Address to the Regional Committee for Europe (59th Session)

Dr Margaret Chan
Director-General of the World Health Organization

Copenhagen, Denmark
15 September 2009

Mr Chairman, honourable ministers, distinguished delegates, Dr Danzon, ladies and gentlemen,

Let me begin with an expression of appreciation to Dr Danzon and to this region for the many achievements during his leadership. These achievements moved on from a time when European countries were envied as a largely privileged group, with high standards of living, excellent population health, long life expectancies, and well-functioning health systems.

From this vantage point, the region expanded the health agenda to cover new frontiers. You pioneered work on health and the environment, the impact of urbanization on health, including mental health, the health needs of the elderly, and the role of healthy lifestyles as preventive medicine. You sounded the alarm about the rise of chronic diseases, and again, the need for prevention.

You laid the foundation for understanding the social determinants of health and tackling them through policies that valued social cohesion and protection as worthy political goals.

This turned out to be forward-looking work for the entire world. As we know, these issues are now among the top concerns for public health in every region of the world.

The health agenda for the region changed dramatically in the 1990s, as countries in Central and Eastern Europe underwent rapid political and economic transition. Old health problems resurged or became more apparent, especially when government health spending dropped.

What had previously been pockets of poverty, or pockets of problems, spanned entire countries. The close links between wealth and health came into even sharper focus.

Specific events, such as the resurgence of tuberculosis and the return of vaccine-preventable diseases, pointed to an alarming deterioration in basic health system capacity. The consequences of unhealthy behaviours became more acutely visible, again forcing a look at the social determinants of health.

The region responded to these disparities in a true spirit of solidarity. Privilege was interpreted as responsibility. Resources were made available for direct support to countries.

The agenda turned to weak health systems as a fundamental barrier to more equitable health outcomes, and tackled the need for reform. In so doing, health officials in this region took on what must be one of the most critically important and difficult challenges in public health today: health care reform. You did so with discipline and rigour.

In 1998, the European Observatory on Health Systems and Policies was established, with this regional office as a founding partner. The Observatory approached a sometimes elusive area of research and policy, extracted context-specific lessons and best practices, and made a long-standing problem look much more manageable. Standardized studies of health systems in transition brought the power of scientific evidence and analysis to bear on a fundamental cause of health disparities in Europe.

This was just one of the broad measures for improving health that Dr Danzon promoted as he moved the agenda forward, again to the benefit of international public health.

The WHO European Ministerial Conference on Health Systems and the resulting Tallinn Charter made the case that well-functioning health systems contribute to national wealth as well as health. The Charter pulled together many lines of thinking and debate into a coherent and sensible framework, with well-defined options for action.

Phrases such as “health in all policies”, “every minister is a health minister”, and “health is wealth” have entered the vocabulary of international health development. This has happened at a time when world leaders and ministers in other sectors have been primed, by crises, to listen very closely. This is quite a legacy.

Marc, it has been a great personal and professional pleasure to work with you. Under your leadership, the achievements of this region have again expanded the health agenda. This will hold the world in good stead as we seek to reach international health commitments, like the Millennium Development Goals, at a time of multiple global crises on multiple fronts.

As you in this region have noted, strong health systems are essential for weathering current and coming storms, like the economic downturn, climate change, the influenza pandemic, and the many other global crises that our imperfect world is certain to deliver.

Ladies and gentlemen,

Let me quote from one of your documents. “Health authorities across Europe are concerned that the present economic system does not distribute wealth on the basis of values of solidarity and equity, thus hindering improvement in health outcomes.”

Precisely. This is the heart of the problem. The report of the Commission on Social Determinants of Health, issued last August, includes one particularly striking statement. “Implementation of the Commission’s recommendations depends on changes in the functioning of the global economy.”

At the time, that statement raised some eyebrows. A review, published in The Economist magazine, praised the report’s ambitions but suggested that its attempt to correct global imbalances in the distribution of power and money was basically “howling at the moon”.

A month later, the financial crisis hit the world like a sudden jolt, and 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.

In a world characterized by radically increased interdependence among nations, mistakes made in one country or one sector are highly contagious. And the consequences are profoundly unfair. Developing countries have the greatest vulnerability and the least resilience. They are hit the hardest and take the longest to recover.

In a sense, the Millennium Development Goals are a corrective strategy. They aim to compensate for international policies and systems that create benefits, but have no rules that guarantee the fair distribution of these benefits.

The Goals and the many new initiatives and instruments for improving health are badly needed and doing great good. But they do not address the root causes of the great gaps in health outcomes. The root causes lie in flawed policies. This conclusion, I believe, is one of the most important outcomes of the Commission on Social Determinants of Health.

