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BBC Radio 4 - Reith Lectures 2000 - Respect for the Earth
Lecture 4: Health & Population - Gro Harlem Brundtland - Geneva
In October last year, the UN Secretary General Kofi Annan went to a hospital in Sarajevo to welcome "baby number six billion". Nobody - and least of all the Secretary General - would deny that the choice of Fatima Mevic's baby, born just after midnight on October 12 had more to do with the Secretary General's travel schedule than with demographics. We can imagine that Mr and Mrs Mevic were rather bemused about all the fuss surrounding their little baby boy. The key point, though, is that Kofi Annan's purpose was not to talk about numbers. For the Secretary General, this birth was an occasion to focus on a different moral issue.
He said that the "Day of Six Billion" challenged us all "to live up to the promise of our time to give every man, woman and child an opportunity to make the most of their abilities, in safety and in dignity."
I share his view. More than that, I have a mission. I want to state it clearly, now, to all who are listening.
I want the fight against poverty to be our global cause as we straddle the millennium. Our goal must be to create a world where we all can live well fed and clothed, and with dignity. We must do this without undermining future generations' ability to do the same.
Tonight I want to suggest a fresh way of joining this fight. I will argue that poor people will only be able to prosper, and emerge from poverty, if they enjoy better health. I want health to be at the heart of our struggle for sustainable development.
Let us look around the world as it is now.
About three billion people live on less than two dollars a day. In other words half of the global population do not have anything close to a decent standard of living. That means that 3 billion people live in such poverty that they cannot afford proper housing, proper health care and proper education for their children. Almost half of those people live on less than one dollar per day. That means more than a billion people not having enough to eat every day and at constant risk of malnutrition. The poor really do die young.
Poverty has a woman's face; of the 1.3 billion poorest, only 30% are male. Poor women are often caught in a damaging cycle of malnutrition and disease. This plight stems directly from women's place in the home, and in society: it often also reflects gender bias in health care. Women from poor households are more than a hundred times more likely to die as a result of childbirth than their wealthier counterparts.
Over the past few years, the human development index has declined in more than 30 countries. Almost one third of all children are undernourished. The average African household consumes 20% less today than it did 25 years ago! And development assistance is falling too. Only a few countries have fulfilled past commitments to provide 0.7 per cent of their GDP for development assistance. In actual fact the world average is now closer to 0.2 per cent.
Beyond the dry statistics lies tragedy. When I visited Africa some months ago, I saw first hand the malnourished children and the despair that follows from some of the conflicts that rage in this continent. These are not so much territorial disputes as they are rooted in general misery, the aftermath of humanitarian crises, shortages of food and water and the spreading of poverty and ill-health.
In a number of mega cities around the world, the quality of life among the five, ten, fifteen million people and the poor who scrape out a living in their vast slums is dismal. The noise, pollution, squalor and dangers for those who have made their cardboard housing underneath the large overpasses make modern living for the poor seem like a latter-day realisation of Hell. The damage from pollution and the continuous threat of violence add to the infectious diseases which always leave their deepest imprint on poor people's lives.
Most of us agree that this state of affairs is unacceptable. Yet still we do little or nothing about it. The rich have lived next door to appalling squalor for centuries without being sufficiently disturbed to take any action.
But now, in our global economy, this may be beginning to change.
Over the past twenty-five years or so, population growth in many countries has slowed rather faster than demographers had first expected - especially in east Asia. Thanks to this slowing down, the experts now believe the earth's population will stabilise around 9 billion - rather than 12 to 15 billion as some feared.
At the same time, the world's capacity to produce food has grown at a fantastic rate, as a result of new grain varieties and economic incentives to producers. In 1989 the Vietnamese government allowed farmers to sell their rice freely on the market, encouraging new seed varieties and farming techniques. Within two years, Vietnam went from having to import rice to becoming the world's second largest exporter.
