Protecting global health in a time of crisis

Keynote address at the South-South Development
Solutions Forum on Global Health
*Dr. Anarfi Asamoa-Baah,
Deputy Director-General, World Health Organization.
Washington, DC, USA, 16 December 2009.

Dr Roses, Mr Zhou, distinguished participants, ladies and gentlemen,

Let me begin with a word of appreciation to Dr Roses and Mr Zhou for organizing this important event, and for the leadership they and others are showing.

I have been asked to speak to you about the need to protect public health at a time of crisis. This world is facing crises - multiple crises on multiple fronts. As Dr Margaret Chan sometimes says: We are in a mess.

At the end of last month, a Time magazine cover story referred to the first ten years of this 21st century as "the decade from hell". The story took readers through a gauntlet of trying, sometimes dispiriting events.

Like Y2K fears and all those expensive precautions that started the decade off. Then terrorist attacks, wars, human rights abuses, multi-billion dollar hurricanes, a tsunami that killed 200,000 people in a matter of hours, a financial crisis ignited by greed, and a subsequent economic meltdown that quickly spread around the world.

The cover illustration pictured the usual year-end baby with a party hat, but this time bawling and wincing instead of cooing and smiling.

If public health had to write a similar cover story, the picture would not exactly be heaven, but it would show far less doom and gloom.

To start with, we could rightly show a smiling and cooing child.

The decade saw a breakthrough in the long impasse that seemed to hold childhood immunization coverage at 80%. Immunization coverage reached record heights, and childhood deaths dropped below the 10 million mark for the first time in almost six decades.

With support from the GAVI Alliance, launched at the start of the century, an estimated 4 million childhood deaths have been averted.

We saw the power of high-level commitment. The health-related goals of the Millennium Declaration, also signed at the start of the century, continued to drive momentum and spur innovations, in funding, strategies, partnerships, and new initiatives.

More than four million people living with HIV/AIDS in low- and middle-income countries are now seeing their lives prolonged by antiretroviral therapy - an achievement considered impossible a decade ago. Many countries are on track to reach the targets set for tuberculosis. In 2007, the global treatment target for TB was actually surpassed. For the first time in at least two decades, we are beginning to make some progress against malaria.

We saw some major boosts from research, and most especially for diseases that disproportionately affect the poor. We saw new vaccines for cutting childhood deaths from pneumonia and diarrhoeal disease and for preventing cervical cancer.

We also saw evidence that simple measures, like home-based management of malaria, kangaroo care for the newborn, and community-directed distribution of medicines, can work wonders. A new breed of public-private partnerships for R&D yielded new medicines for malaria and a much better vaccine for epidemic meningitis.

At the policy level, we saw some frank recognition of problems. Despite the best intentions, much aid, also for health, is ineffective. The Paris Declaration on Aid Effectiveness and the related Accra Agenda for Action provided instruments for addressing this long-standing problem. In doing so, these instruments also acknowledge that some of the fault lies with donors, and not just with weak capacities and poor leadership in recipient countries.

We learned, too, that the answer does not lie in circumventing these weaknesses by building parallel systems, such as for drug procurement and distribution, data collection and analysis, financial management, or monitoring and reporting. This increases the burden on recipient countries, creates duplication, fragments service delivery, and undermines government accountability for the health of its citizens.

Corrective instruments, like the Paris Declaration and Accra Agenda, have now been joined by operational approaches, such as the Harmonization for Health in Africa initiative and the International Health Partnership. With the problems frankly acknowledged, solutions are on the way.

We saw some collective solutions to shared problems. During the second half of the decade, two legal instruments, aimed at reducing global threats to health, came into force: the Framework Convention on Tobacco Control, and the revised International Health Regulations. Both respond to the increasingly trans-national nature of many threats to health. Parties to these instruments showed their willingness to give up some of their national sovereignty in exchange for strengthened collective defence against shared threats.

This willingness coincides with growing recognition that health all around the world is being shaped by the same powerful forces. The speed and volume of international travel have made emerging and re-emerging infectious diseases a much larger menace. We have seen this with the H1N1 influenza pandemic, which spread further in less than six weeks than past pandemics have spread in more than six months.

Unhealthy lifestyles have been globalized. Chronic diseases, once considered the close companions of wealthy societies, are now taking their heaviest toll in the developing world. The distinctions between health conditions in rich and poor countries are no longer so clear. Every rich country has pockets of poverty. Every poor country has pockets of wealth, sometimes fabulous wealth. Everywhere, the poor are about a century behind their wealthy counterparts, in health status, life expectancy, and access to basic care.

