Public health challenges are no longer just local, national or regional. They are global. They are no longer just within the domain of public health specialists. They are among the key challenges to our societies. They are political and cross-sectoral. They are intimately linked to environment and development. They are key to national, regional and global security.

Historically, disease in other places was seen as an impediment to exploration, and a challenge to winning a war. Cholera and other diseases killed at least three times more soldiers in the Crimean War than the actual conflict. Malaria, measles, mumps, smallpox and typhoid felled more combatants than did bullets in the American civil war. And the Panama Canal went over-schedule because of “tropical” diseases – then unknown, untreatable and often fatal.

Today on that front, there are very few unknowns. Globalization has connected Bujumbura to Bombay, and Bangkok to Boston. In an interconnected and inter-dependent world, bacteria and viruses travel almost as fast as e-mail messages and money flows. There are no health sanctuaries. No impregnable walls between the world that is healthy, well fed, and well off, and another world, which is sick, malnourished and impoverished. Globalization has shrunk distances, broken down old barriers, and linked people together. It has also made problems half way around the world everyone's problem. And we know that, like a stone thrown on the waters, a difficult social or economic situation in one community can ripple and resonate around the world.

Now, there are solutions for those diseases, which plagued the explorers, soldiers and colonialists of historical times. We know how to prevent and treat malaria. There are vaccines for yellow fever. There are treatments for TB. The striking feature is: while we diligently take antimalarials and top up our vaccinations when we travel to developing countries – the people living there, those threatened most by these diseases – don't have this access. 3,000 Children in Africa die each day from malaria. They die of vaccine preventable diseases – like measles, by the hundreds of thousands. And, people are dying, by the millions every year, of HIV/AIDS.

Hiv/Aids

Twenty years ago, HIV was a specter, all but invisible on the horizon. It was considered a disease, which affected specific minorities – gay men and intravenous drug users. Science was slow to respond. The rare cancer, Kaposi's sarcoma, was a marker, and a sentence to die a painful, slow and often lonely death.

The world took more notice with the realization that the human immunodeficiency virus knew no borders. Given the right vector, it could infect anyone – man, woman, gay, straight, healthy and haemophiliac. By 1990 in wealthy countries, we were screening blood donors and teaching our kids how to protect themselves against HIV. Condom use had increased. Incidence declined. And then antiretroviral were made available to those who could afford them. People in countries with health insurance gained access, giving tremendous hope for a longer, healthier life. In short, HIV diminished – for those in rich countries – as an urgent public health problem.

Today, more than 42 million people are HIV positive. 30 million of them are living in sub-Saharan Africa. They are trying to survive in some of the poorest countries and conditions – with no access to the most basic health care – much less sophisticated and expensive treatment. Many have died. Many are dying. They are mothers and fathers, teachers, and nurses and other health professionals, civil servants, miners, and soldiers. They are leaving a huge social and professional gap – an imminent threat to countries struggling to develop. They are leaving orphans, penniless grandmothers caring for their children's children, family members and communities frightened, hurt, stigmatized. Health systems stretched well beyond their often-frail capacities. We will see the effects of this unfolding tragedy for decades to come.

Many places in Africa we see a downward spiral, making countries increasingly weak. The important challenge is to address the underlying causes and arrest the descent, before we are forced to deal with the ultimate consequences – famine, unrest and human suffering. Consequences that will touch everyone – the loss of so much human potential will indeed resonate around the world.

Let us think of other areas where HIV is creeping in – China, India, the Central Asian Republics. Knowing the impact in so many other areas, we cannot stand on the sidelines, only to see another HIV crisis unfold before our eyes with the economic, social, and political devastation it will bring.

The short, sharp impact of conflict more quickly brings to light the inevitable links between health and development, between health and security. The obvious – the war wounded soldiers and civilians. The medium-term impacts – people uprooted, displaced to camps with little sanitation or health services, schools disrupted, and food insecurity.

Sars

And last year, the shortest, sharpest shock of all – an outbreak which captured imaginations, often more column inches than the war in Iraq, and always more headlines than Aids, TB or malaria. Severe Acute Respiratory Syndrome (SARS) put the world on high alert, and drove unprecedented cooperation to stop a disease, which had an immediate and negative impact on markets, on tourism, on trade. And, on hospitals, even in the most well developed countries with the most advanced health systems.

One person infected, staying at an international hotel, put the world at risk. And, unlike other diseases which we can prevent or treat, SARS was undiagnosable, untreatable, and, for one of every six people, fatal.

The way the world responded to SARS was global public health at its best. Scientists put aside their differences and drives to be the first, and came together, to share sequencing and study results. Doctors from around the world came together in virtual conferences, to share advice on how best to treat patients. Public health authorities from opposite sides of the globe flew to Geneva, to share their experiences with SARS, their success and failures with 192 member states at the World Health Assembly. And as a result, in just four short months, we had identified a new disease and contained a global outbreak, which could have become a global catastrophe.

