Problems, Politics, and Policies
Health is precious. For all of us. For every child. For every woman. For every society. How can we hope to live productive lives if the right to health is beyond reach?
We cannot hope to reduce poverty, create economic growth, and integrate the poorest parts of our world in a global economy unless we drastically beat back the epidemics that are killing millions and draining the energy from hundreds of millions more.
When I took the helm of the World Health Organization seven years ago, AIDS, TB, and malaria were expanding mostly unchecked through large parts of the world, and there was little hope that we could treat the tens of millions already infected with HIV or turn around the malaria epidemic. Rates of routine immunization of children had stagnated or were declining.
Treatment for AIDS was out of the question. Now the prices of drugs for AIDS are no longer prohibitive, and we are rolling out treatment to millions.
New drugs and long-lasting bed nets have given us hope that we can drastically reduce deaths from malaria.
There is progress in the fight against the age-old threat of tuberculosis, which had seen a deadly revival, preying on those already weakened by HIV and AIDS.
Today immunization levels have begun to climb, and new vaccines are protecting many more children.
New financing has been made available to begin the real battle for health.
New private and public initiatives have made a big difference. The Gates Foundation; GAVI; The Global Fund to fight AIDS,TB, and Malaria; the Global TB Drug Facility; and numerous others are already securing results unthinkable five years ago.
Today we can say with certainty: We can do it! We know what works! Poor, understaffed, and unskilled health systems struggle to cope. AIDS treatment is no simple procedure. Combinations of pills, monitoring for resistance and side effects are unavoidable. Patients need to take their pills, every day for the rest of their lives. A challenge for any doctor here in the U.S. A formidable one in a village in Zambia or Cambodia.
Yet, it is happening. More than a million are now given treatment. Within this decade, six million worldwide could have the same opportunity. As we have drastically increased the resources and opportunities for health over the past few years, we have learned some important lessons
- We can move—even in very weak health systems.
- By providing drugs, vaccines, and diagnostics—we energize and motivate.
- Financing must be predictable, sustainable, and long-term
- Countries must set the priorities and create one national plan that donors respect and follow.
We have seen a tremendous turnaround in global health. We can actually reach the targets of halving the number of deaths from malaria, TB, and vaccine-preventable diseases by 2015 and reduce new HIV infections by a quarter.
These commitments, set at the Millennium Summit of the UN, have now been reconfirmed by the leaders of the world in New York in September.
We are far behind so far, but we also know: We can do it, with the necessary political and economic support from rich countries, and with a clear commitment from developing countries themselves.
Today public health challenges are no longer just local, national, or regional. They are global.
They are no longer just within the domain of public health specialists. They are among the key challenges to our societies. They are political, economic, and cross-sectoral. They are intimately linked to environment and development. They are key to national, regional, and global security.
Historically, disease in other places was seen as an impediment to exploration and a challenge to winning a war. Cholera and other diseases killed at least three times more soldiers in the Crimean War than did the actual conflict. Malaria, measles, mumps, smallpox, and typhoid felled more combatants than did bullets in the American Civil War. And the Panama Canal went over-schedule because of “tropical” diseases—then unknown, untreatable, and often fatal.
Today on that front, there are very few unknowns. In an interconnected and interdependent world, bacteria and viruses travel almost as fast as email messages and money flows. There are no health sanctuaries. No impregnable walls between the world that is healthy, well fed, and well off, and another world, which is sick, malnourished, and impoverished. Globalization has shrunk distances, broken down old barriers, and linked people together. It has also made problems halfway around the world everyone’s problem. And we know that, like a stone thrown on the waters, a difficult social or economic situation in one community can ripple and resonate around the world.
Now, there are solutions for those diseases, which plagued the explorers, soldiers, and colonialists of historical times. We know how to prevent and treat malaria. There are vaccines for yellow fever. There are treatments for TB. The striking feature is, while we diligently take antimalarials and top up our vaccinations when we travel to developing countries—the people living there, those threatened most by these diseases—don’t have this access. Three thousand children in Africa die each day from malaria. They die of vaccine-preventable diseases—like measles—by the hundreds of thousands. And, people are dying, by the millions every year, of HIV/AIDS.
Twenty years ago, HIV was a specter, all but invisible on the horizon. It was considered a disease that affected specific minorities, gay men, and intravenous drug users. Science was slow to respond. The rare cancer, Kaposi's sarcoma, was a marker and a sentence to die a painful, slow, and often lonely death.
