Director-General

WHO Director-General addresses the Asian Investment Conference

Dr Margaret Chan
Director-General of the World Health Organization

Keynote address at the 2014 Credit Suisse
Asian Investment Conference: Are we winning the fight against infectious diseases?
Hong Kong, the People's Republic of China

24 March 2014

Distinguished participants, members of the press, ladies and gentlemen,

I thank Credit Suisse for this opportunity to address the 2014 Asian Investment Conference.

I also thank Credit Suisse for last year’s report on Sugar consumption at a crossroads. Sugar consumption is an issue of interest for economic markets and world trade but also for public health, given its contribution to the obesity epidemic and the associated risks of diabetes, heart disease, and several diet-related cancers.

I entirely agree with the report’s overarching premise. “The global obesity epidemic and related nutrition issues are arguably this century’s primary social health concern.” As I have said before, chronic diseases are a slow-motion disaster for economies as well as for health.

Today I will be talking about a more abrupt and acute shock to economies: outbreaks and epidemics of infectious diseases.

Ladies and gentlemen,

Throughout much of human history, plagues, pests, smallpox, and the great pox (syphilis) ravaged populations, decimated armies, quarantined cities and ships, killed a third of Europe’s population, altered power structures, and kept lives short and generally miserable.

All that deadly and disruptive power began to diminish with the development of the first vaccine in the 18th century, Pasteur’s germ theory in the 19th century, and the discovery of penicillin in the early 20th century as the first of many miracle drugs.

Humanity was gaining the upper hand.

Smallpox could be prevented. Tuberculosis and syphilis could be cured. Death was no longer inevitable from an infected scratch or a soldier’s battle wounds. Epidemic-prone diseases, like yellow fever and malaria, famous for stopping construction of the Panama Canal, were brought under control in many areas through the elimination of mosquito breeding sites. As hygiene and living conditions improved, cholera continued to sail along international trading routes but no longer left millions of dead in its wake.

Infectious diseases lost much of their sting.

Today, it is hard to imagine the dread, death, and sorrow, the towns full of funerals with small coffins, caused by scarlet fever, a disease that could rob a family of all its children in a matter of days.

So, are we winning the fight against infectious diseases? We are certainly better armed and defended, on multiple fronts, than at any time in history. And since the start of this century, we have certainly made great progress against the three biggest killers: AIDS, tuberculosis, and malaria.

More money and powerful new tools, produced in partnership with industry, supported this progress. The epidemics of AIDS and TB, which had been raging out of control, peaked and began a slow but steady decline.

The malaria situation, described for decades as stable, since it could hardly get any worse, was turned around, with some African countries reporting 50% drops in cases and deaths. The number of childhood deaths, stuck above 10 million for at least 30 years, was cut by nearly half.

This is stunning progress, but these are not clear-cut wins. The only decisive victory over an infectious disease is its eradication.

In the centuries-long fight against infectious diseases, this has happened only once, with the eradication of smallpox in 1979. Only two other diseases have been targeted for eradication: polio and guinea worm disease.

For multiple reasons, infectious diseases are extremely resilient. Abundant evidence tells us that, if control measures lapse, the disease will come roaring back.

This happened most dramatically with yellow fever and dengue. Both diseases were brought under control in the mid-20th century. As the number of cases and deaths fell, so did the level of concern. Today, both diseases are again causing explosive and disruptive outbreaks, also in new areas. Compared with the situation 50 years ago, the worldwide incidence of dengue has risen 30-fold.

The need to maintain control efforts is clear but so is one lesson that emerged during the past decade. International commitment and cooperation can bring well-known infectious diseases to their knees.

Today, the biggest threat from infectious diseases comes from the unknown: the next new virus lurking in the jungles of sub-Saharan Africa or in the wet markets and teeming cities of Asia.

These two geographical areas have traditionally been regarded as the breeding ground for new diseases. Around 75% of new diseases emerge following close contact between humans and domestic or wild animals. Africa and Asia offer multiple opportunities for these contacts to occur.

As the SARS outbreak of 2003 made abundantly clear, new diseases have become a much larger menace in a world of radically increased interdependence, with its phenomenal volumes of international travel and trade. SARS put every city with an international airport at risk of imported cases and cost the Asian economy at least $30 billion.

Ladies and gentlemen,

The world of viruses, bacteria, and parasites is volatile and highly unpredictable. But one thing is certain: new diseases will continue to emerge, most likely at an accelerating pace.

