Healthier, fairer, safer: the global health journey, 2007–2017

HEALTHIER FAIRER SAFER THE GLOBAL HEALTH JOURNEY 2007-2017 Healthier, fairer, safer: the global health journey, 2007–2017 ISBN 978-92-4-151236-7 © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https:// creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Design and layout by 22 Design, London Printed in France. 01 01 CONTENTS HEALTH IE R, F AI RE R, S AF ER : T he G lo ba l H ea lth J ou rn ey 01 Introduction 02 HEALTHIER 02 Populations: the vital signs 04 03 Saving mothers and children 10 04 Microbes: old and new 16 05 The ascendancy of noncommunicable diseases 24 FAIRER 06 Closing the gap in a generation 30 07 Healthy ageing 34 08 Good health services for all 38 SAFER 09 Vaccines: protecting young lives 44 10 Airs, Waters, Places 48 11 Emergencies: protect and mitigate 56 12 Conclusions 62 Prepared by Professor Sir Liam Donaldson, supported by Dr Paul Rutter 02 01 H EA LT H IE R, F AI RE R, S AF ER : T he G lo ba l H ea lth J ou rn ey This report describes and analyses key aspects of global health over the last decade. It considers trends and policies that are relevant to the role and potential influence of the World Health Organization (WHO). It deals with themes and areas of the world’s health, where progress would have been expected, was explicitly pledged, or was urgently needed. A backdrop of forces, beyond the health arena, have an impact on health. Since the beginning of the 21st Century, the march of globalization has quickened, the world has suffered a major financial crisis, whilst serious armed conflicts and deteriorating security situations in some parts of the world have led to displacements and migration of populations on a massive scale. Public health workers have been targeted and killed when carrying out their humanitarian work. Climate change has precipitated many extreme weather events with devastating effects for human settlements. All these factors have had a major bearing on the health and wellbeing of nations and communities, particularly those in the poorest parts of the world. WHO works in partnership to achieve its goals. The global health architecture has evolved greatly over the last decade. In documents describing its own reform story, WHO has defined its primary role as directing and coordinating international health and summarized the way it discharges this: • Providing leadership on matters critical to health • Shaping the health research agenda • Defining norms and standards for health • Articulating policy options for health • Providing technical support and building capacity • Monitoring health trends This report is not intended to be a work of scholarship, nor to address every aspect of global health. It is intended to look back and reflect on the trends, achievements and challenges of global health over the last decade – and to explore the needs of the future. INTRODUCTION

04 02 The world is home to 800 million more people than it was just a decade ago. The number of births has been more than double the number of deaths, so the population has expanded. The greatest growth has been in the lowest income countries, where mortality rates have been falling much more quickly than birth rates. This is an expected phase of demographic transition. The number of people living to an advanced age has grown extraordinarily. Between 2007 and 2017, the number of people aged over 90 years has increased by two-thirds, and the number over 100 years has practically doubled – substantial shifts over such a short slice of human history. The populations of different countries remain very different in their structures. Low-income countries have the youngest populations – on average, half of their population is aged less than 18.5 years. This number rises markedly to 28.9 years for middle- income countries and 39.7 years for high-income countries. Human life expectancy has grown at a remarkable rate. The global average life expectancy at birth is now more than 71 years. With every passing year, it has been increasing by four months. In 2007, 15 countries had a life expectancy at birth of more than 80 years. By 2015, that number was 29 countries. Meanwhile, the number of countries with a life expectancy of less than 60 years fell from 36 to 22. 29 countries with life expectancy over 80 years in 2015 compared to 15 in 2007 POPULATIONS: THE VITAL SIGNSHEALTHIER H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 05 Life expectancy gain has been greatest in the African region – five and a half more years in a period of just eight years. Zimbabwe, Malawi and Zambia climbed fastest (gaining 14 years, 9.8 years, and 9.2 years respectively). Women have longer life expectancy than men, by four and a half years. Almost every country has shown increased life expectancy over the last decade. War has created the exception. In the Syrian Arab Republic, life expectancy has fallen by 9.3 years. Life expectancy gain greatest in Africa There are two primary elements to life expectancy growth. The first, particularly in the richer countries of the world, is that older people are getting even older – with the major social, economic and healthcare consequences that are well known and too often seen negatively. The second element, particularly in the poorer countries of the world, is that life expectancy is growing because a much higher proportion of those born into this world are surviving childhood and living a full life. This too has major social and economic consequences, almost all very positive. Globally, the important expansion in life expectancy over the last decade has been driven by a number of changes, including: • The reduction in under-5 mortality rate of 32% between 2005 and 2015 • The fall in the maternal mortality ratio of 25% over the same period • The HIV mortality rate drop of 50% • The drop in the malaria mortality rate of 49% • The reduction in the age-specific risk of cardiovascular disease mortality of 14% • The reduction in the age-specific risk of cancer mortality of 11% • The 7% drop in the injury mortality rate The first four of these in particular were the areas of the three primary Millennium Development Goals related to health: to reduce child mortality, to improve maternal health, and to combat HIV, malaria, and other diseases. The question is often asked: what truly lies behind these major gains? Socioeconomic development has played a part. Changes that go along with this have included improved female (and male) education, and falling fertility rates. Effective health interventions delivered successfully on a greater scale (particularly anti-retroviral drugs, insecticide-impregnated bed nets, measles vaccines) have also made an impact. The balance between the impact of general development and the impact 20172007 1.4 Bn 2.4 Bn 3.0 Bn 0.7 Bn Low income countries Lower-middle Upper-middle High 0.5 Bn 2.6 Bn 1.3 Bn 2.2 Bn Low income countries Lower middle income Upper middle incom High income Age (years) 0 -4 5 -9 10 -1 4 15 -1 9 2 0 -2 4 2 5 -2 9 3 0 -3 4 3 5 -3 9 4 0 -4 4 4 5 -4 9 5 0 -5 4 5 5 -5 9 6 0 -6 4 6 5 -6 9 70 -7 4 75 -7 9 8 0 -8 4 8 5 -8 9 9 0 -9 4 9 5 -9 9 10 0 + 31% increase 16% 8% 6% Deaths - 0.6 billion Births + 1.4 billion 2007 6.7 billion Global population 2017 H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 06 of specific interventions in the field of health can be debated, but ultimately both have been important. As childhood mortality has fallen, so the global health spotlight has fallen on the causes of premature death that come later in life. Over the last decade, progress has been made in preventing and treating noncommunicable disease. This has contributed to the improvements in life expectancy. This is often misunderstood, because noncommunicable disease is also causing more illness and death than it was a decade ago. These statements are not contradictory: at any given age, the mortality associated with noncommunicable disease is decreasing, hence the positive contribution to life expectancy. But this is outweighed by the increasing numbers of people in the higher age bands, creating a greater overall burden in the population. Noncommunicable disease is also becoming more important in relative terms; the gains made against it have been less impressive than those made against communicable disease. The United Nations Millennium Development Goal era has ended. The Sustainable Development Goals are what matters now. Good Health and Wellbeing is the third Sustainable Development Goal. Its 13 targets demand progress on maternal, childhood and communicable disease, as well as to: reduce premature mortality from non-communicable diseases by one third; halve the number of global deaths and injuries from road traffic accidents; reduce the number of deaths and illnesses from hazardous chemicals, as well as air, water and soil pollution and contamination; achieve universal health coverage; promote mental health and well- being; strengthen the prevention and treatment of substance abuse; and achieve universal access to sexual and reproductive healthcare services. Good progress on the Sustainable Development Goals will bring further growth in life expectancy. Taken together, the targets imply an overarching goal of reducing premature mortality. When the Sustainable Development Goals were being developed, a number of prominent experts argued for such a goal to be made explicit and quantified, but it was not. Maintaining progress on maternal, childhood and communicable disease is of a somewhat different nature than achieving progress in the areas newly Life expectancy at birth 2008-2015 66.3 +2.7 69.0 75.1 +1.5 76.6 67.2 +1.6 68.8 55.5 +4.5 60.0 74.6 +2.2 76.8 75.6 +1.3 76.9 69.1 73.771.166.6 2007 2015 2007 2015 5 5 5 6 5 7 5 8 5 9 6 0 6 1 6 2 6 3 6 4 6 5 6 6 6 7 6 8 6 9 70 7 1 72 7 3 74 75 76 Life expectancy at birth 6.6 YEARS 8 countries < 50 years 5.1 YEARS 31 countries 50-60 years 2.6 YEARS 44 countries 60-70 years 1.6 YEARS 85 countries 70-80 years 1.6 YEARS 15 countries > 80 years Life expectancy at birth 2015 2007 H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 07 02 set out. Achieving the first, essentially the unfinished Millennium Development Goals agenda, cries out for tackling inequity in the provision of the most basic health services. The leading diarrhoeal cause of death in the under-5s is rotavirus, and of death from pneumonia is pneumococcus. Both are vaccine- preventable. Water and sanitation, nutrition, and contraceptive access remain current and critical issues. To populations in richer countries, these seem absolutely the basics. But the basics are not yet available for all. Very little is basic either about the areas of newer focus, primarily noncommunicable disease. At a macro- and policy-level, prevention needs political courage and multi-sectoral collaboration. The delivery of primary prevention through healthcare systems requires those systems to have a fair degree of sophistication; secondary prevention and other treatment requires this even more so. During 2015, more people became refugees than at any time since the Second World War. There are now 21 million refugees. This has been a hugely adverse trend. The number of refugees has grown by more than 40% over just three years, largely from the Syrian Arab Republic. In addition, some 40 million people are now internally displaced. They no longer have a stable home but remain within the borders of their own country. Two-thirds of the world’s refugees and half of its internally displaced people are in the Eastern Mediterranean region. This forced displacement is a small fraction of the total number of migrants worldwide, which now stands at 244 million. The level of international migration has remained constant – at between three and four percent of the total global population – for several decades now. Refugees and internally displaced persons can face extreme health threats. Their suffering includes: violence, torture, rape and sexual exploitation, slavery, and mental illness. The wider group of migrants also faces social economic and health disadvantage, though usually less severe (for example, barriers in access to services, as well the challenges of a new language and culture). In 2008, the World Health Assembly put the issue of 20172007 1.4 Bn 2.4 Bn 3.0 Bn 0.7 B Low income countries Lower-middle Upper-middle High 0.5 B 2.6 Bn 1.3 Bn 2.2 Bn Low income countries Lower middle income Upper middle income High income Age (years) 0 -4 5 -9 10 -1 4 15 -1 9 2 0 -2 4 2 5 -2 9 3 0 -3 4 3 5 -3 9 4 0 -4 4 4 5 -4 9 5 0 -5 4 5 5 -5 9 6 0 -6 4 6 5 -6 9 70 -7 4 75 -7 9 8 0 -8 4 8 5 -8 9 9 0 -9 4 9 5 -9 9 10 0 + 31% incre se 16% 8% 6% Deaths - 0.6 billion Births + 1.4 billion 2007 6.7 billion Global population 2017 H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 08 02 migrant health firmly on the agenda, with a resolution calling on both Member States and the WHO secretariat to act. The Director-General was asked “to promote migrants’ health on the international health agenda, in collaboration with other relevant organisations”. Over the subsequent years, the needs of migrants have become increasingly considered in WHO policies, plans and programmes, notably in approaches to HIV, tuberculosis, mothers and children, and reproductive health. Migrant health on the international agenda In 2016, with growing international attention to the plight of refugees, the United Nations General Assembly made a political declaration for refugees and migrants. WHO has started to develop a framework of priorities and guiding principles on the health of refugees and migrants, which the World Health Assembly in 2017 will consider further. H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey

10 03 H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey Two bleak events are without equal: the death of a baby, just months into a life that has barely begun; the death of a young woman, leaving a family without a mother. There is no starker reminder of inequity: that in some parts of the world, such events are rare to the point of being scandalous and newsworthy, whilst in others they are a common fact of life. Speaking to the World Health Assembly as Director- General Elect in 2006, Dr Margaret Chan said: “Let me be clear about the results that matter most. Reducing the burden of disease is important. Improving the strength of health systems is important. Reducing the threat of risk factors for disease is important. These are all vital. But what matters most to me is people. And two specific groups of people in particular. I want us to be judged by the impact we have on the health of the people of Africa, and the health of women.” SAVING MOTHERS AND CHILDREN Deaths per 100,000 live births, globally Achieved: 44% reduction MDG target: 75% reduction 1990 2000 2005 2015 530 thousand maternal deaths 440 thousand died 380 thousand died 300 thousand died 216 per 100,000 288 per 100,000 385 per 100,000 385 per 100,000 11 03 Where were the maternal deaths in 2015? One represents 2000 deaths Democratic Republic of the Congo United Republic of Tanzania All other countries Nigeria India Ethiopia Pakistan Kenya H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey The stunning reductions in maternal and childhood mortality are rightly a source of pride and celebration for global health leaders and practitioners. They addressed the two most-cited health-related Millennium Development Goals: to reduce the maternal mortality ratio by three-quarters, and to reduce the under-5 mortality rate by two-thirds. These were ambitious goals, around which so many rallied. They were clear and specific. Neither was fully achieved, but both were transformative, showing that with concerted action, passion, and commitment major change is possible. Maternal mortality ratio cut by 25% between 2005 and 2015 Many data used to estimate maternal and child mortality are drawn from surveys, not formal death registration systems. There is a time lag in their production and a degree of uncertainty in making statements about reductions. However, there is little doubt that the much-acclaimed major decreases are real. Year-on-year improvements were occurring in the 1990s, but they accelerated in the current Millennium. These declines in maternal mortality are consistent with: the big reduction in HIV mortality; the widespread introduction of incentives to encourage facility-based delivery; greater access to antenatal care; the easier availability of antibiotics to treat puerperal sepsis; and decreasing fertility rates (including through better availability of contraceptives and family planning services). The improvement in childhood mortality has also been multifactorial. Nutritional improvements and more available vaccines (particularly measles) have been crucial. The reductions are not attributable to the health sector alone. Socioeconomic development has played a very significant role. Under-5s mortality rate cut by a third between 2005 and 2015 Yet, the story of these gains in maternal and child health does not sit easily with the widely quoted statistics about inequity. This is enduring and even widening. The lifetime risk of maternal death in sub- Saharan Africa is 1 in 36; in high-income countries it is 1 in 4900. The risk of dying before the age of five averages just 1 in 400 in the ten best performing countries. It is 50 times worse – an average risk of 12 03 H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 1 in 8 – in the ten worst performers. In 24 countries, maternal mortality is still classed as high – most of them fragile states, conflict-affected areas, or both. Sadly, statistics like this are so familiar that they do not always create the shock that they should. They have to be viewed as unacceptable. They have to be writ large if the momentum that has saved so many lives is to be maintained. On the surface, the Sustainable Development Goals give maternal and child mortality less prominence than the separate and specific Millennium Development Goals. But ambitious targets for both measures are now embedded within the Sustainable Development Goals. Early opportunities to meet these harder targets are possible. There can be simple upgrades to those birth facilities that are so basic that they even lack water. Other solutions are more difficult to implement: for example, millions more health workers – including skilled birth attendants – are required. Individual technical and social interventions have made a major difference and can continue to do so. There is a need, though, to move beyond individual initiatives, towards the more complex work of true Niger NigeriaSierra LeoneMali Benin DR of the CongoCentral African RepublicChad Somalia Luxembourg Iceland Andorra Singapore Japan Cyprus SloveniaNorway FinlandEstonia Worst 10: On average, one in 8 die before age 5 Best 10: On average, one in 400 die before age 5 Angola 2015 data, pooled MDG target: 67% reduction 1990 2000 2005 2015 >100 75 to 100 50 to 75 25 to 50 <25 No data Deaths per thousand live births, globally Achieved: 53% reduction 12.7 million children under 5 died 9.8 million died 8.3 million died 5.9 million died 76 per 1,000 63 per 1,000 43 per 1,000 91 per 1,000 Under-5 mortality Deaths per 1,000 live births, 2015 13 03 H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey systems development. To address the dual issues of maternal and newborn mortality in a way that is truly sustainable and equitable means creating a foundation of universal antenatal care, skilled birth attendance in quality facilities, and ultimately reaching the point of comprehensive and quality integrated care. It also requires effective humanitarian responses where conditions are unstable. Conflict- related migration, health service disruption and food emergencies are all too evident in 2017, with young children their first victims. Much of the progress to date has relied on socio- economic development. This must be sustained, which is not a given. Corruption, food insecurity and climate change are amongst the forces to be reckoned with. It is critical to tackle deaths in the neonatal period (the first 28 days). Neonatal mortality has reduced less than other indices in early life, so neonatal deaths are a large and growing share of childhood mortality. In 2015, one million babies died on the day of their birth. More than 2.6 million died in the first month of life. The World Health Assembly’s 2014 endorsement of Every Newborn: An Action Plan To End Preventable Deaths gave prominence to this need. It asks every country to achieve a neonatal mortality rate of 12 or fewer deaths per 1,000 live births by 2030. It also aims to end preventable stillbirth. The 2030 target for each country is a rate of 12 per 1,000 live births on that measure too. In the areas of maternal and child health, the Millennium Development Goals gave prominence to reducing mortality. This is good and essential but it has overshadowed other important needs and work: on early childhood development, for example. As mortality falls further, these other major issues need to come to the fore. The World Health Organization has used its position in the wider United Nations family very effectively to address maternal and child health. The Global Strategy for Women’s and Children’s Health in 2010 was led by the United Nations Secretary- General, as was the associated Every Women Every Child initative. The strategy was later updated and expanded to include adolescents. The WHO secretariat has worked in close support, whilst the World Health Assembly has reviewed and endorsed the strategies. The Global Strategy for Women’s, >100 75 to 100 50 to 75 25 to 50 <25 No data Under-5 mortality rate Deaths per 1,000 live births, 2015 MDG target: 67% reduction 1990 2000 2005 2015 Deaths per thousand live births, globally Achieved: 53% reduction 12.7 million children under 5 died 9.8 million died 8.3 million died 5.9 million died 76 per 1,000 63 per 1,000 43 per 1,000 91 per 1,000 14 03 H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey Children’s and Adolescent’s Health covers the period 2016-2030. Its ambition goes beyond reducing mortality to envisage: “A world in which every woman, child and adolescent in every setting realizes their rights to physical and mental health and well-being, has social and economic opportunities, and is able to participate fully in shaping prosperous and sustainable societies.” It sets out how objectives and targets, aligned with the Sustainable Development Goals, can be achieved through actions spanning country leadership and health system resilience, to community engagement, research and innovation. Every Woman Every Child adopted by the United Nations WHO and the World Health Assembly were pivotal in the more recently launched United Nations Decade of Action on Nutrition, 2016-2025. Malnutrition remains a substantial contributor to childhood deaths and illness. It continues to hold children back from achieving their physical and cognitive potential. There remains a great deal to learn in this area. The gains in maternal and child health have been golden achievements for global health – major, measurable improvements, of great human and economic importance. As with each of the other major developments of the last decade, the challenge now is to build on them. 

