21 January 2002
Health and Sustainable Development
Chairperson, Ministers from SADC Member States and the E9 Group, colleagues from the South African Cabinet, country delegates, representatives of international organisations and honoured guests
It is a great pleasure for me, as a representative of the host country of this important meeting, to reinforce earlier words of welcome. I would also like at the outset to encourage all participants to use this opportunity to the full to exchange ideas on the global dynamics of health and sustainable development and the challenges that we all face in this regard.
It is an honour to have you with us and we feel particularly fortunate to have a good number of delegations headed by a Minister of the country concerned. Welcome to you and to all other country representatives. We'd like to mention that the Health Minister of Zambia, Mr Chituwo, appointed in the last week, is in our midst and that his counterpart from Tanzania, Mrs Abdallah, is attending a meeting of this region for the first time. We would also like to extend a very warm greeting to representatives of various international organisations and non-governmental organisations whose contributions will undoubtedly enrich the proceedings.
A special welcome to representatives of the World Health Organisation, our co-organiser and the major sponsor of this meeting. I would also like to recognise members of the media attending this opening session and acknowledge their important role of relaying our debates to the public at large.
Before addressing the central concern of our meeting, I would like to extend the condolences to the people of Goma in the Democratic Republic of Congo, for the loss and suffering they have experienced. I'm sure I speak for us all when I say that there is a willingness to assist beyond the borders of your country and your region.
Fellow Ministers and delegates, your presence in Johannesburg this week is testimony to the fact that decision-makers in health recognise that sustainable development -- resting as it does on economic growth, social development and environmental protection -- is a matter that profoundly informs the engagement between the world's richest and poorest countries and reaches to the core of achieving healthy nations.
It is our collective task over the next few days to spell out very clearly the relationship between health and sustainable development and to place the relevant issues in large print on the agenda of the World Summit on Sustainable Development that is scheduled to take place in this city in August this year.
Since the 2002 Summit is a sequel to the United Nations Conference on Environment and Development -- popularly known as the Earth Summit -- that took place in Rio de Janeiro a decade ago, it is useful to look back at the profiling of health issues at that historic meeting.
We find that the declaration endorsed by the Earth Summit refers quite explicitly to health as a key goal of sustainable development. It asserts that "human beings . . . are entitled to a healthy and productive life".
The Rio Summit also gave birth to global plan of action, known as Agenda 21, which contains a chapter on protecting and promoting human health. It recognises the vital interconnection between health, the environment and socio-economic development and it advances an inter-sectoral approach to health.
However, with the benefit of hindsight, we would surely want to reinforce and extend certain aspects of Agenda 21 in the area of health and development. For instance we would like to:
Within the health field itself, we have had to extend our global vision of Health for All by the Year 2000 into the third millennium and we have had to concede that we are generally not up to speed in terms of the Millenium Development Goals that we have set.
However, I think that it is true to say that our understanding of the link between health and development - and the role of health systems in modifying that relationship - has grown and matured in the last decade.
More than ever, we have come to recognise that the relationship between development and health is not a one-way street. Just as the state of development of a nation influences the health status of its people, the disease burden of any country has a critical impact on its development path. Furthermore, it has been shown that effective health systems can make an enormous difference to the size and nature of a nation's disease burden -- and therefore to the course of national development. The World Health Report of 2000 examined at great length the critical impact of health systems on the well being of populations.
The report of the Commission on Macroeconomics and Health, published by WHO just a month ago, is a valuable asset for those of us who would argue that health is not an appendage of development but is indeed a key driving force. WHO's director-general, Dr Gro Harlem Brundtland, makes the claim that the report of the Commission is not simply a well-intentioned plea for more resources for health care - it is an argument for a comprehensive, worldwide approach to sustainable development.
The report estimates that by the year 2010, as many as 8-million lives could be saved every year if a global programme of essential interventions against infectious diseases and nutritional deficiencies could be implemented. It attempts to quantify what all this extra human life would mean in terms productivity, growth and social contribution. And it contrasts this with the cost of the package of interventions - a mere US$34 per person per year.
