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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.”

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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Mutual respect between

peoples

Security

Peace

Solidarity

Free and fair tradeEradication of

poverty

Protection of

human rights

Protection of the rights

of the child

Respect for international

law

Respect for the principles

of the UN Charter

TF-AU/3 European Commission :

Sustainable development

of the earth

The external Objectives of the European Union: upholding and promoting the EU Values and Interests

Global health strategy

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Health Societies

Post modern societies are health societies and are defined by five major characteristics –

  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

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….

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

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

“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 Peter Singer 2002

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Millennium Development Compact

CollectiveIntentionality to reducepoverty through buildingon mutual responsibilities:

The Millennium DevelopmentGoals are the first global development visionthat combines global politicalendorsement with a clearfocus on, and means toengage directly with, theworld’s poor people.

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The Millennium Development Goals 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 2. achieving universal primary education3. promoting gender equality 4. reducing under-five mortality by two-thirds5. reducing maternal mortality by three-quarters6. reversing the spread of HIV/AIDS, malaria and TB7. ensuring environmental sustainability8. developing a global partnership for development, with targets

for aid, trade and debt relief

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Goal 8: Partnership for development

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

0 1 2 3 4 5 6

NetherlandsDenmarkPortugal

New ZealandSwitzerland

GermanySpain

SwedenAustriaNorway

United KingdomBelgiumGreeceFrance

ItalyIrelandFinlandCanada

AustraliaUnited States

Japan

Aid Trade Investment Environment Migration Peacekeeping

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Caskets galore

Richard Morin Washington Post

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The health wars………..

In modernity the sharpest discourse on difference always takes its starting point from the body

Michel Foucault

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The health wars…….different concepts

ThreatRisk

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……..

: “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

BONO

CLINTON

MSF

150 PPPH

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In the 21st century Health is….

Foreign policy Security policy Economic policy/Trade policy Demographic development Geopolitics

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Dimension 1

The growth of epidemics

AIDS, SARS etc Global obesity/tobacco epidemics Increasing Global risk factors Unhealthy consumption The threat of bio terrorism

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Dimension 2

The lack of sustainable health systems

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

The socio-economic-political context

Unstable world New emerging poverty People movement: 1 bill on the move Negative impacts of globalization

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Dimension 4

The values

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

The international actors

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

Systems default:

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……

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 global governance

Security

Rule of law

Social welfare

Identity and participation

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 IFCTCodes, treaties, conventions

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ACCESS : No more business as usual

WTO/TRIPS/pricing

Global social movements

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Political advocacy

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

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

Pooling sovereignty and right to intervene on behalf of the global community:

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

“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

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

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

Health is a collectiveCommunity effort

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Political determinants

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

“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