Almost exactly 24 years ago, I was called at
midnight from a wedding dinner and informed that there was a blow-out
of a well at the Ekofisk field in the North Sea. As an environment
minister, I was less shocked about such an accident than many of my
colleagues. I knew the oil drilling in the North Sea was pioneering
work. I had been arguing that risks were real and that oil spill
equipment must be put in place.
Luckily, after an intense week with little time for
sleep and food, we managed to cap the well, and the spill turned out
to do less environmental damage than we had feared.
The Ekofisk blow-out was a turning point for the
Norwegian people as well as for its politicians. For many, this was
the first time they fully realized that environmental questions were
not a peripheral issue for conservationists, but a policy area right
at the centre of the country’s economic development. Investment in
the environment was an integral part of investment for the nation’s
Over the past forty years, I have been deeply
involved with three powerful movements: for democracy and
participation of women, for the environment and for global public
health. Environment moved centre stage in the 1980s. We have been
through a decade of real gains for democracy, and women’s
participation have made substantial strides too. Major interest in
global health is scaling up now. Are there parallels to be drawn?
The first reflection is on the key importance of
awareness raising. Progress in such areas are very limited without a
solid and informed public debate which creates a real political
momentum for action. This process is primarily driven by civil society
and the media.
With the environment major events that triggered
attention were Rachel Carson’s "Silent Spring" and later
the report from the Club of Rome. This not only raised awareness but
also inspired a profound ethical debate.
That debate flourished within open and democratic
societies. It was enhanced by eastern European peoples as their
countries underwent transition. It was taken on by women the world
over. It has been sped up by the developments in communication
At first, however, this debate was mainly limited
to those with special interests. The issue did not move into central
decision making. What was lacking was a convincing, undeniable link to
As a young environment minister I came to the
conclusion that you cannot make real changes in society unless the
economic dimension of an issue is fully understood. I firmly believe
that this is what took the environment from being a cause for the
convinced and marginal green to becoming an issue for real societal
attention by major players. It was necessary for the scientific facts
to come in. The true costs of environmental degradation were analysed
and spelled out in figures. The political importance of environment
changes became an issue for voters. Then, gradually, governments and
parliaments started to establish incentives to change behavioural
patterns among industry and consumers.
Indeed, with an increasingly strong and robust
economic argument, it was possible to make sense both of government
investment in the environment, and commercial investment in the
development of cleaner technologies. We moved from a situation of
market failure to one in which the market was made to serve global
interests: sustainable environment has gradually come to be seen as a
global public good.
The success in engaging finance ministers and heads
of state and make them understand the developmental consequences of
environmental policies, combined with an active collaboration with
media, non-governmental organizations and other parts of civil
society, were the elements that made the findings from the World
Commission on Environment and Development significantly change events.
This also helped create the momentum which drove the process towards
the Rio Summit in 1992.
His Royal Highness shared his commitment to the
issues of sustainable development through his presence in 1987, when
we launched "Our Common Future" here in London.
Your Royal Highness: Your interest and dedication
left an impression on us all at a time when we could still not judge
the impact of the report, its analysis and recommendations on
international debate and on policy change.
Recently, we have been witnessing similar processes
with the issues of health.
The moral case has been made for years, and - by
and large - has been ignored: Until recently the illness of poor
people was not seen to have an impact on those who are better off. The
international community saw the ill health of poor people mainly as an
issue for minimal levels of development assistance and charitable
For global health, the HIV/AIDS pandemic seems to
be eye-opener that the Ekofisk accident was to environmental issues
among Norwegians. The debate over the moral, economic, social and
security consequences of this catastrophe now unfolding around the
world, has forced health onto the agenda in a way we have not seen
Health has now taken a central place; within the
context of debt relief discussions, as a central element of campaigns
around structural causes of poverty, the new focus on women and
children issues. There is growing awareness and a movement for change.
It is utterly unacceptable that preventable diseases should be partly
responsible for keeping billions of people in poverty.
I mentioned that for the environment, the link to
the economic impact was central in creating a momentum towards change.
What about health?
When I took up my post at the World Health
Organization, there were some early indications that there was more to
the relationship between health and development than what had
traditionally been accepted.
To increase our understanding about this key
relationship, I formed the Commission on Macroeconomics and Health.
Now, a good year into its work, it is beginning to assemble some
powerful evidence for saying that we have massively under-estimated
the role that health can play in determining the economic prospects of
the world's poor communities.
