well good morning and welcome to New York City there’s been some who have mentioned that CGH 2018 has a gap there’s insufficient amount of genomics and genetics at this conference our keynote speaker mr. Stephen Lewis and his family are going to fill that gap mr. Lewis himself his father and yes his grandfather great grandfather and Russia we’re all major leaders in social justice and in human equity David Lewis his father was one of the key architects of the Canadian New Democratic Party the NDP an opposition party which really brought universal health access to Canada Medicare to the Canadian Medicare program in the 1970s mr. Lewis Stephen Lewis was the leader of the Ontario New Democratic Party before becoming Canada’s ambassador to the United Nations Stephen Lewis is the co-founder and co-director of aids-free world an international advocacy organized organization that exposes injustice in abuse and inequality the social ills that underpin and continue to sustain HIV he is a professor of distinction at Ryerson University and he’s the board chair of the Stephen Lewis foundation a not-for-profit that makes major contributions to helping solve HIV problems in Africa he’s an Emirates board member of the International AIDS vaccine initiative served as a commissioner of the global Commission on HIV in the law and on the Lancet Commission on Public Health and international drug policy Stephen Lewis was the UN Secretary General’s special end boy for HIV AIDS in Africa from 2001 until 2006 and he then became deputy executive director of UNICEF here at the headquarters in New York Stephen Lewis is a Companion of the Order of Canada Canada’s highest honor for lifetime achievement and he holds 42 honorary doctorates from Canadian and American universities one last point I noted in his biography that on November 14th 1957 at the University of Toronto Stephen Lewis debated Senator John F Kennedy the debate question was 1957 has the United States failed in its responsibilities as a world leader so what we’re going to hear now is not just a talk on health disparities but a person who really takes the time for action and makes it real mr. Stephen Lewis [Applause] well that was entirely embarrassing most a most extravagant and unusual introduction I am I am in your debt I am glad that my political lineage is now intact in the presence of this vast and auspicious audience although I must admit that my work with aids-free world and my colleagues in aids-free world is what gives my life meaning I I think and I’ve said this before allow me to say it to an audience which hasn’t been subjected to my rhetorical spasms as yet I I think that I should address the the underlying laughter which coerced through the audience the sotto voce with the reference to the honorary degrees and it’s important for me to make a public admission I attended for post-secondary institutions in Canada of celebrated higher learning over an infinite number of years and managed never but ever to acquire a degree I have therefore spent my entire adult life shamelessly lusting after honorary degrees in order to receive through the backdoor what was so lamentably denied me through the front and I actually have a an adroit and infinitely creative strategy to acquire degrees and I’ll be glad to talk to any of you who feel somewhat subordinate in this realm I I talked to dr. Keith Martin about this speech and he told me that he wanted some sort of clarion call to action if at this hour of the morning that seems a little strenuous I fully agree nonetheless keeping the theme of the conference firmly in mind I shall do my best and if my best fall short you have Keith Martin to blame however this I can say at the outset I intend this speech to be entirely unorthodox in terms of the likely expectations I ask only that you bear with me to the end when threads of coherence may emerge this is not for me an exercise in calibrating the obvious the Occupy movement the annual Oxfam reports detailing the obscene concentrations of wealth the huge disparities in human health between struggling nations in Africa and the Western world the grotesque indignity of poverty in the United States chronicled by Philip halston the UN Special Rapporteur for human rights and and poverty the hegemony of the 1% who parade their self impressed beneficence at the World Economic Forum these are all too well known by anyone who follows the quest for social justice in global health I don’t want to drive the nail through the wall with a litany of examples of inequality with which this audience is familiar I want instead to attempt to make an argument about what to do about it let me start briefly if I may with the temper of the times because that’s the necessary context this is not a philosophical riff on my part this is I think accurately descriptive and by no means novel we’re in a wildly volatile period of right-wing populism from chile to italy to poland to india to zimbabwe to the united states the winds of change are for the most part hostile reactionary suffocating and at times misogynist racist and malevolent when