16 04 A series of goals to combat, conquer, or control communicable diseases has been high on the global health agenda over the last decade. The big killers – diseases like HIV, tuberculosis, and malaria – remain priorities on which major progress is being made. The threat of new and emerging diseases – and the risk of their global spread – is an ever-present concern. Particularly at times of natural disaster, famine, and conflict, diseases like typhoid and cholera can surge and cause havoc. Infective agents in tropical and subtropical areas of the world are longstanding sources of disability. They cause diseases that are seldom visible to the richer parts of the world but are devastating in their impact in the poorest parts of the countries and regions affected. Many common healthcare-associated infections can cause serious illness and costly hospital stays. Uncontrolled infection can lead to death and disability. A large-scale outbreak can even weaken national economies. Success requires good planning, strengthening resilience, excellence in surveillance, effective prevention and control measures, as well as treatments reaching people in the right way and at the right time. Over the last decade, there have been major successes in the fight against communicable diseases, although familiar challenges remain. The HIV epidemic – and the world’s response to it – has changed the face of global public health. At the turn of the Millennium, the epidemic was well underway, but the response to it was nascent. That changed, as a huge civil society movement was followed by widespread political commitment and the flow of very substantial funding. Since its foundation in 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria has disbursed MICROBES: OLD AND NEW H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 17 04 $16 billion to HIV programmes. Thanks to the Global Fund’s donors and many others, the scale of antiretroviral use has exploded – 16 million people are now receiving treatment today, up from 0.7 million in 2000. The price of these drugs dropped dramatically through negotiation. Between 2005 and 2015, the HIV mortality rate fell by 50%, contributing significantly to reducing childhood and maternal mortality. The number of new cases fell by 18%. HIV mortality cut in half between 2005 and 2015 In the second half of the 2000s, the treatment scale- up was well underway and the response started to grow in its sophistication. It was recognised that prevention was lagging behind treatment, and efforts were made to right this balance. The WHO Director- General’s Health In All Policies approach saw HIV being considered in drug control policies, in the human rights dialogue, and in discussion of gender-related issues. Granular data were increasingly used to find and work with populations at the greatest need – particularly young and teenage girls in sub-Saharan Africa. There was rapid innovation, in both technology and service delivery models. The protective benefit of male circumcision was recognised, and particularly promoted in eastern and southern Africa. Global Fund disbursements, 2000-2015 TB $5 billion HIV/AIDS $16 billion Malaria $8 billion Over recent years, there has also been a shift away from individual projects, and towards integrated national programs. Some are more developed than others, but the best offer a continuum of HIV services – risk reduction, testing, and treatment and care throughout the course of life and the disease. WHO now recommends antiretroviral treatment from immediately after diagnosis. This benefits the individual treated, and substantially reduces the risk of transmission. It brings into sharp focus the estimate that half of all people who are infected with HIV are unaware of their infection. In 2016, the World Health Assembly adopted a new global health sector strategy on HIV. This centres on strengthening HIV services within a framework of Universal Health Coverage. It highlights linkages to tuberculosis and hepatitis efforts in particular. The sixth Millennium Development Goal included to “have halted by 2015 and begun to reverse the spread of HIV/AIDS”. This was achieved. The lessons are substantial: on the catalytic role that civil society can play; on co-creating health services with communities; and on rapid and massive scale-up. A number of the lessons, including the power of drug price negotiations, are now being applied to hepatitis. But, as the global strategy makes clear, HIV is far from over. Major gains 2005 to 2015 Reduction in new cases rate Reduction in death rate HIV 18% 50% Malaria 21% 49% Tuberculosis 16% 25% H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 18 04 Malaria is a disease that affected the first human populations and was chronicled in records of Antiquity. When the final history of malaria is written, the past decade will be featured prominently. Mortality from malaria was cut almost in half between 2005 and 2015. This was achieved largely through the prevention of malaria cases, and through improved diagnosis and treatment of the disease. Malaria mortality cut by 49% between 2005 and 2015 More than six million deaths from malaria have been averted since the turn of the Millennium – mostly in children under five living in sub-Saharan Africa. The massive scale-up of prevention, diagnosis and treatment are responsible for saving these lives. First, and foremost, the increased coverage of insecticide- treated bed nets - since 2004, more than 900 million nets were distributed in sub-Saharan Africa alone. Second, the increased use of rapid diagnostic tests, which were instrumental in increasing the percentage of suspected malaria cases being tested in sub- Saharan Africa from 40% in 2010 to 76% in 2015. Third, the increased access and use of effective artemisinin- based combination therapies. Based on modelling of parasite prevalence and case incidence, it is estimated that malaria interventions contributed to 70% of the reduction in malaria cases in sub-Saharan African between 2000 and 2015. Diagnosis and treatment interventions were crucially important in achieving this breakthrough in malaria control, but the preventive mainstay of bed nets has made the greatest impact, accounting for an estimated 50% of the decline. These tools were implemented through major scale-ups, made possible by large financial investments through the Global Fund and other bilateral donors in addition to domestic investments. 900 million mosquito nets distributed in Africa since 2004 In addition to the notable declines in the number of malaria cases and deaths, countries are moving forward toward elimination. Between 2007-2016, six countries were certified free of malaria and an additional 13 countries reported zero local cases. Despite these achievements, malaria is still endemic in more than 90 countries, causing an estimated 200 million cases and 429 thousand deaths in 2015. WHO and partners have a clear vision for what should be achieved by 2030. This is articulated in the Global Technical Strategy for Malaria 2016-2030. Using 2015 as a baseline, the target is a 90% decrease in malaria incidence and mortality rates, and elimination in 35 more countries. Over the last decade, progress has also been made against tuberculosis. The rates of new cases and deaths from tuberculosis were reduced by 16% and 25% respectively, between 2005 and 2015. Tuberculosis diagnosis and treatment saved an estimated 50 million lives between 2000 and 2015. These gains are meaningful, though less impressive than the gains achieved against both HIV and malaria. This was partly because big gains had already been made against tuberculosis in the preceding decade, which was not the case with HIV or malaria. Tuberculosis remains a leading cause of death amongst people infected with HIV, causing one-third of such deaths. Six countries now account for 60% of all tuberculosis worldwide. India alone accounts for 27% of cases. A further 33% are from Indonesia, China, Nigeria, Pakistan and South Africa. Managing tuberculosis tests many different aspects of public health. Malnutrition is a key risk factor, particularly for mortality, as is tobacco smoking. Surveillance – H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 19 04 generally based on case notification – is a vital element. Diagnosis and treatment require healthcare systems to have a degree of sophistication. In 2014, the World Health Assembly endorsed the End TB Strategy. The broad goal of ending the tuberculosis epidemic is included within the Sustainable Development Goals. By 2030, the End TB Strategy aims to achieve an 80% drop in incidence, a 90% reduction in mortality, and to ensure that no TB patients and their households face catastrophic costs as a result of TB disease. Its three pillars are: integrated patient-centered care and prevention; bold policies and supportive systems; and, intensified research and innovation. Managing the tuberculosis epidemic is made more complex by antimicrobial resistance. Currently, fewer than half of all patients with multidrug-resistant tuberculosis are successfully treated. Just one- quarter of patients with extensively drug-resistant tuberculosis are successfully treated. Tuberculosis has not had the same level of funding that HIV or malaria have had. It has also not had the same degree of high-level political attention – a deficit which a planned WHO Ministerial Conference on tuberculosis in November 2017 and a United Nations General Assembly meeting in 2018 should help to rectify. 2000-2015: 50 million TB deaths averted A group of diseases characterized by their ability to cause long-term disability and physical disfigurement, as well as sometimes death, affect one billion people in 149 countries. This is an extraordinary 1 in 7 of all people on the planet. These 17 diseases are the neglected tropical diseases. They affect the poorest communities in the world. They are “neglected” because they are not visible to the affluent countries of the world, few pose a threat of transmission globally, and the affected people are impoverished – without power or voice in the world. Addressing the World Health Assembly in May 2007, WHO Director-General, Dr Margaret Chan said: “Last month, the first meeting of global partners for the neglected tropical diseases was held. This was a turning point. Prospects for reducing the burden of debilitating diseases for at least one billion people have never looked brighter”. In 2012, WHO produced Accelerating work to overcome the global impact of neglected tropical diseases: a roadmap for implementation. This plan set targets for each disease and addressed key Human African Trypanosomiasis Chagas Disease Visceral Leishmaniasis Leprosy Schistosomiasis Soil-transmitted Helminths Trachoma Onchocerciasis Lymphatic Filariasis and Onchocerciasis Lymphatic Filariasis 2015201420132012201120102009 200 0 400 600 800 1,000 M ill io ns o f t re at m en ts d on at ed b y ph ar m a 1,200 1,400 1,600 1,800 Source: Uniting to Combat NTDs H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 20 04 mechanisms to achieve change, including how to deliver large-scale distribution and use of safe, single-dose medicines for diseases that can be treated in that way. Other measures included: vector and intermediate host control, public education, establishing safer water supplies and good sanitation, and addressing the risks in the human-animal interface. This very focused action plan was a big step forward. Another key breakthrough was a meeting held in London, England in January 2012, called Uniting to combat NTDs. Leaders of global health organisations came together, with representatives of 13 pharmaceutical companies and some major donors. They were ready to commit to a highly specific goal to achieve the WHO Roadmap’s targets for 10 neglected tropical diseases. They made the London Declaration. The pharmaceutical companies’ commitment to expand the supply of drugs was crucial. Bill Gates, Co-Chair of the Bill and Melinda Gates Foundation, said at the meeting: “Maybe as the decade goes on, people will wonder if these should be called neglected diseases. Maybe as the milestones go on, we will call them just tropical diseases.” 40 treatments for neglected tropical diseases every second in 2015 The largest public health-private partnership: pharma companies donated 1.5 billion tablets to treat neglected tropical diseases in 2015 2017 is the fifth anniversary of the London Declaration. Strong progress has been made overall, in relation to specific diseases, and in particular countries. In 2015, 1.2 billion treatments were given, equivalent to 40 every second. Since 2013, one country every year in the Americas has freed its population from River Blindness. Only one small region is left and the Americas will be clear of the disease. Overall 330 million fewer people have required treatment in 2015, as compared to 2011. Guinea-worm is down to only 25 cases in the world. Action on antimicrobial resistance on the agenda of the United Nations In the last decade, the world has had to think the unthinkable: that even with access to care and essential treatments, the growth of resistance of pathogens (bacteria, viruses, fungi, parasites) to a wide range of antimicrobial drugs may mean that, for millions of people around the world whose survival will depend on such drugs, time is running out. In 2010, WHO found that resistance to new courses of anti-retroviral therapy in people who had HIV was 7% in low- and middle-income countries, and 10- 20% in high-income countries. In 2014, there were an estimated 480,000 cases of multidrug-resistant tuberculosis (MDR-TB) worldwide, and 10% of these were extensively drug-resistant tuberculosis (XDR-TB). In 2016, resistance to first-line treatments to malaria was confirmed in five countries. The global focus on antimicrobial resistance has increased greatly over the last decade. In 2015, the World Health Assembly agreed a Global Action Plan on Antimicrobial Resistance that delineated five key areas of action: • To improve awareness and understanding of antimicrobial resistance through effective communication, education and training • To strengthen the knowledge and evidence base through surveillance and research • To reduce the incidence of infection through effective sanitation, hygiene and infection H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 21 04 prevention measures • To optimize the use of antimicrobial medicines in human and animal health • To develop the economic case for sustainable investment that takes account of the needs of all countries and to increase investment in new medicines, diagnostic tools, vaccines and other interventions In developing this blueprint, WHO worked closely with the Food and Agriculture Organization of the United Nations (FAO) and the World Organisation for Animal Health (OIE) in a One Health approach to promote best practices to avoid the emergence and spread of antibacterial resistance, including optimal use of antibiotics in both humans and animals. In some parts of the world, 50% of all antimicrobial drug usage is in food-animals. In medical practice, underuse, overuse, and misuse of antibiotics are all problematic. This happens in a variety of ways, for example: poor access to full courses of required drugs so that a patient is only able to get two or three tablets; unnecessary prescription of drugs for infections that would resolve spontaneously; over-the-counter availability so that the criteria for use are not medically determined; and use in just-in-case clinical situations. Antimicrobial resistance has moved from being only a subject of professional and scientific interest to a global priority for political leaders. It is now also a matter of urgency for all national governments and ministries of health around the world. This has not happened by accident. It is the result, over the last decade, of sustained technical analysis, advocacy, influencing, and leadership. The United Kingdom, Sweden, the Netherlands and other governments have championed the need for action. In September of 2016, Heads of State attending the United Nations General Assembly made a declaration of their political commitment to tackling antimicrobial resistance. The Political Declaration of the High-Level Meeting of the UNGA on Antimicrobial Resistance recognizes that prevention and control of infections in humans and animals are essential Polio Guinea-worm 1315 cases 2016 37 cases 2007 9585 cases 25 cases H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 22 04 to tackling antimicrobial resistance. The importance of affordability of, and access to, existing and new antibiotics and vaccines was also emphasized during the deliberations. Heads of State pledged to: • Strengthen surveillance and regulation on the use and sales of antimicrobial drugs for people and animals • Encourage innovative approaches using alternatives to antimicrobials and new technologies for diagnosis and vaccines • Raise awareness of citizens and health professionals on how to prevent drug resistant infections • Foster increased international cooperation to advance national plans Speaking after the historic commitment was made, WHO Director-General, Dr Margaret Chan said: “Antimicrobial resistance poses a fundamental threat to human health, development, and security. The commitments made today must now be translated into swift, effective, lifesaving actions across the human, animal and environmental health sectors. We are running out of time.” Important action need not always be big-picture and political. For example, researchers in the United Kingdom and China collaborated on research to understand resistance to the antibiotic colistin. The importance of this drug is two-fold. Firstly, it is heavily used as a growth promoter in animal feed, particularly pigs. It is cheap. Secondly, it is a last-line- of-defense antibiotic in treating seriously-ill patients whose infection is resistant to other antibiotics. This is typical of the story of antimicrobial resistance more generally: an antibiotic used in veterinary and agricultural practice in animals produces drug-resistant strains of the infective organism, and when people acquire similar infections they face a situation in which the antibiotic will not work. The researchers found a resistance gene (MCR-1) in the E. coli bacterium in pigs. The gene also had the dangerous capability to transfer and confer resistance on other bacteria. In response to this research, in November 2016, the Chinese Ministry of Agriculture banned the use of colistin as an animal feed additive. One of the lead researchers, Professor Jianzhong Shen, of Beijing Advanced Innovation Center for Food Nutrition and Human Health, said: “The antibiotic usage in food animals is indeed becoming a global issue associated with food safety and public health. All countries in the world should use antibiotics in animals more prudently and rationally. On the basis of the evaluation of risk assessments of such antibiotics, the Chinese Government worked promptly to remove colistin in the list of feed additives for the purpose of growth promotion. We suggested that our Government take the AMR problem very seriously and in this instance they responded very efficiently to tackle this issue.” These words sum up one of the key challenges in mitigating the threat, but also show the opportunity for decisive action. In complex problems like antimicrobial resistance, there are no easy solutions. That does not mean there are no solutions. Action needs top level leadership, coordination, and monitoring of action plans. It also needs partnership and cooperation across all sectors and constituencies: governments, health and medical, science, policy-making, industry, agriculture, food production, farming, pharmaceutical companies, and civil society. 6.4 billion people living in countries with national action plans for antimicrobial resistance WHO oversight of progress at national level showed H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 23 04 that by April 2017, 69 countries had finalised or approved a National Action Plan on antimicrobial resistance. These countries are home to over 6.45 billion people, more than 90% of the world’s population. In February 2017, WHO published its first ever list of twelve antibiotic-resistant pathogens for which the development of new antibiotics is a priority. Tuberculosis was not included in the prioritization exercise, which focused on identifying previously unrecognised health threats. WHO reaffirmed that tuberculosis remains a top priority for the research and development of new antibiotics. Guinea-worm eradication: down to 25 cases worldwide in 2016 Disease eradication is an attractive proposition. Once achieved, humanity is free of a pathogen for the rest of time. To date, the list of eradicated human pathogens remains at only one: smallpox. Polio and Priority 1: Critical Priority 2: High Priority 3: Medium Acinetobacter baumannii, carbapenem-resistant Pseudomonas aeruginosa, carbapenem-resistant Enterobacteriaceae, carbapenem-resistant, 3rd generation cephalosporin-resistant Enterococcus faecium, vancomycin-resistant Staphylococcus aureus, methicillin-resistant, vancomycin intermediate and resistant Helicobacter pylori, clarithromycin-resistant Campylobacter, fluoroquinolone-resistant Salmonella spp., fluoroquinolone-resistant Neisseria gonorrhoeae, 3rd generation cephalosporin-resistant, fluoroquinolone-resistant Streptococcus pneumoniae, penicillin-non-susceptible Haemophilus influenzae, ampicillin-resistant Shigella spp., fluoroquinolone-resistant WHO list released February 2017: Urgent antibiotics needed guinea-worm are now tantalisingly close. WHO is a leader in both eradication efforts, alongside Member States and a formal set of partners that is slightly different for each. Over the last decade, both polio and guinea-worm eradication efforts have advanced substantially. But in both, the annual rate of disease decline has slowed very significantly since the early days. As eradication nears, the challenges become greater. By definition, the last places in which the pathogen remains are the places in which elimination is the most difficult. So the slowing of progress is not a surprise, but the sheer scale of this effect was not fully anticipated. Placing a definite bet would be foolhardy, but eradication now seems imminent for both polio and guinea-worm. Both campaigns have major lessons to offer, whether or not the world decides to embark on further eradication goals. H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 24 05 In 2010, WHO published a Status Report on Noncommunicable Diseases. This made it clear that: • Noncommunicable disease was the world’s leading health problem, causing nearly two- thirds of all deaths. Most of the burden was due to cardiovascular disease, cancer, diabetes and chronic lung disease. • This is not a rich countries’ problem alone: 80% of the burden of noncommunicable disease was falling in low- and middle-income countries. • The prominent causes were four behavioural risk factors, which were symptoms of economic transition, rapid urbanisation, and modern lifestyles. These were: tobacco use, unhealthy diet, insufficient physical activity and the harmful use of alcohol. The report was action-oriented, spelling out a series of “best buys” for governments. These are interventions that are effective, feasible, and affordable, even in resource-constrained settings. Some are population- wide, such as smoke-free public places and reducing the salt content of food. Some are healthcare interventions – such as using aspirin in the treatment of myocardial infarction, and providing simple inhaler treatments for asthma. WHO Director-General, Dr Margaret Chan, said in the foreword of the 2010 report: “The warning remains stark. The epidemic already extends far beyond the capacity of lower-income countries to cope. In the absence of urgent action, the rising financial burden of these diseases will reach levels that are beyond the capacity of even the wealthiest countries in the world to manage.” THE ASCENDANCY OF NONCOMMUNICABLE DISEASES H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 25 05 In September 2011, the United Nations General Assembly held a High-Level Meeting on the Prevention and Control of Non-communicable Diseases, and issued a Political Declaration acknowledging that: “The global burden and threat of non-communicable diseases constitutes one of the major challenges for development in the twenty-first century, which undermines social and economic development throughout the world, and threatens the achievement of internationally agreed development goals. We recognize that non-communicable diseases are a threat to the economies of many Member States, and may lead to increasing inequalities between countries and populations”. Goal set: 25% drop in NCD mortality by 2025 Eight months later, in May 2012, the World Health Assembly established a bold goal, known as ’25 x 25’. It aimed, by 2025, to reduce by 25% the number of premature deaths