The short sharp shock made us all stand up and pay attention. Due to the speed of science and using the best evidence, we quickly knew that SARS could infect anyone. Governments were committed. Resources made available. People made aware. Health workers given tools for action. Information shared across borders. In short, there was global mobilization to fight a global threat. The result – we probably won't find ourselves 10 years down the road with SARS also endemic in the countries, which can least afford it – devastating lives and economies. Because we acted to make sure that wouldn't happen.

And, we found that it was in everyone's interest to act. In today's connected societies, there was no choice. It was impossible to hide SARS in a world with the Internet and e-mail. Impossible to pretend it didn't exist, or that it was already contained. The consequences of doing so were mistrust in government, and in economies. Societies have been shaken to their foundation, fundamental questions raised about the handling of disease, of media and information, of constituents.

An unsafe world

But to better understand the even wider picture, we must go back to the slow creep of disease. Who is affected? And why? These diseases we can protect ourselves against – malaria, TB, HIV, measles, diarrheal diseases, respiratory infections – are impacting people in the poorest countries – where economies don't grow, where social unrest, unemployment and the threat of civil conflict force the stagnation of health and education systems.

I am not talking about small numbers. Between 1990 and 2000, the human development index declined in nearly 30 countries. Well over a billion people – more than one fifth of the world's population – are unable to meet their daily minimum needs. Almost one third of all children are undernourished. In many countries, which have seen economic growth, increasing inequality means that the poorest part of the population has seen little or none of the benefits from this growth. The average African household consumes 20 per cent less today than it did 25 years ago!

A world where a billion people are deprived, insecure and vulnerable is an unsafe world. The separation between domestic and international health problems is losing its usefulness as people and goods travel across continents. More than two 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.

We also know that, in poor countries where people feel powerless, and watch as much of the world gets richer, they can bundle hatred and channel it in the most devastating ways. A giant construction site where the World Trade Center used to be will always remind us of a world of conflict, a world divided. It exposes a new awareness of our vulnerability.

We must counter this manipulation of despair. We should seek to engage even more strongly with countries in crisis, to promote the values of democracy, justice and human rights.

There are many more compelling reasons for engaging in and supporting the rebuilding of weak and failed states. Diseases are spreading, mainly as a result of reduced efforts to control them and health systems weakened by poverty. We cannot afford to have large neglected areas where the population is left to fend for itself against diseases.

Health can be a bridge for peace. Efforts to eradicate polio have brought entire regions together – 16 countries across West Africa, where health workers cross borders to vaccinate children in neighboring villages. Where warring factions have laid down their weapons and picked up a vaccine vial. Where 60 million children were protected against polio in less than a week.

In the spring of 2003, the world also came together in the largest act of unity for health. 192 countries adopted the Framework Convention on Tobacco Control – the first truly international health treaty. Implementation of the treaty will see tobacco advertising banned, increases in the price of tobacco products, efforts to control smuggling and more smoke free places.

This Tobacco Convention had many opponents – many actively fighting to undermine the spirit and the letter. But those who wanted, and needed it most prevailed. Developing countries made the strongest push to see the convention adopted. Through this instrument, they have the power to keep the tobacco industry from encroaching further. And the power to reverse the current trend, which if left to fester, would kill 10 million people every year by 2020. That is foresight – for health, development, and for global security. It illustrates the world creating a global public good.

Investing in health

As the 18 leading economists and health experts who formed my Commission on Macroeconomics and Health have argued, disease holds back development and weakens societies. Malaria alone taxed Africa's combined GDP by about $100 billion compared to what it could have been if that disease had been tackled 30 years ago, when effective control measures first became available.

The Commission has presented a definitive argument for the need to invest in health as part of a basic development strategy. It shows, quite simply, how investments in health are an important pre-requisite for economic development. In fact, competition in a global market place will not provide enough incentives for poor countries to move out of poverty. The idea that little help should be given to any country apart from supporting free-market reforms and democracy, is now fortunately being seriously challenged.

Humanitarian aid and development assistance have contributed greatly to reduce suffering and increased security. We should expect even more: after a decade of shrinking resources for international development, donors have become increasingly focused on support for quality programs that promise to yield measurable results. It is a sign of hope that key donors have made commitments to raise, not lower their levels of ODA.

After a decade of shrinking resources for international development assistance, donors have become increasingly focused on achieving measurable results.

I am myself a strong proponent of this approach. We do need to direct aid into activities and interventions that give concrete and measurable outcomes if we are to build a momentum for increasing development assistance. And more aid is needed if we are to meet the Millennium Development Goals, to which all countries have committed. Not surprisingly, many of those goals are health-related.

International co-operation

We see the change disease brings to our world. And we see that foresight, investment and cooperation can make the difference. HIV has been with us for three decades, and the impact on societies and economies is too well known. By contrast, the global effort to contain SARS with determination and speed limited the impact to thousands, not hundreds of thousands, of cases.

We also face threats from the environment, and what humans can do to manipulate it. We have already had one anthrax scare. Each of us in this room has probably considered the threat of bioterrorism. SARS jumped from nature to humans – a rare occurrence requiring perfect conditions. And while far from a simple undertaking, bioterrorism is controlled by people, not nature. How to counter this threat?

