Mike Rowson

Achieving the Millennium Development Goals

Eleven years ago, the leaders of 189 countries c a me together at the Millennium Summit and pledged to eliminate poverty; create a climate for sust ainable development ; and ensure human right s , peace, and securit y for the entire world’s people. Eight overarching Millennium Development Goals (MDGs) measure progress towards this vision. While none of the MDGs explicitly references protecting young people’s reproductive health, this is essential to alleviating poverty.

A new Director General for WHO--an opportunity for bold and inspirational leadership.

But further discussion is needed before the election of a new Director-General this November. What challenges are faced by WHO and its new head, and how can individuals and institutions strengthen WHO’s capacity to respond eff ectively to the world’s health challenges? These are not idle questions, for all is not well at WHO. For millions of people, the prospect of a basic level of health security remains a distant hope. Furthermore, as the importance of global and supranational determinants of health increases, so does that of global public-health institutions. In this article, the People’s Health Movement, a worldwide network of individuals and civil society organisations committed to the vision and principles of the 1978 Alma Ata Declaration, identifi es three sets of global health challenges and the kind of response it would like from WHO. We also discuss the constraints and barriers faced by WHO itself, and suggest actions that should be taken by WHO and its new Director-General, as well as by governments and civil society. Key global health challenges Poverty and the global political economy Poverty remains the world’s biggest health problem, underlying the HIV/AIDS crisis, the high mortality attributed to tuberculosis and malaria, and the 30 000 deaths of children every day from preventable and treatable causes. It also results in governments being unable to foster socioeconomic development and invest in eff ective health, welfare, and education systems. Frequent references are made to the World Bank calculation that the number and proportion of people living on less than US

Effect of the financial crisis and rescue plan on ordinary Americans

1 per day has fallen since the late 1980s. However, less is said about this calculation’s systematic underestimation of the extent of impoverishment. 4

The Global Health Watch: A global health report with a difference

The last time taxpayers were asked to bail out poorly regulated banks was during the East Asian Financial Crisis of 1997–99. East Asian governments were persuaded to close fi nancial institutions, negotiate repayment to western banks, and cut government spending. Our analysis of the Asian crisis in Indonesia showed that the Indonesian government disproportionately cut health spending compared with other economic sectors. Primary health care was cut by 25%. Not surprisingly, a fall in access to basic health care followed. Childhood immunisation coverage rates fell by 25%; the use of services such as clinics and health centres fell between 26% and 47%. After decades of steady improvement in life expectancy, infant mortality comparison used a two-sided 95% CI corresponding to signifi cance level of 5%, a value commonly accepted by the US, EU, and other regulatory bodies. Because the upper limit of the CI lies below zero, the p value associated with the test of superiority can be used to assess whether the treatment diff erence is due to chance alone. The p value of 0·0023 is substantially less than the chosen signifi cance level of 5%—meeting the typical statistical requirement for declaring superiority. Garattini and colleagues question the clinical importance of the mean treatment difference. As described above, the non-inferiority margin of 0·4% is that uppermost limit for the two-sided 95% CI for the difference between treatments in HbA1C change from baseline. Not only did the upper limit of the CI fall below 0·4%, indicating that exenatide once weekly is no worse than exenatide twice daily, but it also fell below zero, which shows the superiority of exenatide once weekly. It is well established that improvements in HbA1C reduce the risk of microvascular complications; thus, we assert that the observed mean diff er ence between treatments does represent a clinically important im prove ment. Furthermore, the clinical signifi cance of exenatide once weekly was shown by the 1·9% HbA1C reduction as well as the signifi cantly greater proportion of patients who achieved an HbA1C of 7·0% or less (77% vs 61%).

Expanding Access to Antiretroviral Therapy in Sub-Saharan Africa: Avoiding the Pitfalls and Dangers, Capitalizing on the Opportunities

With impressive advances in science and technology, the unprecedented wealth generated over the past century, and the widespread ratification of the Universal Declaration of Human Rights, health professionals and advocates should feel embarrassed that so many people live in a state of poor health. Last year, a new global initiative was launched to help clarify the causes of this situation and offer alternatives: Global Health Watch 2005–2006: An Alternative World Health Report [1]. What makes this publication ‘‘alternative’’? First, it has an equity orientation, and one that looks at disparities and interrelationships between the poor, powerless, and unhealthy, and the wealthy, powerful, and healthy. Second, the report is explicitly political in its analysis, highlighting the socially constructed barriers to better and fairer health outcomes. Third, the report acknowledges the importance of a multi-sectoral approach to health, with chapters on climate change, food security, conflict and the arms trade, and access to water, a perspective sadly underemphasized in current health discourse and policy. Finally, the Global Health Watch is alternative in the sense that it tries to draw together civil society’s perspective on health as a counterpoint to the views put out by the international institutions whose decisions affect people’s health and livelihoods around the world, and who are themselves the subject of scrutiny in the report. Many of these themes are brought together in the opening chapter of the Watch, which describes the effects on health of the current process of globalization. It questions the success story painted by uncritical proponents of this process, pointing to increases in poverty in Africa, Eastern Europe, central Asia, and Latin America, and a rise in income inequalities in many countries (including wealthy ones) in recent years. These trends are underpinned by a profoundly unfair global trading system. For example, in Mexico, the liberalization of the corn sector under the North American Free Trade Agreement led to a flood of imports from the United States, where agribusiness is massively subsidized. Mexican corn production stagnated whilst prices declined. Small farmers became poorer and 700,000 agricultural jobs disappeared. Rural poverty rates rose to over 70%, the minimum wage lost over 75% of its purchasing power, and infant mortality rates amongst the poor increased [2,3]. Such damage highlights the need for sophisticated national management of global economic change – a daunting challenge for developing countries with run-down or underdeveloped public sectors. Furthermore, whilst many – especially richer – economies have social contracts, progressive taxation systems, and laws and regulations to manage the human consequences of market failures at the national level, there is no ‘global social contract’ to manage the failures of globalization for the world’s majority poor. Those global mechanisms that do exist often reinforce unequal power relations or aggravate problems. World Trade Organization agreements that liberalize trade in goods and services are biased towards protecting and promoting the interests of multinational corporations, whilst decreasing the space for governments and health agencies to