Grand challenges for the next decade in global health policy and programmes
Dr Margaret Chan
Director-General of the World Health Organization
Honourable ministers, distinguished fellow speakers, faculty and staff at the University of Washington, colleagues in public health, ladies and gentlemen,
For global health, this is a jubilee year for the University of Washington’s Department of Global Health and at least seven other Washington-based health organizations.
I congratulate the Department of Global Health on its tenth anniversary celebration. With well over 600 current research projects in nearly 130 countries, your contribution to global health is broad and your productivity is astonishing.
Many of these projects are operating at the cutting edge of innovation and several are being conducted in close collaboration with WHO. Several are dear to my heart, especially in the era of sustainable development.
Like support to school-feeding programmes that use home-grown food, the integration of cervical cancer control into existing HIV services, and the promotion of community-based primary health care, especially by training rural health workers.
I have been asked to speak about grand challenges for health policy and programmes in the coming decade.
Your interdisciplinary panels will be exploring four of these challenges: preparedness for outbreaks of emerging and re-emerging diseases, the control of noncommunicable diseases, the health impact of environmental degradation and climate change, and the need for innovative approaches to education and training. I would add antimicrobial resistance, and its nightmare bacteria, to that list.
In our world of radically increased interdependence, the forces that have shaped these challenges are universal, and they are not easily reversed. The world has changed dramatically since the start of this century, when the Millennium Development Goals were put forward as the overarching framework for development cooperation.
World leaders at the Millennium Summit sought to create what they called “a more peaceful, prosperous, and just world”. That did not happen as planned.
To understand the newer challenges now embodied in the 2030 Agenda for Sustainable Development, we need to look at the larger sea in which these trends were set afloat.
Since 2001, terrorist attacks that deliberately target civilians have become more deadly, daring, and common. Armed conflicts are now the largest and longest experienced since the end of World War II. The refugee crisis in Europe taught the world that wars in faraway places will not stay remote.
International humanitarian law is now largely ignored, with the deliberate bombing of health care facilities and the use of siege and starvation as weapons of war.
Warnings about the consequences of climate change are increasingly shrill. Records for extreme weather events are being broken a record number of times. The past three years have been the hottest ever.
The phrase “mega-disaster” entered the humanitarian vocabulary following devastating earthquakes, tsunamis, tropical cyclones, droughts, and floods.
The world population is now bigger, more urban, and a lot older, adding dementia to the list of top health priorities. Everywhere in the world, people are living longer sicker lives, increasing the burden on health services, budgets, and the workforce.
Hunger has persisted, but most of the world got fat. The world has 800 million chronically hungry people, but it also has countries where more than 70% of the adult population is obese or overweight.
The globalized marketing of unhealthy products opened wide the entry point for the rise of lifestyle-related chronic conditions. Noncommunicable diseases have overtaken infectious diseases as the biggest killers worldwide.
This is a unique time in history, where economic progress, improved living conditions, and greater purchasing power are actually increasing diseases instead of reducing them.
Social media have become a new voice with considerable force, yet few safeguards governing the accuracy of its content. The proliferation of front groups and lobbies, protecting commodities that harm health, has created arguments that further muddle public thinking and challenge the authority of evidence.
The Oxford Dictionary of the English Language chose “post-truth” as its word of the year for 2016. In a post-truth, post-fact world, views that appeal to emotions and personal beliefs are more influential than objective evidence-based facts.
What does this mean for public trust in the evidence produced by science, medicine, and public health?
The 21st century has been rocked by the emergence of four new human pathogens: SARS, the H5N1 and H7N9 influenza viruses, and the MERS coronavirus. Other older diseases have remerged in ominous ways, including Ebola, yellow fever, and Zika virus disease.
As the century progressed, more and more first- and second-line antimicrobials failed. The pipeline of replacement products has nearly run dry, raising the spectre of a post-antibiotic era in which common infections will once again kill.
The world is also much richer than at the start of this century. Countries like China and India lifted millions of their citizens out of poverty, but in many countries, the benefits of growing wealth have gone to the privileged few.
The number of rich countries full of poor people has grown, changing the poverty map. Today, 70% of the world’s poor live in middle-income countries.
The consequences of the world’s extreme social inequalities are profound. Last month’s World Economic Forum identified growing inequalities in income and wealth as the single most significant trend that will shape global development over the next ten years.
In essence, the SDGs are a corrective strategy that looks at the root causes of inequality and aims to transform them. The international systems that govern finance, business relations, trade, and foreign affairs need a corrective strategy.
As some critics argue, the long-standing social contract that obliges the privileged few to care for those less fortunate has been broken in a world that has lost its moral compass.
Ladies and gentlemen,
As we collectively address these challenges, I ask you to keep in mind four overarching priorities that should guide health policies and programmes.
First, tackle inequality. Second, improve information. Third, stimulate innovation. Fourth, and above all, show impeccable integrity.
For inequality, the 2030 Agenda for Sustainable Development has the focus right. Leave no one behind. This is not easy, especially in these uncertain times.
Decades of experience tell us that this world will not become a fair place for health all by itself. Health systems will not automatically gravitate towards greater equality or naturally evolve towards universal coverage.
Economic decisions within a country will not automatically protect the poor or promote their health. Globalization will not self-regulate in ways that ensure the fair distribution of benefits. International trade agreements will not, by themselves, guarantee food security, or job security, or health security, or access to affordable medicines.
All of these outcomes require deliberate policy decisions.
I call on you to promote the SDG target for universal health coverage as the ultimate expression of fairness. It is one of the most powerful social equalizers among all policy options.
For information, some 85 countries, representing 65% of the world’s population, do not have reliable cause-of-death statistics. This means that causes of death are neither known nor recorded, and health programmes are left to base their strategies on crude and imprecise estimates. Until more countries have good systems for civil registration and vital statistics, health programmes will be working in the dark, throwing money into a black hole.
This is totally unacceptable in the current climate that places a premium on transparency, accountability, and independent monitoring of results. I am aware of the many current projects, undertaken by the Global Health Department and its partners, which are using the latest information technologies to address precisely this problem.
For innovation, we know that the supremely ambitious health targets set out in the SDGs cannot be met without powerful new medical tools. We know that new vaccines can prevent infections that currently contribute to the overuse of antibiotics.
We know that at least 11 epidemic-prone human pathogens, including the Zika, Lassa fever, and Nipah viruses, have no vaccine to protect populations during outbreaks.
We know that R&D incentives preferentially encourage the development of new products for markets that can pay.
One strategy that has worked well at WHO is to let the people, working in the field and seeing practical constraints on a daily basis, design the profile of an ideal new product, right down to its price. This was the strategy used so successfully in the Meningitis Vaccine Project, funded by the Bill and Melinda Gates Foundation, and coordinated by WHO and PATH. I encourage others to use a similar approach.
Finally, we must all work according to the highest standards of scientific integrity. Like others, I see a number of disturbing trends. Let me respond to just one.
Regulatory agencies everywhere must resist the push to replace randomized clinical trials, long the gold standard for approving new drugs, with research summaries provided by pharmaceutical companies.
As some argue, making this change would speed up regulatory approval, lower the costs to industry, and get more products on the market sooner. This kind of thinking is extremely dangerous.
We must not let anything, including economic arguments or industry pressure, lower our scientific standards or compromise our integrity. This is an absolute duty.
Don’t let politicians, the public, or industry forget the lessons from the thalidomide disaster.