A MESSAGE FROM WHO: TOWARDS BUILDING A NEW HEALTH PARADIGM IN THE 21ST CENTURYt HIROSHI NAKAJIMA
Mr Chairman, distinguished colleagues and guests, ladies and gentlemen, I should like first to say a word of thanks to my friend Professor Yukio Yamori, without whose untiring and dynamic efforts this Forum could not have taken place. As many of you are aware, Professor Yamori holds a Chair in Pathology at Shimane Medical University, and is also the Director of the WHO Collaborating Centre for Research on Primary Prevention of Cardiovascular Diseases. This Centre, which has already made great contributions to the field of cardiology, is located at the Shimane Institute of Health Science. We are now endeavouring to delineate and define a paradigm, in other words a framework, that will provide a guide in accelerating practical implementation of health for all, a social target for all Member States ofthe World Health Organization proclaimed by the World Health Assembly as long ago as 1977. At the historic International Conference on Primary Health Care, held in Alma-Ata in 1978, primary health care was declared to be the strategy for achieving that goal. The paradigm has many components. Perhaps the most fundamental and basic is our recognition that health is a human right. When I say health is a human right I am echoing an affirmation in WHO's Constitution, which came into force on 7 April 1948. One of the introductory paragraphs ofthis Constitution affirms "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition". Even distinguished human rights scholars are sometimes unaware that this right was proclaimed by the founding fathers of our Organization well before the adoption Of the Universal Declaration ofHumanRights. What it implies, in practical terms for the individual, is a right to know about health, tOpening address by Dr Hiroshi Nakajima, Director-General of the World Health Organization at the WHO Forum and Cardiac Meeting, Kobe, Japan, 2-3 October 1991. 69
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a right to be protected against major risks, a right to have access to services in the field of health promotion, prevention, care, and rehabilitation, and the right to live in an environment that is supportive of health. Associated with this right is the responsibility of the individual to promote a healthy environment and to follow a healthy lifestyle. The paradigm also recognizes that health is at the very centre of human development. In fact, as an essential element of the quality oflife, health is a major objective of human development. As a precondition for social and economic productivity, investments in health are therefore major investments for human development. Health for all, and the primary health care approach for its implementation, are to me, and to our Organization, synonymous with the concepts of equity and social justice. People must be given an equal opportunity to make healthy choices, although I recognize that this may have consequences on governmental policies on such matters as income distribution, housing, education, food, security, and so on. Nor must we neglect the international dimensions of equity and social justice-our efforts to achieve national and international solidarity in the health sector need to be oriented even more than they are today towards meeting the basic needs of the most deprived and vulnerable countries and groups within countries. We must strive towards an equitable distribution of health resources, meaning infrastructure, manpower, and technology, the aim being to serve people according to their real needs. The new framework will clearly reflect the fact that health is closely related to other sectors of human development. Demographic changes, technological developments, the economic situation, and environmental factors are among the elements that strongly influence the health sector and the capacity of ·governments at all levels to provide the population with adequate personal and environmental health services. All sectors of society must be made aware of their responsibility to work with and support the health sector, and be given reasons and incentives to contribute to health improvement. Governments and ministries are important, but people themselves represent the most important resource for health development. Individuals, families, and communities, even at the most peripheral levels, should participate actively in identifying and implementing solutions to their own problems. The cooperation of the community, and of individuals, will be enhanced by a clear recognition by governments that they have a particular responsibility to assure respect for human rights and for social and ethical values. Governments must orient and coordinate the actions of all partners, as they seek to achieve the highest attainable degree of equity and social justice. Within this framework, the role of nongovernmental organizations and of private initiatives must be encouraged, and we in WHO are very much aware that our efforts to promote health for all are being greatly aided by nongovernmental organizations, both in this country and throughout the world. Let me turn now to some of the priority orientations I am giving the
