Healthy People, Healthy Planet
By Dr. Gro Harlem Brundtland
Feb. 20, 2004, Nobel Peace Prize Forum

Last September, the Secretary General of the UN, Kofi Annan, made an urgent call to the nations of the world, in an address to the General Assembly. Having seen the shared vision at the Millennium Summit 3 years ago, a vision of global solidarity and collective security, he reminded delegates that recent events have called that consensus into question, and announced that he would establish a high level panel of eminent personalities to analyze the current challenges to peace and security, to consider the contribution which collective action van make in addressing them, and to recommend ways of strengthening the United Nations. I am honored to be part of that crucial process, and will focus much of my attention to the challenges of social injustice, disease, lack of development and poverty. We need to refocus attention to the achievement of the Millennium development goals, the common struggle to protect our environment, and the struggle for human rights, democracy and good governance.

Let me share with you some of my own experience, which has led me to concentrate on the links between people and the environment, between health and development, and the crucial observation that there is no common future unless we invest in people, in all people, in the future health and well-being. Without it, there will be no hope of sustainable development, prosperity and peace.

Twenty-four years ago, I was called at midnight from a wedding dinner and informed that there was a blowout of a well at the Ekofisk field in the North Sea. As an environment minister, I was less shocked about such an accident than many of my colleagues. I knew the oil drilling in the North Sea was pioneering work. I had been arguing that risks were real and that oil spill equipment must be put in place.

Luckily, after an intense week with little time for sleep and food, the well was capped, and the spill turned out to do less environmental damage than we had feared.

The Ekofisk blowout was a turning point for the Norwegian people as well as for its politicians. For many, this was the first time they fully realized that environmental questions were not a peripheral issue for conservationists, but a policy area right at the center of the country's economic development. Investment in the environment was an integral part of investment for the nation's future.

Over the past forty years, I have been deeply involved with three powerful movements: for democracy and participation of women, for the environment and for global public health. Environment moved center stage in the 1980s and has stayed there. We have been through a decade of real gains for democracy, and women's participation have made substantial strides too. Major interest in global health is scaling up now. Are there parallels to be drawn?

The first reflection is on the key importance of awareness raising. Progress in such areas is very limited without a solid and informed public debate which creates a real political momentum for action. This process is primarily driven by civil society and the media.

With the environment major events that triggered attention were Rachel Carson's "Silent Spring" and later the report from the Club of Rome. This not only raised awareness but also inspired a profound ethical debate.

At first, however, this debate was mainly limited to those with special interests. The issue did not move into central decision-making. What was lacking was a convincing, undeniable link to economics.

As a young environment minister, I realized that you cannot make real changes in society unless the economic dimension of an issue is fully understood. This is what took the environment from being a cause for the convinced and marginal green to becoming an issue for real societal attention by major players. It was necessary for the scientific facts to come in. The true costs of environmental degradation were analyzed and spelled out in figures. The political importance of environment changes became an issue for voters. Then, gradually, governments and parliaments started to establish incentives to change behavioral patterns among industry and consumers.

Indeed, with an increasingly strong and robust economic argument, it was possible to make sense both of government investment in the environment, and commercial investment in the development of cleaner technologies. Finance ministers and heads of state were made to understand the developmental consequences of environmental policies. We moved from a situation of market failure to one in which the market was made to serve global interests: sustainable development has gradually come to be seen as a global public good.

Recently, we have been witnessing similar processes with the issues of health.

The moral case has been made for years, and - by and large - has been ignored. Until recently, an overwhelming majority of finance officials and economists believed that health is relatively unimportant both as a development goal and as a strategy for reducing poverty. Health spending was seen as consumption of scarce resources rather than investment in a common future.

For global health, the HIV/AIDS pandemic seems to be eye-opener that the Ekofisk accident was to environmental issues among Norwegians. The debate over the moral, economic, social and security consequences of this catastrophe now unfolding around the world, has forced health onto the agenda in a way we have not seen before.

When I took up my post at the World Health Organization, there were some early indications that there was more to the relationship between health and development than what had traditionally been accepted.