Constant mutation and adaptation are the survival mechanisms of the microbial world. Any organism, like the influenza virus, that can copy itself more than a billion times a day in a single person has a distinct evolutionary advantage.

Some of these mutations will ensure survival when pressures arise, allowing the virus to adapt to new environments, adopt a new way of spreading, jump from an animal host to humans, evade the defenses of the immune system, or escape the killing effect of drugs.

Microorganisms are well-equipped to take advantage of every opportunity to invade or evade. Changes in the way humanity inhabits the planet have given the microbial world multiple new opportunities to exploit. These changes are driven by powerful global trends that are difficult, if not impossible to reverse.

Overpopulation and the resulting pressures on finite land and resources have encouraged humans to enter previously uninhabited areas. These incursions, whether for logging, plantation development, or in search of food or adventure, can disrupt finely-tuned, delicately balanced ecological niches that have been undisturbed for centuries.

Many new diseases, including Ebola and Marburg haemorrhagic fevers, emerged following human incursions into jungles and rainforests.

Environmental mismanagement, including deforestation, is another global trend that opens opportunities for new diseases to emerge.

Nipah virus emerged in Malaysia following the slashing and burning of millions of acres of forest, which were the natural habitat of fruit bats. The bats resettled in fruit orchards near pig farms. The virus spread from bats to pigs and then to humans, eventually causing 265 cases and 115 deaths.

Climate change is likely the most global of all recent trends. Diseases that involve an insect, rodent, or other vector in their transmission cycle are extremely sensitive to changes in climate variables.

Hantavirus pulmonary syndrome, a severe respiratory disease, was first detected in the US after unusual patterns of rainfall forced deer mice to leave their wild habitats and search for food near human settlements.

Evidence is mounting that the geographical distribution of infectious diseases will be altered as the climate continues to change. A study published earlier this month provided evidence that climate change will increase the malaria burden in the densely populated highlands of Africa and South America.

Our world is further characterized by a food supply that is globalized, highly industrialized, and driven by competitive pressures to produce more and more food at ever lower prices.

This is especially true for meat, and this is especially relevant to Asia, where the growth of increasingly affluent consumers has increased the demand for meat and dairy products.

The industrialization of food production is an especially worrisome trend, as agribusiness, also in Asia, increasingly adopts the model of confined animal feeding operations. These operations can produce large quantities of cheap meat. But these are not farms anymore. They are protein factories with multiple hazards for health and the environment.

These hazards come from the crowding of large numbers of animals in very small spaces, the stressful conditions that promote disease, the huge quantities of dangerous waste, the need for frequent human contact with the animals, and the use of large volumes of antibiotics, at sub-therapeutic levels, to prevent disease and promote growth.

The low doses are a recipe for the development of drug resistance, as they kill the weakest bacteria but let the strongest ones survive.

The pressure to cut costs can lead to additional risks. The emergence of mad cow disease in Europe, with associated human cases, is thought to have followed the practice of feeding cattle bone meal produced from the carcasses of other cattle. In other words: cattle eating cattle. Fortunately, this practice has been abandoned.

A strong preference for freshly slaughtered poultry keeps the wet markets open in several parts of Asia. Most scientists view wet markets as hotspots for the emergence of new viruses that could spark the next influenza pandemic.

The practice or raising chickens near homes has been the source of numerous human cases of H5N1 infection, also among very young children who play or crawl near birds or their droppings.

All of these trends, like unprecedented population density, incursions into previously uninhabited areas, people crowded together with domestic animals, a changing climate, and the industrialization of food production, put our world on a dangerous trajectory, with new diseases just one of many prices to pay.

Ladies and gentlemen,

Through the International Health Regulations, WHO is mandated to keep the world alert to emerging and epidemic-prone diseases and ready to respond.

The Regulations were significantly revised and strengthened following the SARS outbreak. Previous efforts relied on stopping international spread at national borders. The revised Regulations aim to stop outbreaks at their source, before they have a chance to spread internationally.

The world is better prepared for new diseases than it was in the previous century. For example, it took scientists more than three years to discover the virus that causes AIDS. It took scientists one month to discover the causative agent of SARS.

The rise of social media has introduced a form of electronic transparency that makes it almost impossible to hide an outbreak. Rumours will always surface and spread in real-time.

WHO uses a dedicated search engine that constantly scans newsrooms, chat rooms and blogs, in multiple languages, for rumours and hints of an unusual disease event.