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World Health Organization in this final decade of the 20th century. In the first place, I am endeavouring to place health at the very centre of human development. WHO is engaged in many studies on the relationships between health status and health coverage, and such factors as demographic and economic trends, the environment, and technological developments. WHO is seeking to ,develop appropriate methods for health promotion and advocacy for healthy lifestyles. Our Organization is endeavouring to promote the role of women in health and development, a subject we shall be discussing in depth at the 1992 World Health Assembly. I need hardly emphasize the priority I am according to programmes intended to improve child health, p~rticularly in the developing countries. Here I have in mind our Expanded Programme on Immunization, which already has considerable achievements to its credit. Achievements which, I emphasize, could not have occurred in the absence of fruitful partnership with the countries concerned and, of course, with other organizations and bodies of the United Nations system, including UNICEF. I have in mind our continuing efforts to ensure that children, pregnant women, and other vulnerable groups are assured adequate standards of nutrition. I place great emphasis on prevention, while recognizing that successful prevention programmes are contingent upon health education and information programmes that are sensitive to the cultural and psychosocial specificities of the populations and communities to which they are addressed. I am convinced that such programmes, developed and conceived with a view not merely to health protection but also to health promotion, can make a real impact on people's health. We must focus on the causes of illhealth-not merely those of microbial origin but also those intimately linked with lifestyle. It should be borne in mind that the diseases oflifestyle, among them heart attacks, stroke, hypertension, cancer, pulmonary diseases, diabetes, and osteoporosis, are the cause of between 70% and 80% of deaths in the developed world. To cope with these and the continuing burden of communicable diseases, we must devise integrated approaches to disease prevention and control, that make appropriate use of existing health technology, including its application at the most peripheral level, that are based on the cooordinated training of health workers in different aspects of disease prevention and control, and that incorporate the evolving ideas of health promotion, a topic to which I shall return later. WHO and its partners, and particularly its Member States, have undoubtedly registered major successes in the past decade or so. Thus, global infant mortality has fallen from 86 to 63.per 1000 live births, and life expectancy at birth has increased from 60 years to 66 years. For the first time in history, the rate of growth of the world's population has started to slow down, and is currently 1.73%. But, much remains to be done, and the challenges facing our Organization are indeed formidable. You will have discerned from what I have said so far that the challenges faced by the global health community under the leadership of WHO are
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indeed formidable. In confronting these challenges, one of WHO's key roles is to engage in technical cooperation with its Member States. How, you may ask, do we select the programmes on which to concentrate our limited resources? The answer is that the priorities for WHO's technical cooperation must be based not only on the current health situation and immediate needs of a country, but must reflect forward-looking objectives and strategies for sustainable health and social development. Health for all is happily coming to be interpreted as meaning that the entire life-cycle of an individual must be taken into consideration through safe motherhood, child survival and development, adolescent health, health throughout the span of his or her productive life, and finally, a predominantly disability-free old age. We are faced with the question of how to generate and distribute the resources needed to solve, by promotive, corrective and rehabilitative means, the emerging health problems of each phase of this life cycle. For this, special efforts must be made to determine the major existing health problems and how they can be addressed. The basic principle for decision-making for health for all must seek harmony, that is equity and involvement among peoples in the community, and creativity in the use of technology and resources to these ends. We must continuously monitor and evaluate the cost-efficiency of outputs, and ultimately the effectiveness of outcomes, in terms of impact on human health and overall socioeconomic development. Let me turn now to the environment, which still makes great inroads on human health and on the quality of life. It is clear that the paradigm will clearly recognize the interdependence between health and the environment. It is noteworthy that in the aftermath of the 1972 Stockholm Conference on the Human Environment, some 70 countries have created ministries of the environment or environmental protection agencies. While in many respects this is a positive development, it has to be recognized that there may sometimes be a tendency to address environmental problems independently, with the possible distancing of health issues. It is sometimes contended that concern for the environment is primarily a phenomenon of the industrialized countries. Permit me to quote from the Beijing Ministerial Declaration on Environment and Development, adopted on 19 June 1991 by the Ministerial Conference of Developing Countries on Environment and Development: "We are deeply concerned about the accelerating degradation of the global environment. This is largely· on account of unsustainable development models and life styles. As a result, the basic elements indispensable for human life-land, water and atmosphere-are gravely threatened. The more serious and widespread environmental problems are air pollution, climate change, ozone layer depletion, drying up of fresh water resources, pollution of rivers, lakes and the marine environment including the coastal zones, marine and coastal
