Address to the Regional Committee for the Eastern Mediterranean (56th session)

Dr Margaret Chan
Director-General of the World Health Organization

Fez, Morocco
5 October 2009

Your Royal Highness, Madam Chair, honourable ministers, distinguished delegates, Dr Gezairy, ladies and gentlemen,

Let me begin with a quote from Dr Gezairy’s report to this Committee. “It is essential that, in times of crisis, public spending on health and other forms of social security should not be cut, but rather increased.” I agree entirely.

Since I addressed this Committee last year, the world has entered the most severe economic downturn since the Great Depression began in 1929. The climate has changed for the worse, and new evidence indicates that the impact, also for health, has been seriously underestimated. In April of this year, the entirely new H1N1 influenza virus emerged. The world is in the midst of the first influenza pandemic of the 21st century, and further spread is now unstoppable.

In addition, the Commission on Social Determinants of Health published its final report. The World Health Report on primary health care was issued. New global initiatives, including innovative funding schemes, were launched to accelerate progress towards the Millennium Development Goals. And countries in this region unanimously adopted the Qatar Declaration on primary health care.

How should public health position itself in this cross-current of trends? From one side, prospects for better health are battered by global crises that introduce new threats to health, sometimes on a massive scale, and undermine financial support for health.

From another side, prospects for better health are bolstered by steadfast commitment and momentum. We should be strongly encouraged by this enduring commitment. This tells us that past thinking has indeed changed.

Health is not just a consumer of resources, a luxury that can be cut when times are bad, as has happened so often in the past. Instead, health is a producer of economic and social gains that must be preserved – at all times, at all costs.

Again, I agree entirely with your Regional Director. In times of crisis, individual governments and the international community need to redouble their efforts to preserve hard-won gains and persist in efforts to reach agreed goals, especially when greater equity and fairness are at the heart of these goals.

We have good reasons for making this argument. Because of these crises, the price of failure, especially for health, keeps getting higher. At a time of radically increased interdependence, a crisis in one country or one sector is highly contagious, moving rapidly from country to country, and from one sector to many others.

But though the consequences of this contagion are global, they are not evenly felt. Developing countries have the greatest vulnerability and the least resilience. They are the hardest hit and take the longest to recover.

While we can be glad for signs that commitment to health may weather at least some of these storms, we must also be realistic. Even when bolstered by great good will and the best intentions, public health must brace itself for some hard times ahead.

Health will suffer. The depth of the economic recession means that less money will inevitably be available for health, at household, national, and international levels. We see this already.

The health consequences of climate change will hit developing countries first and hardest. Countries with weak health systems will be least able to cope with the added shocks of more frequent and intense adverse weather events

The world population is universally susceptible to infection with the new H1N1 virus. But the consequences will be most severe in countries with weak health systems, inequitable access, and few financial resources to compete for limited supplies of vaccines and medicines.

Apart from these obvious crises, health everywhere is being shaped by the same powerful forces. Demographic ageing, rapid unplanned urbanization, and the globalization of unhealthy lifestyles are now universal trends.

Today, countries in this region face a triple burden of ill health. Infectious diseases persist. Chronic diseases are on the rise. And countries are seeing an explosive increase in accidents, injuries, violence, and mental disorders that are, so often, the dark side of modernization.

What all this means is more poverty, more ill health, greater strain on already overburdened health systems, most costs for health care, and even greater gaps in health outcomes. This is a bitter irony at a time when the international community is engaged in the most ambitious drive in history to reduce poverty and reduce the gaps in health outcomes.

Ladies and gentlemen,

In times of crisis, it is wise for public health to focus on what it does best: prevention. At a time of economic crisis, it is wise to seek greater efficiency, also for the long-term, by making preventive services as important as curative care. It is wise to seek ways to get services in the public and private sectors to work together in tandem, under the oversight of government, and with support from its regulatory bodies.

At a time when we are warned to expect more droughts, floods, storms, famine, water scarcity, and food shortages, it is wise to strengthen health systems in ways that give communities the resilience to withstand these added shocks. At a time when chronic diseases, often requiring costly life-long care, are on the rise, it is wise to attack the risk factors for these diseases as far upstream as possible.

These observations are fully supported by the documents before this committee. They tell us three main things.

First, they show the need for a whole-of-government approach to health in which health features in the policies of all sectors. Simply stated, the threats to health have become too big and too broad in their causes to be handled by the health sector alone.

The prevention of road traffic injuries and deaths is a widely multisectoral issue. The report on road traffic injuries spells out the need for a public health approach that puts the health sector in the lead. Otherwise, injuries, deaths, disabilities, and demands for trauma care are the price that public health pays for weak preventive policies in other sectors.

The same is true for tobacco control. The health sector can produce overwhelming evidence of the damage caused by tobacco use. The health sector can pay the very heavy price of a list of diseases that keeps getting longer.

But prevention, which is entirely feasible, depends on decisions and actions in sectors beyond the direct control of health. It depends on tax and trade policies, government regulation of prices and packages, bans on advertising, and bans on smoking in public places.

A second clear message is this: weak health systems remain one of the biggest obstacles to better health. At a time of global health initiatives, we have learned that powerful interventions and the money to purchase them will not bring better health outcomes in the absence of efficient systems for delivery. We need both approaches.

The importance of health systems is readily apparent in your documents. The response to hepatitis B and C infections, cancer prevention and control, the improvement of hospital performance, and reductions in the incidence of multi-drug resistant tuberculosis – all of these issues are essentially health systems issues. In this region, many hepatitis B and C infections are acquired in the health care setting, putting the focus on the need for infection control, injection safety, and blood safety programmes.

