Discussion
Introductory paragraph by Richard Jolly
It is a great pleasure, Dr Gro Harlem Brundtland, to welcome you. It is a special honour and privilege for us to have your participation as honorary chairperson for today. You agreed to play this role even before your selection as nominee to the high post of Director-General of the World Health Organization. It is now therefore a double honour for us. Your nation-wonderful Norway - has already given the United Nations its first Secretary-General. Your country has inspired many of us with its principle of internationalism and its generous humanitarian commitments. I remind those from outside Norway, that we are in a country that for many years has far exceeded the 0.7% target in aid. We thank you, Dr Brundtland, for Norway’s intellectual contributions and leadership, and we thank you especially for your country’s long concern for human rights. We wish you every success on drawing on this wonderful heritage in what we trust will be your future role of leadership for health with the United Nations.
Thank you very much. Dear guests and dear participants at this symposium, our development minister has already greeted and welcomed you all to Norway with the enthusiasm expected from someone with her portfolio and field of responsibility in this country. Based on my own experience from the Norwegian political scene, let me first share with you my deep feelings of gratitude that Norway’s role, profile, and contribution to international cooperation and humanitarian work will certainly continue as you have known it over decades. I could applaud every word that the development minister of the other party - the Christian Party, now in government - was addressing to you. There is a strong consensus on the priorities of our international cooperation as well as our national nutrition policy and health policy. Indeed, the Christian Party has been a long-standing partner with the Social Democrats when setting our priorities in development cooperation. I feel confident that Norway will have a strong voice on the alleviation of poverty, on focusing on the countries with greatest needs, and on taking seriously the broad human rights perspective in our follow-up to the series of global conferences during the last decade. We have focused on the basic needs of health and education as being central in an environmentally friendly and sustainable development process. We have focused on the key role of women in all societies, on the importance of empowerment of women in social development for the potential of the next generations and for the economic prosperity of nations and populations.
We hove focused on the importance of empowerment of women in social development for the potential of the next generations and for the economic prosperity of nations and populations.
But now, at the very outset of my speech, I believe it is important that there is no misunderstanding as to my platform while addressing you. I am speaking in my own personal capacity. I am between chairs. I am the former, not the present Prime Minister of Norway. I am the future, if indeed elected, Director-General of the WHO. So I will not today be speaking on the political and technical priorities of the WHO. That address I will give to the Health Assembly in May.
During the whole of this century, with the milestones of creating our international institutions, the conviction has been that we must face common concerns and that we share the responsibility for our common future. The founding fathers addressed war, hunger, poverty, and disease. This conference has links to them all. We are still far from a world freed from these scourges of humanity. But we have more tools to do so, we have more knowledge, more lines of communication, more shared experience, more democracy and I believe we have more shared values and beliefs - in short, we do have more opportunities. In Hot Springs, Virginia, 55 years ago, an act on food and agriculture, with seven short paragraphs, was formulated. They pointed the way ahead. They declared their belief that the goal of freedom from want of, food, suitable and adequate for the health and strength of all peoples, can be achieved. They declared that there has never been enough food for the health of all people, but that this is justified neither by ignorance nor by the harshness of nature. They called for concerted efforts to economise consumption, to increase supplies and distribute them to the best advantage. They identified the first cause of hunger and malnutrition - poverty. They solemnly declared it useless to produce more food unless men and nations provide the markets to absorb it. With full employment, enlarged industrial production, the absence of exploitation, increasing flow of trade within and between countries, an orderly management of domestic and international investment and currencies, and sustained internal and international economic equilibrium, the food that is produced can be made available to all people. They were very good at that time in formulating short and precise documents.
They identified other important aspects. The primary responsibility lies with each nation for seeing that its own people have the food needed for life and for health. Steps to this end are for national determination, but each nation can fully achieve its goal only by working together. These were fine words. They were wise and it was a good analysis 55 years ago. They still hold true, but we can easily identify some reasons why it went wrong. We have not achieved an orderly management of domestic, economic and international investment, economic equilibrium, and absence of exploitation. This is why the minister today spoke about debt, why she spoke about the importance of the WTO, even from a health perspective. Our global scene and our scene internally in nations have not met these fundamental objectives of fairness, of an economy that works and where democracy in a wide sense can take the lead.