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resources deterioration, floods and droughts, soil loss, land degradation, loss of biodiversity, acid rain, proliferation and mismanagement of toxic products, illegal traffic of toxic and dangerous products and wastes, growth of urban agglomerations, deterioration of living and working conditions in urban and rural areas, especially of sanitation, resulting in epidemics, and other such problems. Furthermore, poverty in the developing countries is becoming aggravated, hampering the efforts to meet the legitimate needs and aspirations of their people and exerting greater pressures on the environment." I emphasize that this represents the views of ministers from no less than 41 developing countries. The Declaration, and similar declarations by other ministerial conferences, will be on the agenda at the United Nations Conference on Environment and Development, being held in Brazil in 1992. WHO will be playing a very important role in ensuring that health considerations are at the forefront of the agenda. I think the key issue is how to ensure an equitable consumption of natural resources which, at the same time, will protect our ecosystem so that our descendants will be able to enjoy their birthright in the way we do today. Our concern for the environment is, in the ultimate analysis, a concern about health. The relationship between health and the environment can be no better demonstrated than by the problem of cholera. We have all been concerned in 1991 with the outbreaks of cholera in Latin America and Africa. When the social conditions are not protected, when the quality of life falls below a critical minimum, such outbreaks come as no surprise. The tragedy is that knowledge and technology are both available to prevent and to contain the disease. The key issue is poverty and underdevelopment and how we, in the health sector, can contribute to their resolution. The epidemiological transition that is taking place means that infectious diseases are being replaced by noncommunicable diseases as major causes of morbidity and mortality. One exception is AIDS. Worldwide, between 8 and 10 million HIV infections may have occurred in adults and an estimated one million children have been born infected with HIV. Between 10 and 20 million new infections may be expected in adults in the 1990s, and the cumulative total HIV infections in men, women, and children is expected to reach 40 million by the year 2000. It has become clear that the most appalling consequences of this disease will be seen in the developing countries where poverty, ignorance, and a weak health infrastructure all conspire to make the situation desperate. But there is much goodwill among nations in fighting this pandemic and I have no doubt that before too long man's ingenuity will give us the specific tools we need. But AIDS has also brought about the recrudescence of tubercluosis, often in its malignant and exotic forms. The goal of socioeconomic development must ultimately be the fulfilment
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of the human potential. After many painful mistakes the human being is once again at the centre of the development process. As I mentioned at the beginning of this address, our Constitution unequivocally states that health is a fundamental human right. The primary health care approach accepts that the State has an obligation to ensure that care is accessible to all its citizens. If this is so, then the citizens in turn have a responsibility to contribute to the maintenance of their own health and at the same time exercise an informed restraint on the consumption of services. The rights of the individual must be central to all health action but at this time the right to know, for example, has almost become a demand for infallible prognostications of outcomes of health interventions. Even proven conventional public health measures have become polemical. There is still much work in education and empowerment if we are to remove the conflict. I would like to say a few words about the importance of diet and nutrition, because of their crucial importance to health. I should like to remind you that a diet that is high in animal fat, salt, and refined sugar, and low in fresh vegetables and fruit, carries the risk of heart attack, stroke, and hypertension, as well as colorectal, stomach, and breast cancers. A lack of vitamins A and C, which are found in vegetables and fruit, carries the risk of chronic pulmonary diseases, notably emphysema and chronic bronchitis. A lack of calcium, particularly in the diets of adolescent girls and postmenopausal woinen, carries the risk of osteoporosis. Improper diets may also lead to gastric ulcers, as well as to malnutrition and to obesity, which in turn carries the risk of cardiovascular disease, cancer, diabetes, and arthritis. I should now like to return to the concept of health promotion, since I believe it is central to the thrust of the policies and programmes that WHO is advocating. We recognize that health promotion is a concept that is still evolving. As currently understood, health promotion covers measures at both the individual and the collective levels, that are intended to facilitate sustained behavioural change and to secure needed environmental changes that will help to reduce or even eliminate the social and other environmental causes of ill health. The Ottawa Charter on Health Promotion, adopted in 1986, identified five component areas that, taken in conjunction, delineate the field of concern: these are health promotive public policy, supportive environments, strengthening community action, developing personal skills, and reorienting health services to health promotion. The range of actions that need to be taken in line with the principal thrusts of this Charter include policy measures as well as organizational, political, and other interventions directed towards: -providing education and work in conformity with a person's physical and mental capacity; and ensuring a safe and healthy working environment; -making available suitable housing and safe water and sanitary facilities; and ensuring safe and adequate nutritious food supply;
