Maintaining momentum in an era of austerity
Dr Margaret Chan
Director-General of the World Health Organization
Mr Chairman, excellencies, honourable ministers, distinguished delegates, Dr Shin, ladies and gentlemen,
This century began with the Millennium Development Goals and the elevated place they gave to health as part of the drive to reduce poverty and human misery.
Great progress has been made in broad-based efforts that also gave us many innovations, from new funding agencies and financial instruments to public-private partnerships to develop new products for diseases of the poor.
Nearly 7 million people in low- and middle-income countries are seeing their lives revived and prolonged by antiretroviral therapy. The tuberculosis epidemic, once declared a health emergency, has been turned around. Malaria cases and mortality have dropped in some African countries by more than 50%.
The most recent UNICEF/WHO estimates demonstrate tremendous progress in reducing child mortality in the Asia Pacific region. This group of countries has achieved a nearly 70% decline in under-five mortality in just 20 years, dropping from 2.2 million in 1990 to just under 700 000 in 2010.
This is dramatic. This amounts to 4 000 young lives being saved each and every day. That is also 4 000 mothers and fathers being spared the immense grief of losing a child.
Yet this progress has been made against some ever-growing odds.
In reality, the first decade of the 21st century evolved in turmoil. A world of radically increased interdependence found itself beset by one global crisis after another.
The global economic downturn has deepened. Food prices continue to soar, and food security has become a far more critical issue, difficult to address. Last year, the World Bank estimated that 64 million people in low- and middle-income countries had been forced into extreme poverty as a result of the fuel, food, and financial crises.
Emerging infectious diseases are now a much larger health and economic menace in a world tied together by the speed of international travel, and live-wired by chat rooms, blogs, and Twitter.
As the vaccine-autism scare taught us, countering unfounded public fears and ignorance with first-rate science has become much harder than it was just a decade ago.
The climate is warming. Natural disasters are becoming more frequent and destructive. And civil strife and conflict, sometimes brief, sometimes sustained, mar nearly every region in the world.
Chronic noncommunicable diseases have spread everywhere, fuelled as they are by universal trends, like rapid unplanned urbanization and the globalization of unhealthy lifestyles. Diseases like heart disease, diabetes, and cancer know no north-south, tropical-temperate, or rich-poor divide.
These are the diseases that break the bank. Just last month, an expert study concluded that the costs of treating cancer are now unsustainable in even the richest nations. In some developing countries, the costs of treating diabetes alone devour 15% of the entire national budget for health.
The year 2011 has experienced this turmoil in concentrated form.
The face of the Middle East is changing. Populations have risen up to demand democratic reforms and respect for human rights, and this includes the right to health. These transformational events have been, at times, highly inspiring, at other times, deeply disquieting.
The triple tragedies that struck Japan in March quickly became the most expensive natural disaster on record. In the wake of last year’s devastating earthquake, Haiti remains crippled by the worst cholera outbreak in modern history.
Drought, crop failure, livestock deaths, and human starvation ravage the Horn of Africa in the worst food security crisis experienced in decades.
For multiple reasons, humanitarian agencies have been able to deliver only a fraction of the aid that is needed. Levels of malnutrition are at a record high. The crisis is expected to continue for some months. Tens of thousands have already died.
In September, WHO received confirmation that the most dangerous strain of poliovirus has spread from Pakistan to China. China eradicated polio in 1994 and has since been entirely free of this disease, save for a single imported case in 1999. Again, this tells us that endemic transmission of the poliovirus anywhere in the world threatens the world everywhere.
I want to congratulate China on its impressive response to this setback. Health officials are following an ambitious outbreak response plan that fully aligns with guidelines issued by the World Health Assembly in 2006. This gives all other countries confidence that a sudden setback can be swiftly countered with a massive aggressive response.
This year also saw the UN General Assembly address a health problem, for only the second time in history, during its special session on noncommunicable diseases. AIDS was the first disease to be considered by the General Assembly a decade ago.
The UN event on NCDs unquestionably raised the profile of these diseases, focused attention on their costs to economies as well as to health, and gave appropriate priority to population-wide interventions.
The event also made it clear that the responsibility for preventing and controlling NCDs cannot fall on the health sector alone. The determinants of these diseases are too broad. A whole-of-government approach is needed with health included in all relevant policies.
The forces driving the globalization of unhealthy lifestyles are too powerful. The response to these trends must come with equal power, with top-level power that can command the right protective policies across all sectors.
The growing prevalence of obesity throughout many populations is not an indicator of a failure of individual will power. It indicates a failure of the social environment, as shaped by high-level policies.
More and more we see that many of today’s biggest health challenges have global dimensions with broad root causes that demand whole-of-government approaches. This is true for NCDs, for antimicrobial resistance, and for food safety, items you will be discussing during this session.
The high-level meeting on NCDs had another bright side, with another smart acknowledgement. Consensus is now solid that a robust primary health care system is the only way that countries will be able to cope with the growing burden of chronic diseases.
As challenges like these mount, the question on the tip of the tongues of anyone concerned about future prospects for public health is this. Can the striking momentum for better health that marked the start of this century be maintained in the current climate of deepening financial austerity?
For HIV/AIDS, this question is not on the tip of the tongue. It is loudly spoken. Growing evidence tells us that antiretroviral therapy is more than just a treatment.
It is also our most powerful preventive tool, capable of reducing the risk of transmission when patients are detected early enough and promptly receive the right treatment. But treating more people earlier and therefore for a longer period of time has huge financial implications. Who will pay?
When money is tight, donors start comparing how much health can be bought for a given sum, with childhood vaccines usually coming out as the winning investment by far. This is a dangerous calculus, as it fails to take into account the magnitude of human suffering, especially when this suffering is chronic.