it comes to global health we struggle with everything from disabling financial shortfalls to eviscerating gag rules the terrible toll that’s taken on the uprooted and disinherited of the earth seems to cause barely a ripple of concern if Dickens were still alive he would say it was the worst of times and the worst of times if as in the sustainable development goals health is one of the most important measures of the human condition then we are notably failing it’s 2018 and UNICEF reports last week that there are 650 million children in 52 countries who are unlikely to reach even 2/3 of the goals we still have nearly 6 million children dying of preventable diseases before the age of 5 its 2018 and the UN women reports last week that a hundred and twenty-two women live in extreme poverty for every 100 men and three hundred and three thousand women and girls still die from pregnancy related illnesses every year and those who struggle and those who die are not in the rich countries of the north this is not to deny the significant gains that have been made this is simply to say that there remains far too much pain in this world in the poorest countries of the world the drama of disparities as they pertain to health can be viewed if I may be so bold through a three-part lens the first is climate change the same UN woman’s report states that 14 times the number of women as compared to men died in climatic disasters from tsunamis to hurricanes induced by global warming I don’t wish to be on Julie apocalyptic but my own view is that climate change presents the single greatest threat to humankind will you permit me a personal aside in June of 1988 I chaired the first international conference on climate change it was held in my home city of Toronto Canada there were assembled 300 scientists politicians and activists from around the world for a week of intense sometimes splenetic debate and at the end a conference statement was issued whose opening paragraph read in part quote Humanity is conducting an unintended uncontrolled globally pervasive experiment whose ultimate consequences could be second only to a global nuclear war the best predictions available indicate potentially severe economic and social dislocation for present and future generations it is imperative to act now close quote at the time those words were considered extravagantly hyperbolic today no longer it’s 30 years later and the imperative to act now was never heated why do I make much of this two reasons first the pulverizing consequences of sea level rise small island states disappearing beneath the waves massive droughts concomitant famine agricultural dislocation the ice evaporating in the Arctic and the Antarctic inundation of coastal regions heat waves leading to asphyxiating deaths plus the huge and proliferating range of climate induced catastrophes is collectively a recipe for illness death and despair and that doesn’t begin to touch on the tens of millions of environmental refugees who are about to be unleashed on the world I needn’t drive home the obvious the consequences for human health fall far more heavily on the poorest parts of the planet and when the richest parts of the planet are so far assailed by climate change it hurts momentarily but they can cope what is so galling is the profound intellectual hypocrisy that pretends that progress is being made the world went into hyperactive overdrive at the Paris climate conference when in December 2015 196 countries agreed to the Paris climate Accord by consensus you will recall that the centerpiece of that Accord was the commitment that temperature rise would not exceed 2 degrees Celsius over pre-industrial levels indeed the second half of the Accord set the target at 1.5 degrees Celsius now here is the intellectual rub the entire Accord is voluntary there is absolutely no mandatory requirement whatsoever to meet the agreed-upon objective more countries set their own targets and can change them at will or discard them at will it is a grand illusory facade it approximates a conspiratorial hoax on the planet the most reputable climate scientists and experts have pointed out that the targets presently set and arithmetic Li computed will drive the temperature up by 4 degrees Celsius or higher that spells an incomparable calamity why am i exercised because this is the ultimate definition a disparity that will haunt the rest of this century and the greatest casualty of all as everyone in this room can into it will be human health in the poorest regions and conditions of the globe it seems to me that in this room of scientists experts researchers advocates there lies a compendium of knowledge that should galvanize the world I know you didn’t achieve the celestial heights of excellence in order to mount the barricades but surely voices must be heard whether it’s a research study or an article in a learner journal or a press conference or a media interview or an op-ed in The New York Times or a conference like this one or an expert panel or a Lancet Commission or a review of academic materials you must I say this with great