Colleagues in public health, ladies and gentlemen,
I am pleased to address this audience on the occasion of the annual lecture of the Coalition for Health, Ethics and Society. I would like to share with you my views on how I see the world moving forward, my observations for the five years I have been the WHO Director-General.
This year could go down in history as the time when the quest for greater social equality became a mass-media story and a high-level political imperative.
At the start of the year, the events in the Middle East grabbed world attention. Social media amplified this attention into mega-publicity. The face of the Middle East changed.
The initial uprisings coincided with the World Economic Forum in Davos. I was there. I heard speech after speech attributing this unrest to inequality, especially inequality in income levels and opportunities, most notably for youth.
As the Executive Chairman of the World Economic Forum concluded, “Greater social equality must become the new economic and political imperative for a stable and secure world.”
Others noted that the uprisings were not just an Arab thing, an Arab problem. They were symptoms of a deep-seated social malaise that had spread nearly everywhere, like a dense fog.
That proved true, as seen in social unrest, protests, and strikes in many other regions, including Europe. The Occupy Wall Street movement, a protest against financial inequality, quickly spread to thousands of cities around the world.
In one sense, this high-level and sustained attention to social equality should please all of us. WHO and its Member States have long been concerned about equity, fairness, and social justice, and the interplay between social conditions and health outcomes.
The Millennium Declaration and its Goals are all about fairness and social justice. As stated in the Declaration: “The central challenge we face today is to ensure that globalization becomes a positive force for all the world’s people. Those who suffer or who benefit least deserve help from those who benefit most.”
This was a noble and inspiring social contract, and I fully agree with its ambition. In my view, the net result of policies, in all aspects of government and in all systems governing international relations, should be to reduce misery and improve the quality of life for as many people as possible.
Greater equity in the health status of populations, within and between countries, should be regarded as a key measure of how we, as a civilized society, are making progress.
In reality, this year’s welcome attention to social equality has its roots in some ominous trends. They seemed to explode this year in unprecedented disasters, disruption, turmoil, and humanitarian crises.
This year has seen more than its share of natural disasters, including droughts, floods, a tsunami, and a related nuclear accident, unprecedented hunger and starvation in the Horn of Africa, unprecedented financial losses, especially for the middle classes, and unprecedented challenges facing disaster relief and humanitarian aid in dangerous parts of the world.
The protests that toppled some governments in the Middle East were a quest for democratic and economic reforms, not handouts and empty promises. Protesters sought basic human rights, dignity, and a chance to get jobs with wages they can live on. They were not easily appeased.
This is understandable. In some of these countries, GDP has grown steadily, year after year, while more and more people fell below the poverty line, year after year.
This is inequality.
The Occupy Wall Street movement has been described as a protest against the practices of large corporations and financial institutions that brought misery to the lives of ordinary people. The movement’s main purpose is to seek economic justice and a restoration of balance to society.
Such discontent, such widespread social malaise, is deeply disturbing and pleases none of us. It tells us our world is in a mess, and that we made much of this mess all by ourselves.
Ladies and gentlemen,
We are living in a world beset by one global crisis after another. We are living in a season, a winter season, of broken promises, a winter of discontent.
This is not a plague of locusts, but a plague of broken promises, when social contracts, that sense of responsibility, if not duty, to serve society’s best interests, vanished into thin air.
Differences, within and between countries, in income levels, opportunities, and health outcomes are greater today than at any time in recent history. The difference in life expectancy between the richest and poorest countries now exceeds 40 years. Annual government expenditure on health varies from as little as $1 per person to nearly $7,000.
In short: our world is dangerously out of balance. This is clearly an unhealthy condition, for people, but also for economic prospects, for world stability and for security.
I believe one conclusion is obvious. That noble social contract, set out in the Millennium Declaration at the start of this century, has been broken. The people who deserve help are getting more misery instead.
Countries are losing their middle classes, the very foundation of a democratic society and of economic prosperity. A new statistic emerged this year. In some countries, the difference in the quality of life between the older generation and today’s youth is the greatest ever recorded.
Think for a moment: in some places, young people who get married today cannot even afford to live together. The man has to go back to live with his family and the woman does the same. Both struggle to find scarce moments of privacy. What world are we living in?
Globalization was not, after all, the rising tide that would lift all boats. Instead, it tended to lift the bigger boats and swamp or sink many smaller ones.
Trade liberalization was put forward as the sure route to prosperity for the developing world. In reality, it is economic suicide to ask a country with an immature economy to open itself to global competition.
China and India have lifted many millions of their people out of poverty, but they liberalized trade only after their own economies were mature. Just one example makes the point. In the Americas, the country with the most liberal trade policies is Haiti.
The international banks encouraged debt-ridden countries to reduce spending on social services, resulting in sharp cuts in publically-financed health services. Market forces, we were told, would then operate to expand coverage.
This never happened. Instead, coverage shrank as did the overall use of health services, also for essential preventive care.
