News & Media Opinion Pieces The impact of global crises on health: money, weather and microbes

The impact of global crises on health: money, weather and microbes

This is an Address by Dr Margaret Chan, Director-General of the World Health Organization, given at at the 23rd Forum on Global Issues, Berlin, 18 March 2009

This is an inspirational Address. I see it as clarion call for health professionals to make heard their case in the halls and corridors of bad governments. To those members of DEA who are briefing their elected representatives. please print out a copy and take it to your meeting. We acknowledge WHO– Editor.

“The world is in a mess, and much of this mess is of our own making. Events such as the financial crisis and climate change are not quirks of the marketplace, or quirks of nature. They are not inevitable events in the up-and-down cycle of human history.

Instead, they are markers of massive failure in the international systems that govern the way nations and their populations interact. They are markers of failure at a time of unprecedented interdependence among societies, capital markets, economies, and trade.

In short, they are the result of bad policies. We have made this mess, and mistakes today are highly contagious.

As the economists tell us, the financial crisis is unprecedented because it comes at a time of radically increased interdependence. Its effects have moved rapidly from one country to another, and from one sector of the economy to others.

The contagion of our mistakes 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 will suffer the consequences. Likewise, the countries that have contributed least to greenhouse gas emissions will be the first and hardest hit by climate change.

The financial crisis and climate change are not the only markers of bad policies and failed systems of governance. The gaps in health outcomes, seen within and between countries, are greater now than at any time in recent history. The difference in life expectancy between the richest and poorest countries now exceeds 40 years. Globally, annual government expenditure on health varies from as little as US$ 20 per person to well over US$ 6000

Medicine has never before possessed such a sophisticated arsenal of tools and interventions for curing disease and prolonging life. Yet each year, nearly 10 million young children and pregnant women have their lives cut short by largely preventable causes.

Something has gone wrong.

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. If businesses, like the pharmaceutical industry, are driven by the need to make a profit, how can we expect them to invest in R&D for diseases of the poor, who have no purchasing power?

In far too many cases, economic growth has been pursued, with single-minded purpose, as the be-all, end-all, cure-for-all. Economic growth, as many believed, would cure poverty and improve health. This did not happen.

Globalization was embraced as the rising tide that would lift all boats. This did not happen. Instead, wealth has come in waves that lift the big boats, but swamp or sink many smaller ones.

Greater market efficiency, it was thought, would work to achieve greater equity in health. This did not happen.

Trade liberalization was put forward as a sure route to prosperity for developing countries. But trade liberalization slashed tariff revenues and brought no alternative source of finances for public services, including health care. This has meant a disaster for health and social protection in the many countries where most labour is concentrated in the informal sector and the tax base is small.

User fees for health care were put forward as a way to recover costs and discourage the excessive use of health services and the over-consumption of care. This did not happen. Instead, user fees punished the poor.

WHO estimates that, each year, the costs of health care push around 100 million people below the poverty line. This is a bitter irony at a time when the international community is committed to poverty reduction. It is all the more bitter at a time of financial crisis.

We are at the start of what the experts say could be the most severe financial crisis and economic downturn seen since the Great Depression began in 1929.

Last week, the World Bank issued an assessment of the impact the crisis is having on developing countries. The assessment was far worse than just two months ago, and it predicted more grim news to come. In affluent countries, people are losing their jobs, their homes, and their savings, and this is tragic. In developing countries, people will lose their lives.

We are also in the midst of the most ambitious drive in history to reduce poverty and reduce the great gaps in health outcomes. No one wants this momentum to slow.

But between the need and the good intention falls the reality. What happens if the enormous financial bailouts break the bank? What happens if the money simply is not there to continue domestic health programmes or finance health development abroad? At the individual level, what happens if people simply cannot afford to take care of their health?

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 lopsided 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.

As last week’s World Bank report clearly states, financial conditions facing developing countries have deteriorated sharply, the delivery of essential social services is in danger, and the implications will be long-term.

The likelihood of achieving the Millennium Developing Goals, and benefitting from their corrective strategy, is now in jeopardy. What happens if the financial crisis kills our best chance ever to transform this world towards greater social justice?

The world desperately needs a corrective strategy. The current huge gaps, in income levels, opportunities, and health outcomes, are a precursor for social breakdown. A world that is greatly out of balance in matters of health is neither stable nor secure.

Let me be 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 have to say this: the market does not solve social problems.

The policies governing the international systems that link us all so closely together need to look beyond financial gains, benefits for trade, and economic growth for its own sake. They need to be put to the true test.

