April 6, 2009 Dear Friends and Colleagues; For several weeks, the Global Health Program of the Council on Foreign Relations has warned that much of the world economy was at risk, should the April 2nd G20 Summit in London fail to produce meaningful agreements. In the lead up to the Summit, the signs were not good, as Europe (particularly Germany and France) seemed miles apart from the U.S. and China on questions related to the balance between strong regulatory changes in the global financial markets, versus significant infusions of liquidity in the form of government-backed stimuli for both banking bail-outs and infrastructural development. On the sidelines, hoping not to be ignored, were the IMF, World Bank, and developing countries. The VERY good news is that the G20 managed to function in a style of ad hoc governance akin to the performance of the G7 twenty years ago, albeit with a far broader representation of the global community. Further, strong commitments were made for the poor, world hunger, and global health. Catastrophe has been averted. In this Global Health Update please see:

• Upcoming events at the Council on Foreign Relations • G20 Summit Averts Catastrophe (for now) • Good News on U.S. Foreign Assistance and Food Aid • Muslim Brotherhood Embraces Indonesia’s Stance on H5N1 • Pharmaceuticals in Wild Fish

Upcoming events at the Council on Foreign Relations On April 21st from 12:30 -2:00 pm, CFR Global Health Fellow, Peter Navario will moderate a discussion with Dr. Dambisa Moyo at the Council on Foreign Relations in New York. In her recently released book, “Dead Aid: Why Aid is Not Working and How There is a Better Way for Africa,” Moyo offers a fresh critique of international development aid from an African perspective. Moyo’s arguments for a new approach to African development are informed by her unique combination of Western

education, professional experience at the World Bank and Goldman Sachs, and Zambian heritage. If you are interested in attending the event, please email Curran Kennedy (ckennedy@cfr.org). Space is limited, so RSVPs will be accepted on a first come basis. The Council on Foreign Relations, in partnership with the Global Health Council, and U.S. Doctors for Africa plan to convene a special reception at CFR in Washington D.C. with visiting African First Ladies to discuss their work in raising awareness on maternal health, girls' education, and HIV/AIDS related issues throughout Africa. The First Ladies will first travel to Los Angeles to participate in the "The Leadership for Health African First Ladies Health Summit": (http://leadershipforhealth.org/index.cfm?views=summit) The CFR event will take place during the First Ladies’ visit to DC on April 23 and 24, 2009. Please save the date, and more details will be sent shortly.

G20 Summit Averts Catastrophe (for now) It was headlined a 20-Government Summit, though 29 leaders were present in London on April 2nd for what all participants labeled an historic gathering, culminating in commitments of $1.1 trillion for IMF-led programs for emerging market economies and poor countries. Buried in the piles of documents produced at this week’s London Summit, were agreements for the wealthy nations to put $250 billion into an International Monetary Fund account designated to stimulate ailing emerging market economies, such as those of Iceland, Bulgaria, Ukraine, and Romania. Another $250 billion will be used by the World Bank and IMF to stimulate global trade (and presumably to block protectionism). Still another quarter trillion dollars will be given to the IMF for an overdraft facility, which governments can use as a sort of credit line to cover debts for a designated amount of time. Another $100 billion can be used by regional development banks to extend loans to poor countries. And the G20 (29) gave the World Bank permission to sell off $6 billion of its gold reserves in order to finance more bail-out and development schemes for poor countries. It was, overall, a success. Analysis of the G20(29) Summit can be found at the Council on Foreign Relations website: http://www.cfr.org/media/world_this_week.html?id=1405

Further analysis and copies of the key Summit documents can be found at the CIGI/Chatham House site: http://g20london.wordpress.com/

(The G28 Leaders, absent Canada’s Stephen Harper, who missed the photo shoot.)

The Leaders were pleased with themselves, joining British Prime Minister Gordon Brown in hailing their collective achievements. "This is the day that the world came together, to fight back against the global recession. Not with words but a plan for global recovery and for reform and with a clear timetable,” Brown told reporters on Thursday. "There are no quick fixes, but with the six pledges that we make today we can shorten the recession and we can save jobs…Today we have reached a new consensus, that we take global action together to deal with problems we face, that we will do what is necessary to restore growth in jobs, that we will take essential action to rebuild confidence and trust in our financial system.” Leading up to the Summit, French President Nicolas Sarkozy and German Chancellor Angela Merkel protested the U.S./China push for stimulus packages akin to the more than $2 trillion the Americans have infused into their banking system and general economy. Instead, the French leader decried the “Anglo-American style of capitalism,” blaming it for the entire global mess, and insisting on creation of some form of international regulatory body that could shut down rogue hedge funds or banks engaged in improper activities. "I defended what I believed and also what Chancellor Merkel believed," Sarkozy said in a press conference on Thursday, conceding that there had been tense moments in the Summit debates. "Of course there were tensions, of course there were wrestling matches, as it were. But even our Anglo-Saxon friends are totally convinced that, yes, we need rules…We've all of us been forging ahead, understanding we need to strike the right balance between stimulus and regulation. And in terms of regulation it means in-depth change…Never could we have imagined that we would achieve such a broad-based agreement," Sarkozy said. "And this is not the victory of one camp over another, one way of looking at things over another. It's an awareness by all that the world needs to change.”

