Challenges
to the Health of Children in the 21st
Century Delivered June 14, 2000 by Dr.
James Orbinski, President, MSF International
Council, at the 27th Annual Global
Health Forum, A Century of Health for the Children of
2000
Thank you for asking me to speak today, where
I am asked to do the impossible—to lay out the key challenges for
the health of children into the next century. It is impossible
because, to oversimplify, it presupposes that these can be listed
like a shopping list against which we must simply apply our
efforts—and with enough effort, at the end of the day, our
bellies—and the bellies of our children—will be full. Reality is not
so simple.
The reality of MSF today is in our therapeutic
feeding centres for children in Ethiopia, in the Congo with women
and girls who are victims of rape as a weapon of war, in Sierra
Leone with unaccompanied children, in Cambodia and Guatemala with
sex workers and street children pulverized by poverty, in Kosovo,
Sudan, Timor, Belgium and Italy, and more than 60 other countries
around the world. Our mission is very simple: it is to seek to
relieve suffering, to reveal injustice, to provoke change, and to
locate and insist on political responsibility. By definition,
children are always among the most vulnerable, and thus, by
definition, we are always among children.
MSF is not perfect, as many of you know. We do not
pretend to be, and should we ever pretend to be so, it would be the
end of what has been and is today a fluid, dynamic and decentralized
movement of people committed to humanitarian principles and most
importantly, to practical humanitarian action. And this is an action
that is by definition fraught with paradox, dilemmas and
uncertainties. Indeed, we know only too well, that there are often
no right answers, but only what are so obviously wrong answers,
actions, and postures that acquiess to reality—or the way the world
is. We were founded in 1971by a group of French journalists and
doctors. The doctors had worked for the Red Cross during the Biafra
war, and were outraged at the fact that IHL prevented the Red Cross
from speaking out against what was effectively a state policy of
forced starvation and migration. . For many, silence has long been
confused with neutrality, and has been presented as a necessary
condition for humanitarian action. From our beginning, MSF was
created in opposition to this assumption. We have, do, and will
refuse to remain silent in such circumstances. In the last 29 years,
Médecins sans Frontières has been and is irrevocably committed to
this ethic of refusal. This ethic affirms MSF's commitment to
universal medical ethics; to its understanding that all
people—regardless of state borders or existing interpretations of
international law—be it humanitarian law, or law governing trade in
intellectual property rights, or any law—that all people have a
right to exist as human beings. This morning it was emphasized that
in practice, all rights are not equal, and that the right to survive
is the most obviously elemental . Well, MSF couldn't agree more.
More than anything else, at the heart of our work is
an irreducible respect for human dignity. Bringing direct medical
action to bear, and doing so without regard for borders or other
artificial barriers, this is the heart of MSF's work. It is at its
root a commitment that sees human beings not as a means, but as an
end in themselves, possessing an inherent dignity. It affirms that
how human beings are treated anywhere, concerns everyone everywhere.
And it demands that this authentic and irreducible human dignity
must be at the centre of any political project.
Today, the reality is that we live in a social order
that excludes, that marginalizes, and that literally leaves open to
sacrifice the lives of billions of people—men, women, and
children—in the name of some future economic benefit that will
trickle down to the worlds' poor, given enough time. Well, quite
frankly, that is not good enough.
The new buzzword is poverty—either its alleviation
or eradication. Lets be clear. Ours is a time of unprecedented
wealth. And yet politicians and their patrons tell us ceaselessly
that we live in an era of limited resources, and this cry has been
taken up by those responsible for formulating social policy. But
there is more money, more wealth today that at anytime in human
history. There is not less of it, but it is in fewer and fewer
peoples' hands—least of all "the peoples"—as states retreat from
their responsibility to protect and achieve social goods. The market
rules, and the few win while the many languish in unfettered
poverty; more than 1 billion people are unable to secure food and
water, the most basic measure of health prevention. The market is
powerful for the powerful, and it fails for those it has always
failed, and whose numbers are growing—those who must live in the
refuse of others peoples' more priveleged existence. A rising tide
of wealth does not lift all boats. It lifts some but capsizes many
many more. A commitment to the right to access health care must be a
fundamental political imperative, and the results today are simply
"not good enough".