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-improving the physical, economic, cultural, psychological, and social environment; and developing and maintaining social support; -raising people's awareness about health matters; enabling them to cope with health problems by helping them develop personal skills; providing them with valid information on such basic matters of lifestyle as appropriate diet, physical activity, relaxation, and sleep; and -strengthening support to community efforts of self-care and self-reliance through the ready availability of professional advice and services where needed, to ensure that community action develops and is sustained in a way which most effectively protects and promotes the community's health. We do not of course envisage the creation of a specific health promotion "subsector", nor the assignment to health protection agencies of existing and established rules of bodies concerned with environmental health, occupational health and safety, and so on. What we do encourage is a concerted cooperative effort on the part of the different professions concerned, in whatever sector they may be located. We do seek to foster intersectoral action, with people at the centre. Evidence of effective action will be manifest in the relevant environmental changes, in the reduced prevalence of risky behaviours, improved levels of population health, and observable and self-perceived improvements in the quality of life. Another concept that we have evolved over the past decade is that of "safety promotion", closely linked with both health promotion and the more traditional forms of health protection. For a number of reasons, it is unrealistic to conceive of a supportive environment, whether at the neighbourhood and workplace levels, or indeed at the national and global levels, that is entirely without danger, whether man-made or natural. Confronting hazards and taking risks of various kinds constitute natural behaviour, and can be seen daily in, for example, the voluntary activities of persons engaging in various ~ports and other leisure pursuits. At the same time, there are also generally recognized limits to what is acceptable in the exposure of people to hazards and risks. In some situations, there may be a social consensus that the objective of public policy should be total elimination of the risk. In others, there is more controversy, usually over the trade-off between the level of safety to be achieved, and the economic cost of ensuring safety to a public authority, or to an employer or supplier of services or products. In yet other settings, a consensus may exist on the acceptable level of hazard and risk. Safety promotion is concerned with raising awareness of hazard, risk, and safety at the political and social levels, as well as within communities and the industrial and other sectors concerned, the aim being to secure: an informed debate on safety issues; the introduction of enforceable safety legislation and standards in various sectors; an appropriate level of research and
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development activity and .technology assesl'ment; and the wide dissemination of a rational safety culture in the community and in particular settings, such as to assure compliance with legislation and the adoption of and adherence to reasonable safety systems and practices. Finally, I should like to emphasize that all the lines of action in the concepts I have discussed represent essential elements of a coherent health for all strategy. The key to attaining this goal remains the primary health care approach, as articulated in the Declaration of Alma-Ata. This focuses on, or emphasizes, the following aspects, in particular: -meeting the essential prerequisites for health (notably economic and social development, equitable distribution of resources, and participation of communities, groups, and individuals in matters affecting their health); -the central place of education and information for health; -the prevention and control of disease; and -the provision of essential care for common diseases and injuries. This in turn implies self-reliance and self-care, community involvement, and intersectoral action. It is obvious that what is required cannot be provided by governments alone, or indeed by the unaided professional services of the health sector. These represent merely one set of actors and institutions in the health system, the latter in turn being a subsystem of society. We perceive the health system to be a multisectoral complex of interrelated actors and institutions, working on and through the physical, economic, psychosocial, and other environments, each contributing directly or indirectly to health in homes, schools and other educational institutions, the workplace, and public places. The aim must be to harness the entire health system (including elements beyond the health sector) towards the goal of health development, in other words, a continuous progressive improvement in the health status of the population.
