Dr Margaret Chan, Director-General of the World Health Organization
29 December 2009 | Geneva
A decade into the 21st century: what do world events mean for public health and WHO?
The first decade of the 21st century has been a tumultuous one for the world, and also for public health. A decade that began with fears of the YK2 “millennium bug” saw terrorist attacks, wars, ethnic strife, human rights abuses, billion-dollar storms, a tsunami that killed 200,000 people in a matter of hours, irrefutable evidence that the climate is changing, a financial crisis ignited by greed, and an economic meltdown that quickly spread around the world.
The decade also saw the signing of the Millennium Declaration, with its health-related goals, and the creation of multiple new initiatives, partnerships, and funding mechanisms to pursue these goals. At the international level, the determination to improve health remained steadfast, despite some setbacks and much bad news on the economic, political, and environmental fronts. The impact of this commitment has been felt in measurable ways.
With support from the GAVI Alliance, launched in 2000, childhood immunization coverage reached record levels, and deaths among young children dropped below the 10 million mark for the first time in at least six decades. From 2000 to 2008, measles deaths fell by a remarkable 78%, prompting some to call for the elimination of this highly contagious disease. By the end of the decade, the Integrated Management of Childhood Illness approach had been adopted as the child survival strategy in well over 100 countries.
Antiretroviral therapy was extended to more than 4 million people living with HIV/AIDS in low- and middle-income countries – an achievement considered impossible a decade ago. In parallel, the number of new HIV infections dropped by 17% in the eight years following the 2001 UN Declaration of Commitment on HIV/AIDS. In 2007, the global treatment target for tuberculosis was surpassed. Since the DOTS approach to treatment was introduced 15 years ago, an estimated 36 million people with TB have been cured. The World malaria report 2009 demonstrated significant reductions in malaria deaths and all-cause deaths among children in countries with good implementation of recommended measures, indicating that impressive increases in development aid can bring impressive gains for health.
Commitment and determinations were also evident in the continuing drives to eradicate polio and guinea worm disease. Both initiatives show how difficult the last stretch can be, but also how ultimately rewarding it is to rid the world of a disease.
Research brought important gains, especially for diseases that disproportionately affect the poor. Vaccine discovery and development enjoyed a renaissance. New vaccines were developed to reduce childhood deaths from pneumonia and diarrhoeal disease and to prevent cervical cancer. Research further showed that simple measures, like zinc supplements, home-based management of malaria, community-directed distribution of medicines, kangaroo care for the newborn, and a checklist to reduce surgical complications, can work wonders.
Public-private partnerships for R&D yielded new medicines for malaria and a much better vaccine for epidemic meningitis. With the WHO prequalification programme acting as a catalyst, manufacturers of vaccines and other medical products in developing countries were able to compete on an equal footing with the pharmaceutical giants, resulting in increased supplies, more predictable markets, and lower prices. After many years of discussions and sometimes tense negotiations, member states adopted the Global Strategy and Plan of Action for Public Health, Innovation, and Intellectual Property. Many interpret this agreement as a major step forward in the quest for greater fairness in access to high-quality and affordable medicines.
part from the need for better control tools, the search for new medical products acquired added urgency as studies documented growing problems of drug resistance, especially for TB and malaria.
In the spring of 2003, the SARS virus began to spread internationally, sparking an equally rapid international response that stopped this new disease dead in its tracks within four months. WHO earned high marks for leading this response, and the public health community learned many lessons about the importance of swift action and transparent international collaboration.
At the end of that year, surveillance systems alert to a possible return of SARS picked up the first human infections with the highly lethal H5N1 avian influenza virus in Asia, the traditional birthplace of new influenza viruses. As human cases grew in number and spread to more countries, fears of an especially severe influenza pandemic likewise grew, sparking a drive to increase national and international preparedness.
The long-feared influenza pandemic was eventually ignited by a different virus on another side of the world. On 11 June, 2009, WHO declared the start of the first influenza pandemic since 1968. In my view, the fact that the pandemic has been moderate to date is the best good fortune of the decade.
Events during the decade showed the power of both success and statistics to draw attention to neglected problems or alarming trends, and garner support. In 2006, the World Health Report documented an estimated shortage of more than 4 million doctors, nurses, and auxiliary health workers, with the shortage most acute in the world’s poorest countries. Data and statistics also brought needed attention to unmet mental health needs, the significance of childhood injuries and violence, and the massive toll of road traffic crashes.
The world woke up to the universal threat from chronic noncommunicable diseases. Long considered the close companions of affluent societies, diseases like heart disease, stroke, cancer, diabetes, asthma, and other chronic respiratory diseases now impose their greatest burden on the developing world, where most health systems are ill-equipped to manage the demands of chronic care. In turn, the rise of these diseases in the developing world further underscored fundamental issues of health care financing, with emphasis on the sometimes catastrophic consequences of out-of-pocket payments for health care.
Smart strategies, good will, and good results brought the neglected tropical diseases into the spotlight. Supported by a strong coalition of partners, the introduction of integrated approaches to mass preventive chemotherapy raised the possibility, for the first time, that many of these ancient diseases could be eliminated by 2015.
In the second half of the decade, two legal instruments, aimed at reducing global threats to health, came into force: the Framework Convention on Tobacco Control and the International Health Regulations. Both respond to the increasingly trans-national nature of many threats to health. Parties to these instruments showed their willingness to give up some of their national sovereignty in exchange for strengthened collective defence against shared threats.
