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Why Investing in Global Health is Good Politics

Author: Gro Harlem Brundtland
December 6, 1999
Council on Foreign Relations

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Note: Remarks as prepared for delivery

Brian Atwood,

Ladies and Gentlemen,

I see it as an illustrative sign of change that the Council of Foreign Relations, traditionally known to be driving the debate on national and international security, has invited the Director-General of the World Health Organization to talk about the need to invest in global health. And you did it before we all had the vivid impressions from Seattle last week.

I hear you sending a message: we need to redefine the notion of security in the age of globalization. Today I will be responding to that message by saying: Yes – it is high time to revisit the notion of security and fully appreciate the role of global health for the future of your country and the entire system of international cooperation.

Last week, the world’s financial journalists were coughing from tear-gas as they reported from the frontlines of our day’s trade disputes. 100 years after Winston Churchill reported from the fronts of the Anglo-Boer war, it was as if these reporters had just become the war correspondents of the next century – communicating to us new dividing lines and areas of conflict in the age of globalization.

I remember the launch of the last round of trade negotiations in 1986 when ministers gathered further south in the Americas, in Punta del Este. As Prime Minister of Norway, I was preparing national positions for the negotiations. For the government it was no small event. But for the public opinion the launch passed unnoticed. Few would have guessed that the next round of negotiations some 13 years later would provide the occasion for a global civil uprising in the streets of Seattle.

What was the message of the protesters? Very little unified the Argentinean cattle-farmers, the American environmentalists and the famous French McDonald’s demolisher. But that is not the main point. The main point is that global issues really start to matter for people’s daily lives. Global issues trigger popular response. Global issues are paving their way to the limelight of decision makers. And maybe we are seeing that national political leaders, many of whom remain confined within the logic of their nation-states, are lagging behind their electorate’s perception of security.

Earlier this year, the Global Health Council conducted a nationwide public opinion survey aimed at assessing what Americans know and think about global infectious diseases. People were asked what issues they saw as key national security issues. The immediate response was not surprising: National security was predominantly viewed as military security.

But when the poll probed deeper, people began to turn to their own security. That revolved around the health and safety of their children, their families, and their communities, and led the focus on to global health issues. Half of all Americans knew someone who has suffered from one or more of the four global infectious diseases on which the survey was focused: Tuberculosis, HIV, malaria and hepatitis.

When asked to rate a set of global problems in terms of their importance, 70 percent rated the spread of global infectious diseases as very important, whereas 58 percent put regional and civil warfare at the same level.

This is all the more noteworthy as this poll was conducted in the midst of the Kosovo war.

Americans are right. Global health matters for their own health and security and for the future of their children. Conditions of ill-health around the world directly and indirectly threaten the lives of large numbers of Americans.

Over the course of the last 50 years, at least five times as many Americans have died from communicable diseases that have come to the U.S. from developing countries, than have died in all the military conflicts of the same period. West Nile Fever made headlines just recently, the most current example of what is likely to be a growing river of microbes that find their way from distant lands to your ports of entry.

Even the most ardent isolationists will not be able to argue that the United States can handle this challenge by turning inwards.

With globalization – on which this nation’s prosperity so much depends - all of humankind today paddles in a single microbial sea – and we have to conclude: There are no health sanctuaries.

In his recent talk to this Council, President Clinton’s National Security Adviser Sandy Berger pointed to the futility of the United States hiding behind a shield of armour, fearing an increasingly dangerous world outside.

Such reflexes have been evident in some U.S. thinkers on health. Since there has been a number of tuberculosis cases coming to this country from across the border with Mexico, they have held the view that the U.S. should concentrate its fight against tuberculosis on preventive measures along the U.S./Mexican border.

But this approach, as an historical analogy, may be seen as the health equivalent of relying on another Maginot Line. Diseases cannot be kept out by rearguard defensive action. The separation between domestic and international health problems is losing its usefulness as people and goods travel across continents. 2 million people cross international borders every single day, about a tenth of humanity each year. And of these, more than a million people travel from developing to industrialized countries each week.

This is an accelerating trend, and is not likely to be reversed.

Health is tradable – as is ill-health. Health may indeed be the single most important bridge to tie together – whether we like it or not – the destinies of the fortunate and the unfortunate.

What is emerging today is a notion of "human security". The levels of ill-health in countries constituting a majority of the world’s population pose a direct threat to their own national economic and political viability, and therefore to the global economic and political interests of the United States and all other countries. Territorial dispute is no longer the prime source of conflict. It is increasingly rooted in general misery, aftermaths of humanitarian crises, shortage of food and water and the spreading of poverty and ill-health.