To increase our understanding about this key relationship, I formed the Commission on Macroeconomics and Health that has assembled very powerful evidence for saying that we have massively under-estimated the role that health can play in determining the economic prospects of the world's poor communities.

Recent evidence shows how disease undermines economic progress. Consider the burden of HIV infection. HIV prevalence rates of 10-15% - which are no longer uncommon - can translate into a reduction in growth rate of GDP per capita of up to 1% per year. TB, which is exacerbated by HIV, takes an economic toll equivalent to US$12 billion dollars from the incomes of poor communities.

Africa's GDP would probably be about US$100 billion higher now if malaria had been tackled 30 years ago, when effective control measures first became available. Even today, half a billion cases of malaria each year lead to the loss of several billion days of productive work.

Health is far more central to poverty reduction than our macroeconomist colleagues previously thought, and that realization is now beginning to shape governments' and global policies.

Leaders of developing countries and industrialized countries then joined in a strong call to sharply increase investment in health for the poorest. UN Secretary-General Kofi Annan put a figure to this increase, saying we need US$10 billion in new money each year for at least ten years to fight HIV/AIDS, malaria and TB. The new Global AIDS and Health Fund will channel new resources fast and without cumbersome bureaucracy to projects that are proving to be effective. Through this renewed action on health, we are also reforming the whole way we are channeling development assistance. This is no longer business as usual.

Ladies and Gentlemen,

What about our environment since the 1980's? There is much that we can take pride in. New global conventions; reduced pollution in many countries; keen awareness about the value and importance of sound environmental policies; people, and especially young people, on board.

But let us also face up to some less welcome facts. Emissions of CO 2 are still increasing. Current international actions are not yet sufficient to prevent that the world facing significant changes in climate and sea levels.

Having unintentionally initiated a global experiment, we cannot wait decades for sufficient empirical evidence to act. That would be too great a gamble with our children's future. We know enough to defend effective measures to reduce CO 2 emissions. More knowledge is needed, but it must go hand-in-hand with immediate commitments to reduce CO 2 output.

We have every reason to be concerned about the adverse consequences to human health. Long-term changes in world climate will affect many pre- requisites for health - sufficient food, safe and adequate drinking water, and secure dwellings. Some of the health impacts will be direct, such as heat wave or flood related deaths. Others come from disturbance on complex ecological processes, changes in water supply, food availability and patterns of vectors and infectious diseases.

During periods of extreme temperature or altered rainfall, many areas of the world have been shown to experience a marked increase in malaria cases. Substantial leaps in malaria incidence have been recorded in recent decades in Colombia, Ecuador and Venezuela in South America, in Rwanda in Africa, and in Pakistan and Sri Lanka in South Asia.

In several locations around the world, malaria is now reported at higher altitudes than in preceding decades, such as on the mountain plateau in Kenya. We cannot yet be sure of the reason - and there are probably several. One possibility that we have to take seriously, if the trends continue, is that climate change is contributing to the spread of this major disease.

Closely associated with climate change is ultraviolet radiation due to depletion of the stratospheric ozone. This environmental change, now well documented, results from an essentially separate process from that of greenhouse gas accumulation in the lower atmosphere. Nevertheless, the two processes influence one another.

Increasing exposure to ultraviolet radiation will result in a rise in non-melanoma skin cancer, particularly in light-skinned people. It is also a near-certain cause of cataracts. Less certain, but potentially very important, is the suppressive effect of ultraviolet radiation on the human immune system.

The fossil fuel combustion responsible for CO 2 emissions also produces a number of other air pollutants, which have a direct impact on health. There are multiple ways that industry, transport and domestic use of fossil fuels affect health. This is crucial guidance for the choice of strategies to reduce fossil fuel transmission. If we count the costs and benefits of reduction in particles and ground level ozone together with those from reducing CO 2 , we end up with a much better picture of existing policy choices.

