Steadfast in the midst of perils

Dr Margaret Chan
Director-General of the World Health Organization

Keynote address at the 12th World Congress on Public Health
Istanbul, Turkey
27 April 2009

Mr President, Paolo Buss, Your Excellency, President Abdullah Gul, Honourable Minister of Health, Recep Akdag, Professor Ishan Dogramaci, colleagues in public health, ladies and gentlemen,

First, let me thank the government of Turkey and the Turkish Public Health Association for organizing and hosting this world congress. It is a pleasure to meet in beautiful and historic Istanbul, where so many cultures converge.

In the recent past, some world trends have converged to the vast benefit of public health. Others threaten to set us back. We are meeting at a time when public health is caught in a cross-current, with a potentially lethal undertow.

From one direction, public health is bolstered by unprecedented commitment, determination to reach ambitious goals, and creativity in finding ways to do so. From another direction, public health is battered by the consequences of bad policies made in other sectors.

Since the start of this century, we have seen the launch of new funding mechanisms, new initiatives, and a host of new partnerships for health development.

Since the start of this century, commitments of official development assistance for health have more than doubled. Health has never before enjoyed such attention or benefitted from such wealth.

No one wants to see this momentum falter. But it is definitely under threat. We have made some impressive progress, but new challenges keep arising.

Last year, our imperfect world delivered, in short order, a fuel crisis, a food crisis, and a financial crisis. It also delivered compelling evidence that the impact of climate change has been seriously underestimated.

All of these events have global causes and global consequences, with serious implications for health. They are not random events.

Instead, they are the result of massive failures in the international systems that govern the way nations and their populations interact. In short: they are the result of bad policies.

Under the unique conditions of the 21st century, the consequences of faulty policies are highly contagious. This contagion shows no mercy and makes no exceptions on the basis of fair play.

Even countries that managed their economies well, did not purchase toxic assets, and did not take excessive financial risks are suffering the consequences.

Likewise, the countries that have contributed least to greenhouse gas emissions will be the first and hardest hit by climate change. The health sector, which had no say when these policy decisions were made, will bear the brunt of the consequences.

Already, nearly one billion people are living on the margins of survival. These people have no coping capacity. It does not take much to push them over the brink. There is no cushion to absorb the shocks of an economic downturn, high food prices, climate change, more floods and droughts, and a shrinking food supply.

Already, the costs of health care push an estimated 100 million people below the poverty line each year.

These are bitter ironies at a time when the international community is engaged in an unprecedented drive to reduce poverty and reduce the great gaps in health outcomes.

Ladies and gentlemen,

Collectively, we have failed to give the systems that govern international relations a moral dimension. The values and concerns of society rarely shape the way these international systems operate.

In far too many cases, economic growth has been pursued, with single-minded purpose, as the be-all, end-all, cure-for-all. The assumption that market forces could solve most problems has not proved true.

Too many models of development have assumed that living conditions and health status would somehow automatically improve as countries modernized, liberalized their trade, and improved their economies.

This did not happen. In fact, some would argue that the rise of chronic diseases is an indication that a country has successfully liberalized its trade and modernized its economy.

Between the policy decisions and the assumed results falls the reality. The rising tide of globalization has not lifted all boats. Instead, wealth has come in waves that lift the big boats but swamp or sink many smaller ones.

In reality, the differences, within and between countries, in income levels, opportunities, and health status are greater now than at any time in recent history.

Something has gone terribly wrong.

As the economists tells us, the current financial crisis is so severe because it comes at a time of radically increased interdependence among countries.

But it is not just nations, financial markets, and economies that are closely interdependent. Different sectors are also closely intertwined. Policy spheres are no longer distinct.

Our world’s fate and fortunes are truly interconnected in a web, so that if you pull one string in one sector or system, the vibrations are felt in many others. A policy that seems perfectly sound and good for one sector can have severely negative side-effects in others.

The single-minded pursuit of economic growth, compounded by behaviours motivated by greed, has had negative consequences well beyond the financial and economic sectors.

Policy-makers have either failed to anticipate these consequences or assumed that problems would be solved by market forces. This did not happen.

Let me be perfectly clear. I am not against free trade. I am not in favour of protectionism. I am fully aware of the close links between greater economic prosperity, at household and national levels, and better health.

But I do need to say this. The market does not solve social problems. Public health does.

Ladies and gentlemen,

The financial crisis has ushered in a time of great soul-searching. As some ask: have we gone adrift? Have the great ships of state lost their rudders?

According to many experts, the financial crisis is a watershed event. They foresee transformational changes as the world rethinks how it works and redesigns its international systems.

Where does public health stand as the world rethinks itself? How can we keep this cross-current of promises and perils, of commitments and crises, from turning into a deadly undertow for health?

I personally believe that public health offers much of what is now accepted as missing in our flawed systems of international governance.

At the end of last month’s G20 summit in London, Prime Minister Gordon Brown declared that the reign of the Washington Consensus is over. It needs to be replaced by a new consensus that incorporates moral values. This view was echoed by many others.

What we are now hearing is calls for a fundamental re-engineering of the international systems. We are hearing clear calls, from leaders around the world, to give these systems a moral dimension and to invest them with social values – like equity, sustainability, community, and social justice.