Lets also be clear about what some of the problems
are. Treatable infectious diseases are the leading cause of death
world wide, and more than 90% of all death and suffering from
infectious diseases occurs in the developing world. One—not all, but
one—of the reasons that people die from diseases like AIDS, TB,
Sleeping Sickness and other tropical diseases is that life saving
essential medicines are too expensive because of patent
protection.
What do I mean? Since the beginning of the AIDS
epidemic, 16 million are dead, there are now 5.6 million new HIV
infections every year, so that now 34 million people live with HIV
world wide, 90% of these are in the South, 83% of all AIDS deaths
are in the South, and 90 % of all HIV+ children are in the South.
And let there be no mistake, what happens to adults, impacts on
children: there are 11 M AIDS orphans today.
The vast majority of the people with HIV have no
access—not some access, but no access—to essential life saving
medicines—medicines for the treatment of opportunistic infections
and for HIV itself. Not because the drugs do not exist, but because
in part, the majority of people with disease do not exist on the
balance sheets and profit calculations of the major pharmaceutical
producers. And where have our governments been on these issues? Who
have they represented? Certainly not the majority of people with HIV
or TB, or malaria. I welcome President Clintons' recent directive on
anti-retrovirals for sub-Saharan Africa. But frankly, its not good
enough. It's too little, it protects the interests of the big
pharmaceutical industry, and it will do little if anything for the
people of sub-Saharan Africa—beyond the elites—and the rest of the
people in the south, who simply cannot afford anti-retroviral
treatment. The world's poor are not a market. They are people who
have need, but not enough money. Its that simple. Do we accept that
millions are confined to the fate of "Market Failure"? Quite simply,
I say "No".
Today we see the heralding of public private
partnerships as a new solution to global health inequity. While
there are some positive elements to these initiatives—and I do
believe this and am participating personally in the Rockefeller
Foundations' initiative to develop new Anti tuberculosis drugs—we
must be appropriately skeptical. Recently 5 big pharmaceutical
companies announced that in partnership with a range of UN agencies,
that they would significantly reduce the cost of antiretrovirals for
use in Africa. While a good concept, it is short on concrete
commitments from drug companies, national governments or other
international funders. Most importantly , the proposal does little
to address a long-term political strategy and responsibility for the
AIDS epidemic. It is a positive step, but as the director of MSF's
Access to Essential Medicines Campaign said, it is disappointing in
that "it is like an elephant that gives birth to a mouse".
Why? Because it Allows Big Pharma to sidestep the
question of Voluntary and Compulsory licenses that are central to
the question on health equity. How? By oiling the squeaky wheel with
an extremely limited price reduction program that will benefit very
few of the very many—34 million—who live with HIV. This is not a
solution to a global public catastrophe. Governments and
International government organizations are failing while allowing
Public private partnerships to be seen to save the day. There is
nothing structural or systemic in this initiative, nothing that will
increase generic drug manufacturing capacity in the south, or help
increase the health infrastructure in the developing world. At the
same time, Bristol Myer Squib's100 million dollar "secure the
future" program in Africa is apparently focusing on Infrastructure.
Is this the role of private companies, or the role of states? The
Big 5 public private initiative apparently depends on public money,
your tax dollars and mine, to pay for drugs that will only benefit a
few. That public money, if it is forthcoming, will not go to support
infrastructure or Public health capacity, but to buy drugs from the
existing Big PI.
