GLOBAL ETHICS FOR THE THIRD MILLENNIUM:
a series of interviews with outstanding personalities
 
Interviews by Patricia Morales
Globus Institute, Tilburg University, The Netherlands
 
Gro Harlem Bruntland: From Our Common Future (1987) to the WHO Report Making a Difference (1999)
 Interview by Patricia Morales and Ann Ferrara

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Q.            Morales (M): This series of interviews is about Global Proposals for the Third Millennium. Therefore, the first question starts with Our Common Future, because it was a key document in the relationship between human rights, sustainable development, and the global agenda, as well as the inclusion of intergenerational responsibility. What do you think about development in relation to this intergenerational responsibility?
 
A.        Well, first of all, we should maybe be reminded of the key definition that we formulated: that sustainable development amounts to meeting the demands of the present generations while preserving the rights of future generations to meet their own needs. I think that concept is important, because it illustrates the environmental dimension of sustainable development. In fact, if we misuse nature, and the relationship between man and nature, we will not be in a situation one generation from now, or two generations from now, to have choices and opportunities in life which make for a healthy and prosperous future. That intergenerational picture came forward in Our Common Future, and I think that was really what made the strongest impression on people, notwithstanding the clear links that were made between poverty and the environment (which also means between poverty and development). If people are poor, they don't have choices. They are not empowered often neither by knowledge, or by health, or by choices in their daily lives to take care of their children's future, and the future of the next generations, because immediate need dominates their lives and their choices. That also made an impression on many people. And the fact that this is not only a national question inside each nation, but also a global challenge, because of the big gaps, both inside countries and between countries. So, the global perspective of being in this together came very strongly forward in 1987, when the report was delivered. And those dimensions are as relevant today as they were in 1987.
 
Q.        M: But the gap between poor people and rich people is bigger than before.
 
A.        Yes, it is not really improving. There is a big analytical debate about the gaps: where are they growing, and where not? But basically, there is no improvement, and in some cases, yes, the gaps are increasing. So, since 1987, we have seen many developments.
 
Q.        M: Can you describe the evolution of the global agenda from Our Common Future to the WHO Report Making a Difference?
 
A.        From 1987 to 1999, when we wrote Making A Difference this is twelve years and in that span, many fundamental things influenced the global picture: the fall of the Iron Curtain, and all the changes in the former Soviet Union and Eastern Europe, which really changed the world. The world was shifting between a market economy and a centrally-denominated economy, and the competition in ideologies between the two. All of these things created a lot of fundamental changes in people's minds. And there were also economic crises during the 1990s: one at the beginning of the decade, and another at the end. Global economic crises hit the Asian economies particularly in the last phase, which moved many formerly middle-class people into poverty. So, while gains had been happening in Asia over decades, there were now setbacks.
 
At the same time in Africa, for the last 25 years, there have been reductions in the average African household income and consumption rate by 20 percent. Development assistance has been falling too. Only a few countries have fulfilled past commitments to provide 0.7 percent of their GDP for development assistance. In actual fact the world average is now closer to 0.2 percent. So, while we were writing in 1987 that we need to bridge the gaps, overcome the gaps, to alleviate poverty and to take care of the future, we have seen that many African countries have a worse situation now than they had in 1987. They are on a downward economic trend. It is in many ways a depressing picture.
 
And as I now enter into the health field, and look at the health dimension of sustainable development, there are partly-deteriorating health indicators instead of improvements. For example, in Africa, where the HIV/AIDS epidemic has taken force and changed the outlook, average life expectancy statistics are at present 59 years, with projections for 2005 2010 down to 45 years. Thus, the drama of the added health burden in economic and social terms is really strong. So, those are some of the things that have changed.
 
Until now, I have been explaining some of the negative changes. However, the pace of technological change has also been strong during those 12 years, which illustrates even more the need to counter the gaps, because information technology is to the benefit, if it is used and spread and made available, but it increases the gaps if that doesn't happen. There are many other areas where there have been improvements since the report came, because it did increase awareness, it did awaken a sense of global responsibility in civil society, parliaments, and governments. And, many positive things have been happening with regard to pollution, reduction in industrial pollution, and, in some countries, even reduction of traffic pollution, which is increasingly the worse part, because of the density of the population and the density of the cars. So, until we develop new transport technologies, we are really in big trouble.
 
Q.        M: There is more awareness.
 
A.        But the results are not what they should have been.
 
Q.        M: The following question is a really key one for you. You have pledged to place health at the core of the global development agenda, and you urge wise investments in health and a technical, political, and moral leadership. Could you formulate how intra- and intergenerational responsibility will be used to improve world health?
 