I believe we are now standing at the threshold of a
major shift in thinking. Until recently, many development
professionals argued that the health sector is only a minor player in
efforts to improve the overall health of populations. And the
overwhelming majority of finance officials and economists believed
that health is relatively unimportant both as a development goal and
as a strategy for reducing poverty. Health spending was seen as
consumption of scarce resources rather than investment in a common
future. But this is changing. Health may be far more central to
poverty reduction than our macroeconomist colleagues previously
We have known for years that people who are poor
are more likely to get sick. But we now know much more about how ill
health also creates and perpetuates poverty, triggering a vicious
cycle which hampers economic and social development and contributes to
unsustainable resource depletion and environmental degradation. We are
seeing evidence that health gains trigger economic growth and, if the
benefits of that growth are equitably distributed - this can lead to
We find too that societies whose health status is
good are societies where people are able to learn to their full
potential, earn their living and nurture others - be they children,
older people or those with disabilities. This observation underlines
the importance of placing health in a wider social and political
Think about it: in poor countries, it would take
very little to increase life expectancy by addressing the main killers
of children and adolescents. And yet a five-year difference in life
expectancy may yield an extra annual growth of 0.5%. It is a powerful
boost to economic growth. Modest improvements in health can help
children, women and men to better achieve their potential, unlocking
value in every area of their lives.
As in Europe at the end of the 19th and
beginning of the 20th century, we have seen that developing
countries which invest relatively more, and well, in their peoples
health are likely to achieve higher economic growth.
In East Asia, for example, life expectancy
increased by over 18 years in the two decades that preceded the
most dramatic economic take-off in history.
A recent analysis for the Asian Development Bank
concluded that fully one-third of the phenomenal Asian economic growth
between 1965 and 1997 resulted from investment in people’s health.
Today, more and more economists and development
specialists recognize that if public funds are carefully spent and
lead to improvements in people's health, they represent an investment
in any country’s prime asset: its people. Developing country
leaders - from Africa, central and South Asia and Latin America,
maintain that if the world’s poorest countries are to have any
chance of catching up with the rest, they need to invest in health.
The stewards of the global economy - in the World Bank and IMF, and in
the treasuries of the richer nations, are reaching the same
The new economic analysis is starting to yield
One is the growing recognition that our world is
turning into a two speed global society: perhaps a billion people are
enjoying unprecedented prosperity and advantage, while nearly half are
living on less than $ 2 per day and have extremely limited prospects
for prosperity. This is the unacceptable - but not inevitable -
consequence of globalization.
Another is the realization that this perpetuation
of poverty and deprivation creates an insecure world for us all. Ill
health undermines human security.
A third is new evidence on the ways in which
frequent and severe illness keeps people and their societies poor, and
prevents them from taking advantage of opportunities to earn, to learn
and to have a better life. Widespread illnesses, such as HIV/AIDS,
malaria or TB, also reduce the size of global markets and the
prospects for international companies in large parts of the world.
Recent evidence shows how disease undermines
economic progress. Consider the burden of HIV infection. HIV
prevalence rates of 10-15% - which are no longer uncommon - can
translate into a reduction in growth rate of GDP per capita of up to
1% per year. TB, which is exacerbated by HIV, takes an economic toll
equivalent to $12 billion dollars from the incomes of poor
Africa's GDP would probably be about $ 100 billion
higher now if malaria had been tackled 30 years ago, when effective
control measures first became available. Even today, half a billion
cases of malaria each year lead to the loss of several billion days of
productive work: we do not need to accept this continuing inequity
when we have access to measures that will reduce the impact of this
disease on poor populations.
The economic burden of tuberculosis infection in
India alone is $ 300 million annually. Some 100 million work days
are lost due to TB, and one third of the total economic impact of TB
is incurred by those who suffer from the disease. Most of them are
poor and they can ill afford this extra burden. The World Bank has
shown that the economic costs to society resulting from
tobacco-related disease by far outstrips the gains from tobacco
production, sales and taxes, even in large tobacco producing countries
like Zimbabwe and Indonesia.
The concern that "we will all go together,
when we go" was central to the argument of the World Commission
on Environment and Development. The new analyses, now being pulled
together by the WHO Commission on Macroeconomics and Health, are
Illness does not respect national boundaries. The
patterns of globalization that promote increasing inequities will
encourage the spread of illnesses - particularly those which are
associated with extreme poverty. In the modern world, bacteria and
viruses travel almost as fast as money. With globalization, a single
microbial sea washes all of humankind. There are no health
The separation between domestic and international
health problems is no longer useful, as over two million people cross
international borders every single day. A tenth of humanity each year.
The Government of the United States has declared
that the global epidemic of HIV/AIDS is a national security threat.
Russia's people, and those in neighbouring countries, are seriously
concerned with the rapid spread of multidrug resistant tuberculosis:
governments and partners are doing their best to respond.