These are not real solutions to the problem of
access to medicines that are priced beyond people's reach, and to
the challenge of strengthening health infrastructure. What we want
is for this epidemic managed properly and responsibly by
Governments, states, and intergovernmental institutions. Two
approaches are needed, and these are not mutually exclusive; in
other words, you cannot do one without the other. The first is to
expand existing health infrastructure, and the second is to increase
access to essential life saving medicines. To get these, there needs
to be:
- lower market prices for life-saving essential drugs,
- voluntary or compulsory licenses for drug manufacturing in the
South,
- transfer of manufacturing technology to the south, for
- generic Rx manufacturing in the South, and
- northern government support for infrastructure and for the
preceding points.
These will require Gov. intervention in the "market"
to regulate and correct this market failure.
The as yet unsolved problem with public private
partnerships—be they of the corporate or large foundation variety,
is that by virtue of the sheer magnitude and power of their
financial resources and political influence, they have enormous
influence on the "public goods" agenda—an influence that can both
determine the "public goods" agenda, and drive it. However, control
of resources does not equal responsibility or accountability. Funds
allocated by private actors can just as easily be decreased or
stopped by private actors, based on outcomes or goals that may or
may not reach privately determined goals. Ultimately, such actors
are not charged with the burden of long term political
responsibility for public goods like access to health care. This is
the exclusive domain of governments and publicly constructed
institutions. Public private partnerships are an important positive
step, but they cannot serve to mask the long term political
responsibility for public goods.
It was said this morning that "there is no them,
only us". I agree completely. Why? Well, its not simply a question
of global security, but of basic human dignity. The other is my
brother or sister, and not as J.P. Satre put it, "My hell". For too
long political masters have offered platitudes and lets face
it—meaningless political commitments. And have allowed charity to
mask the responsibility of political office. And lets face it too:
we as NGOs have been complicit in this humanitarian alibi. We have
allowed ourselves to become co-managers of misery with the state. We
have stood passively, accepting charity, and we have failed to
demand change. We have failed to insist on political responsibility
for—not just the rich or the included—but for everyone—the rich, the
poor, the dispossessed, the excluded. Now, that the sufferings and
diseases of the poor are a "threat" to national security and to
expanding global markets, there is political interest. Well this is
not good enough. We must take this new-found political interest, and
not allow a fiscal and state-security agenda to drive our agenda,
which is one that is irreducibly committed to social justice. We can
and we must demand more.
The economist Amartus Sen has argued that poverty is
not about simply about economics, but also about a fundamental lack
of freedoms. It is also about choices in how we use our liberty. We
here in this room are free to use our liberty in what ever way we
choose. We must now choose to demand more. What has passed as a
reply to our calls to action is not good enough. Dr. Rohde
challenged this group this morning by asking " are we really telling
the story accurately enough?". My answer is an unequivocal "no". We
are too passive, too polite, and too deferential to partial and
imperfect initiatives.
The 19th Century German doctor and
politician, Rudolph Virchow, the father of public health, said that
(and I paraphrase) that "Public health (PH) is simply politics by
other means." We need today to mobilize politically, and not allow
our PH or health language to sanitize, to homogenize, to cleanse
suffering of its real meaning. Language is determinant. How we
phrase the problem defines the solutions we seek. We use phrases
like ‘Complex humanitarian emergency', or like ‘global public health
crisis'. Well, no one calls a rape a complex gynecologic emergency,
.A rape is a rape, just as a genocide is a genocide, and just as the
AIDS, the TB, the malaria, the sleeping sickness epidemics are not
simply global public health crises; they are obscene acts of
political negligence that cannot go on. We need to be clear in our
diagnosis, to locate political responsibility, and to insist not on
political platitudes, but on definitive, clear, effective, political
action.
Trade law around Intellectual property rights for
pharmaceuticals, the political process around their application, the
deification of profit over people, and the fact that trade has
become a barrier to the health of literally billions of people, is
nothing short of the most profound obscenity I can imagine. How is
it possible that their fate can be dismissed with political
platitudes that mean nothing—that say "yes" while meaning "no"?
These are not simply public health diseases or complex humanitarian
emergencies these are political obscenities that no "call" to action
couched in sanitized language will remedy. We have been "calling"
for too long. We must here and now demand political action.