Under the unique conditions of this closely interdependent world, policy spheres are likewise no longer distinct. As we have seen, faulty or short-sighted policies made in one sector, like trade, energy, or food and agriculture, can have adverse consequences for multiple other sectors, and most especially so for health.

Ladies and gentlemen,

Though the past decade looks rosy from some perspectives, public health has also experienced some rude awakenings and days of reckoning. Time magazine predicted that the worst in the string of bad news is probably over, at least for the American public.

The same cannot be said for international public health. Some of the trends that became apparent during that "decade from hell" are especially ominous, with lingering consequences that are likely to shape health challenges for many years to come.

Let me mention three of these rude awakenings and the events behind them.

First, progress towards the Millennium Development Goals stalled. As the international community now recognizes, powerful interventions and the money to buy them will not improve health in the absence of well-functioning systems for delivery. In the final analysis, the failure to make better progress towards international goals is the result of decades of failure to invest adequately in basic health infrastructures and capacities.

The international community can no longer close its eyes to the need to invest in fundamental capacities. The ability to implement the Framework Convention on Tobacco Control depends on regulatory and enforcement capacity, especially in developing countries that are now being targeted by the tobacco industry.

The full power of the International Health Regulations depends on national surveillance, laboratory, and reporting capacities, especially in the developing world where most epidemics occur and most new diseases emerge.

While an emergency response to diseases like HIV/AIDS, malaria, and tuberculosis is fully justified, solutions that fail to build national capacities cannot be sustained in the long term. And here we face a dilemma. The Millennium Development Goals are results-oriented and time-limited. Donors are impatient, yet building fundamental capacities takes time.

As a second rude awakening, this decade has demonstrated how often health is on the receiving end of bad or short-sighted policies made in other sectors. More and more, health is being shaped by policies set in sectors where health has no control and often very little say.

When food prices soar, health - and especially health of the poor - suffers. When policies support the industrialization of food production and the globalization of its marketing, health suffers from a wave of diet-related chronic diseases. The health sector had no say in the policies that made climate change inevitable or set the stage for economic meltdown. But public health pays the price.

The final rude awakening can be interpreted, in part, as a setback in the quest for greater equity. As the statistics show, globalization has not turned out to be the rising tide that lifts all boats. Instead, it has lifted some of the bigger boats but tended to swamp or sink many smaller ones.

We all know the problem. Too many models for development assumed that living conditions and health status would somehow automatically improve as countries modernized, liberalized their trade, and experienced rapid economic growth. This did not happen.

Instead, differences, within and between countries, in income levels, in opportunities, in health status, and in access to care, are greater today than at any time in recent history. As just one example, the difference in life expectancy between the richest and poorest countries now exceeds forty years.

As noted in the report of the Commission on Social Determinants of Health, the blame for these growing inequities rests on the shoulders of policy-makers.

Equity is very rarely an explicit objective in the policies that govern the international systems for finance, economics, commerce, trade, and foreign policy. Globalization creates benefits, but has no rules that guarantee the fair distribution of these benefits.

As we have seen during this decade, more and more crises have global causes and global consequences. In this century of radically increased interdependence, the effects of mistakes are highly contagious, though the consequences are not evenly felt.

Developing countries have the greatest vulnerability and the least resilience. They are hit the hardest and take the longest to recover. Inequities in a world that is already greatly out of balance seem destined to grow even greater.

Already, nearly one billion people live on the margins of survival. It does not take much to push them over the brink.

Ladies and gentlemen,

The financial crisis hit the world like a sudden jolt and it hit the world where it hurts the most: money. Understandably, this event was quickly followed by a time of great soul-searching and finger-pointing. As the economists note, the crisis arose from a failure of corporate governance and risk management at every level of the financial system.

In this process of revisiting and revision, the experts were quick to find fault with some prevailing economic theories and to make heroes out of past thinkers who now look like they got things right, after all.

For example, the Economist news magazine recently ran a profile of Argentina's Raul Prebisch. His work during the previous century showed how the pattern of economic relationships at the international level kept developing countries from building the basic infrastructural links with one another that could support the growth of trade and technical cooperation. As he argued, the benefits of international trade and technical innovation accrue to wealthy nations, and not to developing countries that need these benefits most.

Describing Prebisch as a misunderstood moderate, the Economist concluded that, like Keynes, his work may be due for a comeback. In the end, he was looking at structural factors that perpetuate dependency and thus allow poverty to persist. Given the continuing persistence of poverty, and the almost perpetual need for aid, public health should pay attention as well.

In a sense, South-South cooperation is an important, and vibrant, corrective strategy for building these infrastructural links. In fact, all of the trends that I have mentioned help explain why this form of cooperation is so badly needed and holds so much promise.