respect you must shared your inhibitions and speak truth to the fossilized anti de lluvia n— establishment there’s too much at stake there’s too much hurt in Prospect Global Health will be shredded and those who need health most will be abandoned to the gale force of climate change because those of us with voice chose not to use it the second representative manifestation of disparity of inequality is more prosaic tuberculosis forgive me for repeating what you already know TB is now the greatest killer among infectious diseases 1.8 million deaths a year more than HIV and malaria put together further there were well over 10 million active cases of TB in 2016 and an accelerating web of multi drug-resistant TB MDR and extensively drug-resistant TB xdr-tb in several countries India and South Africa above all if ever there was evidence of disparity and inequality TB is the exemplar let me take you on a quick travelogue last september with georgia white a close call from aids-free world I travel to the territory of Nunavut the Arctic home of the indigenous Inuit people of Canada they were experiencing a significant tuberculosis outbreak in 14 of the 25 remote communities it was appalling the incidence of TB was 260 times higher than any level of TB among the non-indigenous people of Canada and it became clear that a pattern of neglect had been government policy for decades in fact it was a pattern of ceaseless historical discrimination all the elements of transmission were there terrible overcrowding dreadful shortage of housing ubiquitous poverty astronomic food prices desperately poor nutrition it was like a case study in the violation of the social determinants of health we were there on a TB fact-finding mission and believe me there was a lot to find the community struggled heroically the Inuit people showed astonishing resilience their indigenous organizations were strong and tenacious the medical officer of Health and her staff were extraordinarily impressive but the lack of doctors and nurses and community health workers particularly those who could speak Inuktitut and grasp the culture were sorely lacking there were no gene expert machines the best diagnostic tool in the outlying communities or even digital x-ray machines and at root there was a fatal lack of funding in Canada the treatment of indigenous peoples like almost everywhere else in the world has been characterized by stigma exploitation indifference and savage racism when the trip was over we wrote a very strong and critical report I can’t pretend that it had undue influence but the times they are a-changin the government of Justin Trudeau by the way I am NOT of his political party is working hard at reconciliation and with the creation of a new Ministry of Indigenous Services and the appointment of a minister to head it dr. Jane Philpott one of the best ministers in the government cabinet the pendulum is swinging as recently as one month ago the Minister announced a four hundred million dollar plan for housing and the pledge of an initial 27 million dollars to fight TB which she promised to eliminate over the next five years the Inuit people are 65,000 in total in number it should be possible i dwell on this because it has ever thus indigenous communities racialized communities communities of diverse sexual orientation and gender identity marginalized communities at the fragile cliffs edge of society are always beleaguered mostly without voice submerged in feelings of hopelessness that’s the meaning of inequality that’s how it poisons the anatomy and the soul in October my colleague and I traveled to India again on a TB fact-finding mission I’m not sure we’ve yet recovered India has approximately 27% of the global TB case load some 2.8 million cases and a quarter of multi-drug resistent TB cases some hundred and forty-seven thousand it was MDR TB on which we concentrated primarily in Mumbai if ever there was a disease of poverty and inequality MDR is it but what’s most discouraging is the behavior of the Indian government this is not a government that lacks for funds but it has starved the response to MDR TB and XDR TB in a thoroughly callous way it was perfectly prepared to watch patients die as they struggled to locate and be treated with life-saving drugs and in the most recent famous case it took the lawyers collective going to court on behalf of a 17 year old girl to get the drugs released thanks to a remarkable physician dr. Zuri red whadya the young woman with xdr-tb is still alive and now TB free but in our trip the episode spoke volumes the rhetoric we heard from virtually every government representative right up to deputy ministers was a combination of dissembling vacuity and soothing fatuity in fact in one memorable encounter at the very senior level of the Ministry of Health we were told and quote exactly everything is perfect close quote but of course nothing was perfect the struggles around TB between the public and private sectors was ongoing the new drugs for MDR TB the first new drugs in 40 years but a colon and a laminate were just beginning to be rolled