Winterthur,
3 October 2000

Opening Dinner
Massive Effort Advocacy Meeting

I am very pleased to see you all here tonight. I would like to thank the City of Winterthur and its co-sponsors for the warm hospitality and commitment you have shown by hosting this forum. I also thank the Canton of Zurich for hosting us all in this evening’s dinner.

The coming few days will be interesting, I am sure. Hard work, too. But in a beautiful city and excellent venue. Unfortunately, I am not going to be able to join you in your work throughout this week. I would therefore like to use this opportunity to share with you some of my ideas about what we are trying to do and what our challenges are - for this week and beyond.

Poverty is the underlying obstacle to human well-being. Despite the unprecedented prosperity and quality of life enjoyed in large parts of the world, 1.2 billion people survive on less than one dollar a day and another 1.3 billion scrape out a living on less than two dollars a day.

The difficult question has always been: how do we reduce poverty on a large scale? People are poor not only because their income is low, but because they do not have access to basic services, such as health and education, which would have increased their freedom. Poverty deprives people of the opportunity to live a real life.

For poor people, becoming ill frequently means becoming poorer – both directly, because you have to spend a part of your small income to pay for treatment and medicines, and indirectly, because your choices become so limited.

A rickshaw driver in Khulna, Bangladesh may well know that he lives in a place where the risk of tuberculosis is high. But his poverty deprives him of the choice to live somewhere else. When he gets infected, he cannot compete so well for work. His income goes down. This sends the family into a spiral of debt and increasing poverty. His children - particularly the girls - may be kept from school. The family may have to cut out fish from their meals most days. Their malnutrition increases vulnerability, risk of illness - and death.

Being too poor to go to an ordinary bank, the family has to borrow from loan sharks who charge crippling interest, in order to pay for medicines. With such costs, our rickshaw driver understandably chooses to cut the treatment as soon as he feels better. It is likely that the infection will return, the next time maybe resistant to the normal drugs used for treatment. The health of others, who live nearby, is in real danger.

During the early 1990s, the world began to accept that there is a complex, but close-knit relationship between health and poverty. Being poor is bad for your health. But being ill also reduces your chances of getting out of poverty.

There is new data about the extent to which ill-health is impacting on the economy of some communities and nations, particularly in Africa. We now know that a few diseases, such as malaria, HIV/AIDS, tuberculosis, the traditional childhood killers and reproductive health conditions, are directly biting into the economic growth of poor countries.

Analysis of data from thirty-one African countries during the period 1980 to 1995 showed that the annual loss of economic growth due to malaria has been as high as 1.3% per year. If this loss had been compounded for that 15 year period, GNP would have decreased by nearly 20%.

When HIV prevalence reaches 8% in the population - as is the case in at least 21 African countries - per capita growth is reduced by 0.4 percentage points each year. Given that annual per capita growth in Africa for the past three years has averaged 1.2%, this is a significant reduction.

There is an increasing recognition of the sheer difficulty faced by developing nations as they seek to counter these health threats. It is becoming clear that health systems which spend less than $60 or so per capita are not able to even deliver a reasonable minimum of services, even through extensive internal reform. It doesn’t matter how good the structure is – as long as you can’t afford to pay your doctors and nurses proper salaries and fill the shelves with essential medicines and vaccines, a health system will not be performing at a reasonable level.

It should not be like this. A number of health interventions can dramatically reduce mortality from the main killers. Supervised medication regimes for TB; nets impregnated with insecticide against mosquitoes, and wide distribution of malaria treatment among children and pregnant women; prevention programmes for HIV/AIDS – or access to care programmes that can substantially slow the mortality among those living with HIV. There are many more interventions, proven to be effective on a local or national level.

This is what we have given the working title: "The Massive Effort".

The Massive Effort, therefore, is a process to scale up actions, to achieve widespread outcomes, a road to follow, a framework for thinking and a set of values.

At this stage, a lot of the work lies ahead of us. We do not have all the answers. But several things are clear:

• We are not thinking of replacing or substituting existing health or poverty reduction initiatives. We want to use good work, already underway, scaled up and bringing tangible benefits.
• National authorities of developing countries will be stewards of this effort. They have called for it and we in the international community are responding.
• We must strengthen health systems. We must also go beyond the traditional health sector – working with people in their homes, their work places, their schools, their community halls and their places of worship.
• We will need better mechanisms to channel and disburse more funds in ways that bring clear benefits to poor people.
• We must stimulate development of new drugs and vaccines that can replace those that are threatened by increasing resistance. And break new ground – such as malaria and HIV/AIDS vaccines. We must also work to reduce the prices of those medicines we need so they can become available to all those who need them.
• Finally – and crucially – in order to succeed, substantial new resources are needed.

Current estimates suggest that an additional $1 billion dollars annually will be required to combat malaria effectively. The situation with TB is similar. Another billion dollars annually spent on drugs - linked to work on health systems - could result in a 50% drop in mortality over the next five years. With HIV/AIDS, we need even more. Sums in the order of $2.5 billion dollars annually are needed for prevention alone. Add the cost of care, and the figures rise dramatically.

In July, the G8 leaders committed themselves to support significant improvements in health outcomes among poor communities. As Councillor Dreifuss has told us, they committed to targets set by international fora for reducing the toll from HIV, from malaria, and from TB by 2010.

The European Commission has shown a strengthened push to fight HIV/AIDS, malaria and tuberculosis. It has adopted a policy framework to increase access for poor people to essential health goods and services; works to reduce prices of vital medicines and commodities; and aims to create incentives for strategic research to develop new and more cost effective products for prevention, diagnosis and treatment.

This is a long-term affair. We are talking about the need for sustained, additional financing for 10- 15 years.

• We need a movement that can keep up the pressure on decision makers.
• We need a movement that stimulates people in all countries to find their own best ways of carrying forward the Massive Effort.
• We need a movement that is inclusive, pluralistic and positive, but at the same time doesn’t lose its focus and its determination.

It must be a movement that is based on a shared and strong set of values. It must be a movement that is oriented towards action – with measurable, clear goals and outcomes. And it must be a movement that celebrates plurality and new ideas.

This leads us to Winterthur. You are invited here this week to become seeds of something new and ambitious. We invite you to immerse yourself in the ideas and the values of the massive effort and make them your own. Above all, we are asking you to contribute your knowledge and experience to build an effective, popular, global movement for the beginning of the 21^st century.

This is not a forum for finding solutions to medical, developmental and financial challenges facing the massive effort, although many of you have the expertise to provide valuable input also in these matters.

Instead, we will focus on the task of building a global movement. How do we build popular support? How do we engage the media? How do we create ownership of this movement – among mothers and fathers from Afghanistan to Zambia as well as among voters from America to Switzerland?

We are not expecting finished products by the end of this week. But we do hope we have taken the process significantly forward.

Colleagues and Friends

You come from 70 countries and represent a wide variety of backgrounds, professions and political convictions.

When people with vastly different backgrounds come together with a shared purpose, new energy can be released and expertise used in innovative ways.

We hope that we can all build on our shared basic values – and work towards a common goal. In short – we are asking for a Massive Effort.

Thank you.