The Summit did agree to some of the Franco-German proposals, including imposition of regulations on some types of derivative marketing, tax havens, and overly-leveraged banks. That was, apparently, enough for Sarkozy: "Since Bretton Woods, the world has been living on a financial model, the Anglo-Saxon model -- it's not my place to criticize it, it has its advantages -- clearly, today, a page has been turned."

U.S. President, Barack Obama, also put a positive spin on the Summit: "I think we did OK. We have agreed on a series of unprecedented steps to restore growth and prevent a crisis like this happening again... We have created as fundamental a reworking of resources to these international financial institutions as anything we've done in the last several decades."

GORDON SHEPHERD, DIRECTOR OF GLOBAL POLICY, WWF ENVIRONMENTAL GROUP

"There are some words about it but there is no clear evidence that this money will go into the green economy. We are looking for money that will go into low carbon development.

We were hoping the world's leaders would show real leadership."

JOHN SAUVEN, EXECUTIVE DIRECTOR, GREENPEACE

"Hundreds of billions were found for the IMF and World Bank, but for making the transition to a green economy there is no money on the table, just vague aspirations, talks about talks and agreements to agree."

There are no specific references to global health issues in the final communiqués. Rather, it is assumed that poor and troubled emerging market countries will use IMF and World Bank funds to, at a minimum, stay the course on their public goods. There is an implicit aspiration that funds will be directed to bolstering health systems and maintaining commitments to such entities as the Global Fund to Fight AIDS, Tuberculosis and Malaria: This is not, however, explicit.

Now comes the challenge that global health people are sadly accustomed to facing: Making donors come through with their commitments in an honest and timely fashion. Leading up to the Summit, the OECD released a detailed summary of donor commitments versus actual pay-outs up to the end of December 2008. The good news is the donated total of $119 billion was the largest sum ever given for official development assistance (ODA) by wealthy nations, and represented a 10.2% increase of 2007. The bad news is threefold, according to OECD: This net sum is still about $10 billion shy of the amount experts say must be spent annually to meet the Millennium Development Goals; the overwhelming majority of donor monies were delivered in the form of bilateral aid, with little increase in support of multilateral institutions save the Global Fund; and the world financial crisis has increased the needs levels dramatically in nearly all poor countries.

UN Secretary-General, Ban Ki-moon, warned the London Summit leaders that failure to make, and keep, bold commitments will result in what he called a “catastrophe,” marked by, “growing social unrest, weakened governments and angry publics who have lost all faith in their leaders and their own future.”

Writing in The Guardian on April 2nd, Ban berated the G20 leaders: “In good times, economic and social development comes slowly. In bad times, things fall apart alarmingly fast. It is a short step from hunger to starvation, from disease to death, from peace and stability to conflict and wars that spill across borders and affect us all, near and far. Unless we can build a worldwide recovery we face a looming catastrophe in human development.”

He asked for $1 trillion over two years to slow the downward spiral of poverty and disease in poor countries. We assume Ban is pleased with the London Summit results, but knows he will have to pressure governments to, on the donor side, come through on their promises. And on the recipient country side, Ban will want to ensure that spending is properly directed to public goods, market development, and the MDG targets.

WHO Director-General, Margaret Chan, gave the speech of her life in the lead-up to the Summit, entitled, “The impact of global crises on health: money, weather and microbes.” The breadth of her remarks and insights was so vast that we have attached her speech, in its entirety, at the bottom of this update.

Keeping donors honest on their commitments will be tough because Obama, Sarkozy, Brown, Hu, Merkel and the rest of them have to face the music back home. In Obama’s case, this means selling more fiscal pain to Congress and the American people. Among the major donor nations only Germany and China currently have reasonable GDP/debt ratios.

Moreover, the worst is yet to come, despite all the Summit bravado. World economic growth is expected to slow sharply, with the UK among the hardest hit.

Obama’s tough sell to Congress comes amid recognition that the U.S. bail-out already dwarfs the Marshall Plan after WWII.

Only China’s stimulus spending comes close to that of the U.S. As a percentage of Chinese GDP, it exceeds US proportional spending. And though Japan and EU countries have put some government resources directly into the financial system, only the U.S. and UK have made substantial investments in that direction.