caused by the main four noncommunicable diseases - cardiovascular disease, cancer, diabetes, and chronic respiratory disease. A plan and monitoring framework followed: a Global Action Plan for the Prevention and Control of Noncommunicable diseases 2013-2020. The plan provides guidance on reducing harmful alcohol use, physical inactivity, salt intake, tobacco use, and raised blood pressure. It aims to halt the rise in diabetes and obesity; to increase the proportion of people receiving basic cardiovascular preventive care; and to boost the availability of basic technologies and medicines needed for treatment. The plan builds on its predecessor report, providing Member States with clear “best buy” policy options for achieving each target. Triennial status reports are planned, as are further High-Level meetings of the United Nations General Assembly. In parallel with developing this overarching framework, there has been some strong – and some less strong – progress on a number of its key elements. The WHO Framework Convention on Tobacco Control has been in place since 2005. WHO uses MPOWER, a set of six cost-effective and high impact measures to help countries implement the Convention’s key demand reduction provisions. Since 2007, the number of people protected by at least one MPOWER measure has tripled, but all countries can do more. MALES FEMALES 2007 2013 2007 2013 Number of countries fully impl menting tobacco policy F U L L G L O B A L P O L IC Y C O M P L IA N C E 23% of over-15s currently smoking globally 21% 8% 7% 65 49 24 39 29 33 2015 2008Monitoring tobacco use and prevention policies Protecting people from tobacco smoke Oering help to quit tobacco use Warning about the dangers of tobacco Enforcing bans on tobacco advertising, promotion and sponsorship Raising tobacco taxes H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 26 05 The prevalence of tobacco use has fallen a little, but one billion people still smoke – 80% of them in low- and middle-income countries. Six million people die each year as a result. The 2013-2020 Global Action Plan includes a target of reducing tobacco use prevalence by 30%. This is well off-track. WHO is monitoring both MPOWER implementation and – where data and modelling allow – tobacco use prevalence. The WHO Framework Convention on Tobacco Control is a pioneering approach in global health and some hope that it is a model that could be applied to other elements of noncommunicable disease. WHO issued Global recommendations on physical activity for health in 2010, citing that one in four adults and four in five adolescents were not meeting the necessary standards. The strength of physical inactivity as a risk factor has become more widely recognised during the last decade. It is established in its own right, not just on the causal pathway to overweight and obesity. WHO has shown high profile leadership on diet and health over the last decade. The statement on sugar resounded very powerfully. In March 2015, WHO strongly recommended that free sugars should account for less than 10% of people’s total energy intake, and that reducing to 5% would bring additional health benefit. This was underpinned by technical analysis that examined free sugar’s relationship to both weight gain and dental caries. The guideline provided policy options for countries. It particularly highlighted sugar-sweetened beverages, pointing to the research links to obesity. The announcement of the guideline drew extensive media coverage, and prompted substantial engagement with the food and beverage industries at both international and national levels. A year later, the WHO Commission on Ending Childhood Obesity released its report. This included an explicit recommendation that Member States “implement an effective tax on sugar-sweetened beverages”. New sugar intake guidelines for children and adults The Commission on Ending Childhood Obesity was launched in 2014, at the Director-General’s initiative. The alarming rise in childhood obesity prevalence provided a clear epidemiological rationale - and new evidence was emerging on the epigenetic basis of obesity, meriting close attention. 2007 180 million (8%) 280 million (13%) 2014 270 million (11%) 370 million (15%) 2007 730 million (34%) 780 million (35%) 2014 950 million (38%) 980 million (39%) 111 Overweight MEMBER STATES IN WHICH THE MAJORITY OF ADULTS ARE NOW OVERWEIGHT Obese 2007 180 million (8%) 280 million (13%) 2014 270 million (11%) 370 million (15%) 2007 730 million (34%) 780 million (35%) 2014 950 million (38%) 980 million (39%) 111 Overweight MEMBER STATES IN WHICH THE MAJORITY OF ADULTS ARE NOW OVERWEIGHT Obese H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 27 05 The Commissioners were a broad group. Alongside senior public health practitioners were scientists, economists, a senior industry executive, a well- known athlete, and others. The food and beverage industry engaged closely in the Commission’s work, with senior representatives meeting the Director- General on several occasions. The Commission made its report to the World Health Assembly in 2016, and an implementation plan is due at the World Health Assembly in May 2017. Its report made recommendations to Member States in six areas: • Promoting healthy food intake, and reducing the intake of unhealthy food and sugar-sweetened beverages • Promoting physical activity and reducing sedentary behaviour • Integrating measures to reduce the risk of childhood obesity into pre-conception and pregnancy care • Supporting diet and physical activity in early childhood • Promoting healthy school environments, physical activity, and health and nutrition literacy amongst school-age children and adolescents • Managing the weight of children and young people who are obese The Commission on Ending Childhood Obesity was also important because it showed the complexity of tackling obesity, the crucial role of multiple sectors, and the vital role of industry. Each of these strands is a valuable part of the approach that will need to continue over the coming years, across the whole field of noncommunicable disease. Commission on ending childhood obesity provides global action plan Other elements of noncommunicable disease have not been so prominently covered. The burden of these diseases falls more heavily on those in lower socioeconomic groups. Many of the risk factors are more common in these groups; the incidence and impact of many noncommunicable diseases is greater; and the costs of care can be catastrophic for the poor. Some have argued that a goal to directly address the socioeconomic determinants should have been included in the 2013-20 Action Plan. In 2013, the World Health Assembly endorsed a 2013- 2020 Mental Health Action Plan – the first such plan. This focuses not only on tackling mental disorder, but on positively improving mental health. It established a series of targets and recommended actions for Member States, and for bodies including WHO. WHO has had a Mental Health Gap Action Programme in place since 2008, launched by the Director-General. This works to improve the care for a people with a prioritised set of conditions (depression, dementia, psychoses, epilepsy, and others) in 90 countries, primarily in resource-poor settings. WHO initiatives including the current Depression: Let’s Talk campaign, have brought important mental health issues to greater prominence. On World Mental Health Day 2012, WHO partnered with writer and illustrator Matthew Johnstone, releasing a short video “I had a black dog, his name was depression”. The aim was to raise awareness, and to encourage people with depression to take effective actions to help tame their own black dog. The video has so far been viewed 7.5 million times on YouTube. WHO has estimated that 4.4% of the world’s population is suffering from depression (more than 300 million people), 3.8% from anxiety, and that there are nearly 800,000 suicides every year. Mental health makes an appearance in the targets of the Sustainable Development Goals. It is to be hoped that, a decade from now, mental health will have moved more firmly into the spotlight. H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey 28 05 Over the last five years, the important issue of dementia has come to greater prominence. In May 2017, the World Health Assembly will review a Dementia Action Plan. In 2013, the G8 held a special summit on dementia. Speaking at that event, WHO Director-General Dr Margaret Chan said: “Dementia is a costly and heart-breaking epidemic with an immense impact, medically, psychologically, emotionally, and financially. I can think of no other condition that has such a profound effect on loss of function, loss of independence, and the need for care. I can think of no other condition that places such a heavy burden on society, families, communities, and economies. I can think of no other condition where innovation, including breakthrough discoveries, is so badly needed.” Tackling noncommunicable disease is complex. The complexity is increasingly being embraced, and this must continue and grow. Tackling noncommunicable disease involves engaging far beyond the sphere of health and healthcare, to tackle the causes at their root. It involves dealing with vested interests – working productively with industry if possible, and drawing red lines if not. It involves being criticised as a Nanny – a hazard that communicable disease programmes do not have to bear. It involves sustained political will. And it requires building health systems that can deliver an increasingly sophisticated spectrum of prevention, treatment and care. It is not easy – but it is central to the future of public health globally. MALES FEMALES 2007 2013 2007 2013 Number of countries fully implementing tobacco policy F U L L G L O B A L P O L IC Y C O M P L IA N C E 23% of over-15s currently smoking globally 21% 8% 7% 65 49 24 39 29 33 2015 2008Monitoring tobacco use and prevention policies Protecting people from tobacco smoke Oering help to quit tobacco use Warning about the dangers of tobacco Enforcing bans on tobacco advertising, promotion and sponsorship Raising tobacco taxes H EA LT H IE R, F A IR ER , S A FE R : T he G lo ba l H ea lth J ou rn ey

30 06 H EA LT H IE R , F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey The Commission on Social Determinants of Health led by British-Australian epidemiologist, Sir Michael Marmot, presented its report to the Director-General of WHO in the summer of 2008. In welcoming the report, Dr Chan said: “Health systems will not naturally gravitate towards equity” and called for “Unprecedented leadership to compel all actors, including those beyond the health sector to examine their impact on health.” WHO has had a longstanding commitment to health equity, but in presenting to the world the work of its Commission, Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health, it fired the starting gun on a deeper and more fundamental approach linking equity, social justice, poverty and health, driven by some of the compelling inequalities spelled out in the report at the time of its launch: • Life expectancy for Indigenous Australian males shorter by 17 years than all other Australian males • Maternal mortality 3–4 times higher among the poor than among the rich in Indonesia • Child mortality in the slums of Nairobi is 2.5 times higher than in other parts of the city • A baby born to a Bolivian mother with no education had a greater than 10% chance of dying in the first year, while one born to a woman with at least secondary education had less than a 0.4% chance • In Uganda, the death rate of children under 5 years in the richest fifth of households was 106 per 1000 live births but in the poorest fifth of households in Uganda it was even worse – 192 deaths per 1000 live births (that was nearly a fifth of all babies born alive to the poorest households destined to die before they reach their fifth birthday) CLOSING THE GAP IN A GENERATIONFAIRER 31 06 H EA LT H IE R , F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey Despite the stark statistical picture that the Commission revealed, its report was not all bad news. There were many examples where targeted action, local and country innovation, and committed leadership were making a difference. The examples highlighted in the report included: a comprehensive approach to early childhood development in poor Jamaican communities; the establishment of universal child development services in Cuba; and, the expansion of pre-primary education for socially disadvantaged children in Chile. The Commission on Social Determinants of Health set out three guiding principles through which to organize programmes of action to address the challenges and needs that it identified: • Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age • Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally • Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health WHO had previously taken high-level strategic positions on the fundamental causes of poor health. For example, Director-General Brundtland in the 1999 World Health Report estimated that around half the mortality reduction in the 30 years since 1960 in low-income and middle-income countries had been due to two main underlying influences: income and education. Nevertheless, much of the emphasis on solutions in the report was on strengthening health systems rather than broader-based initiatives in other sectors. In 2001, the Commission on Macroeconomics and Health, led by Professor Jeffrey Sachs, focused on the potential benefits to health of investment in areas such as education, sanitation, and water, and explored the relevance of poverty and the gains to health through tackling it. The Commission on Social Determinants of Health has been one of the most important policy initiatives that WHO has launched in the last decade. It has cascaded through the regional and country networks, not just as a technical reminder of the importance of health equity but as a transformative approach to thinking about the meaning of “health” itself, and how, in practical terms, to really address the root causes of poor health and social and economic disadvantage. Traditionally, although the global health community has recognized the wider and deeper influences on health in a diagnostic sense, action has tended to concentrate on the established risk factors (e.g. smoking, physical inactivity, obesity, high blood pressure, unhealthy nutrition, excess alcohol intake). Social determinants have not been viewed as modifiable in the same way that these established risk factors are. However, the case studies in the Commission’s report, and the way in which many of WHO’s regions as well as national governments have constructed their own Marmot-style reviews and plans, has created a sense that practical action is not just feasible, not just necessary, but almost a moral imperative. A Commission on Social Determinants of Health cascading action through regions and countries 32 06 Di sa bi lity a dj us te d life y ea rs pe r 1 00 ,0 00 p op ul at io n Human Development Index Very high 300 250 200 150 100 50 0 300 250 200 150 100 50 0 High Medium Low Human Development Index Very high High Medium Low Cervical cancer Breast cancer Years of life lived with disability Years of life lost H EA LT H IE R , F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey In 2011, the Brazil government and WHO convened an important meeting of Heads of Government, Ministers and government representatives, which issued the Rio Political Declaration on Social Determinants of Health. This included the clause: “We reaffirm that health inequities within and between countries are politically, socially and economically unacceptable, as well as unfair and largely avoidable, and that the promotion of health equity is essential to sustainable development and to a better quality of life and well-being for all, which in turn can contribute to peace and security”. It is of particular importance that the orientation of the meeting was “political”. This is where the commitment, ideas, and will needs to come from if the “causes of the causes” of ill health, premature mortality, and disability are to be really acted upon. The fact that health is often determined in other sectors has become a recurrent topic in global policy fora. It was clearly understood and expressed by the Heads of Government at this meeting. The Rio Political Declaration established five action areas, to: 1. adopt better governance for health and development 2. promote participation in policy-making and implementation 3. further reorient the health sector towards reducing health inequities 4. strengthen global governance and collaboration 5. monitor progress and increase accountability Continuing to have a laser focus on the social determinants of health is one of the most important roles of WHO in the future. This is not simply to ensure that the many inequities in health are matched Figure source: Soerjomataram I, Lortet-Tieulent J, Parkin DM, et al. Global burden of cancer in 2008: a systematic analysis of disability-adjusted life-years in 12 world regions. Lancet 2012; 380: 1840–50 Opposing trends: the relationship between economic development and disease is not always straightforward 33 06 with practical programmes of action but to act as a custodian of a philosophy of public health that is broad-based, inter-disciplinary, and multi-sectoral. The last decade has brought a broadening awareness of the social determinants of health, and the programs of action needed to address them. This will be critical in the era of sustainable development. The Sustainable Development Goals’ promise of “leaving no-one behind” means that health is protected and promoted to fulfil potential in life, but also that targeting adverse social circumstances will enable attainment of the best possible health. H EA LT H IE R , F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey 34 07 H EA LT H IE R, F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey The numerical challenges of population ageing are formidable. In 40 years’ time, 80% of the world’s over-60s will be in low- and middle-income countries. They will number more than the entire population of high-income countries combined. In the same time frame, there will be 330 million people over 60 years in China and 200 million in India, and a quarter of the population of Latin America and the Caribbean will also be in this age group. With the rise in life expectancy, attention in many parts of the world is increasingly being focused on the question of healthy life expectancy. This varies greatly between and within countries. It is often assumed that because death rates are falling, levels of disease and disability are coming down too. Some have asserted that this is not the case, saying that those countries that have experienced gains in life expectancy will find that the extra years are marked by ill-health and disability. The reality is that no one really knows for certain, though figures are regularly quoted. Routinely available information on healthy life expectancy is scarce and very inadequate. Discussing the quality of information may seem a technical argument. It is not. It will not be possible to plan properly for the impact of population ageing, nor evaluate public health programmes aimed at healthy ageing, without comprehensive valid measurement of health and functioning in older populations. There is also disagreement amongst experts on the choice of methods. For example, measures based on the presence, or absence, of disease do not take account of the fact that some older people experience much more disability from them than others. Also, the presence of multi- morbidity complicates the construction of metrics. Simple measures of functioning in which older people HEALTHY AGEING 35 07 H EA LT H IE R, F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey are asked about or assessed for their ability to carry out activities of daily living, are easily understood. However, it can be difficult to determine whether the deficit is the individual or the environmental circumstances. For instance, someone might declare that they have difficulty in shopping for food because their walking is impaired or because there are no neighbourhood shops, so that the problem is access rather than loss of capacity. To address these uncertainties in characterizing health in older age, WHO has adopted the concept of functional ability: “The health-related attributes that enable people to be and to do what they have reason to value; it is made up of the intrinsic capacity of the individual, relevant environmental characteristics and the interactions between the individual and these characteristics.” As people, and populations, age, the proportion of years spent in a state of health and vitality is of major significance. It has implications for quality of life of the individual, the level of social support required, and for families. Most importantly, it has a great relevance to the need and demand for healthcare. Many discussions about the future of healthcare start gloomily with a consideration of the growing numbers of old and very old people, with multiple chronic diseases, who are spoken of as a burden. This is misleading. The facts do not bear out assumptions that older people are largely dependent and unproductive. On a world view, and also within countries and regions, this population is hugely diverse in its state of health, its outlook and attitudes, as well as its relationship with work, family life and civil society more generally. Older people become involved in the societies that they live in through a wide range of forms of participation, including as: mentors, caregivers, artists, consumers, innovators, entrepreneurs and members of the workforce. These roles can themselves promote older people’s health and well-being. Low- and middle-income countries have become used to being characterized by their youthful populations, but these are the very groups who will be ageing. If present levels of resources and disease patterns persist, higher levels of poverty will make ageing in low- and middle-income countries more complex. So too will: weak health systems; the Expectancy at birth; totals rounded ‘Years of health’ refers to equivalent years of full health. ‘Years of ill-health’ refers to equivalent years of full health lost due to disability and ill-health. 2000 58.5 years of health 7.9 years of ill health 2015 63.1 years of health 8.3 years of ill health 36 07 H EA LT H IE R, F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey greater threat of serious communicable and parasitic diseases; vulnerability to natural disasters; extreme weather events; and regional conflicts that displace populations. Older people will be at additional jeopardy because of these influences. The policy response to these challenges has developed slowly over the past decade as heads of state and health ministers have realized that the rapid population ageing that their countries are experiencing will have a major impact on all aspects of their societies. In 2015, the Director-General of WHO contributed to a publication (Facing the facts: the truth about ageing and development) by the NGO Help Age International, along with Mary Robinson (one of The Elders) and other leaders and experts. At the time of the report’s launch, the Director-General said: “The health needs of the world’s population are being transformed by global ageing yet governments, development and health practitioners have been slow to react. The increase in the number of older people is one of the success stories of international development and how we respond to this reality will be one of the keys to prosperity in the future.” WHO produced a landmark document in 2015, the World Report on Ageing and Health. The report set out a vision for healthy ageing, defined as: “the process of developing and maintaining the functional ability that enables well-being in older age”. The World Report on Ageing and Health expressed key priorities: Expectancy at birth; totals rounded ; 2015 data ‘Years of health’ refers to equivalent years of full health. ‘Years of ill-health’ refers to equivalent years of full health lost due to disability and ill-health. South-East Asia Eastern Mediterranean Africa Americas 67.3 years of health 9.6 years of ill-health Europe 68 years of health 8.8 years of ill-health Western Pacific 7.9 years of ill-health 68.7 years of health 52.3 years of health 7.7 years of ill-health 60.1 years of health 8.7 years of illhealth 60.6 years of health 8.4 years of ill-health 37 07 H EA LT H IE R, F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey • aligning health systems with the needs of the older populations they now serve • developing systems for providing long-term care • creating age-friendly environments • improving measurement, monitoring and understanding. These priorities were picked up again in another important action when the World Health Assembly in 2016 was asked to adopt The Global Strategy and Action Plan on Ageing and Health. This aimed to gain Member States’ commitment and political leadership to take practical steps and engage multi-sector partners to implement the goal and priorities of the earlier World Report. Global strategy on Ageing and Health: by 2050, 80% of the world’s over-60s will be in low- and middle-income countries The World Report and the Global Strategy and Action Plan set an ambitious but exciting agenda to create a decade of healthy ageing in which the growth in life expectancy is treated as an opportunity and not a threat: “If people are experiencing these extra years in good health and live in a supportive environment, their ability to do the things they value will have few limits.”   