Charting the future
By the end of the 20th century we could be living in a world without poliomyelitis, a world without new cases of leprosy, a world without deaths from neonatal tetanus and measles, a world without dracunculiasis. In 1993 measles killed nearly 1.2 million children and infected more than 45 million; poliomyelitis killed 5 500 children and as of that year 10 million people were disabled; leprosy killed 2 400 people and infected 600 000; neonatal tetanus killed 560 000 newborn babies; dracunculiasis infected 2 million people.
By the end of the century maternal mortality could be half what it was in 1993, when more than 500 000 women died in childbirth. Infant mortality rates could be no higher than 50 per 1 000 live births. At least 70 countries had higher rates than this in 1993. By 2000 mortality of children under 5 years could be no more than 70 per 1 000 live births. At least 60 countries had higher rates than this in 1992. We could be living in a world where less than 10% of babies are born weighing under 2.5 kg. In 1990, 17% of babies were born below this weight. For babies born at the beginning of the 21st century life expectancy could be at least 60 years in every country of the world. In 1993, 50 countries were below this target.
In the year 2000 at least 85% of the world's population could be within one hour's distance of medical care. In 1993, about 1 billion people had no access to local health services within a one-hour journey. Deaths from malaria could be cut by a fifth in at least 75% of affected countries; the number of deaths and new infections from tuberculosis could be substantially reduced; the number of new carriers of hepatitis B could fall by 80% as a result of childhood vaccination; deaths from heart disease in people aged under 65 could be reduced by at least 15%; all pregnant women could have proper care.
The year 2000 could see a world where malnutrition among children under 5 years will fall by 50%; where micronutrient deficiencies from vitamin A and iodine will be eliminated; where the prevalence of iron deficiency anaemia in women of childbearing age will be reduced by 33%; and where 85% of the population will have access to safe water and 75% to safe sewage disposal.
These are neither utopian goals nor naïve wishes for a perfect world. They are achievable - provided the world cares enough and the necessary resources are made available. WHO sees four main priorities for action in the future.
The first priority is to ensure "value for money" by using the available resources as effectively as possible and redirecting them to those who need them most. The aim is to create self-help environments in which men and women can solve their own problems, establishing and sustaining a development process that will ensure a brighter future for their children.
The second priority is poverty reduction through better health. Investing in health saves money as well as lives. It must be accepted that expenditure on health is not a drain on national resources but a prerequisite for economic and social progress. Poor health inhibits an individual's ability to work, reduces earning capacity and deepens poverty. Poverty should thus be tackled on two fronts: one to meet people s basic minimum needs including access to health services, housing and education; the other to provide opportunities for people to earn their way out of poverty through better health and increased productivity. In addition to the economic aspect there is another side to poverty which must be corrected - social discrimination and low status for some groups, particularly women.
The third priority relates to public health policy, which in the decade of the 1990s has been influenced not only by the health-for-all movement, with its emphasis on equity, but also by political and economic changes in the world at large. At the same time it is recognized that ensuring equal access to health care, a traditional goal of public health authorities, will not necessarily reduce gaps in health status insofar as disease is determined by individual behaviour and by the working and living environment. Any genuine improvement in health will thus call for integrated, intersectoral action in addressing all the determinants of ill-health. The training of health professionals will have to be reoriented accordingly. The fourth priority is to strengthen national capabilities for emergency relief and humanitarian assistance in the health sector. The new policy of "emergency management for sustainable development" will provide a bridge between relief work and development proper, the aim being to reduce human suffering and economic loss due to epidemics, complex emergencies and mass population displacements.
The health problems of the future are awesome. Yet much can be done to tackle them with what we know already. In order to succeed the world will have to care more, and try harder, but the situation is not hopeless. Martin Luther King, writing about the civil rights struggle in the United States in the 1960s, said:"We shall have to repent in this generation, not so much for the evil deeds of wicked people, but for the appalling silence of the good people". Today, as a new generation approaches a new century, it is time for the appalling silence over global health inequities to be broken.