The U.S. stock markets went up on the day of the London Summit, but slumped again on Friday as unemployment reports poured in. It was a dismal picture, with 663,000 Americans having lost their jobs in March, alone. Since December 2007, more than 5 million people in the U.S. have lost their jobs.

"It's an ugly report and April is going to be equally as bad," Mark Zandi, chief economist at Moody's Economy.com, told the Associated Press.

Bad as the U.S. economic picture may be, things are far worse in the United Kingdom. Rage-filled protestors who filled the streets outside the London Summit tapped into anger throughout the UK over job losses; and Gordon Brown is fighting to hold onto his job. At the end of 2008 – the most recent data point – the UK economy shrank more than at any time in decades, and 2009 contraction is expected to be far worse.

Good News on U.S. Foreign Assistance and Food Aid

Given the grim U.S. economic picture, we have remarkable news to report. On April 2nd President Obama announced that he will double American food aid and agricultural development support, bringing it to $1 billion for FY 2010, which commences in October. Earlier in the week, an amendment to restore $4 billion in cuts to the President’s International Affairs budget, introduced by Senators John Kerry (Democrat) and Richard Lugar (Republican) of the Foreign Relations Committee, passed the Senate in a unanimous voice vote. Kerry said, “If the first years of the twenty-first century have taught us anything about national security, it is that in a globalized world, our problems are interconnected, and so-ultimately-is our security. We are endangered by weak and failed states as well as by strong states. We are endangered by diseases and climate change emissions half a world away. We are endangered when we allow chaos and crisis to create the conditions for ideologies of radical hatred and violence to take root. And it is clear to all that meeting these global challenges will require far more than our military: it will require a strengthened commitment to diplomacy and development.”

“The reality is that right now, we are not doing nearly enough to invest in diplomacy and development,” Kerry continued. “That's the finding of numerous studies conducted inside and outside of government. Funding for the Department of Defense is over half a trillion dollars. In 2008, the Army added about 7,000 soldiers to its total; that's more people than serve in the entire American Foreign Service. 1,100 Foreign

Service officers could be hired for the cost of a single C-17 military cargo plane. And four billion dollars is less than two percent of what the government has given to AIG.” ”That is vital context for any discussion of the President's proposed increase in the international affairs budget. The President requested $53.8 billion in FY 2010 to fund next year's budget-an increase of 8%, or $4 billion, over last year's funding level of $49.8 billion.” Lugar, who is from the farm state of Indiana, has boldly pushed language into legislation (approved on Thursday) that allows the President or Secretary of State to de-couple U.S. food aid from the American agricultural and transport industries. For the first time, U.S. food aid can be in the form of cash, used to buy locally produced crops from farmers in famine-hit regions. This constitutes an enormous breakthrough. Lugar is a much-admired member of the Senate, known to deviate from his Party’s dictums when he feels good policy leads elsewhere. Lugar and Obama were good friends when Obama served on the Senate Foreign Relations Committee. In a sign of additional cause for optimism, Secretary of State Hillary Clinton on April 1st announced a sweeping program to reform U.S. foreign assistance. Some her comments echoed suggestions put forward in the Global Health Program’s Foreign Assistance Action Plan(http://www.cfr.org/publication/18167/future_of_foreign_assistance_amid_global_economic_and_financial_crisis.html?breadcrum

b=%2Fbios%2F1781%2F) as well as the Modernizing Foreign Assistance Network proposals (http://modernizingforeignassistance.net/index.html).

"USAID has been turned into a kind of distribution channel where the expertise that had taken years to build up has now migrated outside of the government," Clinton said. "And the result is that we don't get enough of a dollar of aid delivered to the final destination, and we

don't have uniform accountability measures because there's so many distributors of aid. This is a very big issue to me." Secretary Clinton indicated the Administration is working on filling the positions of USAID director and leader of PEPFAR, though no date for completion of the task has been set.