The structure of societies is changing. Young adults in India, Algeria and Iran struggle to find jobs, to earn an income and to see a hope for the future. The Governments of Japan, Sweden and Spain struggle to find answers to a rapidly ageing population, and to the challenge this poses for their production and welfare systems. Ironically, many developing and middle-income countries are caught with both problems: they face a swelling population of older folk, while they still have to cope with population growth.
Years of observation and experience have shown that families living in freedom and given the opportunity to fulfil their basic needs, have fewer children. These children are more likely to be healthy and educated. Societies that have satisfied the basic needs of their populations tend to reduce pollution and environmental destruction.
As population structures change, the role of the State becomes clearer. Empower people to make meaningful choices. Create a supportive environment for families. Look after the interests of children, for they are the future. These principles are as relevant in India as they are in Norway, or indeed Switzerland, where we are tonight.
None of this should surprise us. Ground-breaking consensus was reached six years ago, when the International Conference on Development and Population - in Cairo - firmly established that development, poverty reduction and respect for women's reproductive rights are vital to stabilising the world's population.
We do not yet, however, have a consensus about the importance of good health in global development. Europe learned about the existence of infectious agents around the middle of the 19th century. The importance of hygiene and clean water became apparent. The rich finally began to do something about the dreadful slums that surrounded their wealthy areas. It was self-interest that finally prompted action. As hygiene and health care improved, the average life expectancy increased by nearly 20 years in many countries. Following this development was the huge industrial push that brought the current wealth and affluence to the West and practically eradicated absolute poverty from most of Europe.
Unfortunately, the fear of disease that scared politicians, city planners and corporate leaders to invest in health and sanitation for the populations of Europe, did not then extend as far as to their former colonies and the other countries far away from their own cities.
As we learn how to manage a global economy, the situation should change.
Again, as in the 19th century, it is self-interest that lies at the heart of this change. In the modern world, bacteria and viruses travel almost as fast as money. With globalisation, a single microbial sea washes all of humankind. There are no health sanctuaries.
Diseases cannot be kept out of even the richest of countries by rearguard defensive action. The separation between domestic and international health problems is no longer useful, as people and goods travel across continents. Two million people cross international borders every single day, about a tenth of humanity each year. And of these, more than a million travel from developing to industrialised countries each week.
This is an accelerating trend, and is not likely to be reversed. I suggest "health security" is as important as national security. Threats to health undermine what I call our " human security". The levels of ill-health experienced by most of the world's people threatens their countries' economic and political viability: this, in turn, affects economic and political interests of all other countries.
Interestingly enough, not only infectious diseases that spread with globalisation. Changes in lifestyle and diet prompt an increase in heart disease, diabetes and cancer. More than anything, tobacco is sweeping the globe as it is criss-crossed by market forces. Only weeks after the old socialist economies in Europe and Asia opened up to Western goods and capital, camels and cowboys began to appear on buildings and billboards.
Those who think that tobacco-related death and disease is mainly a burden for the rich countries are mistaken. If the growth in tobacco use goes unchecked, the numbers of deaths related to its use will nearly triple, from four million each year today to 10 million each year in thirty years. More than 70% of this increase will take place in the developing countries.
The people in most rich and middle income countries have come to expect much better standards of health in the past fifty years. In that time we have failed miserably in securing even a basic level of health among the 3 billion who are poor. In the interval, some of their health problems have become even more difficult to solve.
Recently, in Mozambique, I saw children with their eyes glazed with fever from a malaria that could have been prevented if their parents could afford bed nets. Deforestation had changed malaria from a nuisance to a curse in a matter of twenty years.
More people are suffering from this killing and debilitating disease now than ever before, and deforestation, climate change and breakdowns in health services have caused the disease to spread to new areas and areas that have been malaria-free for decades, like in Europe.
In the Philippines, I have watched how beggars sit exhausted on the pavements convulsed with coughing. Tuberculosis, which we long believed had been brought under control by effective treatment, is on the rise again. Increasingly, we see forms of tuberculosis which are resistant to all but a very expensive cocktail of drugs.
