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Dr Desai,
Ladies and
Gentlemen,
My key message today is uncompromising: it is high
time to expand our ideas about what determines economic growth.
The new evidence gathered over recent years
concludes that health must be seen as a central factor not only in
social development, but also in countries’ ability to compete on the
global economic stage and achieve sustainable economic progress.
Health, therefore, must no longer be seen as an expenditure only the
rich countries can afford, but as a necessary investment by the
poorest countries of this world. I will also argue that this is an
investment we cannot leave to these countries to shoulder on their
own.
Simply, enlightened self interest compels both
industrialized country governments and private corporations to do what
it takes to drastically reduce the current burden of disease in the
developing world. To do so will be good for economic growth, be good
for health and be good for the environment. Not only for the three
billion people who have yet to benefit from the technological and
economic revolution of the past fifty years - but for us all.
At the beginning of this new century, I see two
critically important forces shaping the world we live in: the
revolution that is taking place in information and biotechnology, and
the growing momentum of globalization.
Both of these forces carry with them immense
potential for good. But, as we are all aware, they carry risks.
Between them, they can help to transform the lives of millions. But
they will not do so just because we want it to happen.
Let us start with globalization. Despite what the
critics may say, it is not inevitable that it will lead to inequity.
If it does, it is a sign of failure. Our challenge is to make positive
things happen. To shape the world. To make certain that the forces of
globalization contribute to a more just and inclusive global society.
A world in which the divide between the rich and
the poor continues to deepen; a world in which only a privileged few
have access to the fruits of the technological revolution, is a world
which will become ever more insecure. In the past, desperate
conditions on another continent might cynically be written out of one’s
memory. The process of globalization has already made such an option
impossible.
In the modern world, bacteria and viruses travel
almost as fast as money. With globalization, a single microbial sea
washes all of humankind. There are no health sanctuaries.
The separation between domestic and international
health problems is no longer useful. Millions of people cross
international borders every single day. A tenth of humanity each year.
It is not only the infectious diseases that spread
with globalization. Changes in lifestyle and diet can 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.
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 time.
Practically the entire growth in tobacco-related mortality, more than
70% of these ten million deaths, will take place in developing
countries.
Differences in health status dramatically
illustrate the divide between the rich and the poor in today’s
world.
We know, for instance, that the poor - those living
on less than $ 2 dollars a day - suffer disproportionately from the
ravages of communicable diseases. In 1998, communicable diseases were
responsible for about 34% of the total burden of disease world-wide,
but nearly twice that - 64% - among the fifth of the global population
living in countries with the lowest per capita income.
Most of these diseases can be prevented or easily cured with
available vaccines and drugs, but poor countries and poor people do
not have access to them.
We know too that communicable diseases -
particularly HIV/AIDS, TB and malaria are themselves major causes
of poverty. The success or failure of our collective response to these
threats is critical. It holds the key to the economic and physical
security - not just of individuals and communities - but of nations
and continents.
Health is not just one of the most potent symbols
of a divided world, it is an integral part of the remedy for healing
that divide.
A good year into its work, WHO's Commission on
Macroeconomics and Health, which I formed to provide a solid
evidence-base for future action, has already assembled some powerful
evidence for saying that we have massively under-estimated the
devastating effect of ill health on the economic prospects of the
world's poor communities.
HIV prevalence rates of 10-15% - which are no
longer uncommon - can translate into a reduction in growth rate of GDP
per capita of up to 1% per year. TB, which is made worse by HIV, takes
an economic toll equivalent to $ 12 billion dollars from the incomes
of poor communities.
Africa's GDP would probably be about $ 100 billion
more now if malaria had been tackled 30 years ago, when effective
control measures first became available.
Globalization does not have to lead to human
insecurity because of the spread of illness. Inequities in health are
not inevitable. Better health will result in major economic
benefits - for families and for nations. All this is now quite clear.
But to reap those benefits there is a need for a completely different
approach to investment.
There is an increasing recognition of the sheer
difficulty faced by developing nations as they seek to counter these
health threats. Poor countries cannot reduce the burden of diseases
associated with poverty if they can only spend $ 5-10 per person on
health each year. It is becoming clear that health systems which spend
less than $ 60 or so per capita are not able to even deliver a
reasonable minimum of services, even through extensive internal
reform. It doesn’t matter how good the structure is - as long as you
can’t afford to pay your doctors and nurses proper salaries and fill
the shelves with essential medicines and vaccines, a health system
will not be performing at a reasonable level.
