Director-General

WHO Director-General addresses US Department of Health and Human Services

Dr Margaret Chan
Director-General of the World Health Organization

Public health in the 21st century: too big to fail? The Secretary’s Global Health and Human Services Lecture Series
Washington, DC, USA

27 September 2013

Secretary Sebelius, our good friends in the Department of Health and Human Services, ladies and gentlemen,

It is a great pleasure to speak to the officers and staff of the Department of Health and Human Services. WHO has long worked closely with the Centers for Disease Control and Prevention, the Food and Drug Administration, and the National Institutes for Health.

We share the values set out in the HHS mission statement. Your job is to protect the health of all Americans and provide essential human services, especially for those who are least able to help themselves.

This concern with the needs of the most vulnerable is in line with what I believe is one of the most powerful statements in the Millennium Declaration: As stated, “The central challenge we face today is to ensure that globalization becomes a positive force for all the world’s people. Those who suffer or benefit least deserve help from those who benefit most.”

This is the principle of fairness, and this principle guides much of the work of WHO. This is the social contract that gives the world its moral compass.

The Millennium Development Goals represent the most ambitious attack on human misery in history. Progress in reaching the health-related goals tells us clearly that investment in health development works.

Let me give you just one example of this progress. Today, more than 10 million people living in low- and middle-income countries are seeing their lives prolonged and improved by antiretroviral therapy for AIDS.

This is up from 200,000 people just eleven years ago. This is the fastest scale-up of a life-saving intervention in history. All of these millions of people can now work, take care of their children, and enjoy nearly normal life expectancies.

On behalf of these and many millions more, let me thank the US government, its agencies, and its leaders for contributing so much to the control of HIV, tuberculosis, and malaria, to dramatic reductions in maternal and child mortality, to better nutrition, especially during the first 1000 days of life, and to the eradication of polio.

Ladies and gentlemen,

The job of protecting the health of the American people increasingly requires action on the global stage.

Protecting health has always been a broad endeavour since so many of the determinants of good and bad health lie in non-health sectors. But today, these determinants have taken on global dimensions.

Health is profoundly shaped by the policies of the international systems that govern finance, trade, and business relations in a world of radically increased interdependence. Health is profoundly shaped by recent trends that are global in nature and extremely difficult to reverse.

Is health too big to fail simply because its success has been so dramatic and so well-documented? Is health, like the big banks, so intricately interwoven into the fabric of what a good life means in modern society that it cannot possibly be allowed to unravel?

Or do other factors make better health especially important, even indispensable, under the unique conditions of the 21st century?

Let me approach these questions through three brief examples that raise some relevant issues.

The first is a photograph taken in New York City in 1947. It shows long lines of people slowly snaking through the sidewalks and streets of the Bronx, waiting to be vaccinated against smallpox.

The stimulus was a single imported case in a business traveller, with onward transmission to two other New Yorkers. Millions of city residents were immunized within a few weeks.

Those were the days when health officials could advise the public to do something, and they did it. Those were the days when impeccable science was sufficient to persuade behavioural change. Those days are fading.

The second example is from April of this year, when CDC Drs Timothy Uyeki and Nancy Cox published a perspective article in the New England Journal of Medicine.

They outlined global concerns following the detection in China of human infections with H7N9, an entirely new strain of avian influenza. They stressed the need for intensified surveillance of what they called a “very troubling disease”. As they concluded, “We cannot rest our guard.”

We cannot rest our guard against H7N9, or H5N1, or the novel coronavirus responsible for the Middle East Respiratory Syndrome, or the next surprise coming from some unknown virus lurking in some unknown animal reservoir.

The unprecedented speed of international travel and volume of trade have made emerging and epidemic-prone diseases a much larger menace for the entire world. The days when any outbreak can be considered a strictly local event are likewise fading.

My final example concerns diabetes. Three years ago, a paper published in the Lancet expressed grave concern about the growing prevalence of diabetes in Asia, which is emerging as the epicentre of the epidemic.

In Asia, people develop the disease earlier, get sicker, and die sooner than their counterparts in wealthier nations. The costs, as reported in the paper, are enormous and rising.

In some countries, care for diabetes alone absorbs 15% of the entire health budget. The costs for individuals are even higher. In rural parts of some Asian countries, a diabetic can spend more than a third of total household income on the costs of care.

The paper raised the possibility that the diabetes epidemic, if left unchecked, could cancel out the benefits of economic gain in rapidly developing parts of Asia.

These observations became even more dramatic earlier this month, when the Journal of the American Medical Association published a report by Chinese researchers on the prevalence and control of diabetes in their country.