A.        Yes, at present we have about three billion people living on less than US$ 2 dollars a day. Half of the global population do not have anything close to a decent standard of living. That means that they cannot afford proper housing, proper health care, or education for their children. In that picture, of the 1.3 billion who are the poorest, 70 percent are women. Poverty has a woman's face: poor women are often caught in a damaging cycle of malnutrition and disease. Women from poor households are more than one hundred times more likely to die as a result of childbirth than their wealthier counterparts. I maintain that if people's health improves, they make a real contribution to their nation's prosperity. In my judgment, good health is not only an important concern for individuals; it plays a central role in achieving sustainable economic growth and an effective use of resources. In East Asia, for example, life expectancy increased by over 18 years in the two decades that preceded the most dramatic economic take-off in history. A recent analysis for the Asian Development Bank concluded that fully a third of the phenomenal Asian economic growth between 1965 and 1997 resulted from investment in people's health.
 
So, you also see the dimension we had in Our Common Future: the centrality in families and communities of women's empowerment, and women's choices in life; the importance of their reproductive health; their right to be able to choose how many children to have. And so in the lives of poor women, these aspects are still dominating. Although child survival has improved, maternal mortality is very high in many countries. When we wrote the World Commission Report, we believed that the number of billions, i.e. the increase in the world population, could be even higher. At least now the projections are that it might stabilize around 9 billion, while there were indications that it could rise to 12 to 15 billion.
 
Q.        M: When?
 
A.            Earlier, about 15 years ago. So, this is a positive after all. And the ability to get reduced fertility rates, and positive development in that sense, is very much linked to family and women's roles and opportunities. As we know, these issues were very strongly focused at the Cairo Conference and then at the Beijing Conference. The International Conference on Development and Population in Cairo firmly established that development, poverty reduction, and respect for women's reproductive rights are vital to stabilizing the world's population. And there are some improvements with regard to the number of women who have access to family planning and to reproductive health services. So, there are some positives to mention. It really shows how much those outcomes count. They really have a great impact on society and give rise to improvements.
 
Q.        M: You talked about a "health revolution" with major achievements such as the increase of life expectancy, eradication of smallpox, and diminution of risk from infectious diseases in the twentieth century. In your opinion, what are the major challenges for the WHO in this century?
 
A.        Going back to your earlier question, I have placed health at the core of the global development agenda, and that is absolutely right and I have identified that it is an important part of sustainable development. Both health and education are fundamental to people's lives and opportunities. I think that the centrality of education has been more generally understood in the last 25 years than health. I'm not talking only about experts in the development field, but also politicians, people who are active in society, in public debate. If you look at the last 25 years, awareness of the importance of education is generally acknowledged those are facts in people's minds but health, less so. Although health is obviously so closely-linked to people's abilities, to people's resources, to their ability to live and not to die as babies or children, or in childbirth, and so on. Health is key to the whole human resource development and to people's choices in life. And even for learning. If you are not healthy, you are not going to be able to go to school, and you are not going to be able to learn. So, these two are the two most important factors. As you look at the health aspect, and you look at the global economy, health takes 10 percent of the world GDP. That's a big figure, a high figure. If you look at how that money is spent worldwide, it is very badly distributed. In many countries, only US$ 5 per head per year is used to promote health. Of course, in other countries, it is $5000 per person per year. The range is shockingly big.
 
But the other point is how is that figure invested? Because many investments in health that are cost-effective are not made. So, children die because they haven't been immunized against the basic childhood infections. And to vaccinate every child with all of the available vaccinations would cost not more than $20 per child. And that investment is still made for around 50 percent of the world's children. So, those are the kinds of things that we are focusing on. How can wise investments in health reach many more, and lead to considerably improved health outcomes: lower infant mortality, lower morbidity for malaria, HIV, diarrhea, and all the illnesses that take a big toll on human suffering and mortality?
 
Q.        M: Which actors do you have to motivate to realize this project: the world's religious leaders, the politicians, the business sector, etc.?
 
A.        Yes, absolutely. In the last 10 years or so, with all of the big global conferences for example the Rio Conference in 1992, the Population Conference, the Human Rights Conference, the Women's Conference in Beijing, the Child Summit all of these have focused on the thinking and the philosophy of Our Common Future, in one way or another. As you say, a rights perspective. And the importance which this has for economies is what I try more and more to get across. It's not only a question of human rights it is, but that's not the only argument. The other argument is that its wise to invest in human resources, in health, in education, and the security of families. Because for societies, that means social development and higher economic growth, which benefits the whole of the global system, and would be helpful to avoid the financial crises and the things we have seen. So, we need a more practical approach to investing in people its not only the rights-based approach but a question of economics too.
 
