In October last year, UN Secretary General Kofi Annan
went to a hospital in Sarajevo to welcome "baby number six
billion". Nobody – least of all the Secretary General – would
deny that the choice of Fatima Mevic’s baby boy, born just after
midnight on October 12 had more to do with the Secretary General’s
travel schedule than with demographics. We can imagine that Mr and Ms
Mevic were rather bemused about all the fuss surrounding their baby.
The key point, though, is that Kofi Annan’s purpose was not to talk
about numbers. For the Secretary General, this birth was an occasion to
focus on a different moral issue.
He said that the "Day of Six Billion" challenged us all
"to live up to the promise of our time to give every man, woman and
child an opportunity to make the most of their abilities, in safety and
in dignity."
I share Mr Annan’s view. More than that, I have a mission. I want
to state it clearly, now, to all who are listening.
I want the fight against poverty to be our global cause as we
straddle the millenium. Our goal must be to create a world where we all
can live well fed and clothed, and with dignity. We must do this without
undermining future generations’ ability to do the same.
Tonight I want to suggest a fresh way of joining this fight. I will
argue that poor people will only be able to prosper, and emerge from
poverty, if they enjoy better health. I want health to be at the heart
of our struggle for sustainable development.
Let us look around our world as it is now.
About three billion people live on less than two dollars a day. In
other words half of the global population do not have anything close to
a decent standard of living. That means that 3 billion people live in
such poverty that they can’t afford proper housing, proper health care
or proper education for their children. Almost half of those people live
on less than one dollar per day. That means more than a billion people
not having enough to eat every day and at constant risk of malnutrition.
The poor really do die young.
Poverty has a woman’s face; of the 1.3 billion poorest, only 30%
are male. Poor women are often caught in a damaging cycle of
malnutrition and disease. This plight stems directly from women's place
in the home, and in society: it often also reflects gender bias in
health care. Women from poor households are more than a hundred times
more likely to die as a result of childbirth than their wealthier
counterparts.
Over the past few years, the human development index has declined in
more than 30 countries. Almost one third of all children are
undernourished. The average African household consumes 20% less today
than it did 25 years ago! And development assistance is falling too.
Only a few countries have fulfilled past commitments to provide 0.7 per
cent of their GDP for development assistance. In actual fact the world
average is now closer to 0.2 per cent.
Beyond the dry statistics lies tragedy. When I visited Africa
some months ago, I saw first hand some of the amputees, the malnourished
children and the despair that follow from some of the conflicts that
rage in this continent. These are not so much territorial disputes as
they are rooted in general misery, the aftermath of humanitarian crises,
shortages of food and water and the spreading of poverty and ill-health.
In a number of mega-cities around the world, the quality of life
among the five, ten, fifteen million poor who scrape out a living in
their vast slums is dismal. The noise, pollution, squalor and dangers
for those who have made their cardboard housing underneath the large
highway overpasses make modern urban living for the poor seem like a
latter-day realisation of Hell. The damage from pollution and the
continuous threat of violence add to the infectious diseases which
always leave their deepest imprint on poor people's lives.
Most of us agree that this state of affairs is unacceptable. Yet
still, we do little or nothing about it. The rich have lived next door
to appalling squalor for centuries without being sufficiently disturbed
to take any action.
But now, in our global economy, this may be beginning to change.
Over the past twenty-five years or so, population growth in many
countries has slowed rather faster than demographers had first
expected – especially in east Asia. Thanks to this slowing down, the
experts now believe the earth’s population will stabilise at around 9
billion – rather than 12 to 15 billion as some feared.
At the same time, the world's capacity to produce food has grown at a
fantastic rate, as a result of new grain varieties and economic
incentives to producers. In 1989 the Vietnamese government allowed
farmers to sell their rice freely on the market, encouraging new seed
varieties and farming techniques. Within two years, Vietnam went from
having to import rice to becoming the world’s second largest exporter.
