The increasing importance of global health
Dr Margaret Chan
Director-General of the World Health Organization
Colleagues in public health, ladies and gentlemen,
In addressing the place of global health in international affairs, I will be speaking about success, shocks, surprises, and moral vindication.
The 21st century began well for public health. When the governments of 189 countries signed the Millennium Declaration in 2000, and committed themselves to reaching its goals, they launched the most ambitious attack on human misery in history.
The contribution of health to the overarching goal of poverty reduction was firmly acknowledged, as was the need to address the root causes of ill health that arise in other sectors.
World leaders were optimistic, visionary, and determined to see their visions realized. A host of global health initiatives sprung up, with many designed to deliver life-saving interventions on a massive scale.
New financing instruments were created, and clever ways were found to secure new money for purchasing medicines and vaccines.
Presidents and prime ministers launched international programmes for diseases rarely seen within their own borders. Official development aid for health more than tripled.
Unmet needs for new drugs and vaccines drove the creation of a new breed of strategic R&D partnerships that have already licensed impressive innovations.
Not surprisingly, this desire to cooperate internationally for better health, these innovations, these dramatic increases in resources, had an impact.
The number of people in low- and middle-income countries receiving antiretroviral therapy for AIDS moved from under 200 000 in late 2002 to nearly 7 million today. The number of under-five deaths dropped to its lowest level in more than six decades.
The number of people newly ill with tuberculosis peaked and then began a slow but steady decline. For the first time in decades, the steadily deteriorating malaria situation turned around. Countries following WHO-recommended strategies are seeing drops of 50% and higher in malaria deaths.
Yet, for much of the decade, the number of maternal deaths stayed stubbornly high. The explanation is not hard to find. Reaching the goal for reducing maternal mortality depends absolutely on strong and accessible health services.
The strengthening of health systems was not, initially, a core purpose of most single-disease global health initiatives. But it is now.
As the drive to reach the goals taught us, commodities, like pills, vaccines, and bednets, and the cash to buy them will not have an impact in the absence of delivery systems that reach the poor. When the overarching objective is poverty reduction, if you miss the poor, you miss the point.
In my personal view, one of the biggest bonuses of all this progress came in the form of a frank realization, in the large single-disease initiatives, in the Global Fund, in the GAVI Alliance, that goals cannot be reached and progress cannot be sustained in the absence of well-functioning health systems.
I believe this renewed focus on health systems is one reason why 2010 estimates finally showed a significant worldwide drop in maternal mortality, with the greatest declines, of around 60%, reported in Eastern Asia and Northern Africa.
Like others, WHO welcomed last week’s news of dramatic price slashes for vaccines sold by the pharmaceutical industry to the developing world. This represents a sea change in pharmaceutical policies.
As one chief executive stated, the pharmaceutical industry can no longer view itself as detached from the well-being of society.
Not all the news is good. Of course, many countries will not reach the MDGs, especially in sub-Saharan Africa. But striking progress over the past decade tells us two things.
First, investment in health development is working. And second, despite the many crises and obstacles thrown our way, the high place of health on the development agenda has held steady. The momentum to improve health outcomes has persevered.
But so much for the success of public health when left to its own devices.
Ladies and gentlemen,
The year 2008 will likely go down in history as the tipping point that demonstrated the perils of living in a world of radically increased interdependence.
That year experienced a fuel crisis, a food crisis, and above all, a severe financial crisis.
That year also demonstrated that these crises are entirely different from those experienced in previous centuries. They are not just temporary dips and blips in the up-and-down cycle of human history.
Their origins are so deeply embedded in the international systems that govern today’s interdependent world that we must begin to accept them as recurring, if not permanent features of life in the 21st century.
These days, the consequences of an adverse event in one part of the world are highly contagious and profoundly unfair. 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, have also been hit hard.
In a similar way, the countries that contributed least to greenhouse gas emissions are being the first and hardest hit by climate change.