So investing in global health is investing in national security. This very notion has diverse and profound implications for the way we perceive national investments, foreign aid and private-public collaboration. The awareness of these shifts is gradually sinking in. The US State Department has defined public health as an area of attention in its own strategy for defending national interests. And it is indeed a small sign of changing times when the Clinton Administration, for the first time in U.S. history, has added a global health specialist to the staff of the National Security Council

But there is a long way to go. I have read with interest Brian Atwood’s reflections – and frustrations - as he summed up his years in charge of USAID. Brian saw what it will take to pursue U.S. interests and security into a new millennium. And he saw what a dilemma any U.S. administration is facing as the means to pursue such policies are steadily being cut.

Two years ago, the Institute of Medicine of the National Academy of Sciences produced a small but important report, "America’s Vital Interest in Global Health". Under the headline triology: "Protecting our people; enhancing our economy; and advancing our international interest", it made a strong case for why the United States will benefit from investing in health abroad.

Let me dwell on three arguments for U.S. investment in global health.

First about protecting people. From food safety, through disease spread by airline passengers, to the danger of bacteriological attacks from rogue states and terrorists; protecting US citizens means improving global health levels; improving international food standards; and by concerted attempts help limit the spread of deadly virus and bacteria; and international action to contain terrorist elements.

From where I sit I see a rapid increase of awareness of these facts. It is remarkable to notice how decision-makers who used to know very little about health now start querying about the global health threats and challenges. That is very encouraging. But as Brian Atwood has experienced, to move from knowledge to action is a taller order.

I see this as a real challenge also to the UN system. No country stands ready to invest in general ambitions to do good. As Director-General of WHO I have stressed the need to communicate the needed actions in a way which will make sense to decision makers outside the health sector. We must be able to convey arguments that can persuade Prime Ministers, Trade Ministers and Finance Ministers that they are truly Health Ministers themselves.

This leads to the second argument: the economic gain. There are moral and ethical arguments why the United States and other developed countries should invest in halting the global AIDS epidemic which is accelerating at a dreadful pace in Southern Africa – or join forces to stop the spread of tuberculosis and join us in Rolling Back Malaria.

But beyond these arguments there is an economic logic which we need to develop and communicate more convincingly. There is the obvious argument that healthier populations abroad would make better markets for U.S. goods and services. Increasingly in a global economy, one region’s poverty is another region’s opportunity loss. The more affluent the rest of the world is, the better are the economic gains for the United States.

In addition, health care itself has become a vast global industry, absorbing in 1994 over 9% of the world product, or 2.3 trillion dollars. I hardly need to remind an American audience about the centrality of health care to the economy. With a health bill approaching one trillion dollars per year, or 15% of GDP – that must be a world record - you know very well that health care has major effects on key macroeconomic variables like inflation, employment, and the capacity to compete in global markets.

Looking at the world, we have to be clear about it: So far the war on poverty has failed. Differences are spreading inside countries and between countries. This degrades us and threatens us. It looms as a threat to the environment – not only that of the poor – but of all of us.

As these facts stand out, the commitment to invest in development is fading. Year by year the level of foreign development assistance is shrinking. OECD countries have agreed to spend 0.7% of GDP on development assistance, but the OECD average is now around 0.2% and sinking. The United States, as you are all well aware, spends less than half of that average.

This development has taken place during a decade where both the World Bank and the International Monetary Fund increasingly have voiced warnings that trade and private-sector investment alone are not sufficient to ensure equitable development in low-income countries. Reductions in poverty will not happen by themselves. They are the result of conscious political action.

We need effective and targeted policies. General programmatic declarations aimed at poverty reduction rarely bring much success.

However, there is a growing and solid body of evidence which shows that investing in health reduces poverty. In fact, health may be far more central to poverty reduction than macro-economists have previously thought.

It doesn’t take much thinking to realize that the links between poverty and ill health go both ways. But reducing poverty to improve health is not in itself the kind of sharp policy formulation we need to achieve results. Investing in health to reduce poverty may be just the kind of sharp, focused intervention we need to achieve progress.

It is our role to define and present such interventions. We have important lessons to learn from the market. We need clearly defined products which can attract investments because they are likely to deliver.

Take tobacco. We know it is bad for health. A detailed study by the World Bank now explains how it is also bad for the economy. 3 million people will have died from tobacco-related diseases this year. But there is worse to come. Tobacco-related diseases are spreading like an epidemic and are likely to be killing 10 million people a year around 2020.

