Report to the Executive Board, 124th session
Dr Margaret Chan
Director-General of the World Health Organization
Mister Chairman, members of the Executive Board, excellencies, ladies and gentlemen,
Let me welcome two new colleagues: Michel Sidibe, who was appointed as Executive Director of UNAIDS in December 2008, and Dr Chris Wild, who was appointed as Director of IARC in January 2009.
When I took office two years ago, I established a new cluster devoted to health action in crises. I did so based on projections that the number of humanitarian crises, whether caused by natural disasters or by conflict, would continue to increase, with many requiring international assistance.
Climate change and preparedness for an influenza pandemic are items on your agenda. Both events will cause global humanitarian crises. The health effects of more frequent and more severe extreme weather events are already being felt. Influenza pandemics are historically recurring events. We are wise to prepare.
On World Health Day this year, we will be looking at ways to ensure that hospitals and health care facilities survive, structurally and functionally, in times of natural disasters and conflict. This is another part of preparedness.
We are also seeing health crises that should not have happened. I am referring to the recent cholera outbreak in the Democratic Republic of the Congo and the ongoing cholera outbreak in Zimbabwe. In Zimbabwe, we have seen more than 40 000 cases. The death toll passed 2000 last week. The case-fatality rate exceeds 5%.
Cholera outbreaks on such a scale and with such high mortality should not happen in this day and age. They are the tell-tale symptom of public health services on the verge of collapse. They remind us, once again, that we are right to make the strengthening of health systems an urgent priority.
The protection of health during conflicts brings an additional set of challenges. I have a duty to draw your attention to the humanitarian crisis in Gaza.
It is not my intention to make a political statement. We are all grateful to the many world leaders who have joined the UN Secretary-General in pressing for an immediate end to hostilities. We all welcome the news of a ceasefire, announced this weekend.
But we know that this is a fragile truce, dependent on many conditions in a highly volatile situation. This is a pendulum of violence that swings to both sides.
The bloodshed, trauma, misery, and tears will end only when enduring ways are found to silence the guns and stop the rockets.
As public health professionals, we need to be deeply concerned about the health of Gaza’s civilian population. This is one of the most densely populated areas in the world. Civilians have been locked into a combat zone, in the line of fire, with no place to flee and no safe haven. The toll has been heavy.
The 1.5 million people of Gaza are served by a mere 2000 hospital beds. These facilities have been completely overwhelmed by the emergency needs of the wounded. Medical staff, including surgical teams, are exhausted.
This experience has shown the absolute need for safe corridors to evacuate the severely wounded. We have seen the absolute need to protect civilians, but also to ensure the safety of health workers, hospitals, ambulances and supplies for humanitarian relief.
While we welcome the ceasefire, many severe health problems remain. Again, the health sector is grateful to world leaders who are, right now, planning ways to step up humanitarian aid.
Border crossings must be opened more frequently to allow delivery of emergency medical supplies, which WHO is coordinating together with the health ministry and other UN agencies.
The wounded, who number in the thousands, continue to need care. Many civilian infrastructures, including hospitals and primary care clinics, have been badly damaged or destroyed.
The health of people with chronic conditions, like cancer, heart disease, and diabetes, depends on the rapid restoration of health services and supplies. Pregnant women need care, and they need a hospital bed for safe delivery.
Right now, we very sadly see ideal conditions for outbreaks of disease. Densely packed and displaced populations are weakened by hunger, little power for cooking and heating, and severe psychological trauma. Drinking water is scarce, sewage lines have been broken, and garbage is piling up.
Immunization, along with most routine health services, has been interrupted for more than three weeks. An outbreak under such conditions would be another health crisis that should not happen.
WHO will step up its assistance as soon as access and security clearances are granted. I join many others in expressing my gratitude for the ceasefire and my fervent wish that peace can be maintained.
Ladies and gentlemen,
Outbreaks, disasters, and conflicts remind us of the primary purpose of public health: to protect populations from harm, whether arising from the microbial world, human behaviours, or the environment.
We do this under the spotlight when an emergency occurs. But we also do this every day in a quieter way that is barely noticed until we fail, for one reason or another, to protect health from harm.
In many ways, the items before this Board take us back to the basics of public health. Prevention is the heart of public health. Equity is the soul. The documents before you remind us of these principles over and over again.
But they do so with a distinctly 21st century slant. Traditional differences between the health needs of wealthy and developing countries have become blurred. Many health problems today have global causes and a global sweep. Some pose a global threat, endangering our collective security. Most depend for their solution on global solidarity.