User fees were put forward as a way to recover costs and reduce the overconsumption of care. This did not happen. Instead, user fees punished the poor.
Numerous countries watched their government-run health services fall into disarray, forcing impoverished people to pay private practitioners high fees for routine care, while the best care and services were reserved for the privileged few.
This is inequality.
Through all these troubled times, through all these broken promises, Europe looked smarter than the rest of the world, somehow shielded by their social policies.
In 2009, an article in Foreign Affairs advised affluent countries to learn a lesson from European democracy. As stated: “A generous well-designed welfare state is not the enemy of globalization. Instead, it is the saviour.”
And now this saviour is itself at risk as European governments grapple with a severe debt crisis and public finances for social services, including health and education, continue to shrink.
Ladies and gentlemen,
The fuel, food, and financial crises of 2008 proved highly contagious in a world of radically increased interdependence and connectivity. They were also profoundly unfair, adversely affecting countries that had nothing to do with the causes.
The financial crisis, in particular, hit the world like a sudden jolt, turning it from an outlook of prosperity to one of austerity almost overnight. Governance became a hotly debated issue. Analysts cited a failure of governance, corporate responsibility, and risk management at every level of the financial system.
That system had run wild, cut off from any obligation to society, from any concern about the impact of reckless practices on the lives of ordinary people. That impact has meant a loss of the homes people owned, the jobs they held, the savings they put aside, their hopes for a better life for their children, and their willingness to work hard to make those hopes a reality.
The philosophy that greed is good had a quick payback for the privileged few but a very heavy bill for everyone else. As the world learned, corporate profits and economic growth were not, after all, the be-all, end-all and cure-for-all.
I am fully aware of the close links between economic prosperity and good health, as set out in the 2008 Tallinn Charter on health systems for health and wealth. A market-based economy is still the best way to lift people out of poverty and improve their health status. Look at Brazil, China, and India.
But one thing is now crystal clear: market forces do not solve social problems.
This is the essence of the mess. The international systems that govern financial markets, trade, and business create multiple benefits. They have rules for engagement.
But they have no rules that guarantee the fair distribution of these benefits. Equity is almost never an explicit policy objective in the way these systems operate.
The Washington Consensus of 1989, which largely failed, set out economic policy prescriptions as a standard “reform package” for debt-ridden developing countries. According to the principal author, the notion of making equity a policy objective was regarded, at that time, with “contempt”.
In 2008, when the financial crisis shook the world, at least one report from economists singled out WHO as one of the few agencies producing broadly accepted instruments for good global governance that address social concerns.
I am proud of this, not as a tribute to the effectiveness of WHO, but as a sign of the genuine high priority given to health issues, and the collective will of WHO Member States to compromise, even to give up a little of their national sovereignty, in return for collective security against shared threats.
Moreover, public health has vast experience in the management of risks. We do this so well, in fact, that much of our work is invisible until something terrible goes wrong.
Risk management is part of the core business of safeguarding public health, whether from surprises delivered by the volatile microbial world or health threats arising from the globalization of unhealthy lifestyles.
Since the start of this century, WHO and its Member States have been managing internationally shared health risks through the development of new global governance regimens.
We have the WHO Framework Convention on Tobacco Control, the first international health treaty negotiated under the auspices of WHO, and one of the most widely-embraced treaties in the history of the United Nations.
We have the International Health Regulations, revised after the SARS outbreak of 2003. They move from a passive, reactive response to outbreaks at borders and points of entry, to a proactive response aimed at snuffing out a threat at source, before it has a chance to spread internationally.
Let me thank the Chair of CHES, David Byrne, for his role in steering the IHR revision process. I, together with all WHO Member States, have the deepest respect for his astute diplomacy and negotiating skills, his personal charm that helped diffuse tensions, and his stamina during sessions that lasted until the crack of dawn. He carried the day.
WHO Member States also agreed on a global strategy and plan of action that tackles the need to manage intellectual property rights in fair ways, fair for industry, but also for public health.
We have agreed guidelines for addressing the marketing of unhealthy foods and beverages to children.
And we have a new framework that sets out obligations for the sharing of influenza viruses and of resulting benefits, like medicines and vaccines, during an influenza pandemic. This is the newest governance instrument, approved by the World Health Assembly this May.
The negotiations behind the framework were the most intense and potentially explosive that I have ever witnessed during my 35 years in public health. They dragged on for nearly five years. But the spirit of consensus and fair play eventually won, and we got a square deal for everyone, including the pharmaceutical industry.
These new governance regimes tell us that countries really want collective security against shared threats. They want risks to be proactively managed, with an emphasis on prevention. They want rules of proper conduct, with clearly assigned responsibilities, and they want fairness, a square deal for everyone.
Should negotiations about marketing practices, intellectual property rights, and issues of international trade be undertaken by a health agency like WHO? Probably not. But these negotiations came to WHO at the express request, even insistence, of our Member States.