Muslim Brotherhood Embraces Indonesia’s Stance on H5N1 Indonesia’s total number of human cases of H5N1 avian influenza has now hit 120, with a mortality rate of 88%. Despite this remarkable fatality rate, including a 2-year-old girl who succumbed days ago in Jakarta, the Minister of Health Supari continues in her quest to force worldwide change in pharmaceutical practices, and persists in claiming the U.S. is making and releasing biological weapons. Until the world meets her demands, samples of H5N1 found in humans and birds in Indonesia will remain locked in the MOH freezers, never shared with WHO or outside scientists. Now, remarkably, MOH Supari has threatened to decline foreign-made childhood vaccines for pertussis, measles and polio – again, on the grounds that vaccines are part of a vast conspiracy from the western capitalist nations. However, later in the week a senior MOH official clarified that Indonesian children would continue to receive immunization, but did not clarify the source of the vaccines (http://www.thejakartapost.com/news/2009/03/30/health-ministry-clears-vaccine-dispute.html) Minister of Health Supari has, since late 2006, claimed that there is a bizarre conspiracy in the West – chiefly in the U.S. – to force emerging market Islamic societies to buy American pharmaceuticals at exorbitant cost. Further, she claims that the Americans, through our NAMRU-2 laboratory in Jakarta, actually manufacture germs, and release them in poor countries, in order to create a demand for U.S.-made vaccines. Further, the U.S., and its “collaborator” the World Health Organization, allegedly steal viral samples from Indonesian patients in order to turn about and use them for profitable vaccine production. Supari continues to claim that the 40-year-old NAMRU-2 lab in Jakarta is a bioweapons center that must be closed down. All of this was initially written off by outside observers as conspiracy drivel and political shenanigans for domestic Indonesian consumption. Sec. Rice did little, if anything, in response. The USTR was also publicly silent, despite Indonesia’s insistence that the World Trade Organization and “globalization” were all contributing to this strange conspiracy to sicken and rob Indonesians. Now three disturbing things have happened:

- The Muslim Brotherhood in Egypt has jumped on the bandwagon, claiming the U.S. NAMRU-3 laboratory in Cairo is spreading bird flu in the Middle East, and calling for the lab to be shut down.

- Indonesia’s MOH Supari has, for more than two years, refused to share any samples of bird flu viruses that have infected people in her country with WHO. A year ago she

also stopped sharing basic case information. This is deeply disturbing because Indonesia has since 2007 had the most H5N1 avian influenza cases, with the highest mortality rate in the world (88%). If the strains are evolving into more dangerous forms in Indonesia, there will be no early warning for the rest of the world, or time to produce vaccine. Now Supari is refusing to renew the NAMRU-2 lease, and demands that U.S. scientists leave her country. She is also insisting in Indonesian press conferences that the United States operates an aggressive, offensive biological warfare program, primarily targeting Islamic peoples.

- Egypt has become another major focus of H5N1 spread in poultry and people, and genetic analysis of strains found in Egyptians show the virus has mutated into three distinct lineages, which have spread from Egypt to Nigeria and other northern African countries.

Egyptian MP Ali Laben, a member of the Muslim Brotherhood Bloc in Parliament, declared in a speech from the parliamentary floor last week that NAMRU-3 allows Israeli scientists access to its Cairo facilities, and is spreading H5N1 all over the country. (See: http://www.globalpost.com/webblog/egypt/who-spread-h5n1-egypt) Founded in 1942 under orders from President Roosevelt, the U.S. Naval Medical Research Unit No.3 (NAMRU‐3) is an infectious disease research institute based in Cairo that has gone far beyond its original mission of fighting typhus in the Middle East. NAMRU-3 is now the most important, best-equipped disease surveillance center for the region. It has played a pivotal role in saving lives, not only in Egypt but throughout the region, fighting West Nile Virus, leishmaniasis, Ebola and Marburg viruses, drug resistant TB and malaria, and now H5N1. It is, simply put, one of the best things America does for the people of the Middle East and northern Africa. The Muslim Brotherhood started attacking the Mubarak government’s handling of H5N1 in May 2006, claiming government agents slaughtered infected chickens in public, allowing contaminated blood to spatter on bystanders. Further, the MB attacked government purchase of Chinese-made flu vaccines, which apparently were contaminated. Now the MB has gone well beyond condemning government incompetence, to join in Indonesia’s call to reject WHO, case sharing viral samples, and shut down U.S. lab facilities. NAMRU-2 opened in Jakarta in 1970, and has played a pivotal role in disease surveillance of disease throughout the Pacific Islands region and Southeast Asia. A year ago, MOH Supari warned Indonesians that there would be “repercussions” if they continued to work with NAMRU-2. The lab directly employs 150 Indonesians, collaborates with, and trains, dozens of other institutions and individuals regionally, and is the only sophisticated facility of its kind between Australia and Hong Kong. (http://jakarta.usembassy.gov/press_rel/April08/FactSheetNAMRU2.html), Meanwhile, Supari’s refusal to share her country’s human H5N1 samples may be hurting her in an unexpected way. Scientists in Indonesia report that H5N1 viruses extracted from native pigs are less virulent than those found in chickens, hinting at the possibility that the virus will become less virulent in mammals over time. That would obviate the need for Supari to stockpile those dreaded American-made vaccines.

