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Christopher J. Elias M.D.,M.P.H.

President

Program for Appropriate Technology in Health (PATH)

Washington State Model United Nations

University of Washington

Keynote Address

Opening Ceremony

29 March 2001

Christopher Elias MD, MPH
President
PATH (Program for Appropriate Technology in Health)
4 Nickerson Street
Seattle, WA 98105
celias@path.org

You are crossing the threshold into an exciting -- and I expect exhausting -- few days.

When you begin to think globally and work to unravel the tangled webs of health, human rights, peacekeeping, and poverty, you are engaging in a sobering exercise. The more you learn about these issues, the more you see how much there is to learn.

Thinking globally is about digging more deeply into important issues -- digging much deeper into the substance of problems around the world, deeper than you're used to when information is provided in sound bites, or as answers to "FAQs."

By participating in the Washington State Model United Nations, you are afforded the opportunity to do just that -- to look at a problem, explore its roots, face up to its complexity, get a vision for how best to address it, and then begin to invent appropriate solutions.

The longer you spend with these issues, the more clearly you will see that they are thorny, and complex. You may feel overwhelmed at times: Overwhelmed by the extent of human suffering around the globe. Overwhelmed by the sharp divide between rich and poor. Overwhelmed by the ways in which good intentions have sometimes made problems worse in the poorest countries. Overwhelmed by the undercurrent of greed that so often pollutes efforts to alleviate suffering in the developing world.

At times, you may be saddened, even paralyzed, by all of this.

But, you'll need to move beyond that, as those who are committed to working in the international arena must choose to do. You will accept the fact that the issues are very difficult, and then you will need to act, to attempt to find solutions, to build bridges, to take modest steps toward beginning to right the wrongs that exist.

The United Nations is one of the best mechanisms we currently have to address the moral and ethical imperatives that we face as human beings ­ to implement the drive toward global equity and social justice that is reflected in documents such as the Universal Declaration on Human Rights.

One of the rights addressed in that Declaration is a right to good health.

In the field of international health, we at PATH often face problems that seem overwhelming, even impossible to solve. In the face of such impressive problems, however, the UN's specialized agencies and non-governmental health organizations like PATH are moved to action. We identify a health need and then begin to look at its root causes and its connections. We then try to solve the problem, sometimes in increments. We know that in order to affect positive change, we will need interdisciplinary teams of professionals who can look at all of the many facets of the problem.

Some solutions are simpler than others.

Over the years, PATH has invented many simple and inexpensive tools for addressing common global health problems. I invite you to visit our web site at www.path.org to learn about some of these innovative approaches to problem solving.

Sometimes, however, a health crisis requires the implementation of more wide-ranging initiatives. Let's take a quick look at how PATH addresses one such crisis.

As you may have read in last week's Seattle PI, PATH has recently expanded its efforts to improve childhood immunization in the poorest countries of the world. With the support of the Bill and Melinda Gates Foundation, we have joined with our UN partners ­ the World Health Organization, the UN Children's Fund (UNICEF), and the World Bank ­ in a Global Alliance for Vaccines and Immunization to ensure that children in poor countries have equal access to the same vaccines that we take for granted here in the US.

At present, more than 3 million children die a year from easily preventable diseases. This is mainly attributed to the fact that more than 30 million children born annually-one in four-do not receive any immunizations. The lack of immunizations alone results in the death of about 8,000 children every day. This is a terrible tragedy, especially considering that numerous studies have shown that childhood immunization is the single most cost-effective health intervention we have at hand.

Challenged by significant donations from the Bill & Melinda Gates Foundation (now totalling well over a billion dollars), the world has been given an opportunity to close the gap between children who now have access to immunization and those who do not. A new global partnership between developing country governments, UN agencies and other global health groups, such as PATH, has been formed over the past eighteen months to address the need for childhood immunization ­ and we are already beginning to see results. The first delivery of vaccines to be supported by the new Global Fund for Children's Vaccines will take place next week in Mozambique. We have finally gained some traction against one of the most common causes of child mortality in less developed countries. These are exciting times.

As you participate in the model UN exercise, I encourage you to view these problems and their solutions from the perspective of governments in the developing world,

Because saving these children's lives involves much more than simply buying and supplying vaccines to poor countries. There is a complicated set of issues related to economics that affect this problem. For example, in order to immunize the world's poorest children, collaboration with -- and assistance from -- the pharmaceutical industry is needed. And, like it or not, the shareholders who invest in the pharmaceutical industry expect profits and vaccines for the developing countries are not big moneymakers for these companies. Vaccines and medicines often are priced for the industrialized world, making them unaffordable to those in poor countries. If we want to expand access to vaccines for people in the world's poorest nations, we must understand the requirements of industry, bargain to find ways to work with them, and compromise. Compromise is a word used at the UN often and may be one of the words you hear most frequently over the next few days.

