Greater equity in health should be a progress indicator

Dr Margaret Chan
Director-General of the World Health Organization

Address at the United Nations Secretary-General’s Forum on Advancing Global Health in the Face of Crisis
New York City, USA

15 June 2009

Secretary-General, Mr Ban Ki-moon, distinguished Ministers and Ambassadors, colleagues in the UN system, colleagues in public health, ladies and gentlemen,

I welcome this opportunity to speak at a forum that seeks to advance global health, despite the multiple crises we face.

Last year, our imperfect world delivered, in short order, a fuel crisis, a food crisis, and a financial crisis. It also delivered compelling evidence that the effects of climate change have been seriously underestimated.

And now we have another great global contagion to contend with. As announced last week, the world is at the start of the 2009 influenza pandemic.

These are urgent times, and I can be brief, especially as I think many points I want to make will be self-evident to health professionals. We have been making these points for decades, if not forever.

However, precisely because of these multiple crises, some of our arguments, some of our insights into how this world ought to work, are now being voiced by experts and leaders in other sectors, including sectors with far more clout than health.

Perhaps now, our messages will have some resonance. Perhaps now, deaf ears will hear.

I will cover three issues. First, why we must maintain the current momentum for health development. Second, why we must do so with a firm focus on fairness. And third, why we must do so with a call for transformational policy changes in the international systems that govern this world.

About the need for continued momentum, let me state the obvious. We are in the midst of the most ambitious drive in history to reduce poverty and to reduce the great gaps in health outcomes.

The need to stay the course is greater today than ever before. Precisely because of these global crises, the price of failure keeps getting higher.

The crises we face are global, but the consequences are not evenly felt. Developing countries have the greatest vulnerability and the least resilience. They will be hit the hardest and take the longest to recover.

Your agenda says it all. We need to do more for vulnerable groups. We urgently need to strengthen health systems. And we need to increase impact and efficiency through smart and strategic partnerships.

If we do not maintain the momentum in these areas, keep our promises, and strive to reach our goals, a bad situation is certain to get worse under the pressure of these crises. Already, we are seeing the trends.

More people will sink into poverty, health status will worsen, life expectancy will shrink, and health systems will be over-burdened to the breaking point.

Because of the economic downturn, people in affluent societies are losing their jobs, their homes, and their savings, and this is tragic. In developing countries, they will lose their lives.

The pressures of a pandemic, on top of the rise in chronic diseases, could alone cripple fragile health services.

On present evidence, the main risk factors for severe or fatal H1N1 infection are two-fold: pregnancy, and underlying medical conditions, like asthma, cardiovascular disease, diabetes, and obesity.

To make my point, I need just two figures: 99% of maternal mortality, and 85% of the burden of chronic diseases are concentrated in low- and middle-income countries.

I firmly believe that this pandemic will reveal, in a highly visible, measurable, and tragic way, exactly what it means, in life-and-death terms, when health needs and health systems have been neglected, for decades, in large parts of the world.

We will see, in extremely tragic ways, the consequences of our long-standing failure to ensure basic care during pregnancy and childbirth.

Ladies and gentlemen,

This brings me to my second point: fairness.

Fairness, I believe, is at the heart of our ambitions in global health. A quest for greater fairness dominates the agenda for this forum.

We see this in your concern about vulnerable populations, and about health systems that exclude the poor. We see this in your support for global health initiatives and funding mechanisms that redistribute some of the world’s riches towards health needs of the poor.

On the issue of fairness, let me again state the obvious. Our world is dangerously out of balance, also in matters of health. Differences, within and between countries, in income levels, opportunities and health status are greater today than at any time in recent history.

Part of the world feasts itself into obesity, while part of the world fasts and starves for want of food. Part of the world thrives into old age, while part of the world dies young from easily and cheaply preventable causes.

As the historians tell us, such huge extremes of privilege and misery are a precursor for social breakdown.

Is this where the progress of our civilized, advanced, high-tech, sophisticated society has brought us? To the brink of social breakdown?

Let me make another obvious point. A health system is a social institution. It does not just deliver pills and babies the way a post office delivers letters. Properly managed and financed, a health system that strives for universal coverage contributes to social cohesion and stability.

I further believe that a failure to make fairness an explicit objective, in policies, in the systems that govern the way nations and their populations interact, is one reason why the world is in such a great big mess.

Globalization has not turned out to be the rising tide that lifts all boats. It lifts the big boats, but swamps or sinks many smaller ones.