Meanwhile, Egypt has suffered six new human H5N1 cases in the last month, bringing the country’s total to 61. Egypt’s death rate is lower than Indonesia’s, but still grim: 23 have died. What is going on? Well, H5N1 has branched into several evolutionary trees around the world, which appear to pose variant risks of human transmission and fatality. A team of

Chinese researchers has discovered that an as yet unidentified host factor in human beings facilitates conversion of H5N1 hemagglutinin into a form that can bind human upper lung cells. (See: Ying Guo, Emily Rumschlag-Booms, Jizhen Wang, Haixia Xiao, Jia Yu, Jianwei Wang, Li Guo, George F Gao, Youjia Cao, Michael Caffrey and Lijun Rong, Virology Journal 2009, 6:39.)

Pharmaceuticals in Wild Fish Sure, you already have plenty to worry about. But this item from the U.S. Environmental Protection Agency is pretty tough to ignore. Last week [March 25] the EPA released data that shows over-the-counter and prescription drugs are saturating the tissue and livers of fish caught in waterways around Chicago, Orlando, Dallas, Philadelphia, and Phoenix. According to the EPA, the common antihistamine diphenhydramine, an anticonvulsant and two types of antidepressants were among the seven types of pharmaceuticals found in the wild-caught fish. This is not the first time drugs, dumped into toilets and down sinks by human beings, has turned up in American fish and wildlife. But it is the first time combinations of drugs have been detected in significant amounts in individual fish. The EPA believes the levels of these drugs are sufficient to affect the animals’ behaviors, sexual reproduction and growth. Previous surveys in Europe and Canada have detected statin drugs in wild-caught fish. As always, the Global Health Program of the Council on Foreign Relations will endeavor to keep you informed about these and other global health-related events. Sincerely,

Laurie Garrett

Address at the 23rd Forum on Global Issues Berlin, Germany 18 March 2009 

The impact of global crises on health: money, weather and microbes

Dr Margaret Chan Director-General of the World Health Organization

Mr  Silberberg,  Secretary  of  State,  members  of  parliament,  members  of  the  scientific community, representatives of industry and civil society, colleagues in public health, colleagues from sister organizations of the UN, ladies and gentlemen, 

First and  foremost,  I would  like to thank the organizers  for the kind  invitation to address this audience. 

The world is in a mess, and much of this mess is of our own making. Events such as the financial crisis and climate change are not quirks of the marketplace, or quirks of nature. They are not inevitable events in the up‐and‐down cycle of human history. 

Instead, they are markers of massive  failure  in the  international systems that govern the way nations and their populations interact. They are markers of failure at a time of unprecedented interdependence among societies, capital markets, economies, and trade.  

In short, they are the result of bad policies. We have made this mess, and mistakes today are highly contagious. 

As  the economists  tell us,  the  financial crisis  is unprecedented because  it comes at a  time of radically  increased  interdependence.  Its  effects  have  moved  rapidly  from  one  country  to another, and from one sector of the economy to others. 

The contagion of our mistakes shows no mercy and makes no exceptions on  the basis of  fair play. Even countries that managed their economies well, did not purchase toxic assets, and did not take excessive financial risks will suffer the consequences. Likewise, the countries that have contributed  least  to  greenhouse  gas  emissions will  be  the  first  and  hardest  hit  by  climate change. 

The  financial  crisis  and  climate  change  are  not  the  only markers  of  bad  policies  and  failed systems of governance. The gaps  in health outcomes, seen within and between countries, are 

greater now than at any time  in recent history. The difference  in  life expectancy between the richest and poorest countries now exceeds 40 years. Globally, annual gov ernment expenditure on health varies from as little as US$ 20 per person to well over US$ 6000. 

Medicine has never before possessed such a sophisticated arsenal of tools and interventions for curing disease and prolonging life. Yet each year, nearly 10 million young children and pregnant women  have  their  lives  cut  short  by  largely preventable causes. 

Something has gone wrong. 

Collectively, we have  failed  to give the systems that  govern  international  relations  a  moral dimension.  The  values  and  concerns of  society rarely  shape  the  way  these  international systems  operate.  If  businesses,  like  the pharmaceutical industry, are driven by the need to make a profit, how can we expect them to invest in R&D for diseases of the poor, who have no purchasing power? 

In far too many cases, economic growth has been pursued, with single‐minded purpose, as the be‐all,  end‐all,  cure‐for‐all.  Economic  growth,  as  many  believed,  would  cure  poverty  and improve health. This did not happen. 

Globalization was embraced  as  the  rising  tide  that would  lift  all boats.  This did not happen. Instead, wealth has come in waves that lift the big boats, but swamp or sink many smaller ones. 

Greater market efficiency, it was thought, would work to achieve greater equity in health. This did not happen. 

