Address to the Regional Committee for South-East Asia (62nd Session)

Dr Margaret Chan
Director-General of the World Health Organization

Kathmandu, Nepal
8 September 2009

Mr Chairman, honourable ministers, distinguished delegates, Regional Director Dr Samlee, colleagues in the UN family, ladies and gentlemen,

I appreciate the determination that is demonstrated in the documents before this committee. You are building on the striking success of strategies for intensified measles control.

You are looking at practical ways to bring care provided in the private sector into better alignment with national strategic priorities, and into the fold of government regulation and quality control. You are doing so as a way to make governments more fully accountable for the health care provided in their countries. And you are doing so as part of a greater drive to reach universal health coverage, a tenet of primary health care.

You are addressing the need for an adequate and balanced distribution of competent and motivated health workers. Again, you are doing so as a contribution to the higher goal of ensuring equitable access to health services, a tenet of primary health care.

With support from collaborating centers in this region, you are training nurses and community health workers to manage many health problems, including acute respiratory disease. This is a smart move at the right time.

And we have another mark of your determination. This region now stands on the brink of success in the drive to eradicate polio. Only parts of two states in India, namely Uttar Pradesh and Bihar, remain endemic. Outbreaks in countries that were previously polio-free were stopped, and no new re-infections have occurred this year.

Type 1 polio, the most dangerous strain, is beginning to loosen its grip on the world’s most tenacious reservoir, in western regions of Uttar Pradesh. The quality of vaccination campaigns there is now second-to-none, and new tools are available to overcome the unique technical challenges in this area.

In Bihar, the other remaining reservoir of type 1 polio, operations must be further optimized in the very difficult Kosi river basin. Every child under the age of five years must be reached during every vaccination campaign. Special strategies to immunize children in migrant populations must be fully implemented.

Let me take this opportunity to thank the government of India for its steadfast political commitment to finish the job of polio eradication. And let me thank the Prime Minister for his recent decision to allocate extraordinary financial support to overcome these remaining challenges.

There is a second commitment equally apparent in the documents before this committee: this region’s strong commitment to a renewal of primary health care. This is a commitment not only to primary health care as an approach, but also as a set of social values and ethical principles.

Determination and commitment are greatly needed at a time of global economic recession, a climate that is changing for the worse, and an influenza pandemic that is now unstoppable.

Ladies and gentlemen,

The new H1N1 pandemic virus rapidly established itself and is now the dominant influenza strain. This pandemic will be with us for quite some months to come.

The virus reached this region somewhat later than elsewhere. Only a few countries, like India, Indonesia, and Thailand, are feeling the brunt of the pandemic, right now. But I can assure you: the pandemic will come to all of your countries, and this is not just the same as seasonal influenza.

The pandemic will test the world, in a vivid way, on the issue of fairness. I believe it will reveal, in a measurable and tragic way, the consequences of decades of failure to invest adequately in basic health systems and infrastructures. It will show what the failure to care about equity in international policies really means in life-and-death terms.

The same virus that causes manageable disruption in affluent countries can have a devastating impact on countries that lack diagnostic and laboratory capacity, have too few clinics and staff, have few facilities for intensive care, have frequent stock-outs of essential medicines, have poor infection control in health facilities, lack the safe water and basic sanitation needed for personal hygiene, and cannot regulate the sale of useless products to desperate people.

What will advice like “wash your hands” or “phone your doctor” or “rush to the emergency ward” mean for all these people?

I am not using scare tactics. WHO continues to assess the severity of the pandemic as moderate. The overwhelming majority of cases continue to experience mild illness and recover fully within a week, even without any medical treatment.

But this virus can kill and does so in a comparatively young age group. For seasonal influenza, around 90% of deaths occur in the elderly. For this pandemic, most deaths have occurred in people under the age of 50. Countries must be prepared for the added burden on health services.

Clinically, this is a virus of extremes. It does not seem to have a middle ground. At one extreme are the mild cases I have just described. At the other extreme is a small subset of patients who quickly develop very severe disease.

Though the numbers are small, the demands on health services are disproportionately high. Saving these lives depends on highly specialized intensive care, with highly specialized equipment and highly skilled staff. Again, we will see how different health care capacities in different countries can make a life-and-death difference.

At present, scientists and clinicians do not understand why some patients experience a much more severe clinical course, though research is under way. Some of these patients are young and healthy with no known risk factors.

But we do know, without question, that pregnant women face a higher risk of death during this pandemic. This increased risk takes on added importance for a virus, like this one, that preferentially infects younger people. This risk takes on even more importance in a region like this one, where maternal mortality is already way too high.

As I have said before, we are all in this pandemic together, and we must all get through this together. Rest assured of support from WHO and the broader humanitarian community.

Ladies and gentlemen,

Let me raise an obvious question. How do we position public health at a time of multiple global crises on multiple fronts?

More and more, experts and analysts in sectors with far more clout than public health are coming to terms with some failures in the international systems that govern the way this world works.

They have to. The financial crisis hit the world like a sudden jolt, and it hit the world where it hurts the most: money. Greed seeded the financial crisis, which sprang out of control as corporate governance and risk management failed at every level of the system.

Climate change is now the price we will inevitably pay for short-sighted policies. The pursuit of economic wealth took precedence over protection of the planet’s ecological health.

Too many international policies have worked in ways that favour those who are already well off. The international systems that govern financial markets, economies, commerce, trade, and foreign affairs have not operated with equity as an explicit goal. These systems create benefits, but have no rules that guarantee fair distribution of these benefits.

World leaders now recognize that blind faith in the power of market forces to solve all problems has been misplaced. Too many models for development assumed that living conditions and health status of the poor would somehow automatically improve as countries modernized, liberalized their trade, and improved their economies. This did not happen.

Greater market efficiency, it was long assumed, would work automatically to achieve greater equity in health. This did not happen. Instead, what we see, especially in this region, is an increasingly great divide between the quality of care in publicly-financed health services and that provided in the private sector, which keeps the wealthy healthier.

Fortunately, the old thinking and the old assumptions, so dramatically proved wrong by the financial crisis, are starting to change. At the April G20 summit in London, world leaders called for a fundamental re-engineering of the international systems.

They expressed the need to give these systems a moral dimension and make them responsive to the genuine values and concerns of societies. They spoke about critically missing values, like community, equity, and social justice.

This may be new thinking for world leaders, but the vocabulary is deeply familiar to public health, dating back, as it does, to the Declaration of Alma-Ata.

For once, the ironic twists of history turn in our favour. Thirty years ago, the potential of primary health care to revolutionize the way health care is delivered was cut short by an oil crisis, an economic recession, and the introduction of structural adjustment programmes.

Today, a financial crisis and severe economic recession have encouraged world leaders to seek the kind of value system that primary health care has always represented. Perhaps now, finally, as the world faces multiple crises on multiple fronts, our messages will have greater resonance.

Let me conclude by again expressing my appreciation for this region’s renewed commitment to primary health care. This is a proven way to promote fair and efficient health care and build sturdy resilience for the next global crisis that our imperfect world is certain to deliver.

Thank you.