But today, we are assembled under the headline ‘a gender perspective’. I know it’s a long philosophical discussion whether ‘men’ also means women, but I prefer to say it outright, ‘men and women’. They spoke about men - we must speak about women and children. We must speak more loudly about equity and solidarity. We must speak about nature and the environment to secure the long-term living conditions on earth. We must speak about human rights. When doing so, we are in the midst of political decision-making - of making an impression on political decision-making, on opinion building around the world, the allocation of resources, the values that they build on and the choices that are taken by governments and societies. It raises the questions, how can we best stimulate positive change in these political processes? How can we move more people and civil society to take more enlightened action? How can we build public opinion and create the basis for more concerted action? The programmes have been formulated and declared at the Rio conference, in Vienna, in Cairo, in Copenhagen and in Beijing. I take the perspective of the major conferences over the last few years to illustrate an important part of the political framework that we live in. The conferences on environment and development, women and human rights are as important to the issues involved in our agenda today, as are those mentioned in your Commission report to this conference, where nutrition goals have been addressed directly and have been adopted at the World Summit for Children, the International Conference on Nutrition, and the World Food Summit.
Just as health inequities cannot always be resolved through action by health professionals and experts, so nutritional action is not always appropriate to tackle malnutrition. As concerned citizens, as experts, policy makers or practitioners, we know that the test of all our efforts is only what can be measured on the ground. That is the public health perspective. Not the declarations, but the implementation on the ground.
Poverty is the greatest polluter. This was what Indira Gandhi, the Indian Prime Minister, said when she came to Stockholm in 1972 to the first Conference on the Environment. The alleviation of poverty is still, 25 years later, a major concern and a key challenge in all of our development efforts. This comes clearly to the forefront also in the report to this meeting. Poverty-related human suffering and tragedy are still an unmet challenge to us all. We know the effects of lack of food, clean water, and unsafe motherhood. Still, we are only underway in implementing the cure and in applying the preventive and practical steps. We know the long-term effects of malnutrition in pregnant women and young children. We know about stunting in unbelievable numbers of children in some parts of the world, but do we in fact realise the terrifying long-term results when children grow to become adults deprived of their full mental and intellectual capacity? Do political leaders know the consequences? There is reason to doubt it. So we need to speak out. This is part of a major public health problem.
Prevention of disease, disability and ill health is a good investment in the future, not only in humanitarian terms, but also in economic terms. The burden of disease is at the same time the burden of unfulfilled human and societal development. When one billion adults in developing countries are underweight, this impairs work capacity, leads to infection, and increases the risk to future generations. A strategy of investing in health and education, in meeting basic needs, cannot be questioned. There is a long way to go in partnership and coordinated efforts at the country, regional, and international levels. However, we must not shy away from taking seriously the changing total picture of the disease burden that is related to food, nutrition, daily life conditions and behavioural change. The chronic disease burden is to a great extent linked to diet; diet-dependent diseases are increasing worldwide. Some of you in this audience feel very strongly that these facts are not taken seriously enough given the emerging scientific evidence. I believe it is psychologically easy to take this attitude. If you eat too much, it is your problem. If you eat too little, it is everybody’s problem. The changing total picture of nutritional deficiencies is partly two sides of the same point as you have noted in the Commission report.
The burden of disease is at the same time the burden of unfulfilled human and societal development.
We do face a double challenge - to counter both the consequences of dietary deficiencies, poverty and undernutrition, and the consequences of unbalanced overnutrition that often occur side-by-side in the same countries. Increasingly, they pose a double disease burden. It also means a greatly added burden on health budgets and competes for the resources so sorely needed to secure basic community service and health care. Prevention is clearly called for on both these aspects. The burden of chronic diseases is emerging so rapidly that the developing world already carries the greatest numerical burden. In Central and Eastern Europe, there are dramatically rising rates of chronic diseases and falling life expectancy.
Let me briefly mention a Norwegian experience when trying to link global and national concern on food security, food production, and nutrition. Based on the recommendations from the FAO/WHO World Food Conference in 1974, a national nutrition and food policy was formulated in Norway in the seventies as a policy document to the Norwegian parliament from the Norwegian government. Taking into account the existing scientific knowledge and drawing up guidelines for the necessary regulations and economic incentives and disincentives to be used, the government advised a reduction in fat and an increase in vegetables, potatoes, whole grains and fruits, and of course, fish! We have seen results. Teaching, information, and opinion building have been underpinned by economic and social policies that have an impact on household choices, and on the production, distribution, and pricing of food.