Greed ignited the financial crisis, which turned into an economic downturn, which is turning into economic meltdown for some poor and vulnerable nations.

The financial crisis proved highly contagious, and this contagion showed no mercy and made no exceptions on the basis of fair play.

In terms of impact, the financial crisis has behaved, roughly, like the economic equivalent of a drive-by shooting. The innocent bystanders, the countries that managed their economies well and did not take excessive risks, have also been hit.

Let us look again at the influenza pandemic. The world’s preparedness for a pandemic is unprecedented. But the level of preparedness and the capacity to cope are strongly biased towards wealthy countries.

In terms of measures to mitigate the health impact, many poor countries are virtually empty-handed. Even the use of non-pharmaceutical measures has limited relevance in poor countries, especially in sub-Saharan Africa.

How can you practice home quarantine in the extended African family? How can you practice social distancing in a bustling African market, the heartbeat of social and economic life?

How can we expect poor people to practice respiratory and hand hygiene when we know that millions lack even the most basic access to safe water and sanitation?

As I said, the price of failure in our out-of-balance world keeps getting higher.

Ladies and gentlemen,

Let me turn to my final point, a call for transformational changes in the policies that govern international relations.

In a sense, the Millennium Declaration and its Goals operate as a corrective strategy. They aim to give this lopsided world a greater degree of balance: in opportunities, in income levels and in health.

They aim to compensate for international systems that create benefits, yet have no rules that guarantee the fair distribution of these benefits.

They give us our best chance ever to introduce greater fairness in this world. But the Millennium Development Goals do not address the root causes of these inequities. The root causes reside in flawed policies.

In calling for policy change, public health has powerful support from the findings of the Commission on Social Determinants of Health, which issued its report just a month before the financial crisis began.

I sincerely believe that the Commission’s findings have even greater relevance, and resonance, now. The financial crisis ushered in a period of great soul-searching and finger-pointing. What went wrong and why?

As the economists and political analysts were quick to note, the crisis followed a failure of corporate governance and risk management at every level of the financial system.

As the critics themselves have noted, blind faith in economic growth and gain as the be-all, end-all, cure-for-all has been misplaced.

At the April G20 summit in London, we heard calls for a fundamental re-engineering of the international systems. The reign of the Washington Consensus, we were told, is over.

We heard clear calls, from leaders around the world, to give the international systems a moral dimension, to redesign them to respond to social values and concerns.

In the midst of these calls, here is my big question. When will the world finally see what most of us in public health regard as self-evident?

A focus on health as a worthy pursuit for its own sake is the surest route to that moral dimension, the surest route to a value system that puts the welfare of humanity at its heart.

Greater equity in the health status of populations, within and between countries, should be regarded as a key measure of how we, as a civilized society, are making progress.

Can we really define as progress policies that have brought this world to the brink of social breakdown?

The market, all by itself, does not solve social problems. Public health, when supported by the right polices in other sectors, solves social problems in sustainable, efficient, evidence-based and equitable ways.

Ladies and gentlemen,

Our imperfect, lopsided, unfair and gradually warming world still turns on its axis. We can and must stay on course. Crises and setbacks bring out the best of human courage, creativity and ingenuity. This forum will do this as well.

We are making steady progress with HIV/AIDS and TB, and some huge progress with malaria.

The number of children dying from vaccine-preventable diseases continues to decrease, year after year.

For the neglected tropical diseases, everything is in place. If we stay on course, we can actually eliminate some of these ancient causes of misery by 2015.

The momentum can be sustained.

Presidents and prime ministers have launched initiatives for health problems long gone from their own countries.

Commitment to the health-related Millennium Development Goals remains high.

At the G20 summit in London, nations pledged to keep their promises for official development assistance.

We can do more.

A levy on airline tickets is being used to purchase medicines for developing countries.

World leaders and economists have joined forces to find additional innovative sources of financing for health development, including stronger health systems.

Ministers of health from around the world are returning to the wisdom of primary health care.

They recognize primary health care as an approach that brings fairness as well as efficiency, and allows health systems to reach their potential as cohesive, stabilizing social institutions.

I am personally seeing some heart-warming signs of good will, generosity, and solidarity in the response to the influenza pandemic and the need to extend protection to the developing world.

Let me thank the Secretary-General for his invaluable support in this area, especially for working with WHO to mobilize resources for the procurement of pandemic vaccines for developing countries.

Let me thank him for making health development one of his top priorities.

Let me thank every one of you for your unwavering determination to advance global health, and all the more so at a time of multiple crises.

Thank you.