38 08 Since its foundation in the second half of the 20th century, through to the turn of the Millennium, WHO’s commitment to health services was based on a development approach that aligned with donor governments’ and foundations’ drive to strengthen health systems. There was also particular emphasis on primary care, notably with the touchstone Alma Ata Declaration of 1978, that saw the advancement of primary care as the most important route to achieving the goals of Health for All. The goal of strengthening health systems is still an important one, but has not always been clear and specific enough to guide action and investment. Some speak of it in more critical terms as a development “mantra” that has led to untargeted donor aid with few demonstrable gains. Whilst this is unfair, there is no doubt that the introduction of the more focused, citizen-oriented, and rights-based goal of Universal Health Coverage (defined as “people having access to the health care they need without suffering financial hardship”) has elevated concern about the inadequacy of health systems to a much higher level of prominence. Universal health coverage as an overarching goal Speaking at the Ministerial meeting on Universal Health Coverage in Singapore in February 2015, WHO Director-General Dr Margaret Chan said: “Universal health coverage is one of the most powerful social equalizers among all policy options. It is the ultimate expression of fairness. If public health has something that can help our troubled, out-of- balance world, it is this: growing evidence that well- GOOD HEALTH SERVICES FOR ALL H EA LT H IE R , F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey 39 08 functioning and inclusive health systems contribute to social cohesion, equity, and stability”. Particularly over the last five years, WHO has worked with other global bodies, heads of state, and health ministers to put the achievement of Universal Health Coverage high on everyone’s agenda. The United Nations General Assembly has called upon Member States to “urgently and significantly scale-up efforts to accelerate the transition towards universal access to affordable and quality healthcare services.” The World Bank has set out three key aims of Universal Health Coverage: • To achieve better health and development outcomes • To help prevent people from falling into poverty due to illness • To give people the opportunity to lead healthier, more productive lives. The inclusion of a target in the Sustainable Development Goals (SDGs) framework is of vital importance. SDG 3, target 8 is: “To achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.” WHO’s leadership has also engaged other key constituencies and stakeholders, importantly civil society. For example, after widespread consultation with its members, the International Association of Patient Organisations (IAPO) has developed a set of principles governing universal access to health coverage based on: • Accessibility • Patient-centredness and equity • Choice and empowerment • Quality • Partnership and collaboration • Sustainability and value • Accountability and transparency Achieving universal health coverage has multiple dimensions. WHO has done strong work on many fronts – most notably in the areas of financing, governance and alignment. Population: who is covered ? Services: which services are covered ? Direct Costs: proportion of costs covered Coverage mechanisms Towards universal health coverage Inc lud e oth er ser vice sReduce cost sharing and fees Extend to non-covered H EA LT H IE R , F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey 40 08 It is clear from the discussions on Universal Health Coverage that the offer of health services to populations around the world should not just be of any health services, but those based on strong foundations of safety and good quality. This is an area in which WHO has done much ground-breaking work over the last decade. WHO’s focus on the quality of health services started with a comprehensive global programme in patient safety, spearheaded by two global patient safety challenges. The first Global Patient Safety Challenge was aimed at engaging the world to reduce the level of healthcare infection. The aim of the Challenge was highly visible and easily understood by politicians, health professionals and civil society. It was relevant to all countries: rich, poor, and emerging economies. Everyone had a vested interest in its success because anyone could need treatment in a health facility and could therefore become the victim of harm by acquiring an infection. In driving forward Clean Care is Safer Care, a wide range of supporting activities and campaigns was implemented. The idea of this Challenge generated huge interest and enthusiasm across all six WHO regions. As ministers signed pledges of commitment to the Challenge in country and regional launches and events, from a small start, the commitments grew to cover more than 85% of the world’s population. A Global Patient Safety Challenge on hand hygiene covering 85% of the world’s population The WHO hand hygiene global campaign (SAVE LIVES: Clean Your Hands), launched in 2009, has been particularly successful. Before the Challenge, alcohol-based hand rubs (hand sanitizers) were not commonplace in hospitals around the world. The core message was that the lack of consistent, immediate, access to a sink equipped with soap and single-use towels (high-income countries) and/ or the unavailability of clean water (many low-income countries) put patients at risk. The evidence of higher efficacy, effectiveness, and skin tolerability of alcohol- based hand rubs made them the method of choice to assure hand hygiene. WHO made alcohol-based hand rubs more affordable to the poorest hospitals of the world by ensuring that the University Hospital of Geneva formulation became available with no patent restriction for local manufacture. WHO campaign: Five moments for hand hygiene Overall, the first Challenge represented a proven change model that mobilised the world around infection prevention through: a) raising awareness about the burden of the problem to engage stakeholders; b) an approach to engage nations through demonstrable commitment; and, c) the availability of evidence-based guidance and implementation tools to drive improvement. A second Global Patient Safety Challenge recognised the relatively high burden of disease arising from unsafe surgical care. Safe Surgery Saves Lives created a surgical checklist that was piloted, evaluated and promoted for use globally. Early studies of its use showed that the checklist reduced morbidity and mortality associated with surgery. Major professional bodies across the world endorsed it. It is H EA LT H IE R , F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey 41 08 Over 400 million people worldwide lack access to essential health services in widespread use in hospitals in many countries and, increasingly, it is seen as essential if the key risks of surgery are to be avoided. A surgical safety checklist in hospitals throughout the world The checklist concept was developed further with the creation of the WHO Safe Childbirth Checklist, which focuses on reducing risk and adverse outcomes related to childbirth for both mothers and babies. The Checklist supports the delivery of essential maternal and perinatal care practices and addresses the major causes of maternal death, intra- partum related stillbirths, and neonatal deaths. The Safe Childbirth Checklist Collaboration has already made significant strides to improving maternal and neonatal health. It is hoped that the Checklist can become an effective life-saving tool that can be used in a wide-range of settings. These programmes – the two Global Challenges, the research and knowledge management programme, and the Patients for Patient Safety initiative – have all had a global reach. The WHO Patient Safety Programme has raised awareness across the world of the key concepts and strategies in patient safety. It has inspired passion for the universal cause of making health care safer. It has secured commitment at the highest level amongst health ministers and health leaders in Member States of the World Health Organization. It has provided standards, evidence-based guidance and practical tools to support those involved in the design of patient safety programmes within nations’ health care systems. It has championed the use of the stories of patients and families who have been the victims of unsafe care. All of these approaches are fundamentally important in the drive to strengthen all elements of quality health service delivery - with safety being central to this, but not the whole story. To further shape the nature of Universal Health Coverage, and how it is delivered, WHO developed a Framework on Integrated, People-Centred Health Services. This sought to promote a fundamental H EA LT H IE R , F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey 42 08 shift in the funding, management and delivery of health services. It also aimed to provide a blueprint to address two common adverse features of many healthcare systems: that they are poorly coordinated and fragmented. Framework on integrated, people- centered health services The framework eschews purely disease-based models of care, instead advocating putting people and communities at the centre of health systems. Development of the Framework drew on evidence demonstrating that health systems designed around people’s and communities’ needs are more effective, cost less, improve health literacy and patient engagement, and are more resilient to health crises. Giving a clear priority to Universal Health Coverage has also meant that there is an imperative to measure and monitor progress, as well as to stimulate interest in the academic world to consider the effectiveness of new models of care and to evaluate progress. H EA LT H IE R , F AI RE R, S A FE R : T he G lo ba l H ea lth J ou rn ey

44 09 The opportunity to prevent a vast swathe of human disease over a lifetime is the greatest development in the history of public health. Lifelong protection, by immunization in childhood, is too often taken for granted. The aim of the Global Vaccine Action Plan, launched by the World Health Assembly in 2012, was to create: “A world in which all individuals and communities enjoy lives free from vaccine-preventable disease”. Vaccines were already saving 2.5 million lives – mainly of children – every year. Yet, 1.5 million were dying from diseases that vaccination can prevent. The action plan sounded a clarion call: “Overwhelming evidence demonstrates the benefits of immunization as one of the most successful and cost-effective health interventions known. Over the past several decades, immunization has achieved many things, including the eradication of smallpox, an accomplishment that has been called one of humanity’s greatest triumphs. Vaccines have saved countless lives, lowered the global incidence of polio by 99 percent and reduced illness, disability and death.” The World Health Organization had launched its Expanded Programme on Immunization (EPI) in 1974. At that time, great progress was being made towards eradicating smallpox – the first time (and, so far, the only time) that a human pathogen was wiped from the planet. This momentous feat demonstrated the immense power of vaccines, and created enthusiasm to spread the benefit more widely. When the Expanded Programme on Immunization was launched, just one in 20 of the world’s children received the basic set of vaccines: protection against VACCINES: PROTECTING YOUNG LIVES SAFER H EA LT H IE R, F AI RE R, S AF ER : T he G lo ba l H ea lth J ou rn ey 45 09 India Nigeria Ethiopia All other countries 2007 2015 Target: 90 low and middle income countries introduce one or more new or under-utilised vaccines, 2010-2015 Target: 90% DTP3 coverage in all 194 member states, 2015 Achieved: 99 Achieved: 126 194 120,000 children under-5 died from measles 74,000 GLOBAL MEASLES DEATHS 2015 polio, diphtheria, tuberculosis, pertussis, measles, and tetanus. By 2010, that earlier paltry figure of 5% coverage had grown to 85%. In the first decade of the new Millennium, a new focus and determination came into play. Gavi, the vaccine alliance, was founded in 2000. WHO then led the creation of the first Global Immunization Vision and Strategy, intended to cover the period 2006 to 2015. This established a global framework for regions and countries. But more was needed. In January 2010, at the World Economic Forum in Davos, Bill Gates, Co-Chair of the Bill and Melinda Gates Foundation, announced that: “We must make this the decade of vaccines. Vaccines already save and improve millions of lives in developing countries. Innovation will make it possible to save more children than ever before”. The coalescence of action necessary to deliver this transformation started to happen. In 2011, the World Health Assembly discussed and agreed on its strategic direction. A substantial but rapid consultation received input from more than 1000 people in 140 countries. And so, in 2012, the Global Vaccine Action Plan was launched. Decade of Vaccines launched The Global Vaccine Action Plan set out a number of key challenges: • Achieving global polio eradication – the last ever case of wild polio to occur no later than 2014 • Regional tetanus, measles and rubella elimination – there were no new targets, but reiteration of those already endorsed by the regional and global bodies • Improving vaccine coverage – goals at national level and the aim of enhancing the equity of coverage within countries • Introducing new vaccines – targets to expand use of existing vaccines to countries where they were not used • Research and development – making at least one new disease vaccine-preventable The Plan also pledged to help achieve the fourth Millennium Development Goal – reducing under-5 mortality – towards which vaccines were already making a substantial contribution. India Nigeria Ethiopia All other countries 2007 2015 Target: 90 low and middle income countries introduce one or more new or under-utilised vaccines, 2010-2015 Target: 90% DTP3 coverage in all 194 member states, 2015 Achieved: 99 Achieved: 126 194 120,000 children under-5 died from measles 74,000 GLOBAL MEASLES DEATHS 2015 Since the Plan’s launch, great progress has been made to introduce new and under-utilised vaccines. Scaling up of pneumococcal and rotavirus vaccines was particularly promising, preventing the leading causes of under-5 deaths from pneumonia and diarrhoea respectively. Between 2000 and 2015, $10 H EA LT H IE R, F AI RE R, S AF ER : T he G lo ba l H ea lth J ou rn ey 46 09 billion was committed to Gavi – an alliance of which WHO is a key member. Three-quarters of the money was to fund vaccine introductions directly. Its work accelerated in step with the Decade of Vaccines. It has introduced the pentavalent vaccine to 68 countries since 2000, pneumococcal vaccine to 58, rotavirus vaccine to 43, and more. Most recently, it has introduced the human papillomavirus vaccine – primarily to prevent cervical cancer in women – to four countries so far, following pilot projects in 27. The authors of the Global Vaccine Action Plan, thinking of tuberculosis, influenza, and malaria, could not have envisaged the Ebola crisis. But, with Ebola came a need and an opportunity to rapidly find a usable candidate vaccine. WHO and its Strategic Advisory Group of Experts on Immunization (SAGE) rose to this challenge. There was real innovation, in both technical and regulatory terms. The lessons learned from this will hasten the development of other vaccines in the future. WHO’s Strategic Group of Experts on Immunization (SAGE) was asked to monitor implementation of the Global Vaccine Action Plan, and report on this to the World Health Assembly. Their successive reports have highlighted the residual problems of vaccine coverage: “There are still 19 million un-vaccinated and under- vaccinated children in the world, representing the least privileged members of society: those who are fleeing disaster, marginalized, dispossessed or simply uncounted”. Globally, since 2010, there has been no significant improvement in vaccination, as measured by DTP3. In 2015, 68 countries were falling short of the mid- decade target of 90% coverage. These percentages have flat-lined, or deteriorated, in more than 50 countries. Variation in performance on this measure has persisted, both within and between countries. Where delivery of vaccines is failing, it indicates weakness in the basics needed for a health system – a supply chain, simple management measures, training of staff, availability of frontline workers, and financing. There are gaps in data availability and quality – a perennial theme in public health. In turn, this holds back the quality of analysis needed to improve coverage. Polio eradication: only three polio endemic countries remaining; fewest cases in history Eradication has a special, but controversial, place in the field of immunization. Smallpox eradication was a momentous public health achievement. Over the last decade, considerable progress has been made towards eradicating polio. In 2007, there were 1315 cases in 12 countries; in 2016, there were just 37 cases in three countries. But the “last mile” of India Nigeria Ethiopia All other countries 2007 2015 Target: 90 low and middle income countries introduce one or more new or under-utilised vaccines, 2010-2015 Target: 90% DTP3 coverage in all 194 member states, 2015 Achieved: 99 Achieved: 126 194 120,000 children under-5 died from measles 74,000 GLOBAL MEASLES DEATHS 2015 H EA LT H IE R, F AI RE R, S AF ER : T he G lo ba l H ea lth J ou rn ey 47 09 polio eradication is taking far longer than anybody anticipated, when the 1988 World Health Assembly set off along this track. Meanwhile, each WHO region has now set a goal of eliminating measles. These are on different timelines, with 2020 the latest targeted date. The step of converting these regional goals into a global eradication target has not been taken, largely because of the polio experience. However, higher levels of measles vaccination have substantially contributed to the decade’s decreases in childhood mortality. In two-week window in 2016, more than 150 countries switch to bivalent oral polio vaccine Vaccine financing is becoming increasingly contentious. In 2015, the World Health Assembly passed a resolution on vaccine pricing, encouraging greater transparency and collective efforts from Member States. It requested a series of actions from the WHO Secretariat. The greatest concern surrounds countries “graduating from” Gavi (i.e. becoming ineligible for financial support), and also those middle-income countries that were never eligible for Gavi support. The Decade of Vaccines has three years left to run. The World Health Assembly is monitoring its progress annually. The Global Vaccine Action Plan has reaffirmed that vaccines are a cornerstone of global health policy. However, many of the children who need them most are still out of reach. At the start of this decade, Melinda Gates, Co-Chair of the Bill and Melinda Gates Foundation, made the case afresh: “Vaccines are a miracle,” she said, “With just a few doses, they can prevent deadly diseases for a lifetime.” This continuity of purpose must infuse the closing years of this decade and shape the years that follow. H EA LT H IE R, F AI RE R, S AF ER : T he G lo ba l H ea lth J ou rn ey 48 10 H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey The World Meteorological Organization confirmed that 2016 was the hottest year on record. It combines data from a wide range of sources to produce its global and regional average annual temperatures. Carbon dioxide and methane concentrations – both indicators of human-induced climate change – are at record levels. Over the last decade, the United Nations, national governments, public health bodies, non- governmental organisations, civil society, scientific organisations, and the academic community have given unprecedented attention to climate change, to addressing ways to slow and mitigate its effect, and to reaching formal and binding international agreements. The majority continues to emphasise that it is the single dominant threat to the planet’s future. This is reinforced by the judgments and reports of the Intergovernmental Panel on Climate Change. The Panel prepares comprehensive Assessment Reports about the state of scientific, technical and socio-economic knowledge on climate change, its causes, potential impacts and response strategies. It also produces special reports, which are an assessment on a specific issue, and methodology reports, which provide practical guidelines for the preparation of greenhouse gas inventories. The Fifth Assessment Report was released in 2013/2014. Amongst the Panel’s key findings were the following summary conclusions: “Anthropogenic greenhouse gas emissions have increased since the pre-industrial era, driven largely by economic and population growth, and are now higher than ever. This has led to atmospheric AIRS, WATERS, PLACES 49 10 H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey concentrations of carbon dioxide, methane and nitrous oxide that are unprecedented in at least the last 800,000 years. Their effects, together with those of other anthropogenic drivers, have been detected throughout the climate system and are extremely likely to have been the dominant cause of the observed warming since the mid-20th century.” and “Continued emission of greenhouse gases will cause further warming and long-lasting changes in all components of the climate system, increasing the likelihood of severe, pervasive and irreversible impacts for people and ecosystems. Limiting climate change would require substantial and sustained reductions in greenhouse gas emissions which, together with adaptation, can limit climate change risks.” Despite these clear and consistent conclusions, some continue to dispute that human factors have made a major contribution to climate change, and hold that current meteorological observations are not out of the ordinary. Throughout the entire last decade of WHO’s work, climate change and its bearing on planetary health and human populations has been a towering backdrop. Extensive work has been undertaken to scope, document, and model the specific health effects of climate change. These include: a greater risk of injury, disease or death from extreme weather events (such as prolonged heat waves and major floods); greater transmission of vector- and water- borne diseases as well as