Beyond the basic but important questions related to the cost of producing vaccines for those who do not now receive them, many other kinds of questions must be addressed. At the very least, we must analyze the basic health infrastructure at the community level in poor countries and ask:

• Are there trained health care workers who could administer vaccines?
• How will parents receive the information they need regarding the vaccine schedule?
• Can parents get their child to a clinic?
• Are there ways to follow up with parents and to remind them when subsequent doses are needed?
• How can we ensure the quality of heat-sensitive vaccines that might be housed in clinics that do not have refrigeration?
• Are there other health problems in these settings that would be solved if other new vaccines were developed and introduced?

The staff at PATH working on vaccines struggle with these and other thorny questions regarding how to reach children in developing countries with affordable and sustainable immunization services. Sustainable ­ that is another word you will hear often over the next couple of days. A key challenge for the United Nations and its partners in development is not only how to make things better ­ but how to make them better in ways that last.

HIV and Poverty in SSA

In order to look even more closely at what it means to think globally, let's look at what may be the most complicated and most thorny issue of our time -- HIV/AIDS. I'm going to focus on HIV in sub-Saharan Africa, the region where it has hit the hardest. HIV in this region is a particularly devastating problem to explore and is a particularly instructive example of the complexity of global issues.

First a few figures:

At the end of 1999, sub-Saharan Africa accounted for 92% of the world's AIDS orphans. These are children whose mothers or both parents have died before the child has reached age 15.

• At the end of 2000, 70% of all people living with AIDS lived in sub-Saharan Africa. That figure represents over 25 million people.
• There were 2.4 million AIDS deaths in the region in 2000. This number represents 80% of all AIDS deaths, globally, in that year.
• Also in 2000, 3.8 million people in the region became infected with HIV. This constitutes about 72% of all new HIV infections globally.

Bear in mind, as those staggering numbers wash over you, that the 49 African countries that comprise sub-Saharan Africa contain only 13% of the world's population. Thirteen percent of the people in the world and 92% of the children orphaned by AIDS, 70% of those who are sick with AIDS, 80% of those who die from it, 72% of all new HIV infections.

Of course, it begs the question: Why are such disproportionate numbers of people affected by HIV in sub-Saharan Africa?

If you want a jumping off place, or a way to frame the discussion, you could start with the statement that HIV devastates sub-Saharan Africa because the region is very, very poor.

According to United Nations Secretary-General Kofi Annan, 44% of all Africans -- and 51% of those who live in sub-Saharan Africa -- live in absolute poverty.

Absolute poverty refers to a condition of life characterized by malnutrition, illiteracy, disease, squalid surroundings, high infant mortality, and low life expectancy.

In terms of dollars and cents, absolute poverty is generally considered the state of those whose income is no more than $370 a year.

As those of you who are serving on the model UNDP have found, many factors are commonly identified as key contributors to HIV in sub-Saharan Africa. These include migration patterns, the presence of other sexually transmitted infections, the breakdown of traditional cultures and the poor status of women that arises from gender inequities. All of these are inextricably linked to poverty.

Let's take a brief look at how this is so.

• When people are poor, they are more likely to be malnourished and less able to fight off infections, including sexually transmitted infections.
• When people are poor, they are less likely to have access to treatment for other sexually transmitted infections. The presence of other infections greatly enhances the chances of HIV transmission during unprotected sexual exposure.
• When people are poor, they are likely to be forced to move from their homes to look for work. Their families and communities are not likely to have the resources needed to weather sudden, even short-lived, economic disruptions (like natural disasters, military conflicts, or loss of work). In difficult economic times, the poor are more likely to be forced to leave rural communities and move to the city to find work. In the cities, they are more likely to engage in multiple sexual relationships that may have been outside of the norm "back home" in the countryside. Migration, brought on by poverty, contributes to higher rates of HIV transmission.
• When people are poor, they cannot afford the "drug cocktails" that people with AIDS in industrialized countries use to manage their disease. ("Drug cocktails" can cost about $15,000 per patient per year and many African governments spend less than $10 per person per year for all health services.)
• When people are poor, they are not likely to live in relationship to institutions that provide good, current public health information regarding HIV, other sexually transmitted infections, or ways to prevent them. You are all in school. Most people your age in the developing world have already left school to support their families.

We could go on with this, but you see the pattern.

If poverty is a major cause of HIV in sub-Saharan Africa, what are the roots of this poverty? What is making it continue to grow?

Digging down to the roots of this problem is a challenging, and often controversial, task.

Here are a few of the complex and, of course, interconnected explanations of the region's poverty which policy makers, diplomats, and other international authorities wrestle with:

• The insufficient agricultural output of many African nations has been a cause of poverty. After independence from colonial rule, many African nations focused on stimulating the industrial sector to the exclusion of promoting agriculture. Droughts, civil strife, and other problems also limited farming production. Many African nations now rely on foods grown in other parts of world and cannot afford enough food to adequately feed their people. As one means of addressing this problem, some nations and foreign donors initially invested in costly, large-scale agricultural programs. These often were not well-suited to the farmers or to the geography and, however well-intentioned, did not transform agricultural output. In recent years, however, smaller-scale improvement strategies, funded by the same kinds of donors, have shown great promise, have begun to increase productivity in specific areas, and, unlike earlier efforts, allow Africans to employ more traditional and appropriate farming practices.
• Ethnic conflict causes poverty. Conflict between different ethnic groups often results in warfare and poverty in Africa. In 1998, UN Secretary-General Kofi Annan stated that, "With the frequent lack of peaceful means to change or replace leadership and the often violent politicization of ethnicity, conflict becomes virtually inevitable."