But how do we have people work together for these goals? This is an important question. And I think that the global targets that the Conferences and now the Millennium Summit of the United Nations have set are important benchmarks important goals which many people can share. For instance, to reduce maternal mortality by 75 percent by the year 2015, which is in the Millennium Summit. As an example, that is a globally-set goal. All governments and NGOs have participated in the formulation, and heads of state have signed the document at the UN. Now, that means that our international institutions, our NGOs, civil society, and certainly the governments, will be striving towards those goals. And our development assistance, the advice that is given, the support that is given, whether its by international institutions or by NGOs to government efforts, will be focusing on reaching those outcomes. And I think it helps. Although development efforts need to be country-driven countries need to have ownership of their own development plans. The global targets that have been set by the whole of society globally, including governments, are benchmarks on which to strive, because they are key like the example on maternal mortality. Every country would want to reduce considerably their maternal mortality; and with functioning health systems reaching all, those targets will be met.
 
Q.        M: Are you happy with the Millennium Declaration of the United Nations (September 2000)?
 
A.        I think that it is a good Declaration. I really think that the responsibility of the global effort and the international community as a whole is clearly stated, but also the responsibility of every national government and also of every civil society. There is no good solution to developing a program to meet the needs of people worldwide, if you don't realize that democracy is built from the basis of communities, villages, people, who become active in trying to take care of their own destiny. So, democracy has to be built bottom-up. But that process can be supported by globally-set principles, standards, and targets which help the debate and the priority-setting, and also guide the direction of all those who want to support improvement in governance, democracy, human rights, and health.
 
Q.            Ferrara (F): Since you focus on education, how could universities and students in higher education become better-prepared for the challenges ahead? What kind of education should they be receiving or supplementing; for example, those with a traditional medical education?
 
A.        Well in the whole field of medical and biological education, and moreover social education, you need to have a global perspective, a public health perspective, and a development philosophy which bases its awareness on the need for democracy-building and capacity-building in developing countries. So, I think that its very important that universities really have those dimensions present early on in young people's education. Why is investing in health one major avenue towards the alleviation of poverty? I talked about the health revolution and its major achievements. So, what are the other major challenges in this century? I think a major one is the alleviation of poverty to allow the 3 billion poor to benefit from the health revolution. That I think is something that we have as an important basis of our program of work. And to participate in making people aware that it is not only poverty that leads to ill- health, but that ill-health leads to poverty. So, you need to invest in health, and invest in people to move out of poverty. That's important.
 
Q.        M: Could you explain the "health revolution" of the twentieth century through primary health-care and the transformation of the quality of life, creating the conditions favoring sustained fertility rate reductions and demographic change?
 
A.        We talked about this earlier about the centrality of the family, about women's choice and reproductive health, and the ability for raising children who will survive.
 
Q.        M: What role do you expect the United Nations and global governance to play in the Third Millennium, in particular, for improving world health?
 
A.        As I see it, part of the UN's role is to focus on developing democracy, participation, and capacity-building at the regional level, in villages and communities. We are seeing that democracy is gaining ground, that human rights is gaining ground, which is very positive. The UN should also be instrumental in:
 
               Supporting, by globally-set targets and support-mechanisms.
               Creating common understanding and shared goals. So that people who are active, whether they are churches, other NGOs, or a collaboration between universities whatever is happening in the global community that there are some shared standards or goals to be pursued. So that it's easier to work together for those goals, which means alliances of people supporting democratic action. There the United Nations plays an important role in convening all those forces in developmental shared goals and principles.
            And supporting action at the country level as well, although we have limited resources too limited, as you know. Keeping our attention on the global agenda and the advocacy for the global targets, but also doing it on the ground, supporting the action there.
 
Q.        M: Like the proposal made by Kofi Annan (Secretary General of the United Nations) for a Global Compact?
 
A.        Yes, and that illustrates the need for the private sector to get involved as well. Not only the NGOs of the classical type, but other parts of civil society, which is important of course the private sector the business community. They are having a lot of impact on the world. They work multinationally, they have an influence on almost every country, and they are dependent on human resources. Even looking at it from that perspective, if a business is working in a community riven by tuberculosis and AIDS, there is unlikely to be a good, lasting, working-force or the stable conditions necessary for normal economic progress. So, the Global Compact thinking is to make the private sector aware of the needs that they have, even from their own private interests, and their responsibilities at the same time. So, I think that it has been a good philosophy to state more clearly, that it is not the governments of the world, and then the United Nations, and its international institutions, who are going to carry every burden; because without the private sector working actively to support common goals, we cannot succeed.
 
