Director-General

WHO Director-General delivers lecture at Georgetown University’s Global Futures Initiative

Dr Margaret Chan
Director-General of the World Health Organization

Governance: Global health's 21st century challenge
Washington, DC, USA

30 September 2015

President Jack DeGioia, faculty at the campuses of Georgetown University, students and post-graduate students, ladies and gentlemen,

It is a great honour to address an event organized by Georgetown University, America’s oldest Catholic and Jesuit university. I am well aware of the ethical values that guide the work of this university and its several institutes and centres.

I fully agree with the principles that underpin the Global Futures Initiative. Issues of governance, especially in health, will profoundly affect the future of humanity.

The Pope’s visit to this country has done much to underscore the human dimensions of climate change and the refugee crisis. He asks us all to remember the people.

Three examples from the previous century offer some perspective on the complexity of governance challenges facing health in the 21st century.

In 1945, Alexander Fleming and two other physicians were awarded the Nobel Prize in medicine for their discovery and development of penicillin, the world’s first antibiotic.

In his acceptance speech, Fleming asked clinicians to administer penicillin with the utmost care, as both overuse and underuse would hasten the inevitable development of drug resistance. The era of modern medicine was thus ushered in with a prediction that it could, through irresponsible use of fragile medicines, also abruptly end.

A photograph taken in New York City in 1947 shows long lines snaking along the city’s sidewalks and streets as tens of thousands of people patiently waited 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 vaccinated within a few weeks. Those were the days when people had full confidence in science, trusted the advice of health officials, and did as they were told.

In 1954, the first frozen TV dinners entered the market and quickly changed the way millions of households spent their evenings. That convenient invention illustrated the ability of industry to capture emerging social trends, cater to them with innovative products, and reinforce those trends through aggressive marketing.

A generation of sedentary chubby couch potatoes, shaped by sinking prices for TV sets and the appeal of convenience foods, was born.

The discovery of miracle drugs, public faith in the certainty of science, and the use of new technologies to improve the food supply were all good things that went bad.

Fleming’s warnings fell on deaf ears. Widespread underuse and overuse of antibiotics sparked the development of microbial resistance to more and more mainstay medicines, beginning a trend that would eventually threaten to end modern medicine as we know it.

The public lost its faith in science. People no longer line up obediently to follow public health advice. Vaccine refusals show how health decisions can be influenced by the most popular website, the most articulate blogger, or the politician with the loudest voice and the most press.

Advances in food technology made the food supply more secure, but they also changed its nature. The industrialization of food production paved the way for a corporate approach to the food supply that concentrated almost exclusively on increasing the quantities and reducing the costs of food.

The primary purpose of the food system, that is, to sustain human life in good health, got lost along the way. As the previous century drew to a close, obesity began to reach epidemic proportions, first in adults in wealthy countries, then in their children, then nearly everywhere.

Ladies and gentlemen,

Despite these ominous trends, the 21st century began well for public health. The Millennium Declaration and its eight goals, including three directly related to health, provide an outstanding example of how an instrument for global governance, aimed at reducing human misery, can do enormous good.

Fifteen years ago, human misery was thought to have a discrete set of principal causes, like poverty, hunger, poor water and sanitation, several infectious diseases, and lack of essential care during childhood, pregnancy, and childbirth.

The results of that focus, and all the energy, resources, and innovations it unleashed, exceeded the wildest dreams of many. It demonstrated the power of international solidarity and brought out the best in human nature.

Maternal and child mortality fell at the fastest rate in history, with some of the sharpest drops recorded in sub-Saharan Africa. Each day, 17,000 fewer children die than in 1990. AIDS reached a tipping point when the number of people newly receiving antiretroviral therapy surpassed the number of new infections.

Since the start of the century, an estimated 37 million lives were saved by effective diagnosis and treatment of tuberculosis. Over the same period, deaths from malaria declined by 60%. An estimated 6.2 million lives, mainly in young African children, were saved.

Drug donations by the pharmaceutical industry allowed WHO to reach more than 800 million people each year with preventive therapy for leprosy, sleeping sickness, river blindness, and other neglected topical diseases.

These are ancient, debilitating diseases that anchor more than a billion people in poverty. By reaching so many millions, we are paving the way for a mass exodus from poverty.