zoonoses; poor air quality causing cardiac and respiratory illness; reduction in levels of safe drinking water; adverse effects of exposure to ultraviolet light; malnutrition due to poor crop yield; and, social and economic impacts on mental health and well-being. Record coolest Source: NOAA-NCEI Cooler than average Warmer than average Much warmer than average Record warmest Near average Much cooler than average 2016: the hottest year since records began 50 10 H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey WHO estimates that, between 2030 and 2050, climate change will cause approximately 250,000 additional deaths per year, from malnutrition, malaria, diarrhoea and heat stress. The direct damage costs to health (i.e. excluding costs in health-determining sectors such as agriculture and water and sanitation) is estimated to be US$ 2-4 billion per year by 2030. Since a landmark resolution by Member States in 2008, WHO has developed and implemented workplans to prevent and mitigate the health effects of climate change. The latest, endorsed in 2015, covers: • Partnerships: to coordinate with partner agencies within the UN system, and ensure that health is properly represented in the climate change agenda • Awareness raising: to provide and disseminate information on the threats that climate change presents to human health, and opportunities to promote health while cutting carbon emissions • Science and evidence: to coordinate reviews of the scientific evidence on the links between climate change and health, and develop a global research agenda • Supporting the public health response: to assist countries to build capacity to reduce health vulnerability to climate change, and promote health while reducing carbon emissions. Building on this, a broader action agenda for the whole health community was agreed at the 2016 WHO Conference on Health and Climate. The major threat of climate change maintained on the global health agenda In 2015, The Lancet Commission on Health and Climate Change produced a series of reports and papers on the health aspects of climate change and the potential response which it described as “the greatest global health opportunity of the 21st century”. Annual mean ambient level of particulate matter (PM2.5) < 10 11 - 15 16 - 25 26 - 35 36 - 69 70 or more ug/m3 Air pollution: the growing bands of yellow and red 51 10 H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey Chemicals of Public Health concern Hazardous PesticidesMercury Lead Fluoride CadmiumDioxin Benzene AsbestosArsenicAirPollution The Commission, and indeed other global health panels established by The Lancet medical journal, are an excellent example of how independent groups of scientists, experts, and thought-leaders, are indispensable to advancing global health. In this case, The Lancet Commission on Health and Climate Change made a series of policy proposals and pledged to monitor progress on them: • Invest in climate change and public health research, monitoring, and surveillance • Scale-up financing for climate-resilient health systems worldwide. This must enable the strengthening of health systems in low- and middle- income countries, and reduce the environmental impact of health care • Protect cardiovascular and respiratory health by ensuring a rapid phase out of coal from the global energy mix • Encourage a transition to cities that support and promote lifestyles that are healthy for the individual and for the planet • Establish the framework for a strong, predictable, and international carbon pricing mechanism • Rapidly expand access to renewable energy in low- and middle-income countries, thus providing reliable electricity for communities and health facilities; unlocking substantial economic gains; and promoting health equity • Support accurate quantification of the avoided burden of disease, reduced health-care costs, and enhanced economic productivity associated with climate change mitigation • Adopt collaborative mechanisms between Ministries of Health and other government departments, ensuring integration of health and climate considerations in government-wide strategies • Agree and implement an international agreement that supports countries in transitioning to a low- carbon economy. Many of the same unsustainable and polluting technologies that are driving climate change also contribute to the more immediate and local threat of air pollution. In March 2017, speaking to the BBC, Dr Margaret Chan, Director-General of WHO, said: “Air pollution is one of the most pernicious threats facing global public health today and on a bigger scale than HIV or Ebola.” WHO has estimated that 92% of the world is breathing air above the limit for levels of particulate matter. Called PM2.5, these particles have a diameter less than 2.5 micrometres, or one seventh of that of a human hair. For this reason they can travel deep into the lungs. Together with carbon monoxide, nitrogen oxide and ozone, small and ultrafine particles are the most damaging components of polluted outdoor air. WHO has estimated that poor indoor and outdoor air quality kills around seven million people a year, with the highest number in Asia. Air pollution has an 52 10 H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey impact on health right across the life course, having been causally linked to low birth-weight, acute and chronic lung disease, stroke, dementia, coronary heart disease, cancer, as well as damage to DNA and the immune system. The impact on children is particularly marked - every year, nearly 600 thousand children aged under 5 years die from respiratory infections attributable to indoor and outdoor air pollution and second-hand smoke. Between 2008 and 2013, global urban air pollution levels rose by 8%, although there were improvements in some regions. The sources of outdoor air pollution are diverse: energy use in domestic and commercial settings traffic (particularly diesel engines); farming; power generation; industrial outputs; burning of living and dead vegetation (e.g. in land clearance). Additional sources of poor outdoor pollution in some parts of the world include sand and dust storms from deserts and deforested areas. Indoor air pollution is also important in causing premature death, illness, and poor health across the world. WHO estimates that it kills 4.3 million people a year. At the World Health Assembly in May 2016, a Road Map for An Enhanced Global Response to the Adverse Health Effects of Air Pollution was adopted, covering actions to be taken between 2016 and 2019. It sets out four areas of action. Firstly, to expand the knowledge base in respect of evidence on the impact on health of air pollution, and the effectiveness of policies to prevent Win-win strategies for the environment and health 9. Always use a health in all policies approach to create healthier environments and prevent disease. 8. Pass smoking bans to reduce exposure to second-hand tobacco smoke. 7. Implement interventions that can increase sun protective behaviour. 6. Change consumption patterns to lower the use of harmful chemicals, minimize waste production and save energy. 5. Increase access to safe water and adequate sanitation and promote hand washing. 4. Reduce occupational exposures and improve working conditions. 1. Apply low carbon strategies in energy generation, housing and the industry. 2. Use more active and public transportation. 3. Introduce clean fuels for cooking, heating and lighting and clean technologies. 53 10 H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey and mitigate them. Secondly, to develop better monitoring and reporting systems, and measures of progress towards the air pollution-related targets of the Sustainable Development Goals. Thirdly, it seeks to design approaches to leverage health sector leadership and coordinated action at local, national, regional and global levels in order to raise awareness of air pollution. Fourthly, the Road Map aims to strengthen institutional capacity of the health sector to analyse policy and decision-making in support of joint action on air pollution and health. A Road Map for an Enhanced Global Response to Health Effects of Air Pollution: action 2016-2019 The emphasis in the Road Map is on securing multi-sectoral engagement across transport, energy, waste management, agriculture, urban planning, and industry. The importance of the core human needs of water (for drinking, bathing, and household uses), sanitation (access to toilets, safe disposal of solid waste), and hygiene have risen up the global health agenda over the last decade. Populations in the poorest parts of the world suffer badly from the lack of these basics. Safe water for drinking was a Millennium Development Goal target and was one of the first to be met. However, the situation is still very serious as the United Nations data show: • 2.6 billion people have gained access to improved drinking water sources since 1990, but 663 million people are still without • At least 1.8 billion people globally use a source of drinking water that is faecally contaminated • Water scarcity affects more than 40 per cent of the global population and is projected to rise • Over 1.7 billion people are currently living in river basins where water use exceeds recharge • 2.4 billion people lack access to basic sanitation services, such as toilets or latrines • More than 80 per cent of wastewater resulting from human activities is discharged into rivers or sea without any pollution removal • Each day, nearly 1,000 children die due to preventable water and sanitation-related diarrhoeal diseases • Floods and other water-related disasters account for 70 per cent of all deaths related to natural disasters. The Sustainable Development Goals take a broad- based approach. Goal 6 states:“Ensure access to water and sanitation for all.” Water, Sanitation and Hygiene (WASH) is now part of many global health programmes, notably those run by a wide range of non-governmental organisations. Particular expertise is needed in delivering such programmes at times of floods and other extreme weather events as well as in refugee and migrant camps and settlements. Toxic land pollution is another route through which health is damaged. Many people in poorer communities in low- and middle-income countries can come into contact with toxic compounds. This happens in a number of ways. They may be living near, or on, an abandoned industrial site where heavy metals and other hazardous substances can stay in the soil for years, or even decades. Children playing in such environments are particularly vulnerable. A greater and concerted international effort is needed to clean up these sites but also to assess the risks more comprehensively, educate and inform the communities affected, and find creative ways to provide alternative employment. There have been some encouraging programmes. For example, in a $25 million program, the World Bank has removed over 3,000 tons of obsolete and dangerous pesticides from around 900 contaminated sites in Ethiopia, Mali, Tanzania, Tunisia and South Africa. 54 10 Soil contamination is just one of the many ways in which health is harmed by exposure to hazardous chemicals. The dangers remain too commonplace in the workplace, the home, and even in schools. The hazards exist in all countries, but are often more marked in poorer countries. People may visit sites with industrial waste to try to harvest anything of value to provide a small income. Increasingly, this can include so-called e-waste where discarded electronic products are broken apart, again exposing someone to toxins, including lead. They may work in unregulated or exploitative industries with no safeguards or protection for workers. Or, they may try to make a living through a hazardous process such as battery recycling or attempting to extract gold using mercury. In such circumstances, levels of knowledge or awareness of the dangers are usually very low. These are examples drawn from a wide spectrum of hazards. Drawing on expert opinion, WHO has estimated that over 12 million people die each year from exposure to hazards of all kinds in the environment. A roadmap for how the health sector can address chemical concerns will be considered by the World Health Assembly in 2017. The Ancient Greek physician, Hippocrates, wrote On Airs, Waters, and Places. He was one of the first to speculate that the quality of air, water, and soil as well as climatic conditions was likely to have a strong influence on health. Nearly 2500 years later, concerns about the impact of climate and environment on health are still centre stage. H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey

56 11 WHO’s global health leadership role comes to greatest public prominence at times when outbreaks or epidemics of communicable disease pose a serious international threat. This can be because of the novel nature of the infectious agent, the scale and speed of transmission, or the severity and consequences of the resulting illness. The 21st Century began with just such an emergency, when a respiratory virus that had not previously caused widespread human illness struck with a force that precipitated a global crisis. Severe Acute Respiratory Syndrome (SARS) caused massive economic and social upheaval and threw a critical spotlight on national and international public health systems. By the time the disease had run its course, it had been reported from 29 countries and areas, there had been more than 8000 cases, and nearly 800 people had died. SARS triggered many fundamental reviews of public health capacity and capability, particularly in countries such as China and Canada that had been worst affected. It also led to the broadening of the International Health Regulations, which now cover a wide range of risks and represent a major agreement between 196 countries to work together to protect global health. Many key lessons came out of the experience of SARS, including: the need for early sharing of surveillance data between countries and with WHO; getting virus isolates to specialist laboratories as quickly as possible; and, strong global coordination of response. Central to the future was recognition of the importance of the leadership role of WHO. Much of this learning was invaluable for the public health emergencies that were to dominate the EMERGENCIES: PROTECT AND MITIGATE H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey 57 11 EMERGENCIES: PROTECT AND MITIGATE succeeding period, notably pandemic influenza, Ebola virus disease, and Zika virus. However, each brought a new set of challenges. In the 20th Century, there had been three well documented influenza pandemics (1918, 1957, and 1968) causing up to 100 million deaths. By 2007, pandemic influenza planning was intensive, because: 40 years had passed since the last pandemic; there had been alarming outbreaks of “bird ‘flu” with human cases; and, there was worldwide infection of wild and domesticated bird populations with H5N1 influenza virus, with such viruses having high propensity to re-assortment. In March 2009, a new influenza virus emerged in Mexico (initially described as “swine ‘flu”) with early reports suggesting a case fatality rate of 64%. Had this virulence been borne out by further evidence, it would have been catastrophic to the world’s population. The subsequent course of the influenza A [H1N1] pdm09 virus pandemic, the first for 40 years, made it one of the mildest on record. The figure of an estimated 105,700 to 395,000 deaths globally is certainly much less than the three 20th Century pandemics, and more comparable to seasonal influenza mortality. However, what was largely overlooked by many commentators was that it killed a disproportionate number of children and young adults. This was typical of an influenza virus “shift” and not of seasonal ‘flu. Had the world’s public health services left their extensive pandemic plans on the shelves, and shrugged their shoulders that the effort would not be worthwhile, then more children and young adults would surely have died. To an epidemiological eye, the numbers would still have been small, but that is of little comfort to the mother or father of a dead child. Public perceptions of risk are very different to those of 40 years ago and clusters of children’s deaths and the hospitalization of young people are not readily accepted in a rationale of “mildness.” At WHO, strong pandemic plans were in place and these were implemented. The eventual outcome could not have been reliably forecast. In the event, the 2009 H1N1 pandemic was invaluable as a “dress rehearsal” for a more severe future pandemic. It was the first test of the 2005 International Health Regulations. The independent review of the pandemic response concluded that some things had gone well, notably: the early identification and characterisation of the Reported intensive natural hazards in Africa Nu m be r o f d isa st er s Source: UNISDR 19 85 19 86 19 87 19 88 19 89 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 14 20 15 140 120 100 80 60 40 20 0 H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey 58 11 virus, the provision of candidate vaccine strains, and the creation of strong collaborative networks to help manage the pandemic. Other areas were criticized, for example: the slow distribution of the vaccine; the inadequate vaccine production capacity (that could only provide for a third of the world’s population); the weakness of the definition of a pandemic that relied purely on the scale of spread, not severity, leading to public announcements that lacked credibility; the absence of transparency about membership of scientific advisory committees and perceived conflicts of interest. Recommendations were made to strengthen the approach for the future. One of the most important actions should be to drive research harder for a pluripotent influenza vaccine that could block the prospect of a future influenza pandemic. The transformative nature of this to save millions of lives in a severe pandemic has not been fully appreciated. Perhaps the global health community is allowing themselves to believe that influenza pandemics come in 40-year cycles. The reality, of course, is that a novel, easily transmitted, and highly virulent influenza virus could emerge next week. One of the most important aspects of the SARS crisis was the extent to which the outbreaks moved dangerously out of control once infections were treated within hospitals, if prevention and control standards were weak. Whilst this was understood at the time, the need to look more generally and critically at the risks within healthcare facilities especially in low-income countries was not systematically addressed. In 2014, Ebola virus disease, an infection with a high case fatality, began to surge in larger conurbations in three countries in West Africa: Guinea, Sierra Leone, and Liberia. Outbreaks in other neighboring countries, Mali, Nigeria and Senegal, were rapidly controlled. The outbreaks in the three main countries were prolonged beyond anything that had been seen before. Previously Ebola had only ever occurred in sparsely populated areas and as a result been contained. This time it emerged in settings with poor healthcare infrastructure, and significant gaps in infection prevention and control procedures. There was no early intervention. As a result, it posed a much greater threat to regional populations and potentially globally. Recommendations of the WHO Review Committee on the Functioning of the 2005 International Health Regulations (IHR) in Relation to the 2009 H1N1 Influenza Pandemic Accelerate the implementation of the core capacities required by the IHR Enhance the WHO Event Information Site Reinforce evidence-based decisions on international travel and trade Ensure necessary authority and resources for all National Focal Points Strengthen the internal capacity of the WHO for sustained response Improve practices for the appointment of an emergency committee Revise pandemic-preparedness guidance Develop and apply measures to assess the severity of a pandemic Streamline the management of guidance documents Develop and implement a strategic, organization-wide communications policy Encourage advance agreements for vaccine distribution and delivery Establish a more extensive public health reserve workforce globally Create a contingency fund for public health emergencies Reach an agreement on the sharing of viruses, access to vaccines, and other benefits Pursue a comprehensive influenza research and evaluation program H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey 59 11 WHO was criticized for its slow initial response to the threat of Ebola. After a difficult start, the response got stronger - thanks both to WHO and to many of its partners. There were three strong features of the response. Firstly, a public health Emergency Operations Centre that had been created by WHO and other Polio Partners for the purpose of coordinating action to eradicate polio in Nigeria was immediately and successfully deployed against Ebola. It is widely accepted that had Ebola been allowed to spread into densely populated Lagos, Nigeria, the world could have been tipped into a public health catastrophe. Secondly, the team in WHO that led the first Global Patient Safety Challenge, Clean Care is Safer Care, had developed a very strong capability in healthcare infection prevention and control, together with extensive experience of implementation in low- resource settings and a wide network of international experts. This team joined forces with other infection control experts in WHO. It was given the mandate to coordinate efforts and also deployed in the affected areas to help reduce risks and strengthen resilience in the affected countries. Thirdly, WHO and partners forged a strong multinational alliance of Member States, international agencies, donors, and NGOs to coordinate action and provide the necessary support in funding, expertise, personnel, and supplies. A Polio Emergency Operations Centre in Nigeria that halted Ebola virus in that country The Ebola epidemic was declared over on 14th January 2016. The official figure for deaths was 11,315 but the true figure will be much higher. The Review Committee on the Role of the International Health Regulations (2005) in the Ebola Outbreak and Response reported to the World Health Assembly in 2016. It noted that many of the recommendations from the earlier review of the pandemic response (2011) had not been fully implemented. This meant that the world was still ill-prepared and vulnerable when Ebola struck. The 2016 recommendations therefore focused on the need to ensure full implementation of the International Health Regulations with all that this would entail. Critically, it was recognized that improvements sought, including substantial capacity building, would require a multi-sectoral approach. In addition, significantly greater funding would be required. WHO has been leading programmes of work to build resilience in healthcare systems post-Ebola. Subject to the availability of the necessary financial support, WHO will be able to provide the urgent help needed to address poor infrastructure and limited implementation of infection prevention and control practices, and quality of care principles. Evidence is also emerging that the delivery of essential maternal and child health services – such as antenatal care and immunization – has reduced since the Ebola epidemic was declared over. WHO is helping countries to assess their International Health Regulations core capacities. These capacities form an essential platform for the detection, assessment, notification and reporting of events, and for the response to health risks and emergencies of international concern. A programme of Joint External Evaluations is assessing countries’ capacity to prevent, detect and respond to public health risks, highlighting the most critical gaps. The improvements that will flow from the post- Ebola reforms of WHO will have the dual benefit of preparing countries better to face the next new disease, and also the current killers. Major outbreaks of communicable disease over the last few years have included: avian influenza A (H7N9) in China; plague