What impact do they have on poverty, misery, ill health, and premature death? Do they contribute to greater fairness in the distribution of the benefits of socioeconomic progress? Or are they leaving this world more and more out of balance, especially in matters of health?

I would argue that equitable access to health care, and greater equity in health outcomes are fundamental to a well-functioning economy. I would further argue that equitable health outcomes should be the principal measure of how we, as a civilized society, are making progress.

This world will not become a fair place for health all by itself. Economic decisions within a country will not automatically protect the poor or guarantee universal access to basic health care.

Globalization will not self-regulate in ways that favour fair distribution of benefits. Corporations will not automatically look after social concerns as well as profits. International trade agreements will not, by themselves, guarantee food security, or job security, or health security, or access to affordable medicines.

All of these outcomes require deliberate policy decisions.

Health had no say in the policies that led to the financial crisis or made climate change inevitable. But the health sector will bear the brunt of the consequences.

Countries at all levels of development are concerned about the impact of the financial crisis on health.

Officials are worried that health in their own countries may worsen as unemployment rises, safety nets for social protection fail, savings and pension funds erode, and spending on health drops.

They are also concerned about mental illness and anxiety, and a possible jump in the use of tobacco, alcohol, and other harmful substances. This has happened in the past.

They are concerned about nutrition, and rightly so. Recent dramatic changes in the world food supply make this economic downturn different in terms of health threats arising from poor nutrition. Food production has become highly industrialized, and distribution and marketing have a global reach.

When times are hard, processed foods, high in fats and sugar and low in essential nutrients, become the cheapest way to fill a hungry stomach. These foods contribute to obesity and to diet-related chronic diseases, and they starve young children of essential nutrients.

And there are other threats to health that we need to anticipate. In times of economic crisis, people tend to forego private care and make more use of publicly financed services. This trend will come at a time when the public health system in many countries is already vastly overstretched and underfunded.

In many low-income countries, more than 60% of health spending comes in the form of direct out-of-pocket payments. Economic downturn increases the risk that people will neglect care, with prevention falling by the wayside. Less preventive care is particularly disturbing at a time when demographic ageing and a rise in chronic diseases are global trends.

We know, too, that women and young children are among the first to be affected by a deterioration in financial circumstances and food availability. Women are among the last to recover when times get better.

Health officials are also worried that current levels of financing for international health development may not be maintained. The assessment issued last week by the World Bank fully justifies these concerns. The consequences will be dire.

Well over 3 million people in low- and middle-income countries are now receiving life-prolonging antiretroviral therapy for HIV/AIDS. Their lives have been rejuvenated. Families and communities have been revived. Treatment is, of course, lifelong. Can we, ethically and morally, cut back spending in this area?

Dire consequences can also be contagious. Interruptions in the supply of drugs, especially for diseases like AIDS, TB, and malaria, contribute to preventable deaths in high numbers. Such interruptions also accelerate the development of drug resistance.

Drug-resistant forms of disease can quickly spread internationally. We are seeing this, right now, with the rise of multi-drug resistant TB, and the even more alarming rise of extensively-drug resistant TB. This form of the disease is virtually impossible to treat, with fatality rates approaching 100%.

Its further international spread could take us back to the treatment era that pre-dates the development of antibiotics. Can the world really afford another risk of this magnitude?

Surveillance for emerging diseases contributes to global security. If basic surveillance and laboratory capacities are compromised, will health authorities catch the next SARS, or spot the emergence of a pandemic virus in time to warn the world and mitigate the damage?

We know that external assistance for health has more than doubled since the start of this century. Despite this trend, around half of the world’s countries do not have the capacity to finance even the most rudimentary “survival kit” of basic health services.

Reduced external financial assistance will truly be a killer.

Globally, around 1 billion people are already living on the margins of survival. It does not take much to push them over the brink. This can happen because of the financial crisis. This can also happen because of climate change.

The scientific evidence is overwhelming. The climate is changing. The effects are already being felt.

The warming of the planet will be gradual, but the increasing frequency and severity of extreme weather events, like intense storms, heat waves, droughts, and floods, will be abrupt and acutely felt. Both trends can affect some of the most fundamental determinants of health: air, food, and water.

I am fully aware that I am speaking to an audience in a country that has been at the vanguard of environmental protection, and the cutting edge of technology development and application. In this regard, let me pay my deep personal respects to the government of Germany and its citizens.

I also thank this country for its strong support for health development and for the work of WHO, including support from your scientists, epidemiologists, laboratories, and renowned research institutes.

Several consequences for health have been identified with a high degree of certainty. Malnutrition will increase, as will the number of deaths from diarrhoeal disease. More storms and floods will cause more deaths and injuries, and cholera outbreaks will occur with greater frequency.