Last week, the United Nations General Assembly finalized a new agenda for sustainable development. The agenda shows how dramatically the world has changed in just the past 15 years. The number of development goals has grown from 8 to 17, while the number of targets shot up from 21 to 169.

The factors that now govern the well-being of the human condition, and the planet that sustains it, are no longer so discrete. The new agenda will try to shape a very different world.

This is a world that is seeing not the best in human nature, but the worst: international terrorism, senseless mass shootings, bombings in markets and places of worship, ancient and priceless archaeological sites reduced to rubble, and the seemingly endless armed conflicts that have contributed to the worst refugee crisis since the end of the second World War.

Ladies and gentlemen,

Since the start of this century, newer threats to health have gained prominence. Like the other problems that cloud humanity’s prospects for a sustainable future, these newer threats to health are much bigger and more complex than the problems that dominated the health agenda 15 years ago.

All around the world, health is being shaped by the same powerful forces, like population ageing, rapid urbanization, and the globalized marketing of unhealthy products.

Under the pressure of these forces, chronic noncommunicable diseases have overtaken infectious diseases as the world’s biggest killers. This shift in the disease burden has profound implications. It challenges the very way socioeconomic progress is defined.

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.

The world is ill-prepared to cope. Few health systems were built to manage chronic if not life-long conditions. Even fewer doctors were trained to prevent them. And even fewer governments can afford to treat them.

In some countries, the costs of treating diabetes alone absorb from 25% to 50% of the entire health budget. Every new cancer drug approved in 2014 by the US Food and Drug Administration cost more than $120,000 per patient per year. Some of these drugs extend life for only a few months.

The climate is changing. WHO’s recent estimate that air pollution kills around 7 million people each year has finally given health a place in debates about the consequences of climate change.

Worldwide, this past July was the hottest since at least 1880, when records began. This year’s thousands of deaths associated with heat waves in India and Pakistan provide further headline evidence of the health effects of extreme weather events.

Antimicrobial resistance is now regarded as a major health and medical crisis. Highly resistant superbugs haunt emergency rooms and intensive care units around the world.

Gonorrhoea is now resistant to multiple classes of drugs. An epidemic of multidrug-resistant typhoid fever is rolling across parts of Asia and Africa. Even with the best of care, only around half of all cases of multidrug-resistant tuberculosis can be cured.

The blockbuster drugs for the pharmaceutical industry are those that manage chronic conditions, not brief episodes of infection. With few new antimicrobials in the pipeline, the world is heading towards a post-antibiotic era when common infections will once again kill.

Some sophisticated interventions, like joint replacements, organ transplants, cancer chemotherapy, and care of preterm infants, would become far more difficult or even too dangerous to undertake.

These newer threats to health do not neatly fit the biomedical model that has historically guided public health responses. Their root causes lie outside the traditional domain of public health.

Preventive efforts that aim to address these root causes often face fierce opposition from powerful economic operators, like the tobacco, alcohol, food, and beverage industries, and their equally powerful lobbies. Economic power readily translates into political power.

World Bank data show that, in 2011, more than 60% of the world’s 175 largest economic entities were companies, not countries. Data also show that this concentration of power is rapidly growing.

Long experience tells us that ministers of health look at the medical and scientific evidence. But ministers of trade and finance often listen to other voices.

No one working in public health should underestimate the challenges that lie ahead. The health sector acting alone cannot protect children from the marketing of unhealthy foods and beverages, persuade countries to reduce their greenhouse gas emissions, or get industrialized food producers to reduce their massive use of antibiotics.

Ladies and gentlemen,

The newer threats to health also lie beyond the traditional domain of sovereign nations accustomed to governing what happens in their territories. In a world of radically increased interdependence, all are transboundary threats.

The globalized marketing of unhealthy products respects no borders. By definition, a changing climate affects the entire planet. As sharply illustrated by malaria, tuberculosis, and bacteria carrying the NDM-1 enzyme, drug-resistant pathogens travel well internationally.

Some multinational corporations can be another transboundary threat. Countries wishing to protect their citizens through larger pictorial warnings on tobacco packages or by introducing plain packaging are being intimidated by the reality of lengthy and costly litigation initiated by tobacco companies. Mechanisms for settling investor-state disputes are being used to sue governments for tobacco legislation that hurts industry profits. To date, Australia has spent nearly $50 million defending its right to introduce plain packaging.