The tools are in fact the same. Boosting capacity for disease surveillance is key to detecting all disease – whether created by nature, or humans. Currently, the system is not strong enough. Our experience with SARS exposed the weaknesses. Globally, including in developing countries, we must strengthen disease surveillance and control. SARS was a warning, which pushed even the most advanced public health systems to the breaking point. We must take this opportunity now to rebuild our public health protections.

This means more public health specialists, who can tell us where a disease came from, and where it is going. But, we can only find disease when we have the tools to look for it. Disease surveillance and response systems are critical, with strong national, regional and global linkages in reporting. And, governments need to invest more in infection control.

At the World Health Assembly in May 2003, member states adopted a resolution, which would see revised and strengthened International Health Regulations. The key is a system where infectious diseases are found, reported, and stopped. Depending on the threat, this will require continued international cooperation – a system where all recognize that any disease, no matter if it is affecting rich or poor, will touch us all at some point.

The challenge of unhealthy life-styles

Globalization also carries with it rapidly changing lifestyles. In our preparation for World Health Report 2002, we focused on “Reducing risks, promoting healthy life”. Surprising to many, not only underweight, but also overweight was to be found among the twenty most important risk factors globally.

Until recently, blood pressure, cholesterol, tobacco, alcohol and obesity, and the diseases linked to them, had been thought to be concerns just for industrialized countries. The report showed how they are becoming more prevalent in developing nations, creating a double burden, on top of infectious diseases.

There is a risk transition happening, with marked changes in patterns of living. In many developing countries, rapid increases in body weight are being recorded, particularly among children, adolescents and young adults. And, as you know, obesity rates have risen dramatically, threefold or more in some parts of North America, Eastern Europe, the Middle East, Pacific Islands, Australia and China since 1980. Changes in food processing and production and in agricultural and trade policies have affected the daily diet of hundreds of millions of people. The rise in inactivity was also identified, accounting for 15% of the risk to develop cancer, diabetes and heart disease.

In 2002 the World Health Assembly adopted a resolution to develop a global strategy on diet, physical activity and health, inspired by the joint WHO/FAO expert consultation held in January/February that year. Now, in 2004, the Assembly has adopted that global strategy, and I am happy to say that the scientifically based recommendations were taken seriously by responsible member states, not watered down due to strong pressure from industry, such as many had feared.

No denial is a good slogan. The conclusions are clear: We need to limit the consumption of saturated fats and trans fatty acids, salt and sugar. We need to increase the consumption of fruits and vegetables and the levels of physical activity.

Earlier this year in an exchange with the food industry, I saw the following statement: “There is a movement in Europe, the US and parts of Asia to legislate what people eat and drink. Affixing blame and passing new laws won't move us towards a solution.” My reply was: Yes, we must recognize that there is no quick fix, no silver bullet. Laws are no quick fix, but they are the expression of common responsibility, within and across nations. Well prepared they can help foster solutions, help set the right standards, help true competition in a level playing field.

I told them about my own experience, as a doctor, as a political leader. As a young environment minister, 30 years ago I argued strongly for road safety and our responsibility as a society to promote safe school walks for our children. “Action school roads” was created with public funds supporting walking paths across the country, within a four kilometers zone around the schools. My concern was avoiding death and disability due to car hits.

Today we can be grateful that those infrastructures are preventive tools in a much broader perspective. More children walk and more children bicycle than would otherwise have been the case. And more adults have easy access to safe roads for walking and cycling.

The WHO strategy recommends a prevention-oriented approach and the need for countries to develop coherent multisectoral national strategies with a long-term, sustainable perspective, to make the healthy choices the preferred alternatives at both the individual and community level. It recommends the control of food marketing to children and of health claims to packaging, improved nutrition labeling and health education.

It provides ideas on ways to make more healthful choices easier at school, work and home. Working with industry, with food retailers, consumers groups is the right way to go, and to choose a broad approach. Inspiring active lifestyles, sports, walking and less sugar, fatty and salty foods must be key areas of focus. We have already seen programs regarding marketing and promotion of junk food to children. There is a broad agreement and scientific evidence behind such recommendations. A US study showed that children younger than eight could not tell the difference between advertising and reality.

Conclusions

With the great costs both in human suffering and economically to our societies, I have no doubt that the questions of diet, lifestyles and marketing will remain with us. People and parliamentarians are now fully alerted. Initiatives will be taken in a number of countries.

Experience in WHO is that strategies developed in collaboration, have a considerable impact. Governments have guidelines to follow, they have informed NGO's and public opinions. Questions will be asked in the case of inactivity. With the key problem of rising costs for health services and ageing, the search for prevention and for cost-effective solutions will continue.

In today's world we need a shift in awareness towards the idea of building global public goods that can help us reap the huge potential benefits of globalization while at the same time containing the risks and vulnerabilities that comes with it. The main question is one of taking responsibility, of using our democracies to promote change.

Investing in health is an obvious choice. It saves lives, millions of lives. But it will also boost the economy, of poor countries and of the world.

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Dr Brundtland is a former Prime Minister of Norway and a former Director-General of the World Health Organization.

*

This is the speech Dr Brundtland prepared as a key-note lecture for the annual meeting of the European Public Health Association in Oslo (Norway), October 7, 2004.

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