The world took more notice with the realization that the human immunodeficiency virus knew no borders. Given the right vector, it could infect anyone—man, woman, gay, straight, healthy, and hemophiliac. By 1990 in wealthy countries, we were screening blood donors and teaching our kids how to protect themselves against HIV. Condom use had increased. Incidence declined. And then antiretrovirals were made available to those who could afford them. People in countries with health insurance gained access, giving tremendous hope for a longer, healthier life. In short, HIV diminished—for those in rich countries—as an urgent public health problem.
Today, more than 42 million people are HIV positive. Thirty million of them are living in sub-Saharan Africa. They are trying to survive in some of the poorest countries and conditions—with no access to the most basic health care—much less sophisticated and expensive treatment. Many have died. Many are dying. They are mothers and fathers, teachers, nurses and other health professionals, civil servants, miners, and soldiers. They are leaving a huge social and professional gap—an imminent threat to countries struggling to develop. They are leaving orphans, penniless grandmothers caring for their children’s children, family members, and communities frightened, hurt, stigmatized, and health systems stretched well beyond their often-frail capacities. We will see the effects of this unfolding tragedy for decades to come.
Let us think of other areas where HIV is creeping in—China, India, the Central Asian Republics. Knowing the impact in so many other areas, we cannot stand on the sidelines, only to see another HIV crisis unfold before our eyes with the economic, social, and political devastation it will bring.
The short, sharp impact of conflict more quickly brings to light the inevitable links between health and development, between health and security. The obvious—the war-wounded soldiers and civilians. The medium-term impacts—people uprooted, displaced to camps with little sanitation or health services, schools disrupted, and food insecurity.
Two years ago, the shortest, sharpest shock of all—an outbreak which captured imaginations, often more column inches than the war in Iraq, and always more headlines than AIDS, TB, or malaria. Severe acute respiratory syndrome put the world on high alert and drove unprecedented cooperation to stop a disease that had an immediate and negative impact on markets, on tourism. And, on trade—and on hospitals, even in the most well-developed countries with the most advanced health systems.
One person infected, staying at an international hotel, put the world at risk. And unlike other diseases that we can prevent or treat, SARS was undiagnosable, untreatable, and, for one of every six people, fatal.
As you all know, we now face the risk of a new, major influenza pandemic, in the wake of the Asian flu now spreading across the world. Until now, there has been no spread from humans to humans, although more that a hundred people have been infected from animals. Our public health systems are preparing by stockpiling medications and to initiate the production of a vaccine, in case such a new situation could be evolving. The experience with SARS has improved our international network's ability to respond.
The way the world responded to SARS was global public health at its best. Scientists put aside their differences and drive to be the first, and came together to share sequencing and study results. Doctors from around the world came together in virtual conferences, to share advice on how best to treat patients. Public health authorities from opposite sides of the globe flew to Geneva to share their experiences with SARS, their success and failures, with 192 member states at the World Health Assembly. And, as a result, in just four short months, we had identified a new disease and contained a global outbreak, which could have become a global catastrophe.
The short, sharp shock made us all stand up and pay attention. Due to the speed of science and using the best evidence, we quickly knew that SARS could infect anyone. Governments were committed. Resources made available. People made aware. Health workers given tools for action. Information shared across borders. In short, there was global mobilization to fight a global threat. The result—we probably won’t find ourselves ten years down the road with SARS also endemic in the countries that can least afford it—devastating lives and economies. Because we acted to make sure that wouldn’t happen.
And, we found that it was in everyone’s interest to act. In today’s connected societies, there was no choice. It was impossible to hide SARS in a world with the Internet and email. Impossible to pretend it didn’t exist, or that it was already contained. The consequences of doing so were mistrust in government, and in economies. Societies have been shaken to their foundation, fundamental questions raised about the handling of disease, of media and information, of constituents.
But to better understand the even wider picture, we must go back to the slow creep of disease. Who is affected? And why? These diseases we can protect ourselves against—malaria, TB, HIV, measles, diarrheal diseases, respiratory infections—are impacting people in the poorest countries—where economies don’t grow, where social unrest, unemployment, and the threat of civil conflict force the stagnation of health and education systems.
I am not talking about small numbers. Between 1990 and 2000, the human development index declined in nearly 30 countries. Well over a billion people—more than one-fifth of the world's population—are unable to meet their daily minimum needs. Almost one-third of all children are undernourished. In many countries, which have seen economic growth, increasing inequality means that the poorest part of the population has seen little or none of the benefits from this growth. The average African household consumes 20 percent less today than it did 25 years ago!