out the community health workers indispensable to patient recovery were catastrophic ly few in number the patients with whom we met described a nightmare experience of treatment and continuing stigma with which they had to contend if it hadn’t been for the work of MSF we would have been thoroughly depressed it’s necessary to ask and I feel that this platform should be met with with absolute candor so it’s necessary to ask how does the Indian government get away with it for all these years and no one except for a courageous view confronts them yes India still a developing country seething with more than a billion people has desperate poverty though not at the top where the human resources for health and the laboratory components of Health and the infrastructure of Health have been ignored for years do none of us have a responsibility for the toll on the human condition in another part of the world let me take a cautious risk at this point as we meet here today the Stop TB partnership the leading international force outside w-h-o against TB happens to be holding an executive meeting in India that makes good sense where TB is concerned India is the fulcrum and India’s Prime Minister Narendra Modi will be a guest of honor he will undoubtedly be festooned with adoration and tributes lavishly paid for his unexpected commitment to ending TB by 2025 and doubling the budget for tuberculosis you can be sure that not a critical word will be heard now as it happens I have great admiration for the Stop TB partnership and what it does but I respectfully disagree on the strategy employed and in this instance I can draw directly from my own experience it is a mistake I think to cozy up to heads of state for the rhetoric they discourage when passed evidence suggests that the delivery is or has been negligible it doesn’t work I spent five and a half years as the UN envoy for hiv/aids in Africa I met with the President and cabinet of virtually every high prevalence country and most of them more than once I learned early on that ashes and sackcloth never led to a policy change on AIDS the only thing that worked whether it was with an egomaniacal president Daniel arap Moy of Kenya or a denialist like president Thabo Mbeki of South Africa the only thing that worked was to lay the cards on the table with unequivocal candor at times it was necessary to offend it was never necessary to mollify it was uncompromising but respectful lives were at stake lives many lives are at stake in India there’s not a day to lose sure the budget has been doubled but it’s laughably Picayune compared to the way in which the health budgets have been starved for decades as of our trip the overall health budget was 1.2 percent of GDP projected to rise to 2.5 percent of GDP by 2025 frankly that’s pathetic even compared to a majority of developing countries sure the year 2025 has been trotted out as the end of TB but everyone significantly ensconced in the TB world knows that’s nonsense why can’t it be said you see that again is the message I want to convey wherever in the world there is oppression on the basis of squalor or class or race so that human health is imperiled it’s necessary to take a stand it’s necessary to find an opportunity to speak out about the indignity of increased morbidity and mortality where none need occur let impatience be your by word just last month my colleague and I made the final visit in our tuberculosis Odyssey this time to South Africa South Africa has the highest number of TB cases in the world and everyone in this audience will know that the co infection rates with HIV are staggeringly high and the TB is the greatest single killer of those with AIDS South Africa also has a very serious outbreak of MDR and XDR TB concentrated in the townships around Cape Town and kwazulu-natal we went first to Cape Town and spent more than a day in the primary township of Khayelitsha observing MDR TB what a difference from India in South Africa the government is on site the Ministry of Health knows it has a crisis and it’s moving mountains to contain it the Minister of Health is an eloquent advocate Jean expert has been rolled out more widely than any country in the world but a colon is commonplace to laminate is only available on a compassionate use basis but the government and activists are placing great pressure on the manufacturer Otsuka to register in South Africa community health workers are valued and have just received a major jump in pay there are social grants for patients and families struggling with the disease research is valued and supported everyone with HIV takes a TB test and everyone with TB takes an HIV test and above all groups like MSF that lead the response at a Township like Khayelitsha have the minister on their side this is not to paint a romantic panacea we encountered some heartbreaking realities too many patients recovering at home have no food prevention has been neglected in the rush to treatment short-term treatment runs for nine months with painful daily injections that can lead to deafness plus 15 pills a day children of two three