Transcript Turning point for Public Health

The end of public health
as we know it
Ilona Kickbusch
Leavell lecture
WFPHA Brighton, 2004
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“There is no single time: all of our times
are alive, all of our pasts are present.”
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Carlos Fuentes
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The past is alive
Streetchildren 1890
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The past is present
Salgado
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A turning point
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New global social contract on health
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The new Europe
Koolhas
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The external Objectives of the European Union: upholding
and promoting the EU Values and Interests
Sustainable development
of the earth
Security
Respect for the principles
Peace
of the UN Charter
Global health
strategy
Solidarity
Respect for international
law
Protection of the rights
Mutual respect between
of the child
peoples
Free and fair trade
TF-AU/3
Eradication of
poverty
Protection of
human rights
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European Commission :
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Health Societies
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Post modern societies are health societies and
are defined by five major characteristics –
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a high life expectancy,
an expansive health and medical care system,
a rapidly growing private health market,
health as a dominant theme in social and
political discourse and
as a major personal goal in life.
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The wealth gap
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1.2 billion people live on less than $1 a
day
Thirty years ago the gap between the
richest 5th and the poorest 5th stood at
30:1
Now it is 74:1 (UNDP 1999)
Gender: No country treats its women as
well as its men.
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Poorest countries….
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A falling life expectancy in many African
countries
A lack of access to even the most basic
services
An excess of personal expenditures for health
of the poorest
Health as a neglected arena of national and
development politics
Health as a matter of survival
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MDG 4 – Reduce child mortality
Infant mortality rate
 IMR 5.1 (Canada), 62.0 (Bolivia) and
97.1 (Haiti)
Under five mortality rate
 500,000 deaths annually
 Mortality 16.5 times greater in Haiti
than in Canada
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MDG 5 - Improve Maternal Health
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23,000 maternal deaths annually in LAC
(1,000 in adolescents)
RR of maternal death 35 times higher in
LAC than in North America
Life time risk of death 1 in 7,700
deliveries in Canada - 1 in 17 in Haiti
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New global mindset
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“Implicit in the idea of “globalization”
rather then “internationalization” is the
idea that we are moving beyond the era
of growing ties between nations and are
beginning to contemplate something
beyond the existing conception of the
nation state”
Concept: One World
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Peter Singer 2002
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Millennium Development Compact
Collective
Intentionality to reduce
poverty through building
on mutual responsibilities:
The Millennium Development
Goals are the first
global development vision
that combines global political
endorsement with a clear
focus on, and means to
engage directly with, the
world’s poor people.
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The Millennium Development Goals
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The Millennium Development Goals are time-bound and
measurable goals and targets to be achieved between 1990
and 2015, they include:
1.
halving extreme poverty and hunger
achieving universal primary education
promoting gender equality
reducing under-five mortality by two-thirds
reducing maternal mortality by three-quarters
reversing the spread of HIV/AIDS, malaria and TB
ensuring environmental sustainability
developing a global partnership for development, with targets
for aid, trade and debt relief
2.
3.
4.
5.
6.
7.
8.
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Goal 8: Partnership for
development
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The last goal-global partnership for
development-is about the means to achieve
the first seven. Many of the poorest countries
will need additional assistance and must look
to the rich countries to provide it. Countries
that are poor and heavily indebted will need
further help in reducing their debt burdens.
And all countries will benefit if trade barriers
are lowered, allowing a freer exchange of
goods and services.
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Commitment to Development Index
Netherlands
Denmark
Portugal
New Zealand
Switzerland
Germany
Spain
Sweden
Austria
Norway
United Kingdom
Belgium
Greece
France
Italy
Ireland
Finland
Canada
Australia
United States
Japan
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Aid
Trade
1
Investment
2
3
4
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Environment
5
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Peacekeeping
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Caskets galore
Richard Morin Washington Post
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The health wars………..
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In modernity the sharpest discourse on
difference always takes its starting point
from the body
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Michel Foucault
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The health wars…….different
concepts
Threat
Risk
justice
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No excuses……………
There are no excuses left, no
rationalizations to hide behind, no murky
slanders to justify indifference – there
will only be the mass
graves of the
betrayed.”