Personally, when I hear these calls, I cannot help but think of primary health care and the value system articulated in the Declaration of Alma-Ata 30 years ago.

Even before the financial crisis, many public health leaders saw great merit in returning to the values, principles, and approaches of public health.

In my view, values like equity and social justice are more important now, in this out-of-balance world, than ever before.

Human society has always been characterized by inequities. History has long had its robber-barons, and its Robin Hoods. The difference today is that these inequities, especially in access to health care, have become so deadly.

Technical tools for saving and prolonging lives keep getting better, yet more and more people are left behind, excluded from the benefits of even the older tools.

And there is a second difference. The revolution in information technology makes these inequities highly visible, in real time. All around the world, people’s expectations for health care are rising.

They want health care that is fair as well as affordable and of good quality. Governments would be wise to heed this rising tide of expectations. As the economists, and the historians, tell us, vast inequities, also in health outcomes, are a precursor for social breakdown.

Ladies and gentlemen,

I see some good reasons for hope. Without question, public health is already being used as a platform and a lever for giving this lopsided world greater balance. And rightly so.

The principle of fairness in health is straightforward. People should not be denied access to life-saving and health-promoting interventions for unfair reasons, including those with economic or social causes.

In the health sector, fairness is not an abstract utopian ideal. It is a matter of life or death.

The HIV/AIDS epidemic brought unprecedented attention to the issue of fair access to health care. When effective antiretroviral treatments became available, an ability to pay became equivalent to an ability to survive for many millions of patients.

AIDS made inequitable access to health care both highly visible and ethically unacceptable. This, in turn, helped build determination to tackle many other inequities in health outcomes, especially when an inability to pay for existing, effective interventions was considered a leading cause.

When we look at the health sector, we find some good evidence that fairness is a priority for the international community, that equity matters, and that the health sector is a prime entry point for its pursuit.

In a sense, the Millennium Declaration and its Goals operate as a corrective strategy. They aim to ensure that globalization is fully inclusive and equitable, and that its benefits are more evenly shared. They aim to give this world a greater degree of balance: in opportunities, in income levels, and in health.

The underlying ethical principle is straightforward: those who suffer or benefit least deserve help from those who benefit most. In other words, the Millennium Development Goals aim to compensate for international systems that create advances and advantages, yet have no rules that guarantee the fair distribution of these benefits.

In a sense, the Global Fund is a mechanism for the redistribution of wealth in ways that bring down mortality in populations that cannot afford life-saving interventions.

GAVI exists to help ensure that children are not denied the benefits of new and more expensive vaccines simply because they were born in a poor country.

Advance market commitments for new vaccines aim to compensate for the fact that industry will not invest in vaccine R&D for diseases of the poor, who have no purchasing power.

UNITAID is a drug purchasing facility that draws funds from a levy on airline tickets, graded according to class. Its slogan is telling: making globalization equitable.

All of these initiatives and mechanisms are, in a sense, corrective strategies for market failure, corrective strategies for a world that has been growing more and more unfair, in deadly ways.

They are absolutely essential. This world will not, all by itself, become a fair place for health. This must be a deliberate effort, underpinned by an explicit value system.

It would be better, of course, if public health did not always have to correct and compensate for flawed policies in other sectors, and flawed systems of international governance.

But let me be frank. Support for public health can be fickle. We see very welcome support for the purchasing of interventions, like vaccines, bednets, and medicines for AIDS and TB. But investment in the health systems needed to deliver these interventions has been neglected for decades.

We see a significant rise in funding for health, but not in support for the general budgets of health ministers. Such budget support is essential for planning, the training and retention of staff, national ownership, and the responsibility and accountability of governments to their citizens.

Perhaps most telling, when policies aimed at health promotion cross purposes with economic goals or corporate business strategies, economic interests trump health concerns time and time again.

Can this change in the current climate of critical re-thinking?

The health sector remains chronically short of funds, and this situation risks deteriorating further during the economic downturn.

We have long had to sell health to the highest bidder. We sell health to ministers of finance as a good economic investment. We sell health to ministers of foreign affairs as an investment in health security, or human security, or epidemiological security. We sell health as human capital, social capital, and an engine for productivity.

Can this change? In a better world, health would be pursued for its own sake, its own intrinsic worth as a condition that allows people to develop their human potential. In fact, as a basic human right.

Some political analysts in affluent countries have taken yet another lesson from the financial crisis. As they say, it is time to understand that a well-managed and generous welfare state is not an enemy of globalization. Instead, it is the saviour.

Ladies and gentlemen,

In these difficult times, we have some powerful arguments and instruments at our disposal.

We have a strong value system, eloquently articulated in the Declaration of Alma-Ata. We have corrective strategies and facilities for steering, or at least nudging, this world towards greater fairness, and thus upholding these values.

We have a powerful policy instrument in the report of the Commission on Social Determinants of Health, issued last year. And we have a powerful approach for operationalizing these values, strategies, and policies. This is, of course, primary health care.

In conclusion, let me say this to all my colleagues in public health. Stay steadfast. Steer steady through this turbulent sea of perils, old and new.

After all, public health has always been on course.

Thank you.