in Madagascar; Yellow Fever in Brazil, Angola, Democratic Republic of Congo and Uganda; MERS- CoV in Saudi Arabia; Hepatitis E in Chad; Seoul H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey 60 11 International Health Regulation implementation 0% 20% 40% 60% 80% 100% Legislation Coordination Surveillance Response Preparedness Risk communication Human Resources Laboratory Points of entry Zoonosis Food safety Chemical Radionuclear Countries that have implementedBased on 127 reporting countries, 2015 virus in the United States of America and Canada; meningococcal disease in Togo; and Lassa Fever in West Africa. The frequency and severity of these events not only emphasizes the need for strong public health in countries, but the need for WHO’s role in global coordination and response. A further important post-Ebola development is the new African Union-funded Africa Centers for Disease Control and Prevention in Addis Ababa, Ethiopia. It became operational on 31 January 2017. It will play a pivotal role in helping the continent respond to public health emergencies. The plans include regional centres across the continent – Kenya, Zambia, Egypt, Gabon and Nigeria. The work of Africa Centers for Disease Control will surely enhance understanding of the higher risk populations in Africa, and advise on what prevention and control measures are necessary to provide better protection. New Africa Centers for Disease Control and Prevention WHO has broadened its perspective from major outbreak and pandemic preparedness, to a wider concept of public health emergencies. Understanding and responding to the direct and indirect impact of disasters and humanitarian crises on health is advancing. The United Nations Office for Disaster Risk Reduction (ISDR) was established in 1999, mandated by a United Nations General Assembly resolution (56/195), to serve as the focal point in the United Nations system for the coordination of disaster reduction. It ensures synergies among the disaster reduction activities of the United Nations system and regional organizations and activities in socio-economic and humanitarian fields. It received nearly 350 reports of disasters from across the world in 2015. They caused over 22,000 deaths, affecting 98.6 million people, and resulting in $66.5 billion in economic damage. H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey 61 11 Closely linked to its work is The Sendai Framework. This is a crucial development. It is a United Nations initiative to address disasters, bringing together public health and disaster risk reduction. It is part of the so-called “all-hazards” approach, and aims to reduce disaster risk and associated losses of lives, livelihoods, and health. WHO is not only involved in public health emergencies, but in the health elements of natural disasters (such as the Nepal earthquake) and complex humanitarian situations (such as in Syria and Iraq). The building blocks of its approach include an Early Warning and Response Network (EWARN), a Health Resources Availability Monitoring System (HeRAMS), and an Emergency Medical Teams initiative. It has an increasing leadership role in the Inter Agency Standing Committee, particularly for infectious hazards. WHO’s new Health Emergencies Programme is changing the way WHO works with countries to respond to crises and emergencies, from being primarily a technical agency, producing norms and standards, to a fully operational agency. New WHO Emergencies Programme for All Hazards: prepare, prevent, protect, respond, recover The Programme has five technical and operational divisions: • Infectious hazards management: to ensure strategies and capacities are established for priority high-threat infectious hazards. • Country health emergency preparedness and the International Health Regulations (2005): to ensure country capacities are established for all-hazards emergency risk management. • Health emergency information and risk assessments: to provide timely and authoritative situation analysis, risk assessment and response monitoring for all major health threats and events. • Emergency operations: to ensure emergency- affected populations have access to an essential package of life-saving health services. • Emergency core services: to ensure WHO emergency operations are rapidly and sustainably financed and staffed. This is a very big shift of emphasis, and expansion of role, for WHO. The Programme works with countries and partners to prepare for, prevent, respond to and recover from all hazards that create health emergencies, including disasters and conflicts as well as the traditional locus in disease outbreaks and conflicts. The Programme will also lead and coordinate the international health response to provide effective relief and recovery to affected people. H EA LT H IE R , F A IR ER , S AF ER : T he G lo ba l H ea lth J ou rn ey 62 12 In reviewing some of the challenges, developments, intractable problems, crises, emergencies, and successes in global health over the last decade, the words “One World” seem to float high above a complex landscape of global and national health architecture. Within it, so many dedicated individuals, teams, and organisations work tirelessly, as the sun rises and sets in the 24 different time zones of the world, to bring the gifts of good health, longevity, well-being, and the relief of suffering to seven billion people. One World reverberates in many of the goals of global health: Universal Health Coverage; Every Woman, Every Child; access to essential life-saving medicines. The two words echo in the aim of “One WHO”, in which Member States, regional and country offices, global partners, NGOs, and civil society seek to strike a common purpose. They are unavoidable when thinking of the assailants on the world’s health: climate change, pandemics, natural disaster, conflict, antimicrobial resistance. They inspire solidarity, compassion, and idealism when the statistics of health and poverty, health inequity, life and death are on the table or projected on the screen. They are relevant, too, when discussions turn to the need for alignment and collaboration between: science and policy; public and private; national and local. WHO and its Director-General have powerful roles in creating and sustaining this holistic view of global health and in trying to forge a broad-based coalition to lead the quest to make lives healthier, fairer, and safer. The power of WHO is delivered through its roles in leadership, technical expertise, standard- setting, coordination, facilitation, and influencing agendas on the global stage. Looking back over the last decade, it is clear that the world’s health needs are so diverse and urgent, that WHO cannot simply concentrate on a small number of priorities as some would advocate. This is demonstrated by the breadth of areas in which progress in global health has been made over the last decade, by organisations and individuals working at global, national, and local level in partnership with WHO and often in response to its leadership. CONCLUSIONSHEALTHI ER , F AI RE R, S AF ER : T he G lo ba l H ea lth J ou rn ey 63 12 This Report documents many of the achievements of the last decade, for example: improved outcomes for mothers and children, breakthroughs in vaccine provision, two diseases brought to the brink of extinction, reductions in deaths from the major killers, measures to halt the rise of noncommunicable diseases, new frameworks and structures for public health emergencies (building on the learning from pandemic influenza and the Ebola virus crisis). Serious problems and challenges remain, many centered on the sources of inequity and on the burden of disease, premature death and disability suffered by the poorest populations in the world. Looking across all these fields in which gains in global health have been made, a number of important themes stand out. Inspiring a healthier and fairer future On occasion throughout its history, WHO has launched big ideas that have transformed policy- making, inspired major initiatives, and continued to shape action at global and country level over years and sometimes decades. A good example of this is Dr. Halfden Mahler’s vision of Health for All that he set out in 1981. Dr. Mahler was Director-General of WHO between 1973 and 1983. He died, aged 93 years, in December 2016, when WHO staff mourned his passing and celebrated his life and achievements. When he spoke about his idea in 1981, Dr. Mahler said: “Health For All means that health is to be brought within reach of everyone in a given country. And by ‘health’ is meant a personal state of well-being, not just the availability of health services – a state of health that enables a person to lead a socially and economically productive life. Health For All implies the removal of the obstacles to health – that is to say, the elimination of malnutrition, ignorance, contaminated drinking water and unhygienic housing – quite as much as it does the solution of purely medical problems such as a lack of doctors, hospital beds, drugs and vaccines.” The role of WHO in thought leadership is not often talked about. When ideas like Health for All emerge, they are not mere slogans. They are powerful forces for change. They can become an organising principle for global health. Often, too, they are underpinned by a strong moral rationale: in this case, health as a human right. 2016 Shanghai Declaration on Promoting Health in the 2030 Sustainable Development Agenda In her leadership of WHO, Dr. Margaret Chan has continued this focus on the fundamentals. At a number of points in the last decade, WHO has called on the world to see health through a different lens, not just with a focus on disease. One was the Commission on the Social Determinants of Health that WHO established and subsequently championed. Almost immediately after publication, the Commission’s report began to influence thinking and shape the health agenda. It has cascaded through regions and countries, challenging those who review existing policies and plans to think differently. A second was the idea of Universal Health Coverage. This is fundamental in nature, and driven by strong emphasis on social justice, equity, and compassion. A third was equally transformative but in a different way. The World Report on Ageing and Health, and its companion implementation plan, The Global Strategy and Action Plan on Ageing and Health, set out a vision of the future not just for health and healthcare, but one with the potential to strengthen the very fabric of societies, to buoy economies, to transform H EA LT H IE R, F AI RE R, S AF ER : T he G lo ba l H ea lth J ou rn ey 64 12 the nature of cities, and to promote the cohesion of generations. Shifting the world of tomorrow from unhealthy to healthy ageing is as profound a goal as any international agency has ever set. Moreover, the do-nothing option will be disastrous. A fourth watershed moment for global health was the first Global Report on Disability. Professor Stephen Hawking said in the foreword: “In fact, we have a moral duty to remove the barriers to participation, and to invest sufficient funding and expertise to unlock the vast potential of people with disabilities. Governments throughout the world can no longer overlook the hundreds of millions of people with disabilities who are denied access to health, rehabilitation, support, education and employment, and never get the chance to shine.” The Report gave clear global guidance on how to take action on the United Nations Convention on the Rights of Persons with Disabilities. About 15% of the world’s population lives with some form of disability. WHO has a distinguished tradition in the classification and measurement of disability, but much of this past work was based on a medical perspective. The Global Report on Disability, released in 2011 (jointly with the World Bank), shifted the paradigm of disability within the global health arena. It set out a vision of a social model of disability. Here, disability is seen as arising as an interaction between people and their environments. The emphasis is on breaking down barriers that prevent inclusion. First Global Report on Disability marking a paradigm shift in approach With these four foundational areas of work, WHO is helping not only to inspire action to achieve better health but to shape the way that health should be viewed in the future. It is also seeking to reinforce the fundamental values that underpin it. These key policies will also provide a powerful stimulus to think differently about the way that health systems are designed and delivered. They will also create a vital backdrop to public policy-making more generally within countries. Health at the world’s top table In the past, WHO, as one of the main United Nations specialist agencies, has worked on its own agendas. Health was infrequently part of main United Nations business at the highest level. In the past decade, there has been an unprecedented scale of engagement of the United Nations in global health. In September 2011, a High-Level meeting of the General Assembly of the United Nations made a Political Declaration on the Prevention and Control of Non-Communicable Diseases. In June 2011, a similar declaration from a High-Level meeting called on Member States to intensify efforts to eliminate HIV and AIDS. In December 2012, the United Nations General Assembly passed a Resolution on Universal Health Coverage. In December 2016, the United Nations Member States signed a declaration to combat Antimicrobial Resistance. In 2014, the United Nations General Assembly and the Security Council discussed the Ebola crisis and authorized a wide range of actions. NCDs, AMR and UHC on agenda of UN General Assembly The importance of gaining United Nations commitment to global health priorities is of immense significance. It moves them from being solely programmes within the health sector to formal commitments that presidents and prime ministers take ownership of and accountability for. It has also been significant that global health has increasingly been part of the discussions of the G7 and G20 groups of nations. H EA LT H IE R, F AI RE R, S AF ER : T he G lo ba l H ea lth J ou rn ey 65 12 The overarching nature of the United Nations Sustainable Development Goals is another vital part of this agenda. There are 17 universal goals, 169 targets, and 230 indicators. It is still early days for implementation of the Sustainable Development Goals. The examination of the health-related goals, targets, and indicators is just beginning. They have the potential to be transformative in global health. It will be essential to decide to what degree future priorities should be only in the currency of the Sustainable Development Goals, and how much they have to be driven forward in a different way. New ways of working Over the last decade, WHO has initiated its own process of reform, discussing it with its Member States, partners, and a wide range of individuals and organisations. Some of the debate has focused on first principles: what should a global health body, made up of all countries of the world, actually do? The complexity of the global health landscape is one the main drivers of the need for WHO to re- examine its own role and positioning. The number of organisations and interests has increased and, as a result, mapping out inter-relationships is a constant work-in-progress. Also there has been a worsening of the funding climate for WHO’s work, particularly in the aftermath of the global financial crisis. In an era of open and healthy discourse in global health, it is right that WHO’s role comes under regular scrutiny. An intermittent stream of criticism comes from academia, and other sources, asserting that WHO is not doing what it has the potential to do to improve global health. Generally, WHO is seen by commentators as having a choice to work in a number of ways: as a normative, standard-setting body orientated towards development; as a global activist and advocate for better health and action on the economic and social determinants of poor health; as an advisory body and provider of technical support and facilitation to its member states. In reality, there is no choice between these approaches. In advancing global health, WHO’s work must involve all of them. In fulfilling its mandate for global health in a 21st Century context, WHO has an immensely difficult task. At its heart is the immutable premise that the improvement of population health requires not only evidence-based technical interventions but also a swathe of other essential activities including political commitment and alignment, leadership, successful partnership working, multi-sector collaboration, and engagement with communities and citizenship. This complexity is evident in so many areas where action or change is necessary. It is evident when reflecting that the Ebola crisis had implications for many of the other United Nations specialist agencies, not just WHO. It is evident in the need to dismantle obesogenic environments around the world that might have 20 or more nodal points of influence on a community’s patterns of calorie intake and physical activity. It is evident in the recognition that the task of eradicating poliovirus from the planet involves reaching children in conflict-affected areas where vaccinators may be targeted and murdered. Frustrations with the slow pace of global health change has led to some major donors providing funding linked to the achievement of measurable improvements in health and disease outcomes. Also, specialist agencies and partnerships have emerged (for example, UNAIDS; the Global Fund to Fight AIDS, Tuberculosis and Malaria; Gavi, the Vaccine Alliance) and some have received major allocations of funds in a similarly focused way. This approach has achieved some success but it also raises fundamental questions about how best to achieve beneficial change in global health. So- called vertical programmes usually achieve their results at the expense of broad-based horizontal H EA LT H IE R, F AI RE R, S AF ER : T he G lo ba l H ea lth J ou rn ey 66 12 actions to strengthen in-country health systems to be self-determining, self-sustaining and to deliver improved outcomes in that way. Ministries of health in low-income countries are encouraged to chase the money and risk narrowing their thinking to circumscribed, packaged, programmes. WHO’s funding model has changed over the last decade from one that was based largely on core-funding with discretion to determine, with Member States, how to deploy it. Now, 80% of its entire budget is non-core and much earmarked for donor-determined priorities. The popularity of vertical programmes is understandable. They can and do achieve positive outcomes. In turn, the traditional development agenda of strengthening health systems has led, in the past, to the allocation of big sums of money by the larger donor nations without always yielding demonstrable benefits. Taking an overview of how change has been achieved, and where there has been little progress, over the last decade, there are many other factors that need to be addressed that are not a specific element of the WHO’s role. They include: • The limited extent of the essential multi-sectoral approach getting off the ground at country level • The poor quality of health data to monitor progress and evaluate change, especially in many low- and middle-income countries • The diffuse and unclear nature of many mechanisms of accountability for performance • The inability to consistently scale-up and spread best practice and innovation • The difficulty in moving to command and control processes in emergencies. Not enough time in global health is spent in critical discussion of the right ways to achieve strategic change. The striking improvement in the performance of the global polio eradication programme as a result of independently derived pointers to the need for systemic action is a small but important example of this. With the valuable sources of constructive criticism and support of WHO’s role, the organisation’s own reform process has addressed three areas: priorities and programmes; governance; and, management. It has made major changes in the way that it operates in each of these areas, including establishing: • Clearly defined priorities, with country offices allocating most of their budgets to priority areas • Effective managerial accountability, transparency and risk management • Strengthened engagement with stakeholders (particularly non-state actors) • Improved strategic decision-making • Increased capacity to respond to outbreaks and emergencies with health consequences • Better management of human resources • Information managed as a strategic asset. The Framework for Engagement with Non-State Actors (FENSA) is an important development. It was negotiated and adopted by Member States. It acknowledges that WHO needs to work with a broad span of partners (NGOs, private sector entities, philanthropic foundations, and academic institutions) to be effective, and guides it clearly in doing so. In particular, working with the private sector, under carefully defined conditions, has moved forward. This is an area that WHO has shied away from in the past, with consequent lost opportunities. H EA LT H IE R, F AI RE R, S AF ER : T he G lo ba l H ea lth J ou rn ey 67 12 The development of FENSA, which covers a wide spectrum of WHO’s work, builds on efforts over the last decade to unite diverse stakeholders. Most notably, the Pandemic Influenza Preparedness Framework – adopted by the World Health Assembly in 2011 – brings together public and private sectors for the crucial common goals of sharing viruses with human pandemic potential and improving poorer countries’ access to vaccines and other pandemic- related supplies. These reforms put WHO in a strong position to combine its traditional strengths of power of convening, and the expertise in formulating norms and standards, with its acknowledged position of overall leadership in global health. A great deal has been achieved in the last decade, as this Report documents. And important seeds have been planted that can and must bear fruit over the decades to come. H EA LT H IE R, F AI RE R, S AF ER : T he G lo ba l H ea lth J ou rn ey

Unless otherwise specified, data are derived from official publicly available UN sources