This is another symptom of our times. Countries are increasingly suspicious that the rules of the international systems are rigged to favour those who are already rich and powerful, that decisions will be taken with little regard for their impact on the lives of poorer populations and their prospects for socioeconomic development, that health and development will be neglected, but never by WHO.
The success of these new regimes for global health governance stands out in the midst of multiple failures. World trade negotiations continue to break down over issues that seem to defy agreement, no matter what economic gain is ultimately at stake.
The Kyoto treaty on climate change is said to be on life support until it expires next year.
Agreement among G-20 countries seems increasingly elusive, leading some to suggest that we live in a G-zero world, with no great powers truly in charge. This is a sign, others suggest, that the world’s traditional leaders have lost their intellectual and moral authority.
Some ask: has the world lost its collective mind? Others agree: it has certainly veered off course.
Ladies and gentlemen,
Can the values and principles of public health change the way this world works? Is this what I am suggesting?
Of course not. After nearly five years in my job, I have no illusions. But I do retain my optimism.
I am convinced that WHO, its multiple partners, and individual countries can keep up the striking momentum for better health that marked the start of this century. And in the process we will do a tremendous amount of good for humanity, especially for those “who suffer or who benefit least.”
As I just asked: can we keep up the momentum? This is a question now facing European countries as they likewise ask:
Can we maintain this region’s outstandingly high quality of life in the face of a changing climate, more frequent extreme weather events, soaring health care costs, rising public expectations for care, shrinking health budgets, and a generation of baby-boomers now entering retirement?
Of course we can.
We can do so through two main routes.
First, health programmes must shift to thrift. They must demonstrate value for money. They must show a thirst for efficiency and an intolerance of waste. There are many models for doing so, including last year’s World Health Report on health financing.
Second, we need to do much more to stimulate innovation, but the right kind of innovation. That is: innovation with a social purpose.
The EC’s flagship Innovation Union initiative addresses many of the questions I have just raised. The Innovation Convention gives us a clear conclusion: “Innovation is the only answer”.
Innovation does the most good when it brings clear social benefits and ensures that these benefits are evenly and fairly shared.
If we have learned anything from the turmoil of the past few years, it should be this. Innovation must respond to societal needs and concerns, and not be driven by greed.
This year, CHES has focused debates and discussions on broad-based ways to promote active and healthy ageing, including the role of innovative technology in supporting this goal.
Everyone wants to find ways to keep older people healthy, active, contributing to society, and living at home for as long as possible. Everyone wants to see grey power grow.
I am pleased to announce that WHO and the European Union are right now exploring ways to join forces to harness innovation for active and healthy ageing.
I regard the challenge to Europe’s scientists, academics, industries, and business to innovate as an immense opportunity and a highly interesting one, as the tables are now turned.
In forging ahead to care for its elderly, Europe will need to define the best innovations in terms of their ability to reduce costs and simplify care while also promoting health and postponing or assisting disability.
European leaders in public health have frequently been trail blazers, the first to tackle difficult problems that looked like luxury items on the health agenda, yet later proved of universal concern.
This has been true for the link between lifestyles and health, the social determinants of health, the health of migrants, the health effects of unemployment, the environment as a source of health threats and, most recently, the need to strengthen health systems and find ways to finance universal access to care.
Europe was way ahead of the rest of the world on all these issues.
Medicine is one of the few areas of commercial activity where new technologies, like the next generation of antibiotics, a new vaccine, or a new medical device, are nearly always more sophisticated and much more costly.
This is certainly not the case with other areas of technology, like flat-screen TVs, airline prices, or computers, where devices become increasingly easy to use and cheaper to buy. Just last month, a study concluded that technologies for the treatment of cancer now carry costs that are unsustainable, even in the wealthiest societies.
In its drive to extend essential care to poor people living in poor places, public health has long sought to simplify technologies, so they can be used in households or by non-specialized health staff, and cut the costs, with no compromise of safety, quality, or efficacy.
Europe needs to do something similar as it seeks ways to keep its greying population healthy and active. This calls for a shift to thrift and simplicity, as well as effectiveness.
In doing so, you will be finding solutions that may likewise serve the developing world well, again in a trail-blazing way.
Ladies and gentlemen,
I have a final comment. In reality, the MDGs are a corrective strategy. With their overarching objective of poverty reduction, they aim to introduce a greater sense of balance into this lopsided world.
They aim to compensate for international systems that create benefits, yet have no concern about the fair distribution of these benefits or the impact of their policies on the lives of ordinary people.
This world will not become a fair place for health all by itself. Health systems will not automatically gravitate towards greater equity or naturally evolve towards universal coverage.
Economic decisions within a country will not automatically protect the poor or promote their health. Globalization will not self-regulate in ways that ensure fair distribution of benefits.
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.
Indeed, fairness will come only from the top, when greater social equality really does become the new economic and political imperative for a stable and secure world.
Thank you.