It is not only the infectious diseases that spread
with globalization. Changes in lifestyle and diet prompt an increase
in heart disease, diabetes and cancer. More than anything, tobacco is
sweeping the globe as it is criss-crossed by market forces. Only weeks
after the old socialist economies in Europe and Asia opened up to
Western goods and capital, camels and cowboys began to appear on
buildings and billboards.
New global health emergencies arise with little
warning. The issue of BSE and its link with Creutzfeldt-Jakob disease
has led to a global emergency within a period of a few months. None of
us knows the final cost of BSE and the threat it carries of
Creutzfeldt-Jakob disease, but it looks likely to run in the order of
several tens of billions of dollars. It will certainly be associated
with several ministerial resignations and crises for more than one
Your Royal Highness,
Now we can clearly see the powerful relationships
between health, environment, economics and society.
Global warming, air and water pollution, biological
and chemical pollutants in the food chain: all have an impact on
Environment and health are both inextricably linked
to development. "Poverty is the greatest polluter", said
Indira Ghandi. She did not blame the poor. She pointed to the obvious:
As long as people are poor the immediate issue is survival. Caring for
the future is a luxury.
So poverty links health and environmental issues
together. We are moving towards a comprehensive view of development,
focused on poverty reduction, participatory democracy and empowering
of all groups in society.
As we look to the future, we are presented with two
sharply different scenarios. Which of them we will turn into reality
depends on the extent to which we can secure the political backing for
firm global action.
The first scenario is truly horrendous. The
incurable illness caused by HIV has already infected 36 million
people in our world, and could still bring about devastation that far
exceeds our most pessimistic expectations. The number of people
infected with HIV doubles every year in Russia. HIV infection has
progressed from a disease experienced mostly by the country’s
intravenous drug-users to joining tuberculosis as one of the country's
largest public health threats.
India could well be the scene of the next explosive
increase in HIV infections: the pessimistic projection is that it will
supersede what we have experienced in Africa over the past decade.
China is also under threat of a major epidemic.
Climate change as a result of global warming is
already breaking down century-old borders for malaria, spreading the
disease into areas which have been free of the disease for decades or
may never before have been under threat. Increasingly, malaria
parasites are becoming resistant to commonly used and inexpensive
Climate change may also be linked to the recent
increase in violent weather patterns with a growing number of natural
disasters bringing death and destruction in their wake.
Air pollution will be a growing health hazard. WHO
estimates that close to half a million people are dying prematurely
world-wide from exposure to air pollution, much of it linked to
increased car density. In many Asian cities there has been an
explosive rate of growth of cars, by as much as 600% during the last
The combination of pollution, lack of sanitation,
the growing migration from the countryside to the cities and extreme
poverty, have made many of the cities in the developing world
extremely dangerous to the health of those who live there. One of my
staff members who until recently lived in Manila - one of the great
urban centres of Asia - saw both his children infected by TB and some
of their neighbourhood children die from dengue fever. And he didn’t
live in a slum. These diseases had already jumped the barbed-wire
fences protecting the neighbourhoods of manicured lawns and swimming
In addition, developing countries must deal with
the double burden caused by increasing levels of noncommunicable
diseases. This is brought about by rapid changes in lifestyle and
eating patterns. Urbanising developing countries will increasingly
have to cope with the cost of treating cancers, diabetes and heart
disease, as well as a growth in mental illness.
Tobacco, is of course, the cause of most heart and
cancer-related diseases. If the growth in tobacco use goes unchecked,
the numbers of deaths related to its use will nearly triple, from four
million each year today, to 10 million each year in thirty years.
Practically the entire growth in tobacco-related mortality, more than
70% of these ten million deaths, will take place in developing
If we do not act positively, with courage and
resources, the gap between the three billion who live on less than $ 2
per day and the rest of us will increase. It will also threaten the
economic development of large parts of the world – and in doing so
affecting both the prosperity and the political and military stability
of our whole world.
There is a real alternative. The second scenario is
one where the mortality of the main infectious diseases, such as
malaria, tuberculosis and HIV/AIDS is drastically reduced. Where
issues such as global warming and serious pollution are dealt with
through forceful international action. And where global negatives,
such as the impact of tobacco sales and marketing can be dealt with
through internationally negotiated regulation.
Such a scenario calls for powerful political
leadership, and democratic action by all - women as well as men. This
means joint working by governments, civil society and the private
sector. There is no other way.
There are signs that we are moving in this
direction. The political commitment is evident. Heads of state
recognize that good health is essential - to fuel the engine of
development, to unleash the forces of economic development and to
permit the reduction of poverty.