Some political analysts and academics are now predicting an end to the capitalist market model and point to signs that globalization is in retreat. We hear some sweeping conclusions: blind faith in the power of market forces to solve all problems has been misplaced.

World leaders struggling to re-position the management of their economies have been advised to look to Europe for guidance. A well-managed welfare state is not the enemy of globalization. Instead, some say it is the saviour.

As we know, the international policies and systems that govern financial markets, economies, commerce, trade, and foreign affairs have not operated with fairness as an explicit policy objective.

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.

Too many international systems have worked in ways that favour those who are already well off. In reality, gaps in health outcomes will be reduced, and health systems will strive for fairness only when equity is an explicit policy objective, also in sectors well beyond health.

Money makes the world go round. This will never change. But, as we have seen, market forces, all by themselves, will not solve social problems. The world needs to turn with a value system at its axis. We need this symmetry. If not, an already dangerous situation of vast imbalances, in income levels, in opportunities, and in health status, will only grow worse.

Leaders in sectors with far more clout than health are making a similar point . At the April G20 summit in London, world leaders called for a fundamental re-engineering of the international systems to incorporate a moral dimension and make them responsive to genuine social values and concerns. They voiced a need to invest these systems with values like community, solidarity, equity, and social justice.

While this is welcome new thinking for world leaders, this is a familiar vocabulary for public health, dating as far back as the Declaration of Alma-Ata.

For once, the ironic twists of history may turn in the favour of public health. The potential of the Declaration of Alma-Ata to revolutionize the delivery of health care was cut short by an oil crisis, an economic recession, and the introduction of structural adjustment programmes that reduced budgets for social services, including health care.

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 this time around, in a world jarred awake by crises, some long-standing arguments will finally be heard.

Ladies and gentlemen,

Public health had no say in the policies that seeded the financial crisis or set the stage for climate change. But public health has much to say about the influenza pandemic, how it is managed, and how its impact can be reduced.

This is one occasion when heads of state and ministers of finance, tourism, and trade will listen closely to ministers of health. This is one occasion where the need for “health in all policies” becomes readily apparent. This is one occasion when standard arguments about the need to build up fundamental health capacities in an inclusive way will ring true.

To date, we have been fortunate in the way the pandemic has evolved. The overwhelming majority of cases continue to experience mild symptoms and recover fully within a week, even without any medical treatment.

But clinically, this is a virus of extremes. It does not seem to have a middle ground. At one extreme are the mild cases. 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. In countries that lack such capacities, these lives will be at great danger.

Of course, this is true for a multitude of other diseases and health problems. Weak capacities cost lives. But this pandemic, I believe, will make the same old point in an especially visible and tragic manner.

I believe that this pandemic will be a watershed event. It is taking place at a time when differences, within and between countries, in income levels, in health status, and in levels of care, are greater than at any time in recent history. The pandemic will test the world on the issue of fairness in a substantial way.

The same virus that causes manageable disruption in affluent countries will almost certainly have a devastating impact in countries with too few health facilities and staff, no regular supplies of essential medicines, little diagnostic and laboratory capacity, and vast populations with no access to safe water and sanitation. For these populations, advice such as wash your hands, call your doctor, or rush to the emergency ward will mean very little.

Let me give just one precise example. We know, from all outbreak sites, that pregnant women are at increased risk of severe or fatal infections. Increased deaths of these women, because of the pandemic, will be tragic everywhere, but most especially so in the developing world, as the numbers will be so much greater.

Already, more than 99% of maternal mortality occurs in the developing world, where it is one of the strongest indicators of poorly functioning and inequitable health systems.

Since taking office, the health of women has been one of my priority concerns. A renewed commitment to primary health care underpins efforts to improve the health of women. This relationship is starkly evident in a report on Women and Health that I have commissioned. The report, which will be issued in November, explores the many health risks that women face throughout the life course, and sets out an agenda for change.

As this region has done with health systems, we need to make the agenda for women’s health look manageable, with clear policy options, and compelling arguments for more attention and greater investment based on solid evidence.

Ladies and gentlemen,

Let me conclude with another brief expression of appreciation.

Many of the countries represented in this room have played a leading role in the creation of new health initiatives for the developing world and in finding innovative ways to secure additional funds. You are also addressing the pressing need for more effective aid.

When privilege is interpreted as responsibility, we again see those values, like equity, solidarity, social cohesion and protection, that are at the heart of your contribution to better health, not only regionally but also internationally.

Thank you.