Q.        Financially, too?
 
A.        Yes, also.
 
Q.        F: Has one project been to get the pharmaceutical industry to provide less-expensive medicines for developing countries. Is that a big effort?
 
A.        It is a big issue. And there was an important breakthrough in what was called the Uruguay Round of trade negotiations, where intellectual property rights were centrally-placed in the rules of trade (including pharmaceuticals). Now there are some safeguards and some balances in that trade agreement, which illustrates that many countries have used compulsory licensing, which means not respecting the concept of intellectual property which we are using in Western Europe, for instance. Instead, this is where you give a license to a company to produce medicines, by taking what is available and using it, even if it is patented in other countries. This whole area is a very complicated one. But the pharmaceutical companies have to be balancing their economic interests with some ability and willingness to be giving developing countries much cheaper medicines, even though patented drugs have high pricing. We call this "tier pricing," "dual pricing," and "equity pricing." So, that discussion goes on. How far can we get in really differentiating between poor communities and their needs, and much lower costs? Those are the kinds of discussions of a global nature that are important.
 
Q.        M: What support do you expect from the national governments, the NGOs, and the private sector to realize the mission of the WHO, particularly in relation to reproductive health, malnutrition, and access to health-care and medicines?
 
A.        We support governments. We must start by placing responsibility on governments, and then ask questions such as "What can governments do together?" and "What can the international institutions do which serve the populations of the world and the governments of the world in their collaboration?" Otherwise, how can we then add momentum and increase what we are able to do? I'm very scared of thinking, or concepts, or debates which seem to abolish the responsibility of the national institutions of the governments, and even of the peoples of the world, because there is no way to develop good societies if you don't have a functioning, active, democracy and participation. The rest of the world will never be able to take care of a country that doesn't see its own destiny. Basically and fundamentally a country should be shaped by developing its own capacities, its own institutions, but reasonably requesting others to support them. If it is a poor country in the developing world, and certainly after colonial times, the people have been left behind in a situation that they really couldn't even avoid. So, we all have a responsibility for this global solidarity, but I think that building awareness in every country with regard to putting the right priorities in their development thinking is very important.
 
Q.        F: Could it be a function of WHO, with various governments, to effectively choose several countries that don't yet have nursing schools or medical schools and establish them in order to start training from within?
 
A.        Well, this is what we do. That's why I say we support governments to be able to develop their capacity, but it is not governments that support us. That is, in a way, turning it around. It gives the right angle to things, I believe.
 
Q.        M: The problem is when a country is outside the system of the United Nations.
 
A.        But there are very few.
 
Q.        M: OK, there are very few.
 
A.        But there are other things: there are emergencies; there are wars; there are conflicts; and there are countries without government. And with all of the crises in the last 10 15 years, especially in Africa, you have many groups of people and big populations who don't have a functioning government system. And then, UNHCR and other international institutions including the World Health Organization and NGOs try to go in and help and support. But in those situations, there is no authority at the national level, or at the regional level, which is our challenge to raising international institutions. So, when I talk in general here, in most situations there is an acting government and some responsible body, and in more and more cases those are democratically-elected, which is a very good development in the last twenty years.
 
Q.        F: For example, on malnutrition, where you work together with the World Food Program?
 
A.        Yes, absolutely, because of the five big infectious diseases, which take half of the toll of mortality in developing countries: tuberculosis, malaria, and HIV/AIDS and childhood diarrhoea. All of these, which are the big ones the big killers they are all linked also to malnutrition. They are worsened, and the numbers increase with respect to morbidity and mortality, due to the weaknesses, because there is malnutrition. So, if you don't have a fundamental living standard of health and education, so that you're not malnourished linked to poverty once again you really cannot move out of these illnesses. So that illustrates the importance of alleviating poverty, but also the way that health and nutrition plays an important role in making that possible.
 
Q.        M: And education, too.
 
A.        Yes, and education, absolutely.
 
Q.        M: Could you explain the relationship between malaria and underdevelopment, and the significance of the Roll Back Malaria project, with a reference to the Organization of African Unity?
 