Into the next century, tobacco will climb the ladder to be the leading cause of disease and premature death worldwide. I repeat the leading cause, bypassing communicable diseases such as AIDS, malaria and tuberculosis. The epidemic is spreading and it is first of all coming in the developing world -countries in which the health systems are already overburdened.

We have the evidence. We know what works. Tightening legislation against advertising, increasing tobacco taxes and controlling the marketing of cigarettes will make a difference for the health of future generations worldwide. To control tobacco, WHO is leading in the elaboration of the first public health international convention ever. This is not a challenge confined to independent states. It is a global challenge.

Take malaria. Research shows that the total cost of malaria to the Sub-Saharan region is 1% of the region’s total GDP. The disease is expanding in all of WHO’s regions. 3000 people die from it every day, each year there are more than 300 million cases.

The direct and indirect cost of malaria in Africa exceeds 2 billion dollars every year. When macroeconomists have added in hard-to-measure costs associated with malaria’s impact on trade and foreign investment, they have concluded that 2 billion dollars in losses per year is likely to be far too low an estimate.

We believe that malaria may be controlled in Africa for about one-tenth of this amount. WHO, together with its partners, the World Bank, UNICEF and UNDP, have launched Roll Back Malaria, an initiative that aims at reducing the burden of malaria worldwide by half within ten years. We can achieve this by using solutions currently available – by providing insecticide impregnated bednets to every woman and child – by making existing drugs available to families and communities and by enabling communities and the health sector to respond.

We have cost-effective health interventions to reduce dramatically the excess burden of disease among the poor. Remember smallpox eradication. Witness the great reductions in mortality from the spread of other immunizations. And how we are likely to eradicate polio by the end of next year, eventually freeing the world from $1.5 billion in annual traditional vaccination costs, and giving substantially higher savings in treatment and loss of productivity.

Many have realized this, and interestingly enough the private sector is waking up to a new reality. Bill Gates has committed $750 million to the new Global Alliance for Vaccines and Immunization, which is another result of the World Bank, UNICEF and WHO working together in partnership. In the Medicines for Malaria Venture, a venture capital fund which will finance the development of new malaria drugs, WHO, the pharmaceutical industry, bilateral and private donors have come together to overcome the market obstacles to getting drugs to populations who cannot afford to pay high prices.

This private involvement is absolutely necessary. But there is no way in which this can replace a strong public commitment to global health – through investments, dedicated research and political attention. Again, looking at the WTO negotiations – what this is all about is building a regulatory system to match the reality of a global economy. It is about extending democracy and the rule of law to another level – to the global level. And hand-in-hand with this lies the crucial need for promoting certain global public goods – of which health is a critical one.

Today, 90 per cent of resources allocated to health are spent on 10 per cent of the world population – the wealthy part - whereas 10 per cent of the resources go to cover 90 per cent of the disease burden which lies with the poor.

This clearly has to change. And it can be changed as we begin to take seriously the interdependence and the enlightened self interest which should lead the developed world to take global health seriously. President Clinton recently pointed out that only 2 percent of biomedical research focuses on the needs of the poor. Addressing this challenge is within the realm of technology and is a major part of the contribution that biomedical sciences can make to our common future.

Finally - what will it cost to make a real difference – to launch a massive effort at reducing poverty through well targeted health interventions?

At WHO we are working on presenting a realistic and combined package of interventions – based on existing technology and knowledge – addressing the leading health killers of poverty. I believe that with around 10 billion dollars the world could realistically make a giant leap towards halving the number of fellow human beings living in absolute poverty by 2015.

It will not be a blueprint for action – but a clear illustration of concrete interventions – or products if you like – that are likely to lead to very concrete results. This is about human security – and ultimately about national and international security.

So my answer to your question is: Yes - investing in global health is indeed good politics, it is good economics and it is good for national and international security. It means addressing up front the many components of global health; reproductive health, immunization, environmental health, nutrition, the emerging tide of non-communicable diseases such as cancer, heart disease and diabetes and the growing burden from mental health disorders.

Beyond this there is another, perhaps deeper, rationale. In a world torn by economic, ethnic, religious and cultural divisions, health remains as one of the few truly universal values. All major systems of belief and all mainstream political movements give primacy to the preservation of life, the promotion of well-being and the respect to the intrinsic dignity of the human being.

We have witnessed the unifying power of health when civil strife has stopped to allow vaccination campaigns to reach both bands. Health is truly a bridge to peace, an antidote to intolerance, a source of shared security.

One of the key challenges to everyone who will help build the 21st century will be to find the anchor points for a better common future. Health is one of them. The question that each and everyone of us has to answer is: Can we face up to that challenge?

Thank you.