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WHO World Health Organization |
Dr Gro Harlem Brundtland, Director General of the World Health Organization paid an official visit to Russia 31 October – 4 November 2000. She met with Deputy Prime Minister Valentina Matvienko, Minister of Health Yuri Shevchenko, Chairman of the State Duma Gennady Seleznev and Chairman of the Health and Sports Committee Dr Nikolai Gerasimenko. She visited the Ministry of Foreign Affairs, Ministry of Justice, Ministry of Economy and Trade, the Russian Academy of Medical Science and the Poliomyelitis Institute named after Professor Chumakhov. To better understand the realities of Russia, she also went to see the Butyrskaya prison tuberculosis hospital and talked with the inmates there. This visit was very important in strengthening the presence of WHO in Russia and identifying the priority areas for collaboration. Dr Brundtland emphasized the importance of joint concerted action of the whole UN family for a better future for the Russian people. Dr Brundtland addressed the Russian Academy of Medical Science in Moscow on November 2, during her visit to the Russian Federation.
Dr. Gro Harlem Brundtland, Director General of the World Health Organization addressed to the Russian Academy of Medical Science in Moscow, 2 November, 2000, during her visit in Russian Federation.
The health revolution of the 20th century was made possible by scientific advances and increased knowledge. Improved health for large parts of the world population counts as one of the most profound social changes in the history of humanity. One set of figures tells it all: Global average life expectancy is about 66 years today. It was 46 at the end of World War II.
Russia has played an important role in this revolution. As we face the challenges of this new century to finish the work left undone in the past one, Russia will continue to be a significant player.
As it did in the past century, science will stand at the centre of the changes in this one. We know that new and daunting advances will continue to challenge our imagination and provide new opportunities. And what is driving all of this is our ability to generate and process knowledge - to search for new knowledge and make the existing knowledge available to all.
We cannot predict the breakthroughs. But we can prepare our ability to handle them as they come. To an increasing extent the scientific advances will challenge our ability to make innovation available to all and to take ethical and well informed decisions in new areas of science such as genetics and biomedicine.
As we look into the future, we see the outlines of a world where the main infectious diseases can be controlled given the wise use of substantial extra resources. We see a world where tobacco-related diseases, injuries and mental disorders will demand considerably more resources of health systems than they do today. We see a world where developing and rich countries alike must focus on using the resources at their disposal better to deliver more cost effective and fair health services to their populations.
In the wealthy industrialized countries, which already spend substantial amounts on health, we are talking about more health for the money rather than more money for health. In the countries less well off, we need to spend more on health, but we must do so in a cost-effective, result oriented way.
WHO sees the need for concerted, global action in order to achieve these tasks. We have therefore taken a more active approach to health questions, by pointing out the political implications of global health, the resource needs and the possible strategies needed to make progress with the main health issues of the coming years.
Of course, Russia is undergoing a process of profound social and cultural transformation. Its people face a unique set of health issues. Its health systems are trying to respond to the challenges. Both the issues and responses should be analysed within their geographical, demographic, social and economic context.
Health systems should improve health, respond to people’s interests and be financed fairly. Scientific evidence states that the structure and emphasis of the health system will need to change. This is, inevitably, a long-term reform process. Abrupt changes will not succeed: they may lead to back-lash and set-backs. There is no doubt that increased resources are needed to help address the health challenges faced by Russia’s people.
Complex problems need visionary solutions. We must not be deterred from difficulties we encounter on the way. We will apply the best science, learn the lessons of experience and keep the context firmly in our minds.
I would like to focus on Tuberculosis. This has long been a serious health issue in Russia, but the incidence and prevalence has increased dramatically over the past ten years. Adding to this is the increasing incidence of multi-drug resistant TB, which is difficult and forbiddingly expensive to treat.
It is becoming clear that the number of people infected with TB is overwhelming the current capacity for treatment. Russia need to implement a new control strategy for TB treatment, based on general principles of direct observation of patients, but adapted to the specific needs and conditions of Russia.
Through pilot projects, such as the one in Tomsk oblast, we have seen the potentials and limitations of such direct-observation treatment. They have made it clear that TB control is intimately linked with health sector reform. TB now makes up nearly a quarter of the total public health spending in Russia. Effective TB control programmes taking into consideration the need to make use of the capacity and expertise that exist under the current system, will in itself be a significant contribution to health system reform.
The key to improving cure rates and reducing incidence of multi-drug-resistant TB is to ensure an adequate and steady drug supply. This must be an absolute priority that cut through all work by both donors and Russian authorities.
In TB control and treatment, as in other areas of the health system in Russia, you face a problem of a top-heavy structure, with too many doctors and too few nurses. Too many hospitals and sanatoria are deteriorating because of insufficient budgets, while there is an acute lack of primary health stations.
The current prison regime undermines attempts to reduce infection levels of tuberculosis in the general population. Currently, nearly one per cent of the Russian population is behind bars. Of these 10% are ill with TB, and within those who are ill, a shocking 30% develop multi-drug resistant TB. A thorough reform of the current system of incarceration will be an essential part of any action to reduce the prevalence of TB in the country as a whole. I welcome the draft legislation on penal reform.
There is another infectious disease that is threatening to take on epidemic proportions. If we allow it to, it will cause more damage to society than even the TB epidemic. It has no cure and there is no vaccine. I am of course talking about HIV/AIDS.
Over the past five years, there has been an exponential increase in HIV infection in Russia. Registered infections have doubled each year and have reached a level of nearly 60,000 people. The estimated infected population is at least five times that number.