Based on the findings of a large national survey, the authors estimated that China now has 114 million adults living with diabetes, representing a prevalence in the adult Chinese population of nearly 12%. Less than a third of those surveyed were aware of their condition and only a quarter reported receiving treatment.

In perhaps its most shocking finding, the study estimated that nearly half of the entire adult Chinese population has pre-diabetes, amounting to an additional 493 million people at risk of this debilitating disease, with all its costly complications.

Think about what this means in the world’s second largest economy. Looking for an explanation, the authors suggested that modernization and rising incomes were propelling rapid lifestyle changes, including a shift from traditionally healthy diets to westernized diets.

Media coverage of this alarming news prompted a Chinese newspaper to run a cartoon, showing a patient with his doctor. “Is there a cure for diabetes?” asks the patient. “Yes,” says the doctor. “Poverty.”

This raises a number of questions about where modernization and economic development are leading the world.

Should the rise of diabetes and other chronic noncommunicable diseases be regarded as an unpleasant side-effect of economic progress, as some economists have argued?

Or are these diseases a signal that something fundamental is amiss in the way progress itself is defined? When the costs of disease devour economic gains, doesn’t health deserve a prime place in the equation of what progress really means?

Ladies and gentlemen,

The work of public health is largely invisible until something bad goes wrong. Like dangerously high levels of air pollution. A contaminated water supply. Tainted food. Fake or unsafe medicines. An outbreak. The sudden appearance of a new disease. Or a sharp increase in the prevalence of a well-known disease.

These are all familiar risks, and most governments in wealthy countries have regulations, infrastructures, institutions, and agencies set up to mitigate these risks. The US is blessed with some of the best agencies in the world dedicated to safeguarding the health of Americans.

Unfortunately, opportunities for something bad to go wrong have increased considerably under the unique conditions of the 21st century. The threats to health are more numerous, the causes more ominous, and the burden more onerous.

The climate is changing in ways that can worsen some of our biggest and most stubborn health problems, like undernutrition, diarrhoeal disease, malaria, and outbreaks of cholera, dengue, and other epidemic-prone diseases.

The geographical distribution of vector-borne diseases is likely to change. Variations in climate can also accelerate the emergence of new diseases, especially when alterations in weather patterns and disruptions in the food supply force wild animals to leave their natural habitats and invade new areas.

Protecting the public from unsafe foods and medicines has become far more difficult, entangled as these products are in the intricacies of global trade. Outbreaks of foodborne disease increasingly involve multiple countries and food recalls in the tons. Investigation of their causes is likewise far more complex, especially when a single meal can contain ingredients from all over the world.

The criminal operations that flood the market with counterfeit medicines have become far more sophisticated in their ability to imitate the packaging and appearance of legitimate products, and much better organized in their distribution networks.

The food supply itself has changed. Food production is industrialized. Its marketing and distribution have been globalized.

The products themselves are researched, engineered, processed, packaged, priced, and marketed to make them nearly irresistible. As a result, the cheapest, most convenient, and tastiest foods are also the most unhealthy: high in energy and sodium, but low in nutrients.

Their market penetration over a very short time is astonishing. Junk food is becoming the new staple in the global diet.

The consequences for health are multiple, with the obesity epidemic being the most visible result. This is a worldwide trend. Since 1980, WHO estimates that the prevalence of obesity has doubled in every region of the world.

Perhaps most alarming of all is the loss of more and more first-line medicines as microbes develop resistance. With few replacements in the R&D pipeline, we are moving towards a post-antibiotic era in which common infections will once again kill.

New diseases are now emerging at the average rate of one per year. Right now, we are nervously watching three viruses that have the potential to ignite public health emergencies of international concern.

This should come as no surprise. Constant mutation and adaptation are the survival mechanisms of the microbial world. These organisms are well-equipped to exploit every opportunity to evolve and spread. Changes in the way humanity inhabits the planet have given them multiple opportunities to do so.

All of the threats I have described are amplified by the lack of fundamental capacities throughout the developing world. These are capacities to conduct surveillance for unusual disease patterns, to control the quality and safety of medicines and food, even to know which diseases are the killers within a population and whether control interventions have an impact.

Some 85 countries, representing 60% of the world’s population, do not have reliable systems for vital registration.

In fact, these weak capacities are so widespread, and have such widespread consequences, that we are prudent to view them as yet another global threat to health.

It is here where we appreciate the work of CDC and FDA most especially. That is, in building fundamental capacities, such as for laboratory work and regulatory control.

Given these pervasive trends, it is easy to see how threats to health have become more numerous. At the same time, their causes are more ominous and their burden more onerous. Nothing illustrates this reality better than the rise of chronic noncommunicable diseases.