and four months languish in pediatric wards with extra pulmonary TB some of them facing a life of disability and several critics from the treatment action campaign - respected academic researchers feel that the Minister of Health relies too readily on fanciful not fanciful nostrums of success rather than hard-headed recognition of limited progress but that’s the point there is open public dispute ation unlike India No one feels constrained intimidated or silenced it’s understood that breakthroughs occur when a spirit of unrestrained debate prevails and that’s the way you overcome disparity it’s identified and confronted does that does that mean that South Africa is a crucible of equity far from it health care in the private sector still confers huge benefits on the 16% of the population that gets to use it and the public sector by comparison though having some of the most talented clinicians in the country is woefully rundown overcrowded and struggling but again I emphasize that even the Minister of Health himself is provocatively vocal rather than defensive about the state of health in South Africa am i off track here have I lost my way I don’t think so none of it is in an opulent ly wealthy developed country whose governments through the decades have chosen racism over equity that changed with unbridled activism India is a so-called developing country with enormous wealth concentrated at the top while the masses struggle for health care how do you break that paradigm of inequality I would argue that you achieve it through tenacious indefatigable pressure on the government driven by crescendos of activism until capitulation is the only alternative South Africa is the proof of the equation it’s also deemed a developing country but a country where almost all of the beneficial institutional change has come through the application of unrelenting advocacy in this case a combination of rousing public demonstrations combined with brilliant use of the courts do you remember how three hundred and thirty thousand people died of AIDS who should never have died of AIDS on Tabo and becky’s watch because of his refusal to roll out anti retrovirals he was forced to relent because the arsenal of protest wore him down that’s what I’m asking of this audience and it leads me to the final issue I want to recognize her conflict and set violence I would posit that the health consequences of sexual violence surpass any communicable or non communicable disease that seems to me unarguable I shall assume agreement yesterday March 15th marked seven years of the war in Syria half a million killed 12 million displaced 13 million in need of humanitarian assistance the carnage defies linguistic definition war crimes and crimes against humanity seem inadequate approximations of the barbarism suffusing that barbarism reported widely by human rights groups is an explosion of rape that strangles credulity you will note that the world has done virtually nothing since August 25th of last year 360 wroking two villages had been burned to the ground in Myanmar 688 thousand have flared 900,000 and total are now refugees in Bangladesh there has not been a single Security Council resolution on the reinga not one it’s incredible we’re witnessing a genocide against a Muslim ethnic minority and the world is utterly indifferent but we’re also witnessing a femicide a war on women rooted in rape and finalized in slaughter the stories and images out at Mian were women and children sacrificed to rapacious madmen in the Myanmar army make you wonder wherein lies hope for this world Yemen is the ultimate killing ground more than 1000 days of war it’s also the world’s longest humanitarian crisis 75% of the population of 22 million require assistance and eight million face famine women and children are helpless collateral damage the primary perpetrator Saudi Arabia sits on the United Nations Human Rights Council the very embodiment of mockery of the United Nations Charter and all of its international human rights instruments the social determinants of health have collapsed so dramatically that Yemen has had to face the largest cholera epidemic anywhere Haiti included since the turn of the century Burundi the Democratic Republic of the Congo South Sudan Darfur the Central African Republic Mali Zimbabwe Afghanistan Venezuela Pakistan Egypt Ukraine Turkey Iraq Iraq need I remind you of the Yazidis torn from their ancestral home by ISIL a catalog of massacres abducted tortured beheaded burned alive agonizing death from dehydration starvation and for the Yazidi women and children the torment of sexual slavery sold in the OR open marketplace like some pre feudal cattle call lives ruined forever is there a greater inequality where was I Iraq the list is never-ending of those countries and regions where conflict or deplorable governance leave women and girls overwhelmingly women and girls at the mercy of sexual violence and this doesn’t begin to mirror the statistic in the UN women’s report that one out of five women and girls have experienced physical and/or sexual violence by an intimate partner