Trade liberalization was put forward as a sure route to prosperity for developing countries. But trade  liberalization  slashed  tariff  revenues  and brought no  alternative  source of  finances  for public services, including health care. This has meant a disaster for health and social protection in  the many countries where most  labour  is concentrated  in  the  informal  sector and  the  tax base is small.  

User  fees  for  health  care were  put  forward  as  a way  to  recover  costs  and  discourage  the excessive  use  of  health  services  and  the  over‐consumption  of  care.  This  did  not  happen. Instead, user fees punished the poor.  

WHO estimates that, each year, the costs of health care push around 100 million people below the poverty line. This is a bitter irony at a time when the international community is committed to poverty reduction. It is all the more bitter at a time of financial crisis. 

Ladies and gentlemen, 

We  are  at  the  start  of what  the  experts  say  could  be  the most  severe  financial  crisis  and economic downturn seen since the Great Depression began in 1929.  

Last  week,  the  World  Bank  issued  an  assessment  of  the  impact  the  crisis  is  having  on  d eveloping countries. The assessment was far worse than just two months ago, and it predicted more grim news to come.  In affluent countries, people are  losing their  jobs, their homes, and their savings, and this is tragic. In developing countries, people will lose their lives. 

We are also  in the midst of the most ambitious drive  in history to reduce poverty and reduce the great gaps in health outcomes. No one wants this momentum to slow. 

But between the need and the good intention falls the reality. What happens if the enormous financial bailouts break the bank? What happens  if the money simply  is not there to continue domestic health programmes or  finance health development abroad? At  the  individual  level, what happens if people simply cannot afford to take care of their health? 

In a sense, the Millennium Declaration and its Goals operate as a corrective strategy. They aim to  ensure  that  globalization  is  fully  inclusive  and  equitable,  and  that  its  benefits  are more evenly shared.  

They aim to give this  lopsided world a greater degree of balance:  in opportunities,  in  income levels, and  in health. The underlying ethical principle  is  straightforward:  those who  suffer or benefit  least  deserve  help  from  those who benefit most.  

In  other  words,  the  Millennium Development Goals aim to compensate for  international  systems  that  create advances  and  advantages,  yet  have  no rules that guarantee the fair distribution of these benefits. 

As last week’s World Bank report clearly states,  financial  conditions  facing developing  countries have deteriorated  sharply,  the delivery of  essential  social  services  is  in danger, and the implications will be long‐term.  

The  likelihood  of  achieving  the  Millennium  Developing  Goals,  and  benefitting  from  their corrective strategy, is now in jeopardy. What happens if the financial crisis kills our best chance ever to transform this world towards greater social justice? 

The world desperately needs  a  corrective  strategy.  The  current huge  gaps,  in  income  levels, opportunities,  and  health  outcomes,  are  a  precursor  for  social  breakdown.  A world  that  is greatly out of balance in matters of health is neither stable nor secure.  

Let me be  clear.  I am not against  free  trade.  I am not  in  favour of protectionism.  I am  fully aware of the close links between greater economic prosperity, at household and national levels, and better health.  

But I do have to say this: the market does not solve social problems. 

The policies governing the international systems that link us all so closely together need to look beyond financial gains, benefits for trade, and economic growth for its own sake. They need to be put to the true test.  

What  impact  do  they  have  on  poverty, misery,  ill  health,  and  premature  death?  Do  they contribute to greater fairness in the distribution of the benefits of socioeconomic progress? Or are they leaving this world more and more out of balance, especially in matters of health?  

I would argue that equitable access to health care, and greater equity  in health outcomes are fundamental  to  a  well‐functioning  economy.  I  would  further  argue  that  equitable  health outcomes  should  be  the  principal  measure  of  how  we,  as  a  civilized  society,  are  making progress. 

This world will  not  become  a  fair  place  for  health  all  by  itself.  Economic  decisions within  a country will not automatically protect  the poor or guarantee universal access  to basic health care. 

Globalization will not self‐regulate in ways that favour fair distribution of benefits. Corporations will  not  automatically  look  after  social  concerns  as  well  as  profits.  International  trade agreements will not, by themselves, guarantee food security, or job security, or health security, or access to affordable medicines. 

All of these outcomes require deliberate policy decisions. 

Health  had  no  say  in  the  policies  that  led  to  the  financial  crisis  or  made  climate  change inevitable. But the health sector will bear the brunt of the consequences. 

Ladies and gentlemen, 

Countries at all levels of development are concerned about the impact of the financial crisis on health. 

Officials are worried  that health  in  their own  countries may worsen as unemployment  rises, safety nets for social protection fail, savings and pension funds erode, and spending on health drops.  

They are also concerned about mental  illness and anxiety, and a possible  jump  in  the use of tobacco, alcohol, and other harmful substances. This has happened in the past. 