The figures are a concise argument for health programmes and services to be treated as an investment in development.
The Commission's work is also notable for the way it cuts through the sterile chicken-and-egg debates about whether internal health system reform in developing countries should precede an increase in donor investment, or vice versa. The report argues the case for massive additional donor funding, accompanied - at the same time - by increased commitment of effort and resources for health within the countries that benefit from this scaled-up assistance.
A cynical response to the work of the Commission on Macroeconomics and Health would be that it merely adds to the gap between understanding and performance, it painfully emphasises our inability to achieve our potential. But I believe this would be a fatal mistake and a misreading both of our responsibilities and of the unique opportunities of this moment.
I believe our meeting in advance of the World Summit is an indication that we share a strong awareness of the need to mobilise support for health to be treated as a priority within the global development agenda. We are here because we believe it is critical and possible to call forth political will at the highest level and across the development spectrum to engage health issues with greater seriousness.
Furthermore, there are indications that conditions are ripe for the type of intervention that we are contemplating. Largely as a result of the catastrophic impact of HIV/AIDS, the international community has shown signs of a new sensitivity to the suffering of people in the developing world. In the last year, we have seen concessions on patent protection of essential medicines at the WTO meeting at Doha; and we have seen the birth of a totally new international assistance vehicle in the Global Fund to Fight HIV/AIDS, TB and Malaria. In short, there is a growing recognition that health cannot be relegated exclusively to health professionals. Through our efforts, it is gaining ground as an issue that touches every sector and that cannot be overlooked in any serious strategy for sustainable development.
I am sure we would agree that these are only signs of hope - they do not constitute the final victory that we seek. I also have no doubt that all countries represented here stand as one behind the goal of finally achieving our promise of health and a productive life for all persons on this globe. To succeed, however, we must be able to select and articulate clear actions around which to unite our energies, actions that match the complexity of our reality and that may therefore secure the dream we treasure.
It is our firm intention to walk from this meeting with a Declaration in our hands, a declaration that outlines these priorities in a coherent and compelling way.
While it is not my role to anticipate what the detail of this Declaration will be, I would like to sketch some of social and economic dynamics - and the health patterns associated with these - that we must take account of in formulating our collective position.
Firstly, there is the fact that poverty -- or, more accurately, poverty in a world of plenty - remains an absolutely fundamental determinant of how disease is distributed.
The World Health Report 2000 provides ample evidence of the inequities in health status -- for example, in terms of disability-adjusted life expectancy, the variation in the responsiveness of health systems and the fairness of financial contribution to health systems. The role of poverty as the root cause of a range of diseases is absolutely clear. So is its impact on the development of adequate health services for the most vulnerable people on this planet.
The diseases associated with poverty are largely the communicable diseases that take a heavy toll of populations throughout the African continent. WHO has reported that communicable diseases contribute 70-80% of the world's morbidity rates, particularly in developing countries.
The catastrophic impact of HIV/AIDS has registered in a sharp upsurge of Emerging and Re-emerging Infectious Diseases on a global scale. UNAIDS reported in June 2000 that 34,3 million adults and children were living with HIV/AIDS and that 24.5 million of these were in Sub-Saharan Africa. More than seventy percent (70%) were living in the poorest part of the world
The effect of globalisation on health has been the subject of much debate and there is real concern about its negative impact on particular regions, nations and classes within nations.
A paper delivered by the Institute for Development Studies estimated that the number of people living in absolute poverty increased between 1987 and 1998 from 1 197bn to 1 214bn
The World Bank has conducted research showing that poverty rates decreased between 1990 and 1999 in developing countries as a whole -- from 29% to 23,4% -- but that two regions stood out as stark exceptions: The transition economies of Europe and Central Asia (where poverty rates increased from 1,6% to 3,7%) and Sub-Saharan Africa (which registered an increase from 47,7% to 48,4%).