As the World Health Report on primary health care notes, health problems all around the world are increasingly shaped by three common conditions of modern life: demographic ageing, rapid unplanned urbanization, and the globalization of unhealthy lifestyles.
The report on the prevention of avoidable blindness and visual impairment provides a good example. An estimated 45 million people are blind. Around 80% of this blindness could be prevented or treated. Conditions such as cataract, glaucoma, and diabetic retinopathy are leading causes. These are age-related conditions, and their prevalence is increasing.
The report also documents the major contribution that strong international partnerships and alliances can make. Cost-effective interventions are available, and partners bring vast international experience in their implementation. Inadequate priority, a lack of resources, and a shortage of appropriately trained staff are major constraints.
This is another classic public health function: to focus attention on unmet needs, raise the level of concern, document effective interventions, and forge partnerships to get the job done.
But sometimes, health problems, and most especially those of the poor, do not have effective interventions. We should all welcome the global strategy and plan of action on public health, innovation and intellectual property. This is a major step forward in addressing long-standing unmet needs.
As just one example, the report on Chagas disease vividly documents the impact of inadequate tools for diseases of the poor.
The global strategy and plan of action demonstrate that international agreements that affect the global trading system can indeed be shaped in ways that favour health. The forces that govern the development and pricing of products can indeed be steered in directions that favour greater fairness in health. R&D can indeed be needs-driven as well as profit-driven.
Last week, WHO convened an expert working group to assess financing for R&D and look at opportunities for more gains through better coordination. The experts also considered proposals for innovative ways to secure new funding. We are moving forward on this front as well.
During this session, you will also be considering an overarching strategy defining WHO’s roles and responsibilities in health research.
Ladies and gentlemen,
I have mentioned the shortage of appropriately trained staff. You have before you a draft code of practice for the international recruitment of health personnel. This is another global problem of huge significance.
Many countries cannot hope to achieve the health-related Millennium Development Goals without adequate numbers of appropriately trained staff. Many countries and conferences have called for a renewal of primary health care. Objectives such as universal coverage and more preventive care likewise depend on adequate numbers of appropriate staff.
Demographic ageing increases the need for chronic care, bringing added demands on the health workforce. The growing focus on the strengthening of health systems makes it imperative to find solutions.
I can tell you: this is not an easy problem to address. Patterns of health worker migration have become more complex and more countries are now involved. Addressing the problem means balancing the interests of health personnel, source countries, and destination countries. The draft code of practice contains a number of proposals. I look forward to hearing your views.
You will also be considering the issues of counterfeit medical products and human organ and tissue transplantation. Again, these problems are global in their scope.
Common sense tells us that counterfeiting of medical products and trafficking in human body parts are unethical practices that must be forcefully prevented. Both are motivated by greed. And both harm public health.
Counterfeit medical products put patients at risk. They undermine the credibility of health systems, waste money, and reduce confidence in the authorities responsible for public safety.
I heard your concerns on this issue during last year’s Health Assembly. The draft resolution explicitly recognizes the need to ensure that combating counterfeit medical products does not hinder the availability of legitimate, good quality generic medicines.
For human organ and tissue transplantation, it is my understanding that the previous guiding principles, in effect for 17 years, have been broadly welcomed and have done much good.
Revisions reflect the need to take account of practices that have since been identified. Profiteering in the trade of human body parts finds a market in the exploitation of poor and vulnerable people. People who sell a kidney to a broker often do so out of financial desperation. Despair, like greed, is a powerful motivation.
These two items are examples of the growing need for regulatory oversight in our closely interconnected and interdependent societies. We need regulatory oversight to address counterfeit medical products and transplant tourism, but also tainted food, huge mark-ups on the price of medicines, cigarette smuggling, road safety, drink-driving, unethical practices in the private sector. And the list goes on.
The draft code and guiding principles you are considering will be important additions to other international regulatory instruments for protecting health, most notably the Framework Convention on Tobacco Control and the revised International Health Regulations.
Guiding principles, treaties and regulations contribute to good governance in public health and help standardize the international response to shared problems. They can introduce a measure of ethically-based order to our imperfect world.
Ladies and gentlemen,
Let me turn to three items on your agenda that help us operationalize good governance in public health: the Millennium Development Goals, the Commission on Social Determinants of Health, and primary health care.
All three uphold the values of equity and social justice. All three aim to prevent avoidable deaths and ill-health through actions in multiple sectors. All three take us back to the basics of public health.