Two months ago, the World Bank and the International Monetary Fund cited skyrocketing food and fuel prices as the most serious immediate threat to developing countries, and warned that we could lose an entire generation of the poor.
At WHO, we have been advised by outside experts to accept financial austerity as the new reality. We have done so, and this has added urgency to the sweeping administrative, managerial, and technical reforms being introduced at WHO.
Under the conditions of this century, the health and economic costs of chronic diseases have created an impending disaster. The burden of these diseases has shifted from affluent societies to the developing world, where nearly 80% of mortality is now concentrated.
Most health systems in the developing world are designed to manage brief episodes of illness from infectious diseases. They are entirely unprepared to cope with the demands and costs of chronic, sometimes life-long care.
Prevention is by far the better option. Unfortunately, the forces that drive the rise of chronic diseases, including demographic ageing, rapid urbanization, and the globalization of unhealthy lifestyles, lie beyond the direct control of the health sector.
It is my sincere wish that the September high-level meeting on noncommunicable diseases, being held at the UN, will produce broad-based plans for urgent action.
To combat the rise of these diseases, policies in other sectors, like food, agriculture, and trade, must change.
Using the WHO Framework Convention on Tobacco Control, the world must get tougher in resisting the increasingly aggressive tactics of Big Tobacco.
Ladies and gentlemen,
We are just halfway through this year, but 2011 has already delivered an unprecedented cascade of calamities, catastrophes, and humanitarian crises.
We are seeing waves and waves of social unrest in the Middle East and in parts of Africa. Haiti and Pakistan are still suffering from the mega-disasters of the previous year.
In March, Japan was hit with the triple tragedies of a magnitude 9 earthquake, a massive tsunami, and a related accident at a nuclear power plant. Some countries are now questioning the safety of nuclear power and rethinking their energy policies for the future.
In May, an outbreak of a rare strain of E. coli began in northern Germany. The strain had been detected in isolated human cases before but had never been associated with an outbreak.
To date, cases have been detected in 15 countries. Almost all patients had a recent travel history to northern Germany, many have required intensive care, and many have died.
This event demonstrates how rapidly a disease can spread in our highly mobile world. It shows how difficult it can be to pinpoint the source when investigations are complicated by the intricacies of world food trade.
And it tells us how much outbreaks can cost economies, with EU officials estimating weekly losses to vegetable farmers of more than US$ 610 million.
Ladies and gentlemen,
I mentioned moral vindication earlier.
Our world is dangerously out of balance. The gaps in health outcomes, within and between countries, are greater now than at any time in recent history.
The difference in life expectancy between the richest and poorest countries exceeds 40 years. Annual government expenditures on health range from as little as US$ 1 per person to nearly US$ 7 000.
A world that is greatly out of balance is neither stable nor secure.
Perhaps the biggest lesson from all these recent events concerns the impact of social inequalities on national and international security.
In their analyses of the recent waves of social unrest, top experts from around the world cite vast inequalities, within and between countries, in opportunities, especially for youth, in income levels, and in access to social services, as the root cause of unrest and protests.
Some cite the crumbling of public health services, after years of utter neglect, so that the best care goes to the elite and the poor pay unregulated, exaggerated prices for even the most routine care.
In one speech, editorial, news report, or article after another, we hear that greater social equality must become the new economic and political imperative for a safer, more secure world.
This is nothing new for public health. We have been making this same point since the Declaration of Alma-Ata. The MDGs are all about ensuring that those who suffer most or benefit least get help from those who benefit most.
This is the essence of social justice and solidarity.
Again we see how fragile our advanced, sophisticated, high-tech, intertwined, modern world has become as the climate slowly warms, some 44 million pre-schoolers are obese or overweight, and social fabrics in so many places begin to unravel.
Public health has been on the right moral and ethical track for ages.
It is good to see the world’s politicians and economists wake up and open their eyes to the moral imperatives that have always driven the best in public health, and always will.