Nutrition and Health, 1992, Vol. 8, pp. 69-76 0260-1061192 $10 © 1992 A B Academic Publishers. Printed in Great Britain
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Mr Chairman, distinguished colleagues and guests, ladies and gentlemen, I should like first to say a word of thanks to my friend Professor Yukio Yamori, without whose untiring and dynamic efforts this Forum could not have taken place. As many of you are aware, Professor Yamori holds a Chair in Pathology at Shimane Medical University, and is also the Director of the WHO Collaborating Centre for Research on Primary Prevention of Cardiovascular Diseases. This Centre, which has already made great contributions to the field of cardiology, is located at the Shimane Institute of Health Science. We are now endeavouring to delineate and define a paradigm, in other words a framework, that will provide a guide in accelerating practical implementation of health for all, a social target for all Member States ofthe World Health Organization proclaimed by the World Health Assembly as long ago as 1977. At the historic International Conference on Primary Health Care, held in Alma-Ata in 1978, primary health care was declared to be the strategy for achieving that goal. The paradigm has many components. Perhaps the most fundamental and basic is our recognition that health is a human right. When I say health is a human right I am echoing an affirmation in WHO's Constitution, which came into force on 7 April 1948. One of the introductory paragraphs ofthis Constitution affirms "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition". Even distinguished human rights scholars are sometimes unaware that this right was proclaimed by the founding fathers of our Organization well before the adoption Of the Universal Declaration ofHumanRights. What it implies, in practical terms for the individual, is a right to know about health, tOpening address by Dr Hiroshi Nakajima, Director-General of the World Health Organization at the WHO Forum and Cardiac Meeting, Kobe, Japan, 2-3 October 1991. 69
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a right to be protected against major risks, a right to have access to services in the field of health promotion, prevention, care, and rehabilitation, and the right to live in an environment that is supportive of health. Associated with this right is the responsibility of the individual to promote a healthy environment and to follow a healthy lifestyle. The paradigm also recognizes that health is at the very centre of human development. In fact, as an essential element of the quality oflife, health is a major objective of human development. As a precondition for social and economic productivity, investments in health are therefore major investments for human development. Health for all, and the primary health care approach for its implementation, are to me, and to our Organization, synonymous with the concepts of equity and social justice. People must be given an equal opportunity to make healthy choices, although I recognize that this may have consequences on governmental policies on such matters as income distribution, housing, education, food, security, and so on. Nor must we neglect the international dimensions of equity and social justice-our efforts to achieve national and international solidarity in the health sector need to be oriented even more than they are today towards meeting the basic needs of the most deprived and vulnerable countries and groups within countries. We must strive towards an equitable distribution of health resources, meaning infrastructure, manpower, and technology, the aim being to serve people according to their real needs. The new framework will clearly reflect the fact that health is closely related to other sectors of human development. Demographic changes, technological developments, the economic situation, and environmental factors are among the elements that strongly influence the health sector and the capacity of ·governments at all levels to provide the population with adequate personal and environmental health services. All sectors of society must be made aware of their responsibility to work with and support the health sector, and be given reasons and incentives to contribute to health improvement. Governments and ministries are important, but people themselves represent the most important resource for health development. Individuals, families, and communities, even at the most peripheral levels, should participate actively in identifying and implementing solutions to their own problems. The cooperation of the community, and of individuals, will be enhanced by a clear recognition by governments that they have a particular responsibility to assure respect for human rights and for social and ethical values. Governments must orient and coordinate the actions of all partners, as they seek to achieve the highest attainable degree of equity and social justice. Within this framework, the role of nongovernmental organizations and of private initiatives must be encouraged, and we in WHO are very much aware that our efforts to promote health for all are being greatly aided by nongovernmental organizations, both in this country and throughout the world. Let me turn now to some of the priority orientations I am giving the
Downloaded from nah.sagepub.com at CARLETON UNIV on June 25, 2015