It should not be like this. A number of health
interventions can dramatically reduce mortality from the main killers.
Supervised medication regimes for TB; nets impregnated with
insecticide against mosquitoes, and wide distribution of malaria
treatment among children and pregnant women; prevention programmes for
HIV/AIDS - or access to care programmes that can substantially slow
the mortality among those living with HIV. There are many more
interventions, proven to be effective on a local or national level.
Quite simply, if we can take these intervention to
scale - and by that I mean to a global scale - we have in our hands a
concrete, result-oriented, and measurable way of starting to reduce
poverty.
We estimate that to reach agreed targets for
malaria in Africa will require an additional 1 billion dollars a year.
For TB, around half a billion dollars per year in high burden
countries. For HIV/AIDS the gap is even larger - probably in the order
of 3 billion dollars for expanded prevention and support in
Africa alone. Add in the use of antiretroviral drugs and the costs
rise even more dramatically.
To achieve the targets that national leaders have
set means we must go to scale. Matching new ambitions with realistic
levels of resources. Business as usual is no longer an option.
Ladies and Gentlemen,
Let me then briefly turn to the power of modern
science.
Here too globalization is at work. It is quite
clear, for instance, that the development, marketing and sales of
genetically modified agricultural products might have taken a very
different course in the absence of a global debate about their value
and safety.
But let me keep the focus on health. No matter
where they are - in Rio, in Lusaka, in Mumbai or Moscow - people
living with HIV know that now there are drugs available which can
effectively prolong their lives. They can read news articles
describing what they are called and how they work. And they know that
only the most privileged among them can afford to buy them. This
widespread knowledge, a consequence in part of globalization,
radically changes the social and economic context in which these drugs
are developed and sold.
There is no doubt that these changes add to the
pressures placed on the global pharmaceutical and health technology
sector, which is among the most competitive and profitable in the
modern economy.
We cannot ignore the fact that essential drugs are
not an ordinary commodity. Access to health care is a human right and
governments and international agencies have an obligation to see that
this right is progressively realized. Access to essential drugs is
part of this obligation.
We have been witnessing an unprecedented effort,
driven by committed people from governments, nongovernmental
organizations, UN agencies and the private sector, to dismantle the
obstacles that are preventing essential drugs from reaching the
millions who need them.
Popular outrage, political will, market forces and
the best science are enabling the pursuit of a fundamental principle
of public health: the supply of essential medicines on the basis of
need rather than on the ability to pay.
A year ago, when WHO, UNAIDS and other UN Agencies,
embarked on a joint effort with 5 leading pharmaceutical companies,
the prices of medicines needed to slow the progression of AIDS were
far beyond what most Africans, Latin Americans and Asians, or their
governments, could afford. At a cost of $ 10,000 to $15,000 per person
per year the drugs were out of reach.
Today, antiretroviral combination drug therapies
have become available to African countries for around $ 1000 dollars
per patient per year - a tenth of what they used to be.
True, such prices are still beyond what almost any
African health system and most patients are able to spend. But it must
not stop here. We must ensure that not only HIV/AIDS drugs but all
essential medicines and vaccines are accessible to all. It will take
time, but we must make sure that no moment is wasted.
All of us would take the view that an effective
regime for international trade is one which allows countries to
implement workable systems that secures people's basic needs -
including their health needs - while respecting intellectual property.
We can only make this happen through political negotiation and legal
process. That is what is happening, now: I welcome the increased
public attention being given to the limited access to health care to
prevent and treat priority conditions within Africa.
Yes, the process is difficult. Along the road,
there will be disputes about how trade agreements are to be
interpreted. There will be challenges to those national drug policies
which seek to change the ways in which patent rights are applied.
These can only be solved by testing their limits through a legal
process: this is costly and frustrating to all concerned, but the
stakes are very high indeed.
Over the past weeks, we have seen the beginnings of
just one such legal process - in South Africa.
The World Health Organization strongly supports the
1996 South African National Drug Policy, whose objectives are "to
ensure an adequate and reliable supply of safe, cost-effective drugs
of acceptable quality to all citizens of South Africa and the rational
use of drugs by prescribers, dispensers and consumers."