Heat waves, particularly in large cities, will cause more deaths, largely among the elderly. Finally, climate change could alter the geographical distribution of disease vectors, including the insects that spread malaria and dengue.

All of these health problems are already huge, largely concentrated in the developing world, and difficult to control.

Although climate change is, by its nature, a global phenomenon, its consequences will not be evenly distributed. Scientists agree that developing countries will be the first and hardest hit.

According to the latest projections, Africa will be severely affected as early as 2020. A decade from now, crop yields in some parts of Africa are expected to drop by 50%. By 2020, water stress could affect as many as 250 million Africans.

Imagine the impact on food security and malnutrition. Imagine the impact on food aid. In many African countries, agriculture is the principal economic activity for 70% of the population. Among Africa’s poor, 90% depend on agriculture for their livelihoods. There is no surplus. There is no coping capacity. There is no cushion to absorb the shocks.

Women and young girls in parts of Asia currently spend from six to nine hours collecting water each day. What will this burden be when water scarcity increases, as is happening right now?

We also need to consider what these changes mean for the international community. More disasters, more floods and famines mean greater demands for humanitarian assistance. These demands for help will come at a time when most countries are themselves stressed by climate change.

The international community will also have to cope with a growing number of environmental refugees. If land is parched or salinated, if coastal and low-lying areas and small island nations are under water, these people cannot simply go home. Environmental refugees thus become a new wave of settlers, possibly adding to international tensions.

Anything we can do now to reduce existing burdens of disease will increase national and international capacity to cope with the new stresses that come with climate change. This gives us another very good reason to remain steadfast in our pursuit of the health-related Millennium Development Goals.

Up to now, the polar bear has been the poster child for climate change. We need to use every politically correct and scientifically sound trick in the book to convince the world that humanity really is the most important species endangered by climate change.

Can the health sector give a human face to the other problems we see in this big mess of a world? Is the health sector in a position to bring a moral dimension, to introduce a value system to the policies that govern our international systems?

Given my current job description, I will definitely say yes. But I have some solid reasons to back up this view.

Let me turn to a third issue: global crises that arise from the constantly changing microbial world. This issue is different from the financial crisis and climate change.

It is different because the health sector is in the lead. The health sector makes the policy, and implements governance through the International Health Regulations. We do not have to compete against economic interests. In fact, the tables are turned.

Emerging and epidemic-prone diseases are considered threats to international security precisely because of the tremendous economic and social disruption they can cause.

Public health has very few estimates that come even close to the multi-billion dollar financial bailouts we seem to hear about every week. But according to the latest World Bank estimate, the next influenza pandemic could easily cost the global economy US$ 3 trillion.

World leaders tell us that the financial crisis is so severe and unpredictable because it is the first such event under the unique conditions of the 21st century.

SARS, which emerged in 2003, was the first severe new disease of the 21st century. Like the financial crisis, it emerged at a time of radically increased interdependence.

SARS was the first disease to move rapidly around the world along the routes of international air travel. It put every city with an international airport at risk. It closed airports, businesses, schools, and some borders. It paralysed economies, and paralysed the public with fear.

But never forget: the response to SARS was a deliberate effort to prevent this new disease from becoming permanently established in this world, to keep it from joining the league of killer diseases like AIDS, TB, and malaria.

This was one severe global contagion that was quickly ended. WHO and its partners stopped SARS, dead in its tracks, within four months.

The health sector was prepared. Surveillance, alert, and response mechanisms were in place. We managed the risks. And this crisis did not spiral out of control.

From the beginning of the outbreak, the world’s top scientists set aside competition and worked together, in a virtual laboratory, around the clock. They identified the virus within a month.

This is the brighter side of globalization. This is an example of collaboration and solidarity before a shared threat.

We see this same international solidarity in support for the drive to eradicate polio, including humanitarian support from Rotary International, and support from several enlightened governments, including Germany.

Concern for health can also motivate ethical behaviour in industry, as when pharmaceutical companies dramatically cut prices for AIDS medicines. Concern for health can persuade the international community to agree on the control of harmful, yet profitable products, like tobacco.

There is hope.

If we have to rethink the way this world works, and overhaul some of our international systems, I personally believe that health deserves careful consideration for a leading role.

Our policies are guided by scientific evidence, and not by vested interests. We have the power and the objectivity of the scientific method on our side. The health sector has humanity’s best interests at heart, a strong moral dimension, and a strong set of social values among its many stars.

Let us all continue to provide the hope this world so badly needs at a time of severe crises – and transformation”.

 The full speach is at