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World Health Organization in this final decade of the 20th century. In the first place, I am endeavouring to place health at the very centre of human development. WHO is engaged in many studies on the relationships between health status and health coverage, and such factors as demographic and economic trends, the environment, and technological developments. WHO is seeking to ,develop appropriate methods for health promotion and advocacy for healthy lifestyles. Our Organization is endeavouring to promote the role of women in health and development, a subject we shall be discussing in depth at the 1992 World Health Assembly. I need hardly emphasize the priority I am according to programmes intended to improve child health, p~rticularly in the developing countries. Here I have in mind our Expanded Programme on Immunization, which already has considerable achievements to its credit. Achievements which, I emphasize, could not have occurred in the absence of fruitful partnership with the countries concerned and, of course, with other organizations and bodies of the United Nations system, including UNICEF. I have in mind our continuing efforts to ensure that children, pregnant women, and other vulnerable groups are assured adequate standards of nutrition. I place great emphasis on prevention, while recognizing that successful prevention programmes are contingent upon health education and information programmes that are sensitive to the cultural and psychosocial specificities of the populations and communities to which they are addressed. I am convinced that such programmes, developed and conceived with a view not merely to health protection but also to health promotion, can make a real impact on people's health. We must focus on the causes of illhealth-not merely those of microbial origin but also those intimately linked with lifestyle. It should be borne in mind that the diseases oflifestyle, among them heart attacks, stroke, hypertension, cancer, pulmonary diseases, diabetes, and osteoporosis, are the cause of between 70% and 80% of deaths in the developed world. To cope with these and the continuing burden of communicable diseases, we must devise integrated approaches to disease prevention and control, that make appropriate use of existing health technology, including its application at the most peripheral level, that are based on the cooordinated training of health workers in different aspects of disease prevention and control, and that incorporate the evolving ideas of health promotion, a topic to which I shall return later. WHO and its partners, and particularly its Member States, have undoubtedly registered major successes in the past decade or so. Thus, global infant mortality has fallen from 86 to 63.per 1000 live births, and life expectancy at birth has increased from 60 years to 66 years. For the first time in history, the rate of growth of the world's population has started to slow down, and is currently 1.73%. But, much remains to be done, and the challenges facing our Organization are indeed formidable. You will have discerned from what I have said so far that the challenges faced by the global health community under the leadership of WHO are
Downloaded from nah.sagepub.com at CARLETON UNIV on June 25, 2015
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indeed formidable. In confronting these challenges, one of WHO's key roles is to engage in technical cooperation with its Member States. How, you may ask, do we select the programmes on which to concentrate our limited resources? The answer is that the priorities for WHO's technical cooperation must be based not only on the current health situation and immediate needs of a country, but must reflect forward-looking objectives and strategies for sustainable health and social development. Health for all is happily coming to be interpreted as meaning that the entire life-cycle of an individual must be taken into consideration through safe motherhood, child survival and development, adolescent health, health throughout the span of his or her productive life, and finally, a predominantly disability-free old age. We are faced with the question of how to generate and distribute the resources needed to solve, by promotive, corrective and rehabilitative means, the emerging health problems of each phase of this life cycle. For this, special efforts must be made to determine the major existing health problems and how they can be addressed. The basic principle for decision-making for health for all must seek harmony, that is equity and involvement among peoples in the community, and creativity in the use of technology and resources to these ends. We must continuously monitor and evaluate the cost-efficiency of outputs, and ultimately the effectiveness of outcomes, in terms of impact on human health and overall socioeconomic development. Let me turn now to the environment, which still makes great inroads on human health and on the quality of life. It is clear that the paradigm will clearly recognize the interdependence between health and the environment. It is noteworthy that in the aftermath of the 1972 Stockholm Conference on the Human Environment, some 70 countries have created ministries of the environment or environmental protection agencies. While in many respects this is a positive development, it has to be recognized that there may sometimes be a tendency to address environmental problems independently, with the possible distancing of health issues. It is sometimes contended that concern for the environment is primarily a phenomenon of the industrialized countries. Permit me to quote from the Beijing Ministerial Declaration on Environment and Development, adopted on 19 June 1991 by the Ministerial Conference of Developing Countries on Environment and Development: "We are deeply concerned about the accelerating degradation of the global environment. This is largely· on account of unsustainable development models and life styles. As a result, the basic elements indispensable for human life-land, water and atmosphere-are gravely threatened. The more serious and widespread environmental problems are air pollution, climate change, ozone layer depletion, drying up of fresh water resources, pollution of rivers, lakes and the marine environment including the coastal zones, marine and coastal