I have expressed my commitment to primary health care on numerous occasions. Last year’s World Health Report makes the case that primary health care is more relevant now than ever before. When we consider recent trends, primary health care looks more and more like a smart way to get health development back on track.
The Millennium Declaration and its goals breathed new life into the values of equity and social justice articulated in the Declaration of Alma-Ata. Again, they did so with a 21st century slant, aimed at ensuring that the benefits of globalization are more evenly distributed.
The AIDS epidemic showed the relevance of equity and universal access in a significant 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.
Stalled progress towards the health-related Millennium Development Goals brought another lesson. Powerful interventions and the money to purchase them will not buy better health outcomes in the absence of efficient systems for delivery.
The rise of chronic diseases, and their costs, brought a renewed call for prevention, this time with a clear need for action in multiple non-health sectors.
The Commission on Social Determinants of Health makes a compelling call for close attention to health in all government policies, in all sectors. Gaps in health outcomes are not a matter of fate. They are markers of policy failure.
Not surprisingly, the Commission’s report champions primary health care as a model for a health system that acts on the underlying social, economic, and political causes of ill health.
The World Health Report on primary health care offers practical and technical guidance for reforms that can equip health systems to respond to health challenges of unprecedented complexity. The report also asks political leaders to pay close attention to rising social expectations for health care. More and more, people want care that is fair as well as efficient and incorporates societal values and concerns.
We must always remember that health systems are social institutions that can operate as agents for social change. A health system does not simply deliver pills and babies the way a post office delivers letters.
Properly managed and financed, a health system contributes to social cohesion and social stability. These are assets in the best and worst of times.
When we seek fairness and efficiency in service delivery, primary health care is our best bet and our best buy.
Ladies and gentlemen,
You will be considering the proposed programme budget for 2010–2011. You will be doing so at a time described by the experts as the most severe financial crisis and economic downturn seen since the Great Depression that began in 1929.
No one wants the current drive to improve health, both nationally and internationally, to stall or suffer setbacks. But what if the money simply is not there? What happens if the enormous financial bailouts taking place break the bank? How do we decide what to keep and what to cut?
These decisions also apply to the work of WHO. I have followed the deliberations of the Programme, Budget and Administration Committee very closely. I am aware of the views and concerns and will respond, as guided by you.
To gather advice, I convened a high-level consultation on the financial crisis and global health, which met, as you know, this morning. I am grateful for the interventions and the experiences that were shared.
Public health always tries to be prepared, to seize every opportunity to prevent and pre-empt. We need some best guesses about the impact of the crisis on health spending. No health minister in any country should be taken by surprise.
Above all, we need compelling evidence and arguments to convince ministries of finance and foreign affairs to protect spending on domestic and international health.
Since the start of this century, health has enjoyed unprecedented attention and financial support. The high profile of health on the development agenda was earned, in part, by a wealth of evidence, such as that collected by the Commission on Macroeconomics and Health.
A financial crisis does not change the weight of evidence. A financial crisis should not make the world’s moral compass point in another direction. On the contrary.
I will close with an example that I personally find encouraging. This is a time of uncertainty, and a time of much soul-searching and finger-pointing in financial and economic circles.
In November of last year, the World Economic Forum held a summit on the financial crisis. One session was devoted to governance mechanisms that might protect the world from similar crises in the future.
Participants at that meeting noted a failure of corporate governance and of risk management at every level of the financial system. They called for a much-needed introduction of societal values and concerns into the capitalist market model. They called for new governance mechanisms that have a moral dimension.
To demonstrate feasibility, participants put together a list of seven examples of good global governance in other sectors. Five of the seven come from public health.
First, the health sector manages risks. Surveillance, alert, and response systems are in place to protect the world against the threat of emerging and epidemic-prone diseases.
Second, health inspires collaboration. During the SARS outbreak, leading scientists put aside competition and collaborated around the clock. The SARS virus was identified within four weeks.
Third, health can tap the power of goodwill, as with unflagging support from Rotary International for polio eradication.
Fourth, health can motivate ethical behaviour in industry, as when pharmaceutical companies reduced the prices of antiretroviral drugs.
And finally, health can persuade the international community to agree on the control of harmful, yet profitable products, like tobacco.
Again, we are back to the basics of public health: prevention, protection, equity. Public health has risk management. And societal values and concerns are embedded in everything we do.
Let us continue to show other sectors what good governance can mean, especially in times of crisis.