I think that HIV/AIDS may be the most serious threat to face sub-Saharan Africa and other developing regions. space. Already, the AIDS epidemic is the leading cause of death in several African countries. AIDS has reversed the increases in life expectancy we have seen over the past thirty years. The social and economic devastation in countries that could lose a fifth of their productive populations is heart-rending.
I believe we are facing this alarming situation largely because of an outdated approach to development. Our theories have to catch up with what our ears and eyes are telling us - and fast.
There was a period in development thinking - not so long ago - when spending on public services, such as health and education, would have to wait. Good health was a luxury, only to be achieved when countries had developed a particular level of physical infrastructure and established a certain economic strength. The implicit assumption was that health was to do with consumption. Experience and research over the past few years have shown that such thinking was at best simplistic, and at worst plainly wrong.
I maintain that if people's health improves, they make a real contribution to their nation's prosperity. In my judgement, good health is not only an important concern for individuals, it plays a central role in achieving sustainable economic growth and an effective use of resources.
As in Europe at the end of the 19th and beginning of the 20th century, we have seen that developing countries which invest relatively more, and well, on health are likely to achieve higher economic growth.
In East Asia, for example, life expectancy increased by over 18 years in the two decades that preceded the most dramatic economic take-off in history.
A recent analysis for the Asian Development Bank concluded that fully a third of the phenomenal Asian economic growth between 1965 and 1997 resulted from these gains.
I am rarely able to persuade people to share these views using just moral arguments. I have much more confidence in what I will describe as "enlightened self interest".
We all fear the spread of disease and increasingly, corporations appreciate the market opportunities provided by affluent populations. This encourages investment in health as a means of reducing poverty.
Think about it. Globalisation is about much more than trade. It is about communicating with an infinity of new people, about relating to them - and therefore also getting involved in their lives.
The company which sets up a production plant in Vietnam or Peru may do so based on an evaluation of economic opportunities, but it will soon find itself having to relate to the political, social and economic reality of the country.
One large engineering company ran an advertising campaign some time ago saying that being global meant being local world-wide. True. Companies that show commitment to the countries and communities they work with find that they are better appreciated - whether by prime ministers or their own work force. Productivity increases too.
A company that deals with developing countries has to confront the challenge of poverty and ill-health. A company's stock price can fall on Wall Street because workers in a subsidiary's plant in Malaysia are not provided with health insurance. As communication and social activism become globalised, large companies find that labour standards are important. Ignoring them can be costly both to public image and stock price.
We need an enlightened response to the challenge of a "managed global economy"
New technology, almost inflation-less growth and soaring stock markets in many Western countries have created an almost dizzying sensation that the old rules don't apply anymore. Sometimes I wonder what has happened to the ideologies that used to guide us. Marx is dead, Adam Smith is certainly gone, and so it seems has every economist who ever provided any rules for decision-makers to follow. For pessimists, there may be much to worry about, but for anyone with belief in human creativity, these are times of opportunity.
Several countries - including the United States - now recognise that improving international levels of health is a matter of national security. Earlier this year, the Security Council met and discussed the global AIDS epidemic. The rationale for debating global health, has indeed changed.
Also, with less than four hundred billionaires holding assets that equal the cumulative worth of 45% of the world's population, we start to see a change in the flow of resources for poverty reduction. There are many implications of this extremely skewed distribution of wealth. One of the positive ones is the emergence, among these billionaires, of individuals who have philanthropic ambitions. Any one of them could single-handedly can cover the cost of eradicating - or at least controlling - a life-threatening disease.
I am delighted to see unorthodox new alliances being forged to support human development.
Industry and international agencies are coming together to find ways to get medicines and vaccines to those who cannot afford to pay. They have established new partnerships to fight malaria, river blindness and leprosy. As they reform their health care systems, governments build networks that involve the private and voluntary sectors to get vital services to people in need.
I am not so naïve as to believe that our world has, all of a sudden, become a more altruistic place. But there are many new possibilities.