Downloaded from nah.sagepub.com at CARLETON UNIV on June 25, 2015
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resources deterioration, floods and droughts, soil loss, land degradation, loss of biodiversity, acid rain, proliferation and mismanagement of toxic products, illegal traffic of toxic and dangerous products and wastes, growth of urban agglomerations, deterioration of living and working conditions in urban and rural areas, especially of sanitation, resulting in epidemics, and other such problems. Furthermore, poverty in the developing countries is becoming aggravated, hampering the efforts to meet the legitimate needs and aspirations of their people and exerting greater pressures on the environment." I emphasize that this represents the views of ministers from no less than 41 developing countries. The Declaration, and similar declarations by other ministerial conferences, will be on the agenda at the United Nations Conference on Environment and Development, being held in Brazil in 1992. WHO will be playing a very important role in ensuring that health considerations are at the forefront of the agenda. I think the key issue is how to ensure an equitable consumption of natural resources which, at the same time, will protect our ecosystem so that our descendants will be able to enjoy their birthright in the way we do today. Our concern for the environment is, in the ultimate analysis, a concern about health. The relationship between health and the environment can be no better demonstrated than by the problem of cholera. We have all been concerned in 1991 with the outbreaks of cholera in Latin America and Africa. When the social conditions are not protected, when the quality of life falls below a critical minimum, such outbreaks come as no surprise. The tragedy is that knowledge and technology are both available to prevent and to contain the disease. The key issue is poverty and underdevelopment and how we, in the health sector, can contribute to their resolution. The epidemiological transition that is taking place means that infectious diseases are being replaced by noncommunicable diseases as major causes of morbidity and mortality. One exception is AIDS. Worldwide, between 8 and 10 million HIV infections may have occurred in adults and an estimated one million children have been born infected with HIV. Between 10 and 20 million new infections may be expected in adults in the 1990s, and the cumulative total HIV infections in men, women, and children is expected to reach 40 million by the year 2000. It has become clear that the most appalling consequences of this disease will be seen in the developing countries where poverty, ignorance, and a weak health infrastructure all conspire to make the situation desperate. But there is much goodwill among nations in fighting this pandemic and I have no doubt that before too long man's ingenuity will give us the specific tools we need. But AIDS has also brought about the recrudescence of tubercluosis, often in its malignant and exotic forms. The goal of socioeconomic development must ultimately be the fulfilment
Downloaded from nah.sagepub.com at CARLETON UNIV on June 25, 2015
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of the human potential. After many painful mistakes the human being is once again at the centre of the development process. As I mentioned at the beginning of this address, our Constitution unequivocally states that health is a fundamental human right. The primary health care approach accepts that the State has an obligation to ensure that care is accessible to all its citizens. If this is so, then the citizens in turn have a responsibility to contribute to the maintenance of their own health and at the same time exercise an informed restraint on the consumption of services. The rights of the individual must be central to all health action but at this time the right to know, for example, has almost become a demand for infallible prognostications of outcomes of health interventions. Even proven conventional public health measures have become polemical. There is still much work in education and empowerment if we are to remove the conflict. I would like to say a few words about the importance of diet and nutrition, because of their crucial importance to health. I should like to remind you that a diet that is high in animal fat, salt, and refined sugar, and low in fresh vegetables and fruit, carries the risk of heart attack, stroke, and hypertension, as well as colorectal, stomach, and breast cancers. A lack of vitamins A and C, which are found in vegetables and fruit, carries the risk of chronic pulmonary diseases, notably emphysema and chronic bronchitis. A lack of calcium, particularly in the diets of adolescent girls and postmenopausal woinen, carries the risk of osteoporosis. Improper diets may also lead to gastric ulcers, as well as to malnutrition and to obesity, which in turn carries the risk of cardiovascular disease, cancer, diabetes, and arthritis. I should now like to return to the concept of health promotion, since I believe it is central to the thrust of the policies and programmes that WHO is advocating. We recognize that health promotion is a concept that is still evolving. As currently understood, health promotion covers measures at both the individual and the collective levels, that are intended to facilitate sustained behavioural change and to secure needed environmental changes that will help to reduce or even eliminate the social and other environmental causes of ill health. The Ottawa Charter on Health Promotion, adopted in 1986, identified five component areas that, taken in conjunction, delineate the field of concern: these are health promotive public policy, supportive environments, strengthening community action, developing personal skills, and reorienting health services to health promotion. The range of actions that need to be taken in line with the principal thrusts of this Charter include policy measures as well as organizational, political, and other interventions directed towards: -providing education and work in conformity with a person's physical and mental capacity; and ensuring a safe and healthy working environment; -making available suitable housing and safe water and sanitary facilities; and ensuring safe and adequate nutritious food supply;