When countries need support in outbreak investigation and control, WHO uses the Global Outbreak Alert and Response Network as a strike force that can get experts with the right mix of skills to the outbreak site within 24 hours. WHO also has a network of specialized laboratories equipped to handle the world’s most dangerous pathogens.

These and other mechanisms strengthen our collective defence against the infectious disease threat. But true global security against this threat will occur only when more countries have their own capacity to prevent, detect, and respond. And this will happen only when doing so becomes a higher political priority.

A second threat to our collective health security needing urgent political intervention comes from the rise of antibiotic resistance. As WHO and others have been warning for more than a decade, this trend carries especially grave dangers for medical care everywhere.

We are losing our first-line antibiotics, our miracle cures. Replacement treatments are more costly, more toxic, need much longer durations of treatment, and may require treatment in intensive care units. For some diseases, the death rate doubles when drug resistance develops.

Many common bacteria have developed resistance to multiple drugs, some to nearly all. Hospitals have become hotbeds for highly-resistant superbugs, increasing the risk that hospitals kill rather than heal. These are end-of-the-road pathogens that are resistant to last-line drugs.

If current trends continue, the future is easy to predict. Some experts say we are moving back to the pre-antibiotic era. No. This will be a post-antibiotic era. In terms of new replacement antibiotics, the pipeline is virtually dry, the cupboard is nearly bare.

A post-antibiotic era means, in effect, an end to modern medicine as we know it. Common infections will once again kill. Some sophisticated interventions, like hip replacements, organ transplants, cancer chemotherapy, and care of preterm infants, will become far more difficult or even too dangerous to undertake.

Even simple interventions, like surgery to treat myopia, will become too dangerous to perform.

Ladies and gentlemen,

What does all this mean for the Asian investment community? What lies ahead? Without doubt, new diseases will continue to emerge, but not all will be socially or economically disruptive on a global scale.

Some new pathogens never develop an ability to spread efficiently from one human to another. Fortunately, this is still the case with the H5N1 and H7N9 viruses in Asia and the MERS coronavirus that has been causing severe human infections in the Middle East for the past two years.

The incubation period is also important. A short incubation period of a day or two reduces spread by international travel. The person gets sick too quickly. AIDS, with an incubation period of up to 10 years, could easily and silently spread to every corner of the world.

For a disease like Ebola, patients are physically and visibly too ill to travel during their most infectious period. SARS, with an incubation period of up to 14 days, was ideally well-suited to spread along the routes of international air travel.

The costs of an outbreak are usually out of proportion to the severity of the threat. As the World Bank has cautioned, the greatest economic losses come not from the costs of medical treatment or control measures but from the uncoordinated and irrational efforts of the public to avoid infection.

Human behaviour adds to the costs in a second way. Governments often introduce costly measures, such as insecticide fogging or the use of fever scanners at airports, that have no evidence of effectiveness. They do so because such highly visible measures calm public fears and raise confidence that the government is taking steps to protect its citizens.

I cannot overemphasize the importance of accurate information during an outbreak. Use your influence and communication channels to get the facts out, to your employees but also to the wider public.

Experience during the SARS outbreak makes this point well. Areas with outbreaks prior to the WHO global alert in March accounted for 98% of the global total number of cases and 79% of total deaths.

The additional 26 sites, characterized by high levels of vigilance and preparedness, were able to prevent further transmission or limit it to just a handful of cases.

Some experts regard the global food supply as broken. With the current emphasis on producing more food at ever-cheaper prices, the food supply is dangerously removed from its historical purpose of sustaining life in good health.

Few question the world’s capacity to feed its 7 billion people. But many do question the wisdom of cheap prices that encourage overconsumption of unhealthy foods produced in environmentally unsustainable ways.

In terms of managing the associated risks, consumer pressure can shift food production towards a healthier and more sustainable model. In Denmark, consumer preferences and pressures led to one of the earliest bans on the use of antibiotics in animal husbandry.

An international review panel, set up by WHO at the request of the Danish government, concluded that the ban reduced human health risks, while antibiotic resistance on farms declined and livestock and poultry production actually increased.

Finally, please do anything you can to reduce the misuse of antibiotics and encourage R&D for replacement medicines.

The pharmaceutical industry has few incentives to develop medicines for usually short episodes of infectious diseases, especially when misuse of a new antibiotic is almost certain to give it a short market life.

At a time of multiple calamities in the world, we cannot allow the loss of essential antibiotics, essential cures for many millions of people, to become the next global crisis.

Thank you.

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