The structure of societies is changing. Young adults in India,
Algeria and Iran struggle to find jobs, to earn an income and to see a
hope for the future. The Governments of Japan, Sweden and Spain struggle
to find answers to a rapidly ageing population, and to the challenge
this poses for their production and welfare systems. Ironically, many
developing and middle-income countries are caught with both problems:
they face a swelling population of older folk, while they still have to
cope with population growth.
Years of observation and experience have shown that families living
in freedom and given the opportunity to fulfil their basic needs, have
fewer children. These children are more likely to be healthy and
educated. Societies that have satisfied the basic needs of their
populations tend to reduce pollution and environmental destruction.
As population structures change, the role of the State becomes
clearer. Empower people to make meaningful choices. Create a supportive
environment for families. Look after the interests of children, for they
are the future. These principles are as relevant in India as they are to
Norway or indeed Switzerland where we are tonight.
None of this should surprise us. Ground-breaking consensus was
reached six years ago, when the International Conference on Development
and Population - in Cairo - firmly established that development, poverty
reduction and respect for women’s reproductive rights are vital to
stabilising the world's population.
We do not yet have a consensus about the importance of good health in
global development .
Europe learned about the existence of infectious agents around the
middle of the 19th century. The importance of hygiene and
clean water became apparent. The rich finally began to do something
about the dreadful slums that surrounded their wealthy areas. It was
self-interest that finally prompted action. As hygiene and health care
improved, the average life expectancy increased by nearly 20 years in
many countries. Following this development was the huge industrial push
that brought the current wealth and affluence to the West and
practically eradicated absolute poverty from most of Europe.
Unfortunately, the fear of disease that scared politicians, city
planners and corporate leaders to invest in health and sanitation for
the populations of Europe, did not then extend as far as to their former
colonies and the other countries far away from their own cities.
As we learn how to manage a global economy, the situation should
change.
Again, as in the 19th century, it is self-interest that
lies at the heart of this change. In the modern world, bacteria and
viruses travel almost as fast as money. With globalisation, a single
microbial sea washes all of humankind. There are no health sanctuaries.
Diseases cannot be kept out of even the richest of countries by
rearguard defensive action. The separation between domestic and
international health problems is no longer useful, as people and goods
travel across continents. Two million people cross international borders
every single day, about a tenth of humanity each year. And of these,
more than a million travel from developing to industrialised countries
each week.
This is an accelerating trend, and is not likely to be reversed.
Threats to health undermine what I call our " human security".
I suggest human security is as important as national security. The
levels of ill-health experienced by most of the world's people threatens
their countries' economic and political viability: this, in turn,
affects economic and political interests of all other countries.
Interestingly enough, not only infectious diseases spread with
globalization. Changes in lifestyle and diet prompt an increase in heart
disease, diabetes and cancer. More than anything, tobacco is sweeping
the globe as it is criss-crossed by market forces. Only weeks after the
old socialist economies in Europe and Asia opened up to Western goods
and capital, camels and cowboys began to appear on buildings and
billboards.
Those who think that tobacco-related death and disease is mainly a
burden for the rich countries are mistaken. If the growth in tobacco use
goes unchecked, the numbers of deaths related to its use will nearly
triple, from four million each year today, to 10 million each year in
thirty years. More than 70% of this increase will take place in
developing countries.
The people in most rich and middle income countries have come to
expect much better standards of health in the past fifty years. In that
time we have failed miserably in securing even a basic level of health
among the 3 billion who are poor. In the interval, some of their health
problems have become even more difficult to solve.
Recently, in Mozambique, I saw children with their eyes glazed by
fever from a malaria that could have been prevented if their parents
could afford bed nets. Deforestation had changed malaria in these areas
from a nuisance to a curse in a matter of twenty years.
More people are suffering from this killing and debilitating disease
now than ever before, and deforestation, climate change and breakdowns
in health services have caused the disease to spread to new areas, and
areas that have been malaria-free for decades, like in Europe.
In the Philippines, I have watched how beggars sit exhausted on the
pavements convulsed with coughing. Tuberculosis, which we long believed
had been brought under control by effective treatment, is on the rise
again. Increasingly, we see forms of tuberculosis which are resistant to
all but a very expensive cocktail of drugs.