For example, dust and smoke particles have been associated with increased mortality, hospital admissions for lung and heart disease, and use of medication among asthmatics. Ground level ozone can exacerbate lung respiratory disease by damaging lung tissue and reducing lung function, and sensitizing the lung to other irritants. Carbon monoxide has been linked to hospitalization from myocardial infarction.

Such dramatic events place a disproportionate burden on the poor. Some question this - clinging to the belief that the weather treats all people equally. As the saying goes: no matter whether you are rich or poor, everybody gets wet when it rains.

Wrong. Even when it comes to weather, the poor are worse off. Much worse.

When a storm hits, the poor are most likely to live near the waterfront and in low-lying areas. Their sheds are made of flimsy material, which easily get smashed to bits by wind and water. And when the storm has passed, leaving destruction and disease in its path, the poor have no insurance to pay for damage and treatment. Their water supply is more likely to be contaminated, and the risks of them falling victim to epidemics are much greater than for the better off.

This we all know. But what is becoming increasingly clear is that the poor are also bearing the main burden of the long-term climatic changes to our environment.

Health scientists working within the Intergovernmental Panel on Climate Change have confirmed that poor populations tend to be the most vulnerable to the health impacts of climatic variation and climate change.

Deprived communities, lacking wealth, social institutions, and depending on others for information, resources, and expertise, are more vulnerable to ill health in the face of climate change stresses. This vulnerability is most extreme among the poorest.

This is a serious cause for concern. Social inequality and environmental issues are intimately connected.

What can we do to address these profound challenges? We need to revert to the broader agenda of sustainable development. The message of Our Common Future - reiterated at Rio - and in Johannesburg - was the link between environment and development. We called for a new era of economic growth - growth that is forceful and at the same time socially and environmentally sustainable.

In that process the industrialized countries must show their share of solidarity. Populations have a right to lift themselves out of poverty. The developed world cannot pull up the ladder and say: sorry - we filled the wastebaskets - there is no room left for you. We need to continue the work to take the Climate Convention further - step by step - based on evidence, and new mechanisms of burden sharing.

Health is a yardstick for how we succeed. In the health field, concerted action over the past 50 years has led to significant progress. Half a century ago, the majority of the world's population died before the age of 50. Today average life expectancy in developing countries is 64 years and is projected to reach 71 years by 2020.

As we look to the future, we are presented with two sharply different scenarios. Which of them we will turn into reality depends on the extent to which we can secure the political backing for firm global action.

The first scenario is truly horrendous. The spread of HIV/AIDS, tuberculosis and malaria, the emergence and antibiotic resistance, climate change leading to spread of vector born diseases, increase in extreme weather events and disasters, and threatening food security. This is not a worst-case scenario. It is where we are headed today. Unless we take action now. Not in ten or fifteen years, but this year and next.

The second scenario is one where the mortality of the main infectious diseases, such as malaria, tuberculosis and HIV/AIDS is drastically reduced. Where issues such as global warming and serious pollution are dealt with through forceful international action. And where global negatives, such as the impact of tobacco sales and marketing can be dealt with through internationally negotiated regulation.

Such a scenario calls for powerful political leadership and democratic action by all. This means joint working by governments, civil society and the private sector. There is no other way.

Consensus achieved during the last two years, on children, on HIV/AIDS, on financing and on trade and public health, makes a real difference. It enables us all to be clear and focused about what needs to be done, by whom, in what time frame, with which resources.

I believe that in health we also have the foundations of a lasting consensus.

We can demonstrate with confidence that investment in health pays major dividends: both as a precious asset in itself and in terms of economic development, poverty reduction and environmental protection.

We know that environmental threats may cause up to one-third of the global burden of disease. Contaminated water and air, polluting fuel, lack of sanitation and disease-bearing insects, together kill millions of people each year. Children are particularly vulnerable.

We know that it costs to scale up health actions that can transform the lives of poor women, men and children. We have goals and measurable targets agreed at the Millennium Summit by political leaders from developing and developed countries.

The challenge is to move from knowledge to action.

Healthy people - healthy planet. Healthy planet - healthy people. It works both ways.

Thank you.