更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 01 更健康、更公平、更安全 全球卫生十年历程（2007—2017） 吴岩玮 / 译 Healthier, Fairer, Safer the global health journey, 2007–2017 在 Paul Rutter 博士的协助下，本报告由 Liam Donaldson 爵士、教授撰写 译  　者：吴岩玮 出版发行：人民卫生出版社（中继线 010 - 59780011） 地    址：北京市朝阳区潘家园南里19号 邮    编：100021 E - mail：pmph @ pmph. com 购书热线：010 - 59787592 010 - 59787584 010 - 65264830 印    刷： 经    销：新华书店 开    本：787×1092 1/16 印张：4 字    数：95千字 版    次：2018 年 6 月第 1 版 2018年 6 月第 1 版第 1 次印刷 标准书号：ISBN 978-7-117-26120-3 定    价：40.00元 打击盗版举报电话：010 - 59787491 E-mail：WQ @ pmph.com （凡属印装质量问题请与本社市场营销中心联系退换） 更健康、更公平、更安全  全球卫生十年历程 本书英文版于2017年由世界卫生组织（World Health Organization）出版，书名为：Healthier, fairer, safer: the global health journey, 2007–2017 World Health Organization 2017 世界卫生组织（World Health Organization）授权人民卫生出版社翻译出版本书中文版。中文版的 翻译质量和对原文的忠实性完全由人民卫生出版社负责。当出现中文版与英文版不一致的情况 时，应将英文版视作可靠和有约束力的版本。 中文版《更健康、更公平、更安全——全球卫生十年历程2007—2017》 人民卫生出版社 2018 图书在版编目 (CIP) 数据 更健康、更公平、更安全：全球卫生十年历程／世界卫生 组织主编；吴岩玮译．—北京：人民卫生出版社，2018 ISBN 978-7-117-26120-3 Ⅰ．①更… Ⅱ．①世… ②吴… Ⅲ．①医疗保健事业- 产业发展-研究-世界 Ⅳ．①R199.1 中国版本图书馆CIP数据核字（2018）第032330号 版权所有，侵权必究! 人卫智网  www.ipmph.com　医学教育、学术、考试、健康， 购书智慧智能综合服务平台 人卫官网  www.pmph.com 人卫官方资讯发布平台 03 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 01 01　引言  04 更健康 02　人口：至关重要的指标  06 03　保护母亲和儿童  10 04　微生物：古老与现代   16 05　非传染性疾病流行  24 更公平 06　用一代人时间弥合差距  30 07　健康老龄化  34 08　人人享有良好卫生服务  38 更安全 09　疫苗：保护年轻的生命  44 10　空气、水、土壤  48 11　紧急情况：保护和缓解  54 12　结束语  60 目录 04 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 01 本报告介绍并分析了过去 10 年（2007—2017 年）全球卫生的重要领域，探讨了与世界卫 生组织（World Health Organization，WHO）的 作用和潜在影响力相关的趋势与政策，涉及 期望取得进展、已明确承诺或有迫切需求的 世界卫生的主题与领域。 卫生领域之外的因素对健康有影响。自 21 世 纪初，全球化的进程加快，世界遭受了金融 危机的重创。同时，一些地区严重的武装冲 突和日益恶化的安全形势导致了大规模的人 口迁移。在进行人道主义援助时，公共卫生 工作者被杀害。气候变化带来了许多极端的 天气，严重影响了人类的生产、生活。所有 这些因素都与国家和社区的健康和福祉密切 相关，对世界上最贫困地区的影响尤为严重。 世界卫生组织通过建立伙伴关系来实现其目 标。过去 10 年，全球卫生体系构架发生了很 大的变化。世界卫生组织在关于其改革的文 件中明确了其主要作用为指导和协调国际卫 生，具体如下 ： · 在重要的卫生问题上发挥领导作用 ； · 制订卫生领域研究规划 ； · 制定卫生规范和标准 ； · 阐明与卫生相关的政策 ； · 提供技术支持、开展能力建设 ； · 监测卫生状况变化趋势。 本报告并非一项学术研究，也不涉及全球卫 生的方方面面。旨在回顾过去 10 年全球卫生 的发展趋势、取得的成就和面临的挑战，并 探讨未来的需求。 引言 05 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 01 06 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 02 目前世界人口比 10 年前增加了 8 亿多。因 出生人数比死亡人数多一倍以上，因此人口 数不断增长。而最低收入国家死亡率下降的 速度远远超过出生率，因此，这些国家人口 增长速度最快。这是已预测的人口结构转变 阶段。 高龄人口数量显著地增长。2007 年到 2017 年， 90 岁以上的人口数增加了 2/3，而 100 岁以上 的人口数几乎翻了一番，这是人类历史上瞬 间发生的变化。 不同国家的人口结构存在很大差异。低收入 国家的人口最年轻，其半数人口的平均年龄 不足 18.5 岁，这一数字在中等收入国家上升 到 28.9 岁，在高收入国家则达到了 39.7 岁。 人类的期望寿命以惊人的速度增长。目前全 球平均期望寿命超过了 71 岁，而且以每年 4 个月的速度递增。2007 年只有 15 个国家的出 生期望寿命超过 80 岁，而 2015 年达到了 29 个国家。与此同时，期望寿命不足 60 岁的国 家从 36 个减少到 22 个。 2015 年 29 个国家的期望寿命超过 80岁，而 2007年只有 15个国家 非洲地区期望寿命增长迅速，在短短 8 年里 增了超过 5.5 岁。在津巴布韦、马拉维和赞 比亚增长最快，分别增加了 14 岁、9.8 岁和 9.2 岁。女性的期望寿命比男性长 4.5 岁。近 人口： 至关重要的 指标 07 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 02 10 年来，基本上每个国家的期望寿命都有所 增加。但是，也有战争造成的例外，阿拉伯 叙利亚共和国的期望寿命下降了 9.3 岁。 非洲的期望寿命增长最快 期望寿命的增加主要带来两方面的影响。第一， 世界上较富裕的国家老年人口的年龄更大，众 所周知地给社会、经济和医疗带来负面影响。 第二，世界上较贫穷的国家因出生人口的存活 率上升，提高了期望寿命。这对社会和经济也 有重大影响，而且基本上是正面的。 过去 10 年全球期望寿命快速增长是一系列变 化的结果，主要有 : · 2005 年至 2015 年间，5 岁以下儿童死 亡率下降了 32% ； · 同期孕产妇死亡比例下降了 25% ； · 艾滋病死亡率下降了 50% ； · 疟疾死亡率下降了 49% ； · 心血管疾病年 龄 别 死 亡 风 险 减 少 了 14% ； · 癌症年龄别死亡风险减少了 11% ； · 伤害死亡率下降了 7%。 上述 1 ～ 4 项属于千年发展目标与卫生相关 的 3 个领域，即减少儿童死亡率、改善产妇 保健及与艾滋病、疟疾和其他疾病作斗争。 经常有人问 ：取得这些成就的原因是什么？ 社会经济发展起到了一定作用。随之而来的 变化有男女受教育水平提高，生育率下降， 成功地实施大规模、有效的卫生干预，特别 是抗逆转录病毒药物、杀虫剂浸泡蚊帐、麻 疹疫苗等取得成效。虽然对社会发展和卫生 领域具体干预措施的作用谁更重要有争论， 但总的来说两者都非常重要。 随着儿童死亡率的下降，全球对健康的关注 已转移到生命历程中导致过早死亡的原因上。 过去 10 年非传染性疾病的预防和治疗取得了 进展，这有助于提高期望寿命。因目前非传 染性疾病所导致的伤残和死亡比 10 年前多， 所以经常产生误解。其实，这个陈述并不矛盾， 因为在任何年龄段与非传染性疾病相关的死 亡率都在下降，这有利于延长期望寿命。但是， 这被高龄人口数量不断增加所抵消，而且给 人口造成了更大的负担。因此，相对而言非 传染性疾病更加重要。但是，与传染性疾病 相比，非传染性疾病预防控制的成效不显著。 死亡 -6亿 出生 +14亿 2007 67亿 2017 75亿 全球人口 20172007 14亿 24亿 30亿 7亿 低收入国家 中低收入国家 中高收入国家 高收入国家 5亿 26亿 13亿 22亿 增长31% 16% 8% 6% 08 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 02 联合国千年发展目标的时代已结束，可持续 发展目标才是当今最重要的。其中第 3 个目 标为良好健康与福祉，它的 13 个分目标要 求在孕产妇、儿童和传染病防治方面取得进 展 ；非传染性疾病导致的过早死亡减少 1/3 ； 全球道路交通事故造成的死亡和伤害人数减 半 ；减少危险化学品及空气、水和土壤污染 导致的死亡和患病人数 ；实现全民健康覆盖 ； 促进精神卫生和健康 ；加强对药物滥用的预 防和治疗 ；确保普及性健康和生殖健康卫生 服务。 随着实现可持续发展目标的顺利推进，期望 寿命将进一步增加。总的来说，最终实现这 些分目标就是降低过早死亡。在制定可持续 发展目标时，一些知名专家主张将目标 3 细 化和量化，但最终没有这样做。 巩固妇幼卫生和传染性疾病方面取得的成绩 与在新划分的领域取得进展性质有所不同。 实现第一个基本上未完成的千年发展目标议 程，迫切需要解决最基本卫生服务方面的不 平等问题。5 岁以下儿童的主要死亡原因是轮 状病毒导致的腹泻和肺炎球菌性肺炎，两者 都可通过疫苗加以预防。目前，水、卫生设施、 营养和避孕药具可及仍然存在问题。对于富 裕国家的人口来说，这些只是基本保障。但是， 这些基本保障并不是全世界人人可及。 除非传染性疾病之外，基本没有新增的关注 点。在宏观和政策层面，预防非传染性疾病 需要政治承诺和多部门合作。卫生系统提供 的一级预防要求整个系统相当精细，二级预 防和治疗对该系统的要求更高。 2015 年有很多人沦为难民，这是第二次世界 大战以后难民人数最多的一年，现有 2100 万 难民，这是一个非常不好的趋势。3 年来难 民人数增长了 40% 以上，难民主要来自阿拉 伯叙利亚共和国。此外，目前约有 4000 万人 出生期望寿命 6.6 岁 8 国家 < 50 岁 5.1 岁 31 国家 50-60 岁 2.6 岁 44 国家 60-70 岁 1.6 岁 85 国家 70-80 岁 1.6 岁 15 国家 > 80 岁 出生期望寿命 2015 2007 09 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 02 流离失所，他们没有固定的家园，只是还留 在自己的国家里。2/3 的世界难民和半数国内 流离失所者都在东地中海地区。 这种被迫流离失所者只占全球移民总数的一 小部分，目前全球移民有 2.44 亿人。10 年来 国际移民人数一直比较稳定，占全球总人口 的 3% ～ 4%。 难民和国内流离失所者都可能面临严重健康 问题，遭受暴力、酷刑、强奸和性虐待、奴 役以及精神疾病。移民这个群体也会面临通 常不严重的社会经济和健康方面的问题，例 如服务可及性的障碍、新的语言和文化的挑 战等。 2008 年世界卫生大会将移民健康问题列入议 程，决议呼吁各成员国和世界卫生组织秘书 处采取行动，要求总干事“与其他有关组织 合作，在国际卫生议程上促进移民健康”。在 随后的几年里，世界卫生组织的政策、计划 和项目越来越多地考虑到移民的需要，特别 是在艾滋病、结核病、妇女儿童以及生殖健 康领域。 移民健康纳入国际议程 随着国际社会对难民问题的日益关注，2016 年联合国大会发表了关于难民和移民的政治 宣言。世界卫生组织已着手制定难民和移民 健康的优先领域及指导原则的框架，2017 年 世界卫生大会将审议这一框架。 低收入国家 中低收入国家 中高收入国家 高收入国家 年龄（岁）0- 4 5- 9 10 -1 4 15 -1 9 20 -2 4 25 -2 9 30 -3 4 35 -3 9 40 -4 4 45 -4 9 50 -5 4 55 -5 9 60 -6 4 65 -6 9 70 -7 4 75 -7 9 80 -8 4 85 -8 9 90 -9 4 95 -9 9 10 0 + 2017年全球人口 10 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 03 保护 母亲和 儿童 两个悲惨、不平等的事件 ：一个婴儿死亡， 几个月的生命凋零了 ；一个年轻女子死亡， 一个家庭失去了母亲。世界的一些地区这样 的事件是罕见的丑闻，而在另一些地区这样 的事件是生活中的常态，这反映了不公平现 象的存在。 2006 年陈冯富珍博士作为总干事候选人在世 界卫生大会上表示 : “我想明确一件最重要的事情。减轻疾病负担 很重要，强化卫生体系很重要，减少疾病危 险因素的威胁很重要，这些都是至关重要的。 但对我来说最重要的是人，特别是两个特定 人群。我希望通过我们对非洲人民健康和妇 女健康的贡献来评价我们的工作。” 全球每10万活产儿死亡数 实现：下降44% 千年发展目标：下降75% 53万孕产妇死亡 44万死亡 38万死亡 30万死亡 216/10万 288/10万 385/10万 385/10万 11 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 03 孕产妇和儿童死亡率大幅度地下降是全球卫 生领导人和工作者引以为荣的也是值得庆祝 的。孕产妇死亡率降低 3/4 和 5 岁以下儿童 死亡率降低 2/3 是两个备受关注、与卫生相 关的千年发展目标，这两个目标明确而具体， 雄心勃勃地将众人凝聚起来。尽管两个目标 都没有完全实现，但是具有创新性，展现了 共同行动、激情和承诺可产生重大变化的可 能性。 2005—2015 年孕产妇死亡率下降 了25% 尽管许多用来估计孕产妇和儿童死亡率的数 据源于调查非正式的死亡登记系统，时间上 有些滞后，下降的结论也有些不确定性。但是， 毫无疑问大幅度地下降是实实在在的。20 世 纪 90 年代，与前一年同期相比，每年都有改 善。21 世纪前进的步伐加快了，孕产妇死亡 率的下降与艾滋病死亡率大幅下降、鼓励在 医疗机构分娩、普及产前检查、易使用抗生 素治疗产后败血症、通过避孕措施和计划生 育服务降低生育率等因素有关。儿童死亡率 下降的因素也是多方面的，营养改善和各种 疫苗（特别是麻疹疫苗）接种是至关重要的。 死亡率下降不能仅归功于卫生部门，社会经 济发展也起到重要的作用。 2005—2015 年 5 岁以下儿童死亡 率下降了1/3 尽管在妇幼卫生方面取得成绩，但是不平等 的问题仍然存在，而且很严峻、很普遍。撒 哈拉以南非洲地区孕产妇死亡风险为 1/36， 而高收入国家仅为 1/4900。在 10 个情况最佳 的国家，5 岁以下儿童死亡风险仅为 1/400， 而在 10 个情况最差的国家平均风险达到 1/8， 两者相差 50 倍。在 24 个国家孕产妇死亡率 2015年孕产妇死亡在哪里？ 一个 代表2000人死亡 刚果（金） 坦桑尼亚联合共和国 其他国家 尼日利亚 印度 埃塞俄比亚 巴基斯坦 肯尼亚 12 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 03 仍然很高，这些大多数是脆弱国家、受冲突 的地区或者两者兼而有之。不幸的是，人们 对这样的统计数据并不陌生，这些数据也不 是总能引起人们应有的震惊。但是，这些数 据必须被视为不可接受的，如果能拯救众多 生命，可以强调这些数据。 表面上可持续发展目标对孕产妇和儿童死亡 率的重视不及单独和具体的千年发展目标。 但是在这两方面雄心勃勃的目标现在都纳入 了可持续发展目标。尽快实现这些较困难目 标还是可能的。对于分娩的基本条件，如缺水， 加以改善即可。有些方案实施起来比较困难， 例如需要数百万包括熟练接生员在内的卫生 人员。 个体技术与社会干预的影响大不同，可以继 续进行。然而，需要从个体干预转向复杂的 系统建设，以真正可持续和公平的方式解决 孕产妇和新生儿死亡率的双重问题，为普及 千年发展目标：下降67% 1990 2000 2005 2015 全球每千活产儿死亡数 实现：下降53% 1270万5岁以下儿童死亡 980万死亡 830万死亡 590万死亡 76/1000 63/1000 43/1000 91/1000 尼日尔 尼日利亚塞拉利昂马里 贝宁 刚果（金）中非共和国乍得 索马里 卢森堡 冰岛 安道尔 新加坡 日本 塞浦路斯 斯洛文尼亚挪威 芬兰爱沙尼亚 最差10国： 5岁以下儿童死亡率平均为1/8 最佳10国：5岁以下儿童死亡率平均为1/400 安哥拉 2015年合并数据 13 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 03 产前检查、医疗机构有熟练的接生员，最终 实现全面、优质保健的目的打下基础。还需 要在条件不稳定的情况下采取有效的人道主 义行动。2017 年发生了与冲突有关的移民、 卫生服务中断和粮食危机等，幼儿是首当其 冲的受害者。 迄今为止很多进步都依赖于社会经济发展。 社会经济发展必须可持续，这并不容易，必 须要加以维护。腐败、粮食不安全以及气候 变化等都是不容忽视的影响因素。 控制新生儿期（出生后前 28 天）死亡是至关 重要的。新生儿死亡率比生命早期其他指标 下降得慢，因此，新生儿死亡率在儿童死亡 率中所占比例很大。2015 年 100 万婴儿在出 生当天夭折，260 多万婴儿出生后一个月内死 亡。2014 年世界卫生大会通过了《终止新生 儿可预防性死亡行动计划》（Every Newborn: An Action Plan To End Preventable Deaths）， 突出了这一需求。行动计划要求各国到 2030 年将新生儿死亡率降至 12/1000 活产儿以下， 也要求终止可预防的死产。对于各国来说， 2030 年的目标是新生儿死亡率 12‰。 妇幼卫生领域千年发展目标的突出了降低死 亡率，这是好的而且是必要的，但是，它掩 盖了儿童早期发展等其他重要方面的需要和 工作。随着死亡率进一步下降，其他的重要 问题就显现出来。 世卫组织有效地利用其在联合国大家庭中的 地位解决妇幼卫生问题。2010 年联合国秘 书长领导了《全球妇幼卫生战略》（Global Strategy for Women’s and Children’s Health） 的实施，即“每个妇女每个儿童”倡议。后 来对该策略进行了更新和扩展，将青少年纳 入其中。世界卫生组织秘书处一直在密切 地支持着，世界卫生大会审查并批准了这 些战略。《全球妇女、儿童和青少年卫生战 略》（Global Strategy for Women’s，Children’s and Adolescent’s Health）的周期是 2016 年至 2030 年，其目标不仅仅局限于降低死亡率。 “世界上每个妇女、儿童和青少年在任何环境 >100 75~100 50~75 25~50 <25 无数据 5岁以下儿童死亡率 2015年每千活产儿死亡数 14 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 03 中都拥有身心健康的权利，有社会和经济生 存发展的机会，并能够参与建设繁荣和可持 续的社会。” 战略阐述了如何通过强化国家领导力和卫生 体系、社区参与、研究和创新等行动来实现 与可持续发展目标相一致的目标。 联合国批准了“每个妇女每个儿童” 倡议 世界卫生组织和世界卫生大会在最近公布 的 联 合 国《2016—2025 年 营 养 行 动 10 年 》 （Decade of Action on Nutrition，2016-2025） 起到了关键作用。营养不良仍然是导致儿童 死亡和患病的主要原因，它还阻止孩子们发 挥他们的身体和认知的潜能。在这方面还有 很多东西要研究。 妇幼卫生领域取得的成绩是全球卫生的辉煌 成就，重大、可衡量的改善，对于人类、对 于经济来说都是很重要的。就像过去 10 年其 他重大进步一样，成就之后面临新的挑战。 15 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 03 16 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 04 微生物： 古老与现代 过去 10 年一系列抗击、征服或控制传染病的 目标在全球卫生议程中占有重要地位。艾滋 病、结核病和疟疾等重大疾病防治取得重大 进展，但仍然是重点。新发疾病的威胁及它 们在全球范围内传播的风险成为一个问题。 特别是在自然灾害、饥荒和冲突的时候，伤 寒和霍乱等疾病会凶险起来，造成严重后果。 世界上热带和亚热带地区的传染媒介一直是 残疾的源头。它们所致疾病在世界富裕地区 很少见，但对受影响的贫困国家或地区的打 击是毁灭性的。许多常见的医源性感染导致 严重疾病，需要住院治疗，费用很高。未控 制的感染可导致死亡和残疾。大规模的传染 病爆发甚至会削弱国家经济实力。成功需要 好的计划、不断提高的应变能力、完善的监 测系统、有效的预防控制措施，以及及时、 恰当的治疗。 过去 10 年尽管传染病防治仍然面临着已知的 挑战，但是成绩斐然。 艾滋病的流行和世界对它的反应改变了全球 公共卫生的面貌。在世纪之交疫情蔓延，但 对它的反应刚刚起步。随着众多社会团体的 活动、广泛的政治承诺和大量资金的投入， 情况发生了变化。 全球抗击艾滋病、结核病和疟疾基金自 2002 年成立以来已向艾滋病项目提供了 160 亿美 元。全球基金的捐赠者和其他许多人的资助， 扩展了抗逆转录病毒的使用范围，目前有 17 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 04 1600 万人接受这一治疗，而 2000 年只有 70 万人。通过谈判，这些药物的价格大幅度降 低。从 2005 年到 2015 年艾滋病死亡率下降 了 50%，相应使儿童和孕产妇死亡率大幅度 降低，新病例数减少了 18%。 2005—2015 年艾滋病死亡率下降 了一半 21 世纪的下半叶，治疗规模不断扩大，但对 治疗的反应开始复杂起来。人们认识到预防 滞后于治疗，并努力纠正这种现象。从世界 卫生组织总干事提出的《健康融入所有政策》 （Health In All Policies）这一策略中可以发现 在药品管控政策、人权对话和与性别有关的 讨论之中都考虑到艾滋病。越来越多地利用 数据分析发现最需要帮助的人群，并与他们 一起工作，特别是撒哈拉以南非洲地区的年 轻女孩。技术和服务模式都有快速的创新。 在非洲东南部男性包皮环切术的保护作用被 认可，并广泛开展。 近年来出现了从独立项目转向国家综合规划， 有些进展较好，最好的是提供了一整套的艾 滋病服务，即在生命和疾病过程中降低风险、 检查、治疗和护理。 现在世界卫生组织建议在确诊后立即接受抗 逆转录病毒治疗，这有利于个体的治疗，并 大大降低了传播的风险。值得注意的是大约 有一半艾滋病病毒感染者不知道他们已经 感染。 2016 年世界卫生大会通过了一项新的全球卫 生部门艾滋病战略，中心是在全民健康覆盖 框架内加强艾滋病服务，强调了其与结核病 和肝炎的联系。 第 6 个千年发展目标提出“到 2015 年遏制并 开始扭转艾滋病毒 / 艾滋病的蔓延”。这个目 标已实现，并取得丰富的经验，如社会团体 可以发挥的促进作用，与社区共同创建卫生 服务，以及迅速扩大规模等。这些经验，包 括药品价格谈判的经验，正应用于肝炎防治。 但是，正如全球战略指出的艾滋病防治还远 远未结束。 2000-2015年全球基金分配 结核病 50亿美元 艾滋病 160亿美元 疟疾 80亿美元 2005-2015年的主要成果 减少新 发病例率 减少 死亡率 艾滋病 18% 50% 疟疾 21% 49% 结核病 16% 25% 18 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 04 疟疾是一种人类早期就有影响的疾病，这在 古代就有记录。在最终被完整记载的疟疾历 史，过去的 10 年将非常突出。2005—2015 年， 疟疾死亡率差不多下降了一半。这主要是通 过预防疟疾病例发生、提高诊断和治疗疟疾 患者来实现。 2005—2015 年疟疾死亡率降低了 49% 自世纪之交以来，已避免了 600 多万人死于 疟疾，其中大部分是撒哈拉以南非洲地区 5 岁以下儿童。这通过大规模的预防、诊断和 治疗来实现的。第一，也是最重要的是扩大 了经过杀虫剂处理的蚊帐的使用范围。2004 年以来仅为撒哈拉以南非洲地区就提供了 9 亿多顶蚊帐。第二，推广快速诊断试验，这 使撒哈拉以南非洲地区发现疟疾疑似病例的 比例从 2010 年的 40% 提高到 2015 年的 76%。 第三，提高了有效的基于青蒿素的联合疗法 的可及性和使用率。 根据寄生虫病患病和发病的模型，估计 2000 年至 2015 年，疟疾干预措施使撒哈拉以南非 洲地区疟疾病例减少了 70%。诊断和治疗对 于疟疾控制方面突破性进展至关重要，但是 蚊帐的预防效果非常明显，在减少疟疾发生 中的作用约占 50%。通过全球基金和其他双 边捐助者大量投资加上国内投资，这些工具 已大规模使用。 2004年以来在非洲分发了9亿顶蚊帐 除了疟疾病例和死亡数显著减少外，各国正 朝着消除疟疾的方向前进。2007 年至 2016 年 有 6 个国家被认证无疟疾，另外 13 个国家报 告无本地病例。尽管取得了这些成就，疟疾 仍然在 90 多个国家流行，2015 年约有 2 亿患 者，且 42.9 万人死于疟疾。世界卫生组织及 其合作伙伴明确了 2030 年的目标，如《2016— 2030 年全球疟疾技术战略》（Global Technical Strategy for Malaria 2016—2030）所阐以 2015 年为基线，将疟疾发病率和死亡率降低 90%， 在至少 35 个国家消除疟疾。 过去 10 年结核病防治也取得了进展。从 2005 年到 2015 年，结核病新增病例和死亡人数分 别减少了 16% 和 25%。2000 年到 2015 年期 间，结核病诊断治疗挽救了大约 5000 万人的 生命。尽管不如抗击艾滋病和疟疾所取得的 成果令人瞩目，但是这些成果还是很有意义。 这在一定程度上源于在十几年前结核病防治 就取得了巨大的进展，而艾滋病和疟疾则不 然。结核病仍然是艾滋病病毒感染者死亡的 主要死亡原因，占死亡的 1/3。 目前全世界 60% 的结核患者集中在 6 个国家， 仅印度就占了 27%，另外 33% 的患者来自印 度尼西亚、中国、尼日利亚、巴基斯坦和南 非。结核病防治涉及公共卫生许多不同方面。 营养不良是一个关键的危险因素，特别是对 死亡率来说，吸烟也是如此。病例监测也是 至关重要的。诊断和治疗要求医疗系统功能 完善。 19 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 04 非洲人类锥虫病 美洲锥虫病 内脏利什曼病 麻风 血吸虫病 土壤传播的蠕虫 沙眼 盘尾丝虫病 淋巴丝虫病和盘尾丝虫病 淋巴丝虫病 2015201420132012201120102009 200 0 400 600 800 1,000 药 企 捐 赠 的 数 百 万 种 药 物 1,200 1,400 1,600 1,800 来源：Uniting to Combat NTDs 2014 年世界卫生大会通过了《终止结核病战 略》（End TB Strategy），终止结核病流行的 总目标已纳入可持续发展目标之内。《终止 结核病战略》的目标是到 2030 年发病率下 降 80%，死亡率减少 90%，保证没有结核病 患者和他们的家庭因结核病而负担沉重费用。 该战略的三大支柱是 ：综合的、以患者为中 心的治疗和预防 ；大胆的政策和支持性的体 系 ；加强研究与创新。 抗生素耐药使控制结核病疫情变得复杂起来。 目前，只有不到半数的耐多药结核病患者治 疗成功，仅有 1/4 的广泛耐药结核病患者治 疗成功。 结核病的资金投入没有达到艾滋病或疟疾的 水平，政治关注也没有达到同等高度。计划 于 2017 年 11 月举行的世界卫生组织结核病 部长级会议和 2018 年联合国大会将有助于解 决这一问题。 2000—2015 年避免了 5000 万结 核病患者死亡 有一组疾病，其特点是能够造成长期残疾和 身体缺陷，甚至死亡，影响 149 个国家的 10 亿人—全球 1/7 的人口。这 17 种疾病统称 为被忽视的热带病，受其影响的是世界上最 贫穷的社区。他们之所以被“忽视”，是因 为在世界上富裕国家不存在，这些疾病也很 少通过传播构成全球威胁，而受其影响的是 贫穷的人群，他们在世界上没有权力也没有 声音。 2007 年 5 月世界卫生组织总干事陈冯富珍博 士在世界卫生大会上致辞时说 : “上个月召开了被忽视的热带病全球合作伙伴 第一次会议，这是一个转折点。为至少 10 亿 人减轻疾病负担的前景从未有如此光明。” 2012 年世界卫生组织推出了《加快消除被 忽视的热带病对全球的影响 ：行动路线图》 （Accelerating work to overcome the global impact 20 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 04 of neglected tropical diseases: a roadmap for implementation）。该计划设定了每一种疾病 防治目标，并提出了实现目标的关键机制。 这些机制有如何大规模分发和使用安全、 单剂量药物治疗疾病，控制虫媒和中间宿 主，公众教育，建立安全供水系统和良好 的卫生设施，以及应对人畜之间传播的风 险。这个非常具体的行动计划向前迈出了一 大步。 另一个重要突破是 2012 年 1 月在英国伦敦召 开的一次会议，呼吁《联合抗击被忽视的热 带病》（Uniting to combat NTDs）。全球卫生 组织的领导人、13 家制药公司代表和一些主 要捐赠者聚集在一起，他们做好准备支持一 个非常具体的目标以实现世界卫生组织行动 路线图中 10 个被忽视的热带病的防治目标， 并 发 表 了《 伦 敦 宣 言 》（Uniting to combat NTDs）。 制药公司扩大药品供应的承诺至关重要。比 尔和梅林达·盖茨基金会联合主席比尔·盖 茨在会议上说 : “随着时间的推移，人们也许会怀疑是否应该 称这些疾病为被忽视的疾病。随着这些重要 活动的进行，我们将称之为热带病。” 2015 年每秒钟就有 40 次针对被忽 视的热带病的治疗 2015年最大的公共健康私人合作伙 伴—制药公司捐赠了 15 亿片药 物用于治疗被忽视的热带病 2017 年《伦敦宣言》发表五周年。总的来说， 不论是在具体疾病防治还是在某些国家，都 取得了很好的进展。2015 年开展了 12 亿次 治疗，相当于每秒钟 40 次。自 2013 年以来， 每年美洲有一个国家消除盘尾丝虫病，现在 仅剩一个很小的疫区，美洲将清除这种疾病。 与 2011 年相比，2015 年需要接受治疗的人数 减少了 3.3 亿人。世界上只有 25 例麦地那龙 线虫病例。 联合国议程上关于抗菌药物耐药的 行动 过去 10 年世界不得不去思考一个不可思议 的事情 ：即使可以获得护理和基本治疗， 对于数百万依赖抗菌药物生存的人们来说， 耐广谱抗菌药物的病原体 （细菌、病毒、真 菌、寄生虫）生长可能意味着他们的时间 不多了。 2010 年世界卫生组织发现，在中低收入国 家艾滋病患者中对于新的逆转录病毒治疗的 耐药性为 7%，高收入国家为 10% ～ 20%。 2014 年估计全世界有 48 万耐多药结核病例， 其中 10% 是广泛耐药结核。2016 年在 5 个国 家发现了对一线治疗药物耐药疟疾。 过去 10 年全球对抗菌药物耐药的问题越来越 关注。 2015 年世界卫生大会通过了《控制细菌耐 药 全 球 行 动 计 划 》（Global Action Plan on Antimicrobial Resistance），这个全球行动计 划确定了 5 个主要行动领域 ： · 通过有效的沟通、教育和培训，提高对 抗菌药物耐药的认识和理解 ； · 通过监测和研究加强对耐药的认识和 循证 ； 21 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 04 · 通过有效的卫生和预防措施降低感染发 生率 ； · 在人类和动物中优化抗菌药物的使用 ； · 考虑到所有国家的需求，发展可持续投 资，增加对新药、诊断工具、疫苗和其 他干预措施的投资。 在制定这个蓝图中，世界卫生组织与联合 国 粮 食 及 农 业 组 织（Food and Agriculture Organization of the United Nations，FAO） 和 世 界动物卫生组织（World Organisation for Animal Health，OIE）密切合作通过《一个健康》（One Health）的策略推广最佳实践，以避免发生 耐药菌感染及其传播，在人类和动物中合理 使用抗生素。 世界上有些地区 50% 的抗菌药物用于食用动 物。在医疗过程中，存在剂量不足、过度使 用和滥用抗生素等问题。情况是各种各样， 无法获得疗程所需药物的患者只能得到 2 ～ 3 粒药，治疗感染的药物不需要处方就能购买， 不按照临床规定剂量使用非处方药物，在临 床上预防性用药。 抗菌药物耐药已经从单纯的专业和科学领域 转变为政治领袖关注的全球重点领域，成为 目前世界各国政府和卫生部门面临的紧迫问 题。这并不是偶然发生的，而是过去 10 年持 续的技术分析、宣传、倡导和引领的结果。 英国、瑞典、荷兰和其他国家政府都支持采 取必要的行动。 2016 年 9 月参加联合国大会的国家元首做 出了他们对解决抗菌药物耐药问题的政治 脊髓灰质炎 麦地那龙线虫 1315病例 2016 37病例 2007 9585病例 25病例 22 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 04 承诺，《联大抗菌药物耐药高级别峰会政 治 宣 言 》（Political Declaration of the High- Level Meeting of the UNGA on Antimicrobial Resistance）认识到预防控制人类和动物感染 对于解决抗菌药物耐药至关重要。在讨论过 程中强调了对已有的和将问世的抗菌药物和 疫苗的负担能力和可及性。 国家元首们承诺 : · 加强对用于人和动物的抗菌药物的使用 和销售的监管 ； · 鼓励创新，使用抗菌药物替代品、新的 诊断技术和疫苗 ； · 提高公众和卫生人员对预防耐药菌感染 的认识 ； · 促进国际合作，实施国家计划。 在作出历史性的承诺之后，世界卫生组织总 干事陈冯富珍博士说 : “抗菌药物耐药性对人类健康、发展和安全构 成了严重威胁，今天所作的承诺必须立刻转 化为人类、动物和环境卫生部门迅速、有效、 挽救生命的行动，我们的时间不多了。” 重要的行动不一定总是全局性和政治性的。 例如，英国和中国的研究人员合作进行了对 抗菌药物多粘菌素耐药性的研究。这种药有 两个重要特点 ：其一，它作为促生长剂广泛 用于动物饲料，特别是猪的。它很便宜。其二， 它是用于治疗其他抗菌药物耐药的重症感染 患者的最后一种抗菌药物。这有一个典型的 抗菌药物耐药的现象 ：畜牧业和农业生产中 使用抗菌药物在动物中产生了耐药菌株，当 人们患有类似的感染时，就会出现抗菌药物 无效的情况。研究人员在猪大肠杆菌中发现 了一种耐药基因，该基因具有转移和赋予其 他细菌耐药性的危险。 因此，2016 年 11 月中国农业部禁止使用多粘 菌素作为动物饲料添加剂。这项研究的主要 研究者之一，北京食品营养与人类健康高精 尖创新中心沈建忠教授说 : “在食用动物中使用抗菌药物成为全球性食品 安全和公共卫生的问题，各国应该更谨慎、 更理性地对待动物使用抗生素。基于对此类 抗生素的风险评估，中国政府迅速地将作为 促生长剂的多粘菌素从饲料添加剂清单中抹 去。我们的政府非常重视抗菌药物耐药问题， 因此，非常有效地解决了这个问题。” 这些话概括了在减少威胁的行动中面临的关 键问题之一，但也说明了采取果断行动的时 机。像抗菌药物耐药这样复杂的问题，没有 简单的解决方法，但是，这并不意味着没有 办法。行动需要有高层领导支持、协调和监 督行动计划，还需要建立伙伴关系以及政府、 医疗卫生、科学、政策制定、工业、农业、 粮食生产、养殖业、制药公司和社会团体等 多部门合作。 64亿人生活的国家有国家级抗菌药 物耐药行动计划 世界卫生组织对国家进展的监测显示，到 2017 年 4 月有 69 个国家完成或批准了抗菌药 物耐药国家行动计划。这些国家的人口超过 64.5 亿，占世界人口的 90% 以上。 2017 年 2 月世界卫生组织公布了第一份 12 种 抗菌药物耐药病原体目录，开发新的抗菌药 物成为当务之急。因为重点是发现以前未识 别的健康威胁，结核病不在重点之列。但世 界卫生组织重申结核病仍然是研究和开发新 抗生素的首要任务之一。 23 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 04 麦地那龙线虫病 :2016 年全球范围 内减少到25例 消灭疾病是个很有吸引力的主张。一旦实现， 在接下来的时间里人类就生活在没有病原体 的世界。到目前为止，被人类消除了病原体 的疾病只有一个—天花。脊髓灰质炎和麦 地那龙线虫现在几乎接近消除。世界卫生组 织在消除这两种疾病的过程中发挥着领导者 的作用，与会员国和一组正式的、各不相同 的合作伙伴共同努力。 过去 10 年消除脊髓灰质炎和麦地那龙线虫的 工作都取得了很大进展。但是，早期之后这 两种疾病发病率下降的速度逐年递减。越接 近疾病根除，困难就越大。根据定义，病原 体残留之处也是其最难被消除之地。因此， 进展渐缓并不令人意外，但根除的困难规模 之大是完全出乎预料的。给出一个明确的选 择可能不太理智，但根除脊髓灰质炎和麦地 那龙线虫似乎迫在眉睫。无论今后是否还有 全球根除其他疾病的行动，根除这两种疾病 的过程都有可借鉴的重要经验。 优先顺序1: 紧急 优先顺序2: 高度 优先顺序3: 中度 鲍氏不动杆菌, 耐碳青霉烯类抗生素 绿脓杆菌, 耐碳青霉烯类抗生素 肠杆菌科, 耐碳青霉烯类抗生素 , 耐第3代头孢霉素 肠球菌, 耐万古霉素 金黄色葡萄球菌, 耐甲氧西林, 万古霉素中介和耐药性 幽门螺旋杆菌, 耐克拉霉素 弯曲杆菌, 耐喹诺酮类 沙门菌, 耐喹诺酮类 淋球菌, 耐第3代头孢霉素,耐喹诺酮类 肺炎链球菌, 青霉素不敏感 流感嗜血杆菌, 耐氨苄青霉素 志贺杆菌, 耐喹诺酮类 2017年2月世界卫生组织发布急需抗生素清单 24 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 05 非传染性 疾病流行 2010 年世界卫生组织发表了《非传染性疾病的 状 况 报 告 》（Status Report on Noncommunicable Diseases），明确提出 ： · 非传染性疾病是世界上最主要的健康问 题，造成的死亡占总死亡人数的近 2/3， 大部分由心血管疾病、癌症、糖尿病和 慢性肺病所致。 · 这不仅仅是富裕国家的问题，非传染性 疾病负担的 80% 源于中低收入国家。 · 主要原因是经济转型、快速城市化和现 代生活方式带来的 4 种行为危险因素， 即烟草使用、不健康饮食、缺乏运动和 有害使用酒精。 该报告以行动为导向，为政府提供了一系列 “最佳干预措施”。即使在资源有限的条件下， 这些干预措施也是高效、可行、可负担的。 有些是人群干预措施，如无烟公共场所、减 少食物含盐量。有些是医疗干预措施，如治 疗心肌梗死时使用阿司匹林，使用简单吸入 器治疗哮喘。 世界卫生组织总干事陈冯富珍博士在 2010 年 报告的前言中指出 : “情况依然严峻。这些疾病的流行早已大大超 出低收入国家的应对能力。若不采取紧急行 动，这些疾病不断加剧的经济负担将会失控， 即使全世界最富裕国家届时也会无力掌控。” 25 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 05 2011 年 9 月联合国大会举行了关于非传染性 疾病预防控制高级别会议，并发表了政治宣 言，承认 : “非传染性疾病给全球带来的负担和威胁是 21 世纪发展的主要挑战之一，有损世界各地的 社会和经济发展，并威胁到国际认同的发展 目标的实现。我们认识到非传染性疾病对许 多会员国的经济是一个威胁，可能导致国家 之间及人群之间的不平等加剧。” 设定的目标：到 2025 年非传染性 疾病的死亡率下降25% 8 个月后，2012 年 5 月世界卫生大会制定了 一个大胆的目标，即“25×25”。这个目标是 到 2025 年，心血管疾病、癌症、糖尿病和慢 性呼吸道疾病这 4 种主要非传染性疾病导致 的过早死亡人数减少 25%。 随后制定了计划和监测框架，即《2013— 2020 年预防控制非传染性疾病全球行动计 划 》（Global Action Plan for the Prevention and Control of Noncommunicable diseases 2013- 2020）。这个计划提供了关于减少有害使用酒 精、缺乏活动、盐摄入量、烟草使用和高血 压的干预措施。该计划的目标为遏制糖尿病 和肥胖的上升，增加接受基本心血管预防保 健的人的比例，提高治疗所需的基本技术和 药物的可及性。该计划以之前的报告为基础， 向会员国提供了对应明确“最佳干预措施” 的政策选择以实现各目标。计划每 3 年报告 一次进展状况，联合国大会还将举行进一步 的高级别会议。 与总体框架平行进展的一些主要领域，部分 进展很快，部分进展较缓。 《世界卫生组织烟草控制框架公约》（The WHO Framework Convention on Tobacco Control）于 2005 年开始实施。世界卫生组织 使用 MPOWER 这一由六项具有成本效益和影 响力的措施组成的控烟策略，帮助各国执行 《公约》中关键的减少需求的条款。2007 年以 来受到至少一项 MPOWER 措施保护的人数增 加了 2 倍，但是所有国家需要做的工作还有 很多。 男性 女性 2007 2013 2007 2013 全球15岁以上人群的现在吸烟率为23% 21% 8% 7% 26 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 05 尽管烟草使用率略有下降，但是仍有 10 亿人 吸烟，而且其中 80% 的吸烟者来自中低收入 国家。每年有 600 万人因吸烟死亡。将烟草 使用率降低 30% 是《2013—2020 年预防控制 非传染性疾病全球行动计划》的目标之一。 进展远远落后于计划，世界卫生组织不仅监 测 MPOWER 实施情况，也利用数据和认可的 模型监测烟草使用率。《世界卫生组织烟草控 制框架公约》是全球卫生领域一个创举，希 望它成为用于其他非传染性疾病预防控制的 模式。 鉴于 1/4 的成年人和 4/5 的青少年没有达到 必要的身体活动的标准，2010 年世界卫生组 织发布了《健康身体活动全球建议》（Global recommendations on physical activity for health）。过去 10 年普遍认识到缺乏运动是一 个危险因素，这是就它本身而言，而不仅仅 是导致超重和肥胖。 过去 10 年世界卫生组织在饮食和健康方面表 现出了高调的领导地位。关于糖的声明非常 有力。2015 年 3 月世界卫生组织强烈建议游 离糖占人的总能量摄入的比例应不高于 10%， 如将糖摄入量降至总能量摄入的 5% 以下还会 有额外的健康好处。这个建议源于游离糖与 体重增加和龋齿之间关系的研究，为各国制 定政策提供了指导。其中，还特别强调了含 糖饮料，公布了它与肥胖关系的研究。该指 南的发布被媒体广泛地报道，并促使食品业 和饮料业在国际和国家层面的参与。1 年后世 界卫生组织终止儿童肥胖委员会发布了报告， 报告中明确建议成员国“对含糖饮料实行有 效的税收”。 新的儿童和成人糖摄入量指南 在总干事的倡议下“终止儿童肥胖委员会” （Commission on Ending Childhood Obesity）于 2014 年成立。儿童肥胖患病率惊人地上升提 供了明确的流行病学原理和遗传学方面新的 证据，值得密切关注。 个成员国 大多数成年人超重 2007 1.8亿 (8%) 2.8亿 (13%) 2014 2.7亿 (11%) 3.7亿 (15%) 2007 7.3亿 (34%) 7.8亿 (35%) 2014 9.5亿 (38%) (39%)9.8亿 超重 肥胖 27 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 05 该委员会成员来自多个领域，除了资深的公 共卫生专业人员外，还有科学家、经济学家、 资深企业高管、知名运动员等。食品业和饮 料行业密切参与了委员会的工作，其高级代 表几次在会议上见到了总干事。2016 年该委 员会向世界卫生大会提交了报告，将于 2017 年 5 月在世界卫生大会上提交一份执行计划。 该报告向会员国提出了 6 个方面的建议 ： · 促进健康食品的摄入，减少不健康食品 和含糖饮料的摄入 ； · 促进身体活动，减少久坐行为 ； · 将降低儿童肥胖风险的措施纳入孕前和 孕期保健 ； · 支持幼儿时期饮食控制和身体活动 ； · 在学龄儿童和青少年中推广健康的学校 环境、体育活动、健康和营养素养 ； · 管理肥胖儿童和年轻人的体重。 终止儿童肥胖委员会非常重要，体现了解决 肥胖问题的复杂性、多部门合作的重要性 以及行业的关键作用。这些方法都很重要， 将在未来几年继续用于非传染性疾病整个 领域。 终止儿童肥胖委员会提供全球行动 计划 非传染性疾病的其他因素并没有被如此重视。 这些疾病的负担对于社会底层的人群来说很 沉重，在这些群体中许多危险因素更为常见， 许多非传染性疾病的发病率更高，影响更大。 对于穷人而言，医疗费用可能是灾难性的。 有人认为，直接解决社会经济决定因素的目 标应该列入 2013—2020 年行动计划中。 2013 年 世 界 卫 生 大 会 通 过 了《2013—2020 年 精 神 卫 生 行 动 计 划 》（2013—2020 Mental Health Action Plan），这是第一个关于精神卫 生的全球计划。这个计划不仅要解决精神疾 病，而且要改善心理健康。它为会员国和包 括世界卫生组织在内的机构制定了一系列目 标和行动建议。 2008 年世界卫生组织总干事宣布《精神卫生 差 距 行 动 计 划 》（Mental Health Gap Action Programme）开始实施，这个计划旨在改善 90 个资源匮乏国家主要精神疾病（抑郁、痴 呆、精神分裂、癫痫等）患者的护理。世界 卫生组织发起了很多活动，如正在进行的“心 情不好？我们聊聊吧！”，以提高对精神卫 生问题的重视。2012 年世界精神卫生日上， 世界卫生组织与作家、插画家马修·约翰斯 通（Matthew Johnstone）合作，发布了一个短 视频“我有一只黑狗，他的名字叫抑郁症” “I had a black dog，his name was depression”。 其目的就是提高人们的认识，鼓励抑郁症患 者采取有效措施来驯服他们自己的黑狗。到 目前为止，这段视频在 YouTube 上已经被浏 览了 750 万次。 世界卫生组织估计，世界人口的 4.4%（超过 3 亿人）患有抑郁症、3.8% 患有焦虑症，每 年近 80 万人自杀。精神卫生已列入可持续 发展目标，希望 10 年以后，精神卫生更加被 关注。 在过去的 5 年痴呆症这个问题越来越突出， 2017 年 5 月世界卫生大会将讨论《痴呆症行 动 计 划 》（Dementia Action Plan）。2013 年 8 国集团召开了痴呆症特别峰会，世界卫生组 织总干事陈冯富珍博士在会上说 : “痴呆症是一种费用高、令人心碎的流行病， 在医学上、心理上、情感上和经济上都有巨 大的影响。我想不出来还有什么其他情况比 28 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 05 失去功能、丧失独立性和需要照顾更糟糕。 我想不出还有什么其他情况会给社会、家庭、 社区和经济造成如此沉重的负担。我想不出 还有什么其他情况迫切需要创新和突破性 发现。” 解决非传染性疾病问题是复杂的，这种复杂 性正在被越来越多的人接受，这种情况必须 继续下去。如果想从根本上解决非传染性疾 病问题，需要医疗和卫生领域之外的许多部 门参与。还会涉及既得利益，如果可能的话， 与企业界一起卓有成效地工作，如果不行， 就明确底线。还可能被批评为“保姆”，这在 传染病项目中是不存在的。需要持续的政治 意愿，需要加强卫生体系建设以提供越来越 复杂的预防、治疗和护理服务。尽管不容易， 但这是全球公共卫生未来的核心。 全面实施烟草政策的国家数 完 全 遵 循 全 球 政 策 65 49 24 39 29 33 2015 2008监督烟草使用与预防政策 保护人们免受烟草烟雾危害 提供戒烟帮助 警告烟草危害 确保禁止烟草广告、促销和赞助 提高烟税 29 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 05 30 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 06 用一代人时间 弥合差距 2008 年 夏 季 由 英 国 澳 大 利 亚 流 行 病 学 家 Michael Marmot 爵 士 领 导 的“ 健 康 问 题 社 会 决 定 因 素 委 员 会 ”（Commission on Social Determinants of Health）向世界卫生组织总干 事提交了报告。在接受报告时陈冯富珍博士 说 :“卫生系统不会自然地转向公平”，并 呼吁“前所未有的领导力量迫使包括卫生 部门之外的所有参与者检查他们对健康的 影响。” 世界卫生组织长期致力于卫生公平，在向世 界展示这个委员会的工作《用一代人时间 弥合差距 ：针对健康的社会决定因素采取 行动以实现健康公平》（Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health） 的 同 时， 在更深层次、用更基础的方法阐述了公平、 社会正义、贫困、健康与引人注目的不平等 ： · 澳大利亚土著男性的预期寿命比其他澳 大利亚男性少 17 年 ； · 印 尼 穷 人 孕 产 妇 死 亡 率 比 富 人 高 3 ～ 4 倍 ； · 内罗毕贫民窟的儿童死亡率是城市其他 地区的 2.5 倍 ； · 玻利维亚一个没有受过教育的母亲生下 的婴儿出生第 1 年死亡概率超过 10%， 而一个至少接受中等教育的妇女生下的 婴儿第 1 年死亡概率不到 0.4% ； · 乌干达最富有的 1/5 家庭的 5 岁以下儿 31 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 06 童死亡率是 106/1000 活产儿，但是最 贫穷的家庭 1/5 家庭的 5 岁以下儿童死 亡率达 192/1000 活产儿（1/5 出生在最 贫穷家庭的婴儿注定不能过他们的 5 岁 生日）。 尽管委员会公布的统计数据很不乐观，但报 告中并不全是坏消息。报告中有许多例子说 明，目标明确的行动、地方和国家的创新以 及有力的领导可改变状况。报告列举了牙买 加贫困社区儿童早期发展综合方法，古巴普 及儿童发展服务，智利扩大了面向社会弱势 儿童的学前教育。 健康问题社会决定因素委员会设立了 3 个指 导原则来制订行动方案以解决相应的问题、 满足需求 ： · 改善日常生活环境，即改善人们出生、 成长、生活、工作和老年环境 ； · 在全球、国家和地方各级改变造成这些 日常生活环境的结构性因素，解决权力、 金钱和资源分配不公平问题 ； · 衡量问题，评估行动，扩大知识基础， 向员工讲解健康的社会决定因素，并提 高公众对健康的社会决定因素的认识。 世界卫生组织此前曾对健康状况不佳的根本 原因进行了高级战略分析。例如，在《1999 年世界卫生报告》（1999 World Health Report） 中布伦特兰总干事估计，1960 年以来 30 年中、 低收入国家死亡率下降约一半主要由收入和 教育这两个影响因素推动的。但是，报告中 强调的是加强卫生体系而不是与其他部门广 泛的行动。 2001 年由 Jeffrey Sachs 教授领导的“宏观经济 与健康委员会”（Commission on Macroeconomics and Health）关注教育、环境卫生和水安全等 领域的投资对健康潜在的益处，并探索解决 贫困对健康的益处。 健康问题社会决定因素委员会是世界卫生组 织近 10 年来推出的最重要的政治举措之一。 通过区域和国家广泛参与，不仅在技术上探 讨健康公平的重要性，而且用转换的方法来 思考“健康”本身的意义，以及如何在实际 应用中真正从根源上解决健康状况不佳和社 会经济损失。 传统上，尽管全球卫生界从诊断的角度已经 认识到对健康更广泛、更深层次的影响，但 是行动往往还是集中在已确定的危险因素， 如吸烟、缺乏活动、肥胖、高血压、不健康 营养、过量摄入酒精。不同于这些已确定的 健康危险因素，社会决定因素一般被认为不 可改变。然而，委员会这个报告中的案例以 及世界卫生组织各区域和各国政府建立马莫 特（Marmot）式诊断和计划的方式，使人们 认识到实际行动不仅是可行的、必要的，而 且在道义上也势在必行。 一个健康问题社会决定因素委员会 让区域和国家行动起来 2011 年巴西政府和世界卫生组织召开了政府 首脑、部长和政府代表出席的一次重要会议， 会议发表了《健康问题社会决定因素里约政 治 宣 言 》（Rio Political Declaration on Social Determinants of Health）。宣言道 ： “我们重申国家内部和国家之间存在的卫生不 公平现象在政治、社会和经济上是不容接受 的，也是不公正的，而且在很大程度上是可 以避免的，促进卫生公平对于可持续发展和 改善全体人民的生活质量和福祉必不可少， 而这反过来又可以促进和平与安全”。 32 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 06 特别重要的是会议的方向是“政治性的”。如 果到了对疾病、过早死亡和残疾的原因采取 行动的时候，那么承诺、思想和意愿都要来 源于政治性。 事实上，在全球政策领域卫生往往是由其他 部门决定的，这次会议上政府首脑们清楚地 意识到这点，《里约政治宣言》提出了 5 个行 动区域 : 1. 采纳更好的卫生和发展治理方式 ； 2. 促进参与政策制定和实施进程 ； 3. 进一步调整卫生部门的方向，使之注重 减少卫生不公平现象 ； 4. 加强全球治理与合作 ； 5. 监测进展和加强问责制。 继续使健康问题的社会决定因素受到关注是 世界卫生组织未来发挥的最重要作用之一。 这并不仅意味着世界卫生组织要确保卫生领 域的许多不公平现象与实际行动方案相匹配， 更意味着其要成为一种广泛的、跨学科的、 多部门的公共卫生哲学的管理者。 过去 10 年使人们对健康问题的社会决定因素 有了更广泛的认识，需要采取行动来解决这 些问题。在可持续发展时代，这将是至关重 要的。可持续发展目标承诺“不让任何人掉 队” （leaving no-one behind），意味着健康受到 保护并被提升，以实现生命的潜能。同时， 改善不利的社会环境使人们获得尽可能好的 健康。 伤 残 调 整 生 命 年 （ 每 10 万 人 ） 人类发展指数 很高 300 250 200 150 100 50 0 300 250 200 150 100 50 0 高 中 低 人类发展指数 很高 高 中 低 宫颈癌 乳腺癌 残疾状态生存年数 寿命损失年数 相反的趋势：经济发展与疾病之间的关系并不总是简单明了的 33 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 06 34 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 07 健康 老龄化 人口老龄化的数据令人生畏。未来 40 年世界 上 80％的 60 岁以上的老年人将生活在中、低 收入国家，他们的数量将超过整个高收入国 家人口的总和。同时期中国将有 3.3 亿 60 岁 以上老年人，印度有 2 亿，拉丁美洲和加勒 比地区 1/4 人口也将处于这个年龄段。 随着期望寿命的提高，世界许多地方越来越 关注健康的期望寿命问题，不同国家之间差 异很大。通常认为，随着死亡率下降，疾病 和残疾水平也在下降。也有人认为那些期望 寿命提高的国家，其增加的期望寿命是不健 康和残疾的。事实上，尽管这些数字经常被 引用，没有人知道真相。关于健康期望寿命 的常规信息很少，非常不足。 信息质量的讨论似乎是技术性的，其实并非 如此。如果没有进行老年人口健康和功能全 面有效的测量，就无法对人口老龄化的影响 进行恰当的规划，也不能评估健康老龄化相 关的公共卫生规划。专家们对所选方法也有 不同意见，例如关于疾病的讨论，就没有考 虑一些老年人比其他老年人更可能残疾的事 实。此外，多发病的存在使得测量指标的构 建复杂化。对老年人功能的测量很容易理解， 如询问或评估老年人日常生活活动能力。但 是，这些问题是个人还是环境状况造成的， 很难确定。例如，有人可能会说他们在购买 食物方面有困难，因为他们的步行道路受到 破坏或者因为附近没有商店，所以问题在于 可及性而不是能力丧失。 35 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 07 为了解决老年人健康状况的这些不确定性， 世界卫生组织采用了功能性能力的概念 ： “健康相关属性，使人们能够做他们认为值 得做的事情 ; 它由个人的内在能力、相关环 境特征以及个人与这些特征之间的相互作用 组成。” 随着人口和年龄的增长，在健康和活力状况 下花费的时间多少具有重要的意义。它对个 人的生活质量、所需的社会支持水平和家庭 具有重要影响。最重要的是，它与医疗卫生 需要和需求有很大关联。由于对老年人和超 龄老年人数量的考虑越来越多，他们患有多 种慢性病，被认为是一种负担，因此，许多 关于未来医疗的讨论开始不太乐观。这具有 误导性，事实表明老年人并非在很大程度上 依赖他人且无生产力。从世界范围看，国家 和地区间人口的健康状况、前景和态度以及 工作、家庭生活和民间社会的关系在很大程 度上是多样化的。老年人以多种方式参与社 会并做出贡献，包括作为指导者、照护者、 艺术家、消费者、创新者、企业家和劳动队 伍的成员。这种社会参与也可以增进老年人 自身的健康和福祉。 中、低收入国家已经习惯以年轻人为特征， 但这些群体将是老龄化的群体。如果目前的 资源水平和疾病模式保持不变，高水平的贫 困将使中、低收入国家的老龄化更加复杂。 还有卫生保健系统薄弱、严重传染病和寄生 虫病的威胁、易受自然灾害的影响、极端天 气事件以及区域冲突造成人口流失等因素的 影响，这使老年人将面临更多的危险。 过去 10 年国家元首和卫生部长已经意识到， 他们国家正在经历的人口老龄化将对其社会 各个方面产生重大影响，然而，应对这些挑 战的政策措施发展缓慢。 2015 年世界卫生 组织总干事与帮助老龄国际非政府组织、玛 丽·罗宾逊（Mary Robinson）（一位老人）以 及其他领导人和专家出版了《面对事实 ：老 龄 化 与 发 展 的 事 实 》（Facing the facts: the truth about ageing and development）。 在报告 发布时，总干事说 ： “世界人口的卫生需求正在由于全球老龄化而 发生转变，但各国政府、社会发展和卫生从 业人员的反应迟缓。老年人数的增加是国际 发展的成功事例之一，我们如何对待这一事 实将是今后繁荣的关键之一。” 出生期望寿命; 总计的“健康年”是指完全健康的年数。 “不健康年”是指由于残疾和患病而导致的健康损失的年数。 2000 58.5 健康年 7.9 不健康年 2015 63.1 健康年 8.3 不健康年 36 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 07 世界卫生组织于 2015 年发布了《老龄化与 健康全球报告》（World Report on Ageing and Health）。该报告提出了健康老龄化的愿景， 即“发展和维护老年健康生活所需的功能发 挥的过程”。 