in the last 12 months nor does it mirror the me2 movement or the proliferation of sexual harassment sexual exploitation and abuse sexual misconduct sexual assault that has been revealed in the international humanitarian NGO community and the United Nations system I want to add with some pride that my co-director of aids-free world Paula Donovan she is here this morning launched our code blue campaign designed initially to end impunity for sexual exploitation and abuse in UN peacekeeping operations but code blue has now emerged as one of the strongest forces with the most credible solution against sexual harassment and abuse within the entire UN system and believe me it’s a challenge because the UN system is rife with sexual abuse the toll on women physical emotional psychological in all of these particulars is indescribable it’s an absolute assault on health and of course the women who suffer the most are the women who are most disadvantaged and vulnerable or compromised and fearful or desolate and alone I’m not asking that people in this room fashion world peace but I would argue that what knits everything together is inequality on the one hand and health on the other it’s no accident that the World Health Organization is urgently considering a Framework Convention on global health it’s no accident that public health insurance plans Medicare as it’s known in countries like Canada are now the rage in country after country health is the tie that binds and if we can bring home the unconscionable damage to human health to the health of women and children caused by these conflicts clause by the use of rape as a strategy of war caused by the use of use of rape as the ugliest excrescence of the patriarchy then maybe one day we’ll get world leaders to shift from the politics of self aggrandizement to the politics of social justice and the human condition it would not have been difficult in this speech to parse specific indicators of disparity and inequality I could have relied on hiv/aids alone just to examine the situation of the LGBT community or sex workers or injecting drug users and juxtapose their grievous predicament with the way in which we treat mainstream groups would make the case a careful examination of cervical cancer as described by dr. Martin would be equally true or take adolescent girls and young men women in the context of HIV for how many years have we bemoan dar collective failure to persuade adolescents and young women of prevention how many academic papers have been written in the hope of precipitating action yet in a UN AIDS publication of 2016 it’s established that there are 8,000 600 new HIV infections a week amongst adolescent girls and young women a week talk of inequality the HIV pandemic is the showcase for inequality gender inequality so it would have been possible using research papers published by many in this audience to make the case for and confront the use of disparity but I chose otherwise and as I close let me explain why this is intensely personal non antolín non analytic even faintly ideological so if you want to leave the hall please do people have been walking out on me all my adult life I’m in my dotage I’m 80 years old I can sort with geriatrics and I’m frightened not about the issue of mortality but about the life of the planet I think things have gone haywire Glaber global warming was once an existential threat now it’s terrifyingly real and on top of that we appear to have the re-emergence of the Cold War with aggressive belligerence on both sides of the divide but that’s only the half of it these intractable conflicts in so many regions threatened to engulf other geopolitical players with disastrous results and in the hands of two of the most irresponsible of those players there are nuclear weapons it’s no wonder that The Bulletin of the Atomic Scientists just move the hands of the Doomsday Clock to two minutes to midnight I think of my grandsons and the world they’re about to inherit so how do we fight back how do we mobilize civil society to mount the greatest push for survival the world has ever known what is the motivator striking the alarm of poverty doesn’t seem to do it we can’t even raise the funds to feed the starving on an emergency basis the sustainable development goals writ large sound good but they’re far too esoteric both for the noisy patricians and for the lumpin proletariat water doesn’t do it sanitation doesn’t do it you trician doesn’t do it education doesn’t seem to do it but the one unifying force that engages everyone’s attention is health and if you could make an argument from any platform any podium for the preservation of health then you have an instant audience I beg you to believe that it’s worth doing it has an elemental sanity of enormous appeal the appeal is to decency not malice the appeal is to caring not rejection the appeal is to sympathy not hostility when you concentrate on health you touch the mind and you touch the heart in biblical terms please go forth and do exactly that the world is actually worth saving thank you for the privilege of this [Applause]