closing remarks at 62nd World Health Assembly
Geneva, Switzerland
22 May 2009

Mister President, honourable ministers, excellencies, distinguished delegates, ladies and gentlemen,

I believe we can all agree. This has been an exceptionally intense session of the Health Assembly.

You have covered much ground, made some key decisions, and adopted important resolutions, in a budget year, and in a timeframe cut in half.

You covered items on pandemic influenza preparedness and implementation of the International Health Regulations. You did so as an attentive world watched nervously to see whether a capricious new virus would deliver some more surprises.

You gave the world a strong signal of enduring commitment to health programmes and national capacities that we need on a day-to-day basis, as well as during emergencies.

Items, such as the ones on blindness and drug-resistant forms of tuberculosis, remind us of the power of public health, and of partnerships, to prevent, treat, and cure.

But they also reinforce a reality we know very well. The power of public health and all our best interventions is blunted when health systems are weak.

As some delegates noted, the strength of a country’s health system will make the biggest difference in sickness and survival during an influenza pandemic.

Let me congratulate you for completing your work under the item on public health, innovation and intellectual property. You have found some elegant ways forward after many years, and many intense hours of negotiation, consensus building, and compromise.

The same is true for the Intergovernmental Meeting on the sharing of influenza viruses and access to vaccines and other benefits. You have found some elegant ways forward, and I thank you.

Much discussion focused on items devoted to the health-related Millennium Development Goals, primary health care, and the findings of the Commission on Social Determinants of Health. Your discussions showed a profound understanding of how these “big three” instruments for greater equity are interlinked and mutually supportive.

You also argued that the three, working together and supported by appropriate policies, will give countries and communities the resilience needed to cope with the “big three” global crises: the financial crisis, the prospect of an influenza pandemic, and climate change.

Though chronic diseases are not among the Millennium Development Goals, your concerns were very clear. Prevention and treatment are best managed through a primary health care approach. A whole-of-government approach to health, as advocated by the Commission, is the best way to tackle, upstream, the root causes of these diseases.

Whole-of-government policies that explicitly strive for fairness, fairness in opportunities, fairness in access to health care, and fairness in social protection, contribute to social cohesion and stability. They are not the enemies of globalization. Instead, they are its saviour.

Ladies and gentlemen,

During the high-level consultation on pandemic influenza, several delegations called on WHO to consider criteria other than geographical spread when evaluating the phases of influenza pandemic alert.

I have listened closely to your concerns. Phases 5 and 6 are virtually identical in terms of the actions they launch. Intensified preparedness measures, also by industry, are already fully under way.

When we moved to phase 5, I asked all countries to activate their pandemic preparedness plans, and most have done so.

But even the best-laid plans need to be fluid and flexible when a new virus emerges and starts changing the rules. We were expecting, and fearing, that the highly lethal H5N1 avian virus would spark the next pandemic. As the Egyptian delegation reminded us, this avian virus remains very much a threat.

But our most pressing concern is with the new H1N1 virus.

For the first time in history, we are watching the conditions conducive for the start of a pandemic unfold before our eyes. On the one hand, this gives us an unprecedented opportunity. The world is alert and on guard as never before.

On the other hand, this gives us a dilemma. Scientists, clinicians, and epidemiologists are capturing abundant signals. But we do not have the scientific knowledge to interpret these signals with certainty. We have clues, many clues, but very few firm conclusions.

As I said, preparedness measures on multiple levels have already been launched. In these matters, we cannot go any higher.

Let me set out, on the basis of current knowledge, what we might expect to see in the coming weeks and months.

First, this is a very contagious virus. We expect it to continue to spread to new countries and continue to spread within countries already affected. Here, we have little doubt.

Second, this is a subtle, sneaky virus. It does not announce its presence or arrival in a new country with a sudden explosion of patients seeking medical care or requiring hospitalization. In fact, most countries need a sudden explosion of laboratory testing to detect its presence and follow its tracks.

This creates yet another dilemma. We can all be grateful to the many countries that have engaged in rigorous detection and investigation, and rigorous studies of clinical cases, especially those requiring hospitalization.

These efforts contribute to our understanding of the virus, its patterns of spread, and the spectrum of sickness it can cause. But these efforts are disruptive and extremely resource intensive. How long can they be sustained? You have heard this question from several delegations during the high-level consultation.

The answer depends on the situation, the capacities, and the risks in each individual country, and even in different areas within a country. WHO cannot, at this point, solve the dilemma through universal guidance. Countries should adjust their responses in line with the changing patterns of disease.

We are in the early days and do not know enough to make sweeping recommendations.

Third, up to now, the new virus has largely circulated in the Northern Hemisphere, where epidemics of seasonal influenza should be winding down.

We need to watch the behaviour of H1N1 very carefully as it encounters other influenza viruses circulating during the winter season in the Southern Hemisphere. The current winter season gives influenza viruses an opportunity to inter-mingle and possibly exchange their genetic material in unpredictable ways.

Fourth, in cases where the H1N1 virus is widespread and circulating within the general community, countries must expect to see more cases of severe and fatal infections. We do not, at present, expect this to be a sudden and dramatic jump in severe illnesses and deaths.

But countries, especially in the developing world, where populations are most vulnerable, should prepare to see more than the present small number of severe cases, which are being picked up under the best detection and testing conditions possible.

Ladies and gentlemen,

The decision to declare an influenza pandemic is a responsibility, and a duty, that I take very, very seriously.

I will consider all the scientific information available. I will be advised by the Emergency Committee, established in compliance with the International Health Regulations.

But I will also consider the fact that science finds its application and its value in serving people. And in serving people, we need their confidence, their comprehension, and their trust.

Thank you.