Breaking the cycle of poverty, misery, and disease

Dr Margaret Chan
Director-General of the World Health Organization

Health promises and perils in an interdependent world: breaking the cycle of poverty, misery, and disease
Lecture at the Korea Foundation for International Healthcare – Dr JW Lee Memorial fund
Seoul, Republic of Korea

13 November 2012

Officials, friends and fellows of this foundation, students, young professionals, ladies and gentlemen,

It is a great pleasure for me to address an audience in the Republic of Korea.

Once torn by oppressive occupations, civil strife, and wars, this country transformed itself, within a generation, into a major economic force, a fully democratic and stable society, a regional powerhouse, and a respected player at the global level.

This country is also famous for producing famous people. Korea was the birthplace of United Nations Secretary-General, Ban ki-Moon, my predecessor, Dr JW Lee, and the President of the World Bank, Dr Jim Kim.

Life was not easy in Korea in the time when these men were born. But like the country itself, they were ambitious and determined, in transformational ways. They knew the value of hard work and especially of education. They set high personal goals and pursued them with discipline.

All three eventually chose public service as their career paths. They championed peace, the poor, and the dignity of human life. They were rewarded with success and respect, though they themselves remained humble.

Before becoming the Director-General of WHO, Dr Lee demonstrated a personal focus on health interventions that could relieve the misery of the poor. His earliest work was with leprosy patients. This was voluntary work, and it was extremely demanding. He was one of only two doctors treating Korea’s roughly 80 000 leprosy patients.

During his time as Director-General of WHO, Dr Lee was probably best known for his 3 by 5 initiative. That initiative, launched in 2003, aimed to provide treatment for 3 million people, living with HIV/ADS in poor countries, by 2005.

Announcement of this audacious goal provoked quite some raised eyebrows and skeptical criticism in public health circles.

Who in the world would try to bring this complex and expensive treatment to poor people living in poor places where, in some parts of Africa, one doctor was available to serve more than 20 000 people?

Many thought that giving these medicines to poor people would be reckless, as it would hasten the development of drug resistance and render these precious medicines useless for everyone.

Who would do this? Dr Lee would. “Somebody has to do this,” he said, “and we are that somebody.” He was soon joined in this ambition by Dr Jim Kim.

A graduate of Harvard Medical School, Jim Kim co-founded Partners in Health, a health care organization with a unique philosophy. The poor deserve the very best health care because they have been given so little else in life. Where there is health, there is hope.

Working with very poor communities in Haiti, Partners in Health demonstrated that AIDS and other difficult diseases, like multidrug-resistant tuberculosis, could be successfully treated, even in severely resource-constrained settings. In fact, using innovative approaches that engaged communities, the results were nearly as good as those achieved in countries like the USA.

JW Lee brought Jim Kim to WHO headquarters first as a policy adviser, then as head of the 3 by 5 initiative. Though the goal was not met until two years after the target date, the initiative changed the face of the AIDS epidemic.

In less than a decade, the price of these medicines dropped by 99%. WHO streamlined, simplified, ,and standardized treatment protocols, making it increasingly easy to get good treatment results in poor settings.

Today, some 8 million people in low- and middle-income countries are receiving antiretroviral therapy for AIDS. This is a 27-fold increase compared with the situation when the 3 by 5 initiative was launched. This is the fastest scale-up of a life-saving intervention in history. This is the job that “somebody had to do.”

In a just society, people should not die for unfair reasons, including an inability to pay for medicines. Making life-prolonging treatment available to millions of poor people was the right and moral thing to do.

Fighting HIV/AIDS was never only about medicine and science. This was a social mission built on a respect for human rights and the dignity of every single life.

Today, Dr Kim, as the newly appointed President of the World Bank, maintains his personal commitment to poverty reduction. He wants the World Bank to be a “solutions” bank, to use its influence to provide solutions that help the poor, as was done for impoverished AIDS patients in Haiti.

Ladies and gentlemen,

People, like Drs Lee and Kim, who earn medical degrees and then choose a career in public health, often provoke surprise, if not some degree of disapproval, among their colleagues.

“Are you crazy?” they want to know. Why would anyone trade the rewarding and well-paid work of a doctor for all the frustrations of public health? I understand that view. I have worked in public health for more than 35 years. I can tell you: this is not an easy job.

Public health is engaged in three constant struggles. A struggle against the microbial world. A struggle to change human behaviours. And a struggle to get attention, including enough money to do the job. These struggles never end.

Constant mutation and adaptation are the survival mechanisms of the microbial world. Pathogens develop resistance to mainstay antimicrobials. Entirely new pathogens, like the SARS virus, emerge.

Or pathogens adapt to new geographical areas, and become permanently established there. Like West Nile fever, which first arrived in North America in 1999, and now causes cases, every season, throughout the USA.