该报告提出几个优先领域 ： · 将卫生系统与所服务的老年人口需求相 结合 ； · 发展可提供长期护理的体系 ； · 创建老年友好的环境 ； · 改进测量、监测和理解。 2016 年世界卫生大会通过了《老龄化与健 康全球战略和行动计划》（Global Strategy and Action Plan on Ageing and Health）再次明确了 这些优先事项。这是为了获得成员国承诺和 政治领导人采取实际行动，并使多部门伙伴 更早地参与实施《世界报告》提出的目标和 重点。 出生期望寿命；总计的；2015年数据“健康年”是指完全健康的年数。 “不健康年”是指由于残疾和患病而导致的健康损失的年数。 东南亚 东地中海 非洲 美洲 67.3 健康年 9.6 不健康年 欧洲 68 健康年 8.8 不健康年 西太平洋 7.9 不健康年 68.7 健康年 52.3 健康年 7.7 不健康年 60.1 健康年 8.7 不健康年 60.6 健康年 8.4 不健康年 37 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 07 老龄化与健康全球战略：到 2050 年全球 80％的 60 岁以上老人将在 中、低等收入国家 《老龄化与健康全球报告》和《老龄化与健康 全球战略与行动计划》制定了雄心勃勃、令 人兴奋的议程，以创造健康的老龄化，将期 望寿命的增加视为机会而不是威胁 ： “如果人们在延长的生存时间内健康状态良好 并生活在支持性的环境中，那么他们去做他 们认为有价值的事情的能力就很少受限。” 老年人的情况各异 什么影响老年人的健康 什么是健康老龄化所必需的 我们对老龄化和老年人的看法改变 创建老年友好环境 将卫生系统与老年人的需求相结合 发展长期关怀系统 有些老年人身体机能与 30岁的人相当 健康对于我们老年生活至关重要 有些老年人日常生活起居需要 全天候的照料 个人 生活环境 住宅 辅助技术 交通 公共设施 行为 年龄相关的变化 遗传 疾病 世界卫生组织 38 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 08 人人享有良好 卫生服务 20 世纪下半叶以来直至千年之交，世界卫生 组织致力于卫生服务的承诺是建立在一种将 捐助国政府和基金会加强卫生系统的需求相 结合的一种发展方式之上。强调初级卫生保 健，特别是 1978 年的《阿拉木图宣言》（Alma Ata Declaration），将初级卫生保健提升为实 现人人享有健康目标的最重要途径。 加强卫生体系仍然是一个重要目标，但不能 清晰明确地指导行动和投入。有些人将其作 为发展的“口头禅”，导致了几乎没有明显收 获、没有针对性的援助。这是不公平的，毫 无疑问，需要引入更为集中、以公民为导向 和以权益为目标的“全民健康覆盖”（定义为 “所有人都获得其所需的卫生服务，而不会遭 遇经济困难”），将对卫生系统不足的关注提 高到更高、更突出水平。 全民健康覆盖是一项首要目标 2015 年 2 月在新加坡举行的全民健康覆盖部 长级会议上，世界卫生组织总干事陈冯富珍 博士说 ： “全民健康覆盖是所有政策选项中最有力的一 个社会平衡器，它是公正的终极表达。公共 卫生如果能对我们这个扰攘不断的、失衡的 39 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 08 世界有所帮助，那就在于 ：越来越多的证据 显示，运转良好的包容性卫生系统将促进社 会的凝聚、公平和稳定。” 特别是在过去 5 年世界卫生组织与其他全球 机构、国家元首和卫生部长合作，将实现全 民健康覆盖列入每个人的议程。 联合国大会 呼吁成员国 ：“紧急和大幅度扩大努力，加速 过渡到人人享有可负担起的和高质量的医疗 卫生服务。” 世界银行提出了全民健康覆盖的 3 个主要 目标 ： · 实现更好的健康和发展成果 ； · 防止人们因疾病而陷入贫困 ； · 让人们有机会过更健康、更有成效的 生活。 将该目标纳入可持续发展目标框架至关重要， 可持续发展目标 3 的第 8 次目标为 ： “实现全民健康保障，包括提供金融风险保 护，人人享有优质的基本保健服务，人人获 得安全、有效、优质和负担得起的基本药品 和疫苗。” 世界卫生组织的领导层也与一些重要的团体、 利益相关者和民间组织接触。 例如，广泛咨 询成员之后，国际患者组织协会制定了一套人 人获得卫生保健的管理原则，这个原则基于 ： · 可及性 · 以患者为中心和公平 · 选择和授权 · 高质量 · 伙伴关系和合作 · 可持续和有价值 · 问责和透明 实现全民健康覆盖有多个维度。世界卫生组 织在多方面做了大量工作，尤其是在筹资、 治理和协调方面。 人口：谁在覆盖范围内? 服务： 覆盖哪些服务? 直接成本： 覆盖成本的比例 覆盖机制 实现全民健康覆盖 包括 其他 服务降低分摊成本和费用 扩展至未覆盖的 40 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 08 从全民健康覆盖的讨论中可以清楚地看到， 在世界各地向人民所提供的卫生服务不仅仅 是任何卫生服务，而是基于安全和高质量的 服务。在这一领域，世界卫生组织在过去 10 年做了大量突破性工作。世界卫生组织对卫 生服务质量的关注始于全面的全球患者安全 计划，由两项全球患者安全行动为先导。 第 一项全球患者安全行动旨在让世界各地降低 医疗感染的程度，这个行动的目的很明显， 很容易被政治家、卫生专业人员和民间社会 理解。这与所有国家—富裕国家、贫穷国 家和新兴经济体有关。每个人都能从它的成 功中受益，因为任何人都需要在医疗卫生机 构接受治疗，因此可能会因为感染而成为受 害者。 为了推进主题为“清洁护理更安全”第二项 全球患者安全行动，组织了广泛的宣传活动。 这一行动的理念引起了世界卫生组织 6 个区 域的极大兴趣。部长们签署了承诺，在国家 和区域启动这个行动。尽管一开始范围不大， 这个承诺逐渐覆盖世界 85% 以上的人口。 关于手部卫生的全球患者安全行动 覆盖全球85％的人口 2009 年世界卫生组织发起的手部卫生全球运 动—拯救生命 ：清洁你的手（SAVE LIVES: Clean Your Hands），非常成功。在这项行动之 前世界各地的医院很少以酒精为基础的手部 消毒液（洗手液）。核心信息是缺乏连续的、 即时的、可使用的配有肥皂、一次性毛巾（高 收入国家）的水槽和（或）无清洁水（许多 低收入国家）会置病人于危险之中。以酒精 为基础的手部消毒液的功效、效果和皮肤耐 受性方面的证据使这种消毒液成为确保手部 卫生的首选方法。世界卫生组织通过确保日 内瓦大学医院的配方没有对本地制造的专利 限制，使世界上最贫困的医院可负担酒精为 基础的手部消毒液。 世界卫生组织运动：手卫生5时刻 接触患者 之前 在清洁/无菌 操作之前 可能接触 患者体液 之后 接触患者 之后 接触患者 周围之后 总的来说，第一项行动是一个成熟的变革模 式，通过以下方式动员了世界各地预防感染 ： a）提高对问题负担的认识，吸引利益相关者 参与； b）通过可证明的承诺来吸引国家参与 ; c）提供基于证据的指导和实施工具来推动 改进。 第二项全球患者安全行动认识到由不安全的 外科手术治疗引起的相对较高的疾病负担。 “安全手术拯救生命” （Safe Surgery Saves Lives） 设计了一个手术检查清单，经过试点、评估 和推广在全球范围内使用。早期对其使用的 研究表明，该清单降低了与手术相关的发病 率和死亡率。世界各地的主要专业机构认可 它，它在许多国家的医院广泛使用，如果要 避免手术关键风险的话，它越来越被认为是 必不可少的。 41 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 08 全世界医院的手术安全清单 通过制定关于减少母亲和婴儿与分娩有关的 风险和不良后果的《世界卫生组织安全分娩 检 查 表 》（Safe Childbirth Checklist）， 进 一 步制定了清单概念。清单支持提供必要的孕 产妇和围产期保健实践，解决产妇死亡、产 后相关死胎和新生儿死亡的主要原因。《安 全分娩清单合作》（Safe Childbirth Checklist Collaboration）已经在改善孕产妇和新生儿 健康方面取得了重大进展。希望清单可以成 为一个有效的挽救生命的工具，并可以在广 泛的环境中使用。 两项全球行动、研究和知识管理方案以及 患者安全倡议等项目都已经在全球范围内 产生影响。 世界卫生组织患者安全项目提 高了全世界对患者安全关键概念和策略的 认识，激发了人们对提高医疗安全的关注， 已获得会员国卫生部长和卫生领导最高级 别的承诺。它提供了标准、以证据为基础 的指导和实用工具，以支持在国家卫生保 健系统设计患者安全方案。它支持使用病 人和家庭的故事，因为他们是不安全护理 的受害者。 所有这些方法在加强优质卫生服务提供方面 都是至关重要的，安全是核心，但不是全部。 为了进一步塑造全民健康覆盖的性质以及 如何实现，世界卫生组织制定了《综合的、 以人为本的卫生服务框架》（Framework on Integrated, People-Centred Health Services）， 旨在促进资金、管理和服务提供的根本转变。 同时，它还提供一个蓝图，以解决许多医疗 卫生系统协调较弱和条块分割的两个常见 不足。 全世界有4亿多人得不到基本的卫生服务 42 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 08 综合的、以人为本的卫生服务框架 该框架避开纯粹基于疾病的医疗模式，倡导 将人和社区置于卫生系统的中心。框架的开 发利用证明，围绕人们和社区需求设计的卫 生系统更有效、成本更低，能提高健康素养 和患者参与度，并且更能抵御健康危机。 明确优先考虑全民健康覆盖也意味着必须测 量和监测进展情况，并激发学术界的兴趣， 考虑评估新的医疗模式的有效性和进展情况。 43 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 08 44 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 09 疫苗： 保护 年轻的生命 能够有机会终生预防一系列且数量众多的疾 病是公共卫生发展过程中的重大成就。 这种 通过儿童时期的免疫所实现的终生保护，常 常被视为是理所当然的。2012 年世界卫生 大会发起的“全球疫苗行动计划”（Global Vaccine Action Plan）希望能够建立 ： “一个所有人和社区都能够免受疫苗可预防疾 病的世界。” 疫苗每年已经挽救了 250 万生命，其中大部 分为儿童。但仍有 150 万人死于可通过疫苗 进行预防的疾病。该行动计划有着清晰的 目标 ： “无数证据已经表明免疫所带来的益处是目前 所知的最成功的、也是最具有成本效益的健 康干预措施之一。过去的 10 年免疫带来了巨 大的成功，包括根除天花，一项被称为人类 最伟大胜利之一的成就。疫苗已经挽救了无 数的生命，使全球小儿麻痹症的发病率降低 了 99%，减少了疾病、残疾和死亡。” 1974 年世界卫生组织发起了“扩展免疫规划 项目”（Expanded Programme on Immunization）， 自此，开展了大规模根除天花的行动。天花 的根除是首次（也是目前唯一一次）人类病 原体从世界上彻底消失。这一里程碑式的胜 利展现了疫苗巨大的力量，也激励着人们继 续推广疫苗所带来的成效。在扩展免疫规划 项目开展初始，全球每 20 个儿童中仅有 1 个 45 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 09 儿童接种了基本疫苗 ：能够预防脊髓灰质炎、 白喉、肺结核、百日咳、麻疹和破伤风。到 2012 年，这一比例已经由最初微乎其微的 5% 提高至了 85%。 在 21 世纪的第一个 10 年免疫工作有了新 的 侧 重 点 和 决 策。 全 球 疫 苗 免 疫 联 盟 于 2000 年成立。此后，世界卫生组织领导起 草了第一份 《全球免疫愿景与战略》（Global Immunization Vision and Strategy），周期为 2006 年至 2015 年。这一文件为各地区和国家建立 了一个全球框架。但仍有许多工作需要继续 开展。2010 年 1 月比尔及梅琳达·盖茨基金 会的联合主席比尔·盖茨先生在达沃斯世界 经济论坛上这样说道 ： “我们必须实现‘疫苗 10 年’。疫苗已经在发 展中国家挽救和改善了数百万人的生命。创 新将帮助疫苗去拯救前所未有的更多儿童的 生命。” 能够带来这些改变的联合行动已经开始。 2011 年世界卫生大会讨论并在策略方面达 成一致。迅速开展了大规模咨询，收到来自 140 个国家的 1000 余位专家的反馈意见。因 此，在 2012 年，“全球疫苗行动计划”正式 启动。 “疫苗10年”启动 “全球疫苗行动计划”主要目标如下 ： · 实现全球范围内根除脊髓灰质炎，包 括到 2014 年消除最后 1 例野生脊髓灰 质炎 ； · 实现区域性消除破伤风、麻疹和风疹， 没有新增目标，重新确认已经被区域或 全球机构认可的地区 ； · 提高疫苗覆盖率，实现国家目标和加强 国家内覆盖的公平性 ； · 引进新疫苗，以扩大现有疫苗的覆盖至 此前未被覆盖的国家 ； · 研究和发展，至少使一种新疾病成为疫 苗可预防的疾病。 该行动计划同时承诺，通过已经贡献巨大的 疫苗来帮助实现千年发展目标 4—减少 5 岁以下儿童死亡率。 印度 尼日利亚 埃塞俄比亚 其他国家 2015年全球 麻疹死亡 自该行动计划实施起，已经在引入新的和尚 未充分利用的疫苗方面取得了瞩目的进步。 特别是在扩大肺炎球菌和轮状病毒疫苗应用 方面，成就斐然，预防了肺炎及腹泻，这两 个 5 岁以下儿童死亡的主要原因。在 2000 年 到 2015 年间，已有 100 亿美元投入至全球疫 苗免疫联盟（世界卫生组织为该联盟主要成 员之一），3/4 的资金直接用于疫苗的引入。 2007 2015 12万5岁以下儿童死于麻疹 74,000 46 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 09 “疫苗 10 年”的开展也助推了全球疫苗免疫 联盟的工作。自 2000 年以来，在全球疫苗免 疫联盟的努力下，五价疫苗已经引入到 68 个 国家，肺炎球菌疫苗已经引入到 58 个国家， 轮状病毒疫苗已经引入到 43 个国家等等。最 近，全球疫苗免疫联盟将主要用于预防女性 宫颈癌的人类乳头瘤病毒疫苗引入到 4 个国 家，并在 27 个国家开展了试点项目。 “全球疫苗行动计划”的制定者虽然考虑到了 肺结核、流行性感冒和疟疾，但仍难以想象 埃博拉危机。但埃博拉也带来了急需发现可 用候选疫苗的需要和机会。世界卫生组织和 其免疫策略专家咨询组迎难而上，在技术和 规制层面都取得了切实的创新性进展。从应 对埃博拉危机中得到经验教训也将推动未来 其他疫苗的发展。 世界卫生组织免疫策略专家咨询组被委任以 监督“全球疫苗行动计划”的实施，并就此 在世界卫生大会上进行报告。咨询组的系列 报告强调了疫苗覆盖方面仍需解决的问题 ： “全世界还有 1900 万未接种疫苗和接种疫苗 不足的儿童，代表着社会中最困难的成员— 那些遭受灾害的、被边缘化的、被剥削的和 被遗忘的人群。” 自 2010 年以来，以百白破三联疫苗为衡量标 准，全球接种疫苗方面并没有取得明显的进 步。2015 年，68 个国家未能实现 10 年中期 目标，即实现 90% 的覆盖。这一覆盖率在超 过 50 个国家中没有明显变化，甚至出现了退 化。覆盖率的差异广泛存在于国家内部和国 家间。疫苗覆盖缺失也暴露了这一地区在医 疗系统的基本需求上的问题，供应链、简易 管理措施、员工培训、一线工作人员的可用 性和资金。在数据可用性和质量方面同样存 在问题，一项难以回避的公共卫生难题。反 过来，这一问题也牵制了提高覆盖率所需研 究的质量。 脊髓灰质炎的根除：仅剩 3个流行 的国家；越来越少的病例 根除某种疾病，在免疫领域有着特殊又充满 争议的地位。天花的根除是一项意义深远的 公共卫生胜利。在过去的 10 年间，不懈的努 力正推动着脊髓灰质炎的根除。2007 年在 12 个国家出现了 1315 个病例 ；2016 年，仅在 3 个国家出现了 37 个案例。当 1988 年世界卫 生大会设定了根除脊髓灰质炎的目标时，没 有人预想到根除脊髓灰质炎的“最后一步” 是如此漫长。同时，各世卫区域也提出了消 除麻疹的目标。两种疾病的最后根除时间都 目标：2010—2015年90个中低收入国家引进一种或多种新型或未充分利用的疫苗 目标：2015年194个会员国DTP3覆盖率达90% 实现: 99 实现: 126 194 47 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 09 设定在 2020 年。然而根据根除脊髓灰质炎的 经验，尚未将麻疹消除上的区域性目标转化 成全球根除的目标。尽管如此，更高的麻疹 疫苗接种率也持续地减少了 10 年间儿童的死 亡率。 2016 年在 2 周内超过 150 个国家 已采用双价口服脊髓灰质炎疫苗 疫苗资金愈发成为一个充满争议的问题。在 2015 年，世界卫生大会通过了一项有关疫苗 价格的决议，鼓励更透明的价格，号召成员 国在此问题上通力合作。这一决议要求世界 卫生组织秘书处采取一系列的行动。最大的 担心来自于那些已经从全球疫苗免疫联盟“毕 业”（不再符合有关资金支援的要求）了的国 家，以及一直不符合全球疫苗免疫联盟支援 要求的中等收入国家。 “疫苗 10 年”还剩下 3 年。世界卫生大会每 年都对此进行监测。“全球疫苗行动计划”再 次重申疫苗是全球健康政策的基石。尽管如 此，许多儿童却仍然难以获得他们最急需的 疫苗。在这 10 年之初比尔及梅琳达·盖茨基 金会的联合主席梅琳达·盖茨，再次强调 ： “疫苗是一个奇迹”她说，“只要注射几剂， 就能终身免疫于那些致命的疾病。” 在这 10 年的最后关头我们仍应一以贯之，并 将这一势头保持到未来。 48 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 10 空气、水、 土壤 国际气象组织确认 2016 年是有记载以来最热 的一年。国际气象组织通过综合多渠道获得 的数据来测算每年全球性和区域性的平均温 度。二氧化碳和甲烷浓度，作为人类导致气 候变化的标志，都达到了有记录以来的最高 水平。 在过去的 10 年间联合国、各国政府、公共 卫生机构、非政府组织、民间团体、科学组 织和学术界都对气候变化给予了前所未有 的高度关注，寻找能够减缓气候变化所带来 影响的方法，并达成正式的、具有约束力的 国际协定。大部分机构始终强调气候变化 是对地球未来最大的单一威胁。政府间气 候变化专门委员会（Intergovernmental Panel on Climate Change） 的 论 述 和 报 告 也 支 持 了这一观点。委员会准备了全面的评估报 告，用于评估在气候变化方面的科学、技 术和社会经济知识的情况，以及气候变化 的原因、潜在影响和应对策略。委员会还 撰写了用于评估特定问题的报告和为温室 气体清单的准备工作提供了实际准则的方 法论报告。第 5 份评估报告已于 2013/2014 年发布。 委员会的一些重要发现如下 ： “自前工业时代，在经济和人口增长的推动下， 人为的温室气体排放就开始增加，并且现在 的排放比任何时候都高。这导致了大气层中 二氧化碳、甲烷和一氧化二氮的浓度达到了 49 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 10 近 80 万年来的最大值。在气候系统中已经可 以探测到这一现象和其他人为因素所带来的 影响，它们也极有可能就是导致 20 世纪中期 以来温度上升的决定性因素。” “持续的温室气体排放将导致温度的进一步上 升和长远的气候系统组成的变化，增加对人 类和生态系统产生严重的、广泛的和不可逆 影响的几率。控制气候变化需要持续地减少 大量温室气体的排放，与适应气候变化相配 合，可以限制气候变化所带来的风险。” 尽管这些结论是清晰而一致的，但仍有人怀 疑人类对于气候变化的巨大影响，并且认为 目前的气象观测并无反常之处。 通过世界卫生组织过去 10 年间的努力，已经 证实了许多气候变化及其对于地球健康和人 类的影响。就了解、记录和模拟气候变化带 来的特定健康影响开展了大量的工作，包括 ： 由极端天气现象（如持续的高温和大型洪水） 导致的受伤、疾病和死亡几率大大增加 ；更 多的疾病传播媒介 - 介水传染病和人畜共患 疾病 ；空气质量不好而导致的心脏和呼吸疾 病 ；安全饮用水水位下降 ；暴露于紫外线而 带来的不良影响 ；粮食质量低下而导致的营 养不良，和对精神健康和舒适所带来的社会 和经济影响。 世界卫生组织预计在 2030 年到 2050 年间， 气候变化每年将会导致由营养不良、疟疾、 腹泻和热应激带来的约 25 万的额外死亡。到 2030 年对健康造成的直接损失（不包括与健 康相关的领域如农业、水及卫生设备的损失） 每年预计可达 20 亿～ 40 亿美元。 记载的 最低温度 来源：NOAA-NCEI 低于平均 温度 高于平均 温度 比平均温度 高得多 记载的 最高温度 接近平均 温度 比平均温 度低得多 2016年：有史以来最热的一年 50 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 10 自 2008 年成员国通过了里程碑式的决议后， 世界卫生组织起草并执行了工作计划来预防 和减缓气候变化对健康所带来的影响。于 2015 年签署的最新计划包括 ： · 合作 ：与联合国系统中的其他伙伴组织 合作，确保健康问题在气候变化议题中 得到适当的体现 ； · 提高认识 ：提供并传播有关气候变化对 人类健康的威胁和利用减少碳排放的机 会来推动健康的信息 ； · 科学和证据 ：协调对气候变化与健康之 间关联的科学证据的审阅，并起草全球 研究议程 ； · 为公共卫生应对提供帮助 ：帮助国家进 行能力建设以减少公共健康面对气候变 化时的脆弱性，以及在减少碳排放的同 时促进公共健康。 在此之上，2016 年的世界卫生组织全球健康 与气候会议就一项针对整个健康界的、更广 泛的行动议程达成一致。 气候变化的主要威胁仍然是全球卫 生议程之一 2015 年《柳叶刀》健康与气候变化委员会 （the Lancet Commission on Health and Climate Change）发布了一系列的报告和研究，从健 康视角阐述了气候变化，以及被誉为“21 世 纪最大的全球卫生机会”的气候变化应对 措施。 委员会和由《柳叶刀》医学期刊成立的其他 全球卫生委员会，作为绝佳的实例，展示了 独立科学家、专家及意见领袖团体对推动全 空气污染：越来越多的黄色和红色区域 μ 51 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 10 球健康来说是不可或缺的。《柳叶刀》健康与 气候变化委员会提出了一系列的政策建议并 承诺将监测这些政策的进展 ： · 向气候变化和公共卫生的研究、监测和 监督方面投资 ； · 增加全球范围内对于气候适应型的卫生 系统的投入。确保加强低收入和中等收 入国家的卫生系统，并减少医疗所带来 的环境影响 ； · 尽快在全球范围内不再使用煤炭能源来 保护心血管和呼吸系统健康 ； · 鼓励城市向个人、环境健康生活方式促 进型城市转变 ； · 建立一个稳健、可预测的国际碳定价 机制 ； · 在低收入和中等收入国家迅速开展可再 生能源的推广，为当地的社区和卫生设 施提供稳定的电力 ；极大地激发经济发 展 ；以及推动健康公平 ； · 支持对于减缓气候变化带来的疾病负担 减少、医疗开支削减以及经济生产力提 高的量化工作 ； · 在卫生部门与其他政府部门之间采取合 作机制，以保证健康与气候变化能够在 政府所有政策中得以体现 ； · 就支持向低碳经济转变的国家达成国际 协议并加以实施。 许多导致气候变化的不可持续的并伴有污染 的技术，同时也带来了更直接的区域性空气 污染威胁。在 2017 年 3 月，世界卫生组织总 干事陈冯富珍这样对 BBC 表示 ： “空气污染是当今全球公共卫生面临的最大的 致命威胁之一，其影响规模超过艾滋病或埃 博拉。” 世界卫生组织估算约有 700 万人死于糟糕的 室内和室外空气质量，其中对于亚洲的影响 最为严重。空气污染对健康的影响伴随整个 生命过程，已被证实与低新生儿体重、急性 和慢性肺病、中风、痴呆、冠心病、癌症、 DNA 和免疫系统损害有关。 特别是对儿童的影响尤为突出，每年约有 60 万 5 岁以下儿童死于由室内和室外空气污染 和二手烟导致的呼吸感染。 在 2008 年至 2013 年间，全球城镇空气污染 水平上升了 8%，虽然在有些地区情况得到缓 解。室外空气污染来源多样 ：家用和商用交 通中的能源使用（特别是柴油发动机）；农业； 能源生产 ；工业排放 ；焚烧农作物（以进行 土地清理）。在世界一些地区，室外空气污染 来源还包括从沙漠和荒漠化区域而来的沙尘。 室内空气污染对导致全球范围内的早逝、疾 病和健康水平不佳方面的影响同样不可小觑。 世界卫生组织估算每年约有 430 万人死于室 公共卫生关注的化学物质 有害杀虫剂汞 铅 氟化物 镉二　 英 苯 石棉砷空气污染 52 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 10 双赢的环境与健康策略 9. 通过健康融入万策的 策略营造更健康的环 境并预防疾病。 8. 通过禁烟令，减少二手 烟草烟雾暴露。 7. 实施干预措施，增加 防晒行为。 6. 改变消费模式，减少有 害化学品的使用，减少 废物，节约能源。 5. 使更多人获得安全的水和 适当的卫生设施，推广洗手。 4. 减少职业暴露， 改善工作环境。 1. 将低碳策略应用于能源 生产、住宅及工业中。 2. 使用有利于体力活动的 公共交通工具。 3. 在烹饪、取暖、照明和 清洁技术中使用清洁燃料。 内空气污染。 在 2016 年 5 月召开的世界卫生大会上，通 过了《增强全球应对空气污染造成的不良 健康影响能力的路线图》（Road Map for An Enhanced Global Response to the Adverse Health Effects of Air Pollution），行动周期为 2016 年至 2019 年。《路线图》提出了四大行 动领域。首先，收集有关空气污染对于健康 影响的证据，扩大预防或控制其影响的政策 有效性的知识基础。其次，建立更加完善的 监测和报告系统，测算可持续发展目标中与 空气污染相关目标的进展。再次，寻求能够 发挥卫生部门领导作用和加强在地方、国家、 区域及全球层面协作的路径。最后，《路线图》 旨在增强卫生部门机构能力，以便分析和影 响决策过程，支持采取共同行动应对空气污 染与健康问题。 增强全球应对空气污染造成的不 良健康影响路线图：2016—2019年 行动 《路线图》强调包括交通、能源、废物处理、 农业、城市规划及工业等多部门的参与。 过去 10 年，人类对于水（用途包括饮用、洗 澡以及家庭使用）、环境卫生（马桶、安全处 理固体废弃物）和个人卫生的基本需求在全 53 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 10 球健康议程中的地位更为凸显。最贫困地区 人口的这些基本需求仍没有得到实现。 安全饮用水是一项千年发展计划，也是第一 批实现的目标之一。但是，根据联合国的数 据显示，情况仍不容乐观 ： · 自 1990 年以来，26 亿人已获得经改善 的饮用水源，但仍有 6.63 亿人依靠未经 改善的水源生活 ； · 全球至少有 18 亿人使用的饮用水源受 粪便污染 ； · 全球超过 40% 的人口受水源短缺影响， 这一比例预计还将增加 ； · 超过 17 亿人口居住在江河流域，那里 的用水量超过蓄水量 ； · 24 亿人缺乏基本的卫生设施如坐厕或公 共厕所 ； · 超过 80% 的人类生活废水未经任何去 污处理直接排入至河流或海洋 ； · 每天将近 1000 名儿童死于可预防的与 水和卫生相关的腹泻疾病 ； · 洪水和其他水患导致的死亡人数占所有 与自然灾害相关总死亡人数的 70%。 可持续发展目标采取了基础广泛的措施。目 标 6 这样表述 ：“确保为所有人提供水和卫生 设施。”水、环境卫生和个人卫生已经成为许 多全球健康项目的一部分，特别是那些由领 域广泛的非政府组织开展的项目。 在洪水和 其他极端天气灾害来临时，以及难民和移民 营地中，都急需有关专家来开展此类项目。 有毒土地污染是健康面临的另一大威胁。许 多来自低收入与中等收入国家贫困社区的人 们接触着这些有毒的化合物。这一接触通过 多种路径实现。他们可能住在废弃工业旧址 或周围，重金属和其他有害物质可在土壤中 存在数年或数十年之久。在这样环境中玩耍 的孩子们更加容易受到损害。 需要国际社会更大、更凝聚的努力来清理这 样的场所、开展更加全面的评估风险、对受 到影响的社区进行告知，并寻找新的方法来 提供其他的就业方式。现在已经出现了一些 令人鼓舞的项目。例如，在一个总额为 2500 万的项目中，世界银行清理了位于埃塞俄比 亚、马里、坦桑尼亚、突尼斯和南非的约 900 个被污染场所，共移除超过 3000 吨的废物和 有毒农药。 土壤污染是有毒化学制品暴露对健康损害的一 种方式。这一危险非常广泛地存在于工作场所、 家中，甚至是学校中。所有国家都面临着这样 的危险，特别是那些更为贫困的国家。人们可 能为了获取有价值的农作物，维持生计而进入 残留有工业废物的区域。所谓的“电子废物”， 也就是已经解体了的被丢弃的电子产品，越来 越多的出现在工业废物中，使人们暴露于包括 铅在内的有毒物质。它们可能来自未经监管的 血汗工厂，在那里工人们得不到任何的保障和 保护。或者，工人可能通过参与包括电池回收 和从水银中提取金等危险工作来谋生。通常在 这样的情况下，工人缺乏对危险的知识或认识。 这仅仅是许多种危害的一个缩影。根据专家的 意见，世界卫生组织估算每年有超过 1200 万 的人死于环境中各种危害的暴露。2017 年的 世界卫生大会将商讨卫生部门如何能够解决化 学危害问题的线路图。 古希腊著名医生希波克拉底，著有《论空气、 水和场所》（On Airs，Waters，and Places）， 也是最早一批推测空气、水、土地和气候的 状况可能对健康产生显著影响的人。近 2500 年后，环境和气候对于健康的影响仍然是一 个重要议题。 54 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 11 紧急情况： 保护和缓解 在传染病爆发或传染病造成严重国际威胁的 时候，世界卫生组织在全球卫生中的领导作 用受到公众最大重视。这可能是因为新型传 染病的性质、传播的规模和速度，或者由此 导致的疾病的严重性和后果。 21 世纪始于这样一个紧急情况，一个之前没 有引起广泛人类疾病的呼吸道病毒爆发，造 成了一场全球危机。 严重急性呼吸系统综合 征（severe acute respiratory syndrome，SARS） 引发了严重的经济和社会动荡，将国家和国 际公共卫生系统至于聚光灯下。到目前为止， 已有 29 个国家和地区报告了 8000 多例病例， 死亡人数近 800 人。 SARS 引 发 了 对 公 共 卫 生 能 力 的 许 多 基 本 审查，特别是在受影响最严重的中国和加 拿大等国家。它还导致《国际卫生条例》 （International Health Regulations）的扩展， 目前涵盖了广泛的风险，意味着 196 个国家 共同致力于保护全球卫生的重大协议。 SARS 给了我们许多重要经验教训，其中包括： 需要早日分享国家与世界卫生组织之间的监 测数据 ；尽可能快地将病毒分离到专科实验 室 ；强大的全球协调响应。未来的核心是承 认世界卫生组织领导作用的重要性。大部分 经验教训对于主导以后公共卫生突发事件是 非常宝贵的，特别是流感、埃博拉病毒和寨 卡病毒的爆发。然而，每一个都带来了新的 挑战。 55 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 11 20 世纪有 3 次有记载的流感大流行（1918 年、 1957 年和 1968 年），导致 1 亿多人死亡。 到 2007 年大流行性流感规划是密集的，因为自 上一次大流行以来已经过去了 40 年 ；惊人地 爆发了 “禽流感”的人类病例 ；野生和驯养鸟 类 H5N1 流感病毒的全球感染，这些病毒具 有高度的重新分类倾向。 2009 年 3 月，墨西哥出现了新型流感病毒 （最初被称为“猪流感”），早期报告表明病 例死亡率为 64％。这种毒力如果后来持续下 去，它对世界人口将是灾难性的。作为 40 年 来的第一次流感大爆发，甲型流感病毒（甲 型 H1N1）后来的发展，使其成为有史以来 最温和的爆发之一。估计全球死亡人数为 105 700 ～ 395 000 人，远低于 20 世纪的 3 次 大流行，更可以与季节性流感死亡率相比较。 然而，在很大程度上被许多评论家忽视的是， 它杀死了不成比例的儿童和年轻人。这是典 型的流感病毒“转变”而不是季节性流感。 如果世界公共卫生服务机构把他们广泛的流 行病计划束之高阁，并且耸耸肩，这样的努 力是不值得的，那么更多的儿童和年轻人肯 定会死亡。对于流行病学来说，这一数字虽 然很小，但对死亡的孩子的母亲或父亲来说 并不轻松。公众对风险的看法与 40 年前截然 不同，儿童死亡人群和青少年住院不容易被 “温和”接受。 世界卫生组织制定了强大的流行病计划，并 实施了这些计划。 最终结果无法可靠地预测。 在这种情况下，2009 年的 H1N1 大流行是极 其有意义的，是对未来更为严重的大流行病 的“彩排”。 这是对 2005 年《国际卫生条例》 的第一次测试。 大流行响应的独立审查得出结论，有些事情 进展顺利，特别是早期识别和鉴定病毒，提 供候选疫苗株，以及建立强大的协作网络来 帮助管理这一大流行。其他方面则受到批评， 例如 ：疫苗分发缓慢 ；疫苗生产能力不足（只 能提供 1/3 的世界人口）；纯粹考虑扩散规模 而不考虑大流行病严重性的定义的弱点导致 公信力不足 ；科学咨询委员会成员资格缺乏 透明度和可感觉到的利益冲突。 非洲报告的严重的自然灾害 灾 害 数 来源: UNISDR 19 85 19 86 19 87 19 88 19 89 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 0 0 20 0 1 20 0 2 20 0 3 20 0 4 20 0 5 20 0 6 20 0 7 20 0 8 20 0 9 20 10 20 11 20 12 20 14 20 15 140 120 100 80 60 40 20 0 56 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 11 未来需加强的做法建议。最重要的行动之一 应是更多地推动可能阻止未来流感大流行前 景的、多功能流感疫苗的研究。这种在严重 大流行中拯救数百万人生命的变革性质尚未 得到充分的认识。 也许全球卫生界正在允许 自己相信流感大流行每 40 年一轮。当然，现 实是，下周可能出现一种新的、易传播的和 高毒性的流感病毒。 SARS 危机最重要的一个方面是，如果预防 和控制标准薄弱，那么一旦在医院内部发生 感染，爆发的危险程度就会大大增加。虽然 这已是当时的理解，但更全面、更严格地看 待医疗卫生机构，特别是低收入国家的医疗 卫生机构风险的需求，并没有得到系统的 解决。 2014 年西非 3 个国家几内亚、塞拉利昂和利 比里亚，高死亡率的埃博拉病例开始大幅增 加。其他邻国马里、尼日利亚和塞内加尔的 疫情得到迅速控制。3 个主要国家的疫情爆 发已经严重超出了以前见过的（疫情）。 以前， 埃博拉病毒只发生在人烟稀少的地区，因此 受到控制。 这次出现在医疗基础设施较差的 环境中，感染预防和控制过程存在重大差距。 没有早期干预。因此，对区域人口和潜在的 全球形势构成更大的威胁。 世界卫生组织因在初期对埃博拉威胁的反应 缓慢而受到批评。艰难起步后，反应越来越 强烈 ，感谢世界卫生组织及其许多合作伙伴。 响应有 3 个明显特点。首先，世界卫生组织 和其他脊髓灰质炎合作伙伴为协调消灭尼日 利亚脊髓灰质炎行动的公共卫生应急行动中 心立即并成功部署抗击埃博拉。人们普遍认 为，埃博拉已经传播到人口密集的尼日利亚 最大城市拉各斯，世界可能已经陷入公共卫 生灾难。其次，世界卫生组织领导第一项全 球患者安全挑战“清洁护理更安全”在医疗 卫生感染预防和控制方面建立了非常强大的 能力，此外，还有低资源国家实施的广泛经 验和广泛的国际专家网络。该团队与世界卫 生组织的其他感染控制专家联手。有责任协 调努力，并在受灾地区部署，以帮助减少受 灾国家的风险和增强抵御力。第三，世界卫 生组织和合作伙伴建立了会员国、国际机构、 捐助者和非政府组织的强大的跨国联盟，以 世界卫生组织审查委员会关于与 2009 年甲型H1N1 流感大流行有关的 《国际卫生条例(2005)》实施情况的建议 加快实施《国际卫生条例》要求的核心能力 加强世界卫生组织事件信息网站 增强以证据为基础的国际旅行和贸易决定 确保所有《国际卫生条例》国家归口单位必要的权威和资源 加强世界卫生组织作出持续反应的内部能力 改进突发事件委员会的任命惯例 修订大流行防范指南 制定和运用评估严重程度的措施 优化指导文件的管理 制定和实施战略性的全组织范围沟通政策 鼓励事先缔结疫苗分发和提供协定 建立更广泛的全球公共卫生预备队伍 创建突发公共卫生事件应急基金 在共享病毒以及获得疫苗和其他利益方面达成一致 开展综合性流感研究和评价规划 57 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 11 协调行动，并为资金、专门知识、人员和供 给品提供必要的支持。 尼日利亚脊髓灰质炎紧急行动中心 中断了该国的埃博拉病毒 2016 年 1 月 14 日宣布埃博拉病毒疫情，官 方的死亡人数为 11 315 人，但真实数字将高 得多。 审查委员会于 2016 年向世界卫生大会报告了 《国际卫生条例（2005 年）》在埃博拉疫情反 应中的作用。它指出，早先审查大流行病应 对措施（2011 年）的许多建议尚未全面实施。 这意味着当埃博拉爆发的时候，世界仍然没 有准备好，而且十分脆弱。 因此，2016 年的 建议集中在需要确保全面执行《国际卫生条 例》的一切内容。 重要的是，人们认识到， 包括实质性能力建设在内的改进需要采取多 部门的做法。 此外，需要大量增加资金。 世界卫生组织一直主导开展埃博拉后医疗卫 生体系的适应力工作。在获得必要的财政支 持的情况下，世界卫生组织将能够提供解决 不良基础设施、预防和控制感染措施受限以 及医疗保健质量原则所需的紧急帮助。证据 显示，自宣布埃博拉疫情以来，已经减少了 孕产妇和儿童保健基本服务（如产前保健和 免疫）的提供。 世界卫生组织正在帮助各国评估其《国际卫 生条例》核心能力。 这些能力来自发现、评估、 通报和报告事件以及应对国际关注的健康风 险和紧急情况的基本平台。联合外部评估方 案正在评估各国预防、发现和应对公共卫生 风险的能力，突出强调最严重的差距。 后埃博拉时期世界卫生组织的改革将有助于 国家准备更好地面对下一个新的疾病和当前 的杀手。 过去几年的重大传染性疾病包括 ： 中国的甲型禽流感（H7N9），马达加斯加的 瘟疫，巴西、安哥拉、刚果民主共和国和乌 干达的黄热病，沙特阿拉伯的中东呼吸系统 综合征，乍得共和国的戊型肝炎，美国和加 国际卫生条例实施情况 0% 20% 40% 60% 80% 100% 立法 协调 监测 响应 准备 风险沟通 人力资源 实验室 入境地点 动物传染病 食品安全 化学品 核放射性 实施的国家基于2015年127个有报告的国家 58 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 11 拿大的汉城病毒，多哥的脑膜炎球菌病，以 及西非的拉沙热。 这些事件的频率和严重程 度强调了国家不仅需要强大的公共卫生，而 且还需要世界卫生组织在全球协调和响应中 的作用。 后埃博拉时期另一个重要的发展是非洲联盟 资助的在埃塞俄比亚的斯亚贝巴的非洲疾病 控制和预防中心，它于 2017 年 1 月 31 日开 始运作，将在非洲大陆应对突发公共卫生事 件方面发挥关键作用。这些规划包括整个非 洲大陆的区域中心—肯尼亚、赞比亚、埃及、 加蓬和尼日利亚。非洲疾病控制中心的工作 必将增强对非洲高危人群的了解，并建议采 取哪些必要的预防和控制措施，以提供更好 的保护。 新建非洲疾病预防控制中心 世界卫生组织将其从重大爆发和大流行防范 的角度扩大到更广泛的公共卫生突发事件 概念。推动了解和应对灾害和人道主义危 机对健康的直接和间接影响。联合国减灾 办 公 室（United Nations Office for Disaster Risk Reduction）成立于 1999 年，由联合国大 会 （United Nations General Assembly） 决 议 （56/195）授权，担任联合国协调减灾系统 的协调中心。它确保了联合国系统的减灾活 动与各区域组织之间的协同作用以及社会 经济和人道主义领域的活动。2015 年，全 球共收到近 300 起灾害报告，造成 22 000 多人死亡，9860 万人受影响，665 亿美元 的经济损失。 紧密围绕《仙台框架》（Sendai Framework）。 这是一个关键的发展。联合国倡议应对灾害， 将公共卫生和减少灾害风险汇集在一起。 它 是所谓的“全危险”方法的一部分，旨在减 少灾害风险和相关的生命、生计和健康损失。 世界卫生组织不仅涉及公共卫生突发事件， 还涉及自然灾害（如尼泊尔地震）的健康因 素和复杂的人道主义局势（如叙利亚和伊拉 克）。其方法包括早期预警和应对网络、卫生 资源可用性监测系统和紧急医疗队计划。它 在机构间常设委员会中的领导作用日益增加， 特别是传染性危害。 新建立的世界卫生组织《突发卫生事件规划》 （Health Emergencies Programme） 正 在 改 变 世界卫生组织与各国应对危机和紧急情况的 方式，主要是从技术机构、制定规范和标准 到全面业务机构。 新建立的世界卫生组织危害突发事 件规划：准备、预防、保护、应对、 恢复 该规划有五个技术和业务部门 ： · 传染性危害管理 ：优先确保应对高威胁 传染性危害战略和能力。 · 国家突发卫生事件准备和《国际卫生条 例（2005）》：确保建立国家全危害的突 发风险管理能力。 · 卫生应急信息和风险评估 ：为所有重大 健康威胁和事件提供及时和权威的情况 分析、风险评估和响应监测。 · 紧急行动 ：确保受到紧急情况影响的人 们可以获得挽救生命的基本卫生服务。 · 紧急核心服务 ：确保世界卫生组织的紧 急行动得到迅速和可持续的资助和人员 配备。 59 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 11 世界卫生组织的重点和作用的扩大是一个非 常大的转变。该规划与国家和合作伙伴合作， 准备、预防、应对和恢复造成卫生突发事件 的所有危险，包括灾害和冲突以及疾病暴发 和冲突中的传统场所。该规划还将引导和协 调国际卫生应对，为受影响人群提供有效的 救济和恢复。 60 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 12 结束语 在回顾过去 10 年全球卫生的挑战、发展、棘 手的问题、危机、紧急情况和成就时，“一个 世界”浮动在全球和国家卫生架构的复杂格 局之上。世界上有许多敬业的个人、团队和 组织孜孜不倦地工作，就像太阳在世界 24 个 不同地区升起和落下一样，给 70 亿人带来了 健康、长寿、幸福，并减轻其痛苦。 全球卫生的许多目标都体现了“一个世界”， 例如，全民健康覆盖、一个妇女一个儿童、 基本救生药物可及等。这四个字呼应了“一 个世界卫生组织”的目标，即成员国、区域 和国家办事处、全球伙伴、非政府组织和民 间团体努力达成共同的目标。在考虑世界卫 生的影响因素时，气候变化、疾病流行、自 然灾害、冲突、抗菌药物耐药等是不可避免。 当健康与贫困、卫生不公平、生与死的统计 数据呈现在桌面上或投影到屏幕上时，它们 激发了团结、同情和理想主义。当讨论科学 与政策、公共与私人、国家和地方之间的协 调合作时，它们也很重要。 世界卫生组织及其总干事在创造和维持全球 卫生观念以及建立一个广泛的联盟使人们生 活得更健康、更公平、更安全方面发挥着重 要的作用。世界卫生组织通过其在领导、技 术专长、标准制定、协调、促进和影响全球 议程而发挥作用。 回顾过去 10 年，很明显世界卫生需求是如此 的多样和迫切，不能简单地把注意力集中在 少数几个优先考虑的事情上。过去 10 年在全 球卫生多方面取得的成就证明了这一点，在 全球、国家和地方各层面与世界卫生组织合 作的组织和个人以及对世界卫生组织领导地 位的响应都证明了这一点。 这份报告展示了过去 10 年的许多成就，如改 善妇女儿童的健康、疫苗方面的突破、基本 消除了两种疾病、减少重大疾病死亡、遏制 非传染性疾病流行的措施、从应对流感大流 61 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 12 行性和埃博拉病毒爆发的实践中总结出突发 公共卫生事件新的框架和结构。严重的问题 和挑战仍然存在，主要集中在不平等的根源 以及世界上最贫穷人口的疾病、过早死亡和 残疾。 纵观全球卫生取得成就的领域，一些重要的 主题脱颖而出。 鼓励更健康、更公平的未来 在世界卫生组织的历史上，世界卫生组织的 倡议转化为国家政策，激发创新，形成全球 和国家层面持续多年的行动。一个很好的例 子就是哈夫丹·马勒（Halfden Mahler）博士 在 1981 年提出“人人享有卫生保健”（Health for All）的目标。马勒博士在 1973 年至 1983 年担任世界卫生组织总干事，于 2016 年 12 月去世，享年 93 岁。当时，世界卫生组织 工作人员哀悼他的逝世，纪念他的一生和成 就。1981 年马勒博士谈他的想法时说道 ： “人人享有初级卫生保健意味着一个国家人人 都健康。‘健康’指的是一种个人的幸福状态， 而不仅仅获得卫生服务，一种能使人们过上 社会及经济富裕生活的健康。人人享有初级 卫生保健意味着消除导致不健康的因素，如 营养不良、知识缺乏、被污染的饮用水和不 卫生居住环境等，此外，还有纯粹的医学问题， 如缺乏医生、医院病床数不足、缺乏药物和 疫苗等。” 世界卫生组织在思想领导方面的作用不常谈 起。像“人人享有初级卫生保健”这样的想 法问世时，它们就不仅仅是个口号，而是变 革的强大力量。它们成为全球卫生的组织原 则。当然，他们也有着坚实的道德基础，在 这种案例中，健康是一项人权。 2016年《2030可持续发展中的健康 促进上海宣言》 在陈冯富珍博士的领导下，世界卫生组织继 续关注这个方面。 过去 10 年世界卫生组织呼吁全世界通过不同 的视角来看待健康，而不仅仅是关注疾病。 其中之一是世界卫生组织成立并支持的健康 问题社会决定因素委员会（Commission on the Social Determinants of Health）。该委员会 的报告出版之后，立刻对卫生议程的设计和 制订产生影响。它跨越了地区和国家，挑战 那些审视现有政策和计划的人，使其以不同 方式思考问题。 第 二 个 是 全 民 健 康 覆 盖（Universal Health Coverage）的理念。在本质上这是基本的，并 受到强烈的社会公正、公平和同情的驱动。 第三是同样的变革，但以不同的方式。《老龄 化与健康全球报告》及其配套的实施方案《老 龄化与健康全球战略和行动计划》勾画了卫 生和医疗保健未来的愿景，而且可以加强社 会的基础结构，支持经济发展，改变城市的 性质，促进几代人的凝聚力。把明天的世界 从不健康的状态转变为健康的老龄化是所有 国际机构设立的意义深远的目标。如果不做 任何事情将是灾难性。 第四个全球卫生的分水岭是首份《世界残疾 报 告 》（Global Report on Disability）。 斯 蒂 芬·霍金（Stephen Hawking）教授在报告的前 言中说道 : “事实上我们有道德上的责任为残疾人参与消 除障碍，并投入足够的资金和技能来开发他 们巨大的潜力。全世界的政府机构不再忽视 62 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 12 无数没有机会得到卫生保健、康复、支持、 教育以及就业的残疾人，并且他们也从来没 有获得展示自己才华的机会。” 该报告是如何在联合国《残疾人权利公约》 （Convention on the Rights of Persons with Disabilities）的指导下采取行动的全球指南。 世界上约有 15% 的人口有某种形式的残疾。 世界卫生组织在对残疾的分类和测量方面有 着杰出的传统，但是过去的大部分工作都是 纯医学研究。2011 年与世界银行联合发布的 《世界残疾报告》改变了全球卫生领域残疾模 式，提出了残疾的社会模式的愿景。在此， 残疾被看作是人们与环境之间的互动，重点 是打破阻碍包容性的障碍。 首份《世界残疾报告》标志着方法 的转变 有了这 4 个基本的工作领域，世界卫生组织 不仅能帮助激发实现更好健康的行动，而且 还能帮助塑造未来如何看待健康的方式。它 也在试图巩固支撑它的基本价值。这些关键 政策也将激发人们从不同的角度思考卫生体 系建设和卫生服务提供。它们还将为各国公 共政策的制定创造一个至关重要的环境。 健康成为全世界的重中之重 过去世界卫生组织作为联合国的专门机构， 按照其自身的议程运作。健康仅偶尔作为联 合国最高级别事务的一部分。过去 10 年联合 国以前所未有的规模参与到了全球健康中来。 2011 年 9 月联合国大会的高级别会议发表了 “预防和控制非传染性疾病政治宣言”。2011 年 6 月另一次高级别会议也发表了类似的宣 言，号召成员国加强消除艾滋病病毒和艾滋 病。2012 年 12 月联合国大会通过了“全民 健康覆盖决议”。2016 年 12 月联合国成员国 签署了抗击抗菌药物耐药性的宣言。2014 年 联合国大会和安全理事会讨论了埃博拉危机， 并批准了一系列的后续行动。 非传染性疾病、抗菌药物耐药和全 民健康覆盖被纳入联合国大会议程 获得联合国对于全球健康首要问题的承诺有 着至关重要的意义。这将推动这些项目从单 一的卫生领域项目，变为由总统和首相投入 并负责的官方承诺。全球健康正逐渐在 G7 和 G20 国家的讨论中占有一席之地，这一改变 也有着非同小可的影响。 联合国可持续发展目标包罗万象的特性也成 为这一议程的另一重要组成部分。可持续发 展目标共包括 17 个全球目标，169 个具体目 标以及 230 项指标。现在仍处于实施可持续 发展目标的初期阶段，对于和健康相关的目 标，具体目标和指标的考察也刚刚起步。它 们有可能对于全球健康产生转变性的作用。 在何种程度上未来的首要事务应仅作为可持 续发展目标，在何种程度上这些首要事务又 应该通过其他方式来得以推动，是一个意义 深远的问题。 新的工作方法 过去 10 年世界卫生组织启动了其自身的改革 进程，并就此与其成员国、合作伙伴和来自 不同背景的个人、组织进行了讨论。一些讨 论集中在这些基本原则上 ：一个由世界各国 组成的全球健康机构，究竟应该开展怎样的 工作？全球健康问题的复杂性是促使世界卫 生组织重新审视其角色和位置的原因。各种 63 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 12 组织和关切领域的不断增多，致使相互间的 关系需要不断的梳理。特别是在全球金融危 机后，世界卫生组织的资助环境出现了恶化。 全球健康进入了一个开放和健康的语境，世 界卫生组织的角色也需要经常受到审查。时 常也有来自学界和其他地方的批评声音，质 疑世界卫生组织没有发挥其最大的潜力来提 升全球健康。 一般来说，世界卫生组织被评论家视为一个 有多种工作方式选择的角色 ： 作为一个设定 规范和标准的机构来推动发展 ；作为全球活 动家和倡导者，推动健康发展，呼吁更多解 决健康低下的经济、社会主导因素的行动 ； 作为一个咨询机构和向其成员提供技术支持 和推动的提供者 ；在现实中，为了更好地推 动全球健康，世界卫生组织并不能仅从中选 择某一个角色，而是需要扮演好全部的角色。 为了在 21 世纪更好地实现其推动全球健康的 义务，世界卫生组织面临着巨大的挑战。作 为重中之重，推动人口健康不变的先决条件 不仅包括循证的技术干预，还有包括政治承 诺和联盟、领导力、成功的合作关系、多边 协作以及社区和公民参与在内的一系列重要 活动。在许多需要行动或改变的领域，复杂 性是显而易见的。这一复杂性体现在埃博拉 危机不仅影响到世界卫生组织，还影响了联 合国其他的专门机构 ；体现在改变全球致胖 环境至少需要 20 个或更多的影响节点来改变 某一社区的卡路里摄入和体育活动的习惯 ； 还体现在全球根除脊髓灰质炎病毒，需要覆 盖那些生活在疫苗接种员可能被针对，甚至 被谋杀的冲突区域的儿童。 由于全球健康改善进程缓慢带来的失望，一 些主要的捐赠者向那些能够实现可衡量进展 的健康和疾病领域提供资金。 专门机构和合 作关系正蓬勃发展（例如联合国艾滋病规划 署，全球抗击艾滋病、结核病和疟疾基金， 全球疫苗免疫联盟等），同样的，它们的主要 资金配置也有着类似的侧重点。 这一方式在实现了一定的进展之余，也提出 了一个重要问题 ：如何能够最好地实现全球 健康进步。所谓的“垂直项目”，在实现自身 成果的同时，牺牲了以广泛的横向行动来加 强当地卫生系统向自治、自立方向的转变， 并通过这样的卫生系统来推广项目成果的可 能性。 低收入国家的卫生部长出于国家考虑， 往往乐于寻求这样的资金，并可能将自己的 思维囿于这样的有局限性的一揽子项目中。 过去 10 年世界卫生组织的资金提供模式已经 由主要依赖核心资金，并赋予成员国自由支 配资金的方式发生了转变。现在，80% 的预 算都为非核心资金，其中大部分为由捐赠者 指定的专款专用资金。垂直项目的流行也情 有可原，它们确实可以实现积极的成果。但 反过来，在过去，加强卫生系统的传统发展 议程主导了由主要援助国提供的大量资金的 分配，且通常并不要求这些资金能够带来显 著的成效。 回顾过去 10 年取得成就的经验和进步缓慢的 教训，还有一些因素需要世界卫生组织突破 其常规角色来加以强调，包括 ： · 核心多领域合作在国家层面能够取得的 成效的局限性 ； · 特别是在低收入和中等收入国家，那些 可用于监测成效，评估改变的健康数据 质量低下 ； · 许 多 成 效 问 责 机 制 充 满 冗 余 和 不 确 定性 ； · 推动突发事件指挥和控制过程的难度。 参考了许多对于世界卫生组织角色的建设性 意见和支持后，世界卫生组织的自身改革进 64 更 健 康 、 更 公 平 、 更 安 全  全 球 卫 生 十 年 历 程 （ 20 07 — 20 17 ） 12 程专注于这三个主要领域 ：首要事物和项目、 治理、管理。在各个领域的运行方面都实现 了主要的转变，包括建立 ： · 有明确定义的优先事务，国家办公室将 大部分的预算应用于这些领域 ； · 有效的管理问责、透明性和风险管理 ； · 得以强化的利益相关者参与（特别是非 国家行为者）； · 得以改进的战略决策过程 ； · 应对可带来健康后果的紧急事件或疾病 爆发方面的能力得以提高 ； · 更加进步的人力资源管理 ； · 将信息作为一项策略财富进行管理。 《与非国家行为者交往框架》（Framework for Engagement with Non-State Actors）是一项重 要的进展。它由成员国商议并通过。它承认 世界卫生组织需要与多类型的伙伴（非政府 组织、私营企业、慈善基金会和研究机构） 开展有效的合作，并就此给出了清晰的指导 方向。特别是在特定的条件下，与私营企业 的合作已经有所进步。这也是世界卫生组织 在以前没有涉及的领域，丧失了不少良机。 《与非国家行为者交往框架》的发展涵盖了 许多世界卫生组织的工作领域，过去 10 年累 积的努力之上继续团结各类利益相关者。特 别是于 2011 年世界卫生大会上通过的“大 流行性流感防范框架”（the Pandemic Influenza Preparedness Framework），团结公立和私营领 域，共同实现共享可能产生人类大流行的病 毒和提高贫困国家疫苗和其他流行病有关的 物资覆盖的重要目标。 这些改革使世界卫生组织能更好地融合其一 直以来的优势，如召集各方的能力，在确立 规则和标准方面的专业性，以及被广泛认可 的全球健康领导者的地位。 就像这一报告所记录的，过去 10 年取得了广 泛的成就。希望的种子已经被根植，在未来 的几十年中，它们可以，也必将会开花结果。 除非另有说明，本报告引用的数据均源自联合国的公开资料。