WHO worked closely with the South African
Government in the formulation of this policy and has actively assisted
South Africa in implementing the policy. The policy is consistent with
long-standing WHO views on national drug policies, access to essential
drugs, drug quality, safety and efficiency, and rational use of drugs.
WHO fully supports the intent of the 1997 Medicines
Act 90, which is to operationalize key elements of the National Drug
Policy, including generic substitution, greater competition in public
drug procurement, improved drug quality, and more rational use of
medicines. We recognize that language within parts of the act is seen
as a challenge by some companies. During the past few years we have
worked with the different interests involved as numerous attempts have
been made to find a way forward that is acceptable to all.
Unfortunately, negotiations have so far failed to
achieve any agreement. 39 pharmaceutical companies have challenged
parts of the 1997 Medicines Act 90, contending that the law would
destroy patent protections by giving the health minister overly broad
powers to produce, or import more cheaply, versions of drugs still
under patent.
At the request of the South African Department of
Health, WHO has assisted in identifying relevant international legal
expertise to support, and report to, the Government of South Africa.
The court case as you know is now temporarily
suspended. We hope that renewed efforts will be made to resolve the
dispute, and that they will succeed quickly. The only acceptable
result is that all parties work together for a rapid expansion in
equitable access to essential medicines for all South Africans who
need them.
We need to act at the global level too. The new
political environment makes it essential for WTO and WHO to start
developing principles for improving access to essential drugs through
differential pricing along with increased international finance. In
April, the two organizations will host a meeting of an international
group of experts in Norway to further develop these principles and
possible solutions.
It would be naive, however, to think that reducing
the prices of medicines is enough to bring all people's access to
health care up to the desired standard. For example, 25 million
persons in Africa are thought to be infected with HIV. 5 million of
them are estimated to need health care that includes anti-retroviral
medication. Currently, only about 10,000 are thought to be receiving
this care. This calls for scaling up access by a factor of 500, using
medicines that cost around $ 600 per person per year. Similar
calculations suggest the need for a 30-fold scale up in the number of
Africans that use insecticide-treated mosquito netting, and are able
to access effective treatment for malarial illness.
Some, however, are pessimistic, in particular when
it comes to the issue of wider access to antiretrovirals. They claim
that bringing complicated HIV/AIDS treatment regimes to poor settings
is impossible. Such positions miss the point. We cannot deem a task
too difficult and then abandon it. Our job is to push the limits of
what is possible, making use of the best science and the dedication
that health workers already have shown in abundance.
True, work is needed before we can effectively
administer combination therapy without the elaborate laboratory
monitoring which is routine in industrialized countries. Clinicians
and researchers must work together to define essential components for
diagnosis, laboratory support, and effective care. Finding a minimum
standard that ensures safe use of quality drugs in poor countries is a
challenge we cannot shrink away from.
Ladies and Gentlemen,
I have focused so far on the present: how to make
the technologies that we have today accessible to a greater proportion
of the world’s population. But let me now turn to the future.
To sustain our efforts to reduce human suffering
and promote equitable development, we will need better tools - the
best that science can offer. New vaccines, new drugs and new
diagnostics - designed, developed and priced to respond to the health
needs of the poorest countries.
We need to ask ourselves: which essential global
public goods are unlikely to be developed or distributed at a
reasonable price through normal market forces alone? We need to think
about how we structure incentives to promote the necessary changes. We
need to decide who should pay the cost of R&D for diseases that
drive poverty. These, I believe, are policy questions for which we
need urgent answers.
We also need to look ahead and think about the
implications of knowledge resulting from new advances in genomics and
other areas of biotechnology.
The basic knowledge on the human genome is, of
course already in the public domain.
Today, most biotechnology research is carried out
in the developed world, and is primarily market-driven. It is
inevitable therefore, if this pattern continues unchanged, that the
knowledge and technology gap between developed and developing
countries will widen, and that the health needs of poor nations will
fail to get the attention they deserve.
Our challenge will be fourfold:
- to anticipate the consequences of new discoveries rather than
reacting to the effects;
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to assess the ethical aspects of this new
knowledge;
-
to determine which of the downstream
products of this discovery are public goods and therefore should
enjoy some protection from commercial exploitation; and
-
to ensure widest possible access.
Ladies and Gentlemen,
Scaling up our response to the diseases that create
and perpetuate poverty. Creating the conditions which will allow more
equitable access to the information, services and technologies that
have the potential to transform peoples lives. Pursuing a more
inclusive agenda for research and development. These are the
challenges as I see them today.