Stephen Lewis
Photovault.com
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The problem……..
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: “the pervasiveness of today’s crises
suggests that they might all suffer from a
common cause, such as a common flaw
in policy making, rather than from issue
specific problems. If so, issue specific
responses, typical to date, would be
insufficient – allowing global crisis to
persist and even multiply”
(Kaul et al 1999 “Global Public Goods”)
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WHO
Gates Foundation
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NEW POLITICAL ECOSYSTEM for health
MSF
CLINTON
BONO
150 PPPH
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In the 21st century Health is….
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Foreign policy
Security policy
Economic policy/Trade policy
Demographic development
Geopolitics
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Dimension 1
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The growth of epidemics
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AIDS, SARS etc
Global obesity/tobacco epidemics
Increasing Global risk factors
Unhealthy consumption
The threat of bio terrorism
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Dimension 2
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The lack of sustainable health systems
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Lack of health care coverage of the poor
Insufficient national capacities for public health
in rich and poor countries
The dramatic fall of investment in universal
health systems.
Lack of human resources //export and brain
drain
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Dimension 3
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The socio-economic-political context
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Unstable world
New emerging poverty
People movement: 1 bill on the move
Negative impacts of globalization
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Dimension 4
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The values
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Lack of value attached to human lives in
the south
Lack of support for strong public systems
Lack of support for new global financing
mechanisms
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Dimension 5
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The international actors
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An ever denser network of actors with
lack of transparency
Increasing lack of accountability
“Balkanization” of global public health
and unintended consequences
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Dimension 6
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Systems default:
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Focus on disease
A world of vertical programs and quick fix
solutions
A tendency to invest in technologies and
drugs and not in social protection,
health systems and people
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Expansions……
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the expansion of the territory of health
into an increasing array of personal,
social and political spaces
the expansion of risk and a changing
nature of risk
the expansion of the do-ability of
health.
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Global solidarity/human rights
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Health is an individual right
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Nation state
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Security
global governance
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Rule of law
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Social welfare
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Identity and
participation
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Human Security and
Human Rights
International rule of
law/global ethics
Fairness in Global
Distribution
Common Identity as
global citizens and a
global voice and
channels of participation
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Signing the IFCT
Codes, treaties, conventions
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ACCESS : No more business as usual
WTO/TRIPS/pricing
Global social movements
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Political advocacy
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Governance and policy questions will begin to
move to the center of the global health debate
Public health advocates and associations will
have to move their advocacy forcefully into the
political arena
New financing mechanism for global public
goods
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5 Global Health action areas
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health as a global public good
health as a key component of global
security
health a key factor of global governance
of interdependence
health as responsible business practice
and social responsibility
health as global citizenship.
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International law
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Pooling sovereignty and
right to intervene on
behalf of the global
community:
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Revised International
Health Regulations
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Transparency and
Accountability
Accountability to “own” constituency and global community
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Global Ethics: From charity to
entitlements
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“the very values of an enlightened and
civilized society demand that privilege be
replaced by generalized entitlements –
if not ultimately by world citizenship then
by citizens rights for all human beings of
the world”
Ralf Dahrendorf
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5 Global Health action areas
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health as a global public good
health as a key component of global
security
health a key factor of global governance
of interdependence
health as responsible business practice
and social responsibility
health as global citizenship.
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Phases of Collective
Intentionality
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Health is a collective
Community effort
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1. Fight disease
Small pox eradication
2. Create Health
Primary Health Care 1978
HFA 2000
Ottawa Charter 1986
3. Invest in Health
World Bank Report 1993
Macroeconomic Report
2001
4. Health as a global
public good
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Political determinants
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The key challenge in this new phase of
globalization will be political because it
addresses distribution of wealth
Governance and policy questions will begin to
move to the center of the globalization debate
Public health advocates and associations will
have to move their advocacy forcefully into the
political arena: political will matters
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The third public health
revolution
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“to act that you treat
humanity whether in
your own person or
any other person
never merely as a
means but as an end
in itself.” (1785)
Immanuel Kant
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