The agenda for cancer prevention and control too often focuses on specialized curative care for the privileged few, neglecting the importance of prevention and the need for equitable access to all cancer-related services, from screening and early detection to palliative care.

The item on improving hospital performance stresses the need to manage hospitals, and the costs and quality of their services, as part of the wider health system. The creation of a culture of cost analysis and containment in the hospital sector will benefit the wider health system as well.

The emergence of drug-resistant tuberculosis is a failure not just of the TB control programme, but of the entire health system in which that programme operates. Countries will not be able to prevent and manage drug-resistant TB in the absence of a well-functioning health system.

Equally of concern, drug-resistant TB creates enormous additional demands and pressures on components of health systems that are already weak. In other words, drug-resistant TB severely strains and erodes the very capacities needed to prevent it in the first place.

A third message is equally clear. Primary health care is the right way forward. I warmly commend this region for last year’s Qatar Declaration on health and well-being through health systems based on primary health care.

Last year’s report of the Commission on Social Determinants of Health concluded that health systems organized to achieve universal coverage do the most to improve health outcomes. The Commission endorsed primary health care as a model for a system that deliberately aims for equity, but also acts on the underlying social, economic, and political causes of ill health.

Primary health care provides an operational framework for enfranchising communities, giving them a voice, and aligning care with their needs and aspirations. Health systems are social institutions. Properly managed and financed, they contribute to social cohesion and stability. These are assets for any country, for any region.

Primary health care also provides a framework of values and principles for attacking a host of worrisome problems, rationally, fairly, and in a cost-effective way. We need to think about these problems from a primary health care perspective, at a time when a global economic recession forces a hard look at efficiency as well as equity.

As we all know, weak health systems are wasteful. They waste money, and dilute the return on investments in health. They waste money when regulatory systems fail to control the price and quality of medicines, or the cost of services provided in the private sector. They waste health when an emphasis on curative services leaves preventive care by the wayside. They waste training when health workers are lured away by better working conditions or better pay.

They waste efficiency when needless procedures are performed, or when essential procedures are precluded by interruptions in the supply chain. They waste opportunities for poverty reduction when poor people are driven even deeper into poverty by the costs of care or by the failure of preventive services.

Above all, weak health systems waste lives.

This is where we must argue especially hard for continued focus and support. The strengthening of health systems has risen high on the health development agenda, and it must stay there. I believe the influenza pandemic will make this need clear in a visible, measurable, and tragic way.

At a time of multiple crises, it is also wise to reduce existing disease burdens, thus freeing resources and capacities. Disease eradication is the ultimate form of sustainable progress.

For polio eradication, this region faces challenging conditions in two countries, Afghanistan and Pakistan, that have never stopped polio, and in a third country, Sudan, which is now chronically re-infected.

In responding to these challenges, the region is fortunate to have the full commitment and tireless leadership of Dr Gezairy. As you will be hearing, I have established an independent evaluation team to obtain a better understanding of the remaining barriers to polio eradication. Recommendations from this evaluation, which are now being finalized, will map out refined strategies for interrupting transmission once and for all.

As Dr Gezairy states in his annual report, the response to polio has been aided by a very good surveillance system. This system will hold you in good stead as the influenza pandemic takes hold in the region.

Ladies and gentlemen,

To date, we have been fortunate in the way the influenza pandemic has evolved. Outbreaks initially spread in countries with good surveillance and reporting systems. Data have been quickly generated and shared. Parts of the world are now entering a second wave of spread with a reasonably good body of knowledge and experience.

The overall picture remains largely reassuring. The overwhelming majority of cases continue to experience mild illness and recover fully within a week, even without any form of medical treatment. We have no signs, at either the epidemiological or the virological level, that the virus has mutated to a more virulent form. Despite the administration of many millions of doses of the antiviral drug, oseltamivir, fewer than 30 instances of drug-resistant virus have been detected worldwide.

But the pandemic does have some features that cause concern. The virus affects a much younger age group, and it kills in a much younger age group. During epidemics of seasonal influenza, around 90% of severe and fatal cases occur in the frail elderly. In this pandemic, deaths in people over the age of 50 are comparatively rare.

In a small subset of patients, the new virus causes very severe illness, characterized by primary viral pneumonia and very rapid clinical deterioration. Patients can go from normal respiratory function to multi-organ failure within 24 hours. Saving these lives depends on rapid access to highly specialized treatment in highly specialized facilities, which are rarely found in the developing world.

We also know, from all outbreak sites, that pregnant women are at increased risk of severe or fatal infections. This increased risk takes on added significance for a virus, like this one, that preferentially infects a younger age group.

In terms of our response capacity, the international community can be thanked for its foresight in thoroughly revising and strengthening the International Health Regulations. The pandemic is the first major test of the revised regulations. They have given countries an orderly rules-based way to act collectively, and we are reaping the benefits.

Led by the US, nine countries are donating a portion of their pandemic vaccine supplies to developing countries. Industry is also donating millions of vaccine doses. The first donated supplies of the antiviral drug, oseltamivir, have already reached 121 countries.

Ladies and gentlemen,

As we know from the past, the emergence of a new infectious disease is one occasion when ministers of health receive the attention they deserve, from heads of state as well as other sectors of government. The response to this influenza pandemic is largely in our hands.

This is an opportunity to repeat some age-old arguments about the importance of fairness in access to health care and interventions, and the vital need for well-functioning health systems.

The pandemic is spreading in a world where differences in income levels, in access to health care, in resources for health, and in health outcomes, are greater than at any time in recent history. Crises, like the economic downturn and climate change, threaten to make these differences even greater. The pandemic will test this world on the issue of fairness in a significant way. Let us all hope that the solidarity we are seeing, right now, will continue to grow in this and many other areas that mean so much for our common humanity.

Thank you.