Challenges to the Health of Children in the 21st Century

Delivered 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 19^th 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.