There has, from the very start, been close cooperation and dialogue between sectors, of course with the academic world - the experts - but also with the different ministries of agriculture, health, and social affairs. We have seen results in the improvement of the disease pattern and health indicators in Norway from this policy that was formulated by political bodies. And I say that because I think more countries need to do so than those who are doing it today.
Along that road, however, I remember some instances of slow decision making, of strong interests that succeeded in spending an enormous amount of effort and time producing political and practical counter arguments to the right cause. Although political decisions had already been taken in principle by the Norwegian cabinet, which also had a majority in the parliament, it sometimes took years and years before implementation happened. Why? I will give you this example. The National Nutrition Council had proposed to the government the good idea of having a new product - low fat milk - on the Norwegian market. The government, after a discussion, supported this, and also agreed to price it at a lower level than the regular milk product.
Several years later, when I had been out of government, I asked what had happened to this political decision, because I didn’t see the low fat milk in the stores. What happened? I had this explanation given to me by the cabinet ministers. Firstly, it would have cost more for the farming and food production sector to make this new product. Secondly, it would convey the impression that the regular milk product, for many consumers, had too much fat. Indeed, that message was the message! When Professor Kaare Norum demonstrated to the public on TV that you could indeed mix the regular milk and the skimmed milk to achieve the wanted result, people started doing this in practice and gradually we were able to overcome the resistance. We now have low fat milk, skimmed milk and regular milk on the Norwegian market, and what happened? Low fat milk is the product that most households prefer. I tell you this because it is a lesson: constructive, well-founded policies require consistent effort. We must not give up, even when pressure groups and strong industrial or other economic actors are working against us.
...constructive, well-founded policies require consistent effort and we must not give up, even when pressure groups and strong industrial or other economic actors are working against us.
We should never give up, we should continue. You have said that in the struggle for improvement in nutrition and health. I also want to mention that the same struggle has been true to stop the decline and then secure an increase in breastfeeding. It started in this country in the 1960s and, when I went to the Harvard School of Public Health, I wrote a paper that studied the patterns of breastfeeding around the world and looked at why we had this decline. But in the 1960s and onwards in Norway we have been working hard to change the pattern. Baby-friendly hospitals, support of mothers, and advocacy of best practices completely changed the downward trend. Much work is needed on this issue globally, however, in close cooperation between WHO, UNICEF, and other actors in the field. We have to speak of course with the business sectors who are influencing in many ways the total picture and our ability, but it has to be done in an open and substantive dialogue on the effects and the consequences in this area, as well as in all others relating to nutrition and health.
Economic growth and more equity will not by themselves create nutrition improvement. We need to realise that we are dependent upon a targeted policy to improve nutrition. The experience of South Asia shows this very clearly, where the incidence of pre-school malnutrition still affects half of all children. Investing in health and nutrition can be an effective investment to abate poverty and to improve economic growth.
Building a healthy economy is the most direct road to ensuring a healthy people.
There is one specific area of importance that I think should be mentioned. In the most recently produced food-based dietary guidelines of the WHO, the importance of micronutrients has been highlighted. There has not been sufficient emphasis in international health on the important contribution that micronutrients make to human health. Look at the facts. A simple inexpensive vitamin A capsule taken two or three times a year by a child deficient in that micronutrient can reduce a child’s chance of dying from measles by some 50%, from diarrhoea by 40%, and cut the overall risk of death by about 25%. Of course we also know about the importance of vitamin A in pregnancy - the risks to the foetus and newborn. But this is only one of several examples where it is important that we base our action on results-substantive results - that can be advocated and that can spread the knowledge needed for action. Clear goals, advocacy, political commitment, and community action must all be part of the answer. This is a consistent public health experience and approach. With primary health care available, nutrition concerns can also be addressed more consistently.
In these last couple of months I have addressed the Executive Board of the WHO, putting forward my vision, my beliefs and my view of some of the global health issues and the role and priorities of the WHO. I can share some of the points on which I focused in that address. I have also addressed the World Bank during my recent visit to the United States and emphasised the close partnership that will be needed between these two important institutions for world health. I would also like to share with you some of this, which is related I think to the theme of this Symposium.