Later this year, the Commission on Macroeconomics
and Health will provide a road map setting out what can be done. It is
already evident that the sum total of current government, development
agency and corporate effort is no where near enough to make a real
difference over next decade. A massive increase in finance and human
resources is needed.
There are signs that world leaders have grasped the
necessity of such investments. Both the European Commission and the G8
leaders have agreed to targets for reducing the mortality caused by
malaria, TB and HIV/AIDS. Currently, detailed discussions among these
countries’ governments focus on how a new flow of money can best be
disbursed and invested. I would be surprised if we will not see
commitments of substantial amounts of funds by the time the G8 leaders
meet again in Genoa in July.
Scaling up involves a level of finance and human
effort that is way beyond what the poorest developing countries and
their health systems can be expected to deliver. To make matters more
complex, the widely reported prospects of cheaper medicines stimulates
increased public demand for care. This puts massive pressure on
national governments and their health ministers. Fortunately, some of
this pressure is beginning to reach the international community.
No matter how low the prices of medicines and
commodities fall, a massive increase in funding is needed to improve
the poorest people’s access to prevention and care for malaria,
tuberculosis, HIV, together with childhood and maternal illnesses.
Most of this money must come through increased development assistance
as well as debt relief. This has to be new money. Early results from
WHO's Commission on Macroeconomics and Health suggest that it must be
of the order of $ 10 billion per year. We can’t take from the little
that is already being spent on other development priorities.
To trigger such a massive increase in funding, WHO
is working with officials from developing countries and donor agencies
to develop new systems for efficient handling and monitoring the use
of resources. For example, we are working with countries to help
improve the performance of their health services to prevent and treat
those at risk, and their capacity to purchase medicines and other
commodities, distribute them and ensure they are well used.
We are talking about a fundamental break from
"business as usual". It will mean that governments go beyond
their traditional avenues for dealing with bilateral and international
questions. By shaping a global response to global health issues, we
are exploring new ways to collaborate.
Some times individual countries take a lead and
inspire others, such as Brazil’s effort to build a comprehensive
care system for people living with HIV.
Some times the world unites to regulate global
negatives, such as the growing sale and marketing of tobacco, through
the International Framework Convention for Tobacco Control, which is
currently being negotiated.
This break also includes a realization that
governments can only do so much. The private sector and civil society
play a crucial role if we are to succeed. New partnerships are formed;
partnerships where all parties are out to find the best possible
solutions. Partnerships that are driven by enlightened self interest,
not charity.
This is the way forward. Often the best
partnerships are those that are forged between unorthodox entities.
When people with vastly different backgrounds come together with a
shared purpose, creativity is released and expertise is used in
innovative and constructive ways.
We see such partnerships taking shape in the
discussions between countries, international agencies and major
pharmaceutical companies to find ways of increasing access to
essential drugs and vaccines.
We see them in the shape of the Global Alliance for
Vaccines and Immunization, GAVI, which combines contributions from
private sources such as the Gates Foundation, with funds from national
governments and which is testing out a new model of allocation of
funds as countries "compete" for money to improve their
vaccination coverage through "bids" that are evaluated for
quality and feasibility.
We see them in efforts to provide new purchasing
models that will encourage development and production of medicines and
vaccines needed for populations too poor to pay for them.
We see them in venture capital funds such as the
Medicines for Malaria Venture and the Global Alliance for TB Drug
Development, which finance the development of new medicines which
normally don’t have a market potential that would make
pharmaceutical companies invest in them.
This is just the beginning. As it becomes more
commonplace to consider health one of the prerequisites for
development and economic growth, along such basics as physical
infrastructure, good governance and a proper educational system, I
expect we will see a wide variety of new interventions and
collaborations. Most of them will involve the private sector in one
way or the other. Many will present governments with unorthodox
challenges, but all - if they are well designed an executed - will
yield significant, measurable, returns in terms of better health and
reduced poverty.
Better health provides people with an opportunity -
both as a good in its own right, and as a means which can enable many
of the world’s poorest to emerge from poverty. Better health is a
duty in the sense that we cannot ignore or condone growing inequity.
But the key point I want to leave you with is this: We have an
unprecedented opportunity to make a difference.
Thank you. |