Within various countries, too, inequality as measured by the Gini co-efficient has also grown in the era of globalisation.
In the context of Sub-Saharan Africa the process of urbanisation may represent a less pressing and immediate influence on health than absolute poverty - but it is nevertheless a factor of growing significance as the flow of population to the cities is an irreversible trend in every region of the globe.
The diseases usually associated with urbanisation are the non-communicable diseases that are linked to tobacco use, sedentary lifestyles, stress factors, unhealthy working conditions and poor nutrition. In addition, urbanisation inevitably results in far-reaching environmental changes. And the significance of the environment as a factor in public health grows in direct proportion to the density and size of human settlements. The risks are all the greater in poor countries where the resources to manage urbanisation are inevitably lacking.
Pollution of the environment is concentrated in urban settings; the risk of exposure to hazardous waste grows; and the vulnerability of large populations to natural disasters emerges with the growth of large informal settlements of poor people, who are desperate for a foothold in the city and will trade their safety for a corner of hazardous land.
The negative effects of globalisation may also be expressed through these uniquely "urban" health problems. For instance, developing countries have often become dumpsites for hazardous waste from developed countries.
Intrinsic to urban lifestyles is increased access to global communication and the programming of international media giants. The explosion of communication technology has broad implications for health. Not only has it contributed to a sedentary lifestyle, been a powerful purveyor of unhealthy foods, tobacco and alcoholic commodities but it has created a global village in which high-cost, high consumption lifestyles are established as the norm -- even in societies where they are totally unattainable.
This brings me to the factor of social instability, which is so often driven by the struggle for access to resources. At its most extreme, social instability takes the form of armed conflict. But it also occurs in less obvious forms - urbanisation, migration, political change.
The most obvious health implication of social instability is the emergence of high rates of trauma - injury caused in armed conflict or resulting from assault, suicide, homicide, rape or domestic violence.
Less visible are the mental health problems associated with social conflict and social instability. Currently unipolar depression is the fourth leading cause of disability-adjusted life years lost. This is second only to HIV/AIDS in the 15 - 44 year age group. The relative burden of mental health problems is expected to increase significantly by the year 2020. There is evidence in cross-national studies to suggest that common mental disorders - like physical disorders - occur more frequently among poor people.
Across Africa we have all too often experienced the destructive effect of social conflict on our health infrastructure. The impact of extreme instability is felt right across the health system and even well established services and programmes may crumble in the face of violence and uncertainty. Children and young people often bear the brunt of this collapse in services and, because of this, the impact is likely to be felt well into the future.
The New Plan for Africa's Development (NEPAD) takes very serious account of the need to ensure the security of our people and the stability of representative governments. On the African continent we are quite forthright in viewing this as a pre-requisite for sustainable development and therefore, also, as a necessary condition for the attainment of health. We will strive tirelessly to capture the elusive bird of peace.
Chairperson, delegates and guests I have taken a bit of time to position health issues within the major social and economic realities of our age precisely because I want to make the point that that the advancement of a health agenda does not imply a narrow, blinkered, clinical approach.
As advocates for health, we approach the World Summit seeking linkages, rather than claiming exclusive turf. We believe that, as health specialists, we have a particular and dynamic contribution to make to development. But we have an equally serious expectation that specialists in other areas will underpin health by striving for development in its broadest sense.
Fellow delegates, we meet at a time when the world is alert to the fact that the marginalisation of entire nations and their virtual exclusion from the benefits of technological advancement are a threat to global peace. The meaning of development as a global issue has seldom been so keenly and widely felt. It is more than fortunate that this awareness coincides with a meeting of the magnitude of the World Summit. Let us not fail in our duty as representative governments of some of the planet's most health-hungry nations to press home our just claim for action to make health for all a reality.
The ultimate prize in the quest for sustainable development is LIFE - life experienced in a fulfilling and comfortable manner; life lived in the light of good health. Let us get down to work on it!
Dr Manto Tshabalala-Msimang
Minister of Health
South Africa