Capacity building in countries with greatest need must be a priority issue for the international community. That is why I have stated my ambition of introducing health sector development as a dimension in all WHO programmes. Building a healthy economy is the most direct road to ensuring a healthy people. The fundamental cure, as you have heard, is economic and social development, it is the empowerment of people - both women and men - and it is in this overall framework that we shall place our comeback for global health. It is not a separate task. There are important lessons to be learned from the way structural adjustment programmes have been devised and carried through. There are successes and failures and we can learn from both so we can avoid victimising the vulnerable by cutting essential social services, and this we need to monitor, measure, and address. This is the role of the WHO - to help to do. And you can expect the WHO to be there with its advice on sector-wide reform, speaking out for the need to safeguard the role of health and social services. But that message will not only go to the World Bank and to financial institutions, it must also reach the governments themselves. They too, have to make the right priorities. Health has no real quid pro quo. It is not a question of ‘it is my money so do it my way’. Health has no border and few issues illustrate the global interdependence better.
During my recent visit with Jim Wolfensohn, he said that too often health ministers are absent from the meetings he has with governments. That, he said, has to change, and I agree. But I would add that we also have to remind presidents, prime ministers, and finance ministers that they are truly health ministers themselves. Their overall decisions are decisive for the wellbeing of their people. I believe that WHO as a leading advocate in health can help set the agenda around the world. But then we need to provide the evidence that health is key, not only as a moral obligation and an ethical obligation, not only as a human right, but also because it is pure and sound economics.
A decade ago it became widely accepted that education, especially of young women, was crucial for development. It still is, but now we have new evidence, clearer evidence of the central role of health in this context. Finance ministers around the world need to know it. And we need to remind them and be able to back our statements up with facts. What we need is evidence-based policy, i.e., evidence-based health policy and evidence-based nutritional policy. And this is what you in this forum help create.
Health has no border and few issues illustrate the global interdependence better.
We need what I call the scientific underpinning of policy, because it is the only thing that carries solidly across borders, across the world, into all nations, into all parts of population groups. As communication possibilities increase, the only real common language is science.
The Sub-Committee on Nutrition and the ACC itself symbolise the cross-sectoral approach and the inter-agency cooperation that are absolutely necessary to address the global nutritional challenge.
We need a broad, concerted effort, and the test is on the ground at the local, national, and international levels. The SCN was an early undertaking to share responsibility among a number of agencies. It also incorporated the essential component of non-governmental actors similar to the present UN reform. Those are the initiatives that are now carried forward with open contact with the rest of the world, including the business community and civil society - not only our institutions talking together internally. And certainly, in this context, the WHO has a key role to play. The Sub-Committee on Nutrition and the ACC itself symbolise the cross-sectoral approach and the inter-agency cooperation that are absolutely necessary to address the global nutritional challenge. Partnership, the involvement of science, the public and private sectors and the whole of civil society are key in this area as in other vital areas for human progress. At the national level we need open dialogue. We have experienced that in many countries, and we need a broad process to create positive change. Developing clear policy guidelines and securing practical implications are key to success. But the same holds true at the global level. It is not only at the national level that you need to have serious dialogue between the different institutions to avoid overlapping of mandates and duplication of effort.
I want to end by referring to this picture. The Secretary-General of the United Nations, drawing upon the whole UN family of agencies and institutions, needs to promote an integrated, unified approach to global issues and this indeed is his ambition for UN reform. To succeed, he and his colleagues will need the support of the world of science, of concerned citizens, of a broad range of governmental and non-governmental actors working together. All the discussions - ’this is my table and not your table’ - have lead to a lot of wasted effort. We have to speak openly and directly and look each other in the eye around the table, as if the Secretary-General was the Prime Minister or president and his cabinet ministers were the leaders of agencies. He should be able to ask each and every one of us to answer his questions about how the mandates of UN agencies are like one integrated approach, with no overlap and no duplication. There is only one audience - the people of the world, the nations of the world, the populations of the world - not the mandates of single organisations. If they don’t fit together today because they were made at different times, then we have to rearrange them. We have to discuss how we avoid this tendency of overlap and, of course, have the discussion with the whole of civil society, understanding how we cooperate, how we are coherent in our message and how we work together for the common goal. Without that kind of thinking, we will continue losing efficiency and not reaching the goals that have been set by the big international conferences or the goals set by each separate agency. I think we have a great challenge. You have a lot of experience on how that needs to be done.