They are concerned about nutrition, and rightly so. Recent dramatic changes in the world food supply make  this  economic  downturn  different  in  terms  of  health  threats  arising  from  poor nutrition.  Food  production  has  become  highly  industrialized,  and  distribution  and marketing have a global reach.  

When  times  are  hard,  processed  foods, high  in fats and sugar and  low  in essential nutrients, become the cheapest way to fill a hungry stomach. These foods contribute to  obesity  and  to  diet‐related  chronic diseases, and they starve young children of essential nutrients.  

And there are other threats to health that we  need  to  anticipate.  In  times  of economic  crisis, people  tend  to  forego private  care and make more use of publicly  financed services. This  trend will  come at a  time when  the public health  system  in many  countries  is already vastly overstretched and underfunded.  

In many low‐income countries, more than 60% of health spending comes in the form of direct out‐of‐pocket payments. Economic downturn  increases  the  risk  that people will neglect care, with prevention falling by the wayside. Less preventive care is particularly disturbing at a time when demographic ageing and a rise in chronic diseases are global trends. 

We  know,  too,  that  women  and  young  children  are  among  the  first  to  be  affected  by  a deterioration  in  financial  circumstances  and  food  availability. Women  are  among  the  last  to recover when times get better.  

Health  officials  are  also  worried  that  current  levels  of  financing  for  international  health development may not be maintained. The assessment issued last week by the World Bank fully justifies these concerns. The consequences will be dire. 

Well  over  3  million  people  in  low‐  and  middle‐income  countries  are  now  receiving  life‐prolonging antiretroviral therapy for HIV/AIDS. Their lives have been rejuvenated. Families and communities have been revived. Treatment is, of course, lifelong. Can we, ethically and morally, cut back spending in this area? 

Dire consequences can also be contagious.  Interruptions  in the supply of drugs, especially  for diseases  like AIDS, TB,  and malaria,  contribute  to preventable deaths  in high numbers.  Such interruptions also accelerate the development of drug resistance. 

Drug‐resistant  forms  of  disease  can  quickly  spread  internationally. We  are  seeing  this,  right now, with the rise of multi‐drug resistant TB, and the even more alarming rise of extensively‐drug  resistant TB. This  form of  the disease  is virtually  impossible  to  treat, with  fatality  rates approaching 100%.  

Its  further  international  spread  could  take  us  back  to  the  treatment  era  that  pre‐dates  the development of antibiotics. Can the world really afford another risk of this magnitude? 

Surveillance  for  emerging  diseases  contributes  to  global  security.  If  basic  surveillance  and laboratory capacities are compromised, will health authorities catch the next SARS, or spot the emergence of a pandemic virus in time to warn the world and mitigate the damage? 

We  know  that  external  assistance  for  health  has more  than  doubled  since  the  start  of  this century. Despite  this  trend, around half of  the world’s countries do not have  the capacity  to finance even the most rudimentary “survival kit” of basic health services. 

Reduced external financial assistance will truly be a killer.  

Globally, around 1 billion people are already  living on the margins of survival. It does not take much to push them over the brink. This can happen because of the financial crisis. This can also happen because of climate change. 

Ladies and gentlemen, 

The scientific evidence is overwhelming. The climate is changing. The effects are already being felt. 

The warming of the planet will be gradual, but the increasing frequency and severity of extreme weather  events,  like  intense  storms,  heat waves,  droughts,  and  floods, will  be  abrupt  and acutely felt. Both trends can affect some of the most fundamental determinants of health: air, food, and water.  

I am fully aware that I am speaking to an audience in a country that has been at the vanguard of environmental protection, and the cutting edge of technology development and application. In this  regard,  let me  pay my  deep  personal  respects  to  the  government  of  Germany  and  its citizens.  

I also thank this country for its strong support for health development and  for  the  work  of WHO,  including  support  from  your  scientists, epidemiologists, laboratories, and renowned research institutes.  

Several  consequences  for  health  have  been  identified  with  a  high degree of certainty. Malnutrition will  increase, as will  the number of deaths  from  diarrhoeal  disease. More  storms  and  floods will  cause 

more deaths and injuries, and cholera outbreaks will occur with greater frequency.  

Heat waves,  particularly  in  large  cities, will  cause more  deaths,  largely  among  the  elderly. Finally, climate change could alter the geographical distribution of disease vectors, including the insects that spread malaria and dengue. 

All of  these health problems are already huge,  largely concentrated  in  the developing world, and difficult to control.  

Although climate change  is, by  its nature, a global phenomenon,  its consequences will not be evenly distributed. Scientists agree that developing countries will be the first and hardest hit. 

According to the  latest projections, Africa will be severely affected as early as 2020. A decade from now,  crop yields  in  some parts of Africa are expected  to drop by 50%. By 2020, water stress could affect as many as 250 million Africans. 

