The world health report

Global health improvement and WHO: shaping the future

A world torn by gross health inequalities is in serious trouble. The global health community can do much to reduce suffering and death among vulnerable groups. WHO is changing its way of working, alongside member states and financial and technical partners, to reach key national health goals and strengthen equity. The most urgent objectives include the health-related Millennium Development Goals, the 3 by 5 target in HIV/AIDS treatment (to provide 3 million people in developing regions with access to antiretroviral treatment by the end of 2005), and addressing the growing epidemics of non-communicable diseases. The key to achieving these objectives is strengthening of health systems guided by the values of Health For All.

Global public health: major challenges

The World health report 2003 provides a detailed picture of the current worldwide health situation. From these findings, urgent challenges emerge, to which WHO will lead an aggressive response.

Although aggregate global health indicators have improved substantially since the middle of the past century, the gross health inequalities highlighted in the Alma-Ata Declaration persist. Indeed, the gaps are widening between the world's poorest people and those better placed to benefit from economic development and public health progress. Over the last 50 years, average life expectancy at birth has increased worldwide by almost 20 years, from 46·5 years in 1950-55 to 65·2 years in 2002. The large gap in life expectancy between developed and developing countries in the 1950s has changed to a gap between the very poorest developing countries and all other countries. Thus, life expectancy at birth in 2002 ranged from 78 years for women in developed countries to less than 46 years for men in sub-Saharan Africa- a 1·7-fold difference in total life expectancy.

Of the 57 million deaths in 2002, 10·5 million were among children younger than 5 years, and more than 98% of these deaths were in developing countries. Worldwide, substantial progress has been made since 1970, when more than 17 million children died. In 14 African countries, however, current rates of child mortality are higher than they were in 1990. Overall, 35% of children in Africa are at higher risk of death today than they were 10 years ago. Across the world, children are at increased risk of dying if they are poor and malnourished, and the gaps in child mortality between the haves and the havenots are widening in many regions.

The state of adult health at the beginning of the 21st century is characterised by two major trends: slowing of gains and widening health gaps; and the increasing complexity of the burden of disease. The most disturbing sign of deteriorating adult health is that adult mortality rates in Africa have reversed so drastically that, in parts of sub-Saharan Africa, they now exceed those of 30 years ago. The most important cause of the reversal is the HIV/AIDS pandemic. Worldwide in 2002, despite trends of declining burden of communicable disease among adults, HIV/AIDS was the leading cause of mortality and the most important contributor to the burden of disease among adults aged 15-59 years.

The outbreak of severe acute respiratory syndrome (SARS), in early 2003, reminded the world of our shared vulnerability to new infections.1,11 In addition to the human tragedy of more than 8000 cases and more than 900 deaths, SARS caused serious economic damage. International travel to affected areas fell by 50-70%. Businesses, especially those related to tourism, failed, and some large production facilities were forced to suspend operations when cases arose among workers. The Asian Development Bank estimated the total cost of the epidemic to Asian economies at US$60 billion.12 Such effects show the importance that a severe new disease can assume in a closely interdependent and highly mobile world. And while SARS was the first major lethal infection to emerge in the 21st century, it will not be the last. Meanwhile, the burden of non-communicable diseases is increasing, especially in developing countries. Almost 50% of the adult disease burden in the high-mortality regions of the world is now attributable to noncommunicable disease; most of this burden is preventable on the basis of existing knowledge-the challenge is to convert this knowledge into effective national prevention policies and programmes. Today, the commitment to Health For All must include intensified work with countries to confront and reduce the double burden that threatens already fragile health systems.