I hope scholars and students at Georgetown will watch all of this very closely. What is at stake here is nothing less than the sovereign right of a nation to enact legislation that protects its citizens from harm.

In this regard, WHO warmly welcomes the Lancet-Georgetown Commission on Global Heath and Law.

We face other challenges. The poverty map has changed. Today, 70% of the world’s poor live in middle-income countries. This is a game-changing statistic. Growth in GDP has long been the yardstick for measuring national progress. If the economy is doing well, where is the incentive to invest in equitable health care? The world does not need any more rich countries full of poor people.

Our world is profoundly interconnected and this, too, has consequences. The refugee crisis in Europe shattered the notion that wars in faraway lands will stay remote. The Ebola outbreak shattered the notion that a disease of poor African nations will have no consequences elsewhere.

Ladies and gentlemen,

In Guinea, where the Ebola outbreak began in late 2013, the virus circulated, undetected, off every radar screen, for at least three months. In Liberia and Sierra Leone, the virus also circulated undetected for several weeks.

In all three countries, the health system was broken following years of civil war and unrest. This meant no isolation wards, no culture of preventing disease transmission in health care settings, many hospitals with no electricity or running water, a severe shortage of doctors and nurses, and a deeply mistrustful population that preferred care from traditional healers.

WHO, and the international community, were too slow to recognize the explosive potential of the outbreak. The world, as a whole, lacked adequate response capacity. The virus ran ahead of control efforts for many months. Though Ebola had been known for nearly four decades, clinicians had no vaccines or treatments to reduce the horrific loss of life.

With the agreement of WHO member states, I am putting in place a number of reforms designed to increase surge capacity during outbreaks and health emergencies, speed the deployment of staff and supplies, and secure the funds to do so.

The Ebola outbreak is not yet over, but we are very close. We are in a phase where we can track the last chains of transmission and break them. To get to this phase, WHO deployed more than 1000 staff to 68 field sites in the three countries.

The world is on the verge of having a safe and effective Ebola vaccine. The ongoing WHO clinical trial in Guinea was recently extended to Sierra Leone, at the government’s request. Being able to vaccinate close contacts of confirmed cases gives us another ring of protection.

WHO has prequalified four rapid point-of-care diagnostic tests. These tests are especially important as health systems begin to recover. Being able to rapidly screen new admissions, especially in high-risk maternity and surgical wards, builds confidence and trust in the health system for patients and staff alike.

As a contribution to preparedness, we are developing a blueprint, with generic clinical trial protocols and arrangements for fast-track regulatory approval, to expedite the development of new medical products during the next emergency.

Ladies and gentlemen,

I have a final question. Can the international community compensate for the absence of strong health systems, with surveillance and laboratory capacity, in any given country? Can an international agency, like WHO, do this?

Not entirely. Managing the global regime for controlling the international spread of disease is a central and historical responsibility of WHO. But no regime for global governance can manage the invisible.

I am not alone in this thinking. In the most dramatic and tragic way possible, the Ebola outbreak focused international attention on the need to build strong and resilient health systems, especially in fragile and vulnerable states.

In fact, some analysts argue that universal health coverage is the best defence against the infectious disease threat, nationally and globally. Having good data on normal disease patterns at the community level aids recognition of an unusual disease event.

The attention given to health systems is a most welcome focus that was not present when the Millennium Development Goals were agreed 15 years ago. The global health initiatives that brought such spectacular results did so largely through the delivery of commodities, like bednets, vaccines, and cocktails of medicine. Confronted with weak health systems, the initiatives often built their own parallel systems for procurement, delivery, financial management, and reporting.

Fortunately, many development partners now recognize that virtually all health goals on the international agenda need a well-functioning and inclusive health system to achieve sustainable results.

The Ebola outbreak in West Africa had many exceptional features that contributed to its explosive spread. But it was not a worst-case scenario. The world is dangerously ill-prepared to cope with a severe new disease that spreads by the airborne route or is contagious during the incubation period, before tell-tale signs of illness appear.

In my view, getting robust, responsive, and resilient health systems in place in more countries is critical to better preparedness. This is an investment that has been neglected far too long, especially given its capacity to so broadly benefit humanity.

Thank you.