Imagine the impact on food security and malnutrition. Imagine the impact on food aid. In many African  countries,  agriculture  is  the  principal  economic  activity  for  70%  of  the  population. Among Africa’s poor, 90% depend on agriculture for their livelihoods. There is no surplus. There is no coping capacity. There is no cushion to absorb the shocks. 

Women and young girls in parts of Asia currently spend from six to nine hours collecting water each day. What will this burden be when water scarcity increases, as is happening right now?  

We  also need  to  consider what  these  changes mean  for  the  international  community. More disasters, more floods and famines mean greater demands for humanitarian assistance. These demands for help will come at a time when most countries are themselves stressed by climate change. 

The  international community will also have to cope with a growing number of environmental refugees. If land is parched or salinated, if coastal and low‐lying areas and small island nations are under water, these people cannot simply go home. Environmental refugees thus become a new wave of settlers, possibly adding to international tensions. 

Anything  we  can  do  now  to  reduce  existing  burdens  of  disease  will  increase  national  and international capacity to cope with the new stresses that come with climate change. This gives us  another  very  good  reason  to  remain  s  teadfast  in  our  pursuit  of  the  health‐related Millennium Development Goals.  

Up to now, the polar bear has been the poster child for climate change. We need to use every politically correct and scientifically sound trick in the book to convince the world that humanity really is the most important species endangered by climate change. 

Can  the health  sector give a human  face  to  the other problems we  see  in  this big mess of a world? Is the health sector in a position to bring a moral dimension, to introduce a value system to the policies that govern our international systems? 

Given my current job description, I will definitely say yes. But I have some solid reasons to back up this view. 

Ladies and gentlemen, 

Let me  turn  to  a  third  issue:  global  crises  that  arise  from  the  constantly  changing microbial world. This issue is different from the financial crisis and climate change.  

It is different because the health sector is in the lead. The health sector makes the policy, and implements  governance  through  the  International  Health  Regulations. We  do  not  have  to compete against economic interests. In fact, the tables are turned.  

Emerging  and  epidemic‐prone  diseases  are  considered  threats  to  international  security precisely because of the tremendous economic and social disruption they can cause. 

Public health has very  few estimates that come even close to the multi‐billion dollar  financial bailouts we seem to hear about every week. But according to the  latest World Bank estimate, the next influenza pandemic could easily cost the global economy US$ 3 trillion. 

World leaders tell us that the financial crisis is so severe and unpredictable because it is the first such  event  under  the  unique  conditions  of  the  21st century.  

SARS, which  emerged  in  2003, was  the  first  severe new  disease  of  the  21st  century.  Like  the  financial crisis,  it  emerged  at  a  time  of  radically  increased interdependence.  

SARS was the first disease to move rapidly around the world  along  the  routes  of  international  air  travel.  It put every city with an  international airport at  risk.  It closed  airports,  businesses,  schools,  and  some borders.  It  paralysed  economies,  and  paralysed  the public with fear. 

But never forget: the response to SARS was a deliberate effort to prevent this new disease from becoming permanently established  in  this world,  to  keep  it  from  joining  the  league of  killer diseases like AIDS, TB, and malaria.  

This was one severe global contagion  that was quickly ended. WHO and  its partners stopped SARS, dead in its tracks, within four months.  

The health sector was prepared. Surveillance, alert, and  response mechanisms were  in place. We managed the risks. And this crisis did not spiral out of control.  

From  the  beginning  of  the  outbreak,  the  world’s  top  scientists  set  aside  competition  and worked  together,  in a virtual  laboratory, around  the  clock. They  identified  the virus within a month.  

This  is  the  brighter  side  of  globalization.  This  is  an  example  of  collaboration  and  solidarity before a shared threat. 

We see this same  international solidarity  in support for the drive to eradicate polio,  including humanitarian  support  from  Rotary  International,  and  support  from  several  enlightened governments, including Germany. 

Concern  for health  can  also motivate ethical behaviour  in  industry,  as when pharmaceutical companies  dramatically  cut  prices  for AIDS medicines.  Concern  for  health  can  persuade  the international  community  to  agree  on  the  control  of  harmful,  yet  profitable  products,  like tobacco. 

There is hope.  

If we have to rethink the way this world works, and overhaul some of our international systems, I personally believe that health deserves careful consideration for a leading role. 

Our policies are guided by scientific evidence, and not by vested interests. We have the power and the objectivity of the scientific method on our side. The health sector has humanity’s best 

interests at heart, a strong moral dimension, and a strong set of social values among  its many stars. 

Let us all continue to provide the hope this world so badly needs at a time of severe crises – and transformation. 

Thank you.