A world where a billion people are deprived, insecure, and vulnerable is an unsafe world. The separation between domestic and international health problems is losing its usefulness as people and goods travel across continents. More than two million people cross international borders every single day, about a tenth of humanity each year. And of these, more than a million people travel from developing to industrialized countries each week. Trade flows—of raw materials, goods and services—have increased 15-fold since 1945. Investment flows have multiplied more dramatically still, fundamentally changing the way that economies and societies interact.
Despite the long list of successes in health achieved during the twentieth century, the balance sheet is indelibly stained by the avoidable burden of disease that the world’s disadvantaged population continues to bear.
Successes in health have been unevenly distributed: 1.3 billion people have entered the twenty-first century without having benefited from the health revolution. These are the people who are still living in absolute poverty. That is, living on less than US$ 1 a day.
The health impact of this inequality gap is staggering. Despite the rise in average global life expectancy, in the least developed countries, three out of four people die before the age of 50. Infant mortality is almost seven times higher in a developing country than in industrialized countries. A child born in a developing country today runs a 1,000-fold greater risk of dying from measles than a child born in an industrialized country. Children living in absolute poverty have a five-fold greater probability of dying before their fifth birthday than their wealthier counterparts.
And tragically, giving birth in Africa is a perilous undertaking for far too many women. Where the statistics are the worst, one woman in every 16 faces death because of poor health and because she does not receive the care she needs when pregnant. By contrast, in most of Europe and North America, such a tragedy will hit only one woman in 4,000. No other indicator so starkly reflects the disparities in this world.
For many years we have heard a certain conventional wisdom going like this: The poor nations just need time, perhaps more than anticipated, before they will start the natural process of export-led growth and penetration of global markets. Today we know that this is not wisdom at all for a growing number of countries. The truth is that many countries and hundreds of million of people are not only stagnating, they are going backwards in a downward spiral.
A descent into poverty and lawlessness leads to rapid declines in health indicators such as infant mortality and life expectancy. At the CIA, where the analysts used to count warheads and troops, they are now paying attention to changing child mortality rates as a telling sign of a state heading for collapse.
The experiences over the past years show that we neglect countries in crisis at our peril. Economic crises in distant countries now reverberate in financial markets around the world. Mass migrations from failed states can topple governments and provoke conflict, even genocide. Pandemics—such as AIDS—can cut so deeply into the basic fabric of countries that their social, economic, and political repercussions destabilize whole regions.
Health can be a bridge for peace. Efforts to eradicate polio have brought entire regions together—16 countries across West Africa, where health workers cross borders to vaccinate children in neighboring villages. Where warring factions have laid down their weapons and picked up a vaccine vial. Where 60 million children were protected against polio in less than a week.
In the spring of 2003, the world also came together in the largest act of unity for health: 192 countries adopted the Framework Convention on Tobacco Control—the first truly international health treaty. Implementation of the treaty will see tobacco advertising banned, increases in the price of tobacco products, efforts to control smuggling, and more smoke-free places.
This tobacco convention had many opponents—many actively fighting to undermine the spirit and the letter. But those who wanted, and needed it most prevailed. Developing countries made the strongest push to see the convention adopted. Through this instrument, they have the power to keep the tobacco industry from encroaching further. And the power to reverse the current trend, which if left to fester, would kill ten million people every year by 2020. That is foresight—for health, development, and for global security. It illustrates the world creating a global public good.
Poverty breeds ill health. But we now know much more about how ill health also breeds poverty, triggers a vicious cycle, hampering economic and social development and contributing to unsustainable resource depletion and environmental degradation.
Now we are learning an even more powerful lesson. Health gains trigger economic growth, and, if the benefits of that growth are equitably distributed—this can lead to poverty reduction.
As in Europe at the end of the nineteenth and beginning of the twentieth century, we have seen that developing countries that 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 takeoff in history.
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 conclusion.
There are several reasons for this recent shift in thinking. 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. Another is the realization that this perpetuation of poverty and deprivation creates an insecure world for us all. A third is new evidence on the ways in which frequent and severe illness keeps poor people and their societies poor and prevents them taking advantage of opportunities to earn, to learn, and to have a better life.
At WHO I put a key emphasis on the need to get our science and evidence right, not only our health evidence, but also the evidence about the interaction between health and development. Led by Professor Jeffrey Sachs, now at Columbia University, the Commission on Macroeconomics and Health delivered a report that will remain a landmark in improving our understanding of how wise health interventions can spur development.
Malaria alone taxed Africa's combined GDP by about $100 billion compared to what it could have been if that disease had been tackled 30 years ago, when effective control measures first became available.
The commission’s report provides a reference for any policy maker—in rich and poor countries alike. It offers a strategy for investing in health for economic development, especially in the world’s poorest countries, based upon a new partnership of the developing and developed countries.