Philip James has spoken to me about what we can do to improve implementation and to improve practical results on the ground. Well, the test is on the ground at the country level where people live, and if the international institutions all go together to support a country-oriented integrated approach at that level, then we can succeed in supporting what governments decide. But we can never get away from building on the political decision making in each country and then supporting what they want. Of course, if we have vulnerable groups and the violation of human rights, we have to speak out to governments and to the world about issues that are not being taken care of according to basic guidelines for human rights. Thank you for your attention.
Richard Jolly (SCN Chairman): Thank you very much, Dr Brundtland, for covering such a wide range of important issues for the SCN, and for focusing them so well at many different levels of implementation. From your own experience, what do you think are the two or three critical steps to get across to a Prime Minister concerning how she or he could mobilise more attention to nutrition?
Dr Brundtland: You have to put nutrition into the context of health and education. Without nutrition, you don’t have the ability to learn and to become a productive and active human being. Coupled with that are not only the humanitarian concerns but also the economic consequences for any country, any population, of not having the building blocks from the start in young children. You have to put it into the context of economic and social development, not only on a humanitarian basis, because we can see that this is not always sufficient for all political leaders who are under strain of many different pressures. They need to have a clear argument about why it is also a good idea from a economic point of view.
Aileen Robertson (WHO): Based on your personal past experience in environmental issues, do you see a means by which nutrition can be more firmly placed on the political agenda through environmental movements? Is there an opportunity for the health sector to work closer on environmental issues and with environmental movements?
Dr Brundtland: The answer is yes, and that is why I also referred to the Rio Conference. The links between health, nutrition, and the grass roots level, even looking at it environmentally with regard to agricultural patterns and food security, are clear. There is a lot to be said in this common concern from an environmental and health point of view, which is also already part of the WHO programme today. I think that generally the answer is ‘yes’ because you cannot take care of nature and the environment without being concerned about people. That is the key message in our common future - environment and development, concern for choices, and the ability for future generations and not only for present generations, to have their rights, possibilities and opportunities. So this generational perspective requires us to look at the environmental aspects also, going further than considering only the children of today.
Judy McGuire (World Bank): At the beginning of your speech you cited a number of international conferences: the World Food Conference of 1973, the World Summit for Children, the International Conference on Nutrition, and the World Food Summit. All of these conferences have set goals to reduce malnutrition by half in ten or twenty years. Twenty years is far too long for any political or even economic planning, and I wondered what your thoughts are on shortening the duration of our goals or changing our perspective on how we get the UN system moving. The UN system is 50 years old. The right to food was set out at its outset as you pointed out. We still have not fulfilled that goal. We have had major changes, both in the Secretary-General and in the three major UN organisations concerned with nutrition - UNICEF, FAO and now WHO - and I wondered what your thoughts are on getting the UN system moving in the short-term, not 20 years hence, but now.
Dr Brundtland: I think one of the problems is that the UN system is an inter-governmental system; an inter-country system. When we say ‘test on the ground’ it means that you have to measure what has happened in each country with all the different goals that have been set, not by the UN, but by the countries who sit together in the conference hall signing a common document. We have to monitor and survey what is happening on the ground in each part of the world, in close cooperation with civil society and governments. The international organisations become a source of setting common goals and a source of giving support, stimulus, and debate about results. We have to be more aware of what I am saying because sometimes I listen to people talking as if we, at a kind of philosophical global level, have set goals. Then the UN Secretary-General or one of the leaders of the institutions are asked why they have not reached the goal, as if it were a personal goal for the one person sitting at that time at the head of the agency. No, the goals have to be made by humanity and they have to be achieved using democracy. Moving democracy, putting requests to governments and political leaders, and working at the national level and at the local level to implement. But I agree with you, one should have shorter targets and shorter time frames. If the time frames are too long, the existing people in every position will never have to answer to why nothing has happened, and that relates to the country level and to all our different agencies.