We need to bring the new approaches into the mainstream of development activity. Many international organisations still have no adequate mechanisms for working beyond the country level, reaching directly to communities in need. We also find it hard to work for people ruled by corrupt despots, by weak leaders caught up in power-struggles, or by plain war-lords. As Chris Patten has already argued in this lecture series, sustainable development cannot work without good governance.
So, in all our efforts we have to give special attention to the challenge of reducing poverty. The Nobel economics prize laureate Amartya Sen defines poverty as "deprivation of capability". He argues that people are poor not only because their income is low, but because they do not have access to basic services, such as health and education, which would have increased their freedom. Poverty, he says, seriously deprives people of a number of choices they must have available in order to live a satisfying life.
This must be right. If you don't have an adequate form of health insurance, becoming ill means becoming poorer - both directly, because you have to spend part of your income to pay for treatment and medicines, and indirectly, because your choices become even more limited.
The challenge for us all is to look at the world through the eyes - and spirit - of poor people.
We need to start with poor people's realities, and trace upwards and outwards to design services that really make a difference to their lives, as Deepa Narayan suggests in a recent book, Voices Of The Poor.
Quite simply, poor people all over the world dread being ill. It can so easily be a disaster. It can throw a whole family into destitution. Poor people have very limited choices. Medicine costs, fees charged by health workers, and transport costs quickly eat into whatever funds are available.
A rickshaw driver in Khulna, Bangladesh may well appreciate that he lives in a place where the risk of tuberculosis is high. But his poverty deprives him of the choice to live somewhere else. When he gets infected, he cannot compete so well for work. His income goes down. This sends the family into a spiral of debt and increasing poverty. His children - particularly the girls - may be kept from school. The family may have to cut out fish from their meals most days. Their malnutrition increases vulnerability to illness - and risk of death.
Being too poor to go to an ordinary bank, the family has to borrow from loan sharks who take perhaps 20% interest, perhaps 60% or more, in order to pay for medicines. With such costs, our rickshaw driver understandably chooses to cut the treatment as soon as the fever goes down and he feels better. It is likely that the infection will return, though next time resistant to the normal drugs used for treatment. The health of others, who live nearby, is in real danger.
It does not have to be like this. There are examples of TB programmes that work properly for poor people. They would help our rickshaw driver to be cured in six or nine months, and enable him to get back to work - non-infectious - within weeks. He would be able to avoid crippling debt. He would not need to take his children out of school. His own poverty, and that of his family, would be reduced.
Take another example. Plantation workers in Indonesia were treated for chronic anaemia was has been reported to result in a 20% increase in productivity, increasing the earnings of the workers and the output of the plantation.
Relatively simple health interventions, like effective treatment for TB, getting a bed net against malaria in every African household, eradicating polio, or providing an integrated child health programme, can ensure that children are healthy and well nourished. They also improve the economic situation and productivity of individual households.
Quite simply, we have - in our hands - a concrete, result-oriented, and measurable way of starting to reduce poverty.
To complete the task, education and infrastructure should improve. Private investment and trade must increase. But good health is a pre-requisite. Unless we help improve the health of the world's poorest billion and a half people, they are destined to live lives of continuing poverty.
All this means that health must be moved from the periphery of the development process to the centre, where it belongs.
The health minister must not sit at the far end of the Cabinet table, but be up there next to the prime minister or president, together with the finance minister and planning and industry minister. In developing countries, they often cannot even be found at the Cabinet table. This, surely, is where they are most needed.
Are we ready to scale up our investments in poor people's health? - investments vital for sustainable development?
Think about it. Great advance in health care have been made over the past hundred years. Our generation risks going down in history as the one that allowed the hard-won health achievements of the 20th century to be lost - lost because it decided to ignore the billion and a half people that had been excluded from the health revolution. I use the word "decided" - because we can't say we failed to act because we didn't know better.
The evidence is there - and so are the opportunities. I challenge you to accept this new thinking and act on it.
