1. IK Brighton 20041 The end of public health as we know it Ilona Kickbusch Leavell lecture WFPHA Brighton, 2004

2. IK Brighton 2004 2 “There is no single time: all of our times are alive, all of our pasts are present.” Carlos Fuentes

3. IK Brighton 2004 3 The past is alive Streetchildren 1890

4. IK Brighton 2004 4 The past is present Salgado

5. IK Brighton 2004 5 A turning point

6. IK Brighton 2004 6 New global social contract on health

7. IK Brighton 2004 7 The new Europe Koolhas

8. IK Brighton 2004 8 Mutual respect between peoples Security Peace Solidarity Free and fair trade Eradication 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

9. IK Brighton 2004 9 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.

10. IK Brighton 2004 10 The wealth gap 1.2 billion people live on less than $1 a day Thirty years ago the gap between the richest 5 th and the poorest 5 th stood at 30:1 Now it is 74:1 (UNDP 1999) Gender: No country treats its women as well as its men.

11. IK Brighton 2004 11 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

12. IK Brighton 2004 12 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

13. IK Brighton 2004 13 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

14. IK Brighton 2004 14 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

15. IK Brighton 2004 15 Millennium Development Compact Collective Intentionality to reduce poverty through building on mutual responsibilities: The Millennium Development Goals are the first global development vision that combines global political endorsement with a clear focus on, and means to engage directly with, the world’s poor people.

16. IK Brighton 2004 16 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 education 3. promoting gender equality 4. reducing under-five mortality by two-thirds 5. reducing maternal mortality by three-quarters 6. reversing the spread of HIV/AIDS, malaria and TB 7. ensuring environmental sustainability 8. developing a global partnership for development, with targets for aid, trade and debt relief

17. IK Brighton 2004 17 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.

18. IK Brighton 2004 18 Commitment to Development Index

19. IK Brighton 2004 19 Caskets galore Richard Morin Washington Post

20. IK Brighton 2004 20 The health wars……….. In modernity the sharpest discourse on difference always takes its starting point from the body Michel Foucault

21. IK Brighton 2004 21 The health wars…….different concepts Threat Risk justice

22. IK Brighton 2004 22 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

23. IK Brighton 2004 23 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”)

24. IK Brighton 2004 24 WHO Gates Foundation

25. IK Brighton 2004 25 NEW POLITICAL ECOSYSTEM for health BONO CLINTON MSF 150 PPPH

26. IK Brighton 2004 26 In the 21 st century Health is…. Foreign policy Security policy Economic policy/Trade policy Demographic development Geopolitics

27. IK Brighton 2004 27 Dimension 1 The growth of epidemics AIDS, SARS etc Global obesity/tobacco epidemics Increasing Global risk factors Unhealthy consumption The threat of bio terrorism

28. IK Brighton 2004 28 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

29. IK Brighton 2004 29 Dimension 3 The socio-economic-political context Unstable world New emerging poverty People movement: 1 bill on the move Negative impacts of globalization

30. IK Brighton 2004 30 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

31. IK Brighton 2004 31 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

32. IK Brighton 2004 32 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

33. IK Brighton 2004 33 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.

34. IK Brighton 2004 34 Global solidarity/human rights

35. IK Brighton 2004 35 Health is an individual right

36. IK Brighton 2004 36 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

37. IK Brighton 2004 37 Signing the IFCT Codes, treaties, conventions

38. IK Brighton 2004 38 ACCESS : No more business as usual WTO/TRIPS/pricing Global social movements

39. IK Brighton 2004 39 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

40. IK Brighton 2004 40 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.

41. IK Brighton 2004 41 International law Pooling sovereignty and right to intervene on behalf of the global community: Revised International Health Regulations

42. IK Brighton 2004 42 Transparency and Accountability Accountability to “own” constituency and global community

43. IK Brighton 2004 43 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

44. IK Brighton 2004 44 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.

45. IK Brighton 2004 45 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 collective Community effort

46. IK Brighton 2004 46 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

47. IK Brighton 2004 47 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