In all of public health, there is probably nothing harder than changing human behaviours, like getting people to eat and drink the right things or avoid risky behaviours. When a programme brings success, the results often cannot be replicated in another setting. Or they cannot be brought to scale. Or, most often, they cannot be sustained.

We are like Sisyphus, the mythical king from ancient Greece, who is condemned to roll a huge boulder up a hill, only to watch it roll right back down again.

And, of course, we never have enough money, especially to look after the health of the estimated 1 billion people who have no access to care whatsoever.

As I said, addressing these challenges is not an easy job. But it is a job that someone has to do. In many cases, it is a job that WHO is expected to do.

Ladies and gentlemen,

The World Health Organization was established in 1948 as a specialized agency of the United Nations. From the outset, WHO was given a mission with a strong sense of social purpose.

The WHO Constitution set out a series of health-related principles considered basic to the happiness, harmonious relations, and security of all people. These principles regarded the enjoyment of the highest attainable standard of health as a fundamental human right.

They articulated a value system driven by the goals of equity and social justice and best pursued through the collective action of all nations. As stated, “Unequal development in different countries in the promotion of health and the control of disease, especially communicable disease, is a common danger.”

In other words, the common pursuit of better health could build societies that are more equal, more just, and more secure. I would argue that the relevance of this objective is just as great today as it was in 1948.

At that time, the most immediate need was to restore basic health services in a world badly damaged by war. Some of the Organization’s earliest activities were urgent response to emergencies: the delivery of medicines and vaccines, the containment of outbreaks, and the provision of relief to refugees.

These functions continue today. In fact, the WHO response to outbreaks, and most especially dramatic and deadly ones like Ebola or SARS, is probably our most visible and well-known role today.

In the broadest sense, WHO was established to provide a mechanism through which all countries of the world could collaborate in the pursuit of better health. As our founders noted in the earliest days, “Political, social, and economic differences have no meaning when the health of people is at stake.”

International cooperation also meant that the kind of health protection offered by individual well-off countries could be extended worldwide, again in the interest of equity and social justice.

Dr Lee was probably thinking along similar lines when he decided that poverty must not be a barrier when the health of people with AIDS was at stake. Dr Kim was surely thinking along these lines when he decided that the poorest people in Haiti deserved care up to the standards of Harvard Medical School.

Early on, WHO constructed a protective fabric of international guidelines, norms, and standards on the assumption that people everywhere deserve the same assurance that the air they breathe, the water they drink, the food they eat, and the medicines they take are safe.

Today, the protection provided by these standards is largely invisible and usually taken for granted by citizens until something bad goes wrong. For example, when you hear in the news that air pollution in a city has reached dangerous levels, the WHO safety standard will be used as the reference.

WHO certified the eradication of smallpox in 1979 and is moving ever closer to the eradication of polio and guinea worm disease.

The Framework Convention on Tobacco Control, which entered into force in 2005, rapidly became the most widely endorsed treaty in United Nations history. The treaty puts countries under legal obligation to do things like stop tobacco advertising, raise taxes and prices, and enact smoking bans. I thank Korea for hosting the fifth session of the Conference of the Parties to this treaty, which is being held this week.

The collection of health statistics and the monitoring of global trends is another core function of WHO. As the second half of the 20th century progressed, monitoring revealed that gaps in the health outcomes of different countries and populations, of particular concern when WHO was founded, were actually growing wider.

Advances in medicine and science were racing ahead at unprecedented speed, yet more and more people were being left behind. The best medical care was going to the people who needed it least. Underprivileged populations were dying in large numbers for want of access to inexpensive medicines and basic health care.

In 1978, WHO responded to these trends with a call for sweeping changes in the way health services were being organized and delivered. WHO gave public health its strongest social goal when the Declaration of Alma-Ata was signed at an international conference on primary health care.

That declaration launched primary health care as a set of guiding principles for a more equitable and efficient organization of health services. With its emphasis on community participation, primary health care honoured the resilience and ingenuity of the human spirit and made space for solutions created by communities, owned by them, and sustained by them.

The WHO ambition in 1978 was bold. It assumed that enlightened policy could raise the level of health in deprived populations and thus drive overall development. Almost immediately, the ambition fell on hard times.

The 1980s, the so-called “lost decade for development”, began with an oil crisis, a global economic recession, and the introduction, by development banks, of structural adjustment programmes that shifted national budgets away from the social services, including health. As resources for health diminished, the aim of fundamentally reshaping health care looked less and less attainable.

The emergence of HIV/AIDS, the associated resurgence of tuberculosis, and an increase in malaria cases moved the focus of international public health away from broad-based programmes for building fundamental capacities. The focus shifted towards the urgent management of high-mortality emergencies.

The challenges facing public health today are far more complex than they were in 1948. But the bold ambition, the quest for greater equity and fairness in health, never lost its relevance.