We know how to reduce suffering in poor
Quite simply, if proven interventions are taken to
scale - and by that I mean to a global scale - we can contribute to
real reduction in poverty and sow the seed of longer-term prosperity
Later this year, WHO's Commission on Macroeconomics
and Health will provide a road map setting out what can be done. It is
already evident that the sum total of current government, development
agency and corporate effort is nowhere near enough to make a real
difference over the next decade. A massive increase in finance and
human resources is needed.
We expect nations that support development to
contribute to a steep increase in levels of resources for better
health of poor people. The G8 and European Commission have already
made commitments. Several billion dollars of additional funding are
The discussions that are underway in London, in
Brussels, in Washington, focus on how best to use these unprecedented
amounts for health in countries with under-resourced health systems
and weak governmental infrastructure. When the focus shifts to
outcomes, how do you make sure interventions reach the furthest
village? How do you measure performance? How do you assess progress?
In short, how can we be sure we are buying real health for our money?
At WHO, we are working hard to provide answers to
these questions, to reassure donors that money invested in health will
bring tangible returns. WHO is identifying the best technical
strategies to tackle the diseases that cause poverty. We are helping
to ensure that effective channels get funds and services to those who
need them. We are preparing systems to monitor progress and assess the
What I am talking about is a fundamental break from
"business as usual". This break includes a realization that
governments can only do so much. The private sector and civil society
must play a crucial role if we are to succeed.
Let me give you an example. Triggered by the
terrible realities of the HIV/AIDS epidemic, the pharmaceutical
companies have come under pressure to change the entire structure it
uses for pricing drugs that are needed in developing countries, but
which these countries cannot afford. This is a complex process. Drug
prices are only one of several key factors that will improve access to
medicines for all those who need them.
What has changed is the combination of new
awareness, negotiation, competitive pressures and political support
that drives this process forward. The research-based pharmaceutical
industry has pledged understanding and support for the principle of
widening access to drugs.
This is not trench warfare. It is a partnership for
change where all parties are out to find the best possible solutions.
Partnership that is driven by enlightened self interest, not charity.
This is the way forward. Often the best
partnerships are those that are forged between unorthodox entities.
When people with vastly different backgrounds come together with a
shared purpose, creativity is released and expertise is used in
innovative and constructive ways.
In that spirit, we are working with companies and
foundations - to develop new treatments, vaccines and preventive
We encourage approaches to health action that
involve all sections of society. People themselves, joined by public
and private partners who promote best public health practice with new
energy, commitment and enthusiasm.
The private sector’s role is crucial - also for
its own future interest. Brusquely put: reducing poverty and ill
health is good for business.
The private sector plays a central role in the
economic and social fabric of any country - but often more so in
developing countries which suffer from under-developed and
under-resourced public sectors. A single company can have better
distribution networks and communication capacities than the government
in the country it works. Through its workforce, some companies can
reach whole communities or sectors of society. From their presence in
a large numbers of countries, many companies possess a set of
experience and a perspective that no national government or public
sector entity can match.
In this new age, being global means being local
world-wide. Companies which show commitment to the countries and
communities they work with find that their standing among people -
ranging from prime ministers to their own work force - improves. So
does productivity. In the long term, markets are increased.
Some companies have already given higher priority
to people's health, working within the context of global initiatives.
They contribute to polio eradication through the Rotary Movement; to
the elimination of leprosy through the Novartis and Sasakawa
Foundations and to the control of river blindness through the Mectizan
By joining partnerships - like Roll Back Malaria,
GAVI and Stop TB - companies support the adoption of tried and tested
strategies in communities affected by illness. They implement what
works and focus on results. Take the example of ENI, the Italian
petroleum company, which is working with government and civil society
in Azerbaijan to reduce the risk of malaria infection and increasing
people’s access to effective treatment.
Many companies have now joined the movements to
reduce the risk of HIV infection and to enable people living with HIV
and AIDS to access care. The companies that have established the
Global Business Council on HIV-AIDS have set a powerful example,
encouraging individual action, collective advocacy and the sharing of
Much more could be done, if companies commit
themselves to global health, work together, using best
practices, to promote better health for all and help find ways to
bridge the resource gap.
Your Royal Highness,
Healthy people - healthy planet. It works both
ways. People influence the trends that destines the planet. The planet
affects people. Our environment is a major determinant of health. Our
societies, communities and individuals affect the environment.
The world has set major goals for improvements in
health. The benefit will be extraordinary - not only for the poor half
of the our world, but for all of us. Through its effect on reducing
poverty, it will also improve the health of the planet. That, in the
end, will benefit all the generations to come.