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Chapter 16 of 16

A call for healthy development

By Dr Gro Harlem Brundtland, Director General, World Health Organization

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Health indicators are a common measure of progress. For decades, governments and donor agencies have used life expectancy and infant mortality to demonstrate the impact of social and economic development. The underlying assumption for this is sound. By improving the economic prosperity of countries in a sustainable and equitable way, improvements in health usually follow.

The opposite is also true. Development and a good social infrastructure are indicators of a healthy population. Where there are significant improvements in the health of families and the workforce, economic and social conditions often improve as well as economic output. The interrelationships between health and development are so intertwined, that it is impossible to address one without the other. Improvements in community health depend on sustainable development. At the same time, health is a minimum requirement for development.

In the past two decades, the AIDS epidemic has made this interdependence obvious. One example is the relationship of AIDS with education. Prevention strategies are much more difficult where basic literacy skills are absent. At the same time, efforts to increase literacy have become an uphill struggle in many countries where the workforce has been devastated by HIV. In the United Republic of Tanzania, the investments in education required to yield expected standards have been increased substantially because HIV/AIDS is affecting an increasing number of teachers. Additionally, 20% fewer children attend school because parents are ill or dying as a result of HIV/AIDS.

Good health is at the heart of poverty alleviation
How does one break through the vicious circle of poverty causing illness, and illness causing poverty? Frustrations in identifying a simple path for human development can lead to ineffective responses.

One is to compartmentalize and focus health and development activities on singular, isolated projects as they can yield rapid and measurable progress. Unfortunately, accomplishments can soon unravel and prove to be unsustainable. Efforts to cure TB in refugee situations provide one such example. Well-meaning health workers often begin with what seems to be a straightforward task: treating every person diagnosed with TB. After a few weeks of treatment, the patient's health will improve. But when refugees are returned to communities lacking health services, it is unlikely that TB patients can continue their treatment for the entire six months required to cure the disease. These patients may ultimately develop virtually incurable multidrug-resistant types of TB and spread the disease throughout their communities.

Another way is to plan initiatives that are as comprehensive and encompassing as possible. But while well-coordinated multisector responses to poverty abound in theory, producing the desired results in practice has proven to be a challenge. Widespread reforms, prioritization and collaboration are more likely to succeed in countries where there is exceptional political leadership and the capacity to carry it through. Where such political leadership does not exist, development initiatives that attempt to address everything across sectors often risk achieving few measurable results.

Poverty and underdevelopment cannot be made to disappear by magic. To make progress, concrete and measurable contributions must be made in a coordinated way to remove the obstacles that prevent people from reaching their full human, economic and social potential. In any country, careful analysis of the evidence can identify priority health needs that can be addressed cost-effectively. This evidence must be advocated to new partners and other sectors, and they must be persuaded to contribute to an integrated approach. The vicious cycles of illness and underdevelopment cannot be broken by health projects alone. But progress can be achieved by a new generation of people concerned about health and development, who can involve new partners through persuasive presentation of the evidence.

This is why the World Health Organization believes that evidence-based decision-making and advocacy are at the core of its leadership role in health. The task of furthering health and development begins by identifying achievable and cost-effective initiatives that provide substantial benefits to communities. It also recognizes that in political decision-making, facts often do not always speak for themselves. Social conditions must be created through partnerships with governments, NGOs, the private sector, the media and grassroots community organizations to encourage leaders to make responsible choices.

Reducing the burden of infectious diseases is an achievable objective
Poverty breeds infections; infections breed poverty. The road out of this vicious cycle begins with efforts that contribute to a person's ability to meet basic needs. People cannot contribute to the economic progress of their family and community when they are rendered helpless by infectious diseases. By fighting infectious diseases, major obstacles to development are removed. As this report has shown, infectious diseases are the heaviest health burden faced by the poor and the young. Just six infectious diseases cause over 90% of deaths due to infections. But in every case at least half - and in some cases nearly all - of these deaths could be avoided simply by using affordable interventions. Effective disease control strategies such as DOTS, IMCI, ORT, childhood vaccinations, insecticide-treated bednets, social marketing of condoms and many other interventions can make a big difference to people's lives.

Healthy development
Healthy development requires the alleviation of the most devastating and avoidable health obstacles that slow economic and social development. It addresses the greatest health crisis of developing countries - infectious diseases - without simultaneously exchanging it for chronic and costly health problems that are rampant in richer countries. Healthy development implements poverty alleviation strategies in ways that contribute - and do not damage - the health of communities.

In the past 25 years, we have witnessed significant progress in sustainable development. The end of the Cold War and the reversal of nuclear proliferation have reduced global military spending and have provided opportunities to increase spending in other sectors. On average, life expectancy has increased by nine years. Since 1975, child death rates in developing countries have been cut nearly in half.

This progress must be tempered with the sobering reality that one out of two people in developing countries will still die from an infectious disease and by the fact that HIV/AIDS is changing their demography. On average, most of these deaths could have been prevented for $5 per person.

Infectious diseases inflicted a new magnitude of suffering after the world entered the last millennium. Western civilization had emerged from the Dark Ages and was beginning to take advantage of new knowledge afforded by travel and urbanization. Unfortunately, bubonic plague, syphilis, cholera and other diseases also capitalized on these opportunities. The population of Europe was reduced by nearly half. Will the new millennium be any safer from infectious diseases?

Two futures are equally conceivable as we enter the 21st century. The rapid economic and scientific advances of the past decade can be built upon, and the impact of infectious diseases can be cut dramatically. Or, infectious diseases can continue to burden human development, new diseases can emerge and drug resistance can reverse the scientific progress of the past century. Unlike our ancestors of a thousand years ago, we know both the causes and the solutions for most of the epidemics that plague us. How will history refer to us if we fail to control infectious diseases at the beginning of the new millennium?

Priority steps for overcoming the burden of infectious diseases
Political support - particularly money, policies and multisector involvement - is required to overcome the burden of infectious diseases. By mobilizing political support to address the following priorities, much of the death and suffering caused by infectious disease could be prevented.

  • Support for proven, effective and affordable priority strategies in controlling the most devastating infectious diseases, including:
    • Bednets and treatment strategies for rolling back malaria.
    • DOTS (Directly-Observed Treatment, Short-course) for stopping TB.
    • Childhood vaccinations for reducing deaths from measles and other preventable diseases.
    • IMCI (Integrated Management of Childhood Illnesses) for addressing diarrhoeal diseases.
    • HIV prevention strategies such as condom promotion, sex education and STI treatment for reducing the spread of HIV/AIDS.
    • Antibiotics used timely and appropriately for preventing pneumonia.
  • Strengthened health services and delivery systems in developing countries.
  • Intensified efforts to eradicate polio and guinea worm, and eliminate neonatal tetanus, leprosy, lymphatic filariasis, Chagas disease and onchocerciasis.
  • Expansion of surveillance systems that can alert the world to unexpected outbreaks, the emergence of new diseases and increased drug resistance.
  • Investment in the development of diagnostic tools, drugs and vaccines that can further improve our ability to affordably address the most serious and widespread infectious diseases.
© World Health Organization 1999
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