While I mentioned the conferences that have specifically talked about goals in nutrition and malnutrition, some of the other conferences that I mentioned may be even more important. If we don’t reach the goals set by the Cairo, Beijing and Rio Conferences - which are even more fundamental in many ways - you will never be able to pursue and implement the goals set by the food conferences without getting into focus education, health systems, development and reaching women and children at the local level. How can you change habits of everything from cooking and energy use to eating habits if you don’t have a system to do it and to help do it? We are in it together. That is why I speak about the Secretary-General and his cabinet. Also in the cabinet is the leader of the World Bank, the IMF, and the WHO, all of them around the table trying to look at what goals also can be abbreviated. What are the common goals for a broader agenda of agencies? It is easier to set shorter-term goals if we focus.
Judy McGuire (World Bank): When we look at the Third Report on the World Nutrition Situation, we see very little nutrition improvement, and the improvement we do see would have come anyway from economic development. When we list the commitments we have made, I think we have failed. Based on your experience with the Rio Conference on the Environment, what can we learn here? What have you learned from your own experience on how to move from words to action?
Dr Brundtland: It is my experience that this is due to the sectorisation of political decision making and public opinion making. The people who are active, who go to meetings and conferences where commitments and resolutions are made, stretch their imagination about what they can sign, what they can say, and what they can hope for. It is not the same as a political programme in a specific country that can be checked point-by-point after several years. General resolutions and commitments cross country lines, and the person who signs these resolutions is usually not responsible for the implementation. It is not my suggestion that we stop making resolutions or having conferences and discussing the issues, because then public opinion, which puts pressure on the political decision-makers, would be even less. I think we have to live with this kind of tension in order to move, at least at some pace.
When you say that much of what we have discussed as targeted approaches in the area of nutrition has not been the main reason for change, and that it is economic development that has resulted in most of the change, you may be right. But I have no doubt that the scientific work, the advocacy work, and all the sectoral work that have been done also have made a difference. I am not one of those who give up. To give you one example, I remember leading the Norwegian delegation at a conference in 1976. When I came to the conference hall on the first morning, there were a number of journalists asking me questions. One question made a deep impression on me - ‘does this meeting have any meaning - will it make a difference?’ Already this showed a basic cynicism towards international work. Such cynicism is understandable, but it will never move the world ahead. So I answered as a young minister ‘even if this conference does not make a major difference, I am convinced that the work that has been going on in different countries to prepare for this conference, has moved some important issues higher up the consciousness of many people - including decision-makers’. This was 22 years ago, and I still feel the same way.
I have tried to move and focus by being more direct in my discussion with government leaders. If the cabinet does not take seriously what the foreign ministry is giving as instructions to the different delegations, and if they agree to more than what they are willing or ready to do, then they should modify what they say. The inconsistency between the big declarations and what is happening on-the-ground is undermining the credibility of political work and democratic decision making. We have to try to bring these things together, not by lowering to the lowest denominator, but by speaking about targets for a shorter-time span, and differentiating between the philosophical, long-term, value-based goals and the goals that are related to on-the-ground systematic implementation.
In any political programme, you have the principle guidelines and value-base of a party. These are discussed and debated and they focus on long-term visions. Then you have a programme for a 4- or 5-year period saying what the party intends to carry through within that time frame. It then becomes more concrete. So, we should not mix principles with more practical, short-term goals to the extent that I feel is being done - both at the country level, and at the international level.
I mentioned that the Hot Springs declaration was one page with 7 paragraphs. They were mostly basic guidelines, but they were based on a discussion and analysis that they felt was practically possible to carry through, I think, within a 5- to 10-year timeframe. You can see that the people who wrote it thought that it was possible. Out of the points they made, those that we have not been able to achieve are the economic policy points of income creation, income distribution, public concern and state efficiency. It is not enough to privatise, and discuss competitive economies and other things that have dominated the last 10-15 years. Although many of these things are very important, without a determined, strong, government that takes care of common concerns, you cannot do what the people in Hot Springs said. In order to have a sufficiently strong government, there is a necessity for democracy with a strong civil society making it effective and making the choices.
Decision-makers have to be met within countries - at the country level, or at regional conferences. We must reach them with the necessary information and imagination to move them to rethink some of their allocation. It’s a vast work, and all of you here are needed to make it possible.
