February 2015 WHO DG; Mister Chairman, distinguished members of the Executive Board, Excellencies, colleagues in the UN system, ladies and gentlemen,
We are meeting at a time of profound economic, social, and demographic transitions in a world in turmoil from multiple causes. Social inequalities have increased, with more of total global wealth held by just a few rich and powerful people. Numerous conflicts, sectarian clashes, and terrorist acts show the bleak side of humanity’s inhumanity.
Last year provided a brutal reminder of the continuing threat from emerging and epidemic-prone diseases. Ebola is by far the biggest and most tragic example.
Currently, we face threats from the Middle East respiratory syndrome virus now circulating widely throughout the Arabian Peninsula, multiple new strains of highly pathogenic avian influenza that have devastated poultry farms, and continuing human cases of H5N1 and H7N9 avian influenza with a high fatality rate.
The WHO Constitution refers to the “common danger” of unequal development and the importance of activities that contribute to the “harmony of human relations”.
If public health has something to offer the world at large, it is this: growing evidence that well-functioning and inclusive health systems contribute to social cohesion, equity, and stability. They hold societies together and help reduce social tensions.
As I have said before, universal health coverage is one of the most powerful social equalizers among all policy options.
Health systems and supporting infrastructures, like laboratories and hospitals with electricity and running water, backed by road systems and enough staff and ambulances, are not a luxury to invest in when funds are available or other priorities have been met.
They are an essential cushion against the shocks our 21st century societies are delivering with ever greater frequency, whether from a changing climate or a runaway virus. Without this cushion, a shock to health can take on much broader dimensions. What begins as a health crisis can become a humanitarian, social, financial, and security crisis.
Ladies and gentlemen,
Your agenda covers some of the most pressing public health problems of the day: the health effects of a changing climate, the threat from the failure of more and more antimicrobial medicines, and the need to overcome the dynamics of market failure that left clinicians empty-handed when treating a long-established and lethal disease like Ebola.
Last year’s WHO conference on climate and health reminded the world that humans really are the most important species endangered by climate change. That conference, which attracted around 400 participants, was also the first carbon-neutral meeting ever held by WHO.
Many vector-borne diseases are highly sensitive to climate variables. Dengue is one. In recent years, the principal insect vectors that transmit this disease have silently spread worldwide and are now present in more than 150 countries. Dried mosquito eggs travel very well as stowaways in international cargo. Climate change may propel even wider spread.
Resistance to antimicrobial medicines is happening in all parts of the world for an increasingly broad range of pathogens. The consequences for human health are severe, especially with so few replacement products in the pipeline. The world is moving towards a post-antibiotic era in which many common infectious diseases may once again kill.
In the absence of effective antibiotics, some of the most advanced interventions available to modern medicine, like organ transplantations, hip and joint replacements, cancer chemotherapy, and care of pre-term infants, could become too dangerous to perform.
The consequences can be succinctly expressed: the end of modern medicine as we know it. Clinicians managing some cases of tuberculosis and gonorrhoea are already empty-handed as even “last resort” medicines no longer work.
Clinicians are empty-handed for another big reason as well: the failure of current systems and incentives to stimulate the development of new medical products for diseases that disproportionately affect the poor. If we are serious about our commitment to fair and inclusive health care, we are morally obliged to use the powers of scientific research and pharmaceutical innovation to reduce some of the health-related misery of the poor.
Ladies and gentlemen,
As the international development community transitions into the post-2015 era, we can celebrate some extremely encouraging trends and achievements. The Millennium Development Goals have been good for public health.
Last year, especially good news came from a report showing that child mortality rates are falling faster than ever before. In 2013, 17 000 fewer children died each day than in 1990. Maternal deaths have also fallen, but not far or fast enough. While these efforts continue, WHO’s additional objectives include ending neonatal deaths and doing more to improve adolescent health.
Of all the health-related MDGs, reducing maternal mortality has been the most problematic. Doing so depends not on the delivery of a single intervention, like vaccines, bednets, and cocktails of medicine, but on a well-functioning health system, with access to skilled birth attendants and emergency obstetric care. Ending neonatal deaths likewise depends on multiple health system functions.
Many AIDS experts believe the epidemic reached a tipping point last year. At the end of 2013, close to 13 million people worldwide had received antiretroviral therapy, nearly 12 million of them in low- and middle-income countries. The AIDS experts will also tell you how much WHO’s public health approach to this disease and streamlined and simplified clinical guidelines contributed to this monumental achievement.
The Global Programme on Malaria issued its most encouraging report to date. Progress has been real and substantial, supported by large-scale distribution of treated mosquito nets. Progress has also benefitted from WHO’s work to prequalify medicines and diagnostics, to keep a close watch over the development of resistance to medicines and insecticides, and to tailor control strategies to the local context.
Building on past success, ambitions for tuberculosis rose, with WHO targeting more than 30 countries for elimination of the disease. That goal was supported by improvements in diagnosing TB’s multidrug-resistant forms.