A rationale and platform of action for South-South cooperation was set out thirty years ago in the Buenos Aires Plan of Action. That document launched a new model of technical cooperation that is based on mutual assistance and guided by common problems, histories, cultures, experiences, and the demands and aspirations of citizens. It also recognized South-South cooperation as an instrument of foreign diplomacy.

The emphasis is firmly on capacity building, self-reliance, and sustainability. The goal is not to save some lives through initiatives targeted at individual problems, but rather to tackle some of the structural causes of persistent poverty. Capacity-building is key.

The logic for good aid - whether North-South, South-South, or triangular - is straightforward. Good aid builds the foundation, the capacity, and the infrastructure needed to move towards self-reliance. Good aid aims to eliminate the very need for aid. If aid does not explicitly aim for self-reliance, the need for aid will never end.

Though the logic for good aid has held true for ages, the challenges facing health development have changed considerably in the decades since the Buenos Aires plan was launched. The basic problems remain largely the same: the persistence of poverty, the need to develop capacities and infrastructural links, and the need to share the benefits of progress with greater fairness.

But approaches needed to tackle 21st century threats to health are now very different. More and more, protecting public health means finding ways to counter or correct powerful universal trends that arise from policies or in sectors beyond the control of public health.

In recent years, the notion of "glocalization" has been put forward as a strategy that uses local forces to temper the effects of global pressures. The strategy was initially devised by Japanese managers as a way for businesses with a global reach to sell more to local markets. Its relevance has since grown, and glocalization has also been used as an alternative way of conceptualizing and delivering aid.

This gives us another way to consider the importance of South-South cooperation. In a sense, it can be viewed as an instrument for tailoring aid for health development to conform to local needs, demands, and capacities, and this, in turn, should shape international policies that govern the delivery of aid.

This form of cooperation creates a new dynamic, not between the extreme poles of wealth and poverty, but closer to a middle-ground. What works in public health, especially for capacity building, is often highly context-specific.

The chances of success are much greater when the contexts and experiences of cooperating countries are similar. The South has a vast resource of tested solutions to health development challenges. This translates into a great creative capacity to find solutions aligned with local needs, demands, and capacities.

The players, too, have changed over these 30 years. As we start the second decade of this 21st century, the geography of the world can longer be reduced to simple categories of rich and poor, wealthy and powerful, and impoverished, excluded, or dependent.

Several countries in the South have developed advanced technical capacities, especially in the biosciences. In terms of health outcomes, national wealth is no longer decisive. Several countries in the South have achieved levels of access to health care, life expectancy, and progress on basic health indicators that are not seen in wealthy countries with far greater per capita expenditures on health.

One consequence of these multiple global crises has been a recognition that many developing countries are now key players on the international stage. These new economic and technical powerhouses have a presence and voice that deserves, sometimes demands, a say when policies governing the international systems are devised. As we have seen during the Copenhagen summit on climate change, their concerns can no longer be side-lined, side-tracked, or side-stepped.

Ladies and gentlemen,

Let me conclude with a practical example. Vaccine manufacturers located in the South have changed the dynamics of the market for public health vaccines. During this past decade, ministers of health in the South, supported by partners like WHO, UNICEF, and GAVI, led the drive for increased immunization coverage, and this led to increased demand. Supplies have increased together with demand. The market is more predictable, supplies are more reliable, and prices have gone down, sometimes considerably. This benefits public health in every corner of the world.

WHO, through its pre-qualification programme, has played a catalytic role in this transformation of the vaccine market. By effectively granting manufacturers of high-quality products a seal of approval, the programme allows companies in the South to compete on an equal footing with the established pharmaceutical giants. Apart from supporting capacity in the South, this is also an important step towards greater fairness in access to pharmaceutical products.

I should also add, as I conclude, that greater fairness in matters of health is a top priority for WHO Director-General Dr Margaret Chan, and for PAHO. its leadership, and its member states as well.

Thank you.

SPEECHES:

Fostering Cooperation in Health among Developing Countries
   Dr. Mirta Roses-Periago, Director, Pan American Health Organization.

Unleashing Southern Capacities for Development
   Mr. Yiping Zhou, Director, UNDP Special Unit for South-South Cooperation.

Message at the Opening Ceremony of the Global South-South Development Expo 2009.
   Dr. Margaret Chan Director-General, World Health Organization.

The Global South-South Development Expo showcases successful southern-grown development solutions. The Expo has served as a vibrant platform for the international community to celebrate achievements; share development successes; explore new avenues for collaboration; forge innovative South-South, triangular and public-private partnerships; and launch concrete collaborative schemes towards achieving internationally agreed development goals, including the Millennium Development Goals.