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-improving the physical, economic, cultural, psychological, and social environment; and developing and maintaining social support; -raising people's awareness about health matters; enabling them to cope with health problems by helping them develop personal skills; providing them with valid information on such basic matters of lifestyle as appropriate diet, physical activity, relaxation, and sleep; and -strengthening support to community efforts of self-care and self-reliance through the ready availability of professional advice and services where needed, to ensure that community action develops and is sustained in a way which most effectively protects and promotes the community's health. We do not of course envisage the creation of a specific health promotion "subsector", nor the assignment to health protection agencies of existing and established rules of bodies concerned with environmental health, occupational health and safety, and so on. What we do encourage is a concerted cooperative effort on the part of the different professions concerned, in whatever sector they may be located. We do seek to foster intersectoral action, with people at the centre. Evidence of effective action will be manifest in the relevant environmental changes, in the reduced prevalence of risky behaviours, improved levels of population health, and observable and self-perceived improvements in the quality of life. Another concept that we have evolved over the past decade is that of "safety promotion", closely linked with both health promotion and the more traditional forms of health protection. For a number of reasons, it is unrealistic to conceive of a supportive environment, whether at the neighbourhood and workplace levels, or indeed at the national and global levels, that is entirely without danger, whether man-made or natural. Confronting hazards and taking risks of various kinds constitute natural behaviour, and can be seen daily in, for example, the voluntary activities of persons engaging in various ~ports and other leisure pursuits. At the same time, there are also generally recognized limits to what is acceptable in the exposure of people to hazards and risks. In some situations, there may be a social consensus that the objective of public policy should be total elimination of the risk. In others, there is more controversy, usually over the trade-off between the level of safety to be achieved, and the economic cost of ensuring safety to a public authority, or to an employer or supplier of services or products. In yet other settings, a consensus may exist on the acceptable level of hazard and risk. Safety promotion is concerned with raising awareness of hazard, risk, and safety at the political and social levels, as well as within communities and the industrial and other sectors concerned, the aim being to secure: an informed debate on safety issues; the introduction of enforceable safety legislation and standards in various sectors; an appropriate level of research and
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development activity and .technology assesl'ment; and the wide dissemination of a rational safety culture in the community and in particular settings, such as to assure compliance with legislation and the adoption of and adherence to reasonable safety systems and practices. Finally, I should like to emphasize that all the lines of action in the concepts I have discussed represent essential elements of a coherent health for all strategy. The key to attaining this goal remains the primary health care approach, as articulated in the Declaration of Alma-Ata. This focuses on, or emphasizes, the following aspects, in particular: -meeting the essential prerequisites for health (notably economic and social development, equitable distribution of resources, and participation of communities, groups, and individuals in matters affecting their health); -the central place of education and information for health; -the prevention and control of disease; and -the provision of essential care for common diseases and injuries. This in turn implies self-reliance and self-care, community involvement, and intersectoral action. It is obvious that what is required cannot be provided by governments alone, or indeed by the unaided professional services of the health sector. These represent merely one set of actors and institutions in the health system, the latter in turn being a subsystem of society. We perceive the health system to be a multisectoral complex of interrelated actors and institutions, working on and through the physical, economic, psychosocial, and other environments, each contributing directly or indirectly to health in homes, schools and other educational institutions, the workplace, and public places. The aim must be to harness the entire health system (including elements beyond the health sector) towards the goal of health development, in other words, a continuous progressive improvement in the health status of the population.
Nutrition and Health, 1992, Vol. 8, pp. 69-76 0260-1061192 $10 © 1992 A B Academic Publishers. Printed in Great Britain
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