Like many other programmes at WHO, the ones for AIDS, TB, and malaria have been good at stimulating innovation and seizing the advantages of new technologies.
Next month WHO will launch a report on the global status of the neglected tropical diseases. As you know, these diseases anchor more than a billion people in poverty. Just 3 statistics from that report give you an idea of the results achieved, and their scale.
Verification that lymphatic filariasis has been eliminated has begun in 6 countries. Sustained efforts by a network of African countries have reduced the incidence of African sleeping sickness by 90%. Since 2006, over 5 billion anti-parasitic treatments have been delivered to some of the poorest people on earth.
This initiative is paving the way for an exodus from poverty.
Ladies and gentlemen,
The health challenges we will face in the post-2015 era are considerable. With the rise of chronic noncommunicable diseases, the sharp divide between health problems in wealthy and developing countries is dissolving.
Health everywhere is being shaped by universal pressures, like the globalized marketing of unhealthy products, population ageing, and rapid urbanization. These forces have created multiple health burdens that need to be addressed at the same time, but with different strategies.
The ancient burden of deaths from infectious diseases has been joined by a newer burden of even more deaths from NCDs. Rapid unplanned urbanization has added a third burden: deaths from road traffic crashes and the mental disorders, substance abuse, and violence that thrive in impoverished urban settings.
The report on adolescent health gives a good indication about how these burdens vary from one WHO region to another.
In the Americas, interpersonal violence is responsible for 1 in every 3 deaths among adolescent males in low- and middle-income countries. In wealthy countries, most adolescent deaths follow traffic injuries.
In the Eastern Mediterranean, war or conflict is the leading cause of deaths in youth. For girls in South-East Asia, it is suicide. In sub-Saharan Africa, it is HIV/AIDS.
Last year’s second International Conference on Nutrition underscored another dual burden. The extremes of undernutrition and overnutrition increasingly coexist in the same countries, communities, and even households. Once again, that conference showed how international systems, such as those that govern trade, have a major, sometimes detrimental impact on health.
Such non-health drivers of disease underscore the need for governments to establish coherent policies that avoid a situation where strategies that are good for one sector have costly adverse consequences for health.
The nutrition conference gave WHO many urgent assignments, as did the UN General Assembly’s review of progress in controlling NCDs. We also have a heavy workload ahead as programmes transition into the post-2015 era and adjust their goals and strategies.
As guidance, we have a growing number of global action plans and technical strategies approved by our governing bodies. You will be reviewing one for malaria during this session.
WHO reform is also on your agenda. I am confident you will go through reform-related reports and proposals with your usual care and eye to the future roles and responsibilities of WHO.
Ladies and gentlemen,
The challenges ahead are more complex than they were at the start of this century. For many of them, delivering medical commodities will not be enough, as reducing several major health threats requires action from multiple non-health sectors.
It also requires behavioural change. This includes changes in human behaviours, one of the hardest jobs in public health, but also changes in the behaviours of powerful economic operators.
Public health, with its emphasis on population-wide prevention and fairness in access to health-promoting and life-saving interventions, increasingly operates in a world fraught with dangers around every corner. Many arise from human mismanagement of our crowded planet’s environment, systems for food production, and resources, including fragile antimicrobial medicines.
Some dangers, like obesity, are highly visible. Others come from the invisible and volatile microbial world. Still others are made visible by WHO’s watchdog functions that monitor global trends and sound the alarm when these trends turn ominous.
The fact that the price of essential medicines more than doubles as economies grow is one. The harm caused by air pollution is another. In calls to reduce that harm, we can see how much the world depends on WHO’s monitoring functions and trusts the safe standards we set.
You noted many other dangers during yesterday’s special session on Ebola. Let me close with a brief description of another current outbreak that is receiving very little attention: plague in Madagascar.
This is the kind of geographically focused and readily manageable outbreak that WHO was designed to contain. Plague is endemic in Madagascar, where seasonal outbreaks are amplified by the dual forces of poverty and unplanned urbanization. Detected early, the disease responds well to treatment. Researchers at the country’s Institut Pasteur, supported by WHO, have developed a cheap and reliable diagnostic test that delivers results in 15 minutes.
But the outbreak that started last November has some disturbing dimensions. The fleas that transmit this ancient disease from rats to humans have developed resistance to the first-line insecticide. Plague established a foothold in the capital city, affecting densely populated slums. This is alarming, as around 8% of cases progress to the lethal pneumonic form, which transmits directly from person to person.
Last week, floods from a tropical storm in the Indian Ocean and a cyclone hit Madagascar, displacing tens of thousands of people and untold numbers of rats, raising the risk of more rodent-borne epidemics.
As you discuss the items on the draft programme budget 2016–2017 and WHO reform, I ask that you keep in mind the need for a strong and flexible WHO well-equipped to respond to these kinds of surprises, setbacks, and complex dangers.