I think that HIV/AIDS may be the most serious threat to face
sub-Saharan Africa and other developing regions.
Already, the AIDS epidemic is the leading cause of death in several
African countries. AIDS has reversed the increases in life expectancy we
have seen over the past thirty years. The social and economic
devastation in countries that could lose a fifth of their productive
populations is heart-rending.
I believe that we are facing this alarming situation largely because
of an outdated approach to development. Our theories have to catch up
with what our ears and eyes are telling us – and fast.
There was a period in development thinking - not so long ago - when
spending on public services, such as health and education, would have to
wait. Good health was a luxury, only to be achieved when countries had
developed a particular level of physical infrastructure and established
a certain economic strength. The implicit assumption was that health was
to do with consumption. Experience and research over the past few years
have shown that such thinking was at best simplistic, and at worst
plainly wrong.
I maintain that if people's health improves, they make a real
contribution to their nation's prosperity. In my judgement, good health
is not only an important concern for individuals, it plays a central
role in achieving sustainable economic growth and an effective use of
resources.
As in Europe at the end of the 19th and beginning of the
20th century, we have seen that developing countries which
invest relatively more, and well, on 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 take-off in history.
A recent analysis for the Asian Development Bank concluded that fully
a third of the phenomenal Asian economic growth between 1965 and 1997
resulted from investment in people’s health.
I am rarely able to persuade people to share these views using moral
arguments. I have much more confidence in what I will describe as
"enlightened self interest".
We all fear of the spread of disease, as I have already mentioned.
Increasingly, corporations appreciate the market opportunities provided
by affluent populations. This encourages investment in health as a means
of reducing poverty.
Think about it. Globalization is about much more than trade. It is
about communicating with an infinity of new people, about relating to
them – and therefore also getting involved in their lives.
The company which sets up a production plant in Vietnam or Peru may
do so based on an evaluation of economic opportunities, but it will soon
find itself having to relate to the political, social and economic
reality of the country it has chosen to invest in.
One large engineering company ran an advertising campaign some time
ago saying that being global meant being local world-wide. True.
Companies that show commitment to the countries and communities they
work with find that they are better appreciated - whether by prime
ministers or their own work force. Productivity increases too.
A company that deals with developing countries has to confront the
challenge of poverty and ill-health. A company’s stock price can fall
on Wall Street because workers in a subsidiary’s plant in Malaysia are
not provided with health insurance. As communication and social activism
become globalised, large companies find that labour standards are
important. Ignoring them can be costly both to public image and stock
prices.
We need an enlightened response to the challenge of a "managed
global economy."
New technology, almost inflation-less growth and soaring stock
markets in many Western countries have created an almost dizzying
sensation that the old rules don’t apply anymore. Sometimes I wonder
what has happened to the ideologies that used to guide us. Marx is dead,
Adam Smith is certainly gone, and so it seems has every economist who
ever provided any rules for decision-makers to follow. For pessimists,
there may be much to worry about, but for anyone with belief in human
creativity, these are times of opportunity.
Several countries - including the United States - now recognise that
improving international levels of health is a matter of national
security. Earlier this year, the Security Council met and discussed the
global AIDS epidemic. The rationale for debating global health has
changed.
Also, with less than four hundred billionaires holding assets that
equal the cumulative worth of 45% of the world’s population, we start
to see a change in the flow of resources for poverty reduction. There
are many implications of this extremely skewed distribution of wealth.
One of the positive ones is the emergence, among these billionaires, of
individuals who have philanthropic ambitions. Any one of them could
single-handedly cover the cost of eradicating - or at least controlling
- a life-threatening disease.
I am delighted to see unorthodox new alliances being forged to
support human development.
Industry and international agencies are coming together to find ways
to get medicines and vaccines to those who cannot afford to pay. They
have established new partnerships to fight malaria, river blindness and
leprosy. As they reform their health care systems, governments build
networks that involve the private and voluntary sectors to get vital
services to people in need.
I am not so naïve as to believe that our world has, all of a sudden,
become a more altruistic place. But there are many new possibilities.