This morning Dr. Rohde very rightly said that
democracy is a key to better health for our children. Well, that
must mean too that here in the West, here in Washington—the home of
the so-called "Washington consensus"—that we must insist on and
demand change, and resist the sanitized language of "political
concern". Dr. Daulaire said this morning, that "you can't say no to
children" , but our political leaders have been saying "yes" while
meaning "no" for too long. And we have been helping them. Dr.
Daulaire said as well that " the dream is fading for the world's
poorest children" and I add that " the nightmare is only going to
get worse" unless as Dr. Rohde suggested, we drop our niceties, drop
our politically correct approach to change.
It was said this morning that the Global Health
Council is a place of alliances, for determining best practices and
for advocacy. We know in looking at the history of social
movements—the movement against slavery, the labor rights movement,
the movement against child labour, the women's' suffrage movement,
the civil rights movement, the human rights and the environmental
movement, that each of these began in a confrontation of sources of
power—be they political or economic powers that seek to maintain the
status quo—and that this confrontation then moved on to interaction
with sources of power, to partnership, and then to co-optation of
the principles and values that gave birth to the movement in the
first place. But we know that social change is rarely if ever a
straight linear process, or that its process can be easily located
on the simplistic continuum I have just painted of ‘confrontation,
interaction, partnership and co-optation' . We know too that rights
achieved must be defended, and that that constant vigilance is
required to maintain hard won gains—here the slave trade in Sudan
today, the status of African Americans in the United States today,
and the rights of women that are not yet won the world over—are
examples where gains must be constantly reasserted and constantly
demanded. The powerful have never given away anything simply because
of a polite request. Today, for the health of children, we must
guard against putting the cart before the horse, we must guard
against settling for premature partnerships, and guard against
premature co-optation. We must be clear in our focus, clear in our
purpose and clear in what we will and will not settle for. 100
million children have died in the 10 years since the signing of the
Convention on the Rights of the Child—a convention that is now
signed by all but 2 nations. We cannot settle for this. And we
cannot settle for the political platitudes and lack of
accountability that have led to this failure.
My challenge to you is this. How can you as a Global
Health Forum be strategic in your goals? How can you mobilize the as
yet unrealized power that exists in this place of alliance, of
networks, and advocacy to pacifically achieve justice for our
children—not the world's children represented in a sanitized
obscurity of "averages" but our children—their each and their
all?
A key challenge is for NGOs to organize into a
movement for social justice—a movement that recognizes the political
context in which it exists, that confronts and engages sources of
power, that becomes a movement that does not simply determine a
shopping or priority list, but that demands not charity, but change,
a movement that is able to separate from the political while
engaging it through interaction and pacific confrontation.
The challenge is to insist that those who are
responsible, be responsible. Dr. Rohde said this morning that our
vision must not be blurred by a rights-based approach. As well, it
must not be blurred by short-term gains with either the state or the
private sector. The challenge is to not displace the role and
responsibility of the state, or to become co-managers of misery with
the state, or to allow a public-relations coup for the private
sector to over-ride our long-term commitment to equity and justice.
The challenge is not simply to achieve a technical standard for the
few, but to demand that each human beings' dignity be at the center
of any political project—a political project that is just, equitable
and accountable.
This morning Queen Noor greeted a group of children
on this stage. She did not give them a blanket acknowledgment—a
platitude that masks indifference. She listened to each child, she
spoke to each child, she embraced each child, and for the last among
them, she made sure that the little girl did not feel to be the
least of them. Children are our most precious, our most vulnerable,
and how we treat them, honor them, respect them, protect them, and
nurture them—each of them—how we see and respond to their inherent
and irreducible dignity as human beings—this is the mark and measure
of our humanity. Today, this ‘mark and measure' is not good enough.
And our challenge—the challenge of every one here today—can be
nothing less than to relieve the inhuman suffering of negligence, to
reveal injustice, to provoke change, and to locate and insist on
political responsibility.
Thank you. |