Ladies and gentlemen,

All around the world, health is being shaped by the same powerful forces, like demographic ageing, rapid urbanization, and the globalization of unhealthy lifestyles.

Under pressure from these forces, noncommunicable diseases have overtaken infectious diseases as the leading cause of mortality worldwide.

Long considered the close companions of affluent societies, these diseases have changed places. Today, 80% of their burden is concentrated in low- and middle-income countries. This is a seismic shift that calls for profound changes in the mindset and practice of public health.

Beginning in the 19th century, improvements in hygiene and living conditions were followed by vast improvements in health status and life-expectancy. These environmental improvements aided the control of infectious diseases, totally vanquishing many major killers from modern societies.

Today the tables are turned. Instead of diseases vanishing as living conditions improve, socioeconomic progress is actually creating the conditions that favour the rise of noncommunicable diseases. Economic growth, modernization, and urbanization have opened wide the entry point for the spread of unhealthy lifestyles.

In the developing world, most health systems were designed, financed, staffed, and equipped to manage brief episodes of acute infections, in which the patient either survives or dies. These health systems are absolutely, totally unable to cope with the demands of costly long-term or even life-long care.

The consensus is overwhelming. Prevention must be the cornerstone of the global response to these diseases. But prevention, like so many of our jobs, has become much more complex.

In the past, broad-based preventive efforts meant collaboration with friendly sister-sectors, like education, nutrition, housing, water supply, and sanitation. Today, efforts to prevent noncommunicable diseases pit health concerns against the interests of powerful economic operators.

Market power readily translates into political power. When public health policies threaten industry profits, this political clout trumps health concerns time and time again, with predictable results.

As we learned from experiences with the tobacco industry, a powerful corporation can sell the public just about anything. This is yet another barrier to effective prevention.

The need to promote behavioural change comes at a time when the public is confused about health issues, bombarded with conflicting advice, and swayed by multiple voices.

The science that underpins sound public health polices and sound advice to the public is being eroded on several fronts.

The popularity of social media is one, where opinions, also on scientific issues, get taken as fact and instantly propagated, while traditional safeguards, like peer review and rigorous scientific and statistical methodologies, fly out the window.

A decline in the quality of medical and health reporting is another, as a cash-strapped industry can no longer afford to keep its top-flight reporters. Health stories make headlines, but findings are often reported at face-value, with no critical assessment of study design, methodology, or the credibility of the authors.

No wonder the public is confused. One week eggs are as bad for the heart as cigarettes. The next week they are a good source of protein.

Science is also being eroded by lobbyists and PR firms hired by large corporations. These companies do not want to see their products regulated or taxed as a strategy for reducing their well-known health risks.

As a result, scientific studies that substantiate these risks are routinely challenged, misinterpreted, discredited, or directly countered by industry-funded research, with all its inherent bias.

Under pressure from these trends, we are losing the persuasive power of science to help shape healthy behaviours. Other strategies are being used. Let me congratulate CDC on the success of its hard-hitting Tips from Former Smokers national anti-smoking campaign.

Ladies and gentlemen,

The rise of noncommunicable diseases is one of two trends that worry me the most. The second is the world’s vast and growing inequalities.

Nine years ago, former president Jimmy Carter addressed the World Health Assembly. He expressed his conviction that the greatest challenge facing the world today is the growing gap between the rich and the poor, both within and between nations.

As he noted, modern communications make it possible for the poor to actually see what a better life is like. They feel resentment over the perceived indifference of the rich to their own miserable plight.

One of the many dangers of social inequalities is the inability of the privileged elite to imagine the lives of others. This, in turn, makes it hard for them to care or to feel a sense of responsibility for making things better.

I agree entirely with his views. When those who benefit most do nothing for those who suffer or benefit least, the social contract that gives this world its moral compass is broken.

What makes health too big to fail is its value system, its concern with fairness in the provision of essential services, especially to those who are least able to help themselves.

I would argue that health operates as a counterweight to many of the global trends I have described that have such a heavy impact on the health and well-being of millions.

Health indicators, which are readily measured, can hold the world accountable for unfair polices made in other sectors. This needs to be done. Unfair policies have left us with a dangerously lopsided world. A world that is greatly out of balance is neither stable nor secure.

The United States looks set to move towards universal health coverage. In my strong view, this is the right direction to take.

Universal health coverage is one of the most powerful social equalizers among all policy choices. Universal health coverage contributes to social cohesion and stability.

Nations with these assets are the envy of the world. This is what modern progress really means.

Thank you.

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