We need to bring the new approaches into the mainstream of
development activity. Many international organizations still have no
adequate mechanisms for working beyond the country level, reaching
directly to communities in need. We find it hard to work for people
ruled by corrupt despots, by weak leaders caught up in power-struggles,
or by plain warlords. As Chris Patten has already argued in this lecture
series, sustainable development cannot work without good governance.
In all our efforts we have to give special attention to the challenge
of reducing poverty. The Nobel economics prize laureate Amartya Sen
defines poverty as "deprivation of capability". He argues that
people are poor not only because their income is low, but because they
do not have access to basic services, such as health and education,
which would have increased their freedom. Poverty, he says, seriously
deprives people of a number of choices they must have available in order
to live a satisfying life.
This must be right. If you don’t have an adequate form of health
insurance, becoming ill means becoming poorer – both directly, because
you have to spend a part of your income to pay for treatment and
medicines, and indirectly, because your choices become limited.
The challenge for us all is to look at the world through the eyes -
and spirit - of poor people.
We need to start with poor people's realities, and trace upwards and
outwards to design services that really make a difference to their
lives, as Deepa Narayan suggests in her recent book, "Voices of the
Poor".
Quite simply, poor people all over the world dread being ill. It can
so easily be a disaster. It can throw a whole family into destitution.
Poor people have very limited choices. Medicine costs, fees charged by
health workers, and transport costs quickly eat into whatever funds are
available.
A rickshaw driver in Khulna, Bangladesh may well appreciate that he
lives in a place where the risk of tuberculosis is high. But his poverty
deprives him of the choice to live somewhere else. When he gets
infected, he cannot compete so well for work. His income goes down. This
sends the family into a spiral of debt and increasing poverty. His
children - particularly the girls - may be kept from school. The family
may have to cut out fish from their meals most days. Their malnutrition
increases vulnerability to illness - and risk of death.
Being too poor to go to an ordinary bank, the family has to borrow
from loan sharks who take perhaps 20% interest, perhaps 60% or more, in
order to pay for medicines. With such costs, our rickshaw driver
understandably chooses to cut the treatment as soon as he feels better.
It is likely that the infection will return, though next time resistant
to the normal drugs used for treatment. The health of others, who live
nearby, is in real danger.
It does not have to be like this. There are examples of TB programmes
that work properly for poor people. They would help our rickshaw driver
to be cured in six or nine months, and enable him to get back to work -
non-infectious - within weeks. He would be able to avoid crippling debt.
He would not need to take his children out of school. His own poverty,
and that of his family, would be reduced.
Take another example. Plantation workers in Indonesia were treated
for chronic anaemia. Results showed a 20% increase in productivity,
increasing the earnings of the workers and the output of the plantation.
Relatively simple health interventions, like effective treatment for
TB, getting a bed net against malaria in every African household,
eradicating polio, or providing an integrated child health programme,
can ensure that children are healthy and well nourished. They also
improve the economic situation and productivity of individual
households.
Quite simply, we have - in our hands - a concrete, result-oriented,
and measurable way of starting to reduce poverty.
To complete the task, education and infrastructure should improve.
Private investment and trade must increase. But good health is a
pre-requisite. Unless we help improve the health of the world's poorest
billion and a half people, they are destined to lives of continuing
poverty.
All this means that health must be moved from the periphery of the
development process to the centre, where it belongs.
The health minister must not sit at the far end of the Cabinet table,
but be up there next to the prime minister or president, together with
the finance minister and planning and industry minister. Today, health
ministers are in the hottest seats in industrialised countries. In
developing countries they often cannot even be found at the Cabinet
table. This, surely, is where they are most needed.
Are we ready to scale up our investments in poor people's health –
investments vital for sustainable development?
Think about it. Great advances in health have been made over the past
100 years. Our generation risks going down in history as the one that
allowed the hard-won health achievements of the 20th century to be lost
– lost because it decided to ignore the billion and a half people that
had been excluded from the health revolution. I use the word
"decided" deliberately. We cannot say we failed to act because
we did not know better.
The evidence is there – and so are the opportunities. I challenge
you to accept this new thinking and act on it.
Thank you.