This willingness coincided with growing recognition that health all around the world is being shaped by the same powerful forces. The speed and volume of international travel have made emerging and re-emerging infectious diseases a much large menace. We have seen this with the H1N1 influenza pandemic, which spread further in less than six weeks than past pandemics have spread in more than six months.
Unhealthy lifestyles have been globalized. This trend, together with demographic ageing and rapid unplanned urbanization, has contributed to the rise of chronic diseases everywhere. The distinctions between health conditions in rich and poor countries are no longer so clear-cut. Every rich country has pockets of poverty. Every poor country has pockets of wealth, sometimes fabulous wealth. Everywhere, the poor are about a century behind their wealthy counterparts, in health status, life expectancy, and access to basic care. As WHO data have shown, catastrophic health care costs drive an estimated 100 million people below the poverty line each year. This is a bitter irony at a time when health is being pursued as a poverty-reduction strategy.
Near the end of 2009, WHO issued its first report on the health of women and girls, worldwide and throughout the life course. It is my sincere wish that the findings set out in this report will galvanize the efforts of partners, focus their actions, and stimulate research to fill the many knowledge gaps.
During the decade, the international community came face-to-face with some especially difficult challenges that can no longer be ignored. Let me mention four.
First, much aid, also for health, is ineffective. The Paris Declaration on Aid Effectiveness and the related Accra Agenda for Action provide instruments for addressing this long-standing problem. In doing so, these instruments also acknowledge that some of the fault lies with donors, and not just with weak capacities and poor leadership in recipient countries. We learned, too, that the answer does not lie in circumventing these weaknesses by building parallel systems, such as for drug procurement and distribution, data collection and analysis, financial management, or monitoring and reporting.
This approach increases the burden on recipient countries, creates duplication, fragments service delivery, and undermines government accountability for the health of its citizens. In contrast, good aid builds the foundation, the capacity, and the infrastructure needed to move towards self-reliance. If aid does not explicitly aim for self-reliance, the need for aid will never end.
Second, health systems and other fundamental capacities, including for data collection and analysis, must be strengthened. Progress towards the health-related Millennium Development Goals stalled. As the international community now recognizes, powerful interventions and the money to buy them will not improve health in the absence of well-functioning systems for delivery. In the final analysis, the failure to make better progress towards international goals is the result of decades of failure to invest adequately in basic health infrastructures and capacities.
The international community can no longer close its eyes to the need to invest in fundamental capacities, also for reasons unrelated to the Millennium Development Goals. The ability to implement the Framework Convention on Tobacco Control depends on regulatory and enforcement capacity, especially in developing countries that are now being targeted by the tobacco industry. The full power of the International Health Regulations depends on national surveillance, laboratory, and reporting capacities, especially in the developing world where most epidemics occur and most new diseases emerge.
As a third harsh reality, this decade has demonstrated how often health is on the receiving end of bad or short-sighted polices made in other sectors. More and more, health is being shaped by policies set in sectors where health has no control and often very little say. When food prices soar, health – and especially health of the poor – suffers. When policies support the industrialization of food production and the globalization of its marketing, health suffers from a wave of diet-related chronic diseases. The health sector had no say in the policies that made climate change inevitable or set the stage for economic meltdown. But public health pays the price. What this means, unfortunately, is more and more natural disasters and health emergencies, and more and more demands for humanitarian assistance at a time when resources in all countries are strained.
Finally, we saw even more reasons why a renewal of primary health care is the best way forward for the development of health systems and the delivery of equitable, inclusive, and comprehensive services, including those for preventive care. Worldwide, inequities have increased. As the statistics show, globalization has not turned out to be the rising tide that lifts all boats. Instead, it has lifted some of the bigger boats but tended to swamp or sink many smaller ones.
We all know the problem. Too many models of development assumed that living conditions and health status would somehow automatically improve as countries modernized, liberalized their trade, and experienced rapid economic growth. This did not happen. Instead, differences, within and between countries, in income levels, in opportunities, in health status, and in access to care, are greater today than at any time in recent history.
As noted in the report of the Commission on Social Determinants of Health, the blame for these growing inequities rests on the shoulders of policy-makers. Equity is very rarely an explicit objective in the policies that govern the international systems for finance, economics, commerce, trade, and foreign policy.
As we have seen during this decade, more and more crises have global causes and global consequences. In a century characterized by radically increased interdependence, the effects of mistakes are highly contagious, though the consequences are not evenly felt. Developing countries have the greatest vulnerability and the least resilience. They are hit the hardest and take the longest to recover.
Inequities in a world that is already greatly out of balance seem destined to grow even greater. Already, nearly one billion people live on the margins of survival. It does not take much to push them over the brink. In this sense, too, a renewal of primary health care is an important corrective strategy, as well as a protective one.
In conclusion, I believe we are on the right track. During the decade, public health experienced some remarkable achievements, despite many serious challenges thrown our way from events in sectors beyond our control. I thank the Regional Directors for supporting my agenda with such solidarity, adapting agreed approaches to regional and country conditions. After two meetings with the heads of WHO country offices, my appreciation and admiration for the work done in country offices has increased considerably.
My sincere thanks to all staff, at all levels of the Organization, for a decade of steady, solid progress as we work together to improve world health.