Extending the coverage of crucial health services, including a relatively small number of specific interventions, to the world’s poor could save millions of lives each year, reduce poverty, spur economic development, and promote global security.” These conclusions, illustrated my own observations and convictions: We need to invest in people, in their health and education, not only to promote human rights, but to spur economic growth.
In fact, competition in a global marketplace will not provide enough incentives for poor countries to move out of poverty. The idea that little help should be given to any country, apart from supporting free-market reforms and democracy, is now fortunately being seriously challenged.
Humanitarian aid and development assistance have contributed greatly to reduced suffering and increased security. We should expect even more. After a decade of shrinking resources for international development, donors have become increasingly focused on support for quality programs that promise to yield measurable results. It is a sign of hope that key donors have made commitments to raise, not lower their levels of ODA.
Public responsibility, local and national government action are, of course, indispensable to deal with the human and environmental challenges involved.
One key issue I would like to underline is that public policy should not allow fees at point of service to become an obstacle for obtaining necessary health care or become a catastrophic financial burden on households.
This means sustaining the health system, based on other sources, including general and earmarked taxes, social insurance, private insurance premiums, and community insurance prepayment.
A key responsibility of the health system is to narrow health equity gaps, and government needs to play a central role in making that happen.
Historically speaking, improvements in health and life expectancy were phenomena linked with the dramatic technological and economic changes taking place since the last part of the nineteenth century. Better health and nutritional status were both a result and a cause of higher income levels.
In contrast, the twentieth century health revolution has resulted far more substantially from the generation and application of new knowledge.
While life expectancy in England and Wales varied around an average of 40 years during the two centuries preceding 1870, in the subsequent 130 years it almost doubled. Other countries shared this pattern in the twentieth century.
As an example: The life expectancy for a Chilean female in 1910 was 33 years. Today it is 78 years, an increase of a remarkable 45 years.
From an average of 5.3 children at midcentury, her fertility has dropped to 2.3, barely above replacement level. This is what we call the demographic transition. Typically, following improved health and life expectancy, fertility falls. She will have fewer infections, less anemia, greater strength and stature, and a quicker mind. Her life is not only much longer, it is much healthier as well.
Other low- and middle-income countries are undergoing a similar transformation.
Tragically, recent exceptions to these favorable trends are seen in AIDS-ravaged parts of Africa, and for a variety of reasons, among adult males in Central and Eastern Europe.
However, the effects of democracy are even more clearly understood, when we reflect upon its impact with regard to the right to health and education for all. This has greatly helped generate and apply new knowledge.
Health systems have increasingly been developed that cover the whole population, although we know there still are big gaps between rich and poor countries, as well as within countries.
Health has therefore been centrally placed within the so-called Millennium Development Goals that were reaffirmed at the recent Summit of the United Nations.
Indeed, rather than continuing to point to poverty as the root cause of ill health, decision makers now increasingly focus on the two-way relationship between poverty and ill health, identifying health as one of the root causes of poverty—and one that is particularly amenable to public intervention.
Paradoxically, however, the poorest countries typically spend a much lower percentage of their GDP on health. As development cooperation is seen to be sorely needed to help poor countries to improve access to health and education, there is also a commitment made, in the UN Summit Declaration, to improve governance, fight corruption, and invest more in human development by the poor countries themselves.
Another paradox: Rich countries typically have a well-functioning health system with universal coverage, although there are remarkable exceptions. Such as in this continent, they spend 6–15 percent on health care. However, being highest in that range is no guarantee you are the best with regard to total health impact. Rich countries are on the average much more financed through public resources, typically between 50 and 70 percent, than poorer ones.
In poor countries, the poor are left to fend for themselves and have little or no access to health care. We can say they are the victims of a still privatized society and the lack of a real and vibrant democracy, one that pursues citizens' rights and focuses on alleviating poverty and inequality.
The importance of good governance and a functioning health system that reaches all has also been clearly demonstrated by the dramatic developments in China and also some of the other socialist countries after their rapid transition towards a market economy.
Dismantling of public services, also in health, has been followed by a reduction in health indicators and large inequities in access to health services.
In China, 71 percent of the people were insured, in 1981, only 21 percent by 1993.
These are some illustrations of why we need to invest in people, in their health, environment, and education, to create a world that is more prosperous, more just, and more secure.
The main question is one of taking responsibility, of using our democracies to promote change.
Investing in health is an obvious choice. It saves lives, millions of lives. It is a basic human right, and a question of social justice. But it will also boost the economy, of poor countries and of the world.