So far, infections have spread predominantly among the rapidly growing group of intravenous drug users. But at the infections rates we are now experiencing and with the close link that exist between drug use and commercial sex, there is an imminent danger of the virus spreading more widely. This, I need not tell you, is a public health emergency.
We know about it. We can see it coming. We can prevent it. But to do so will mean making a series of difficult decisions, many of which lie outside the area of health. The key to limiting the spread of HIV lies in harm reduction among intravenous drug users. In other words, efforts to stem the spread of drug use must contain an acceptance of the need to provide needles and condoms to those who already are addicted to these drugs.
Research has shown that in order for such programmes to be effective, at least 60% of the high-risk groups must be covered. There is already important experience gained from several pilot projects, but the projects, which work well, need to be taken to scale.
This means that harm reduction must become a central element in the public drug treatment centres, clinics for sexually transmitted diseases and AIDS centres. But it also means involving Non Governmental Organizations and outreach groups in the main HIV/AIDS prevention strategy. And it means cooperation across ministries, involving police and prosecutors in this strategy.
There is strong evidence that harm reduction programmes work better if they are done in the wider context of effective drug treatment. We therefore need to develop effective methadone treatment programmes, drawing on the best practices from other countries, but adopting them to the special Russian context.
In short, Russia needs a multi-sectoral response to HIV, to which all concerned Ministries are fully committed. Moreover, the response needs to become an integrated part of the core activities of the Ministry of Health. WHO is willing to support this process in every way we can.
Additional funds are crucial in this effort. I encourage intensive effort by all concerned to meet the needs for funding HIV/AIDS prevention activities in the coming year, and to co-ordinate their responses around agreed strategies.
Let it be clear: many of Russia’s health problems can only be eased through changes that lie outside the field of health. We must for example understand the role alcohol plays in coping with the process of social and economic transformation large parts of the Russian population are currently going through.
Price increases have adverse side effects, such as the danger of poisoning through illegal alcohol production. But price increases coupled with information campaigns would lead to an overall reduction in alcohol consumption and therefore an easing in the burden of disease caused by excessive consumption. It worked in the mid-1980s, leading to an almost instantaneous jump in life expectancy of two years. It can work again.
Yet the largest cause of serious non-communicable diseases in Russia may be tobacco. The smoking rates of Russian men are among the highest in the world. The rate of youth smoking is also alarming. And here, the opening up to the capitalist world has brought only harm: between 1995 and 1997 alone, there was a 30% increasing in tobacco use – clearly a result of the strong marketing powers of international tobacco companies. This is translating into a major health problem, taking a big toll of suffering and economic loss.
New knowledge has demonstrated how tobacco use is growing in countries and how young people take up the habit. A devastating global epidemic of tobacco use is now threatening the developing world. We also have the knowledge about how to control this threat. As we speak, nations are working on a Global Treaty that will help put the knowledge into practice.
Firm action to tackle issues of tobacco, alcohol and drug addiction will go a long way in stemming the decline in life expectancy and the general demographic development of Russia in the years to come. But there is also a need to look at the other end of the life-spectrum. Of course, as Russia works itself out of the transition period and onto a more firm economic and social setting, couples will feel more inclined to have more children. But we also need to ensure that maternal, infant and child mortality is reduced. This is a complex issue that can briefly be summarized in two basic elements: more and better primary health care; and a steady supply of essential drugs. These two issues are intimately linked with health sector reform and they will take some time to accomplish. But the priorities must be set now if change is to follow later.
Next year, mental health will be the focus of World Health Day on April 7. No country and no community are immune to mental disorders and their impact in psychological, social and economic terms is huge. Yet, societies raise barriers to both care and the integration of people with mental disorders. What makes our task doubly urgent is that there is no reason for inaction - much less exclusion. World Health Day, the World Health Assembly in May 2001 and the World Health Report 2001 - all will focus on mental health.
I want to stress that although Russian scientists have tremendous challenges at home, they are also part of an increasing globalized exchange of information and research. We will encourage a wider Russian participation in the discussion around global health issues.
One such central issue is: how do we deal with knowledge that is relevant to the public’s health? Is it a private good, to be traded in markets, closely guarded, tightly protected and used to enrich its owners? Or is it a global public good, openly available to all who need it and make good use if it? The cold war limited the access to knowledge. Today, we are threatened by another limitation – between the “haves” and the “have-nots”. Currently there is an imbalance of knowledge goods, leading to an under-provision of such knowledge among those who need it the most.
If we accept that medical knowledge is a global public good, then all countries stand to benefit equally from its equitable distribution. All countries should share and cooperate in the creation and utilization of knowledge for the collective benefit of humankind.
WHO is promoting and supporting the world that is being done world-wide to increase our knowledge base. WHO will contribute to the effectiveness of regional and global health research efforts. Hence, we will continue work with others, bringing together the health research capacity within countries, within other organizations, and within both public and private entities. Russia currently has 53 WHO collaborating centres, which make important contributions to our work. We hope to strengthen this collaboration in the years to come.
The researcher has to strike a difficult balance – building on evidence, taking risks, striving for a vision – and contributing to a better society. In health we have seen it so many times. Decades ago a vaccine against poliomyelitis was just a dream. Many people feared that the spread of polio would take on epidemic proportions. Now, we are about to relegate polio to the history books. As we do so, let us not forget how difficult the decision was to keep investing in a dream - a vaccine - that no one could know would become a reality. Let us keep dreams alive.
We have a chance, now, to establish better ways of working together, more effective ways of responding to need. We can build on extraordinary improvements in recent years, on substantial health gains for so many people. But the hardest part is yet to come. Let us turn aspirations into realities. This requires superhuman effort by all. I can assure you that WHO is ready and willing to support this effort.
Thank you.