A.        We have programs, such as Roll Back Malaria together with HIV/AIDS, the big challenge in Africa. Malaria takes a big economic toll, in addition, because people are sick. Many children die, pregnant women have worse results higher mortality when added to that burden or challenge of going through pregnancy. So, from pregnancy through childhood and into adulthood, malaria is a big toll to Africa. Really there are no big improvements, and in the last 5 10 years, the situation has even been worsening. So, it has been necessary to put up the matter up for global attention. Now, how to address the malaria challenge? You can prevent half of the cases of malaria illness by using bed nets impregnated bed nets. It's a quite simple procedure, but you have to have a system of making it available at low prices to families in villages in Africa. So, again it illustrates that an illness prevention method was not, or is not available, and we have to develop a program that makes it possible at a low price to distribute and get it into the villages to save many children's and family's lives. Why is this an economic burden? Because, when the working population are for days and weeks in bed due to fever and malaria, it takes a big drain on the efficiency of the economy.
 
Q.        F: Yes, recently, it was published that in Kenya, not only Malaria, but also HIV/AIDS affects the economy. For example, one-third of the Police Force have HIV/AIDS how do you replace those trained personnel?
 
A.        Yes, and its also teachers.
 
Q.        F: Yes, teachers and public officials. Shouldn't they, at least, be eligible for the Triple Therapies that The North can offer, before we lose all of the vital capacities of the country's trained personnel?
 
A.        Yes, I know. This is why we are working so hard, not only on prevention of HIV/AIDS, but also now more and more on care. Care of those who are already ill and treatment. With opportunistic infections, like TB and other diseases, people get sick more easily, because they have HIV/AIDS. So, we have to treat those, to keep them going; but secondly, we have to get a much lower cost of the Triple Therapies, so that increasingly, Africans can have the same treatment that we have in the West. But that is a very big challenge, because the cost is so high, and thereare so many cost-effective interventions which are not financed, and which are also not done. But that adds to the gap the financing- resource gap with regard to health-care in poor communities.
 
Q.        M: There was a case here of an asylum-seeker, who had not yet received the status of a refugee, but had AIDS, and some people said, "If he returns to Africa, he will die. We have to care for him." It was a big problem a social problem because if the refugee were accepted, it would be likely that many others in similar positions would follow.
 
            F: We wanted to make that a question actually. Could you foresee that we would have a period of "health refugees" therefore?
 
A.        I think we have. I think that we have had for many years already. Oh yes, absolutely. One part of the people who come from Africa, or even from some Asian countries to Europe, they not only seek a better economic future, but also, if they are sick, they are aware of their chances of surviving or becoming healthy again. If you live in one of the Western European countries, it is completely different. So, we obviously have that already. And it illustrates that capacity-building and a reasonable level of health-care and health interventions needs to be there in poor countries, because it's in everybody's interests that the world functions everywhere.
 
Q.        F: One of the other areas, along the same lines, would be transplantation-donors being able to be coordinated through an organization such as the WHO, to bring the possibility of both donors and transplant recipients in contact with the materials and technologies that they need. Do you see that as a function of the WHO?
 
A.        Well, at the moment it isn't, but when governments see the need to use the World Health Organization to move into a new era a new area of responsibility it happens. Because when governments need to bring intergovernmental attention to health issues, we are the organization that can do it. So, it happens. We have a very different agenda today than 20 years ago, because new challenges have come up.
 
Q.        M: Could you explain the significance of the reduction of tobacco use in the light of health? Do you consider that the Tobacco Free Initiative will reduce consumption and be globally supported?
 
A.        We have 4 million deaths from tobacco today, globally. That's a very high number. That's equivalent to TB, malaria and HIV combined, even today the number of deaths. When you go 25 years forward in time and you make the projections, the numbers will increase to 10 million deaths. Smoking will then cause the highest number of deaths worldwide. In fact, every second person out of two people who start smoking young people one of them will die from the habit. That's a quite shocking number. Here, in The Netherlands, too many people smoke. I see it everywhere, and you put that in the interview. It's terrible, really. But I don't think that people are aware of this: that every second smoker will die from the habit. They don't die when they are 80, or at least some do, but mostly they die in middle age from heart conditions, pulmonary conditions, or from different kinds of cancers, not only cancer of the lung. So, it is really a terrible drain. It is the developing countries that will have most of the increase, because of their size. Seventy percent of the increase, from the 4 to 10 million, will come from developing countries. It is very costly to their health systems, because people, of course get sick; they are not productive, they live for several years with their illness before they die, so it is a big economic cost.
 
Q.        M: There is also a relationship to the business sector.
 
A.        Yes. One really has to counter it by not allowing advertising for tobacco, but having advertising campaigns against it, and having high cost of tobacco and cigarettes.
 
Q.        M: What is your dream for the Third Millennium?
 
A.        In the coming decades, the need for working together, across countries, is essential. We need to bring 3 billion poor into society and make it possible for them to lead healthy lives, to get the health interventions that we all take as something self-evident. It can be done. It is within reach. We need to invest in the future. We need to invest in the health of all people worldwide.