Ethnic conflict can result in warfare, displacement of people, and in poverty. At the same time, poverty, paucity of natural resources, and a weak infrastructure exacerbates ethnic conflicts in many regions.

• AIDS: AIDS has a devastating economic affect in sub-Saharan Africa and so is not only an effect of poverty, but, sadly, one of its causes. The disease strikes young adults who may otherwise have made significant contributions to African society. To care for sick or dying family members, many children drop out of school -- and this sacrifice often hinders their future success. Businesses are losing skilled workers to the disease. And, instead of inventing new and creative businesses, serving as key members of their families or communities, or otherwise strengthening African culture, most of those living with AIDS get sick and die before they have the chance to become vital parts of their society.
• Political corruption is also a tragic contributor to poverty in sub-Saharan Africa. Some national leaders, after independence, filled their garages with a fleet of Rolls Royces while the people who depended on their just governance starved. As Brady Anderson, former Administrator of the US Agency for International Development, lamented a year ago "Mobutu Sese Seko was worth an estimated $4 billion in the early 1980s when Zaire's annual per capita income was about $170."

And then there is the debate about globalization. The potential benefits of globalization are considerable ­ a freer flow of ideas, goods and services, and information - and a tremendous opportunity for synergy in solving the world's problems.

As your topic notes explore, however, concerns about globalization are often less about the creation of a "global culture" and more to do with addressing the inequities related to the way companies from industrialized nations have sometimes sought to produce -- or export -- consumer goods.

In some tragic cases, multinational corporations use their presence in poor countries to secure a very inexpensive work force. Meanwhile, western consumer goods have been imported and marketed to communities who cannot afford them.

Odour Ong-wen, a Kenyan with the non-governmental organization EcoNews Africa, recently stated, "we in Africa are reduced to producing what we do not consume and consuming what we do not produce."

In addition, many developing country governments perceive that there are significant barriers in the way of their access of industrialized country markets.

Another very problematic issue preventing the world from realizing the benefits of globalization is the burden of debt that many poor countries shoulder. Currently, poor countries are spending large amounts of money annually to make payments on decades-old loans from industrialized nations for past development projects.

Some "structural development" loans have endeavored to encourage economic growth by helping to

• privatize public entities,
• enhance private sector participation,
• strengthen financial and regulatory frameworks, and
• improve access to basic education.

These efforts have resulted in lowered inflation and improved school enrollment in some areas which, of course, contribute markedly in efforts to reduce poverty.

For many countries, however, making payments on a large debt inhibits their ability to invest in health and educational services. In the 1990s the Kenyan government spent more repaying debt that it spent on health, education, and infrastructure together.

Institutions, including the World Bank, recognize this grave problem and have created debt relief programs for poor countries who struggle under the burden of weighty debt.

Given the complexity of political, economic, and social problems in the world's poorest countries, the work of the UN specialized agencies, such as UNICEF and non-governmental organizations like PATH is crucial. They work to deliver health services and information to people within the context of their cultures.

We view our counterparts -- health care workers and community leaders -- not only as equals, but truly as the experts who drive and define the work that needs to be accomplished.

CLOSING

I've briefly touched on the sort of issues you have before you in the next few days. It won't be easy, but you will be puzzling over the kinds of issues that your counterparts at the UN wrestle with every day. What an important, unique opportunity.

Before closing, I want to say a word about youth ­ and what you can do next week after the model United Nations is finished. There are currently 6 billion people alive on the globe. One billion of them are between ages 10 and 20. You are the largest generation this planet has ever seen.

If we count up the the people with HIV infection around the world, half of them are between ages 15 and 24. The thorny problems you will wrestle with over the next few days are your problems and, ultimately, they will be solved by your solutions. It is important for today's youth to use opportunities such as the model UN exercise as a springboard to greater and more sustainable global action. Sustainable ­ there is that word again.

I cannot be with you at your closing ceremony this weekend because on Saturday I fly to Ghana and then Botswana to participate in the launch of the African Youth Alliance ­ a new partnership between PATH, the United Nations Population Fund, and others and supported by the Bill and Melinda Gates Foundation ­ to develop effective AIDS prevention programs for African youth. Next week in Accra and Gabarone national youth groups will join with us in launching the program. The participation of these youth in designing appropriate and sustainable solutions is essential. I urge you to think seriously about how to stay involved in global development after the close of the model UN session.

In closing, I'd like to applaud the University of Washington student body for their work in developing topics for the WASMUN conference. You all are in for a fascinating few days. I'd also like to congratulate Jorge Sebastian Roberts, the WASMUN Secretary General, for his Herculean effort in organizing this event. Jorge, you have done something important, something that will change the way all of these participants will see the world's problems.

Think globally, dig deeper, and have a wonderful few days. Thank you.