The social values so evident in the WHO Constitution and so eloquently articulated in the Declaration of Alma-Ata were revitalized, in an even more ambitious form, at the dawn of the 21st century.

Ladies and gentlemen,

In 2000, the governments of 189 nations signed the Millennium Declaration and committed themselves to reaching its 8 development goals by 2015. That commitment marked the most ambitious attack on human misery in history.

The goals breathed new life into the values of equity and social justice, this time with a view towards ensuring that the benefits of globalization are more evenly distributed.

They tackle the root causes of poverty, including the poor health of mothers and children and the brake on development caused by deadly epidemics of HIV/AIDS, tuberculosis, and malaria. Other Goals address nutrition, education, the environment, water and sanitation, and the social status of women.

The beauty of the MDGs is that they are interactive and synergistic. If you reduce parasite infections in children, you improve nutrition. If you improve nutrition, you improve educational outcomes. If you improve educational outcomes, especially of girls, you improve the health and nutrition of families and entire communities.

In this way, the chain of poverty, ill health, and misery, passed from one generation to the next, can be broken.

The MDGs have been good for public health. Achievements during the past decade tell us clearly that increased investment in health development is working.

During the first decade of this century, the epidemics of AIDS, tuberculosis, and malaria peaked and began a slow but steady decline. The number of deaths in young children dipped below 10 million for the first time in almost six decades, and continued to drop. Deaths linked to pregnancy and childbirth also began to decline after decades of stagnation.

This is progress, impressive progress, but it is by no means a victory. All of these achievements have been rendered especially fragile by another set of events during the first decade of this century. In fact, that decade may very well go down in history as the time when nations came face-to-face with the perils of interacting in a world of radically increased interdependence.

Since the start of this century, the world has been beset by one global crisis after another: a fuel crisis, a food crisis, a financial crisis, and a climate that has begun to change.

These crises are revealing the dark side of living in a closely interdependent and interconnected world. As the past decade has shown, the consequences are highly contagious, quickly moving through the international systems that bind countries together.

The consequences can also be profoundly unfair. Developing countries have the greatest vulnerability to adverse events and the least resilience. They are often hit the hardest and take the longest to recover.

Globalization produces numerous benefits, but it has no rules that guarantee the fair distribution of these benefits. Today, the international systems that govern trade, capital markets, and business relations have more power than a sovereign government to influence the lives and opportunities of citizens, including their chances to enjoy a healthy life expectancy.

Unfortunately, equity is rarely an explicit policy objective in the way these systems function. As a result, the world has become dangerously out of balance. Differences, within and between countries, in income levels, opportunities, life expectancy, health outcomes, and access to care are greater today than at any time in recent history.

The difference in life expectancy between the richest and poorest countries now exceeds 40 years. Annual government spending on health ranges from as little as US$ 1 per person to nearly US$ 7000.

A world that is greatly out of balance is neither stable nor secure. This is that “common danger” referred to in the WHO Constitution so many decades ago.

And there are other ominous trends, again linked to the world’s unprecedented interdependence. All around the world, health is being shaped by the same powerful forces.

Universal trends, like urbanization, population ageing, and the globalization of unhealthy lifestyles, have sparked a sharp increase in chronic diseases, like heart disease, cancer, and diabetes. Long considered the close companions of affluent societies, these diseases now impose around 80% of their burden on low- and middle-income countries.

Mounting evidence shows that obesity and diabetes, strongly linked to unhealthy diets, have reached epidemic proportions in parts of Asia, where the loss of traditional diets has been especially rapid. People in Asia are developing diabetes in greater numbers and at a younger age than in Europe and North America, and they are dying sooner.

Diabetes is an especially costly disease: costly for societies, costly in terms of chronic care, and extremely costly in terms of hospital bills for well-known complications.

Some economists have described this rising prevalence of obesity and diabetes as a “side effect of progress”, a consequence of economic development.

But I would raise a question. Is this progress at all? What is the net gain when economic development sets health development backwards? Economic growth, I would argue, is not the only measure of progress in a fair and just society.

Ladies and gentlemen,

Earlier this year, the Organization for Economic Cooperation and Development issued a report on Korea’s outstanding health achievements.

As stated, “Few countries have had as remarkable an expansion in health coverage over the past three decades. That Korea has achieved this at modest costs relative to other OECD countries is all the more remarkable.”

I have been speaking to an audience with many students and young professionals. As you pursue your careers in a prosperous, well-governed, and healthy country, let me give you just a little advice.

In a just society, positions of privilege carry responsibility. This is a responsibility to care about the welfare of fellow citizens, but also the welfare of people in less privileged parts of the world.

Money is important. Look at what economic growth has meant for life in Korea. But wealth is not the only measure of progress in a civilized society.

Remember the convictions of your countrymen, Drs Lee and Kim. The poor deserve the very best health care because they have been given so little else in life. Where health thrives, hope thrives as well.

Never lose your moral compass.

Thank you.