Ladies and gentlemen,
Dr Shin has articulated the top priority for this region very clearly and succinctly. That is, strengthening health systems based on primary health care.
And that means striving for universal health care coverage, finding fair ways to finance health services, improving access to medical products and health information, and developing the health workforce.
This is the mind-set behind some shifts in thinking about the role of traditional medicine in this region, as set out in the draft regional strategy for traditional medicine.
Compared with the previous strategy, the draft gives increased emphasis to the values of primary health care and to the contribution that traditional medicine can make to universal coverage. This makes perfect sense, especially in a region where traditional medicine has an ancient centuries-old home.
Most appropriately, the strategy emphasizes the importance of adequate regulatory frameworks for ensuring the quality, safety, and efficacy of traditional medicines and practices.
The alarming problem of antimicrobial resistance is on your agenda. As noted, countries in this region have a number of so-called “perverse incentives” that encourage and sustain the misuse and overuse of antibiotics. This includes the policy of using money from the sale of medicines to finance health services.
The unethical promotion of antibiotics adds to the problem. As a result, many countries have an abundance of expensive, non-essential medicines amidst a shortage of essential medicines.
For far too long, we have taken precious, fragile medicines for granted, assuming that the ones lost to drug resistance will simply be replaced by newer and better ones. This is not at all what is happening, with the pipeline for new antimicrobials all but dried up.
The threat of returning to a pre-antibiotic era is genuine and probably most vividly illustrated by the rise of multidrug-resistant and extensively drug-resistant tuberculosis.
For malaria, stepped-up surveillance has detected treatment failures with the currently used artemisinin-combination therapy along the Thai-Cambodian border. This failure is due to resistance to artemisinin, our best and last class of effective antimalarials.
Such trends herald a financial catastrophe as well as a health catastrophe. Second-line drugs are sometimes more toxic and nearly always more expensive than first-line drugs, often hundreds of times more costly.
This is the last thing we need at a time of deepening financial austerity worldwide. We need the opposite. We need health programmes that show a thirst for efficiency and an intolerance of waste.
Condoning behaviours, whether by prescribers, consumers, or veterinarians, that contribute to the loss of front-line treatments is an extreme expression of waste.
In supporting primary health care, health officials must explode the myth that inexpensive care, including inexpensive medicines, is second-rate care for the poor. More spending on health does not automatically bring better health outcomes. Buying the most expensive drugs and medical devices does not automatically buy better health.
A draft food safety strategy is on your agenda. The strategy emphasizes the development of national food control systems and makes frequent reference to the capacities needed for compliance with the International Health Regulations and for participation in the International Food Safety Authorities Network.
INFOSAN was initiated by WHO in 2007 and operates as the investigative arm of efforts to protect the safety of the food supply. The network conducts trace-back studies that give particular attention to contaminated items that may have entered international commerce.
Outbreaks of foodborne disease have become an especially large menace in a world bound together by huge volumes of international trade and travel.
They are large in their potentially wide geographical spread, often involving multiple countries, large in the costs of recalls measured in the tonnes, and large in the complexity of investigations, especially when a meal may contain food items and ingredients from all around the world.
Today, problems can arise from any link or kink in a convoluted food chain.
Adding to the complexity are the increasing use of formerly exotic cuisines where ingredients like, say, a sprinkling of bean sprouts as a garnish, are almost subliminal and unlikely to be recalled in a food history. This problem was experienced most recently in Germany’s especially large and lethal E. coli outbreak that began in May.
The strategy’s particular emphasis on risk-based regulatory frameworks and strengthened capacity for inspections is a wise move. Such a move protects consumers and protects economies.
A progress report on dengue is on your agenda. The prevention and control of dengue has high priority in this region, and rightly so. We need to address this priority more aggressively through collaboration with other sectors, including environmental sanitation.
The recent ASEAN initiative to mark dengue day on 15 June is a commendable way to improve awareness and encourage responsible preventive behaviours at the community and individual levels. I thank the government of Singapore for organizing last year’s dengue workshop which continues to benefit this region and two others.
Ladies and gentlemen,
You will devote some time to noncommunicable diseases.
I have a final comment, which is a simple reminder of the importance of educating the public and engaging civil society organizations. These are resources that can help quench that thirst for efficiency I mentioned earlier, especially as you work to combat the rise of NCDs.
Worldwide, the prevalence of obesity and overweight in young children is rising several times faster than in the adult population. Children the world over love the same cartoon characters that tell them what to eat and drink.
Big Tobacco’s efforts to subvert the WHO Framework Convention on Tobacco Control have reached new heights. Tactics that were previously covert are now out in the open and extremely aggressive.
The high-profile commercial and investment arbitrations targeting Uruguay and Australia are deliberately designed to instil fear in other countries wishing to introduce similarly tough tobacco control measures.
Numerous other countries are being subjected to the same kind of aggressive scare tactics. It is hard for any country to bear the financial burden of this kind of litigation, but most especially so for small countries.
I urge all these countries to stand firm together. Do not bow to pressure.
Big Tobacco can afford to hire the best lawyers and PR firms that money can buy. Big Money can speak louder than any moral, ethical, or public health argument, and can trample even the most damning scientific evidence. We have seen this happen before.
It is horrific to think that an industry known for its dirty tricks and dirty laundry could be allowed to trump what is clearly in the public’s best interest.
In the face of such pressures and tactics, my reminder is this: a health-wise population fights back street-wise.
Keep the importance of health information, as stressed by Dr Shin, in mind, and exploit the capacity of primary health care to make your populations health-wise.